UNITED STATES OF AMERICA M£C FOUNDED 1836 WASHINGTON, D. C. GPO 16—67244-1 ,'V/ 'A ' ii(-h.7923 ■^5-i. ~-* Be it remembered, that on the fourth day of June, in the fifty-fourth „ ( year of the Independence of the United States of America, A. D. 1830, I John Eberle, M. D. of the said district, has deposited in this office the -*v^~ * title of a Book, the right whereof he claims as Author, in the words following, to wit:— " A Treatise on the Practice of Medicine. In Two Volumes. By John Eberle, Professor of Materia Medica and Obstetricks in Jefferson Medical College; Member of the American Philosophical Society, &c. &c." Vol. II. In conformity to the Act of the Congress of the United States, entitled, " An act for the encouragement of learning, by securing the copies of maps, charts, and books, to the authors and proprietors of" such copies, during the times therein mentioned:" and also to the act entitled, "An act supplementary to an act, enti- tled, ' An act for the encouragement of learning, by securing the copies of maps, charts, and books, to the authors and proprietors of such copies, during the times therein mentioned;' and extending the benefits thereof to the arts of designing, engraving, and etching historical and other prints." D. CALDWELL, Clerk of the Eastern District of Pennsylvania. A TREATISE ON THE PRACTICE OF MEDICINE. CHAPTER I. CHRONIC NERVOUS AFFECTIONS. GENERAL OBSERVATIONS. The nervous system gives to organized matter all the pecu- liar functions of animal life, and in its higher states of deve- lopment renders it a fit recipient for the powers of reason and moral feeling. In a state of health, or freedom from irritation, it qualifies man for the enjoyment and communication of hap- piness—when disordered, it may render him the most deplora- ble and abject of created beings. Exalted mental endowments, equanimity, and benevolence, may be converted into imbecility, waywardness, and misanthropy; meek piety, into the wild- ness and intolerance of fanaticism ; confidence, into universal mistrust; and friendsliip into hatred, by morbid conditions of this component of the human organization. The chronic diseases of the nervous system may be divided into two classes—viz : 1. Those in which the sensorial or muscular functions are morbidly affected, cither separately or conjointly; 2. Those in which the intellectual and moral powers are disordered. The first of these classes comprehends a great variety of af- fections—characterized either by a perversion, or a morbid ac- tivity, or abolition of one or more of the sensorial functions; or by spasm, or convulsion, or paralysis, of a greater or less portion of the muscular system. The examples of singularly perverted sensorial function are numerous. Reil mentions a case in which the whole surface of the body was insensible to heat or cold, and incapable by the touch of distinguishing hardness from softness in bodies. VOL. n.—1. 2 GENERAL OBSERVATIONS. Dufour gives an account of a similar case.* Sauvages relates the case of an individual who always heard two voices, one an octave higher than the other when any one spoke to lnm. Individuals have lost the power of distinguishing colours ; and some have been much harassed by various visual illusions. Instances of very distressing morbid increase of sensorial power are frequently met with. The sense of hearing has be- come so exceedingly acute that the weakest sounds gave rise to pain and uneasiness, and the same has been observed with re- gard to the other sensorial powers. In some cases nervous disorder manifests itself by excruciating pain in some part of the body, as in the various forms of neuralgia. The sensorial functions may also be weakened or entirely destroyed, by affections seated in the nervous system. When such affections are local, one sense alone may be obliterated ; but when the disorder implicates the whole of the sensorium commune—the brain—all the sensorial powers will be suspend- ed. This general state of nervous oppression or inactivity is attended with manifest respiration and arterial action, and constitutes what is termed coma ; a condition which must not be confounded with syncope, or asphyxia. These latter affec- tions are not accompanied by any perceptible respiratory and arterial actions, and although like coma the immediate conse- quence of impeded cerebral function, yet they are manifestly dependent on different conditions of the encephalic circulation. The pathology in relation to this subject, however, will be il- lustrated hereafter. When the nervous irritation passes upon the muscular sys- tem, it gives rise to irregular, spasmodic, or convulsive ac- tions, either in one, or in several, or in the majority of the muscles of the body. These convulsive or spasmodic muscu- lar contractions, are divided by authors into tonic and clonic. In the former the contractions are permanent, as in tetanus; in the latter they occur in quick alternation, with relaxations, as in hysteria and epilepsy. There exists, however, no essen- tial difference between these varieties of convulsive muscu- lar action. They indeed often occur at the same time in the same individual, some muscles remaining in a state of firm contraction, whilst others are alternately relaxed and con- tracted. In general, however, convulsions of the clonic form are attended with less danger than those of the rigid or tonic spasmodic affections. The former are frequently the result of a mere temporary sympathetic irritation of the brain, from causes of a transitory character, or susceptible of beine re- moved ; whilst the latter usually depend on a more intimate affection of the nervous system from causes over which we have little or no control. Convulsions, or general spasmodic * Reil, Fieberlehre, bd. iv. p. 64. GENERAL OBSERVATIONS. 3 affections of the voluntary muscles, must, therefore, be regard- ed as the external manifestations of certain morbid actions or conditions of the brain and nerves. The brain is always the immediate source of the muscular irritation ; and the violence, duration, character, and extent of the convulsive affection de- pends on the nature of the cause, and the constitutional habit of the patient. In some instances, the cerebral affection which gives rise to the convulsive muscular contractions is so great as to produce a temporary suspension of consciousness, and of the sensorial functions. In others, as in tetanus and chorea, the mind and sensorial powers remain unaffected until the disease becomes inveterate. Spasmodic contractions are often confined to one part, and indeed frequently to a single muscle. Of this kind are, tonic spasm of the muscles of the eyes, producing strabismus; or convulsive action of these muscles giving rise to rolling of the eyes, {hippus;) spasm of the muscles of the lips and face, {sardrosis, risus sardonicus,) giving an expression of malig- nant laughter to the countenance; tonic contraction of the muscles of the jaws {trismus;) spasmodic affection of the oeso- phagus ; convulsive action of the diaphragm, producing hic- cough {singultus;) tonic spasm of the erector muscles of the penis, giving rise to painful, and sometimes protracted pria- pism; tonic or clonic spasmodic contractions of the abdominal muscles ;* and other local spasms or cramps of the voluntary muscles, are among the most common affections. The involuntary muscles also are subject to spasmodic affec- tions ; but these appear to depend more frequently on some local irritation than upon a reflected cerebral impression. The whole arterial system is sometimes affected with clonic con- vulsive action. This is particularly apt to occur from sudden and violent mental agitation; from gastric irritation; and from organic affections of the heart, {angina pectoris, palpita- tion.^) The stomach, the intestinal tube, the common gall duct, the uretha, uterus, &c. are all particularly liable to painful spasm. The second class of nervous diseases, those in which the ce- rebral irritation produces mental derangement, presents a va- riety of modifications, both in relation to the degree, and the particular character of the hallucination. In some instances, there is a general derangement of all the intellectual faculties, with violent excitement of the passions ; occasional exacerba- tions of raving delirium and agitation, {mania.') In other cases, the insanity is only partial—the patient retaining the * Whytt mentions the case of a young woman who was affected with constant convulsive action of the abdominal muscles during the day, though free from them at night when in bed. 4 GENERAL OBSERVATIONS. regular powers of his understanding on all but a few, or a sin- gle subject, (monamania.) Sometimes the reasoning powers become defective or imbecile, and the memory weak or obli- terated, {dementia,) a state of mind which is most frequently met with in very old people, and in such as have suffered fre- quently from convulsive affections, as epilepsy, chorea, or apo- plexy. In some instances, almost every trace of intellectual power is wanting, either from a congenital defect in the cere- bral organization, or from diseases or accidental causes af- fecting the brain. These varieties of mental disorder some- times pass into each other, and present an almost infinite di- versity in their particular plienomena. They may arise from causes acting directly on the brain, and from impressions con- veyed sympathetically to this organ from remote visceral af- fections. Whatever be the nature of the remote cause, how- ever, insanity of every variety is always the immediate conse- quence of some peculiar dynamic or organic disorder of the sensorium commune. Under the particular head of these af- fections, I shall enter more fully into the etiological considera- tion of this subject. APOPLEXY. 5 CHAPTER II APOPLEXY. Apoplexy may be defined, a sudden loss or suspension of the animal functions, with a slow and full pulse, laborious breathing, genecally attended with stertor; whilst the organic or vital functions continue with little or no perceptible disturb- ance. In some instances, the apoplectic attack comes on suddenly without any precursory indications of its approach. Occa- sionally, indeed, patients feel unusually well for some time pre- vious to an attack of this affection, and this is most apt to be the case in individuals of a gouty habit. (Richter.) Much more frequently, however, various premonitory symptoms, in- dicative of cerebral disturbance, precede the attack; and amongst these the following are the most common:—vertigo; a dull and deep-seated pain, or sense of weight in the head, particularly on stooping or suddenly turning the head round ; a turgid state of the veins of the head ; throbbing of the tem- poral arteries; ringing in the ears ; inability to articulate dis- tinctly ; dimness of sight; transient obtuseness of hearing; sparks and flashes of light before the eyes; bleeding of the nose; drowsiness; confusion of ideas, manifested by incohe- rent talking; disturbed and heavy sleep; loss or unusual weakness of the memory; general sluggishness, both of body and mind; irregular spasmodic contraction of the muscles of the face; and, occasionally, transient pains in the pit of the stomach, and nausea. In some instances, a numbness is felt in the fingers, or in one side of the body shortly before the attack supervenes. In general, the symptoms which an- nounce the approach of an apoplectic attack, indicate an unu- sual determination of blood to the head. Of these symptoms, however, vertigo, ringing in the cars, dimness of sight, and pain and heaviness in the head, are by far the most common precursors of an attack of this disease. The duration of these symptoms is extremely various. In some cases, they do not continue more than a few hours before 6 APOPLEXY. the attack ensues; in others, they are experienced with occa- sional remissions or intermissions, for several weeks, or months, and even years. Occasionally, the most alarming of the foregoing symptoms occur and continue for a longer or shorter time, without terminating in an attack of this disease. The premonitory symptoms often become very considerably aggravated immediately before the apoplectic attack super- venes. The fulness, weight, and pain in the head become suddenly very severe; a sense of tension and drawing is felt in the muscles of the back of the neck; and, in some instances, pain in the epigastrium, with nausea, occurs just before the at- tack. In some cases, the apoplectic attack comes on by a sudden deprivation of all sensorial power and motion; the patient sinking almost instantaneously into a state of profound stupor, resembling deep and heavy sleep, from which it is impossible to rouse him in the slightest degree. This mode of seizure constitutes what authors term perfect or strong apoplexy, {apoplexiaperfecta, apilepsis, sideratio ;) and generally termi- nates fatally in a very few hours, and sometimes in less than an hour. In other cases, the patient is seized with sudden deep-seated pain in the head; tremor of the extremities; confusion of ideas; nausea or vomiting; and vertigo. He then becomes insensible, and sinks down as from syncope; in a short time, however, he recovers sufficiently to converse, and perhaps, to walk about, but still complains of pain and other unpleasant sensations in the head, with confusion of the mind and giddi- ness. In the course of a few hours, after this temporary reco- very, the brain becomes gradually more and more oppressed, until complete insensibility is induced, and the patient lies in a state of deep coma. Sometimes paralysis of one side suddenly occurs, with loss of speech; pain in some part of the head; slowness and confu- sion of the mind ; and vertigo;—the sensorial functions and consciousness remaining. By degrees, however, the brain be- comes more oppressed, and the sensorial powers gradually de- cline until profound apoplectic stupor ensues.* In whatever way the apoplectic attack comes on, the following phenomena attend its course, and serve to distinguish it from the other forms of soporose affections. Immediately after the accession of the fit, the pulse and respiration are weak and often scarcely perceptible. Both, however, soon recover from the first shock; the pulse becomes full, slow, regular, and often hard; and the respiration slow, oppressed, interrupted or irre- gular, and generally sterterous. Some writers, indeed, contend - Abercrombie. Edin. Med. and Surg. Jour. vol. xiv. p. 554. APOPLEXY. 7 that in true apoplexy, sterterous breathing is invariably pre- sent; but this is not confirmed by general experience.* In violent instances, expiration is attended with a puffing motion of the lips, and a frothy saliva is blown out with a sputtering noise. The face is sometimes livid and of a turgid appear- ance; more frequently, however, it is pale and somewhat bloated. In some instances, the eyes are blood-shot; in others, they are dull, glassy, and fixed, or rolling about in their sock- ets. In general, the pupils are considerably dilated; but in some cases, they are permanently contracted. Dr. Cook states, that he has seen instances in which the pupils were al- most entirely closed. The extremities are usually below the natural standard of temperature, but the skin about the body, and particularly of the head, is warm. The jaws are generally spasmodically closed; sometimes they remain widely open. The power of swallowing is occasionally, in very violent cases, entirely de- stroyed ; but in most instances, though greatly impeded, it re- mains to a degree sufficient to enable the patient to swallow small portions of fluids. In all instances, very considerable torpor of the bowels exists ; and this is sometimes so great as to re- sist every effort to evacuate them by cathartic remedies. Clammy sweats usually break out about the head and neck, and the same sometimes occurs on the extremities. In mode- rate cases, the temperature of the skin, and appearance of the countenance, do not differ from their natural condition ; and in such cases, the power of deglutition is generally sufficiently strong to permit the easy administration of medicines by the mouth. This is particularly apt to be the case in what is term- ed apoplexia hydrocephalica, or the apoplectic stage of hydro- cephalus. Towards the termination of fatal cases, the pulse becomes small, irregular, and frequent; and the respiration slow, short, and interrupted by long intervals. If the disease does not end in death, it may terminate:— 1. In the perfect restoration of all the suspended functions, and the enjoyment of good health. This favourable issue may be expected when the various organs gradually resume their respective functions, more especially if consciousness and a command over the voluntary muscles gradually return. The tongue is often the first organ that obeys the commands of vo- lition ; after this the upper extremities, then the inferior ones, resume their power of motion; the muscles of the face being in * I have seen a case of fatal apoplexy, in which the breathing was throughout free from stertor. On post-mortem examination, a coagulum of extra vasated blood was found in the centre of the right anterior lobe ef the brain, and blood was also effused into the lateral ventricle of that side. 8 APOPLEXY. general the last to return to their regular action. Not unfre- 'quently, during the progress of recovery from an attack of apo- plexy, general and pretty free perspiration, or diarrhoea, ana in some instances active vomiting occurs. Sometimes sangui- neous evacuations attend the favourable termination of the a ur- ease ; such as epistaxis or hemorrhoidal and menstrual un- charges.* , .,. .„. £. In paralysis of certain parts of the body, with a restora- tion of health in all other respects. More or less paralysis, indeed, remains after the majority of apoplectic attacks, in some instances, the palsied muscles soon resume their natural power; in others, they slowly recover a certain degree 01 power, without however ever regaining their natural state 01 activity; whilst in some cases little or no perceptible diminu- tion of the paralytic affection ensues—the affected muscles re- maining permanently palsied. In most cases in which perma- nent paralysis is left by an attack of apoplexy, the mind be- comes very perceptibly weakened. The power of comprehend- ing complex ideas and the memory are often almost entirely obliterated in persons who recover from a severe apoplectic seizure. Paralysis from apoplexy is usually of the hemiplegiac variety; but in some instances, the palsy is confined to a sin- gle member or to certain muscles, more especially to such as derive their nerves immediately from the brain, as those of the face. 3. The apoplectic fit may terminate in a general febrile con- dition after the sensorial oppression has passed off. In some instances, strong synochal fever is developed in proportion as the nervous functions are restored; in others, fever of a ty- phoid character, with manifest gastric irritation, ensues. Seve- ral years ago, I was called to a gentleman who a few minutes be- fore had been seized with a fit of strong apoplexy. Under the usual treatment he gradually recovered so as to be able at the end of the fourth day to set up and converse without difficulty. On the next day strong febrile reaction, with a hot and dry skin supervened, and notwithstanding the most vigorous anti- phlogistic measures, violent delirium ensued, and continued for several days before it subsided. The patient eventually reco- vered. Diagnosis.—The diagnosis of apoplexy is not, in general, attended with difficulty. Where a loss of consciousness of the sensorial functions and voluntary motion suddenly come on, and continue with an active state of the pulse and full respira- tion, the case must be regarded as apoplexy. From syncope and asphyxia, this form of soporose disease is distinguished by the absence or almost imperceptible action of the pulse and * Richter's Specielle Therapie, Bd. viii. p. 711. APOPLEXY. 9 respiration in the two former affections. It is sometimes diffi- cult, however, to distinguish apoplexy from deep intoxication. The habits of the individual, the smell of his breath, and the general relaxation of all the muscles, particularly those of the jaws and the sphincters will generally lead to a correct diagno- sis on this point. Dr. Cook observes, that "as the treatment for true apoplexy would not be improper for intoxication, a mistake respecting the cause would not be hurtful to the pa- tient." This is no doubt correct in reference to mistaking intoxication for apoplexy ; but if a case of apoplexy were mis- taken for intoxication, the consequence might be very injuri- ous to the patient; for under .this mistake the case would pro- bably not be subjected to any efficient medical treatment what- ever. Prognosis.—Apoplexy is always to be regarded as a highly dangerous affection. When the sensorial functions are com- pletely abolished, and the respiration is strongly sterterous, intermitting, and attended with a sputtering discharge of sali- va from the lips, distortion of +he mouth, immobility of the pu- pils, and an entire loss of the power of swallowing, no reason- able hope can be entertained of a recovery. Nevertheless, patients do sometimes, though indeed extremely seldom, reco- ver from this affection after the most profound coma, sterter- ous respiration, and foaming of the mouth have supervened.* In general, however, if an appropriate and energetic treatment does not soon make a favourable impression upon the disease in its violent form, the case may be regarded as hopeless, f The duration of the apoplectic attack varies from a few mi- nutes to two or three days. In some instances, death almost immediately follows the apoplectic seizure. This indeed has been doubted by some. Dr. Cook thinks that the cases of sud- den death which have been ascribed to apoplexy depended,' probably, on some affection of the heart or large vascular trunks within the chest. There is good reason for believing that this has sometimes been the case; but it is by no means improbable that sudden and extensive extravasations of blood into the sub- stance of the brain, particularly in that part of this organ which gives rise to the respiratory nerves, may suddenly abolish, not only the sensorial powers and voluntary motion, but also the action of respiration, and thus produce speedy death. Death from this affection, however, seldom takes place before the second or third hour from the attack. In most in- stances, indeed, from twenty to thirty hours, and in some cases five or six days pass before the fatal termination occurs. Besides the unfavourable symptoms mentioned above, there * Portal, Observations sur la Nature etle Traitement de l'Apoplexie, p. 404. + Cook on Nervous Diseases, p. 113. Boston edition. VOL. II.—2 10 APOPLEXY. are various others which are said to indicate especial danger. When the attack commences with sudden severe pain in tlie head,* or with vomiting,! or a general spasmodic rigidity ol the muscles, the utmost degree of danger is to be apprehended. General, clammy, and profuse perspiration, with a small ana frequent pulse, is also a peculiarly unfavourable sign. Hip- pocrates says that the supervention of fever in apoplexy is fa- vourable; but Richter observes that this observation can only be regarded as generally correct when the fever is of the syno- chal grade and commences early, for when it supervenes at a late period and assumes a typhoid character, it never fails to increase the danger. (Loc. cit. 774.) The prognosis is also influenced by the character of the ex- citing cause, and still more by the presence or absence oT that corporeal habit, which experience has shown to predispose especially to this affection. When there are evident manifestations of some degree of sensibility remaining; such as contraction of the pupils from the stimulus of light; some power of swallowing, &c. toge- ther with free and regular respiration, without stertor or dis- charge of saliva from the lips ; a warm and general perspira- tion ; the occurrence of sanguineous discharges, particularly from the nose or haemorrhoidal vessels ; diarrhoea, or a copious flow of urine, reasonable hopes may be entertained of a favour- able issue of the case. It was formerly supposed that apoplexy from the rupture of a vessel, and extravasation of blood into the substance of the brain, is always necessarily fatal. This opinion has, however, been satisfactorily controverted by the experience of many of the ablest pathologists of the present day4 The observations and dissections of Riobe, Rochoux,§ Cruvelhier, Bricheteau, and Serres ;|| and we may add, of Baillie and Sir Astley Cooper,^ place the occasional recovery from strong apoplexy beyond all doubt. From the numerous dissections made in the Parisian hospitals by the French pathologists just mentioned, we learn that when sanguineous extravasation into the sub- stance of the brain does not soon terminate in death, a mem- braneous, vascular structure is formed around the coagulum, and that the coagulum is afterwards absorbed by the vessels of this membrane or cyst. In the progress of time this cyst itself becomes absorbed, and leaves a yellowish cicatrix or * Cheyne. t Richter, Specielle Therapie. Bd. viii. p. 773. \ Recherches sur l'Apoplexie. § Considerations et Observations sur l'Apoplexie. || Nouvelle Division des Apoplexies, Annuaire Medico Chirure vol 5 IT Cook, loc. cit. p. 129. 8*V01, u APOPLEXY. 11 laminated, cellular structure, which in some instances is found to contain a small portion of reddish serum. (Rochoux.)* Sir Astley Cooper thinks that in apoplexy from sanguineous extravasation " the blood never becomes absorbed, but that the brain gradually acquires the power of bearing its pressure, and that thus the symptoms which are produced at the first moments of general extravasation gradually diminish."! That the brain is capable of accommodating itself in some degree to unnatural pressure from extravasation, or other causes, cannot he doubted. I knew an instance of considerable depression of a small portion of the superior and lateral part of the os frontis from a fall. The child remained in a state of apoplectic insensibility for about twelve hours, and very gradually recovered a state of perfect consciousness in about three days. The depression still continues, and, with the exception of occasional headach, no inconvenience appears to remain from the accident. The numerous and well-attested facts that have been brought to light by the authorities already mentioned, are nevertheless sufficient testimony to establish the truth of the occasional ab- sorption of sanguineous effusions in the brain. Brecheteau and Riobe have reported numerous dissections, " all proving, not only the resorbtion of the effused fluid, but a reunion of the lacerated surfaces afterwards by a kind of cicatrization.^: Causes.—A variety of circumstances, both in relation to the constitutional habit of individuals, and extraneous influences, appear to predispose to this affection. Of these predisposing causes, the following are the principal: 1. A peculiar conformation of the body; consisting in a large head ; thick, short neck; broad shoulders; ample chest; florid, and full face; short' stature ; globular abdomen, with a tendency to plethora and obesity. Such individuals are often subject to haemorrhage from the nose, as well as to sen- sations of weight and fulness in the head, particularly on stooping, or making strong corporeal exertions. When they sleep with the head lying low they are restless, disturbed with dreams, and the respiration is heavy and sonorous. Such a corporeal structure constitutes, no doubt, in many instances the hereditary predisposition to this disease, noticed occasion- * "After the absorption of the extravasated coagulum," says Ro- choux, " the sides of the cavities approximate, and unite into a kind of cicatrix by the intervention of a cellular and vascular structure, forming various areolae, between which a reddish, serous fluid is found. These parietes are much more dense than the rest of the brain, about a line or two in thickness, and of a yellowish brown colour. He asserts that these caverns are invariably found after apoplexy terminating in para- lysis, and that their number constantly corresponds with the number of previous attacks." t Cook on Nervous Diseases, p. 129. \ Med. Chir. Rev. June, 1820. 12 APOPLEXY. ally in particular families.* It is to be presumed also that a peculiar condition of the intimate organization may, in some cases, establish a constitutional tendency to inordinate deter- minations to the head, and to the consequent occurrence ot apoplexy and other cerebral affections. 2. Age. The observations of- Hippocrates that apoplexy oc- curs chiefly between the fortieth and sixtieth years ot age, {Aphor. sect. vi. Aphor. 27.) still holds good at the present day. Instances of apoplexy occur indeed at a much earlier period of life, particularly between the thirtieth and fortieth years ; but in a general estimate, it will be found that a very large majority of cases happen after the age of forty. Rochoux states that out of sixty-three cases of this disease, two occurred between the ages of twenty and thirty—eight between thirty and forty—seven between forty and fifty—ten between fifty and sixty—twenty between sixty and seventy—twenty-three between seventy and eighty—and one between eighty and ninety years of age. It would appear from this statement, that apo- plexies occur more frequently after the age of sixty than at any previous period ; and this corresponds with the sentiments of Cullen and Portal. This greater liability to apoplexy at an advanced period of life, cannot be referred to a mere in- creased tendency to a preternatural determination of blood to the head ; for in infancy this tendency is acknowledged to be generally greater than at any subsequent period of life ; and yet apoplexy at this early age is an extremely rare occurrence. Some other circumstance, therefore, connected with advanced age, must be the cause of this greater aptitude to the disease. Many pathologists have ascribed this increased tendency to apoplexy in old people to an ossified state of the cerebral ves- sels ; but this opinion is not verified by post-mortem examina- tions. Others, with more plausibility, have supposed that it may depend on a weakened state of these vessels, similar to that morbid condition of the arterial coats which favours.the occurrence of aneurism. It is probable, however, that this pre- disposition depends on various circumstances of a general cha- racter connected with old age, independent of a morbid con- dition of the cerebral vessels. 3. Whatever tends to produce general plethora, or to keep up a preternatural determination of blood to the brain, increases the liability to apoplexy. A full and nourishing diet; the ha- bitual use of stimulating drinks, particularly in connexion with an inactive and sedentary course of life, are especially calculated to increase the predisposition to this disease. Im- * Dreysig, (Handwoerterbuch der Med. Klinik. B. i. p. 450J);mentions some remarkable cases of this kind. Potal and Van Hoven also state atS^WMk™SLted.ll,e, " Whichaheredit-y Predisposition to APOPLEXY. 13 moderate venereal indulgences at an advanced age; frequent, and long-continued warm bathing ; a sudden change from an active or laborious to a quiet or indolent course of life ; in- tense and protracted study ; and the free use of strong coffee, are mentioned among the predisposing causes of this disease. 4. Various organic affections, such as aneurism of the aorta; hypertrophy of the heart; visceral indurations ; and stumours about the neck, increase the liability to apoplexy. The exciting causes of apoplexy are very numerous. In ge- neral, whatever produces inordinate determinations of blood to the head, or impedes its free return from the brain to the heart, may give rise to this disease. Over-distention of the stomach by immoderate eating, more especially if the ingesta are stimulating and of difficult diges- tion, and the digestive powers weak, is one of the most com- mon and powerful exciting causes of apoplexy. The intem- perate use of spirituous liquors, violent exertions in lifting, much straining in evacuating the feces, strong fits of coughing, sneezing, and great exertions in declaiming, playing on wind instruments, singing, laughing, or speaking, by causing sud- den and strong determinations of blood to the head, may pro- duce this disease in individuals predisposed to it. Exposure to the direct rays of the sun in warm climates, gives rise to that sudden and fatal affection called stroke of the sun, and which is generally regarded as apoplexy. Extreme cold also is capable of producing this affection, by diminishing the cir- culation in the external vessels, and causing strong internal congestions. Violent and sudden mental excitement, rage, excessive joy, terror, and deep sorrow, have been known to produce this disease. The suppression of habitual discharges, whether sanguineous or serous, may give rise to apoplexy. This is particularly the case with habitual hemorrhoidal dis- charge or epistaxis in plethoric subjects. The healing up of old ulcers has a tendency also to produce this disease in per- sons otherwise predisposed to it, {Schmucker's Vermisch. Schriften. B. iii. p. 149;) and the neglect of customary vene- section in full habits may tend to the same effect.* Stoll men- tions the sudden disappearance of oedema of the feet as an ex- citing cause of apoplexy, (Ratio. Medend. Pars. iii. .p. 305.) Women in the puerperal state, " are in some degree liable to apoplexy." Dr. Davis, of London, states that he has met with four or five apoplectic seizures and consequent hemiplegia in puerperal women. In all these cases, the habitus apoplecticus mentioned above, was present.f Tumours or visceral indura- tions in the abdomen, by pressing on the aorta, may give rise * Vogel. Prselectiones Academ. § 558. t Dr. Davis. Medico-Chirurg. Rev. April, 1825. 14 APOPLEXY. to this disease. Morgagni related an instance which was pro- duced apparently by an enlarged spleen pressing on the aoria. Apoplexy may also occur in consequence of the repulsion ot chronic cutaneous diseases; and it is frerjuently the result ot metastasis of gout. Authors mention also translations ot rheu- matism, erysipelas, and of other exanthematous affections among the exciting causes of this disease. I knew an instance in which it appeared to be brought on by a very severe attack of mumps. Violent rigors or chills, particularly the severe and protract- ed chills of intermittents, sometimes give rise to apoplexy. I have known several fatal instances of this kind. In one case, I stood by the patient when he was seized with the chills ; in about ten minutes after they commenced he became insensible ; fell into convulsions, and quickly passed into a profound apo- plectic stupor, from which he did not recover. The patient was an old, corpulent, and very plethoric man. Intestinal ir- ritation may also cause so strong a determination of blood to the brain as to give rise to this affection.* Besides the foregoing causes, which operate apparently by causing undue determinations to the vessels of the brain, apo- plexy may also be produced by causes that impede the free re- turn of the venous blood from the head to the heart. Stoop- ing, or other situations in which the head remains in a depend- ing position; wearing tight cravats, and turning the head round to look back, by which the jugular veins are in some de- gree compressed ; impeded circulation through the lungs ; or- ganic diseases of the heart;] tumours on the neck, or in situa- tions where they may press upon the veins which convey the blood from the head, are the principal of these causes. Authors mention also excessive evacuations among the oc- casional causes of this disease. Boerhaave states, that he knew an instance of apoplexy apparently produced by an ex- cessive haemorrhage from the nose. The tendency of excessive sanguineous evacuations to produce soporose or cerebral op- pression very similar to apoplexy, has already been adverted to under the general head of haemorrhages. The work of Marschall Hall, referred to in that place, gives some very in- teresting observations on this subject. It is certainly a very remarkable circumstance, and not accordant with the present- ly received pathology of apoplexy, that entire insensibility, with sterterous breathing, sometimes results from profuse ha> * There is, indeed, much reason to believe that gastro-intestinal irri- tation is a very common exciting cause of apoplexy. Thilenius (Me- dian. Chirurg. Bemerkungen, p. 66.) Also Schroder, (De Apoplexia ex Pmcordior. Vitris Ongme Analecta in Opusc. vol. ii p 388 }—as quoted in Jahn's Klinik der Chronischen Krankheiten. Bd i d 340 | See Medico-Chirurg. Rev. January 1820. pp. 343 and 345' APOPLEXY. 13 morrhage.* Diabetes sometimes terminates fatally, under symptoms strongly resembling apoplexy ; and the same termi- nation has been noticed in excessive diarrhoea and cholera. (Richter.) Peculiar atmospheric constitutions have also been ranked among the exciting causes of apoplexy; and from causes of this kind, this disease has at times prevailed epide- mically.f Besides the authorities referred to below, we have also the more recent testimony of Weikard, {Vermisch. Schriften, st. i. p. 292. st. ii. p. 65,) and of Jalin, {Klinik d. Chronish. Krankheit. B. i. p. 333,) in confirmation of this fact; and Baglivi mentions the epidemic occurrence of this affection. Richter states, that a humid, cold, and variable state of the atmosphere, appears to be most favourable to the occurrence of apoplexy. It is not improbable, however, that such a condition of the atmosphere depends more upon its elec- trical and barometrical state, than on its relative degrees of humidity and temperature. This atmospheric tendency to pro- duce or favour the production of apoplexy, is sometimes limit- ed to a few days of continuance. Thus Thilenius states, that in the course of a few days, nine persons were seized with apoplexy in one district. {Bemerk. B. i. p. 67—Richter.) Various organic affections of the brain and its meninges, and the narcotic poisons, are also enumerated among the ex- citing causes of this disease. Gregory doubts whether these latter can, with propriety, be considered as exciting causes of apoplexy. As they tend, however, to cause strong conges- tion in the vessels of the brain, they may, no doubt, excite this affection in persons otherwise predisposed to it, as other causes do that strongly determine the circulation to the head. Pathology.—What is the immediate cause of the abilition of sensorial power and voluntary motion in apoplexy? Patholo- gists arc far from being unanimous in their answers to this question. Some maintain, that pressure on the cerebral mass is always the immediate cause of the characteristic phenome- na of this disease; others suppose that they depend not on pressure, but simply upon interrupted circulation in the brain ;\ whilst some believe that the encephalic effusions are the con- sequence of a previous morbid change in the brain, (Rochaux,) upon which the loss of sense and motion depends. Some pa- * For an interesting example of this kind, see Mr. Brown's case of uterine haemorrhage, reported in the London Medical and Physical Journal—1827. t Agathias. De Bello Gothico, in Hugo Grotii. Histor. Gothorum. p. 568. See also, Lepecq. de Clotiere. Anleit. f. Aerzte, Epidem. Krankh. Zubeobacht. p. 412. Fr. Hoffman. Medic. Ration. System. torn. ii. p. 11. s. 11. p. 529—as quoted by Richter, Specielle Therapie, vol. viii. p. 755. X Abercrombie. Researches on the Pathology of the Brain in Apo- plexy. 16 APOPLEXY. thologists confine the term apoplexy strictly to sangume extravasation within the brain ; others include serous enosions among the immediate causes of the disease ; and many ™™y* and correctly too, that mere vascular turgescence, witnoui ei- fusions of any kind, frequently produces apoplexy. From a careful examination of much that has been written on this subject, as well as from my own observations, it ap- pears to me clear that the opinion which assigns the charac- teristic phenomena of apoplexy to pressure of the brain, is the correct doctrine on this point. Post-mortem examination detects in those who die of apo- plexy one or more of the following phenomena:—1, vascular turgescence of the brain ; 2, sanguineous extravasation into the substance of the brain; 3, serum effused into the ventricles or upon the surface of the brain; and 4, no cognizable cerebral disorder whatever. Of these four conditions, the first only ought, I think, to be considered as primary or essential; the others being consecutive, and not immediately concerned as a cause in the apoplectic seizure. When the blood flows more rapidly into the arteries of the brain than it can be returned by the veins, preternatural disten- tion of the cerebral vessels must be the consequence ; and this ge- neral vascular turgescence must exert an unusual degree of pressure on the cerebral mass. That such vascular engorgement and consequent pressure on the brain is capable of producing all the peculiar symptoms of apoplexy admits of no doubt. In some instances of fatal apoplexy, the vessels of the brain are found so much engorged with blood as to render even the smallest branches very con- spicuous, and to give a more or less deep red tint to certain portions of the cerebral mass without any sanguineous or se- rous effusions.* Richter says that an extremely congested state of the cerebral vessels is sometimes the only morbid con- dition visible within the head.f Bricheteau also observes, " that we often find a general turgescence of the cerebral ves- sels, which congestion causes a general pressure on the ence- phalic mass sufficient to extinguish the nervous influence, and destroy life.":): Morgagni has related a case in which he found on dissection, the whole vascular system of the brain extreme- ly engorged with fluid blood. Dr. James Johnson, in com- menting on this case, observes—"that apoplexy is frequently produced by turgescence of the vessels alone, was believed in ancient times as well as in modern. It is, indeed, reasonable to suppose, that in the majority of apoplectic recoveries, con- * Portal. Resultats de l'Ouverture des Corps. t Specielle Therapie. Bd. viii. p. 718. X Journal Complimentaire du Diet, des Scien. Med p 296 APOPLEXY. 17 gestion only had taken place in the vessels of the brain. But if congestion gives rise to the most favourable cases, it appears capable of producing the most desperate and instantaneously fatal ones also."* Dr. Fouquier, also, has reported a case of fatal apoplexy, which was manifestly the result of mere san- guineous engorgement of the brain. "The exterious vessels of the brain and those of the choroid plexus were much engorg- ed with blood;" and the interior of the cerebral mass when sliced off presented a multitude of red points. Neither serous nor sanguineous effusion was present.f Strong and sudden sanguineous engorgement of the cerebral vessels is, probably, always one of the first morbid conditions in the occurrence of apoplexy, or the immediate and primary result of the combined agency of diminished vital resistance in the vessels of the brain, and a preternatural afflux of blood to the head. (Johnson.) This vascular turgescence may either pass off again under proper remediate measures, or it may ter- minate speedily in sanguineous extravasation into the brain, or continue finally without any effusions until it terminates the patient's life. What is usually termed serous apoplexy is per- haps only one of the terminations of apoplexy from vascular turgescence. A sudden violent determination of blood to the brain, and consequent cerebral compression, may immediately destroy all sense and voluntary motion. If the vessels are not relieved by extravasation or by remediate applications, they may, in the course of some hours, relieve themselves by se- rous effusion, as they do in hydrocephalus acutus; and this ef- fusion must then become a secondary but permanent cause of cerebral compression. It is unnecessary here to adduce any arguments in support of this pathology of serous apoplexy. We often meet with striking examples of sudden serous or lym- phatic effusions from vascular engorgement. Every one has heard of the affection usually called apoplexy of the lungs. Sudden and often fatal effusions of this kind occur into the sub- stance of the lungs from violent engorgement of its blood-ves- sels. It appears highly probable, therefore, that strong vascular turgescence of the encephalic mass constitutes the primary pa- thological condition of apoplexy. This state often terminates almost immediately in sanguineous extravasation, or at a la- ter period in serous effusion; and both these consequences con- stitute, of course, additional causes of cerebral compression.^ * Medico-Chir. Rev. June, 1820, p. 9. t Annuaire Medico-Chirurgicale,vol. i. p. 376. X M. Serres contends that both sanguineous and serous effusions are always the effect, and not the cause of apoplexy. He denies that pres- sure, in any case, is capable of producing either this disease or hemi- VOL. II.—3 18 APOPLEXY. To this view of the pafliology of apoplexy, it has been obJe^* ed, that cases sometimes occur in which the brain on dissection exhibits no traces whatever of vascular congestion, nor any other obvious lesions. Petzold has related instances ot this kind, which he ascribes to inanition of the cerebral vessels, and in which not the slightest unnatural appearances were disco- vered on dissection, except an empty and collapsed state ot the vessels of the brain.* Such cases are, however, extremely un- common ; and do not, upon proper inquiry, militate against the doctrine advocated above. Upon this point Dr. Johnson observes, "that there is nothing more certain than that the vascular turgescence in the brain may so far subside, in the interval between death and dissection, as to leave no trace of its previous existence. This in fact," he continues, " we con- sider to be the natural and true solution of the difficulty re- specting the cause of apoplexy in those cases where the scalpel cannot detect deviations from the healthy structure."! There is, however, another objection that has been urged against the doctrine of cerebral compression as the exclusive cause of apo- plexy, which, though plausible, possesses no real weight. It is stated, and correctly, that all the external manifestations of strong apoplexy are sometimes the immediate result of exces- sive haemorrhage. I have already referred to the case report- ed by Mr. Brown, in which entire insensibility and sterterous breathing were the immediate consequences of excessive uterine haemorrhage, and which were removed by transfusing blood plegia. He thinks that what is usually termed serous apoplexy depends on disease of the meninges ; apoplexy with paralysis, he says, is the immediate consequence of an altered state of the cerebral structure, attended generally with sanguineous extravasation as a secondary result. His reasons for denying the agency of pressure in the causation of this affection, are derived from the fact, that fatal apoplexy some- times occurs without any effusion or extravasation, or even vascular turgescence appearing on dissection ; and from some experiments which he made on animals, in which the cranium was opened, and a vessel wound- ed, and the blood carefully confined within the head by closing up the external opening. Although much blood was thus extravasated and lodged into the great interlobular scissure and upon the surface of the brain, no comatose or paralytic affections ensued. These views so far as cerebral pressure is concerned in the production of the disease are however, directly contradicted by the results of some experiments'made in relation to this subject by Portal. This pathologist trepanned the cranium of a dog. By different degrees of pressure made on the brain through the opening with the finger or a piece of wood he could at pleasure produce convulsions, or coma, and apoplectic stertor; and Sir Astley Cooper obtained the same results from similar experiments made on a dog. (a) * Dissert, de apoplexia ex inanitione vasorum cerebri Goett 17ft* t Med. Chir. Rev. June, 1820, p. 8. cereori, Uoett. 1785. (a) Cook on Nervous Diseases. APOPLEXY. 19 from another person into the patient's veins.* Dr. Denman has also related an instance of apoplectic symptoms superven- ing on very profuse haemorrhage,! and indeed many more cases of this kind might be collected. In relation to such cases it is to be observed, that great losses of blood appear to be peculi- arly favourable to extraordinary determinations to the brain, or as Marshall Hall expresses it, "to increased action and ful- ness of the cerebral vessels.":}: The experiments of Kellie on animals show that serous effusion within the head is a pretty constant concomitant or consequence of excessive sanguineous depletion ; and the experiments of Dr. Seeds go to establish the same fact.§ The sanguineous extravasations are usually found in the corpus striatum, or in the thalami nervorum opticorum. Out of forty-one dissections, Rochoux met with but five or six in- stances of extravasation in other parts of the brain; and ob- servations of Morgagni give nearly the same result. || Ex- travasation of blood into the cerebellum is an extremely rare occurrence. According to Rochoux it hardly happens once in fifty cases; and Morgagni reports only one instance of this kind. " Blood is rarely effused, in the first instance, into the ventricles. During ten years' observation in the different hos- pitals, M. Bricheteau saw only two cases of this kind. The fluid is generally extravasated in the neighbourhood of the ventricles, and bursts into them by a ragged opening." {Med. Chir. Rev. loc. cit.) Occasionally blood has been found effused on the surface of the brain. Rochoux relates a case of this kind ; and Richter states that sometimes the brain, on remov- ing the cranium, appears dark, brown, or blackish, through the membranes from extravasated blood underneath, {loc. cit. B. viii. p. 719. The old division of apoplexy into sanguine- ous and serous, possesses no importance in a practical point of view. I have already stated that the effused serum sometimes * Lond. Med. and Physical Journal, 1827. t Trans, of a Soc. for the Improv. of Med. and Surg. Knowledge, vol. iii. p. 315. X Medical Essays, p. 68. § M. Seeds, in six experiments performed on animals which he bled to death, he found the contents of the cranium and spinal canal so en- gorged with blood, that it might at first sight have been thought that blood-letting would have saved the animals."—Medico-Chirurg. Jour. and Review, vol. i. || In explanation of this fact, M .Bricheteau observes, " an attentive Btudy of the vascular system of the brain shows us that a number of ar- teries penetrate directly into these parts—the corpus striatum, &c. without dividing themselves in the pia mater, as the other vessels do which serve to nourish the brain. In consequence of this they are without an additional membraneous support in the middle of the cerebral mass, the consistence of which is but illy calculated to support them against the impulse of the blood.—Loc. cit. 20 APOPLEXY. found within the head on dissection, is very probably nol; the immediate cause of the apoplectic seizure, but one of the resuns of the vascular engorgement, upon which the apoplexy ue- pends. There are, never theless, some circumstances conrieciea with this distinction which it may be proper to notice. 1 nus, it appears, from the observations of M. Serres, that when the apo- plectic attack is complicated with hemiplegia we may infer that there is extravasation into the cerebral substance. When, on the other hand, the disease is unaccompanied with paralysis, we may presume that the substance of the brain remains uninjured, and that more or less serum, or sero-sanguineous fluid is effused by the congested and irritated meninges upon the surface, or into the natural cavities of the brain. The former variety— that is, the complicated or paralytic form of the disease, M. Serres calls cerebral apoplexy, from the cerebral mass itself being the principal seat of the morbid changes. The latter, or uncomplicated variety, he denominates meningeal apoplexy, on account of the manifest traces of vascular irritation and congestion, discovered by dissection in the meninges. Jt ap- pears from the observations made in the Parisian hospitals that meningeal or serous apoplexy occurs chiefly before the fifteenth and after the sixtieth years of age ; and that females are more liable to this variety of the disease than males. When blood is extravasated into one hemisphere of the brain, the consequent paralysis occurs almost universally on the op- posite side of the body. The paralysis is occasionally general— both sides of the body being equally affected. In such cases the mouth is not drawn to either side, and the patient dies as from asphyxia; or as animals do who have the pneumo-gas- tric nerves of both sides divided. The extravasation, in cases of this violent character, takes place into the substance of the tuber annulare, or bursts from thence and spreads along the basis of the skull. {Serres.) The existence of hemiplegia may, in general, be readily detected by the distortion of the mouth ; for however profound the apoplectic stupor may he, more or less deviation from the natural position of the mouth is almost universally present. Treatment.—The main object to be kept in view in the treatment of apoplexy, is the removal of the vascular turges- cence within the head. This fundamental indication is to be answered by a prompt reduction of the general mass and mo- mentum of the blood ; and by the employment of means calcu- lated to lessen the determination of the blood to the brain and to derive it from the cerebral vessels. In the actual paroxysm of apoplexy, the patient should be immediately removed to an airy and cool situation, and placed in a position which least favours the flow of blood to the head All ligatures, particularly those about the neck, should be APOPLEXY, 21 speedily removed, and his head and shoulders supported in an elevated position. In this posture a large orifice should be made into a vein, and the blood suffered to flow un- til a very decided impression is made on the pulse, at the same time that cloths, wet with cold water, are applied to the shaven scalp, and warm or stimulating applications—such as fomen- tations, sinapisms, or frictions with tincture of capsicum, made to the legs and feet. Cups may also be very beneficially ap- plied to the temples and back of the neck, conjointly with the means just mentioned. Some advise bleeding from the tempo- ral artery or the jugular vein in preference to brachial vene- section ; but others do not regard this preference as founded on good grounds. It is nevertheless very probable that blood promptly drawn from the jugular veins or temporal arteries, will have a more direct and speedy effect in diminishing the san- guineous congestion in the brain than if it be taken from the arm ; and as the accomplishment of this effect constitutes our chief purpose in the employment of blood-letting, we may with propriety adopt this mode of depletion. In whatever way the blood is drawn, little or no advantage will be obtained, unless a sufficient quantity is abstracted to produce a very obvious impression on the action of the pulse; and this effect can sel- dom be produced without the loss of from thirty to forty ounces of blood at once. If in the course of an hour the pulse resumes its activity, a second venesection should be practised, and re- peated afterwards at longer or shorter intervals, as long as the pulse indicates the propriety of further depletion. It is some- times necessary to abstract a vast quantity of blood before the disease begins to subside. " From six to eight pounds of blood have been taken from a person by no means robust, before the disease began to yield."* I have myself drawn five pounds of blood from an apoplectic patient in the course of six hours af- ter the seizure, with entire success. In the employment of blood-letting we may suffer ourselves to be guided by the pulse, as has just been stated. Nevertheless, the judicious practition- er will regulate the extent to which this evacuation is carried, not only by its effects on the pulse, but by an attention also to the age and constitutional habit of the patient. I have met with a case of apoplexy which ultimately proved fatal, in which the loss of thirty ounces of blood produced, almost im- mediately, much feebleness of the pulse. The patient was a female, beyond the seventieth year of age. Leeching is of no service beyond what may result from the ge- neral diminution of the circulation. Cupping, however, is a most important auxiliary. After an efficient venesection, the appli- cation of cups along the temples and back of the neck, or to * Cheyne. 22 APOPLEXY. the shaven scalp, will sometimes speedily rouse the patient from his stupor.* i :„ The application of ice, or very cold water to the scaip, is one of the most useful remedies in this disease. 1 his was a favourite measure with Thilenius,f and his praise of its pow- ers, though great, can scarcely be deemed extravagant, its efficacy will be much enhanced by the simultaneous applica- tion of warmth, or stimulating frictions to the legs and feet. Of course, where the pulse is feeble, and the countenance pale, cold must be cautiously applied, but stimulating and warming applications to the lower extremities are always proper, for- merly blood-letting was regarded as of very doubtful proprie- ty in this affection; but at the present day its usefulness, or rather its indispensableness, in every case of genuine apoplexy, is universally acknowledged. Active purgatives also are among our most efficient reme- dies in this affection. As the advantages derived from them depend, no doubt, in most instances, chiefly on the tendency they have to direct the circulation more particularly to the in- testines, and to excite a free secretion from their internal sur- face, and consequently to diminish the afflux of blood to the head, it is evident that the more rapidly they operate, the more beneficial will be their influence. On this account, as well as from the great intestinal torpor which prevails in this affection, it is necessary to employ the most active articles of this class of medicines. It is, however, often extremely diffi- cult, and in violent instances, sometimes impossible to admi- nister cathartics by the mouth, from the paralyzed state of the organs of deglutition. Where the power of swallowing is wholly destroyed, we may introduce a purgative fluid into the stomach through an elastic stomach tube. Calomel and ex- tract of jalap are recommended by Sir Gilbert Blane as the best purgative in this affection. Calomel and colocynth form also a suitable purgative. I have used the oil of croton, rubbed up with a little gum arabic and water, with excellent effect in two instances of apoplexy. This article generally acts with much energy, and from its small bulk and fluidity, is more easily introduced into the stomach than other remedies of this kind. Castor oil with turpentine, also forms an excellent pur- gative in this disease. At the same time that cathartics are given by the mouth, active purgative enemata should he re- peatedly administered. For this purpose we may use a solu- tion of aloes in warm water, in the proportion of from thirty to forty grains to the pint of water; or a strong infusion of senna. Richter advises a solution of tartar emetic for * Dreysig, loc. cit. p. 481. t Medicinische und Chirurgische Bemerkungen, p. 62. et seq. APOPLEXY. 23 this purpose. Where the vascular reaction is vigorous, this solution may be peculiarly serviceable, by the nausea and con- sequent reduction of arterial excitement which it is apt to pro- duce, as well as by its evacuant effects on the bowels. Purgatives are particularly useful where the bowels are in a loaded condition. Dr. Abercrombie relates some instances of this disease, in which blood-letting afforded but very little advantage. As soon, however, as the bowels were freely eva- cuated, a very obvious improvement took place. Where the inordinate flow of blood to the brain is caused or supported by intestinal irritation from accumulation of feculent matter, or the presence of vitiated secretions, it would seem in vain to expect decided benefit from bleeding or any other remedy, un- less the bowels are freely moved; and it is in such cases espe- cially, that cathartics are of primary importance. Formerly emetics were much extolled for their remediate powers in apoplexy. Van Helmont, Riverius, Stoll, and Burserius, placed much dependence on them in the treatment of this disease.* Since the time of Culleh, however, they have been generally abandoned, as much more calculated to do mis- chief than good.f Unquestionably, as a general rule, emetics must be regarded as hazardous remedies in apoplexy ; for the tendency of vomiting to propel the blood to the head is always very considerable. Nevertheless, this disease may occur un- der circumstances of gastric irritation, which may not only render emesis useful, but absolutely indispensable to success. When the apoplectic seizure occurs soon after taking a very full meal of stimulating food, an emetic ought undoubtedly to be given. But even under the most urgent indications for the exhibition of an emetic, a copious and efficient abstraction of blood should always be premised. A few years ago, I met with a striking instance of the usefulness of emetics in apo- plexy, under the circumstances just mentioned. A robust man, about fifty years of age, fell down in a fit of apoplexy about an hour after he had taken a very full meal of animal food with several glasses of brandy and water. The coma was profound, and the respiration steterous and sputtering. He was immediately bled to the extent of about forty-eight ounces, but although the pulse was considerably reduced no percepti- ble improvement ensued. Twenty grains of sulphate of zinc were with difficulty introduced into his stomach, and free vo- miting ensued in about ten minutes after. Almost immediate- ly after the contents of the stomach were thrown off he be- came better; and by the use of purgatives, enemata, and cups * Burserius. Inst. Med. Pract. vol. iii. § 131, p. 106. t See Lond. Med. and Phys. Jour. vol. v. and vi. for an ample discua- aion on this subject. 24 APOPLEXY. to the head, he recovered without any further difficulty. Dr. Gregory says, " in certain cases vomits are proper; butiney should never be given till after large evacuations by WooU-iei- ting. They are most proper where the disease P"J^ ir?,™ a surfeit; and in serous habits vomits are very efficacious. Authors generally advise the mildest emetics in cases where they are indicated. Heberden gave a weak infusion of chamo- mile; Cheyne used lukewarm water with hartshorn; and others recommend warm water with mustard. It is very questionable, however, whether any peculiar advantages at- tend the use of these milder emetics. Indeed, the system is almost always so insensible to the impressions ot medi- cines, that nothing but the most active articles in large doses, will procure emesis. Where there are indications present to justify the exhibition of an emetic, the more promptly the sto- mach is evacuated the better. Richter, who speaks very fa- vourably of the employment of emetics in cases of this kind, advises the most active articles of this class.f Blisters do not appear to afford any advantage in apoplexy, unless the pulse is weak, small, and quick, which, though rarely, is sometimes the case, in old and enfeebled persons of leucophlegmatic habits. At all times, however, it is better to apply them to the ankles and wrists than to the head or back of the neck. It is scarcely necessary to say, that stimulants are decided- ly improper in the early period of apoplexy. Where, after co- pious evacuations, some degree of consciousness and a power of voluntary motion returns, with much prostration and a fee- ble pulse, some benefit may perhaps be obtained from the cau- tious exhibition of the carbonate of ammonia or camphor, (Richter,) in the form of a mucilaginous mixture. The prompt and judicious employment of the foregoing means, embraces every thing that may be deemed efficient in the remediate management of apoplexy. From whatever cause the disease may arise, our whole efforts should be directed to the removal of the inordinate vascular action or turgescence within the head. Some modifications in the mode of employing the measures mentioned, according to the general constitution- al habit, the age, and the character of the exciting causes, will of course he necessary. Thus, in cases which succeed the sud- den suppression of habitual hsemorrhoidal discharge, some pe- culiar advantage may perhaps be gained from the application of leeches to the anus; if the healing up of old ulcers on the lower extremities appears to have given occasion to the apo- plectic seizure, blisters, issues, or sinapisms to these parts will * MS. Lecture as quoted in the Med. Chirurg. Rev. June, 1820. p. 26. t Med. Chir. Bemerkungen. B. ii. p. 109. APOPLEXY. 25 be proper; and I have already adverted to the usefulness of emetics when the attack takes place soon after a surfeit, and the indispensableness of cathartics when the bowels are loaded with feculent and other irritating matters. During convalescence from apoplexy, nothing but the light- est unirritating diet should be allowed; and unless great pros- tration exists, all kinds of vinous liquors should be interdicted. The prophylactic management, in persons labouring under the usual premonitory symptoms of apoplexy, or constitution- ally predisposed to this affection, constitutes a very important point of medical attention. A simple, abstemious diet, exer- cise in the open air, and the avoidance of all kinds of sti- mulating drinks, as well as of sudden and violent mental ex- citement, are among the most important precautionary mea- sures in cases of impending apoplexy. If the bowels are tor- pid, and cannot be brought to a regular state by vegetable diet, it will be necessary to use an occasional dose of some mild laxative, as castor oil, or small portions of rhubarb; and where there is reason to suspect hepatic torpor or derange- ment, three or four grains of blue pill with a few grains of pulvis antimonialis, taken occasionally at night on going to bed, will be useful. When alarming premonitory symptoms come on, with an active, full, and hard pulse, blood should be immediately drawn to an extent sufficient to reduce considera- bly the momentum of the circulation, and a brisk cathartic administered. It should be recollected, however, that blood- letting affords only temporary benefit. A copious abstraction of blood may obviate an approaching attack of this disease, but frequent venesection will do little or no good in preventing that general plethoric habit which is so favourable to the oc- currence of this affection. This must be done by abstemious living; and above all, by an active course of life. Persons predisposed to apoplexy from corporeal conforma- tion, should be particularly careful not to interfere with, or check hsemorrhoidal discharges, unless they become excessive. The same precaution is necessary with regard to epistaxis in individuals of the apoplectic habit, as well as with other habi- tual evacuations. Drs. Cheyne* and Stokerf recommend the internal use of small doses of James's powders, or pulvis antimonialis, where there is an habitual tendency to inordinate sanguineous deter- minations to the head. In one instance of this kind, I have known the daily use of two grains of James's powder, mornings * Dublin Hospital Reports, vol.i. p. 315. t Dublin Medical Essays, anno. 1806. Transactions of the Associa- tion of Fellows and Licentiates of the Queen's College of Physic. Dub- lin, vol. ii. VOL. II.—4 26 APOPLEXY. and evenings, of unequivocal benefit. Green tea also is saiu to possess the power of diminishing or obviating cephalic con- gestions. Drs. E. Percival* and Stoker strongly recommend it for this purpose in comatose affections; and my own expe- rience leads me to think that it possesses considerable powers in this way. Coffee, however, is decidedly injurious where there is an 'apoplectic tendency. Some eight years ago, a gen- tleman in this city, of a strongly developed apoplectic habit, was seized with an attack of this affection. He was in the habit of taking large quantities of very strong coffee twice daily. I advised him to leave off taking this beverage entire- ly. He did so; and has not since experienced even the ordi- nary premonitory symptoms of the complaint. Apoplectic subjects should be very careful not to bath their feet in very cold water—more especially when they are subject to habitual perspiration from these parts. The frequent use of the warm bath also is hazardous in persons of this habit; and excessive venereal indulgence is equally apt to do injury. CHAPTER III. PALSY. Palsy consists in impaired or abolished power of voluntary motion, or of sensation, or of both, in certain parts of the body, without coma, or a loss of consciousness. Cases in which both sensibility and the power of motion are at once destroyed, are however extremely rare. Instances even occur in which the sensibility of the palsied part is morbidly increased. I have met with a case of this kind. The patient had lost all com- mand over the muscles of the lower extremities ; but the sen- sibility of the skin from the knees downwards was so great that even moderate pressure with the fingers gave rise to con siderable pain. An instance is related in" a recent French journal, in which the surface of the paralyzed limb was entirely insensible, but the muscles beneath were the seat of acute nain which was always much increased by pressure.! In general the paralyzed parts become soft and flaccid, and at last usually * Dublin Medical Essays, vol. ii. p 44 t Med. Chir. Rev. Oct. 1829, p. 168. PALSY. 27 emaciated, or occasionally cedematous. Sometimes a peculiar tingling, or creeping sensation (formicatio) is felt in the af- fected parts, " as if small insects were creeping over them." The opinion generally entertained, that the temperature of parts affected with palsy is lower than natural, does not appear to be founded on correct observation. It is indeed true, that we very frequently find such parts cooler than the rest of the body ; hut this circumstance would seem to depend on the di- minished power of the paralytic part to maintain its specific temperature ; or in other words, to resist the physical laws of the distribution of heat, in consequence of which, such part becomes cooler when exposed to a temperature below that of the human body, and warmer than natural when exposed to a temperature above this point.* Patients sometimes complain of a severe sense of cold in the affected parts, although to the touch the temperature does not appear to be materially di- minished. The pulse is often considerably smaller and weak- er in the paralyzed limb than in the healthy ones ; in some cases, however, it is fuller and stronger in the affected than in the sound side ; and occasionally no difference whatever can be perceived in this respect. When palsy arises from disease of the encephalon, it is gene- rally attended with an evident impairment of the mental pow- ers—amounting, in some instances, to complete imbecility. The memory, especially, is apt to suffer in this affection ; and in some cases in a very singular manner. Individuals affected with cerebral palsy have lost the power of recollecting particu- lar words, numbers, letters, localities, or even their own names ; whilst in other respects no material defect was mani- fested in this faculty. The natural temperament and disposi- tion also sometimes suffer a total change from a stroke of palsy. Individuals of amiable and placid dispositions have become sullen, peevish, irascible; and persons of an irritable and passionate temperament have been rendered mild and sim- pering by a paralytic seizure. (Cook.) Paralysis has been known to occur periodically. A case of palsy is related by Musgrave, {Philosoph. Transact.) which regularly returned every eight days, and continued each time to the fourth day. The duration of palsy is very various. Occasionally the affected muscles recover almost entirely their healthy powers in a few days; but the progress of amendment is much more commonly very gradual and slow. It is a sin- gular fact that the extreme parts of a paralyzed limb are often the first that manifest any degree of returning muscular power. I attended a hemiplegiac patient about two years ago, for * Dr. Abercrombie.—See Cook on Nervous Diseases, p. 227. Boston, 1824. 28 PALSY. three weeks without any apparent amendment; at last, how- ever, he found that he could move his toes; by degrees he re- gained the power of moving the foot, then the leg, and finally the thigh. The same progress of amendment occurred in the paralyzed arm. The power of motion began in the fingers, and gradually extended upwards. When palsy occurs in the whole of one side of the body it is termed hemiplegia; if both the inferior extremities, from the hips downwards, are paralyzed, it is called paraplegia; and when only some one particular part is affected with palsy it constitutes the paralysis partialis of authors. Paralysis, with- out coma, affecting the whole body, is an extremely rare occur- rence. Cases of this kind, however, have been recorded. A very curious instance of general palsy occurred lately in one of the Parisian hospitals. The paralysis in this case corn- commenced in the feet, and gradually ascended towards the body; when it had arrived at the knees the palsy seized also upon the hands, and slowly passed upwards to the trunk ; finally every voluntary muscle, excepting those of the face, neck, and tongue became paralyzed. The patient's general health was good, and his intellect perfect.* Tissot relates an instance of a boy who, apparently in consequence of a repelled scabby affection of the head, became paralytic throughout nearly the whole of the muscular system, attended with much torpor of the sensorial functions, and mental weakness, though wholly free from coma or somnolency.f M. Bretonneau has related a somewhat similar case. "A lady was seized with paralysis of the little finger of the left hand, which gradually extended to the whole of that side ; the right became similarly affected, with the exception of the thumb and two fingers. The whole body was thus palsied—the tongue was motionless, and deglutition extremely difficult; but her intellectual faculties remained unimpaired."^: Cook mentions a case, from a publi- cation of M. Keratry, in which there was paralysis of the u arms, thighs, and of the whole exterior surface of the body, with the exception of the face." HEMIPLEGIA. This is by far the most common of those forms of palsy which depend on oppressed function of the sensorium commune. In its essential pathological character it does not appear to * Medico Chirurg. Rev. Oct. 1829, p. 168. f Medical Works, vol. iv. p. 552. X Med. Chir. Rev. Oct. 1826, p. 604. Clinical Report of the Hospice de Perfectionnement. Rev. Medicale, 1826. HEMIPLEGIA. 29 differ materially from apoplexy ; and it occurs frequently as an immediate concomitant affection of this disease. Hemiplegia is indeed almost always ushered in with more or less distinctly marked apoplectic symptoms. Occasionally the hemiplegiac attack occurs suddenly, with- out any distinct manifestations of its approach. Much more frequently, however, some of the ordinary premonitory symp- toms of apoplexy precede the attack for several days ; and just before the seizure, strong symptoms of sanguineous determina- tion to the head, and cerebral disturbance, are particularly apt to occur—such as flushed face; distention of the veins about the head and neck : vertigo ; a sense of fulness, weight, and sometimes pain in the head ; ringing in the ears ; drowsiness; impeded articulation of words, or loss of speech ; slight delirium, or confusion of the mind; loss of memory, and a change of habitual disposition. M. Serres states that he has noticed in cases that came on gradually, distortion of the mouth for seve- ral hours before the hemiplegia supervened ; and immediately before the seizure he has sometimes remarked that in the act of respiration one side of the chest was quiescent, whilst the other was very conspicuously dilated and contracted. The reproductive or vital functions are seldom much dis- turbed in the ordinary cases of hemiplegia. In some instances, however, the whole tract of the alimentary canal is extremely torpid, and it would appear that the liver is sometimes affect- ed.* The countenance generally acquires a vague or fatuous expression ; the mouth is drawn to one side ; the lower lip on the palsied side hangs down and suffers the saliva to dribble away. Articulation is always more or less difficult and indis- tinct, and deglutition is generally somewhat impeded and diffi- cult—more especially on attempting to swallow liquids. It is in this form of paralysis, particularly, that the mind is apt to suffer from the long continuance of the disease. General im- pairment of the intellectual powers usually occurs ; but the memory, especially, is most apt to become conspicuously en- feebled, and even wholly effaced. Very remarkable anomalous circumstances are sometimes connected with hemiplegiac affections. Cook has collected a great variety of curious cases of this kind. Thus, an instance is related in which the arm of one side and the leg of the op- posite one were palsied, (Fabricius ;) another, where the sen- sibility, but not the power of voluntary motion, was destroyed in one leg, whilst in the other the power of motion was lost, with the sensibility unimpaired. (Ramazzini.) Cases are re- ported in the Memoirs of the Royal Academy of Sciences, in which there was an entire loss of sensibility, without any im- * Morgagni. Epist. xi. art. xiv. 30 HEMIPLEGIA. pairment of voluntary motion. In some instances the sensi- bility is morbidly increased. Falconer mentions a case in which cold bodies communicated the sensation of heat to the palsied parts; and in the case Dr. Vieusseux, (Med. Chir. Trans, vol. ii. p. 216, 217,) the right side was at first so in- sensible that it could be pinched or pricked without giving him pain ; afterwards this insensibility seized on the left side. In the right side cold bodies excited the sensation of heat, and hot bodies that of cold, or only coolness. Dr. Cook has seen a case of hemiplegia in which the muscles of the left arm, from the shoulder to the elbow, were much emaciated, and greatly impaired in activity ; whilst those of the forearm were in a perfectly natural state, both as to fulness and power. The condition of the right arm was directly the reverse, the mus- cles of the part above the elbow were natural in size and energy, but those of the forearm were wasted and powerless." In some instances little or no improvement takes place, and the patient remains helpless often for a long time, and at last dies either from gradual exhaustation, or suddenly from apo- plexy. More commonly, however, more or less amendment slowly occurs, until the patient is perhaps able to support him- self with but little aid in a sitting posture, or even to walk about, with some assistance, without any further improvement. Occasionally the paralysis passes off almost entirely in a few days; but the progress of improvement is usually very slow and gradual, and rarely goes on at once equally throughout the whole of the paralyzed part. PARAPLEGIA. The palsy, in this form of the disease, is confined to the lower half of the body—that is, to the pelvis and the inferior extremities. When the immediate cause of abolished nervous function is seated in the upper parts of the spine, the paralysis will affect the superior parts of the body ; but the term para- plegia is generally restricted to palsy of the inferior extremi- ties and parts about the pelvis. Paraplegia generally comes on gradually, and when it arises from an affection of the brain is often preceded and accompa- nied in its course by pain in the head, giddiness, drowsiness dimness of sight, and impaired memory. Sometimes a feeling of heaviness and numbness is felt in the upper extremities as a precursory symptom of this form of palsy. At first the patient usually experiences a slight stiffness and awkwardness in the motions of the lower extremities, which gradually increase PARAPLEGIA. 31 until the patient finds himself unable to maintain the due ba- lance of the body without the aid of a cane. As the disease advances, " the stream of urine becomes more and more feeble, and at length dribbles off involuntarily." The bowels are ge- nerally constipated ; but when the sphincter muscles of the anus become paralyzed, the feces are evacuated without the consent of the will. I have met with an instance of paraple- gia in which a retention of the urine, requiring the use of the catheter for five or six days before any paralytic affection was experienced in the lower extremities. Sometimes the palsy is complete, the patient being unable to maintain even a sitting posture; in other cases the power of motion does not become wholly destroyed, so that with a little assistance the patient may be supported in a sitting position. (Baillie.)* When pa- raplegia depends on an affection of the spinal marrow, which is indeed most commonly the case, it usually approaches very gradually, unless it occurs as the immediate consequence of some mechanical injury of the spine. The patient at first feels a languor and weakness in the knees ; after some time a difficul- ty in directing the feet occurs, and the legs in walking are involuntarily thrown across each other, causing frequent tripping or stumbling. By degrees the insensibility and loss of muscular power in the legs and thighs become more and more conspicuous, until, at length, a total paralysis of these parts occurs. The loss of vitality is sometimes so great that gangrene and sloughing of the legs ensue from the mere pressure of the parts against the bed. About six years ago, I met with a case of paraplegia in an adult, which, from the at- tending symptoms of cerebral disturbance, depended, I pre- sume, on some affection of the brain. In the course of about ten days after the accession of the paralysis the heal first, and then rapidly all the soft parts of the right leg; from the ankle to near the knee, became gangrenous, and sloughed off, in a few days, to the bones. Paraplegia from cerebral affections occurs most commonly after the forty-fifth year of age, and, according to the obser- vations of some, more frequently in males than in females. That variety of paraplegia which depends on diseasf or injury of the spine, is most common in childhood, and seldom occurs spontaneously after the age of puberty. Contrary to cerebral paraplegia, it is more frequently met with in females than in males. * Observations upon Paraplegia in Adults. By Mathew Baillie, M. D., in the sixth volume of the Medical Transactions of the London College of Physicians. 32 PARALYSIS PARTIALIS. PARALYSIS PARTIALIS. Every sensitive and motive part of the animal system may lose either its power of feeling, or of motion, or of both. In some instances the palsy is confined to a particular organ, but when the muscles are the seat of the affection it generally em- braces either all the flexors or extensors, or both, of a part or the whole of a limb. Some cases of partial paralysis are attended with loss only of sensorial power. Of this kind are the para- lytic affections of the olfactory nerves; of the retina ; of the gustatory nerves ; of the auditory nerves ; and of the nerves of general feeling or touch. In other cases the palsy is confined to a deprivation of the power of motion, with or without the loss of sensibility, in a particular part. In some instances a single muscle alone is paralyzed. Abercrombie mentions a case of this kind which continued for along time without either extending to other muscles or becoming better. Paralysis of the muscles of one side of the face is by no means uncommon, and in some cases the under lip only becomes thus affected. The eyelids also sometimes become palsied ; and a loss of the power of voluntary motion in the muscles of the hands, feet, fingers, wrists, legs, and thighs is of frequent occurrence. The bowels, the oesophagus, the pharynx, the bladder, the dif- ferent sphincters, and the erector muscles of the penis, are occasionally affected with palsy; and it is not improbable that some of the secretory organs—particularly the kidneys and liver, may sometimes be thus affected. Of the Causes of Paralysis. The predisposing and exciting causes of those forms of palsy which arise from an affection of the common nervous centre, so far as they can be ascertained, do not differ from those which have already been mentioned under the head of apo- plexy. In relation to the immediate or proximate cause of palsy, whether of a general or local character, it would seem that so far as it is dependent on the state of the brain, it may be the consequence of a great variety of morbid conditions of this organ. It has been generally supposed that pressure on the brain is the chief immediate cause of hemiplegia. That sanguineous or serous effusions, and other causes producing pressure on the brain, often give rise to paralysis, appears to be well estab- lished. "When the causes which produce cerebral pressure act generally and powerfully," says Dr. Cook, " they seem to produce apoplexy, and to give occasion to palsy when they act PARALYSIS PARTIALIS. 33 partially or with less violence; so that by an increase of pow- er of the cause, palsy may terminate in apoplexy ; and by a di- minution of it, apoplexy may terminate in palsy." Hemiple- gia is, indeed, a very frequent consequence of apoplexy; and, on the contrary, paralysis very often terminates at last in an apoplectic attack. It is, nevertheless, equally evident from the many pathological investigations which have been made on this subject within the last ten or twelve years, that both general and partial palsy depends sometimes on affections of the brain or its spinal prolongation, wholly unconnected with any circumstances that might be supposed capable of ex- erting any pressure on the encephalon. Reasoning, indeed, upon the general nature of palsy, we would be led, a priori, to suppose that every thing which is capable of greatly disor- dering the source of nervous power, might give rise to this af- fection. Dr. Powel, in an interesting paper on the subject of paralysis from sudden exposure to cold, has adduced some cases which would seem to show that both general and local palsy sometimes depends on a morbid condition of the nerves alone, wholly independent of any diseased state of the encepha- lic mass. So far, however, as post-mortem examinations can throw any light upon the nature of the proximate cause of ge- neral paralysis, we have direct evidence that almost every va- riety of cerebral lesion and disorder may produce hemiplegia and other forms of palsy. We not only find this affection con- nected with sanguineous extravasation into the brain, but also sometimes with serous effusion; or with traces of recent in- flammation and vascular turgescence; with encysted suppu- ration ; with induration of some portions of the cerebral mass ; with softening of the brain, or with destruction and entire loss of a portion of it; and with other morbid conditions of this organ. (Abercrombie.) Willis states, that in cases of protracted palsy, he has found the corpora striata in a diseased condition ; and Peyrouse, in one instance, found a firm tubercle about the size of a bean in the middle of the corpus striatum. (Cook.) The most frequent morbid appearances, however, discovered on dissection, is organic lesion or injury of the cerebral substance, particularly about the corpora striata, thalami nervorum opti- corum, and in the medulla oblongata or its immediate vicinity. M. Serres mentions a case of apoplexy attended with palsy, in which every part of the brain was perfectly sound, except the tubar annulare, which was completely destroyed by a cen- tral cavity containing a clot of blood. Although some of these phenomena usually present themselves on the dissection of pa- ralytic subjects, yet each of these morbid conditions of the brain not unfrequently exists without any, or with but very slight manifestations of palsy. There exists also much diver- sity in the extent and particular form of the paralytic affec- VOL. II.—5 34 PARALYSIS PARTIALIS. tions connected with apparently similar morbid states wlthin the brain. In one patient, a particular lesion ordiseaseu con- dition of the brain will be attended with almost universal palsy ; in another, a similar state of cerebral affection, wim regard to its location and general character, will be accompa- nied with hemiplegia; in a third patient, perhaps with pa- raplegia; and in a fourth one, only with partial paralysis. It would appear also that in hemiplegia the immediate cause may be in the spine. Dr. Prichard has published some obser- vations which render this opinion at last highly probable.* Notwithstanding, therefore, the light which dissection has thrown on the etiology of palsy, we are yet far from possess- ing any very satisfactory or precise information on this inte- resting subject. The general fact that pressure or organic lesion of the brain is often attended with paralysis, and ap- parently its direct cause, is indeed sufficiently established; but the various and opposite results or phenomena just men- tioned, assure us that our knowledge upon this subject, as in truth upon most other points of pathology, is but general and vague. What has been hitherto said relates chiefly to hemiplegia. It would appear that paraplegia also is frequently dependant on cerebral disease. Paraplegia in adults, says Dr. Baillie, is by most pathologists considered as the result of some dis- ease, " either in the bones or ligaments of the spine, or in the cavity of the spine most commonly at the loins, independently of any disease of the brain."f He denies the correctness of this opinion, and expresses his conviction that, like hemiple- gia, this form of palsy " depends most commonly in adults, in a great measure upon a disease affecting the brain itself." The same sentiments appear to be entertained by Mr. Earle, Mr. Halford, and Mr. Copeland ;f and several recent French writers have expressed similar views. Both Dr. Baillie and Dr. Abercrombie mention cases of paraplegia, in which, on dissection, the cause of the disease was discovered in the brain. In a strongly marked case the arachnoid was much thickened and opaque; the substance of the brain considerably softer than natural; vascular congestion of the pia mater, and a large quantity of serum in the lateral ventricles, as well as in the theca vertebralis, and between the membranes of the brain. Dr. Baillie thinks that the serum which is sometimes found in the theca vertebralis in this affection descends into it from the brain. We cannot doubt that paraplegia may sometimes be entirely dependant on cerebral disease; yet observation ren- * Med. Repository, No. I. New Series. X Loc. cit. p. 17. X Med. Ghir. Rev. December, 1820; p. 392, PARALYSIS PARTIALIS. 35 ders it equally certain that disorder, lesion, or pressure upon the spinal cord, is even in adults very frequently the imme- diate cause of the paraplegiac affection ; and in children this is unquestionably by far the most common source of the dis- ease. In relation to the disease in adults, a great number of well authenticated dissections might be adduced presenting un- equivocal evidence of its spinal origin ; and facts illustrative of this point, in reference to the disease in children, must be fa- miliar to every one. It has already been observed, that pa- ralysis depending on disease of the brain, occurs almost uni- versally on the side opposite to that in which the cerebral af- fection exists. Some exceptions indeed to this fact have been noticed by pathologists, but these are extremely rare. Mr. Bayle has collected from different authorities, eight cases in which palsy took place on the same side of the cerebral affec- tion.* When paraplegia depends on disease seated within the head, the primary affection extends probably to both sides of the brain. This opinion is at least strongly countenanced by the phenomena developed on post-mortem examination. (Bail- lie.) Partial paralysis depends on a great variety of causes, both of a general and local character. It may depend on disease within the head, on spinal affections, and disease or local inju- ry of a particular nerve. The latter source of this form of palsy is probably the most common. Local paralysis is some- times excited apparently by intestinal irritation in children. In cases of this kind, the palsy is usually confined to one of the arms.f I have seen cases of palsy of the arm in young children, which appeared to have been occasioned by the irri- tation of worms in the bowels. Much attention has, within a few years past, been bestowed on local paralysis of the muscles of one side of the face. IC appears from the researches of Shaw and Bell, that this varie- ty of palsy depends most commonly on some injury of the portio dura of the seventh pair; and in some instances, also on a diseased condition of that part of the brain which gives origin to this nerve.£ The occasional causes of this variety of palsy are, inflammation of the ear spreading to the portio dura; surgical operations about the ear a«d consequent inju- ry of this -nerve; disease of the temporal bone; tumours press- ing on this nerve; sudden exposure Co cold;§ injuries inflicted on the head ; and disorganization and other morbid conditions within the brain implicating the portio dura. The paralysis * Revue Medicate, Janvier, 1824. f C. Bell. See Cook's Treatise on Nervous Diseases, p. 268. \ On Partial Paralysis. By John Shaw. Med. Chirurg. Transact, vol. xii. p. 1. § Dr. Powell. Transactions of the College of Physicians, vol. v. 36 PARALYSIS PARTIALIS. in cases of this kind is not complete—the muscles of the face being deprived only of " the power of those actions which are to a certain degree involuntary, and to perform which it is ne- cessary there should he a combination with the organs ot res- piration ;" the sensibility, and those actions which are deriv- ed from the trigeminus, namely, the action of the orbicularis oris of the eyelids of the buccinators, and of the muscles sub- servient to mastication remaining undiminished. Mr. Shaw remarks, in the paralysis of the face after an attack of apo- plexy, just the reverse condition in this respect obtains—the actions just enumerated as depending on the fifth pair of nerves being abolished; whilst those which are influenced by the portio dura remain unimpaired. Among the exciting causes of partial paralysis, the poison- ous influence of lead is the most remarkable. The tendency of this article, in whatever way it may be brought to act on the system, to produce paralysis of the muscles of the forearm and wrists is peculiarly strong, as is evident from the frequen- cy of this affection in persons who work in lead mines, in plumbers, manufacturers of white led, painters and glaziers. There exists, however, much diversity, with regard to the constitutional predisposition of different individuals, to become thus affected by this article. Some persons appear to enjoy almost an entire immunity from its poisonous influence, al- though much exposed to its operation; whilst others are pecu- liarly liable to its effects. Paralysis of the extensor muscles of the hands and wrists sometimes occurs, apparently from pressure of the nerves which go to these muscles. Cases of this kind generally come on during sleep, and seem to be occasioned by a particular po- sition of the arm, while the head is resting upon it and com- pressing perhaps its principal arteries and nerves. I met with a case lately in a young gentleman who fell asleep while sit- ting at his desk. On awaking, he found that he could not ex- tend the hand nor use the fingers ; the palsy continued for four weeks before it yielded. Dr. Healy has published an inte- resting paper on this variety of palsy, in the third volume of the Dublin Hospital Reports. The question why the power of motion is often entirely de- stroyed whilst that of swusation remains undiminished, has at all times greatly perplex^ physiologists. Galen supposed that two sets of nerves were distributed to every part of the body—one to endow them with sensibility, and the other to give to the muscles the power of voluntary motion. What was thus alleged from mere theoretical views by this very sagacious physician, has been recently actually demonstrated by M Ma- gendie and Mr. C. Bell. The nerves which originate from the spinal prolongation of the brain, and which supply the PARALYSIS PARTIALIS. 37 power of voluntary motion and sensibility, are composed of two packets of fibres, proceeding from distinct parts of the spinal marrow. It has been ascertained that, by dividing or compressing the posterior of the two fasciculi by which the spinal nerves originate, the sensibility of the part to which the nerves go is grea>tly diminished, whilst the power of motion remains unimpaired ; and, on the contrary, if the anterior of these heads of the nerve be divided or materially injured, the power of salutary motion is destroyed in the parts to which it is distributed, but the sensibility remains unaffected. This physiological fact throws much light on the curious phenome- non in question, and may be regarded as full an xplanation of it as anatomical investigations are capable of furnishing on any subject. Treatment.—The prophylactic treatment of approaching hemiplegia does not differ from that which is proper for ward- ing off an attack of apoplexy. In the apprehension of a stroke of palsy, a low diet, gentle exercise in the open air, and the avoidance of all kinds of stimulating liquors, as well as of full and heavy meals, should be enjoined ; and the bowels kept in regular motion by gentle laxative medicines. Where predisposition to apoplexy exists, and particularly when the ordinary premonitory symptoms of this affection oc- cur frequently, a drain, by means of setons or issues estab- lished in the neighbourhood of the head, will contribute mate- rially in obviating the paralytic seizure. Much discrepancy of opinion has been expressed with re- gard to the value of blood-letting in hemiplegia. Some speak strongly in praise of its powers ; whilst others condemn its use as often decidedly injurious. An attention to the various pathological conditions of the brain in cases of this disease, must at once show the folly of sweeping declarations either in favour or against this measure. We meet with cases, for in- stance, in which there are unequivocal manifestations of san- guineous engorgement in the vessels of the head; and with others, in which the face is pale and shrunken, and the pulse small, weak, and irregular. The immediate cause may con- sist in vascular turgescence with sanguineous extravasation into the brain; or in a slow disorganization of a portion of this organ, with little or no engorgement or inordinate action of the cerebral vessels. The pulse must be our guide in the employment of this evacuation. If the artery beats strongly and is full and hard under the finger, blood should be drawn freely and promptly as in apoplexy, until the momentum of the circulation is adequately moderated. When, on the other hand, the pulse is weak, the extremities cold, and the face pale and contracted, as it will sometimes be in old, weak, and ner- vous individuals, blood-letting to any considerable extent is 38 PARALYSIS PARTIALIS. just as obviously contraindicated. In a few cases, I have ab- stracted from forty to fifty ounces of blood in the course ot twelve hours after the hemiplegiac attack with decided benefit; but I have met with cases also, in which even a moderate bleeding brought on faintness and alarming weakness without any favourable impression on the paralytic affection. Ot course, even where the state of the circulation indicates the propriety of this evacuation, regard must be had to the age of the patient, his constitutional habit, and perhaps the nature of the exciting cause. Purgatives are as useful here as in apoplexy. In no in- stance, whether the action of the pulse be strong or weak, can evacuants of this kind be properly omitted. "All writers," says Dr. Cook, ''agree as to the propriety of keeping the body open in hemiplegia. The neutral salts and other purga- tives of the refrigerant kind, may be given where there is much determination of blood to the head and in full habits; but in debilitated, leucophlegmatic, and dropsical cases, the more sti- mulating purgatives, such as aloes, calomel, scammony, colo- cynth, jalap, &c. may with more propriety be administered." An excellent mode of giving purgatives in habits of this latter kind, is to administer them in combination with powdered mustard. From ten to twelve grains of* calomel, mixed with about twenty grains of mustard, and succeeded in about three hours by a dose of infusion of senna, will rarely fail in such cases to procure free and copious evacuations. In relaxed and sluggish habits* cathartics will almost always operate with more certainty and force when given with a stimulant of this kind. I have frequently, under such circumstances, adminis- tered a small portion of Cayenne pepper with purgatives with excellent effect. Emetics also are much recommended by some writers in the treatment of hemiplegia. In recent instances, ushered in by apoplectic symptoms, and particularly in robust and plethoric subjects, they are of doubtful propriety. When hemiplegia comes on during a dyspeptic condition of the stomach, or soon after taking food of difficult digestion, an emetic may, no doubt, prove very serviceable. At a more advanced period of the disease, when the momentum of the circulation is mode- rate and no symptoms of cerebral congestion exist, emetics will occasionally do much good, and may be freely employed with but little risk of doing mischief. In addition to the general remedies already mentioned re- vulsive applications constitute important auxiliaries in the treatment of this affection. In recent cases, blistering or cup- ping the nape of the neck and sinapisms to the ankles, will sometimes contribute materially to the removal of the disease. Stimulating enemata also are highly recommended in this PARALYSIS PARTIALIS. 39 variety of palsy; and I have myself witnessed several in- stances of their good effects. In paraplegia attended with symptoms of cephalic disorder, besides the local applications just mentioned, Dr. Baillie re- commends the use of calomel, or the blue pill in union with squills, together with purgatives. He directs a grain of calo- mel, or five grains of the blue mercurial mass with one grain of dried squills every night for several weeks, with an occa- sional dose of one of the neutral purgative salts. When paralysis continues until all symptoms of undue de- termination to the head have disappeared, or the disease has assumed a strictly chronic character, antiphlogistic and de- pletory remedies are no longer appropriate means. Exciting remedies, both internally and externally employed, must now be resorted to. Frictions, stimulating liniments, sinapisms, blisters, stimulating baths, cold affusions, electricity and gal- vanism, are the principal external exciting applications; and, under proper management, often prove decidedly beneficial. Frictions with the flesh-brush or a piece of dry flannel, will sometimes answer better than the more exciting or rubifacient applications. These frictions should be made twice or thrice daily, and continued each time at least half an hour. Along with dry frictions the occasional application of blisters to the leg and wrist of the affected side may prove beneficial. Where the palsy is complete, however, the sinapisms or blisters should not be left on too long lest gangrene and sloughing be produ- ced. A conspicuous rubifacient effect is all that it will in ge- geral be prudent to excite in causes of this kind. Cullen in- deed observes, that when external stimulants produce violent inflammation, they are apt to do less good than when they act merely as rubefacients, or at most, create but a moderate de- gree of superficial inflammation. Anciently the application of nettles was much recommended; and from the very pun- gent irritation they produce in the skin, they may, no doubt, be serviceable. I have known the application of dolichospru- Hens to a paralytic limb to be of manifest advantage. Electricity being peculiarly adapted to excite the nervous system, has been much employed in the treatment of paralytic affections ; and, under judicious management, it will sometimes do much good. I have known several cases of local palsy completely cured by this agent; and the records of medicine furnish us with no small number of instances in which it was successfully employed. It would appear, however, that it has sometimes proved decidedly injurious. Mr. Cavallo observes, that electricity has not only often proved wholly inefficacious in paralysis, but in some instances, highly pernicious and even fatal. It would seem probable, however, that where its effects have been attended with unfavourable or fatal consequences, 40 PARALYSIS PARTIALIS. it was applied in too powerful a manner; for it is now admit- ted, on all hands, that it proves most beneficial when it is moderately and repeatedly applied. Shocks should never be given. The electric fluid must be passed through the af- fected part without sparks, by means of wooden points ; or, at most, by discharging but very weak sparks into it from the prime conductor. Dr. Cook remarks, that this agent " is only to be considered safe when its operation is confined to parts somewhat remote from the head;" and that it is most apt to prove injurious when the disease depends upon disease or compression of the brain. Galvanism also has been particularly recommended for the treatment of this affection ; and is said to be safer, and in ge- neral, more effectual than electricity. Dr. Bardsly, from considerable experience in the use of galvanism in paralysis, concludes, that if no sensible benefit arise from a steady and well-regulated application of this influence, after a trial of a week or ten days, its use ought to be discontinued ; that when the brain forms a part of the galvanic circle, it is to be very cautiously employed; and that when the activity and firmness of the pulse, as well as the temperature of the affected part are increased—the corporeal and mental feelings somewhat enli- vened, and the secretions improved, we may persist in the ap- plication of this agent with a prospect of ultimate and perma- nent advantage. When the affected parts are so torpid as to render them insusceptible of the galvanic stimulus, the cuticle ought to be removed by a small blister, and the metallic points applied to the raw skin. (Bardsly.*) Moxa has been used with success in paralysis. Dupuytren has reported a case of general paralysis, in which moxas ap- plied on each side of the spine, near the first and second dor- sal vertebra, procured immediate benefit. Larrey mentions a case of palsy from disease of the spine which was cured by thirty-two applications of moxa ; and two other cases of para- lysis of the forearm from gun-shot wounds yielded completely to this remedy. He also states, that he cured several cases of paralysis of the muscles of one side of the face from cold, by the application of moxa; but he observes that the application of moxa to this part is dangerous, unless the cones of cotton are small, and suppuration be prevented by the application of am- monia, f The instances on record of the successful applica- tion of moxa in paralysis are, indeed, sufficiently numerous to entitle this remedy to particular attention in the treatment of this affection. * Medical Reports, p. 183. Cook, 1. c. p. 296. tRecueil de Memoires de Chirurgie. par le Baron D. L. Larrey p. 94. PARALYSIS PARTIALIS. 41 Internally a variety of remedies have been recommended for the cure of this disease. Among these the nux vomica, or its pre- paration strichnine, has of late years been a good deal used in palsy, and occasionally with decided benefit* Mr. Purcell has recently reported a case of paraplegia, in which this article, in conjunction with the application of moxa, was successfully used.f My own experience with this remedy in paralysis has by no means been encouraging; but there can be no question of its occasional usefulness, although it seems now to be gene- rally admitted that it is also frequently pernicious. When the peculiar convulsive motions which result from the operation of this narcotic, appear early in the palsied limb, in connexion with transient tremours, formication, and free perspiration in this part, and particularly if these affections do not directly pass to the sound parts, the prospect of benefit from this reme- dy is said to be considerable. In paralytic affections connect- ed with an inflammatory or congested condition of the brain or spinal marrow—and in hemiplegia from sanguineous extra- vasation into the cerebrum, this remedy cannot be employ- ed without considerable risk of injurious consequences. From two to four grains of the nut may be administered three or four times daily, until spasmodic motions of the extremities ensue, or gastric distress is experienced. The extract is given in doses of from two to three grains ; and of the strichnine, which has latterly been used, one-sixth of a grain may be exhibited thrice daily. Somewhat analogous to the nux vomica is the rhus toxico- dendron in its occasional effects in paralytic disorders. This article was formerly highly extolled for its remediate powers in affections of this kind, and in Germany it has lately again attracted considerable attention in this respect.:}: In two in- * Decaudolle, Husson, Dumeril, Lescure, Asselin, Magendie, Briche- teau, and Fouquier, have reported cases in which the happiest effects were produced by the use of this remedy in palsy. M. Fouquier gave the nux vomica to the extent of from four to twenty-four grains of the powder daily to an habitual drunkard affected with hemiplegia from apoplexy; and in the course of one month he was entirely cured. t Medico-Chirurg. Rev. November, 1829, p. 203.—Prov. Med. Gazette, No. XI. July, 1829. . X M. Dufresnay, Professor of Botany at Valencia, was, I believe, the first who used the rhus toxicodendron in palsy. Mr. Alderson, an Eng- lish physician, next published a small work on the medical effects of this article, in which he relates seventeen cases which were more or less benefited by its use. Dr. Horsefield, in his inaugural dissertation on dif- ferent species of rhus, published in this city in 1798, testifies to its useful- ness in paralytic affections. Mangrat, (Journ. de Phys. Chim. d'Histoir. Nat. vol. Ii. p. 370.) Elz. (Dissert. deToxicodend., 1800.) Hunold, (Pie- penbrings' Archiv. f. Pharmacie. Bd. i. st. iii. p. 276.) Kok. Van Mons. Augustin, (Asklepeion, 1811, No. IV. s. 57.) Sybel, (Asklepeion, 1811, No. XXXII. p. 497.) Gisovious, (Rust's Magazine, Bd. xiv. s. 386.) D'Al- VOL. II.—6 42 PARALYSIS PARTIALIS. stances of hemiplegia I prescribed the saturated tincture of the leaves of the rhus with unequivocal benefit. In a letter_ to me from professor Osann of Berlin, I am informed that the toi- lowing mixture has been used with decided benefit at the Poly- clinic Institute, in paralysis of the lower extremities : R. Tinct. rhois. toxicodend. 5ss. — aconiti -----guaiaci. volat. aa3ii. M. S. Take forty drops every three hours. The effects of this article are often very similar to those which result from the full operation of the nux vomica. In one of the cases in which I used it the patient experienced oc- casional convulsive actions in the muscles of the palsied limb, with a sensation of tingling or prickling in the affected part. The powdered leaves may be used, commencing with half a grain, and gradually increasing it to four grains, three times daily. The effects of this article when given in large doses, are headach, vertigo, nausea, and sometimes profuse diarrhoea, and when these manifestations of its operation ensue its use must be discontinued. The oil of turpentine is strongly recommended by Dr. Prichard, (Med. Repos. No. I. new series,) in paralytic affec- tions, after the necessary depletory measures have been ade- quately pursued. He gives it in doses of from one to two drachms, three times daily. Mr. Manson has related several striking instances of the successful use of iodine in paralytic affections.* The fores arnicse appear to have been frequently used with entire success in cases of this kind. They are said to be par- ticularly useful in paralysis of the bladder, f and in local pal- sies of the organs of sense. Richter indeed says that they may be used with occasional success in almost every variety of palsy. Hufeland states that he cured a case of scrofulous deaf- ness with this article, in conjunction with antimonials.^: With- in the present year I prescribed this remedy in an instance of hemiplegia, which came on very gradually in an elderly fe- male, and its effects were very manifestly beneficial.§ quen, (Harles Rhein-Westphal. Jahrb. ect. Bd. x. st. i. s. 135.) Osann, (Hufeland's Biblioth. d. Heilkund, 1823, Mai. s. 324.) Buchheim, (All- gem. Med. Anual. 1825.) Hennin (Archiv. fur Med. Erfahr. V. Horn, ect. 1823, Nov. and Dec. s. 393,) have all published cases illustrative of the remediate powers of this article in different forms of palsy. * Medical Researches on the Effects of Iodine, &c.—Lond 1825 p 87—90. ' *' X Hufeland's Journal. Bd. ix. st. iii. p. 95. \ Ibid. Bd. xxxiv. st. v. s. 33. § The arnica is highly extolled for its virtues in paralytic affections by Junker, Colin, Plenk, and others. (Cook.) PARALYSIS PARTIALIS. 43 The internal use of mustard seed, and of horse-radish, have also been recommended in paralysis ; and I have known the former of these articles prescribed by the late Dr. Barton in the Pennsylvania Hospital with much advantage. A number of other remedies are said to have been employed with success in various forms of palsy. Cantharides in substance, " in the dose of one grain to a scruple of volatile salt, and gradually increased to two grains of the former and forty of the latter, every three hours," have been employed with decided benefit. (Cook, Med. Comment, vol. xiii. p. 96.) Dahlberg and Kol- pin speak highly of the effects of the tincture of colycinth,* in doses of ten drops every two hours, and gradually increased to sixty or seventy drops. The chenopodium ambrosioides is said to have produced excellent effects in aphonia from para- lysis of the muscles of the larynx, f It is given in substance, in doses of from a scruple to half a drachm, twice or thrice daily. Jahn (Klinik. der Chron. Krank. B. i. p. 365,) says the bel- ladonna is one of the most efficacious remedies in paralysis. Besides the foregoing remedies, almost every active tonic and stimulant has been recommended in such affections—phospho- rus, camphor, volatile salts, valerian, bitters, chalybeates, the essential oils, savin, &c. have all found advocates as remedies in paralytic affections, but they deserve little or no attention in this respect. In that variety of local palsy which arises from the poison- ous influence of lead ; the use of mercury, so as to produce moderate ptyalism ; in conjunction with the repeated applica- tion of blisters, or other active, irritating substances to the wrist; and the use of the splint or battledore, recommended by Dr. Pemberton ;\ with mild aperients, and occasional warm-bathing, constitute our most useful remediate means. Dr. Gregory is not willing to attribute any powers to mercury against this affection, notwithstanding the authority of Dr. Clutterbuck in its favour. I have met with one case in which gentle salivation, with local stimulants to the palsied parts, succeeded in removing the disease. It is not improbable, how- ever, that the chief advantage in this instance was derived from the local irritating applications.^ In paralysis of the tongue we may direct the patient to chew the rootpyrethrum, or other irritating and pungent substances; such as cloves, senega, squills, pepper, calamus aromaticus, * Hufeland's Journal. Bd. ii. st. iv. p. 570. t Borries—Ibid. Bd. xiv. st. ii. p. 201. X This consists simply in applying a carved splint to the inner side of the arm, so that the broad surface supports the hand. § A gentle mercurial action is recommended for the cure of this va- riety of palsy by Hunter and Dr. Clarke. Dr. Clutterbuck regards it as the most effectual means we possess in this affection. 44 PARALYSIS PARTIALIS. &c. The oil of cajeput has also been recommended in this va- riety of local palsy. A few drops of it are to be put on the tongue three or four times daily. Blisters, or frictions with tartar emetic ointment under the chin and ears, may also be used ; and a very moderate excitation of the tongue by the gal- vanic influence, which may be done by two flat pieces of silver and copper, the one applied to the upper, and the other to the un- der surface—the parts projecting from the mouth being brought in frequent contact. In partial paralysis of the face, cupping, leeching, and blistering over the origin of the portio dura, mercurial purgatives, and a scton in the neck, may be account- ed the most efficient remediate measures. Dr. Delafield, of New-York, has related several instances of this affection which yielded under the employment of these remedies.* I have known a case of this kind, produced, or at least accompanied, with indurated swelling of the parotid gland, cured by the use of iodine. CHAPTER IV. AMAUROSIS. This disease consists in a diminution or total loss of sight, from impaired or abolished sensibility of the retina to the im- pressions of light, or from decreased or lost power in the optic nerve to convey the visual impressions from the retina to the sensorium commune. This impairment, or loss of sensorial function of the optic nerve, and its expansion, may depend either on organic disease of the retina, optic nerve, and thalamus, or merely on functional torpor, or palsy of these parts, without any perceptible structu- ral lesion. Among the organic affections of the optic apparatus, which give rise to this disease, the following are the principals Extravasation of blood ; opacity; structural lesion, and de- position of lymph upon the surface of the retina ; fungous or other morbid growths ; dropsy, and atrophy within the eye • and all such disorganizations as directly oppress or derange the texture of the retina; and lastly, morbid conditions within the head, oppressing or disorganizing the optic nerve or its thalamus—as sanguineous or serous effusions, tumours sun purative destruction in the vicinity of the optic nerve'or its origin, and thickening, atrophy, absorption or ossification of its sheath.f * New-York Med. and Phys. Jour. Dec. 1824. t Travers. Synopsis of the Diseases of the Eye, p. 141. AMAUROSIS. 45 The causes which are capable of suspending or destroying the functional powers of the retina and optic nerve, independ- ent of perceptible organic change, are extremely various. Functional torpor of the optic apparatus may depend either on vascular turgescence of the retina of the sheath of the nerve, or of its thalamus, or on deficient arterial circulation in these parts ; or finally, it may be the result of an idiopathic paralysis, or loss of sensorial power of the retina and its nerve. When the organic disorder that produces the amaurosis is seated in the eye-ball itself, several or all of the following phe- nomena accompany the disease:—namely, dilated pupil, its con- tracting power being feeble or null ; congestion of the veins of conjunctiva ; a bluish grey tint of the sclerotica ; loss of regu- lar shape of the globe of the eye, the sides either bulging out or appearing flattened ; a turbidity or milkiness in the poste- rior chamber of the eye, " resembling the humours in the eye of the horse." In many instances of organic amaurosis, a small circular spot of a pearly or greenish yellow colour may be seen at the fundus of the eye, a small distance from the visual axis.* When the disease is the consequence of inflammation of the retina or choroid coat, and the inflammatory action has entirely subsided, we usually find the conjunctival veins varicose, the iris discoloured, thick, very vascular, and inelastic ; the bulk of the crystalline lens diminished, or liquefied and discoloured, with opacity and deep yellow colour of the vitreous humour. {Travers.) In such cases there is usually a feeling of tension, and at times of uneasiness, hut rarely any distinct acute pains in the globe of the eye, and the sclerotica becomes thinner and semitransparent, admitting the reflection of the vascular tex- ture of the choroid coat, which occasions the above-mentioned bluish grey tint of the sclerotica. {Stevenson.) In some cases of organic amaurosis, an opake white spot, or projecting whitish substance, may be seen on some part of the concave surface of the retina when the eye is examined in a good light. This constitutes the medullary fungus of the retina, which in the progress of the disease involves the eye in one undistinguishable disorganized fungous mass. Functional amaurosis, as has just been said, sometimes de- pends on vascular turgescence of the optic apparatus. In such cases the pupil is dilated, sluggish in its motion, or immova- ble; more or less strabismus, ptosis; or double vision of the affected eye often exists; the carotids beat strongly ; the face is apt to be flushed ; a sense of fulness and tension in the globe of the eye is felt, with pain and a feeling of pressure of the * " This appearance has been attributed to a circumscribed opacity of the retina, answering to the porus opticus. Others have supposed it to be the maculae lutea of Soemmering. It is, however, with more pro- priety ascribable to a diminished secretion of the black pigment."— Stevenson on the Nature, Symptoms, and Treatment of Amaurosis. 46 AMAUROSIS. scalp; occasional ringing in the ears; disorder and irrita- bility of the stomach; and somnolency. Luminous sparks or flashes appear before the eyes, particularly on stooping, straining, or on first lying down. {Trovers.) These cases sometimes come on suddenly. Mr. Stevenson has known se- veral instances in which the patients went to bed apparently well, and awoke with more or less complete loss of sight in one or both eyes. Functional amaurosis from depletion occurs sometimes im- mediately after excessive haemorrhages, particularly uterine floodings. In this variety, as in that which arises from vascu- lar congestion, the pupil is dilated and immovable, and there is usually deep-seated pain in the head, and occasional vertigo. This pain is attended with a feeling of circumscribed pressure on some part of the brain, accompanied sometimes with a jarring noise "like that of a mill or threshing floor." In cases result- ing from this cause, there exists in fact strong vascular con- gestion in the head; for there is no pathological fact better established, than that strong determinations to the head often supervene as the immediate consequence of excessive sangui- neous discharges.* It is of much importance to distinguish this from the former variety in a therapeutic point of view;— for, amaurosis from excessive sanguineous evacuations, is al- ways increased by even small abstractions of blood; whereas that which is attended with a plethoric state of the system de- mands sanguineous evacuations. Symptoms.—Functional amaurosis usually comes on very gradually. The patient at first* complains of some weakness of sight. When he looks at small objects, as, for instance, the letters of a book, he finds that his vision is variable and irre- gular—the letters "being at one time more distinctly visible than at another, the sight of which he alternately loses or re- gains by shutting or rubbing his eyes, or by moving his head in different directions." Sometimes the approach of the dis- ease is announced by a peculiar dimness of sight, as if a fine piece of gauze or spider's web were held before the eyes; at others, by the perception of spots, threads, or other imaginary appearances floating in the air a short distance from the face ; and at a more advanced stage of the disease, coloured spectra, or luminous impressions of objects remaining upon the retina often occur. Sometimes the objects looked at appear to have a tremulous or wavering motion. Connected with these symp- toms there is generally more or less pain in the head and tem- ples, diminishing in proportion as the dimness of vision in- * See the observations of Marshall Hall on this subject in his " Me- dical Essays." The experiments of Dr. Seeds on the effects of exces- sive abstractions of blood in animals.—Med. Chirurg. Jour. No. VI. p. AMAUROSIS. 47 creases, and ceasing altogether when the amaurosis is com- plete. When the pain continues severely, with but slight re- missions, and is readily aggravated by whatever excites the sys- tem, we may presume that it is connected with organic disease within the brain ; and such cases are almost invariably accom- panied by torpor of the bowels ; gastric derangement; disposi- tion to lethargy ; occasional confusion of mind ; indisposition to corporeal or mental exertion ; and paralysis in one or more of the muscles. In some cases, very severe spasmodic pains occasionally shoot through the eye into the head, coming on every night or second night about the same time, and continu- ing an hour or two, and "is accompanied with convulsive qui- vering of the muscles of the eye and eyelids, and profuse lacry- mation." Some patients affected with incomplete functional amaurosis, see more distinctly on first waking in the morning ; and in others, the sight is clearest in the evening. (Travers.) When one eye only is affected, the iris, in functional amaurosis, will generally act in accordance with that of the sound organ, "provided both be allowed to remain open at the same time ; but if the latter be closed, the pupil of the diseased eye will be found to have lost its power of motion on the admission of the usual degrees of light."* In the majority of cases, the pupil is dilated and immovable; and frequently misshapen or irre- gular. It is sometimes smoky or clouded, or dark grey or greenish grey, and occasionally of a reddish or yellowish white appearance. Diagnosis.—Immobility and dilatation of the pupil furnishes no certain evidence of amaurosis. In some cases of complete amaurosis, though indeed very rarely, the pupil acts regular- ly; in others, it retains its ordinary size, but is motionless ;f and in others, it is fixed and contracted.^: Moreover, the ci- liary nerves may be paralized, occasioning enlargement and immobility of the pupil, without amaurosis. Among the symp- toms which may aid us in distinguishing amaurosis from cata- ract, writers particularly mention the different appearances which the flame of a candle presents to persons labouring un- der one or the other of these diseases. To a person affected with the latter disease, the flame of a candle appears as if it * Loc. citat. p. 68. t M. Travers is of opinion that, in cases of complete amaurosis where the pupil is of the natural shape but motionless, the retina has, most pro- bably, undergone some structural change. X When this is the case, says Mr. Stevenson, the disease is generally the result of inflammation of the internal occular textures, and is usually attended " with an angular or irregular form of the pupillary border in one or more points of the circumference, and with an opacity of the cap- sule of the crystalline lens." 48 AMAUROSIS. were surrounded with a uniform thin mist or white semitrans- parent cloud ; to one labouring under the former affection, an iridescent halo seems to encircle the flame or to emanate from the mist. In imperfect amaurosis, the faculty of vision is oc- casionally increased or diminished "under different states of the circulation, as influenced by a full and stimulant meal, by which some find their sight improved, others greatly deterio- rated. Enlivening or distressing mental emotions and other physical causes that have a tendency to excite or depress the energy of the nervous system, have a correspondent effect in affording temporary benefit, or in causing diminution of vi- sion, which does not occur in cases of incipient cataract." Prognosis.—Those cases which depend on organic lesion may be regarded as incurable; where, with total loss of sight, the iris is immovably dilated, or preternaturally contracted, accompanied with violent pain in the head, or eye, or cranium ; when the disease occurs as a consequence of apoplexy, blows on the head or eye, syphilis, or protracted internal ophthal- mia; and in cases where the above-mentioned whitish projec- tion appears at the bottom of the eye, little or no hopes of a cure can be entertained. Where, on the contrary, the amaurosis is not complete, and no severe and protracted pains in the head or eyes, or sense of constriction in the eye-ball accompanies the development of the disease ; and where at the same time the pupil retains its natural shining black colour, and some degree of sight still re- mains, there is reason to expect relief from remediate manage- ment. Periodical amaurosis also, unless of very long stand- ing, is of a favourable character; and in general, all those instances of the disease which are purely functional or sympto- matic of visceral irritation, or metastasis of gout, rheumatism, &c. may be regarded as susceptible of being cured. Causes.—When amaurosis is not the result of organic or structural disease of the optic apparatus, it arises probably, in most instances, from pressure on some portion of the visual nervous texture. Even in those cases which occur in conse- quence of excessive losses of blood, vascular turgescence, and pressure of the retina, optic nerve or its thalamus, is, perhaps, the immediate cause of the disease. I have already adverted to the great tendency to cephalic congestion in that exhausted state of the system which results from profuse haemorrhage, and in this state, vascular congestion of the capillary vessels of the retina and consequent pressure of this structure may, it is to be presumed, readily occur. It may, nevertheless, in some instances, depend also on mere functional torpor from pre- vious over-excitation of the retina and optic nerve, or from the vitality of the nerve being too much depressed.* * Weller. Manual of the Diseases of the Human Eye. AMAUROSIS. 49 It would appear from the observations of pathologists, that persons who have dark-brown, blue, or black eyes, are in ge- neral much more liable to amaurotic affections than such as have light-coloured or grey eyes. It has been stated, that the proportion of instances of this disease in dark-eyed persons, is to that of the cases which occur in individuals with light or grey eyes, as twenty-five to one.* The exciting causes of amaurosis are very various. It may depend on metastasis of other affections, particularly of gout, and from the sudden suppression of habitual sanguineous or serous evacuations; as of the catamenial or hemorrhoidal dis- charges ; the healing up of old ulcers ; and the sudden retro- cession of cutaneous eruptions ; and of habitual perspiration of the feet. It is sometimes symptomatic of hysterical, epileptic, hypo- chondriacal, and other nervous affections, (Beer ;) arises from the excessive use of narcotics, as well as from the poisonous influence of lead ; is the result of abdominal irritation, from a loaded state of the bowels ;f suppressed, or deranged, or exces- sive secretions in the liver, kidneys, or uterus; intestinal worms; and dyspeptic affections. Sudden mental emotions, particularly rage, terror, and protracted grief, sometimes pro- duce this disease. The sudden suppression of the secretion of milk in the puerperal state has produced it; and it has arisen from rapid and copious salivation; from excessive venereal in- dulgence, particularly habitual self-pollution; from intoxica- tion ; and from the sudden influence of cold. Among the most common external causes of amaurosis is intense application of the eye to the inspection of minute and bright objects:):—which Mr. Stevenson thinks, tends to produce preternatural vascu- lar turgescence in the retina and choroid coat. It may also he occasioned by falls or blows on the head; insolation; straining in parturition; evacuating the feces ; or lifting— in short, by whatever is capable of causing preternatural san- guineous determinations to the head. Treatment.—When amaurosis arises from organic disease * Jahn's Klinik der Chronischen Krankh. Bd. v. p. 295. t Dr. Wishart has related an interesting case of amaurosis in the Edin- burgh Medical Journal for July, 182-5, which was manifestly the conse- quence of intestinal irritation from indurated fecal matter. X " Hence the frequency of weakness of sight among silk stocking weavers, milliners, embroiderers, and other mechanics and artists whose occupations oblige them to exercise their visual organ with too little in- termission and variety, in looking intently at their delicate, light-co- loured, and highly-illumined manipulations. Persons addicted to read, write, or perform much fine needle-work by the aid of candles, and what is much worse, by the brilliant and artificial light of lamps, rarely fail, if their organ of vision be constitutionally feeble, to discover, sooner or later, the greater or less decay of sight."—Stevenson. Loc. cit. p. 121. VOL. II.—7 50 AMAUROSIS. of the visual organ, or the brain ; or from epilepsy, or in con- sequence of violent forms of fever and other acute constitution- al diseases, nothing is to be expected from remediate treat- ment. The functional or symptomatic varieties of the disease, however, will often yield under a proper course of manage- ment. The treatmeat of amaurosis must of course be modihed ac- cording to the nature of the occasional cause ; and the remov- al of the primary irritating cause ought to be the first object in prescribing for this disease. Mr. Travers remarks that the treatment of amaurosis is almost entirely constitutional ; and he attaches no value to the external application of stimulating vapours, lotions, ointments, and etherial embrocations, &c. al- though setons, leeching, and blistering are important auxilia- ries. Upon this point, however, Mr. Stevenson, as well as many others, differ widely from Mr. Travers. The former agrees with Mr. Ware in regarding errhines as often particu- larly useful in chronic functional amaurosis; and he thinks favourably of the use of stimulating applications to the eye in cases unattended with fever, or local vascular irritation in the eye. When the momentum of the circulation is preternaturally increased and the eye is somewhat tender and irritable, and particularly when the habit is robust and plethoric, the treat- ment should be commenced by both general and local abstrac- tions of blood. " Bleeding in the early stage of acute amauro- sis," says Dr. Stevenson, "is the sheet-anchor of our hopes. It should be repeated," he says, "at short intervals, until the violence of the symptoms shall have been moderated." Immediate attention must also be paid to the bowels. So long as the general habit is phlogistic, free purging with calo- mel, succeeded by a portion of Epsom or Glauber's salts, should be practised every second or third day, and antimoni- als in nauseating doses administered during the intermediate time. In relation to the employment of sanguineous evacua- tions in this affection, Mr. Travers observes, that although ob- viously proper in cases attended with general plethora and ce- rebral compression ; yet where the undue determination of blood to the eye is attended with diminished tone of the vessels of this organ—a circumstance \cry common, he says, after deep-seated inflammation, or irritation and relaxation from over-excitement—depletion is always decidedly detrimental. In cases of recent imperfect amaurosis making rapid pro-' gress, and attended with signs of obscure inflammation, the employment of mercury, so as speedily to produce soreness of - the gums, but not salivation, will sometimes suddenly arrest the disease. Mr. Travers asserts that salivation does no good, and may readily prove hurtful. "When mercury is benefi- AMAUROSIS. 51 cial," he says, "its efficacy is perceived as soon as the mouth becomes sore." When the pupil shows a disposition to con- tract, or has actually formed adhesions with the capsule of the lens, the application of belladonna, or stramonium in solution to the eyes, says Mr. Stephenson, "must on no account be omitted," in order to prevent permanent contraction and obli- teration of the pupil. The light should be excluded from the eyes where there is tenderness and irritability of the organ ; and all kinds of com- pressing or tight bandages be carefully avoided. When the local and general excitement has been moderated, or where the disease from the beginning is free from manifest general vascular irritation, revulsive applications, particular- ly blistering, or a seton on the nape of the neck, and leeching at the temples and around the eye may be resorted to with ad- vantage. In conjunction with the occasional employment of these external means, alterative and aperient remedies should be regularly used until there is reason to think that the heal- thy condition of the visceral functions is restored. For this purpose a great variety of remedies has been recommended, but the use of four or five grains of blue pill with two grains of ipecacuanha at night on going to bed, and a dose of rheu- barb, or of the compound extract of colocynth every second or third day, will probably do all that can be effected in this re- spect.* Benefit may also be derived with this view, from the frequent use of very minute portions of tart, antimony dissolv- ed in an infusion of sarsaparilla, or of the root of burdock {arctium lappa.) A grain of this antimonial may be dissolv- ed in a pint of infusion, and drank in small portions through- out the day. If the visceral functions have been brought to a healthy state, and there is an entire absence of general and lo- cal vascular irritation, recourse should be had to tonic reme- dies, such as arsenic, bark, iron, and the mineral acids. The eyes should be kept in a state of repose; and the pa- tient be directed to take gentle exercise in the open air when the weather is dry ; to use a nutritious but digestible diet, the cold bath, and regular rest. * Schmucker's visceral pills were formerly much employed in Germa- ny for the cure of this disease. They are made according to the follow- ing formula. R. G. Sagapen.—Galban.—Sapo. venet. aa 31. Pulv. Rhasi 3iss. Tart. Emetic gr. xvi. Succ. Glycyrrh. 3i. Fiant. pill,singul. °r v Of these pills three are to be taken every morning and evening for a month. Richter recommends the following pills: R. G. Ammon.— Assafoetid.—Sapo. venet.—Rad. Valerian.—Sumitat Arnicae.—aa 3ii. Tart Emetic, gr. xviii. Fiant. pill, sing. gr. v. Six to be taken thrice daily for three or four weeks. The following combination forms an ex- cellent purgative for this purpose: R. Masste Hydr. 3i. G. Aloes 3ss. Tart. Antim. gr. ii. Fiant pill, No. xx. Take one every night on go- ing to bed. 52 AMAUROSIS. When amaurosis is strictly chronic, or devoid of general or local irritated action, general depletion is not only useless, out frequently pernicious. Small abstractions of blood, however, by means of leeches, will sometimes be useful by relieving the local congestion in the affected organ. In cases ot this kind, much advantage maybe derived from a seton in the back of the neck, or from the repeated application of blisters to that part. To lessen sanguineous congestion in the eye, some writers recommend the use of errhincs, and there can be no doubt of their occasional beneficial influence, by the irrita- tion they produce in the immediate vicinity of the affected or- gan, as well as the consequent increased discharge from the mucous membrane of the nose. Some advantage may also, at times, be derived in cases of this kind, from stimulating appli- cations directly to the eye ; such as the ungt. hydrarg. nitrat., the vapour of volatile alkali; weak infusion of capsicum ; vi- nous tincture of opium, &c. Electricity does not appear to possess any particular remediate powers in this affection ; and it is said to be even frequently injurious. Mr. Travers has not seen a single instance of benefit derived from electricity. Emetics were formerly much recommended in the treatment of amaurosis, not only for the purpose of evacuating the sto- mach, but also with a view to their general influence upon the nervous and sanguiferous systems. Mr. Travers does not speak favourably of their effects in this disease. Richter, on the other hand, gives the most favourable account of their in- fluence in amaurosis. That they have been employed with success in some instances is unquestionable, and under peculiar circumstances may, do doubt, be again used with advantage; although they are certainly not so efficacious as they were for- merly represented to be by physicians of high authority. In complete amaurosis of a chronic or asthenic character, the German writers recommend exposing the eye to a bright light, and even to the direct rays of a meridian sun, with a view of stimulating the palsied retina. Mr. Stevenson says, that he has heard of an instance of the success of this practice; although his own experience does not furnish him with an ex- ample of its usefulness. Mr. Stevenson recommends dry cup- ping applied to the ball of the eye and its appendages. " By carefully fixing a well adapted strong glass, fitted with an ex- hausting syringe upon the edges of the orbit, the instrument may be made capable of exerting a more or less powerful in- fluence upon the organ of vision, in proportion to the extent to which the atmospheric air contained in the cupping-glass is exhausted. The effect of this application is to occasion a great redness and tumefaction of the eye-lids; an immediate disten- tion of the conjunctiva ; and a bulging forward or protrusion of the whole globe of the eye, the obvious tendency of which AMAUROSIS. 53 must be to relieve the deep-seated vessels." He mentions a few cases in which this practice was employed with the most decided advantage. Some modification in the treatment will, of course, always be made by the judicious practitioner, according to the occasional cause of the disease. Thus, when the disease appears to be the consequence of suppressed hemorrhoidal discharge, aloetic pur- gatives, stimulating enemata, and leeching around the anus are indicated. If it be the result of an arthritic or rheumatic dia- thesis, advantage may probably be obtained from the internal use of the tinctura guaiaci or colchicum, and sinapisms or blisters to the ankles. In instances that arise from a syphili- tic irritation, a slow mercurial course with infusion of sarsa- parilla, &c. will be particularly indicated, and the same reme- dies are to be relied on where manifest hepatic disorder is pre- sent. If suppressed perspiration lie at the bottom of the dis- ease, the warm bath, diaphoretics, particularly antimonials, both in nauseating and emetic doses, will be appropriate means. In short, the practitioner should always endeavour to ascer- tain the cause of the disease, and to counteract or remove this cause, if possible, by an appropriate course of remediate ma- nagement. CHAPTER V. EPILEPSY. Epilepsy, whether considered in its immediate phenomena or in its remote consequences, is unquestionably one of the most distressing and deplorable of human maladies. Its ten- dency to impair the understanding, to produce hebetude, and even total abolition of the rational powers, leads often to a condition infinitely more lamentable than death itself. So frightful and distressing a disease could not fail to attract the particular attention of the physicians of every age; and we accordingly find it minutely described, and its nature and treatment extensively discussed in the works of the Greek and Roman physicians.* * Hippocrates describes epilepsy under the name of morbus sacer—a name which was given to it from its supposed origin; it being generally regarded at his day, as an infliction of the Gods, or of demoniac influ- ence. Aristotle treats of it under the name of morbus herculius, be- 54 EPILEPSY. The soporose and convulsive affections arc so closely allied to each other, both in relation to their general phenomena and their pathological character, that it is extremely difficult to give an unexceptionable definition of any one of them. Epi- lepsy may, perhaps, be defined a disease primarily seated in the nervous system, manifested by convulsions recurring at uncertain periods in paroxysms, accompanied by a temporary loss of consciousness, sense, and voluntary motion, and termi- nating in somnolency. The epileptic attack sometimes comes on suddenly without any manifestations of its approach. More frequently, however, certain symptoms precede the occurrence of the paroxysm, and of these the following are the most common:—A peculiar con- fusion and distressing feeling in the head ; an absent, wander- ing, and confused state of the mind ; giddiness ; dimness of sight; ringing and loud sounds in the ears ; sparks and flashes of light before the eyes; distention of the veins of the head and neck ; a trembling and feeling of restlessness in the extre- mities; an anxious feeling in the precordial region ; restlessness and starting during sleep ; loss of the power of distinct arti- culation ; complete temporary deafness ; and drowsiness. In some instances, there is a manifest change in the moral dispo- sition a short time before the accession of the attack. Sullen gloominess with an irritable temper is manifested by some pa- tients. In some cases, the mind falls into a kind of revery from which it cannot be drawn, which terminates often speedi- ly in total insensibility. Some epileptics evince an unusually timid disposition ; others are spiteful, resentful, and mischiev- ous, shortly before the accession of the paroxysm. Occasion- ally, spasmodic twitches of particular muscles, especially in those of the face, precede the attack. Richter states, that pain- ful sensations in certain parts of the body, particularly spas- modic pains in the stomach, with a rumbling noise in the bow- els, occur as the precursors of the epileptic paroxysm. The most remarkable of the premonitory symptoms of epi- lepsy, however, is that which is technically called aura. The sensation to which this term is applied, and which, I believe, occurs in no other disease, is compared by patients to the feel- ing which is communicated by a gentle stream of cool air di- rected on the part. This sensation generally commences in the feet or legs, and gradually ascends until it reaches the cause Hercules is said to have been afflicted with this disease. The most common appellation of this affection among the Roman physicians however, was morbus comitialis. We nevertheless find it mentioned also under various other names in their writings—such as morbus sonti- cus, morbus caducus, morbus pueriles, morbus insputatus, seleniacus ma- jor, magnus, vitriolatus, mensalis, &c. In the sacred writings, epileptic persons are called lunaticos. EPILEPSY. 55 head, when the patient instantly becomes insensible and epi- leptic. Some patients are enabled by this symptom to tell with accuracy the nearness of the attack, and to avail tliemselves of this intimation to place themselves in a situation in which they will be less liable to sustain injury during the attack. Spiculse of bones, tumours, and foreign bodies pressing upon and irri- tating some nerve, have been found to exist at the starting point of this singular sensation.* The primary irritation is, however, almost invariably seated elsewhere, and transferred sympathetically to the part in which the aura commences. In many instances, the attack always occurs at night while the patient is sleeping. In this respect epilepsy differs conspi- cuously from chorea, the convulsive motions of which, however violent during the day, are almost always wholly suspended during sound sleep. When the epileptic seizure occurs while the patient is sitting or standing, he suddenly falls down in a state of insensibility, and immediately becomes more or less violently convulsed. In some cases, the convulsive actions of the muscles, particularly those of the face, are frightfully violent; the whole frame is violently agitated; the eyes roll about; the lips and eyelids are convulsed ; the tongue often spasmodically thrust from the mouth, which, \sith "the gnashing of the teeth, and the foam- ing at the mouth, give the countenance a horridly wild ex- pression." Sometimes the teeth are firmly pressed together; at others, the jaws are widely and fixedly distended ; the thumbs are almost invariably firmly pressed in upon the palms of the hands. The spasms are generally of the clonic kind; hut in some instances, the muscles remain for a time rigidly contracted, the body being bent either backwards, forwards, or to one side, as in tetanus. Occasionally, the abdominal mus- cles are violently drawn in towards the spine. In many in- stances, there are strong erections of the penis, with spasmo- dic retraction of the testicles and occasional seminal discharge. (Richter.) The face is occasionally pale, but more commonly livid, with a turgid state of the veins of the head and neck. The heart palpitates rapidly ; the pulse is usually contracted, irregular, and frequent;! and respiration oppressed, laborious, and in violent cases, sonorous. About the termination of the paroxysm a considerable quantity of frothy saliva usually flows from the mouth; and in some cases, the feces and urine * Van Swieten's Commentaries, vol. iii. p. 419.—See falso Medical Experiments and Observations by a Society, &c. at Edinburg, vol. iv. p. 334. t Dr. Burnett relates a singular case of epilepsy in which the pulse became so slow at times, as to beat only fourteen strokes in a minute. —(Med. Chir. Transact, vol. xiii. part i. p. 202.) Morgagni relates two similar cases. 56 EPILEPSY. pass off involuntarily. Sooner or later these spasmodic symp- toms abate—generally gradually, but sometimes abruptly. 1 ne respiration becomes freer; the pulse fuller and more regular■; the countenance more composed; and the patient finally talis into a state of stupor or deep sleep, out of which he awakens with a feeling of languor and confusion and torpor of mind, which generally continues for ten or twelve hours. The coun- tenance exhibits a vacant and stupid expression, and the eyes are dull, staring, and wandering. In violent attacks the mind remains obtuse and fatuous, and the temper irritable and morose, for several days after the paroxysm. During this somnolent state the patient usually perspires freely, particu- larly about the head, neck, and breast; and the perspiration has frequently a very peculiarly offensive smell.* The sweat- ing has been known to be distinctly confined to one side of the body only.f Epilepsy does not, however, always assume the violent grade just described. Sometimes the attack supervenes sud- denly, and after a few moments of partial convulsions of the muscles of the face and neck quickly subsides, and restores the patient to consciousness. I once attended a girl affected with this disease, in so light a manner, that the convulsions seldom lasted longer than a few minutes. In relation to the duration of the epileptic paroxysm, there exists great diversity. The convulsive stage generally con- tinues from ten to fifteen minutes, sometimes for half an hour, and occasionally for several hours. The paroxysm is most apt to become protracted in children. In most instances one pa- roxysm only occurs at a time. Sometimes, however, they recur several times—the patient passing from one into another, with but a very short interval between them. In general the first attacks are shorter than those which occur after the disease has continued for some time. The contrary, however, gene- rally takes place when the first attack is caused by some sud- den and violent mental impression, as terror. With regard to the interval between the epileptic seizures, also, there exists the greatest diversity. In some cases the paroxysm returns almost daily ; in others at various intervals, from a few days to a whole year. Many instances observe a more or less perfect periodicity in the recurrence of the fits ; whilst others are quite irregular in this respect. Richter ob- serves, that cases arising from gastric or intestinal irritation— and from catamenial irregularities, are most apt to assume a periodical character.^: Occasionally the paroxysms recur re- * De Haen, Ratio Medend. torn. v. p. 123. t Voigtel's Handbuch der Patholog. Anatom. B. i. p. 70. \ Specielle Therapie. Bd. vii. p. 570. EPILEPSY. 57 gularly at the periods of new or full moon. Nearly twenty years ago I treated a case successfully, in which for several years previously the paroxysms had returned regularly oq the night of each full moon. Examples of this kind may, however, occur as mere coincidences, without any relation, as cause and effect, between the two phenomena.* Epilepsy seldom proves fatal, except through the intervention of apoplexy. When it recurs very frequently, however, the mental powers gradually fail, until at last a total imbecility or idiotism is induced. The most complete state of idiotism I have ever seen was produced in less than two years in a fine, intelligent boy, by the ferocious attacks of this malady. Post mortem appearances.—The morbid appearances disco- vered on dissecting subjects who die of epilepsy, are often simi- lar to those which occur in apoplexy and palsy. No man has, perhaps, dissected so great a number of bodies that had died of epilepsy as M. Wentzel. Previous to the dissections of this indefatigable anatomist, it was generally thought that the cere- brum is the chief seat of the proximate cause of epilepsy. M. Wentzel, however, in a very great proportion of heads he ex- amined found the cerebrum perfectly sound, whilst the cere- bellum was uniformly in a diseased condition. The part of the cerebrum which he found most frequently affected was the pineal gland. The cerebellum was generally of a dusky red, approaching to a blackish colour; in some cases it exhi- bited a whitish or yellow hue, and in a few instances the pos- terior lobe was of a grey colour. This portion of the encephalon was sometimes very soft; more frequently it presented a pre- ternaturally hard and compact structure. In ten out of twenty- one cases, a morbid, yellow, friable matter was found between the lobes of the cerebellum, which in some instances not only se- parated the lobes, but caused also the destruction of a portion of their substance. Notwithstanding these observations of Went- zel, dissections made by other pathologists render it certain that the substance of the cerebrum is often materially diseased in epilepsy. This indeed Wentzel does not deny, but his observa- tions convinced him that this is much less frequently the case than we might be lead to believe from the observations pre- viously published on this subject, f Both Greding,^: and Roe- derer relate cases in which the cerebrum was disorganized to a greater or less extent. Some French pathologists have * For a full discussion of this point, the reader may consult Mead, de Imperio Solis et Lunaein Corpus Humanum; also, Balfour on Sol-lunar Influence. That the moon governs the epileptic paroxysm, appears in- deed to be a very ancient opinion. Galen, Aretraeus, and Alexander Trallianus entertained this opinion. (Cook on Nervous Diseases.) t Cook on Nervous Diseases, &c. p. 342. X Sammtliche Medic. Schriftcn. ii. Theil. VOL. II.—8 58 EPILEPSY. pointed out various morbid appearances of the mucous mem- brane of the intestinal canal as being intimately concerned in the causation of this disease. Causes.—Observation has informed us that in some cases of this disease the original exciting cause is seated within the head, or acts directly on the cerebral mass ; whilst in others the cause is located in some other part of the system, and affects the encephalon secondarily, through the medium of the nerves* It is evident, therefore, that we may with propriety divide this malady into two general varieties—namely, into idiopathic and symptomatic. Experience has shown that the latter is in general much more apt to yield to remediate treatment than the former. In some individuals there appears to exist a constitutional predisposition to epilepsy; and it is, without doubt, in some instances of hereditary origin. Bberhaave mentions an in- stance in which all the children of an epileptic father died of this disease;* and Stahl has related a similar occurrence.! Tissot also mentions a remarkable instance of this kind. An epileptic man had eight sons and three grandsons, all of whom, he says, became affected with this disease. (Cook.) Children, it has been observed, are much more liable to this disease than adults ; but the age at which there appears to ex- ist the strongest predisposition to epilepsy is the period of pu- berty. Some writers assert that females are more subject to this affection than males ; others, however, contradict this assertion. Probably hysteria has been frequently mistaken for epilepsy, which may have given rise to this opinion. Those who have once had this disease, and have been freed from it by remediate treatment, generally retain a particular predis- position to its recurrenee. The exciting causes of epilepsy are exceedingly various. Of these causes some act immediately on the brain, and others make their impressions on distant parts, and affect the senso- rium commune secondarily through the medium of the nerves. The most common of the former variety of causes are: injuries and malformation of the cranium; exostosis from the internal surface of the bones of the skull; spicule of bones driven in upon the brain ; preternatural distention of the cerebral ves- sels ; various organic affections of the brain, and effusions of different kinds within the cranium. (Cook.) Sudden and violent mental emotions frequently produce this disease by a morbid excitement originating in the brain. Fear, * Praslectiones in Prax. Med. torn. v. p. 30. X De Hereditar. Dispos. ad Varios. Affectus. Halle, 1706, p. 48. Also in his Dissertatio de Epilepsia Hereditaria Casum Exhibens, as quoted in Richter's Specielle. Therapie. Bd. vii. p. 594. EPILEPSY. 59 terror, grief, and other disagreeable sensorial and mental im- pressions have been known to give rise to epilepsy. I have met with three instances that were excited by terror. Locker states that six out of fourteen cases of this disease, which came under his care hi the Hospital St. Mark at Vienna, were pro- duced by terror. Many remarkable instances of epilepsy, ex- cited by disagreeable and strong impressions on the senses, have been reported. Strong odours, sudden and vivid light, loud and peculiar sounds, and certain colours have produced this disease in weak and irritable habits. Weikart relates the case of an individual in whom the smell of red beets excited epileptic paroxysms.* The odour of the garden ranunculus has also given rise to the disease ;f and Cook quotes from Buchner an instance of an epileptic child in whom the sight of a vivid red colour seldom failed to excite a paroxysm of the disease. Cases of this kind are of course connected with idiosyncracies by which the influence of these exciting causes is peculiarly fa- voured. This disease has frequently been excited by the sight of a person affected with the epileptic paroxysm. Dr. Rush men- tions several instances of this kind. The principle of associa- tion exerts indeed a powerful influence over the actions of the animal economy; and in no disease has this been more strik- ingly exemplified than in the present one. The mere recollec- tion, or sight of the causes or circumstances which attended the first attack of the disease, has re-excited the paroxysm.:}: Among the causes of this disease that act upon the brain through the general system, gastric or intestinal irritation is perhaps the most common. Epilepsy from this cause is most frequently met with in children. Worms, and indeed every other substance which is capable of producing an irritation in the nervous extremities of the mucous membrane of the aliment- ary canal, may give rise to this affection in weak and irritable subjects. A protracted case is related, which ceased entirely after the expulsion of a tape-worm.§ Leeches swallowed into the stomach have produced epilepsy. (Giidenklee.) The suppression of habitual evacuations, whether sanguine- ous or serous, is another powerful exciting cause of epilepsy. Suppressed or morbidly postponed catamenial discharge soon after the age of puberty, is particularly apt to give rise to this affection in individuals otherwise predisposed to it.|| The heal- * Hufeland's Journal, Bd. xii. st. i. s. 174. t Acta. Natur. Curios. Dec. iii. Ann. ix. x. Obs. 92, p. 170. X Van Swieten. Commentar. Tom. iii. p. 414. § Mursinna's Journal, f. Chirurg. Arzneik. u. Geburthshuife. B. i. st. ii. p. 306. (Richter.) || Falk, Dissert, de. Epilepsia s. Motib. Convuls. Virgin. See also the interesting observations of Prichard on this subject in his Treatise on Nervous Diseases. 60 EPILEPSY. ing up of old ulcers, setons, issues, &c. may give rise to epilep- sy. Richter mentions the suppression of habitual sweating ot the feet as a strong exciting cause of this and other convulsive affections. The repulsion or sudden drying up of chronic cu- taneous eruptions, particularly the itch and tinea capitis, also may produce epilepsy; and in the exanthemata, either just before the'eruption is about coming out, or from its sudden retroces- sion, this form of convulsive disease is by no means uncom- mon. Excessive evacuations are also among the exciting causes of epilepsy ; and this is particularly the case with inordinate semi- nal evacuations, either from excessive venery or masturba- tion.* Various poisons, more especially of the narcotic kind, some- times produce this disease. It is said that in Kamtschatka, epilepsy is frequently occasioned by the use of an indigenous species of toad-stool, which the inhabitants of that country are much in the habit of eating on account of its exhilarating ef- fects.! The abuse of opium in children has a tendency to pro- duce this malady; and among the mineral poisons, lead and arsenic are said to be most apt to excite it. Wendt mentions a case produced by lead, and Dr. Warren relates a fatal case produced by this poison. (Cook.) In the second volume of the Medico-Chirurg. Transactions, five cases are reported which arose from the reception of arsenic into the stomach. The habitual intemperate use of alcoholic liquors is a very common cause of epilepsy. It is probable that epilepsy from this cause proceeds from the combined influence of hepatic dis- order, and a constant preternatural determination of blood to the brain. Painful dentition, pregnancy, and parturition oc- casionally excite the disease. Tissot relates three cases which arose evidently from pregnancy. In one case, the patient was affected with epileptic paroxysms almost every week in three of her pregnancies until quickening commenced. Irritation from biliary concretions, as well as from urinary calculi, has sometimes give nrise to this affection. Dr. Cook refers to the works of Bertholini for examples of this kind. Habitual tendency to congestion or plethora of the vessels of the brain is perhaps one of the most frequent exciting causes of the epileptic paroxysm. This may be the result either of a constitutional habit, or of the operation of some one of the fore- going exciting causes, particularly intestinal irritation, and suppressed sanguineous and serous discharges. Atmospheric influences also have been supposed capable of exciting this dis- * Zimmerman on Experience, vol. iv. chap. 10. t Langsdarf in d. Weterauschen Annalen. Bd. ii. hft 2 CRichter Spec. Ther.) v ' EPILEPSY. 61 ease. Great heat or cold, and sudden vicissitudes of tempera- ture are mentioned as exciting causes; but their influence in the production of this affection is perhaps rather predisposing than exciting. On the subject of the proximate cause of epilepsy, a very great diversity of opinions has been expressed. Without entering in- to a detail of these opinions, all of which are hypothetical and many of them absurd, I shall content myself with a statement of those circumstances, which experience and observation ap- pear to sanction in relation to the pathology of this affection.* 1. The immediate cause of the epileptic paroxysm, what- ever its essential character may be, is always seated in the brain. 2. In the majority of fatal cases, organic and other obvious affections of the brain, particularly of the cerebellum, or of the meninges, are found on dissection, and which, we may infer, contributed to the excitation of the epileptic paroxysms. 3. The cerebral affection is in some instances primary, and the result of causes that act directly upon the brain. In others, probably in the majority of cases, it is secondary, depending on primary irritations located remotely from the brain. 4. Immediately before the accession of the epileptic attack, it would seem that vascular turgescence takes place in the en- cephalon ; and the pressure thus created, in co-operation with the general predisposition to the disease and the organic cere- bral affection, where such disorder exists, is probably the im- mediate exciting cause of the paroxysm. It would be useless to enter into any discussion concerning the causes of the paroxysmal character of this affection, or of the occasional strict periodicity of its recurrence. The influ- ence of habit has been adduced in explanation of these myste- rious points of pathology. The term habit, however, in a phy- siological sense, can mean nothing else than a tendency to repeat an action, whether morbid or healthy, that has been produced by some exciting cause, without the presence or further co-ope- ration of such cause. This, however, is merely expressing the general fact, and offers no explanation of it whatever. Diagnosis.—The affection with which epilepsy is most liable to be confounded is hysteria, when this disease assumes the con- vulsive form. They may be distinguished from each other, however, by the following circumstances. In hysteric convul- sions, the countenance is less livid and distorted than in epi- lepsy ; and there is seldom any foaming at the mouth or pro- fuse discharge of saliva, nor does it terminate in heavy sleep, * Mr Mansford, in a work published on epilepsy a few years ago, gives it as his opinion, that the proximate cause of this disease consists in an accumulation of the electric matter in the brain, or what he considers the same thing, a superabundance of the nervous power in the sensorium commune. 62 EPILEPSY. or in a confused and torpid state of the mind, so general at the conclusion of the epileptic paroxysm. In hysteria too there are always some concomitant phenomena which indicate its character, such as the globus hystericus, involuntary laughing or weeping, and in many instances a continuation of some de- gree of consciousness, &c. Prognosis.—Although the immediate danger of the epileptic paroxysm is not in general very great, yet in relation to its sanability, the prognosis is always highly unfavourable. Even where a cure or suspension of the disease has been effected, the liability to a relapse is always considerable. When epilepsy depends on organic disorder within the head, no remediate ma- nagement can effect a cure. Epilepsy, however, unconnected with cerebral lesion, may sometimes be cured.* That variety of the disease which occurs in young females about the age of puberty, from menstrual irregularities, is not unfrequently curable, and indeed sometimes passes off spontaneously after the catamenia begin to flow regularly. The longer the disease has continued, or rather, the more frequently its attacks have been repeated, the greater will be the difficulty, in general, of effecting a cure; and when the mind has once become obviously affect- ed or impaired by its attacks, all hopes of a cure may be aban- doned. Experience too has shown that those epilepsies which commence soon after birth, or during early infancy, rarely, if ever, yield to remediate treatment. From the period of den- tition to that of puberty, is the most favourable age for the cure of this affection. Hippocrates observes, that those who are at- tacked with epilepsy after the twenty-fifth year of age, will continue to have it as long as they live—an observation which, though very generally correct, is not confirmed by the experi- ence of subsequent practitioners.f When the disease is the con- sequence of excessive venereal indulgence or masturbation, it * Dr. Dewees, in his work on the "Practice of Physic," has inadver- tently expressed contradictory sentiments in relation to the curableness of this disease. Under the head of treatment, he asks, " What plan of treatment has ever succeeded in curing epilepsy? Has epilepsy ever been cured?" Under the head of diagnosis, however, he says," When the disease is symptomatic, it is occasionally curable," again, " those attack- ed between the fourth and tenth year may be cured by proper treat- ment." Most assuredly this latter sentiment accords with the experi- ence of the ablest of the profession of all ages. However appalling and really intractable this disease may in general be, perfect cures are by no means so uncommon as the Doctor's interrogatories might lead one to suspect. I have known at least five distinctly marked cases cured under my own observation, two of which were of more than two years standing and one above six years. t He says, moreover, that when epilepsy commences before the four- teenth year, and is not connected with an hereditary predisposition to the disease, it frequently terminates spontaneously in after-life.—Aphor xv. s. 7.—Aphor. vii. s. 5.—Aphor. xlv. s. 2. EPILEPSY. 63 may sometimes be removed, provided the mental powers have not as yet suffered considerably from its repeated attacks or from the influence of its cause. The epileptic paroxysms, which sometime occur in the exanthematous diseases, are sel- dom followed by serious consequences, and very rarely recur afterwards. When the premonitory symptoms consist of some affections in the head, it may be regarded more unfavourable than if they manifest themselves in remote parts of the body, particularly in the extremities. Richter observes, that a long continuance of the sleep, and subsequent mental stupor and confusion after the subsidence of the paroxysm, is a very unfavourable sign. Epilepsy from moral causes, particularly from violent anger or grief, is said to be very rarely cured. (Jahn. Klinik d. Chronisch. Krankh. Bd. i. p. 267.) It is also asserted, that those cases which come on at night during sleep, are in gene- ral more intractable than such as occur during the day and are preceded by premonitory symptoms. (Richter.) It has been affirmed by men of great experience, that epilepsy occasional- ly ceases spontaneously on a change of climate.* Treatment.—There is perhaps no disease in which medical treatment is so frequently purely empirical as the one now un- der consideration. The causes are so multifarious, and gene- rally so obscure, or so wholly beyond our cognizance, that we are seldom enabled to prescribe with any degree of reliance upon general and rational therapeutic principles. In this state of perplexity and uncertainty, we have often no other alterna- tive left us, than to administer remedies, without being able to give any other reason for their use than that they have been occasionally successfully employed. True as this observation unquestionably is, we have nevertheless in some instances at least sufficient lights in the symptoms and causes to lead us to a consistent and rational plan of treatment. When called to a case of epilepsy, the first object of the practitioner should be to inquire into the nature of its exciting cause, its duration, the time and manner of the first attack, the general constitu- tional habit of the patient, his age, previous or concomitant diseases, his habitual temper and disposition of mind, his man- ner of living, his probable hereditary predisposition, in short, in- to every thing which can throw light on the particular charac- ter of the disease, and on the constitutional or acquired habits of the patient. Authors assert, that when the premonitory sensation, termed aura, commences in one of the lower extremities, the epileptic paroxysm may sometimes be effectually prevented when it is approaching, by compressing the limb firmly with a tourniquet * Lentin. in Hufeland's Journal. Bd. xiv. s. iii. p. 17. 64 EPILEPSY. or ligature above the part at which the aura may have reached. Dr. Cullen observes, "that a ligature upon the limb above the part from which the aura arises, should always in those cases be applied, both because the prevention of a fit breaks the habit of the disease, and because the frequent compression renders the nerves less fit to propagate the aura." Dr. Cook mentions an instance from the London Medical and Physical Journal, in which pressure made in this way prevented the paroxysm. Richter states, that when compression is thus made on a limb, above the ascending aura, the patient generally experiences great anxiety of feeling in the precordia, with extremely pain- ful twitches in the compressed limb, accompanied sometimes with a sensation as if a heavy stone were thrown upon it. Brechstedt and Michaelis assert that the application of the tourniquet upon a leg has been known to put a speedy stop to the epileptic paroxysm after it had actually supervened.* In persons of robust and plethoric habits, prompt and efficient bleeding on the occurrence of the premonitory symptoms has been known to keep off the epileptic attack. Active purga- tives have also been recommended with the view of obviating or palliating the impending paroxysm, where the premonitory stage is protracted; but their tendency in this respect deserves little or no attention. Richter and other of the earlier Ger- man writers speak favourably of the employment of emetics with this intention. They cannot, however, be used without considerable risk in cases attended with strong congestion in the vessels of the head. Richter states that they are only adapted to those cases which continue to recur from habit, after the original exciting cause has ceased to act. It even appears from the observations of this writer that a radical cure may be effected in this way. He states, that he cured a woman of this disease, by frequently suspending the paroxysms with the administration of emetics a short time before the ex- pected occurrence of the epileptic attack.f It must be observ- ed, however, that many highly respectable authorities might be adduced against the use of emetics, in this affection ; and as a general rule they are indeed to be regarded as of very doubtful propriety. Jahn, in his excellent work on chronic diseases, says that a draught of cold water will occasionally do more towards keeping off an impending attack of epilepsy than any other means ; and Dr. Busmann has published some cases tending to confirm this observation.^ Some fifteen years ago, while practising in Lancaster, I knew an old epileptic patient who could generally keep off the paroxysm for some * De Artuum Ligaturis ad Nonnullos Morbos Internos. Michaelis—in Medizin. Pract. Bibhothek. Bd. i. st. iii. p. 397—as quoted bv Richter t Specielle. Therapie. Bd. vii. p. 630. H y itlcnier- X Hufeland's Journal. Bd. x. st. ii. p. 133. EPILEPSY. 65 months by taking a large draught of cold water as soon as the premonitory symptoms came on. Without this precaution he seldom escaped having one or two fits a week. In the epileptic paroxysm, our principal object should be to diminish the preternatural congestion of the cerebral vessels. The immediate danger of an epileptic fit arises chiefly from this condition of the cephalic circulation ; for when death occurs during the paroxysm of this disease, it is almost invariably by apoplexy from vascular turgescence, or sanguineous extravasa- tion. When the patient is plethoric, and the signs of inordinate sanguineous congestion in the head are considerable, it will be prudent to abstract blood, and to remove every thing which may compress the veins of the neck, or impede the free return of blood from the brain to the heart. It is very doubtful, how- ever, whether any treatment, during the epileptic paroxysm, can materially mitigate its violence, or shorten its duration. It is almost exclusively with the view of protecting the brain, that remediate measures can be resorted to during the fit with a prospect of advantage. The most important part of the treatment of epilepsy, how- ever, is that which is proper during the intervals of the parox- ysms, for the purpose of effecting a permanent removal of the disease. I have already adverted to the importance of attending to the nature of the exciting cause in instituting a course of treat- ment for its radical cure. If our inquiries in this respect are successful, it will not be difficult to lay down an appropriate plan of treatment. Thus, if on a careful examination, it ap- pears that the bowels are in a loaded and irritated state, and particularly if the signs of intestinal irritation existed, in a very obvious manner, previous to the occurrence, it would be exceedingly unwise to neglect the state of the bowels, and to resort at once to some one of the numberless remedies usually recommended in the disease. Epilepsy from this cause is principally confined to infancy and childhood. It is in this variety of the disease that emetics have been most frequently found useful. When symptoms of gastric irritation—such as nausea, flatulency, disturbed sleep, and other manifestations of indigestion, are present in children affected with this dis- ease, a course of emetics has been used with decided success. (Richter.) In a child which had been affected with occasional epileptic paroxysms for upwards of eighteen months, I suc- ceeded in removing the disease entirely by a course of emetics, (ipecac.) administered e\evy third day.* Dr. Clark recom- * This case came on after an attack of ague, which was cured by Fowler's solution. VOL. II.—9 66 EPILEPSY. mends a solution of sulphate of zinc, in an aqueous infusion of ipecacuanha, to be given every six, eight, or ten days. Absorbents also have been recommended in the epilepsies of infants, attended with gastric disturbance; used in conjunc- tion with mild tonics, and an occasional aperient, they are sometimes beneficial, particularly where there is much acidity in the primal vise.* Richter observes, that we have reason to presume that the remote cause of the disease is seated in the stomach when vo- miting occurs at the close of the paroxysm. lie mentions also a peculiar tremulous motion of the tinder lip as a sign of the existence of gastric irritation, from vitiated secretions or other offensive matters. Van Svvieten relates a case of epilepsy, the (its of which were always preceded by a remarkable tremour of the under lip. 'I he case was treated by emetics and purga- tives, and thereby permanently removed.f If symptoms of in- testinal worms are present, anthelmenitic remedies are decid- edly indicated. Small and repeated doses of calomel, with an occasional dose of castor oil, with a small portion of spirits of turpentine, or infusion of spigelia. followed with a full dose of calomel and jalap, will sometimes answer in such cases. In verminous epilepsy, full doses of powdered valerian with the elutriated oxyd of tin, has been successfully used. From one to two drachms of the former, with thirty to forty grains of the latter, may be taken three times daily. Should it appear that the disease arose in the first instance from sudden suppression of the perspiration, a course of dia- phoretics, and whatever else may have a tendency to keep up a regular action of the cutaneous exhalents, should be resorted to. Frictions with dry flannel : the occasional use of the warm bath, rendered more stimulating by the addition of com- mon salt; fhmnel worn next the skin: active exercise when the weather is dry ; the internal use of diaphoretic remedies— such as the pulvis antimonialis,- camphor in union with tartar emetic; the tincture, of guaiacum ; and sulphur, are appropri- ate and occasionally beneficial remedies in such cases. When epilepsy arises from the repulsion of cutaneous erup- tions or the drying up of old ulcers, the manifest indication is to restore these affections ; or, if this cannot he done, to estab- lish others artificially in their stead. For this purpose we * The famous powder of margrave, which is still a good deal used by some of the German practitioners in infantile epilepsy, owes whatever powers it possesses to its absorbent, tonic, and aperient virtues It is composed of one ounce of powdered mistletoe, the same quantity of su- gar, and half an ounce of the c-Prbonate of magnesia. The dose is a tea- spoonful two or three times daily for a child under five years old — Bidder's Spec. 7 herap. Bd. vii. p. 645. | Comment. T. iii. p. 439. EPILEPSY. 67 may employ issues, sctons, blisters, and particularly frictions with tartar emetic ointment, together with diaphoretics, warm bathing, and stimulating frictions. Richter says, that in such cases, vomits are occasionally very useful; he also speaks fa- vourably of the use of musk and camphor in epilepsy arising from causes of this kind. Prichard recommends mercury, gi- ven to the extent of producing ptyalism, in this variety of the disease. One of his patients was perfectly cured by a copious salivation. In those cases which occur in young females in consequence of an unsuccessful or imperfect menstrual effort, the indica- tions are, to remove the preternatural determination to the head, and to establish or restore the natural determination to the uterine system, and thereby the regular performance of the menstrual function. This variety of the disease occurs chiefly in young females of sanguine temperament; and bleeding, therefore, can seldom be dispensed with. Indeed, in all cases of this kind I have met with, bleeding was decidedly indicated by the condition of the pulse, the occasionally flushed counte- nance, and sense of fulness in the head. Dr. Prichard, speak- ing of this variety of the disease, which he calls uterine, ob- serves—"The immediate effects of blood-letting are generally relief of the pain and oppression of the head, and a subsidence of the carotid and temporal pulsations. Sometimes the use of the lancet is speedily followed by a restoration of the catame- nia.*' He advises that the blood be taken while the patient is sitting up, and that it be suffered to flow until syncope begins to come on. In addition to bleeding in cases of this kind, the warm semicupium is a valuable remedy.* We may also em- ploy frictions about the loins, back, and pubic region, and sti- mulating enemata, with advantage. Prichard recommends glysters composed of spirits of turpentine and castor oil in such cases. An ounce of each should be occasionally thrown into the rectum. After the plethoric or phlogistic state of the system has been reduced by the foregeing measures, it will be proper to resort to emmenagogue remedies, if the menstrual evacuation has not already been restored. The following pill maybe employed for this purpose, f According to the experience of Dr. Prichard, the best emmenagogue we possess in the treat- ment of uterine epilepsy is the oil of turpentine. It should be given in doses of from half a drachm to two drachms once or twice daily. I used the turpentine in a case, about eighteen * The bath, says Prichard, should be about the temperature of 96° or 98° of Fahrenheit's scale.— Treatise on Diseases of the Nervous System. Lond.1822 t R. Extract, sabina; jii. G. aloes lace. 9i. Sulphat. ferri. gr. x. M. Fiant. pil. No. 40. Take one every six hours. 63 EPILEPSY. months ago, with complete success. Setons in the nape of the neck, or on the arms, or on the sacrum, have also been recom- mended. This variety of epilepsy is almost invariably sus- pended by pregnancy. Iu epilepsy from onanism, besides the proper moral influ- ences, Richter strongly recommends the use of camphor in re- gular and full doses. That this article possesses the power of lessening the venereal propensity 1 am fully persuaded, and its general influence, independent of this particular effect, ren- ders it a suitable remedy in cases of this kind. Patients af- fected with epilepsy from this cause, should sleep on a hard mattress, rise early, take exercise in the open air, and use a mild and unirricating diet. The tepid shower-bath, and la- borious occupations will sometimes assist materially in remov- ing the habit upon which the disease depends, and without the discontinuance of this habit, nothing useful can be expected from remediate treatment. Epilepsy from local injuries of the head has been cured by surgical operations. Boerhaave, Theiner, Stalpart, and Van der Weil, relate instances in which trepanning succeeded in re- moving the disease. Tissot also mentions several instances of this kind. Dr. Massie gives an account of a case of epilepsy which was produced by a blow on the head, and consequent de- pression of a portion of the cranial bones. After the disease had continued about four years, the patient was trepanned, and a spicula of the bone removed, after which the paroxysms re- turned no more.* Instances have also occurred in which epilepsy was cured by surgical operations on other parts of the body than the head. Portal relates a case, where the paroxysms always commenc- ed with violent pain in the index finger. This patient was cured by dividing the radial nerves.f The disease has some- times terminated spontaneously after the removal of spiculse of bones, balls, tumours, or other foreign bodies pressing upon particular nerves.J Dr. Dudly of Lexington succeeded in curing a case of epilepsy by removing a spicula of bone which had penetrated the substance of the brain to a considerable distance ; and Dr. Rogers of New-York succeeded in a case by a similar operation. Where we can ascertain the remote cause of the disease, wc should always found the plan of treatment on the general indi- cations which such a knowledge is capable of affording. In the majority of instances, however, we are wholly left in the * Philadelphia Med. and Phys. Jour. 1809. No. 35. t Cours d'Anatomie Mcdicale. T. iv. p. 247. 272. X Memoires sur la Nature et le Truitement de Plusieurs Maladies Par. Ant. Portal, vol. xi. p. 229. (Richter.) EPILEPSY. 69 dark with regard to this point, and very frequently indeed all our efforts to cure the disease under the guidance of what we may deem the most unequivocal curative indications are un- successful. In this case we are obliged, if we wish to pursue our endeavours to effect a cure, to resort to some one, or many, by turns, of that long list of remedies which, according to the reports of eminent practitioners or our own experience, have occasionally succeeded in lemoving the disease, without our be- ing able to give any other satisfactory reason why they are re- sorted to. The following are the most celebrated of these anti- epileptic remedies. Valerian.—This is one of the most ancient remedies employ- ed in this disease. Aretajus and Dioscorides recommend it as a valuable medicine in this affection ; and it is favourably men- tioned by many of the most celebrated of modern writers.* It should be given in as large doses as the stomach will bear. From a drachm to two drachms may be taken three times daily. This article is said to be most apt to do good in epilepsies from verminous irritation, suppressed catamenia, terror, and repell- ed cutaneous eruptions. Quarin used it with success in epilepsy of infants. (Richter.)f Biett generally employs the oil of va- lerian in this affection in doses of from 40 to 50 drops three times daily. (Casper. Character, d. Fanz. Med. p. 192.) The mistletoe also is a very old remedy in epilepsy; and if we are to place any reliance on the testimony of Boerhaave, DeHaen, Van Swieten, Hufeland, Stark, and Richter, we can- not doubt of having proved effectual in removing this aeffction. * Hoffman, De Haen, Burserius, Haller, Murray, Selle, Tissot, Tille- nius, Vogel, Hanneman, Horn, Quarin, and others recommend it as a va- luable remedy in epilepsy. On the other hand, Cullen, Home, Heber- den, and Woodville regard it of but little value in this disease. t The famous anti-epileptic powder of Ragolai contains a large propor- tion of valerian. According to Knopf's analysis this nostrum is compos- ed of one drachm of valerian, one scruple of orange leaves, two grains of muriate of ammonia, and a few drops of cajeput oil. Jahn thinks that it contains a portion of the powdered root of the convallaria mojalis; and some assert that it consists of a mixture of valerian, agaric, and an ethereal oil. This remedy, according to the testimony of Richter and others, has cured obstinate and even inveterate cases of epilepsy. Rich- ter succeeded in curing a case of four years standing by a powder com- posed of one drachm of valerian, with three drops of cajeput oil taken four times daily for six weeks. (Therap. Speciel. vol. vii. p. 672.) In this city the following composition has been used with complete success in some instances, and frequently with the effect of postponing the pa- roxysm for many months. R. Pulv. zingeberis. ---- fol. salvias. ---- sem sinapi aa §i. Dose. A tea-spoonful three times daily. I have myself employed this powder with advantage in a few cases, though never with complete success. 70 EPILEPSY. Cullen admits that in large doses it may perhaps be useful; but be thinks it probable, and with justice, that the reputation it once had arose in a great measure from its having been an object of superstition, and thus calling in the powerful aid of the imagination to whatever powers it may really possess of itself. Frazer, in a small work published on the powers of this article, asserts that he cured nine cases out of eleven with this medicine. He gave it in powder, in doses of from two scruples to two drachms, twice daily in a draught of camphorated emul- sion. (Cook.) We have moreover the testimony of Fothergill and Dr. Willan in favour of this article as a remedy in epilep- sy. Of late ye;irs, however, it has fallen into total neglect. I knew an empiric who succeeded in curing several old cases with this article. The animal oil of Dipple* also was formerly a good deal employed in the treatment of this disease; and we have the testimony of Hoffman, Cullen, Bang,f Kortrum, Quarin, Werlhof, Thouvetiel, Van Hoven, and others in its favour. It is given in doses of from 20 to 50 drops three times daily. It is said by Richter to be most useful in epilepsies originating from metastastic gout, rheumatism, and from repelled cutane- ous eruptions. The oil of turpentine has at present no inconsiderable re- putation as a remedy in this disease. I have already mention- ed its usefulness in epilepsy from menstrual disorder, on the au- thority of Dr. Prichard. It has also been successfully used in other varieties, particularly in cases depending on intestinal irritation from worms and other offensive matters. Dr. La- tham cured several cases of epilepsy with this remedy. Dr. Young has given an account of two cases which yielded under the use of this remedy;} and Dr. E. Percival relates three in- stances of its successful employ ment.§ Dr W. Money also tes- tifies to the usefulness of this article in epilepsy ; and Dr. Pri- chard assures us that of all other remedies which he has tried in this disease, he has found none so frequently useful as the oil of turpentine, (loc. cit.) Biett is said to employ this oil frequently for the cure of epilepsy in the Hospital St. Louis. 1 his article should be given in doses varying from a half to two drachms three times daily. Fresh milk is perhaps the best vehicle for administering it. Theroottfthepseonyv,™ anciently highly esteemed for its powers in this disease. It was a favourite remedy with Stark ; * Dippel. Disquisitio de Vitae Animalis Morbis p 89 t Acta Societ. Med. Hav. vol. i. p 500 ' I V?? k CSr°"f °f ?c CollTege of Physi^ans. Lond. vol. v. § Edinb. Med. and Surg. Jour, vol ix. p. 271. EPILEPSY. 71 and it is particularly recommended by llufcland, Jahn,* and Thorn. Hufeland says, it is especially useful in the epi- leptic affections of children. The powder is gi\en in doses of half a drachm three times daily, or an infusion of one ounce of the root to eight ounces of water, given in table-spoonful doses every two hours. Agaricus muscanus was first employed in this disease by Bcmhard. Wistling and Gruner afterwards published state- ments illustrative of its powers in this affection. (Richter.) It is said to be most useful in cases originating from repelled cutaneous eruptions. The dose is from a scruple to a drachm three times daily. Artemisia vulgaris, or mugwort, has been lately much com- mended for its virtues in this disease by several eminent Ger- man practitioners. About; eight years ago, Dr. Burdach, an eminent physician and writer, published an account of the suc- cessful treatment of several ca'-es of epilepsy by this root; and in a recent number of Hufeland's Journal, he has adduced fur- ther evidence of its usefulness in this disease. It is a remark- able circumstance, he says, that in nearly every case in which this article proved successful, an evident amendment of the disease took place from the, first dose. It appears further, from the experience of this physician, that in cases of epilepsy occuring in male subjects about the age of puberty, this reme- dy very seldom does any good. In young females about the same age, " its beneficial effects are often prompt and decisive. He occasionally found it very speedily successful in apparent- ly very obstinate cases, while in others, seemingly quite simi- lar, it was wholly inefficient. An interesting instance of the successful employment of this remedy, is related by Dr. Wag- ner, in Hufeland's Journal, (vol. for 1824.) and in the 12th Annual Report of the Berlin Polyclinic Institute, there is ano- ther case related which yielded under the use of the artemisia. It is usually given according to the following formula.f This is not a new remedy. Etmuller mentions its use in epilepsy ; and Zwinger, speaking of this plant says, mire in epilepsia valet. The internal ligneous part of the root is inert. The cortical portion alone is said to possess medicinal powers. The artemisia is indigenous to this country, particularly to Pennsylvania.^: ' Klinik d. Chron. Krankb. Bd. i p. 282. t R. Pulv. rad. artem. vulg. ^ss. Pulv. sacch. albi. >sji. M. Of this, about a tea-spoonful is to be taken four times daily; the dose being gradually increased. X Besides the foregoing remedies, a p;reat many others of a similar character have been recommended in this affection. Veratrum Album, (Stark, Schulze, Greeding.) The roots of the white lily, (Hufeland's 72 EPILEPSY. Of the narcotics, belladonna,* opium,f camphor,^ and stra- monium.§ have been most recommended in this affection, borne of the antispasmodics also have been employed with benefit in epilepsy. Among these, musk, castor, and assafcetida, are generally supposed to be the most useful. Very communally, however*, no advantage whatever is to be derived from reme- dies of this kind ; and they are often manifestly injurious, by their tendency of increasing preternatural determination to the head. Of late years, phosphorus has been strongly recommended by some as'a remedy in this affection. I gave it in one case about two years ago, and although it did not perform a cure, it suspended the paroxysm above three months beyond its usual period of recurrence. Four grains may be dissolved in half an ounce of sulphuric aether. Of this, from eight to ten drops should be given three times daily in some mucilaginous fluid.|| This article cannot, however, be employed with propriety, in cases attended with general plethora, or habitual congestions Jour. B. xxxi. p. 30;) Phelandrium aquaticum; faba St. Ignatii; the fresh juice of white onions, (Hufeland's Annalem;) Radix meu (Jahn,) the juice of unripe grapes, (L. Frank, Loebstein—Loebel;) sedum acre (Za- chorn, Hufeland's Jour. Bd.xl. p. 19;) folia aurantiorum, (Van Swieten, De Haen, Stoerk, Werlhof, Stark,Hufeland, Thilenius.) "The carbonate of potash in large doses, is recommended in recent cases. (Hufeland's Jour. Bd. viii. p. 170.) * Stoll, (Ratio Medend. vol. iii. p 406,) Hufeland, (Journal d. Prack. Heilk. Bd. ix.) Greeding, (VermischteShriften,) and Jahn, (Klink d. Chron. Krank. B. i. p. 282,) speak favourably of this narcotic as a reme- dy in epilepsy. Richter says, it should never be given to children—or in cases attended with habitual congestion of the cerebral vessels. t Tralles, (Ussu Opii Salubris et Noxius, &c. p. 16.) Fothergill, (Med. Observ. and Inquir. vol. vi. p. 80,) asserts that opium may be very bene- ficially used in cases attended with a weak, irritable, and nervous habit of body; and in cases that arise from violent pain or mental excitement. Dr. Huxy relates an instance of the successful employment of opium in epilepsy; and Dr. Darwin tells us that in two cases in which the fit al- ways occurred at night during sleep—a grain of opium given at bed time removed the disease completely. X Richter says, that camphor is sometimes particularly useful in cases that depend on onanism, or the repulsion of chronic cutaneous eruptions. (Loc. cit. B. vii. p. 682.) § This article is much praised as a remedy for epilepsy by some of the Swedish writers. Ohdelius speaks favourably of it; and Greeding cured a few cases with its use. Hufeland asserts, that he has used the tinct. sem. stramon. with decided benefit in this disease. ("Journal Bd ix. st. S. K ' || in Horn's Archives of Medicine (Bd. x. hft. ii. p. 270,) the follow- ing formula is given for the administration of this article. R. 01. tereb. §ss. 01. olivar 3iii. Phosphor, gr. ii.; put them into a half ounce phial, and digest it in warm water until the phosphorus is dissolved; then add mucilage of gum arabic ^iv. Syrup of cinnamon §ss. M. Dose, a desert-spoonful every 3 or 4 hours.—(Richter, 1 c.) EPILEPSY. 73 in the cephalic vessels. Where symptomatic epilepsy is con- nected with torpor of the vascular and nervous systems, or ge- neral debility and relaxation, advantage may be expected from it. Lohestein-Loebel, Van Hoven, and Horn, relate in- stances of its successful employment. The oxyde of zinc is generally regarded as one of our most efficient remedies in epilepsy; and from the testimony extant in relation to its powers, as well as from facts which have come under my own notice, I am inclined to regard it as a me- dicine of considerable value in this affection.* This article is generally given in much too small doses to do any good in epilepsy. It may be commenced with in doses of three grains thrice daily, and gradually increased to the amount of forty or fifty grains a day. Dr. Gutherie cured a case in which the paroxysms returned three or four times daily, with this article, given to the extent of eight grains on the first day, and gradually increased to forty grains in twenty-four hours. (Duncan's Annals of Med. v. iv. p. 473.) It is generally gi- ven by itself; hut it would seem that its powers may at times be enhanced by combining it with bitter and laxative reme- dies. Lentin (Hufeland's Jour. Bd. xiv. st. iii. p. 13,) cured an inveterate case with a powder composed of fifteen grains of magnesia, from two to eight grains of oxyde of zinc, two grains of the extract of quassia, and two drops of cajeput oil, twice daily. Stroubel (Hufeland's Jour. Bd. 52. st. i. p. 40,) used this metallic preparation, in union with mistletoe, with complete success, in a case attended with much nervous irrita- bility. The sulphate of zinc has also been occasionally used with success in this affection. It is favourably mentioned, in this respect, by Lettsom, Weikart, Cullen, Ideler, (Hufeland's Jour. Bd. iv. p. 114.) Cuprum ammoniacum. This was the favourite remedy in epilepsy with Cullen. I have given it in ten or twelve cases, one of which only derived any decided benefit from its use. This article is indeed a very old remedy in this affec- tion. Arasteus mentions it as a valuable antiepileptic. Rich- ter observes, that the cuprum ammoniacum is only calculated to do good in cases attended with a torpid, in irritable, and * This remedy has been used with success by Bell and Percival, (Edinb. Med. Comment, v. i. p. 229, and v. ii. p. 316;) Beireis, Home, (Clinical Experiments, p. 223;) Ranoe, (Acta. Societ. Med. Hafn. vol. i. p. 451, 457;) Metzcher, (Adversar. Med. p. ii. p. 98;) Osiander, (Denkwuir- digk. Bd. ii. p. 188;) Hirschel, Richter, (Med. Chir. Nebenst. pp.161, 190;) Shearman, (Lond. Med. and Pbys Repos. Sept. 1822;) P. Frank, (Prax. Med. Univ. Praec. P. II. torn. i. p. 409;) Dr. Hay garth, Dr. White, (Cook, on Nervous Diseases, p. 398;) Van Hoven, (Handbuch, Bd. ii. p. 131.) VOL. II.—10 74 EPILEPSY. phlegmatic constitution, and a healthy state of the digestive functions, and when it is continued from habit.* According to Stark, it is especially beneficial in cases depending on vermin- ous irritation, or on repelled herpetic eruptions. Haase, an eminent German writer, asserts that it is much better adapted to the cure of epilepsy in adults than in children ; and he agrees with Richter, in regarding inirritable and phlegmatic subjects as most apt to derive benefit from its use. The dose at first is from a quarter to half a grain, and gradually in- creased to one or one and a half grain three times daily, or un- til it creates considerable nausea and gastric disturbance. Dippel refers to a preparation of copper, consisting of a union of this metal with potash, ammonia, and oil of turpentine, which, he avers, has been used with the most decided benefit in epilepsy. (Richter, Specielle Therapie. Bd. vii. p. 701.) The mode of preparing this mixture is given by Durr (in Hufeland's Journal, Bd. xxviii. st. iv. p. 117.) Richter says, that when given in union with valerian, its effects are gene- rally more beneficial. The nitrate of silver possesses at present more reputation as a remedy in epilepsy than perhaps any other remediate arti- cle. It would be an easy matter to collect a very considera- ble number of instances of its successful employment in this disease.f From the various and highly respectable testimo- nies we have in relation to its powers, it is, without doubt, entitled to much attention as a remedy in this affection. In order to obtain its beneficial effects as an antiepilcptic, this preparation should be given in as large doses as the stomach * Numerous authorities may be quoted in favour of the antiepileptic powers of this preparation. The most celebrated are, Burserius, (Instit. Pract. vol. iii. p. 11. § 289;) Lobcstein-Loebel, (Wesen, u Heilung d. Epilepsie, p. 234;) Duncan, Harks, (Jour d. Auslaend Med. Liter. Bd. iv. st. 2;) Bland, (Medical Commentaries, vol vii. p. 300;) Greding, (Vermischte Schriften, Bd. i. p. 103;) Michaelis, (Med. Pr. Bibl. 1785. B i. st. 3;) Stark, (Handbuch Z. Erkennt. &c ;) J. Frank, (Praxeos Med. Univ. Praec. P. II. vol. i. p. 412,) Haase, (Chron. ICrankh.Bd. ii. s. 103;) Thilenius, (Med. u. Chir. Beinerk. Bd. i. p. 103;) Bally, (Dun- can. Medical Annals, vol. i. Lust. p. 377.) + It has been used with success, in well marked and often long stand- ing cases of epilepsy, by Sims, (Mem. of the Med. Societ. of Lond. vol. vi. p. 397;) Cappe, (Duncan's Annals, for 1798, p. 56;) Bostock Hull, Heberden, (Commentaries;) Sauchier, (Annal. de la Societ de' Med de Montpell. T. vii. pp. 369, 384;) Valentin, (Ibid, T viii p 182-) Heim, Nord (Med Nationalzeit. 1798;) Born,(Hufeland's Journal, Bel. xlv.st. i p. 9b;) Shaeffer (Ibid Bd. xlviii. p. 43;) Pitschaft, (Ibid, Bd. h. st. 3. p. ^4;) Lobestein-Loebel, (Wesen u. Heil. d. Epilepsie p 243') Portal, Fouquier, (Diet, des Sciences Med. T. xxxvii. p. 120 •) Harrison Baillie, Roget, Johnson, (Cook on Nervous Diseases, p. 394-) Barladi- ni, (Ornodei Annal. di. Medic 1826. p. 41;) Jahn, (Arzneinuttell, Bd. i. and Khmk d. Chron. Krankh. B. i. p. 283;) Kruiger, (Archiv f Med Erfahr. v. Horn, Maertz, April, 1823;) Toel, (Ibid, 1824, Nov and De pemb.;) Biett, (Casper. Charakt. d. Franzoesish. Med. p. 191.) EPILEPSY. T5 will bear. Dr. Powel observes, that the nitrate of silver may be taken into the stomach in much larger quantities without inconvenience in the form of pills than in solution. We may commence with one grain, and gradually increase the dose to three or four grains or more three times daily. Richter states, that this article seldom does any good unless the digestive or- gans are in a healthy and vigorous condition; and Dr. Harri- son considers it particularly adapted to those cases which are connected with a morbid irritability of the nervous system. I have given it in a number of cases—in one case only, however, did it prove permanently successful. Rruiger employed this article with success according to the following formula.1* The nitrate of silver will sometimes manifest no beneficial effects until its use has been continued for many months. Toel (Horn's Archives, 1824,) relates a case in which the parox- ysms recurred regularly every month at night during sleep, which yielded at last to this remedy after it had been regular- ly taken for more than a year and a half. It is a common practice to discontinue the use of this and other similar reme- dies, if no perceptible advantage is derived from it in the course of six or eight weeks. This, I am persuaded, is not unfre- quently the source of defeat in our attempts to subdue this complaint. I once succeeded in curing a case of seven years' continuance, by persisting with the same remedy for nine months. Tin.—This article has recently been strongly recommended in the cure of epilepsy. Dr. Shearman states, that in his hands the elutriated oxyd of tin has more frequently succeeded in curing this affection than any other remedy he has ever em- ployed. He gave it in doses of from two scruples to one drachm, night and morning, for about four days. At the end of that time he ordered a purgative, and again gave this pre- paration, or not, according to its effects on the system.f The filings of tin, given in large doses, have been used with success in epilepsy from verminous irritation by Richter, {Asklepeion, IS 11. st. 67. s. 1060,) and Monro, {A Treatise on Med. and Pharm. Chem. vol. i. p. 289.) From the acknowledged an- thelmintic properties of this article, it is manifestly peculiarly adapted to cases which depend on irritation from worms. Lead.—The acetate of lead has been employed with entire success in a few instances of this disease. About sixteen years * R. Nitrat. argenti. gr. vi. G. opii gr. x. Extract, gentian Ji. Extract, aloes ^i. M. Divide into two grain pills. Take one three times daily, in- creasing the number from time to time. t London Medical Repository. 76 FPILEPSY. ago, I succeeded in curing a case with this remedy vvhich had continued for upwards of seven years. The patient was a young man about 22 years old ; and the disease was excited, in the first instance, by violent terror. The paroxysms returned regularly at each period of full moon. I prescribed three grains of sugar of lead mornings and evenings, commencing three days before the time of full moon, and continuing two or three days after this period. He took the medicine in this manner for nine successive lunar periods ; but the disease did not return after the fifth period from the time the treatment was commenced.* Dr. Rush gave this remedy in two grain doses with complete success in a case of this disease;! and Drs. Spence and Agnew employed it, in some instances, with decid- ed benefit. Saxdorph also gave it with marked advantage.:): Quarin (Animadv. Pract.) and Portal condemn its use in epi- lepsy, as being inefficacious in small doses and dangerous in large ones. Besides the foregoing remedies, many others have been used With advantage. Dr. Johnson speaks favourably of the inter- nal use of cantharides ; Dr. Kirkhoff has used the prussiate of iron with success; and Underwood has derived advantage from the use of savin. Mercury, with a view to its salivant effects, was formerly much recommended. Burserius speaks highly of the powers of cinnabar in this affection. Mercurials, particularly mercu- rial frictions, were used with success by Bang, Willis, Ett- muiller, J. Frank, Tissot, Locher, and others. Richter states, that the sulphuric acid sometimes produced the happiest effects in epilepsy. Advantage, however, is to be expected from its use only in cases attended with a general nervous irritability, and erethism of the vascular system. In such cases, from two to four drachms of the acid should be ta- ken during the day. Zimmerman, Tissot, and Hildebrand, (Hufeland's Jour. Bd. ix. p. 54,) commend the antiepileptic powers of this acid. Various external remediate applications also have been re- commended, and occasionally used with advantage in this af- fection. Statements have been published which go to show that gal- vanism may occasionally be employed with benefit. It is said to be most efficacious in this disease when its influence is ap- plied some time before the accession of the expected paroxysm ; and (when the case is preceded by the aura,) if the positive current of the galvanic fluid is passed through the part where * New-York Medical Repository, vol. ii. No. 1.1815 t New-York Med. Repos. vol.ii. No. I. new series 1813 X Osann. Dissertatio de Saturn i Usu Medico, &c. 1809 EPILEPSY. 77 the aura commences.* According to the experience of Mans- ford, little or no advantage is gained from galvanism in epi- lepsy, unless it be applied steadily and constantly, and only with a weak power. He thinks that the negative point should be as near the brain as possible, and the positive one in some distant part of the body.f Electricity has also been recommended for the cure of epi- lepsy. Richter states, that this agent has been employed in several obstinate cases with great advantage. Both galvan- ism and electricity, however, may, and have done unequivocal harm, particularly when applied with much force. It is only in cases attended with a torpid and inirritable state of the ner- vous system, that these powers appear to be applicable with a prospect of benefit.:): Setons and issues were at one time much used in epilepsy. Hippocrates cured a case by an issue on the crown of the head, (De Morb. Sacro. § vii.;) and Tulpius relates a case cured in the same way. Mead used blisters on the back of the neck with success, (De Imperio Solis et Lunse. cap. xi.) Fabricius cured an obstinate case with a seton in the nape of the neck, (Observ. et Epistol. Franc, cent. i. ob. 41.) The actual cautery has also been successfully applied in this disease. Van Svvieten, Heister, Willis, De Haen, Larrey, and others, have related cases cured by this severe application. This remedy is mentioned by the ancients as a cure for epilepsy, particular- ly by Cselius Aurilianus. (Richter.) Larrey has published an account of some cases of epilepsy, in which local bleeding from the. vessels of the head, and the subsequent application of moxas, blisters, and other counter- irritants, proved completely effectual. (Revue Medicale.) Of late years a good deal has been said in favour of pustu- lation with tartar emetic ointment, as a remedy in this affec- tion. Mr. John Creighton has related six cases treated by frictions with this ointment along the course of the spine with very obvious benefit, though not with entire success in any one.§ More recently, Dr. Carter has given an account of five cases of epilepsy vvhich go to show the usefulness of this appli- cation. || Music has been employed to overcome this distressing mala- dy. Quarin states, by means of this delicious power he suc- * Walther. Uber d. Therapeutisch Indie, d. Galvanism. Richter, Spe- cielle.Therapie. Bd. vii. p. 716. f Galvanism is favourably mentioned as a remedy by Martens, (An- sweis. Zur Therapeut. Anwend. d. Galvanismus, p. 333 ;) Whitlam, (Med. and Phys. Jour. vol. xiv.) Burdach. X Electricity is particularly recommended in this disease by Albans, Stoll, Kuihn, Spengler, Wilhelm, and others. § Dublin Transactions, vol. iv. U Med. Chir. Rev. vol. ix. July, 1826. 78 EPILEPSY. ceeded in gradually weakening and finally subduing the epi- leptic paroxysms in one case. Whatevermode of treatment or remedies be employed, par- ticular attention should always be paid to proper regulations in relation to the diet, exercise, and the action of the bowels. CHAPTER VI. CATALEPSY. We find this very remarkable and rare disease described in the books under a variety of names—such as stupor vigilans, congelatio, extasis, catoche or calochus, lethargus, carus cata- lepsia, &c. Catalepsy consists in a temporary suspension of conscious- ness, sensorial power, and volition—the body remaining in the precise position in which it was when the attack came on, withoutcoma, muscular rigidity, or spasm; the respiration and circulation continuing. The attack generally comes on without any warning of its approach. In some instances, however, symptoms, premoni- tory of the cataleptic seizure occur, such as vertigo, cephalal- gia, flushed face, a certain inactivity of mind and body, pain in the prsecordium, a feeling of heaviness or tremor in the ex- tremities, forgetfulness, flatulent pains in the bowels, yawning, sensorial obtuseness, depressed spirits; and in some instances a sensation similar to the aura epileptica. When the attack occurs, every part of the body remains in precisely the same position in which it was at the moment of the seizure. If the paroxysm comes on while the person is in the act of doing any thing, as, for instance, drinking, the hand will be suddenly arrested with, perhaps, the glass near the lips and the mouth open. Even the expression of the coun- tenance continues fixed during the cataleptic state, as at the moment of the attack.* The eyes are generally open, fixed, and slightly turned up. Sometimes they arc spasmodically closed. One of the most remarkable circumstances of this af- fection is the wax-like flexibility (flexibilitas cerea) of all the members of the body, with sufficient tonic muscular action to cause an extremity, or the whole of the body, to remain in the exact position in which it is put by another person. Thus, if during the cataleptic state, the arm he raised up, or in any way extended or flexed, it will remain so until the paroxysm * Richter's Specielle Therap. Bd. viii. p. 471. CATALEPSY. 79 is over. To this, however, the eye-lids sometimes form an ex- ception. When they are closed, they will not remain open when separated with the fingers; and when open, they immediately separate again, if forcibly closed, as soon as the force is re- moved. Van Swieten mentions an instance of the former,* and Heberden one of the latter.f In complete catalepsy, all the sensorial functions are entirely suspended, and the patient on recovering, remembers nothing either of his own internal sensations, or of what is done about him during the paroxysm. The period occupied by the attack is a perfect blank in the pa- tient's existence; and if the paroxysm comes on while he is conversing, or in the performance of any other continuous act, he will resume the thread of the conversation, or even finish the half-pronounced word, or continue his acts, as soon as the pa- roxysm is over, as if no interruption had taken place. Al- though voluntary motion is almost universally suspended during the cataleptic attack, cases have occurred in which locomotion continued without, however, the least consciousness in the pa- tient of its performance. Dr. Stearns:]: relates a case in which if the paroxysm came on while the patient was walking, the same pace was unconsciously continued. Dr. Good also re- lates a similar instance in which the involuntary walking con- tinued during the attack.§ Fernelius states, that he saw a cataleptic patient, who, when pushed forwards, walked with a regular and firm step. || In cases less perfect, some degree of sensorial power re- mains, and the patient retains an indistinct recollection of what occurred during the paroxysm, on emerging out of it. But even in cases of this kind, all power of voluntary motion, or of manifesting, in any manner, a consciousness of their si- tuation, or a desire for any thing, is wholly suspended. A case is mentioned by Galen^y in which the patient, one of his fellow- students, lay motionless like a log, w ith his eyes open ; but he heard and remembered what occurred during the paroxysm. A remarkable case is related by M. M. Lenormand, seen also by Laennec and Recamier, in which there was complete immo- bility, rigidity of the whole body, pulse weak, expression of the countenance natural, and abolition of all the,senses, except that of hearing; the patient (a young female) heard every thing that was said in her presence, but totally unable to make the least sign or utter the weakest sound. In the course of the third week, her hearing also failed, and her limbs became flexible, and readily assumed any position in which her attendants plac- ed them. During the intervals of the attacks, she suffered * Comment, vol. x. p. 183. t Comment, on the History and Cure of Diseases, p. 291. j American Medical Register, vol. i. art. viii. § Study of Medicine, vol. iii. p. 387. |{ Patholog. lib. v. cap. xi. p. 70. IT Liber i. Prorrhetic. p. 756. so CATALEPSY. much anxiety and pain in the pit of the stomach.* It is even stated that instances have occurred of catalepsy ononesideonly.f In some cases the respiration and pulse become so feeble as to be imperceptible, and the whole surface is cold and contract- ed, as in death. The flexibility of the limbs, however, remains throughout—a circumstance which is never observed in dead subjects.:}: The duration of the cataleptic attack varies from a few mi- nutes to several days. A deep inspiration generally announces the return of consciousness, sensation, and voluntary motion. In many cases the paroxysm passes off suddenly, the patient recovering in an instant all his mental and physical powers. I saw a case lately with my friend Dr. Stadiger, which regularly recurred three or four times daily, and in which the paroxysms never continued longer than between one and two minutes, and always came on and passed off suddenly. In other instances, particularly in those of protracted duration, the attack goes off gradually, the power of feeling and motion generally returning first in the fingers, then in the arms, and finally in the whole of the body. In transient cases, the pa- tient experiences no unpleasant feelings, or sensible diminution cither of the mental or corporeal powers, after the paroxysm; in others, a feeling of weight and fulness in the head, with slight cephalalgia, lassitude, and some degree of sensorial ob- tuseness remain for some time after the attack has passed off. The cataleptic attacks in some instances recur with more or less frequency for months or even years ; but it has very rarely been found to assume a strictly periodical character. Sometimes several attacks may occur in the course of one hour.§ F. Hoff- man mentions the case of a woman in vvhich upwards of one hundred paroxysms occurred during the period of forty days.|| Occasionally individuals will suffer a cataleptic attack, without ever afterwards becoming affected with it again. TYiftet.—Iliad, lib. viii. v. 299. At Argos there was anciently an annual festival, called Cyrocephantes, during which, all the dogs that were running at large Were killed.__Gor- rey, Sur la Rage. Jour, de Mtdecine, T. xiii. p. 93. X De Morb. Acut. p. 206, edit. 1722, as quoted by Van Sweiten. HYDROPHOBIA. 135 ease may be communicated by bringing the contagious virus in contact with an excoriated or wounded surface in any manner. This has indeed been verified by direct experiment. Magendie and Brechet inoculated two dogs with the saliva of a rabid man, One of these dogs became rabid, and bit two others, which also became mad. Instances have moreover been recorded of the pro- pagation of hydrophobia by the accidental contact of the morbid saliva with wounds, or excoriations on the lips, hands, or other exposed parts of the body.* In the dog, fox, and wolf, and in the domestic cat, and per- haps in some other animals, hydrophobia is sometimes deve- loped by causes of a general character, independent of a conta- gious principle. By what particular influences the disease may be generated without the agency of a contagion, is however as yet, in a great degree, a matter of conjecture. It has been sup- posed that intense cold and high atmospheric temperature have a particular tendency to promote the development of this affec- tion. Experience does not sustain this opinion sufficiently to entitle it to especial credit. It is indeed true, that in our own climate, canine rabies is, in general, of much more frequent occurrence during the hot months of summer, than in any other season of the year; yet in some extremely warm and cold coun- tries, this disease is said to be entirely unknown, or at most, exceedingly uncommon. In South America, Egypt, f Syria, the West Indies, Sweden, and Kamtschatka,^: hydrophobia, we are told, has been rarely if ever known to occur. Its spontaneous occurrence has also been thought to be particularly favoured by certain occult atmo- spheric constitutions ; and this,opinion is countenanced by the fact that the disease has been known to occur at certain times and places in an epidemic manner.§ Besides these presumed occasional or predisposing causes of hydrophobia, it has been alleged that putrid food; the protracted want of food and drink; unsatisfied venereal passion ;|| and violent rage, are capable of originating this affection. Dr. Mease states that a number of dogs fed upon the carcases of horses that were left unburied near this city, and that many of them soon afterwards became affected with rabies. Rougemont relates similar examples of the apparent generation of this affection by putrid animal food. On the other hand, however, it has been observed, that the *Callisen in Colect. Societ. Med. Havn. vol. i. ob. 32. Gruner's Almanach fuir Aerzte. 1786. p. 184. Salzb. Med. Chir. Zeitung, 1795, b. iii. p. 80. f Le Cointre, Jour, de Med. torn. vi. p. 365, as quoted by Richter. X Langsdorf's Reisen. B. ii. p. 443. § Fehr, Etwas Uiber d. Hundswuth. Mease on Hydrophobia. || Hildenbrand, Eein Wink zur Naehern Kenntniss u. Heilung d. Hundswuth, p. 4. 136 HYDROPHOBIA. dogs that crowd the streets of Constantinople feed almost ex- clusively on putrid animal substances, and yet hydrophobia is said to be almost wholly unknown at that place. "Tutridity," says Dr. Good, "is perhaps the ordinary state in which dogs and cats obtain the offal, on which for the most part they feed: they show no disgust to it, and it offers a cause far too general for the purpose." With regard to the want of food and drink, as a cause of hydrophobia, Richter states, that in hot climates dogs have been known to perish for want of water, without having been seized with rabies. Direct experiments, too, have been made by confining dogs, both during very warm and cold seasons, and allowing them nothing but water without food, or salted and putrid meats, but no drink, without any of them becoming affected with this disease.* It is nevertheless probable that these causes, though not of themselves capable of producing this disease, co-operate often with other influences in exciting its development. With re- gard to the tendency of violent rage to impart properties to the saliva of certain animals, capable of producing affections very similar, or as some assert, identical with hydrophobia, many confirmatory observations are extant. Lister mentions an in- stance of fatal hydrophobia produced by the bite of an enraged dog;f and similar cases are related by Dr. Parkinson, and Linguet4 The bite of an enraged cat, also, has been known to give rise to fatal rabies in the human species. Rossi gives an account of three cases of this kind.§ Weikard states that a woman, in separating two fighting fowls, was bit by one of them, from which she became affected with fatal hydrophobia;! and Le Cat mentions a similar event from the bite of an en- raged duck.^j The instances in which affections simulating hydrophobia have arisen from the bite of infuriated men are by no means very rare. Van Swieten mentions a case of this kind,** and other examples are related by Weikard, Meekreen, Wolff, and Zacutus Lusitanus, as cases of genuine rabies. It is not improbable, however, that many of the reputed cases of hydrophobia said to have arisen from injuries of this kind, were in reality peculiar forms of tetanic affections; for the dread of water, which has been generally regarded as pathognomonic of rabies, has been frequently known to occur in cases unequi- vocally tetanic. The contagion of rabies belongs to the palpable of fixed mor- bid animal passions, and does not admit of being diffused in the * Ribbe. Natur u. Medic Geschicte der Hundswuth Krankheit. t Tract, de Quibusd. Morb. Chronc. p. 43. t Jour. Politique, No. 1775, quoted by Richter. §Turiner Med. Abhand. 1802. ||Philosoph. Arzt. s. iv. p. 186, quoted by Richter. IT Recueil Periodique, ii. p. 90. ** Commentaries, § 1130. HYDROPHOBIA. 137 atmosphere—at least not in such a state as to retain its power of infecting. It would seem, however, to retain the power of affecting the system a very long time after it is generated. Cases are related in which the saliva of hydrophobic patients adhering to clothes, has given rise to the disease in persons who afterwards were employed to clean or mend them. Richter mentions the case of a woman who became affected with rabies in consequence of having mended a garment that was torn by the bite of a rabid dog.* The period which intervenes between the insertion of the contagion of rabies and the commencement of the disease is ex- ceedingly various. It very rarely appears before the end of the third week, and in some instances the contagion remains dormant for six, nine, or even twelve months before its effects are manifested. From forty to sixty days may be regarded as by far the most common latent period of this contagion. Dr. Dickson states, that of seventeen persons who were bitten by the same dog, ten became affected with the disease at different periods from the fifteenth to the sixty-eighth day after the inflic- tion of the bites.f Instances indeed have been noticed, in which the disease came on as early as twenty-four hours after the bite of a rabid dog; and Boudot mentions a case which su- pervened during the first night.^i It is exceedingly doubtful, however, whether these cases were truly hydrophobic. The alarm occasioned by the bite of a rabid dog, may of itself be sufficient to cause spasmodic and nervous symptoms, similating this disease, in persons of nervous temperaments. Authors moreover mention cases which did not supervene until several years after receiving the hydrophobic contagion ; but the in- stances which are related as having occurred eighteen, twenty, and evenforty§ years after the insertion of the virus, require an ef- fort of faith which few, I presume, are willing to exercise. There however is a very remarkable and well authenticated case re- lated, of a woman who had been bitten by a mad dog, and in whom the wounded part inflamed and broke open every spring for eighteen years in succession. In the spring of the nineteenth year, the part became red and painful, without opening, and the immediate consequence was furious mania, with an in- surmountable horror of water. By the application of blisters to the affected part, blood-letting, and mercurial purgatives, she was cured. || Without doubt, however, the occurrence of this affection after the infliction of a bite from a rabid animal, may he promoted * Specielle Therapie. Bd. viii. p. 378. t Med. Observ. and Inquiries, vol. iii. art. 34. {Essais Antihydrophobique, 1771, p. 121—Richter. § Rougemont, loc. cit. p. 123. || Ricbter's Chirurg. Biblioth. b. v. p. 686. VOL. II.—18 138 HYDROPHOBIA. by the alarm and mental anxiety which an accident of this kind always excites to a greater or less degree. It would appear also that violent anger, or vehement mental emotions of every kind, and from whatever cause they may arise, have no incon- siderable tendency to hasten the occurrence of this affection after its contagion has been introduced into the system. Obser- vation would seem to show, too, that high atmospheric tempera- ture has a similar tendency of promoting the activity of this con- tagion. It is said ,thatthe disease almost invariably comes on much earlier in hot climates than in the temperate latitudes. Richter mentions the free use of spirituous drinks and inordi- nate venereal indulgences as causes capable of hastening the supervention of the disease. Several very striking examples illustrative of the influence of the latter cause, in this way, are mentioned by Rougemont. It is a fortunate circumstance that the bite of a rabid animal is by no means generally follow- ed by hydrophobia. The predisposition to the morbific in- fluence of this contagion does not appear to be very strong in the human species; and in many instances an entire insuscepti- bility seems to exist to its operation. It is from this cause, in part at least, that we sometimes find only one or two out of a number of individuals bitten by the same dog, become rabid. Without doubt, too, the circumstances attending the infliction of the bite, often have a particular agency in hastening, retarding, or preventing the occurrence of the disease. When the animal bites through clothes, more especially woollens, the virus is probably often so completely wiped from the teeth before they penetrate the skin, as to prevent infection. It has already been observed, that in the human subject hy- drophobia, or genuine rabies, appears to have but one origin; namely, the application of the hydrophobic contagion to a raw or excoriated surface. It has, nevertheless, been asserted, that unequivocal rabies has occurred in the human species without the agency of a specific virus; and Richter, as well as many other respectable authorities, are inclined to admit the possi- bility of such an occurrence. Mangor gives an account of an instance, where a melancholic man became affected with hydro- phobia wholly unconnected with contagion, of which he died on the sixth day. His wife, who during the course of the disease frequently kissed him, also became affected with the disease, and died of it on the fifth day. Symptomatic affections closely similating hydrophobia are not very uncommon. A dread of water—exciting spasms and feelings of indescribable horror when attempts are made to drink, has been frequently noticed as an accidental occurrence in various diseases. Inflammation of the brain, uterus, and particu- * Act. Reg. Soc. Med. Hav. vol. ii. p. 408. Richter. HYDROPHOBIA. 139 larly of the heart, and of the cardiac extremity of the stomach, are most apt to become complicated with hydrophobic symp- toms. Nervous affections, more especially hysteria and hypo- chondriasis, may also assume the phenomena of rabies; and instances are mentioned, in which mania and epileptic pa- roxysms have terminated in symptoms of hydrophobia.* The narcotic poisons—particularly stramonium, belladonna, and aconitum, have been known to produce spurious hydrophobia;! and it has been the consequence of suppressed menstruation by violent mental emotions. (Richter.) Malignant and other violent forms of fever are sometimes attended in the advanced period of their course with many of the characteristic symptoms of rabies. Schmucker relates a case of dropsy in which the " water-dread," was for a time as strongly manifested as it usually is in genuine hydrophobia; and Frank saw an instance of its occurrence in diabetes.:): In the last stage of pulmonary consumption, in hepatic obstructions, in jaundice, and in other chronic visceral affections, hydrophobic symptoms have been known to occur; and the occurrence of phenomena of this kind in tetanus is far from being uncommon. Symptoms.—In nearly all instances of this affection, certain local and general premonitory symptoms occur for a longer or shorter period previous to the appearance of the characteristic phenomena of the disease. If the wound, by which the conta- gion was communicated be not yet fully closed, it assumes a more or less livid appearance, with raised and inflamed edges, and begins to discharge a thin ichorous matter a few days before the accession of the proper hydrophobic symptoms. Where cicatrization has been fully completed before the disease begins to develope itself, the cicatrix generally becomes slight- ly elevated, painful, inflamed, and finally, often opens, forming an ill-looking ulcer with elevated borders, from which a thin, acrid, and offensive matter is discharged. The pain in the affected part is often very severe; and sometimes gradually extends itself throughout the whole limb. It is said, that the pain in passing inwards from the part that was bitten always proceeds along the course of the nerves towards their origin. Sometimes, however, little or no inflammation and pain in the injured partis noticed before the accession of the disease, with the exception usually of an occasional transient stinging sen- sation in the cicatrix. In some instances the patient experien- ces a peculiar torpor and numbness of the injured extremity. The general premonitory symptoms consist usually in lassi- tude, muscular prostration, indisposition to corporeal and * Richter Specielle Therapie. B. viii. p. 197. t Harles. Ueb. d. Behandl. d. Hundswuth, p. 72. % Epitom. &c. lib. v. p. 1. p. 64. 140 HYDROPHOBIA. mental exertion, flushes of heat alternating with transient sensations of chilliness, nausea, sometimes bilious vomiting, thirst, constipation, want of appetite, anxious respiration, and in general all the symptoms which usually precede the deve- lopment of febrile diseases.* In some cases a constrictive sense of pain is felt in the extremities, passing generally from the wounded part, and finally fixing itself in the head. (Richter.) The sleep is commonly disturbed by alarming dreams, and attended with slight spasms of particular muscles, and twitch- ing of the tendons. The temper is almost invariably promi- nently affected shortly before the invasion of the disease. The patient is unusually reserved, suspicious, taciturn, and torment- ed with gloomy forbodings; sometimes, though indeed seldom, he is animated and talkative. There is commonly an extreme degree of sensibility and repugnance to the impressions of cool air. In men, the desire for venery is often almost irresistible a short time before the disease comes on, and Hamilton states that the scrotum is usually very strongly, and as it were, spas- modically contracted. These precursory symptoms sometimes continue for seven or eight days before the actual occurrence of the disease; but their ordinary duration varies from two to four or five days. Occasionally indeed, no premonitory symptoms whatever, are noticed before the accession of the disease. The only symptom which is never wholly absent in this dis- ease, as it affects the human species, is the extraordinary dread or horror of liquids—more especially of water. Patients la- bouring under rabies, may indeed sometimes experience a tem- porary abatement or even absence of this torturing symptom, but in all instances it occurs in a greater or less degree, and general- ly remains throughout the whole course of the malady. In gene- ral, the mere sight of liquids, or the sound of pouring water from one vessel into another, brings on violent suffocative spasms; and the attempt to swallow water, or to bring it to the lips, commonly excites a degree of horror and agitation truly frightful. Even the sight of polished surfaces, as of a mirror, or the rustling sound of bed curtains, of currents of air, or of run- ning water, will, in the more violent grades of the disease, imme- diately renew the spasms and feeling of horror. Occasionally, however, this extraordinary horror is manifested only against water; for patients have been known to take small portions of other fluids, as of soups, milk, and wine in a lukewarm state. The thirst is always extremely urgent, and although the suf- fering from this source is generally very great, the patient dares not attempt to swallow any liquids. The secretion of saliva is profuse, and from an inability to swallow it, the pa- * Richter, loc. cit. p. 129. HYDROPHOBIA. 141 tient continually spits it out in every direction, " often desiring those around him to stand aside, as conscious that he might thereby injure them." During the whole course of the disease occasional remissions occur. Whilst these continue, the patient often appears calm, talks deliberately about his feelings or his affairs, and cautions those who are about him not to approach him too closely when under the paroxysm of madness, lest he should injure them. Notwithstanding this partial calm, there is always a peculiar wildness and appearance of alarm in the expression of the countenance; the motions are quick and hur- ried ; the eyes cast about with an air of suspicion; and if the patient attempts to lie down and obtain some rest, he usually soon starts up again with great agitation and anguish of feel- ing. During the exacerbations, the expression of the counte- nance is wild, furious, agitated, and agonized ; the eyes are blood-shot, sparkling, projecting, and expressive of rage and terror; the muscles of the face, throat, and chest, and sometimes of the extremities, are thrown into spasms; respiration is inter- rupted or convulsive; the arms are thrown about; the fists clenched; the teeth violently gnashed; the mouth foaming; with an unconquerable disposition to bite every thing that comes with- in the patient's reach. In violent paroxysms, furious and mania- cal raving occurs, attended often with an entire absence of con- sciousness. These paroxysms usually last from about fifteen to thirty minutes. Many patients, however, do not become furious or maniacal during the spasmodic exacerbations, and retain almost the full command of their mental powers from the commencement to the fatal close of the malady. In some instances a tormenting degree of salacity is experienced during the intermissions, attended with continued painful erections and occasional involuntary discharges of semen. Patients af- fected with rabies, generally walk about through the room, or remain sitting up as long as their strength admits of this effort, for the horizontal posture is almost always borne with much difficulty. Hydrophobia is very rarely attended by distinct febrile symptoms, except sometimes towards the conclusion of the dis- ease. At first the pulse generally does not materially differ from its natural condition; but in the latter periods of the com- plaint it always becomes small, irregular, weak, and very fre- quent. The eyes are in general very sensible to light; and the countenance is pale during the remissions, but turgid and flushed during the paroxysms. Some patients are from time to time affected with vomiting, attended with a burning heat in the pit of the stomach. The morbid sensibility to the im- pressions of low temperature which occurs generally among the premonitory symptoms, often rises to an extreme degree during the course of the disease. Towards the termination of the 142 HYDROPHOBIA. malady the tongue becomes rough, harsh, chopped, and often aphthous. The surface of the body is usually constricted and dry, the bowels constipated, and the blood drawn from a vein often dissolved and very fluid. (Richter.) The duration of hy- drophobia is fortunately not long. Most patients die as early as the second or third day of the disease. It is rarely pro- tracted beyond the fifth or sixth day ; although instances have occurred, which did not terminate under fourteen or fifteen days. Post-mortem appearances.—The morbid phenomena, detected by dissection, in those who die of hydrophobia, are extremely various in different cases, and throw but very little or no light on the true nature of this affection. It is said that the process of decomposition often commences very early after death, and proceeds with great rapidity.* The surface of the body is usually of livid redness, and the muscles, and particularly the tendons, are unusually rigid. Strong vascular congestion of the meninges and brain, with serous, or sero-sanguineous effu- sion between the membranes and into the ventricles, are among the most common phenomena. In some instances the brain has been found unusually firm and dry, (Morgagni;) in others ex- tremely soft. The mucous membrane of the mouth and fauces, and particularly about the glottis, is usually inflamed and sometimes considerably tumefied or cedematous. In some in- stances, however, these parts did not exhibit any material de- viations from their natural condition, (Morgagni, Vaughan ;) in others, instead of inflammation, the mucous membrane of the mouth and fauces were of a rose-red colour, with a varicose dilatation of some of its blood-vessels.f The cervical ganglia have been found inflamed. The lungs are often greatly engorged with blood, and its mucous membrane irritated or inflamed. In some cases the mucous tissue of the stomach and bowels exhibits evident marks of previous inflammation; and the same phenomena are occasionally met with in one or more of the abdominal viscera. Metzler, Benedict, Gherardini, and Auten- reith have found the nerves leading from the wounded part mani- festly inflamed to a considerable extent of their course. It must be observed, however, that many instances have been reported in which scarcely any morbid appearances whatever were de- tected on post-mortem examination. With regard to the proximate cause or pathology of hydro- phobia, there is but very little, or nothing known of a satisfac- tory character. The very numerous opinions that have been expressed upon this subject, resolve themselves into; 1, those •Sauvages—De la Rage. Morgagni—DeSedeb. et Caus. Morbor. lib. ii. art. xix. t Krukenberg, as quoted by Richter. HYDROPHOBIA. 143 which regard the sanguiferous system as the primary location of the disease, viewing it as essentially an inflammatory affec- tion ; and 2, those which place the essential irritation exclu- sively in the nervous system. The general sentiment, at pre- sent, is in favour of the latter doctrine; but there exists nothing beyond plausible conjecture and hypothesis with regard to the particular character of the nervous affection, or the portion of the nervous system chiefly implicated. Without entering into any discussions on this obscure subject, it may be observed, that although the essential phenomena of the disease point unequivocally to a morbid condition of the brain and nerves, we have equally conclusive evidence that the arterial system is in a state of morbid excitement; for without diseased vascular action, there could be no hydrophobic virus secreted. The opinion, however, that it is an inflammatory affection, is cer- tainly not sustained by the symptoms of the disease. That local inflammation should sometimes occur during the progress of the malady, is indeed to be expected; but even this occur- rence does not appear to be so common as has been asserted ; for many of the reputed examples of local inflammation, were probably, merely instances of strong vascular injection or en- gorgement, with its occasional consequent serous effusion, produced either during the course of the disease, or in articulo mortis. Rabies is, I presume, essentially a cerebral affection. The peculiar dread of liquids, the paroxysms of fury, or men- tal agitation, spasms, and general feelings of anguish and alarm, without any manifest febrile symptoms, all indicate that the disease is essentially connected with, or dependent on a morbid excitement or condition of the brain, independently, it would seem, of diseased vascular action or phlogosis. Treatment.—After all that has been said and done in rela- tion to the nature and remediate treatment of rabies, there is, perhaps, no other affection which is so decidedly beyond the control of all the resources of our art as this appalling malady. That it is essentially an incurable disease, cannot indeed be affirmed; for, however unsuccessful the efforts of physicians may hitherto have been, there is certainly nothing in its characteristic phenomena, which should lead us to assert that it is necessarily fatal, or to abandon the hope that some mode of management or remedy may yet be discovered, capable of arresting its progress. Indeed, unless we discredit the autho- rity or judgment of several physicians of good repute, we must admit, that (instances of genuine hydrophobia have been suc- cessfully subdued by remediate treatment. Unfortunately, however, such favourable results have been so exceedingly rare, that they can scarcely sanction any expectations of advan- tage from remediate applications, after the disease has made its appearance. 144 HYDROPHOBIA. Our reliance must, therefore, be entirely placed in the prompt and energetic employment of prophylactic measures ; and for this purpose, local applications to the wound, with the view of preventing the absorption of the hydrophobic virus, are decid- edly the most efficient remedies. As soon as possible after the infliction of the bite, the wound and surrounding surface should he carefully washed with warm, or as Hunter recommends, cold water; and immediate efforts made to prevent the further passage of the virus into the system. If the bite be of a character, and in a part which admits of its entire excision, this, if speedily done, affords undoubtedly the most certain protection against the occur- rence of the disease. If the bite be on the hand, particularly when the teeth of the animal have penetrated deeply between the bones, it will be best to amputate; and this is especially proper if only the fin- gers are wounded. Some have preferred destroying the wound- ed part with the actual cautery, and there can be no doubt of the efficiency of this measure, if employed soon after the bite has been received. The free application of caustic potash may also be resorted to with success where the wound is super- ficial ; but where it has penetrated deeply, it cannot supply the place of excision, or the actual cautery. In slight wounds the application of cupping-glasses, as is recommended by Dr. Barry for the purpose of arresting the effects of poisoned wounds, would, perhaps, in most cases, be sufficient to prevent the oc- currence of rabies. Dr. Good, "strenuously recommends the immediate application of a tight ligature to the affected part a short distance above the wound, if its situation will admit of it." Besides these local measures, which alone deserve our confi- dence, a vast variety of internal remedies have been recommend- ed with the view of counteracting the hydrophobic virus. Of all other diseases, indeed, rabies has afforded the widest scope for empiricism and charlatanry. Innumerable remedies have, at different times, been lauded as infallible preventives of this affection ; but sad experience has hitherto nullified all these pre- tended specifics. The most celebrated of these remedies is belladonna. This article was first used by May erne. Mianch asserts, that in 176 instances the occurrence of the disease was prevented by this medicine ;* and we have the authority of Stark, Jahn, Buch- holz,f Sauter,^: and Hufeland,§ in favour of its prophylactic * Dissert, de Belladonna Efficaci in Rabie Canina Remedio. t Hufeland's Journal. Bd.v. p. 378. X Ibid. Bd. vi. p. 679. § Ibid. Bd. xvi. p. 113. HYDROPHOBIA. 145 powers against this affection. Anagalis arvensis. This is one of the oldest remedies for the prevention of rabies. Both Galen and Aetius recommend it for this purpose. It formed the basis of several celebrated nostrums, formerly vended in this country ; and its powers have been particularly extolled by Ravenstein, Cartheuser,* Chabert, Ribbe, Stoeller, and other writers on this disease. Lichen cinereus constituted the principal ingredient in the pulvis antifyssus of Dampiere.f— The celebrated Mead asserts, that in more than one hundred instances, he prevented the disease by this remedy. The water plantain {alisma planlago) has, of late years, attracted much attention as a prophylactic remedy in this af- fection. It was first employed in Russia; and many respecta- ble names might be cited in favour of its powers in this respect. The powdered root or bulb is given in doses of from a scruple to a drachm once daily. The root, it is said, should be collected about the latter end of August. The Scutellaria lateriflora is fresh in the recollection of every one as a highly boasted pre- ventive of this malady. Like other articles of this kind, it has had its day; and there are probably now very few, if any, phy- sicians who would place the least reliance on its powers—as it certainly does not appear to deserve any confidence whatever.!; Boerhaave, Erpenbeck, Moneta, and others, speak highly in fa- vour of the internal and external use of vinegar as a preventive in this affection. A table-spoonful of strong vinegar is to be given three or four times daily for several weeks. Much has also been said in praise of the internal use of cantharides as a pro- tection against rabies. This remedy is mentioned by Rhazes : and among the moderns, Werlhof,§ Buchholz, and particularly Rust,|| have spoken decidedly in its favour. Axter, a German surgeon of deserved celebrity, states, that he never knew the * Fundameuta Materia Medica. t Two drachms of this substance, with half an ounce of black pepper, was given every morning, for four days in succession, in a cup of warm milk; and the patient directed to use the warm bath daily for a month afterwards. t Besides the vegetable substances mentioned in the text, the follow- ing have been employed, and especially recommended, for the preven- tion of rabies. Rad. cynosbati, (Van Swieten;) Celtis australis; Phyto- lacca decandra, (Harles;) celtis ambralis,{Bufelnnd's Journal, Bd. xxxii.;) valerian, (Bouteille;) nux vomica, (Thebesius, Leidenfrost ;)/aia St. Ig- natii; datura stramonium, (Mease, Cooper, Harles, Brera, Hanemann;) tobacco, (Barton's Med. and Phys. Jour. vol. ii. p. 122;) lycopodium cla- vatum, (Hildebrand;) camphor, (Schmucker;) gentiana pneumonanthe; hypericum dubium; thalictrum flavum; paris quadrifolia; cichorium in- tybus; genista tinctoria; ranunculus sceleratus; campanula patula, and glomerata; polypodium bistortajmercurialis perennis, &c. § Opera Omnia, part iii. p. 699. || Uiber d. durch den biss ein. hundes veranlaste Wasserscheu—in dessen Magazin. f. d. gesammte beilkunde, 1816. B. i. p. 97. TOL. II.—19 146 HYDROPHOBIA. internal administration of cantharides to fail in preventing ra- bies. As principal surgeon of the general hospital at Vienna, he had frequent opportunities of treating cases of this kind, and his opinion, as Richter observes, is entitled to great weight, as it is founded on a long course of very extensive experience. He gives one grain of the powdered cantharides daily, in union with tartar emetic, for five or six days in succession, and keeps the wound open for six weeks, by vesicatories and powdered cantharides.* No remedy has had more repute as a preventive of hydro- phobia than mercury. Astruc, Sauvages, Van Swieten, De Haen, Tissot, Portal, and Werlhof, regarded this article as the most certain prophylactic we possess against rabies. Many examples, illustrative of its good effects, have been reported; but the instances in which salivation has failed to prevent the occurrence of the disease are, perhaps, no less numerous, and it is now generally regarded as entitled to hut very little con- fidence in this respect, j Within the last few years, M. Coster, a French surgeon, has published some statements which would seem to show that chlorine has the power of decomposing and destroying the hydrophobic virus. Two table-spoonfuls of chloruret of lime are to be dissolved in half a pint of water, with which the bitten part must be frequently bathed. It is said to have proved successful when applied six hours after the bite was received. Cold bathing or affusion, is recommended by Celsus and Ccelius Arelianus, as a powerful prophylactic means in this affection. Cases of its successful application are mentioned by Van Swieten, Sabatier, Andry, and others; and it can scarcely be doubted, that by its invigorating and alterative effects, it is, at least, a very proper auxiliary to whatever other measures may be employed to obviate the disease. Besides the remedies already mentioned, a vast number of nostrums and mixtures have had a temporary reputation as pro- phylactics against rabies. These, however, have all passed into merited neglect; and at present, there is perhaps no article of this kind that is countenanced by any respectable member of the profession. Most of the foregoing remedies have also been employed for the purpose of curing the disease after it has actually made its appearance. Stark asserts, that he cured two cases of hydro- phobia by the exhibition of belladonna in large doses; and • Richter's Specielle Therapie. B. viii. p. 278. X The carbonate of ammonia, (Martinet, Darlue;) musk, (Dalby Nugent, Tissot, Gmelin;) acetate of copper, (Leib.;) copper filings, (Cothenius;) phosphorus, (Zinke;) arsenic, (Lond. Med. and Phys. Jour. 1789 ) have all been recommended for their prophylactic powers in this affection HYDROPHOBIA. 147 Sauter relates several remarkable instances which yielded to the powers of this remedy.* He gave it in doses of from eight to twelve grains of the powdered root every forty-eight hours. Shallern also cured a case of completely developed rabies by the use of this narcotic, f A case is related in Hufeland's Jour- nal, (B. 44) which was successfully treated by a combination of anagalis, marum verum, and basilicum ; and the celebrated Vogel asserts, that he cured several well-marked cases with a decoction of the anagalis. \. According to Martinet, the li- quid caustic ammonia has arrested the disease in four instan- ces. He gave sixty drops at first, and afterwards fifteen drops every two hours, with a few ounces of a strong decoction of cin- chona every four hours. § Rust states, that he succeeded in subduing the disease, in one instance, with large and repeated doses of cantharides ;|| and Axter prevented the full development of the disease after unequivocal symptoms of its attack had al- ready made their appearance. The meloe majalis was used suc- cessfully by Kortum; and Selle employed them with decided benefit. The very free use of mercurial remedies—particularly in the form of frictions, in conjunction with baths and musk—is said to have been employed with success in some instances of rabies, (Callisen, Rougemont.) Dr. Munckly has related a case which yielded under the influence of a free mercurial sali- vation.^} Olive oil, both externally and internally employed, is said to have removed this affection. Both Celsus and Ccelius Arelianus recommended frictions with warm oil as an efficient remedy in rabies. Vater has ad- duced facts, illustrative of its curative powers in this affection,** and Shadwell, an English physician, has given an account of a case, which would appear to have yielded to the internal and external use of sweet oil.ft The cold plunging-bath, or copi- ous affusions, is mentioned by Van Swieten, as having succeed- ed in arresting the progress of rabies ;ff and Morgagni refers to similar instances of success; although he himself saw an instance in which the patient died almost instantaneously, on being plunged into cold water. Dr. Arnell has related a case, in which pumping for two hours and a half on the patient, was decidedly beneficial. §§ * Hufeland's Journal. Bd. xi. p. 3. t Bernstein's Neu. Beitraeg. B. ii. See also Hecker's Annal. d. gesammt. Med. Bd. ii. p. 90—quoted by Richter. | Praelectiones. § Richter's Specielle Therapie. Bd. viii. p. 320. II Salzb. Med. Zeit. 1811. No. 76. 1T Med. Transact, vol. xi. art. xii. ** Programma de 01. Olivar. efficacia contra morsum canis rabida~«M quoted by Richter. tt Mem. of the Med. Society of London, vol. iii. XX Commentaries, vol. iii. p. 576. §§ Med. Recorder, 1824. us HYDROPHOBIA. Copious blood-letting also, has been much insisted on as a remedy in hydrophobia, and there are not wanting well authen- ticated instances of its beneficial effects. Poupart asserts that prompt and very copious abstractions of blood, so as to induce complete syncope, has effectually arrested the disease ;* and Dr. Hartley cured a case by taking away 120 ounces of blood in the course of a fewT days.f In one case, blood was drawn to the extent of producing syncope during each paroxysm of the rabies, with the happiest effect ;f and Dr. Russel states that a vein was opened in a young woman affected with rabies, and suffered to bleed until she fell down in a state of syncope, with the effect of arresting the disease.§ Dr. Rush was a strenuous advocate for copious venesection in hydrophobia. We may also cite the cases reported by Burton, Grisley, Willoughby, and particularly the interesting instances related by Tymon,|| Schoolbreed,^y Wynne,** Goeden,ff as striking examples of the occasional good effects of decisive bleeding in this affection. In Dr. Tymon's case, blood was at once drawn until the pulse could be scarcely felt, and 100 drops of laudanum admi- nistered, with injections of 300 drops of laudanum every two hours. On the following day two grains of opium with four grains of calomel were administered every two hours and con- tinued to the sixth day, when ptyalism with gradual subsidence of the disease occurred. In the case reported by Dr. School- breed, about fifty ounces of blood was drawn from a large ori- fice at once. Syncope ensued, and the disease wTas for a time manifestly moderated. As the symptoms appeared to increase again, he was once more bled to fainting, which had the effect of completely subduing the water dread, and paroxysms of fury. Calomel and opium were given for some time, under the use of which the patient's health was re-established. Parry never- theless considers these two cases as very equivocal instances of rabies; but the histories given of them leave us little or no room to doubt that they were genuine instances of hydropho- bia. A number of cases have indeed been reported in which the most energetic depletion did not produce the slightest im- pression on the disease. Dupuytren, Magendie, Brechet.ft Bellingen, Horn, Marshal, Olbers, Hufeland, Rust, and others, state that they have not derived the least advantage from this measure. * Histoire de l'Aeademie de Sciences. Paris, 1699. f Philosophical Transactions, 1738. X Gentleman's Magazine, Sept. 1752. § Historical Magazine for 1792. || Edin. Med. and Surg. Jour. 1813, p. 22. IT Ibid. Jan. 1813, p. 30. ** Med. and Phys. Journ. Nov. 1814. tf Hufeland's Journal, Bd. xlii. p. 64. XX Orfila, Toxicology, &c. HYDROPHOBIA. 149 In conclusion, it is proper to state, that among the prophy- lactic measures, a regulated regimen, gentle exercise, an atten- tion to the regular action of the bowels, and particularly avoiding violent mental emotions, over-heating, violent exercise, as well as the influence of sudden atmospheric vicissitudes, and all kinds of stimulating drinks, are all important observances. CHAPTER XI. MENTAL DERANGEMENT. Without stopping to inquire into the nature and laws of the human understanding, or into its mysterious connexion with the animal body, it will be enough for our purpose to observe, that all the perceptions of the mind, and consequently all the materials upon which alone it can exert and manifest its powers, are derived from impressions communicated to it through the medium of the body. It is here assumed, there- fore, that without a morbid condition of those parts of the or- ganization which receive and convey to the mind the elements of thought, and which thus constitute, as it were, the connecting link between intellect and the external world, insanity can have no existence. Pathologists have endeavoured to ascertain the seat of the primary irritation of insanity; but the observations we have upon this point are as yet vague and unsatisfactory. Pinel maintains that the primary seat of mental derangement is located in the epigastric region, from which the morbid irritation is propagated to the common sensorium. This is an old doctrine. Aretamsf observes, " verum praicipuse furoris et melancholia; sedes viscera sunt;" and it is indeed extremely probable, that in some instances at least, the primary source of insanity consists in an irritation seated within the abdomen. The intimate sympathetic relation that subsists between the brain and the chylopoietic viscera, is well known. A de- rangement in the functions of the one, seldom fails to induce a corresponding disorder in the functions of the other. Sudden fear, or disappointment, or violent anger, dissipates in a moment the keenest appetite; and a disordered state of the digestive organs is no less apt to give rise to torpor of intel- lect, irresolution, despondency, and waywardness of temper. * De Caus. et Sign. Morb. Diut. 1.1. c. 37. 150 MENTAL DERANGEMENT. In whatever part of the body the primary irritation may be located, it must however, always be communicated to the brain, the mental organ, before the intellectual faculties can he de- ranged ; and the proximate cause of insanity may therefore be regarded, as consisting in morbid cerebral excitement, existing either as a sympathetic or an idiopathic affection. As the musician cannot draw melodious tones from an instrument that is defective, so the mind cannot produce harmonious and correct thought, when its organ, the brain, is in a state of morbid excitement; and, it matters not whether this morbid condition be the result of causes acting immediately on the brain, or of such as primarily affect other organs whose sym- pathetic relations are such as to throw the irritation upon the common sensorium. What is the nature of the cerebral affection upon which the deranged action of the intellectual faculties immediately de- pends? According to Dr. Rush, it consists essentially in a morbid action of the blood-vessels of the brain ; whilst others view it as simply a state of nervous or cerebral irritation, with- out any necessary connexion with diseased vascular excite- ment. That the capillary blood-vessels of the brain are in a state of morbid excitement in perhaps all instances of mental derangement, is, I think, extremely probable. Whether, how- ever, this irregular vascular action in the brain constitutes the primary and essential condition of insanity, or whether it be only one of the consequences of the primary cerebral irritation, may admit of some doubt. No nervous irritation can be long maintained without inducing diseased action in the blood-ves- sels. From the very cogent arguments of Dr. Rush, as well as from my own observations, I am nevertheless well convinc- ed, that insanity consists essentially in a local fever of the brain ; that is, in a morbid condition of this organ, in which both its medullary and vascular structures are in a state of diseased action. Causes.—The predisposition to insanity, is, in many instan- ces, very evidently dependent on an hereditary peculiarity of organization. Dr. Rush mentions several very striking exam- ples of this kind.* Esquirol asserts, that according to his own observations, on half of the cases of insanity among the wealthy, and at least one-sixth of those which occur among the poor, depend on an hereditary predisposition ;f and according to a tabular statement given by Dr. Casper,\ it appears that in the different hospitals at Paris, the proportion of cases depending * On the Diseases of the Mind, second edition, p. 48. X Diet. Des. Sciences Medic. Art. Folie. Characteristic der Franzoesischen Medicine. Von. J. L. Casper, page MENTAL DERANGEMENT. 151 on an hereditary predisposition, is to the whole number as about 1 to 43. Esquirol states that he has met with an instance of seven sisters and brothers out of one family having been affect- ed with insanity ;# and Haslam mentions ten families in each of which several cases of mental derangement occurred.f Dr. Rush observes, that the following, among other peculiarities attend this disease, where the predisposition to it is hereditary ; 1, weaker exciting causes develope the disease than where the predisposition to it has been acquired; 2, it is apt to come on about the' ame period of life at which it appeared in the patient's ancestors; 3, children born previous, are less apt to become insane, than such as are born after the occurrence of mania in their parents; 4, in some instances of families in which mad- ness has existed, the disease passes by the understanding in their posterity and appears in great strength and excentricity of memory and of the passions, or in great perversion of their moral faculties." The liability to mental derangement is greatest between the twentieth and fortieth years of age; and according to the ob- servations of Esquirol, still more particularly between the ages of twenty-five and thirty. The following tabular summary in relation to this point, drawn up by Dr. Casper from the observa- tions of Pinel, Esquirol, Haslam, and others,:}: shows that from the thirtieth to the fortieth year of age, the occurrence of insanity is decidedly more common than during any other equal period of life. During childhood, or before the age of puberty, mania occurs very rarely. Instances are nevertheless mentioned, in which insanity appeared at a very early period of life. Dr. Rush saw7 two cases in children only two years old ; in one instance it appeared during the seventh, and in an- other during the eleventh year of age. Haslam also relates an instance which occurred in a girl only four years old; in an- * Loc. Citat. t Observations on Madness and Melancholy, p. 231. X Pinel, in the Bicetre from 1784—94 (males) admitted, Esquirol in Salpetriere from 1811 —14 (females) admitted, Haslam, Bethlehem hospital, from 1784—94 admitted, Esquirol's private institution, 1811 —14 (wealthy patients,) Hospital of Retreat at York,1796— 1811 (quakers,) Age. 15 to 20 20 to 30 30 to 40 40 to 50 50 to 60 60 to 70 70 to 80 65 339 380 236 130 51 0 171 135 403 205 115 66 23 113 488 527 362 143 131 0 0 150 78 30 46 15 8 8 44 28 28 27 9 4 357 1156 1416 861 661 172 35 152 MENTAL DERANGEMENT. other instance the disease came on in the seventh, and in a third one about the tenth year of age. Old age, also, is almost equally unfavourable to the occur- rence of mania. Dr. Rush states that he has met with but four instances in which the disease came on after the sixtieth year of age. It has moreover been observed, that maniacs rarely live to a very protracted age. Dr. Casper, however, mentions a very remarkable exception to this general fact. A coloured woman, he says, who had laboured under mental derangement for upwards of eighty years, was bronght into the Hospital Salpetriere in a state of raving insanity, at the very advanced age of one hundred and seventeen years.* In relation to the relative frequency of insanity in the two sexes, it is pretty generally admitted that it is more common in females than in males. Haslam gives a statement from which it appears, that during a period of forty-six years, there were 48S2 female, and only 4042 male lunatics admitted into the Bethlehem Hospital in London. It appears, however, from the inquiries of Dr. Casper, that the proportion of female over male lunatics, is much greater in France than in England. It is worthy of notice that the predisposition to mental de- rangement is very generally connected with black or dark brown hair and a dark complexion.. Esquirol states that out of two hundred and twenty-seven females affected with mania, one hundred and fifty-two had dark, thirty-nine fair, and thirty-six gray hair. Dr. Rush informs us, that of nearly se- venty patients in the Pennsylvania Hospital, who were exa- mined with a reference to this fact, in the year 1810," all except one had dark-coloured hair." In some regions mental dis- eases are manifestly endemic. This is the case with the cre- tins in many of the gorges of the mountainous districts of Europe : and it would appear that this disease is found only where the soil is calcareous.] The exciting causes of mental derangement are usually divided into the moral and physical—or into those which affect the animal organization through the medium of the mind, and those which act directly upon the body. Of the former kind are—intense mental application to one subject; violent rage; jealousy; excessive joy; sorrow; hatred ; terror; surprise; fanaticism; unrestrained imagination ; disappointed love, am- bition, or vanity; mortified pride; chagrin; protracted mental depression; and religious enthusiasm. From the following table it would appear that grief, distress, want, and disap- pointed love, are decidedly the most common exciting causes * Med. Chir. Rev. Sept. 1820. p. 25. t Ibid. MENTAL DERANGEMENT. 153 of insanity.* Mr. Pinel observes, that a frequent and powerful source of insanity is the struggle between tbe principles of religion, morality, and education on the one hand, and the ur- gent influence of the natural propensities and the passions on the other. Among the causes that act directly on the body, the follow- ing are the principal : Inanition from excessive hemorrhage or defect of food ; intoxication ; suppressed habitual discharges, particularly the catamenial; onanism ; inordinate venereal in- dulgence; restrained or unsatisfied venereal passion; worms in the alimentary canal; blows or falls on the head; apoplexy, Physical Causes. Hereditary, ------- Pregnancy, ----- Epilepsy, ....... Suppressed Menstruation, - Puerperal State, ------ Old Age, ------- Coup du soleil, ------ Injuries of the Head, - - - - Congenital, ------- Fever, Apoplexy, - - Malformation of the Skull, - Fire and other injurious Substances, Syphilis, ------- Imprudent use of Mercury, - - - - Onanism, ------- Intoxication, ------ Worms, ------- Suppressed Cutaneous Diseases, - Suppressed Haemorrhoids, - Moral Causes. Grief,........ Unfortunate Love, - - - - - Fanaticism, _------ Fright, - -..... Jealousy, - - - - Anger,....... Distress and Want,..... Mortified Pride,..... Disappointed Ambition, - Intense and Protracted Study, - Misanthropy,...... Vives Revolutions d'esprit, ... (a) Political Causes, ----- (a) Casper, loc. cit. p. 380. vol. II.—20 Salpetriere, in the years 1811-12. Esquirol's private hos. 1811-12. 105 150 11 4 11 2 55 19 52 21 60 4 12 4 14 4 13 12 60 10 8 1 14 18 24 4 105 31 46 25 8 1 38 8 18 14 16 77 14 1 16 12 13 2 14 31 154 MENTAL DERANGEMENT. epilepsy ; repercussion of chronic cutaneous eruptions ; preg- nancy ; parturition; the puerperal state; syphilis; intense pain; very low and high atmospheric temperature; the inordi- nate or improper use of mercury; various narcotic poisons; atmospheric influences; gastro-intestinal irritation ; the healing up of old ulcers ; and various forms of acute diseases. From the table given above, it appears that verminous irrita- tion is no uncommon cause of insanity. Dr. Casper informs us that Esquirol stated in his lectures, that he had known ele- ven persons cured of mania after the expulsion of a large num- ber of lumbrici by the use of anthelmintics. Mania appears indeed often unequivocally connected with intestinal irritation. The observations of Dr. E. Percival and Dr. Prichard, on what the latter terms enteric mania, may he consulted with much advantage. In these cases the morbid condition of the alimentary canal is generally decidedly marked. The gastric, biliary, and intestinal secretions are depraved ; the bowels are loaded, tumid, flatulent, and much constipated; sharp and transient pains are felt in the abdomen; the tongue, fauces, and velum pendulum, become red, injected, and tender; the appe- tite is irregular, or there is much aversion to all kinds of food. The puerperal state too is a frequent exciting cause of mental derangement. According to Haslam, eighty-four out of sixteen hundred and sixty-four maniacal patients admitted into Beth- lehem Hospital, came on soon after parturition. The propor- tion of cases from this cause, in relation to the whole number of admissions into the hospitals in Paris, has been estimated at about 1 to 13. Esquirol observes, that moral influences are generally more concerned in the production of puerperal mania, than the phy- siological changes that are effected in the system by child-bear- ing.* The despair and heart-rending grief which seduction, loss of reputation, and abandonment inflicts upon some; the blighted hopes of success in life, and the consequent anticipa- tions of poverty and want; the faithless and unkind conduct of the cherished father; these, and a number of other similar moral influences, frequently act in co-operation with the debili- ty, exhaustion, and general physiological condition present in the puerperal state, in the development of mental derange- ment. Out of ninety-two cases of puerperal mania admitted into the Hospital Salpetriere during a period of four years, thiry-seven became affected with the disease between the first and fourteenth days after parturition ; seventeen, between the fifteenth and sixtieth days; nineteen, between the sixty- first day and the eleventh month after confinement, and during lactation, and nineteen immediately after ceasing to suckle. (Casper.) * Journal de Medicine, par Sedillot, Tom. 61. MENTAL DERANGEMENT. 155 Atmospheric influences also have a manifest agency in the causation of insanity. It appears that summer and spring are decidedly most favourable to the occurrence of mental diseases. Casper asserts, that the admissions into Esquirol's private in- stitution, during the six months from March to September, amounted to double the number that were admitted during the remainder of the year ; and by the following statement of the admissions into the Hospital Salpetriere, for each month, during eight years, we perceive this fact sufficiently illustrat- ed.* It appears, therefore, that high atmospheric heat is more favourable to the occurrence of mania than cold weather. Prostitution and its train of evils, syphilis, intoxication, and mercury, appear to be a very common source of insanity in populous cities,—and according to Esquirol, particularly so in Paris. It is asserted, that a twentieth part of the insane females admitted into the Salpetriere are previously prosti- tutes. It is stated by Casper, that mental derangement from intoxication is found by the records of the Parisan hospitals to bear a proportion to the whole number of admissions, as I to 23 with females; and 1 to 10 with males. In England, the pro- portion of lunatics from this cause appears to be greater. It has been estimated to amount to about one-fifth of all the cases that occur, (Casper.) Dr. Rush states, that at one time the number of maniacs in the Pennsylvania Hospital, in whom the disease was excited by the excessive use of ardent spirits, amounted to one-third of the whole number! Onanism, says Dr. Rush, is much more frequently the cause of insanity in young persons than is generally suspected.f According to the foregoing etiological table, it would appear that in Paris, insanity from this cause occurs in the proportion of one out of fifty-eight in women of the lower order of society; and one out of fifty-one in males of the same class. In the higher classes it occurs in both sexes in the ratio of about one to twenty-three. Sudden suppression of the cutaneous transpiration often gives rise to mental derangement. Esquirol mentions the case of a man who was subject to copious sweating about the head. He became insane in consequence of having washed himself with cold water, with the view of restraining the pro- fuse perspiration. "A young man waded across a rivulet while freely perspiring. He had a rigour on going to bed, and immediately afterwards became maniacal." • Admissions of lunatics in the Hospital Salpetriere from 1806 to 1814. January 162, February 173, March 187, April 196, May 243, June 251, July 265; August 239, September 206, October 197, November 198, and December 191. t " La masturbation, ce fleau de l'espece humaine, est plus souvent, qu'on pense, cause de folie, sourtout chez le riches." Esquirol Die. des Scien. Med. Art. Folie. 156 MENTAL DERANGEMENT. Mental derangement, from repelled cutaneous affections, is by no means uncommon. Some very striking instances of this kind are related by Dr. Casper. He saw in one of the hospi- tals in Paris, a maniacal female of a plethoric habit, in whom the healing up of an old fistulous ulcer, on the left arm, ex- cited the disease. A blister was laid upon the arm, which caused violent phlegmonous erysipelas over the whole extremity and the re-opening of the ulcer. The patient was almost im- mediately relieved of her mental disease. In a short time, however, the ulcer cicatrized again, and the mania returned. He mentions another instance of mania, which came on imme- diately after healing an old ulcer on the leg. The ulcer was re-opened by local applications, and the mental affection dis- appeared. A young physician became affected with erysipelas: the inflammation subsided, and was substituted by mania. After a long time he suffered a second attack of erysipelas, and the mania disappeared. Mania sometimes occurs in connexion with consumption. There is, at this time, a young lady under my care, who has, for the last nine months, been in a state of complete insanity from this cause. About a year ago, phthisis pulmonalis deve- loped itself in her system. Three months after unequivocal symptoms of the pulmonary affection had come on, she be- came taciturn, morose, and finally maniacal. The consump- tive symptoms continue, but she does not appear to he con- scious of any disease of this kind. She coughs much, expecto- rates but little, has irregular hectic exacerbations, and night sweats. Haslam, indeed, denies that such a complication has ever occurred ; and maintains, that cases of this kind are to be regarded as co-existing or concomitant diseases, without any mutual dependence between them.* The occurrence of insa- nity, as a consequence of pulmonary phthisis, is, however, well established. Dr. Casper saw an instance of this kind, in the Hospital Salpetriere. When the cough and hectic symptoms were present, the patient was entirely free from derangement of mind; but in the absence of the phthisical symptoms, the patient was furiously insane. Sudden reverses of fortune is one of the most frequent causes of melancholy. Out of 482 melancholic patients admitted into the Hospital Salpetriere in the course of four years, forty- eight cases arose from this cause. It is generally believed that the moon has a decided influence upon maniacal subjects—an opinion which I do not doubt is founded on correct observation. Esquirol, however, entertains a different opinion. He observes, indeed, that the insane are generally much more agitated and boisterous about the full moon; but the same thing, he says, occurs about the break of day every morning. He thinks that light is the cause of this increased excitement of the maniacal symptoms at both periods. Light, he says, agitates all lunatics. * Loc. cit Second edition, p. 591. MENTAL DERANGEMENT. 157 Prognosis.—The degree of sanability of maniacal cases has of late years been an object of very particular inquiry; and the various reports that have been published on this head, show that the number of instances in which a cure is effected is by no means inconsiderable. From the following tabular state- ment, drawn up by Dr. Casper from official reports, it appears as a general result, that in France 0.44T9T of maniacal patients are cured; whilst in England the proportion is not so great, being only 0.37| of the whole number. FRANCE. Period. 3 ^ n c £3 O c >-< CD P. CD 5 5" Discha'd partially relieved. a in-o V Decimal propor-tion of cured. Hosp. Salpetriere Pinel, Esquirol, the same, Pinel, Hospital Bicetre,— Chamseru, Hospital Charenton, Pinel, Fodere', Royer,—Collard, Chamseru, Esquirol's priv. Ins. Dubuisson's, 1801-1805 1806 1807 1812-1814 1807 1789-1800 1803 1806 i of 1807 1801-1813 1002 333 289 891 102 97 499 355 214 335 300 473 160 136 413 33 33 161 134 91 173 177 250 33 70 36 270 140 83 142 5 0.47 1-5 .48 .47 1-18 .46 1-5 .32 1-3 .34 .32 1-4 .36 2-3 .42 1-2 .51 7-11 .59 Sum for France, 4427 1984 0.44 9-11 ENGLAND. Betblem, according to Haslam, Haslam, (dif. acct.) St. Luke's, Tuke, Hospital at York, Foderd, Retreat at York, Tuke, Hosp. at Manches-ter, Foder6, Hosp. at Montrose, Act of Pari. Hosp. at Notting-ham, Burrows, Hospital at Exeter, Burrows, Hospital at Glasgow, Burrows, Hosp. at Manches-ter, Burrows, Bethlem, Act of Par-liament, 1748-1794 1784-1794 1751-1819 1777-1807 1796-1811 1766-1805 1805-1815 1812-1819 1801-1819 1819 1820 1800-1815 8874 1664 12173 1739 149 1686 154 336 626 183 350 4810 2557 574 5091 746 49 667 34 179 355 39 74 1839 1013 192 26 190 36 39 53 10 31 166 141 47 85 54 48 45 106 190 410 18 220 25 2 5903 250 9 324 5 70 173 28 71 .28 7-9 .34 1-2 .41 5-6 .42 7-8 .32 4-5 .39 1-2 .22 1-13 .53 1-4 .56 5-7 .21 1-3 .21 1-7 .39 1-4 Sum for England, 32744 12254 0.372-5 158 MENTAL DERANGEMENT. From this statement it would appear, as a general result, that in France 0.44 T\ of maniacal patients are cured. In England the proportion is not so great, being only 0.37f. In looking over the foregoing table, we observe that the an- nual number of cures effected in the Hospital Charenton is pretty uniform during a period of fourteen years. At Bethle- hem, on the contrary, we perceive that the difference in the pro- portion of cures effected, in the forty-six years from 1748 to 1794, and the fifteen years from 1800 to 1815, is eleven per cent, in favour of the latter period—a strong evidence, says Dr. Casper, that in England the treatment of mental diseases, has, within the last twenty-five years, received great improve- ments. From the following summary of the cures effected by Esqui- rol in the Salpetriere, we perceive that the chances of recovery decreased very rapidly after the second year; and that after thefourth year, not more than one out of about 225 were cured. There were treated in the years 1804 209 1805 212 1806 206 1807 204 1808 1809 1810 1811 1812 208 1813 216 Total number. 188 209 190 163 total Of which were cured during the 1st year, 64 73 78 60 64 48 48 44 75 50 604 2d, 47 54 49 55 57 64 51 30 41 49 493 3d, 7 4 10 11 4 0 7 8 11 71 4th, 4 2 3 1 2 4 1 3 20 5th, 3 2 1 1 1 3 11 6th, 2 1 1 2 3 9 7th, 1 1 3 8th, 1 1 9th, 1 1 10th, 11th, 1 1 129 317 143 129 130 129 110 85 127 99 1218 Veitch, in his report in 1816, states, that of twenty-eight ca- ses of recent insanity, admitted into his private institution, he cured eighteen, but of one hundred and twenty-five inveterate cases he succeeded only in five instances. In the Retreat at York, England, out of sixty-six patients cured of insanity, twenty-seven were effected during the first year, thirteen in the second, three in the third, one in the fourth, five in the fifth, three in the seventh, two in the ninth, one in the thirteenth, and one in the fifteenth, (Casper.) Pinel observes, that after three years' ineffectual treatment, the chance of cure in insanity will be about as one to thirty. Unfortunately, relapses are very common in mental diseases. In the Hospital Salpetriere, relapses, according to the observa- MENTAL DERANGEMENT. 159 tions of Esquirol, have occurred in the proportion of about one in ten.* This agrees pretty well with the facts stated by other writers, on this point. Relapses are most apt to occur during the spring and summer months, and particularly at those sea- sons in which the disease made its attack in the first instance. (Ksquirol.) Dr. Hallaran observes, that when a violent fit of mania subsides rapidly, it is particularly apt to return. If the patient, soon after recovery from an attack of mania, becomes corpulent, there is not, in general, much probability of a relapse, f According to the observations of Esquirol and Georget, the mortality is greatest during the autumn and winter. Of seven hundred and ninety insane females that died during ten years, (1804-14) in the Hospital Salpetriere, one hundred and seven- ty-five died in the months of March, April, and May ; one hun- dred and seventy-four in June, July, and August: in Septem- ber, October, and November, the number of deaths amounted to two hundred and thirty-four, and in the three remaining winter months, to two hundred and seventy. With regard to age, it appears from the same observations, that the greater number of deaths take place between the ages of forty and fifty in males, and between thirty and forty in females. Maniacal patients appear to be much less obnoxious to con- tagious and epidemic diseases than individuals who are of a sound mind. This fact has been particularly noticed by Rush, Dubuisson, Mead, Willis, Reil, and Cox. Mania sometimes terminates spontaneously, in consequence, apparently, of some critical evacuation. Dubuisson saw it cured by the supervention of dysentery; Esquirol by epistaxis; Pinel and Hallaran through spontaneous salivation; and in- stances are mentioned, of the subsidence of mental derangement soon after the occurrence of profuse discharges of urine or tears, and, according to Buffon, of the semen. In general, the difficulty of curing monomania and melan- choly, is greater than of the other forms of mental derange- ment. Haslam observes, that when melancbolly alternates with raving madness, the chance of a cure is extremely small; and when monomania or melancholy is converted into mad- ness, almost every hope of a fortunate issue may be abandoned. Casper states, that Esquirol in his lectures observes, that when maniacs are able to recollect recent occurrences, with an oblivion of events long passed, the prognosis is much better than when they have a recollection of remote occur- rences, without being able to remember what has recently trans- * Casper, 1. cit. p. 405. t Haslam, 1. cit. p. 79. 160 MENTAL DERANGEMENT. pired about them. Mania, connected with paralysis or epilep- sy, may be regarded as absolutely hopeless; and, in general, acute and furious mania is much more under the control of remediate management than low, torpid, and fatuous insani- ty. Mental derangement, from physical causes, in general, yields more readily and permanently than when it arises from moral causes. A recovery of the general health of the system, without a corresponding melioration of the mental disease, is said to be an unfavourable sign. Puerperal mania appears to be more frequently treated with success than any other form of mental derangement. Post-mortem phenomena.—Notwithstanding the zeal and industry with which post-mortem examinations have been pur- sued in relation to mental diseases, we have as yet derived but very little information from such researches concerning the nature and seat of insanity. Esquirol assured Dr. Casper that he had dissected the brains of more than twelve hundred subjects who had died of mania, and that he did not in a single instance discover any morbid appearances which are not found also in subjects who had never suffered any mental diseases whatever. In almost every instance, however, he found the two hemispheres of the cranium of unequal size—and this, he says, "is the most constant phenomena, and perhaps the most worthy of attention."* Haslam, Reil, Esquirol, and others, state that in the majority of cases, the brain is found preternaturally soft. Esquirol found the brain very soft in twenty-nine instances out of forty- four subjects ; in fifteen it was of a firm consistence. Ac- cording to Georget, however, softening of the brain is much more frequent than would appear from Esquirol's statement. Os- sification of the dura-mater, is, according to the observations of Esquirol, no uncommon occurrence in maniacal subjects. He observes, moreover, that he invariably found a very firm ad- hesion of the lining membrane of the lateral ventricles to the adjoining substance of the brain. In several instances, Georget found the cerebellum totally disorganized. (Casper.) Among the abnormal circumstances discovered in the thorax and abdomen, Esquirol mentions one in relation to the position of the transverse colon, which is of a very remarkable character. This portion of the intestinal tube, he says, is sometimes found sunk down so low as to pass into the pelvis, and so as fre- quently to be placed in a perpendicular instead of a transverse position. The phenomenon occurs most commonly in persons who labour under melancholia. It must be observed, however, that Mr. Lawrence asserts that instead of having found this position of the colon in those who had laboured under insanity * Diet, des Sciences Med. Art. Idiotism. MENTAL DERANGEMENT. 161 he has seen it only in such as had never been affected by any mental diseases whatever. We perceive from these contradic- tory observations, how little reliance is, in general, to be placed on the sweeping inferences which are so frequently drawn from post-mortem appearances, in relation to the proximate cause and essential location of diseases. The diseases of the mind may be divided into four classes: viz. mania, monomania, dementia, and idiotism. I. Mania. General mental derangement is characterized by a rapid succession of incoherent ideas and violent excitement of the passions, expressed by great agitation, loud vociferation, sing- ing, menaces, and fury. Mania is generally preceded by a marked change in the ha- bits, tastes, attachments, and passions of the patient. He is usually animated, his sensibilities are keen, his ideas rapid, his temper irritable, jealous, and wayward. He is eccentric in his conversation and conduct; often betrays an unusually vicious disposition; he sleeps but little; is harassed by fright- ful dreams; forms various and extravagant plans for the in- crease of his fortune, or the good of the public; enters into ru- inous speculations, or squanders away his means in childish or extravagant amusements, or in the purchase of unnecessary or useless articles of furniture, clothing, &c. Costiveness, a craving appetite, vertigo, cephalalgia, a sense of throbbing and tension in the head, and a dull and wild expression of the eyes, are among the common premonitory symptoms of mania. When the disease is once completely developed, the expression of the countenance is wild and often ferocious; the eyes are promi- nent, sparkling, and in constant motion; the patient sings, whistles, vociferates, halloos, walks to and fro with rapidity, "or stands still with his hands and eyes often raised towards the heavens ;" he does not sleep for many nights, sometimes not for weeks ; he often manifests great muscular power; the skin is dry, cool, and occasionally covered with profuse perspira- tion ; the sensorial organs are extremely excitable ; the appe- tite is sometimes craving, at others wholly absent; the bowels constipated, and the urine small in quantity and high-coloured. The pulse is variable—sometimes full and strong, at others small, irregular, and tense, or slow and intermitting, and occasionally morbidly natural. (Hush.) Perhaps the most constant and remarkable among the physical phenomena of mania, is continued watchfulness, and a very peculiarly disagreea- ble odour, which exhales from the patient's body and excre- VOL. II.—21 162 MENTAL DERANGEMENT. tions, and impregnates his clothes and bedding. (Esquirol.)* Some patients are tortured with a constant severe internal heat; and the majority experience pain in the head, or in some part or organ in the abdomen or thorax. In the violent grades of mania, the mind forms erroneous perceptions of the impressions of external objects on the senses, or the senses convey erroneous impressions to the mind. In this case the patient does not recognize the objects and persons around him; mistakes " friends for strangers, and common visitors for his relations," loses the consciousness of his indivi- duality, and " is ignorant of the place he occupies, of bis rank and condition in society, and of the lapse of time." The im- agination is sometimes so powerfully excited, that its represen- tations prevail over those of the senses. The patient hears voices, holds conversations with persons, who he imagines are present, and in some cases these voices pursue and harass him wherever he goes, by day and by night, in public and in pri- vate. (Esquirol.) Sometimes the empire of volition seems to be entirely suspended, and the patient is no longer master of his own determinations. An irresistible impulse leads him to injure himself, or to inflict injury on others, to tear the clothes from his body, run out naked into the streets, leap out of windows, and to commit various other acts of fury. The sense of modesty and delicacy is generally wholly obliterated, and "people of the finest previous feelings will deliver themselves up to the most indecent or culpable actions without the con- sciousness of impropriety." Mania may be continued, intermittent, or remittent. A sin- gle paroxysm may continue from a few days to several months, before it terminates in a remission, intermission, or in death. Some patients experience paroxysms of maniacal excitement at regular intervals of a day, a week, or months—the intervals being passed in a state of quiet and inoffensive insanity.! Mania may also assume a chronic form, with little or no dis- tinct exacerbations. This constitutes what Dr. Rush has call- ed manalgia. It is usually characterized by " taciturnity, downcast looks, a total neglect of dress and person, long nails and beard, dishevelled or matted hair, indifference to all sur- rounding objects, and insensibility to heat and cold." * This peculiar smell issuing from the bodies of maniacal patients is al- so particularly noticed by Wagnor, Simes, and Reil.—Reil, Fieberlehre, B. iv. p. 348. t These remissions, says Esquirol, sometimes offer very remarkable anomalies. A patient will, for instance, remain in a state of profound melancholy lor three months, the three following months will be pass- ed in a state of high maniacal excitement, and to Ibis three months of complete fatuity will succeed. MENTAL DERANGEMENT. 163 II. Monomania. Monomania consists in a state of partial insanity—the pa- tient being insane upon some one subject only, with a full and regular use of his intellectual faculties " upon all, or nearly all other subjects." This class of mental diseases comprehends many varieties, as nostalgia, fanaticism, hypochondriasis, me- lancholia, misanthropy, satyriasis, &c. This is by far the most common form of mental derange- ment, and is always entirely free from delirium or paroxysmal raving. In that variety, which is usually denominated hypo- chondriasis, the hallucination relates to the patient's own body, or to the circumstances which he conceives have an especial sinister influence upon his own system, fortune, or happiness. The suggestions of his morbid imagination are taken for reali- ties. He believes himself afflicted with certain incurable and fatal diseases, "particularly with consumption, cancer, stone, and above all, with impotency and the venereal disease." He fancies that some poison has been maliciously introduced into his system ;* or that he has a living animal, or some other very injurious substance in his stomach or bowels. Some patients believe themselves transformed into inferior animals, as dogs, cats, wolves,f oxen,:): cocks,§ &c. Others imagine themselves converted into trees, plants, pots, clocks, candles, glass, but- ter, straw, wax, &c. The following lines, by Pope, give a sufficient enumeration of these singular hallucinations. Unnumbered throngs on every side are seen, Of bodies changed by various forms of spleen. Here living tea-pots stand, one arm held out, One bent; the handle this, and that the spout; A pipkin there, like Homer's tripod walks, Here sighs a jar, and there a goose-pye talks. Men prove with child, as powerful fancy works, And maids turned bottles, cry aloud for corks. * Some years ago there was a foreigner—a barber in Lancaster, who continued to occupy himself regularly and cheerfully with his customers, and to converse rationally upon all subjects except his own fortune, and the universal conspiration among his neighbours to poison him. He cooked his own victuals, and regularly every morning went about a mile to the river Conostoga to supply himself with water, which he asserted could contain no poison, since the fish continued to live in it. t Qui lyncanthropia detinentur, noctu, domo egressi, lupos in cunctis imitatur, et donee dies illucessat, circa defunctorum monumenta plerum- que vagantur.—P. Aegineta. Dere Med. lib. iii. cap. 16. X This was the case with the daughter of the king of the Argives; whom Virgil mentions.—Protides implerunt falsis mugibus agros. Eclog. vi. The madness of Nebuchadnezzar appears also to have been of this kind. § Alter gallos cantare audiens, ut hi alarum ante cantum, sic ille bra- chiorum plausu latera quatiens, animuntium sonum imitatus est.— Galen. de locisaffectis. 1. iii. c. vi. as quoted in Reil's Fieberlehre. 164 MENTAL DERANGEMENT. Tissot mentions an instance, in which the patient believed himself to be a lump of butter, and would not suffer any fire near him, lest he should melt. An eminent painter imagined him- self made of wax, and avoided all contact with hard substances. (Tulpius.) Zacutus Lusitanus mentions a person who believed that his posteriors were composed of glass, and would on no account, sit on any thing but the softest pillows. Some hypo- chondriacs have thought themselves dead; others imagined that their souls formerly resided in some inferior animal, or in some fellow-creature; in short, almost every imaginable hal- lucination of this kind has been known to occur in this variety of mental disease. In many instances of monomania, the hallucination is n< t of a distressing or sombre character. Some patients, though per- fectly sane upon every other subject, have an unalterable belief, that they are destined to make some great discovery, as the perpetual motion, the philosopher's stone, the squaring of the circle, &c. Others imagine themselves the legal heirs of crowns, princely fortunes, and hereditary honours. Professor Titel of Jena, continued to perform his professional duties for some time, although labouring under the fixed hallucination of believing himself to be Emperor of Rome.* I knew a person who for more than twenty years was firmly persuaded that he was the President of the United States; and yet this individual would converse and think rationally upon all the ordinary con- cerns of life. Some believe themselves invested with a special commission from heaven to perform certain pious acts, or to commit some deed, often cruel and horrid, under the persuasion that it is the command of providence, and necessary for the general welfare of the world.f Others fancy they converse with spirits, angels, and messengers from heaven. Tasso, in the latter years of his life, obstinately maintained, that a spirit regularly visited, and held conversations with him.^: Was not the celebrated Swedenborg a monomaniac ?§ Some monoma- niacs have believed themselves to be the Messiah. Dr. Rush informs us that he has seen two instances of this kind. "We see this form of mania," says Dr. Rush, " in the enthusiastic * Reil, Fieberlehre, b. iv. p. 39. + Pinel mentions the case of a monk, who imagined that the holy vir- gin had commanded him to murder a person whom he considered an un- believer. X Hoole's Life of Tasso, p. 48. § Of this kind of hallucination was that of the man mentioned by Ho- race :— ------Fuit haud ignobilis Argis Qui sc credebat miros audire tragccdos, In vacuo, latus sossor, plau.oique theatro. Cetera qui vitee servaret inunia recto More; &c. MENTAL DERANGEMENT. 165 votaries of all pursuits and arts of men. The alchymists, the searchers after perpetual motion, the metaphysicians, the politi- cains, the knight-errants, and the travellers, have all in their turns furnished cases of this form of derangement."* III. Dementia. This variety of mental disorder " consists not in false per- ception, like the worst grades of madness, but of an association of unrelated perceptions, or ideas, from the inability of the mind to perform the operations of judgment and reason. The judgments are generally excited by sensible objects; but ideas, collected together without order, frequently constitute a pa- roxysm of the disease. It is always accompanied with great volubility of speech, or with bodily gestures, performed with a kind of convulsive rapidity. We rarely meet with this disease in hospitals ; but there is scarcely a city, a village, or a coun- try place, that does not furnish one or more instances of it. Persons who are afflicted with it are good-tempered and quar- relsome, malicious and kind, generous and miserly, all in the course of the same day."f Dementia is therefore directly opposed in its phenomena and character to monomania; for in this latter variety of insanity, the mind is fixed upon some particular subject, and upon which alone it hallucinates; whilst in dementia, there is no leading idea, and "the mind," as Dr. Rush expresses it, "maybe considered as floating in a balloon, and at the mercy of every object and thought that acts upon it." IV. Idiotism. This variety consists in a defective development, or impair- ment of all the intellectual faculties, amounting sometimes to a total absence of mind ; and, in some instances, even to a desti- tution of the instinct which leads to the gratification of the ani- mal appetites. Idiotism is frequently congenital. It may how- ever be produced by various causes, as apoplexy, epilepsy, chorea, blows on the head, onanism, &c. It is the most hopeless form of mental disease; and, when congenital, or produced by the spasmodic affections just mentioned, it may be regarded as absolutely irremediable. Treatment.—In France, England, and the United States, there is in general but little medicine employed in the treatment of mental diseases. In the year 1819, the expenses incurred * Boileau says:— Tous les hommes sont fous; et malgre tous leur soins, Ne different cntre eux, que du plus au du moins. Sat. iv. p. 27. t Rush, On the Diseases of the Mind, chap. ix. 166 MENTAL DERANGEMENT. for medicines at the Glasgow Lunatic Asylum was but eighteen pounds sterling, whilst the sum expended for food and beer amounted to £1225. At the Exeter Hospital £1162 was ex- pended for food, and only £33 for medicines and instruments during the year 1819; and in the Institution at Nottingham, the necessaries of life cost £920, whilst the expense for medi- cine was only seven pounds, during the same period. Fifty years ago, the amount of expenses for medicines for the same number of patients, during an equal period, would have been much reater, although the proportion of cures effected was then considerably smaller than at present. Even at the present day, much more medicine is employed, according to Dr. Casper, for the cure of insanity, in the German hospi- tals than in those of England and France, although the success of the former appears to be considerably less than that obtained in the latter.* The truth is, medicines, properly so called, are by no means the most useful agents in the treatment of a ma- jority of mental diseases. Much more is in general to be effected by appropriate moral influences—by kind and humane treat- ment, and comfortable seclusion. The physician who looks for particular success in the management of lunatics, must enter into their feelings—take an interest in their real or ima- gined pleasures and pains, soothe and admonish them in a tone of kindness and affection, and appear among them, not as a stern ruler, but as a sympathizing friend and protector. It is by a moral treatment of this kind, more than by the materia medica, that the most good may in general be done in the ma- nagement of patients labouring under mental diseases. The cruel and coercive measures that were formerly so generally adopted in the treatment of insane persons, are as injurious as they are repugnant to the best feelings of the heart. Humanity and reason combine against the employment of such remediate measures; and the triumph of reason and good feeling over cruelty and error, is no where more delightfully illustrated than in the improvement that has of late years been effected in this respect. Instead of subduing the miserable maniac with implements of terror and torture, or keeping him in trembling subjection by threatening looks and menaces, or endeavouring to put reason right by drugs, chains, cells, and hand-cuffs, physicians now know that a kindlier mode of management will often call back the unsettled and wandering intellect, when a contrary course would only fix it the more firmly in its wild and distracted mood. One of the first measures in the treatment of mania, should * In Berlin, the proportion of cures effected has been estimated at about 0.28; at Vienna about 0.27—whereas in France it averages about 0.44. Casper, loc. cit. p. 413. MENTAL DERANGEMENT. 167 be to remove the patient from his friends and home, and to place him in some quiet and secluded situation. Dr. Rush strongly insists upon the importance of separation and proper seclusion ; and the most eminent of the English, German, and French writers, advise the adoption of this measure. " Confin- ed to a regular life and discipline," "says Esquirol," the patient is naturally led to reflect on this change in bis situation ; while the necessity of living among and submitting to the control of strangers is to him a powerful stimulus to regain his lost free- dom and reason." When thus confined, the medical attendant must in the first place endeavour to obtain the confidence and good will of the patient; kindness, consolation, affability, and in some cases a moderate yielding to the hallucination, will in general soon acquire the patient's confidence. Having gained this point, he must "soothe the irritable, repress the insolent, cheer the desponding, calm the excited, check the forward, encourage the timid, resist the importunate and petulant, but carefully attend to all reasonable requests." (Knight.) Let it be observed, however, that in recommending separa- tion and confinement, it is not intended to object to regular exer- cise in the open air, or even to enjoy the society of suitable individuals during the patient's intervals of comparative calm- ness. Whenever the weather is favourable, and the patient's condition will admit of it, free air and ample exercise should be allowed. The mutual association of patients similarly affected, and particularly during convalescence, has also a favourable tendency. "Nothing, says Georget, contributes more to the recovery than the mutual association of convales- cents ;" and for this purpose, it is particularly important that the institutions in which insane patients are placed, should have extensive gardens, well furnished with trees and flower-beds, and instruments of bodily amusements, such as swings, &c. Idleness in monomaniac patients should be discouraged. Va- rious amusing exercises—" as playing at quoits, the chase, shooting, and even chess, checkers, cards, and push-pin, should he preferred to idleness." (Rush.) Indeed, in cases of a mo- derate grade of maniacal excitement, travelling will sometimes do much good. Esquirol states, that he has always found the disease conspicuously moderated, after a long journey, particu- larly if it has been attended with difficulties and privations, and performed through a strange country. It is on this account, perhaps, that foreigners are more apt to be cured in England, than natives, (Wills;) and that strangers sent to Paris are more readily restored to reason than the inhabitants of that city. I have stated above, that in order to obtain the patient's con- fidence, it may be proper, occasionally, to give way in some degree to his hallucinations. This, however, must be done with caution. In general, it is improper to encourage in any 168 MENTAL DERANGEMENT. degree, the particular error, or false ideas under which the patient labours, and this is more especially to be observed with monomaniac patients. On the other hand, however, perempto- ry and absolute contradiction, is perhaps still more unfavoura- ble than indulgence ; for it seldom fails to excite the anger and contempt of the unfortunate sufferer against the person who thus vehemently opposes the current of their hallucinated notions. " In the furious state ,insane patients," says Dr. Rush, " should never be contradicted, however absurd their opinions and assertions may be, nor should we deny their requests by our answers, when it is improper to grant them. In the second grade of the disease, we should divert them from the subjects upon which they are deranged, and introduce, as it were accidentally, subjects of another and of an agreeable nature. When they are upon the recovery, we may oppose their opinions and incoherent tales, by reasoning, contradic- tion, and even ridicule." Where the insanity turns upon some prominent idea, or passion, much benefit may sometimes be obtained by dexterous- ly exciting some counteracting emotion, or sentiment. Esqui- rol states, that a melancholic man, who was in a state of great despondency, had his intellectual energies restored, by having been told that he had a law-suit on hand. An insane soldier was informed that the campaign was about to open. He imme- diately requested permission to join the army ; it was granted, and he arrived at his regiment perfectly sane. "The excite- ment of new turns of thought, says Georget, the rousing of inert faculties, form a third principle of moral treatment. For instance, endeavour to convince a king that he is without pow- er, with the hope of reflecting that he may have been in error. Take the patient to the situation whence the subject of his hal- lucination proceeds; as for instance, fancied voices, enemies, &c, and assure him of their non-reality. Awaken the passions, by reproaching them with indifference to parents, &c.; relate to them their past conduct, by telling them of their designs, as suicide, destruction of children, hatred to husbands, &c ; and by this management, cures may sometimes be effected. In some instances it will he proper to substitute a real for an ima- ginary grievance." If a melancholic ie harassed by ennui, with- draw from him his usual sources of amusement, so as to inflict on him real privations. The real ennui which he will then suffer, will often prove a powerful means of diverting his mind from its hallucinations. If a patient, says Esquirol, imagine himself abandoned by his friends, we may sometimes promote his recovery by depriving him of every testimony of their affection, and thus awakening him to a sense of his real loss. Dr. Rush relates some remarkable instances in which sudden terror, excited by actual danger, had the effect of curing in- MENTAL DERANGEMENT. 169 sanity. During the exacerbations or periods of excitement, it sometimes becomes necessary to employ coersive mea- sures. The only means employed for this purpose, in the hospitals of this country, and I believe also in those of Paris, is the strait jacket and Rush's tranquillizer. Haslam con- demns the former mode of restraining patients, in strong terms. It is certainly an offensive and oppressive mode of coersion in a state of furious mania. Haslam employs, in- stead of it, a belt from eight to ten inches wide. This is passed round the lower part of the body, above the arch of the pubis, and fastened on the back by strong buckles. On each side, leather bags are fastened. Into these the hands of the patient are thrust, and secured there by proper bandages. By this contrivance the respiration is not impeded, as is always more or less the case with the strait waistcoat; nor is the per- spiration suffered to become offensive and injurious by being absorbed and retained in the waistcoat. Patients, too, may walk about with this belt without much inconvenience, and they are said, always to endure it with much more patience than the jacket. In Dubuisson's private institution, an arm-chair resembling Dr. Rush's tranquillizer, is used as a mode of coer- sion. It consists of an arm-chair with a high back and foot- board. The arms, legs, feet, and body are fastened to this chair by strong and broad straps furnished with buckels. A simple and very excellent means for moderating the vio- lence of a paroxysm of mania, is the total exclusion of light from the patient. This is daily practised in the Salpetriere. When a maniac begins to rave violently, a piece of thiok cloth is quickly thrown over his head, and fastened over the eyes. This, it is said, almost always immediately moderates the patient's fury, and he may then be easily conducted into his apartment and properly secured. Esquirol particularly lays great stress on the soothing influence of darkness on maniacs ; and Dr. Rush enjoins it as a measure of much importance during the first stage of the disease. Confinement, darkness, solitude, low diet, and cold affusions will rarely fail to subdue the most turbulent and furious maniacs. Medicinal treatment.—Blood-letting was formerly much more commonly resorted to in maniacal diseases, than is now done. Dr. Rush was a strenuous advocate for the employment of this evacuation in general mental derangement; and the old established traitment deV Hotel-Dieu, says Pinel, consisted almost entirely of repeated blood-lettings. In the Parisian and English institutions, we are told that venesection is now but rarely employed in mental diseases. There can be no doubt, however, that the abstraction of blood will often contribute considerably to the reduction and removal of acute mania; and we may safely, and generally advantageously, resort to this vol. n.—22 170 MENTAL DERANGEMENT. measure in all instances in which the pulse is full and active, or tense, corded, and quick, in connexion with " great wake- fulness, redness of the eyes, a ferocious countenance, and a noisy and refractory behaviour." When the disease assumes the grade of phrenitis, with raving delirium, a hard and bound- ing pulse, throbbing of the carotids, flushed face, red eyes, prompt and free venesection cannot with propriety be dis- pensed with. Georget* says, that in cases that occur about the pubertal period, accompanied, as they usually are with general plethora ,repeated small bleedings are particularly useful; and the same observation applies to cases that occur at the turn of life in females. In monomania, or generally in all those va- rieties of mental alienation that are unattended with paroxysms of high cerebral excitement, bleeding can do no good, and will often prove permanently injurious. Purgatives are often very useful auxiliaries in the reme- diate management of lunatics. Where there is reason to believe that the bowels are in a loaded condition, or irritated by vitiated secretions, that is, where the tongue is furred, with pain on pressure in the region of the liver, a hard abdomen, and constipation, active purgation is particularly proper. Dr. Prichard observes, that in cases of this kind {enteric mania,) that the rectified oil of turpentine, in union with castor oil, is decidedly the most valuable purgative. Esquirol prefers mercurial purgatives, with the view of exciting the biliary secretion ; and in the instances just referred to, where there is tension and tenderness in the right hypochondrium, there can be little doubt of their superiority. There are cases, says Dr. Rush, "in which purges should be given daily, so as to excite an artificial diarrhoea, and calomel and jalap should be preferred for this purpose. Where there is reason to suspect the existence of verminous irritation, anthelmintics should be given in conjunction or alternation with active purgatives. An infusion of the root of spigelia, followed by a full dose of tur- pentine and castor oil, will in general answer this purpose better than any other articles of this kind. Emetics may occasionally be employed with manifest advan- tage, in the milder forms of mental derangement—more espe- cially in melancholia, and in recent cases of hypochondriasis. They are improper, however, where there is much cerebral irritation, or in cases attended with much febrile excitement. Esquirol has found emetics useful in puerperal mania. Mercury is much recommended by some writers, whilst others condemn its use in maniacal affections. With Dr. Rush, it was a favourite remedy in mania. ''Too much," he ob- serve, " cannot be said in favour of salivation in general mad- * Da la Folic, p. 293 MENTAL DERANGEMENT. 171 ness;" and he strongly recommends it also in partial Insanity. As an alterative, it may occasionally be used with very con- siderable advantage in chronic mania, particularly where the disease is attended with functional disorder of the biliary and digestive organs. Dr. Knight states that he has found the blue pill a valuable medicine in cases of long standing, and that he never knew it to be productive of any injurious effects; but he apprehends, that in recent cases of mania, the constitu- tional influence of mercury must be prejudicial in any form.* Narcotic and antispasmodic remedies were formerly much employed in the various forms of mental derangement, and although by no means generally applicable, they may in certain cases be used with advantage after the general indications have been adequately attended to. Opium, when given in small doses, says Dr. Rush, may be useful, but it should never be given in large doses, with a view of procuring sleep in general mania. Regimen, exercise, and purgation, with the use of the warm bath, will do more towards procuring sleep than any other remedies that can be employed. Indeed, opium never fails to increase the wakefulness, and when given in strong doses, before the general and cerebral excitement has subsided, it rarely fails to aggravate the disease. In chronic mania from mastur- bation, camphor has been recommended as often particularly beneficial; but almost all recent writers agree that it very rarely produces any good effects, but on the contrary often does manifest injury. In puerperal mania, however, Dr. Gooch asserts that camphor, given in union with the extract of hyos- cyamus, (ten grains of each) is the most useful anodyne we possess-! Dr. Knight also has found this combination very useful as a somniferous remedy in mania unattended with cere- bral congestion, or a general phlogistic habit.:}: In maniacal affections succeeding sudden suppression of the catamenia from cold, or any powerful mental emotion, advan- tage may he expected, says Dr. Prichard, from stimulating emmenagogues, in conjunction with frequent and efficient ab- stractions of blood, and warm semicupium. He considers the tincture of melampodium and the oil of turpentine as decidedly the best emmenagogues in cases of this kind. Georget also recommends the use of emmenagogues in conjunction with mus- tard, pediluvia,hip-baths, and leeches to the pudenda, in cases attended with suppressed menstruation and cephalalgia. The warm bath is a cardinal remedy in the treatment of in- sanity in the Parisian hospitals. In the Salpetriere, the women * Observations on the Causes, Symptoms, and Treatment of Derange- ment of the Mind, &c. By Paul Knight, M. D. t Observations on Puerperal Insanity. Transact, of Lond. College of Phys. 1820, vol. vi. X Loc. cit. 172 MENTAL DERANGEMENT. use the warm bath two or three times a week, unless an apo- plectic tendency, or some other circumstance contra-indicating its use, be present. They remain in the bath from a half to two hours. (Casper.) Patients of a thin, nervous, and irritable habit of body, says Esquirol, may be kept in the warm bath-a very considerable time with advantage. When the vessels of the head are strongly congested, and there is much cerebral irritation present, cloths saturated with cold water should be kept constantly applied to the head, while the patient is in the bath. The heat of the water should be about 99 or 100° of Fahrenheit. The cold bath, also, has been much employed in maniacal affections. In young, robust, and sanguineous patients, and particularly when the skin is dry and preternaturally warm, considerable benefit will occasionally accrue from cold affusions. More advantage, however, is in general to be obtained from the application of cold water or ice to the head, in young and excited maniacs with much sanguineous determination to the brain. In the early stages of mania, where there is much head- ach, redness of the face and eyes, and turgidity of the vessels of the head, cold affusions "from a cock, funnel, or pitcher," upon the top of the head, after leeching or cupping, with stimu- lating pediluvia and laxative enemata, often produce the most excellent effects.* "The signal for removing the cold applica- tions," says Dr. Rush, "should be, when they produce chilli- ness, and sobbing or weeping in the patient." Dubuisson, in conformity with the recommendation of Hill and Cox, has applied sether to the head with much advantage.! Counter-irritating applications may occasionally be employ- ed with benefit in insanity. Esquirol was formerly much in the habit of applying moxas to the back part of the head, in cases attended with much torpor; but he has for some years past in a great measure discontinued this practice. "They augment," he says, "the erythism, torment the patient, in- crease his irritability, and convince the insane that he is a vic- tim to our cruelty.\ Georget, however, speaks strongly in favour of setons, moxa, and blisters to the neck in monoma- nia, and other varieties of mental derangement accompanied with stupor, insensibility, and cerebral inactivity. These, he says, in conjunction with the repeated exhibition of vomits, rouse the energies of the nervous system, in the most desperate cases of alienees stupides. Dr. Rush, also, speaks decidedly in favour of the use of blisters. "They have," he says, "been considered as remedies of doubtful efficacy; but it is only be- * Esquirol, loc. cit. t Des Vesanies au Maladies Mentales, p. 225. X Loc. citat. MENTAL DERANGEMENT. 173 cause they have not been employed in the manner, or the pre cise time that was necessary to obtain benefit from them. In the first stage of tonic or violent madness, the disease is en- trenched as it were in the brain. It must be loosened, or weak- ened, by depleting remedies, before it can be dislodged, or translated to another part of the body. When this is effected, blisters easily attract it to the lower limbs, and thus often con- vey it at once out of the body. The circular swing has been much used in the institution for lunatics at Glasgow, and "in some cases, with wonderful good effects." Dr. Knight also asserts that 'this agent pos- sesses " immense power" in subduing general and cerebral excitement. "A patient, subject to its action, is speedily affected with giddiness and sickness, and the peristaltic motion of the whole alimentary canal seems to he excited, and in some instances to such a degree that the patient vomits, and passes faeces in rapid succession and great abundance, along with his urine. Apprehensions have been expressed lest the use of the circular swing should induce apoplexy: having attentively exa- mined the sources of these fears, I conclude them to be ground- less ; nor have I ever seen the slightest reason to apprehend such result; nor do I believe it can occur, if the patient be not in a furious state when put into the swing" The best time, says Dr. Knight, for using the swing, "is a little before retir- ing to rest at night, as the unloading of the alimentary canal, the lowering, and the relaxation of the skin, very generally predispose to sound and refreshing sleep.* Music often has a most soothing influence over the distracted and raving minds of maniacal patients. Dr. Rush observes that " lively tunes are as offensive as comic representations in this disease." Tissot relates an instance of insanity which was permanently removed by music ;f and we read, that Saul's melancholy was dissipated by the harp of David—Tange lyram digitis, animi dolor omnis abibit dulcisonum reficit tristia corda melos. * Loc. cit. p. 63. t Reil's Fieberlehre. 174 DELIRIUM TREMENS. CHAPTER XIII. DELIRIUM TREMENS. Mania a Potu. This very remarkable variety of mental disease, is character- ized by general inquietude, tremor, continued watchfulness, cool skin, perspiration, dejirious loquacity, and sensorial illu- sions. It occurs only in habitual drunkards, and in such as are ad- dicted to the inordinate use of opium, and, perhaps, other nar- cotic stimulants. So long as the customary quantity of the stimulus is taken, the disease seldom, if ever, supervenes; but, if from necessity, sickness, or a temporary disgust, the ordi- nary stimulating potations are suddenly left off, or greatly di- minished, the activity of the brain becomes morbidly increased, and mental disorder, in many instances, speedily ensues. "It is important to bear in mind," says Dr. Coates, "that this dis- ease is the result, not of the application, but of the sudden in- termission of the use of these articles."* The disease usually commences with lassitude, general indis- position, a feeling of distress in the epigastrium, anorexia, nau- sea and vomiting, giddiness, a sense of confusion in the head, want of sleep, an anxious expression of the countenance, and tremor of the hands. After a day or two, the countenance ex- hibits an expression of alarm and suspicion, the eyes are cast about with quick and scrutinizing glances, or often fixed, ap- parently upon some object that attracts the attention for a mo- ment, and then quickly withdrawn ; the tremor of the hands increases; the patient becomes irritable and sometimes iras- cible ; he is extremely restless, walks continually to and fro, and is wholly unable to obtain a moment's sleep. He now be- gins to manifest mental disorder, becomes loquacious, says he feels well, and is tormented with a more or less continued suc- cession of various alarming, disgusting, and ludicrous appari- tions. He fancies that he sees dogs, snakes, cats, mice, and other animals in his room, and disgusting vermin crawling over the * See an able and highly interesting memoir on this disease, by Dr. Coates of this city, published in the North American Med. and Surg. Jour. vol. vii. p. 34. DELIRIUM TREMENS. 175 bed, and on his clothes, or that various individuals have enter- ed his room, for the purpose of robbing, killing, or annoying him; and to avoid these and other horrid illusions, he often calls out loudly for assistance; runs to the door to make his escape, or to the window to leap out; is greatly agitated, vo- ciferates, threatens, and sometimes raves violently. Some- times he fancies that he hears loud and strange noises around him, over head, in an adjoining apartment, or loud and frequent knocking at the door. His mind and body are in a continued state of action ; he calculates, projects, walks hurriedly about the room, picks up money, runs up to the window and calls out loudly to some imaginary person in the street, starts with terror and agitation from the presence of frightful and disgust- ing apparitions, insists that he is well, and confined with some sinister intentions against him, and requests to be suffered to go out in pursuit of his usual occupations. If the patient is flatly contradicted, he usually becomes much exasperated, and insists with vehemence on the correctness of his notions; but, when he is soothingly dealt with, he will now and then answer certain questions mildly and even distinctly, and by judicious management, may, in general, be restrained without any vio- lent coersive measures. When the disease rises to a high grade, the patient becomes violently and often furiously deli- rious, talks incessantly, is restrained with difficulty, and is unable to recognize his friends and acquaintances. Patients affected with this disease do not appear to be sus- ceptible of much bodily pain. " They never seem to experience any sufferings from fractures, though they may be at the time subjecting these to the most constant friction and concussion; and when the delirium supervenes upon a pleurisy, or other inflammatory affection, accompanied with pain, the principal disease seems to disappear, even to the eye of the experienced practitioner, to be reproduced at a later period, when the brain and nerves regain their ordinary tranquillity." (Coates.) The pulse in this disease varies considerably in different cases. In some instances it is hard, full, and frequent, but it is much more commonly soft, full, and quick, without strength or tension. The skin, generally, retains its natural degree of temperature and moisture; the tongue is moist, and covered with a white fur; the bowels are torpid, and there is usually an entire loathing of food throughout the whole course of the disease, but the thirst for cold drinks is almost always con- siderable. The duration, as well as the degree of violence of delirium tremens vary much in different cases. Sometimes slight tre- mor of the hands, with occasional transient manifestations of delirium, sensorial illusions, and watchfulness, continue for a day or two, and then pass off. At others, the wakefulness, 176 DELIRIUM TREMENS. tremor of the hands, and general restlessness and agitation continue for five or six days, with delirium and annoying appa- ritions at night, whilst but little mental hallucination is noticed during the day. In some cases, the symptoms described above continue with but slight remissions day and night, for one or two weeks and upwards, and in highly aggravated instances, the disease assumes the character of wild and ungovernable mania. Dr. Armstrong observes, that when convalescence is not restored within the first month, there will be a risk of long- continued, if not permanent alienation of mind. Mild cases of this disease, when left to themselves, have been known to terminate spontaneously, (Stoughton,) on the super- vention of diarrhoea or vomiting. Much more generally, how- ever, the occurrence of profuse discharges of this kind bring on a low and typhoid condition of the system, and this is es- pecially apt to be the case in persons who have been long and exceedingly intemperate, and in whom the disease is accompa- nied by some local inflammatory affection or general fever. In full and robust habits, the disease not unfrequently termi- nates in fatal convulsions or apoplexy. Pathology.—It appears to be generally admitted that this dis- ease has its primary and essential location in the sensorium commune, and that it is wholly independent of inflammation or vascular turgescence in this organ. It would seem to con- sist in a purely dynamic disorder—a morbid activity of the brain, from the sudden abstraction of an habitual stimulus by which its excitability had been long repressed or blunted. Dr. Coates considers it as consisting in " a heightened activity of the sensorium," from the generation, as it would seem, of an inor- dinate degree of vital activity in the brain ;* and similar views of the nature of this affection have been expressed by Dr. James Johnson, Dr. Ay re, and many other eminent British physi- cians, f Dr. Joseph Klapp, of this city, has published a series of cases with observations tending to show that the proximate or essential irritation of this disease is seated in the stomach, and it must be confessed that the arguments adduced in support of this opinion, possess considerable plausibility.:): It is assert- ed in support of this opinion, that dissection almost uniformly discloses traces of previous inflammation in the stomach; that, in nearly all instances, nausea, vomiting, and a foul tongue occur; and that the operation of an emetic, in many cases, brings off from the stomach a viscid, light-brown, or black coloured fluid of the consistence of boiled tar; and finally, that the disease yields more frequently and speedily under the em- * Loc. citat. p. 225. t Med. Chir. Rev. Feb. 1828, p. 484. X Eclectic Repertory, vol. vii. p. 259. DELIRIUM TREMENS. 177 ployment of emetics than under any other mode of remediate management that has hitherto been recommended. In reply to these arguments it may be observed, that post- mortem signs of inflammation cannot be received as a valid proof that the inflammation was primary and causative, in re- lation to the peculiar train of phenomena which characterize the disease; for nothing appears to be more satisfactorily esta- blished, than that mucous inflammation of the alimentary canal very often surpervenes during the latter period of all violent diseases; and that the ordinary signs of inflammation—increas- ed vascularity and sanguineous engorgement—are frequently produced in the last moments of life, or in articulo mortis. If the disease depended on mucous inflammation of the stomach, can it be conceived that emetics should in any instance operate beneficially ? Would any prudent physician prescribe an eme- tic in a case attended with unequivocal gastritis ? Dr. Klapp, indeed, does not appear to consider the morbid condition of the stomach as a state of inflammation ; although Dr. Staughton, who advocates the gastric pathology of this affection, lays par- ticular stress on the post-mortem signs of phlogosis in the sto- mach, as an evidence of the correctness of this pathology. Dr. Klapp seems to consider the gastric affection as rather the reverse of inflammation—as a state of torpor, insensibility, and chronic irritation, or morbid excitement of the stomach. The argument drawn in favour of this opinion from the frequent good effects of emetics in this malady, affords it but little sup- port. The post hoc, ergo propter hoc, is always a fallacious mode of reasoning. We may admit, to the full extent, the bene- ficial influence of emesis, and yet consistently deny our assent to the doctrine which alleges that the stomach is the primary seat of the disease. With regard to the foul tongue, vomiting, &c. mentioned in confirmation of this view of the nature of the disease, it may be observed, that the majority of writers do not bear testimony to the frequent occurrence of these phenomena. Dr. Coates found them "generally absent in the cases that came under his own inspection." Dr. Sutteh mentions them only as symptoms accompanying the disease, where it occurred in con- nexion with typhus fever, scarlatina, or some other acute affec- tion ; and Dr. Brown of New-York has noticed a foul tongue only in two out of eight cases. Within the last six years, I have seen about ten cases of this disease, and although I have paid particular attention to all the phenomena that might throw light on its pathology, I do not remember of having no- ticed a foul tongue in more than three instances, two of which were complicated with pneumonia, and the other with dysen- teric symptoms. Prognosis.—Delirium tremens is not, in general, a very dan- gerous affection, when it occurs in a simple and uncomplicated vol. ii.—23 178 DELIRIUM TREMENS. form, and in systems not yet greatly broken down and depraved by a long course of excessive intemperance. If it supervenes during the course of violent forms of fever, and more especially during the existence of acute visceral inflammation, it almost invariably terminates fatally. The disease is also attended with peculiar danger when it occurs in confirmed drunkards, who have previously laboured under chronic hepatitis, or some similar organic affection. Subjects of this kind generally rapidly sink under the disease, (Armstrong.) When the deli- rium becomes constant, the pulse rapid and very small, the ex- tremities cold and covered with perspiration, the pupils small and contracted, with subsultus tendinum, and an agitated mo- tion of the muscles of the face, death may be regarded as inevi- table. It is also a particularly unfavourable sign when coma, with sonorous respiration or convulsions, ensue. The occur- rence of tranquil sleep, even of short duration, announces a favourable tendency in the disease; and no symptoms can be regarded as indicative of declension of the malady, so long as the patient is unable to obtain some sleep. Treatment.—If delirium tremens depends—as I am well persuaded it does—on a morbid activity of the sensorium, independent of inflammation or sanguineous congestion, the prominent indication is obviously to subdue this inordinate ce- rebral activity; and it remains only to inquire, by what reme- dies or course of treatment this object is best accomplished. If we attend to the circumstance that this peculiar condition of the brain is almost invariably the consequence, not of the application, but of the sudden abstraction of the customary stimulus, we are led, a priori, to infer, that the best mode of removing it, is to supply a stimulus, which may be capable at once of blunting and exhausting the' morbid excitability of the sensorium. For this purpose, opium is decidedly the most valuable remedy we possess. Dr. Coates observes, and correctly too, that sleep must be produced coule qui couie— that the patient must sleep or die. Dr. Coates, however, goes too far, I think, when he expresses his conviction, that every case of simple delirium tremens may be cured by "the opiate treatment." Satisfied as I am, that opium is the remedium magnum—the " sheet anchor" of our hopes, in this affection, there nevertheless exists no doubt in my mind, that important advantages may also be derived, in some instances, from other remedies, auxiliary to this potent narcotic. When the bowels are constipated, and there is reason to presume that they are in a loaded state, a purgative should be administered before recourse is had to the opium. This, like all other affections, may come on while the intestinal canal is charged with vi- tiated secretions and other irritating substances; and when it DELIRIUM TREMENS. 179 is considered, that intestinal irritation from sources of this kind has a powerful tendency to originate and support morbid excitement in the brain, the propriety of administering one or two mild purgatives preparatory and auxiliary to the em- ployment of opium in this disease, would appear to be very obvious. It has appeared to me, indeed, that without this pre- caution, the free use of opium has a tendency, in some instances, to give rise to dangerous determinations to the head, and to bring on coma instead of healthy sleep. About four years ago, I was called to a gentleman, a few miles from the city, labour- ing under the ordinary symptoms of this disease. I found him sitting on his bed, busily engaged in driving away eels and snakes, which, he said, were annoying him ; and he requested me to turn out of the room several negro children, which had placed themselves, he thought, on the tops of the bed-posts. This was the second day of his illness ; his pulse was mode- rately full and compressible, and his tongue covered with a thick white fur. I at once directed two grains of opium to be given to him every hour, and to be continued until sleep should ensue. In the evening I visited him again. I found him lying on his back, apparently perfectly unconscious, his hands and arms, and muscles of the face in continual motion, and uninter- ruptedly muttering indistinct words; the pupils contracted, and the whole frame in a state of tremulous agitation. The skin was moderately warm and moist, and the pulse frequent, small, and more firm than on the preceding day. With much difficulty I got him to swallow about an ounce of castor oil, with three drachms of ol. turpentine, and directed a laxative enema to be administered in two hours afterwards. Early next morning I saw him again, and found him much better. The purgative had acted four or five times, and brought away large and very offensive stools. He immediately recognized me when I entered the room ; his pulse was frequent and feeble, and he was still much harassed by various disgusting and alarming apparitions. I now directed him a grain of opium every hour; after the eighth dose was taken, he fell into a tran- quil sleep, which lasted several hours. He recovered under the use of this narcotic without any other remedy. I cannot, in- deed, assert with certainty that the comatose state mentioned above was the result of the influence of the opium ; but I am led to ascribe it to this cause from having, in another instance, witnessed similar phenomena, after the use of large doses of this narcotic. Dr. Coates says : "I have never seen, read of, or heard of an instance in which opium was productive of harm." I must, indeed, be greatly mistaken in the diagnosis, if I have not seen one unequivocal instance of this kind. In a case which I regarded as pure and uncomplicated delirium tre- mens, four grain doses of opium were given every two hours. 130 DELIRIUM TREMENS. In twelve hours the patient was comatose, became convulsed, and soon expired. I mention these facts, not to deter from the use of this valuable, and I may say indispensable remedy in this affection, but as a caution to the practitioner to watch with assiduity its administration ; " because we know not whether poisonous effects will be produced by an arithmetical or a geo- metrical increase—whether five grains, or thirty grains in ad- dition are sufficient to endanger the patient's life."* The quantity of opium which it is usually necessary to ad- minister, before the desired soporific effect is produced, is often truly enormous. In some instances, from twenty to thirty grains, in divided but frequent doses, are required before the full advantages can be obtained, which it is capable of afford- ing. My usual practice has been, to exhibit two grains every hour, (after free purgation) until sleep is induced. With regard to the employment of blood-letting in this affec- tion, the opinion of the profession seems to be pretty well settled as to its general impropriety and inefficacy. Dr. Sut- ton informs us, that where blood-letting " has been principally relied on, he has observed a fatal termination of the disease in almost every case."f Dr. Armstrong, who is not inclined to undervalue this measure, asserts, that he is " fully persuaded that there are not many instances where the lancet is requi- site ;" yet " in constitutions that have not been shaken by rei- terated drunkenness, he has known early and moderate vene- section of much use." The experience of Dr. Brown, of New-York, coincides with the observations of Dr. Armstrong, on this point. Dr. Stewart " had seen the disease on a large scale. Almost all those patients who were treated on the anti- phlogistic plan died, while those who were treated by opium and stimulants recovered.":}: It appears, also, that the experience of Dr. Gregory, Dr. Shiel, Mr. Lambert, Mr. Mackelan, Mr. Chinnock, and Dr. Ayre, is decidedly in favour of the stimulating and narcotic treatment, in uncomplicated cases of the disease.§ Cupping about the head may, under certain circumstances, provevery useful. Where the.sanguineous determination to the brain is considerable, and the raving becomes constant and violent, cups may be applied to the temples, forehead, and neck with much advantage. Dr. Coates informs us that, in the Pennsylvania Hospital, Dr. Parrish has resorted to cupping in delirium tremens with great benefit. In an instance I attend- ed about six months ago, where there was much vascular tur- gescence of the head, and a state of delirium approaching the • Coates, loc. cit. p. 214. t Tracts on Delirium Tremens, &c. p. 66. t Med. Chir. Rev. February, 1828, p. 484. § Med. Chir. Rev. February, 1828, p. 485. DELIRIUM TREMENS. 181 raving of phrenitis, immediate and very decided benefit was derived from cupping. Blisters also will sometimes act bene- ficially when applied to the legs, or to the back of the neck, in cases attended with violent cerebral excitement. In one case, in which the disease seemed to verge into phrenitis, I have known a large blister, laid between the shoulders, to mitigate the symptoms very considerably. Dr. Coates, referring to the practice of Dr. Parrish in the Pennsylvania Hospital, observes, that blisters appear of more service than cupping, "as they did not equally weaken the patient." Emetics, as has already been intimated, deserve more atten- tion as curative means in delirium tremens, than any other re- medies that have been employed, with the exception of opium. In my own practice I have had unequivocal testimony of the frequent usefulness of emetics in this malady. In several in- stances, however, they failed, in my hands, of doing any good; and in two cases, within the last six years, they were unequivo- cally injurious. To one patient, who had been long a confirmed drunkard, I administered, in divided doses, fifteen grains of tartar emetic. It produced neither purging nor vomiting; but its sedative operation was immediate and powerful. In about an hour after taking the medicine, the pulse became small and extremely feeble—the extremities ice-cold, and a profuse, cold, clammy sweat broke out over the whole body. The patient sunk rapidly, and expired in about four hours after the anti- mony was taken. In the other instance, the emetic brought on the most profuse and exhausting diarrhoea, and soon prostrated the patient below the point of reaction. Nevertheless, in mo- derate and uncomplicated instances of the disease, and in pa- tients who have still considerable constitutional vigour left, we may with safety, and often with decisive advantage, resort to one or two emetics. As an auxiliary or preparatory measure to the employment of opium, I am inclined to regard the exhibi- tion of an emetic as often peculiarly beneficial. I have, indeed, known a few cases cured by emetics, with little or no other re- mediate applications; but experience has convinced me, that they are much more worthy of attention as auxiliaries to opium than as a principal curative means. Dr. Brown ex- presses the same opinion. * * Although it has not been our prac- tice," he says, " to depend exclusively upon emetics in the treatment of delirium tremens, we can bear testimony to the utility, in some cases, of premising an emetic to the use of opium. And, no doubt, this is often an important step in the treatment of this disease."* It is often extremely difficult in this disease to excite vomit- * Observations on Delirium Tremens, &c. by Dr. Stephen Brown, in the Med. Recorder, vol. v. p. 207. 182 DELIRIUM TREMENS. ing, without administering very large doses. Dr. Klapp gave one of his patients twenty grains of tartar emetic before vomit- ing was excited ; and Dr. Brown mentions an instance in which thirty grains of this article was given before the desired effect was produced. I have, in general, preferred giving the tartar emetic in combination with ipecacuanha, in the propor- tion of two grains of the former with fifteen of the latter, re- peated every ten or fifteen minutes, until vomiting ensues. Cold and tepid affusions have also been recommended in this affection. Dr. Armstrong speaks very favourably of the effects of dashing two or three gallons of tepid water, strongly impregnated with salt, over the whole skin, and then immedi- ately drying and rubbing the surface with warm flannel; and, having put the patient to bed, administering forty or fifty drops of tict. opii in a little warm wine. He informs us, also, that in several cases he used cold affusions with decided benefit; but he never resorted to this measure except in patients pos- sessing much apparent vigour of constitution, and he always administered stimulants—such as warm wine—immediately afterwards. Besides opium, various other stimulating remedies have been employed in delirium tremens. Dr. Coates considers camphor and assafoetida " as powerful agents in restoring the mind to its equilibrium." I have used camphor and opium in combi- nation; but I cannot say that more benefit was derived from this mixture than is usually obtained from the latter article, when given by itself. In several instances, I gave the cam- phorated tincture of opium, during the declension of the disease, with the happiest effect. Two drachms of it may be given every three or four hours during convalescence. The carbo- nate of ammonia, also, may be given with more or less benefit in slight cases, or during the subsidence of the disease. I pre- scribed this article lately in a case of incipient delirium tre- mens, with marked advantage. With regard to the employ- ment of ardent spirits, I can say nothing from my own experi- ence, as I have never allowed my patients to take any thing of this kind, except warm wine, and, in a few instances, a little weak brandy toddy. The sentiment of the profession appears now very generally and strongly opposed to the employment of spiritous liquors in the treatment of this affection. There is, indeed, something very revolting in the idea of exhibiting co- pious draughts of the very agent whose destructive influence has caused the wreck of body and mind, which we are called on to remedy. There can be no doubt, that opium will, in general, do all that can be effected by remedies of this kind; and where it may be thought advisable to bring in the aid of a more diffusible stimulus, camphor, ammonia, assafoetida, and Hoffman's anodyne, may be resorted to with propriety. DELIRIUM TREMENS. 183 During the course of the disease, and particularly during convalescence, the diet should be light, unirritating, and fluid. Animal broths will, in general, answer better than any thing else. CHAPTER XIV. ASTHMA. Asthma is a paroxysmal affection of the respiratory organs, characterized by great difficulty of breathing, tightness across the breast, and a sense of impending suffocation, without fever or local inflammation. In the majority of cases, certain symptoms, indicative of gastric derangement precede, often for several days, the pa- roxysms of the disease. Among these symptoms, a sense of weight and fulness in the epigastrium, acid eructations, inap- petency or voraciousness, heart-burn, flatulency, weight over the eyes, anxiety in the prsecordia, and an itching of the skin, are the most common. The paroxysm generally comes on at night during sleep. The patient is seized with great anxiety, difficulty of breathing, and stricture across the breast, and a short dry cough. These symptoms soon acquire a most appalling degree of violence. The breathing becomes wheezing, extremely laborious, gasp- ing, and suffocative, the countenance expressive of intense anxiety and distress, and the heart generally palpitates violent- ly. The desire for fresh and free air is inexpressibly urgent; the patient insists on the doors and windows being widely opened ; or he starts from his bed, and rushes to the window for fresh air, and is wholly unable to remain in the recumbent posture. The extremities are generally cool, sometimes of the natural temperature, and moist; the face is bloated and livid or pale, and the veins of the neck and head are turgid. The pulse is often irregular, intermitting, accelerated, moderately full, and compressible; sometimes it is nearly natural, and occasionally it is full, active, and firm. After these symp- toms have continued for an uncertain time, the breathing gradually becomes less laborious and anxious, and towards morning a copious expectoration of viscid mucus very general- ly ensues, which always brings with it considerable relief. During the ensuing day, the patient usually experiences but little uneasiness or oppression in the chest. On the next night, however, the paroxysm of suffocative respiration re- turns ; and in this way the disease proceeds, with remissions by day, and violent exacerbations at night, for three or four 184 ASTHMA. days in succession, and in some instances much longer, before it finally subsides. During the paroxysm, the urine is almost always pale and copious, and the abdomen distended with flatus. Bree states that the temperature of the body is generally considerably below the healthy standard. He has found the thermometer placed under the tongue as low as 82° during the asthmatic fit. He observes, also, that the violence and inconvenience of the paroxysm is equal, whether the stomach be full or empty ; but that great distress is experienced immediately after the fit, if the stomach be completely empty. Patients often experience a sensation in the abdomen, about the commencement of the paroxysm, as if an evacuation from the bowels would certainly greatly relieve them; hut this feeling is almost invariably deceptive. No distinct pain is felt in the chest during the asthmatic paroxysm. Causes.—Asthma very rarely occurs before the age of puber- ty ; yet Dr. Gregory states, that "the period of youth and manhood is most prone to it." If, indeed, we include the acute asthma of Millar, or as it is more commonly called in this country spasmodic croup, under the head of genuine asth- matic affections, as is done by most of the German writers, there can be no doubt of the correctness of this observation : but the spasmodic croup of children, and the true asthma of adults, are manifestly very distinct diseases. It is generally admitted, that a predisposition to this affection is sometimes hereditary. This predisposition would seem to consist in a peculiarly irritable state of the pulmonary system, or more correctly, perhaps, of the pneumo-gastric nerve. That this nerve is the seat of that peculiar condition which predisposes to asthma, seems probable from the circumstance, that in per- sons who are subject to this disease, almost all the organs to which this nerve is largely distributed are particularly liable, from slight causes, to functional derangement. Thus, there are few asthmatic subjects, who are not especially liable to gastric disorders ; as indigestion, flatulent colic, and gastral- gic affections. These facts would appear to show that the pneumo-gastric nerve which presides over the functions of the stomach and lungs is in a state peculiarly susceptible of being thrown into morbid excitement in asthmatic individuals, and that this condition, has probably an important share in forming the predisposition in question. Authors have divided asthma into various species, founded principally on the different characters of the exciting or proxi- mate causes of the disease. Bree has subdivided the disease into four varieties, namely : 1, those cases that are excited by the irritation of effused serum in the lungs; £, those arising from a gaseous acrimony in the pulmonary cells; S, those ASTHMA. 185 resulting from gastric or abdominal irritation; and 4, those depending on habit. This division is, however, altogether arbitrary, as it is manifestly founded on gratuitous principles ; for its dependence on an aereal acrimony in the lungs, is a mere hypothesis; and the effused serum in the lungs, is an effect probably, and not the cause of the asthmatic paroxysm. It is certain at least, that the difficulty of breathing always com- mences and continues for some time before the effusion of mucus into the bronchial cells becomes copious. Richter describes no less than eleven species of asthma, founded on the character of its prominent exciting causes, namely : asthma hypochondricum et hystericum ; A. plelhoricum ; A. urino- sum ; A. aereum; A. abdominale ; A. nocturnurn incubus; A. meiallicum; A. a causa specifica ; A. ex debilitate ; A. spasmodicum ; and A. acutum periodicum millari. Some writers assume only three varieties:— the spasmodic, the dry, and the asthma from abdominal irritation. Dr. Good has admitted of but two species, namely: the dry or nervous, and the humid asthma. Such divisions do not, however, appear to possess any essen- tial practical usefulness; and the mere dryness or humidity of the cough, cannot, I think, be regarded of sufficient import- ance to form the basis of & pathological distinction. As symp- toms, they unquestionably deserve attention ; and it is no less proper, in a practical point of view, to attend to the nature of the exciting causes. The judicious and careful physician will not, however, require the aid of classification, and subdivi- sions, to bring these circumstances to his attention ; and it may be reasonably doubted whether any distinctions not founded on prominent and essential points of difference, can be useful- ly admitted into the description and pathology of diseases. The exciting causes of asthma, are— 1. Particular conditions of the atmosphere, in relation toils dryness or humidity, electricity, and temperature. In general, asthmatic individuals breathe'easiest in a pure and unconfined air; but there are many who breathe better in the impure atmosphere of populous cities or crowded rooms, than in the fresh and uncontaminated air of the country. Most persons subject to asthma, bear a dry and warm air much better than a cold and humid atmosphere ; but here too, the very reverse sometimes obtains in certain individuals liable to this affection. Some suffer most from this disease during the warm weather of summer ; whilst others experience its attacks only in the winter, or about the autumnal and vernal equinoxes. 2. Various irritating matters inhaled into the lungs, are capable of exciting the disease in persons predisposed to it; such as dust, and the fumes of lead, arsenic, sulphur, nitric acid, tobacco, and other irritating and offensive vapours. vol. ii.—-24 186 ASTHMA. 3. Gastro-intestinalirritation, from indigestible and irritat- ing articles of food, vitiated secretions, or a loaded state of the bowels, is one of the most common exciting causes of the asth- matic paroxysm. Almost all asthmatic subjects are peculiarly liable to gastric disorders from causes of this kind, and even slight irregularities in diet are apt to give rise to oppressed breathing in individuals of this habit. 4. The suppression of habitual sanguineous and serous dis- charges, frequently give rise to this affection. I have, during the last eight years, occasionally attended an old gentleman in whom the temporary drying up of a long standing superficial ulcer on the left leg has invariably been followed by violent paroxysms of asthma. I have seen an instance in which very distressing asthmatic symptoms alternated with the hsemorrhoi- dal discharge. The suppression of the menses sometimes gives rise to nervous or hysterical asthma. 5. Metastasis of rheumatism and gout, and of various cuta- neous affections, sometimes gives rise to more or less violent asthmatic symptoms. One of my patients, a rheumatic sub- ject, has had several violent fits of asthma during the remissions of his arthritic affection. Mr. Andral mentions an extremely violent case, which was produced by the sudden disappearance of a dartrous eruption. Leeches and blisters were applied to the part where the eruption had disappeared; and the asthma, by this measure, was completely removed in a few days.* 6. General plethora, in co-operation with causes that pro- duce strong sanguineous determinations to the lungs, or in- crease the momentum of thecirculation, is particularly favour- able to the occurrence of asthma. Individuals of obese and robust habits, florid and full complexions, with large and tur- gid veins about the neck and head, are especially liable to asthmatic symptoms from over-exertion by exercise, loud speak- ing, singing, or violent mental emotions. 7. Cold, when the body is in a state of free perspiration, and particularly suppressed perspiration of the feet, may excite the disease. I attended a lady about ten years ago, who suffered exceedingly from a protracted and regular paroxysm of asth- ma, which was brought on by bathing her feet in very cold water. She was subject to profuse sweating of the feet. 8. Mental emotions, particularly violent anger and terror, will sometimes excite asthma in those who are predisposed to 9. Particular odours and articles of diet from peculiarity of habit, or idiosyncracy, may give rise to asthmatic affections in certain individuals. Thus, the odour of ipecacuanha has ex- cited the disease in some persons; and instances are mentioned * Med. Chir. Rev. vol. vi. p. 447. ASTHMA. 187 in which asthmatic paroxysms have been caused by the odour of musk, roses, red beets, fresh hay, and of sealing-wax. (Parry.) 10. But by far the most common exciting cause of asthmatic symptoms, is organic affections of the heart and aorta. Ossi- fication of the cardiac valves, hypertrophy, aneurism of the large arterial trunks within the chest, and other organic causes that disturb the action of the heart, are rarely wholly free from symptoms of asthma. It is, generally, in cases of this kind, that we find the disease to alternate with oedema of the ex- tremities, both being merely symptomatic of the cardiac affec- tion. 11. Finally, asthma, like all other paroxysmal, nervous, and spasmodic affections, may continue to recur under the influence of what Dr. Darwin calls association, or that tendency in the animal economy to repeat morbid actions, when once establish- ed in the system, without the renewed application of the ori- ginal exciting cause. Pathology.—Various and very discrepant opinions have been expressed with regard to the pathology or proximate cause of asthma. Of late years, several French writers* have denied, or at least greatly doubted the possibility of asthma, indepen- dent of organic disease within the cavity of the chest. There can be no doubt, indeed, that perhaps the majority of cases of what are usually called asthmatic affections, arise from causes of this kind, more especially from organic cardiac diseases, aneurism of the large arterial trunks, and pulmonary hepati- zation. The occurrence of purely spasmodic asthma, wholly independent of obvious structural disorder, is, nevertheless, equally unquestionable. In relation to the immediate cause of the dyspnoea in spas- modic asthma, there are two doctrines which at present divide the sentiments of pathologists. According to some, the suffo- cative breathing is caused by a spasmodic constriction of the air-cells and smaller bronchial tubes, in consequence of which the free admission of air into the lungs is greatly impeded. Others believe, that the oppressed respiration depends on vas- cular engorgement of the mucous membrane of the bronchia, giving rise, by the tumefaction of this membrane, to a me- chanical diminution of the bronchial tubes and cells, and con- sequent obstruction to the regular intromission of air to the lungs. Laennec, among many others, has adopted the former opinion, and has endeavoured to prove that the bronchial ra- mifications are furnished with a coat of circular fibres, begin- ning where the cartilaginous circles terminate. By the spas- modic contraction of these fibres, the air-passages are obstruct- * Rostan. 188 ASTHMA. ed and the phenomena of asthma produced. He asserts, that he'has "met with many cases in which it was impossible, after the most minute examination, to find any organic lesion what- ever, to which the asthma could be attributed. I am convinced," he says, "that the asthmatic paroxysm may he induced equal- ly by the supervention of a fresh catarrh, and by a deranged state of the nervous influence occasioning pulmonary spasm, or an increase of the necessity of respiration, and sometimes by both causes at once. With the exception of the different kinds of catarrh, the occasional attacks of asthma and dysp- noea are almost always of a kind to give occasion to an imme- diate and evident disturbance of the nervous influence. Of this kind are strong mental emotion; venereal excesses; the influ- enceof light and darkness; retrocession of gout, (a disease which from its mobility and various effects can only be considered a nervous affection;) certain odours, such as those of the tube- rose, heliotrope, stored apples, &c; changes of atmospheric air, electricity, and other less appreciable conditions of the at- mosphere."* Mr. Abernethy appears to entertain a similar view of the nature of asthma. He contends, that one of the principal causes of this disease is a morbid irritability of the mucous membrane of the air-cells. "A man," he observes, "having irritable lungs, may be sitting comfortably enough at the fire-side, but a little smoke comes into the room, and he can breathe no more; he gasps for breath, he cannot enlarge the chest, and he finds the utmost difficulty in respiring ; but where is the difficulty ? Where is the sensation of pain and contraction? Why in the lungs themselves ; the hindrance is there; I believe it is all ir- ritability, and which proceeds from the state of the stomach."! Other writers of eminence have declared it as their opinions, that pure spasmodic asthma depends immediately on a con- striction of the air-cells and smaller bronchial ramifications, by which the ingress of atmospheric air is impeded or prevent- ed, and suffocative respiration produced. It has been objected to this doctrine, that we have no evidence of the existence of muscular fibres in the smaller branches of the bronchia and air-cells ; but M. Laennec observes, that as such fibres do un- doubtedly exist in the larger bronchial tubes, analogy must lead us to admit their existence in the ultimate ramifications. " Be- sides, it is by no means demonstrated," he says, "that mus- cular fibre is the only contractible tissue ; indeed, the contra- ry is proved by the fact, that animals of almost a mucilaginous consistence are capable of evident contraction."^: * On the Diseases of the Chest, last edition, p. 414. t Lectures, p. 375. t Loc. cit. p. 408. ASTHMA. 189 We are not, however, without direct evidence of the existence of contractile fibres in the minuter bronchial tubes. Professor Nasse of Halle, has published some very interesting experi- ments on pulmonary contraction.* He asserts, that in the lungs of sheep, he was able, with a good lense, to trace the lon- gitudinal fibres of the internal surface of the bronchia, described by Soemmering and Reiseisen,f into the smallest bronchial ramifications ; and by means of the galvanic influence he de- monstrated the contraction of these fibres in the most unequi- vocal manner. Morgagni has very particularly noticed the fibres of the bronchia ;\ and although their apparent tendinous character would seem to oppose the idea of their possessing contractility, yet, we perceive that the contractile fibres of the bladder and uterus, possess a somewhat analogous appearance and structure. From the experiments of Nasse, it appears, that the bronchial fibres possess considerable contractility, that by passing the galvanic influence through the pneumo-gas- tric nerves, these fibres and consequently the whole lungs, are thrown into a state of contraction ; and finally, that by dividing the par vaga, the power of pulmonary or bronchial contraction is destroyed, and dyspnoea produced. It is highly probable, therefore, that asthma consists essen- tially in a peculiar irritation of the pneumo-gastric nerves, in consequence of which the smaller bronchial tubes and air-cells are thrown into a state of spasmodic constriction, by which the regular ingress of air to the lungs is prevented. When we advert to the almost invariable antecedent and concomitant manifestations of functional disorder of the stomach in this affection, wc have good reasons to conclude that the nerves which especially preside over the functions of this organ and the lungs, are in a state of irritation or morbid excitement. The suddeness with which the asthmatic paroxysm is sometimes excited by mental emotions and other causes that act directly through the nervous system, and abore all, the rapidity with which it is often dissipated by a few full doses of the lobelia infiata, are directly and strongly confirmatory of this view of the pathology of the disease. The existence of a constricted state of the ultimate branches of the bronchia, dependent we may presume, on the functional derangement or irritation of * Undersuchungen ueber die naechste ursache des hustens. Leipzig, 1829, p. 9. t Ueber den Bau der Lungen. \ Extant in tunica intima ceu lacerti quidam insignes ex albicantibus fibrillis compacti. Hi digitos aliquot supra asperae arteriae divisionem initium capiunt, et secundum ejus longitudinem dispositi, interstititium il- lud, quodmemorabam,tenentes, ubi adsecundam bronchiorumdivisionem pervenerunt, ibi primum solent per omnem undique bronchiorum super- ficiem ad istorum extrema versus decurrere. Quorum lacertorum usus nunc non existimo.—Adversaria Anatom. Adver. I. § 25. 190 ASTHMA. the pneumo-gastric nerves, appears, moreover, to be confirmed by the good effects which, according to Dr. Chiarenti, result from the artificial insufflation of atmospheric air into the lungs in this affection.* Dr. Parry, however, considers this opinion of the nature of asthma as being without the least foundation, and ascribes the dyspnoea to great vascular turgescence in the bronchial mucous membrane, by which the smaller respiratory passages are me- chanically diminished or closed, until the vessels relieve them- selves by a copious effusion of serum. If, however, vascular congestion were the only or principal morbid condition upon which the peculiar symptoms of the disease depend, it would seem extremely improbable, that any impressions made on the stomach would be capable of speedily arresting the progress of the disease; and yet, in a considerable number of instances, I have known violent paroxysms of asthma greatly, and in one case completely, allayed in less than thirty minutes, by the use of the lobelia. There can be no doubt, that congestion always takes place to a greater or less extent in the vessels of the bronchia and air-cells, after the development of the parox- ysm ; but if this congestion were as great as Dr. Parry and others seem to think, is it not very likely that effusions of blood would occasionally show themselves in the expectora- tion ? The mere circumstance of the frequent inordinate se- cretion of mucus into the bronchia, is no satisfactory evidence that great sanguineous congestion pre-existed in the mucous membrane of the lungs. It is well known, that the process of secretion is wholly under the influence of the nerves, and we do no violence to correct physiological data, in presuming that the effluxion of mucus in question, is determined by the irrita- tion of the pneumo-gastric nerves. Prognosis.—An attack of spasmodic asthma seldom proves fatal; and although the frequent recurrence of the disease is apt ultimately to give rise to dangerous pulmonary conges- tions, effusions within the chest, and general exhaustion, it is by no means uncommon to meet with persons of very advanced age, who have been long subject to this disease. Where asthmatic symptoms are connected with, or symptoma- tic of organic pulmonary or cardiac disorder, the prognosis is of course always peculiarly unfavourable, for in such cases fatal dropsical effusion into the cavity of the pleura, or the pericar- dium is almost a never-failing consequence of the disease. Spasmodic asthma, resulting from mental emotions, or some peculiar odour or vapour, is in general less obstinate and pro- tracted than those cases that arise from gastric irritation, or recur from the influence of habit. * Journal de Progress. Vide Med. Chir. Rev. Jan. 1828. ASTHMA. 191 Treatment.—The treatment of asthma is either merely pal- liative, or radical, according as we prescribe for the mitiga- tion and removal of the paroxysm, or the prevention of its subsequent recurrence during the intervals of the fits. A great number of remedies and modes of treatment have been recom- mended for palliating or allaying the asthmatic paroxysm; but the effects of remedies of this kind are extremely variable in differeat cases. Some will do much good in one person, and fail altogether of procuring relief in an apparently similar case in another individual. Nay, the same remedy will in one at- tack afford speedy relief, and fail entirely in another paroxysm in the same person. (Laennec.) According to the pathology advocated above, the principal indications of cure during the paroxysm are to diminish the pulmonary congestion, and especially to relax the spasm of the bronchial tubes and air-cells. Where the pulse is active, and the countenance livid, in young and vigorous subjects, blood should be freely drawn; for, although venesection will rarely by itself make any decisive or permanent impression on the paroxysm, its employment is always proper in robust and sanguineous habits, to obviate any evil consequences that might result from the violent pulmonary and cardiac con- gestion ; and as a preparatory measure to the employment of other remedies, Professor Potter of Baltimore, expresses much confidence in the efficacy of blood-letting in asthma. He con- siders bleeding "not only the most effectual remedy" in strong subjects, but in many instances capable of effecting a radical cure.* Laennec observes, that " we must never omit blood- letting, whenever the lividity of the countenance, the strength of the patient's constitution, or the overaction of the heart, indicate pulmonary congestion ; but we must be careful not to abuse this practice, which, in general, only produces a tempo- rary advantage." In old persons who have suffered much from the disease, it is not in general prudent to abstract blood. It must be observed, however, that many writers regard this measure as always of very doubtful propriety, and often inju- rious in its effects. Judging from my own experience, I am not inclined to place much reliance on its palliative effects, al- though, for the reasons stated above, 1 have very generally resorted to it, in robust and full habits, without having ever known any ill consequences to result from its employment. The narcotics have been a good deal employed with the view of allaying the asthmatic paroxysm. Laennec has found opium and colchicum the most powerful remedies for mitigating and curtailing the paroxysm. Articles of this kind, he says, may act beneficially, both by lessening the necessity of respiration, and by relaxing the pulmonary spasm. Hyoscyamus and * Gregory's Practice, vol. i. p. 187, second edition. 192 ASTHMA. stramonium may also be used with considerable advantage in some instances. The latter article, in particular, has done much good in several instances of habitual asthma, under my own observation. In one case, a quarter of a grain of the ex- tract given every four hours for two days, suspended the disease entirely for upwards of "nine months. The leaves and root of this plant, smoked in a pipe, will sometimes give much ease to habitual asthmatics ; and it is said, that when used in this way, it will occasionally mitigate the paroxysms of the complaint very promptly and decisively. I have prescribed it in a few instances in this manner, but never with any particu- lar advantage; and writers have mentioned instances in which it proved decidedly injurious. In cases attended with catarrhal irritation, and a very co- pious secretion of viscid mucus into the bronchia, emetics will sometimes procure considerable relief. The production of eme- sis is particularly proper, where the paroxysm comes on soon after taking a full meal. It is not necessary, nor, in general, proper to excite strong vomiting. Dr. Akenside asserts that he has derived as much benefit from nauseating doses of ipeca- cuanha in this affection, as from full emesis. It is generally ad- mitted, that ipecacuanha is decidedly the best article for this purpose. It is said that the union of distilled vinegar and ipe- cacuanha forms a particularly useful remedy in this disease. Three grains of the latter with three drachms of the former, may be taken every fifteen minutes, until nausea or gentle vo- miting is excited. The vinegar of squills, too, has been highly extolled in asth- matic affections, both for its emetic aad expectorant powers. Sir John Floyer considered this preparation as a specific in asthma. He asserts, that he has often prevented the paroxysm by taking a dose of it at bed-time. Dr. Bree, also, places much reliance on the powers of this remedy ; and he observes that its efficacy is in proportion to its emetic operation. I have known much relief obtained from this remedy, taken in two drachm doses every half hour until nausea was induced ; more frequently, however, not the slightest advantage resulted from its use. Vinegar is much praised by Bree as a palliative in the pa- roxysm of spasmodic asthma. He found it more frequently and decidedly beneficial, he says, than any other remedy he has tried. One of my patients, affected with occasional paroxysms of this disease, has in several attacks derived great relief from two or three table-spoonsful of strong vinegar taken at inter- vals of half an hour, and from inhaling its fumes. In the last two attacks, however, he derived no obvious advantage from its employment. Bree speaks very favourably, also, of the union of acids and ASTHMA. 193 narcotics as palliatives in the asthmatic paroxysm. He recom- mends the following formula as an excellent combination of this kind.* In the asthma of old people, attended with deficient urinary secretion, oedema of the feet, diuretics sometimes answer an excellent purpose. It is in cases of this kind especially, that the squill may be used with benefit. In general, a good deal of advantage may be derived from diuretics in habitual asth- matic affections. Dr. Ferriar speaks well of the powers of digitalis, combined with small doses of opium, in such cases; and Dr. Percival asserts, that he has known this combination to produce very favourable effects. A copious flow of urine is always a favourable symptom in this affection. Some writers (Pringle, Percival) speak favourably of the use of strong coffee in this affection. I have met with a few individuals who derived advantage from its use during the paroxysm. In another person, however, subject to habitual/ difficulty of breathing, with occasional violent fits of dyspnoea, the use of coffee has, of late years, invariably aggravated the difficulty of respiration. Expectorants also may occasionally be employed with some benefit in this disease; and, for this purpose, the different pre* parations of the squill appear to he the best remedy. I have known the following mixture to give much relieve towards the termination of an asthmatic paroxysm.f Antispasmodics do not often produce any good effects ; yet, in slight cases, considerable relief may be obtained from inhal- ing the vapour of ether; and in old and habitual cases, the aqueous solution of assafoetida has afforded temporary benefit. The only article of this kind which I have found to manifest any particular powers, in allaying the violence of the asthmatic paroxysms, is the root of the skunk-cabbage. {Symplocarpua foetida.') I have occasionally employed this article in attacks of spas- modic asthma, and in several instances, with much temporary benefit. From thirty to fifty grains of the powdered loot may be taken every two or three hours during the paroxysm, ac* cording to the urgency and obstinacy of the symptoms. Of all the remedies we possess, however, the lobelia infiata * R. Tinct. scill. gtt. x. Acid, nitric. gr. vi Extract, hyoscyam. gr. iii. Aquae fontan» |iss. M. This draught is to be repeated thrice daily. t R. G. Ammoniac 3»- solve in Acid, scillae ziss. Tinct. opii. camph. £ss. M. Take a tea-spoonful every hour, in a little clear and strong coffee. VOL. II.—25 194 ASTHMA. is, I think, decidedly the most valuable in this affection. With- in the last five years, I have had an opportunity of witnessing its good effects in four cases, and 1 can truly say, that in two of these, it acted like a charm. I have known the most vio- lent paroxysm of spasmodic asthma completely subdued in less than thirty minutes by this medicine. It appears to me that ergot does not more certainly act upon tl\e gravid uterus dur- ing parturition, than the lobelia upon the pulmonary organs in asthma. I have even found it to mitigate the dyspnoea, which occurs in consequence of organic affections of the heart. The good effects of a full dose of this medicine are often ex- perienced in the course of ten or fifteen minutes after it is taken. The Rev. Dr. Cuttler, in a violent paroxysm of spasmodic asthma, took a table-spoonful of the saturated tincture. " In three or four minutes," he says, " my breathing was as free as it ever was. In ten minutes I took another spoonful, which occasioned sickness. After ten minutes I took the third, which produced sensible effects on the stomach, and moderate puking, with a kind of prickly sensation through the whole system, even to the extremities of the fingers and toes. Since that time I have enjoyed as good health as perhaps before the first attack."* In a case of spasmodic asthma, in which I em- ployed this tincture during the present summer, the dyspnoea was almost entirely allayed in fifteen minutes after the first dose was taken. I have not found it necessary to give it to the extent of producing emesis, though some evidence of its in- fluence on the stomach, as nausea, is desirable. A table-spoon- ful of the saturated tincture may be given every ten or fifteen minutes. A great variety of other remedies have been employed with more or less advantage in asthma. The prussic acid was suc- cessfully given by Dr. Oliver and Dr. Granville. Alkalies, particularly the carbonate of potash, will be proper where there is reason to suspect acidity of the stomach. Dr. Bree strongly recommends the use of prepared chalk and rhubarb, in combination, in cases of this kind—more especially after the operation of a gentle emetic. The use of laxatives, with some absorbent, will, in general, afford some advantage in habitual cases, attended with dyspeptic symptoms, and torpor of the bowels. Tonics also, are said occasionally to produce very good effects in protracted cases, attended with much debility and general relaxation. The hark is especially recommended by Sir J. Floyer. During the intervals of the paroxysms much benefit may, no doubt, be derived from this tonic, in individu- als of exhausted and relaxed habits; but there are few physi- cians, I presume, who would venture on the exhibition of this # Thacher's Dispensatory. ASTHMA. 195 remedy during the paroxysm, except under circumstances es- pecially indicating its employment. Dr. Chiarenti, an Italian physician, has lately published a statement, by which it appears that Ihe artificial insufflation of atmospheric air, by means of a common bellows, is capable of speedily removing the asthmatic paroxysm. " He introduced the pipe of the bellows into his mouth, (he was himself affected with the disease) and, closing the nostrils, he pushed the air forcibly into his lungs, and with instant relief." He after- wards tried the same means in other cases of this disease, and always with the same happy result.* Galvanism has of late years been employed with advantage in chronic asthmatic affections, by Dr. Philip and others. The galvanic influence must not, however, be communicated with much force. The two wires of a weak trough are to be attach- ed, one to a piece of metal placed on the pit of the stomach, and the other on the side of the neck, over the par vagum. With the view of preventing the recurrence of the asthmatic paroxysms, recourse must he had to tonics, a regulated diet, a change of air or climate, and regular exercise; and the usual exciting causes of the disease must be carefully avoided. The tonics usually employed are hark, quina, arsenic, and the carbonate of iron. Laennec states, that he has derived much advantage from the latter article, during the inter- missions of the disease. Whilst tonics are employed, at- tention must also be paid to the state of the bowels, and the hepatic functions. An occasional blue pill at night, followed by a gentle aperient in the morning ; the use of the tepid show- er-bath where the system is relaxed or exhausted, or cold bath- ing in robust and full habits, together with regular exercise out of doors, change of air or climate, agreeable occupation of the mind, a light and simple diet, and the careful avoidance of the usual exciting causes of the disease, are the most effectual mea- sures for preventing, or postponing and moderating the vio- lence of the attacks. Attention must, of course, be paid to the character of the exciting cause in prescribing for asthma, both with a view to its palliation and radical cure. When the dis- ease is attended with a rheumatic or gouty diathesis, colchi- cum, diuretics, and opium are especially indicated. When it succeeds the healing up of an old discharging ulcer, blisters and sinapisms to the part are proper. Andral succeeded in curing a violent case by means of this kind. Here diuretics, also, are generally peculiarly beneficial. Where catarrhal irri- tation has excited the disease, emetics, the warm-bath, squills, and opiates may be resorted to with a good prospect of success; and in cases that depend on gastric irritation, alteratives, the * Med. Chit. Rev. January, 1828, p. 221. 196 ASTHMA. warm-bath, mild aperients, tonics, and regular exercise are particularly proper. "Among the remedies best deserving notice in asthma, says Laennec, I would mention a mild and spare diet, residence in a more temperate climate, and warm bathing. The first of these measures will he found very bene- ficial in cases complicated with gastiic irritation ; the two last are especially indicated in that class of cases which date from the disappearance of cutaneous eruptions, under the use of powerful external applications."* CHAPTER XV. WHOOPING-COUGH. This is unquestionably one of the most remarkable diseases with which we are acquainted. A cough which is highly con- tagious in its nature—which has its regular rise, progress, and declension—and which completely destroys the susceptibility of the system to a subsequent or second invasion of the disease, is a phenomenon, truly mysterious and striking. It is maintained by some writers, that whooping-cough is comparatively a modern disease ; and some assert that it was first brought into Europe out of Africa, in the 13th century. By consulting the works of the ancients, however, it would seem that this disease was known at a very early period of our science. Hippocrates in the 6th book on Epidemics, and also in the 6th section of his Aphorisms, speaks of a cough, which, from the short description he gives of it, may, I think, he regarded as the same affection which is now known under the name of whooping-cough. The first distinct and comprehensive de- scription of this malady, however, was given by Mezeray, in the year 1414, in his Chronological History of France. Since that time, a great many epidemics of this disease have been cir- cumstantially recorded; and medical literature furnishes us with no inconsiderable number of elaborate monographs on its nature and treatment. Whooping-cough usually commences with the symptoms of ordinary catarrh. The patient at first experiences some de- gree of lassitude, headach and sneezing, with a slight hoars- ness and occasional oppression of breathing. The sleep is generally disturbed by dreams and sudden starts ; the appe- tite becomes weak, the bowels torpid, and the pulse slightly febrile towards evening. For the first two or three weeks the cough is almost always dry and ringing; and the paroxysms • Loc. cit. p. 419. WHOOPING-COUGH. 197 are short and free from that peculiar sound which is called whooping. At the end of this time the disease begins to as- sume more of a convulsive or spasmodic character, so far at least as the mere cough is concerned. The paroxysms of coughing now come on more frequently, and are of longer du- ration than previously. The inspirations during the fits of coughing are extremely difficult, slow, and stidulous, and attended with a sense of obstruction or spasmodic stricture of the glottis, rendering the paroxysms distressingly suffocative, and, in a manner, convulsive. The approach of a fit of coughing is generally announced by a peculiar sensation of tightness in the breast and of titration in the larynx and praecordia. These circumstances should be borne in mind, for they throw considerable light on the patho- logy of this remarkable affection. The duration of the fits of coughing is very various. In some instances, the paroxysms are generally over in less than half a minute; in others they last from five to six minutes, and often longer. The spell of coughing at this stage of the disease, is always terminated by the discharge of a large quantity of a viscid mucus ; and the patient frequently experiences some pain in the chest, imme- diately after the cough has subsided. In many cases the cough continues until vomiting comes on, when it is immediately ar- rested, and the patient is greatly relieved. So violent in some instances is the fit of coughing, that it induces a state of par- tial insensibility, and a most distressing sense of impending suffocation. Occasionally, the determination of blood to the head is so great during the paroxysm of coughing, that it bursts out from the nose and mouth ; and it is not uncommon for children to become convulsed, in consequence of the cere- bral compression from this cause. In this aggravated state, the disease usually continues from four to six weeks, before it begins to abate. The declension is always very gradual, continuing commonly from two to four weeks. Fever is not essentially connected with the disease, although in many in- stances there is a manifest febrile irritation present during some period of the complaint. Whooping-cough occurs almost exclusively during child- hood. I have nevertheless met with two instances of the dis- ease in subjects beyond the 50th year of age, and several in persons between the 30th and 40th year. It is highly conta- gious, and occurs almost universally in an epidemic form. I have never yet met with a sporadic case of this affection, al- though it cannot be doubted that such instances do occasionally occur. It would seem as if there existed some latent connexion between the contagions of whooping-cough and measles ; for the former frequently prevails most extensively, either immediately previous, or in alternation, or directly after the occurrence of epi- 198 WHOOPING-COUGH. demic measles.* Spring and autumn appear to be most favour- able to the occurrence of whooping-cough, and it is during the wet and variable periods of these seasons too, that the disease is most liable to become dangerous from the pneumonic affec- tions which atmospheric vicissitudes are so apt to produce. As is the case w ith all other epidemic diseases, considerable di- versity occurs in the grade of violence which different epide- mics of this affection assume. Some ejidernics are so mild that the disease is attended with but little difficulty, and passes by numbers who are still susceptible of it. At other times the disease manifests a violent and dangerous character; and seizes on almost every individual, whether old or young, who has not as yet had the disease. Prognosis.—Whooping-cough rarely terminates fatally, un- less by the supervention of bronchitis, hydrocephalus, pneu- monia, cynanche trachealis, apoplexy, or marasmus. As these secondary and superadded affections are, however, by no means uncommon—especially in variable and humid seasons—the disease, upon the whole, deserves to be regarded as one of con- siderable danger. It would appear to be a vastly more dan- gerous affection in northern or cold climates, than in the mild and equable regions of the middle and southern latitudes. Ro- senstein states, that in Sweden there were 43,393 deaths from this disease between the years 1749 and 1764—and of these, 5832 deaths occurred in the year 1755 alone. (Richter.) In general, the younger the patient suffering under this dis- ease, the more apt is it to terminate fatally. Cullen observes, that by far the greater number of those who die of this disease, are children under three years of age. When it attacks weak and delicate infants within the first few months after birth, it is always attended with great danger; yet robust and healthy infants, even at this early age, generally pass through the dis- ease without much difficulty or danger. In children born with a scrofulous diathesis, whooping- cough is exceedingly apt to call the strumous affection into ac- tion. Scrofulous ophthalmia, and glandular tumours in the neck, frequently succeed whooping-cough. I know of no dis- ease which is more to he dreaded than whooping-cough, in subjects of an hereditary consumptive habit. Where there is a predisposition to the formation of tubercles, or where these exist in an incipient and dormant state, an attack of whooping- cough will rarely fail to develop phthisis pulmonalis. In many instances the disease terminates in chronic bron- chitis, in which case the expectoration becomes purulent, and symptoms of hectic supervene. This is especially apt to occur when the patient takes cold from exposure to a damp and va- * Richter, Specielle Therapie. WHOOPING-COUGH. 199 riable atmosphere—a circumstance which always greatly ag- gravates the violence and danger of the disease. I have seen but few deaths from whooping-cough which were not attended with bronchitis, purulent expectoration, and hectic symptoms from having taken cold. The matter expectorated in these cases has generally a very peculiar appearance, resembling more a mixture of cream and mucus than any thing else I know. In some instances an accidental cold will renew the cough, and protract it for several months in a state of great violence after it had nearly disappeared. Cases are often thus pro- tracted for five or six moriths. When the disease assumes a chronic character, from cold or some other casual circum- stance, it sometimes ultimately terminates in hydrocephalus— more especially if the patient is labouring under the irritation of difficult dentition, or in children habitually subject to disor- dered bowels. Cynanche trachealis, too, not unfrequently su- pervenes during whooping-cough, and this is most apt to happen in children of robust and full habits, during the early stages of the disease, and is almost always the consequence of cold. The occurrence of cynanche in this affection is attended with the greatest danger. It is observed by Richter, that a profuse watery diarrhoea coming on suddenly in this disease when pneumonic symptoms attend, is always to be regarded as one of the most dangerous occurrences. Death, he says, often follows such a discharge very speedily. The appearance of aphthae in the mouth and fauces in the latter period of the disease, is also a very unfa- vourable sign. CEdematous swelling of the feet and face is not an uncommon occurrence in this affection, and when it takes place towards the conclusion of the complaint, it is rarely fol- lowed by unfavourable consequences. When such swellings supervene in the commencement of the disease, however, they portend much danger—more especially if they are accompa- nied with a turbid, milky urine. (Richter.) Hufeland observes, that the occurrence of some degree of strangury in the advanced stage of the complaint, is generally soon followed by a mani- fest mitigation of the symptoms of the disease. A sudden cessation of the cough, it has been remarked, is an unfavoura- ble occurrence, and is frequently followed by pulmonary inflam- mation. In general, the more fever there exists in this affection, the more violent and dangerous it may be considered. It is asserted by some writers, (Hufeland, 1. c. p. 420 : Len- tin, Memorabilia, p. 36: Jahn Kinderkankn. p. 399,) that children affected with some chronic cutaneous affection, as tinea, itch, &c. very rarely take this disease; and if they do become affected with it, almost invariably pass through it in the light- 200 WHOOPING-COUGH. est manner. This, however, is contradicted by others—parti- cularly by Hoffman and Haase. Among the affections which are properly called sequela of this disease, the following are the principal. Strumous swell- ings, dropsy, epilepsy, ophthalmia, rickets, general cachexy, aneurism, deafness, dementia, paralysis, and phthisis pulmo- nalis. I have known most of these affections to occur as consequences of whooping-cough; and of these, epilepsy, struma, phthisis pulmonalis, and ophthalmia appear to be the most common. When these and other consequences are taken into view—and they are by no means uncommon—we cannot but regard this disease as always one of very serious import. Whooping-cough is indeed as much to be dreaded on account of the many affections which are apt to supervene during its course, or to remain after its disappearance, as for its own proper power, however violent it may he. When perfectly free from any adventitious complications, it cannot be regarded as a disease of much danger, unless in very young and feeble subjects. Cause.—There exists no other cause, so far as we know, capable of producing this affection, than the peculiar contagion which is generated by the disease itself. Richter observes, that besides this contagion, cold in conjunction with humidity also, may give rise to this affection. For this opinion there do not exist, however, any good grounds; and it seems to me just as improbable as that small-pox or measles should arise from accidental causes. It may be said that all these diseases must have primitively originated from accidental causes—be- cause the first case could not have arisen from a contagion ge- nerated by the disease itself. Nothing, in truth, is more mysterious and incomprehensible than the origin of those diseases which we now find to be engendered and propagated by a specific agent alone, elaborated by the living body actually suffering under the disease. The only solution we can offer, and it is indeed vague enough, is, that in the infinite combina- tions which the material elements of. the universe are capable of forming, agents may have been evolved by a peculiar con- currence of circumstances, which had the power of originating these affections in the human system. It is in this way alone that we can give any plausible explanation of the occasional rise of new diseases—which when once originated, propagate themselves by elaborating their own specific causes. Whatever may be our speculations in relation to this curious and interest- ing subject, the cause of whooping-cough is undoubtedly in all instances a specific contagion. Riverius, Linneus, Dessault, Rosenstein, and more recently Clesius, maintain that whooping-cough is produced by the in- halation of microscopic animalcula. Whooping-cough does not appear to possess a contagious WHOOPING-COUGH. 201 character until it has made considerable progress, (Richter;) or until the second or convulsive stage has supervened. The contagion of this disease, although very active, does not extend far from the body of the affected person. It is accordingly almost always prevented by separating the healthy from the affected portion of families. Autopsicphenomena.—The appearances discovered on post- mortem examination are various and often quite contradictory. Much diversity must necessarily result in this respect from the various accessory affections which are so common in this complaint, and the different periods of the disease in which death occurs. We cannot, for instance, expect to find the same post-mortem appearances in a case which terminates fa- tally in consequence of pneumonia, as in one in which death occurs from apoplexy; nor is it reasonable to presume that there should be much uniformity in the autopsic phenomena, where the immediate cause of death is so various, or dependent on such a diversity of accidental affections. As the respiratory organs are the parts most obviously implicated in the disease, the principal attention of pathologists has of course been al- ways directed to them, for a solution of the pathological cha- racter of this affection. Many writers speak particularly of the frequency of traces of inflammation in the mucous mem- brane of the bronchia and larynx. Strong, Cullen, Astruc, Lettson, and Danz, mention these appearances as by far the most common; and more recently, Whatt and Marcus have adduced striking instances of this kind. The former lost three of his own children by this disease, and in each the marks of previous inflammation in the mucous membrane of the bronchia, were very conspicuous throughout its whole extent. Marcus gives but two dissections in which bronchial inflammation was discovered ; and in one of these a considerable quantity of pus was found in the air-passages, the smaller branches of which were in the most intense state of inflammation, approaching in some parts to gangrene. In some instances, the lungs have been found exceedingly congested, and the air-cells choaked up with an extremely vis- cid mucus, without any traces of bronchitis whatever. Loben- stein-Loehel relates an instance in which a considerable por- tion of the diaphragm was covered with a number of small pus- tules containing a purulent fluid.* After all, it is incontestible, that in many cases of death from this disease, no morbid appearances whatever are discovered on dissection, and there are good grounds for believing, that the inflammation and other phenomena which have been detected * Richter's Specielle Therapie. vol. ii—26 202 WHOOPING-COUGH. on post-mortem examination, have no essential connexion with the disease, but are altogether adventitious or secondary. Proximate cause.—The opinions that have been advanced, concerning the nature or proximate cause of this disease, are extremely various and contradictory. Hoffman considered it as depending on an acrid serum in the lungs. Sydenham as- cribed it to the effects of irritating effluvia, cast off from the blood into the lungs in consequence of the suppression of the insensible transpiration by the skin, from cold and damp air. Huxham and others placed the primary seat of the disease in some morbid condition of the intestinal canal; Butler, in the liver; and some have considered it, as the consequence of gas- tric irritation, or, according to Stoll, of crude and bilious mat- ters in the stomach. The opinion which appears to be most prevalent, at the present day, is, that the disease depends on a peculiar bronchial inflammation; and this doctrine would seem to receive much support from the appearances which are occa- sionally detected in the mucus membrane of the bronchia and trachea on post-mortem examination, as well as from the fe- brile movements which, in most instances, attend the disease. As, however, ordinary bronchial inflammation does not excite the train of symptoms which characterize this disease, the ad- vocates of this doctrine are forced to assume the position, that the inflammation in question is of a specific kind, capable of exciting the peculiar convulsive cough which distinguishes the disease. Whatever plausibility this doctrine may seem to pos- sess on a superficial view of the subject, strong, and in my opinion, insurmountable objections may be urged against its validity. It is true indeed, that fever is no uncommon attend- ant of this disease, and that unequivocal traces of inflammation are sometimes manifested on post-mortem examination. It is, nevertheless, equally true, that in many instances no febrile symptoms whatever occur during the early period, and occa- sionally none during the whole course of the disease; nor are the signs of previous inflammation in the respiratory passages always manifested on autopsic examination. That inflamma- tion must frequently supervene in the trachea and bronchia in a disease in which the lungs are so violently and frequently agitated as they are in the present one, is indeed to be expect- ed. Besides this accidental source of pulmonary inflammation in whooping-cough, there can be no doubt, that the lungs are especially predisposed, by the same circumstance, to the inju- rious influence of atmospheric vicissitudes, and consequently to the supervention of pulmonary catarrh, or bronchial inflam- mation. From these circumstances, we have the strongest grounds for believing that the inflammation which is frequently detect- ed en dissection in the mucous membrane of the respiratory WHOOPING-COUGH. 203 passages, is always accidental, and by no means essential to the perfect development of the disease. It may be observed, moreover, that bronchial inflammation is probably far from be- ing so common in this disease, as one might be led to think from the appearances discovered on dissection; for it must be recollected, that death occurs chiefly in such instances only as are attended by unequivocal symptoms of inflammation, and we may, therefore, reasonably expect to find traces of inflam- mation in such cases, although in the milder instances no such inflammatory condition may exist. If, however, bronchial in- flammation be the proximate cause of the disease, it must, ne- cessarily, be present in all cases, in the mild as well as in the violent instances of the malady, a circumstance which is deci- dedly contradicted by almost universal observation. The only dissection I ever witnessed of a subject that had died of this disease, presented no evidence of the existence of previous in- flammation in the bronchia. This patient died suddenly of convulsions during a violent paroxysm of coughing. That inflammation of the mucous membrane of the bronchia, is not essential to this disease, or its proximate cough, is proved moreover by the fact, that bronchitis is rarely, if ever, attend- ed with a violent cough, much less with that peculiar cough which distinguishes this disease. Bronchitis, too, in its acute form, is always rapid in its course, and is attended with strong fever and a continued sense of tightness and oppression in the breast. In the chronic form, the expectoration is invariably purulent and entirely distinct in its character from the ropy and transparent mucus which is expectorated in whooping- cough. It is also almost invariably attended with the usual symptoms of hectic fever. When cough depends on acute in- flammation of the respiratory passages, it almost always be- gins to decline as soon as the secretion ©f the bronchial mucus becomes copious. In whooping-cough, however, the reverse very generally obtains. During the first few weeks, there is seldom much mucus secreted in the bronchia ; but as soon as this secretion becomes more abundant, which occurs after the second or third week, the cough also acquires much more vio- lence, and especially that convulsive character which distin- guishes it from other varieties of cough. Very commonly, moreover, the slight symptoms of fever which accompany the development and first few weeks of the disease, vanish entirely in the second stage, when the cough becomes more spasmodic and violent in its paroxysms. (Richter.) This circumstance most assuredly does not favour the idea, that the disease is of an inflammatory character; for if this were the case, the cough, one should think, would decline with the fever; instead of which, it is always found to acquire much more violence. 204 WHOOPING-COUGH. It appears to me that whooping-cough is essentially a spas- modic or nervous affection, the proximate cause of which con- sists probably in a peculiar irritation of the eighth pair, or the pneumo-gastric nerves. If we attend closely to the phenomena which immediately precede and accompany a paroxysm of whooping-cough, we cannot but perceive unequivocal manifestations of a purely spasmodic condition of the respiratory apparatus. The sense of stricture in the breast and of the glottis, which is felt imme- diately before the fit of coughing—the sudden and convulsive character of the cough—the peculiar constrictive feeling in the prsecordia—the stritulous respiration, all point to a spasmodic state of the pulmonary system. That the irritation which calls forth the convulsive action of the diaphragm, and the other parts immediately concerned in the act of coughing, is seated in the eighth pair of nerves, may, I think, be inferred from the known agency which these nerves have in the production of the various phenomena manifested by the repiratory apparatus. The interesting experiments of Professor Nasse, also afford strong support to this opinion. In a series of experiments, in- stituted for the purpose of elucidating the pathology of cough, this experimenter found, that on bruising or strongly pinching the par vagum so as to break down its structure, a violent con- vulsive cough was invariably excited. By injuring in the same manner the diaphragmatic nerve, no such effect ensued. Ac- cording to these experiments, the act of coughing is performed almost wholly by the sudden spasmodic contractions of the di- aphragm. By opening the abdomens of various animals and exposing the lower surface of this muscle, he saw distinctly its viplent convulsive contractions during the cough, which was excited by bruising, with a pair of forceps, the pneumo-gastric nerves. The peculiar tone of the cough, and the sense of con- striction which is felt at the glottis, may arise from the irrita- tion extending to the recurrent branches of the vagus nerve; and that this irritation is peculiar or specific in its character, may be inferred from the nature of its exciting cause. Treatment.—It is very generally believed, that whooping- cough, though susceptible of much mitigation, is wholly un- controllable in its progress, and that no treatment is capable of materially shortening its course. This, I am persuaded, is an unfounded opinion. Sydenham, Werlhof, Hufeland, and several later German, Italian, and French writers, admit that it may be arrested in its course; but it is asserted, that this can never be done before the fourth week after its commencement. (Richter.) Be this as it may, my own experience does not permit me to doubt of its susceptibility of being curtailed in its progress ; and many well authenticated observations in confirmation of this fact might be collected from recent publications. WHOOPING-COUGH. 205 Although inflammation and fever do not constitute essential conditions of this disease, yet blood-letting may often be em- ployed in the first stage of the disease with manifest advantage. An unusual or preternatural momentum of the circulation is not to be regarded as a harmless circumstance, even in diseases strictly spasmodic. Whatever may be the essential character of a disease, if the pulse is full and active, blood-letting may be regarded as proper, and its employment will generally be productive of some benefit. In the present disease, if the ab- straction of blood should even afford no direct advantage over its characteristic symptoms, it tends materially to lessen the danger which may result from the violent cephalic congestions during the paroxysms of coughing, as well as to diminish the liability to the accidental supervention of inflammation. In cases attended with bronchial or pneumonic inflammation, bleeding is obviously indispensable; and should be employed promptly and decisively, both in a general and local way. To tamper with the ordinary remedies in cases of this kind, would be exposing the patient to great danger; for, when inflammation supervenes, it is this, and not the original disease which claims our principal attention, since the danger and obstinacy of pul- monic inflammation must be especially great in an affection, which, like the one under consideration, keeps up so constant and violent an irritation of the respiratory organs, by the fre- quency and violence of the cough. Leeching on the breast, is particularly valuable in cases of this kind. The extensive sympathetic relations which subsist between the intestinal canal and the various organs of the body, cause it to participate, in a greater or less degree, in almost every form of disease to which the human system is liable. Whatever he the nature of the malady, and in whatever system of struc- ture it may be principally located, the alimentary canal, sooner or later suffers functional disturbance, giving rise either to a remora of its recrementitious contents, or to a vitiated secre- tion of the fluids which are poured into it. These latter con- sequences become in their turn sources of intestinal irritation, and I need not say how great a tendency such irritation has to aggravate and sustain diseases, whatever may be their original source or character. The bowels are almost always in an unnatural condition in whooping-cough. The evacuations are sometimes bilious, or almost wholly mucous; and, in many instances, dark and ex- ceedingly offensive stools are passed. In prescribing for whooping-cough, it is of much consequence, therefore, to attend to the condition of the bowels, and to keep them in a moderate- ly loose state throughout the whole course of the disease. Very active purging, however, is improper, as it tends to increase, rather than to moderate the intestinal irritation when fre- 206 WHOOPING-COUGH. quently repeated. A grain or two of calomel in the evening, with a small dose of rhubarb on the following morning, will in general answer very well for this purpose. Where there is considerable febrile irritation present, small doses of the sul- phates of sodse or magnesia may be preferable. Emetics constitute an important class of remedies in the majority of pulmonary diseases. They are especially indicated in those affections of the respiratory organs, in which there is an abundant secretion of bronchial mucus. Much of the suffo- cative distress experienced by patients affected with whooping- cough, arises from the large quantity of viscid mucus which is lodged in the trachea and bronchia; and it is chiefly by ef- fecting the discharge of this impediment to free respiration, that emetics prove serviceable in this disease. It is not im- probable, however, that a part of their beneficial operation may depend also on the impression which they produce on the pneumo-gastric nerves in the stomach. They are particularly useful in the hooping-cough of infants; these are unable to throw off the viscid mucus that clogs the respiratory passages; and instances of death by suffocation from this cause have fre- quently occurred. When, therefore, the cough in very young children is violent, and attended with symptoms of impending suffocation, an emetic should be immediately administered ; or the fauces irritated with a feather, so as to bring on speedy vomiting. In cases of this kind, the sulphate of zinc will ge- nerally answer better than any other article, from the prompti- tude of its operation. It must nevertheless be observed, that the very frequent repetition of emetics, more especially anti- mony, is apt to bring on much weakness and irritation of the stomach, which may have a permanent injurious influence on the future health of the patient. I have in general preferred the ipecacuanha to every other article of this kind. Dr. Fo- thergill speaks very highly of the following combination as an emetic in this affection. R. Pulv. chel. cancror. 3SS« Tart, antimon. gr. ii. Misce. Of this 1, li,or £ grains may be given at a dose, according to the age of the patient. It has been supposed that the union of some absorbent with the emetic is peculiarly beneficial in this affection. The syrup of squills also forms an excellent emetic in very young patients. I have frequently prescribed this pre- paration, in union with a small portion of antimonial wine, with a very good effect. We may also prescribe the antimo- nial wine in union with an emulsion of assafoetida, with much advantage as a palliative. The narcotics furnish us with several very valuable reme- WHOOPING-COUGH. 207 dies for the treatment of this disease. Of these the belladonna is the most celebrated, and unquestionably by far the best arti- cle of this kind we possess. Professor Borda, who, I believe, was the first who employed this remedy in whooping-cough, speaks of its powers with unqualified praise. He asserts, that in a number of instances he has found it to remove every ves- tige of the disease in ten or twelve days; and that where it did not remove the disease entirely, it rarely failed to mitigate it very considerably. He observes, moreover, that he has known cases which appeared to be beyond the hope of recovery, re- stored by this remedy. The observations of Hufeland and Ali- bert, not to add the testimony of many other writers, speak in terms nearly equally favourable, of the virtues of this narcotic in the present disease. A large mass of incontestible evidence might he adduced from the current medical publications, illus- trative of the valuable powers of the belladonna in this singu- lar malady. From my own experience, I can testify with con- fidence to its virtues as a remedy in this affection. I have within the last six years prescribed it in perhaps twenty cases, and in the majority of them with manifest advantage. Since the publication of my work on the materia medica, my good opinion of the value of this remedy has been considerably in- creased. In two cases it arrested the complaint almost wholly in the course of eight days, although the disease was in both instances exceedingly violent. It does not appear, however, to answer any useful purpose in cases that are attended with fever and brochial inflammation. In instances of this kind the lancet with blisters, or tartar emetic ointment rubbed on the chest, are the means upon which our reliance must be almost entirely placed. In the purely spasmodic form of the disease, however, and where all symptoms of inflammation are absent, it is often singularly efficacious. The extract of conium, lactuca virosa, hyoscyamus, and opium, have also been favourably mentioned as palliatives in this disease. Dr. Butler states, that he has frequently used the following mixture with marked benefit.* Opium is ob- jectionable, both on account of its constipating effect, and its tendency to determine the blood to the brain. Some writers recommend the tincture of cantharides.] Dr. Sutcliff asserts, that when given to the extent of producing strangury, it will sometimes, in a great measure, remove the disease in four or five days. This practice has also been pursued with success * R. Extract, conii gr. iii. Magnes. sulphat. *)i. Aq. carui gv. Syrup, rhaed. Ji. M. Take 30 drops three times daily. t Armstrong, Chambers, Millar, Buchholtz, Loder, and others, speak much in favour of this remedy in whooping-cough. 208 WHOOPING-COUGH. by Hufeland, and Lettsom speaks very favourably of it. Sut- cliff used it according to this formula.* M. Fresnoi asserts, that he has used the extract of the rhus vernix with much suc- cess in this disease. He gave half a grain, with half an ounce of syrup, every three hours. Antispasmodics are frequently prescribed in whooping-cough, and sometimes witli temporary advantage. An aqueous solu- tion of assafoetida will occasionally palliate the symptoms con- siderably, in cases unattended with fever or strong pulmonary irritation. This article answers the double purpose of an ex- pectorant and an antispasmodic. I have, in a few instances, known very material relief obtained from a mixture of the vi- negar of squills and an emulsion of assafoetida. Expectorants also will occasionally mitigate the violence of the symptoms. Dr. Pearson strongly recommends the follow- ing mixture, and I have myself known it to give much tempo- rary relief.f Tonics may, in some instances, be used with much benefit in whooping-cough. The Peruvian bark is particularly extolled by Dr. Cullen as a remedy in this disease; but its good effects are in a great degree confined to the latter stages of the dis- ease. In some instances, the cough assumes a chronic charac- ter—continuing long after the usual period of its termination; and these cases are frequently connected with chronic brochi- tis. If they are not subdued by efficient measures they gradu- ally undermine the constitution, until the system is worn down, and the patient dies in a state of marasmus, or under symptoms of phthisis pulmonalis. In such cases, strong doses of cincho- na, or quinine, are often peculiarly servicable. This tonic may also be very beneficially used in cases of a purely spasmodic character, where the disease becomes protracted and kept up by habit. Among the mineral tonics, arsenic has been most commended for its powers in this affection. It is, however, wholly inadmis- sible in cases attended with febrile irritation or bronchial in- flammation. Dr. Ferriar placed much reliance on this remedy in cases free from fever. He asserts, that according to his own experience, " arsenic is the only remedy which promises * R. Tinct. peruv. spirit. 5i. Tinct. opii. camphor. ?ii. Tinct. cantharid. V)ii. Two drachms of this mixture is to be taken thrice daily. X R. Aq. fontanse £i. Syrup. 3 iii. Subcarbonat. sodge gr. xxv. Vin. ipecac. 3i. Tinct. opii gr. vi. M. The sixth part, every four or five hours, is the proper dose for a child between one and two years old. WHOOPING-COUGH. 20fr to shorten the disorder effectually. I have," says he, "employed this article in several cases of infirmary patients with tolerable success; and I have occasionally given it in private practice with so much advantage, that I think it deserving of farther trials." I formerly employed this remedy frequently ; and in some instances its good effects were very obvious. The proper dose for a child between one and two years old, is two drops of Fowler's solution twice or thrice daily. I have usually given it in union with small doses of the extract of belladonna, or conium. The lobelia infiata has proved an excellent remedy in my hands, in whooping-cough. Within the last four years, I have prescribed this article in a very considerable number of cases, and very generally with some advantage, and in several in- stances with the most decided success. It not only often miti- gates the violence of the coughing, but it has appeared to me very obviously to shorten the course of the disease in several cases. I have usually given the saturated tincture in union with the syrup of squills, in doses often drops of each, four or five times daily, to a child about two years old. To several children about this age, I gave as much as twenty drops of the tincture of lobelia, and I have always found it strongly pallia- tive when it excited sickness or slight vomiting. External rubefacient or revulsive applications, are particu- larly valuable in cases attended with bronchial inflammation, or strong and dangerous sanguineous congestions in the head. Dr. Gregory advises frictions with the following" embrocation along the whole tract of the spine, and over the chest.* Fric- tions with tartar emetic ointment over the precordial re- gion, will in many cases make a powerful impression on the disease. This practice originated with Autenreith, and has been much employed by the German physicians. When the disease is complicated with pneumonic affections, blisters and rubefacients, in conjunction with venesection, and especially leeching on the breast, are indispensable. When the disease becomes complicated with chronic bron- chitis in the advanced stage of its course, the balsam copaiva is a very valuable remedy. I have in a few cases of this kind prescribed this article with the most decided benefit; and I know, indeed, no other remedy that promises so much as this one, where chronic bronchitis attends. Various inhalations, also, have been extolled for their good effects in this disease. The nitrous acid vapour, and the fumes * R.—Antimon. tart. ^ii. Tinct. cantharid. 5i. Aq. rosar. |ii.—M. The tartar emetic is to be dis- solved in the rose water, and then the tincture of cantharides added to it. vol. 11.-27 210 WHOOPING-COUGH. of tar, have been particularly recommended for this purpose. I have employed the nitrous acid vapour in a few cases with much benefit. Dr. Gregory states, that he has derived great benefit from small doses of calomel, (a grain twice a day) with a few grains of scammony in the latter stages of whooping-cough, attended with symptoms of marasmus. Change of air and exercise by gestation generally have an excellent influence in tedious and obstinate cases, attended with much exhaustion. In instances of this kind, a change of air, says Dr. Gregory, "is often the only thing that gives the pa- tient a chance of life." I have seen one very remarkable reco- very effected by removing the patient into the country, and the free use of a milk diet. In cases attended with bronchial inflammation, this measure is inadmissible, as it rarely fails to aggravate the symptoms immediately. The diet should be light and digestible, and it is particularly important to guard the patient against the influence of a cold, variable, and damp atmosphere. CHAPTER XVI. ASPHYXIA. The term asphyxia is here used to designate two varieties of suspended animation; namely, those cases which result from the total suspension of the function of respiration, by prevent- ing the ingress of atmospheric air to the lungs, or by breathing an air incapable of converting venous into arterial blood ; and those cases of apparent death which result from the temporary destruction of the sensibility and irritability of the system by the influence of certain external causes. The first variety includes those cases that are produced by hanging, drowning, or strangulation; and by the inhalation of carbonic acid or some other irrespirable gas. The second va- riety embraces the cases that are produced by a stroke of light- ning or electricity, and by the protracted influence of intense cold.* 1. Asphyxia from drowning.—When a person who has been submersed in water until all manifestations of life are destroy- ed, is taken out, the face exhibits a turgid and livid appearance; the eyes are open and staring; the limbs somewhat stiff; the * Good's Study of Medicine, vol. iii. p. 367. ASPHYXIA. 211 tongue usually thrust a little beyond the teeth; and in most instances, the epigastrium is tense and tumid. Considerable controversy has existed concerning the mode in which drowning causes death. Many have contended that suffocation is produced by the water rushing into and filling up the cavity of the lungs. Haller, P. Frank,* Louis, and Por- talf mention cases in which the lungs were charged with an abundance of water, sometimes frothy and bloody. On the other hand, however, it has been satisfactorily ascertained that in many instances of death from drowning, very little, or no water whatever, gains admission into the lungs. Tissot,^ Goodwin,§ Kite,|| Roesler,^ and many other later writers, have published numerous observations in testimony of this fact; and it is now, I believe, universally admitted, that so long as the larynx retains any degree of irritability, no water can enter into the respiratory passages; and, consequently, that whenever water is found in the lungs, it must have entered into them after life was destroyed. Such is the peculiar sensibility of the respiratory passages, that the moment water or any other substance not in harmonious relation with them, comes in contact with the mucous membrane of the larynx, the glottis is instantly thrown into a state of spasmodic constriction, which wholly prevents the ingress of the irritating fluid into the trachea. When the sensibility and contractibility of these parts are extinguished, however, the water may gain admission into the lungs, and hence it is not uncommon to find more or less of this fluid in the air passages in those who have lain a long time under water. Some have supposed that drowning destroys life by apoplexy —that the functions of the brain are at once destroyed by strong vascular congestion and extravasation. Portal** who entertained this opinion states, that he found the vessels of the brain, as well as the right auricle and ventricle of the heart, jugulars, and descending cava, exceedingly turgid with blood in subjects that had died by drowning. This opinion is also advocated by Littre, Kite, Walterff and Boerhaave. On the contrary, however, many observations have been published, which go to show that vascular congestion within the head, * System ein. Vollstaendiger Med. Polizei, vol. i. p. 186. f Instruction sur le Traitment des Asphyxias. t Avis au Peuple, p. 426. | On the Connexion of Life with Respiration, &c. p. 14. || An Essay on the Recovery of apparent Death. 1T Diss. Inaug. &c. See Ed. Med. and Surg. Jour. No. lxxxii. Dr. Roesler states, that in forty-five experiments he made on animals, he did not in a single instance find any thing more than a very small por- tion of frothy mucus about the bifurcation of the trachea. ** Loc. citat. See also Observ. sur les Effects des Vapeurs Mephytiques. tt De Morbis Peritonei et Apoplexia. 212 ASPHYXIA. though an occasional, is by no means a common or general phenomenon. Champreaux and Faissole assert, that they found no marks whatever of unusual sanguineous congestion in the brains of persons who had died by submersion.* Schrage,f and Kuehn,:}: state that they even found the vessels of the brain almost entirely empty. Fothergill, in a number of experiments made on animals with a view of illustrating this subject, fully confirms these observations ;§ and Dr. Curry states, that in every instance he examined, he found the vessels of the brain entirely free from distention. In nearly all instances, however, the lungs are strongly engorged with blood, and the bronchial tubes generally contain more or less of a frothy and bloody mucus. Bichat has given a very interesting and satisfactory explana- tion of the mode in which death is brought on by submersion, and other analogous causes of asphyxia. When respiration is interrupted, the blood ceases to undergo the necessary chemical changes in the lungs; and black or venous instead of florid and arterial blood, is immediately sent to the left side of the heart, and thence throughout the system. Now it is well ascertained, that the regular transmission of arterial or red blood to the brain, is indispensable to the performance of its functions ; and therefore, one of the first effects of interrupted respiration to- wards the destruction of vitality, is a cessation of cerebral action for want of red or arterial blood to excite the brain. The direct and instantaneous consequence of this cessation of cerebral action is cessation of animal functions, from want of excitement in the organs of these functions by the nervous in- fluence and the red blood ; and from the same causes the heart soon ceases to act, and the circulation stops. Death from as- phyxia, by submersion, strangulation, or the inhalation of me- phitic gases, commences therefore in the brain, and those vital actions that are immediately dependent on the exercise of its functions,—namely, sensation, voluntary motion, thought, and the mechanical effort of respiration, cease a short time before those actions which constitute what are called the organic func- tions, that is, the circulation, absorption, exhalation, &c. are obliterated. || Much difference of opinion has been expressed with regard to the time a person may remain under water, in a state of as- phyxia, with sufficient vitality remaining to afford a chance of being resuscitated by proper restorative measures. Mr. Bro- die thinks it extremely improbable that resuscitation can be * Erfahr u. Warneh Ueber d. Ursach d. Todes bei Ertrunk. Danzig, 1772—as quoted by Richter. t Diss, de Submersi—179.—Richter, Sp. Therap. X Diss, de Causa Mortis Submersorum.—Richter, Sp. Ther. $ A New Inquiry into the Suspension of Vital Actions, &c. || Bichat on Life and Death, p. 136. ASPHYXIA. 213 effected after the heart has ceased to act; and this he supposes, always occurs within a few minutes after the cessation of the respiratory function. Dr. Paris, and other late writers have expressed the same sentiments on this point. Unless, however, we reject no small amount of evidence from sources of unques- tionable credibility, we are forced to admit that there is in some instances a possibility of resuscitation after a much longer pe- riod of submersion, than Mr. Brodie and Dr. Paris are willing to allow. The experiments that have been performed on ani- mals in relation to this point, afford us no satisfactory results. Dr. Davy informs us that he has never been able to resuscitate dogs after having been under water two minutes; and Dr. Colhoun of this city states, that in some experiments he made on cats, " they invariably died after six minutes of submersion."* Dr. Roesler asserts, that he succeeded in resuscitating two rab- bits, one after 53, and the other after 9h minutes submersion ; and a cat after having been submersed 11# minutes. He ob- serves, however, that he "several times failed when the animals were taken out of the water instantly after they seemed to have expired." Experiments on inferior animals cannot, however, furnish us with any certain data with regard to the human subject. We learn, nevertheless, from these experiments, that very considerable diversity occurs as to the time that animals may remain under water and still retain sufficient vitality to render resuscitation possible. We see it vary in the same spe- cies of animals, and in experiments conducted under precisely the same circumstances, from a few to ten or eleven minutes ; and we cannot doubt that a corresponding diversity occurs, in relation to this point, in the human subject. Instances of re- suscitation after a period of submersion varying from fifteen to thirty minutes are on record ; and although doubts have been expressed with regard to the accuracy of these statements, we can scarcely with propriety permit our scepticism on this point, to carry us so far as to reject positively the testimony upon which they are made. That such instances of recovery are, however, extremely rare, is sufficiently evident from the fact that the possibility of resuscitation after such protracted periods of submersion, is now very generally doubted. Various circumstances may contribute to hasten or retard the complete destruction of vitality from drowning. Submer- sion in very cold water will no doubt destroy life sooner than when the water is warm or near the temperature of the body; for in the former case the animal temperature will be much more rapidly and completely abstracted than in the latter. Previous debility from disease, spasms and convulsions, inju- ries sustained in falling into the water, asthma, an apoplectic * Gregory's Practice, second American edition, p. 247. 214 ASPHYXIA. predisposition, intoxication, torpor from excessive cold, an over- loaded stomach, &c. may all have a tendency to lessen the chance of resuscitation from asphyxia by submersion; and it is not improbable, moreover, that some diversity may exist in different individuals as to their respective powers of vital resist- ance under similar circumstances of submersion. The morbid appearances observed on dissection in persons who have died by drowning or strangulation are: turgescence of the jugulars, vena cava?, right auricle and ventricle of the heart, pulmonary arteries, and of the pulmonary vessels. The left auricle and ventricle are generally empty and flaccid; and in some instances there is considerable vascular congestion in the brain, but very rarely so much as to justify the belief that any apoplectic torpor proceeded from this cause. In nearly all instances a considerable portion of water is found in the sto- mach, but the lungs very generally contain very little, or no water whatever. Inquiries have been made to discover some mark by which we may decide whether dead bodies found in water have died by drowning, or whether they have been thrown into the water after they had been deprived of life. Mr. Orfila has paid par- ticular attention to this subject, and has examined in detail all the indications that have been mentioned as available guides in making up a judgment on this point. According to his observa- tions, more or less water always enters into the stomach when death occurs by drowning, but never when the dead body is thrown into water. The result therefore of his inquiries on this subject is, that the only certain sign of submersion during life, is the presence in the stomach and respiratory passages of water similar to that in which the submersion took place; pro- vided that it has not been injected into the stomach after death, and that the water in the lungs is found in the ultimate ramifi- cations of the bronchia; and provided, also, that the body was not found in a vertical position. The presence of a frothy fluid in the air-passages, he says, is only to be regarded as a presumptive evidence of submersion during life, and this is strengthened by the appearance of an unusual portion of water in the pulmonary tissue, since this fluid never penetrates so deeply after death, as during life, by the efforts of respiration. The absence of a frothy mucus in the respiratory tubes does not, however, afford any proof that death did not occur by sub- mersion. * Treatment.—When a person is taken out of water, and it may still be deemed proper to make attempts to effect resusci- tation, he should be immediately well dried and wrapped in blankets, and conveyed to a place convenient for the necessary * Revue Medicale, torn. xiii. p. 347. ASPHYXIA. 215 applications. The principal object to be aimed at, is a restora- tion of the action of the lungs, at the same time that warmth is gradually communicated to the body. With this view, artificial inflation of the lungs has always been regarded as the most important resuscitating means we possess in cases of this kind. The inflation may be made by blowing in the air through a tube in the mouth, or by a com- mon bellows, whilst the nostrils are held close, to prevent the return of the air by that channel. It is to be particularly recol- lected, however, that very forcible inflation is calculated to defeat our purpose, even in cases where the chances of resusci- tation may he presumed to be considerable. M. Leroy d'E- tiolles has recently paid particular attention to this subject, and has strongly set forth the injurious consequences of forcible insufflation into the lungs in asphyxia. Leroy, Dumeril, and Magendie, have ascertained by repeated experiments, that sheep, foxes, deer, rabbits, &c. may be speedily killed by rapid and strong inflation of the lungs, even when the insufflation is made with the mouth. When air is forcibly thrown into the lungs, it may lacerate the delicate structure of the air-cells and cellu- lar texture of the lungs, and thus destroy all possibility of restoring the pulmonary functions; for it appears from experi- ments performed by the same gentlemen on dead human sub- jects, that the pulmonary tissue may be readily ruptured by forcible inflation.* In endeavouring to restore the action of the lungs, the air should therefore be but moderately forced into the trachea—alternating the acts of inflation with com- pression of the thorax and abdomen, so as to imitate the me- chanical process of respiration. M. Leroy proposes to introduce two fine needles so as to penetrate the edge of the diaphragm, and to pass a gentle current of galvanism through this muscle. This has been practised on inferior animals in a state of as- phyxia, with complete success, after more than five minutes of submersion. The galvanic circle must be alternately inter- rupted and closed, so as to imitate the act of respiration. Whenever the circle is closed, the diaphragm contracts, and enlarges the thoracic cavity, and the air is drawn in; on taking off the communicating wires, the diaphragm resumes its former position, and expiration takes place. The practice of com- pressing the chest and abdominal parietes in alternation, with gentle insufflation, is particularly recommended. By this me- thod the blood in the vessels of the abdomen and breast is put in motion, and propelled towards the heart and lungs, and the contractibility of the diaphragm is excited. At the same time that the efforts to carry on artificial respira- * Rapport sur un Memoire de M. Leroy d'Etiolles, relatif a Plnsuffla- tion du Paumon, &c—Revue Medicale, vol. xiii. p. 328. 216 ASPHYXIA. tion are made, heat should be gradually communicated to the body, by wrapping it in dry and warm flannel, and by apply- ing heated cloths, or warm bricks wrapped in flannel, or bot- tles filled with warm water to the lower extremities and body. Care must be taken, however, that the warmth be communi- cated in a gradual manner, for the sudden application of a high degree of heat could not fail to do irreparable injury by destroying the small degree of remaining excitability of the or- ganization. Frictions with dry flannel or stimulating sub- stances, such as powdered mustard or capsicum will contribute to excite the circulation and impart warmth to the body. The injection of stimulating fluids into the rectum will be proper, more especially when some manifestations of returning life have been established by the foregoing measures. For this purpose a solution of ammonia, with wine, or camphor, or warm diluted brandy, may be used; and where the abdomen is tense and tumid, we may inject a warm infusion of senna in wine, with the view of exciting the action of the bowels. Galvanism has also been employed as a resuscitating agent in cases of this kind. Wiedemann speaks highly of this in- fluence, more especially when directed upon the external organs of generation. He asserts that he has known the most excel- lent effects produced by it when employed in this manner. It must be observed, however, that both electricity and galvanism can be employed with a prospect of advantage only when com- municated in a very weak state, for when strongly applied, they tend to exhaust rather than to increase the vital energies. Various other modes of exciting the vital powers have been recommended; such as exposing the eyes to the direct rays of the sun ; applying volatile and stimulating fluids to the sny- derian membrane; plucking the hairs; tickling the soles of the feet, sides, and arm-pits; acrid substances applied to the tongue; burying the patient up to the head in warm ashes or sand, &c. Venesection has been much recommended in asphyxia from submersion ; and some have particularly advised opening one of the jugulars. Some advantage may, perhaps, be occasion- ally obtained from this measure, where a flow of blood can be procured, by its tendency to relieve the oppressive venous con- gestions of the lungs. In general, however, no blood can be obtained by opening a vein, except in cases of very transient submersion, or where the action of the heart has been re-ex- cited by the means already mentioned; and here there is much reason to apprehend that injury rather than advantage would generally result from this operation. The return of the vital actions is at first manifested by tran- sient and weak twitches of the muscles of the face, particularly of those about the lips; succeeded by feeble, irregular, and con- ASPHYXIA 217 vulsive efforts to breathe; spasmodic tremor and agitation of the extremities ; a small and weak pulse, beating at very long intervals ; and a discharge of a frothy fluid from the mouth. By degrees sensation and the power of motion return ; the lips assume a red hue, the skin becomes soft and warm, particularly about the scrobiculous cordis, and in some instances vomiting takes place. When recovery has been so far effected, the utmost degree of caution is necessary to prevent, on the one hand, over-exci- tation by stimulants, and, on the other, sinking from deficient support of the vital energies by appropriate excitants. I knew an instance where a person after much exertion was so far re- suscitated from a state of asphyxia by submersion as to breathe freely, and to manifest consciousness and the power of volun- tary motion. The persons about him were directed to give him from time to time, certain portions of warm wine whey. This was wholly neglected, and in four or five hours he sunk and expired. Warm wine, or weak brandy toddy with warm aromatic ptisans, as infusion of balm, sage, or catnep, should be given from time to time, according to the state of the pulse, and the patient must be kept perfectly at rest in a dry and warm bed, with the air freely circulating through the room, if the weather be warm. Our efforts to effect a resuscitation in cases of this kind, where the period of submersion has not been so protracted as to preclude all reasonable hopes of ultimate success, should not be too readily abandoned. Instances have occurred in which the signs of returning life did not manifest themselves for more than an hour after commencing with the resuscitating measures. It has been said, and the observation appears to me very correct, that there is much reason to believe that some lives are lost in this wray for want of duly continued exertions to re-establish the vital actions. In still-born infants, I have known two instances of ultimate recuscitation, where the signs of returning animation were not noticed for above forty mi- nutes after the commencement of the usual measures. It should also be observed, that well-authenticated instances of recovery are on record, where the resuscitating means were not applied until many hours after the person had been taken out of the water; and hence, where the time of submersion has been short, and, for want of assistance, means are not employed, it may still be proper to make suitable efforts to effect a resuscitation, although several hours have elapsed before this can be done. De Haen, whose authority cannot be questioned, asserts that he resuscitated a person seventeen hours after he had been taken out of the water; and other similar instances might be adduced which, though less remarkable, perhaps, are equally encouraging to late attempts of this kind. vol. n.—28 218 ASPHYXIA. 2. Asphyxia from the inhalation of irrespirable gases.—The most common cause of this variety of asphyxia, is the inhalation of carbonic acid gas. When this aeriform poison is undiluted with atmospheric air, it will destroy life almost instantaneously by abolishing at once all the sensibility and irritability of the nervous system. When mixed with a portion of atmospheric air, its sedative effects on the brain are less vehement and sudden ; giving rise to vertigo, faintings, insensibility, asphyxia, or death, according to the degree of its purity and the length of time during which persons are exposed to its influence. When life is suddenly destroyed by inhaling this gas in an undiluted state, the dead body is pale, collapsed, and flaccid. In instan- ces, however, where death or asphyxia is caused by a gradual destruction of the vital powers, from the gas being more or less mixed with atmospheric air, the face exhibits a tumid and livid appearance, the veins about the neck and head are turgid, the tongue somewhat swollen, the lips blue, with suggilations on different parts of the surface, and the body remains warm for many hours, or even for several days. On dissection, the sinuses of the brain, the jugulars, right side of the heart, pul- monary arteries, the lungs, and the cavae are always strongly congested with black and generally fluid blood. The pulmo- nary veins, left side of the heart, and aorta, on the contrary, are empty, or contain but a small quantity of blood. The ventricles of the brain are commonly charged with a considerable portion of bloody serum, and the cellular structure about the head and neck is often found infiltrated with the same kind of fluid. The bronchia are filled with a frothy mucus more or less tinged with blood ; and the mucous membrane of the stomach and intestines, usually exhibits a dark red, ecchymosed, and distended appear- ance. The epiglottis is generally erect, and the glottis patulous.* Carbonic acid gas produces its fatal effects on the animal economy both by excluding the requisite portion of oxygen or respirable air from the lungs, and thereby preventing the conversion of venous into arterial blood, and by a peculiar and exceedingly powerful sedative principle independent of its mere irrespirable character. Animals die much more speedily when confined in this and other mephitic gases, than when placed in an exhausted receiver, or when the atmospheric air is otherwise excluded from the lungs ;f and frogs, worms, leeches, and snails are killed in a few hours by being placed in carbonic acid gas, although capable of living a long time when simply deprived of atmospheric air.^i These facts show conclusively, that in addition to the mere exclusion of respirable air, there is also a * Portal. Observations sur les Effets des Vapeurs Mephitiques. X Fothergill. A new Enquiry into the Suspension of Vital Action in Cases of Drowning and Suffocation. X Carminati. De Animalium ex metphitibus, et noxiis halitibus interitu ejusque Causa?, p. 89. ASPHYXIA. 219 deleterious impression made on the vital powers by inhaling this gaseous poison; and it acts therefore at once like submer- sion or strangulation, and as a powerful sedative poison. There are several other gaseous substances which, when in- haled in a concentrated form, produce immediate asphyxia or death. The fumes of sulphur, sulphurated hydrogenous gas, nitrous gas, azote, hydrogene, and certain gaseous poisons, generated by putrefying animal and vegetable substances, de- stroy life with more or less rapidity. Of these gases, azote and pure hydrogen appear to destroy life simply by their not being respirable, or by preventing the chemical changes of the blood in the lungs, in the same manner that submersion or obstruction of the trachea produces this effect.* Treatment.—When the asphyxia from this cause, (carbonic acid gas) is incomplete, with some degree of sensibility remain- ing, the patient may be generally soon recovered by conveying him immediately into the open air, supporting him in a sitting posture, dashing a little cold water upon his face and breast, applying dry frictions to the extremities, and as soon as he can swallow, giving him small portions of cold wine and water. If the unfortunate individual is in a state of perfect asphyxia, without any manifestations whatever of life, we may sometimes succeed in effecting resuscitation by the following course of management. He should be speedily carried into a free and cool air, divested of his clothes, and laid upon a sheet spread on the floor or the ground, with his head and shoulders somewhat raised. Cold water must now he dashed upon his breast, and cloths dipped in cold water applied to the head ; or he may be supported in a sitting posture and the water poured on the head. In some cases the moment the cold affusion is made, a convul- sive respiratory effort is excited. In an instance to which I was called about a year ago, I found the patient without the slight- est indications of vitality. Having stripped off his clothes, I dashed a bucket full of cold water over the head and breast, and almost at the same moment I observed a short convulsive gasp. By continuing the affusions at short intervals, the re- spiratory efforts were repeated, at first very weak, and at inter- vals of nearly a minute, and by the additional aid of stimula- ting frictions, the respiration was fully established in about an hour after the first symptoms of returning life. Frictions with the flesh-brush, or with stimulating embroca- tions, are important auxiliaries in re-exciting animation in ca- ses of this kind. We may also derive advantage from volatile stimulating applications to the mucous membrane of the nose, by means of a feather—such as aqua ammonia, sether, and camphorated spirits. At the same time, also, stimulating ene- * Bichat on Life and Death, p. 242. 220 ASPHYXIA. mata should be used, particularly a solution of the carbonate of ammonia in a mucilaginous fluid. Richter speaks favoura- bly of the injection of cold water and vinegar for this purpose. If the act of respiration be not soon excited by the cold affu- sions, artificial inflation of the lungs must be resorted to in the way mentioned above. Upon these two means we must chief- ly rely in our efforts to effect resuscitation. When the respi- ration is partially established, but continues very laborious, and with a rattling noise in the bronchia, considerable benefit will sometimes result from the abstraction of from eight to ten ounces of blood from the arm. As soon as the respiration is fully established, the patient should be wiped dry and laid in a comfortable bed, and small portions of warm wine, or wine- whey, or some other gentle stimulating beverage allowed. Galvanism has been employed, and in some instances with manifest advantage, in asphyxia from mephitic gases. The galvanic current should be weak and passed along the course of the pneumo-gastric nerves, by placing the negative conjunc- tive wire in contact with the scrobiculus cordis, and the po- sitive pole with the part immediately over the par vagum in the neck, just below the sterno-mastoid muscle. After the vital actions have been re-established, the arterial excitement, in some instances, becomes violent and tumultuous. The heart palpitates vehemently; the pulse is full, strong, and hard ; the vessels of the head turgid, and a disposition to heavy sleep ensues. Under these circumstances venesection is in- dispensable, and the blood should be suffered to flow until the activity of the circulation is considerably moderated. In ge- neral, much caution is necessary after resuscitation is effected, neither to excite the vital powers too much—which may readily be done—nor to suffer them to languish for want of some gen- tle stimulus. 3. Asphyxia from electricity.—When electricity is passed through the animal system, in currents of moderate intensity, it excites and invigorates the vital energies ; but when its in- tensity is great, it suddenly suspends or entirely destroys the sensibility and irritability of the nervous system, and gives rise to more or less complete asphyxia, or immediate and irre- coverable loss of vitality. The appearances exhibited by persons who have been struck by lightning vary considerably. In most instances, red streaks may be noticed on the breast and arms, of* an acchy- mosed and highly irritated appearance, and generally of a zig- zag form. The hair is usually singed on some parts; and small blisters, like those produced by a scald, occur on differ- ent parts of the body. Sometimes blood is discharged from the ears, and suggilations of large extent are frequently found on the trunk and extremities. Internally structural lesions are ASPHYXIA. 221 but rarely detected in persons who are killed by lightning. In general, the heart is turgid with blood, but the lungs are usually collapsed, and entirely free from vascular congestion. The blood is always deprived of its coagulability by a fatal stroke of electricity; and the body commonly enters into pu- trefactive decomposition with extraordinary rapidity. When the electric stroke does not entirely destroy the vital powers, the face is generally red and bloated; more or less blood often issues from the mouth and nose; respiration is slow and very laborious; the pulse is extremely weak and irregular, or en- tirely absent; and spasmodic twitches of the muscles of the eye-lids, mouth, and throat sometimes occur. Persons who are recovered from a state of asphyxia, caused by lightning, generally suffer for a long time afterwards with tremors, pain- ful sensation, swellings, and some degree of numbness in the extremities, more especially in the legs. Such individuals usually retain a particular susceptibility to the electric influ- ence, and are apt to feel a peculiarly uneasy feeling on the ap- proach of a thunder-storm. The treatment of asphyxia from this cause, does not differ from that which is mentioned for asphyxia from mephitic ga- ses. Cold affusions are particularly valuable to re-excite the latent vital energies in cases of this kind. Cold water should be copiously and frequently dashed over the whole body, and frictions diligently made with the flesh-brush or pieces of rough flannel. Galvanism and electricity also have been especially recommended in asphyxia from a stroke of lightning. Stoll asserts, that animals in a state of asphyxia from an electric shock, have been speedily recovered by a second shock of this power ;* and Bernt assures us that in a case produced by a stroke of lightning, a second shock effected a resuscitation.f M. Abilgaard has also related some instances of asphyxia from this cause, in inferior animals, in which resuscitation was effected by a second shock of electricity.^: 4. Asphyxia from cold.—When the body is subjected to the influence of intense cold, the superficial blood-vessels shrink ; the surface becomes pale and contracted ; respiration oppress- ed ; the extremities benumbed and weak; and finally, an irre- sistible desire to sleep comes on; and unless speedy aid be obtained, insensibility, asphyxia, and death inevitably ensue. For the mode in which these effects are produced by low tem- perature, the reader is referred to the article cold, page 27, of the first volume of this work. * Rettungsmittal in ploetz. unfaellen. p. 63. t Vorlesungen Ueber d. Relungsmittel. beim Scheintode, p. 121; as quoted by Richter. Specu. Therap. vol. viii. p. 647. X Loc. Med. Havnien. Collectan, &c. T. ii—Good. 222 ASPHYXIA. Instances of resuscitation from asphyxia, caused by intense cold, are by no means uncommon; and cases are related in which re-animation was effected many hours, or even several days after the asphyxia was produced.* The principal resus- citating means in cases of this kind is the gradual communica- tion of warmth to the body. The introduction of warmth re- quires, however, the utmost degree of caution; for, if the heat be rapidly communicated, it will inevitably destroy the re- maining vitality, or should a partial recovery ensue, fatal gan- grene would be the certain consequence. When a person is found in a state of insensibility from cold, he must on no ac- count be immediately conveyed into a warm chamber, or placed near the fire. His body should be immersed in spring water, or water fresh drawn from a well. Burying the body in fresh snow has also been recommended for this purpose. Richter states, that the snow-bath is decidedly the most important re- suscitating means we possess in cases of this kind. After the body has been suffered to lie in water or snow for forty or fifty minutes, it should be carefully dried with soft pieces of flannel, wrapped in blankets, and conveyed into an unheated chamber. Gentle frictions with flannel should now be resort- ed to, and if no manifestations of respiration occur, artificial inflation of the lungs should be practised. If these efforts suc- ceed in restoring symptoms of life, the temperature of the room should be very gradually increased, and bottles filled with luke-warm water laid to the feet, and about the body. When the power of deglutition is restored, moderately warm ptisans— such as balm, sage, or elder-blossom tea, and diluted warm wine, may be given with advantage; but the stronger stimu- lants must be rigidly interdicted. CHAPTER XVIT. ANGINA PECTORIS.* Angina pectoris was not noticed as a distinct disease until the attention of the profession was directed to it by Dr. Heber- • Kruinitz. Oekonom. Encyclopaedia, Th. xv. p. 261. Richter. Sp. Ther. t This d isease has been described under a great variety of names, as asth- ma convulsivum, by Eisner; arthritis diaphragmatica, by Butler; syncope anginosa, by Parry; asthma spastica arthriticum inconstans, by Stoeller; strenalgia, by Baumes; sthenocardia, by Brera; asthma dolorificum, by Dar- win; sternodynia syncoptica et palpitante, bySluis; pnigophobia, by Swe- diaur; and cardodyne spasmodica, by Harles. ANGINA PECTORIS. 223 den in a very perspicuous and full account of its peculiar cha- racter, published in the second volume of the Medical Transac- tions of the London College of Physicians. Since that time, it has been frequently and minutely described, and of late years, especially, its phenomena and pathology have received much attention. This disease consists of sudden paroxysms of pain and pres- sure at the lower part of the sternum, or about the region of the heart, extending across the breast to the left shoulder, and to the arm as low as the insertion of the deltoid muscle, or the el- bow, or even to the fingers ; accompanied with some difficulty of breathing, great anxiety, and a sense of impending suffocation. The attack usually commences without any premonitions of its approach, by sudden pain and constriction in the left side of the chest, or near the scrobiculus cordis, and a peculiar numbness with more or less pain in the left arm, particularly on the inside, as low as the elbow. If the paroxysm comes on while the patient is walking, he is instantly obliged to stand still. The least exertion gives rise to intense darting and con- strictive pain in the cardiac region; and the patient feels as if an attempt to move would inevitably cause immediate death. During the paroxysm the countenance is pale and expressive of great anguish, the extremities are cold, the heart palpitates violently, there is more or less dyspnoea, turgidity of the ves- sels of the head, and in some instances syncope and even con- vulsions ensue. Sometimes the pain passes up along the neck and face, or back to the spine, with a sense of retraction at the lower end of the sternum ; and occasionally it is felt in both arms at once. At first the paroxysms last but a few minutes; and recur at remote intervals, generally in walking up hill, or rapidly ascending stairs soon after taking a full meal. By re- petition, however, they become more and more violent and pro- tracted, and return, in aggravated instances, on the slightest bodily exertion. When the attack has passed off, the patient usually feels only numbness of tbe left arm, with some degree of palpitation, and, occasionally, slight headach, hurried re- spiration, and anxiety of feeling in the prsecordia. Pathology.—This disease is very rarely met with in young people; and it occurs indeed but seldom in individuals under forty years of age. I have, nevertheless, seen a well-marked case in a young man of an arthritic habit, who was not more than twenty-three years old ; and I am now attending a girl under eleven years of age, who is occasionally seized with pa- roxysms which appear to me genuine instances of this affec- tion. The majority of cases of angina pectoris occur in individuals of a gouty or rheumatic habit. Jahn states that in the sum- 224 ANGINA PECTORIS. mer of 1814 he met with several instances of this disease which supervened apparently as sequela of typhus fever.* In relation to the immediate or exciting causes of this affec- tion, pathologists have expressed very different opinions. He- berden, Kreysig,f and Parry^: attributed the disease to ossifi- cation of the coronary arteries, and this opinion is still enter- tained by many physicians. Others have ascribed it to ossifi- cation of the semi-lunar valves of the heart; and various other organic affections of this organ and of the adjoining parts, have been mentioned as its cause, such as morbid dilatation and sof- tening of its structure, ossification of the cartilaginous portion of the ribs ; suppurative inflammation of the mediastinum, and disease of the pericardium. That no one of these morbid con- ditions, however, can be regarded as the proximate or essen- tial cause of angina pectoris, is evident from the fact, that in many fatal instances of the disease, no such structural disor- ders are discovered on post-mortem examination. M. Reca- mier, principal physician at the Hotel Dieu, has never witness- ed an instance of ossification of the coronary arteries in the bodies of those who have died of angina pectoris; and he whol- ly rejects the idea of its depending on organic cardiac disease. § M. Laennec, also, denies the necessary connexion between organic affections of the heart and angina pectoris. "In a slight and middling degree," he says, " this disease is very common, and exists very frequently in persons who have no or- ganic affection of the heart or large vessels.|| It must, more- over, be observed that ossification of the coronary arteries, and other structural diseases of the heart, are frequently met with in subjects who had never experienced any of the characteris- tic symptoms of angina pectoris. Mr. Cook says, " I have met with numerous instances of ossification in the coronary ar- teries which had never been attended with symptoms of angi- na ;^| and Mr. Shaw observes, in relation to this subject, that he had often found the coronary arteries like tubes of bone in old people who never had the slightest symptoms of this dis- ease.** The occasional spontaneous removal of the disease, and its susceptibility, in some instances^ of being cured, militate also directly against the doctrine of its necessary dependence on organic affection of the heart. Laennec avers, that " he has known many individuals who had suffered a few very se- vere, but short attacks of angina pectoris, and had had no fur- * Klinic der Chronischen Krankheiten. Band. iv. p. 406. t Die Krankheiten des Herzens. 2 Th. 2. abhand. 5. Kap. X Treatise on Syncope, Anginosa, &c. § Medico-Chir. Rev. March, 1829. p. 573. || On the Diseases of the Chest, last edition; translated by Dr. Forbes. II Treatise on the Digestive Organs, p. 274. ** Manual of Anatomy. ANGINA PECTORIS. 225 ther return of it." Dr. Parry, who believed that the disease was always caused by ossification of the coronary arteries, nevertheless mentions a severe case, that was wholly or near- ly cured by the use of the Bath waters. Dr. Baillie also met with two patients affected with symptoms "exactly resembling those of angina pectoris, who ultimately recovered entirely."* Unquestionably, however, ossification of the coronary arte- ries, and other organic cardiac affections, are very frequently connected with angina; "but nothing proves, even in such cases," says Laennec, "that the disease depends on affections of this kind, inasmuch as they are of various kinds, and as the angina exists without them." A softened structure or flabby and dilated state of the heart, is almost as common in this affection as ossification of the coro- naries. In a most severe case which was seen by Dr. Latham, Dr. Bree, and Dr. Johnson, the heart on dissection was found " pale, flabby, and so lacerable as to be easily mashed between the fingers like wetted paper or putrid meat.*'f Dr. Johnson states, that in all the cases which occurred in his own practice, where post-mortem examination was made, there was a flabby and softened state of the muscular structure of the heart, con- nected in a few instances with ossification of the coronary arte- ries.:}: Dr. Cook also mentions a peculiar flaccidity and soft- ness of the structure of the heart, "as a phenomenon, usually found after this disease," sometimes with, and at others without ossification of the coronaries or cardiac valves.§ Hypertrophy or dilatation of the heart, without any other organic disorder, is mentioned by Laennec as no uncommon condition in this af- fection. About six years ago I attended a gentleman, in con- sultation with Dr. M'Clellan, who was frequently affected with violent paroxysms of angina pectoris. In one of the attacks he suddenly expired. On dissection, the heart was found very large, and its structure so soft as to be easily broken down by pressure between the fingers. From these facts, it appears evident that organic affections of this kind are to be regarded rather as the exciting, than as the essential and proximate cause of the disease. It is now be- lieved by many, that angina pectoris consists in a neuralgic af- fection of the heart, or of the cardiac plexus ; and there can, I think, scarcely exist a doubt of the correctness of this opinion. Laennec conceives that the location of the nervous irritation may vary according to circumstances. "For instance," he says, " when there exists at the same time pain in the heart and lungs, we may presume that the affection is principally * Lectures and Observations on Medicine, p. 18J. t Med. Chir. Rev. April, 1826, p. 497. t Ibid. March, 1828, p. 430. § Loc. citat. vol. ii.—29 226 ANGINA PECTORIS. seated in the pneumo-gastric nerves ; on the other hand, when there is simply a sense of stricture of the heart, without pulmo- nary pain or much difficulty of breathing, we may consider its seat to be in the nervous filaments which the heart receives from the grand sympathetic. Other nerves are also simulta- neously affected, cither by sympathy, or from direct anastomo- sis;—for example, the branches of the brachial plexus, parti- cularly the cubital, are almost always so; the anterior thoracic nerves originating in the superficial cervical plexus are also frequently affected ; and it is also sometimes the case with the branches derived from the lumbar and sacral plexuses, as we find the thigh and leg now and then participating in the pain and numbness." M. Recamier also considers this disease as a species of neuralgia; and the same opinion is expressed by Dr. Johnson,* Jahn,f Jurin, Desportes, and other writers. Al- though this nervous irritation or neuralgia of the heart appears to he most frequently excited by some organic cardiac affec- tion ; it may also be occasioned by other remote causes or irri- tations in the system. There are some well authenticated facts on record, exemplifying the occasional dependence of this dis- ease on dyspeptic irritation. I have already adverted to the two cases mentioned by Dr. Baillie, which ultimately recovered, and were evidently dependent "upon an imperfect digestion." Mr. Cooke, also, to whose excellent work on the diseases of the digestive organs I have referred above, thinks that angina pectoris is occasionally excited "by derangement of the digest- ive organs, especially by dyspepsia." Several eminent writers have supposed that the disease depends on gouty irritation ;J and Lentin§ maintained that it is always of rheumatic origin. From all that has been ascertained, therefore, in relation to this subject, it would seem that angina pectoris may be excited by various causes, both organic and dynamic, and that it con- sists essentially in a peculiar irritation of the cardiac nerves, giving rise to pain, and more or less spastic action of the re- spiratory muscles. Treatment.—When once fully developed, angina pectoris is an extremely unmanageable affection, and almost always sooner or later terminates in death. It must not, however, be regarded as a hopeless affection, even in its most aggravated form; for instances of complete recovery have occurred, after the disease had continued for several years, in occasional pa- roxysms of great severity. For the relief of the paroxysm, we may have recourse to * Med. Chir. Rev. Nov. 1828, p. 197. \ Loc. citat. Bd. v. p. 407. \ Berger, Abhandl. f. Pract. Aerzte. b. x. p. 715. Hesse, Specimen Inaugurate Medicum de Angina Pectoris. § Beitraege zur Ausuebenden Arzneiwissenschaft, b. i. ANGINA PECTORIS. 227 small bleedings, anodynes, and antispasmodics. Ether, cam- phor, opium, hyoscyamus, and the liquor ammonia succinatse, have been most recommended for this purpose. I attended a patient some years ago, who was frequently seized with violent paroxysms of this affection, and who generally obtained consi- derable relief from a draught of very cold water. This patient died suddenly in one of the attacks ; and on dissection the semi- lunar valves of the heart were completely ossified. Perfect rest need scarcely be enjoined, for patients are irresistibly constrained to remain quiet during the paroxysm. It would appear even that where the patient can summon up sufficient firmness of mind to continue walking when the attack comes on, the exertion has a tendency in some instances to mitigate the pain and constricted respiration.* Dr. Good advises that the patient be immediately placed in an inclined position, with the head raised high; and an emetic instantly administered. If the pain and difficulty of respiration continue after the vomiting, " opium intermixed with camphor, ether, or other diffusible antispasmodics, should be freely employed." Emetics were, I believe, first recommended in the paroxysm of this disease by Percival.f Richter admits, that much relief may sometimes be obtained from vomits; but he asserts that they may also readily do a great deal of harm. Where the oppression in the chest is great, and the habit robust and plethoric, blood-letting will occasionally afford some relief. According to Laennec, however, leeches applied to the epigastrium or region of the heart, sometimes prove more beneficial than venesection. In- deed venesection may very readily prove injurious in this com- plaint, and it ought not to be used, unless the indications for its employment are unequivocal. Dr. Parry, w7ho particularly advocates the practice of venesection in this complaint, advises that the blood "should be taken from a small orifice, the pa- tient being placed in the horizontal position, while the physician is to keep his finger on the pulse, to decide the limits to which venesection is carried." Advantage may also be obtained dur- ing the paroxysm from derivative applications, such as sina- pisms to the legs or soles of the feet, and over the epigastrium, and rubefacient frictions to the lower extremities. For preventing the return of the paroxysms, various reme- dies and modes of treatment have been recommended. As the cardiac irritation may be wholly symptomatic of gastric dis- order, it will be proper, in all instances, to pay particular at- tention to the biliary and digestive functions. A mild diet, the occasional use of small portions of blue pill, chalybeate mineral waters, and tepid or cold bathing, are particularly indicated * Parry's Treatise on Angina Pectoris. t Medical and Philosoph. Comment, vol. iii. p. 180. 228 ANGINA PECTORIS. in cases attended with dyspeptic symptoms. In individuals of a gouty or rheumatic habit, much advantage, it is said, has been obtained from the protracted use of guaiacum.* Goodwin states that he derived very great advantage from the frequent application of a strong solution of tartar emetic in spirits of camphor ;f and cases have been published, which go to show that the establishment of a permanent drain from the region of the heart, by a seton or issue, may he resorted to with considerable prospect of benefit.:}: Baumes speaks highly of the internal use of phosphoric acid in this complaint; and thinks it capable of arresting the process of ossification ;§ an opinion which was also entertained by Richter.|| It is given to the amount of a drachm and a half daily in the form, of lemon- ade. In Hufeland's Journal, a writer speaks in the highest terms of praise of the extract of lactuca virosse. Sixteen grains of this extract is to be dissolved in two drachms of cinnamon Water, of which fifteen drops must be taken every two hours.^| Arsenic has been used with considerable benefit by Richter; and Smith employed small doses of James' powder in union with castor and assafoetida, with very good effects in some cases of this complaint.** The celebrated Odier of Geneva re- stricted his patients to an extremely spare and simple diet, as the best means, in his opinion, for preventing the return of the disease. Laennec asserts that the magnet is one of the best means for palliating or preventing the paroxysms of angina pectoris, that we possess. He uses it in the following manner: "I apply," he says, "two strongly magnetised steel plates, of a line in thickness, and of an oval shape, and bent so as to fit the part, one to the left precordial region, and the other exactly opposite on the back, in such a manner that the magnetic cur- rent shall traverse the affected part. This method has suc- ceeded better in my hands in the case of angina than any other, as well in relieving the paroxysm as in keeping it off. After a certain time, the magnetism most commonly produces an eruption of small pimples, which are sometimes so painful as to oblige us to interrupt the process for some.days. This erup- tion almost always takes place under the anterior plate, and cannot therefore be attributed to the action of the oxidized pieces of steel on the skin. By means of these plates, applied to the epigastrium and spine, I stopped at once a hiccup which * Berger. Loc. cit. Bd. p. 708. X Annales de Litterature Medicale Etrangere, vol. iv. as quoted by Richter. \ New-York Medical and Physical Journal, December, 1814. § Annales de la Societe Pratique de Montpellier, torn. xii. || Specielle Therapie, vol. v. p. 195. IT Journal, &c. 1809, st. i. p. 57. ** Medical Commentaries, Edin. vol. v. p. 78. ANGINA PECTORIS. 229 had lasted three years. At the end of six months, the patient having one morning neglected to put on the plates, the hiccup returned, but was removed on their being replaced." When in angina the relief obtained from the magnet is but small, its good effects may be increased by previously blistering the part to a small extent to wiiich the anterior plate is applied. In the management of this affection, it is all important that the patient abstain from spiritous drinks, and avoid strong mental emotions of every kind. Inordinate venereal gratifica- tions, too, are in general decidedly injurious ; and strong cor- poreal exertions, particularly walking up hill, or rapidly as- cending stairs, as well as sudden atmospheric vicissitutes, in- digestible and irritating articles of food, must be carefully avoided. CHAPTER XVIII. OF THE DISEASES OF THE HEART. There is scarcely a subject in pathology that has attracted so much attention of late years, as the chronic affections ef the heart. The researches of Corvisart,* Kreysig,f Testa,:}: La- ennec,^ Burns, [| and Abercrombie,^ have thrown great light on this important class of diseases, and it is from these sources chiefly that the following observations are drawn. Symptoms.—The general symptoms are nearly the same in every variety of structural disease of the heart. More or less habitual dyspnoea almost universally attends in affections of this kind; and a careful attention to the particular modifica- tions of this symptom, is of great importance in a diagnostic point of view, (Corvisart.) The acts of inspiration are either very quick, and effected more by the action of ribs than by the diaphragm, and somewhat wheezing; or the patient breathes as if he had been walking rapidly, and appears to make unusual efforts in filling the lungs; or finally, the respiration is calm, and without any particular effort, hut the air does not appear * Es sai sur les Maladies et les Lesions Organiques du Coeur. t De Krankheiten des Herzens. Berlin, 1814-17. X Delle Malattie del Cuore. § Treatise on the Diseases of the Chest: translated by J. Forbes, M. D.: 3d edition. || Observations on some of the most frequent Diseases of the Heart. By Allan Burns, 1809. IT Contributions to the pathology of the heart. Transact. Med. Chirug. Societ. ofEdinb.vol. i. 1824. 230 DISEASES OF THE HEART. to enter into the lower portion of the lungs. Mental agitation, or corporeal exertions, particularly walking, or ascending acclivities or stairs, never fail to bring on more or less violent paroxysms of dyspnoea; and in the latter stages of the disease, the most trifling excitements of this kind give ris^ to extremely distressing spells of suffocative breathing, attended with great weight and constriction in the breast, inexpressible anxiety, a turgid and usually livid hue of the face, particularly of the lips, which are swollen and purple; distention of the veins in the neck and head, and an expression of extreme distress and suffering in the countenance. These paroxysms of dyspnoea often last but a few minutes, and rarely continue beyond half an hour, and sub- side rapidly to the ordinary state of respiration. During the early period of the disease, or in cases of a less serious character, the patient is able to lie down, (though rarely with any degree of ease on the right side) but the sleep is much disturbed by alarming dreams, frequent startings and spells of palpitation- obliging the patient suddenly to sit up in bed. In violent or in- veterate cases, however, the patient is sometimes obliged to remain day and night in a sitting or half-sitting posture—every attempt to lie down being immediately followed by the most harassing paroxysm of palpitation of the heart and suffocative breathing. One of the most frequent symptoms of cardiac diseases is irregular action of the heart. Sometimes the heart beats tumultuously and indistinctly, which has been compared to the bubbling of boiling water; and at others it seems to be in a state of tremulous agitation. More commonly, however, it beats vehemently against the side of the thorax, so as to enable a person distinctly to hear its throbs, and to communicate a motion to the whole superior part of the body. Syncope, too, is no uncommon occurrence in diseases of this kind. The pa- tient is liable to occasional attacks of partial fainting, often of long continuance, during which he experiences a feeling of great oppression and constriction in the region of the heart, a partial loss of consciousness and sensorial power, inexpressible anxiety in the prcecordia, with an extremely feeble and fluttering or intermitting pulse, and scarcely any perceptible respiration. From this state of adynamia, he sometimes passes suddenly into deep syncope, approaching the character of asphyxia, and after a short period, again suddenly recovers his entire consciousness.* In some cases, paroxysms of angina pectoris occasionally su- pervene ; and instances occur in which the cardiac disease gives rise to convulsions and apoplexy.\ The habitual aspect of the countenance, during the intervals of the exacerbations of the dyspnoea, is usually pale and cachectic, with a leaden * Kreysig. loc. cit. B. i. p 332. X Dr. Forbes. Edition of Laennec on the Diseases of the Chest. DISEASES OF THE HEART. 231 lividity of the prolabia, and a puffy swelling under the eyes. CEdema of the feet and legs is usually one of the earliest symp- toms of organic affections of the heart. In the progress of the disease oedema gradually extends higher, and often invades the scrotum, labia, and even the trunk. In some instances, the pulse differs but very little from its natural state, except during the occasional paroxysms of the dyspnoea and palpitation; but more frequently it is irregular, intermitting, and often has a peculiar jarring beat, or is sharp, exceedingly firm, and incom- pressible. Organic diseases of the heart are very generally attended with a peculiarly irritable temper, and a disposition to melancholy and hypochondriasis.* Symptoms of indigestion, too, are very apt to occur in diseases of this kind; and in many instances there exists a strong tendency to hsemorrhagy, par- ticularly from the lungs and the nose. Patients labouring un- der cardiac affections are liable to sudden and severe pains in different parts of the body. Dissection shows that cardiac diseases have a particular ten- dency to produce great engorgement of the capillary vessels, and it is to this circumstance, no doubt, that we have to ascribe the dropsical effusions into the cellular structure and cavity of the chest, so common in these affections. In almost all those who die of organic disease of the heart, the mu- cous membrane of the alimentary canal exhibits a deep red or violet colour, and in most instances, " the liver and capil- laries situated beneath the serous, mucous, and cutaneous tis- sues, are strongly gorged with blood."f A very vivid redness of the internal surface of the heart and large vessels, is also a very common phenomenon in subjects who have died of such affections, and this is particularly noticed where the affection consists in a morbid dilatation of the ventricles of the heart. Causes.—The etiology of the diseases of the heart is envelop- ed in much obscurity. There exists, no doubt, a natural pre- disposition in some individuals to affections of this kind; but our notions concerning the nature of this predisposition amount only to some plausible conjectures. An inordinate irritability of the heart and arteries has been mentioned as a circumstance predisposing to cardiac affections; and an original defect in the muscular energy of the heart, as well as a disproportion between the activity of this organ and the blood-vessels may also occasionally be the foundation of such diseases. It is said that the predisposition to organic affections of the heart, is in some instances manifestly hereditary, and its occasional prevalence in certain families renders this opinion very proba- ble. Dr. Forbes refers to Lancisi, Albertini, Morgagni, * Testa. 1. citat. t Laennec 1. cit. p. -592 232 DISEASES OF THE HEART. Portal, Corvisart and Testa, for striking examples of this kind ; and a remarkable instance is related in the eleventh vol. of the Medical Commentaries. A strumous habit is considered by Testa as a strong predisposing cause of organic affections of the heart; and Dr. Forbes says, that his own experience has led him to the same conclusion. " In this case," he observes, " I have thought that the disease is developed at a more early period than under other circumstances. Perhaps in this case an original disproportion of the parts usually exists." The remote causes of the diseases of the heart appear to be numer- ous and very diverse in their characters. The following have been mentioned as the most common and powerful. 1. Moral Causes.—Corvisart, Kreysig, and others assert that mental emotions are among the most frequent and powerful causes of structural diseases of the heart; and from the well known in- fluence of violent affections of the mind on this organ, there can be no doubt indeed of their tendency, when frequently repeated, or of protracted duration, to give rise to such diseases. Dr. Forbes states, that he attended a poor woman " affected with organic disease of the heart, of many months standing, which was suddenly produced by horror at seeing her infant scalded to death."* Instances have occurred in which sudden terror, anger, or excessive joy has determined the blood so vehemently to the heart as to cause immediate rupture of its ventricles.f 2. Gout and Rheumatism.—Organic diseases of the heart are probably more frequently occasioned by metastasis of gout or rheumatism than by any other cause. Sauvages mentions instances of cardiac affections alternating with paroxysms of gout ',\ an0< Dr. Scudamore has related a remarkable case of palpitation of the heart of three years standing, which suddenly disappeared on the supervention of an attack of articular gout.§ Rheumatism, however, appears to be still more frequently con- cerned in the production of cardiac affections. Dr. Cox has adduced some interesting examples of the dependence of dis- eases of the heart on metastasis of rheumatism. " Numerous cases of organic diseases of the heart and pericardium which he met with during his connexion with St. Guy's Hospital, were referrible to, or connected with rheumatism.|| Dr. Cox states, moreover, that his observations have led him to believe, that "the majority of cases of organic diseases of the heart in young people are connected with rheumatism. Dr. James Johnson also observes, that "long and attentive observation" • Laennec on the Diseases of the Chest, third edition. t Richter, Specielle Therapie. B. v. p. 129. X Nos >logia Method. Tom. i. p. 518. $ A Treatise on Gout and Rheumatism, fourth edition, p. 44. || Observations on Acute Rheumatism and its Metastasis to the heart, by Thos. Cox, M. D. Lond. 1824. DISEASES OF THE HEART. 238 has convinced him, " that a very considerable proportion of those active enlargements or hypertrophic of the heart, which are now so frequently met with in practice, are dependent on rheumatism." Sir David Dundas* and Dr. Hawkinsf also, have published observations illustrative of the rheumatic origin of organic cardiac diseases; and Dr. Forbes has related seve- ral interesting instances of this kind.:}: 3. Cutaneous diseases.—The repulsion of chronic cutaneous eruptions may give rise to organic diseases of the heart. Kreysig says, that when cardiac affections arise from causes of this kind, the disease is apt to occur in the external or in- ternal membranes of the heart; and according to the observa- tions of Testa, the most common structural lesions resulting from repelled cutaneous affections, are thickening and indura- tion of the pericardium. Osiander mentions ulcerations of the external surface of the heart and of the pericardium ;§ and Me- kel has related a similar instance of disorganization of these parts, apparently the consequence of repelled cutaneous erup- tions. Cardiac affections have also been known to result from the suppression of habitual perspiration of the feet, and from the healing up of old ulcers and issues. (Richter.) 4. Syphilis is also mentioned as no uncommon cause of dis- eases of the heart. Corvisart was of opinion that the excres- cences which are sometimes found on the valves, usually de- pend on a syphilitic taint; and Lieutaud particularly refers to this disease as a cause of various structural disorders of the heart.|| Mr. Bertin, however, thinks, ttiat the influence of this cause, in relation to cardiac diseases, has been much overrated, an opinion which he was led to adopt after an experience of twenty years in the venereal hospital. Laennec also rejects the opinion of Corvisart with regard to the syphilitic origin of the excrescences on the valves. 5. Diseases of other organs, particularly such as are attend- ed with long-continued and severe dyspnoea, are especially apt to give rise to hypertrophy or dilatation of the heart, "through the constant efforts this organ is called on to perform, in order to propel the blood into the lungs against the resistance oppos- ed to it by the cause of the dyspnoea." Chronic pulmonary catarrh, phthisis pulmonalis, chronic peripneumony, empyema, and emphysema of the lungs, frequently give rise to these car- diac affections, and almost necessarily, where there exists a congenital disproportion between the size of the heart and the t Med. Chir. Transact, vol. i. ■J Rheumatism and some Diseases of the Heart. Lond. 1826. Original Cases, &c. p. 112, and p. 165. See also a note at p. 597 of his Translation of Laennec on the Chest, fourth edition. § Denkwuirtigkeiten, &c. Th. i. p. 146, as quoted by Richter. I! Hist. Anatom. Med. Tom. ii. ob. 510-516. Sprengle. VOL. II.—30 234 DISEASES OF THE HEART. diameter of the aorta. (Laennec.) Chronic diseases seated in the abdomen, are also mentioned among the occasional causes of organic affections of the heart. Testa thinks, that indura- tion and enlargement of the liver may give rise to diseases of this kind ; but Corvisart, more correctly I think, regards the hepatic affection as the consequence, rather than the cause, of disease of the heart. " More probably," says Forbes, " it may be merely a concomitant, and the consequence of those chronic disorders of the stomach and upper bowels which are too fre- quent in all classes of people to be safely admitted as either a common cause or effect of affections of the heart." It is sup- posed that visceral enlargements within the abdomen tend to produce cardiac diseases by compressing the large vessels, and by impeding the circulation through the affected viscus, in con- sequence of which, greater efforts of the heart are made to op- pose these causes of obstruction. 6. Scurvy has also been supposed to be capable of giving rise to structural disease of the heart, more especially to a mor- bid softness and flabby state of its structure. 7. Congenital disproportion of the different parts of the heart, and particularly between the left ventricle and the aorta, is no doubt at the bottom of the majority of the instances of hypertrophy and morbid dilatation. Where such a condition of the central organs to the circulation exists, every thing which is capable of causing a long-continued preternatural momentum of the circulation, or an impediment to the free passage of the blood through the lungs, or sudden and forcible determinations to, and congestions of the heart and large vessels, may readily give rise to aneurismal dilatation of this organ. Playing wind instruments, carrying heavy burdens, or straining in lifting heavy weights, running, the inhalation of suffocating vapours, protracted rigors of intermitting and other febrile diseases, in- toxication, mental emotions, lymphatic and other tumours pressing on the carotids or some other arterial trunk, and a great variety of other causes of a like tendency, will be apt to produce structural disease of the heart, in individuals thus predisposed by a congenital conformation of this organ. Blows, falls, and external injuries of the chest may likewise give rise to organic cardiac diseases. Inflammation of the heart, too, is frequently concerned in the development of affec- tions of this organ. Indurations, morbid softening, excres- cences, pseudo-membranous formations, adhesions, effusions into the pericardium, ulcerations, &c. may be regarded as the immediate consequences of cardiac inflammation, in whatever way this latter condition may be produced. Diagnosis.—The diagnosis of the diseases of the heart is at- tended with much difficulty. The symptoms of organic affec- tions of this organ are particularly liable to be confounded with DISEASES OF THE HEART. 235 simple hydrothorax, hydropericardium, neuralgic angina pec- toris, and even with asthma. Laennec asserts that none of the symptoms mentioned above can at all be regarded as pa- thognomonic, or sufficient to indicate disease of the heart, " since they are common to many other affections, and particularly to almost every chronic disease of the lungs." There is much truth in this observation, but I apprehend, nevertheless, that the uncertainty of the diagnosis founded merely on the symp- toms, is not, in general, so great as might appear from the sentiments expressed by M. Laennec. When we find a patient complain of more or less habitual dyspnoea, greatly aggravat- ed on corporeal exertion ; slight oedema of the feet; a puffy and anxious appearance of the countenance, with a livid hue of the prolabia; frequent palpitations or tumultuous action of the heart; an inexpressible feeling of anxiety in the region of the heart during the paroxysms of dyspnoea; the occasional sud- den occurrencc'of elastic puffy swelling of the lower eye-lids and the upper lip; an irascible and gloomy temper; quick and short inspirations; a deep purple and bloated aspect of the face during the paroxysms of dyspnoea ; with an absence of the peculiar wheezing and ratling noise in the lungs; and a free secretion of urine ; when these symptoms are noticed, we have strong reasons for presuming that there exists some disease of the heart. The sudden and exceedingly distressing effects, that arise from bodily exertions in diseases of the heart, are often sufficiently characteristic to distinguish them from simple hy- drothorax. Every muscular effort, or unusual exercise, ag- gravates, to an extreme degree, the dyspnoea and distressing anxiety, and agitation in organic cardiac diseases. Going up stairs, or walking up a rising ground, almost immediately ex- cites the most alarming and suffocative paroxysms of dyspnoea. Although these causes also aggravate, in some degree, the dif- ficulty of breathing in simple hydrothorax, yet these conse-x quences are by no means so violent and agitating in this dis- ease, as in the affections of the heart. Without doubt, however, mediate auscultation affords the most certain means for recog- nizing the presence of organic cardiac diseases ; but the tact for profiting by this diagnostic test, can only be acquired after a long course of careful experience, and it must, moreover, be observed, that even in the most experienced hands, the stetho- scope more frequently gives fallacious indications with regard to the affections of the heart, "than in any of the other diseases which it is calculated to discover." (Laennec.) Prognosis.—In general, the prognosis in diseases of the heart is particularly unfavourable. Nevertheless, much relief may sometimes be procured even in cases of great severity. " We sometimes," says Laennec, "see the judicious combination of blood-letting, diuretics, and tonics, remove the impending suf- 236 DISEASES OF THE HEART. focation, the palpitation, and the dropsy, and restore the patient frequently for a long period to a tolerable degree of health: and it is commonly only after a great many attacks recurring after considerable intervals, that the disease at length proves fatal." Death almost always occurs very suddenly, and not unfre- quently when the patient seems to be free from any unusual disturbance from the disease. Indeed the mere degree of se- verity of the symptoms is often very fallacious in a prognostic point of view. In some instances, much continued uneasiness, with frequent exacerbations of distressing violence, will conti- nue for many years before the disease terminates in death. In other cases, with less structural disorder of the heart, and no very severe symptoms, the disease will unexpectedly terminate fatally in a short period after the first manifestations of its presence. Dilatation and attenuation of the parietes of the ventricles; hypertrophy with softness of the muscular struc- ture; and contraction or diminution of the openings of the heart, appear to be most apt to prove suddenly and unexpect- edly fatal. The occurrence of other diseases in persons labour- ing under organic affections of the heart, always enhances the liability to a speedy unfortunate termination very considerably. Pregnancy, parturition, intermitting fever, &c. are especially calculated to increase the sufferings and dangers of structural cardiac affections. In some instances, diseases of this kind give rise to a protracted state of asphyxia, and cases of spon- taneous resuscitation have occurred after the patient had been supposed to be dead. Forms of structural cardiac disease.—A great variety of or- ganic affections of the heart, and its immediate appendages, are mentioned in the works on this subject. The following are the principal forms of these diseases: 1. Thickening and en- largement of the heart, or hypertrophy; 2. Attenuation of the parietes of the ventricles; 3. A morbid softness and flabby state of the structure of the heart; 4. Dilatation of its cavities; 5. Aneurismal pouches of its ventricles; 6. Ossifications of the valves and other parts; 7. Excrescences of a warty character on the valves, and from the internal surface of the ventricles; 8. Contraction of the openings of the heart; 9. Absence or la- ceration, or ulcerative destruction of the valves; 10. Adhesions between the pericardium and the heart; 11. Tumours on the heart, pericardium, or aorta; and 12. Polypous excrescences. Of these affections the severest and most common are : dilata- tion of the ventricles; hypertrophy, or enlargement and thick- ening of the parietes, or the connexion of both these condi- tions. The following observations on these affections are drawn from M. Laennec's work on the diseases of the chest. DISEASES OF THE HEART. 237 1. HYPERTROPHY OF THE HEART. The term hypertrophy is employed to designate an unnatural thickening or increase of the muscular structure of the heart, without a proportionate dilatation, though frequently with con- siderable diminution of its cavities. (Laennec.) In general, this thickening is at the same time attended with an increased firmness of the structure of the heart; but it is also some- times found connected with a morbid softening of its substance, though the latter condition appears to be the consequence of a distinct disease, as it frequently exists independently of hyper- trophy. In some cases, the hypertrophy is confined to a single ventricle; sometimes both ventricles are affected, with or with- out a similar condition of the auricles; and occasionally, though very rarely, the auricles alone are found in a state of hyper- trophy.* M. Laennec states that he has seen the walls of the left ventricle more than an inch thick, and even as much as eighteen lines at the base. The thickening generally "dimi- nishes gradually from the base to the apex. The columnse carnse of the ventricles and the pillars of the valves acquire a proportionate enlargement, and the septum between the two ven- tricles becomes also considerably thickened in the disease of the left ventricle." In many instances the cavity of the ventri- cles is diminished in size. Laennec has found the left ventricle so small in hypertrophy as "scarcely to he capable of contain- ing an almond with its shell." The symptoms of hypertrophy of the left ventricle are: A strong and full pulse; violent beating of the heart against the chest; and a violet or red tint of the face. The patient almost constantly feels the action of the heart; though very violent and tumultuous palpitations are less apt to occur in this than in some other affections of the heart. These symptoms, though frequently present, are not invariably so; for, in some very severe cases, the pulse is small and weak. The signs furnished by mediate auscultation, however, in connexion with the state of the pulse, and the appearance of the countenance, will in ge- neral enable us to recognize the presence of this affection. Be- tween the fifth and sixth cartilages of the ribs the heart "gives a very strong impulse, and is accompanied by a duller sound than natural, and prolonged in proportion as the thickening is more considerable. The contraction of the auricle is very short, productive of little sound, and consequently scarcely perceptible in extreme cases. The sound of the pulsation of the heart is confined to a small extent, being in general scarcely perceptible under the left clavicle, or at the top of the sternum; sometimes it is confined to the point between the cartilages of Laennec. 238 DISEASES OF THE HEART. the fifth and sev.enth ribs; and the impulse of the heart is rarely perceived beyond the same limits, except during palpitation." Laennec, Bertin, Richerand, and others, consider simple hypertrophy of the left ventricle as peculiarly apt to produce apoplexy; but Dr. Kellie has very ingeniously, though cer- tainly not satisfactorily, controverted this opinion. When the right ventricle is in a state of hypertrophy, there is more dyspnoea, and the countenance is of a deeper hue, and in nearly atl instances the external jugular veins are turgid, and have a manifest pulsating action communicated to them by the re- gurgitation of the blood. Laennec states that he has never found this symptom absent in hypertrophy of the right ventricle. The stethoscope gives the same results as when the left side is af- fected, with the exception that the heart is felt beating with most force at the bottom of the sternum, instead of the space between the cartilages of the fifth and sixth ribs. Laennec asserts, that the place where the action of the heart is most distinctly felt, may be regarded as a certain diagnostic in rela- tion to this subject. When the hypertrophy exists in both ven- tricles, "the signs consist in a reunion of those that belong to hypertrophy of each side; but those of the right side are almost always more marked." 2. DILATATION OF THE VENTRICLES. This constitutes the passive aneurism of the heart of Corvi- sart—the ventricles being preternaturally dilated, their parie- tes attenuated, and the muscular structure, in many instances, so soft that it may be readily broken down by mere pressure between the fingers. The walls of the left ventricle have been found so thin as to measure scarcely two lines at the thickest part, and not more than half a line at the apex : " while the right ventricle is sometimes so completely extenuated as to ap- pear merely composed of a little fat and its investing mem- brane." Though sometimes confined to one ventricle, dilatation usually affects both at the same time. This condition of the heart is very commonly accompanied by other organic affections of this organ—particularly ossification of the valves, and con- genital narrowness of the openings into the aorta or pulmonary artery; and Bertin thinks that the morbid dilatation is always caused by these and other circumstances capable of impeding the free course of the blood as it is thrown out by the ventricles. This appears to be the most common of all the organic cardiac diseases, and seems generally to be produced in a very gradual manner. In dilatation of the ventricles, the pulse is usually soft and weak, and the palpitations of the heart feeble and indistinct. Mr. Forbes thinks that pain or a peculiar feeling of distress in DISEASES OF THE HEART. 230 the region of the heart, extending sometimes to the top of the sternum, between the shoulders and to the left arm, as in angi- na pectoris, deserve notice as signs of dilatation in the heart. He refers also to headach, an affection which he thinks "he can trace in a great number of cases to this condition of the heart, as its exciting cause." When the left ventricle alone is thus affected, the contractions of the heart will be heard very distinctly with a clear and sonorous sound between the cartila- ges of the fifth and seventh ribs, through the medium of the stethoscope ; and " the degree of distinctness of the sound and its extent over the chest are the measure of the dilatation. Thus when the sound of the contraction of the ventricles is as clear as that of the contraction of the auricle, and if it is, at the same time, perceptible on the right side of the back, the dilata- tion is extreme."—(Laennec.) When the right ventricle is in a state of morbid dilatation, the pulse and action of the heart " are nearly the same as in dilatation of the left ventricle." In general the jugulars are distended; the oppression in the chest is apt to be great; anasarcous effusions occur; the countenance is usually livid, and bloody expectoration is very common. Laennec states, that an habitually turgid state of the jugulars, unattended with a pulsatory motion, is the most constant and characteristic " of the equivocal signs of this affection." The only constant and truly pathognomonic sign, is the loud sound of the heart, perceived under the lower part of the sternum, and between the cartilages of the fifth and seventh ribs of the right side. The palpitations which accompany this affection consist principally in an increase of the frequency and sound of the contractions, while at the same time, the impulse of the heart's action is frequently feebler than in the ordinary state of the patient." Laennec places but little reliance on percussion, as a means of forming a diagnosis in cases of this kind. In general, percussion at the bottom of the sternum elicits a dull sound. Dilatation with hypertrophy of the ventricles, is much more common than either of these affections separately, and may exist in one or both ventricles. The contractions of the ven- tricles in this affection may be very distinctly felt by the hand; "and if we attentively observe the patient we frequently per- ceive the head, limbs, and even the bed-clothes, strongly shaken at each systole of the heart. If we press on the region of the heart, this organ seems to be irritated by the pressure, and beats more forcibly still." The pulse is full, hard, strong, fre- quent, and vibrating ; the pulsations of the superficial arteries are often visible. Percussion on the region of the heart almost always elicits a dull and obscure sound. With the stethoscope, the pulsations of the heart are heard distinctly over a great extent —they may be perceived below the clavicles, on the sides, and a 240 DISEASES OP THE HEART. little on the left side of the spine. In some instances, when the heart palpitates strongly, besides the impulse of the heart which seems communicated by a large surface, we can distin- guish another shock which is sharper, clearer, and shorter, al- though occurring at the same time, and which seems to strike the walls of the chest with much smaller surface. This blow seems evidently occasioned by the apex of the heart." 3. ANEURISM OP THE AORTA. Aneurismal dilatations of the aorta are very common. In some instances the dilatation exists without rupture of any of the arterial coats, constituting what authors call true aneu- rism ; in others the internal coat is ruptured, forming the kind of arterial dilatation denominated false aneurism. Sometimes a large extent of the aorta is in a state of morbid dilatation ; but much more commonly the dilatation is confined to the as- cending portion and arch. These aneurismal tumours often acquire a very large size. Laennec has seen them " as large as the head of a full grown foetus." By compressing the heart and lungs these tumours are apt to give rise to very alarming and distressing affections. When the coats of the artery are much diseased, or the dilatation becomes very great, the tumour sometimes bursts and causes immediate death. In some cases the " aneurism compresses the trachea or one of the two bron- chial tubes, flattens and eventually destroys a part of them, and death ensues from the rupture of the tumour." The oesopha- gus may also be thus compressed, but this occurs but seldom. The heart is usually pushed to one side or downwards. Some- times the aneurism bursts into the air-cells of the lungs; but rup- ture into the left cavity of the pleura, is by far the most common. Aneurismal tumours of the aorta often destroy the vertebral column to a great depth, by causing gradual absorp- tion, without leaving any other marks of disease, such as caries, &c. When this takes place, the tumour becomes entirely de- stroyed on the side next the vertebras—the naked bone forming the posterior wall of the sac. The sternum is also in some cases destroyed, when the aneurism is in the ascending aorta. When the arch of the aorta or the arteria innominata are the seat of the aneurism, the tumour often projects at the top of the sternum, or under the cartilages of the first false ribs of the right side. It is not always the largest aneurisms that most readily make their way externally. Sometimes those of the size of an egg produce this effect, whilst occasionally, those of the size of the head of a full grown foetus remain quite covered, and are even compressed by the sternum. (Laennec.) Diagnosis.—The signs of aneurism of the aorta, according to Corvisart, are; inequality of the pulse in both arms; obscure DISEASES OF THE HEART. 241 sound on percussion; a rattling noise in the throat, " and dragging downwards of the larynx when the tumour presses upon the trachea; and a whizzing or rushing at the top of the sternum perceptible by the hand." Laennec, however, places no reliance on these signs, and observes that aneurism of the aorta has no symptoms peculiar to it—the symptoms just noticed " being indicative merely of the change or compression of the adjoining organs. If, however, we find under the sternum or below the right clavicle, the impulse of the circulatory organ isochronous with the pulse, and perceptibly greater than that of the ventricles examined in the region of the heart, we have reason to suspect dilatation of the ascending aorta or arch— the more so as it is extremely rare to feel the impulse of the organ of the circulation beyond the region of the heart, even in cases of the most marked hypertrophy. If this phenomenon is found constant, after repeated examinations, we may consider the diagnosis as certain. Examined with the stethoscope, the aneurismal tumour usually elicits a peculiar purring, thrill, and bellows-like sound. In general, however, aneurism of the aorta can only be recognised with certainty when it shows itself ex- ternally ; but even when it passes through the walls of the chest, " it is not always distinguishable from other tumours. The origin and progress of this affection are indeed sometimes so obscure as scarcely to give any reason for suspecting its existence ;" and the first indication of its presence, is often the death of the individual as instantaneously as if by a pistol-bullet. Treatment of the Organic Diseases of the Heart. The greater number of organic diseases of the heart must be regarded as absolutely incurable. This, however, does not apply to hypertrophy and dilatation, whether existing singly or concomitantly with each other ; for by a judicious and ener- getic course of treatment, both these cardiac affections may occasionally he entirely removed, and almost invariably greatly mitigated. M. Laennec observes, that " the greater number of practitioners are too much in theliabitof despairing of suc- cess in cases of this kind, and therefore content themselves with attacking such urgent symptoms as may arise in its pro- gress ; and yet I believe, there is no one who has not succeeded every now and then even by this symptomatising treatment in prolonging for fifteen or twenty years the lives of individuals affected with organic diseases of the heart." Organic affec- tions of the heart, are indeed much more generally regarded as mere subjects of pathological speculation, than as diseases, in some instances at least, susceptible of cure or melioration by proper remedial management. " We think such an estimate," says Dr. Johnson, " not only a false one, hut pernicious in its consequences both to the patient and practitioner." vol. 11.—31 242 DISEASES OF THE HEART. The general, and paramount indication in the treatment of organic cardiac affections-i-more especially of hypertrophy and morbid dilatation, is to reduce and keep down uninterruptedly the momentum of the circulation ; and this is to be fulfilled by lessening the mass of the blood by venesection, and a reduction in the'quantity and nutrient qualities of the food, and by care- fully avoiding every thing which has a tendency to increase the action of the heart and arteries. When there is reason to believe that there exists hypertrophy, the volumn of the circu- lating fluid should be at once decisively diminished by as large a blood-letting " as the patient can bear without fainting;" and this is to he repeated at intervals of three or four days, until the " palpitations have ceased and the heart yields up a mode- rate impulse under the stethoscope." In cases where there is simple dilatation, without an increased thickness of the muscu- lar structures of the ventricles, the abstractions of blood can scarcely be carried to a very great extent, or at least be very frequently repeated, without the risk of great prostration or fatal syncope. In cases of this kind, it will nevertheless be highly proper to keep down the mass of the blood, but after one or two effectual bleedings this may be most prudently done by an extremely abstemious mode of living. A reduction of the ordinary quantity of food, is indispensa- ble to full success in cases of this kind. The good effects of blood-letting will be but temporary, and in general wholly in- adequate, unless the rapid generation of new blood be at the same time obv iated, by putting the patient on a very spare and diminished allowance of diet. Laennec advises that the food should be diminished to one half, at least, of the ordinary quantity taken by the patient; and it should consist of mild and unirritating articles of diet, at the same time that the mass of the blood is kept down by repeated bleedings. All kinds of stimulating liquids must be rigidly forbidden. This course of depletion and low diet must be steadfastly pursued, the patient at the same time avoiding as much as possible, every thing which may cause inordinate excitement of the circulatory system, particularly exercise, strong mental emotions, and stimulating ingestion. "When the patient has been two months without experiencing palpitations, and without increased impulse of the heart, we may lessen the frequency of the bleedings, and di- minish in some degree the severity of the regimen, if the pa- tient is not at all habituated to, or satisfied with his allowance. But we must return to the same means, and with the same rigour, if the augmented impulse of the heart should return." (Laennec.) This method of treating organic affections of the heart was first practised by Valsalva and Albertine.* In * Morgagni. De Scdibus et Causis Morbor, &c. Epistol. xvii. art. 30. DISEASES OF THE HEART. 243 addition, however, to the foregoing measures, they kept their patients in bed during a period of forty days, and directed the frequent use of laxative enemata. Dr. Forbes states, that he has resorted to this method of treatment with much temporary advantage, and he cites the names of Lancici, Guattini, Saba- tier, Pelletan, Corvisart, Hodgson, Bertin, and others, in favour of its usefulness in organic cardiac affections. Mor- gagni also, speaks of this reducing plan of treatment in affec- tions of this kind with decided approbation ;* and there can be no doubt, indeed, of its direct tendency to lessen the violence of the symptoms, or to effect a cure in hypertrophy of the heart. Laennec observes, that even where the disease has ad- vanced so far as to have induced great dyspnoea, anasarca, and a general cachectic state of the system, " we must nevertheless fearlessly prosecute the plan of starvation and bleeding." When the symptoms just mentioned, namely, habitual dysp- noea and dropsical effusions occur, diuretics will generally assist materially in alleviating the sufferings of the patient. Dropsical effusions into the cavity of the pleura or pericardium almost invariably occur in the progress of organic affections of the heart, and it would appear that the immediate cause of death in many instances are effusions of this kind, impeding the actions of the lungs and heart. Diuretics can therefore rarely be dispensed with in affections of this kind, and they are in fact often decidedly palliative. We may frequently succeed in removing the dropsical effusions from the chest, by the judi- cious employment of this class of remedies, so as to procure much temporary relief. The effusion, it is true, will generally soon return again, hut I have known the life of an individual protracted for four or five years, by occasionally effecting a removal of the dropsical accumulation. I attended an old lady some years ago, who laboured under symptoms of hydrothorax; by low diet and the use of the squill and nitre, in doses of about two grains of the former, to fifteen of the latter, I suc- ceeded in removing the water from her chest, three times in the course of about fifteen months. She finally died suddenly, and on dissection, the heart was not only in a state of remarkable hypertrophy, but the mitral valves were completely ossified. Some writers have strongly recommended digitalis as a diuretic in organic cardiac affections, attended with dropsical effusions ; and from the known powers of this article to curb the action of the heart, it would seem to be peculiarly applicable in cases of this kind. Laennec, nevertheless, does not speak very favour- ably of its powers in the class of diseases now under considera- tion. He observes, that he has never found it to control the action of the heart, "even when the dose was carried to the extent * Morgagni. Dc Sedibus et Causis Morbor, &c. Epistol. xviii. art, 30. 244 DISEASES OF THE HEART. of producing vomiting and vertigo." Its diuretic powers are equally uncertain, but of its occasional sedative, as well as diu- retic influence, no doubt can be entertained, and as both these effects are peculiarly desirable in cases of this kind, it unques- tionably deserves a fair trial, where we find other articles inef- ficient. I have known the infusion of the erigeron hetrero- phyllum to produce very active diuresis, and of course advantage in one instance of cardiac disease accompanied by hydrothorax. Purgatives may also be resorted to with advantage, where the dropsical accumulations become considerable in cardiac affections; and they are more especially necessary where diu- retics fail to procure relief. One of the best medicines for this purpose is the following combination, which rarely fails to procure copious watery discharges from the bowels, and at the same time free diuresis.* When the cardiac affection consists in simple dilatation, the pulse, as has already been stated, is generally feeble and com- pressible, and the depletory measures must therefore be employed with caution. But even in cases of this kind we must endea- vour to obviate a plethoric state of the vessels, by an occasional small blood-letting and an abstemious diet. The principal re- medies, here, are the ferruginous preparations and the vegeta- ble bitters. These may be beneficially given in union with some of the milder aromatic substances, particularly the infu- sions of valerian, cat-mint, and of orange flowers. (Laennec.) To curb the action of the heart, digitalis is particularly useful in instances of this kind. From one-fourth to half a grain of the powder of this vegetable may be given every two hours until the frequency of the pulse is moderated, and it should be repeated afterwards in such a way as to keep up a slight seda- tive impression on the circulatory system. Cases of mere di- latation, however, arc seldom permanently benefited by reme- diate treatment; and the prospect of effecting an entire cure is always exceedingly small. By the employment of chalybeate waters, or some of the officinal preparations of iron, and weak infusions of the tonic vegetable bitters, and a simple and abste- mious course of living, with a careful avoidance of all unusual corporeal exertions and spirituous potations, a considerable de- gree of comfort may be obtained by patients affected in this manner. " One great principle." says Dr. Forbes, " is always to be kept in view in the treatment of diseases of the heart, namely, the removal of all disorders in other organs which can act as a * R. Tart, potass. 5iss. Sulph. potass. 5ss. Pulv. scillae zii. Tart, antimoni. gr. ii.—M. S Take a tea-spoonful four or five times daily. DISEASES OF THE HEART. 245 source of irritation to the heart." It is particularly important to attend to the gastric and hepatic functions; and hence we find that patients almost always experience some relief when these functions are brought into a healthy condition. " 1 would lay it down," says the writer just quoted, " as a general rule in chronic affections of the heart, that previously to having re- course to any remedies intended to act directly on it, we ought to be assured that the digestive organs are in a healthy state— that their mucous surfaces are free from irritation—their vas- cular system not morbidly distended, and that the liver is per- forming the secretory functions freely and regularly. When derangements of this kind are present—a few leeches to the prsecordia or anus, some small doses of oxide of mercury and castor oil, a mild and spare diet, and bodily and mental repose, will often do more to tranquillize the circulation than more active and rougher means. And indeed, in many cases% more especially in the earlier stages, when the stethoscope gives us but little information, it is not until we have restored the or- gans to a comparatively healthy condition, that we can know how far the disordered action of the heart depends on sympathy with these, or is the consequence of incipient organic lesion of the heart."* Concomitantly with the employment of the above-mentioned tonics, very considerable advantage may in general be derived from an occasional dose of three or four grains of blue pill at night, and a mild laxative in the morning ; and to keep up the regular action of the skin, the tepid shower-bath will generally be useful. Sympathetic Affections of the Heart. Symptoms differing in no material circumstance from those which have already been mentioned as belonging to organic af- fections of the heart, are not unfrequently the result purely of a sympathetic irritation of this organ without any structural lesion whatever. 1 do not now allude to those cases of an- gina pectoris which arise from metastastic or sympathetic irri- tation, and vvhich are probably always of a strictly neuralgic character. The heart is liable to be excited into vehement and tumultuous action by a variety of causes not immediately con- nected with lesion or disorder of its structure ; and the most alarming instances of this kind, often result from an irritation located in some remote part of the system. It is of much con- sequence, in a practical point of view, to keep this, indeed, well-known fact in mind in prescribing for cardiac affections. I have, in several instances, been consulted by persons subject to extremely violent paroxysms of palpitation, who were sup- * Laennec on the Chest. By Dr. Forbes. 246 DISEASES OF THE HEART. posed to be labouring under chronic affection of the heart, and who were completely relieved by a course of treatment calcu- lated to restore the healthy condition of the digestive functions and of the liver. When we find paroxysms of palpitation come on while the patient is quiet, perhaps lying down, with- out pain in the region of the heart, at the same time that there are symptoms of indigestion, particularly eructations of flatus, there can be but little doubt that the cardiac affection is symp- tomatic of gastric irritation. Habitual debility and irritation in the digestive organs are particularly apt to give rise to such affections in persons of a plethoric and nervous habit of body. I was consulted, about eighteen months ago, by a gentleman of a very nervous temperament and weak digestive powers, for aid in what he was led to regard as a local affection of the heart. The slightest mental agitation would, occasionally, im- mediately excite vehement palpitations; and frequently simi- lar paroxysms came on about two hours after taking his meals. He had paid little or no attention to the regulation of his diet, although often disturbed with flatulency, acidity, and other un- pleasant sensations in the stomach. He was directed to take four grains of blue pill every other evening, an occasional dose of rhubarb in the morning, and put on a light and digestible diet, with exercise on horseback. In four weeks his complaint left him, and he has not had any return of it since. Irritation located in other organs, as the kidneys, intestinal canal, uterus, liver, and probably the spleen, sometimes give rise to severe fits of palpitation. They are particularly apt to occur about the age of puberty in young females, or just before the irruption of the menses. Nervous females, more especial- ly those who labour under chronic hysteric affections, are al- so especially subject to palpitations of the heart. These cases are, in general, easily distinguished from organic affections of the heart, but as structural disease of this organ may be asso- ciated with mere sympathetic irritation, it may be well to state more explicitly the signs by which nervous palpitation may be distinguished from hypertrophy or dilatation of the heart. "In nervous palpitation, the first impression conveyed by the stethoscope is, that the heart is not enlarged. The sound, though clear, is not heard loudly over a great extent of the chest; and the impulse, although appearing considerable at first, is really not great, as it never sensibly elevates the head of the observer. This last sign seems to me the most import- ant and certain of any when taken in conjunction with the fre- quency of the pulsations. These are always quicker than na- tural, being most frequently from eighty-four to ninety-six in the minute. Nervous palpitations are rarely accompanied by any sign of determination of blood to the head or chest, except in old persons. A feeling of internal agitation, particularly in DISEASES OF THE HEART. 247 the head and abdomen, always accompanies nervous palpita- tions ; and the urine is generally limpid and watery." (La- ennec.) Treatment.—The treatment must of course be regulated ac- cording to the particular condition of the general system, and the local organic irritations that may exist. The digestive functions must be particularly attended to, and the sources of intestinal irritation obviated by gentle aperients. In relaxed and weak habits, the tepid bath ; a mild, digestible, and nutri- tious diet; gentle tonics, especially bitters and iron; gentle exercise by gestation ; and in young and plethoric subjects, small abstractions of blood; warm pediluvium ; and digitalis, will, in general, prove beneficial. Antispasmodics very rare- ly procure any relief, and indeed much more frequently do in- jury. CHAPTER XIX. NEURALGIA. Tic Douloureux. The first account of this affection was given in 1756 under the name of tic douloureux by M. Andre of Versailles. Ten years after this short and rather indistinct description was gi- ven, Dr. Fothergill published a paper in which this painful af- fection is clearly and very circumstantially described under the name of facei morbus nervorum excrucians, and since that period, various interesting and elaborate essays, and a multi- tude of cases, illustrating the character and treatment of this disease, have been given to the public. The term neuralgia, which was, I believe, first given to the disease by Dr. Meglin of Strasburg, is now generally, and certainly with much pro- priety, preferred to the name tic douloureux. Neuralgia is usually divided into different species, according to the seat of this affection ; but the fact, now well ascertained, that its attacks are confined to no particular nerve or system of nerves, that it may occur in almost every sentient structure of the body, in the cerebro-spinal, the pneumo-gastric and phrenic nerves, and even in the ganglionic nerves arising from the solar plexus, renders the propriety of such divisions as specific distinctions very doubtful; and the more so, as they do not appear to involve any essential peculiarities either in a pathological or therapeutic point of view. Unquestionably, 248 NEURALGIA. however, certain nerves are much more liable to become the seat of this affection than others ; and this is especially the case with the three grand divisions of the fifth, and the facial por- tion of the seventh pair of cerebral nerves. Symptoms.—The pain in neuralgic affections is very pecu- liar. It is extremely acute, and darts like lightning from its more fixed point along the course of the nerves. It comes on in sudden paroxysms, with longer or shorter intervals of more or less complete freedom from suffering. In general, much pain is experienced throughout the whole paroxysm, with fre- quent transitory shocks of darting pain, so extremely agoniz- ing as often to cause a temporary loss of reason and conscious- ness. Occasionally, the paroxysm consists of a succession of transient fits of pain coming on with the suddenness of an elec- tric shock with short intervals of comparative ease. During the paroxysms, the surrounding parts are extremely sensitive or tender to the touch; and it is a remarkable circumstance, that the slightest touch, in many instances, causes much more suffering than firm pressure; the former, generally, instanta- neously bringing on a shock of the piercing nervous pain. In general, the pain is attended with considerable turgescence of the blood-vessels in the immediate neighbourhood of the affect- ed part; and this vascular engorgement, says Dr. Macculloch, sometimes "amounts to a species of inflammation, resembling that of rheumatism." Much general soreness in the part is usually left after the subsidence of the acute neuralgic pains; but in some cases only a little tenderness remains, which gra- dually subsides and leaves the patient in his ordinary state of health. In very violent attacks of the disease, we generally find the neighbouring muscles affected with spasms, and occa- sionally spasmodic twitches occur in the muscles of parts dis- tant from the place where the pain is located. When the dis- ease occurs in the nerves of the face, the saliva is often secret- ed very copiously, and in nearly all instances of this kind, there is a profuse flow of tears from the eyes during the paroxysms. In individuals of a nervous temperament it is not uncommon to observe sympathetic affections of other and distant nerves with which those affected have no other connexion than that which exists through the medium of the sensorium commune. In some cases the paroxysms are strictly periodical in their recurrence, with regular intermissions of comparative health, the type being almost always quotidian. This periodicity of the paroxysms occurs only in what may he termed the acute or recent form of the disease; and is particularly pointed out by Dr. Macculloch as an evidence of the affinity or rather identi- ty of this affection with intermitting fever. Sometimes the disease assumes a chronic character, continuing in irregularly recurring paroxysms for mouths or even years, with scarcely any intervals of entire freedom from uneasiness, ill-health, or NEURALGIA. 249 suffering; and this is especially apt to be the case, when the disease occurs in consequence of some mechanical injury of a nerve. This affection occurs much more frequently in the face than in any other part of the body. When the portio dura is affected the pain usually commences on the side of the face near the ear, and darts along the ramifications of the nerve, to the angle of the jaw, the alse of the nose, the angle of the mouth, exter- nal canthus of the eye, and along the temple to the forehead. Sometimes the pain radiates from a point on the cheek just be- low the orbit of the eye and passes to the side of the nose, the upper lip, teeth, gums, and temple, in which case the disease is seated in the second branch of the fifth pair of nerves. When the principal pain is experienced in the internal canthus of the eye, forehead, eye-lids, and in the ball of the eye, we may pre- sume that the first branch of the fifth pair is affected ; and in cases where the tongue and lower jaw are the seat of much pain, the neuralgic irritation extends to the third branch of the tri- geminus. Sometimes the pain occurs in the scalp ; and I have seen an instance of extreme violence, in which the pains were most severely felt behind the ear and along the scalp of the occiput and the posterior portion of the temporal bone. The optic nerve, also, has been known to be affected with neuralgia. Dr. Macculloch mentions a case in which the pain in the eye was described by the patient as if a red-hot needle had been passed through its centre.* The decidedly neuralgic character of this pain was evident from its having occurred the moment after an attack of neuralgia in the upper jaw had ceased. Neuralgia in the nerves of the extremities is by no means un- common. Dr. Macculloch mentions a severe case that occur- red in the radial nerve which runs along the metacarpal bone of the fore-finger. The pain was confined to a space "which a pea could have covered," and continued duriig a period of four months. Mr. Abernethy has related a striking instance of neuralgia, which affected the superficial nerves under and adjoining the inner edge of the nail of the ring-finger of the hand ;f and Dr. Pearson has given an account of a remark- able case affecting the extremity of the left thumb.:): The occurrence of this affection in the nerves of the feet and legs has been frequently noticed. I have lately seen an in- stance of this kind, which had already lasted upwards of six months. Dr. Good, who makes a distinct species of such cases, * An Essay on the Remittent and Intermittent Diseases, including, generically, Marsh Fever and Neuralgia, &c. By John Macculloch, M. D. t Surgical Works, vol. ii. p. 18. X Med. Chir. Transact, vol. viii. Part 1. \QI* II.—32 250 NEURALGIA. under the term neuralgia pedis, describes an instance of this kind, which continued for several years. The paroxysms were transient, of uncertain recurrence, and so severe as nearly to cause fainting, darting up the calf of the leg towards the knee, and downwards into the toes. Dr. Macculloch relates instances of neuralgia of the knee. In two extremely violent cases the pain was situated immediately over the margin of the head of the tibia, and the affected part was not more than an inch in area. In another case, imitating the double tertian type, " there was on one day pain in both knees, and on the al- ternating day a pain in one arm ;" and in this way the disease continued a long time. Neuralgic pains in this joint, says this writer, have been mistaken for scrofulous affections, "and in some cases that had lasted five years, as the pain was very severe, the surprise had long been that no swelling could be dis- covered by the touch." This affection is what Mr. Brodie has described under the name of hysterical white swelling; and he appears to think "that nine out of ten of those unfortunate young women who have been doctored of late years for spinal diseases, have really laboured under nothing but hysterical pains of the back."* The tibia has been frequently the seat of extremely violent neuralgia; and it has also occurred in the thigh, particularly in the anterior crural nerve, shooting down with great severity, from near the groin to the foot or toes. The occurrence of neuralgia in the breasts of females has of late years been noticed by several writers. The third species of Dr. Good's subdivision of this affection, {neuralgix mammae) is founded upon this location of the disease. He describes an interesting case of this kind. The breast, he says, was '« full- formed and soft, without the slightest degree of inflammation or hardness. When the paroxysm ,of pain was not present it would hear pressure without inconvenience, but during the pain the whole breast was acutely sensible. The paroxysms returned at first five or six times a day and were transient, but as the disease became more fixed it became also more severe and ex- tensive, for the agonizing fits at length recurred as often as once an hour and sometimes more frequently." Dr. Addison says, that neuralgic pain under the mammae, or under the margin of the ribs of the left side, is far from being uncommon in females. This pain, he observes, is " very circumscribed, and will often last for weeks, or even months, with but little inter- mission. It is often associated with palpitation of the heart, or what is much more usual, with unnatural pulsation of the organ, i. e. the patient is conscious of the heart's action, or she * Med. Chir. Rev. Nov. 1828, p. 58. NEURALGIA. 251 feels as if its impulse were communicated to a part so sensitive as to excite distinct sensation.* The internal organs, as w-as observed above, are no less lia- ble to neuralgic affections than the external parts. Of the neuralgia of the heart, I have already spoken under the head of angina pectoris, for it will scarcely admit of a doubt, that in some instances at least, this appalling affection is strictly of a neuralgic character. Its occurrence in the abdominal viscera appears also to be much more common than is generally sus- pected. Dr. Macculloch has met with a well-marked instance of neuralgia in the rectum. There is an affection of this kind which occasionally occurs at the extremity of the rectum or coccygis, immediately after parturition, causing indescribable suffering to the patient, and which scarcely any dose of lauda- num is adequate to allay. Dr. Dewees, in his midwifery, mentions a remarkable instance of this kind, and I have not long since met with one equally striking. The pain continued for two hours before it began to decline. The painful affection usually termedgaslralgia, is probably purely neuralgic in its nature. In this variety of the disease, the pain is paroxysmal, sometimes quotidian, and usually ra- diates from the epigastrium to the thoracic parietes, the back, and to the shoulders. The tongue is white, the saliva abun- dant, without thirst, and epigastric tenderness on pressure. Immediately after eating the pain generally abates for some time, but in the course of one, two, or even three hours afterwards, it is renewed with a feeling of weight and distress in the epi- gastrium, as if there was a foreign body in the stomach. Nau- sea, borborygmi, flatulent colic, and eructations of air, are usu- ally experienced some hours after eating. There is generally much constipation, and the urine is usually pale and small in quantity. In violent and protracted cases, difficulty of breath- ing, palpitation of the heart, wandering pains, and a peculiar sensation of coldness in the arms, loins, and lower extremities are wont to occur. In the morning the patient commonly gets up refreshed, and feels quite well until breakfast renews the gas- tric pains. Dr. Prus has recently reported a very interest- ing case of neuralgia of the stomach, which was brought on by violent mental emotion. The patient, a female, was affected with excruciating pains in the epigastrium which came on daily in paroxysms, between the hours of three and half-past seven P. M. Fourteen years after the commencement of her sufferings, the patient consulted Dr. P. The epigastric pain was removed in five days by full doses of quinine, given during * Observations on the Disorders of Females ; connected with Uterine Irritation. By Thomas Addison, M. D. &c. Lond. 1830. 252 NEURALGIA. the intermission, and the patient appeared to be entirely cured. On the twenty-second day afterwards, however, intense pain occurred in the course of the infra-orbital nerve; soon after- wards it seated itself in the cubital nerve of one arm, where it remained but a very short time. It then returned to the face. A blister was now applied beneath each trochanter. After this the sciatic nerves of the right side became violently painful. Blisters were applied along the course of the nerve, and in a few days more the pain suddenly shifted to the left sciatic nerve, and soon afterwards disappeared altogether.* The kidneys, also, may become the seat of this affection. Dr. Macculloch states, that he has met with an unequivocal in- stance of this kiud. There is an exceedingly painful affection which occurs in the right aliac region, usually confined to a very circumscribed space, and which has been generally re- garded as the result of calculous irritation in the ureters, but which appears very manifestly, I think, to be purely neuralgic. I have met with five or six cases of this kind, several of which continued to recur daily for two or three months. Its mere nervous character seems to be demonstrated by the strict peri- odicity which it observes in its recurrence ; although in most instances there is retraction of the testicle on the affected side as in calculous irritation, without however any difficulty or diminution of the discharge of urine. The uterus also is liable to become the seat of extremely painful affections of this kind in females of a nervous or hyste- rical temperament. My friend, Dr. Samuel M'Clellan, lately attended a young lady, who for several months was daily affected with sudden paroxysms of what he justly regarded neuralgia in the region of the uterus. The shocks were so exceedingly agonizing, as in some paroxysms almost to de- prive the patient of reason. At times, instead of the uterus, other parts of the body were seized with similar pains, and the whole nervous system was in a state of morbid irritability, Mr. Shaw has related a case, where the neuralgic affection was seated in the ulnar nerve from the elbow to the little finger. After some local rubefacient applications and the internal use of blue pill and the volatile tincture of valerian, the pain abated in the arm ; but the patient (a female) was attacked with severe pains in the uterus. It would seem too that neuralgia sometimes invades the bladder. In a conversation which I lately had with Dr. Parrish, he mentioned an instance that occurred in his practice, which he called tic douloureux of the bladder. Dr. Macculloch has devoted a chapter of his work to the * Med. Chir. Rev March, 1829, p. 553. NEURALGIA, 253 consideration of neuralgic affections of the glands ; and Dr. Jolly has published an interesting memoir on what he calls visceral neuralgia. The cases, however, that are mentioned by those writers, as instances of glandular or visceral neural- gia, though unequivocally the result of nervous irritation, cannot with propriety be ranked with the neuralgic affec- tions; since little or no pain was present—the prominent symptoms having been either functional disorder or spasm of the muscular structure of the parts affected. Thus Dr. Mac- culloch mentions a case, as neuralgia of the kidneys, which was characterized by a strictly periodical recurrence of profuse diabetes; and the cases related by Dr. Jolly consisted of peri- odical hiccup, in one instance with temporary aphonia, or of paroxysmal spasmodic eructations of flatus from the stomach, without pain, &c. It is certainly a solecism to apply the term neuralgia to such affections, for the term implies pain, and ought in strict propriety to be confined to painful nervous ir- ritations. M. Martinet has related some singular instances of neural- gia,* which assumed the general appearances of cerebral disease. One case commenced suddenly with incomplete para- lysis of the right lower extremity, attended with pain running along the sciatic nerve; next a dull pain, with formication, oc- curred in the region of the loins—in a few days afterwards pains radiating along the temples, forehead, and upper eye-lid of the right side came on—then distortion of the mouth to the left side, embarrassment of speech, with pain in the facial nerves ; darting pains along the scalp, deep-seated cephalalgia in the right side of the head, and finally uneasiness in the epi- gastrium, coated tongue, &c. The case was cured by leeching and purgatives. He mentions another instance still more closely similating disease of the brain. A very singular case is related by M. Hellis, of Rouen. The patient, a young man aged about 15, at first felt a dull pain near the last dorsal vertebrae, which soon extended itself to the epigastrium, attended with hiccup. In this situation he continued with occasional intervals of weeks or months, for several years : at last the pains did not confine themselves to the back and epi- gastrium, but darted through the chest, abdomen, and down the legs to the toes. It also affected the upper extremities, and passed along the course of the nerves to the extremities of the fingers. On closing the hand, the hiccup and the pain would cease, but " on extending a single finger it would appear, and quick as lightning traverse the parts just mentioned."! * Rev. Medicale, Janvier, 1824. t Med. Chir. Rev. Octr. 1826. Journal G£n*ral de Med. April, 1826. 254 NEURALGIA. From the foregoing facts, we perceive that neuralgic irrita- tion is by no means confined to a few points of attack; and we shall presently make it appear that its causes are scarcely less various than the parts which are susceptible of becoming its seat. Causes and Pathology.—Dr. Macculloch strenuously insists on the malarious origin of neuralgia, and there can scarcely exist a doubt, indeed, that in many instances, neuralgic affec- tions are nothing more than masked agues from the influence of koino-miasmata. In miasmatic districts, the occurrence of affections of this kind is far from being uncommon ; and their close affinity to intermitting fever seems to be sufficiently de- monstrated by the strict periodicity of their character, and the remedies most successful in removing them, being the same that are most effectual also for the cure of fully developed in- termittents. The symptoms too, which on a careful examination may be detected in many instances of periodical neuralgia just before the accession of the paroxysms, indicate the close alliance between them and intermittents. "Immediately before the attack," says Dr. M., "if the pulse be examined, it will be found to put on that character which it possesses in the cold stage of intermittents, while through the progress of the pa- roxysm it passes through the other analogous changes." There are also, most commonly "some indications of a cold stage, generally obscure, it is true, as is the case in most of the ano- malous and chronic intermittents, but still discernible." There is much reason to believe that individuals who have laboured under intermittents, may afterwards, even at remote periods, have relapses of the disease in the form of periodical neuralgia. I have seen two instances of this kind, of great severity, which yielded readily to the powers of arsenic given during the inter- missions. True as it undoubtedly is, that many cases of this affection arise from the influence of koino-miasmata, and par- take of the nature of intermitting fever, it is nevertheless far from being so generally dependent on this cause as is alleged by Dr. Macculloch. It is manifest, indeed, from the many cases that have been published of late years, that this painful affection may be originated by a variety of very distinct causes, some of them of a general, and others of a strictly local cha- racter. Sometimes it appears to be dependent on a morbid irritability and irritation in the intestinal canal; and this is probably most commonly the case when the affection occurs in the nerves of the mammae, on the side of the head, and in the heart, producing angina pectoris. I have seen an instance of excruciating pain and tenderness in the left breast, between the nipple and the axilla, without inflammation, swelling, or red- ness, in a lady habitually affected with gastric disturbance. It NEURALGIA. 255 was removed by a course of simple diet, mild tonics, blue pill, aperients, and laxative enemata. The occurrence of neuralgia from mechanical injury of the nerves, is by no means uncommon. In many instances of this kind, the neuralgic pains are seated at a distance from the part where the primary irritation or injury exists; but in others, the affection is located immediately in the injured nervous ra- mifications. Sir Henry Halford has lately adduced some observations which would seem to show that facial neuralgia is occasionally excited by lesion of bone. In one of the cases he relates, "there was an exostosis of the alveolar process—in another there was disease of the antrum highmorianum, and in a third, and the most remarkable of all, there was a prodi- gious deposit on the internal surface of the skull, like frost- work, which must have caused great pressure on the brain. Dr. Pemberton, previously to the development of the neuralgia of which he died, was twice affected with abscess in the frontal sinuses."* In a case of neuralgia of the face, Dessault found the foramen through which the nerve passed in a diseased state. Many cases are on record where neuralgia was produced by accidental injuries, such as wounds, bruises, &c. M. Feron has related an interesting instance of this affection which was produced by a bite from a little girl in a state of delirium, in- flicted on the back of the second phalanx of the little finger of the left hand in an old lady. In a few days excruciating pain was experienced in the little finger, spreading successively to the hand, forearm, and elbow, along the tract of the cubital nerve. After cauterizing the wound, the pain extended to the axilla, and increased in severity; at last a sense of tricture and fulness or stuffing in the chest ensued, which was soon succeed- ed by violent cardialgia and vomiting. These symptoms, recurring in paroxysms, lasted six months.f A most distress- ing case is related, which was caused by a wound of the hand from the explosion of gunpowder. Amputation of the arm was twice performed, but the disease always returned in the stump as soon as it was cicatrized. The patient visited Paris, Lon- don, and Edinburgh, where he consulted the most eminent of the faculty, but he derived no permanent advantage from the measures that were recommended. I once saw a case of great violence, which was produced by a fracture of the forearm. I have not heard whether the disease was ultimately removed or not. Dr. Jeffray has recorded a very aggravated case, which was caused by a wound in the cheek by a piece of chinaware, * Med. Chir. Rev. April, 1828. t Med. Chir. Rev. Sept. 1821—from the Journal Complement, Mai, 1820. 256 NEURALGIA. a small portion of which remained imbedded in the wound. It may also arise from the irritation of a carious tooth. Mr. Swan has given the history of a case of facial neuralgia, which was produced by a blow on the right eye. With regard to the proximate cause of neuralgic affections, pathologists have expressed a diversity of opinions. Dr. Parry attributed the pain to "increased vascularity or determination of blood—perhaps amounting to inflammation—of the neuri- lema or vascular membranous envelope of the affected nerves." M. Vaidy, who has published a valuable memoir on this dis- ease, entertains a similar view of its pathology. He considers all neuralgic affections as consisting in inflammation of the nervous tissues.* The affected nerve, or its neurileme, has indeed sometimes been found preternaturally vascular and in- jected ; yet these conditions may be the consequence, and not the cause of the neuralgic irritation. The nerves, says Mr. Swan, are liable "to become enlarged and inflamed from irri- tation, just as muscles are from continued action, but dissec- tion, he says, has not shown those depositions of coagulable lymph and structural changes which are produced by continued inflammations of the other parts of the body, and of the nerves themselves in stumps and portions along the seat of inflamma- tory action.f" The general opinion at present is, that this painful affection is frequently the result of mere nervous irrita- tion, without any necessary connexion with vascular conges- tion or inflammation. Without doubt,- however, inflammation or increased vascularity of the neurileme may give rise to the disease ; and it may, I think, be assumed as a fact, that neu- ralgia may depend on different causes—on local inflammation or congestion of the affected nerve—on organic disease of the brain—and most commonly on a sympathetic irritation, from latent irritation in other parts or organs. Diagnosis.—The diagnosis of neuralgia is not, in general, attended with difficulty, unless it be seated in the internal or- gans. The pain, as has been stated, is darting, extremely acute, paroxysmal, and usually transient, coming on with the suddenness of an electric shock, and ceasing as instantaneous- ly. These circumstances, together with the exceeding apti- tude of the slightest touch or motion of the affected part to re- new the paroxysm of pain, and the entire absence of swelling or inflammation, and usually of heat in the part, and finally, the transient radiations of the pain along the course of the nerves, are sufficient to distinguish this disease from other pain- ful affections. Treatment.—The mode of treatment must of course be di- * Journ. Complement, Dec. 1820. t Dissertation on the Treatment of Morbid Local Affections of the Nerves. By Joseph Swan, &c. NEURALGIA. 257 versified, according to the nature of. the exciting cause, and the extent and situation of the neuralgic affection. A case pro- duced by local injury of the nerve, will scarcely yield to the same treatment that will be required for one which arises from the influence of miasmata; and an instance depending on this latter cause, will probably yield to remedies that would fail in one which originates from gastric irritation and a gene- ral morbid irritability of the system. Formerly, considerable reliance was placed on dividing the affected nerve; but al- though no inconsiderable number of cases have been related where this operation effected a cure, it is but seldom that it can be resorted to, on account of the number and situation of the af- fected nervous ramifications; and where the disease depends on a sympathetic irritation, or a local injury nearer the origin of the nerve than can be reached with the scalpel, there would appear to be but very little or no chance of ad vantage from this measure. Mr. Swan, in speaking of this operation when the portio dura is affected, says, that the attempt to divide the trunk of this nerve is not only attended with much difficulty, butalso with danger; and "to divide all the branches that go to the face, requires an in- cision from the zygoma to the angle of the jaw. The greatest portion may be divided by making an incision down to the jaw a little below the zygoma, and thus the main branches of the nerve will he cut through ; and if the patient is not relieved by the operation, another incision may be made quite to the angle of the jaw, by which nearly all the principal branches will he divided." When the disease is located in the third branch of the trigeminus, in which case the pain is felt in the side of the tongue and the teeth, the attempt to divide the nerve would be dangerous. When, however, the pain occurs in the lower lip, the nerve may be divided as it passes out of the lower jaw, by passing the point of a knife between the lip and the bone at the first bicuspid down to the foramen and moving it a little from side to side.* Notwithstanding the difficulty and hazard of dividing the trunk of the portio dura, a very interesting exam- ple of the performance of this operation by Dr. Warren of Boston is related in the sixth volume of the Medical Recorder. The patient had laboured under the disease for fourteen years, and had already undergone the operation of dividing the infra- orbital nerve, and the first branch of the trigeminus. The pain passed from a point near the ear over the side of the face. "A dissection was made between the back part of the parotid gland and the mastoid process," the nerve exposed, and a por- tion removed. The pain nevertheless returned. He now cut down over the side of the jaw, through the parotid gland mas- seter muscle, removed a portion of the bone with the trephine, tol. II.—33 * Loc. citat. p. 56. 258H„ NEURALGIA. and exposed the nerve where it enters the lower jaw, and re- moved a piece half an inch long. This completed the cure. In cases of neuralgia in the nerves of the extremities, the re- moval of a portion of the affected nerve has been practised with success in no inconsiderable number of instances. Mr. Earle has reported a case,* where the complaint was cured by cut- ting out a portion of the nerve; and Mr. Abernethy cured a case seated in the integuments of a finger by removing about half an inch of the digital nerve. The propriety of removing, instead of merely dividing the nerve, is founded in part, on expe- rience, and on the fact ascertained by Sir Everard Home and others, that when a nerve is merely divided, and the extremities left close together, they regain the power of transmitting the ner- vous influence in a few (lays. M. Lisfranc cured a case of neuralgia of the scalp, caused by an external injury, "by re- moving an oval piece of scalp, including the seat of the pain, three inches in length and two in breadth."f The practice of dividing the neuralgic nerve has, however, so frequently, we may say so generally, failed, that it is now almost entirely abandoned by practitioners. Where the disease is confined to a single branch and arises from local irritation, it may, ne- vertheless, be resorted to with some prospect of success; and ought most assuredly to be employed where all other remediate measures are ineffectual. In recent cases depending on a constitutional cause, where the paroxysms recur periodically, tonics, particularly quinine and arsenic, will most frequently remove the disease. Instances of this kind, as has been stated, are generally of malarious origin, and will commonly yield to the same mode of treatment that is usually adopted for the removal of intermitting fever. Indeed, neuralgia of this kind sometimes disappears sponta- neously, just as intermittents are known to do, without any medicine. About two years ago, I attended a lady labouring under quotidian paroxysms of the most excruciating neuralgic pains in the portio dura. The autumn previous she had been affected with protracted intermittent, and as she had taken a great deal of quinine, which always affected her head very disagreeably, she now obstinately refused to take it. I there- fore directed a blister to be laid on the epigastrium, and put her on a very simple farinaceous diet. In three days the neu- ralgia ceased, and has not troubled her since. Dr. Macculloch, whose experience in cases of this kind, appears to have been very extensive, says that the Peruvian bark and arsenic are decidedly the most efficacious remedies in intermittent neuralgia; and this observation is confirmed by * Med. Chir. Transact, vol. vii. t Med. Chir. Rev. July 1826. NEURALGIA. < 259 the experience of others. Mr. Shaw has used bark with mark- ed success in neuralgic complaints ; and Dr. Kerrison asserts, that according to his experience, cinchona is the most useful medicine we possess in cases of this kind. M. Vaidy also cured an instance of facial neuralgia, which came on with ex- treme violence every day at 12 o'clock, and lasted four or five hours, by means of the cinchona.* Five or six years ago, I met with a few cases of well-marked intermitting facial neuralgia, which yielded readily to large doses of quinine; but in one instance of a strictly quotidian type, which more recently came under my care, neither this remedy, nor arsenic, made the slightest impression on the disease. Many cases might be col- lected from recent medical publications, illustrative of the good effects of tonics in periodical neuralgia. M. M. Ribes and Dupre have reported an interesting case which was speedily removed by the quinine ;f and M. Piedagnel, succeeded in a very short time in curing this affection with this tonic.:}: Dr. Lalaurie, physician to the Central House of Correction at Eysson, has related an instance of neuralgia which originated from a puncture of a ramification of the frontal nerve, and which had continued for ten years. The attach came onperi- odically. The patient was ordered to take every morning the sixteenth part of a mass, composed of a drachm of white soap and a grain of arsenious acid; drinking immediately after- wards three cups of water containing mucilage and honey. This was repeated every other day, and in two weeks the dis- ease was entirely removed. From the observations that have been published, it appears, therefore, that in intermittent, quotidian, or tertian neuralgia,—and in these only, do the tonics just mentioned manifest any particular curative powers; and in all such cases, whether originating from general or local causes, they ought certainly to be fully tried before recourse is had to other modes of treatment. No article of late years has attracted more attention as a remedy in neuralgia than the carbonate of iron. Mr. Hutchinson has published a small work on tic douloureux, in which he re- lates a considerable number of well-marked cases, that yielded to the powers of this remedy.^ It has also been used with success in this affection by Mr. Richmond,|| Dr. Crawford,^ Dr. Evans,** Dr. Brothwick,ff Dr. Davis, Dr. Yeates, Dr. Ayre, * Journal Complement, December, 1820. f Magendie's Journal de Physiologie—1822. t Lond. Med. Repository—1821. § Cases of Tic Douloureux successfully treated. By B. Hutchinson. London, 1820. || Lond. Med. and Phys. Jour. No. cclxxi. p. 271. IT Ibid. 1823 ** Edin. Med. and Surg. Jour. Jan. 1824. tt Ibid. 260. NEURALGIA. Dr. Marsden, Dr. Payne, Dr. Marshall Hall, and others. The cases related by Dr. Evans furnish very striking testimony of the sanative powers of this article even in very protracted in- stances, and of great severity. It should be given in large doses— from one to two drachms, three times daily. This remedy ap- pears to be best adapted to intermittent cases, attended with de- bility of the digestive powers. It is not, however, superior to the quinine or arsenic in such cases. I have in several instances resorted to it, but only with partial advantage. In one of these cases the disease was afterwards removed with the qui- nine. Some of the narcotics, also, have been strongly recommended for the cure of neuralgic affections. The stramonium, espe- cially, possesses very considerable powers against such pains. It was some years ago recommended by Dr. Marcet as a highly valuable medicine in these and other painful affections unattended with an inflammatory diathesis, and it is unques- tionably entitled to much attention as a remedy in cases of this kind. Dr. Bigbee* has published a paper illustrative of the va- luable powers of this article in painful affections of the nerves, and we have also the testimony of Dr. Elliottson, among others, in favour of its virtues in neuralgic complaints.f I have employed it in four cases of recent neuralgia, in two of which I succeeded in the course of three or four days in com- pletely removing the disease. One fourth of a grain may be given every four hours, until vertigo is produced, when its use must be omitted, and resumed as soon as the vertigo subsides. It has appeared to me most effectual in cases attended with, and probably mainly dependent on a general irritable condition of the nervous system, or on what maybe termed hysteric neural- gic pains. It must not be forgotten, however, that when given in repeated and active doses, it is very apt to produce a species of maniacal delirium, strongly resembling delirium tremens. In two instances, in which I prescribed it for chronic rheumatism, it had this effect. The belladonna, too, has had its advocates as a remedy in neuralgic complaints; but its powers are certainly much inferior to those of stramonium in this respect. Mr. Rodd states that he has cured several cases of painful affections of the nerves by the external application of a strong aqueous solution of the extract of belladonna to the skin over the affected part. In one instance, where the pain was experienced along the course of the sciatic nerve from the hip to the foot, almost im- mediate relief was procured by rubbing the tract of the pain with a solution of two drachms of the extract of belladonna in an ounce of water. Another instance of a similar character * Edin. Med. Chir. Trans, vol. i. p. 285. t Med. Chir. Rev. June, 1828. NEURALGIA. 261 was gradually removed in the same manner.* Mr. Baily speaks highly of the powers of this narcotic in affections of this kind. He has related nearly thirty cases in which this medi- cine was found more or less successful. Of the extract he be- gan with three grains, and repeated it in diminished doses until relief was procured. In some instances he employed the tincture. The oil of turpentine, likewise, has been used with success in certain neuralgic affections. M. Sedillotf cured several in- stances of sciatic neuralgia, by administering this article in drachm doses once or twice daily; and Dr. Wilson, in a com- munication to Dr. Johnson, states that "in three cases of neu- ralgic disease which had lately come under his care, a cure was effected by the combination of calomel, opium, and the oil of turpentine. A pill containing from two to four grains of ca- lomel, and one or two grains of opium, was given each night at bed-time, and next morning one or two drachms of oil of turpentine mixed with a little honey. In each of the three cases a complete and permanent cure was effected by this plan, and in a moderate space of time. M. Recamier, of the Hotel Dieu, also speaks in high terms of the efficacy of the oil of turpentine in neuralgia. Leeching has of late years been employed in neuralgic affec- tions ; and from some accounts that have been published, it would appear that benefit may be derived from this measure in certain cases of the disease. Without doubt, where the malady depends on an inflammatory condition of the nerve or its neu- rileme, the local abstraction of blood is well calculated to do good; but it is by no means probable, I think, that any advan- tage can be derived from this measure in cases connected or dependent on constitutional causes, and there are instances on record where it did much harm, as in the remarkable case related by Dr. Yeates.^ M. Vaidy has reported cases which were cured by the application of leeches along the course of the nerve, {loc. cit.) Of the local applications that have been employed in this affection, moxa is without doubt the most efficacious. Larrey relates cases that were removed by this remedy; and Dr. Bar- ras has given an account of a case of neuralgia of the sperma- tic cord which yielded to this application. M. Feron has reported a highly interesting instance of neuralgia of the ulnar nerve, which was removed almost immediately by the applica- * Transactions of the Surgeons-Apothecaries, vol. i. article vi. On the Treatment of Painful Affections of the Nerves, arising from Local Injury. By Geo. R. Todd, Esq &c. t Medico-Chir. Review. X A History of a severe case of Neuralgia, occupying the nerves of the right thigh, leg, and foot. 262 NEURALGIA. tion of moxa near the elbow. In four or five months, however, the disease returned ; but the moxa now procured only a tem- porary mitigation of the patient's sufferings. Larrey advises that the moxa be applied repeatedly if the first applications afford only partial relief. He has repeated the burning ten or twelve times, and followed the pain with the moxa wherever it fixed itself, before the disease was completely subdued. M. Vaidy has mentioned a case of neuralgia of the sciatic nerve, from the hip to the foot, which was speedily and perma- nently removed by a tight bandage applied over the whole extremity. Acupuncturation has also been resorted to with success in this painful affection. M. Pelletan relates a consi- derable number of neuralgic cases that were completely cured by one or two operations of acupuncture. It does not appear, however, that it has yet been employed with success in facial neuralgia. In the cases mentioned by M. Pelletan, the crural, the sciatic, and the plantar nerves, and in one instance the super- ficial nerves of the chest, were affected.* A case of facial neuralgia is related by Mr. Beddingfield,! in which the application of cerussa, with the view of paralyzing the affected nerve, proved entirely successful. The case was under the direction of Sir Astley Cooper, and had previously resisted every other remedy. Two scruples of the cerussa, formed into an ointment, were rubbed on the affected cheek every morning about an hour before the paroxysm was expect- ed. By continuing this application daily for a month, the disease was completely removed. The application of a strong magnet also, has in a few instances promptly removed the pain in neuralgia of the face. M. Alibert, in his treatise on materia medica, mentions some examples of this kind ; and a remarkable case of this kind oc- curred in my own practice about eighteen months ago. A gen- tleman of this place daily experienced the most agonizing paroxysms of neuralgic pain in the ramifications of the portio dura. Quinine, the carbonate of iron, arsenic, and belladonna were used, but without the least advantage. At last I sent him a strong horse-shoe magnet, and directed him to keep it applied on the side of the face, so as to bring the two poles opposite to the meatus auditorius. He did so. In about two hours after the magnet was applied the pain became more severe than ever, so as nearly to deprive the patient of his con- sciousness. Suddenly, however, the pain ceased entirely, and I found him calm and cheerful in the evening. On the following day the magnet was again applied, and the paroxysm was very * Revue Medicale, Janvier, 1825; and Archives Generales, Fevrier, 1825. t Compendium of Medical Practice. NEURALGIA. 263 slight, and not more than one third the usual duration. In the course of five or six days further the disease was wholly removed. Was this a mere coincidence, or did the magnet control the neuralgic irritation? It is certain that intermitting neuralgia sometimes terminates spontaneously, and it Is possible that this may have been the case in the present instance. An attention to proper dietetic regulations, and to restora- tion or maintenance of the regular action of the liver and bowels, is of much importance in affections of this kind—more especially where the disease is attended with manifest symp- toms of gastric derangement. Gasfralgia.*—For mitigating or removing this painful and distressing affection, which appears to be purely neuralgic, various remedies have been recommended ; but they have sel- dom afforded more than temporary relief. Opium in full doses will indeed always procure perfect ease for a time ; and there are few who are much affected with this complaint, that do not find it necessary to resort to this narcotic. The misfortune, however, is, that those who have once experienced the delight- ful effects of this medicine when suffering under an attack of gastrodynia, will repeat it again and again whenever the pain returns, and as the dose must be progressively augmented, the unfortunate sufferer will almost inevitably contract a habit of taking it in enormous and ruinous quantities. Dr. Dawsonf observes, " it may be said that opium is a great evil, it is so; a most painful necessity; but it is a far greater evil to pass one half of life in excruciating pain, and the other half in mi- serable anticipation. The gastrodynic sufferer has a choice of evils, for him there is no middle path; he must either content- edly endure a pain which makes life a burthen and renders ta- * Although I have already described this affection, I may add the fol- lowing description of its symptoms, as given by Dr. Dawson. " The time and accession of the paroxysm, and the duration of it are alike un- certain. A hearty meal or a copious drink of a stimulating fluid will sometimes bring temporary relief. The pain is aggravated by walking, and slightly mitigated by reclining on the left side and applying pres- sure by the hand. In some cases the pain is always in the stomach only; but in others it does occasionally for a short period quit that organ, and as it were, fancifully and indifferently affects the back, sides of the spine, or the integuments covering the sternum and ribs. The pain it- self is of a peculiar and even of a varying nature. It is not acute, it is not lancinating, it is not spasmodic, it is neither sickening nor dragging. It is of an excruciating aching kind, and of the most soul-depressing na- ture. I have known a gentleman lie on the floor in agony, and have three distinct attacks of three, four, or six hours, during twenty-four hours. Sometimes the stomach feels empty; at others it seems distended, and gives rise to bitter or saltish eructations. Yet the patient, even on the rack of pain, is not ill; and the instant the pain ceases he is as well as he could wish." t Nosological Practice of Physic, p. 300. 264 NEURALGIA. lents useless, or take opium ; for where is the man, who, rack- ed with pain in his stomach night and day, can perform his duties in society and enjoy life as it ought to be enjoyed." Unquestionably the effects of large doses of opium in this dis- tressing malady are delightful for a time; but I am by no means disposed to regard this drug as the only means in our power for procuring relief in cases of this kind. I have my- self suffered much from this complaint, and have taken opium in large doses; but I have found another remedy which is less ruinous in its consequences, and far more permanent in its good effects than this narcotic. This remedy is the saturated tinc- ture of lobelia infiata; a few table-spoonfuls of which has never failed to give me speedy relief, and to procure me long inter- vals of exception from the disease. I have also used it in the case of a gentleman in this city with the happiest effect, hut further than this my experience with this article does not go. The oxyd of bismuth, the carbonate of ammonia in conjunction with magnesia and mint water, the tincture of henbane, and the sulphate of quinine, with a diet consisting chiefly of animal food, have been recommended in this affection, and in some instances considerable benefit may no doubt be derived from them. I have prescribed the oxyd of zinc in a number of cases and occasionally with advantage. Would not the use of the magnet, in the manner recommended by Laennec for the cure of angina pectoris, be beneficial in this complaint? I have just mentioned animal food, as according to the experience of some (Dr. Johnson) most proper in cases of this kind. This may be correct with regard to some instances; hut I have found it best to make as great a change of the customary diet of gas- trodynic patients as could be done. Thus, if a person has been in the habit of using much animal food, he should be put upon a simple vegetable diet; and where the accustomed diet has been vegetable, which is most commonly the case, it should be changed to one consisting chiefly of animal substances. It has appeared to me that this affection is often connected or de- pendent on an ineffectual hsemorrhoidal effort; and advantage might perhaps be obtained from leeches applied to the anus, and the internal use of small doses of aloes. I have been led to this conjecture by the case of a lady in this city who for six years suffered from frequent extremely severe attacks of gas- tralgia, radiating along the muscles of the chest into the left mamma. About a year ago, several large hsemorrhoidal tu- mours appeared at th.j extremity of the rectum, and in a short time began to bleed freely. The discharge has recurred every three or four months, and she has not had an attack of the gas- tralgia since the haemorrhage first appeared. INDIGESTION. 265 CHAPTER XX. INDIGESTION. Indigestion occurs so frequently, and is attended with so discomforting a train of symptoms, that it has the strongest claims upon the attention and sympathy of the physician. The habitual dyspeptic is indeed truly miserable. His sallow and anxious countenance, his irritable and sullen taciturnity, his aversion to social enjoyments, and the occasional overwhelm- ing despondency of his mind, show him to be the prey of deep and harassing sufferings, of which none but those who have experienced them can form an adequate idea. Common, how- ever, as indigestion is, and serious as are its consequences up- on the health and happiness of man, there is perhaps hardly any other malady which is so commonly misunderstood, and consequently mismanaged. In order to obtain a correct view of the pathology of indiges- tion, and of the true indications for its remediate management, it is necessary to be acquainted with the physiology of the pro- cess of digestion. I can here, however, advert only to the pro- minent and essential circumstances that may be considered as ascertained in relation to this subject. It appears then to be satisfactorily demonstrated, that the two following conditions are essential to the regular and healthy performance of the function of digestion. 1. A due tone and peristaltic action of the muscular coat of the stomach in order that the food may be uniformly embraced by the parietes of this organ, and as it successively undergoes chymification where it is in contact with the stomach, be push- ed forwards towards the pylorus and into .the duodenum. 2. Tbe regular secretion of a sufficient quantity of healthy gastric juice. That the fluid called gastric juice is really the solvent which converts the aliment into that pultaceous mass called chyme, and that, therefore, digestion, so far as chymi- fication is concerned, is chiefly affected by the agency of this fluid, is, I think, established beyond all dispute. The experi- ments of Spallanzani, of Stevens, of Gosse, and those quite re- cently performed by Tiedemann and Gmelin of Hiedelberg, and by Leuret and Lassaigne of Paris, have placed this physiolo- gical fact upon the incontrovertible basis of demonstration. It does not appear from some late experiments that the bile has any material agency in the process of chymification. Ac- cording to the experiments performed in relation to this point by Mayo, Brodie, Leuret, Lassaigne, Tiedemann, and Gmelin, vol. ii.—34 266 INDIGESTION. chymification goes on perfectly in animals after the biliary duct has been tied. The principal agency of the bile in digestion is to render the fatty substances of the chyme soluble in the chyle. It is the fat or oil thus suspended, by means of the al- kaline properties of the bile, that gives to the chyle its milky colour. When the common duct is tied, chymification goes on regularly, but the chyle in the lacteals and thoracic duct is transparent and of a yellowish hue. Causes of indigestion.—It has just been said that the imme- diate cause of indigestion consists in a vitiated or deficient se- cretion of the gastric juice, and in deficient or irregular action of the muscular coat of the stomach. Now as both muscular motion and secretion are under the immediate influence of the nervous power, it is obvious that whatever causes an irritation or morbid excitement in the nervous structure of this organ, must necessarily derange also the healthy performance of these two functions. Accordingly every thing which is capable of causing indigestion, does so either by interrupting the regular supply of nervous influence to the stomach, or by irritating the nervous extremities of the mucous membrane of this organ; or by producing both these effects simultaneously. Of the former kind of causes, namely, those that interfere with the regular transmission of nervous influence to the sto- mach, are the mental emotions. It is surprising how suddenly any temporary mental agitation depresses, nay, often wholly suspends for a time the keenest appetite and powers of diges- tion. These temporary depressions of appetite and powers of digestion from sudden emotions of the mind, are converted into protracted and exceedingly unmanageable cases of dyspepsia when the mental perturbations are of a chronic and depressing character. Protracted grief and despondency seldom fail to weaken the digestive powers, and to bring on ultimately con- firmed and unyielding indigestion. Protracted and intense applications of the mind, especially when attended with a sedentary mode of life, is another of those causes which act through the medium of the general system. Such indeed are the sympathetic relations of the stomach with the whole and every part of the organization, that its functions become disturbed by whatever causes either general debility or organic disorder of any of the principal organs of the body. But by far the most common and powerful causes of indiges- tion are those that act. directly upon the nervous extremities of the mucous membrane of the stomach. Whatever is calculated to cause permanent irritation in this membrane has a direct tendency to produce this disease. I think it may be assumed as a pathological axiom, that the function of secretion can never be deranged without the existence of irritation in the secreting organ. Irritation of the vascular extremities that secrete the INDIGESTION. 267 gastric fluid, exists therefore in every case of indigestion. The causes which most frequently give rise to this irritation, consist of over-distention of the stomach and indigestible and irritating articles of food. The manner in which food of this kind pro- duces the irritation in question, is easily to be understood. When the food resists the digestive powers too long, besides its direct irritating impressions upon the stomach, it enters more or less into the fermentative process, and evolves new combinations, such as gas, acidity, &c. which enhance the irri- tating qualities of the contents of the stomach. Besides these consequences of too long a retention of imperfectly digested food in the stomach, the muscular powers of this organ will be diminished by the long and continued exercise to which it is subjected, as well as by the over-distention and irritation caused by the extrication of gas. Portions, too, of the half- digested food will pass into the duodenum, which, being alto- gether uncongenial to the sensibility of this organ, will give rise in it to irritation, spasm, and pain, and by sympathy, functional derangement of the liver. When this state of things is once produced by some error in diet, assisted perhaps by general causes, the slightest causes—even the ordinary digest- ible and plain diet taken in health, will not only sustain it, but often increase its violence, if favoured by other circumstances of a debilitating character. Dr. Philip thinks that over-distention of the stomach, by eating too much, is one of the most common causes of dyspep- sia, and there can be no doubt as to its decided tendency in this way. It is probable, however, I think, that it is not so much by an over-distention of the muscular coat of the stomach which a superabundance of ingesta produces, that indigestion is caused, as by the mere excess of food beyond what the sto- mach is capable of digesting. Suppose the utmost powers of the stomach to be capable of digesting sixteen ounces of food at a time; it is manifest, that if twenty ounces are taken, some of it will remain either in a partially digested, or wholly undi- gested state in the stomach, a longer time than is compatible with the healthy condition of the organ. This portion will therefore irritate the gastric nerves,—enter more or less into a state of chemical decomposition, and give rise to deficient or vitiated secretions in the stomach, as well as debility of its muscular tunic. The effects which follow the reception into the stomach of an undue proportion of food, besides those of mere over-distention, do not differ from those which are caused by indigestible articles of diet. A small portion of food which resists the digestive powers, is capable of bringing on violent dyspepsia, by remaining in the stomach beyond the period which is allotted by nature to the process of digestion, and becoming thereby a source of irritation in -the manner 268 INDIGESTION. already mentioned. Just so does it happen when the portion of food, however digestible, is greater than the stomach is capable of digesting at a time: for the portion which remains in an undigested state, and which the stomach is no longer able to convert into chyme, will act like so much indigestible food, and give rise to the distressing consequences which often result from such articles of diet. The causes which most commonly occasion the reception of more aliment into the stomach than its powers are capable of converting into chyme, are : 1. Eating too fast.—Dr. Philip has satisfactorily explained the way in which rapid eating tends to cause persons to take more food than they are able easily to digest. ** The appetite subsides only in proportion as the gastric juice becomes mixed, and as it were neutralized by the food. When we eat rapidly, time is not given to the gastric liquor to combine with that part of the food which is presented to it; the sensation of hun- ger therefore continues, and we continue to eat until so much food is taken that the whole gastric fluid which the stomach is capable of supplying during the digestive process is not suffi- cient to effect the due chymification of it. Whereas, when we eat slowly, so that a proper time is given for the combination to take place, the appetite abates before the stomach is over- charged. Every one has occasionally observed, that if his meal is interrupted for ten or fifteen minutes after having eaten per- haps not one third of the usual quantity, he finds that he is satisfied. The gastric fluid which had accumulated has had time to combine with, and be neutralized by the food he had taken. It is for the same reason that a few mouth fuls of food taken a little before dinner will often wholly destroy the appe- tite, especially in delicate people in whom the gastric fluid is secreted in small quantity, or of a less active quality." 2. Imperfect mastication acts in the same manner, and as it is always connected with rapid eating, contributes greatly to this latter cause. S. The use of condiments, stimulating drinks, and high- seasoned food. These excite an artificial appetite, and keep up the desire for food longer than it would be sustained by the impressions simply of the gastric fluid. The free use of very cold or warm drinks, particularly dur- ing meals, tends much to weaken the digestion, and to aid other causes in the production of dyspepsia. By drinking freely, the gastric fluid is so much diluted that its powers are weakened, and of course the process of digestion more or less retarded. A very mixed ^/—especially if the articles are of unequal degrees of digestibility—is a frequent cause of indi- gestion. I have stated above, that a tardy peristaltic action of the INDIGESTION. 269 muscular coat of the stomach, by which the digested portions of food are too long retained in this organ, is very often con- cerned in the production of dyspeptic symptoms. I am per- suaded, however, that the reverse condition also very frequently obtains, in cases of painful and imperfect digestion—namely, that the food is too rapidly hurried through the stomach into the duodenum, before it has had time to undergo the full action of the gastric fluid. This appears most commonly to be the case in confirmed instances of the disease—or in such as are attended with a high degree of irritation, or a subinflammatory condition of the mucous membrane of the primae viae. That a morbid peristaltic activity of the stomach often exists in dyspepsia, may be inferred from the consequences which are known to result from high irritation or phlogosis of the mucous membrane of the intestinal tube. The phenomena of indiges- tion in aggravated cases, also confirm the correctness of this opinion. It is a common circumstance, for instance, to hear dyspeptics complain of a sense of fulness in the stomach after eating even a small portion of food. But notwithstanding this feeling of repletion, they soon complain again of the customary sense of emptiness in the region of the stomach, and crave for more food. It is to be observed, likewise, that the chief dis- tress or uneasiness in such cases, is not experienced in the stomach, but rather in the region of the duodenum. Many dyspeptics feel no particular uneasiness until an hour or two after eating, when they begin to experience pain and distention in the duodenum. In some cases the food is speedily hurried off by the bowels in an imperfectly digested condition, under very severe sufferings from tormina and flatulent distention of the intestines. Symptoms and course.—The symptoms of indigestion differ considerably according to the stage of the complaint, or the degree and extent of the irritation. In the commencement the appetite is variable, generally weak, and often entirely de- stroyed : the patient is troubled with flatulency, distention, acid eructations, and colic pains; the mind is, at times, depressed and languid ; the tongue covered with a white fur; the bowels usually constipated ; the whole system languid, particularly during the process of digestion; and there is almost a constant uneasy feeling in the epigastrium. Sometimes the appetite is morbidly craving, but if the patient indulges freely in taking food, he becomes much oppressed, and generally suffers severe pains some hours after eating. After the disease has conti- nued for some time, or it is aggravated by some unusual irri- tating cause applied to the stomach, the pulse becomes tense and quick; the epigastrium tender to the touch; the mind irri- table, discontented, and gloomy. The colic pains are more frequent and severe some time after taking food; the bowels 270 INDIGESTION. irregular, being sometimes constipated ; at others affected with diarrhoea, during which portions of food are occasionally passed off in an imperfectly digested state—the stools varying in colour, consistence, and character. The body now begins to waste, the strength fails, the epigastric distress severe and constant, the countenance assumes a haggard and sallow7 aspect, the patient complains of more or less difficulty of lying on the left side, the skin becomes dry and shrivelled, and there is usually a morbid sensibility to low temperature. From the extensive sympathies which subsist between the sto- mach and every other part of the living body, dyspeptics are frequently much harassed by painful and other distressing affec- tions in parts situated remotely from the stomach. Among these sympathetic affections of indigestion, headach is the most common and annoying. Dr. Warner observes, that there are two sorts of dyspeptic headach, the one occurring while the process of chymification is going on slowly and imperfectly in the stomach, and the other after the chyme has left the stomach and passed into the duodenum. The former is distinguished by a languid and feeble pulse, a slightly coated and whitish tongue, with very pale red edges, mistiness before the eyes, slight vertigo, and an apprehension of falling; slight nausea and uneasiness in the stomach; a sense of constriction about the fauces; and sometimes a coldness and numbness of the fin- gers ; and generally a feeling of weight in the brain. The second, or as Dr. Paris calls it, duodenal dyspeptic headach, is characterized by brilliant occular spectra which constantly distress the patient; the chilliness of the body, and coldness and dampness of the hands and feet. The pain in the head is very severe, attended with a sensation of coldness and tension of the scalp, and a sense of weight and distention in the eye- balls. The tongue is commonly covered with a yellowish white fur and is often much coated. The pulse is natural in fre- quency, but it is always languid. There is usually flatu- lency, and Dr. Paris states that a peculiar feeling of dryness and inactivity of the bowels, as if the intestines had lost their sensibility and were unable to propel their contents, giving rise to a peculiar sensation of weight and obstruction, may be regarded as pathognomonic of this variety of the affection. These headachs rarely continue longer than two or three hours, and are usually diffused throughout the whole head. In a practical point of view, it is of great importance to bear in mind that dyspepsia may depend on two distinct morbid conditions of the digestive organs : namely, 1. On functional debility of the stomach from deficient or vitiated secretion of the gastric fluid, and muscular inactivity, independent of vas- cular irritation or inflammation. 2. On deficient or vitiated secretion of the gastric fluid, with vascular irritation or chronic INDIGESTION. 271 inflammation of the mucous membrane of the stomach and du- odenum, and a morbidly increased peristaltic action of these organs. The characteristic symptoms of the former grade of indiges- tion, are weak appetite ; tongue covered with white fur; absence of epigastric tenderness, except after a paroxysm of colic from flatulent distention ; costiveness; acid and foetid eructations; ab- sense of habitual tension and febrile irritation of the pulse; and the ability of bearing lean and tender animal food better than vegetable and farinaceous articles of diet. The phenomena which characterize the second or inflamma- tory grade of the disease, are tenderness to pressure of the epigastrium, and particularly about the region of the pylorus and duodenum; a red, chopped, granulated or glossy appear- ance of the tongue ; a firm, tense, small, and somewhat accele- rated pulse, with slight manifestations of febrile exacerbations towards evening; emaciations ; irregular action of the bowels, with frequent attacksof mucous, bilious or watery diarrhoea; vi- olent and protracted pain in the lower part of the epigastrium during the process of digestion; fulness about the edge of the false ribs on the right side; an anxious and discontented expression of the countenance ; and an inability, without great suffering, to endure animal food and stimulants. It appears, that the ir- ritation or chronic inflammation of such cases is seated in the mucous membrane of the pyloric extremity of the stomach and of the duodenum, connected usually with a congested state of the liver, and often with faecal accumulations in the colon. Hence the region of the duodenum and pylorus is almost inva- riably somewhat distended, and very tender to pressure in such cases ; and these circumstances, together with the tense and quick pulse, furnishes the most certain diagnosis of the exist- ence of high mucous irritation or chronic inflammation in dyspeptic complaints. In some instances, the pain and tenderness extends across the epigastrium into the left side, and becomes fixed in the region of the spleen, or where the colon turns down to form the descending arch. This pain and tenderness in the left side appear to depend on various causes, "all of which," says Dr. Philip, " are more unfavourable than the circumstances which cause its existence in the region of the pylorus and duo- denum."* It may depend on an inflamed and engorged con- dition of the spleen, in which case this viscus is generally found in an enlarged condition. It arises also sometimes from enlargement of the left lobe of the liver, " which is always the part of this organ most affected in indigestion." According * On the Treatment of the more Protracted Cases of Indigestion. Lond. 1827, p. 19. 272 INDIGESTION. to the observations of Dr. Philip, however, the most common cause of the pain and tenderness in the left side, is the exten- sion of the chronic inflammation from the pylorus to the other parts of the stomach. There is generally much difficulty in distinguishing pain and tenderness seated in that part of the colon which lies over the pylorus, from the same affections in this portion of the sto- mach and duodenum. "The best means for distinguishing affections of the stomach from those of the colon, are the diges- tive process in the latter case being better performed; the state of the bile being less disorded; the patient not experi- encing the increase of uneasiness vvhich often comes on after meals, for a considerable time after eating, and often expe- riencing more or less pain, or some other uneasiness in the re- gion of tin stomach a short time before the bowels are moved, and more or less relief soon after their action." (Philip.) Pain and tenderness on pressure, cannot, however, be regarded as an unequivocal sign of inflammation in the pylorus and duodenum. This part sometimes becomes morbidly sensitive from mere irritation, without capillary congestion or inflammation. Never- theless, where we find this tenderness a little below and to the right of the pit of the stomach, at the same time that the sides and tip of the tongue are very red, with a granulated surface and a dry streak in the middle, together with a tense and quick pulse, we may be assured that the parts just mentioned, are in a state of inflammation. Treatment.—One of the first things to be attended to when we are called to prescribe in a case of dyspepsia, is to obviate, as far as possible, the usual exciting causes of this distressing affection ; and w ith this view, we must direct our attention chiefly to the adoption of proper dietetic regulations. In all cases of dyspepsia, whether simple or complicated, mild or violent, an undeviating observance of suitable regulations in relation both to the quantity and quality of the aliment, and the manner of taking it, is absolutely indispensable to success in the management of the disease. The patient should be di- rected to masticate well and slowly, to take his meals at regular hours, to eat no more at a time than is just sufficient to sustain the powers of the system, and to drink but little du- ring and for a short time after taking food ; and he must avoid taking any active exercise during the first stage of the process of digestion. The presence or absence of the symptoms indi- cative of high irritation or subinflammation in the mucous membrane of the stomach and duodenum, will enable us to say, almost with certainty, whether an animal or vegetable diet will procure most relief to the patient; but in relation to the particular articles of these two kinds of aliment, no specific directions can be given that are applicable to all cases: for INDIGESTION. 273 some dyspeptics arc benefited by certain articles of food that are altogether intolerable with others. This is more especially apt to be the case in those habitual dyspeptic cases which de- pend on mere functional debility, with morbid sensibility of the stomach, unconnected with inflammation. In some cases the dyspeptic symptoms are excited only by particular ali- ments ; ** and we must endeavour to ascertain whether a peculiar idiosyncracy of the stomach prevails in such instances; or whether there is a debilitated condition of the organ that inca- pacitates it from digesting any food demanding considerable powers for its chymification." Every individual affected, and suffering under this grade of dyspepsia, must in a great mea- sure learn from his own experience, what articles of diet will or will not agree with him. In general, however, where the disease depends on mere debility of the digestive organs, with- out a fixed tenderness and fulness in the epigastrium, the more digestible kinds of animal food, are decidedly the most proper. In such cases, a plain abstemious diet of this kind, together with the occasional use of gentle aperients, mild tonics, regular exercise, and a rigid avoidance of the usual exciting causes of the complaint, will rarely fail to establish a cure, or at least to procure an exemption from its more disturbing symptoms. Animal is undoubtedly much more digestible than vegetable food; and where the gastric irritation is not considerable, it will very generally be taken with the least inconvenience by dyspeptic persons. We may lay it down, therefore, as a ge- neral principle, that animal food is the most proper; and of this the most tender muscular parts are to be selected. There is nothing to be apprehended from the stimulant qualities of animal food, in cases depending on debility, without any par- ticular morbid irritability or phlogosis of the digestive organs. Our object here is to obtain the most digestible food, and which is, at the same time, the least apt to enter into fermenta- tive decomposition. By a food of this kind, the debilitated stomach is moderately excited and subjected to less labour; while the chyme is more speedily and perfectly formed, and the development of acid, flatus, &c. thus in a great degree pre- vented. It is very different, however, with those cases of protracted and inveterate dyspepsia, that are attended with a red tongue, tender and somewhat tumid epigastrium, and a firm pulse. Here the food, as I shall presently state more particu- larly, must be as bland and unirritating as possible. Much attention has been directed to inquiries concerning the comparative digestibility of the various customary articles of food. The flesh of old animals, with the exception of beef and veal, is more digestible than that of young animals. The latter contains much more mucilaginous matter than the former; and all mucilages arc of difficult digestion. Animal jellies and vol. 11.—35 274 INDIGESTION. young meats, observes Dr. Philip, are what is commonly called light food, with a reference to their stimulating qualities or tendency to excite fever—and hence in persons recovering from fever, or in extremely irritable habits, we prescribe the animal jellies, or young meats, which contain them in abundance, in preference to the meats of old animals. In dyspepsia, how- ever, from mere gastric debility, animal jellies remain long in the stomach from their indigestible nature, and cause therefore more disturbance and distress than beef or mutton. Tender beef, mutton, and all kinds of game—more especially venison, are usually of easy digestion, and generally agree much better with dyspeptics during the early stages of the disease, than any other articles of diet. Pork and veal are with most persons affected with indigestion altogether inadmissible ; and fish too, seldom agree well except when taken in very small portions and in a boiled state. The most oppressive kinds of poultry are geese and ducks; and "turkey is more oppressive than fowl, which, next to mutton, is perhaps, upon the whole, the lightest animal food in common use, if the skin be avoided." Pheasant is the least easy of digestion of the different kinds of wild game: but partridge and hare are in general readily di- gested by weak stomachs. Soft-boiled eggs will sometimes agree very well with dyspeptics; but care must be taken not to eat the coagulated portions of the albumen. Simple roasting or boiling is the best way of preparing meat for persons labour- ing under indigestion—;fried articles of food being in general very oppressive. There is no aliment more offensive to a weak stomach than new-made bread. By mastication it is converted into a tenacious paste, which "is not easily pervaded by the gastric juice." and is therefore always very slowly converted into chyme. The bread used by a dyspeptic person should always be several days old: and, for a change, crackers, or "pilot bread" may be used. Some individuals derive much advantage from the employment of bran-bread, but I have rea- son to think that where there exists a morbid sensibility of the stomach, it is generally decidedly injurious. The only benefit that can he obtained from bran-bread, beyond what may be derived from common bread, arises from its gently stimulating the bowels, and keeping up regular alvine evacuations; but I have known it to produce disagreeable irritation Jboth in the stomach and bowels, by the small cuticular scales of the grain which it contains, and which are almost insoluble in the gastric fluid. Cheese, milk, cream, and butter, unless taken in very moderate portions, are apt to become oppressive. I have known dyspeptic individuals, however, who were much benefited by the habitual use of cream and crackers at their meals. Fresh vegetables are very generally injurious, particularly cabbage, peas, beans, and above all cucumbers, lettuce, celery, and INDIGESTION. 275 other articles of this kind taken in the form of a salad, or in an uncooked state. Of fruits, pears, currants, gooseberries, whortleberries, and melons, are generally most apt to prove injurious. Mealy potatoes and turnips are among the best articles of this kind for dyspeptic subjects. All kinds of pas- try—such as hot cakes, pies, puddings, &c. are entirely out of the question. The food of a person labouring under dyspepsia from gastric debility should be chiefly taken in a solid state. Soups and broths very rarely do well in cases of this kind. I have already stated that slow eating and perfect mastication are all-important observances in dyspepsia, and that but very little drink should be taken during or soon after meals. Mo- derate portions of brandy and water usually answer well in slight cases of indigestion, but in the more aggravated forms of the disease they are exceedingly improper. Simplicity in diet, too, is of great importance to the comfort of dyspeptics ; and what is of equal, if not still greater importance, is, to take but moderate portions of food into the stomach at each meal. It must not be forgotten, that the foregoing dietetic observa- tions apply only to those cases of indigestion vvhich are free from a morbidly sensitive and irritable, or an inflamed condi- tion of the digestive organs. The signs by which these conditions may be detected have already been mentioned; and it of the utmost importance to form a correct diagnosis on this subject. So far from solid animal food being the best ali- ment in cases of this kind, nothing but the lightest farinaceous articles of diet can be borne with any degree of comfort, or are compatible with the restoration of the healthy state of the stomach. These cases must indeed be treated in every respect as instances of chronic gastro-enteritis, and the observations that I have made witli regard to the diet in these affections, are there- fore fully applicable to inveterate cases of dyspepsia. Medicinal treatment.—When the disease depends on func- tional derangement from mere debility or inactivity of the digestive organs, the bowels are generally torpid and loaded with feculent matter; and hence an important indication in cases of this kind is to procure regular alvine evacuations by diet if possible; if not, by the occasional use of gentle aperients. When first consulted in dyspepsia of this grade of gastric dis- order, it will in general be necessary to prescribe a laxative sufficiently active to evacuate the bowels freely ; but when the infarcted state of the alimentary canal has once been removed, the gentlest articles of this kind, and in doses barely sufficient to procure one or two consistent evacuations, should alone be employed. If, indeed, the action of the bowels can be regularly maintained by dietetic regulations, it ought always to be pre- ferred to the exhibition of laxatives. This, however, can 276 INDIGESTION. rarely be adequately done, and almost all dyspeptics find it necessary to resort more or less frequently to remedial means for procuring regular alvine evacuations. Rhubarb in union with some aromatic or stimulating substance, will in general answer well as an aperient in such cases. The following pill* may be taken a short time before the principal meal; and where there is much acidity in the stomach, the rhubarb may be advantageously given in combination with from ten to twenty grains of the carbonate of soda, or with thirty or forty grains of magnesia. No remedy, however, has appeared to me to act more favourably as an aperient in the milder grades of habitual dyspepsia, than small doses of ipecacuanha in union with aloes and the extract of hyoscyamus. From personal experience, I know that in some instances at least, the effects of this combina- tion are peculiarly soothing and sufficiently aperient, f Emetics were formerly much employed in dyspepsia; but except in recent attacks from a surfeit or very irritating and indigestible ingesta, their use is now very properly almost uni- versally condemned. Where it may be deemed advisable to excite vomiting, we may generally effect this purpose by copious draughts of lukewarm water, or what is still better, a strong infusion of chamomile flowers, or of the eupatorium per- foliatum. When these do not procure adequate emesis, an ordi- nary dose of ipecacuanha may he administered. Tartar emetic is decidedly objectionable, even under the strongest indications for the employment of an emetic in dyspepsia. Where the disease is connected with morbid sensibility of the stomach, or with chronic inflammation, no circumstances, perhaps, can justify the exhibition of an emetic. In the grade of indigestion now particularly under consider- ation, besides the dietetic measures already indicated, and an at- tention to the regular maintenance of the alvine evacuations, mild tonics in combination with alkalies, gentle exercise, and the avoidance of the usual exciting causes of the disease will generally restore the healthy functions of the digestive or- gans. A weak infusion ofcolomba, or of gentian, with a portion of the carbonate of soda, or of potash, may be employed for this purpose. The ferruginous preparations also are often pe- culiarly beneficial in cases of debilitated digestive powers, without any prominent hepatic derangement. The tartrate of iron given in union with a small portion of ipecacuanha, has * R. Pulv. rhaei gr. ii. ----aloes gr. ss. ----capsici gr. i.—M. To be made into a pill. t R. G. aloes soccot. ^i. P. ipecac. Jss. Extract, hyoscyamus 3l—M. Divide into 20 pills. Take on at night on going to bed. INDIGESTION. 277 done much good in my hands in no inconsiderable number of cases.* The chalybeate mineral waters also, will occasionally procure more benefit in instances of this kind than any other tonic. The white mustard seed has of late years been a very fashionable remedy for dyspepsia, and in cases of simple lan- guor and weakness of the stomach very considerable advantage may in general be derived from them. Four or five tea-spoon- fuls of the unbruised seed should be taken during the course of the day. I have known several individuals habitually subject to slow and painful digestion with torpor of the bowels, much benefited by this remedy. It need scarcely be observed, that where the stomach is morbidly irritable and tender to pressure, this article cannot be taken without injurious consequences. Tonics, however, are very frequently much abused in this affection, and may readily do much mischief where there is great irritability of the stomach or a state of phiogosis, and especially where the hepatic functions are prominently de- ranged. They can be employed with a prospect of advantage only in cases of torpor or weakness of the digestive organs. Indigestion seldom continues long, even in its milder grades, without involving the liver in functional disorder; and hence, alterative doses of mercury have of late years been among the most common means in dyspeptic affections. Where from the ic- terode state of the eyes and skin, and the appearances of the stools and urine, there is reason to suspect the existence of functional disorder of the liver, the use of alterative portions of the blue mass is decidedly indicated, and will generally afford unequivocal benefit. From four to six grains of the blue pill may be taken every second or third night, with an occasional dose of some gentle laxative—such as small portions of rhubarb, or one or two Seidlitz powders, or a few of the laxative pills already mentioned. I have been much in the habit of giving the blue mass in union with a laxative, according to the follow- ing formula; and generally, as it appeared to me, with more advantage than when they are given separately and at distinct periods.f Care must he taken, however, in prescribing mer- cury in this affection, not to continue its use until the general system becomes affected; for general mercurial excitement is always improper in dyspepsia. Some individuals are always very disagreeably affected by the blue pill. I have met with dyspeptic patients in whom this mercurial invariably ex- cited the most unpleasant sensations in the stomach, as well * R. Tart, ferri 5i. Pulv. ipecac, gr. v.—M. Divide into 3 equal parts. Take one every morning, noon, and evening. t R. Massae hydrar. 3i. G. aloes soccot. V)iss. Tart, antimonii gr. ii.—M. Divide into 20 pills. Take one every other night, on going to bed. 278 INDIGESTION. as great general restlessness and nervous irritation. When this is the case, we may generally gain our object by the inter- nal use of the nitric acid diluted in a large portion of water ; or what has appeared to me still more advantageous, the nitro- muriatic acid hath in the way mentioned under the head of chronic hepatitis. As palliatives, alkalies and opium are the best remedies we possess—the former for removing the burning and aching sen- sations which are caused by acidity in the stomach, and the latter for allaying the colic pains that result from the irrita- tion of the food, flatus, and acid in the stomach and duodenum. It is to be observed, however, that opium cannot be frequently employed in this affection without still farther impairing the digestive powers of the stomach ; but the pains are often so extremely violent, that we are obliged to resort to this narcotic for relief. In those cases of dyspepsia which are connected with a high degree of morbid sensibility of the mucous mem- brane of the stomach and duodenum, the occasional use of this anodyne is peculiarly valuable. Without it, indeed, patients labouring under this variety of dyspepsia would enjoy but few moments of exemption from suffering. Dr. Philip recommends Dovers' powder, and advises that from two to four grains of it should be given every six or eight hours. This will com- monly he sufficient to allay the general nervous irritation which is apt to occur in cases of this kind ; but when those violent gastric and duodenal pains come on which at times rack the unfortunate dyspeptic, nothing but the largest doses of lauda- num will be sufficient to allay his extreme suffering. I have known persons in the utmost degree of agony for hours from irritation in the stomach and duodenum, who were obliged to take several hundred drops of laudanum before relief was pro- cured ; and in this respect, I may, indeed, truly say with the poet— Atque utinam nurcero ne nos essemus in isto. Weak and slow digestion is frequently connected with a morbid sensibility of the nerves of the stomach and duodenum, independent of chronic inflammation of these organs. When the patient is subject to severe pains an hour or two after taking a meal—and more especially when the gastric distress is par- ticularly excited by certain articles of food, which usually agree with other dyspeptics; and when, moreover, the edges of the tongue remain of a pale red, with a thin white fur over the middle, and the pulse is free from tension, though quick and small, and the skin generally soft, and below the natural tem- perature, and, finally, when with these symptoms there is a disagreeable or painful feeling of emptiness experienced in the region of the stomach four or five hours after taking food, without any particular tenderness to pressure on the epigas- INDIGESTION. 279 trium—when these symptoms exist, there is reason for believ- ing that an exalted sensibility of the gastric nerves is present without phlogosis. The diagnosis in relation to these circum- stances, is of much more importance in a practical point of view, than seems to he generally supposed. Dr. Philip speaks particularly in favour of the employment of ammonia, in what he calls the second stage of indigestion, and it is, indeed, in many cases, deserving of all the encomiums which he has be- stowed upon it. The instances, however, in which, according to my own observations, it is most apt to prove beneficial, are those in which there is a constant tendency to the generation of acid in the primae viae in connexion with morbid sensibility of the mucous membrane of the stomach and duodenum. In cases of this kind, eight or ten grains of the carbonate of am- monia with five or six grains of Dovers* powder may be taken several times during the day with much temporary benefit. Dr. Philip observes, that in cases of dyspepsia, where the sur- face is cold, the pulse feeble, with a feeling of general depres- sion, and chilliness, "the ammonia is invaluable; being less apt, than any other stimulus of the same power, with respect to the nerves, to excite the heart and blood vessels; which, from the tendency of the disease, (in this the second stage) are inclined to a degree of excitement beyond that undue propor- tion to the state of the other powers." Much relief may also he obtained, in cases where the disorder is attended with much irritation and sensibility of the gastric nerves, from the liq. acetat. ammonias, in union with small doses of laudanum, or of the tincture of hyoscyamus. A table-spoonful of the former, with ten drops of either of these narcotic tinctures, may be taken two or three times daily. When there is much gastric irritation, with slight febrile symptoms towards evening, such as dryness and heat of the skin, burning in the palms of the hands and soles of the feet, and tension of the pulse, the nitrate of potash will generally afford considerable relief. It may be advantageously given with mi- nute portions of the tincture of ipecacuanha, dissolved in some mucilaginous fluid. From five to ten grains of the nitre, dis- solved in a few ounces of barley-water, or of a solution of gum arabic, with 50 drops of tinct. ipecac, may be given every 4 hours. When the gastric irritation has assumed the character of chronic inflammation—that is, when in addition to the general symptoms just mentioned, the epigastrium becomes tender to pressure ; the pulse tense and firm, and the edges and tip of the tongue red ; tonics, purgatives, animal food, and all stimu- lating remedies are no longer admissible. Leeching or blister- ing over the region of the pylorus and duodenum, are here among the most important remedial measures. The latter, indeed, will often be found particularly beneficial in cases at- 280 INDIGESTION. tended only with high irritation without actual inflammation. For the removal of that morbidly sensitive condition of the gastric nerves noticed above, there is, perhaps, no remedy so effectual as the application of a blister over the epigastrium. I have known patients who could scarcely take even the blandest articles of food without suffering a great deal of pain, enabled to digest light aliment with tolerable comfort after having the region of the stomach blistered. Pustulation with the tartar emetic ointment, may also be resorted to with a fair prospect of advantage in such cases. Leeching, however, is always an excellent preliminary to vessicating or counterirritating appli- cations. There is but little advantage to be obtained from in- ternal remedies in cases of this kind ; yet the nitrate of potash, dissolved in a large portion of some mucilaginous fluid will occasionally assist in removing the dry and constricted state of the skin and the distressing sense of internal heat. Dr. Philip advises the exhibition of small doses of lartarized anti- mony. I have, occasionally, derived some benefit from its admi- nistration in cases attended only with gastric irritation ; but I doubt much of the propriety of employing this remedy where unequivocal signs of mucous inflammation of the stomach are present. Some writers recommend laxatives in this as in the milder varieties of the disease ; but their tendency to irritate the tender and phlogosed mucous membrane of the stomach and intestines, renders them, I think, decidedly objectionable. Slight relief will, it is true, usually follow the operation of a pur- gative, but this relief is always but temporary, and is very often succeeded by an aggravation of the gastric distress and tenderness. The same objections do not, however, exist against the use of laxative enemata, and I do not, indeed, know any measure which is better calculated to afford ease in cases of this kind, than the daily use of one or two mild laxative clysters. Functional disorder of the liver is a constant attend- ant in cases of this kind; and it becomes necessary to em- ploy mercurials, either internally, or by frictions on the right bypochondrium. The employment of mercurials, however, requires great caution in the severer cases of the disease; for it is not uncommon to find the blue pill even in small doses to excite considerable intestinal irritation and general uneasiness. To avoid this occurrence, we may give this mercurial in union with a small portion of opium, or of the extract of conium. In general, it will be sufficient to administer one grain of the blue mass, with half a grain of opium, every night on going to bed, and care must be taken not to carry it to the extent of causing even a soreness of the gums. The correction of the biliary secretion, by a gradual introduction of mercury into the system, is genenally attended with the additional advantage of INDIGESTION. 281 an abatement in the tension and contraction of the pulse, and a diminution of the temperature and dryness of the skin. After all, however, our principal reliance in cases attended with a high grade of irritation or chronic inflammation, con- sists in the use of a bland and unirritating liquid diet, local depletion, revulsive applications, and the occasional use of al- terative doses of blue pill or calomel, with laxative enemata and gentle exercise by gestation, or where the strength of the system will admit of it, walking, regularly, every day, until a slight degree of fatigue is induced. Let it be constantly borne in mind, that functional derange- ment of the stomach may be the consequence of mere debility and relaxation—or of high irritation and morbid sensibility— or finally of a chronically inflamed condition of the mucous membrane of the digestive organs; and that, therefore, the mode of treatment, both medicinal and dietetic, which is pro- per in the first, will not answer in the second, and will prove decidedly pernicious in the third of these varieties. In the first, our object is to increase the tone and activity of the sto- mach ; in the second, to soothe the irritation and morbid acti- vity of this organ ; and in the third, to subdue inflammation and obviate its consequence, structural disorder. CHAPTER XXI. JAUNDICE. Icterus, aurigo, morbus regius, morbus arcuatus. Jaundice consists in a disordered state of the liver or of the biliary passages, characterized by yellowness of the eyes and skin; clay-coloured faeces; a highly bilious urine; and generally by a languid state of the circulation. In many instances the disease approaches very slowly and insidiously. It commences with a general feeling of languor, disinclination to bodily and mental exertion, an irritable and dejected temper, weakness of appetite, constipation, acid eruc- tations, slow and painful digestion, slight flatulent pains in the bowels, a feeling of fulness and slight tension in the epigas- trium, anxiety in the praecordia, restlessness at night, a tur- bid urine usually depositing a copious pitchy sediment, slow and languid pulse, more or less nausea, and frequently tran- sient creeping chills alternating with flushes of heat. After these symptoms have continued for a few days, a disagreeable vol. n.—36 282 JAUNDICE. itching over the whole body occurs ; the taste becomes bitter; the stools whitish or clay-coloured; the urine of a deep saffron hue; and finally the white of the eyes, and the skin about the lips, neck, and forehead, assume a yellow colour, which spee- dily extends itself until the whole surface acquires a uniform yellow hue. When the disease has arrived at this stage of full development, the general debility and sluggishness, as well as the uneasiness and tension in the epigastrium increase, and although the pulse is generally slow, full, and somewhat firm, slight febrile exacerbations almost always take place in the evening, with some augmentation of the temperature of the skin and occasional transient sensations of chilliness, with much restlessness during the night. The skin is generally dry and husky. If the disease continues a long time, the body be- gins to emaciate; the evening febrile exacerbations become more conspicuous, and night sweats ensue; and in many in- stances, dropsical effusions at last take place into the cavity of the abdomen; respiration becomes anxious and oppressed, and where it verges to a fatal termination, a soporose and torpid condition comes on towards the fatal conclusion of the malady. In some instances, however, the disease comes on so insensi- bly that no particular local or general manifestations of its ap- proach are noticed until the eyes and skin begin to assume a yellow hue. When the disease makes its appearance in these two ways, it depends probably on a morbid viscidity of the bile, in consequence of vvhich, its passage from the liver into the in- testines is impeded or entirely prevented. Sometimes, instead of the gradual manner just mentioned, the disease commences at once with severe, dull pain a little below and to the right of the pit of the stomach, increasing ra- pidly in violence, with excruciating exacerbations, spreading towards the left shoulder, down to the loins, and throughout the whole epigastric region ; at the same time, the patient experiences almost incessant and extremely distressing nausea, attended with so great a degree of gastric irritability that eve- ry thing swallowed is immediately thrown up again with the most violent and painful vomitive efforts. In such cases, the epigastrium is distended and generally exceedingly tender to the touch; but the pulse usually differs but little from its na- tural condition. When the disease comes on in this manner, it generally depends on obstruction of the common duct by a biliary concretion. The intensity and brightness of the icteric colour differ very considerably in different cases. In some instances, it is of a golden yellow, in others of a greenish yellow, and in others again it acquires a dark and almost black shade.* The latter * Cases of this kind are usually called black jaundice, (melasicterus.) JAUNDICE. 283 two varieties are generally connected with organic disease of the liver, such as enlargement, induration, and tubercles. In protracted cases of jaundice, the yellow colour is not confined to the skin, but pervades almost every part of the body. The adipose structure, particularly, becomes of a bright saffron co- lour; and the internal membranous tissues are usually conspi- cuously marked with the same tinge. It is, however, extreme- ly uncommon to find the brain and nerves pervaded with this colour, and its appearance in the cartilages and bones is an al- most equally rare occurrence. The fluids, too, become tinged with yellow. Mursinna gives an account of a fatal case of jaundice, in which he found the viscera of the breast and abdo- men, as well as the meninges of the brain of a deep yellow co- lour, and the serum which he found in the pericardium, and ventricles of the brain was of the same colour and of a bitter taste.* It is from the tinge being communicated to the humours of the eyes, that to some jaundiced patients all objects appear of a yellow hue. Of the secretions, the urine is most conspicu- ously charged with the bilious colouring matter. It is so abundant in this fluid, that pieces of linen or paper dipped into it immediately acquire a yellow stain. In the milk of women affected with this disease, the colour and the taste of bile is hardly ever detected. Heberden, indeed, asserts that the pre- sence of bile in this secretion has never been noticed; but in relation to the taste, I have myself observed an instance in which the milk was very perceptibly bitter. Dr. Good thinks that the cause of the very rare occurrence of yellowness in the milk of jaundiced females, arises "probably from its rapid passage and elaboration from the fluids introduced into the stomach." I am inclined to think that this circumstance de- pends on the bile uniting with the oily portions of the lacteous secretion, and becoming thus suspended with it in the form of an emulsion. We know at least that in the duodenum, it is en- tirely owing to the union of the bile and the fatty portions of the chyme, that the chyle obtains its milky colour ;f and it is * Journal fuer die chirurgie. Bd. ii. s. 322. t Mr. Brodie, from some experiments he performed, inferred that the principal purpose of the bile is to separate the chyle from the chyme: " for he remarked, that when the choledochus duct was secured by a ligature and food then given, chymification went on in the stomach as usual, but no chyle could be found in the intestines or in the lacteals. The lacteals contained a transparent fluid which he supposed to be lymph and the watery part of chyme. Herbert Mayo draws the same results from his experiments. These results are at variance, however, with the experiments of Leuret, Lassaigne, Tiedemann, and Gmehn. The for- mer after tying the duct and clearing out the bowels with castor-oil, ted the animal 12 hours after the operation with bread, milk, and sugar. Eight hours after this meal, the animal was killed. The food was lound 284 JAUNDICE. not improbable that the union of oily and bilious matter may, in part, destroy or precipitate the bitter principle of the latter. This at all events must be the case in the duodenum ; for not- withstanding the union of the chyme and bile, the fluid in the lacteals, resulting from this combination, and the thoracic duct is wholly free from bitterness. The duration of an attack of jaundice is extremely various, and depends, of course, almost entirely upon the greater or less degree of permanency of the occasional cause. In some cases, the icteric symptoms come on rapidly under symptoms of great violence, and in a short time disappear again. This is most apt to be the case when the disease arises from the passage of a biliary concretion through the common duct, or from spas- modic constriction of this part. Sometimes the disease is marked by manifest remissions, the yellowness of the skin and other symptoms increasing and abating at short but irregular intervals for a long time. Not unfrequently this malady as- sumes a strictly chronic character without any particular feel- ings of ill-health except slight dyspectic symptoms, costiveness, and a disposition to indulge in sleep. More commonly, how- ever, protracted instances of the diseaseultimatelycau.se great emaciation and dropsical effusions, and often terminate in a state of apoplectic stupor. Causes.—The etiology of jaundice is, in many respects, still involved in much obscurity. In a general way, it may be said, that all the remote causes of this disease act either by obstruct- digested, and " the thoracic duct.was distended with a yellowish red transparent fluid, which coagulated on standing exposed to the air, and yielded the usual proportion of fibrin, albumen, and saline matters.'* Bro- die, Mayo, Leuret, Lassaigne, Tiedemann, and Gmelin observed that chymification went on as perfectly after the common bile duct was tied as in a sound animal. In the experiments of Tiedemann and Gmelin, the thoracic duct always contained an abundance of fluid which was gene- rally of a yellowish colour, (confirming in this respect the experiments of Leuret and Lassaigne, and partly also those of Brodie'and Mayo.) This fluid coagulated like ordinary chyle, the crassamentum acquired the usual red colour; in short, the only difference between it and the chyle seen in a sound animal was, that after tying the common duct it was never white or milky The reason of this difference appears to be that the white colour is owing to fatty matter taken up from the food by means of the bile, which possesses the power of dissolving fat and probably, therefore, aids in effecting its solution in the chyle at the mouths of the lacteals. " Mr. Brodie appears to have been misled by the absence of the white colour which the chyle usually possesses, but which it is well known equally to want in ordinary digestion if the food does not contain fatty matter." Tiedemann and Gmelin confine the agency of the bile in chylification, simply to the accomplishing the so- lution of the fatty matter. These experimentalists believe that the bi- liary secretion, besides its agency in chylification, is supplementary to the function of the lungs in freeing the blood of its carbonaceous and other heterogeneous principles. JAUNDICE. 2S5 ing or preventing the flow of bile from the liver into the intes- tines ; or by impeding, deteriorating, or suspending the secre- tory action of the liver. Of the former kind of causes are, l. Biliary concretions plugging up the duct. 2. Spasm of the duct, which may be excited by the irritation of acrid bile; duo- denal irritation, and perhaps violent mental emotions. 3. Vis- cid mucus clogging up the orifice of the common duct. 4. In- flammation and thickening of the coats of the duct. 5. Enlarge- ment and induration of a neighbouring part—particularly of the pancreas, and perhaps of the mesenteric glands.* 6. Pre- ternatural viscidity of the bile, by which its flow along the duct is greatly impeded, or altogether prevented ; pregnancy and impacted faeces in the colon. When by any of these caus- es the bile is prevented from flowing into the intestines, and thereby congested in the biliary passages, it is generally be- lieved to gain admission into the current of the circulation either by absorption or regurgitation, and to be afterwards secreted into the subcuticular tissues, giving rise to the yellow tinge of the surface. It is quite certain, indeed, that jaundice will generally supervene speedily when an obstruction of this kind occurs in the common duct, and from the manifest pre- sence of bilious matter in some of the secretions, we can scarce- ly doubt that in relation to such cases this view of the etiology of the disease is in the main correct. M. M. Tiedemann and Gmelin, in their interesting account of a series of experiments on digestion, state, that on passing a ligature round the com- mon duct of animals, they found that about the third day the eyes became vellow, and the urine strongly imbued with a colouring matter, which, by chemical tests, they ascertained to be bile.f To this doctrine it has been objected that no bile has ever been detected in the blood of patients affected with jaun- dice, a circumstance which certainly does not countenance the entrance of the bile into the circulation by regurgitation. Against the opinion that the biliary secretion is absorbed into the circulation, it is alleged that it is not at all probable that a * An interesting case of jaundice, which terminated fatally, is related in the Journal de Progres, and in which the following phenomena were discovered on post-mortem examination. " Two or three inches from the origin of the duodenum there was a tumour with elevated edges, rather larger than a crown piece, the surface of which was uneven, very hard to the touch, of a whitish yellow colour, and very vascular. The different coats of the intestines were involved in the disease, which in- cluded, at one of its edges, the openings of the bilary and pancreatic ducts, which were extremely contracted, and almost annihilated. The gall-bladder was extremely distended, and when strongly pressed a few drops of bile issued forth into the duodenum."—Med. Chir. Rev. July, 1828, p. 440. t Recherches Experimentales Physiologiques et Chimiques sur la Digestion, seconde partie, p. 47. 286 JAUNDICE. fluid so irritating as the bile is would be received by the ex- tremities of the absorbent vessels, and there is indeed much plausibility in this observation. Nevertheless, when we find the bile making its appearance in the urine, and often in the other secretions, together with a uniform yellow tinge, not only of the surface of the body, but also on the internal organs, at the same time that the white or clay-coloured faeces show that there is no bilious matter poured into the intestines, and when finally dissection discovers to us a com- plete obliteration or obstruction of the common duct, we are forced to admit, that in consequence of the engorgement of the excretory ducts of the liver, from the exit of the bile through its natural passages being obstructed, it is in some way or other abundantly secreted by the kidneys, and its colouring matter at least copiously deposited in the subcuticular and various other textures of the body. The admission of the bilious matter into the circulation is most likely by absorption; but it is by no means probable that the bile is thus introduced into the blood-vessels in its state of complete combination. The serous and colouring matter alone may, perhaps, be taken up by the absorbents, whilst the most acrid and irritating por- tions are left in the liver. Both Deyeux* and Clarionf found in the blood of patients labouring under jaundice a considera- ble portion of a yellow matter which communicated a saffron stain to linen, just as the urine of such patients is known to do. Among the above mentioned causes of obstruction to the flow of bile into the intestines, the most common undoubtedly are, biliary concretions, spasm of the duct, and preternatural vis- cidity of the bile. A very viscid state of the bile is probably much more frequently concerned in the production of this dis- ease, than seems to be generally supposed. Dr. Annesley, in his work on the diseases of India, states that he frequently found, upon post-mortem examination, "the gall-bladder load- ed with bile of a dark green colour, and so thick and viscid that it could scarcely be forced through the ducts by squeezing the gall-bladder, although a blow-pipe or probe would pass readily along them, showing that the obstruction was then owing to the viscidity alone." When the disease is preceded and accompanied by a constant aching and soreness, with oc- casional extremely severe paroxysms of pain in the right epi- gastrium, together with great irritability of the stomach, we may infer that it arises from the passage of a gall-stone through the common duct. The suffering in cases of this kind, after a longer or shorter period, suddenly ceases; and this occur- * Considerations Chymiques sur le Sang des Icteriques.—Journal de MeMecine, Messidor an. xii. p. 288. t Considerations Chymiques et Medicinales sur le Sang des Icteri- ques, Presentees et Soutennues a l'^cole de Med. JAUNDICE. 287 rence may be considered as announcing the entrance of the cal- culus into the duodenum. From some late pathological re- searches by Andral, it appears that irritation and inflamma- tion of the mucous membrane will sometimes produce jaundice where no obstruction can be detected in the biliary ducts ; and it is perhaps, in this way that the jaundiced hue of the skin is produced in yellow and other severe forms of bilious fever. Dr. Marsh also has related some cases which render it proba- ble that inflammation of the mucous membrane of the duodenum is sometimes extended to the lining membrane of the ducts, whereby a contraction of these passages is produced, either by spasmodic constriction or a thickening of their coats. Dr. Marsh observes, that hysterical women, of a relaxed and gross habit of body, are subject to a form of jaundice, which, though strongly resembling those cases that arise from the impaction of a gall-stone in the common duct, appear, ne- vertheless, to owe their origin to a less permanent cause. Some mental commotion, and particularly an error in diet, seems, in most instances of this kind, to be the remote cause of the dis- ease. These come on like a violent attack of bilious colic, or with symptoms resembling those which occur from the passage of a biliary concretion through the common duct. "A pain," says Sydenham, " not less severe than that of the iliac passion is felt at the region of the stomach, or somewhat lower, which is succeeded by copious vomitings of matter, sometimes green, sometimes yellow. To these symptoms are added, a depres- sion of mind and despair exceeding that in any other disease. // is accompanied sometimes with a remarkable jaundice, which spontaneously subsides i?i a day or two. The least commotion of mind, whether it be anger or fear, brings back the pain." When the pain subsides, large quantities of flatus pass off, either upward or downward ; and the ejections from the sto- mach, during the continuance of the pain, are usually acid. I have attended an elderly lady in this city, who is precisely of the habit of body just mentioned, in five or six paroxysms of this kind. The disease always commences like a violent at- tack of bilious colic, attended with vomiting of a green and acrid bilious fluid. It seldom lasts longer than about forty- eight hours, by which time the surface of the body begins to become yellow, and soon acquires a deep jaundiced hue. In nearly all the attacks I have been able to trace its origin to errors of diet or some mental commotion. Dr. Marsh says these cases may, in general, be readily recognized by the co- pious secretion of limpid urine which occurs in them. This, however, is only correct with regard to the appearance of this secretion in the very commencement, for commonly in the course of thirty-six hours from the beginning the urine be- comes bilious, as in other instances of jaundice. Dr. Johnson 288 JAUNDICE. thinks that the leading proximate cause, in cases of this kind, is spasmodic constriction of the gall-ducts, or preternatural vis- cidity of the bile; and there can exist but little doubt of the correctness of this view. Duodenal irritation, from flatus or acrid bile, and imperfectly elaborated chyme, appear to con- stitute the principal exciting causes of this variety of the dis- ease. Leeches, fomentations, abstinence from food, purgatives, and full doses of opium, will always soon relieve.the painful symptoms of the complaint. Jaundice, as has been already intimated, may be produced, also, by causes that act upon the liver through the medium of the general system. Some of these causes appear to produce tor- por of this organ and consequent suspension of the biliary se- cretion ; others, perhaps, give rise to the secretion of acrid bile; which, stimulating the ducts, may occasion spasm and retention of the biliary matter in the hepatic ducts ; and others, finally, gradually produce more or less disorganization of the liver. Of this variety of causes, are—intemperance in the use of spirituous liquors ; irritating substances in the primae viae; suppression of acute and chronic cutaneous eruptions ; violent mental emotions, particularly grief;* constipation; suppressed perspiration ; the slow influence of malaria; wounds of the scalp ; metastasis of gout; and perhaps rnercury.f That the cessation or great diminution of the biliary secre- tion whether from mere functional torpor or structural altera- tion of the liver is capable of giving rise to jaundice, admits of no reasonable doubt. Cases of fatal jaundice have been re- ported, in which, upon post-mortem examination, the ducts were found entirely unobstructed, and the small portion of the bile found in the gall-bladder and liver, of a natural consistence.^ When the elimination of the recrementitious matter which enters into the composition of the bile is not duly effected by the organ destined for this office, the blood will necessarily become surcharged with this matter, and by a natural tendency of the animal-economy to cast off what may be injurious to its wel- fare, the kidneys, as wrell as the general capillary system, will in a manner perform the office of the liver, and free the blood * Dr. Marsh gives an account of a case, where a young girl, in the Lock Hospital, who had got cold while under the influence of mercury, was suddenly informed of the death of her uncle, the only one of her relations who had treated her with kindness ; she immediately became universally jaundiced.—Dublin Hosp. Reports, vol. iii. art. 6. X Dr. Colles communicated an instance to Dr. Marsh, where a young gentleman, after undergoing an alterative course of mercury, suddenly became deeply jaundiced. In a few days afterwards, he died in a state of delirium and convulsions. On dissection, not the slightest change of structure was discovered. The internal as well as external parts were strongly tinged with bile. X Stoll. Ratio. Medend. vol. iii. p. 361-—366. JAUNDICE. 289 of a portion of its superabundant biliary elements, by deposit- ing them into the subcuticular textures, as well as into other tissues, and particularly also in the urinary secretion. Prognosis.—The prognosis of jaundice varies of course according to the nature of the occasional cause, and the general constitutional vigour of the system. When the disease does not depend on an organic affection, or obstruction of the com- mon duct by very large biliary concretions, it may, in general, be removed without much difficulty. Cases arising from vio- lent anger, spasm of the duct, mucus clogging the orifice of the duct, ami on preternatural viscidity of the bile, are often speedily removed by an appropriate treatment. In many in- stances that depend on biliary concretions, the obstructing cal- culus is not so large as to cause it to be very long in passing through the duct into the duodenum ; and such cases, though often attended with extreme pain and gastric disturbance, usu- ally disappear in the course of eight or ten days ; but where the disposition to the formation of such concretions is strong, which is not uncommonly the case, these paroxysms of suffering and jaundice are apt to recur again and again, at longer or shorter intervals. It is said, that when jaundice occurs in con- sequence of injuries of the head, it is in general particularly dangerous and difficult to he removed.* The supervention of stupor, coma, or delirium, is always to be regarded as an ex- tremely unfavourable sign. When the icteric tinge acquires a very dark appearance, approaching to a blackish hue, we may infer that the disease will be exceedingly obstinate, or most probably altogether incurable, such cases being almost always dependent on incurable organic affection of the liver, or of the neighbouring organs. If, in cases of this kind, copious hae- morrhages occur from the nose or lungs; 01 if violent colic pains and profuse colliquative diarrhoea come on, the prognosis may he regarded as extremely unfavourable.! When the perspira- tion is so copiously charged with the colouring matter of bile as to communicate a yellow tinge to the patient's linen, there is reason to apprehend a total and obstinate obstruction to the passage of the bile into the intestinal canal. (Jahn.) The oc- currence of tympanitis, dropsical effusions, slow febrile irrita- tion, emaciation, and great muscular debility, leave us but little hope of an eventual recovery. Treatment.—From what has already been said concerning the etiology of jaundice, it is manifest that the treatment re- quires considerable modifications, according to the particular condition of the biliary organs, upon which the symptoms of the disease depend; for it should be recollected, that the phe- • Jahn. Klenik d. Chronish. Krankheiten, b. ii. p. 395. t Richter's Specielle Therapie. b. iv. p. 315. vol. ii.—37 290 JAUNDICE. nomena which we denominate jaundice, are mere manifestations of some local or sympathetic disorder of the biliary organs. When the disease commences with violent pain in the epigas- trium, with constant nausea and frequent vomiting, we may ascribe it either to a spasmodic affection of the bile ducts and perhaps of the duodenum, from some local or sympathetic irritation; or to the impaction of a biliary concretion in the common duct. In cases of this kind, our principal object in the first place must be, to relieve the extreme sufferings of the patient, and for this purpose, opium, the warm hath, leeching, frictions, and emollient applications to the epigastrium, are almost the only remedies that afford any decided benefit. If the patient be robust and very plethoric, blood should be at once drawn to an extent sufficient to make a decisive impression on the system. I am inclined to think that blood-letting is too much neglected in cases of this character. I have in several instances of jaundice, commencing in the way just mentioned, procured manifest advantage from an efficient abstraction of blood. Blood-letting may prove beneficial in various ways in this affection. By it we lessen the tendency to inflammation in the irritated parts; and it may favour the passage of biliary concretions through the duct, by its general relaxing powers. But it forms also, a very proper preliminary measure to the employment of opium, upon the liberal use of which our prin- cipal reliance must be placed, for palliating the painful symp- toms. During the first stage of cases of this violent character, emetics, and even purgatives, are out of the question,— at least until the gastric irritability has been in a great measure allayed. After having drawn blood, where this evacuation is indicated by the pulse and general habit of the patient, a large dose of opium in union with calomel, should be immediately adminis- tered. Small doses of this narcotic will do no good—on the contrary, they often appear rather to add to the general dis- tress of the patient. From four to five grains of opium with ten or fifteen grains of calomel, should be given at once. When administered in such a dose, it rarely fails to allay the pain and gastric distress in a few hours. But in some instan- ces, even this quantity is not adequate to remove the extreme sufferings of the patient; and it becomes necessary to repeat the exhibition of it in smaller doses until the desired effect is produced. It is not simply, however, as an anodyne that this narcotic may he beneficially employed in painful cases of jaun- dice unconnected with febrile irritation. When the pain and obstruction to the flow of bile into the intestines is the result of spasm of the duct, we can resort to no remedy more directly calculated to remove this condition, than opium given in very efficient doses. At the same time that we have recourse to this powerful narcotic, the bowels should be emptied by purgative JAUNDICE. 291 enemata, repeated until a free evacuation is procured. Much benefit may also be obtained in some instances from the warm bath, and where its employment is practicable, it ought to be resorted to in conjunction with the measures just indicated. If by these means we succeed in allaying the violence of the symptoms, we may then have recourse to purgatives and eme- tics. The latter, in particular, have been very generally re- commended in cases where there is reason to apprehend the presence of a biliary concretion in the common duct. The re- laxation and concussive agitation which are produced by the operation of an emetic, may contribute materially to expedite the passage of the concretion through the duct, an event which must be deemed essential to the removal of the disease. We are told by Dr. Darwin, that in two instances he saw upwards of thirty gall-stones voided by stool soon after the operation of an emetic. We must not, however, forget that great pain in the epigastrium, with irritability of the stomach, and a uni- versal jaundiced hue of the surface, may arise from high irri- tation, or inflammation of the mucous membrane of the duode- num, without any obstruction from biliary concretions; and in such cases the exhibition of an emetic could not fail to prove injurious. These cases may be distinguished from calculus ir- ritation of the ducts, by the very manifest presence of fever, or rather the small, quick, tense, and frequent pulse, and the warm and dry skin, which occur in duodenal inflammation; and the slow, full, and rather active state of the pulse, and entire absence of the usual symptoms of fever, in cases depend- ing on obstruction to the course of the bile from biliary calculi. Where there is reason to suspect high duodenal irritation or subacute inflammation, as lying a* the foundation of the malady, recourse must be had to leeching, blistering, and fomenting ca- taplasms to the epigastrium; * bland and liquid diet; laxative enemata; cooling acidised drinks; small portions of opium and ipecacuanha i*> combination; and rest. The use of emetics and purgatives are out of the question. Various remedies were formerly recommended with the view of consuming or dissolving the biliary concretions lodged in the liver or its ducts ; but the age of confidence in such remedies has passed by, and there is now but little attention paid to articles of this kind, with a view to their resolvent powers, although some of them may do good by their tendency to excite and alter the action of the liver. The alkalies; soap; a solution of the yolks of eggs in vitriolic ether; Durande's mixture, composed of two parts of vitriolic ether and one of spirits of turpentine; the natural mineral waters containing carbonic acid gas in an uncombined state; and mercury, have been most generally em- ployed for this purpose. With regard to the vitriolic ether and spirits of turpentine, Dr. Good very justly observes, that 292 JAUNDICE. where there is a tendency to inflammation, they may do harm by their stimulant effects. In one case under my care, this mixture appeared to do much harm, for it manifestly increased the general irritation of the sanguiferous system, and gave rise to much epigastric tenderness. Where spasm of the duct may be presumed to be the primary affection, nauseating doses of antimony ; hyoscyamus; assafoetida; infusion of chamomile; active purgatives; emollient cataplasms or fomentations ; ano- dyne frictions, and enemata, are recommended by the older writers, but they are so greatly inferior to opium, the warm bath, and revulsive applications to the epigastrium, that they scarcely deserve any attention as remedies in this affection. In those cases which come on gradually, with little or no pain in the region of the duodenum and duct, and where, of course, there is little or no probability of the existence of spasm or biliary concretions, the principal indication is to restore the regular functions of the liver and alimentary canal. Unfortu- nately, we cannot determine with any degree of certainty, whether such instances consist merely of functional torpor of this organ ; or of a slow organic change of its structure; or of the gradual formation of an indurated enlargement of the pan- creas ; or of some other latent affection of the bile ducts or duodenum near the opening of this duct; or finally, of a loaded state of the colon; and our remedial measures must, therefore, often be applied under much uncertainty as to their fitness to the actual condition upon which the general icteric symptoms depend. The mere empyrical prescription of remedies for the remote consequences, or symptoms of the fundamental hepatic disorder—or for jauruttt*, as it is usually said, will not satisfy the scientific physician; and yet, in many cases, the minutest attention to the circumstances and phenomena of the disease will enable us to form only a plausible conjecture as to its true nature. Where there is reason to pi t«ume that the primary morbid condition consists in functional inactivity of the liver, mercurials are the principal curative means. As this functional torpor is, however, itself probably only a consequence of an irritation located elsewhere, particularly in the mucous mem- brane of the alimentary canal, it will always be especially proper to attend to the state of the bowels in all cases that come on slowly, and without any particular pains in the epi- gastrium. About two years ago I had a striking example, illustrative of the propriety of this latter observation. A young man, who had for several years laboured under weak digestive powers, became gradually deeply jaundiced, with clay-coloured faeces and highly bilious urine. The liver was manifestly in a very inactive condition, and although there was no distinct pain felt in the epigastrium, moderate pressure about the region of the umbilicus gave rise to great soreness and distress. He JAUNDICE. 293 had already taken a great deal of medicine, under the direction of another physician ; hut without the least perceptible advan- tage. I put him upon the lightest kinds of liquid farinaceous diet, and directed him to have fifty leeches applied to the epi- gastrium, and to use a laxative enema every morning sunn after breakfast, and three grains of blue pill every night on going to bed. In less than a week after this treatment was com- menced he began to mend, and in the course of four weeks his health was entirely restored. Jaundice has been known to recur in a strictly periodical character, and cases of this kind are, perhaps, always intimately connected with intestinal irri- tation. Bang mentions an instance of periodical jaundice which, after many other remedies had been ineffectually used, was speedily cured by the application of a large blister over the right hypochondrium. In cases of this kind, unattended with high irritation of the mucous membrane of the intestinal canal, some advantage may also be derived from the extract or infusion of taraxacum; and some of the German physicians strongly recommend the infusion of saponaria officinalis, a common plant in this country. The taraxacum is supposed to possess considerable powers as a deobstruent; but its useful- ness in affections of this kind, if it really possesses any, arise no doubt wholly from its mild aperient and diuretic opera- tion. Mercurial frictions on the right hypochondrium are highly proper in such cases ; but the best remedy, perhaps, for exciting the action of the liver, and promoting a healthy se- cretion of bile, is the nitro-muriatic acid bath, employed in the way mentioned under the head of chronic hepatitis, at page 250 of the first volume of this work. Many highly respectable tes- timonies might be cited of the beneficial effects of this remedy in cases of chronic jaundice. I have myself used it in two in- stances with marked advantage. Mercury, in alterative doses, and the nitro-muriatic acid bath, appear to be equally well adapted to the treatment of this affection, whether it consist in mere functional torpor of the liver, or in a vitiated biliary se- cretion ; and in general, wherever the disease is gradual in its approach, and unaccompanied with distinct pain, these reme- dies deserve a full trial. When the disease continues a long time, and the icteric hue acquires a dark appearanee, there will be much reason for sus- pecting the existence of some organic affection of the liver. Cases of this kind are almost always entirely beyond the con- trol of remedial measures; yet it will be proper, even under the most unfavourable circumstances, to make an effort to remove, or at least to arrest the progress of the hepatic affec- tion. External revulsive applications, low diet, and the use of mercury or the acid bath, just mentioned, are the only means upon which the least reliance can be placed in cases of this 294 JAUNDICE. character. Where enlargement and induration of the spleen or pancreas exists the tincture of iodine would probably be of service. Whatever be the precise nature of the hepatic derangement, a strict attention to proper dietetic regulations is of great con- sequence. The digestive powers are always weak in cases of jaundice, and an error in diet may not only cause great un- easiness and distress from the ordinary affections of dyspepsia, but what is more to be dreaded, may readily give rise to high irritation in the mucous membrane of the duodenum, as well as of the other portions of the alimentary canal, and thus tend in no trifling degree to increase the hepatic disease, or to inflam- mations. Where there is tenderness in the epigastrium, and in general, in all recent cases commencing with violent symp- toms, the diet should be of the lightest or least irritating kind. In instances that assume a chronic form, the food should be digestible and simple; and where there is reason to suspect the presence of gastro-enteric irritation, it will not even be pru- dent to allow much solid food, even of the lightest and most digestible kind. There are few diseases that have given so great a scope for empiricism as the one now under consideration. Articles of the most opposite, and in many instances of a decidedly perni- cious character have been extolled as specifics for the cure of this affection. The old and exceedingly absurd doctrine of "signatures," gave rise to the employment of the celandine,* and there are not wanting many highly respectable authorities in favour of its use in this malady. The agrimony, too, was formerly highly extolled for its efficacy in jaundice ;f and of late years the sanguinaria has been brought forward as a va- luable remedy in this affection. This remedy is much praised by the late Professor Smith of New-Haven. He gave the tinc- ture in doses of from thirty to fifty drops three times daily. Hemp-seed boiled in milk, is another remedy which has been said to possess very useful powers for the cure of this affection. Sydenham strongly recommends rad. rub. tinctor; and Bal- dinger relied much upon the use of small doses of ipecacuanha. * Jahn speaks very favourably of the following combination, where the disease depends on torpor of the liver, and a sluggish condition of the portal circulation. R. Sulph. aurant. antimon. 9i. Gum. ammon. G. assafoetid. Fel. tauri aa 3ii. Extract, chalidonii maj. q. s—M. Divide the mass into two grain pills. Take from 8 to 12 pills four times daily. t J. Hill. Method of curing Jaundice and other Diseases of the Liver by the Herb Agrimony. London, 1769. JAUNDICE. 295 It is not improbable that these and many other remedies that have been mentioned, may, under peculiar circumstances, be occasionally serviceable; but as we are wholly without any rational indications for their use, their employment is a kind of haphazard practice, which will be more likely to do mischief than good. CHAPTER XXII. DIARRHOEA. Diaruhcea is an affection of the bowels, the characteristic symptoms of which are: frequent and usually copious liquid stools of a feculent character—attended with more or less griping without tenesmus, and generally without febrile irrita- tion. The proximate cause of diarrhoea consists, according to the sentiments of Cullen and some other writers, in increased peri- staltic motion of the intestinal tube. Unquestionably, an inor- dinate peristaltic action does take place in this affection; but this increased action does not constitute the essential patholo- gical condition of the disease, and cannot therefore be properly regarded as its proximate cause. Increased action of the intes- tinal canal may arise in iwo ways, namely : 1. The irritability of the bowels may be Jn a natural state, whilst the substances which are brought to act on them are of a peculiarly irritating or exciting character. In this case the alvine discharges will generally cease soon after the irritating substances which have excited them are expelled, or their activity is destroyed—as is the case with the purging produced by cathartics, or the action of other transient irritants. 2. The irritability of the bowels may be preternaturally increased; in which case, the ordinary secretions and contents of the intestinal canal, and even the mildest substances will produce excessive peristaltic action, and of course frequent alvine discharges. Irritation of the mucous membrane of the bowels, therefore, constitutes the primary morbid condition in diarrhoea, of which the increased peristaltic motion and the inordinate alvine eva- cuations are the consequences. When the diarrhoea continues long, or assumes a chronic form, the mucous irritation becomes fixed, and unless it be counteracted by an appropriate treat- ment, gradually passes into a state of chronic inflammation—■ more especially of the mucous membrane of the colon, and finally terminates in ulceration, and other forms of disor- ganization of this membrane. Broussais observes, that when 296 DIARRHCEA. diarrhoea continues beyond the thirtieth day, it is almost inva- riably connected with organic derangement of the mucous membrane of the colon. When the disease continues until the irritation passes successively into chronic inflammation and disorganization of the mucous tissue of the bowels, slight febrile irritation occurs—particularly towards evening, and a few hours after eating; the pulse becomes quick, small, and frequent; the skin dry and harsh ; the body emaciates more or less rapidly; and at last oedema of the feet and legs, and occa- sionally dropsical effusions into the cavity of the abdomen ensue. In this aggravated form, the patient is apt to experience ex- tremely severe colic pains an hour or so after taking food, and in general even the mildest ingesta arc usually followed by tormina and diarrhoea! discharges, and articles of food are sometimes passed in the stools in an imperfectly digested state. The appetite is generally very variable and capricious; being sometimes voracious, and at others entirely depressed. The stools too vary much both in relation to frequency and appear- ance. They are sometimes slimy, mixed with more or less fecal matter; at others abundant and watery—occasionally dark, reddish, or whitish, and often contain small portions of undigested food. On post-mortem examination of subjects who have died from chronic diarrhoea, or from some other disease accompanied with this bowel affection, we sometimes discover irregular patches of a fugoid appearance, and of a livid or dark red colour, slightly elevated above the surrounding parts, on the mucous membrane of some portion of the intestinal canal. In other instances, small well-defined ulcers with ele- vated edges, or extensive irregular ulcerations with ragged edges are met with. Not unfrequently the coats of the intes- tines are thickened at the parts where these ulcers are situated; and in some instances this thickening is so great as to dimi- nish very considerably the area of the intestinal tube. In cases of this kind, says Broussais, the usual diarrhoeal symptoms are apt to alternate with attacks of obstinate costiveness, and death occasionally occurs under symptoms resembling those of ileus. Sometimes, instead of ulcers, the mucous membrane is covered with numerous tuberculous elevations of different sizes; and occasionally extensive portions of this membrane are found covered with smooth cicatrices of ulcerations which have healed. Broussais observes that these ulcerations are always found most numerous in the coecum, and about the lower portion of the colon. He thinks, and with great probability indeed, that when the feculent matters become fetid and putrid, whether from long retention or imperfect digestion, they cause irrita- tion, and ultimately inflammation in that part of the mucous membrane where they are most apt to become accumulated. When death occurs at an earlier period of diarrhoea, the mu- DIARRHCEA. 297 cous membrane of the colon, and of the ileum, is usually found in a more or less reddened or injected state, with slight thick- ening of its structure. This is particularly observed in those chronic diseases which during the latter period of their course are accompanied with colloquative diarrhoea. In the chronic diarrhoea of children, attending what is usually called maras- mus, I have found in several instances on dissection, the mucous membrane of the lower portion of the small intestines and of the colon, exhibiting extensive tracts, consisting only of a con- geries of minutely injected vessels. Causes.—The remote or occasional causes of diarrhoea are exceedingly various. They may be divided into those which act directly on the mucous membrane of the intestinal canal; and those vvhich act indirectly through the medium of the general system. Of the former kind are all irritating sub- stances received into, or generated in the alimentary canal; and of these the most common are: irritating and indigestible articles of food and drink; acrid and vitiated secretions from the liver and intestinal exhalents ; worms ; acid generated in the bowels; fresh fruit, particularly such as are very sweet, or acid, &c. Limestone water is particularly apt to give rise to copious diarrhoea in those who have not been accustomed to its use; and new made cider, before it has undergone the fer- mentative process, is also extremely apt to excite this affection. Much, however, depends on the previous or habitual state of the irritability of the intestinal canal, with regard to the power of different articles to excite this affection. Some individuals, apparently in a state of good health, cannot take particular articles of diet or drink without suffering more or less from griping and diarrhoea; whilst in others no unpleasant effect whatever will result from the same articles. Idiosyncrasy also appears occasionally to be concerned in the production of this affection by causes of this kind. Thus in some persons, fresh milk almost invariably excites diarrhoeal discharges; and I know an individual who generally becomes affected with diarrhoea when he eats fresh oysters. Diarrhoea produced by causes of this kind is, however, almost always of temporary duration, and depends on simple irritation, which generally readily subsides after the offending matter has been discharged, and other exciting causes do not supervene. Nevertheless, if the bowels have previously been in an irritable condition, or the patient be labouring under some organic visceral affection, instances which commence from such local irritating causes are apt to continue; and unless particular attention be paid to a careful avoidance of the further influence of the exciting causes of this affection, give rise to high irritation, inflamma- tion, and finally ulceration in some portion of the intestinal canal. vol. n.—38 298 DIARRHCEA. Among the causes of diarrhoea that affect the alimentary canal through the medium of the general system, cold, particu- larly when applied in a humid way to the feet or abdomen, is one of the most common and powerful. When produced by this cause, it constitutes the diarrhoea rheumalica or calarrhalis of the German writers. Cases of this kind are most apt to occur during damp and variable weather, and the evacuations are generally very liquid or watery. Slight rheumatic or ca- tarrhal symptoms are apt to accompany the disease—sucli as toothach, transient pains in the extremities, short cough and coryza, together with slight febrile irritation, towards evening, attended with a dry mouth and great thirst. The tormina are usually exceedingly severe. The occurrence of diarrhoea from cold, or the conjoined agency of humidity and cold, depends, no doubt, on the centripetal direction given to the circulation; in consequence of which the liver and capillaries of the mucous membrane of the bowels become engorged with blood, giving rise to a vitiated, or perhaps a superabundant secretion of bile and intestinal mucus, at the same time that the irritability of the bowels is morbidly increased. Diarrhoea appears also sometimes to arise from an epidemic condition of the atmosphere, independent of its thermometrical or hygrometrical states. This variety of the disease usually occurs in the autumn, when the nights begin to he cool, after a very dry and hot summer, and generally during the preva- lence of other forms of intestinal diseases—particularly dysen- tery and cholera. Cases that proceed from causes of this kind are commonly preceded by the same train of premonitory symptoms that usher in miasmatic fevers—such as a feeling of weight and anxiety in the prsecordia, loss of appetite, bitter taste, tension and fulness of the abdomen, disturbed sleep, headach, some lassitude and aching pain in the back, and slight sensations of creeping chilliness. (Richter.) Diarrhoea arising from this cause frequently passes into the dysenteric form of the disease. It is probable that these cases depend on the conjoined influence of koino-miasmata and atmospheric vi- cissitudes—giving rise to increased irritability, functional dis- order, and sanguineous engorgement of the liver and intestinal canal, in a way which will be more particularly referred to under the head of cholera. Besides these, there are many other general causes capable of producing violent and pro- tracted diarrhoea. The repercussion of acute and chronic cuta- neous eruptions sometimes gives rise to obstinate attacks of this disease. It may also be produced by violent affections of the mind, particularly sudden terror and grief. Diarrhoea occurs very frequently in visceral and other local affections attended with suppuration and ulcerative disorganization. Thus in the latter period of pulmonary consumption, colliquative DIARRHCEA. 299 diarrhoea almost invariably occurs ; and the same may indeed be said of every variety of disease attended with hectic fever, or extensive suppurations. In febrile diseases, diarrhoea sometimes occurs as a critical evacuation.* It can never be regarded as salutary, however, where it depends on the supervention of phlogosis, or high vascular irritation of the mucous membrane of the bowels. When the discharge is watery, reddish, or muddy, mixed with flocculi of mucus, and the abdomen is tender and the tongue dry and red along the edges, it always indicates an aggravated condition of the disease, and the existence of mucous inflamma- tion, and is of course a highly unfavourable occurrence. Cri- tical diarrhoea appears generally to depend on a copious secretion of bile, or an increased discharge from the intestinal exhalents, co-operating, probably, with a morbid irritability of the bowels; and hence, salutary discharges of this kind are almost invariably bilious, mixed with more or less feculent matter and intestinal mucus. Watery discharges, free from bile, are rarely if ever indicative of a favourable tendency of the disease. During dentition, children are very liable to diarrhoea; but as this discharge, when moderate and unaccom- panied with much gastro-enteric irritation, is calculated to lessen the tendency to preternatural determinations to the brain, it should not he checked in instances of this kind, unless it becomes excessive and very exhausting. Prognosis.—When the diarrhoeal discharge has been brought on by indigestible or irritating articles of food or drink, and consists principally of feculent matter and vitiated secretions, it may in general be readily checked, and unless greatly mis- managed, will rarely assume a dangerous character. In ge- neral, diarrhoea is most apt to assume a chronic and dangerous character when it arises from the influence of cold and damp air, or from the habitual use of unwholesome and indigestible diet, in individuals labouring under some chronic visceral affection, or whose general health has been much impaired by previous diseases, hardships, or a course of intemperate living. When we find the disease to continue long, with frequent, watery, and acrid discharges attended with tenderness in the abdomen to firm pressure, and extremely severe tormina, we may presume that there exists chronic inflammation, or at least high irritation in the mucous membrane of some portion of the bowels—and consequently that there is much danger of the occurrence of structural disorder in this tissue, if the dis- ease be not soon removed by appropriate measures. Those « Fr. Hoffman. Dissert, de Diarrhoea in Febribus Malignis Morbis Acutus Salutari. Buchner, Dissert.de Diarrhoea in Febribus Exanthema- ticis Salute et Noxa. 300 DIARRHCEA. cases of diarrhoea that assume a strictly chronic character, and in which scanty and painful diarrhoeal evacuations of an unnatural appearance, occasionally alternate with short periods of constipation, and severe pains are experienced in the tract of the colon an hour or two after eating, may be regarded as certainly dependent on mucous inflammation, and most proba- bly with more or less ulceration, and consequently as being attended with great danger and difficulty in effecting a cure. Diarrhoea from the irritation of dentition, as has just been remarked, is rather a salutary than a dangerous affection; but when this symptom of enteric disease is accompanied with a pale and fretful expression of the countenance, a hard and tumid abdomen, frequent picking at the nose, voracious appe- tite, and the discharge of undigested portions of food in the stools, it must be considered as an affection of very serious import. Treatment.—In the treatment of diarrhoea it should always be recollected that the characteristic alvine discharges, by which this affection is recognized, and from which its name has been derived, is a mere symptom of a primary intestinal disor- der, and that our remedies must be especially directed against this, the essential malady. If, then, we reflect that the local intestinal disease consists either in simple irritation—or in ir- ritation with chronic inflammation—or finally, in irritation with chronic inflammation and disorganization of the mucous membrane of a greater or less proportion of the bowels, ac- cording to the grade of violence and duration of the malady, we shall have no difficulty in instituting a rational plan of treatment. In this, as in other affection*, our remedial mea- sures must he modified according to the nature of the exciting cause. Thus, where the disease is produced by suppressed per- spiration from cold, the restoration and maintenance of the cutaneous exhalation, along with the remedies to be presently mentioned, will be peculiarly proper; where the irritation is produced by vitiated or redundant bile, mercurial remedies are especially applicable; and where a surfeit, or acrid and offensive ingesta have given rise to the disease, laxatives are indispensable in recent cases. The principal indications in this form of intestinal disease, therefore, are, 1. To remove as much as possible every source of intestinal irritation; 2. To allay the morbid irritability of the mucous membrane of the bowels ; and 3. To diminish the determination of the bloed to the vessels of the intestinal canal. In recent cases, where there is reason to presume that the intestinal irritation is kept up by vitiated secretions, or other irritating matters lodged in the bowels, recourse must be had to mild purgatives. This is especially necessary where diarr- hoea is the consequence of indigestion, or of the reception into DIARRHCEA. 301 the stomach of indigestible and irritating articles of food ; or where the bowels are infarcted, or loaded with fecal matter, as occurs in the marasmus of children. It must be observed, however, that it is only in the earlier periods of diarrhoea, or where the mucous irritation has not passed into the state of in- flammation, that aHy material advantage may in general be obtained from purgatives; and even in cases depending on simple irritation, the gentlest laxatives alone ought to be em- ployed. Purgatives are, indeed, very often greatly abused in affections of this kind. Nothing is more common than the re- peated use of active purgatives in diarrhoea. An individual becomes affected with looseness of the bowels. If it does not soon cease spontaneously, he takes a purge. The bowel com- plaint, however, continues, and convinces him that there is still something left which must be removed. To make himself sure of his objects, he takes a more active dose ; but the tormi- na and discharges, instead of being mitigated, acquire greater violence. Astonished at the obstinacy with which the offend- ing matter sticks to the bowels, he determines, once and for all, to get rid of the cause of his complaint, and swallows a double dose of the most active cathartic. He now begins to experi- ence tenderness in the abdomen ; the tormina and diarrhoeal dis- charges continue ; in short, he has developed inflammation which the most judicious management may not be capable of removing. We cannot, however, always abstain from laxatives in instan- ces manifestly connected with inflammation of the internal mem- brane of the bowels. Thus, where phlogosis, or a state of irrita- tion closely approaching inflammation exists, in connexion with an accumulation of faeces and vitiated secretions, with a hard and tumid state of the abdomen—a combination of circumstances fre- quently met with in children, no hopes of procuring relief can be reasonably entertained, until these irritating matters are remov- ed out of the bowels by a course of gentle aperient remedies. Fortunately, in cases of this kind, we may, rn general, gain our object in this respect much more readily by mild than the more active articles of this kind, when assisted by an appropriate diet. A grain of calomel at night, and a moderate dose of cas- tor oil on the following morning, assisted with three or four laxative enemata during the day, will, in general, answer well in such cases, {marasmus) without doing any injury to the in- flamed bowels. Castor oil is decidedly the best purgative in cases of diarrhoea, attended,, with a high degree of irritation or phlogosis. One or two grains of calomel, or three or four grains of blue pill, with from one to two grains of ipecacuanha may be occasionally given to an adult, botli with a view to its aperient effects and its influence upon the biliary organs, which always become more or less deranged in diarrhoea of 302 DIARRHCEA. protracted continuance. Many writers recommend rhubarb as a suitable purge in this disease ; and in recent cases from irritating matters lodged in the bowels, it will, no doubt, an- swer all the purposes that may be obtained from a remedy of this kind. In protracted instances, however, where there is high intestinal irritation, or chronic inflammation, it is much inferior to the cold-pressed castor oil. From its tonic, along with its aperient powers, rhubarb was formerly thought to be pe- culiarly suited to the treatment of this affection, under the erro- neous notion, that diarrhoea is generally the consequence of a relaxation or loss of tone in the intestinal tube. Where it may he deemed necessary to administer an aperient in cases mani- festly connected with chronic inflammation, or a highly irritat- ed condition of the bowels, the castor oil may be very advan- tageously given in union with from fifteen to twenty drops of laudanum. In all bowel affections attended with inordinate discharges, a preternatural determination of blood takes place to the vessels of the intestines, with more or less torpor of the cutaneous ex- halents. This is more especially the case in instances of long standing, and contributes very materially to the support of the intestinal irritation. Remedies which are calculated to counter- act this centripetal direction of the humours, are therefore especially proper in affections of this kind. For this purpose, opium in combination with small doses of calomel and ipeca- cuanha, constitutes an excellent remedy after the irritating con- tents of the bowels have been evacuated by suitable laxatives. Opium and calomel have a direct tendency to allay the morbid irritability of the mucous membrane of the alimentary canal, and when given in conjunction with small portions of ipecacu- anha, seldom fail to excite the activity of the cutaneous exha- lents. In recent cases of diarrhoea, where the discharge de- pends on simple irritation of the bowels, the exhibition of one of the following pills every four hours, after the operation of a dose of castor oil,- will seldom fail to check the complaint.* Minute portions of calomel too, will frequently arrest the pro- gress of the disease. (Dr. Ayre.) From a sixth to a fourth of a grain of calomel may he given every hour or two. In the diarrhoea of infants arising from acidity of the primse viae and deficient biliary secretion, this article, given in union with two or three grains of prepared chalk, is often peculiarly bene- ficial, but as the irritation is apt to be transferred from the * R. G. opii gr. iii. Pulv. ipecac. gr. xii. Calomel, gr. ii. Conserv. rosar-. q. $. M. Divide into 12 pills. DIARRHCEA. 303 bowels to the brain in young children, opium may do mischief, by promoting the determination to the head. Very frequently diarrhoea is induced and sustained by im- paired digestion in consequence of a weakened state of the stomach. Here alterative doses of calomel and the use of mild tonics, together with simple, unirritating, and digestible diet, will commonly prove beneficial. Astringent remedies have been much employed in diarrhoea; but where the mucous membrane of the bowels is in a state of high irritation or inflammation, articles of this kind are almost always decidedly pernicious. In instances where the discharge is kept up by a slight degree of irritation and relaxation of the intestinal exhalents, benefit may occasionally be obtained from remedies of this kind ; but even in such cases, they may in general be very properly dispensed with. The astringents most commonly employed in diarrhoeal affections, are kino, alum, acetate of lead, sulphate of zinc, and the infusions of logwood, blackberry-root, the root of geranium maculatum, &c. Astringents should never be resorted to where the tormi- na are very severe, and there is a tenderness or soreness to the touch in the abdomen. I have repeatedly known great injury done by the use of such articles in the ordinary bowel com- plaints of children ; and there can be no doubt that as a general rule, astringents deserve to be reprobated in affections of this kind. . Judging from my own experience, opium and ipecacu- anha are decidedly more efficacious than astringents, even in instances which may be deemed favourable to the beneficial operation of the latter class of remedies. What I have hitherto said, refers more particularly to recent cases of diarrhoea, before the intestinal irritation has become fixed or converted into inflammation and its consequences. When the disease assumes a chronic character, it generally becomes exceedingly obstinate, and often resists every mode of remedi- ate treatment. One of the most important measures in such cases, is the avoidance of every kind of stimulating aliment. The food should consist wholly of farinaceous fluids, light broths, animal jellies, rice, barley, oat-meal gruel, milk, &c. In all cases, indeed, whether recent or chronic, such a diet is decidedly the most proper ; but in the latter form of the disease, it is absolutely essential to success in its treatment. In some instances of chronic diarrhoea, we may succeed in removing the disease by a rigid adherence to this simple and unirritating diet in conjunction with the employment of small doses of calomel and opium, the occasional use of the warm bath, leeching and counter-irritating applications to the abdo- men. I have in several instances derived great advantage from the employment of small doses of Dover's powder, in union with 304 DIARRHCEA. the acetate of lead, according to the following formula.* Not unfrequently, all the means just mentioned, however judiciously employed, will entirely disappoint us in our attempts to remove the disease. I have known instances of this affection to continue for nine or ten months, although all the foregoing remedies, to- gether with an appropriate diet, had been diligently used. In cases of this obstinate character, the internal use of balsam copaive will sometimes do much good. What 1 have already said under the head of chronic ententes, in relation to this remedy, ap- plies fully to the chronic form of the present affection. It is not probable however, that it can procure any permanent relief in cases attended with ulceration of the intestinal mucous tissue; yet, even in cases of this kind, I have known consider- able temporary benefit derived from this article. In a case of pulmonary hepatization, with purulent expectoration, attended for nine months with continued and extremely painful diarr- hoea, the balsam capaive emulsion generally gave very con- siderable relief for four or five days, after which the symptoms recurred witli their usual degree of violence, notwithstanding the use of this medicine. On dissection, a number of irregular ulcerations were detected in the mucous membrane of the colon and the lower portion of the small intestines. In a case of chronic diarrhoea of upwards of six months continuance, I succeeded in effecting a perfect cure by means of this remedy, given to the extent of from thirty to forty drops three times daily, and fifteen drops of laudanum with each dose. In this case the diarrhoeal discharge depended, no doubt, on simple chronic inflammation, without ulceration of the mucous tissue. Dr. Elliotson has lately introduced a new remedy to the notice of the profession, for the cure of chronic diarrhoea, dependent on ulceration, which has been employed with much success at St. Thomas' Hospital in London—namely, the sulphate of cop- per in union with opium. Cases that had resisted almost all the remedies usually accounted the most efficacious in this affection, yielded readily to this remedy. The dose is half a grain twice a day, with a grain of opium, increasing the quan- tity of the former article gradually to two and even three grains in a day. From the known good effects of weak solutions of this preparation when applied to chronic ulcerations, it is not improbable that its operation in this way may occasionally prove very serviceable in diarrhoea depending on ulcers of the mucous membrane of the bowels; and although the vegetable astringents are always unequivocally injurious in such cases, some benefit may also arise from its peculiar astringent influ- ence on the engorged and dilated capillaries of the. mucous membrane. Whatever internal remedies may be resorted to * R. Pulv. ipecac, compos. ^i. Pulv. acetat. plumb. gr. vi. M. Divide into (i equal parts S. Take one every 4 hours. DIARRHCEA. 305 in cases of this kind, it will always be proper to keep up the regular action of the cutaneous exhalents—and it is especially useful to excite the extreme vessels of the external surface of the abdomen. For this purpose, a broad flannel roller should be constantly worn round the body; and the patient must be particularly careful not to expose himself to the influence of damp and cold weather, and above all to avoid getting wet and cold feet. All kinds of alcoholic liquors also must be avoided. Mucilaginous fluids, such as infusion of mallows, or flaxseed, or barley water, slightly acidulated with sulphuric acid, form the best drink. CHAPTER XXIII. CHOLERA. Cholera is an affection of the alimentary canal, character- ized by very frequent and violent vomiting and purging, with severe tormina, and cramps in the muscles of the abdominal parietes and extremities. The disease almost always comes on suddenly. Pain, and a sense of tension in the epigastrium, is generally the first symptom by which it makes its attack. This is soon followed by violent colic pains about the umbilical region, accompanied with exceedingly distressing nausea. In a few moments after these symptoms come on the vomiting and purging commence with extreme violence, and continue, with but very short intervals, until the system is exhausted, if speedy relief be not obtained. During the intervals between the attacks of vomiting, the patient is usually harassed with con- tinual nausea, and an indescribable feeling of distress in the epigastrium. The alvine discharges are at first thin and watery, and generally with little or no admixture of bile; nor is the fluid ejected from the stomach usually of a bilious cha- racter during the early period of the disease. After the disease has continued for an hour or two, however, the bile begins to make its appearance pretty copiously in the evacuations, and towards the conclusion the fluid discharged consists, in many instances, almost entirely of bilious matter. As the disease ad- vances the tormina become more and more severe and continual, and the purging and retching are almost incessant. One of the most distressing affections belonging to this disease, is the ex- tremely painful cramps which, in severe cases, occur in the abdominal muscles, and in those of the inferior extremities. In cases of no great violence the cramps occur principally, and sometimes exclusively, in the muscles of the legs ; but in rapid vol. II—39 *06 CHOLERA. and very severe attacks, the muscles of the trunk, as well as of the upper and lower extremities, are alike affected in thi9 way. The thirst is always exceedingly urgent; but every" thing received into the stomach is almost immediately thrown up again. As soon as the disease is completely developed, the pulse is small, feeble, irregular, or intermitting ; the hands and feet become cold; the countenance pale, shrunk, and expres- sive of great distress \ a cold sweat breaks out on the extremi- ties and face; and extreme prostration speedily ensues. Cholera is one of the most rapid and fatal forms of disease. It seldom continues beyond twenty-four hours, without termi- nating favourably or fatally ; and in many instances it ends in death in the course of three or four hours, and sometimes in a much shorter period. In the cholera of India death generally takes place within two or three hours after its commencement. In this extremely fatal variety of cholera, the patient is gene-- rally suddenly seized with great prostration, unquenchable thirst, a scarcely perceptible pulse, cold and clammy sweats, cramps in every part of the body, inexpressible anxiety of feeling, extreme restlessness, syncope, excruciating tormina, constant retching, and very frequent stools of a thin, whitish, or starchy fluid. If the patient survive this, the first stage of the disease, which is by no means common, some degree of re- action usually ensues in the course of from twenty to forty hours; and the liver begins to pour out an abundance of dark, thick vitiated bile, which is discharged in the stools, and which may be regarded as an indication of a favourable crisis in the disease. Etiology and Pathology.—A superabundance of vitiated bile in the stomach and bowels was formerly, and by some is still regarded as the immediate cause of this very dangerous malady. The term cholera* is, indeed, sufficiently expressive of the notions once universally entertained concerning the na- ture of this affection, Dr. Cullen says, "the matter ejected both upwards and downwards appears manifestly to consist chiefly of bile;" and Dr. Gregory, though he rejects the idea of its dependance on a redundant and vitiated secretion of bile, says that the disease " commences with nausea and unremitted bilious vomiting, &c." In truth, almost all writers, up to the time of Dr. Bateman and Dr. James Johnson, mention a copious and vitiated bile as the exciting cause of this affection *, but the erroneousness of this sentiment is now well known by all who have kept pace with the progress of pathological sci- ence. So far, indeed, frdm there being a redundant secretion of bile in cholera, there is actually a deficient formation of this fluid from functional torpor of the liver; and it would appear that the hepatic torpor is in direct proportion to the violence of * From xiX*-> bile, and '«■«», to AW. CHOLERA. 307 the disease. No one, indeed, who has attentively observed the early symptoms of cholera, can for a moment doubt of the correctness of this statement; for, however abundant the dis- charge of bile may be after the disease has continued for some hours, this fluid never appears in the evacuations during the early period, or what may be termed the first stage of the disease. The observations and researches that have been published of late years—and they have not been limited—in relation to the pathology of cholera, render it evident, that the liver, and in- deed the whole system of the portal circulation, are extremely engorged with blood. In the cholera of India, the liver, in subjects who die during the first stage of the disease, is always found enlarged and greatly engorged with blood, and the in- ternal surface of the stomach and bowels marked with large patches of highly injected and dilated vessels. In the cholera of infants, I have never seen an instance in which bile appeared in the evacuations, except after the disease had taken a favour- able turn ; and in the few dissections which I have witnessed of subjects who had died of this disease, the sanguineous conges- tion of the liver and mucous membrane of the alimentary canal was very conspicuous. So far, therefore, our knowledge of the pathology of this affection appears to he sufficiently certain ; but how are we to account for the extreme irritability of the stomach and bowels, and the excessive vomiting and purging ? Can hepatic torpor and congestion in the portal system of ves- sels give rise to this morbid condition of the alimentary canal ? or are we to consider this state of the liver, and the general engorgement of the portal vessels, only as a concomitant pher nomena, and in no way causative of the characteristic gastric and intestinal affections ? From some of the circumstances just mentioned, it would appear, indeed, that the hepatic torpor and congestion has no small share in the production of the gastro-intestinal disorder. The fact, that the symptoms almost always begin to abate as soon as the liver resumes its functions and pours out a copious flood of bile, strongly favours this opinion. Strong sanguineous congestion, and torpor of the liver, is almost always attended with great irritability of the stomach. In the malignant grades of bilious fever, the vomit- ing during the first stage, is often incessant and extremely dis- tressing ; and the fluid ejected is wholly free from bilious mat- ter. If death takes place in this stage, the liver is always found exceedingly engorged with blood, and the vessels of the stomach are in a similar state of congestion ; but when the disr ease continues until large evacuations of black and pitch-like bile take place from the bowels, an abatement of all the symp- toms usually ensues. With regard to the remote causes of cholera, it is manifest that high atmospheric temperature constitutes the principal 308 CHOLERA. agent concerned in its production. In our own climate this affection appears almost exclusively during the warm months of summer; but it is nevertheless probable that elevated tem- perature acts rather as an essential predisposing, than as an exciting cause of the disease. Cool and damp night air, or ex- posure to a current of fresh air after the liver and skin have been over-excited by the previous influence of solar heat and exercise, is one of the most common exciting causes of this af- fection. When the cutaneous and hepatic functions, while in a state of inordinate activity, are suddenly arrested by the in- fluence of cold, the blood retreats from the surface to the inter- nal vessels; the portal circulation becomes engorged, and the capillaries of the mucous membrane of the bowels strongly con- gested. This injected or engorged state of the capillaries of the mucous membrane of the alimentary canal gives rise, we may presume, to morbid irritability of this structure, and con- sequently to the characteristic phenomena of the disease. Much may also depend on the influence of koino-miasmata in the production of this affection. The tendency of this agent to excite and derange the functions of the liver is well known, and when operating in conjunction with high atmospheric heat, as it always does, its tendency to enhance the predisposition to this affection is, no doubt, very considerable. In some instances of intermitting fever, the paroxysms are ushered in by violent attacks of cholera, the vomiting and purging usually coming on towards the termination of the cold stage, and continuing until the febrile reaction is fully develop- ed. Sometimes cholera returns in quotidian paroxysms, com- mencing with a slight cold stage, and terminating in free per- spiration without any distinct hot stage. Cholera may also be excited by the direct irritation of indi- gestible and irritating articles of food and drink; but causes of this kind rarely produce the disease unless the system is predisposed to it by a debilitated state of the digestive organs, or by general relaxation and exhaustion from the influence of high atmospheric temperature. CHOLERA INFANTUM. The cholera of infants differs in several essential points from the ordinary cholera of adults. It is almost always dis- tinctly febrile, and very frequently commences in a gradual manner with more or less diarrhoea of several days continu- ance before the vomiting supervenes. It is also particularly liable to become protracted in its duration, or to assume a chronic form, a circumstance which is scarcely ever noticed CHOLERA. 309 in the other varieties of the disease. The liver appears to be as inactive in this as in the preceding form of cholera; for when once fully developed, the evacuations during the early period of the disease, are wholly devoid of any appearances of bilious matter, consisting either of a whitish frothy, or of a watery and almost colourless fluid. If the disease does not rapidly exhaust the vital powers and terminate fatally during the first few days, the patient begins to emaciate ; the ex- tremities become cold; the head and surface of the abdomen extremely warm ; the skin dry and harsh ; the countenance pale and shrunk; the eyes dull and sunk; and the pulse small, irri- tated, and frequent. If the disease is not vanquished by pro- per remedial measures, the little patient by degrees becomes somnolent; he sleeps with the eyes half open, rolls about his head when awake, and at last sinks into a state of insensibili- ty and coma, and dies under symptoms resembling those of the last stage of hydrocephalus. When the disease is very pro- tracted in its course, aptlise usually appear on the tongue and inside of the cheeks ; the face acquires an oedematous appear- ance; the alvine discharges become so acrid as to excoriate the parts about the anus; and towards the fatal conclusion, spots of effused blood under the cuticle sometimes appear on various parts of the surface. The duration of this variety of cholera is exceedingly vari- ous. It may prove fatal in five or six hours, or continue for several weeks, and even months, until the body is reduced to a state of extreme emaciation, and yet terminate favourably. The majority of deaths take place before the termination of the ninth day. When death takes place early in violent and rapid cases, the liver and vessels of the mucous membrane of the alimentary canal are found, on dissection, strongly engorged with blood; "and where the disease had continued for some length of time before death, ulceration and even abrasion of the lining mem- brane of the stomach and bowels," are usually discovered.* The etiology of the cholera of infants differs in some impor- tant circumstances from that of the ordinary form of the dis- ease in adults. Both these varieties of cholera are almost ex- clusively confined to the hot months of the year; hut cholera infantum is vastly more prevalent in large and crowded cities than in the country—a circumstance which does not obtain in relation to the cholera of adults. During a practice of twelve years in the country, I met with hut two or three cases of this disease in infants. Again, cholera infantum occurs almost ex- * Dr. Condie. Observations on the Pathology and Treatment of Cho- lera Infantum, &c. in the Philadelphia Journal of Med. and Phys. Sci- ences, May, 1825. 310 CHOLERA. clusively during the third and twenty-fourth months of age; in other words, during the period when the process of primary dentition is going on. There are, therefore, three causes whose concomitant influence is extensively concerned in the production of this variety of cholera, namely, high atmospheric heat; the contaminated air of crowded cities ; and the irrita- tion produced by dentition. From the great prevalence of this disease during the hot months of summer in the more filthy parts of crowded cities, it has been supposed that it is of ma- larious origin, and "a mere variety of the bilious fever of our climate, the force of which is turned inwards upon the intes- tines." (Condie.) In support of this sentiment, it has been alleged by the respectable physician just quoted, that though seldom met with in salubrious districts of the country, "a majority of the children fall victims to cholera infantum in the neighbourhood of marshes, or in low, wet, and otherwise unhealthy situations." This, I apprehend, will not be con- firmed by the observations of those who practise in the neigh- bourhood of paludal districts. Unquestionably, cholera is much more common, both in infants and adults, in such locali- ties, than in the salubrious parts of the country, and there can be no doubt, that miasmata have a considerable tendency to favour the occurrence of cholera, whether in adults or in in- fancy. If, however, koino-miasmata be the principal agent concerned in the production of this malady, why is the disease so exclusively confined to a particular period of infancy in our cities? And why, we may further ask, does it commence so early as the latter month of June, and usually acquire its most extensive sway in July, before the ordinary paludal diseases are wont to make their appearance, except here or there per- haps a few instances? Let it be observed too, that we frequent- ly find this fatal disease of infants extremely rife in this city, when scarcely any of the other diseases justly ascribed to the miasmata in question occur among our inhabitants. High at- mospheric temperature and the irritation of dentition appear to be the principal remote causes of this affection. But as these causes very seldom produce cholera in infants enjoying the pure air of the country, there must be some other circum- stance peculiar to populous cities which especially favours their tendency to develope this disease. This accessory or predisposing cause consists probably in the impure air of ci- ties, by which the infantile system is rendered irritable and peculiarly predisposed to suffer disturbance from the irritation of dentition. It seems to me highly probable that erethism of the brain, caused by the irritation of difficult dentition in the peculiarly irritable habit of body just mentioned, is frequently deeply concerned in the production of this malady. Throughout the CHOLERA^ 311 whole course of the disease, the head is always preternaturally Warm—and in most instances the child is peculiarly restless and fretful some days previous to the accession of the disease. The tendency of cerebral irritation to cause inordinate irrita- bility of the stomach and bowels is well known. Diarrhoea is a very common, and in general a salutary occurrence during the process of painful dentition. In the commencement of hy- drocephalus, great gastric irritability and frequent vomiting is very rarely absent. In concussion of the brain vomiting is often a very troublesome symptom : and sea-sickness, which is often so violent as to resemble cholera, appears to depend en- tirely on the peculiar cerebral excitement occasioned by the swinging or rocking motion of a vessel at sea. The great ten- dency of cholera infantum, in its chronic form, to terminate in a state of cerebral oppression and coma, seems also to show that the brain is especially predisposed to inflammation, or to that peculiar morbid condition which constitutes what is usually called acute hydrocephalus. We may, therefore, presume that in the irritable condition of the system, produced by the influence of a very warm and contaminated atmosphere, dentition causes more or less cerebral irritation, which being reflected on the stomach and bowels, renders them preternaturally irritable. If in this state of the alimentary canal, the cutaneous exhalents are over-ex- cited and debilitated by high atmospheric temperature, the slightest reduction of temperature, a current of fresh air, or damp night air, will readily cause a sudden torpor of these emunctories. The blood will retreat from the surface to the internal organs, and give rise to engorgement of the vessels of the liver and mucous membrane of the bowels, by vvhich the gastro-intestinal irritability will be still further increased, and the characteristic symptoms of lhedisease,excited. Treatment cf Cholera, The principal indications in the treatment of the cholera of adults, are to allay as speedily as possible the irritability of the stomach and bowels ; to restore the action of the skin and liver; and to determine the circulation from the internal to the external parts. As the progress of this disease is always ex- tremely rapid, the most prompt and energetic means should be at once resorted to, with the view of moderating its vio- lence ; and for thispurpose we possess no remedies so powerful and certain in their effects as opium, and the application of a large and active sinapism to the region of the stomach and liver. When the disease supervenes soon after having taken a full meal or some indigestible and irritating articles of food or drink, the patient should be directed to take copious draughts 312 CHOLERA. of chamomile or balm tea, or warm water, in order to obtain the speedy evacuation of the irritating substances lodged in the alimentary canal. In all cases, indeed, it will be proper in the commencement of the disease, to allow the patient the free use of some bland drinks, both with the view of washing out the contents of the intestinal canal, and of moderating the pain- ful and rapidly exhausting effects of frequent ineffectual efforts of vomiting and purging when the stomach and bowels are empty. As soon, however, as the irritating contents of the sto- mach and bowels are evacuated, a large dose of opium should be administered, and the patient kept from taking any drinks for at least thirty minutes after the medicine is taken. From 80 to 100 drops of laudanum should be given at once ; and the same quantity, mixed with a small portion of warm water, thrown into the rectum. If vomiting occurs soon after the first dose is taken, the laudanum should be repeated in doses of from 30 to 40 drops every fifteen minutes, until its influence on the system be fully obtained. At the same time a large si- napism must be laid over the right hypochondrium and epigas- trium. Instead of sinapisms, we may resort with nearly equal advantage to active rubefacient embrocations. I have in seve- ral instances derived very prompt benefit from the application of the oil of monarda punctata to the abdomen, in conjunction with the internal use of large doses of laudanum. This oil is one of the most active local irritants we possess. When ap- plied in an undiluted state it inflames the skin in a few minutes, and causes exceedingly severe pain in the part. The spirit of turpentine may also be used for this purpose, but its effects are less prompt and powerful than those of the ol. monarda. Upon the prompt and free use of opium and external revulsive appli- cations our chief reliance must be placed. The practice of giving warm spiced brandy, and other powerfully exciting arti- cles of this kind, is, I think, highly improper, and well calcu- lated to do much mischief. Brandy may he allowed in the latter stage of the disease when the prostration is extreme, and it is absolutely necessary to support the sinking powers of the system by the most potent of our diffusible stimulants ; but if it be given during the early period of the disease, with the view of moderating the excessive vomiting and purging, it will not only generally disappoint our expectations, but often manifestly aggravate the symptoms of the complaint. The sedative pow- ers of opium, however, are eminently calculated to allay the extreme irritability of the alimentary canal, and when promptly and efficiently giv n, will seldom fail to procure complete re- lief in the course of sixty or eighty minutes. In not a single instance in which I have resorted to this valuable remedy, did it fail to arrest the vomiting and purging within the period just mentioned; and the only fatal case I ever saw was treated CHOLERA. 3i3 chiefly with warm spiced brandy. If from six to eight grains of opium can be introduced into the stomach, and retained for fifteen or twenty minutes, we may calculate, almost with cer- tainty, on the speedy removal of the disease. When the lauda- num is immediately thrown up again, it should be repeated, again and again, until its effects are obtained. I have in the course of an hour given nearly an ounce of laudanum in this way before the gastric irritability was allayed, without any in- jurious consequences from its ultimate narcotic operation. Where this medicine is immediately rejected by the stomach, we may obtain its effects by external application with almost the same promptitude and certainty as if it were retained in the stomach. For this purpose the cuticle should he removed from the epigastrium, which may be speedily done by means of the nitric acid, as practised by Mr. Powel in the cholera of India. Two parts of this acid diluted with one part of water is to be applied by means of a sponge upon the whole region of the stomach ; and as soon as the patient feels considerable pain from its impressions, the part is to be washed with a solution of the carbonate of potash. The cuticle may now be easily de- tached, so as to leave the cutis exposed and raw. Upon this surface from ten to twelve grains of morphia may he applied, either in the form of a plaster, or by sprinkling the powder over it, and covering it with a piece of linen thinly spread with simple cerate. By this procedure we at once obtain the ad- vantage of a powerful counterirritating application, and of the full influence of the opium. When the irritability of the sto- mach and bowels is in some degree allayed, it will be proper to employ calomel in small but frequent doses, with the view of stimulating the action of the liver. Half a grain of this article may be administered every half hour, and continued until the alvine discharges become bilious, or the disease is subdued. Dr. Ayre speaks highly in favour of minute and frequent doses of this remedy in cholera, and there can be no doubt of its entire adaptation to the treatment of this affection. "Where the disease is very violent and rapid, however, we can- not depend on its operation without the conjoined influence of efficient doses of opium. It may be very advantageously given in uhion with powdered opium, in the proportion of two grains of each, every half hour, until the narcotic effects of the former are manifested, when the calomel should be continued alone in half grain doses. The warm hath may be used with occasional ad- vantage in the commencement of the disease; and where the exhaustion is great, and cramps in the muscles of the extremi- ties severe, much benefit will generally result from rubefacient frictions—particularly from frictions with a strong tincture of capsicum. When the pulse sinks and the extremities become cold, the patient should be wrapped in flannels soaked with vol. n.—40 314 CHOLERA. hot brandy, and in this state recourse must also be had to the internal administation of diffusible stimuli. One of the best arti- cles of this kind, according to my own experience, is a solution of camphor in vitriolic ether. Of a solution of a drachm of camphor in an ounce of ether, a tea-spoonful may be given every half hour until the reaction is considerably increased. In one instance, where the pulse was scarcely perceptible and the extremities cold and clammy, this solution, given in the way just mentioned, produced the happiest effects. 1 have stated above, that drinks should be withheld for some time after administering the first dose of laudanum, in order, if possible, to prevent it from being thrown off before it can produce any impressions on the stomach; with this exception, it will always be proper to allow mild mucilaginous fluids in a warm state- such as barley-water—-as long as the vomiting and purging continue; for, as has already been stated, the exhaustion pro- duced by the excessive vomiting and purging is much less rapid when the stomach and bowels are freely supplied with fluids, than when they are nearly empty, and the evacuant efforts are ineffectual or attended with but small discharges. After the disease is subdued, the patient should take light and nourishing diet, such as animal broths. It will also be proper, during the period of convalescence, to wear a flannel roller round the abdomen; and to take a few grains of blue pill, with a grain of ipecacuanha every evening, on going to bed ; and when the digestive powers remain weak, a table-spoonful of the infusions of colomba, or gention, or a wine-glassful of chamomile tea, with a few grains of the carbonate of ammonia, may he taken three or four times daily. Treatment of Cholera Infantum. Although the morbid condition of the liver and alimentary canal in cholera infantum does not appear to differ from that of the cholera of adults, yet the treatment proper in the former, differs in several very essential points from that which is best calculated for the removal of the latter variety of the disease. Besides the indications already mentioned for the treatment of ordinary cholera, we have, in the present variety, the import- ant one of obviating irritation and sanguineous congestion of the brain; and hence opium, which is decidedly the most valu- able remedy in the cholera of adults, cannot be employed with- out great hazard of doing mischief in the cholera of infants. Some practitioners, under an idea that the stomach contains offending matter which spontaneous vomiting is incapable of throwing off, commence the treatment with the exhibition of a gentle emetic ; but this practice is not only founded on an erro- neous view of the pathological condition of the alimentary canal, but what is still more to the purpose, it is generally decidedly injurious. CHOLERA. 315 From what was said above in relation to the pathology of this affection, it would appear that torpor of the liver and skin, in connexion with cerebral irritation, constitutes the immediate cause of the excessive irritability of the stomach and bowels. Our principal object therefore must be, to restore these two functions; to obviate irritation and sanguinuous congestion in the brain ; and to determine the blood from the engorged vessels of the liver and mucous membrane of the alimentary canal. To answer these purposes, I generally commence the treatment with the application of from ten to twelve leeches to the temples, the exhibition of minute portions of calomel and ipecacuanha, and a large stimulating poultice over the abdomen. I am per- suaded by what I have repeatedly observed in my practice, that great benefit will in general result from local depletion from the head, as well as the application of blisters behind the ears, or on the back of the neck, in this affection. Within the last four years I have not treated an instance of this complaint, in which I did not at once apply blisters behind the ears, and in most instances, it appeared to me, with unequivocal advan- tage. This at least I may confidently affirm, that since I have adopted this practice, I have been much more successful in the management of this disease than previously. Where the pulse is irritated and the head very warm, leeching at the temples or behind the ears is particularly indicated, and will seldom fail to procure very manifest relief. In an extremely severe case which I lately attended in a child about eighteen months old, twelve leeches applied to the hack of the ears, was almost immediately succeeded with great abatement of the violence of the symptoms. With the view of moderating the gastrointes- tinal irritation, and of stimulating the action of the liver, minute portions of calomel and ipecacuanha constitute, I think, the most valuable internal remedy we possess for com- bating this disease. From one-sixth to a quarter of a grain of calomel in union with half a grain of ipecacuanha, should be given every hour or two, and continued until the evacuations become mixed with bilious matter. Let it be borne in mind, that so long as the liver remains torpid and the alvine dis- charges free from bilious matter, the disease may be regarded as still possessing all its violence and dangerous tendency, whatever temporary abatement may occur in the severity of the vomiting and purging. The appearance of bile in the stools, whether green or dark, is alw ays to be hailed as a very favourable sign, and the sooner the liver can be brought to re- sume its secretory action, the greater in general will be the probability of ultimate success in our attempts to subdue the disease. Ipecacuanha in small doses is a most excellent aux- iliary to the calomel, in affections attended with morbid irri- tability and excessive peristaltic action of the alimentary canal. 316 CHOLERA. Its tendency to counteract inordinate action of the bowels when given in small doses, is well known ; and its tendency also to excite diaphoresis, still further enhances its applicability in this and other similar intestinal affections. Where from a tumid and tense state of the abdomen there is reason to presume that the bowels are loaded with fecal matter, the quantity of calo- mel at each dose should be larger, so as to procure its purga- tive operation. I have occasionally given a grain every two hours until its evacuant effects were procured, and afterwards continued it in doses of about one-sixth of a grain every hour. Dr. Edward Miller appears to have been the first physician who particularly recommended minute doses of calomel in cholera infantum ; and under judicious management it is un- questionably a very valuable remedy in this affection. Except under the circumstances just mentioned—namely, a loaded state of the bowels, purgatives are not, in general, advisable in the commencement of the disease. Where the disease con- tinues, however, until the liver under the exciting influence of the calomel pours out a large quantity of bile, mild laxatives are highly useful. In a case which I attended during the pre- sent season, the vomiting and purging were in a great measure arrested on the third day of the disease. The infant, however, sunk into a state of stupor from which it was very difficult to rouse it. As the evacuations from the bowels were very dark and small, and the vomiting had ceased, I prescribed a full dose of castor oil. In about two hours after the oil was taken copious evacuations of a pitch-like matter took place from the bowels; and the little patient was almost immediately freed of all the alarming symptoms under which it laboured. Where the disease comes on gradually, and proceeds slowly, it may perhaps he better to commence at once with purgative doses of calomel, than with the minute alterative portions mentioned above. In cases of this kind the bowels are frequently much loaded by fecal matter, which it is of much importance to evacu- ate as speedily and completely as can be done without resort- ing to the more active or irritating purgatives. At the same time that the means already indicated are cm- ployed, external revulsive applications to the abdomen, more especially to the epigastrium and right hypochondriac region should be used. So far as my own experience enables me to judge, blistering the region of the stomach is decidedly the most efficient application of this kind in the present affection. Before the blister is applied, the part should be slightly bathed with spirits of turpentine in order to procure vesication as speedily as possible. I have seldom, however, suffered the vesicatory to remain on the skin longer than four or five hours. As soon as the skin is uniformly inflamed, which in children occurs generally in about four hours, and sometimes CHOLERA. 317 much sooner, the blister should he removed and an emollient poultice applied over the whole abdomen, including of course the inflamed surface. This will in a short time excite the in- flamed vessels to pour out a copious quantity of serum under the cuticle, and form a large blister, which should then be opened and dressed with fresh mercurial ointment, prepared without turpentine or other irritating substances. Where the general habit is phlogistic and the pulse manifestly febrile, leeching botli from the head and the region of the liver are important preliminaries to the employment of visicatories. The warm bath also is an excellent auxiliary in the treat- ment of this disease ; and this measure is more especially neces- sary when the skin is very dry and harsh, and the pulse quick and tense. While the patient is immersed in warm water up to the neck, it will be proper to apply a napkin wet with cold water to the head. Various other external applications to the abdomen have been recommended, for the purpose of modera- ting the gastro-intestinal irritability of this affection. Rube- facient embrocations and cataplasms, made of stimulating herbs and spices, may be beneficially applied to the abdomen; and where the disease is violent and rapid in its progress, recourse should be had to the most prompt and active articles of this kind—such as sinapisms, ol. monarda,* spirits of turpentine, and even diluted nitric acid, in the way mentioned for the treatment of the cholera of adults. I have already stated as a general rule, that the use of opium is highly improper in this affection. The great tendency to congestion and inflammatory action of the brain in this species of cholera, renders all medicines of this kind decidedly preju- dicial, when given in the early period of the disease, or where in its advanced stage symptoms of cerebral oppression are ma- nifestly present. Nevertheless, where the disease assumes a chronic form, and the patient is very restless and wakeful, with a dry, harsh, and withered state of the skin, and no par- ticular marks of cerebral congestion, small doses of Dover's powders, in union with minute portions of calomel, will some- times produce very excellent effects. In a few instances of this kind, I have given half a grain of Dover's powder with the sixth of a grain of calomel and two grains of magnesia, every two hours, to a child under two years old, with unequivocal advan- tage. I must confess, however, that I have witnessed some instances of this kind, in which the employment of this narco- tic was speedily followed by more or less stupor and cerebral oppression, without any beneficial effect on the intestinal dis- order. * R, 01. monardae, 5i. Spirit camphors, rss. 318 CHOLERA. With regard to the astringent and absorbent remedies, for- merly so much employed in the treatment of this affection, we can scarcely express too strong a sentence of condemnation against their use in the acute form or stage of this malady. I am entirely persuaded, that "much of the mortality of the disease has been produced" by the injudicious employment of cretaceous juleps, astringent mixtures, aromatic draughts, and opiates. Where the disease becomes chronic, or continues rather in the form of chronic diarrhoea than of cholera, the milder astringents may occasionally do some good. Thus, I have in a few cases known a decoction of the root of the geranium maculatum in milk procure considerable advantage; but I have much more fre- quently found it either to produce no manifest impression on the disease at all, or to do unequivocal injury. The employ- ment of unirritating tonics in the chronic form of the disease attended with great debility and relaxation, is much better calculated to afford relief than the use of astringents and ab- sorbents. I have frequently procured very considerable bene- fit in the advanced periods of the disease from the employment of a solution of the tartrate of iron. Forty grains of this pre- paration may be dissolved in two ounces of water, to which half an ounce of the lemon syrup is to he added. Of this from thirty to forty drops may be given to an infant four or five times daily. Dr. Robert Jackson speaks very highly of finely powdered charcoal in diseases of the intestinal canal attended with diseased secretions; and Dr. Condie states that he has used this article with very decided advantage "in the latter stage of the disease, when it had become in some degree chro- nic, and the discharges from the bowels were acrid, dark-co- loured, and offensive." From my own experience I can say nothing of this practice, but I do not doubt its usefulness under the circumstances just mentioned. From five to ten grains of the powdered charcoal, with four or five grains of rhubarb and a grain of ipecacuanha, may be given every three hours. (Condie.) When from the violence and rapidity of the disease, or its long continuance, the exhaustion becomes very great, the ex- tremities cold, and the pulse very small and feeble, internal as well as external stimulants become necessary. Under such circumstances, stimulating frictions, together with the internal use of wine-whey, milk-punch, or a weak solution of the car- bonate of ammonia, are indispensable to support the sinking energies of the system. To relieve the colic pains which are apt to occur from flatu- lent distention of the bowels in the advanced periods of chronic cholera infantum, Dr. Condie strongly recommends a few drops of the spirits of turpentine; and my own experience enables me to speak favourably of this remedy. I have generally, how- CHOLERA. 319 ever, preferred the oil of juniper to the turpentine, and I am inclined to think it more certain in its effects in this respect than the latter. No remedy has appeared to me so promptly to allay the colic pain, and promote the expulsion of flatus from the bowels, as a weak solution of common soot sweetened with sugar. Particular attention must he paid to the proper regulation of the diet throughout the whole course of the disease. If the child is weaned, nothing but the blandest liquid articles of food must be allowed. Boiled milk ; liquid preparations of arrow-root, tapioca, sago, and rice; thin oatmeal gruel, barley decoction, or a solution of gum arabic, are the best articles for food and drink in every stage of cholera. In some instances of a chro- nic character, I have known beef tea or weak chicken broth to produce a favourable change in .the state of the stomach and bowels. In chronic cholera infantum, the appetite sometimes suddenly begins to crave urgently for certain strong and sti- mulating articles of food, such as salted herring or shad ; old bacon; salted and smoked beef, &c, whilst the stomach loathes all of the lighter and unirritating articles of nourishment enu- merated above. When this occurs, it will be proper cautiously to gratify the newly awakened appetite, however opposed to the ordinary dietetic rules the indulgence may appear to be. "I have seen many children recover," says Dr. Rush, "from being gratified in an inclination to eat salted fish, and the dif- ferent kinds of salted meat. In some instances they evince an appetite for butter, and the richest gravies of roasted meat, and eat them with obvious relief to all their symptoms." Without these strong determinations of nature, ho wever, it would be highly improper to allow such coarse articles of food ; but where the inclination for them is strongly expressed, it may and ought to be gratified. Nothing contributes more to the removal of this disease than the enjoyment of the pure air of the country. Whenever it is practicable, therefore, the little patient ought to he immediately removed into the country ; for this change is often sufficient in recent cases to remove the disease in a very short time, with- out any other remedial applications. If the circumstances do not admit of a removal from home to a suitable situation in the country, some advantage may be gained by carrying the patient about in the open air; and still more by frequent rides into the country in an open carriage. As preventive measures, gestation, or residence in the pure air of the country; the avoidance of cool night air after a very warm day; nourishment at the breast during the process of dentition, or where circumstances render this impracticable, a very light liquid diet—particularly milk, and a thin prepa- 320 CHOLERA. ration of arrow-root, with beef-tea or weak chickcn-brotlf, tepid bathing, and lancing the gums as soon as they become swollen by the protruding tooth, arc the most important. CHAPTER XXJYr. COLIC. , Wkitebs have divided colic into a great many varieties? but as most of these distinctions are mere nosological refine- ments, I shall notice those only which have a practical bearing. The most common variety of colic is that vvhich is occasioned by irritating and indigestible articles of food, and which Dr. Gregory from this circumstance calls accidental colic, but which is more commonly designated by the term flatulent, from the prominent symptoms of indigestion and flatulency which always attend this painful affection. A weak and irritable state of the digestive organs predis- poses in an especial manner to this variety of colic. In per- sons so predisposed, even the ordinary articles of food will sometimes give rise to the disease ; and when food of an indi- gestible character is taken, more or less suffering from colic is almost inevitable. Salted meats—all kinds of pastry—crude vegetables, such as cucumbers, celery, and unripe fruit—sour fruit—fresh and warm bread, &c, are especially apt to excite the disease in persons labouring under weak digestive powers. When articles of this kind are received into the stomach, no inconvenience is usually felt until an hour or two after they are swallowed. In some instances, where the stomach is weak and iuirritable, the food passes into the bowels in an imperfectly digested state; in which case, the colic pains may not come on for several hours after eating, and usually occur most severely about the umbilical region. More commonly, however, the pain commences in the stomach or duodenum, before the offend- ing substances have had time to pass lower down in the ali- mentary canal. At first the patient experiences a sense of distention and uneasiness in the pit of the stomach, or occa- sionally in the left iliac region. This is soon followed by a dull, peculiarly distressing.and sickening pain in these parts, accompanied with a feeling of strong distention of the stomach and bowels. The pain now rapidly increases in violence until it becomes extremely severe. In some cases the pain continues COLIC. 321 With but short remissions for several hours. More commonly, however, they come on in severe paroxysms, with complete though transient intervals of ease. During the exacerbations of the pain, the patient is apt to move to and fro, with the body bent forwards, and the hands firmly pressed against the abdo- men. When the stomach is the principal suffering organ, large quantities of air are from time to time forced up, and this is generally immediately followed by some mitigation of the pain. When the colon is the part chiefly affected, the flatus passes off downwards ; but this seldom takes place to any con- siderable extent until the disease is about terminating. The bowels are always torpid in this affection, and the tongue soon becomes covered with white fur. Diagnosis-.—The diagnosis of this variety of colic is not at- tended with any difficulty. The relief obtained from firm ab- dominal pressure—the agitation and writhing motions of the patient, as well as the absence of fever, and the paroxysmal character of the pains, and frequent eructations of flatus, dis- tinguish it prominently from gastro-intestinal inflammation. From bilious colic it may be distinguished by the absence of bilious vomiting, as well as of the icterode appearance of the eyes, of the extreme obstinacy of the constipation, and of the headach and bitter taste in the mouth which characterize the bilious variety of colic. From colica pic/onum it is readily distinguished by the hardness and retraction of the abdominal muscles, and the gradual accession of the colic produced by lead. Prognosis.—Flatulent colic is not attended with much dan- ger, unless it terminates in inflammation of the gastro-intestinal mucous membrane—a termination which sometimes, though rarely, occurs. In some instances, where the flatulent dis- tention is very great, it produces paralysis of a portion of the bowels, or destroys to a degree the power of contraction, giv- ing rise to habitual costiveness, and an especial tendency to a recurrence of the complaint. It is not improbable, I think, that paralysis of a portion of the intestinal canal, induced in this manner, may be the principal occasion, in some cases, of in- trosusception, or invagination of the bowels. Where flatulent colic is produced by very indigestible and irritating ingesta, it may give rise to rapid inflammation and gangrene. Treatment.—The treatment of this variety of colic is seldom attended with much difficulty. In slight cases, where the fla- tulent pains are seated in the stomach, and there is no reason to presume the existence of chronic irritation in the mucous membrane of this organ, we may, in general, soon procure re- lief by administering some of the carminative and antispasmo- dic stimulants. Dry frictions with flannels or a flesh-brush, roi. ii.—41 3M COLIC. is an excellent means for removing flatulent pains of the sto» mach. By rapid frictions on the epigastrium the flatus is generally discharged in copious torrents, and where there is no fixed irritating cause in the stomach that requires removal, we may often, in this way, soon put a termination to the gas- tric pains. From five to ten grains of camphor, with about thirty drops of vitriolic ether, and the same quantity of lauda- num, has frequently afforded prompt relief in my hands. The oil of juniper or the spirits of turpentine will also generally allay the pain in slight cases. Articles of this kind will, in general, give relief where there is no particular irritating cause lodged within the alimentary canal; but where the disease is the immediate consequence of crude, indigestible, and irritating ingesta—or where it comes on within an hour or two after tak- ing a full meal of stimulating, mixed, and indigestible food, carminatives and antispasmodics will not only be insufficient, but generally decidedly injurious, unless they are used in con- junction with proper evacuants. Where there is reason to be- lieve that the offending matter is still in the stomach—which may be presumed to be the case when the disease comes on within an hour or two after taking a full meal, recourse should at once be had to an emetic dose of ipecacuanha. To mode- rate the excessive suffering of the patient as speedily as possi- ble, we may administer some carminative along with the eme- tic. From twenty to twenty-five drops of the essence of pep- permint may be advantageously given in such cases, with about thirty grains of ipecacuanha. When the pain is confined to the bowels, occupying the colon, an active purgative, in union with aromatics, or some of the more volatile antispasmodics, ought to be given, and purgative enemata administered at short intervals until the bowels are freely moved. Castor oil with spirits of turpentine is an excellent purgative in colic from the irritation of acrid substances or imperfectly digested articles of food lodged in the bowels. I have often employed this mix- ture with prompt and complete success. In some instances, however, the sufferings of the patient are so extremely great, that we cannot wait for the operation of a cathartic to procure relief. In such cases, almost the only remedy upon which any reliance can be placed is opium, given in large doses. From two to three grains should be given at once, or what is better, an equivalent dose of laudanum. This will always procure relief in the course of forty or fifty minutes ; and in many in- stances of this severe character, nothing but this remedy, in enormous doses, will allay the extreme agony of the patient. The opium, when given in large doses in this affection, does not materially impede the subsequent operation of cathartics— and the administration of a purgative should never be neglect- COLIC. 383 ed as soon as the violence of the disease is moderated.* When the disease occurs in robust and plethoric habits, venesection should be practised, in order to obviate the occurrence of in- flammation, and to promote the operation of the necessary pur- gatives. Little or no advantage usually results from the em- ployment of external revulsive applications; yet when after the subsidence of the colic pains the epigastrium remains ten- der to pressure, and the tongue becomes furred in the mid- dle, with a florid appearance of the edges, leeching and blister- ing cannot be safely dispensed with. After the disease has been subdued, the patient should confine himself to the lightest and most digestible articles of food for several days. BILIOUS COLIC. . There is another variety of colic, which, from the manifest derangement of the biliary organs, and symptoms indicative of a superabundant or vitiated secretion of bile, has with propriety been denominated bilious colic. This variety of the disease appears to depend on the same remote cause which gives rise to intermitting, remitting, and other forms of miasmatic fevers; and it accordingly most commonly occurs during the autumnal months—particularly after a long continuance of a very warm and humid state of the atmosphere. Before the more urgent and characteristic symptoms of the dis- ease come on, the patient generally experiences headach, loss of appetite, a bitter taste in the mouth, thirst, nausea, and occasion- ally bilious vomiting. After these symptoms have continued for an indefinite period of time, acute pain in the stomach and bow- els supervenes, moving at first from one part of the abdomen to another, though generally most severely felt about the umbili- cus. This pain is often intensely severe during the exacerba- tions. In the early stages of the complaint, pressure on the bowels affords some degree of relief; but as the disease advan- ces the abdomen becomes tender to the touch. Nausea and # For this purpose we may use either the castor oil and turpentine, in the proportion of six drachms of the former to two drachms of the lat- ter—or the following pills: R. Extract, colocynth. compos. 5ss. Calomel ^i. Tart, antimonii gr. i. M. Divide into 10 pills. Take 2 every hour until the bowels are freely moved.—Or, R. Pulv. jalapa gr. xvi. Calomel gr. viii. M. To be taken all at once. 324 COLIC. and bilious vomiting occur more or less frequently from the commencement of the malady ; and the patient always experi- ences a temporary abatement of his sufferings immediately after a spell of vomiting. Although the stomach is morbidly irrita- ble, and extremely apt to be excited to vomiting, yet the bow- els are almost invariably extremely torpid, being generally in a state of obstinate constipation from the beginning of the dis- ease. The pulse seldom deviates materially from its natural condition during the early period of the complaint; but in the advanced stage it becomes increased in fulness, force, and fre- quency. In violent cases the hands and feet are sometimes quite cold during the exacerbations of the pains. About the second or third day of the disease the eyes and skin become more or less suffused with a yellow tinge; and in some cases, indeed, these manifestations of biliary disorder occur several days before the pain in the abdomen commences. In cases of great severity the nervous system usually suffers considerable disturbance—the patient becoming despondent, and affected with slight spasmodic twitches in the muscles of the extremities.* Dr. Staley, in the interesting paper on this disease, just referred to, observes, that he has sometimes met with cases in which much numbness and tremor of the superior extremities occurred ; and he saw one case in which the " arms were so completely paralyzed that all power of voluntary mo- tion was destroyed." Paralysis of the wrists has indeed been frequently noticed as an occurrence in this affection, and this circumstance has been adduced as an argument in favour of the identity of this affection with the variety of colic produced by lead. Eructations of flatus are very common in bilious colic ; and as in the former variety of the disease, they are al- ways followed by a temporary mitigation of the abdominal pain. Causes.—I have already said that bilious colic appears to depend on the same remote cause which gives rise to autumnal bilious fever. Dr. Rush includes this variety of colic among the usual forms of miasmatic fevers; and Dr. Staley observes, that he has uniformly found "the cases of bilious colic most numerous after a summer remarkable for the prevalence of bilious remitting and intermitting fever." My own observa- tions correspond fully with these statements. In the autumns of 1821-2 and 3, when bilious remittents prevailed very ex- tensively, I met with a greater number of cases of bilious colic than had previously come under my notice during a period of fifteen years. Although there can scarcely exist a reasonable * An Inquiry relative to the Causes, Nature, and Treatment of Bilious, Colic. By Dr. Henry Staley, of Maryland.—See Medical Recorder, yo'. vi. p. 231. COLIC. 325 doub*) that koino-miasmata'is intimately concerned in the pro- duction of this malady—more especially when it prevails, in a degree, epidemically ; it must, nevertheless, be admitted, I think, that other ( auses of a sporadic character do occasionally give rise to this affection. I have met with cases of strongly marked bilious colic under circumstances that precluded all ideas of the agency of miasmata. It is generally believed that the liver is morbidly active in this disease—and that a redundant secretion of bile is one of its most essential conditions. This idea is favoured by the circumstance, that from the very commencement the fluid thrown from the stomach is always mixed with a considerable portion of bilious matter. There is much reason, however, to doubt the correctness of this opinion. Dr. Staley observes with much plausibility, that if we reflect on the quantity of bile which is secreted in a healthy individual, and the obstruc- tion which exists to its passage downwards from the constipat- ed state of the bowels in this disease, we can have no difficulty in accounting for the quantity of bile discharged by the mouth, although there be a paucity in the secretion. It is not impro- bable, indeed, that so far from there being too copious a secre- tion of bile in this disease, there is, in fact, a deficiency of this fluid. The functions of the liver are unquestionably deranged, and the bile secreted is, without doubt, vitiated. That this is- the case may be inferred from the analogy which bilious colic bears to cholera—an analogy which has been particularly no- ticed by many writers. Dr. Gregory observes, "that bilious colic is closely allied to bilious diarrhoea and cholera, occur- ring along with them, and apparently differing from them only in some unessential features." The opinion that the liver is in a state of torpor, rather than of increased activity, is moreover strengthened by the fact, that so soon as the alvine discharges become bilious, an amendment of the disease usually takes place; and that however frequent the discharges may be, they seldom procure any particular relief when they are devoid of bilious matter. '« When bilious stools are not brought away," says Dr. Gregory, "it is common to find chocolate coloured motions passed, frequently in vast quantity, reducing the patient to a state of great weakness. Dr. Musgrave, in a valuable paper on this disease, states that he invariably found the liver in a highly congested state, and in the majority of instances there were strong marks of intestinal inflammation and its conse- quences.* The etiology of bilious colic does not appear to differ mate- rially from that which is common to cholera, dysentery, &c. The atmospheric heat and miasmata act probably as predispos- * Med. Repository, Nov. 1825. 326 COLIC. ing causes; and sudden changes of atmospheric temperature, by which the cutaneous exhalents and secretory vessels of the liver are struck torpid and the blood determined to the internal organs, constitute perhaps the principal exciting cause of the disease. Treatment.—The principal indications in the treatment of bilious colic are: to free the bowels of their irritating contents; to allay the morbid irritability of the stomach and intestinal tube, and to restore the healthy actions of the liver. Some writers speak much in favour of the employment of emetics in the beginning of the disease, and there can be no doubt of their usefulness where there is much nausea, without full vomiting in the commencement of the attack. Under such circum- stances, the exhibition of an emetic should be among the first measures resorted to for the removal of the disease. Much bilious matter, of a vitiated appearance, is usually thrown off and considerable temporary relief almost invariably ensues. In cases attended with much spontaneous vomiting, however, it will not be necessary to resort to the use of emetics. In such instances, it will be sufficient to request the patient to take copious draughts of eupatorium or chamomile tea, or some other diluent, in order to facilitate the complete evacuation of the vitiated bile and other irritating matters lodged in the sto- mach. Where an emetic is indicated, the tartarized antimony will in general answer better than any other article of this kind on account of its greater tendency to excite the action of the liver and of the alimentary canal. Many writers advise the exhibition of purgatives, as soon as the stomach has been well freed of its irritating contents. In the majority of cases, how- ever, the stomach is so extremely irritable that medicines of this kind cannot be retained a sufficient length of time to ena- ble them to act on the bowels. As the early evacuation of the intestinal canal is, however, all-important, measures should be immediately taken to allay the gastric irritability, so as to en- able us to administer a cathartic with a prospect of advantage as early as possible. So far as my own experience enables me to decide, calomel is decidedly the best internal remedy we possess for preparing the stomach for the reception and reten- tion of purgatives. Given in small and frequent doses, in con- junction with the application of sinapisms or epispastics to the epigastrium, this mercurial will seldom disappoint us in allay- ing the irritability of the stomach sufficiently to enable us to administer with effect the necessary cathartics. What ren- ders this remedy still more useful as an antecedent measure to the use of purgatives, is its well known powers to correct functional disorder of the liver, as well as its tendency to co- operate as an aperient with the purgatives which are to follow. After the stomach has been freed of its contents either by spon- COLIC. 327 taneous vomiting, or the operation of an emetic, half a grain of calomel may be given every half hour, at the same time that a large epispastic is applied to the region of the stomach and liver, and continued until the irritability of the stomach is moderated. When this is accomplished, a full dose of some active purgative should be administered ; and for this purpose We may give from fifteen to twenty grains of calomel, followed in about three hours with an ounce and a half of castor oil, or a draught of strong infusion of senna and manna. In some instances, however, none of the usual purgatives will be retain- ed, notwithstanding the previous employment of small doses of calomel and counter-irritating applications to the epigastrium. Where this is the case, it is best to depend on calomel alone with the view of procuring the evacuation of the bowels. " When the gastric irritability is very great, calomel," says Dr. Staley," "combined with gum-arabic will be retained when every other cathartic will be rejected." This corres- ponds entirely with my own experience. I have in several in- stances ultimately procured free alvine evacuations by admi- nistering from five to six grains of this mercurial every three or four hours until from twenty to thirty grains are taken, and then assisted by repeated purgative enemata. The em- ployment of enemata should, indeed, always accompany the use of purgatives in this affection. An excellent injection for this purpose, is the following mixture of castor oil and tur- pentine ;* or we may use a strong infusion of senna and Glau- ber salts. As soon as the bowels are freely evacuated, a full dose of opium ought to be administered. This valuable nar- cotic allays the irritation and spasmodic contraction of the in- testines ; and when given in combination with calomel, it does not impede the subsequent operation of cathartics, and tends, in no small degree, to equalize the circulation and excite the cutaneous and hepatic functions. When the obstinacy of the disease is very great, and the bowels resist the effects of pur- gatives, the calomel, with an occasional dose of opium, should be given with a view to its constitutional influence. In gene- ral, cathartics will operate freely as soon as the mercurial influ- ence ismanifested by the soreness of the gums. A general mer- curial action has in fact a most beneficial influence upon the dis- ease, whatever may be its grade of violence ; and in prescribing calomel in the commencement of the disease, with a view to its purgative effects, we must not lose sight of the more per- manent and equally important influence, procured by its speci- » R. 01. ricini Spir. terebinth. Infus. sem. lini Sapo venet I 3i. M. 528 COLIC. fie effects upon the system, and particularly upon the liver. Deranged hepatic funet'on constitutes, probably, the founda- tion of the malady : and the removal of this morbid condition constitutes a primary object in the treatment. After the bow- els have once been freely evacuated, we must by all means endeavour to keep up regular alvine evacuations throughout the subsequent course of the disease. For this purpose, cas- tor oil, or infusion of senna and manna, with an occasional dose of calomel and the daily use of one or two purgative enemata, in general answer vcrv well. In robust and plethoric subjects, or where the pulse is vi- gorous and tense, and the tenderness to abdominal pressure considerable, blood-letting is a very important auxiliary re-' medy in this affection. It will not only tend to moderate the irritability of the stomach, and to favour the regular operation of the necessary purgatives, but what is still more important, it lessens the liability to inflammation which in plethoric and robust habits is always very considerable in this affection. When the pulse is vigorous, it will be best at once in the commencement of the disease to draw blood, to the extent of making a decisive impression on the system ; and the opera- tion may be advantageously repeated whenever the state of the pulse, and other symptoms indicate its propriety at every stage of the disease. Epispastics, sinapisms, and warm fomentations, aleo, are valuable auxiliaries to the remedies already mentioned. When the irritability of the stomach is very great, or where the epi- gastrium and abdomen are very tender to the touch, a large epispastic should be applied over the region of the stomach— having previously practised an efficient blood-letting—and an emolient cataplasm laid over the lower part of the abdomen. These applications assist, in no inconsiderable degree, to allay the irritability of the stomach, and they are especially useful to obviate intestinal iuHainmation—an occurrence which it must always be our principal aim to prevent. When, in the beginning, the fluid thrown from the stomach is of an acrid quality, alkaline remedies should be administered. Calcined magnesia may be given either in union or in alterna- tion with other purgative medicines; or from twenty to thirty grains of the bi-carbonate of potash dissolved in a draught of senna and marina, will in general answer well for this purpose. The warm bath will occasionally afford considerable relief in violent cases of this affection ; and warm fomentations to the abdomen may also be very beneficially used. After the disease has been subdued, much care is necessary on the part of the patient, in relation both to diet and expo- sure. There are few diseases which are so apt to be re-exci- ted by even slight errors in either of these respects, as the COLIC. 329 present one. For eight or ten days after an attack of this dis- ease, the diet should be of the lightest and most digestible kind. Rice, sago, dry toast, beef tea, &c. should be used for three or four days, after which small quantities of the most digestible meats may be allowed. It is particularly important to avoid getting cold and damp feet. To lessen the liability of a re- lapse, it will be proper to wear a flannel roller round the abdo- men for some time after the subsidence of the disease ; and the patient must be particularly cautioned against drinking very cold water during the first three or four days of convalescence. CHAPTER XXV. COLICA PICTONUM. This variety of colic has been described under a diversity of names—as dry gripes; Devonshire colic; colica pictavensis; c. saturnina; c. damnoniensis; rachialgia metallica; painter's colic, &c. It generally makes its approaches in a very gra- dual manner—commencing with symptoms of gastric derange- ment, such as irregular and weak appetite, foul eructations, languor, slight nausea, constipation, with transient pains and a feeling of weight and tightness in the abdomen, more or less drowsiness, and disinclination to mental and corporeal exertion. By degrees the pain in the epigastrium and umbilical region becomes more and more severe and constant. The abdomen is hard, retracted, and somewhat tender to pressure, the bowels immovably torpid, and the stomach in most instances very irritable. The pain in the abdomen suffers occasional remis- sions, but except for a moment after vomiting, and in mild cases, no perfect intermissions take place as in the other varieties of colic. The exacerbations of the colic pains are protracted in duration, and exceedingly agonizing; and during the first two or three days the retching and vomiting is generally very distressing, although a momentary mitigation is usually expe- rienced immediately after the contents of the stomach are ejected. In violent and rapid cases, or what may be called the acute form of the disease, the pains extend from the umbi- lical region upwards to the chest and arms, and downwards to the pelvic viscera, giving rise to paroxysms of violent pain in the region of the bladder and rectum, with much difficulty of voiding urine, and a distressing sense of weight, constriction, and bearing down in the lower part of the abdomen. During the exacerbations, the anxiety and agitation are extreme—cold sweats break out on the extremities and face ; the countenance VOL. II.—42 330 COLICA PICTONUM. is pale, contracted, and expressive of great suffering; and in some cases of very great violence, partial syncope, delirium, convulsions, paralysis of the wrrists, and severe pains in the extremities occur. When remedial measures fail to make a favourable impression on the disease, the vital energies at last begin to sink; the abdominal pains abate ; the stomach becomes extremely tender and puffy ; the thirst unquenchable ; vision imperfect; and finally oedema of the feet, drowsiness, a pale livid hue of the face, and occasionally suppression of urine, and more or less tenesmus, with great dyspnoea, ensue ; and the patient dies under symptoms of apoplexy, or in a state of syn- coptic insensibility. Colica pictonum, if not subdued by an appropriate treatment, or where the remote cause continues to act on the system, or the patient has already suffered one or two attacks of the disease, is particularly apt to assume a chronic character, and to become associated with a variety of fixed and peculiarly distressing affections. The excretory and nutritive functions become impaired ; the mental and physical energies torpid ; the capillary circulation extremely inactive, giving rise to a pale, sallow, and leaden hue, and a shrivelled, dry, and harsh state of the surface of the body; the temper becomes irritable, de- sponding, taciturn, and gloomy ; the countenance lurid and ex- pressive of deep suffering; the body emaciates ; the forearms become wasted and palsied; the abdomen exceedingly hard, pain- ful to pressure, and tumid; the legs oedematous, with pains in the joints, particularly in the ankles and toes, and great tender- ness of the soles of the feet. The patient is extremely restless at night, his vision becomes weaker and weaker, the oedema extends up the legs, and the abdomen enlarges with dropsical accumulations. In some cases, paraplegia, epilepsy, mania, or total imbecility of mind ensue ; and the patient is reduced at last to a state of complete exhaustion and emaciation, and dies under symptoms of apoplexy, or of dropsical effusion into the cavity of the thorax or pericardium, &c. On post mortem examination, traces of inflammation with patches of disorganization almost always occur in the mucous membrane of the stomach and intestinal canal. In many instan- ces, considerable portions of the intestines are so contracted as scarcely to admit the passage of an ordinary sized quill into them ; and occasionally the stomach, and whole tract of the bowels, arc in a state of preternatural contraction. The ves- sels of the abdominal and thoracic viscera are generally very turgid with blood ; but the muscular structure, every where, exhibits a pale and exanguious appearance. The omentum is often marked with livid spots. M. Thomas, a late French writer, states, that in the dissection of eleven persons who had died of this disease, he found the meninges of the brain strongly COLICA PICTONUM. 331 injected, with softening and other morbid appearances in the cerebral structure, with serous or sanguineous extravasations between the membranes. Causes and nature.—Lead, in whatever way and form it may he brought to act on the system, is almost the only well ascertained cause of this variety of colic. It would seem that the fumes of melted lead, and the white oxyd of this metal, are most apt to act injuriously on the animal system, and to give rise to this extremely distressing affection. It has been said, that the acetate of lead is incapable of producing this dis- ease, and that no apprehensions need be entertained on this account, in prescribing the internal use of this article. It must be admitted, indeed, that the acetate manifests a much less de- leterious tendency in this way, than any of the other forms under which this metal may exert its poisonous influence on the system. It would appear that the tendency of lead to pro- duce cholic is not confined to the human species. It has been distinctly noticed that in the neighbourhood of smelting furna- ces and white lead manufactories, pigs, poultry, and other ani- mals, occasionally become affected with a similar or the same disease. Plumbers, painters, glaziers, gilders, the workers in lead mines, and in white lead manufactories, are most exposed to the influence of this poison, and of course almost peculiarly liable to this disease. Formerly, it wras the practice in some parts of Europe to put litharge into new made wine, for the purpose of rendering it palatable, or to convert acid into sweet wine. This gave rise to the extensive prevalence of this form of colic in some districts; and it is from its endemic pre- valence at Poitou in France, from this cause, that the disease obtained the name of colica pictonum. It has been contended, nevertheless, that other causes are ca- pable of producing this variety of colic. Crude wine, fresh cider, and other drinks, acidulated with fresh vegetable juices, are mentioned as possessing a tendency, under otherwise fa- vourable circumstances, to produce this disease; but the cor- rectness of this opinion has, I think, with great propriety been doubted; for, if instances of this kind are accurately examined into, it will perhaps generally be found, that in such cases these drinks have been tainted with lead employed in some part of the machinery or vessels made use of. Without doubt, these beverages may give rise to severe colic; but we have no satis- factory evidence that they are capable of producing the pro- tracted train of distressing symptoms which are known to arise from the poisonous influence of* lead. Larrey, and some other late writers assert, that atmospheric vicissitudes, in conjunc- tion with malaria, is a frequent source of this form of colic ; but it is probable that when produced by these causes, the disease does not differ from the preceding variety—namely 332 COLICA PICTONUM. bilious cholic. It has indeed been maintained, that what are called bilious and lead colic, are-essentially the same affection; hut, although the former often bears a very close resemblance in its course and characteristic phenomena to the latter, the more decided manifestations of biliary derangement in the former, and the great aptitude of the latter to pass into a chro- nic state and to become complicated with various affections of a most distressing character, among other distinctive circum- stances, seem to indicate a radical distinction between them. Of the nature or proximate cause of colica pictonum, there is but little known of a satisfactory character. That the nervous system is prominently affected, is indeed very evident, but whether the ganglionic, or the cerebral nerves are the primary seat of the irritation or morbid excitement, is by no means evident. M. Thomas, to whose dissections I have already referred, conceives that the primary location of this affection is in the brain; but the facts upon which he grounds this opi- nion—namely, the very obvious traces of high vascular conges- tion, and other organic affections of the brain which are fre- quently detected on post mortem examination, are by no means satisfactory; since they may, and I presume are, rather the ultimate effects, than the causes of the malady. The disease may be compared to a tetanic spasm of the intestinal canal, the result probably of a primary morbid condition of the ganglionic nerves, gradually extending to the nerves of relation. Treatment.—The indications for prescribing in this affection are: 1, to allay the pain and spasm of the bowels; 2, to evacu- ate the intestinal canal; 3, to correct and excite the hepatic and intestinal secretions; and 4, to obviate the occurrence of inflammation in the stomach and bowels. As the tendency to intestinal inflammation in this affection is always very considerable, it will be proper, in the first place, to reduce the momentum of the circulation, more especially in robust and plethoric subjects. If the pulse is hard and full a vein should be immediately opened, and the blood suffered to flow until a manifest impression is made on the action of the heart and arteries. Blood-letting does not appear to exertany direct influence over the violence of the symptoms, but it is obviously proper as a means to lessen the chances of the super- vention of inflammation, and it tends in no inconsiderable de- gree, to render the operation of the other remedies more cer- tain and beneficial. As soon as the action of the pulse has been moderated, we must prescribe with the view of allaying the pain and spasm of the intestinal canal; for unless this be effected, little or no advantage can be gained from the use of purgatives, on the free operation of which much of our ultimate success depends. For this purpose opium is decidedly the most valuable remedy we possess. When given in large doses COLICA PICTONUM. 333 it not only allays the spasm and excruciating pain in the bowels, but by these effects it contributes also very greatly to the free operation of cathartics. In order to excite the action of the liver, and to obtain the general mercurial influence on the sys- tem as speedily as possible, as well as to predispose the bowels to be properly effected by the subsequent purgatives, it will be proper to administer the opium in union with calomel. Two grains of opium, with five or six grains of calomel, should be given every two hours until the abdominal pains are removed. After the pain has been thus allayed, the calomel should be continued at the same intervals of time in two or three grain doses, with half a grain of opium, until the gums begin to manifest the mercurial influence. As soon as this is per- ceived, recourse must be had to active purgatives; and it will scarcely he advisable to resort to them before the general mer- curial action has been obtained : for previous to this, the most active cathartics will almost universally fail; and what is still more unfavourable, they frequently give rise to severe vomiting and gastric distress, with but very small or no alvine evacua- tions, however vigorously urged. When, however, the mercury has affected the system, the skin generally becomes moist and of a natural temperature, and a full dose of an active purgative will rarely fail to procure free evacuations. I have repeatedly given the opium and calomel for three or even four days before an attempt was made to evacuate the bowels; and I have had much reason to be satisfied with the result. Castor oil in union with the spirits of turpentine constitutes a very excellent purgative in cases of this kind. An ounce of the former with three drachms of the latter may be taken at once, and half this quantity repeated afterwards every hour until the bowels are freely moved. I have not, in a single instance, failed to procure free evacuations from the administration of this mix- ture, after the gums had become affected with the calomel. A strong infusion of senna and manna, with a portion of Epsom salts dissolved in it, will also, in general, answer well as a purgative in this affection; but it is less certain, I think, than the oil and turpentine, and much more apt to produce very se- vere tormina during its operation. If the pain returns after the operation of the purgatives, recourse should be again had to opium, and the mercurial impression must be maintained by the regular administration of a few grains of calomel every three or four hours. Where the torpor and spasm of the intes- tinal canal offer a very strong resistance to the operation of cathartics, purgative enemata will be very useful auxiliaries. A strong infusion of senna with an ounce of Glauber salts dis- solved in it; or an emulsion formed of two ounces of castor oil, with half an ounce of the spirits of turpentine and a pint of 334 COLICA PICTONUM. warm flaxseed tea, should he repeatedly thrown into the rec- tum until the bowels begin to discharge themselves freely. After the use of large doses of opium and calomel, however,— more especially when a general mercurial excitement has been established—the difficulty of moving the bowels will seldom be considerable. The employment of external counter-irritating applications will rarely contribute materially either to mitigate the symp- toms or to shorten the duration of their progress. Neverthe- less, where from the violence and obstinacy of the disease there is reason to apprehend the supervention of gastro-intestinal in- flammation, vesicatories, or pustulation with tartar emetic ointment, and leeching, ought by no means to be neglected. From some reports that have been published in the French journals, it would seem, indeed, that leeching is capable of doing much good in this affection. Recamier cured a case very promptly by the application of fifty leeches to the abdo- men, after the routine treatment pursued in the Hospital La Charite had been ineffectually employed.* Warm fomenta- * This method of treating colica pictonum—which is denominated " traitement des Peres de la Charitt," consists in the following course of management:—On the first day a purgative enema, made by boiling half an ounce of senna in a pint of water, and adding four ounces of the sul- phate of soda, and four ounces of antimonial wine; and during the day the patient takes occasional draughts of a drink made by dissolving an ounce of the sulphate of magnesia and three grains of tartar emetic in two pints of cinnamon-water, with the addition of an ounce of the syrup of buck-thorn. At five o'clock in the evening an enema is administered, consisting of eight ounces of the oil of walnuts, suspended in twelve oun- ces of port wine. Three hours afterwards a bolus containing one grain of opium and a drachm of treacle is given. On the second day the " eau benite"—an emetic potion, consisting of six grains of tartar emetic, dissolved in eight ounces of tepid water, is given; the half at first, and the remainder in half an hour. When the vomiting has subsided, draughts of a diaphoretic ptisan are given during the rest of the day, made by putting china root, lig guaiac. and sarsaparilla, of each a drachm, into two pints of water, and boiling it down to one. An ounce of sassafras and half an ounce of liquorice root are then added, and the mixture gently boiled and strained. At night the above anodyne enema and bolus of opium are again administered. During the third day the pa- tient drinks two pounds of the diaphoretic ptisan, to which, however, an ounce of senna is added—the whole being taken in four equal portions; and besides this he continues the use of the ptisan without the senna. In the evening the above mentioned purgative enema, composed of a de- coction of senna,sulphate of soda, and antimonial wine: in two hours afterwards the anodyne enema, (walnut oil and port wine); and in two hours more the anodyne bolus. The fourth day is commenced with a purgative potion, composed of two drachms of senna boiled from eight down to six ounces, to which is added half an ounce of the sulphate of soda, a drachm of powdered jalap, and an ounce of the syrup of buck-thorn; and the patient drinks the dia- COLICA PICTONUM. 335 tions and the warm bath may also be used with occasional ad- vantage in this variety of colic. Alum is much praised by Richter and other German writers as a remedy in this affection ; and I have myself used it in two instances with remarkable success. Richter declares that it will sometimes procure relief where opium and all other reme- dies fail; and from a case which I treated lately, I am inclined to think that there is much foundation for this assertion. In this instance I employed venesection, vesication to the epigas- trium, and opium with calomel in very efficient doses. The pains and intestinal spasms were but moderate whilst the pa- tient was under the influence of the opium, and on the evening of the third day very free evacuations were produced from the bowels by the castor oil and turpentine purge, assisted by ene- mata of senna infusion. On the following morning, however, the patient's sufferings were as great as at first; and although they were again allayed by opium, and the gums were mani- festly affected by the calomel, it was evident from the general distress and firmness of the abdominal parietes, that the disease was not subdued. Another pretty free action of the bowels was obtained by the oil and turpentine, with the assistance of pur- gative enemata; but the patient's sufferings were still extreme- ly severe on the following day. I now resorted to the alum— giving twenty grains of it with a grain of opium every three hours. On visiting my patient next morning, I found him almost entirely free from pain, and was informed that he had five or six very copious evacuations during the night. He re- covered rapidly under the use of purgative enemata, and an occasional dose of castor oil, with small doses of calomel and opium. This remedy was first employed by Grashuis,* and it is highly praised by Lentin.f It is said that cold water dashed on the body and limbs of the patient has occasionally excited the action of the bowels after opium, calomel, the warm bath, and purgatives had been ineffectually used. phoretic ptisan mentioned above; and in the evening the oleaginous ene- ma and the anodyne bolus are repeated. All the fifth day is occupied with the sudorific laxative ptisan used on the third day; with the purga- tive enema (used on the first day) at four in the afternoon; the anodyne (oil and port wine) enema, at six o'clock, and at eight the opium bolus. This treatment is adopted by Ratier, and it is said that it accomplishes many cures. Dr. Lerminer also follows this practice rigidly, and with no inconsiderable success. Pinel calls this method " empirisime consa- cre" par une tongue suite de success." * De colico pictonum tentamen.'Amstel. 1752. Ejusd. Appendix deca- dem observationum sestens, 1755. t Memorab. circa serem, vitse genus, sanitat,et morbos Clausthaliens. p. 115. 336 COLICA PICTONUM. For the removal of chronic colica pictonum, or the various distressing consequences of this affection, mercury is without doubt the best remedy we possess. It should be given to the extent of producing gentle ptyalism; and this should he regu- larly maintained for three or four weeks, during which the pa- tient ought to go into the warm bath daily, and avoid with all possible care the influence of cold or atmospheric vicissitudes. Dr. Clutterbuck and other writers of eminence have found sa- livation to be the most effectual means we have for the cure of the paralysis of the wrists produced by the poisonous influence of lead. The nitrate of silver has also been used with success in paralysis from this cause. We may commence with half a grain three times daily, and gradually increase it to the extent of five or six grains in the twenty-four hours. When it causes purging, which in this affection it appears to be apt to do, it should be given in union with a small dose of opium.* During the treatment of this variety of colic, the patient should take freely of fat animal broths, or chicken-water; and it is particularly important that he should avoid drinking cold water or stimulating fluids. To prevent the recurrence of the disease, it is of course absolutely necessary to avoid the in- fluence of its remote cause; and therefore to relinquish the employments which render the exposure to this cause unavoid- able, such as painting, glazing, manufacturing white lead, &c. The utmost care is necessary not to take crude and acid articles of food and drink, and to avoid the influence of a humid and cold atmosphere for a considerable time after recovering from an attack of the disease. The free use of fat and oily articles of diet is said to counteract, to a very consi- derable extent, the poisonous influence of lead. Fat pork, and the daily use of two or three ounces of sweet oil in the morning on an empty stomach, will often protect the system a long time from the injurious effects of this poison; and those who are employed in lead mines, and in the manufacture of the prepara- tions of this metal, are fully aware of the protecting influence of such articles of food, and generally use them very freely. ILEUS. Ileus consists in an introsusception, invagination, or inver- sion of one portion of the intestinal tube into another. This unnatural position of parts induces irritation, which eventuates in spasmodic contraction of the muscular coat of the intestine, thus constricting the caliber of the enclosed gut, and preventing the regular passage of the fseces. The invagination commonly * Dr. Roberts. Med. Transactions, vol. v. art. 5. ILEUS. 337 occurs at the termination of the small in the large intestines, the ileum and coecum being enveloped within the colon. It how- ever frequently happens in other parts of the intestinal tube, and it is by no means rare to see invaginations in several places in tiie same individual. Invaginations of the small intestines frequently take place in children, and occasion but slight and temporary inconvenience. Causes.—This disease may be produced by every thing which may tend to excile irritation or spasmodic action in the stomach and bowels. Among these may be enumerated irritating and drastic cathartics, emetics, or indigestible sub- stances taken into the stomach—such as coins, glass, cherry or peach-stones, and unripe fruit. Ileus is also occasionally pro- duced by hernia, by wounds, or other injuries of the ab- domen, by cold externally or internally applied, by intestinal calculi, by organic derangements of the alimentary canal, or by any thing which either directly or indirectly tends to contract or close the intestinal tube. It is highly probable, that in the painful struggles and general convulsions which precede death, many cases of this disease are produced. Symptoms.—The indications of an attack of ileus arc in some instances xevy insidious, and the disease may have continued months or perhaps years unsuspected. It usually, however, comes on suddenly and without any premonition, by violent, spasmodic, and paroxysmal pains in the abdomen, eructations of wind, jactitation, frequent and ineffectual attempts at stool, distention of the abdomen, and all the symptoms of spasmodic colic. The bowels are constipated, although a discharge of the large intestines below the invaginated part may be accom- plished by means of enemata or by nature. The stools are usually mixed with, or consist entirely of coagulated blood. Upon examination of the abdomen, a hard, irregular, convo- luted tumour may often be discovered, showing the situation, and perhaps the extent of the invagination. To the symptoms detailed, succeed obstinate constipation, hiccup, vomiting at first of the contents of the stomach, and ultimately of sterco- raceous matter. The symptoms of inflammation may supervene upon those of spasm, in which case the disease will become greatly aggravated, and the life of the patient put in imminent danger. Should the spasmodic constriction and inflammation of the intestine be sufficiently severe and continued for any great length of time, gangrene and mortification of the bowel will be the result, which will be indicated and accompanied by cessation of pain, prostration of strength, and all the distin- guishing and alarming symptoms of mortification. The inva- ginated portion, however, becoming gangrenous, sometimes sloughs off, and cases of recovery in this manner have been re- corded. Twenty year* ago I saw a case of this kind, in which vol. ii.—43 333 ILEUS. by the efforts of nature adhesions formed, several inches of the bowel sloughed off and passed away by stool, producing imme- diate relief and a rapid recovery. Nature may also accomplish a favourable termination of the disease by overcoming the con- striction, and procuring the disengagement of the enclosed in- testine. Diagnosis.—The diagnosis of this disease is exceedingly difficult and uncertain. Attacking suddenly, with great vio- lence, and without any premonitory symptoms, it is apt to be mistaken for spasmodic colic, colica pictonum, cholera mor- bus, or tympanitis. On the other hand, insidious as it fre- quently is, and accompanied with symptoms uncertain, and common to some other complaints, its very existence is often unsuspected, and it may easily be mistaken for other diseases. So uncertain are the diagnostic symptoms, that John Hunter, who paid particular attention to this subject, has declared that its existence could never be satisfactorily ascertained during life. Violent and spasmodic pains occurring in paroxysms, however, with long continued and obstinate constipation; fecal vomiting ; distention of the abdomen ; with a hard, convoluted tumour about the arch of the colon, will indicate its presence with some considerable degree of certainty. Prognosis.—Ileusis always dangerous. Occurring in robust and plethoric habits, inflammation, followed by gangrene and mortification, is very apt to ensue. In delicate and irritable habits the spasmodic constriction is carried to a great extent, and is productive of effects equally dangerous. The spasmodic or inflammatory action may, however, in some instances be overcome, and the disease relieved. The skill of the physician, however ably and scientifically directed, will generally fail, in which case nature sometimes comes to our aid, and brings about results as unexpected as they are salutary. Pathology.—It has been said that ileus is a spasmodic dis- ease, and that inflammation, gangrene, and mortification are the consequences of the pre-existent spasm. In a late publica- tion upon "the diseases of the stomach and bowels," Aber- crombie has advanced a new theory upon this subject. Having observed in a great number of post mortem examinations, that distention of the bowel above the invagination was a uniform occurrence, he conceives the distention to he a paralytic affec- tion of the intestine, in consequence of vvhich the fecal matter cannot be propelled onward through the canal. The! introsus- ception has, according to this theory, nothing to do with the disease. Ingenious as this theory undoubtedly is, facts are wanting to support its claims to our notice. A careful review of this disease will convince us that it is entirely inadequate to account for the origin, symptoms, causes, effects, and treatment of this disease. The spasmodic nature of ileus appears so ILEUS. 339 plain, that a formal vindication of its claims is unnecessary. We have seen that ileus is produced by all the causes which give rise to spasmodic diseases generally—that it is indicated by symptoms peculiar to this class of affections, and we shall soon observe that every plan of treatment which has been pur- sued with any prospect of success has been based upon the pro- position of the spasmodic nature of ileus. The remedies which Abercrombie himself proposes are such as are eminently calcu- lated to allay spasmodic action, without any view to the para- lytic affection of the bowel. Dissections exhibit very clearly the pathology of ileus. The disease appears to expend its whole force upon the intestines about the introsusception. This introsusception is very satis- factorily presented to our view. One portion of the bowel is drawn within another, and is there firmly constricted—so much so, that in some instances considerable difficulty is ex- perienced in extricating it. Surrounding this invagination, the marks of inflammation are every where apparent. In some parts, and particularly at the constricted point, gangrene and mortification will generally he detected. Above the introsus- ception the intestine will be found distended by faeces or flatus, which had been presented from passing through the constricted portion of the tube. Below, the intestine is generally in a state of emptiness and contraction, In some cases several in- vaginations will be seen in different parts of the fecal tube— each one presenting to a greater or less degree the peculiari- ties just described. In the majority of cases the invagination will be found at the arch of the colon, or at the termination of the small into the large intestines. The invagination, in the great majority of cases, will be observed to take place from below upwards, although the opposite occasionally obtains. Treatment.—The leading indication in the treatment of ileus is to alleviate, and if possible, overcome the spasmodic action of the muscular coat of the intestines, and thus prevent inflam- mation, relieve the introsusception, and open the bowels. At the very onset of the attack we should endeavour, if possible, to ascertain the cause, and if hernia be detected, it should immediately be reduced. Cases of ileus have terminated fatally from a neglect of this precaution. Believing the disease to be spasmodic in its nature, and prone to become inflammatory in its progress, we should keep our attention steadily directed to the pulse, remembering that in this case, as well as in all other diseases of the intestines, it very frequently betrays us into error. The least tendency to inflammatory action should be combated by the free use of the lancet. Keeping in mind the rapidity of the progress, and the extreme danger of this disease, we should, without hesitation or delay, abstract blood largely. This alone will in many 340 ILEUS. instances have a decided effect in subduing spasm and prevent- ing the occurrence of inflammation. Great advantage may also he derived from topical bleeding by means of cups or leeches applied to the abdomen. Blood-letting having been premised, we may have recourse to antispasmodics with the happiest effects. Of these, opium is decidedly the best. To obtain its most beneficial effects, the system should he put com- pletely under its impression, by the administration of large ami repeated doses. Under the influence of opium, spasm will be frequently allayed, the introsusception overcome, and the bowels evacuated. We may, at this period, with great prospects of success, interpose the use of purgatives. In the employment of these remedies, we should select such as are mild in their operation and gentle in their effects. Calomel will be found to possess a superiority over every other cathartic. Given in doses often grains, alone or with one or two grains of opium, it will frequently be retained on the stomach, when every thing else would be rejected. Castor oil in small and repeated doses, will frequently be retained, and may prove a useful adjunct. Much reliance is to be placed in enemata. Acting directly upon the diseased intestine, they will often display effects highly salutary. A great variety of enemata have been recom- mended, all of which may, in particular instances, have had a beneficial influence. Copious injections of warm water will sometimes prove an important auxiliary, by relaxing the spasm, distending the bowels, and perhaps overcoming the constriction. Dr. Wiltbank related to me a case of ileus, in vvhich the only remedy that had any influence in overcoming the disease, was a large enema of warm water administered by means of the stomach-tube introduced its whole length per anum. This remedy is worthy of further trial. That the administration of enemata by means of the stomach-tube may exert a powerful action in overcoming an introsusception, appears very reason- able. Cold water administered in a similar manner may also have a salutary effect. Tobacco is a remedy of pervading in- fluence upon the abdominal viscera, and evinces such decided relaxing properties upon the muscular system generally, that the most happy effects may he anticipated from its employment. Great caution is requisite in its use: beginning with a weak infusion, the strength may be gradually increased, until the system is under its full impression. Of the tercbinthinate enema, I know nothing from experience; but from the adapta- tion of turpentine to many of the diseases of the bowels, I am inclined to think favourably of its powers, more particularly in the sinking stages of the disease. These remedies failing, we should next have recourse to blis- ters. These are particularly efficacious in ca*cs attended with ILEUS. 341 inflammatory action. They should he sufficiently large to cover the whole abdomen. Cold affusions to the abdomen and legs has long been a fa- vourite remedy, and we are led to believe may in some instances have proved serviceable. Crude mercury has been used in introsusceptions from time immemorial, and is still a favourite practice in England. Abercrombie recommends it in this dis- ease in doses of one or two pounds. Whether it has ever proved beneficial is extremely doubtful. John Hunter's practice in ileus consisted in the administration of purgatives when the enveloped gut was drawn upwards, and of emetics when it was drawn downwards. But the difficulty of this plan of treatment lies in the impossibility of determining, during the life of the patient, whether the constricted gut is drawn within the upper or lower portion of the intestine. All our remedies will however occasionally fail, and the sys- tem will sink under the combined effects of spasmodic and in- flammatory action. In this case stimulants are indispensable. In the administration of stimulants, it is desirable to select such as possess a purgative property. The tincture of rhubarb and the wine or tincture of aloes will be found to possess these qualities in an eminent degree. Taking into consideration the difficulty experienced in afford- ing relief, and the imminent danger attending an attack of ileus, surgeons have within a few years advised the Cesa- rean operation. This operation, however, has been performed but in one instance. Dr. Fuschstius* relates a case, in which after every remedy had proved unavailing, this operation was performed, the invaginatcd intestine drawn out, and a per- fect cure obtained. Further trials of its efficacy in the relief of this disease will be required, before we should be justified in recommending it as a general remedy. I have only to remark while upon this subject, that we should resolutely persevere in the use of every remedy that our skill can devise, knowing that recovery is sometimes effected at a very late period, and when to all appearance no human effort could restore life. CONSTIPATION. Constipation is a term of relative import. For the due preservation of health and comfort, it may be laid down as a general rule, that a daily evacuation of the bowels is indispensa- bly necessary. There arc, however, exceptions to this rule. * Journal der Heilkunde, Feb. 1826. 342 CONSTIPATION. It is by no means rare to see individuals who have a natural stool but once or twice in a week ; and cases have been report- ed in which weeks, months, and, in one instance, seven years elapsed w ithout the appearance of a stool. These cases, how- ever, are extraordinary, and should not affect the rule that the bowels should be opened every day. Constipation of the bowels is generally referrible to slug- gishness of the peristaltic action of the intestines, or to torpor of the liver. Good ascribes it, in some instances, to excessive action of the intestinal absorbents, by which the fluid portion of the faeces is too rapidly removed, and they are left dry, scy- balous, and difficult to be evacuated. The symptoms attending constipation of the bowels are highly disagreeable. The breath is offensive ; the mouth dry and out of taste ; the tongue furred, more particularly in the morning, and at its root; there is loss of appetite, nausea, head- ach, flatulence, and distension of the abdomen. The continu- ance of this affection is apt to induce indigestion, varices in the lower limbs, and piles. Causes—Costiveness may be produced by an astringent diet, want of fresh air, and active exercise, confinement to any par- ticular posture of the body, neglect of the calls of nature, stricture of the bowels, and other organic disorders of the in- testines and liver, and pressure of the uterus during pregnancy. Constipation is often a constitutional disease, or it may he- come habitual from the nature and continuance of the causes producing it. The studious, the sedentary, the indolent, and all whose occupation confines them within doors, and especial- ly those who are under the necessity of remaining long in any particular posture of the body, are peculiarly obnoxious to this affection. Females, from their want of active exercise in the open air, and during the period of pregnancy from the pressure of the impregnated uterus upon the bowels, are par- ticularly subject to constipation. Treatment.—In attempting the relief of constipation of the bowels, it should be borne in mind, that simple and dietetic means will, in many instances, be sufficient to accomplish a complete cure. Ripe fruits, such as apples, peaches, pears, prunes, figs, gooseberries, strawberries, possess aperient pro- perties sufficient, in many instances, to overcome the most ob- stinate habitual constipation. Boiled vegetables are also pro- per articles of diet. The brown bread made of unbolted flour is a favourite remedy in this disease, and rarely fails in pro- curing regular and natural stools. All stimulating and as- tringent articles, such as cinnamon, nutmegs, &c. are injuri- ous, and should be sedulously avoided. Meats should be eaten sparingly and under-done: beef, mutton, fowls, and the vari- ous kinds of game are the most proper animal food. CONSTIPATION. 343 Exercise is also an important remedy in this affection. It should be regular, active, and in the open air; walking or rid- ing on horseback will, in general, prove most salutary. Above all, however, we should never lose sight of the neces- sity of a regular attempt at stool. This will frequently over- come attacks of this disease which have resisted every other means. An attempt at evacuation should be made daily at a certain hour, and although for a time we may be disappointed, yet perseverance will ultimately overcome the habit and relieve the disease. Should the treatment recommended fail, or the urgency of the case admit of no delay, we must, without loss of time, ad- minister purgatives. In the selection of these remedies, such should be preferred as operate mildly and effectually. The li- ver being usually implicated in the disease, the use of mercury in some form cannot be dispensed with. Commencing with calomel alone, or in combination, with rhubarb, aloes, jalap, or some other active cathartic, it should be continued until the bowels are freely evacuated. The operation of the cathartics may be greatly aided by the administration of an enema. In- jections are indeed an important remedy in this disease, and have, in this country and in England, been too much neglect- ed. They should be simple, emollient, and frequently repeated. The bowels having been evacuated, should be kept in a solu- ble state by the use of laxatives. The remedy I have found most effet tual for this purpose is a combination of the blue pill, aloes, and tartarized antimony,* which may be repeated as of- ten as occasion requires. Inspissated ox bile, in pills of five grains each, has been highly extolled, and may perhaps, in some instances, have proved serviceable. Powdered charcoal has of late years been much used in this disease ; care should be taken in its administration, as it, like magnesia, is apt to form concretions in the bowels, and thus increase the disease it was intended to relieve. When it is employed, it should be in combination with some more active cathartic. Castor oil with a few drops of the oil of turpentine, will often display ve- ry happy effects. Good quotes two very obstinate cases of constipation, in which affusions of cold water over the legs and pubes produced an almost immediate evacuation of the bowels. Should these remedies fail, and the habit become confirmed, the blue pill should be given every night for two or three weeks, and purged off on each succeeding morning by rhubarb. This will frequently succeed after every thing else has failed. If * R. Massa ex. hydrarg. ^ij. Pulv. aloes grs. xij. Antim. tart. gr. j. M. ft. Maiaa in pillul. No. xij. drvid., one of which is the dose. 344 CONSTIPATION. it, however, prove inadequate to the relief of the disease, the mercury may be pushed to moderate ptyalism. This being ac- complished, the disease will, in general, immediately give way, and a rapid cure be effected. CHAPTER XXVI. INTESTINAL WORMS. The origin of intestinal worms is enveloped in great obscu- rity. In whatever light this interesting subject is examined, insuperable difficulties present themselves to the mind. There are hut two possible modes in which worms may be produced in the alimentary canal. They are either developed from ovula received into the stomach and bowels, from without, along with the food and drink—or they are formed in the intestines, inde- pendently of seminal matter, or ova generated by similar ani- mals, by new chemical combinations, or what is technically called spontaneous generation. It does not comport with the design of this work to enter into a detail of the various argu- ments that have been advanced, both for and against these views of the generation of intestinal worms ; but it may be ob- served, that the supposition of their origin from ova received into the alimentary canal, necessarily presumes the existence of similar worms out of the body, by which these ova are gene- rated. This, however, is not confirmed by accurate observa- tion ; for, although Linncus. Gmelin, and a few others, assert that both taenia and ascarides have been found in stagnant wa- ters and in marshes ; the ablest helminthologists of the present day, affirm that these worms differ very distinctly both in structure and character from those which are found in the in- testines of animals. It must be observed, moreover, that earth worms of this kind are of exceedingly rare occurrence, and that they have been met with only in particular districts and localities—a circumstance which strongly discountenances the supposition that they furnish the seminaof intestinal worms so common in man and in the inferior animals in every country and situation. The fact, too, that all intestinal worms almost immediately die when removed out of the body and exposed to the air, or placed in water, militates against the doctrine that they are the offspring of worms, whose natural habitation is out of the animal body ; and finally, it has been satisfactorily ascertained that earth worms and such as live in water do not change their forms or character when accidentally received in- to the intestinal canal. Another circumstance directly opposed INTESTINAL WORMS. 345 to the opinion that the seminal rudiments of intestinal worms are generated by worms out of the body, and conveyed in some way or other into the stomach and bowels of animals, is the fact that intestinal worms have been repeatedly found in the bowels of new-born foetuses. Kerkringius asserts, that he dis- covered lumbrici in the stomach of a seven-months foetus ; and in another instance he found a great number of small worms in the bowels of an infant soon after birth. Pallas states, that Brendel found a tape-worm in the bowels of a new born foetus 5 and Heim, according to the testimony of Bloch, met with a similar instance. Rudolphi mentions a case which occurred to the celebrated Blumenbach, in which taeniae w7ere found in the intestines of a recently born pup.* If this view of the generation of intestinal worms be rejected, and tome it appears to be altogether untenable, we are obliged either to confess our total ignorance concerning this mysterious process, which would perhaps be the most prudent, or to resort to the doctrine of spontaneous generation to account for the origin of these parasitic animals. I cannot here enter into the arguments which may be adduced in support of this doctrine ; but it appears to me that an erroneous sentiment of religion has here repressed the spirit of genuine philosophy—in other words, that prejudice, founded on a narrow view of the wise and mys- terious scheme of providence, has not permitted the majority of competent minds to view this interesting subject of research in its true light. The ancient dogma, omnia ex ova, may, I think, be rightfully questioned. When experience and sound reason lead us to a conclusion in philosophy, we may safely abide by it, although it may at first sight appear to run counter to the cherished sentiments, drawrn from the highest source of wisdom and goodness. Of the causes that favour the production of intestinal worms. —However uncertain our notions may be, in relation to the origin of intestinal worms, observation has made us acquainted with the principal circumstances which favour their generation and increase. Among the remote causes that appear particu- larly to favour the production of intestinal worms, are—a se- dentary and inactive course of life; habitual exposure to a humid atmosphere; the abundant use of fat, and farinaceous articles of diet, and of fresh milk ; the use of more food than the stomach can readily digest, or than is necessary to main- tain the health and vigour of the system. Dr. Bremser asserts, that in general all articles of food which furnish a very abun- dant supply of nutrient elements, when habitually taken in larger portions Jhan the ordinary wants of the system require, are particularly calculated to favour the generation of worms * Dr. Bremser.—Ueber Lebende W tinner inLebendenMenschen,p. 16. VOL. II.—44 346 INTESTINAL WORMS. in the alimentary canal. Some writers have mentioned the free use of sugar among the causes particularly favourable to the production of intestinal worms—but this has been denied by others, whose opportunities of forming a correct judgment on this point were considerable. From the occasional epide- mic prevalence of verminous diseases, it would seem that there are peculiar atmospheric constitutions, or aerial causes which favour the generation of intestinal worms. The occurrence of epidemics of this kind has, indeed, been denied and even ri- diculed by some ; but if we are to place any reliance on the concurrent testimonies of some eminent writers; the fact of such epidemics having occurred, must be admitted. Marie has given the history of a very remarkable instance of this kind, which occurred at Ravenna and the surrounding district. Bloch, too, has given an account of an epidemic worm-fever. That verminous affections are vastly more common in some coun- tries or districts than in others, is unquestionable. It is said that in Savoy and Chambrey intestinal worms in every class of society are remarkably common, (Daquin, Bremser) and the same observation has been repeatedly made of Holland and Switzerland. Bremser thinks that the abundant use of milk and cheese in the latter country is probably the principal cause of the great prevalence of worm affections among its inhabitants. The occurrence of the tape-worm is partioularly common both in Switzerland and in Holland ; and it is especially remarkable, that in the former country, the bothriocephalus latus, (taenia lata) is by far the most common; whilst in Germany, the greater part of France, in Italy, and even in the Tyrol, the taenia solium (t. cucurbitina) is almost the only species of tape- worm met with. Rudolphi asserts, that in Sweden the bothri- ocephalus lotus occurs very rarely, whilst the taenia solium is by no means uncommon. Species of intestinal worms.—There are five distinct species of intestinal worms, viz : 1. The tricocephulus dispar—{trichuris—tricocephalus homi- nis—ascaris trichuriu.)— Ibis worm, called by the English " the long thread worm," is from an inch and a half to about two inches in length. About two-thirds of its length is almost as thin as a horse-hair, the remaining and posterior part being considerably thicker, terminating in a rounded or blunt extre- mity. The thin part is transversely striated ; and the alimen- tary canal may be seen, by means of a lens, running from its thinner extremity in a direct line through the centre, into the thick posterior portion, where it assumes a flat and spiral form. These worms are seldom numerous, and are principally found in the coecum. 2. Ascaris vermicularis.—(Oxyuris vermicularis—fusaria INTESTINAL WORMS. 347 vermicularis—maw or thread-worm.)—This is a very small white worm—the male being not above two lines in length, with a rounded or blunt extremity anteriorly, tapering to a point posteriorly. The female is considerably larger, be- ing from four to five lines in length, terminating in an extreme- ly fine extremity posteriorly, resembling the point of the finest needle. These worms are found only in the large intestines, and principally in the lower part of the rectum, where they are often collected in almost countless numbers. 3. Ascaris lumbricoides.—(Fusaria lumbricoides—lumbricus teres.)—These worms are from two or three to ten or twelve inches in length, round, of a yellowish-white or brownish-red colour, of nearly a uniform thickness, except at the extremi- ties, which taper to a blunt point. They are from two to three lines in thickness. The head may he distinguished by a circu- lar depression within a line of one of the extremities, terminat- ing in three small tuberosities or valves, which the worm has the power of opening and closing. When they are opened a very minute, patulous projection may he seen, which consti- tutes the mouth of the worm. A very small groove passes longitudinally, from one extremity to the other, on both sides. The alimentary canal terminates in a transverse depression on the under surface near the posterior extremity. The male is smaller than the female, and may be distinguished by its short- ly curved caudal extremity. In some instances the organs of generation are conspicuous—consisting of two small cylindri- cal projections in the curved part of the tail. These worms inhabit the small intestines, and occasionally ascend into the stomach. 4. Taenia lata.—(Bothriocephalus latus—taenia membrana- Cea—t. vulgaris.)—This worm often acquires a very great length—from thirty to forty feet and more. It is from four to ten lines in breadth, flat, white, and composed of a series of concatenated joints, resembling a piece of white tape. The head is armed with two processes, by which the worm attaches itself to the intestines. It inhabits the upper portion of the bowels and the stomach. 5. Taenia solium.—(Taenia cucurbitina—t. osculis marginali- bus.)—This worm is rarely if ever voided whole. It is passed off in pieces of a greater or less number of joints, or in single joints bearing a considerable resemblance to the seeds of gourd. Pieces, however, upwards of twenty feet in length have been discharged, although generally not more than three or four joints pass off together. The anterior part tapers off into a very fine thread-like extremity, the head being extremely small and furnished at its sides with four small apertures {ascula). This is the most common species of tape-worm, and like the taenia lata inhabits the stomach and small intestines. 34S INTESTINAL WORMS. Symptoms.—The symptoms which usually arise from ver- minous irritation, and from the presence of which we may pre- sume the existence of worms in the alimentary canal, are—• countenance pale, lead-coloured, with occasional transient flushes ; eyes dull; pupils dilated, with a bluish semicircle around the lower eyelids ; tickling in the nose ; tumid upper lip; occasional headach, and humming in the ears; copious se- cretion of saliva; tongue slimy or furred ; breath foul; varia- ble appetite—being sometimes voracious—at others wholly gone ; transient pains in the stomach ; occasional nausea and vomiting; pains in the abdomen—particularly about the umbi- lical region ; frequent slimy stools, or costiveness; urine tur- bid, yellowish, or milky; abdomen tumid and hard, with emaciation of the other parts of the body ; lassitude; irritabi- lity of temper. None of these symptoms, however, are certain indications of the existence of worms in the bowels—the only certain indication being the appearance of them in the evacua- tions from the bowels or stomach. The opinion which has been expressed by some writers, that worms are harmless inmates of the intestinal canal, is most assuredly not founded on correct observation. Without doubt, many of the affections usually ascribed to worms arise from other causes ; and it is quite probable, that that peculiar condi- tion of the alimentary canal which favours the production of worms, may he frequently mainly concerned in giving rise to the various general affections which attend the presence of worms in the stomach and bowels. That verminous irritation is, however, sometimes the direct and exclusive exciting cause of severe and dangerous affections, is unquestionable. Chorea, epilepsy, hydrocephalus, emaciation, convulsions, mania, para- lysis, fevers, dropsy, and a vast variety of anomalous disorders are sometimes the immediate consequence of irritation from worms in the bowels, and occasionally speedily disappear after the expulsion of the worms. Esquirol states, that he has known eleven persons cured of mania by the expulsion of a large num- ber of lumbrici with anthelmintic remedies. Treatment.—In prescribing for the removal or destruction of intestinal worms, it is of considerable consequence to confine the patient to a spare and liquid diet, and to exhibit two or three mild purgatives a few days previous to the exhibition of the proper anthelmintic remedies. With these preparatory measures, the ordinary vermifuge remedies will not disappoint us so often as without them. My own plan of management for the expulsion of the long round worm {lumbricoid), is to put the patient on a liquid diet, and to order him a small dose of Epsom salts every morning for three or four days. On the fourth morning I direct a decoction of the root of spigelia, in the proportion of an ounce of the root to a pint of water, boiled INTESTINAL WORMS. 349 down to half a pint. This being sweetened, is to be drunk in the course of three or four hours, by a child of from five to ten years old, commencing in the morning after having taken a little milk and water into the stomach. As soon as the whole of the decoction is taken, an active dose of calomel and jalap is to be administered, or a dose of castor oil and turpentine, in the proportion of half an ounce of the former to two drachms of the latter, given in doses corresponding to the age of the patient. I have rarely failed, by this plan, to procure the dis- charge of worms, where they existed in the bowels. A vast number of remedies and modes of treatment have been recom- mended for the expulsion of this species of intestinal worms. Bremser speaks very highly of the vermifuge powers of the fol- lowing electuary.* A tea-spoonful is to be given to a child every morning and evening for six or seven days. I have used this electuary in four or five cases with complete success. It should not he given to the extent of producing frequent and watery evacuations. I have found it to do most good when it procured three or four consistent stools daily. Rudolphi asserts, that the anthelmintic oil of Chabert {oleum empyreumaticum Chaberti) is decidedly the most efficacious vermifuge we pos- sess; and both Bremser and Brera have added their testimony in favour of its usefulness in this respect, f Fifteen or twenty drops may he taken three or four times daily by children from two to seven years old. Small doses of calomel with the pow- dered roots of spigelia and valerian may also be resorted to with a prospect of advantage. There is danger, however, of producing ptyalism from giving calomel in this way—more especially as it is generally necessary to continue its use for several days before its anthelmintic powers can be properly obtained. The most efficacious vermifuge remedies for the expulsion or destruction of the round worms, besides the arti- cles already mentioned, are—chenapodium anthelminticum; sem. santonic; tin filings ; garlic ; conferva helminthocordon ; spirits of turpentine; geoffrea surinamensis; the green rind of unripe walnut; and camphor. * R. Sem. santon. sive tanacet. rudet. contus ?ss. Pulv. rad. valerian. 3ii. ---------jalapae 3s8-—9'l • Sulphat. potass* 3iss.—3H. Oxymel. scillit q- s. ut fiat electuar. M. X This oil is made by mixing one part of the fetid spirits of hartshorn with three parts of the spirits of turpentine, and suffering them to digest for four days. The mixture is then to be put into a glass retort, and dis- tilled in a sand-bath until three-fourths of the whole have passed over into the receiver. This is to be kept for use in small and well-closed vials. 350 INTESTINAL WORMS. To prevent the rapid reproduction of worms, after they have been expelled or destroyed by anthelmintics, recourse must be had to tonics—particularly chalybeates, in conjunction with minute portions of aloes, and a plain and abstemious diet. A strong decoction of the helminthocordon has appeared to me not only very valuable as an anthelmintic, but particularly also to remove that debilitated and disordered state of the alimentary canal which favours the production of worms. An ounce of this marine vegetable, with a drachm of valerian, should be boiled in a pint of water down to one gill. Of this a tea-spoon- ful may he given every morning, noon, and evening, with peculiar advantage to children labouring under verminous affections. I have in several instances known the use of this decoction to restore perfect health to children who were sup- posed to labour under verminous irritation, without any ap- pearance of worms in the evacuations. It has appeared to me particularly beneficial in cases attended with the usual symp- toms of worms, connected with want of appetite and mucous diarrhoea arising from mere debility of the digestive organs, and vitiated secretions in the bowels. Ascarides.—These little worms are generally extremely an- noying. During the day they seldom give rise to much incon- venience; but in the evening, and particularly soon after lying down, they usually occasion a very distressing, and, indeed, an almost insupportable itching and titilation in the lower part of the rectum and the anus. So extremely distressing is the sensation which they cause in these parts, that nervous children are sometimes thrown into convulsions by it. In females these worms sometimes pass into the vagina, and give rise to very great uneasiness. Dr. Bremser states, that he has known an instance in which symptoms of nymphomania were excited by the irritation of ascarides which had made their way into the vagina. They are generally most troublesome during damp weather. The removal of ascarides is often attended with great diffi- culty, for although the inconveniences which they create may be removed for a time, they almost always recur again and again in those who are once infested with these worms. From the location of these worms in the lower part of rectum, little or no advantage can be obtained from the use of anthelmintics admi- nistered by the mouth; and even active purgatives seldom evacu- ate them sufficiently. Aloes, however, from its decided tendency to act on the lower portion of the bowels, will occasionally expel them in great quantities, particularly when assisted with proper enemata. My usual mode of proceeding for the expulsion of these troublesome worms, is to prescribe three or four aloetic purgatives every second day, together with two or three enemata composed of a mixture of lime-water and INTESTINAL WORMS. 351 milk in equal proportions daily. Injections of a solution of aloes, or of infusions of any of the above named vegetable anthelmintics, will generally bring off an {abundance of these annoying little worms. I have, in a few instances, brought them away in great quantities, by injections composed of spirits of turpentine mixed with milk, in the proportion of a tea-spoonful of the former to a gill of the latter. The introduction into the rectum of a bougie smeared over with mercurial ointment, has been employed with success for the destruction of ascarides; and Nil Rosen speaks very favour- ably of injections composed of a drachm of refined sugar dis- solved in warm milk. When ascarides have passed into the vagina, injections of cold water with a small portion of vinegar, is, according to the experience of Dr. Bremser, the best remedy we possess. Dr. Van Vest asserts, that flowers of sulphur taken in the morning on an empty stomach, is one of the most efficacious remedies for the destruction and expulsion of these worms. Tape-Worm.—For the expulsion of the tape-worm, a very great variety of remedies and modes of treatment have been recommended. The anthelmintics that have been found most effectual against this species of intestinal worms, are—polypo- dium filix; spirits of turpentine; tin ; valerian; the bark of the pomegranate root; and the empyreumatic oil of Chabert. Whatever mode of treatment he adopted, it is always of much consequence to prepare the patient by proper diet and laxa- tives before the proper vermifuges are given. A spare and liquid diet, with the daily use of small doses of saline purga- tives for four or five days, will greatly increase the chances of procuring the expulsion of the worm, by the use of anthelmin- tic or active cathartic remedies. The following is the sub- stance of some of the most celebrated methods of treatment recommended for the removal or destruction of taenia. Alston's method.—On the first day the patient is actively purged with an infusion of senna and manna. On the following morning an ounce of pure tin filings, mixed with common syrup, is to be taken (by an adult;) and on the second and third morning half an ounce of tin filings are administered, which is followed on the fourth morning, by an active dose of senna and manna. Pallas speaks in very favourable terms of this mode of management, and assures us that he has several times succeed- ed completely in effecting the expulsion of taenia with it. Bre- mer also has employed it with success in a few cases. Dessault's method, consists in the employment of mercurial frictions on the abdomen, followed by drastic mecurial purges. Herrenschwand's method.—A drachm of the powdered male fern root is to be taken morning and evening on an empty sto- mach, for two days in succession. On the morning of the third 352 INTESTINAL WORMS. day the following purgative must be taken.* Three hours after this dose is swallowed, the patient must take an ounce of castor oil, and this dose must be repeated in an hour; if in three hours after the second dose of oil the worm has not been expelled, a third dose of it is to be taken, and should all these fail in procuring the expulsion of the worm, an injection of three ounces of castor oil in warm milk and water should be admi- nistered in the evening. Hufeland's method.—A cup of a decoction of garlic in milk is to he taken every morning on an empty stomach; and a table-spoonful of castor oil every morning, noon, and evening, with half an ounce of tin filings daily, and frictions on the ab- domen, with petroleum twice every day. The patient is to eat salted food. This method must be pursued for several weeks, or until the head of the worm is expelled. Nouffer's method.—This mode of treatment was at one time in high esteem; and many very respectable names might be mentioned in testimony of its occasional efficacy for the expul- sion of the tape-worm. In the evening the patient must take a bowl of panada for his supper; fifteen minutes afterwards a glass of wine with a biscuit; and if the bowels were not moved during the day, an enema composed of an infusion of mallows and a little common salt, with a few ounces of sweet oil, is to be administered. Early on the following morning, eight or nine hours after the panada was taken on the preceding evening, the following powder is to be administered while the patient is yet in bed.f If this should be rejected by the stomach, a second dose must be taken. Two hours after this powder is swallowed, the following purgative bolus must be administer- ed ;X- after which the patient should drink a few cups of green tea, and walk about in his chamber. As soon as the purge begins to operate, a cup of weak tea must be drank at short intervals, until the worm passes off. When this occurs, and not sooner, he may take a moderate portion of animal broth. If this course of management does not succeed in bringing off the whole of the worm, it should he repeated in the same man- ner as has just been described. This method will frequently succeed in expelling the taenia bothriocephalus ; but it does not appear that it is capable of effecting the expulsion of the * R. P. gambogise gr. xii. Subcarbonat potaesae gr. xxx. Sapo. venet. gr. ii. Misce. To be taken at one dose. f R. P. rad. filicis mar. Jii.— Jiii.—To be taken in six ounceg of common water. J R. Submuriat hydrarg. ---- P. scammon. aa. gr. x. G. gambogia gr. vi.—vii. M. ft. bolus. INTESTINAL WORMS. 353 t. solium. M. Odier recommends the use of three ounces of castor oil instead of the above purgative bolus; and it would appear from the observations of other writers, that this modi- fication of Madam Nouffer's plan is advantageous. M. Rathier speaks highly of the following composition as a remedy for the expulsion of tape-worm.* Schmucker's method, which has been highly praised, consists in the employment of the seeds of sabadilla. The pods with the seeds are to be finely powdered ; out of which boluses are to he made, containing five grains of the powder. Having purged the patient well with rhubarb or Glauber salts, on the following morning half a drachm of the sabadilla powder, rubbed up with an equal quantity of sugar, is to be taken. This generally causes vomiting. In an hour after this powder is taken, some barley-water or oat-meal gruel should be swal- lowed. On the next morning, another dose of the sabadilla powder must be administered, which will again excite vomit- ing. If no worms are discharged after this dose, the patient must take but fifteen grains of the powder on the following morning, but the saiin' dose should be repeated in the evening; and the same doses are to be taken on the fourth day. On the fifth day a purge composed of thirty grains of powdered rhu- barb with eight grains of rosin, must be taken. On the morn- ing of the sixth day, three of the above named boluses must be swallowed, and the same number on going to bed. In this way the treatment must be continued for twelve, fifteen, or even twenty days ; and Schmucker asserts, that when properly perse- vered in, it will seldom fail to effect theexpulsion of the worm. Bremser's method.—Mr. Bremser assures us that, by the following method of treatment, he has succeeded in more than five Imndred instances in procuring the expulsion of the taenia solium. The cure is commenced by taking three times daily a tea-spoonful of the electuary already mentioned for the ex- pulsion of the round worm. (Sem. cinae ; rad. valerian ; p. ja- lap.; and tart, vitriol.) When the whole of the portion or- dered in the formula is thus used, two tea spoonfuls of Cha- bert's anthelmintic oil must be taken every morning and evening in a little water. If it occasions vertigo, as is sometimes the case, the dose should be diminished. After the patient has taken this oil about ten or twelve days, he must * R. Pulv. herb, saben. gr. xx. Pulv. sem. ruth. gr. xv. Submuriat hydrarg. gr. x. 01. distil, tanacet. gr. xi. Syrup, folior. persicor. g. s. Ft. mass, ex quo form. bol. no. ii. One of these boluses is to be taken in the morning, and the other in the evening. vol. ii.—45 854 INTESTINAL WORMS. take a purgative ;* after which the use of the oil must be con-* tinued. In general it requires from four to five ounces of this oil before the cure is effected. The spirits of turpentine has of late years been strongly re- commended as a remedy for the expulsion of tape-worm. From two to three ounces of this article should be given at once, and followed in about two hours by a strong dose of castor oil. From the accounts which have been published, of the employ- ment of this article as a vermifuge for taenia, there can be no doubt that it is well deserving of attention as a remedy for this purpose. I have known it to be used with complete success in one instance. In a late number of Hufeland's Journal, the fol- lowing formula is highly recommended as a remedy against tape-worm. R. Tereb. venet. |i. Sapon. jalapin. gss. Extract, hyoscyam. gr. iv. Calomel gr. viii. M« Divid. in pil. pond. gr. ii. Take four every three hours—the patient taking nothing but very thin broth for his food. If the worm is not expelled the first day, the use of the pills must be continued for three or four days. Dr. Wilde used this remedy with success in two cases; and an instance was successfully treated with it in the Polyclinic Institute of Berlin .f Of all the remedies, however, that have been proposed for the expulsion of the tape-worm, the root of the pomgranate appears to be the most efficacious. Dr. Ruggia, a physician of Naples, has employed it with great success ; and Dr. Mile in- forms us, that in his hands it has proved very effectual. I am informed by Dr. Mease of this city, that he has used it in one instance with entire success; and he has heard of other in- stances in which it effected a cure, in this country. It is some- what singular that this valuable remedy should so long have been neglected by the profession ; for it is only within a few years past that we have heard any thing concerning its active anthelmintic powers, although among the ancients it appears to have been a favourite and common remedy for this purpose. Celsus prescribed it for the expulsion of taenia ;J and it is » R. Rad. jalap. 9i. P. fol. sennae 5ss. P. sulph. sulph. potass* zi. M. Divide into three equal parts. Take one every hour. t Hufeland's Journal. June, 1826. X Si lati sunt, qua potui dari debet, in qua lupinum, aut cortex mori decoctussit; aut cui adjectum sit contritum vel hyssopum vel piperis INTESTINAL WORMS. 355 strongly recommended by JEtius, as a most efficacious remedy for this purpose.* Two ounces of the fresh root are to be sliced finely, and slowly simmered in a pint of water down to half a pint. Of this decoction one-third must be taken early in the morning on an empty stomach, and another third every two hours. If this does not expel the worm the same is to be repeated next day, and so on. The diet should be liquid, and an active purgative given after the third portion is taken. CHAPTER XXVII. HAEMORRHOIDS. Piles, Hemorrhoids having of late years been considered as more especially belonging to the province of the surgeon, we need not wonder that they are now much too exclusively regarded as mere painful tumours of a local character, the cure of which should never be delayed. Dr. Gregory observes, that the haemorrhoidal flux was formerly " believed to be a salu- tary provision of nature for the advantage of the constitution. The sudden suppression of it, therefore, was highly dreaded. These notions have passed away; and piles are now regarded as a painful and disagreeable complaint, arising in most cases from local causes, the cure of which should never be delayed." Upon this point, however, we may reasonably demur; for, without regarding this affection as "a special effort of the vis medicatrix naturae," observation and experience have, I think, amply demonstrated the fact, that these tumours and the con- sequent effusion of blood, are in many cases the consequence of plethora of the portal vessels generally, attended with a parti- cular sanguineous determination to the vessels of the lower acetabulum, scammoniae paulum. Vel etiam pridie, cum multum alium ederit, vomat. Postero que die mail punici tenues radiculas colligat, quantum manu comprehendet, casque contusas in aquas tribus sextariis de coquet, donee tertia pars supersit; huic adjiciat nitri paulum et jejunns bibat. Interpositis deinde tribus horis duas potiones sumat talis aquas vel muri* dura? huic adjectae; turn desideat, subjecta calida aqua in pelve.—Celsus De Re Med. lib. iv. cap. xvii.—I doubt whether any treatment proposed by modern physicians, is better calculated to effect the expulsion of taenia than the one here recommended by Celsus, * Tetral. iii. serm. i, c. 39, 40. 356 HEMORRHOIDS. portion of the rectum, arising perhaps generally from constl- tutional causes, analogous to the sanguineous afflux to the ute- rus during the menstrual periods in females. The premonitory symptoms which usually precede the appearance of the hae- morrhoidal flux,—the molimina hasmorrhoidalia—strongly in- dicate a preternatural afflux to, and congestion in the vessels of the lower part of the abdomen ; and I apprehend, the precept that the suppression of this haemorrhage should " never be de- layed," would, if it were generally followed, afford no very gratifying illustration of the supposed advancement of ours< i- ence in relation to this subject. Without doubt, haemorrhoidal tumours are sometimes the result also of mere local causes, and may be safely removed as soon as possible. But whether the original cause be local or general, we may well doubt the propriety of suppressing the discharge after it has become ha- bitual. A deranged state of the circulation and plethora of the abr dominal viscera, and especially of the lower portion of the in- testinal canal, is never absent in this affection, unless the piles arise wholly from local causes, and consist rather of an indu- rated or thickened state of the mucous membrane, than of vas- cular or varicose tumours. The veins of the rectum, in con- sequence of this state of the portal circulation, become dilated or varicose, or the blood is effused into the cellular membrane beneath the mucous membrane of the rectum, forming sangui- neous tumours. "Inconsequence," says Montegrc, " of va- rious causes which are sometimes beyond our cognizance, san- guineous determinations occur, at certain periods, towards the lower part of the rectum. This, at first, gives rise only to a feeling of tension and weight in the pelvis and extremity of the rectum—which, as it is not attended with actual pain, is often scarcely noticed, and usually subsides in three or four days. After a longer or shorter lapse of time, these symptoms are re- newed, which generally terminate in a discharge of florid blood, spread over but not mingled with the faeces. This blood issues by a kind of exhalation from the mucous membrane of the rectum, without any lesion or erasion in this tissue what- ever. After these fluxionary movements have returned more or less frequently—sometimes after a few repetitions, tumours of greater or less size, and more or less painful, begin to make their appearance."* As has already been intimated, there arc two kinds of hae- morrhoidal tumours, viz : the vascular or varicose swellings just mentioned; and those firm, spongy tumours more com- monly called piles, which arise from a thickened and condensed state of submucous cellular tissue. These two forms of the dis- * Dictionaire des Sciences Medicales, art. Haemorrhois. HEMORRHOIDS. 357 ease may be readily distinguished from each other by the follow- ing characteristic circumstances. The former or varicose tu- mours are of a dark and bluish colour, soft and elastic to the touch, broader at the base than at the apex, rounded or somewhat he- mispherical, and considerably lessened by gradual pressure with the fingers, though quickly returning to their usual size when the pressure is removed. They generally occur in irre- gular clusters, and often extend high up along the rectum. The other variety of hsemorrhoidal tumours appears like small fleshy tubercles of a pale red or brownish colour, situated a short distance above the margin of the anus, or descending like pendulous excrescences from the rectum. They have a somewhat firm and spongy feel, " and when cut into, present a more or less compact surface, from which the blood oozes, leaving the texture pale and relaxed." When they are situated externally, they are paler and more elastic and transparent. These tumours frequently contain a small cavity in the centre, containing a fluid or coagulated blood. More commonly, how- ever, no such cavity exists, the whole substance of the tumour being infiltrated with blood, becoming at last coagulated and dark.* "The manner in which these haemorrhoidal excrescences are formed, is in general pretty uniform. The patient is at first made sensible of its development by a peculiar pricking, sting- ing sensation, generally within or around the margin of the anus, and on applying the finger to the part it is felt slightly elevated, as if some newly formed substance were forcing its way to the surface. The increase of these tumours, when once they become permanent, does not take place in every direction ; they elongate rather than expand, the body being usually of a conical shape, and larger than the neck. Sometimes more or less blood is exhaled from their surface; on other occasions a serous fluid only is exhaled, or they remain nearly dry; but in either case they generally disappear in a short time, and return again at an uncertain or irregular period, increasing in size, and becoming firmer in texture with each repetition." (Calvert.) General symptoms and consequences of haemorrhoids.—The approach of an attack of haemorrhoids is frequently announced by various symptoms denoting a deranged state of the circula- tion. In most instances the patient experiences for several days before any manifestations of the local haemorrhoidal af- fection, a sense of weight and pressure in the abdomen, with a peculiar feeling of uneasiness in the bowels, constipation, and a sensation of bearing down in the rectum or perineum, attend- * Practical Treatise on Haemorrhoids, &c. by George Calvert, page 35, 356 HEMORRHOIDS. ed frequently with horripilation in the back and loins,* slight flatulent pains in the stomach and colon, scanty and high-co- loured urine, pale countenance, with an occasional confused sensation in the head, general lassitude and heaviness of the extremities, an irritable and discontented state of the mind, anxiety and fulness in the epigastrium, a hard and contracted pulse, and a sense of anxiety and fulness in the epigastrium. In many cases an unusual desire for venereal enjoyment occurs, and strong erections, and even nocturnal pollutions are apt to take place ;f and the patient often experiences a troublesome itching in the glans penis, and occasionally slight swelling and tenderness of the prepuce and testicles, and even a blennorr- hoeal discharge from the urethra.:}: These symptoms are not in general continuous. They are apt to remit very considerably, or to disappear entirely for a short time, and then return again, more especially on commit- ting any errors in diet—taking stimulating drinks, or making any unusual corporeal or mental exertions. They generally continue, in a greater or less degree, until the tumours either burst, and relieve the engorged vessels by a free discharge of blood, or until they begin to decline and disappear. In some cases, however, these molimina haemorrhoidalia continue for some time, and then disappear again, without the occurrence of the local haemorrhoidal affection. The local affections which attend the actual presence of hae- morrhoidal tumours are sometimes extremely severe and dis- tressing. In some instances the elongated fleshy tumours at last become inflamed, and give rise to severe pain—particularly during the expulsion of the faeces. When they are situated high up they are often forced down past the sphincter, and from the irritable condition of the parts, and the enlarged and exquisitely tender state of the tumours, they cannot be again returned. In this situation they give rise to continued and extreme suffering, and the inflammation will occasionally run so high as to cause suppuration and sloughing. When the inflammation extends to the surrounding mucous membrane, it gives rise to a blennorrhceal discharge from the tumours and lower portion of the rectum—consisting of a thin acrid, and mucous secretion, which soils the patient's linen, and causes tenderness and excoriation about the anus. Some- times the tumours break, leaving fissures, which, from the ir- ritation caused by the motion of the parts, and the passage of indurated faeces, as well as the acrid secretions, are con- verted into very painful irritable ulcers. Montegre has class- * Pinel. Nosograph. Philos. vol. ii. t Lentin. Bertraeg. zur Ausuebent Arzneiwiss, vol. ii. p. 265, X Richter Specielle. Therapie. Bd. iii. p. 350, HEMORRHOIDS. 359 fcd the pains which attend haemorrhoids under four heads. 1. The pains which arise from active inflammation, characterized by heat, tension, and throbbing in the part, varying from a mo- derate degree of these sensations to the most excruciating suffer- ings. 2. Nervous pains, characterized by the intermissions and the very sudden increase and diminution to which it is subject, as well as the considerable relief which is generally obtained by pressure. These pains do not appear to depend either on fis- sure or strangulation of the tumour, and often take place with- out any evident inflammation. Not unfrequently they super- vene when the inflammation has subsided, and may continue with variations of intensity for several months, and occasion- ally much longer. (Montegre.) The pain which usually attends fissures, or rhagades of the tumours, or edge of the anus, are distinguished by the follow- ing circumstances. On going to stool the patient experiences a slight stinging pain in a certain part of the rectum or anus. After the faeces are expelled the pain increases more or less rapidly in intensity, until it becomes excruciatingly severe—in which state it usually continues until "exhausted, the patient falls into a sound sleep, from which he awakes free from suffer- ing." No further pain is experienced until the patient again goes to stool, when they are renewed in the same way as be- fore. Contraction of the anus is no uncommon consequence of ha- bitual haemorrhoids, and may arise—1. From a number of tu- mours formed around the internal surface of the rectum, a short distance above the anus, and which, when pressed down on go- ing to stool, approximate each other, and diminish the passage so as to create much difficulty in voiding the faeces—more espe- cially when they are hard. £. From induration of the cellular tissue, near the extremity of the rectum, giving rise to a pro- gressive decrease of the size of the passage, being in general unaccompanied with pain, except when the patient goes to stool, and the faeces are hard. 3. From spasmodic constric- tion of the anus.—This appears to occur almost exclusively in persons of a nervous and irritable temperament. When the pa- tient goes to stool, the sphincter of the anus being irritated by the faeces, contracts spasmodically, and with such force, that extreme difficulty and pain occur in voiding the contents of the rectum, and any attempt to introduce the finger, with the view of examining into the state of the affected parts, is attend- ed with the same difficulty and severity of pain. It is often wholly unconnected with inflammation or fissure. Sometimes ulcers, abscesses, and fistulx are formed near the extremity of the rectum, terminating occasionally in fistula ani. Among the most common consequences of this affection is a kind of tenesmus, with protrusion of the inner tunic of the rec- 360 HEMORRHOIDS. turn, so as to form a prominent and extremely sensitive ring around the anus—particularly after each attempt to expel the faces. The tenesmus seems, in part, to be caused by the afflux of blood to the affected parts, and also by the impressions of the faeces upon the irritable mucous membrane of the lower part of the rectum, by which a frequent desire to stool is created, which being repeatedly assisted by ineffectual efforts to evacu- ate the faeces, gives rise to permanent induration, scirrhus, and even cancer of the rectum. (Montegre.) Causes.—The causes of haemorrhoids may he classed under two heads—namely, general and local. Among the general causes some are evidently simply predisposing; whilst others are more immediately concerned in exciting the haemorrhoidal affection. There appears to be a peculiar physical tempera- ment or abnormal condition of the body, vvhich predisposes in an especial manner to the occurrence of this affection ; and it would seem too that this haemorrhoidal constitution is often manifestly hereditary. Richter supposes that this predisposi- tion consists principally in an original inactivity of the cir- culation in the abdominal viscera, in consequence of vvhich habitual congestion of the portal vessels is established. Be this as it may, it appears very evident that persons of a sanguino- bilious, or as it has also been termed, sanguino-melancholic habit of body, are most prone to haemorrhoidal affections. Of the very great influence of age in favouring the occurrence of this disease there can be no doubt. Haemorrhoids before the age of twenty-one years is far from being common, and when the disease does occur at or before this period of life, it is al- most always the consequence of local causes, or of other dis- eases giving rise to congestion in the portal vessels. From thirty to fifty years of age is the period to which the appear- ance of these tumours is in a great measure confined. Those who remain free from the disease until they attain the age of fifty, seldom afterwards become more than very temporarily affected by it. Although pregnancy, and the final cessation of the menses, are well calculated the favour the occurrence of sanguineous congestion in the vessels of the abdominal viscera, and particularly of the rectum; yet, with the exception of the periods when these conditions are present, haemorrhoidal affec- tions appear to be much more common in males than in females.* The influence of age in favouring the occurrence of this ma- lady, may be accounted for from the natural tendency of the ve- nous to predominate over the arterial system, as individuals advance in age—and especially, from the equally manifest tenden- cy in middle and advanced age to a sluggish state of the circula- tion in, or perhaps an increased sanguineous determination * Jahn. Klink. der Chron. Krank. Bd. iii. p. 453. HEMORRHOIDS. 361 to the abdominal viscera, in consequence, probably, of a natural disposition, aided by the many causes which, as life advances, intervene, and tend to the same effect—such as the depressing passions, a more inactive course of life, debility of the diges- tive organs, and consequent torpor of the liver and bowels. I have stated that the predisposition to haemorrhoids appears sometimes to he hereditary; but it is probably also, in many instances, acquired during infancy from improper dietetic ma- nagement, and the habitual use of purgative medicines, so common, and in its ultimate tendency, so injurious a practice with nurses and mothers. Habits of life tending to determine the blood to the abdominal viscera, or to cause congestion in the portal vessels, are by far the most common source of haemorrhoidal affections. A studious and sedentary habit; a superabundance of high seasoned and stimulating food ; the depressing passions; the intemperate use of spirituous drinks ; and the very free use of strong coffee,* are among the most active general causes of this affection. It is probable that these causes operate towards the production of haemorrhoids chiefly by producing weakness of the digestive organs, as well as torpor of the liver and intestinal canal— giving rise to habitual costiveness, and consequently to a slug- gish and congested state of the portal circulation. When to these conditions is added the local irritation of the rectum and anus by the remora and passage of hardened faeces, which ne- cessarily takes place under these circumstances, the superven- tion of haemorrhoidal tumours must be especially apt to occur. Among the local causes of haemorrhoids, besides constipation, may be mentioned the abuse of active purgatives—particular- ly aloetic preparations; stimulating enemata; the frequent ex- citation of the venereal organs ; pregnancy; parturition ; sup- positories ; clothes worn so tight as to compress the abdomen; ascarides; irritating applications to the anus after going to stool; indurations of the liver or spleen ; riding on a hard trotting horse; dysentery; the irritation of calculus in the bladder; enlargement of the prostate gland; lifting and car- rying heavy burdens. Haemorrhoids have been divided into a great number of spe- cies; but although these classifications may be convenient for imparting a full view of the subject to learners, they do not appear to possess any particular practical value. It is sufficient to bear in mind that there are two kinds of haemorrhoidal tu- mours—one consisting in a dilated or varicose state of the veins, which may inflame, burst, and give exit to copious dis- charges of blood; and another kind, more common—consisting * Richter. Jahn. loc. cit, vol. ii.—46 362 HEMORRHOIDS. in firmer, fleshy, somewhat spongy elongated tumours or ex- crescences ; which may inflame, open iinto fissures, ulcerate or remain entire, and give rise to the various painful and distress- ing affections already described. When the former tumours burst and bleed, they are called haemorrhoides fluentes, or bleeding piles: when the tumours do not bleed, they are termed H. ceecae, or blind piles. Treatment.—May we, with safety, attempt to remove or suppress these tumours; and more especially, is it prudent speedily to suppress the sanguineous discharges to which they give rise ? Upon this subject very discrepant opinions have been expressed. Cullen was of opinion that the disease is but very rarely of a constitutional character; and consequently that it ought, in all cases, to be removed as speedily as possible ; as no danger, he presumed, need be apprehended from the imme- diate suppression of the haemorrhoidal discharge. Dr. Gregory appears to be of the same opinion. This view of the subject, however, would inevitably lead to very disastrous consequen- ces, were it generally adopted in practice; for, although hae- morrhoids are, in many cases, of a purely local character, and in such instances may be removed as soon as convenient, with- out any detriment to the system ; yet both experience and ana- logy present us with abundant testimony of the dangerous con- sequences which are liable to result from a hasty interference with the haemorrhoidal discharge, where the disease is founded, as it very often is, on a constitutional predisposition. In cases that depend on a constitutional haemorrhoidal tendency, and that have become habitual from long continuance or frequent recur- rence ; or where the general health or some chronic affection has been improved by the supervention of haemorrhoidal discharge ; and especially where the disease is preceded and accompanied in its progress by distinct manifestations of an haemorrhoidal effort in the system, very particular caution should be exercis- ed in the application of remedies calculated to suppress the disease. Nevertheless, where the discharge is excessive, and endangers the life of the patient by the great depletion it causes, we need not hesitate to interfere with the progress of the disease so far, at least, as to moderate the haemorrhage, and obviate the im- mediate and remote dangerous consequences from this source. The general indications to be kept in view in the remedial ma- nagement of this affection are—to remove and counteract the tendency to plethora in the portal circulation; to obviate the predisposing and occasional causes; to moderate the haemorr- hage when excessive; and to prevent and remove local inflam- mation and its consequences. During what may he called the latent stage of the disease, when the various premonitory symptoms enumerated above HEMORRHOIDS. 363 ■exist, the molimina haemorrhoidalia, a general treatment cal- culated to remove the plethora of the portal vessels, as well as all irritation and preternatural determination to the vessels of the rectum, should be pursued with the view of obviating or moderating the approaching haemorrhoidal attack. For this purpose, the patient should be put on a light vegetable diet; and if the pulse be full and active, blood should be freely drawn. Particular attention too must be paid to the state of the bow- els. If they cannot be kept in a soluble state by vegetable diet, some of the milder laxatives, particularly the flowers of sulphur and cream of tartar,* with an occasional dose of blue mass in the evening, should be given once or twice every day, in doses sufficient to keep the bowels loose, without producing actual purging. The patient must lie on a mattress, rise early, take gentle exercise by walking, avoid severe mental or very active corporeal exertions, abstain from stimulating drinks, as well as from condiments, and according to the ob- servations of Jahn and Richter, from the use of strong coffee. Treatment of hemorrhoidal discharge.—When the tumours burst and pour out blood, the patient almost always soon feels considerably relieved. The confusion and uneasiness in the head, the irritability and depression of the mind, as well] as the general lassitude, tension, and aching in the loins, pressure and weight in the perineum, and in general all those symptoms which have been mentioned as indicative of the haemorrhoidal effort, abate very materially, and in many instances almost entirely disappear. So long as the haemorrhage remains mo- derate, it may with propriety be regarded as a salutary dis- charge, in reference to the radical affection, or state of the cir- culation in the portal vessels. It should always be recollect- ed that the discharge of blood is only one of the ultimate con- sequences of haemorrhoids; and that as its direct tendency is to lessen the engorgement of the vessels of the rectum, and con- sequently to reduce the vascular haemorrhoidal tumours, it is * R. Flor. sulph. crem. tart, aa ^ss. M. Take a tea-spoonful twice or thrice daily. When the intestinal canal is in a debilitated and very torpid condition, Richter recommends the following composition: R. Tartar, depurat. Magnes. carbon. Flor. sulph. aa 3Ii. P. camphora? gr. viii. -, Pulv. sem. fcenicul. 3iii- M. ; ^Divide into 14 equal parts. Take one every three hours. Hildebrandt speaks very highly of a mixture of sulph. sodas and tincture of rhubarb, as a laxa- tive in such cases. Two drachms of the salt dissolved in two drachms of water, to which the same quantity of the aqueous tincture of rhu- barb is to be added. One half to be taken in the morning, and the other in the evening. 364 HAEMORRHOIDS. obviously most proper to leave the haemorrhage to itself, unless it becomes very profuse, or inordinately protracted. We can- not, however, decide from the mere copiousness of the discharge, whether it should be regarded and treated as a morbid excess or otherwise, for some individuals will bear very large evacu- ations in this way, whilst others will be much debilitated and exhausted by a smaller loss of blood. Whenever the pulse he- comes weak, the countenance pale, and the prolabia exangui- ous, with much debility, general relaxation, and spasmodic symptoms, means should be adopted to restrain or arrest the evacuation. Here it must be recollected that this, as well as other varieties of haemorrhage, may be connected with a mani- fest phlogistic diathesis of the general system on the one hand, or a relaxed, prostrated, and sluggish state of the general and abdominal circulation; in other words, that there is an active and a passive state of the haemorrhoidal discharge. In the phlogistic or active form, the patient must be kept cool and quiet, in the horizontal position ; his drink must be bland, cool, and acidulated; and nitre, dissolved in a mucilaginous fluid, should be exhibited internally.* If these measures do not ade- quately moderate the discharge, recourse may be had to dry cupping over the loins or hypochondriac region; or to sina- pisms and blisters to the inner part of the thighs, or over the hypochondriac regions; and in very obstinate cases we must have recourse to injections of cold water, or water in which a small portion of the acetate of lead or alum is dissolved ; and occasionally it may become necessary to introduce a tampon into the rectum. Considerable benefit may sometimes be de- rived from the internal administration of one or two grains of the acetate of lead in such cases. It very rarely occurs, how- ever, that any particular difficulty is experienced in arresting the discharge where the general habit is not particularly relax- ed. The most obstinate and protracted cases of haemorrhoidal discharge are those which are termed passive, in which the ge- neral system is sluggish, the countenance pale, and usually somewhat bloated ; the pulse small, feeble, and languid ; and the muscular powers debilitated. In such cases, the haemorr- hage will sometimes continue with but short intermissions un- til the system becomes almost entirely exhausted, and anasar- cous effusions take place in the extremities and face, with occa- sional paroxysms of violent palpitation of the heart, and a pe- culiarly pallid, and bloodless appearance of the surface. In instances of this kind, the sulphuric acid with cinchona, cha- lybeate preparations, and particularly the acetate of lead with * R. Pulv. nitrat. potassee Aq. fontan* P. g. arab. ful every two hours. 3iss. gvi. 3ii». M. S. Take a table-spoon- HAEMORRHOIDS. 365 small portions of opium, will, in general, afford considerable advantage. In such cases, the tincture of cinnamon, so gene- rally recommended by the German writers in passive haemorr- hages, will often produce very excellent effects. From thirty to fifty drops of it may be given every three or four hours in conjunction with from eight to ten grains of the prussiate of iron. I have witnessed the good effects of these two articles in a case of remarkable obstinacy. There is no remedy, how- ever, which, in general, produces such speedy salutary effects in chronic cases connected with great languor and relaxation, as aloes in small doses. This article is highly recommended by Jahn in cases of this kind ;* for although one of the most im- proper medicines in the active or ordinary forms of the com- plaint, experience has shown that where the haemorrhage de- pends on debility or relaxation of the vessels, both in menorr- hagia and in haemorrhoids, it is calculated to produce much good by its tendency to excite the action of these vessels. Un- der the head of menorrhagia, I have already spoken of my ex- perience with small doses of aloes in the passive form of the disease, and in relation to the present affection, I can affirm that its effects in two instances were very prompt and most be- neficial. Jahn prefers the watery extract of this article, but I have given it as we find it in the shops, in conjunction with small doses of ipecacuanha.f The diet in such cases should be nourishing, hut not stimulating, such as animal broths, jellies, soft-boiled eggs, &c. Benefit will also result from astringent injections, particularly solutions of alum, sage tea, infusions of the root of geranium maculatum, of the blackberry root, &c. Treatment of haemorrhoidal tumours or blind piles.—When these tumours are situated on the margin of the anus, they may in general be kept from causing any particular inconvenience, by always washing them with cold water after going to stool, and applying moderate pressure by means of a soft linen com- press laid on them and secured by a T bandage. When they become irritated and painful, without much inflammation, washing them with cold water, and the use of mildly astringent and anodyne applications^: will usually afford considerable relief; but the ordinary astringent ointments, particularly those made of powered nut galls, are often decidedly injurious; and where the inflammation is violent, they are almost always * Klinic der Chron. Krankh. Bd. iii. p. 557. X R. G. aloes, socc. gr. xx. Pulv. ipecac. gr. xxx. M. Divide into 40 pills. Take one every morning, noon, and evening. X R.—Axungiae 5'- Cerussae 3^ Pulv. opii 9ii. M. ft. ungt. 366 HEMORRHOIDS. highly pernicious. The most soothing application I have ever used in cases of irritated and painful piles, is the following ointment.* To keep the bowels in a soluble state where there is much irritation, the lenitive electuary, in union with pow- dered nitre, is an excellent medicine.f It is necessary, however, to guard particularly against purging; and where there is much inflammation present, this observance is especially im- portant. The faeces should be kept soft, but not liquid; and one such evacuation daily will be sufficient. When thepiles are inflamed, all astringent applications, with the exception of poultices made with lead water, should be avoided. The patient must remain in a recumbent posture; and as the inflammation is almost always the consequence of some degree of strangulation of the tumour by the contraction of the sphincter ani, an attempt should be made to press them within the sphincter. In many cases, however, the pain caused by even the slightest pressure is so intense, and the tumours are bo much swollen, that all attempts to return them are abortive. In this case we must previously endeavour to reduce the in- flammation ; and for this purpose emollient fomentations and cataplasms—or cold lead-water must he applied, and where the pulse is active, an efficient blood-letting from the arm should be practised. I have also known much good derived from the above named mixture of nitre and lenitive electuary given in small doses, so as not to procure an evacuation for the first twenty-four hours. The patient should take nothing but toast water and very thin farinaceous preparations for his food. Some writers have recommended the application of leeches to inflamed haemorrhoids, but the advantage to be derived from this practice is seldom considerable. Montegre is decidedly opposed to local depletion in this way, and thinks that leeches applied to the inflamed haemorrhoids tend often to aggravate the symptoms by irritating and determining the blood to the parts. Scarifying the tumours, or making free incisions into them, will in general do more towards the reduction of the in- flammation than any other applications. Dr. Hartshorn tells mo, that he always pursues this practice in cases of inflamed piles ; and he has never known any dangerous consequences to follow the operation, but almost invariably unequivocal bene- fit. As soon as the inflammation is sufficiently reduced to enable us to press up the tumours within the sphincters, it • Take two ounces of lard and a drachm of flowers of sulphate ; mix and rub them together between two plates of lead until they acquire a black colour. X R.—Elect, lenitivi. 5i. Pul. nitrat. potass- Zi. Misce.—Take a tea-spoonful once or twice a day. HEMORRHOIDS. 367 should be done; and cold water, with a small portion of the acetate of lead dissolved in it, cautiously injected into the rec- tum. Nothing produces a more soothing effect than cold in- jections in moderately inflamed piles ; more especially, when they are situated within the sphincter. Montegre places great reliance on the use of such injections where the inflam- mation is not very intense, and where, moreover, the piles do not bleed. To relieve the pain and irritation which arise from fissures and ulcers of the lower part of the rectum, some surgeons re- commend the removal of the tumours by which the pain is usually kept up; and there can be no doubt of the propriety of this practice where other means fail to procure relief. The application of caustic and gently escarotic ointments or lotions will in general be necessary, where the ulcers assume a chronic character, with elevated and indurated edges; but undoubtedly the most effectual measure is excision of the tumours, or of the ulcerated part, when they are accessible to the knife. The cxcrutiating intermitting pains which occur after each alvine evacuation, and in many cases without either fissure or much inflammation, apparently from an extreme sensitiveness of the nervous extremities of the affected parts; and which Mon- tegre calls nervous haemorrhoidal pains, are more effectually re- lieved by cold ablutions and injections, than by any other appli- cations that have as yet been recommended. M. Montegre, who dwells particularly on this remedy, states, that he was led to resort to it from having observed, that "when patients af- fected with the complaint, happened to discharge their faeces while bathing in a river or the sea, they sometimes escaped the torment which ensued when they used a common commode." I have known much relief obtained from the application of the following liniment to the protruded piles, after having washed them with cold water.* Having applied the liniment, the tu- mours must be pushed up within the sphincter. It is in cases of this kind, that Ward's paste will occasion- ally procure very considerable relief, f I have used this elec- tuary in a number of instances, and sometimes with great ad- * R. 01. amydalor. 5i. Extract, stramonii. ji. Sulp. morphias. gr. vi. M. ft. linimentum. X R. Pulv. rad. enul. campan. Pulv. peper. nig. aa %v^11- Pulv. sem. faenicul. 3xii. Mel. despumat. Sacch. albi. aa 1XV1, The three first are to be intimately mixed; then melt the honey and sugar over a fire into a clear jyrup; add the other ingredients, and form an electuary. 368 HEMORRHOIDS. vantage. Dr. Gregery very justly observes, that although it may be very difficult to explain on what principles this stimula- ting mixture proves useful, experience has fully demonstrated its powers. When from a state of chronic irritation or inflammation of the mucous membrane of the rectrum, there is a profuse or troublesome leucorrhoeal discharge from the anus, recourse may he had to the internal use of balsam copaiva, oil of tur- pentine, or of cubebs, and slightly astringent injections should be thrown into the rectum three or four times daily. For this purpose, a weak solution of sulphate of copper, (one grain to an ounce of water,) will in general answer xery well. Where, however, the pain arises from haemorrhoidal tumours of a permanent character, located either on the margin of the anus or high up, and brought to view only by pressing down as in going to stool, the removal of them by ligature or the knife, may be considered as the only means for effecting a radi- cal or effectual cure ; and this may always be safely done where the local inflammation and general irritability of the system are not very great, or when no habitual haemorrhagic discharge has been established. Where alarming consequences, or symptoms of general ill health follow the suppression of haemorrhoids, we should endea- vour to re-establish the complaint. This may usually be done without much difficulty by aloetic purgatives, small doses of the extract of savin, stimulating enemata, particularly terebin- thinate, or aloetic injections, leeching about the anus, semicu- pia, and cupping in the neighbourhood. Richter strongly recommends the following combination for this purpose.* CHAPTER XXVIII. DIABETES MELLITUS. Diabetes was known to the ancient Roman physicians, but it does not appear that they had any know ledge of the most essential characteristic of the disease—namely, the saccharine character of the urine. They seem to have considered the • R. G. aloes. G. assafoetid. Extract, hellabor. neg. Ferri sulphur. Crocci orient. 3i. Mucilage, g. arab. q s.----Divide into two grain pills. Take from five to eight every evening. DIABETES MELLITUS. 369 disease only as a rapid discharge by the kidneys of whatever drinks were taken into the stomach, without having undergone any changes by the digestive or assimilative functiohs. " Di- abetes," says.^gineta, "est subitus potulentorum exitus, tali- bus per urinam redditis qualia pota fuerant"—"a sudden dis- charge of liquids drank which are voided by the urine such as they w.tc taken in by the mouth." Celsus too, says diabetes consists in a greater discharge of urine than there are fluids taken in by the mouth ; and Aretaeus, who has given an ex- tremely accurate description of the course and phenomena of this disease, defines it in the same way. The saccharine cha- racter of the urine in diabetes, was not indeed known or pointed out, until Willis directed the attention of the profession to it; and although this morbid condition of the urine is unquestion- ably the es,sential characteristic of diabetes, it has frequently been wholly left out of view in the definitions which have been given of this disease. Cullen himself has fallen into this error in his definition of this malady. "It consists," he says, "in the voiding of a preternatural quantity of urine ;"—and in thus neglecting to notice the characteristic quality of the urine, he confounds it with diseases which are radically distinct from it, and which reremble it only in the accidental circumstance of being attended with an unusually large flow of urine. There are at least three varieties of urinary disease which arc accom- panied with a preternatural flowr of urine, but which are never- theless essentially distinct, as well from each other, as from the disease now under consideration. By diabetes, then, is meant that form of urinary disease, in which the urine is sensibly impregnated with saccharine matter, and voided in an unusually large quantity, being attended with great thirst, voracious appetite, and an obstinately dry and harsh skin. Diabetes usually makes its appearance in a very gradual manner, although in some instances it comes on suddenly, with slight chills and febrile commotions. When its invasion is gradual, it is generally attended from the first with various indications of a disordered state of the digestive organs—such as variable appetite, acid eructations, occasional nausea, and vomiting. The quantity of urine discharged in this affection, is almost always extremely great; and in some instances truly enormous. I have seen two cases in which from twelve to fifteen pints of urine were discharged in the course of twenty-four hours, for several weeks. That such a drain from the system must cause great and rapid exhaustion and wasting of the body, may be readily conceived : and, indeed, the utmost degree of prostration and emaciation never fail to ensue as the disease advances in its course. vol. n.—47 370 DIABETES MELLITtS. The urine in this disease is generally of a pale strnw-cfr- lour, approaching sometimes to a shade of green.* Its smell i» usually faint, resemhling that of milk, or according to some, that of fresh animal broths; and its taste is more or les* sweet, from the sugar which it contains. Diabetic urine al- ways contains very little or no urea, and in most instances it is entirely destitute of lithrc acid. It enters very slowly into putrefactive decomposition, but passes readily into the acetous or vinous fermentation. In these circumstances it differs very essentially from the urine of other varieties of disease resem- bling diabetes—in which latter it always putrefies with great rapidity, and becomes exceedingly fetid. Symptoms.—The constitutional symptoms which attend this disease, are—very urgent thirst; craving appetite; dry skrn ; a distressing sense of weight and uneasiness in the sto- mach after taking food ; dry and parched month ; white, foul, sometimes clean ami red tongue; wasting of the flesh ; a feel- ing of languor and aversion to exercise; debility ; pain and weakness in the loins; irregular action of the bowels, being most commonly eostive ; some degree of inflammation and pain* about the prepuce and glans penis, and especially about the ex- ternal orifice of the urethra; loss of virility; cold feet, with a tendency to eedema in the latter period of the disease; dull and aching eyes; indistinct vision with vertigo; headach 7 and difficulty of breathing. As the disease gains violence and draws towards the fatal termination, the gums become spongy and the breath fetid or disagreeable, and the voice rough, or extremely weak and whispering. The emaciation and exhaus- tion proceed with great rapidity towards the conclusion, and the patient finally sinks into a state of somnolency or drowsi- ness, from which it is often extremely difficult to keep him> roused even for a moment. In general, the pulse is but little or not at all accelerated in the early periods of the complaint "y and in many instances it is even less frequent than in health* In the advanced stage of the disease, however, when the ema- ciation and exhaustion are very great, it is not uncommon to find the pulse very frequent and quick. In some instances the- blood has been found sizy, or covered with a thick inflamma- tory crust. Home states, that the blood of one of his diabetic patients manifested a highly inflammatory character, although the pulse was rather below the regular standard in frequency and strength. It is by no means unusual for this disease to terminate in apoplexy—a circumstance somewhat remarkable, * Cases have been frequently observed, in which the inordinate se- cretion of urine has suddenly ceased without any assignable cause. A distressing strangury has been known to supervene on the occurrence* of such sudden cessations of the diabetic symptoms. (3)x* Carter,. Me saepe emanarint idque dies aliquot.—Sennerti. Opera. Lib. iii. p. viii. s. ii. cap. ix.— Hastings. 400 ISCHURIA RENALIS. a fluid resembling urine was copiously discharged by vomiting* and by stool. Valisneri has given an account of n case of ischuria, in which copious discharges of a urinous fluid oc- curred from the stomach. Water is always found more or less abundantly effused into the cavities of the brain, and has, in general, a very perceptible urinous smell. Causes.—The immediate cause of the suppression of urine may be either inflammation, or paralysis of the kidneys, or mechanical obstruction. Nephritis is always attended with a more or less perfect suppression of the secretion of urine, but as both kidneys are very rarely inflamed at the same time, there is, in general, a sufficient quantity of this excrementitious fluid separated from the blood, by the sound kidney, to obviate any particular danger from this source. Of course, whatever is capable of causing much irritation, or inflammation of the renal organs, may become the remote cause of this affection. Schenk relates a fatal case, which was caused by a blow on the loins, and on post mortem examination, a considerable abscess was discovered between the muscles contiguous to the kidneys. Lcelius a Fonte has recorded a case, in which the left kidney was gangrenous ; and in several cases related by Hildanus and Bonetus, the kidneys and ncigbouring parts were extensively inflamed.* The suppression of haemorrhoids and of the menses has been known to give rise to this affection ; and its occur- rence from gouty irritation has been frequently noticed. Dr. Prout observes, that when there are no signs of renal inflam- mation present, " and the patient has been subject to gout, or if a female, to hysteria, the ischuria may be supposed to depend, in part at least, on spasm." The healing up of old ulcers, has also given rise to total suppression of the urine. A very re- markable case of this kind is related by M. Dupont, physician to the Hospice de Gournay, in which a lady, who had an ulcer on one of her legs of twenty-five years continuance, which was quickly healed by an ointment. Soon after the ulcer was cica- trized she was seized with pains in the abdomen, attended with nausea, some fever, red and dry tongue, and abdominal distention. An almost total suppression of urine speedily en- sued. After a few days continuance and ineffectual treatment, a blister was applied over the cicatrix of the ulcer, and the patient was speedily freed of her disease. The sudden appli- cation of cold to the body, particularly during the flow of the menses, has occasionally given rise to fatal ischuria. The case related by Hastings, mentioned above, was produced in this way ; and one of the cases of suppression from renal para- lysis, mentioned by Sir H. Halford, was excited by the influ- ence of cold while the patient was under the influence of mer- * See Dr. Abercrombie's Memoir, already referred to. ISCHURIA RENALTS. 401 cury. Tt would seem, moreover, that ischuria from paralysis of the kidneys, is, in some instances, a nervous affection, de- pending on a disordered state of the brain or of the nerves. *'Thc presence of a mechanical cause may be suspected," says Dr. Prout, " when the person has been previously subject to calculous affections. Generally, however, in this latter case, the effects cannot he ascribed altogether to the simple opera- tion of the mechanical cause, but in part also to the inflam- mation or spasm, or both, which it is liable to produce, and the affection thus assumes a mixed character." A fatal case of this disease is related by Dr. Tceling, which occurred in a xevy gouty individual. On post-mortem examination, the right kidney was found ('iminished in size, and the cavity of its pel- vis filled with gray-coloured, rough calculi, about the size of small peas, and the whole internal surface of the kidney was " firmly coated over with a fine gravel, resembling pulverized free-stone." In the upper part of the ureter, bcloi-ging to this kidney, a calculus was found as large as acmall almond, vvhich blocked up its cavity." Some calculi were also found in the pelvis of tile left kidney. Prognosis.—The prognosis in ischuria, is always extremely unfavourable. So long as the suppression is not complete, a reasonable hope may lie entertained of an eventual recovery ; for even a small secretion of urine by the kidneys, will in gene- ral keep off the more alarming symptoms of cerebral oppres- sion for a considerable ti::ie, and give greater opportunities for subduing the renal affection. When the suppression is complete, however, the disease almost always terminates fatally in the course of four or five days, and often as early as the third day. Sir Henry Hal ford, in the paper already quoted, states, as the result of his observations, that a complete sup- pression of the secretion of urine cannot continue beyond three days without terminating fatally. This, however, is incorrect. Dr. Laing has related an instance where the secretion of urine was suspended for nine days, and nevertheless terminated fa- vourably ;* and Dr. Brown mentions one case in which the se- cretion was suspended for six days and six hours, and in another, the suppression continued eleven days, yet both patieits recover- ed.f A very extraordinary instance of this complaint is descri- bed in Hufeland's Journal Cor August, 1827, in vvhich the action of he kidneys was wholly suspended for seven weeks, without any particular inconvenience, although no urinous fluid was secreted vicariously. Treat men f.—The treatment in this affection must be modi- fied, according to the particular morbid condition of the kid- * Edinb. Med. and Fmz- Jour. vol. x. t Essays, &c. on Medical Subjects. See Med. Chir. Rev, Dec. 1828. VOL. II.—51 402 ISCHURIA RENALIS. neys, as well as according to the nature of the remote cause. When symptoms of renal inflammation arc present, the treat- ment already pointed out for the cure of nephritis is to be energetically pursued. Venesection, cupping, leeching, the warm bath, purgatives, emollient enemata, sinapisms, and even blistering over the region of the kidneys, constitute the princi- pal remediate measures. In cases attended with no decided ma- nifestations of an inflammatory action in the kidneys, diuretics are the medicines upon which our chief reliance must be placed. In general, the stimulating articles of this kind have been found most beneficial—more especially where the disease appears to depend wholly on a torpor or paralysis of the kidneys. Spirits of turpentine, both in the form of injections, and internally in doses of from twenty to thirty drops every two hours, has been employed with a very good effect. When the bowels are con- stipated or inactive, the turpertine should be given in union with castor oil, in doses sufficient to procure pretty free purg- ing. The remarkable case mentioned above from Hufeland's Journal, was cured by a mixture of oil of amber, Venice tur- pentine, and balsam copaivc, after a great variety of other medicines had been ineffectually applied. I have seen two cases of incomplete suppression attended with a somnolent ten- dency, in nervous females, which were removed by a mixture of juniper oil, sweet spirits of nitre, and laudanum.* Mercury has been recommended for the use of this affection, and some interesting cases have been reported, illustrative of its benefi- cial influence. In the case already referred to, related by Dr. Brown, mercury was freely given, and he states, that very soon after the mercurial fetor of the breath was noticed, a pretty copious discharge of urine ensued, and the patient reco- vered. Valisneri also gives an account of a case which was cured by mercury. In Dr. Laing's case, which, however, was manifestly attended with both local and general inflammatory action, the remedies employed were blood-letting, repeated three times daily, saline diuretics, and the warm hath. Mr. Ray- mond strongly recommends the application of a large blister •across the region of the kidneys. He has related several cases in which the flow of urine soon followed vesication over the loins, after a variety of remedies had been ineffectually employ- «d.f Lieutand recommends emetics for the cure of ischuria renalis.^: * R. 01. juniper 5ss. Spir. nit. dulc. -ri. Tinct. opii 3i.—M. Take a tea-spoonful every 2 hours. t Med. Obs. and Inquir. vol. v. Appendix. X Nonullos enim decumbentes et cum morte colluctantes hocce praesidiis tempestive adhibito ex orci fancibus ereptos vidi.—$ynoj>. Prox. Med. 'lorn. i. p. 269. ( 403 ) RETENTION OF URINE. Retention of urine is by no means an uncommon affection % and though not in general so dangerous and difficult of being, cured as ischuria, yet it is often met with under circumstances- which render it a most alarming malady. The immediate cause of retentionof urine, consists either : T, in a loss of the expulsive power of the bladder and of its detru- sor muscles ; or 2, in mechanical obstruction of the urethra, or neck of the bladder. 1. Paralysis or loss of the expulsive power of the bladder, very generally arises from over-distention of this viscus. After the middle period of life, the sensibility of the bladder, in some in- dividuals, gradually diminishes as age advances ; and this insensibility occasionally becomes so considerable, that the Hrine fails more and more to impart the due degree of stimulus to the bladder; in consequence of which it is often suffered to accumulate inordinately, before the desire to evacuate it is ex- perienced. The bladder then, from its torpid and relaxed condition, is incapable of completely expelling its contents, and the action of the abdominal muscles is called into aid to effect this purpose. From this deficiency of the expulsive powers, the bladder is not entirely emptied ; and more urine is daily left in the bladder, until at last, only a small portion of its contents is evacuated at each attempt to urinate. Finally, either from the supervention of some slight general indispo- sition from cold, or some adventitious local affection, as diarr- hoea, suppressed hemorrhoids, riding on horseback, fatigue from exercise, &c. a total inability in the bladder, even with the aid of the abdominal muscles, to overcome the ordinary power of the sphincter ensues, and complete retention of the urine is the consequence. Retention from paralysis is not,however, entirely confined toi old people, and may arise from blows or falls on the back; injury of the spine ; excessive onanism ; and it occurs sometimes in paraplegia, and in the latter stage of typhus, and other forma of low fever. This variety of the disease is readily distinguished by the fa- cility with which.the catheter may be introduced, as well as the general course and progress of the complaint. No symptoms indicative of a mechanical obstruction of the urethra, or of in- flammation, precede or accompany the disease. The approach or tendency to the complaint is indicated by the stream of urine, though sufficiently large, becoming weaker and weaker. The patient is obliged to stand a long time, and to make con- siderable effort with the abdominal muscles, before the urine 404 RETENTION OF URINE. begins to flow; and the quantity discharged gradually becomes smaller and smaller, whilst the desire to urinate becomes more frequent and urgent. Retention from paralysis of the bladder, is much less alarm- ing and dangerous in its consequences, than when the retention occurs from inflammation or obstruction ; but it often continues for many months. I have known several instances, apparently of spontaneous occurrence, in which the daily use of the ca- theter was necessary for three months before the bladder re- gained sufficient expulsive power to discharge its contents. This form of the disease is not in general attended with much suffering, unless the urine be suffered to accumulate until the bladder becomes very greatly distended. Indeed, Cases some- times occur in vvhich the patient is not even aware that a re- tention of the urine exists ; since the bladder may gradually become enormously distended, and give rise to more or less un- easiness, although more or less urine is regularly discharged at each attempt to urinate. Instances of tiiis kind, have even been mistaken for abdominal dropsy : for when the discharge of urine, though in diminished quantities continues, the abdominal distention and uneasiness may, on a superficial examination, he readily a. crihed to dropsical effusion. A case is mentioned as having occurred in St. George's Hos- pital, where the patient was thought to be labouring under as- cites. Paraccntisis abdominis was in contemplation, "when the house-surgeon happened to introduce a catheter, and drew off many quarts of water with immediate reduction of the ab- dominal swelling."* Similar instances are mentioned in the article on this affection in the Diet, des Sciences Medicates. A woman was supposed to be affected with ascites, and tapping was determined on, at the same time that diuretics were dili- gently e.oployed : finally, from a temporal \ complete retention of the urine, the catheter was introduced, and a large quantity of water drawn off. The abdominal swelling soon disappeared. Another case is related in which retention of the urine was mistaken for dropsy, which, after various ineffectual measures to remove, the supposed dropsical disease was speedily cured by the use of the catheter; and an instance is mentioned in the same work, where the patient died from rupture of the blad- der—the patient having been treated for ascites. Dr. Felici of Milan, has related the case of a woman who considered her- self pregnant. She laboured under oedema of the feet; enor- mous swelling of the abdomen; violent and painful efforts to void urine, which passed off in small quantities; pains in the thighs; dyspnoea; palpitations; a sense of suffocation from the slightest motion ; puflincss of the face ; frequent pulse ; and * Med. Chir. Rev. April, 1825—p 523. RETENTION OF URINE. 405 a dry cough. Under theso symptoms she had laboured a con- siderable time before Dr. F. saw her. He suspected retention of urine. The catheter was introduced, and nearly fourteen pints of water drawn off. 2. Retention of the urine from inflammation.—Inflamma- tion of the urethra and bladder is one of the most common causes of retention of the urin", and may be determined by a great variety of causes—such as irritaiion from calculus; irri- tating diuretics, particularly terebinthinate remedies and can- tharides; gonorrhoea; stimulating injections into the urethra; the incautious introduction of the catheter or bougie ; the spread of inflammation from neighbouring parts; an acrid or irritating state of the urine; the sudden suppression of perspi- ration from the action of cold ; cold and damp feet; the sup- pression of haemorrhoids and the catamenial discharge ; exces- sive veuery and onanism; mechanical injuries received on the pubic region or upon the perineum ; general fever and constitutional irritation; metastasis of gout and rheumatism, &c. When the neck of the bladder or urethra is inflamed, the penis is usually somewhat enlarged and tender to the touch, and when the exciting cause consists of culculous irritation, considerable pain is usually experienced in the glans penis. Cases depending on inflammation are attended with severe burning pain in the neck of the bladder, with tenderness to pressure of the perineum and the parts immediately above the pubis. The desire to evacuate urine is very frequent, and ex- tremely urgent and painful. Fever is an early attendant; and the patient is apt to experience nausea and occasional vo- miting. All attempts to introduce a catheter or bougie give rise to excruciating pain. It must, nevertheless, be observed that the inflammation upon which the suppression depends, is not always seated in the bladder or urethra, but sometimes in the parts contiguous to this viscus. Thus, retention of urine may arise from inflammation of the rectum, by causing high irritation and vascular engorgement of the mucous membrane of the bladder and urethra, or spasmodic constriction of the urinary passage ; or finally, the inflammation may spread to the detrusor muscles, and destroy their powers of regular action. Chronic inflammation of the mucous membrane of the bladder is very frequently attended with dysury, strangury, or retention of urine. Retention from this cause is most commonly met with in old people; and in such as have laboured under pro- tracted and badly managed gonorrhoea; or in individuals af- fected with vesical calculi. It may also arise from metastases of gout and rheumatism ; hemorrhoidal irritation ; and repelled chronic diseases of the skin. The diagnosis of retention from chronic inflammation and vascular engorgement or tumefaction of the mucous membrane 406 RETENTION OF URINE. of the bladder, is often attended with considerable difficulty.. In general, a sense of tickling and uneasiness is at first expe- rienced in the bladder, extending some distance into the ure- thra. After some time an almost constant gnawing pain is felt in these parts, with more or less difficulty of voiding the urine ; and in some instances a temporary incontinence of urine alternates with dysury. The urine discharged contains a large quantity of very viscid mucus, mixed sometimes with considera- ble portions of purulent matter. In this state the disease may continue for a long time, with an occasional attack of more or less obstinate and painful retention of the urine. In such in- stances the whole bladder, on dissection, is usually found con- tracted, so as not to contain more than half a pint of water, with its coats greatly thickened and indurated, and the inter- nal surface varicose, or covered in parts with concretions of the urinary phosphates. Sometimes ulcers of various sizes* warty excrescences, and a pustular eruption occurs on the mu- cous membrane. Retention of uriner from causes of this kind, may be distinguished from enlargement or disease of the pros- tate or stricture near this gland, by the very gradual progress and increase of the difficulty of passing the urine; and parti- cularly by the slight difficulty which is in general encountered in introducing the catheter ; and, finally, the occasional tempo- rary incontinence of urine, which in many instances occurs. Soemmering states, that chronic inflammation and the conse- quences just mentioned, are almost invariably attended with a very peculiar uneasiness and numbness of the thighs, amounting in some instances to a state of incomplete paralysis. The prognosis in such cases is always very unfavourable, more especially when there is reason to suspect structural lesion ef the bladder. S. Spasmodic retention of urine.—In cases of this kind, the retention occurs suddenly. The patient is seized with ex- tremely painful and urgent efforts to void urine : hut only a few drops pass off under great suffering. The pain in tlie bladder is cutting, and attended with a sense of constriction and pressing down, which by females is often compared to the pains of parturition. The urethra is sensible, sometimes painful throughout, and attended often with very distressing erections. The pain is not increased during the flow of the small quanti- ties of water that occasionally pass off; but immediately after the last drops are expelled, it becomes very severe, with a very sensible spasmodic contraction in the perineum. In this way it may continue for a longer or shorter time, until at last the pain and urgency to urinate, pass off by a considerable flow of urine. The pain in this variety is not constant, nor is it in- creased by pressure on the perineum, or pubic region.. There- RETENTION OF URINE. 407 is no fever, but the pulse is small and contracted. The cathe- ter is usually passed with great difficulty, and often it cannot he introduced into the bladder at all. Spasmodic retention does not, however, often occur as a purely spasmodic affection. In many instances, slight inflam- mation of the bladder, or in someneigbouring part, render the neck and upper portion of the urethra so extremely irritable, that the stimulus of the urine causes the sphincter to contract spasmodically. The spasm may also be excited by mechanical irritants. This variety of the disease is most apt to occur in irritable and nervous individuals, and such as are predisposed to colicky affections. In some instances it is suddenly excited by mental emotions, particularly terror and grief. Gouty and rheumatic irritation ; irritation in the rectum from ascarides, and other causes ; cold and humidity, particularly when applied to the feet; irritating diuretics; hsemorrhoidal irritation; gonorrhoea ; stimulating injections, by heightening the irrita- bility of the bladder and sphincter muscles, are often the remote causes of spasmodic retention of the urine. This variety of the disease is not in general attended with any particular danger or obstinacy. By frequent recurrence it is, however, liable to terminate in inflammation, and thus ultimately to give rise to very serious consequences.* 4. Retention from mechanical obstruction of the urethra or neck of the bladder.—Obstruction to the discharge of the urine may depend on a calculus lodged in the bladder, or impacted in the urethra ; stricture, more or less permanent, of the ure- thra ; enlargement and induration of the prostate gland ; thickening and induration of the mucous membrane of the ure- thra ; pressure from tumours in the neighbouring parts, or from the gravid uterus, retroverted, or prolapsed uterus; fo- reign bodies accidentally introduced into the bladder; polypi and fungoid tumours in the bladder; very viscid mucus and coagula of blood clogging up the urethra; hernia; and a va- ricose state of the vessels of the neck of the bladder. Of all these causes, however, stricture and calculi lodged in the ure- thra, are incomparably the most common causes of obstruction. Retention of the urine, from whatever cause it may arise, becomes highly alarming, if it continues beyond twenty-four hours without being in some degree relieved. In general, com- plete retention of urine proves fatal in four or five days ; and I have known an instance which terminated in gangrene and effusion of the urine as early as the end of the third day. It is generally supposed that when the bladder at last gives way and pours out its contents into the cavity of the abdomen, it is -ruptured or lacerated by the violent distention. This, how- * Richter, Spec. Therap. B. iv.p 392. 403 RETENTION OF URINE. ever, is rarely the case, for in nearly all instances that prove fatal, the urine finally gains exit by an opening formed by the ulcerative process in some portion of the vesical parietes, or by the occurrence of gangrene and softening through which the water bursts from the distended bladder. In some instances, the lower portion of the bladder forms adhesions with the sur- rounding parts, and ulcerates—the urine being infiltrated into the cellular structure about the rectum, scrotum, and perineum. In such cases, extensive mortification and sloughing usually take place in these parts before the disease terminates in death. Instances have occurred in which adhesion took p.ace between the bladder and rectum, and the urine was discharged by the anus, with an eventual recovery of the patient. (Richter.) Ul- ceration and effusion of the urine into the vagina sometimes occur in females. The anterior and superior part of the bladder has been known to ulcerate, and to give exit to the mine into the cellular tissue of the a'odom:!ial muscles, giving rise to extensive oedema of {.he anterior part of the body and thighs, with gangrene and fistulous ulcerations. Occasionally, the urine is evacuated by the umbilicus. (Richter.) Most commonly, however, the bladder ulcerates directly into the ca- vity of the abdomen, and occasions, rapid 1;. fatal peritonitis. "When the bladder gives way, the tumefaction of the abdomen suddenly, in a great degree, subsides, and the abdominal parie- tes become soft and relaxed, until peritonitis ensues, when the usual tenderness and tension of this affection occur. Reten- tion of urine does not, however, always terminate fatally by ulceration or rupture of the bladder, and consequent extravasa- tion. Occasionally, death ensues before the bladder gives way, under svmptoms resembling those which have been men- tioned as occurring in the last stage of fatal ischuria renalis. In such cases, the distention is not confined to the bladder, but occupies the whole course of the ureters, which have been found enormously enlarged : and the pelves of the kidneys, even, are sometimes manifestly dilated by accumulated urine. When these conditions occur, the secretion of urine in the kid- neys is ultimately arrested ; the patient becomes comatose, or is seized with convulsions or spasmodic respiration ; the per- spiration acquires a urinous smell ; and he finally dies in a state of apoplectic stupor. On dissection, water of a distinctly urinous smel! is generally found effused between t'ue meninges, and into the cavity of the brain. There is another variety of retention of urine—renal reten- tion—which arises from an obstruction of the ureters, either by inflammation and obliteration of its cavity, or by being plugged up with calculi, coagula of blood, or compressed by a tumour in some contiguous part. In such cases the ureter above the obstruction becomes more and more dilated, until it RETENTION OF URINE. 409 acquires, in some instances, a very great size, and ultimately the kidney itself becomes greatly distended. Callisen has seen the pelvis of the kidney so dilated as to contain nearly a quart of urine ; and the ureters have been found dilated to the size of the colon. (Desgranges.) Walter states, that he saw the kidneys so enlarged as to resemble the bladder, with its parietes attenuated almost into a membrane.* Such cases almost invariably terminate fatally under symptoms of cere- bral oppression. The diagnosis of renal retention is, however, so extremely difficult and uncertain, that its presence can never he inferred with sufficient probability of correctness, to found on it any practical indications; and it is here mentioned, rather as a pa- thological phenomenon, than as a subject for therapeutic obser- vations. Treatment.—From the foregoing observations, it is obvi- ously of the utmost importance, in the treatment of this affection, to be particularly acquainted with the various imme- diate causes of urinary retention ; and never to proceed to the employment of remedial measures until a strict inquiry has been made into the nature of the existing obstacle to the urinary eva- cuation. From ignorance or inattention to this important rule, diuretics are often given where the cause consists in permanent stricture; or persevering, rude, and ruinous attempts made to introduce the catheter, in the same condition of the urethra. There is another point whichshould be strongly impressed on the attention of the practitioner—namely, never to tamper too long with warm baths, tobacco injections, and various similar re- medies, where the obstructing cause resists proper measures for. perhaps forty-eight hours—more especially if it consists of stricture or impacted calculus. I have seen two instances which were thus tampered with for five days, and sacrificed to the timidity or want of decision of the practitioner ; although the lives of both could, in all probability, have been saved, if tapping had been seasonably performed. In one case, where the obstruction was manifestly of a character which precluded all reasonable hopes of being removed sufficiently early to save the life of the patient, tapping was proposed and urged by a surgeon, but postponed by the other two medical attendants until next morning. On the following morning the operation was again put off until the afternoon, to try the effects of a to- bacco enema. In the afternoon the bladder gave way and the patient died. In retention of urine from paralysis, the catheter is the only proper means for evacuating the contents of the bladder; and where the disease is unattended with enlargement of the prostate, its introduction may in general be effected with * Einige Krankh. der Nieren und Harnblase, &c. Berlin, 1802. S. fi- le, tab. ii. iii. and iv. VOL. II.—52 410 RETENTION OF URINE. the rreali \ ease. The object here, both in a palliative and "m-ativo point of view, is to obviate undue distention of tho ui„dd?r; and as the h>ss of its expulsive power is very rarely transient, and the urii:e re-accumulates with more or less ra- pidity, it becomes neressary, in such cases, to draw off the ■^rine every six or eight hours. I have known cases in which this operation was required four times daily for several months, Lcf:re the bladder recovered its powers. When the distention cf the bladder is ve;y great, the urine will often flow off but very slowly thrc^' the catheter, and unless pretty firm pres- sure is made with the- hands on the external vesical region, the greater portion of the urine will remain in the bladder. Some surgeons recommend the introduction of a flexible ca- theter, and leaving it in the bladder. The external orifice must be closed with a small plug, which the patient may from time to time remove, and give exit to the accumulat- ed water. In some cases, attended with an inirritable state of the urethra and neck of the bladder, this practice may answer very well—more especially when the patient is remote from his surgeon, and cannot be conveniently visited at regular hours. With many patients, however, it causes much irritation, and cannot he borne without great inconvenience. Whilst proper attention is paid to the regular discharge of the urine by means of the catheter, remedies should be em- ployed with the view of restoring the lost tone of the bladder. For this purpose, cantharides, used both internally and exter- nally, have been generally esteemed a very useful remedy. From twenty to thirty drops of the tincture may he taken two or three times daily, and continued until slight symptoms of strangury ensue. Richter speaks very favourably of a union of cantharides and camphor, in the proportion of a fourth of a grain of the former to one grain of the latter, given four times daily. Frictions with the tinctura lyttae, and terebinthinate embrocations over the hypogastric region, also may assist in restoring the contractile power of the bladder. I have known unequivocal benefit obtained from a blister applied over the public region ; and Richter recommends the application of a fresh onion, beat up into a pulp, to the perineum. The in- ternal use of the spirits of turpentine, of juniper oil, of the animal oil of Dippel, Peruvian balsam, and according to Jahn, the infusion of solidago virga aurea, may all be used with more or less advantage in cases of this kind. Cold water dashed upon the lower part of the abdomen and perineum, or injected into the rectum, also, has been found beneficial in this affection. * Richter states, that in some cases of retention from vesical paralysis, almost immediate and very considerable re- * Richter, Spec. Therap. Bd. iv. p. 377 RETENTION OF URINE. 411 Uef was obtained by pouring water from the spout of a pifecher in a stream descending several yards, upon the hypogastrium. Old people often find a great deal of difficulty in voiding the urine—they are obliged to stand a long time before the urine begins to flow, and at last it passes off in a very weak stream, though with little or no uneasiness in the bladder. Persons who are thus affected, may sometimes derive considerable ben- efit from the use of the phosphoric acid, as recommended by Dr. Valentin.* One drachm of this acid is to be dissolved in two drachms of distilled water, of which ten drops should betaken every two or three hours in a little water. Retention of urine from inflammation, requires of course the usual efficient local and general antiphlogistic measures. Unless the symptoms of vesical distention be very urgent, it will be most prudent to reduce the inflammatory condition of the parts, before an attempt is made to draw off the water with the catheter. A very efficient blood-letting—ad syncopen, in robust and full habits, together with the free application of leeches to the perineum, cupping on the iliac and public regions, emollient clysters, fomentations, mild purgatives, and the inter- nal use of antimony, constitute the means upon which our main reliance must be placed for removing the malady. Having used local and general depletion, and emptied the rectum by enemata, an anodyne clyster should be given an hour previous to the intro- duction of the catheter. The catheter will be much more easily introduced into the bladder, and with much less suffering to the patient, after these measures are promptly and efficiently employed. The warm bath—more especially the hip-bath, is a valuable auxiliary in such cases. It should be repeated every two or three hours, where conveniences are at hand for its proper employment. The patient should drink moderately of the blandest diluents; and emollient enemata ought to be frequently repeated during the day. After efficient general depletion, calomel and opium will usually procure more ad- vantage than any other internal remedy. Where the disease is the consequence of an ineffectual hsemorrhoidal effort, or of suppressed haemorrhoids, leeching around the anus is especially proper. Whatever other measures be employed, indeed, local depiction in this way, is one of the most important of our cura- tive means in every variety of inflammatory retention of the urine. For the treatment of spasmodic retention of urine, a great variety of remedies have been recommended. The warm bath often causes the urine to flow almost as soon as the patient is immersed ; but in some instances it fails entirely in procuring relief. Various local applications by frictions have been ad- * Arehiv. fur Pharmaice. Bd. i. st. iii. 332. 412 RETENTION OF URINE. vised, and may be employed with occasional benefit. A lini- ment composed of two drachms of spirits of turpentine, the yolk of an egg, with six ounces of peppermint water, is parti- cularly recommended by Kieser.* Richter applied bruised onions to the perineum and pubis, with evident good effects. The application of decoctions of stramonium, conium, and of poppy heads, may also be tried with some prospect of benefit in cases of this kind. Anodyne enemata are particularly indi- cated, and occasionally afford very prompt relief. I have known an instance which had resisted the warm bath, and various other remedies for five or six hours, speedily relieved by an in- jection of two drachms of laudanum in about a gill of warm milk, into the rectum. Bingham and others, strongly recom- mend tobacco injections. Internally, opium, in purely spas- modic cases of the disease, sometimes docs much good ; hut in order to obtain any.decided advantage from this narcotic, it should be given in large doses, so as to bring the system fully under its influence. Richter states, that he has known the fol- lowing pills to relax the urethral spasm, in a very short time.f Of late years, the muriated tincture of iron has been a good deal employed in spasmodic retention of the urine. From twenty to thirty drops should be given every ten minutes, until nausea is produced. The late Mr. Cline, of London, speaks in the highest terms of this article, as a remedy in this variety of the disease. I have known it to be successfully employed in several instances of this kind. It should be particularly ob- served, however, that it is only where the retention depends on spasm of the urethra or sphincter of the bladder, that any benefit can be obtained from this medicine. There is much reason for believing that it is often given in retention from stricture, and even from inflammation ; and that it has thus unjustly lost credit as a remedy in the spasmodic form of the disease. From the decided and speedy relief it procured in the few cases to which I have just alluded, I am well satisfied that it deserves particular attention as a means for removing spasmodic reten- tion. Most writers, in referring to Mr. Cline's experience with this remedy, state that he gave hut six or seven drops at a dose; but Dr. Johnson asserts, and no doubt correctly, that this is a mistake, and that Mr. Cline gave it in doses of from twenty to thirty drops every ten minutes, until nausea was produced. * Hufeland's Journal. An. 1820, st. iii. p. 92. X R. G. assafcetid. Jss. P.rad. ipecac. — opii aa gr. iv. 01 mentb. pip. gtt. iv. M. ft.—Divide into two grain pills. Take ten pills, three or four times daily. RETENTION OF URINE. 413 The attempt to introduce the catheter, so long as the spasm of the urethra continues, is almost invariably abortive ; and it is indeed highly improper to persist in the efforts to pass it into the bladder, where the spasmodic contractions are powerful, and resist the first few moderate attempts. It is surprising with what force the urethra sometimes contracts on the cathe- ter, after it has been introduced to a considerable distance during a temporary relaxation of the spasm. So firmly is the instrument grasped, at times, that it is with difficulty drawn out again. Even where the urethral spasm is so far allayed by the means just mentioned as to enable the patient to force out small and interrupted jets of urine, the catheter can sel- dom he introduced into the bladder without a great deal of dif- ficulty ; for the urethra, in such cases, is so extremely irrita- ble, that the irritation produced by the catheter generally excites immediate and insurmountable spasmodic contractions. If we succeed in introducing the instrument to near the blndder, its progress is almost invariably arrested by the contraction of the sphincter and upper portion of the urethra. By holding it awhile in one hand, and gently rubbing the perineum with the fingers of the other, we may often succeed in slipping it in, with little or no difficulty. Retention from stricture, and other mechanical obstructions, is by far the most alarming form of the disease. The means to be employed when the retention depends on stricture in the urethra are, local and general bleeding—particularly by leeches applied to the anus and perineum, and cupping on the lumbar regions. After the action of the pulse has been reduced by these depletory measures, the patient should be put into a warm bath, more especially the hip-bath, and large injections of warm water and oil thrown into the rectum. When the bowels have been thus evacuated, great relief will in general result from an opiate enema, composed of barley decoction and from fifty to eighty drops of laudanum ; and internally five or six grains of Dovers' powder every two or three hours, together with a repetition of the warm bath, and tepid diluent drinks, should be used until the skin becomes uniformly moist. Should all these means fail in procuring adequate relief, it will be proper to introduce with due caution a small bougie, "not to draw off the urine, but with the view of restoring the natural action of the muscles of the parts." Mr. Bell, from whose excellent work the foregoing mode of management is chiefly drawn, gives the following directions for introducing the bougie in such cases. " The patient should be standing or resting on his knees, if he is in bed. Take a wax bougie, oil it, soften it, give it the proper curve to pass the turn of the urethra, in- troduce it into the bladder; now make gentle pressure above the pubes; make the patient exert himself to discharge 414 RETENTION OF URINE. the urine; sprinkle cold water on his thighs ; withdraw the bougie while he continues the effort; and when he has the sen- sation as if he could pass the urine, withdraw the bougie alto- gether, and the urine will probably flow." Even where we fail to reach the bladder with the bougie, the patient may often he relieved by pressing a small bougie gently forward till the point of it has wedged itself into the stricture, when the hypo- gastrium is to be gently pressed, and the patient directed to exert himself to pass the urine ; and at the same time his hands should be put in cold water, or some of it sprinkled on his thighs, (Bell). If these efforts fail, an attempt may be made with a very small catheter; and where, after all, the stricture is insurmountable, recourse to the operation of puncturing the bladder is the only means left us for preserving the life of the patient. As to the employment of caustic, or of metallic bou- gies for breaking through the stricture, nothing useful can be expected from them, unless the stricture be very narrowr, and not situated too high up ; which, however, is but very rarely the case. When the symptoms become urgent, and the gene- ral and local means already indicated have been ineffectually employed, it would be unnecessarily placing the patient's life in great jeopardy, by relying on the slow, and after all, un- certain process of working through the stricture with caustic. With regard to the mode of operating either for puncturing the bladder or laying open the urethra in perineo, above the stricture, and introducing a flexible tube through the artificial opening into the bladder, the reader must consult the writings of surgeons—particularly the valuable treatise on the urethra, &c. by Charles Bell, edited by Mr. Shaw. It may be observ- ed, however, that in retention from urethral stricture, it is not often necessary to puncture the bladder; since an incision into the membraneous portion of the urethra above the obstruction, will in general answer every purpose that can be obtained from an operation of this kind. It would seem, that, at present, the majority of surgeons prefer the suprapubian operation, where puncture of the bladder is determined on. When re- tention from pregnancy cannot be relieved by pushing up the bladder, or change of position during the efforts to pass water— such as lying down on the hack with the hips raised, the ca- theter is the only proper means for relief. If the pressure of the uterus against the urethra, opposes the introduction of the catheter, the patient must be placed on her back, with the hips elevated, and the womb pushed up with the finger of one hand, whilst with the other the catheter is introduced. When the suppression is connected with retroverted uterus, the blad- der is usually raised so high above its proper location, that it becomes necessary in general to use the male catheter, in order to reach the cavity of the bladder. 415 DYSURY. Difficulty and Pain in voiding Urine. Difficulty and pain in making water, without any parti- cular tendency to retention of the urine, is a very common complaint. In general, whatever is capable of increasing the irritability of the bladder, or of giving rise to the secretion t\f an acrid urine, will cause more or less pain and difficulty in voiding the urine. It is particularly apt to occur where there is an excess of uric acid secreted with the urine ; and where the urine is charged with the earthy phosphates, it is seldom absent,—although in this latter case the urine is generally more copious than natural, and does not properly come under the designation of dysury, vvhich implies difficulty in passing the urine, as well as pain. The usual sensations of dysury are—uneasiness in the neck of the bladder; frequent, painful, and slow micturition, with a sense of tenesmus or straining in perineo,—particularly at the moment the last drops are voided ; and a cutting or burning sensation in the posterior part of the urethra. It may be produced by a great variety of causes, such as excess in eating, and in drinking spirituous liquors; the free use of condiments; irritating diuretics; onanism ; excessive venery ; acid ingesta ; inflamed haemorr- hoids ; ascarides ; suppressed catamenia ; the irritation of ve- sical calculi; astringent injections ; redundancy of lithic acid, or of the phosphatic sediments in the urine ; leucorrhoea ; re pelled cutaneous affections ; rheumatism and gout. It occurs in inflammatory fevers, particularly in hepatitis, jaundice, scurvy, and from verminous irritation and dentition in chil • dren. Treatment.—Where there is reason to suppose that the dis ease depends on simple irritation of the neck of the bladder from some accidental cause—as injections, gonorrhoea, &c.—it will, in general, be sufficient to empty the bowels by mild laxatives, and to order copious draughts of bland diluent drinks, such as barley water, flaxseed tea, or a solution of gum arabic, and perhaps an anodyne enema, and rest. When the disease is dependant on an excess of the lithic or phosphatic sediments, the measures already mentioned under the head of lithiasis, for counteracting these secretions, must be resorted to. " When the urine is perfectly natural both in quantity and quality, and contains no mucous, purulent, or bloody deposite, there is reason to infer that the cause of the irritation is not connected with the urinary system, and must be sought for elsewhere, as in the rectum, or uterine system in females." (Prout.) Should it depend on an hsemorrhoidal 416 DYSURY. effort, recourse must be had to the means mentioned in the chapter on haemorrhoids for counteracting it. Nervous and hysterical females are liable to extremely violent pains in the neck of the bladder and urethra, and which are generally most intensely felt immediately after discharging urine. Opium and camphor is the only remedy that I have found decidedly useful in cases of this kind. Four or five grains of Dover's powder, with three grains of camphor, taken three times daily, will seldom fail to remove the complaint. Infants, as has already been said, are subject to violent pains of this kind, in passing urine during the process of dentition. The existence of the complaint is recognised by the violent shrieks which they utter on voiding the urine. The proper treatment in such cases is to open the bowels freely with cas- tor oil or rhubarb, and to exhibit twice daily one-sixth of a grain of calomel, with a fourth of a grain of ipecacuanha. In the evening a drop or two of laudanum should be administered. I have never failed of speedily removing the affection by these remedies. When these cases are attended with a copious se- cretion of the phosphate of ammonia, which not unfrequently occurs, magnesia, so commonly administered to infants, is de- cidedly prejudicial. In old people, this affection is generally attended with a dis- eased condition of the internal coat of the bladder, or calculous irritation, or disease of the prostate. The careful physician will, of course, endeavour to ascertain the cause ; and for this purpose it is particularly important to examine the urine, and the state of the prostate, by examining through the rectum. Females subject to leucorrhoea, are apt to suffer the most excruciating pains on voiding urine, from an extremely irri- table and tender state of the orifice of the urethra. So sensible is this part, in some cases of this kind, that the slightest touch with the finger gives rise to extreme pain. I have found no remedy so effectual, in cases of this kind, as a weak solution of lunar caustic. Two grains to an ounce of water, to which a watery solution of opium is to be added, should be used two or three times daily as a lotion to the part; and a little lard applied with the finger, after each application of the wash. A strong solution of borax will also sometimes give relief; and I have used the citron ointment, mixed with an equal quantity of oil of almonds, with much benefit. At the same time, how- ever, that these applications are used, it will be necessary to use frequent injections of a tepid solution of sulphate of zinc, or of alum into the vagina, and to employ other means for counteracting the leucorrhceal affection. ( 417 ) ENURESIS. Incontinence of Urine* Tins, though not in general a painful affection, is always a very troublesome and distressing complaint. The urine passes of involuntarily; sometimes constantly, in drops, as it is se- creted and conveyed into the bladder ; at others, only after a considerable portion has been accumulated in the bladder, the impulse coming on so suddenly anil irrisistibly, that the utmost efforts of volition arc not able to restrain its immediate flow. In some instances the involuntary discharge occurs by day and night, whether the patient be awake or sleeping—in other cases, by far the most common, it takes place only at night during sleep. This affection may, therefore, be divided into three varieties. 1. Enuresis paralytica.—In incontinence of urine, from pa- ralysis of the sphincter of the bladder, the urine passes off con- tinually, as it is secreted by the kidneys, without pain, and even without the least sensation of its occurrence. In such cases the diagnosis is not, in general, attended with difficulty. In very old people it is, nevertheless, not uncommon to find the urine to dripple off involuntarily, without any particular para- lytic affection of the sphincter. These cases occur in the slight- er instances of partial retention of the urine, from a weakened state of the expulsive powers of the bladder; for, when the urine accumulates in the bladder to a certain degree of disten- tion, the resistance to a further dilatation of the bladder, in conjunction with the pressure of the abdominal muscles, slowly forces the urine into the urethra, and causes it to pass off gut- tat im. This variety of incontinence often occurs as a symptom of some general disease. Thus, it is frequently met with in the latter stages of low fevers—in paraplegia and hemiplegia; and it is occasionally the consequence of concussion of the brain and spinal injuries. Richter observes, that an inability to re- tain the urine has arisen from plunging into very cold water. Among the local causes of this affection, the most common arc— difficult parturition ; injuries done to the neck of the bladder by the unskilful employment of obstetrical instruments ; a large calculus located in the neck of the bladder ; lythotomic operations ; great dilatation of the neck of the bladder in the extraction of a calculus. The prognosis in this variety of the disease is generally un- favourable, and when it occurs as a symptom in febrile affec- tions, it is always one of the most dangerous indications. VOL. II.—53 418 ENURESIS. Mere local paralysis of the sphincter of the bladder is indeed not dangerous, so far as the life of the patient is concerned, but it is an exceedingly annoying complaint, and by the urine constantly drippling off, very painful and distressing excoria- tions on the inner part of the thighs, scrotum, and perineum, almost always occur. 2. Enuresis from mechanical causes, independent of paraly- sis of the sphincter of the bladder, is not unfrequently met with. Most of the mechanical or organic causes mentioned under the head of ischuria, may, under certain circumstances, give rise to incontinence of urine. Tumours pressing on the bladder—as the gravid uterus ; dropsical or scirrhous enlarge- ment of the ovaria; tumours of the mesenteric glands ; of the rectum, and of the neck of the uterus, have been known to give rise to this affection. It may also be produced by prolapsus uteri; hernia, or prolapsus of the bladder; by the irritation of vesical calculus ; tumours and excrescences from the inter- nal surface of the bladder, &c. These causes seem to operate in the production of incontinence of urine, by the pressure which many of them make on the bladder, and by the almost constant nisus to evacuate the urine, by which the sphincter may at last become so debilitated and relaxed, as to suffer the urine to pass off slowly and involuntarily ; and cases have oc- curred, which arose from ulcerative destruction of a part of the sphincter. 3. There is a variety of incontinence of urine, described by Richter under the name of enuresis spastica, which sometimes occurs in very nervous or hysterical individuals, and which may therefore with more propriety he called nervous enuresis. The inability to retain the urine occurs in sudden and irre- gular attacks. The patient suddenly feels a most urgent de- sire to void the urine, and the impulse is so irresistible, that, in spite of the utmost efforts of volition, the urine immediately passes off without allowing time to withdraw, or even to reach for a vessel. This variety of the affection occurs also occasion- ally in very young children. Its most common exciting causes appear to be—ascarides; hsemorrhoidal affections ; suppressed catamenia; gouty irritation ; and leucorrhoea. Frequently, however, no obvious causes of this kind are present, and the disease apparently arises from a morbid irritability of the uri- nary passages, in connexion usually with a very excitable or nervous state of the general system. 4. Eneuresis nocturna.—This is a very common complaint among children, and occurs also occasionally in adults. When awake, the individual subject to this affection experiences no inconvenience whatever in this respect; but at night, while sleeping, and lying on the back, the urine is apt to pass off, either involuntarily, and without the least consciousness of ENURESIS. 410 its occurrence, or voluntarily, under the influence of a dream. In children this variety of incontinence of urine is often " as- sociated with some tendency to urinary disease, and very fre- quently a disposition to gravel; or sometimes, as in young females, with constitutional irritability and weakness ; and in advanced life this affection is almost always associated with some organic or other affection of the neck of the bladder or prostate gland." In those cases where the discharge occurs in consequence of a voluntary effort during a lively dream, the urine, on examination, will almost invariably exhibit " some unnatural property, and most generally a strong dispo- sition to, or actual deposite of gravel. "Hence," says Dr. Prout, " I have been led to infer that in this species of urinary incontinence, the acrid properties of the urine are chiefly in fault, and that these, favoured, perhaps, by the position of the body, and probably also by the morbid sensibility of the blad- der, excite so vivid an impression on the imagination as actu- ally to lead to a voluntary discharge of the urine." That uri- nary incontinence may occasionally occur in this way cannot be doubted ; but it may justly be questioned whether the causes here assigned are so commonly concerned in the production of this affection as is supposed by the author just quoted. It is certain that we may sometimes prevent the recurrence of the evacuation by exhibiting remedies calculated, and intended to produce an irritation or tenderness in the neck of the bladder ; as, for instance, cantharides—a circumstance which does not seem to favour the idea that the affection depends on the irri- tation of acrid urine. Habit, no doubt, often has a principal agency in keeping up this affection. When children neglect to pass off the urine on going to bed, the bladder is apt to become distended in the course of the night. This stimulus excites the brain, and awakens a lively dream, occupied with a desire to urinate, and the sphincter yields to the instinctive effort to void the urine. In cases where the urine passes off involuntarily, and with- out the person being conscious of it during sleep, Dr. Prout thinks that there probably always exists "some morbid condi- tion of the urinary organs," which it is in general extremely difficult to overcome, and continues, often, long after the age of puberty. Tretament.—From the foregoing remarks on the various and very distinct character of the causes and pathological con- ditions of urinary incontinence, it is obvious, that the modes of treatment proper for its removal must be equally various and diverse in different cases. When the incontinence depends on general palsy, recourse must be had to the treatment mentioned under the heads of paralysis. In instances of urinary incon- tinence from mere local paralysis of the sphincter vesicae with- 420 ENURESIS. out any manifest spinal affection, or organic cause, we must en- deavour by tonics and local stimulants to re-excite the activity of the sphincter. Among the means that have been proposed for this purpose, the following are the most important. Alum, in doses of twenty grains every four hours, with mucilage of gum arabic. This, according to Selle, has occasionally re- moved cases of long continuance. The tincture of cantharides will sometimes produce a very good effect. It should be given in gradually increased doses three or four times daily, until a feeling of ardor urinse or strangury ensues. Externally, cold bathing, or cold water poured from a height on the pubis, and dashed upon the perineum, will sometimes do good. Richter re- commends cold injections into the bladder; and in females cold water may be beneficially injected into the vagina. Electrici- ty and galvanism have also been employed with success in cases of this kind.* Stimulating frictions, of various kinds, will occasionally assist in restoring activity to the sphincter. M. Lair, in a memoir on this affection, refers most cases of incontinence of urine to a want of equilibrium in power between the body of the bladder and its neck, the latter being in an atonic or relaxed condition. This view of the subject, led him to seek for a mode of stimulating the neck of the bladder, with- out affecting its body. With this intention he introduced, by means of a catheter, the tincture of cantharides, so as to touch the urethra in its prostatic part, as well as the neck of the bladder; and he affirms, that by this mode of management ho cured three cases of this malady, f Dry-cupping the perineum, and blisters applied to the sacrum, arc also very useful mea- sures in cases of this kind. M. Canin has lately related two cases, before the French Academy of Medicine, vvhich were cured by these applications. One of them, in a lad about four- teen years of age, the disease had already continued two years. It required eighteen applications of the cups, in the course of a month, before the cure was effected. In the other case, also in a young person, the cups were applied twenty times, and a blister laid over the sacrum, before the cure* was completed. In both instances, various means had been tried without any apparent advantage. In urinal incontinence from mechanical causes, we can sel- dom do more than palliate the disorder, or procure temporary relief. When it occurs from the pressure of the gravid uterus, nothing hut the delivery of the child will in general remove the complaint; yet in some instances, incontinence of the urine oc- curs about the third and fourth month of pregnancy, and after having continued for a time goes off spontaneously, before the * Loder's Journ. der Chirurgie. B. iv. hft. i. f Med. Chir. Rev. January, 1827. p. 244, ENURESIS. 421 termination of tho regular period of gestation. In nervous or spastic urinary incontinence, anodyne enemata ; uva ursi in union with Dover's powder, or the extract of stramonium ; and the employment of tonics—particularly, iron, quinine, and the oxyde of zinc, together with a nourishing and digestible diet, regular exercise in the open air, early rising, and, in general, whatever is calculated to invigorate and to allay the morbid irritability of the general system, constitute the appropriate means in cases of this kind. Wendt speaks very favourably of the expressed juice of the mesembryanthernum crystalli- num, in the incontinence of urine which occurs in very nervous individuals. When the patient labours under leucorrhoea, or ascarides, or an irritated state of the rectum from haemorr- hoids, particular attention should, of course, be directed to the removal or mitigation of these affections. For the removal of enuresis nocturna, a great variety of means have been proposed, but they have not been very often applied with much success. The disease generally disap- pears, as children approach the age of puberty, and often at a much earlier period ; and this occurs apparently from the powerful influence of a sense of shame and a determination during the waking state to resist the desire to micturate, which occurs during dreams of sleep. Mr. Prout observes, "that when the incontinence in children is associated with gravel, it is of the utmost consequence that this circumstance he attended to; and that the remedies appropriate for coun- teracting the formation of these urinary deposites should be employed before any other means are used to restrain the uri- nary incontinence,"—for without this, almost all other reme- dies will be in vain. The urine should therefore be carefully inspected, both in its recent state and after it has stood awhile; and if a sediment either of the lithic acid or phosphatic variety be deposited, recourse should be immediately had to the reme- dial measures mentioned under the head of lithiasis in a pre- ceding chapter of this work. After this object has been accomplished, we may proceed to the employment of tonics, and some one of the various remedies or modes of management which experience has shown to be capable of doing good. Among these, there is no article which has been more general- ly prescribed than the tincture of cantharides, with the view of producing a slight degree of strangury, or considerable ardor urinse ; so that the pain excited by the first efforts to micturate, may excite and awaken the patient, and thus interrupt the habit which always ultimately contributes chiefly to the recur- rence of the discharge. This article does good too, no doubt, by its tendency to increase the sensibility and activity of the sphincter, and causing it thereby to make a greater resistance to the expulsive efforts of the bladder. The same effect may 4*2 ENURESES. sometimes be derived from the application of a blister to the sacrum; I have known an instance of long standing removed by the use of the spirits of turpentine, in doses of from fifteen to twenty drops three times daily, until a considerable degree of ardor urinse was produced. Where these remedies do not afford relief, and there is reason to believe that the incontinence depends on a morbid irritability of the neck of the bladder— which is often the case in adults, an opiate administered on going to bed, will sometimes have the effect of preventing the evacuation during the night. Children should always be re- quired to empty the bladder just before going to bed, and when they awaken at night, they ought to be taught to rise and pass off the urine. By this, we may often prevent the occurrence of the disorder, and even occasionally obviate it after it has occurred. Mr. Charles Bell makes the following observations in relation to this subject, and which are worthy of particular attention in the management of this complaint. " Incontinence of urine," lie says, " never takes place but when the boy is asleep upon his back; and the cure is a simple one. He is to accustom himself to sleep upon his face or side : the urine is not passed, nor is he excited to dream of making urine while he keeps this position. The circumstance is unaccountable, until we reflect on the po- sition of this master-spring of the muscles of the bladder—the sensible spot, a little behind and below the orifice of the bladder. When a person lies upon his belly, the urine gravitates towards the fundus; but when he lies on the back, it presses upon this sensible spot, and distends that part of the bladder which is towards the rectum." CHAPTER XXX. HYDROPS. Dropsy. Dropsy, or rather the effused and accumulated fluid which constitutes the most conspicuous external character of this dis- ease, must be regarded only as an effect of a primary morbid condition of the solids. This morbid condition of the solids constitutes the essential malady, to which the physician's at- tention must be directed in order to obtain rational views con- cerning its nature and remediate management. The cure of this disease does not depend merely on the removal or evacua- HYDROPS. 4* tion of the aqueous accumulation, but principally, if indeed not entirely, on the removal of that disordered state of the vascular system, upon which the dropsical collection depends. Here, then, the fundamental question meets us : In what does this morbid condition of the solids consist, and in what particular structures is it chiefly located ? According to the late Dr. Rush, the morbid action which gives rise to dropsical accumu- lations is seated in the arterial system, and is, in its nature, closely allied to inflammation. Dropsical accumulations, agreeably to his views, are the result of an increased action of the exhalent vessels, attended with a general pyrexial condition of the system. The correctness of this doctrine is now very generally, we might, perhaps, say universally admitted. In- deed, the removal of dropsy from the cachexia to the pyrexia, is justly regarded as one of the most important of modern im- provements in pathology. That the increased secretion or ef- fusion of serum which occurs in dropsy depends on a condition, which, if not identical, is at least closely allied to inflammation, receives the greatest degree of probability from the following circumstances : Every one who has observed the progress of inflammation, knows that at the period when the inflammation is passing off, or changing to the subacute or chronic state, an effusion of serum is apt to occur into the surrounding cellular tissue or contiguous cavities. Thus, rheumatic inflammation, gout, and sprains, frequently pass off by an effusion of serum into the circumjacent cellular structure. It is well known, too, that hydrothorax is by no means an uncommon sequel of pleuritis; and hydrocephalus of arachnitis. Indeed, the pathological fact that all inflammations of the serous membranes, if not very violent, or speedily terminated in resolution, end in effusion, is directly corroborative of the correctness of this view of the pa- thology of dropsy. It is therefore highly probable, that the morbid action which exists in the tissues from which the drop- sical effusions occur, partakes more or less of the nature of in- flammatory excitement; but it seems likely, that it is always of the lowest grade of phlogosis, and in some instances proba- bly amounts only to an irritation bordering on actual inflam- mation. It would appear, indeed, that a considerable degree of inflammation is incompatible with serous exhalation—and that this effect can occur to any material extent, only where the vascular irritation is somewhat below the grade of actual in- flammation. To this doctrine of the nature of dropsy, objections of much plausibility have been urged. When duly estimated, however, they do not appear to possess any solid value. It has been stated, for instance, that dropsy i9 not unfrequently the conse- 421 HYDROPS. quence of profuse haemorrhage and of other exhausting causes, and that in such cases, at least, neither the general symptoms, nor the nature of the causes justify us in considering the dis- ease as one of an inflammatory character. Against this, how- ever, it may be observed, that local irritative or inflammatory action, and great debility and exhaustion, are by no means in- compatible. Sub-inflammation may exist in one structure or organ, whilst the general system exhibits all the characteristic traits of debility and cachexy. The post-mortem phenomena which occur in the human subject, and in animals who have died from haemorrhage, would seem to show, indeed, that even in dropsies from haemorrhage, there exists a morbid state, allied to inflammation in the membranous structures from which the effusion occurs. The experiments of Mr. Seeds and of Kellie, show that in animals bled to death, the meninges of the brain, and other membranous tissues almost invariably exhibit a high- ly injected and congested state, similar, in all respects, to what occurs in actual inflammation. In many instances of this kind a considerable quantity of watery effusion wras found within the head ; and in some instances, high and tumultuous action of the heart and arteries occurred shortly before the animals ex- pired. I have met with several cases in vvhich internal in- flammation occurred, apparently in consequence of excessive losses of blood. I attended a gentleman, a few years ago, who was reduced to the utmost degree of exhaustion compatible with life, in consequence of a long-continued and almost unin- terrupted loss of blood from the rectum, and who, finally, be- came anasarcous over the whole body, while at the same time, his eyes were very considerably and obstinately inflamed. The phlogistic character of dropsy is sometimes strikingly il- lustrated by the conversion of inflammatory diseases into drop- sy, and vice versa. In a late number of the Medico-Chirur- gical Journal, there is a case related in which rheumatism was successfully converted into dysentery, erysipelas, peritonitis, and finally dropsy.* Although it must be admitted, that an increased exhalation of serum constitutes the chief immediate cause of dropsical accu- mulations, yet it is probable, 1 think, that there always exists a simultaneous diminution of absorption in the surface from which the effusion takes place. In the first place, it may he ob- served, that vascular irritative excitement or inflammation in a part, is necessarily attended with a preternatural afflux, and consequently, sanguineous congestion in such part. This being the case, it follows, that the capillaries of the structures from which dropsical effusion occurs, must be in a state of repletion * Med. Chir. Rev. vol. vi. p. 197. HYDROPS. 425 or sanguineous congestion. Now, it is a truth, 1 believe well established, that the function of absorption from the cavities and cellular tissue, is chiefly, if not entirely, performed by the veinous extremities. The experiments of Majendie, of Meckle, of Tiedeman, and Gmelin, have placed this physiological fact beyond all reasonable doiTbt. It appears, moreover, to be equally established, that the process of absorption accelerated or diminished, according as the capillaries contain a lesser or greater quantity of blood. When these are full and congested, and the current of blood moves along sluggishly, absorp- tion is comparatively slow; and vice versa. This fact was long ago noticed by Home in his Essay on Croup. "The less blood," he says, "there is in the veins, the more rapidly will absorption be effected." When it is considered, therefore, that the tissues from which the dropsical effusions occur, are, as is believed, in a state of snbinflammatory action, or at least of vascular irritation, and that the capillaries of these tissues must consequently be in a state of fulness or congestion, it would seem to follow, that the process of absorption must be correspondingly diminished. Hence, in every case of dropsy, there are, probably, twro simultaneous morbid conditions pre- sent, namely, increased exhalation, and decreased absorption. Etiology.—The principal general causes of dropsy are me- chanical obstructions to the free return of blood to the heart; the influence of cold ; excessive haemorrhages ; disease and in- activity of the kidneys; repelled cutaneous eruptions; sup- pressed habitual discharges ; chronic diseases which tend to ex- haust the system ; arsenic; and some of the acute exanthemat- ous affections, particularly scarlatina and measles. Dr. Ayre, in his treatise on this disease, denies that mechanical obstruc- tion ever has any direct agency in the production of hydropic effusions. When dropsy supervenes on scirrhus of the liver, he considers it the consequence of the slow inflammation of the indurated viscus, extending to its peritoneal covering, and thence along the abdominal peritoneum. It is not improbable that the disease may, in some instances, be developed in this way ; but it seems much more likely, that the congestion which necessarily occurs in the portal system in such cases produces, by degrees, that irritated condition of the peritoneal capilla- ries which gives rise to the effusion. It is a well established fact, that habitual sanguineous congestion in a part, tends ulti- mately to excite a low degree of inflammation. We may rea- sonably presume, also, from the above observations on the in- fluence of vascular turgescence in diminishing absorption, that this process is in such cases morbidly diminished, even before capillary irritation and consequent preternatural exhalation have commenced. The influence of obstructions to the return vol. II.—54 426 HYDROPS. of blood to the heart, in producing serous extravasations, is sufficiently illustrated by the oedema which occurs when liga- tures are passed round an extremity. Cold rarely produces hydropic affections, unless there exists a predisposition to the disease. Of all the causes which predispose to the occurrence of dropsy from the influence of cold, the most powerful are scarlatina, measles, and the mer- curial excitement. Neither these two exanthematous affections nor mercury are apt to give rise to dropsy, unless they co-ope- rate with cold, or vicissitudes of atmospheric temperature. They leave the surface of the body in a highly sensible and ir- ritable condition, and the cutaneous exhalation is usually carried on freely during the period of convalescence. When the body in this condition is exposed to the influence of cold, the articular exhalents are peculiarly liable to become torpid; and congestion in the capillaries of the subjacent cellular tis- sue almost necessarily ensues. This tissue being already pre- disposed to morbid excitement from the previous exanthemat- ous affection, passes readily, under the combined influence of these circumstances, into a state of irritation or snbinflamma- tory action, whence dropsical effusions proceed. It is not im- probable, however, that in some instances of dropsy from scar- latina or measles, the disease may be the immediate conse- quence of the extension of the inflammation, or irritation from the skin to the subsequent cellular texture. The fact, how- ever, that dropsy from these affections occurs hut extremely seldom when the patient is carefully protected from the im- pressions of cold, would seem to show, that the disease is not apt to arise from an extension of the inflammation to the cellu- lar tissue. Dropsies from cold are frequently attended with slight catarrhal symptoms, and are always manifestly of a phlogistic character. When blood is drawn, it is almost always found sizy ; and the pulse is tense, quick, and frequent—more espe- cially in those cases which occur as the sequela of scarlatina or measles. The effusion generally takes place very rapidly. The variety of dropsy which most commonly proceeds from cold, is anasarca, although some degree of abdominal effusion is not uncommon. In relation to dropsies from excessive haemorrhages, or other profuse and long-continued discharges, we have two observa- tions to make in elucidation of their etiology. In the first place, it would seem to be well established, that excessive losses of blood are almost invariably attended or immediately followed by irregular determinations, or foci of congestion, in one or more serous membranes. It is thus that the red and injected appearance of the arachnoid and other membranous struc- HYDROPS. 427 tores occur in animals, when killed by bleeding. The struc- tures which may have thus become the foci of determination, gradually pass into a state of irritated action, and which ulti- mately, in most instances, gives rise to dropsical effusions. There is, however, another circumstance connected with the production of dropsy by excessive losses of blood, which, though little estimated by pathologists, has, I am convinced, an im- portant concern in the causation of the disease. I have already observed above, that immediately after a profuse loss of blood, absorption goes on with unusual activity. The blood-vessels are rapidly replenished with crude fluids ; for the absorbents being extremely active, nearly all the aqueous fluids received into the stomach, are speedily absorbed into the circulation ; and this is especially favoured by the very great thirst which almost always occurs after excessive sanguineous losses. The blood being thus inordinately supplied with a crude and watery fluid, becomes more irritating to the heart and capilla- ries, and diluted to such a degree as to pass off more readily by the exhalents. That this is not a hypothetical view of the subject, is shown by the experiments of Harles and Schulze, both of whom rendered animals hydropic by drenching them copiously with water, after they had abstracted from them large quantities of blood. Haller also bears testimony to the fact, that copious haemorrhages produce an increase of serous fluid in the blood. Dropsy from haemorrhage is generally of the anasarcous kind. The blood in these cases always contains a very great over-proportion of serum, the crassamentum being very small, usually cupped, and often covered with a buffy coat. The pulse is frequently full and active, though not hard or tense. Dropsical effusions from haemorrhage, rarely supervene imme- diately after the loss of the blood. Several weeks usually inter- vene between the haemorrhage and the occurrence of the drop- sical swellings. Diseases or torpor of the kindeys, is another, though not a very common cause of dropsy. Dr. Bright,* has recently pub- lished some interesting cases of this kind. In nearly all these instances the kidneys were found in a state of disorganization. In dropsies depending on deficient urinary secretion from renal torpor or organic disease, the urine almost invariably contains a large portion of albuminous matter. Among the causes of dropsical effusions, we may also mention amenorrhcea, diabetes, chronic gout, the intemperate and habi- tual use of spirituous liquors, and in short, almost every chronic * See his Reports of Medical Cases. London, 1827. 428 HYDROPS. affection or cause which is capable of exhausting the constitution, or causing important functional lesions. General symptoms.—A dry and harsh skin is almost uni- versally present. The appetite is usually impaired—but when the disease is the consequence of haemorrhage, the appetite for food is sometimes particularly strong. The thirst is gene- rally considerable, and sometimes very urgent. The bowels are commonly inactive, though readily moved by laxatives. The pulse is irritated, and usually indicative of a pyrexial state of the system ; for however small and febrile, it is almost always quick and frequent. The urine is scanty, and generally of a deep red colour ; sometimes jumentose—and occasionally, though rarely, whey-like or chylous. In a diagnostic point of view, much attention has of late years been paid to the appearance and character of the urine. Dr. Blackall has investigated this subject with minute atten- tion ; and the observations of Ayre and Wells, have thrown further light on it. The circumstance which has particularly occupied the attention of these physicians, in relation to this subject, is the absence or presence of coagulable matter or se- rum in the urine of hydropic patients. In many instances of this disease, a greater or less proportion of coagulable serum exists in the urine, whilst in others this excretion is wholly de- void of coajulable matter. Observation would seem to show, that this occurrence is intimately connected with the general state of the system ; for it would appear that in those casjes of dropsy which are attended with an obvious phlogistic diathe- sis, and especially such as arise from the influence of general causes, the urine, with scarcely an exception, contains a large quantity of coagulable serum. The quantity of serum mixed with the urine, may therefore be regarded as a pretty correct index of the degree of general inflammatory excitement attend- ing the disease. Serous urine may he considered as a kind of pyrexometer in hydropic affections, which, though not univer- sally to be relied on, is yet sufficiently constant to entitle it to the attention of the practitioner. I am satisfied from consi- derable attention to this subject, that in almost every instance where there is coagulable serum in the urine of dropsical pa- tients, the general condition of the system will be found mani- festly phlogistic. In the dropsies which occur after scalatina, the urine generally contains a large portion of serum ; whilst in local dropsies, and in vvhich the general vascular system does not participate, little or no serum is detected in the urine. (Ayre.) When the urine is high-coloured, scanty, and on cooling, deposites a red sediment, or remains muddy, the liver, probably, is in a state of organic disease. (Cruikshank.) After all, it is highly probable from what is said above, that HYDROPS. 429 every case of dropsy is essentially phlogistic, so far at least as relates to the immediate local excitement which gives rise to the effusion. The general system, however, does not always participate in the local affection—the heart and arteries receiv- ing no sympathetic impulse from the local, irritated, or subin- flammatory action. In such cases, the general circulation is languid, and debility and relaxation characterize the disease. Where the heart and arteries do sympathize with the local hy- dropic affection, and this is by far most commonly the case, the pulse will manifest more or less of a pyrexial state, being sometimes full, hard, and active, or small, tense, quick, and frequent. Ascites—Dropry in the Cavity of the Abdomen. Ascites, or abdominal dropsy, is very generally dependent on visceral induration, more especially of scirrhous of the liver or spleen. Whatdver, therefore, has a tendency to produce in- duration of these viscerae, may become the remote cause of this form of dropsy. Among the most common and powerful of these causes may be ranked the habitual and intemperate use of alcoholic liquors : protracted agues ; hepatitis ; and invete- rate dyspepsia. Whatever may be the remote cause of ascites, however, chronic inflammation of the peritoneum constitutes, no doubt, the immediate and essential cause of the abdominal effusion. Subacute inflammation of this membrane, in what- ever way it may be produced, terminates perhaps always in effusion ; although in some instances, this may not be so copi- ous as to constitute dropsy. In the majority of fatal cases of ascites, .the peritoneum exhibits a highly injected state ; and in many instances, the traces of previous inflammation are still more conspicuous and unequivocal, its structure being either thickened and otherwise altered, or covered with an infinitude of miliary tubercles. Occasionally, indeed, no marks of pre- existing inflammation whatever are to be seen ; but the inves- tigations of modern pathologists have rendered it abundantly manifest, that where no disorganization or structural change has been effected, the mere redness, or injected state of inflamed parts, may anddoes of ten disappear in articulo mjrlis, or even post mortem. Besides the causes I have just mentioned, it will be sufficient to observe, that every thing which is capable of producing slow inflammation of the peritoneal lining of the abdominal cavity, may give rise to this variety of dropsy—such as cold ; partu- rition ; blows on the stomach; enteritis; metastasis of cuta- neous eruptions, gout, or rheumatism; suppressed habitual discharges ; and iufarcted bowels. 430 ASCITES. Diagnosis.—The only condition which is likely to be mis- taken for ascites is pregnancy. From this state it may be dis- tinguished by the fluctuation ; the uniformity of the tumour ; the lateral pressure and distention of the abdomen on lying on the back; the oppression of breathing on lying down, so as to raise the pelvis and abdomen higher than the chest; the thirst; the paucity of the urine ; the dryness of the skin, which charac- terize effusion into the abdomen. And, on the other hand, the absence of the peculiar symptoms of pregnancy, assist us in forming a correct diagnosis. When the dropsical accumulation becomes very great, much uneasiness and general disturbance in the system arise from the mechanical irritation which it causes by its pressure on the organs and parietes of the abdomen. Respiration becomes short and anxious ; the stomach will admit of but small quan- tities of drink or food ; the fibres of the abdominal muscles yield, and the whole abdomen becomes sore and tender to the touch, and a dry and short cough generally comes on in the advanced stage of the disease. Ascites is very rarely wholly unconnected with anasarcous swellings. Ultimately oedema of the feet and legs, if not more diffused cellular effusion, ensues. The urine is much more apt to be very high-coloured and sc- dementous in ascites than in the other forms of dropsy. The bowels too are more torpid, especially in aggravated cases. Hydrothorax—Dropsy of the Chest. Hydrothorax generally supervenes gradually, without caus- ing, in its initial period, any particular inconveniences or disturbance, calculated to excite much attention or suspicion of the true nature of the malady. At length, however, the pa- tient begins to experience a sense of oppression and tightness at the lower part of the sternum, with slight difficulty of breathing when at rest and in an erect posture. He now finds that on lying down, or using active bodily exertion, especially on ascending an acclivity or stairs, the dyspnoea and sense of suffocation are greatly increased. When recumbent in bed, he raises his head and shoulders high by means of pillows, which, by diminishing the pressure of the effused fluid on the lungs, generally enables him to obtain some sleep. His sleep is, how- ever, frequently interrupted by sudden and violent starts, and feelings of alarm and terror. The pulse is irregular, and com- monly very hard ; the thirst urgent; the urine scanty, high- coloured, and sedimentous. As the disease advances the feet become oedematous; the countenance is expressive of anxiety and alarm, and of a mixed pallid and livid aspect. There is generally a dry and short cough attending the disease, more HYDROTHORAX. 431 especially when the patient lies down, or uses bodily exertion. All the foregoing symptoms increase, if the disease continues unchecked in its course, until the quantity of fluid in the chest is so great, as to prevent the patient from lying down even for a moment, and obliges him to take his short and disturbed pe- riods of sleep in a sitting or leaning posture. The extremities are generally cold, and more or less benumbed. Of all the foregoing symptoms, the sudden startings during sleep is, according to Baglivi, the most certain pathognomonic symptom of this disease. Laennec, however, asserts that this symptom is sometimes absent; yet, when it does occur, it may be viewed as a very strong evidence of the existence of thora- cic effusion. Hydrothorax may occur either as an idiopathic affection, or as one symptomatic of organic disease of some viscus of the chest or abdomen. The former variety of the disease is very rare. {Laennec.) By far the greater number of cases are of the latter kind. Organic cardiac disease is the most common source of symptomatic hydrothorax. Structural disorder of the liver and spleen may also give rise to the disease, and cases are recorded, which appeared to have arisen from orga- nic disease of the stomach. Chronic inflammation of the pleura, occurring as the sequel of acute pleuritis, is always at- tended with hydropic or scro-puruloid effusion into the chest. A tuberculous state of this membrane, and aneurismal dilata- tions and ossifications of the large vessels within the cavity of the chest, sometimes give rise to this malady. Besides these peculiar causes, hydrothorax may he produced by any of the general and particular causes mentioned above. Dr. Ayre ob- serves, that a plethoric state of the system predisposes espe- cially to serous effusion into the cavity of the chest—more particularly in persons who have passed the middle period of life, and who have indulged freely in the pleasures of the table. The correctness of this observation will be acknowledged by every one who has paid due attention to this subject. When this disease arises from some general cause, the effusion almost invariably occurs only in one side of the chest; but in those cases which come on in consequence of organic or structural disorder, the dropsical effusion, almost without exception, takes place at once in both sides of the thorax. (Laennec.} Prognosis.—Idiopathic hydrothorax is not often a dangerous or unmanageable affection. Laennec says, that he considers the instances of death from the idiopathic variety of the disease, as rare as one in two thousand, when under the control of judi- cious remediate management. Indeed, even in the symptomatic variety of the disease, we may frequently succeed in removing the effused serum; but this affords no permanent relief, since 432 HYDROTHORAX. we cannot thus remove the organic disorder upon which the effusion depends, and which consequently still continues to take place, and gives rise to further accumulation. Dr. Ayre asserts, what indeed I am well inclined to admit, that "the means which are sometimes used for the removal of the water in symptomatic hydrothorax, have now and then the effect at the same time of removing the organic disorder which gives rise to the effusion." Sir Henry Hal ford affirms, that he has ascertained from much experience, that if "the swelling in the feet or legs disappears without an increased discharge of urine, the patient generally dies very soon, and most frequently sud- denly."* I have myself remarked this circumstance in several cases. Diagnosis.—Ability to lie down only on the side affected, if the effusion has taken place only in one side. Percussion pro- duces a very obscure and dull sound. The percussion should be made while the patient is in a sitting posture. General agitation, cough, and a sense of suffocation when firm pres- sure is made on the abdomen just below the ribs so as to push up the viscera against the diaphragm. Inability to rest and sleep in a recumbent posture. If with these symptoms there is habitual co'sgh; starting during sleep; tension and irregu- larity of the pulse ; slight oedema of the feet, and of the integu- ments of the chest; great dyspnoea on ascending an acclivity or stairs, with a disposition to syncope, we may pronounce on the existence of an effused fluid in the cavity of the thorax with confidence. (Roux's edition of Dessault's Surgery.) Anasarca—Cellular Dropsy. This form of dropsy consists in a morbid collection of se- rous fluid in the subcutaneous cellular tissue; and this accu- mulation may he either generally diffused throughout the whole body, or confined to a part of greater or less extent. The or- dinary, and most unequivocal sign by which effusion into the cellular tissue is detected, is the pitting which occurs on firm pressure with the fingers. Anasarcous effusion commonly commences in the feet and legs, and thence rises up over the body, with more or less rapidity. This, of all the forms of hydropic disease, is the most frequently connected with a slug- gish and languid state of the system, and it is this form of the disease especially vvhich is apt to supervene on excessive losses of blood, and other exhausting or debilitating causes. The skin is cxanguious, and of a peculiar sallow or pallid cast; and * Transact. College of Phya. of London, 1820. ANASARCA. 468 the patient frequently manifests a great disposition to drowsi- ness, with a depressed or sluggish state of the intellect. Ana- sarca is often attended with some degree of abdominal effusion, and the latter, when it forms the primary affection, is rarely wholly free from anasarca. When anasarca arises from gene- ral causes, it is, however, rarely connected with ascites. In nearly all instances in which these two forms of dropsy co-exist, the effusions into the internal cavities precede those into the cellular membrane, (Ayre.) Local anasarca may be produced by whatever impedes the free return of the blood by the veins. Hence, the gravid uterus, tight bandages, and the pressure of in- durated glands in the groins, often give rise to oedema of the feet and legs, by compressing in some degree the iliac veins. Mere debility too, especially when aided by a long-continued erect posture, will have the same effect; and hence the frequency of oedema during the debility of convalescence from fevers. In nearly all organic diseases of the heart, oedema ultimately oc- curs in the feet and legs—more particularly in cases attended with ossification of the valves. Anasarca, from suppressed perspiration in consequence of the influence of cold, generally comes on and proceeds to its acme suddenly. Prognosis.—This form of dropsy is not often attended with much danger when it occurs as an idiopathic affection—that is, without organic disease, and in consequence of some general remote cause, such as cold, arsenic, scarlatina, haemorrhage, &c. When unattended with abdominal or thoracic effusion, it is, upon the whole, much more frequently removed by reme- diate treatment than the other forms of dropsy. The more rapidly the disease supervenes, the more easy in general is its removal. Causes—Haemorrhages; suppressed perspiration from cold, particularly after scarlatina, or when the system is under the influence of mercury ; the long-continued internal use of ar- senic ; intestinal irritation ; great debility and exhaustion; repelled cutaneous eruptions ; chronic gout; excessive and long-continued diarrhoea; indurations; organic disease of the kidneys, &c. are the most common causes of this variety of dropsy. Treatment.'—If the pathology which is laid down in the commencement of this chapter be correct, the principal indica- tions to be pursued in the treatment of dropsy are, 1, to subdue the local subinflammatory or irritated action of the structures from which the dropsical exhalation takes place ; and, 2, to pro- mote the absorption and removal of the effused fluid. The first of these general indications is to be fulfilled ; 1, by diminishing the general momentum of the circulation where it is preter- naturally great; and, 2, to derive the blood, as much as pos- sible, from the capillaries immediately implicated in the mor- vol. ii.—55 434 ANASARCA. hid effusion, and to equalise the circulation. The second gene- ral indication is to be fulfilled ; 1, by promoting the activity of the various serous emunctories ; 2, by diminishing the quantity of blood circulating in the venous extremities of the structure from which the dropsical fluid is poured ; and, S, by stimulat- ing the activity of the absorbent system. One of the first and most important measures to be adopted in establishing an ade- quate derivation of blood from a part, is to diminish the gene- ral impetus of the circulation. In vain will we endeavour to di- minish the preternatural afflux of blood to an irritated or inflam- ed part, if the vis-d-tergo of the circulation, or its general mo- mentum, be suffered to remain undiminished. Whenever, there- fore, the pulse is active, or tense and frequent, in dropsy, blood- letting, is an all-important measure. By reducing the mass of the circulating fluid in such cases, we not only predispose the veins to absorb more rapidly, but we contribute, moreover, in a direct way to the reduction of the process of effusion. I have know n one or two efficient bleedings to cause an immediate and conspicuous amendment in the disease.* Muscular debility does not constitute any objection to blood-letting, provided the pulse be active, tense, or hard and frequent. The arterial system may be irritated to vigorous action, whilst the muscular system manifests a state of languor and debility. Of course, where the pulse is feeble and languid, venesection is uncalled for and improper. Having moderated the momentum of the general circulation, where it was too great, considerable advan- tage may, in general, be obtained from local bleeding, by cups, or leeches, applied to the chest or abdomen, according as the effusion may have taken place in one or theotherof these cavities. Blisters, also, often assist materially in the successful treat- ment of ascites and hydrothorax. They tend in a direct way to derive the circulation from the irritated or congested serous membranes, from which the effusion occurs, and consequently to lessen the effusion, and promote the absorption of the drop- sical fluid. In anasarca, or in any other forms of dropsy attend- ed with anasarcous effusion, neither leeching, nor cupping, nor blisters, however, can be applied without some risk of gangrene, or mortification. Little or no peculiar advantage can, indeed, be expected from local abstractions of blood in anasarca; and the same observation applies to blistering. Dr. Ayre speaks very favourably of the effects of a seton fixed in the integu- ments of the chest in hydrothorax. In one instance of this form of dropsy which came under my observation, much benefit ap- peared to result from this measure. I should prefer, however, * Dr. Hohnbaum has recorded a case of ascites, which, after paracente- sis had been repeatedly performed, was removed by a spontaneous epis- taxis.—Analen dw Medizin. vol. iv. p. 266 of the Sequel. ANASARCA. 435 resorting to blistering and cupping, as being decidedly more derivative and prompt in their influence than setons or issues. In ascites, leeching, followed by blistering, or cupping, ought never to be neglected, unless the anasarcous state of the surface be such as to render such measures hazardous. Cathartics.—Drastic purgatives have, from the earliest pe- riods of medicine, held a high rank among the remediate means employed in dropsy. They constitute, indeed, a very important class of remedies in this affection. Very active purgation not only often carries off the effused fluid, but in some instances has the effect of removing that morbid state of the peritoneal capillaries, upon vvhich abdominal dropsy depends. The effi- cacy of hydragogues is generally more conspicuous in abdomi- nal dropsy, than in the other varieties of this disease. Their influence upon the morbid condition of the peritoneum, is much more direct and powerful from its contiguity to the mucous membrane of the intestinal tube, than upon the more remote structures concerned in the other forms of dropsy. Though, in general, less beneficial in anasarca and in hydrothorax, cathartics are nevertheless frequently of considerable service even in these forms of dropsy; nay, in some instances, the effects of active purgation in removing dropsical fluids from the chest, are surprisingly prompt and complete.* Pysicians have varied, and still differ in opinion, as to the particular articles of this class of remedies best calculated to procure the desired advantages. It is, indeed, agreed, that those purgatives which arc most apt to cause copious watery stools—or as they are called, hydrogogues, are decidedly the most efficient in dimi- nishing dropsical accumulations; but there exists some diversity of sentiment in relation to the relative value of this variety of cathartics. Cremor tartar may be placed at the head of this class of articles in reference to hydropic affections. It is mild, cooling, and potent in its operation as a hydrogogue, and possesses the additional and peculiar advantage of exciting, at the same time, considerable diuresis. Dr. Ferriar's statements afford strong testimony of its usefulness in abdominal and anasarcous dropsy. Out of forty-three cases treated chiefly with this re- medy, thirty-three were cured—a result, which, however, has been hut rarely obtained by other practitioners. In my own practice I have had unequivocal examples of the efficacy of a course of purgation with this article. I have for ten years past been in the habit of prescribing it according to the following formula, and as it appeared to me, always with peculiar efficacy. * Pring's Principles of Pathology, p. 269. 436 ANASARCA. R. P. crem. tart. 3iss. P. sulphat. potassae ^ss. P. scillse maritim. jii. Tart, antimonii gr. ii. M. S. A tea-spoonful of this mixture is to be taken four or five times daily. Given in this way, it has never failed, in my hands, to pro- duce copious watery stools, together with a considerable flow of urine, and frequently diaphoresis.* Elaterium is another valuable hydrogogue in the treatment of dropsy. Dr. Ferriar asserts, that it surpasses all other ar- ticles of this kind in the removal of dropsical accumulations ; and it continues to be a favourite hydragogue with many of the most eminent practitioners of the present day. Dr. Clutter- buck, especially, attaches great value to this article as a remedy in dropsy. I have employed it in a considerable number of cases of this disease, but it has not, in my hands, produced advantages equal to those I have derived from cremor tartar. Indeed, I have met with instances in which it manifestly did harm, by the violent irritation it caused in the mucous mem- brane of the bowels. It must be constantly borne in mind, that although an excitation of the serous emunctories of the intes- tinal tube will in general afford advantage, yet when the effects of purgatives on the mucous membrane transcend this grade of excitement and establish an irritation, bordering or actually passing into subacute inflammation, mischief must inevitably be the consequence. In prescribing such active purgatives, therefore, great care must be taken, lest in our anxiety to pro- duce copious aqueous evacuations, wre establish a morbid and permanent irritation in the mucous membrane of the bowels, and thus create a new and highly injurious focus of morbid sym- pathies in the system. Whenever such articles cease to produce copious watery stools when given in ordinary doses, and leave a general sensation of soreness or tenderness in the abdomen, we are admonished to desist from their further employment. Active cathartics will generally bring off copious watery stools for the first two or three times that they are adminis- tered ; by being again and again repeated, they will at last cease to excite the desired evacuations. A larger dose is then perhaps resorted to, but the stools will be still more incom- plete and painful. Determined to overcome the supposed torpor of the bowels, the physician now prescribes a still more pow- * This formula was first published by a German writer of the name of Langhans. I have known it to remove dropsical accumulations very speedily, after a great variety of diuretics and hydragogues had been used without much advantage. ANASARCA. 437 erful dose, but instead of procuring a free and watery evacua- tion, the patient will probably be harassed by small mucous stools, attended with great tormina or tenesmus. Thus, mu- cous inflammation will be established in the intestinal tube, and a disease, which under a more judicious treatment might perhaps have been removed, is rendered incurable. Gamboge is also a favourite hydrogogue with some practi- tioners ; and I have myself employed it with much advantage. I have, however, always given it in union with cremor tartar, in the proportion of from two to four grains to a drachm of the latter article. It has appeared to me less apt to excite perma- nent irritation in the bowels than elatcrium. Gamboge is the hydrogogue which Dr. Ayre prefers. He gives it as Dr. Fer- riar did, to the amount of four or five grains at a dose, tritu- rated with a few crystals of supcr-tartrate of potash. The gamboge rarely fails to cause copious watery stools. With regard to the frequency with which hydrogogue remedies ought to be administered in the treatment of dropsy, we must be governed by the general strength of the system, and the particular effects resulting from their operation. When the strength of the patient will admit, the purgative may he re- peated every two or three days, provided they do not produce great tormina and soreness, and provided also that they cause free evacuations. I cannot but think, however, that the useo* these remedies is frequently carried to an injurious extent in the present disease. Employed occasionally, and interchange- ably with diuretics, they generally contribute materially to the reduction of hydropic affections, more especially of ascites and anasarca. But to exhibit them daily for a week and longer, must put the system to a severe trial, and even if the water be removed, frequently lay the foundation of much future suffering and infirmity. Diuretics, of all our remediate means, are the most univer- sally employed, and relied on in the treatment of dropsy. The kidneys appear to be the most direct and manageable outlet for dropsical effusions, and an important part of the treatment of this disease consists in exciting these emunctories to in- creased action. Observation has shown, that a full and phlo- gistic habit of body is much opposed to the free operation of diuretic remedies; and hence bleeding and purging in such a state of the system, arc indispensable preliminary measures to the employment of remedies intended to promote the renal se- cretions. Equally difficult is it in general to procure the ope- ration of diuretics in cases where the dropsical effusion is very extensive, and where the blood-vessels are drained of the se- rous portion of their contents. To obviate the difficulty which arises from this source, it will often be sufficient to allow the patient copious draughts of water, or of some other bland 438 ANASARCA. fluids. Dr. Cullen states, that dropsies have been cured by the free use of diluent drinks, without any other remedies. I have known an instance of extensive anasarca cured, after a course of ineffectual treatment, solely by the free indulgence in eating water-mellons. Much dispute has existed as to the propriety of allowing patients the free use of aqueous potations. It has been strenuously asserted by some, especially the older writers, that the plentiful use of drinks in this disease, is decidedly pre- judicial. Others, on the contrary, have maintained that this grateful indulgence is not only harmless, but often manifestly beneficial. Upon this subject, however, no universal rule can he laid down ; for the fact appears to be, that, in some instances, a liberal indulgence in the use of drinks is followed by unfa- vourable consequences ; whilst, in other cases, manifest benefit results from it. In all those instances of hydropic effusion which are the result of excessive haemorrhage, copious draughts of diluent drinks are, according to my own observa- tions and views, decidedly detrimental. When the blood-ves- sels are suddenly deprived of a large portion of their contents by haemorrhage, their veinous extremities absorb with great rapidity whatever aqueous fluid may be taken into the system. The blood-vessels will therefore soon be replenished, if much fluid be taken into the stomach ; and as this circumstance— from the large proportion of crude watery fluid in the blood- vessels must favour the dropsical effusion, as explained in the beginning of this chapter, injury can scarcely fail to result from the free use of diluents in such cases. The blood in dropsies from haemorrhage consists almost wholly of serum, the crassa- mentum being always exceedingly small; and the more drink there is taken in such cases, the longer will the morbid dispro- portion between these two constituents of the blood continue. Upon this point, Dr. Parry makes the following observations, which go directly to strengthen the above sentiments. " When dropsy is associated with large haemorrhages it does not usu- ally accompany them, but comes on after they have ceased; and I have concluded, that it is the effect of the fluids taken into the stomach being absorbed too suddenly for the relative state of the vessels, vvhich therefore strive, if I may be allowed the expression, to get rid of it by every outlet." It appears to me manifest, therefore, that in such cases of dropsy, it will he advantageous to abstain as much from the use of drink as the urgent thirst will admit. In instances arising from other causes, however, and in which the general diathesis is mani- festly phlogistic, a moderate indulgence in the use of mild be- verages may he allowed with advantage. When, indeed, the thirst is great and the blood sizy, diluent drinks may be re- garded as decidedly remedial. Among the diuretics recommended in the treatment of drop- ANASARCA. 489 sy, the following are the most important, viz. squill, digita- lis, acetate of potash, nitrate of potash, cantharides, juniper berries, colchicum, spirit of turpentine, erigeron heterophyl- lum, and parsley. Of all these articles the squill is the most generally employ- ed, and, upon the whole, the most useful diuretic in the treat- ment of hydropic affections. It does not, however, appear to be equally beneficial in all the varieties of this disease; for wbere there exists much febrile reaction, and the general dia- thesis is decidedly phlogistic, its effects are rarely conspicu- ously salutary. In instances of dropsy, on the contrary, where the urine is scanty, high-coloured, and sedimentous, with no very decided phlogistic habit of body, its powers are in general peculiarly beneficial. Almost all writers agree that squills are, generally, decidedly the best diuretic we possess in the treatment of hydrothorax. Blackall, M'Lean, Ayre, and many other respectable writers on this subject recommend this article as particularly calculated to do good in this variety of dropsy; and my own experience has furnished me with abun- dant evidence of the propriety of this recommendation. The squill is commonly prescribed in union with other arti- cles, and it would appear that its diuretic powers are frequent- ly considerably enhanced by such combinations. Home thought that its diuretic effects were often much increased by uniting it with some article calculated to promote its emetic powers; but Cullen strenuously opposed this opinion, and pointed out its erroneousness. Perhaps the best adjunct to squills is calomel—more especially in the treatment of hydro- thorax. I have been most satisfied with the triple compound of squills, nitrate of potash, and calomel, according to this for- mula. R. Pulv. scillas 9i. P. nitrat. potassae 3'ii. Calomel gr. v. M. Divide into ten equal parts. S. give one every four hours. The only objection which I have found to exist against this combination, is its tendency in some instances of producing gastric disorder; such as pain in the stomach, nausea, or vo- miting. When effects of this kind occur, and the arterial sys- tem is not too much excited, we may unite one-fourth of a grain of opium, with this mixture, and often with very happy effects. The addition of calomel to the squill, I may again observe, is peculiarly valuable in hydrothorax; for although this mercu- rial will frequently do much good in the other forms of dropsy, yet its tendency to increase diuresis when given in this com- bination, is generally much more conspicuously displayed in the former variety of the disease. Dr. Blackall asserts, that 440 ANASARCA. squills act much more powerfully on the kidneys when given in as large doses as the stomach will bear without nausea. Dr. Ayre, on the other hand, recommends the exhibition of this article in very small but frequent doses, and Richter, also, is in favour of this mode of administering it. I prefer giving the squill in doses of from one to two grains every three or four hours, whether singly or in combination. The squill is also frequently given in combination with digitalis ; and many add to this combination small doses of calomel. In general, in ana- sarca from scarlatina or cold, digitalis may be very advanta- geously given in this manner. The most serious objection to the employment of squills, is its aptitude to irritate and derange the digestive apparatus. Its tendency in this way is so considerable in some individuals, that it cannot be used at all. Indeed, some persons appear to have an idiosyncracy against the influence of this article—ren- dering even the smallest doses injurious. Besides the formu- la given above, I will add another one, which in some instan- ces, has in my hands produced the most copious discharges of urine. R. Pulv. rad. scill. gr. viii. Pulv pip. niga. gr. x. P. nit. potass. gr. xviii. Submuriat. hydr. gr. iv. Pulv. opii gr. ii. This is to be given once daily, (altered from Fordyce.) I have found this combination particularly efficacious in cases attend- ed with much languor and relaxation of the system. Rich- ter mentions it as peculiarly useful in cases of this kind. Digitalis is another valuable diuretic in the treatment of dropsy. The most opposite opinions, are, however, expressed in the books, in relation to its powers in this disease. By many it is highly extolled ; whilst some speak of it as of little or no essential value. The weight of good testimony is, neverthe- less, decidedly in favour of its usefulness; although, upon the whole, it is undoubtedly inferior to the squill as a diuretic in hydropic affections. According to the observations of Wither- ing and others, digitalis will seldom do much good in persons who are of a robust habit and tense fibre. Its beneficial pow- ers are most apt to be manifested in subjects of a relaxed and irritable habit of body. Dr. M'Lean entirely confirms this observation of Withering. He asserts, that he has seldom de- rived any particular advantage from this article in persons of a corpulent habit and an irritable fibre ; but in such as were of " a weak, delicate, irritable constitution, with a thin, smooth, and soft skin," he has generally succeeded well with this re- medy. So far as I am able to judge from my own experience, ANASARCA. 441 I am inclined to think that there are good grounds for these observations. Dr. Blackall observes, that digitalis is our best remedy in those cases of dropsy which occur after scarlatina and measles; an observation which I believe to be well found- ed. I have known the diuretic effects of this article in such cases promptly efficient in removing the dropsical accumula- tion. Digitalis would appear to be especially efficient in those cases of dropsy which are attended with a very scanty secre- tion of urine, becoming turbid when cold, and coagulating when exposed to the heat of a lamp, and depositing a red sedi- ment after standing for some hours. (Blackall.) When the urine, though loaded with serum, is pale and crude, and rather abundant, digitalis, according to this writer, will very seldom do any good in hydropic affections. In such cases, he says, the squill is the best diuretic we possess. These observations deserve particular attention in the selection of an appropriate diuretic ; for although they may not be universally, or per- haps very generally applicable, there is yet sufficient correct- ness in them as a general guide, to afford considerable assist- ance in the adoption of our remediate means. Digitalis is not often employed singly. The most common mode of prescribing it, is in combination with squills. In cases attended with considerable febrile excitement, it may be very advantageously given in union with nitre. In very feeble habits, where there is much restlessness, spasmodic dyspnoea, and frequent and distressing urgency to void urine, I have known a combination of opium with digitalis to afford much relief. The addition of opium to this, or to whatever other diuretic may be used, is especially called for in cases attended with frequent and ineffectual efforts to evacuate the bowels— a condition which is sometimes superinduced by the inordinate use of drastic purgatives. Digitalis ought to be administered in substance; it has appeared to me to do most good when given in small but frequent doses—that is, from one-sixth to one- fourth of a grain every hour or two until its peculiar influence on the system is perceptible. In general, this article is more effectual in removing anasarca than ascites, and ascites than hydrothorax. Many physicians are in the habit of prescribing it, in union with calomel, and there can be no doubt, that under certain circumstances, occasionally present, this combination will act with peculiar advantage. Drs. Blackall and Paris, however, decidedly condemn this practice. Conceiving that the curative powers of digitalis in dropsy are dependant on its se- dative effects, they maintain that calomel, being a stimulant of no inconsiderable powers, is incompatible as a therapeutic agent with the digitalis, and that it must necessarily tend rather to counteract than to promote the salutary influence of the latter. vol. n.—56 442 ANASARCA. This objection appears to me hypothetical; and it certainly i9 frequently contradicted by experience. There is no good ground for believing that the diuretic effects of this article de- pend on its sedative powers; for the former effect is generally most conspicuously evinced when the action of the heart and arteries is least reduced ; and, on the contrary, diuresis is some- times entirely wanting when the sedative influence of the digi- talis is the most conspicuous. In general, the more phlogistic the diathesis is, the more ap- propriate will this article be. In such cases we may employ it with the twofold intention of exciting an increased flow of urine, and of moderating the general vascular irritation. Cantharides have been employed with no inconsiderable de- gree of success in the treatment of dropsy.* Where the gene- ral habit is weak and sluggish—and especially where the dis- ease is connected with an original torpor of the kidneys, this article will sometimes excite copious diuresis. Hufeland re- commends the following formula for administering the can- tharides in this affection. R. Pulv. canthar. 9"ii. Amyd. dulc. 3L Sacch. alb. liss. Rub them together in a mortar, and make an emulsion, by adding gradually ten ounces of warm water. Of this a table- spoonful is to be taken every two or three hours, until symptoms of strangury supervene. I have known this mixture to reduce anasarca from suppressed menses, very speedily. This reme- dy appears to he particularly adapted to cases arising from suppressed cutaneous affections. (Richter.) Colchicum autumna/e has not hitherto been much employed in the treatment of dropsy ; its powers, however, appear to me to deserve more attention in this respect than it has as yet, I believe, obtained. I have derived great benefit from this medicine in a case of anasarca, apparently the consequence of a gouty habit; and I am disposed to give it a trial in all cases attended with a rhumatic or gouty diathesis. I have found it most efficacious as a diuretic, when given in union with the sulphate of potash. In the case just alluded to I gave it in doses of forty drops of the vinous tincture, with a scruple of the powrdered sulphate of potash every six hours. The Nitrate of potash has been much employed, and often with the happiest effects in hydropic diseases. It is usually given in combination with other articles—particularly squills and digitalis. I have employed it by itself with much benefit * Prispane's Select Cases. Chalmers on the Diseases of South Caroli- na. Robertson's Treatise on the Powers of Cantharides used internally. Edinb. 1826. ANASARCA. 443 in a few cases of ascites. It will rarely do any good in hydro- thorax. From its known antiphlogistic powers, it is manifest- ly only in cases characterized by a phlogistic habit of body, that any advantages can be looked for. When the pulse is small, corded, and irritated, nitre and opium in combination, will frequently do much good. From fifteen to twenty grains of the former, with from one-fourth to half a grain of the latter may be given every three hours. I have known this combination to render the pulse soft and expanded, the skin moist, and the urine copious. There are a number of other diuretic remedies, all of which have been used with more or less of success in the treatment of dropsies. It is by no means uncommon to succeed in remov- ing dropsical accumulations through the renal emunctories by means of some simple diuretic article, after the more powerful and esteemed remedies of this kind have been tried without success. I have known the infusion of the erigeron hetero- phyllum to bring on copious diuresis and to reduce dropsical swellings speedily, after the remedies already mentioned had been given unsuccessfully. This is, indeed, an article which merits no small degree of attention as a diuretic in this dis- ease. It may be conveniently employed as a ptisan, along with the squill, digitalis, or some other more powerful article. The infusion of the seed of daucus carota, too, is an excellent diuretic, and has been a good deal employed by the practi- tioners of this country. Of a similar character are juniper berries, lactuca virosa, gallium aperine, horse raddish, and a number of other diuretic vegetables, employed as domestic re- medies, and occasionally also in regular practice. Of the use- fulness of the gallium, lean speak from experience. I knew an instance, where a strong infusion of this vegetable removed a longstanding case of abdominal dropsy in a very short time. Whatever remedies may be prescribed, the concomitant use of some one of these ptisans will generally contribute more or less to the success of the treatment. When the stomach will hear it, the erigeroii will in general answer better than any of the other articles just mentioned. This was a favourite medi- cine with the late Dr. Wistar. It is well to have a variety of diuretics at hand, in the treatment of dropsy ; for in some in- stances, a number of the most active medicines of this kind will he used without the least perceptible action on the kidneys, and yet at last there will be some one found vvhich will speedily produce copious diuresis. It is a good rule to vary the pre- scription, if after a reasonable time and proper auxiliary mea- sures, the desired effect does not ensue.* • Dropsy is a disease by no means so uniform in its character as is ge- nerally supposed. It arises from a great variety of remote causes—in 444 ANASARCA. Diaphoretics are mentioned by Celsus as among our best means for the cure of dropsy. We can very rarely pro- cure the full operation of diuretic remedies so long as the skin remains uniformly dry and harsh. The union, therefore, of an- timonials with diuretics will, in instances of a decidedly phlo- gistic character, often assist materially in removing dropsical accumulations. Sydenham appears to have placed very consi- derable reliance on the employment of antimony in this affec- tion, although his principal object in prescribing it was the production of active vomiting—an effect which will sometimes procure the speedy absorption and removal of dropsical accu- mulations from the abdomen and cellular tissue. 1 have never myself employed antimony with this view, hut as a diaphoretic I have known it to produce very happy effects. In those cases of anasarca and ascites, which occur in consequence of sup- pressed perspiration from cold when the system is under the influence of mercury, or after an acute cutaneous disease, I know of no remedy which will more certainly procure relief than antimony, given in minute arid frequently repeated doses. I have also known it speedily successful in a case of anasarca from a protracted intermittent. In general, wherever the ex- citing cause of the disease is cold, or connected immediately with torpor of the cutaneous exhalents, antimony ought not to be neglected as a means of relief. I have always given it dis- solved in a large proportion of some diaphoretic beverage—- such as infusions of juniper-berries, wild-carrot seed, parsley, or erigeron. One grain may be dissolved in a pint of any of these ptisans, and drank ad libidum during the day, so that at least one, and, if convenient, two pints may be taken in this space of time. Monro speaks favourably of a combination of antimony and opium : when the disease is attended with a rheumatic habit, this mixture is often especially beneficial. It must not be forgotten, however, that very profuse perspiration and diuresis are incompatible ; all that is requisite, in relation to the action of the skin, when we continue to act on the kid- neys, is to render it soft, relaxed, and moderately moist. the most opposite states of the system, with regard to vascular action and repletion—it is dependant on various organic affections ; appears as a consequence of different acute and chronic affections, and is attended with diverse and distinct characters of the urinary secretion. These cir- cumstances point out much diversity in the general character of the dis- ease itself, and it is not reasonable to suppose that any one particular diuretic is equally applicable to the disease under all these diversities of general character. When, moreover, we take into view the diversi- ties of constitutional habit—of idiosyncracy—and the ever-varying state of the organic functions—we can readily conceive, that out of a great number of diuretics, there might not be more than one which is calcu- lated, in a particular instance, to excite the action of the kidneys. It is, therefore, a good rule to vary the prescription, if after a reasonable time and proper adjuvant measures, the desired effect does not follow. ANASARCA. 445 In those cases of anasarca, in which the skin is cold and very dry, with a sluggish action of the pulse, the black sulphuret of iron is a medicine of excellent powers. Dr. Archer, of Nor- folk, has reported an interesting case which was speedily cured by this remedy. It is also mentioned by Alibert,* as an ex- cellent medicine in anasarca attended with great relaxation and weakness. I have had occasion to prescribe it in two in- stances of this kind—both the consequence of immoderate flow of the lochia, and great previous debility ; and the results were highly gratifying. This article generally excites a glow of warmth throughout the whole body, attended with a peculiar tingling sensation in the extremities; and in most instances a profuse perspiration ensues a few hours after it is taken. Be- sides its diaphoretic effects, it is also peculiarly calculated to do good in such cases, by its tendency to invigorate the assi- milating functions. I am not aware that any advantages are to be obtained from this article, in any other cases than such as proceed from excessive haemorrhages, or other exhausting and relaxing causes. Diaphoretics are in general useful only in anasarcous dropsy. Among the ancient Romans it was cus- tomary to excite sweating in this disease, by burying the body uj> to the neck in warm sand ;f and I may here also mention the use of oiled silk, which, when closely applied over the sur- face of the body, generally excites a considerable perspiration. This application is particularly useful in local dropsical effu- sions into the cellular tissue.£ Emetics have by some been highly extolled for their power of removing dropsical accumulations. I have already men- tioned Sydenham as an advocate for their employment in this disease ; and I may add the authority of Richter, Lentin, Cruikshank, and Pinot in their favour. I knew an instance of ascites which was rapidly removed by spontaneous and pro- tracted vomiting; but I have never yet prescribed remedies with a view to their emetic operation in the present disease. Mercury is a favourite remedy with many of the American physicians in the treatment of dropsy ; and there can be no question as to its utility in certain modifications of the disease. In cases depending on hepatic and splenic disorder, it consti- tutes, indeed, our main stay ; and in the treatment of hydro- thorax, it is generally highly beneficial. In instances which occur in consequence of excessive haemorrhage, or other ex- hausting causes, and in subjects of a scorbutic or depraved habit of body, mercury, however, cannot be employed with propriety. Some degree of firmness of the general habit may * Elemens de Therapeutique, torn. i. p. 180. X Celsus. De Medicina, lib. iii. cap. xxx. X Richter Specielle Therapie. vol. iii. p. 59. 446 ANASARCA. be regarded as the most favourable for the exhibition of mer- cury, with a view to its constitutional influence. {Blackall, M'Clean.) A decidedly inflammatory condition of the system, however, is opposed to the beneficial influence of mercury in this disease; and where such a diathesis is conspicuous, anti- phlogistic measures must precede its employment. Calomel is the preparation usually prescribed in dropsy. As a general rule, merciirializatiou should not be carried beyond the extent of producing only a slight soreness of the gums ;—profuse ptya- lisin being not only unnecessary to procure the peculiar advan- tages of this remedy, but sometimes, perhaps generally, inju- rious in its consequences, more especially in anasarca. This article, as has already been stated, is almost always given in combination with some diuretic, particularly squills and digi- talis. In ascites, much benefit may sometimes be derived from mercurial frictions on the abdomen. From some cases vvhich have, been recently published, it appears that subacute inflam- mation of the peritoneum often yields to mercurial frictions, without scarcely any aid from other means. Lsenuec has cured cases of effusion into the abdomen by this application, after various other remedies, usually relied on, had been employed without benefit.* Tonics were at one time much employed in dropsy. The disease was supposed to depend chiefly on debility and relaxa- tion, and every effort was accordingly made to invigorate the system. In general, this class of remedies is not only useless, hut injurious. Occasionally instances are met with, in vvhich tonic remedies produce very good effects. Where the general debility and languor are very great, and the pulse feeble and sluggish, bark, iron, particularly the muriatcd tincture, and the vegetable bitters, may perhaps be used with advantage. Gum kino, in large doses, cured a case, after various other remedies had been used without benefit.f The sulphate of copper has been frequently given with complete success in ca- ses of dropsy attended with great vascular debility. Gardane, Chalmers, and Wright, mention successful instances of this kind. This remedy has been generally given in combination with opium, in doses of a grain of each three times daily. It were, indeed, almost an endless task to give an account of all the remedies which have, under peculiar circumstances, removed dropsical accumulations. The following are, perhaps, the principal articles of this kind. Ipecacuanha, Dover's pow- der, helleborus niger, pillulse hydragogse janini, radix sambuci, * Revue Medicale, Mai, 1824. t Medico-Chirurg. Review, July, 1827. ANASARCA. 447 the fixed alkalies,* millepedes, lactuca virosa, garlic, scandix cercfolium, apium gravcolens, onions, iris palnstris, sorbus au- cuparia, balsam copaiva, turpentine, olive oil, opium,] apocy- num cannabinum, pipsissiwa, trifolium fibrinum, camphor, and asparagus. Dr. Laurie has published cases which tend to show that the internal use of nitric acid is often very effica- cious in those forms of dropsy which succeed to acute febrile diseases.^ Within the last few years, the radix cahicae, a South American product, has been highly recommended for its diuretic powers. In Germany, it has been used with great ef- ficacy in some varieties or dropsy.C) In this country it has not, I believe, as yet been employed as a remedial agent. The external application of diuretic agents, has of late years been employed with considerable success in this disease by some of the French physicians. It would appear from the ac- counts which have been published, that the kidneys may often be as actively excited by the application of diuretics to the sur- face of the body by the way of frictions, as when they are taken internally. Indeed, where the stomach is weak and irritable, a condition so peculiarly opposed to the regular operation of diuretics, the external mode of using them, if, in truth, their remediate influence may be thus fully obtained, would be deci- dedly preferable. I have seen but one instance of this disease in which the production of diuresis was attempted in this way, and this case afforded me sufficient evidence, that some advan- tage at least may, perhaps, frequently result from frictions on the abdomen with diuretic remedies. In a recent number of the Revue Medicale,\\ there are four cases of thoracic and ab- dominal dropsv, which were successfully treated upon the ialraleptic plan. The author, Dr. Guibert, directed frictions * The alkalies are, indeed, sometimes decidedly beneficial. Monro, Pringle, Mead, and Fallot, speak of them, in terms of encomium, as re- medies in dropsy. They are said to be particularly applicable in cases attended with great atony. They have been generally given in union with vegetable bitters. I attended an old lady, during the present year, (1828) affected with ascites and anasarca of the inferior extremities, in whom I found no remedy so useful as the salt of tartar in union with the expressed juice of tansy. She took ten grains of the alkali with a ta- ble-spoonful of the juice, thrice daily. The celebrated Frank, thought highly of the powers of the alkalies in dropsy. His formula is,— R. Kali, carbon. tbj. Herbse absinth. *,x- Infunde c. vin. rhen. tfej- Digere per xxiv. horas. cola. Dose, one ounce every four hours. X I have prescribed opium in a case attended with a rheumatic habit with unequivocal benefit. X Analen der Medizin. vol. iv. p. 266. § Dr. Mcering. || Septembre, 1828, p. 349. 446 ANASARCA. on the chest, or the abdomen, or the thighs, according to the form of dropsy present, w ilh the following fluid. R. Tinctura scillge. -------digitalis. -------sem. colchic aa %ss. 01. camphorat. l'ss' ^* The frictions to be made with flannel three or four times daily, and continued from five to twenty minutes. Concomitantly with this external application, he ordered a diuretic mixture to be taken internally, composed of squills, digitalis, and nitrate of potash in equal quantities, and a somewhat larger portion of thridace, in doses of two grains and a half of the mixture twice daily. "The iatraleptic method of treating dropsy," says Dr. G., "has appeared to me particularly efficacious in abdominal dropsy, and it is chiefly to the external employment of the above diuretic liniment, that I think myself warranted to ascribe the success which attended my efforts, in the above cases. The internal remedies which I employed at the same time, seemed to me very useful auxiliary measures, but they could not, I am persuaded, have by themselves produced the very copious urinary discharges, resembling almost complete diabetes, which occurred in these cases under this treatment. In all of these cases, and I might adduce others equally re- markable, the dropsical swellings were reduced with surpris- ing rapidity. The iatraleptic mode of treating this disease is attended with little or no inconvenience to the patient. It should not, however, be adopted until the phlogistic state of the system is reduced by appropriate antiphlogistic means. In idiopathic ascites and anasarca, this mode of treatment will succeed almost without exception." Among the external means which may be resorted to with occasional advantage in ascites, a tight flannel bandage worn around the abdomen will frequently prove decidedly beneficial. This application was much extolled by the late Dr. Monro in the treatment of abdominal dropsy. 1 have repeatedly found such a bandage of advantage, particularly after the dropsical swell- ings had been in part removed, but continued stationary for some period. The effects of the bandage will be increased, if it be soaked in a strong solution of salt, and dried again before it is applied. Would not the powers of such a bandage be still more enhanced by imbuing it with a strong infusion of squills, or of some other active diuretic ? After all, our efforts to prevent, or remove the accumulation of dropsical effusions, are but too frequently foiled; and it be- comes necessary, in order to prolong the life of the patient, and to gain more time for remediate applications, to evacuate the collected fluid by means of a puncture into the cavity which ANASARCA. 449 confines it.* It is usual to delay this operation until every other measure for the removal of the fluid has been found un- availing, and the distention from the effused water becomes so great as to threaten immediate danger. This is one of those errors in medical practice, which, though readily and generally acknowledged by practitioners, it becomes extremely difficult to correct, on account of the great dread which all surgical ope- rations, and especially such as penetrate into the large cavities, are so apt to excite with patients. Being, moreover, univer- sally viewed as the last resource, and only for a temporary pro- crastination of the fatal conclusion, few are willing to submit to the operation, until all other means for removing the water have been tried. Without doubt, however, tapping is by far the most direct and certain means for removing dropsical accu- mulations, and it is as safe in its consequences as any of the other measures that may be adopted for this purpose. Were tapping more early resorted to in ascites than it always is, there can be hut little doubt, that its permanent usefulness would be greatly enhanced. The mere mechanical irritation of the effused fluid, when the distention is very great, must tend to keep up that morbid condition in the peritoneum which gives rise to the effusion. The earlier this over-distention is taken off, the greater, one may reasonably presume, must be the chance of effecting a radical cure by some of the means al- ready mentioned—more especially by local bleeding, blistering, mercury, and frictions. Indeed, the operation is by no means simply palliative in its consequences. There are many cases on record which were perfectly cured, solely by removing the water by an operation. Frank, Lentin, Richter, Dessault, Fothergill, and others relate cases of this kind ; and there is reason to presume, that if tapping were not so commonly de- layed until the disease has assumed an inveterate character, such fortunate terminations would be much more frequent than they are under the present plan of procrastinating it.-f * It is truly surprising what large quantities of water are sometimes drawn in the aggregate, in cases of abdominal dropsy. M. Lecourt de Cantilly has related an instance in which the operation of tapping was performed one hundred and thirty-five times in the course of six years, and by which the aggregate amount of two thousand seven hundred pounds of water was drawn off. Mead mentions a case (monita) in which tapping was performed seventy times in five years and seven months, and which yielded one thousand nine hundred pounds of water. M. Louyer Villermay relates an instance where tapping was undergone five hun- dred times, the patient having finally tapped himelf.—Revue Medicale, Juillet, 1828. X M. Lhomme, in January, 1827, communicated to the French Royal Academy of Medicine an inveterate case of ascites, which after hydra- gogues, diuretics, and tapping had been fully, but unavailingly employ- ed, wa3 speedily cured by the injection of the* vapour of wine into the vol. ii.—57 ( 450 ) CHAPTER XXXI. SCROFULA. Scrofula appears in a great variety of forms and grades of violence—varying from the slightest habitual deviations from health, to the most distressing, rapid, and fatal forms of local and general disease. In a general way, scrofula may be divid- ed into two distinct forms ; namely, its latent and its active states. The former constitutes what is usually called the scrofulous habit or diathesis ; and the latter, the state of full development and activity of the disease. The scrofulous habit, or predisposition to the active forms of the malady, is characterized by the following phenomena: a peculiar delicacy and languor of the countenance, with a soft, rosy tint of the prolabia and cheeks;* or a pale, soft, flaccid, and apparently tumid aspect of the countenance, with a dull lead-coloured circle round the mouth, and a swollen appear- ance of the upper lip. The hair is generally fair, and the eyes blue or black. The head is usually large, particularly the posterior part, and the temples flattened, or somewhat de- pressed. There is in general a great proneness to slight ca- tarrhal affections, during which the wings of the nose and upper lip are apt to become considerably swollen. The edges cavity of the abdomen through an orifice made with a trochar. He was led to the employment of this anceps remedium by having read in the Annales de la Medicine Physiologique an account of two cases of abdominal dropsy which were cured by the same means. The vapour of wine was injected sixteen times without causing any pain or particu- lar uneasiness in the abdomen, with the exception of some slight colic pains vvhich required no remediate attention. At the time of reporting the case, two years had already elapsed from the period at which the in- jection was made and the malady arrested. M. Lhomme tried the same means in another case, but without success. No unpleasant consequences, however, resulted from the operation. It is not difficult to conceive how such a measure might put a stop to dropsical effusion, if a state of chronic inflammation of the peritoneum be its cause. It is well known that stimulating applications are generally the only means effectual in re- moving inflammations of a low or languid grade of excitement. We thus remove gleet, chronic ophthalmia, and chonic bronchitis, by stimu- lating injections, collyria, and inhalations of the vapour of tar.—Revue Medicale, vol. i. p. 343. * This appearance of the countenance is particularly met with in those instances of a scrofulous habit, in which a particular tendency to phthisis pulmonalis exists. Mr. Lloyd, however, asserts tbat there are no just grounds for regarding the white and rosy cheek, the flaxen hair, and azure eyes, as marks indicative of the scrofulous habit. SCROFULA. 451 of the eyelids are much disposed to become inflamed, and where the scrofulous tendency is strongly developed, the tarsi are almost constantly red and tender. The digestive powerf are usually weak and irregular, and the bowels are apt to be either constipated, or affected with painful mucous diarrhoea. The appetite, also, is very variable—being sometimes entirely depressed, and at others very urgent. The urine commonly deposites a whitish sediment, and becomes turbid some time after it is passed. A disposition to transient swellings of par- ticular parts, as of the face and scrotum, is mentioned by some writers as belonging to this habit; in female children, a leu- corrhceal discharge not unfrequently occurs from time to time. In very young children, excoriations behind the ears, scabby eruptions about the head and lips, obstinate ophthalmia, toge- ther with a fretful and irritable temper, are among the most common phenomena attending the scrofulous diathesis. The growth of the body usually proceeds slowly; but the mental powers are generally precociously developed, and often asto- nishingly active. This dormant or inactive state of the disease may continue for many years, and at last pass off without ter- minating in any particular local affections. More commonly, however, the scrofulous habit gradually acquires strength, and at last, under the influence of the usual exciting causes, shows itself in its more obvious and active form. The lymphatic glands along the neck and other parts be- come enlarged and firm to the touch, in which condition they may remain for years, without either receding or going on to a more active form of disease. In general, however, they pass by degrees into slow inflammation, which at last terminates in suppuration or scirrhus. When they suppurate, which is by far the most common mode of termination, they form chronic indolent ulcers, from which a thin, milky, and somewhat viscid fluid is copiously discharged, and which are always extremely slow in cicatrizing. The cicatrices left by these ulcerations are, in general, easily distinguished from those left by other ulcers. They are peculiarly uneven, irregular, and conspicu- ous. In connexion with these tumours or ulcerations about the neck, the eyelids and conjunctiva are very apt to become affect- ed with obstinate inflammation ; and, in some instances, much irritation occurs in the mucous membrane of the nose and bronchia. In a more advanced state of the disease, the salivary and thyroid glands, as well as the pancreas and other internal glandular parts, become enlarged and indurated. Scabby eruptions appear on different parts of the surface; the extre- mities of the long bones enlarge ; ulcerations occur in the car- tilaginous structures; some of the bones become carious ; the large joints inflame and suppurate; in some instances the ver- tebra? become diseased; and occasionally the bones and soft 452 SCROFULA. parts of the nose, palate, and fauces are more or less rapidly destroyed by ulceration. There is, in short, scarcely any part of the body which is not sometimes the seat of the frightful ra- vages of this affection. The most common forms of scrofula, however, arc, tubercular phthisis pulmonalis ; white swelling, or disease of the hip and knee joints, and ophthalmia. The general progress and duration of scrofula arc exceed- ingly various. In some cases it is developed in infancy, whilst in others the constitutional tendency to the disease remains dormant until the age of puberty, or to a period much later, before it manifests itself in an active state. Some individuals are more or less affected with scrofulous disease of the lym- phatic glands during the greater period of a long life, without experiencing any particular sufferings from this source. Much more commonly, however, some one or more of the distressing and fatal consequences already mentioned, ensue before the age of manhood. Although scrofula is vastly more common during childhood than at any other period of life, yet the occurrence of decided scrofulous affections in new-born infants is an ex- ceedingly rare phenomenon. Mr. Lloyd, nevertheless, states, that he found the lungs of an eight months foetus tuberculous— the mother having died of phthisis pulmonalis; and a few si- milar instances may be collected from writers on this subject. The manifestations of the scrofulous habit seldom make their appearance before dentition commences. Causes.—Scrofula, or rather an especial predisposition to this disease, is one of those constitutional habits or tendencies which often occur in children as an hereditary diathesis. This, however, is by no means the only source of the scrofulous ha- bit ; for that it may be generated in individuals originally of sound constitutions, and horn of parents perfectly healthy in this respect, by various external influences, admits of no doubt. The causes which are acknowledged to be most frequently and actively concerned in the production of a predisposition to this disease, are— 1. Climatic and atmospheric influences. It would appear that the influence of hot climates, in infancy and early youth, has a considerable tendency to predispose the system to the occurrence of the scrofulous diathesis, from the subsequent in- fluence of a cold, variable, and damp atmosphere. Scrofula is a very uncommon disease in the East and West-Indies; but when the children of Europeans, born in these climates, or even the natives, arc brought to reside in the variable climates of Eu- rope and this country, they are in general particularly liable to suffer more or less from scrofulous affections. '• We know at least," says Dr. Allison. ** that a great majority of the in- habitants of the West and East-Indies, both negroes and Hin- doos, are unusually prone to scrofula when they come to tempe- SCROFULA. 453 rate climates."* A cold, humid, and variable atmosphere, more especially when aided by deficient and unwholesome nourish- ment, appears to have a strong tendency to favour the develop- ment of the scrofulous habit. It is from this cause, probably, that in the deep and narrow valleys of Switzerland and Savoy, in which the atmosphere is very variable and humid, certain forms of scrofula are so very common. In Holland, and in some of the marshy districts of England, this disease is said to be peculiarly prevalent. 2. The impure arid confined air of populous cities also seems particularly capable of promoting the occurrence of scrofulous diseases. It is certain, at least, that in the same amount of population, this malady is vastly more common in large and crowded cities than in the salubrious districts of the country. " It is notorious," says Dr. Gregory, "that the population of our large manufacturing towns—Manchester, for instance— pent up during the day in cotton mills, are of all others most affected with it." 3. Deficient and unwholesome food, with the usual attend- ants, squalidness and mental depression, may contribute to the production of the scrofulous diathesis. Without doubt, however, coarse, indigestible, and irritating articles of diet, when habitually and freely used by young children, have a much more decided tendency to produce this affection, that mere deficient or innutritions aliment. An improper dietetic management of very young children, in relation both to quan- tity and quality, is probably one of the most common sources of scrofulous affections. By over-distention of the stomach, or the use of heavy, irritating, or indigestible food, dyspepsia and high irritation of the gastro-intestinal mucous membrane will seldom fail to supervene ; and as this condition of the stomach and bowels is usually attended with a morbid appetite, more food is habitually taken into the stomach than can be digested, and the gastro-intestinal irritation is thus kept up, until the chylopoietic and assimilating functions, and indeed the whole system, become intimately deranged. Nothing is more com- mon than to meet in children, who have been mismanaged in this way, and who are almost constantly eating from morning to night, glandular swellings along the neck, and scabby erup- tions on the head and face, with tense and tumid abdomens, and other symptoms of gastro-intestinal disorder, where, from the helath of the parents, no hereditary taint can be presumed to xeist. Chronic inflammation, or habitual irritation of the mucous membrane of the stomach and bowels, is probably much more frequently concerned in the formation of the scrofu- lous habit than seems to be generally supposed. There are few * Observations on the Pathology of Scrofulous Diseases, &c. p. 397. 454 SCROFULA. children long affected with what is usually called marasmus, who do not subsequently manifest a predisposition to scrofu- lous affections. 4. Various diseases possess a tendency to give rise to the scrofulous diathesis. This is especially the case with measles, scarlatina, and whooping-cough; but it would seem, that it is rather by the influence of cold and errors of diet, during the stage of convalescence from these diseases, that the scrofulous habit is generated, than by any direct tendency in these affec- tions to develope this diathesis. Without specifying any more causes of this kind, however, we may observe, in a general way, that whatever tends permanently to derange the digestive powers, and to debilitate the general system during infancy and childhood, is calculated to engender a predisposition to scro- fula. My own observations, though limited in relation to this dis- ease, have led me to the conviction, that disorder of the diges- tive organs, from whatever cause it may arise, often constitutes the principal source of scrofulous symptoms. Upon this point, the observations of Dr. Carmichael appear to me to possess much interest and value. " I have adduced," he says, "in- controvertible facts, which demonstrate that disorder of the chylopoietic viscera precedes and accompanies the symptoms of scrofula, and that there are the strongest grounds for be- lieving that such disorder is, in a very great majority of cases, the immediate cause of the disease. A defective digestion con- tinued for any length of time, must as certainly produce chyle or blood of a vitiated quality, and unfit to replenish the waste of the body, as the constant use of unwholesome food. A disordered state of the system first ensues, and is fol- lowed by various local complaints. It is highly probable, however, that the gastro-intestinal irritation which always attends, in a greater or less degree, where the digestive func- tions continue long in a disordered condition, contributes as much, and perhaps much more, to the production of the scro- fulous symptoms in such cases, than the vitiated chyle which is prepared by the stomach."* It need scarcely be observed, that where there exists an here- ditary or natural predisposition to scrofula, the foregoing causes have an especial tendency to excite it into a state of activity ; for it is sufficiently obvious, that whatever is capable of originating the peculiar diathesis in question, will be still more apt to call it into action where it already exists. Scrofula cannot be communicated by inoculation, or in the manner of a contagion. Hufeland inoculated healthy children with matter taken from mild scrofulous ulcers, without the * Carmichael on the Venereal Disease, p. 351. SCROFULA. 455 least perceptible consequences on the health of the inoculated individuals.* Mere local ulcers or scabby affections have, indeed, been known to occur from the frequent application of the matter discharged by ulcerations of this kind. Thus, healthy children who sleep with persons affected with scrofu- lous scabby eruptions about the head, will sometimes become affected with similar disorders. Pathologists have expressed a variety of opinions in rela- tion to the essential nature of the scrofulous diathesis ; but the most plausible doctrine upon this point is, that the scrofulous habit consists in constitutional or acquired excess of irritabili- ty in the lymphatic system, in connexion with a weak condi- tion of the assimilative powers. Prognosis.—Where the predisposition is hereditary, the chance of subduing scrofula, after it has manifested itself in an active form, is always extremely small. Nevertheless, it is a fact well established, that even where the diathesis is mani- festly congenital, moderate cases of the disease not unfrequent- ly disappear entirely about the age of puberty, or after the cor- poreal development is completed, and the age of manhood has arrived. It must he observed, however, that these epochs in the physical development of the system, are much more fre- quently attended with results of a very contrary character; for it is precisely at these stages of life, that the scrofulous habit is most apt to pass from a latent to an active state. Si- milar observations apply to the effects of acute general dis- eases. Severe febrile affections have been known to remove incipient scrofula, in habits obviously predisposed to the dis- ease j but, as has been already stated, it is vastly more com- mon to find the disease more or less rapidly developed by violent febrile affections—more especially measles, scarlatina, and small-pox. In some instances, the disease slowly con- tinues to develope itself, until the stage of puberty or manhood has arrived, when it remains stationary during the subsequent period of life. In forming a prognosis, as to the probability of effecting a cure, or of a spontaneous subsidence of scrofula, particular regard must he had to the following circumstances. 1. The nature of the predisposing and exciting causes. Where a number of causes of this kind co-operate in the pro- duction of the disease; and especially where the situation and circumstances of the patient are such as to render an entire removal of them impracticable, the chances of advantage from remedial management must, of course, be exceedingly limited. Among the poor and squalid, who can neither procure proper nourishment, nor protect themselves against the injurious in- * Ueber :die natur, kendniss, und heilart der scrophel krankhert, p. 105. 456 SCROFULA. fluences of cold, it is next to impossible to effect a cure, when the disease shows itself in an active form. I have already stated the greater difficulty of removing hereditary scrofula, than those cases which arise from external influences. 2. The age of the patient and the duration of the malady. The younger the patient is, the more easy, in general, will it be to remove, or effectually counteract the progress of the disease. When the disease makes its first active appearance after the age of puberty or of manhood, the chances of being able to suspend its progress are but small, and still less to remove the symptoms altogether. 3. The degree of violence of the dis- ease. So long as the disease remains in a latent state, and is manifested only by the symptoms which especially charac- terize the scrofulous diathesis, a reasonable prospect of success may be entertained from proper remedial management. Even so long as the disease shows itself only in the usual form of glandular swellings about the neck, without any indications of tubercular formations in the lungs, a judicious treatment will sometimes arrest the further progress of the disease, and occa- sionally gradually effect a removal of the scrofulous symptoms. When these tumours become irregular, uneven, immovable, painful, and inflamed, the difficulty of arresting their progress, and still more of effecting their entire reduction, may be re- garded as nearly insuperable; and the prognosis will be the more unfavourable in proportion as these tumours are nume- rous. Suppurated scrofulous tumours when they are situated externally, and not attended with a strong constitutional ten- dency to the disease—are not, in general, to be regarded either as more dangerous, or difficult of management than mere in- flamed tumours, although they are always extremely tedious in their progress, and cicatrize very slowly. Indeed, the suppu- ration of external glandular swellings is sometimes attended with a manifest melioration of the general scrofulous symp- toms ;* and when suppurations of this kind occur in indivi- duals labouring under slight incipient symptoms of pulmonary tubercles, they should he encouraged rather than suppressed or cicatrized, unless, indeed, they begin to assume very unfa- vourable or dangerous appearances. When febrile symptoms, cough, and emaciation supervene, all hopes of successful treat- ment may be abandoned. 5. The seat of the local scrofulous affections forms, also, an important consideration in estimat- ing the probable issue of cases of this disease. So long as the disease appears to be concentrated upon the external glandular structures, some prospect of an eventual removal of the malady may, with reason, be entertained; but when the ravages of the * Bordeu, Recueil des pieces qui on tremporte le prix de l'Acad. Royal de Chirurg., vol. iii. p. 69, as quoted by Richter. SCROFULA. 457 disease occur in deep-seated structures, or internal organs— particularly in the lungs, and mesenteric glands, all ideas of ultimate recovery may be abandoned as entirely hopeless. Treatment___The first, and decidedly the most important part of the management of scrofulous affections, is a constant and careful avoidance of the various exciting causes enumerated above. Without an especial attention to proper observances in relation to this point, nothing, or at best but very little, can be effected by remedial treatment. The enjoyment of a pure, dry, and equable air; an attention to proper clothing, so as to obviate as much as possible the injurious influence of atmos- pheric vicissitudes ; a wholesome, abstemious, but nourishing diet; regular exercise in the open air ; and cleanliness, consti- tute the means upon which our hopes of successful opposition to the progress of the malady must chiefly be placed. So long as the disease shows itself only by a general scrofulous habit, without any important local affections, the diet should be simple, hut nourishing and digestible; and it is of great importance that the meals be taken at regular intervals, and no more food taken into the stomach at once, than can be easily and complete- ly digested. All kinds of stimulating irritating articles of food must be carefully avoided : and the same observation applies to every species of stimulating drink. The lean parts of ten- der and digestible meats may be moderately taken at noon ; and for children light animal broths; liquid, mucilaginous, or farinaceous preparations ; barley, rice, boiled apples, turnips, and milk, constitute proper articles of nourishment. With re- gard to the clothing of individuals labouring under a strongly developed scrofulous habit, it should be so regulated as to pre- serve as equable a temperature of the body as possible. Flan- nel should be worn next the skin, except in very warm weather, when it may he substituted by cotton. The influence of a pure and dry air, and if possible of an equable climate, is all-im- portant to the successful management of this malady. It would appear, from the observations of some writers, that the air along the sea-coast is often peculiarly beneficial in scrofulous affections ; but these are advantages which can seldom be en- joyed but by the wealthy, and the majority of scrofulous sub- jects in large towns cannot even obtain the benefits of a pure country air, so desirable in the treatment of this affection. In- activity and indolence are to be shunned as decidedly favourable to the progress of the malady. Walking, gestation in an open carriage, or, when the patient is old enough, riding on horse- back, should be regularly practised when the weather is fa- vourable. The patient should rise early from bed, and retire seasonably in the evening, and particularly avoid the damp and chilling night air. With regard to the medicinal treatment—whether for latent vol. ii.—58 458 SCROFULA. or active scrofula, the prominent indications are—to restore or maintain the integrity of the digestive, perspiratory, hepatic, and intestinal functions, and to support the general energies of the system. Of these indications, the regular maintenance of the action of the bowels and of the liver may be regarded of pri- mary importance. For this purpose recourse must be had to calomel, or blue mass, in conjunction or alternation with pro- per aperients. Some diversity of opinion is expressed by wri- ters as to the best mode of administering mercurials in this af- fection ; and some even condemn them almost entirely as remedial means in the treatment of scrofula, but most assured- ly without just grounds. Undoubtedly much caution is required in the employment of mercury in this disease, or where the scrofulous diathesis exists; for it cannot be questioned, that much mischief is apt to result from the constitutional or sali- vant influence of this article. Nevertheless, when it is given in small doses at proper intervals, followed by a mild laxative, or even in occasional purgative doses, its effects are often une- quivocally beneficial in every variety of scrofulous disease. When the bowels are in a loaded condition and torpid, the treatment should be commenced by pretty active doses of some purgative, and this should be repeated every third or fourth day, until there is reason to believe that the fecal accumula- tions have been removed. For this purpose, from two to six grains of calomel, according to the age of the patient, should be given late in the eveniug, and followed next morning by a dose of rhubarb, castor oil, or Epsom salts. When the in- testinal canal has been adequately evacuated in this way, it will in general be better to depend on the exhibition of from two to three grains of blue pill every night, with a pretty smart purgative every fourth or fifth day. From such a course of management, in conjunction with proper dietetic regulations, I have in several instances obtained the most decided benefit. Mr. Lloyd gives five grains of blue pill every night, with half a pint of the compound decoction of sarsaparilla twice a day; and if the bowels are not moved during the forenoon, he admi- nisters some laxative, so as to procure moderate evacuations. This plan he pursues until the action of the bowels becomes re- gular, and then goes on exhibiting the compound calomel pill, in five grain doses, every second night for an indefinite time.* The pills I have already frequently mentioned in the course of this work, appear to me peculiarly well adapted as an altera- tive in scrofulous affections. I have repeatedly prescribed them in cases of this kind with an excellent effect, f The employ- * A Treatise on the Nature and Treatment of Scrofula, &c. X R. Massae pil. hydrarg. ^ss. G. aloes soccot. gr. x. Tart, antimon. gt. 1. M. Divide into twelve pills. S. Take one every night, or second night, according to the state of the bowels. SCROFULA. 459 »ent of mercurial aperients should be persisted in as long as the alvine evacuations continue to exhibit an unnatural ap- pearance. Mr. Farr recommends mercurial frictions, as being preferable, in his estimation, to the internal administration of this medicine, more especially in children. He directs five grains of the unguentum hydrargyri fortius to be rubbed in upon the arm or leg of children from four to eight years old; eight grains in children from eight to twelve years of age, and twelve grains for subjects of from twelve to fifteen years old. "The frictions are to be continued until no portion of the oint- ment can be observed to stain a clean finger when applied to the part."* Mr. Lloyd makes the following judicious observa- tions in relation to the remedial treatment of scrofula in chil- dren. " Every one must have observed that the same medi- cine may act very differently on children even of the same age; and that what purges one violently, will have no effect on ano- ther. We should too he very careful not to exhibit violent purges; and we should particularly avoid large purgative doses of calomel, as I am convinced they often produce more general irritation than the evacuation they occasion from the bowels is able to relieve; and that they often so much weaken the stomach, that it is a very long time before it is able to re- cover its natural powers." To keep up a regular action of the bowels " any of the mild purgatives may be employed ; and if one does not appear to have the proper effect, we should de- sist from its use and substitute another." Although purgative doses of calomel are apt to prove injurious, " we may derive the greatest assistance from exhibiting alterative doses of this article." The dose should be varied from a half to one grain, according to the age of the child, and repeated twice or thrice a week. After the action of the liver and bowels has been in some degree brought to a regular state, benefit will in general re- sult from the employment of the tonic vegetable bitters ; and where the digestive functions are much impaired, it will he proper to resort to the moderate use of tonics, in conjunction with the alterative and aperient treatment, as soon as the fecal accumulations have been evacuated by a few brisk purges in the beginning of the treatment. Tonics are indeed generally recommended as peculiarly advantageous in counteracting the scrofulous diathesis; but I am inclined to think, that, except where the digestive powers are very feeble, and the mucous membrane of the stomach free from irritation, the active em- ployment of remedies of this kind is seldom attended with * A Treatise on the Nature of Scrofula, &c. p. 47, 48. 460 SCROFULA. advantage. Most assuredly they are decidedly indicated where the general system is languid and debilitated ; but in children, high mucous irritation of the alimentary canal is so frequently present in scrofulous affections, and the general habit is often so irritableand prone to inflammatory excitement, that the in- discriminate use of tonics must be frequently productive of mischief. When the alvine and hepatie functions are restored by alteratives, aperients, and proper dietetic regulations, "the symptoms of debility and relaxation almost always soon dis- appear, under the use of a nourishing and digestible diet, re- gular exercise, warm clothing, and the enjoyment of pure air. Most writers speak favourably of sea bathing as a means of invigorating the system and counteracting the scrofulous disposition. When the disease manifests itself in the form of a general scrofulous habit, without the presence of local affec- tions, in a state of active progress, benefit may, no doubt, be obtained from this measure; but it does not appear to possess any peculiar powers, as many formerly supposed, in promoting either the discussion of scrofulous tumours, or the healing of the ulcers which proceed from them. (Lloyd.) It is also de- cidedly objectionable where the scrofulous habit tends strongly to the formation of tubercles in the lungs, or where tubercular matter has already been deposited in the pulmonary tissue; and the same observation applies to the employment of the usual internal tonics. The tonics most generally prescribed are cinchona, gentian, steel, the mineral acids, and the quinine. Of these articles, the quinine appears to be particularly useful in certain states of scrofulous affections. Mr. Rennie, in a very excellent paper on the treatment of this disease, states that he has found this preparation more effectual in allaying irritability, and that febrile diathesis which depends on atony of the stomach, than any other tonic he has ever used.* In the first volume of this work, (p. 345) I have already referred to Dr. Mackenzie's observations on the valuable powers of the sul- phate of quinine in scrofulous ophthalmia; and in one instance of well-marked scrofula in an infant which lately came under my notice, one grain of quinine given three times daily, after proper evacuants, afforded unequivocal advantage. Where along with the symptoms of gastric debility, much acidity prevails in the prima? vise, alkaline remedies should be given, either by themselves, or what is usually more advan- tageous, in union with weak infusions of the tonic vegetable bitters. The alkalies have indeed long been regarded as pecu- liarly beneficial in the management of scrofulous affections. Mr. Farr strongly recommends Brandish's liquor potassae as a remedy for indurated, inflamed, and suppurated scrofulous tu- mours about the neck, as well as "in the thickening of the * London Medical Repository, 1825. SCROFULA. 461 ligaments and periosteum, with caries of the hones." He asserts that he has found this medicine " pre-eminently suc- cessful both in arresting the farther progress, and effectually eradicating a disease so destructive to human life." He employs it in connexion with the mercurial frictions mentioned above. A drachm of this preparation is to be given twice a day to a child from four to six years old ; to a patient of from six to eight years old, one drachm and a half; and to one over eight years old, two drachms are to be given in any agreeable drink. Its operation is slow, and must be long continued.* What has been said, applies particularly to the constitutional treatment of scrofula. When the disease appears in an active form, the same general management may still he proper, to a greater or less extent, with additional remedies adapted to the local affections, and varied according to circumstances. Glandular swellings.—So long as the glandular tumours remain in an indolent state, all active local applications should be avoided; for as discussive means they are wholly useless, where these enlargements depend on a scrofulous diathesis, and by their tendency to irritate and inflame, may greatly hasten the progress of the disease. Nevertheless, with the view of preventing the surrounding parts becoming irritated by the pressure of the enlarged gland, it may be proper to bathe the tumours "with saltwater, or some other cooling lotion." (Lloyd.) When the tumours become inflamed and painful, how- ever, local antiphlogistic applications are in general decidedly indicated. Leeching, saturnine lotions, and cold applications should be resorted to where the skin over the painful tumour is as yet free from tension and inflammation ; but "where seve- ral glands have coalesced, forming a large tumour, and the superincumbent skin is tense and discoloured, the best applica- tions are warm emollient poultices." The leeches should not be applied to the inflamed or discoloured skin of the tumours, but to the sound skin immediately suiToinrdiug_ the swellings. "It often happens that when the swellings have arrived at this height an abscess forms ; but it also happens that they become indolent, and the pain and tension both subside. The tumour, however, remaining undiminished, will upon examination be found to contain in its upper surface a small quantity of fluid. In this case the application of a blister, to be kept open for a few days, and repeated according to circumstances, will often promote rapid dispersion of the fluid, and indeed sometimes of the whole tumour." In general, however, the application of blisters and other stimuli to glandular swellings, in an indis- criminate way, is calculated to do much mischief. The fore- going observations on the local management of scrofulous * The formula for preparing Brandish's liquor potassa is given in the Edinburgh Dispensatory, edited by Dr. Dyckman, p. 459. 462 SCROFULA. tumours are drawn from Mr. Lloyd's excellent treatise on this subject, a work to which the reader is referred for much valuable information in relation to the management of this alarming malady. Scrofulous ulcers.*—The successful management of scrofu- lous ulcerations, is always attended with great difficulty. A great variety of local remedies have been recommended for the cure of ulcers of this kind ; but without a judicious constitu- tional treatment, they are rarely capable of procuring more than temporary benefit, and when applied without great discri- mination, may readily do a great deal of mischief. Mr. Ren- nie, who has paid particular attention to the effects of topical applications in scrofulous ulcerations, states that he has found the following compositions highly beneficial in foul and indo- lent sores of this kind.f When the thickened purple edges of the ulcers overlap the surface, and prevent cicatrization, they should be destroyed with some escarotic, and for this purpose the kali purum, or the nitrate of silver, should be employed. Mr. Lloyd recommends the former, in preference to any other ap- plications of this kind. Slightly astringent ointments or lotions generally agree better with scrofulous sores, than such as are more stimulating. A weak solution of the sulphate of copper, in the proportion of four grains to an ounce of water, or of lunar caustic, or the nitrate of mercury, will in general answer all the purposes that may be expected from such applications. Mr. Lloyd considers the diluted citron ointment as the best local remedy for promoting the healthy granulation and cicatriza- tion of scrofulous sores. * The only signs by which a scrofulous ulcer may be distinguished from one of a different character, are: " its occurring after a suppurated scrofulous tumour—the peculiar dull red, or purple colour of its edges- its remaining indolent for a great length of time, neither increasing nor diminishing in size, and its being attended with that particular state of health which invariably prevails in the scrofulous constitution."—Lloyd. X R. Picis nigra Jfji. ----liquids foiss. ----resinae f£ii. M. ft. emplast.—0., R. Picis liquid. ff^ss. ---- niger. foi. ---- resinae jgi. M. ft. emplast.—Or, R. Picis liquid. fb"1- ---- resinae tfeiv- M. ft. emplas. To be heated and spread at the time of application, not, however, too thinly. The best thickness seems to be from one to two lines. Loc. citat. p. 194. SCROFULA. 463 Whatever topical remedies are employed, and whether the local affection consists merely in enlargement of the lym- phatic glands, or in ulcerations, it must not be forgotten that our main reliance must be placed on an appropriate constitutional treatment. Besides the general remedial measures already men- tioned, and which may be deemed indispensable in all instances of scrofula whatever other medicines may be used, there are a vast variety of remedies which have been strongly recom- mended for the cure of this affection ; and there can be no doubt, that some of them at least may, under certain circum- stances or modifications of the malady, occasionally prove servicable. The iodine has of late years been a good deal used in scro- fulous affections : and in certain forms of the disease, it is, without doubt, deserving of considerable attention. In mere local lymphatic tumours its powers are unquestionable ; but it does not appear to possess any decided remedial powers in glandular enlargements and ulcerations, depending on a scrofu- lous habit of body. In scrofulous inflammation of the eyes, it is said, by some writers, to be very useful—a statement vvhich I have not, however, found verified in my own practice, al- though I have used it a long time, and in efficient doses, in five cases of this kind. For the removal of insulated strumous tumours about the neck, it is decidedly the most effectual re- medy we possess. The only three instances of this kind in which I have employed it, disappeared under the use of fric- tions with the ointment of the hydriotate of potash.* It should be observed, however, that a preternatural sensibility or irri- tability of the system ; a tendency to irregular determinations, and the presence of internal local congestions ; prominent gas- tric and intestinal derangement; febrile symptoms, general plethora, diarrhoea, a disposition to haemorrhages, and an in- flamed or sensible state of the tumours, are decided contra-indi- cations to the employment of this article, whether used exter- nally or internally. Mercury.—This article, as has already been stated, is of unquestionable utility, under cautious management, in scrofu- lous affections, by its tendency to correct the hepatic and alvine functions, and thereby contributing essentially to the restora- tion of the general health and vigour of the constitution. It has been supposed, however, to possess direct and specific pow- ers over the scrofulous action, by its constitutional influence ; * R. Hydriod. potassae ^ii. Axungiae $iss Liq. potassae caust. g. tt. v. M. ft. ungt. Of this ointment, a portion about the size of a •mall nutmeg should be rubbed in upon the tumour twice daily. 464 SCROFULA. but for this opinion there does not appear to exist any good foundation. It is, nevertheless, true, that in old and obstinate ulcerations of a scrofulous character, minute doses of corrosive sublimate, in union with some alterative ptisan, such as the compound decoction of sarsaparilla, will sometimes prove sur- prisingly beneficial. I have succeeded in curing several re- markably severe and obstinate cases of this kind, unequivocal- ly of a scrofulous nature, by the continued employment of a tenth of a grain of this mercurial, thrice daily, in conjunction with the free use of sarsaparilla decoction ; and there are, per- haps, few practitioners who have not witnessed its occasional good effects in similar instances of the disease. Except so far as it is tends to correct the actions of the liver and bowels, this article does not appear to possess any direct power of dispersing scrofulous tumours; but, on the contrary, when its influence is carried to the extent of producing a manifest gene- ral mercurial action in the system, it not unfrequently accele- rates the progress of these enlargements, and deteriorates the general habit of the body. Narcotics.—Most of the officinal narcotic extracts were formerly much extolled as remedies in every variety of scrofu- lous affections. The confidence of the profession in their powers, has, however, long since, in a great measure passed away ; and although some relief may occasionally be obtained from the employment of these articles, their effects on the dis- ease rarely amount to more than a mere palliation of its symptoms, or a temporary suspension of its progress. The most celebrated of these articles, are—conium, belladonna, hyoscyamus, and solatium dulcamara ; hut there are a great variety of other v egetable remedies of a similar character, that have been particularly praised for their occasional good effects in scrofula. Thus, tussilago farfara is much extolled by Hoff- man ; and Meza, strongly recommends digitalis in small doses.* The expressed juice of fumaria; chxreofolium ; beccabunga ; sonchus ; lacluca ; mar ubrium album, and tarax- acum, have all had their advocates as remedies in this dis- ease. Of all these articles, however, conium is decidedly the best; and which, in combination with small doses of muriate of mercury, I have known to do much good in scrofulous ulce- rations. The muriate ofbarytes, some thirty years ago, was much in vogue as a remedy for scrofula. It was introduced to the particular notice of the profession by Dr. Crawfordf; and Hufeland, soon afterwards, published a small treatise with * De digital, purpur ejusque usu in scrofulous medico. Jen*, 179. X Duncan's Medical Comment, vol. iv. Dec. ii. p. 433. SCROFULA. 465, cases illustrative of its remedial powers in this disease.* Many other writers have published statements favourable to the employment of this article; but general experience did not confirm these accounts ; and it has long since sunk almost into total, though, as I have some reason to think, not entirely merited neglect. I have employed it in several cases of scrofulous ophthalmia with unequivocal advantage, and I am persuaded that in some instances, at least, its powers might be very be- neficially called into aid in the management of this intractable malady. It is slow in its effects, and must be used for a con- siderable time, before any obvious amendment occurs in the disease. For the mode of employing it, the reader is referred to page 344 of the first volume of this work. Of a similar character is the muriate of lime.—an article which at one time had considerable reputation as a remedy in scrofulous complaints. Thirty drops of a solution of one drachm of this salt to two ounces of water, is to be taken every three hours, and the dose gradually increased until it begins to affect the stomach. Fourcroy, Beddoes, and Hufeland speak very favourably of its powers. Twenty years ago, I saw it employed in a case attended with several very large scrofulous tumours on the neck, and an ulcerin the left axilla, and although it did not accomplish a complete removal of the ex- ternal affections, its beneficial influence was very manifest. In the early period of my practice, I employed this article in a considerable number of instances of scrofulous ophthalmia, and eruptions about the head in young children, and, as it appeared to me, with some advantage in several cases. General expe- rience, however, has not established its usefulness, and it is now entirely neglected as a remedy in this affection. Antimony, by its tendency to counteract inflammatory action and to keep up the regular cutaneous exhalantion, is a highly useful medicine, under proper management, in certain va- rieties and stages of scrofulous affections. Under the head of phthisis pulmonalis, I have already spoken of its usefulness in counteracting the progress of tubercles in the lungs. This ar- ticle is particularly useful when the glandular swellings mani- fest a tendency to pass into a state of inflammation: and in minute doses, it will co-operate very advantageously, with warm clothing, to prevent the general scrofulous diathesis from pass- ing into the active forms of the disease. That it possesses any direct or specific influence over the scrofulous action, cannot in- deed be admitted ; but by its general operation in promoting the secretions and opposing an inflammatory tendency in the system, it is calculated to do much good in affections of this kind. Weikard and Richter recommend the following combi- * Volstaend. Darstell. d. kraefte u. anwendung d. salzsaur. schwe- rerde, &c. vol. II.—59 466 SCROFULA. nation, as often particularly useful in scrofulous cutaneous eruptions.* Some of the German writers speak very favourably of the effects of large and frequent doses of assafoetida in scrofulous caries of the bones. Schmucker, in particular, has published a very favourable account of its powers in affections of this kind. Where the general circulation and habit is languid, benefit may be obtained from this remedy; but its beneficial influence in cases of this kind, appears to depend solely on the general excitement and invigoration it imparts to the system. Richter recommends the following formula.f Of the import- ance of tonics, in conjunction with aperients and the cautious employment of mercurials, for counteracting the scrofulous diathesis, I have already spoken, and I need here only repeat, that although unquestionably of primary consequence where the system is languid and the digestive powers feeble, they will not only be useless, but often prejudicial, where the general ha- bit is phlogistic, and the alimentary canal in a state of high irritation. During the active progress of glandular swellings, that is, whilst they are in a state of inflammation and suppura- tion, tonics can rarely be given without mischief. After the active state of the inflammation has terminated in foul and lan- guid ulcerations, they may, in general, be used with propriety and advantage. In old scrofulous ulcerations, attended with ge- neral debility and relaxation, the employment of large doses of cinchona, quinine, or steel, is sometimes an indispensable aux- iliary to the local applications and general alterative remedies thetmay be deemed proper. The following combination forms an excellent tonic in old scrofulous ulcerations, or in gene- ral where tonics are indicated in this affection, at any period of its course.:}: • R. Antimon. crude alcoholis %vi. G. guaiaci 5ss. Extract, aconit. 3i. Sacchar. albi. § x. Mucilag. g. arab. q. s. M. To be made into boluses of xv. grains each. One of these is to be taken four times daily by an adult. t R. Antimon. sulphuret. nigr. 3'i- G. assafcetid. 3"1- Extract, cicutae 3ss. -----aconit. gr. xv. M. Divide into four grain pills. S. Take from four to five pills, twice or thrice daily. X R. Ferri limatur. vel pulver. Jiii. P. rhafci 9ii. G. ammoniae ^ii. Tart, antimon. gr. iii. M. Divide into three grain pills. S. Take four pills three times daily.—Or, R. Ferri limatur. zii. G. assafcetid. 3i. G. aloes socc. gr. x. M. Divide into dixty pills. S. Take two, four times daily. SCROFULA. 467 The aromatic tonics, says Richter, deserve much attention, although greatly neglected in scrofulous affections attended with general relaxation and debility, and where the ulcers are foul and indolent. Of course, where there is a disposition to inflammation they are decidedly objectionable. Weikard par- ticularly recommends calamus; Richter speaks favourably of cloves; and Hufeland mentions a decoction of rad. helenii ; cort. winteranus; cort. et lig. sassafras ; and where the general habit is very torpid, Thilenius advises the use of the essential oil of sassafras, as often peculiarly beneficial. BRONCHOCELE—GOITRE. This very remarkable disease consists of a chronic enlarge- ment of the thyroid gland. It commences with a small tumour on one or both sides of the larynx and trachea, which gradual- ly increases in size, until, in the course of years, it acquires, in many instances, an enormous bulk, occupying the whole an- terior part of the throat, from ear to ear, and projecting consi- derably beyond the chin, and occasionally even extending down to near the middle of the chest.* In the early period of the disease, the tumour is always soft, elastic, and spongy to the touch ; the colour of the skin natural, and moveable over the enlarged gland. In the progress of the enlargement, however, the tumour becomes more and more firm, until at last, in severe cases, it acquires great density and firmness in certain parts, whilst small portions retain their original soft and spongy state. Although indolent or free from pain or tenderness during the early period of its progress, and in many cases of moderate size always so, yet in the majority of instances, where the tumour becomes large and indurated, transient pains are at times felt darting through the enlarged gland, at the same time that the skin assumes a slightly red or copper colour, and the veins of the neck become large and tur- gid. No inconvenience whatever is experienced from the dis- ease while the tumour remains soft and of a moderate volume; but when it acquires a large size, it generally gives rise to more or less difficulty of respiration, and a slight change or loss of clearness of the voice. In some cases the enlargement extends inwardly, so as to cause considerable pressure on the (esophagus, and large blood-vessels in the neck, occasioning difficulty of swallowing, and, at times, great anxiety and pal- pitations of the heart, throbbing of the carotids, and dange- rous, and even fatal congestions in the brain. The progress * Alibert, Fodere\ Larrey, Keate, and Sir Robert Wilson, have all re- lated instances of this kind. 468 BRONCHOCELE. of the enlargement is sometimes very irregular. The tumour will, in some instances, remain stationary for a considerable time, and then rapidly increase in size for a short period, and again continue nearly in the same state, or even decrease, until it again rapidly augments in volume. More generally, however, the progress of the tumour is very gradual and regular. In many localities where bronchocele prevails endemically— particularly in the deep valleys of the Alps, the disease is very frequently attended with a stunted and deformed development of the body, and a corresponding deterioration of the intel- lectual faculties. It is thus, that amidst these magnificent and beautiful scenes of nature, man alone is doomed to dwindle—to sink, under the inevitable influences that surround him, from his noblest prerogatives, to the lowest state of cor- poreal and intellectual deterioration. The unfortunate beings who are affected in this manner,—and in some situations, the majority of the native inhabitants are more or less affected— are stunted in growth, with enormous heads, tumid necks, and manifest a degree of mental hebetude which, in aggravated in- stances, amounts to absolute idiotism. This combination of afflictions is called cretinism, and the unfortunates themselves, cretins. Bronchocele has, however, no necessary connexion with the general debasement of the moral and physical consti- tution of man ; for, in many parts where goitre is exceed- ingly prevalent, the development of mind and body is not im- peded by the disease, or the endemic cause upon which it depends. Nevertheless, from the almost inseparable con- nexion of these affections, where cretinism prevails, we can scarcely doubt of their dependance on some peculiar modifica- tion of a common cause. The internal structure or substance of a goitrous tumour, varies according to its age, or stage of progress. Recent en- largements of this kind, consist generally of a gelatinous mass, or a cellular structure, containing a glutinous fluid. Some- times they exhibit a soft and spongy texture, with large cavities or cysts dispersed throughout their structure, containing a serous fluid. Old tumours sometimes contain masses of ossi- fied or cartilaginous substances, imbedded in a soft, friable, or adipose-like matter,* and in some cases the goitrous tumour is filled with dark blood. Morgagni found tumours of this kind composed almost entirely of a number of cysts filled with a viscid transparent fluid ; and occasionally the whole gland resembles a mellicerous, or sfealomatous tumour. Sometimes the goitrous enlargement consists almost wholly of a congeries of varicose veins.f * Morgagni, Benetis, Baillie, Richter. t Foder6, Essai sur le goitre et le cretinage, § 8. BRONCHOCELE. 469 Bronchocele very rarely enters into suppuration; and the occurrence of active inflammation and ulceration is equally un- common, and hardly ever takes place spontaneously, or with- out some external injury or irritating applications. Neverthe- less, instances of spontaneous suppuration have occurred; and this has, in some cases, eventuated in a complete cure of the affection. Petit has mentioned examples of this kind. Alibert has recorded a case, where an enormous strumous en- largement of the thyroid entered into suppuration, and disap- peared after the discharge of above five pounds of purulent matter, (loc. cit. p. 467.) Suppuration does not, however, always, or even generally terminate thus favourably. Some- times the abscess ulcerates into the trachea, and causes suffoca- tion. Instances of this kind are related by Morgagni, Valsal- va, Lieutaud, Baillie, and Portal. Diagnosis.— Although generally sufficiently distinctive in its external character, goitre, when not very large, and situat- ed only in one of the lobes of the gland, may on superficial examination be mistaken for aneurism of the carotid artery, and still more readily with sarcoma of the trachea or neigh- bouring glands; and, perhaps, with dilatation of the internal jugular vein. When the tumour accompanies the motions of the larynx and trachea in the act of swallowing, and is move- able, wholly insensible, soft and spongy to the touch, and free from pulsation, we may conclude that it is of a strumous or goitrous character. When, however, the tumour is situated on one side of the neck, directly over the carotid, a pulsatory motion will be communicated to it by this artery, and in this case, much difficulty may occur in the diagnosis. An instance is mentioned in the Diction, des Sciences Med., where a tu- mour in the neck was pronounced to be aneurismal, by several eminent surgeons, which was afterwards found by Boyer to consist entirely of an enlarged lymphatic gland in the neck. An interesting example of this kind occurred in this city. A tumour on the neck was regarded as aneurism of the carotid by Drs. Griffitts, Chapman, and Dorsey; which, upon dissec- tion by Dr. Parish, was subsequently ascertained to be com- posed wholly of an enlargement of a portion of the thyroid From scrofulous enlargements of the glands of the neck, goitre may in general be distinguished by the position of the tumour—and the firmness and greater proneness to inflamma- tion and suppuration of the former, than the latter form of glandular disease. Mere dilatation of the internal jugular vein is also liable to be mistaken for bronchocele; but the * See an essay on goitre, by Dr. W. Gibson, in the first number of the Philadelphia Journal of Med. and Phys. Sciences. 470 BRONCHOCELE. former may in general be distinguished from the latter by its situation, which is usually just above the sternum ; and by its softness and compressibility, its undulating or pulsatory mo- tion, and the general turgescence of the vein, and the sudden return of the tumour when pressure is removed. Etiology.—One of the most singular circumstances in the history of this affection is its permanent and extensive preva- lence in certain localities, often of limited extent, whilst the inhabitants of the vicinal districts are almost wholly exempt from the malady. In no part of the world is the disease so prevalent, and so distressing in its character, as in some of the valleys of the Alps and Appenines. In certain districts of Switzerland and Savoy, almost the whole of the indigenous population are more or less affected with goitrous enlargements. In the valley of the Rhone, at Martigny, St. Maurice, Aigle, Villeneuve, Bourg, Lucerne, and at Dresden, and in the valleys of Piedmont, this disease is extremely common.— Goitre occurs also extensively in various parts of Asia— particularly in Chinese Tartary, and in Hindostan ; and in certain districts in Africa it is said to be very com- mon. In England the disease occurs very frequently in cer- tain mountainous districts of the counties of Derbyshire, Buckinghamshire, Surry, and Norfolk. In our own country also there are localities in which goitre is of frequent occur- rence. At Bennington, Chittenden, Camden, Sandgate, Windsor, and Chester, in Vermont, bronchocele is very com- mon. In the state of New-York it is frequently met with at Oneida, the German Flats, in the Onondago valley, in the township of Manlius, at Brothertown, in the neighbourhood of Angelica ip Alleghany county, and in various other localities in the north-western district of the state. In Pennsylvania it oc- curs not unfrequently at Pittsburgh, at Cannonsburgh, Browns- ville, and along the Alleghany, Sandusky, and Monongahela rivers. It is met with in Virginia at Morgantown, and on the banks of the Cheat river. Where the disease prevails endemically it occurs at all peri- ods of life, from infancy to old age. Saussure, indeed, asserts, that those who remain wholly free from the disease until they have passed the tenth year, very rarely, if ever afterwards be- come affected with it: and Kortum states, that it never occurs in infants, and in adults of the male sex. These assertions are, however, wholly unfounded, and have been abundantly contra- dicted by later observations. Hacquet, for instance, states that he has met with goitre in infants ; and he has known the disease to come on after the fif- tieth year of age.* It is even asserted, that infants have been * Neue Physic. Politische Reise, durch die Dacischen undSarmatischen oder nord. Karpathen. p. 129, as quo'ted by Richter. BRONCHOCELE. 471 born with goitrous tumours. Fodere,* Consbruchj, and Sterndale^: have related instances of this kind. Iphofen, however, contends that true congenital bronchocele never does take place, and that the cases which have been recorded as such, were in all probability lymphatic tumours of a different character,^ or simply an unusually developed state of the thyroid gland. In general, when the disease occurs in females after marriage, it is during the state of pregnancy that the tumour first makes its appearance. (Fodere.) It would appear that cold weather has a tendency to retard the increase, or even to diminish goitrous tumours; for it is by no means uncommon to find the enlarged gland perceptibly smaller during the winter than in the warm months of summer. Goitre occurs also in the inferior orders of animals—particularly in sheep, horses, and horned cattle.^j In relation to the remote causes of goitre, a great variety of opinions have been advanced ; but our knowledge upon this in- teresting subject amounts, as yet, to little more than to some very general facts, and a few plausible conjectures. It has been supposed that the habitual use of water, impregnated with limestone or other calcareous substances, is the principal cause of this affection (Coxe, de Luc); and this appears to be the general opinion in Switzerland and Savoy. This, however, is satisfactorily contradicted by the fact, that goitre prevails in districts where not the smallest portion of calcareous matter occurs in the water used by the inhabitants ; and in many lo- calities, where the water is highly charged with limestone, this - affection is wholly unknown. (Barton, Iphofen.) Another opinion still entertained by many is, that the use of snow water, abounding in mountainous districts, is the cause of this malady, (Darwin, Selle, Percival, Desgenettes); but there are many facts which conclusively contradict this view of the causation of the disease. Thus, in the valley of Chamouni, " where the water is nothing else than the droppings of snow water from Mont Blanc," bronchocele is but very rarely seen ; " while on the other side of the Col de Baline, in the valley of the Rhone, we see hardly any thing else than goitre and cretinism. Again, in Lapland, where snow water is constantly used, goitre is a very uncommon affection; and on the contrary, the disease is known to prevail extensively in some parts of Africa, and in other warm climates, where snow and ice scarcely ever occur— * Traite du Goitre et du Cretiorisme, p. 18. j Klin. Taschenbuch. T. ii. p. 281. f Lond. Med. Repository, vel. x. p. 200. § Der Cretinismus Philosoph. und Med. Untersucht. Dressten, 1817, p. 4. IT Barton's Memoir on Goitre. Dr. Alexander Coventry—in the New- York Medical and Physical Journal. 472 BRONCHOCELE. as in the island of Sumatra.* The following observations made by Dr. Richardson, who accompanied Captain Franklin in his voyage to the Polar sea, is decisive on this point. " Broncho- cele is a common disease at Edmonston. The disorder attacks those only who drink of the water of the river. It is, indeed, in its worst form, confined almost entirely to the half-breed women and children who reside constantly at the Fort, and make use of river water, drawn in winter, through a hole in the ice. The men, from being often from home on journeys through the plain, where their drink is melted snow, are less affected; and if any of them exhibit, during winter, some inci- pient symptoms of the disease, the annual summer voyage to the sea coast generally effects a cure. The natives who con- fine themselves to snow water in winter, and drink of the small rivulets which flow through the plain, in summer are exempt from the attacks of this disease." Iphofen (I. c. p. 50) maintains that bronchocele is produced by the use of water en- tirely devoid of carbonic acid gas, but this, like the other opinions mentioned, is not sufficiently supported by facts to entitle it to any particular attention. Many writers have attributed this disease to the use of par- ticular articles of food. Thus, Dr. Drug, who saw a great deal of goitre in Derbyshire, conceives that goitrous affections are very generally produced in that district, by the use of sour oat cake, and other in nutritious aliment, more especially infe- rior potatoes, &c. Magneti and Roncalli, also have ascribed the disease to the abundant use of heavy and indigestible arti- cles of food, particularly to fat and oily substances and ches- nuts, which in some parts of Switzerland, constitute a large proportion of the ordinary nourishment of the peasantry. Its dependance. however, on causes of this kind, is decidedly con- tradicted by a variety of facts bearing directly on this point. Thus, of different contiguous localities, we find the disease ex- tremely prevalent in some, whilst in others it occurs but sel- dom, although the general diet and mode of living is the same. Besides the foregoing causes, various others have been men- tioned as the probable source of this affection ; such as the inor- dinate use of vinous liquors ; the repulsion of cutaneous diseases; mechanical injuries of the thyroid gland by carrying heavy burthens on the head, &c. The opinion that the disease depends on certain atmospheric causes, has received many advocates; and there are various circumstances, indeed, which favour this general view of its origin. It is supposed by some, that a dense, stagnant, and humid atmosphere is the ordinary source of the disease; and this idea is countenanced by the circumstance that goitre is * Marden's Geschichte und Beschreibung von Sumatra, p. 64. BRONCHOCELE. 473 known to prevail extensively in many situations where the at- mosphere is constantly loaded with moisture, as in the deep and shady valleys of the Alpine countries. (Fodere, Saussure, Chavassien, d'Audebert.') Fodere asserts that the frequency of the disease is found in many localities to bear a pretty close relation to the hygrometrical states of the atmosphere. In many deep, damp, and woody valleys, goitre is extremely prevalent; but in proportion as we ascend towards the more elevated and dry situations on the sides and tops of the adja- , cent mountains, the disease becomes less and less frequent. It is well known, moreover, that when young persons affected with goitre remove from the valley in which the disease was contracted, to high and dry situations, the tumour almost al- ways becomes considerably diminished in size, and in many instances disappears altogether.* It is even asserted, that in some foundling hospitals, where the air was suffered to become damp and malarious, goitre has been known to occur endemi- cally—-and that it disappeared again, after the air was rendered purer and dryer, f These facts certainly appear very strongly to countenance the opinion that the disease depends on atmos- pheric causes; hut they may be used with equal propriety as arguments in favour of the dependance of the disease on some peculiar impregnations of the water used in the localities where it prevails. It must be observed, too, that bronchocele is known to prevail extensively in some elevated situations, where the air circulates freely, and is not charged either with humi- dity or paludal exhalations. Thus, at Annaberg, at Marienberg, and in several other localities pointed out by Iphofen, (loc. cit. p. 42,) the air appears to be pure and dry, and yet goitre is a very common affection. Again, it is unquestionable that there are a vast number of deep valleys in every country, in which the air is stagnant, and particularly loaded with moisture and terestrial exhalations, but in which goitre is nevertheless en- tirely unknown. Humboldt advanced the opinion, that a deficiency of electri- city in the atmosphere, is intimately concerned in the produc- tion of endemic bronchocele ;£ and the same doctrine is stre- nuously advocated by Iphofen. It would appear from the ex- periments and facts adduced by the latter writer, that in all the situations where goitre prevails endemically, there is a constant deficiency of the electric fluid in the atmosphere; and he asserts, that when goitrous tumours are lessened or removed by a change of residence, from the low and humid situations in which they were produced, to elevated and dry districts, it is * Revue Edinburgh Med. and Surg. Journal, vol. v. p. 53. t Richter Chirurg. Biblioth. Bd. viii. p. 500. X Ueber d. greizte Muskel. und Nervenfassern, B. ii. p. 208.—Kicnter. vol. n.—60 474 BRONCHOCELE. chiefly by the abundance of electricity which the atmosphere contains in the latter situations, that the salutary effect on the disease is produced. Notwithstanding the plausible facts that may be adduced in evidence of the aerial character of the remote causes of goitre, it appears to me much more probable, that it is not in the at- mosphere, but in the water of goitrous districts, that we must look for the cause of this malady. It cannot, indeed, be main- tained that it is either snow water, or calcareous matter con- tained in the common water, that gives rise to the disease ; but there are many facts, which appear to me, very clearly to show that the origin of the disease is connected with some peculiar condition of the water habitually used in those districts of country where the disease prevails. The account given of a goitrous family near Fort Schuyler, in the state of New-York, by Dr. Coventry, demonstrates very conclusively the correct- ness of this view of the etiology of goitre. This family resided on the banks of a small stream, running through a bed of schist and slaty gravel. It consisted of seven members, all of whom, with but one exception, were affected with bronchocele. They were in the habit of using the water of the brook for all culinary and other purposes. In the spring of 1798, Dr. Co- ventry settled within three-quarters of a mile from this family. " There being no well, and prepossessed with the idea of the hereditary nature of the disease," says Dr. C, " my family also used the brook-water; when, towards the approach of winter, to my no small mortification and vexation, I perceived an evident thickening in the necks of my daughters. Then I first began to suspect the water of Kegel's creek. The next summer I sunk a well, and since we commenced the use of it none of my family has been subject to goitre." The goitrous family removed to Onandago, and became entirely freed from the disease.* Dr. Johnson, in relation to the etiology of goitre observes, that "the upper Rhone, where it falls into the lake Geneva, is turbid, even to whiteness, with the attritus which its tributary • Dr. Coventry adds the following highly interesting facts. " A few years after this I leased a small house, standing near the brook, to a Mr. Walworth, who had a son about twelve years old. This lad, in the course of a few months, exhibited appearance of bronchocele; he was sent from home, and his neck returned to its natural size ; but in the succeeding season began to enlarge, and the family moved away. " About the autumn of 1802, I put a small flock of sheep into a pasture, through which the stream ran ; next spring one lamb proved goitrous; the succeeding season every lamb had a swelled neck, and seven out of eight died. My next neighbour had sheep in an adjoining pasture, which was watered by a spring; his sheep had no distemper."—New- York Med. and Phys. Jour. June, 1824. BRONCHOCELE. 475 Alpine streams carry along; but its waters, while nearly qui- escent in the lake, become clear, and pass through the city of Geneva like translucent streams of bluish crystal. Among those who inhabit the banks, and drink the waters of the upper or turbid Rhine, there are twenty cretins and goitres, for one that can be seen on the banks of the lower or filtered Rhone."* Dr. Coventry seems to think it probable that the substance with which the waters that give rise to this disease is impreg- nated, consists in aluminous particles. In dry seasons the sur- face of the schist, after having been acted on by the air, " be- comes covered with a white efflorescence, which, on examina- tion, is found to be alum." The material which furnishes the alum manufactured near Glasgow, in Scotland, is found " in the schist rock which forms tho sides, bottom, and roof of an ex- hausted coal-pit." This observation receives support by the fact, that in certain districts in Europe, where alum is exten- sively manufactured, although elevated and dry, bronchocele is extremely common. (Iphofen.) Whatever may be the remote cause of goitre, Dr. Gibson thinks, that " the disease arises immediately from an obstruc- tion of the tracheo-thyroidal passages of Borden—of the open- ings communicating with the sacculus laryngeus and the thy- roid, and of other passages with which we are unacquainted." "I am inclined," he says, "to draw this conclusion from the circumstance of a watery fluid being found to occupy naturally the cells of the thyroid gland—from this fluid being increased in quantity in almost every goitrous tumour—and from the passages of Borden being much smaller in the first dissection I made of bronchocele than they are usually met with in sub- jects without such disease. This is a mere conjecture ; nei- ther is it original—but was advanced by one of the older writers on surgery." (Loc. cit. p. 65.) Treatment.—Since the discovery of the extraordinary reme- dial powers of iodine in bronchocele, it is scarcely necessary to pay any attention to the various other means that were formerly resorted to for the cure of this affection ; for it can scarcely be presumed, that where the judicious employment of iodine fails, there can he any particular advantage obtained from any other remedies at present known. Although but a few years have elapsed since this remedy has become generally known to the profession, a very great number of instances of its successful employment in this affection have been reported. Dr. Manson has given a tabular statement of 116 cases of bronchocele treated by this article; and of this number, seventy-seven were complete- ly cured, eleven much relieved, and but two not relieved ; the re- mainder were discharged for non-attendance, or remained, im- * Med. Cbir. Rev. April, 1825, p. 44S. 476 BRONCHOCELE. proving under the treatment.* Dr. Manson used the iodine both internally, and externally in the form of a liniment,f rubbed into the tumour. In individuals of a very irritable or pletho- ric habit of body—or where the stomach and bowels are in a deranged condition, the free and protracted internal employment of iodine will sometimes give rise to various unpleasant symp- toms, such as " headach, giddiness, sickness at the stomach, with some degree of nausea, languor, and inaptitude for exer- tion." These affections, however, will in general soon dis- appear, by suspending the use of the medicine for three or four days ; where the inconveniences occasioned by the iodine are moderate, it will be sufficient to exhibit it in diminished doses. It is evident, however, from the experience of Dr. Manson and others, that the tendency of this article to produce unpleasant effects has been much exaggerated by some writers. Dr. M. states that no inconvenience whatever resulted from the in- ternal use of this article in any of the cases in which he em- ployed it; but on the contrary, it generally appeared to pro- duce a cordial and tonic effect, unless it was given in too large a dose. Indeed "patients generally found themselves in better health and spirits after a course of treatment with the iodine, than they had previously been for years; and this observation applies not only to those who laboured un- der bronchocele, but also to those who laboured under other diseases in which iodine was exhibited." I have used this medicine in perhaps twenty cases, both internally and ex- ternally in full doses, continued in some instances for six or eight weeks, without having ever observed any unplea- sant consequences to result from its operation. It cannot be doubted, however, that in certain habits of body, it may give rise to unpleasant and even injurious effects, but this may be said with equal justice of every important article of the materia medica. Dr. Kolley, in a very interesting memoir on the me- dicinal powers of iodine, observes, as the result of his experi- ence, that iodine is incomparably the most powerful remedy in goitre which has yet been discovered ; but in order to employ it successfully, it is necessary: 1, that the disease be confined to the thyroid gland ; 2, that the tumour be devoid of a scirr- hous or sarcomatous character ; 3, that the disease be not inve- terate, or of very long standing ; 4, that the general health be not particularly deranged or impaired ; and 5, that the goitrous tumour be free from inflammation. Where these conditions are not present, the iodine will almost invariably effect a cure. It would appear, that in general this remedy is most apt to give * Medical Researches on the Effects of Iodine in Bronchocele. f R. Liniment sapon. 5i. Tinct. iodii ^j. Misce. This was rubbed into the tumour once, and in some cases twice, daily. BRONCHOCELE. 477 rise to unfavourable effects, where there is a tendency to con- gestions of the head and of other internal organs ; and Dr. Kolley observes, that individuals of a robust, muscular, and what is usually termed atrabilious habit, do not in general bear the action of iodine without more or less inconvenience— particularly when unaccompanied by the use of laxatives. " In such constitutions, the tendency to local congestion increases; the head becomes confused, and cephalalgia often rises to such an extent as to threaten delirium." A deranged state of the digestive organs, all local inflammatory affections, diarrhoea, and phthisis pulmonalis, are unfavourable to the beneficial ope- ration of this remedy.* In general, the external application of the iodine in the form of an ointment or liniment, will procure all the benefit that can be derived from this remedy in goitre. Mr. Coindet has en- tirely left off its internal employment, and recommends fric- tions on the tumour with the following ointment, f Internally, ten drops of a tincture made by dissolving forty-eight grains of the iodine in an ounce of alcohol, may be given twice daily. Of the various other remedies that have been particularly recommended for the cure of bronchocele, it will be sufficient merely to mention the following : Burned sponge; this arti- cle, no doubt, owes its remedial powers, in this affection, to the small portion of iodine it contains. It is given in doses of from a scruple to a drachm daily, and will occasionally remove goi- trous tumours. Calcined egg shells; the external application of sea water, (Lieutaud); hepar su/phuris, (Selle, Fodere); the vinegar of squills ; kermes mineral; belladonna; and espe- cially, conium maculatum; digitalis; burned boletus suaveo- lens, in union with small portions of muriate of soda and lime ; the muriate of barytes ; and the different preparations of mer- cury and antimony. Externally, repeated blistering; frictions with stimulating liniments; mercurial ointment; various sti- mulating plasters ; cataplasms, or bags of emollient herbs, ap- plied over the tumour; and compression, have all been recom- mended, and occasionally used with advantage in this affection. In some cases, however, the disease bids defiance to the powers of medicine, and the tumour goes on increasing until it becomes so large as to endanger suffocation, or some other fatal consequences. In instances of this obstinate and danger- ous character, the passage of a seton through the tumour ap- pears to promise more success than any other mode of treat- * Reflexions et Observations sur l'Emploie d l'lode en Medecine. Par le Docteur Kolley. X R. Hydriod. potassae 9*i- Axungiae §iss- L«ig. potassae causU gr. iv. Ft. ungt. 473 BRONCHOCELE. ment. Dr. Qnari has published an interesting memoir on the treatment of this affection by setons ;* and Mr. Copeland Hutch- inson has adopted this practice with complete success.f " He passed a long and narrow seton needle, armed with half a skein of silk thread, obliquely through the substance of the gland from the left lobe upwards, leaving a space of nearly two inches from the entrance and escape of the instrument." Mr. Hutchinson refers, also, to a case successfully treated in this way, by Mr. Thompson; and to another one by Mr. James, of Exter and Devon Hospital. An instance of the successful use of the seton by Mr. Lyford, is related in the Med. Chir. Rev. for July, 1827. Extirpation has also been resorted to, and, it is said, in a few instances, with success. Fodere refers to some cases where tumours of this kind were removed by excision; and Dr. Har- ris has given an account of two instances of the successful ex- tirpation of bronchocele. It must be observed, however, that this operation is always attended with much danger; and many cases might be collected from writers in which the attempt to extirpate bronchocele, was followed by fatal haemorrhage, or some other disastrous consequences. There is another operation which has been performed with more or less advantage by several surgeons :—the tying up the thyroid arteries. The operation was first performed by Mr. Blizard, of London. The tumour, in the instance he relates, diminished one-third in size, in the course of a week after the operation ; but an attack of hospital gangrene, followed by re- peated secondary haemorrhages, finally destroyed the patient's life. Dr. Jameson, of Baltimore, also took up the superior left thyroid artery in an inveterate case of goitre, with the effect of considerably diminishing the size of the tumour; and other instances of this operation attended, with still more deci- ded success, have been recorded. SCORBUTUS. Scurvy. Sctjrvt does not appear to have been much observed until about the middle of the sixteenth century. Soon after that period, however, it became an object of particular attention, and in conformity with the prevailing notions concerning the * Medico Chirarg. Transact, vol. x. t Medico Chir. Rev. March, 1822. SCURVY. 479 agency of morbid humours in the production of diseases, almost all chronic affections—gout, rheumatism, hypochondriasis, and particularly cutaneous affections, were ascribed to a scrobutic disposition and acrimony of the blood. Masked scurvy was supposed to be present in almost every variety of acute and chro- nic disease; and there has perhaps never been an opinion in pathology, which has been carried to so injurious an extent as the doctrine of a latent scorbutic humoral diathesis.* At pre- sent, however, the term is properly restricted to a peculiar form of the disease, which is undoubtedly connected with a morbid condition of the blood, arisiug from a want of proper nourish- ment, or other causes tending to derange the assimilating functions. This affection seldom occurs in its more aggravat- ed form, except among seamen ; although slight, and occasion- ally even very severe cases, are met with in individuals, de- prived of wholesome nourishment and a pure air, who have always resided on shore. Symptoms.—The disease commences with an unusual degree of lassitude and want of muscular energy ; a feeling of stiffness of the knees and feet is experienced, attended with depressed spirits, and a great disinclination to corporeal exertions. The muscular weakness gradually increases, and the respiration becomes short and panting on the slightest bodily exertions. The countenance exhibits a pale and sallow, or lead-coloured and bloated appearance; the skin is dry, and sometimes pecu- liarly tense and shining, and separates in small scales on dif- ferent parts of the body. Sooner or later, brown or livid spots make their appearance on the surface, generally first on the legs, then on the thighs, and last on the arms and abdomen, but they very rarely appear in the face. In connexion with the appearance of these maculse, edematous swellings of the feet and legs occur ; and in hot climates extensive ansarcous effusions sometimes ensue without any of the ordinary scorbu- tic blotches. Simultaneously with the occurrence of the spots on the skin, and in many instances at an earlier period, the breath becomes fetid, and the gums tender and spongy, and ex- tremely apt to bleed on being even lightly touched. The patient complains of a putrid taste, and usually expresses a strong desire for fresh vegetable food and acids. The urine is turbid and dark-coloured ; the vision becomes more or less impaired; and the muscular powers so prostrated that the pa- tient can scarcely maintain the erect position. The blood is thick, dissolved, and very dark ; the pulse weak and soft. As the disease advances, stiffness of the joints and indurations in the muscles occur, accompanied with severe pains in the thighs, back, and loins, particularly in tho knees; and the patient, at timos, * Richter Specielle Therapie. Bd. p. T95. 480 SCURVT. experiences violent spasmodic or flatulent pains in the bowels, at- tended with retraction of the umbilicus, and constipation. The respiration is constantly more or less oppressed ; subcuticular extravasations of blood appear on the extremities, and occa- sionally on other parts of the body ; and passive haemorrhages occur from the gums, nose, rectum, bladder, &c, at the same time that ulcers are formed on the calves of the legs and thighs, exhibiting an oedematose and flabby appearance, with irregular and bloody edges, and discharging a red ichorous fluid. The gums separate from the teeth and slough, and the teeth be- come loose in their sockets and often drop out; old and cica- trized wounds reopen ; the bones become brittle, and syncope occurs on slight corporeal exertions. If the disease continues unchecked in its progress, extreme prostration at last ensues ; respiration becomes exceedingly anxious, fatiguing, and op- pressed ; syncope, even while the patient is at rest, or merely by turning himself in bed, occurs frequently ; a cadaverous or fetid effluvium exhales from the body ; emaciation goes on ra- pidly, and in some instances paralysis of one or more extremi- ties ensues, or extensive dropsical effusions, jaundice, diar- rhoea, or dysenteric discharges, and finally a rapidly exhaust- ing irritative fever, or coma and convulsions, close the scene. The duration of scurvy is, in general, protracted ; but there nevertheless occurs a very considerable diversity in this re- spect. In violent instances of the disease, where its progress is favoured by previous habits of living, or, perhaps, by a pe- culiar constitutional predisposition, the disease sometimes ac- quires great severity in the course of a few weeks. This, how- ever, is rarely the case with land scurvy—the most rapid and fatal instances usually occurring on board of ships while at sea. Land scurvy very rarely appears in the violent form described above. In many instances it continues for a long while, with no other symptoms than languor, a fetid breath, spongy and hemorrhagic gums, and brownish spots on the legs, with slight oedema of the feet, and a pale and puffy coun- tenance—the patient being all the while able to be up and about. Sometimes it shows itself chiefly by blotches of extra- vasated blood on the inferior extremities, and foul and bleeding ulcers on different parts of the body, with spongy and tender gums. Post-mortem phenomena.—The different cavities of the body generally contain an abundance of serous fluid mixed, in many instances, with more or less blood. The mucous membrane and surface of the viscera commonly exhibit dark and appa- rently gangrenous spots; and blood is found extravasated in different parts of the cellular tissue, under the membranes, and sometimes into the alimentary-canal, the lungs, and even into the abdomen. The heart is flaccid and pale; the spleen soft, SCURVY. 481 and turgid with dissolved blood ; the muscles livid, and often so soft that they may be easily broken down between the fin- gers. The bones are usually very brittle, or preternaturally soft—particularly the epiphyses, which may sometimes be se- parated from the bones with great ease. The blood is univer- sally found in a dissolved state, and very black. Causes.—Persons of a debilitated and phlegmatic habit of body, with a disposition to obesity, are said to be most subject to this disease. The exciting causes are: the habitual use of innutritions, unwholesome, or an exclusive salt animal, or vegetable diet, more especially when conjoined with much fa- tiguing labour, and exposure to a damp and impure atmo- sphere. Anxiety of mind, with a sedentary mode of life ; and the habitual intemperate use of spirituous liquors, contribute also very considerably to the production of scurvy. Damp and impure air, however, in conjunction with a vitiated, or exclu- sive salt animal diet, is by far the most common source of this malady, whether it originate on land or on sea. In relation to the essential nature or proximate cause of scurvy, pathologists have expressed a variety of opinions. That the blood exhibits a morbid condition, is unquestionable; but whether this state of the humours is primary or secondary, in reference to the occurrence of the disease, has been a subject of much controversy. Lind, Milman, Sprengel, and Dreyssig, contend that scurvy consists essentially in a weakened and re- laxed state of the solids, of which the changes which occur in the blood are mere consequences. On the other hand, Hoff- man, Trotter, Jackson, Cullen, and some later writers, con- sider a putrescent or morbid state of the blood, as the primary and essential condition upon which the debility and relaxation of the solids, and the other characteristic phenomena of scor- butic affections, more or less directly depend. From a view of the nature of the most common and powerful remote causes of this disease—namely unwholesome, innutritious, and especially an exclusive salt animal diet, the idea of its dependance on a deranged or vitiated state of the blood appears very plausible; and the more so, as we know that the chyle, and we may pre- sume the blood also, are manifestly modified, according to the nature of the aliment used. The circumstance too, that a scurvy which occurs while the individual is confined to a par- ticular kind of diet, almost invariably soon begins to disappear when the aliment is changed, argues directly and strongly in fa- vour of its humoral origin. It is nevertheless most probable, that the fundamental affection consists in a deranged condition of the chylopoietic functions, and of the process of sanguification; for it can scarcely be admitted, that any considerable change could occur in the composition of the blood, without a pre- vious derangement of the functions that arc more immediately vol. ii.—61 4S2 SCURVY. concerned in the elaboration of this fluid. That the morbid condition of the blood, resulting from a disordered action of the functions just named, has a direct, and perhaps a principal share in the production and support of the characteristic phe- nomena of the disease, cannot, I think, be doubted ; for an in- timate depravation of the general mass of the blood, from whatever cause it may arise, must, one may suppose, necessarily give rise to a universal morbid condition of the organization— more especially to the reproductive or vegetative functions of the system. Prognosis.—In general, the prognosis in scurvy is not very unfavourable; and in the ordinary cases of the disease, mani- festly the result of some peculiar and exclusive aliment, it very rarely resists an appropriate change of regimen. Indeed, it is surprising how rapidly even very aggravated instances con- tracted at sea, will often disappear as soon as the patient is put on shore, or is allowed a fresh vegetable and acescent diet. In severe cases, however, the influence of the land air is occasion- ally, though indeed very rarely, manifestly injurious, and greatly hastens the progress of the malady. (Richter.) After the disease has continued until symptoms of extreme prostra- tion and universal depravation of the solids and fluids are in- duced, such as great difficulty of respiration, frequent syncope, and slouging of the gums, with extensive oedema, or dropsical effusions, there is, indeed, but little advantage to be expected from any mode of management. When the disease occurs in persons of a gouty habit of body, or is complicated with syphi- lis, the prognosis is always to be regarded as unfavourable; and a broken down constitution, by the frequent use of mercury, is also particularly calculated to enhance the obstinacy and dangerous consequences of the malady. Treatment.—The first and most important part of the re- medial management of scurvy is the removal of the causes which produced the disease. When it is the result of impure diet, and a vitiated and damp air, more wholesome food and a purer atmosphere are indispensable. The scurvy which occurs at sea, is almost universally the consequence of the ex- clusive and long continued use of salt animal food, and of bad and impure water; and hence cases of this kind almost always disappear very speedily as soon as the patient is put upon tho use of fresh vegetable and animal food, and vegetable acid drinks—such as lemon juice and good vinegar. The employ- ment of acids of this kind, particularly the lemon juice, is one of the most effectual means for preventing or arresting the progress of this affection when it arises from the use of old and salted meats. It appears, however, that vegetable acids are not so universally beneficial in this affection as has been sup- posed. An interesting account of the total failure of lemon SCURVY. 483 jaice in arresting the progress of scurvy on board of the British ship Leander, is given in the Med. Chir. Rev. for June, 1824.* After this acid had been fully tried, without the least benefit, the disease was quickly vanquished by the free use of fresh animal food, in conjunction with vegetables. Dr. Bampfield, also, in his work on tropical dysentery, speaks of the great benefit which may sometimes he derived from fresh animal food, in sea scurvy. In general, however, a mixed diet, com- posed of fresh animal and vegetable articles of food, is the most salutary in scurvy arising from the exclusive use of old and salted meats, or of unwholesome, coarse, and oily aliment. There are certain vegetables, however, which experience has shown to be especially beneficial in this affection ; and they should undoubtedly be used whenever they can be had. The principal of these are : horse-radish, scurvy-grass, garden- cresses, water-cresses, garlic, onions, the fruit of cloud-berries, lettuce, celery, endive, spinage, carrots, cabbage, oranges, mustard, and all kinds of acid fruits. Of all these vegetable substances, however, cabbage in the form of sour-krout is de- cidedly the most valuable, both as a preventive and curative means. Fermented liquors, buttermilk, fresh milk, vinegar and water, but especially water acidulated with lime juice and a decoction of malt, taken freely as common drink, are highly proper beverages in scorbutic affections. Medicinal articles are seldom of very material service in the treatment of scurvy; and without the proper changes in diet already mentioned, they are always wholly ineffectual, and may even prove injurious under the most careful management. Mr. Patterson, however, speaks very favourably of the effects * " In the year 1822, His Majesty's ship Leander sailed from Trinco- malee for the Cape of Good Hope, taking on board the mechanics of the dock yard establishment then reduced on the island. There were also embarked twenty-six invalids, and all the sick that could be re- moved from the hospital. These invalids and sick were principally affected with chronic hepatitis, dysentery, and phthisis pulmonalis, all of which (even some who were expectorating large quantities of puru- lent matter) recovered on the passage to the Cape. This good fortune was counterbalanced by scurvy, which broke out among the crew, and, in spite of large quantities of lemon juice plentifully administered in conjunction with every other antiscorbutic which the ship could pro- duce spread to an alarming extent, and in one case proved fatal. H.\d they not reached the Cape at the time they did, the Leander would have presented as deplorable a spectacle as the Anson, at Juan Fernan- dez notwithstanding the supposed specific lemon juice, which in no in- stance on board the Leander had the slightest effect in even checking the ravages of scurvy. Immediately the ship reached the Cape, and the crew got plenty of fresh animal food, in conjunction with vegetables, thev rapidly recovered. Specimens of the lemon juice were transmitted to the Victualing Board, and carefully analyzed in London. It was found perfectly good." 484 SCURVY. of a solution of nitre in vinegar, in the proportion of four ounces of the former to a quart of the latter—given in doses of from half an ounce to two ounces twice or thrice daily. During the stage of convalescence some advantage may be derived from tonics, particularly iron, cinchona, calamus aromaticus, cort. aurantior., cort. winteranus, cascarilla, and the mineral acids. Richter mentions the following infusion as often very useful in the treatment of land-scurvy.* An infusion of calamus and Teruvian hark, with the addition of elixir vitriol, is parti- cularly praised by Jahn. Kotrum asserts that he has derived considerable advantage from the use of savin in this affection ; and the bark of the betulae albae is said to have been very bene- ficially employed in this affection. As a local application to scorbutic ulcers, whether situated in the mouth or elsewhere, a strong solution of the muriate of lime will in general answer a very good purpose. Water acidulated with muriatic acid and sweetened with honey, forms an excellent lotion for the gums. A weak solution of the sulphate of copper, or of lunar caustic, may also be beneficially employed for this purpose. CHAPTER XXXII. GONORRHOEA. A running or discharge of purulent matter from the ure- thra, is noticed as a loathsome affection " by successive au- thors, from the earliest periods in which we have any medical records;" but it was not considered as having any essential connexion with syphilis until upwards of half a century after the introduction of this latter disease into Europe. Since that period, the relation subsisting between these two affections has been a subject of much controversy; but the general opinion at present is, that they are radically distinct—each depending on its own specific virus, although many eminent physicians still contend for their identity. The experiments of John Hunter, which appeared to prove that gonorrhceal matter is capable of forming chancre, and, on the contrary, that matter taken from * R. Rasur. raphan. rustic. Siii. Ferri. pulverat. ii. P. rad. rhaei 5ss. Rad. zingiberis zii. Vin. alb. generos. lh. ii.—M. Stent in infus. per xii. horas, cola. Take a tea-cupful three times daily. GONORRHOEA. 485 a chancre, when brought in contact with the urethra, will form gonorrhoea, have been contradicted by various experimenters— more especially by Mr. Benjamin Bell; and the very frequent occurrence of gonorrhoea, where of course the virus is largely and constantly applied to the glans penis, without the appear- ance of chancre, is strongly opposed to the opinion of their specific identity. It must, indeed, be admitted that chancre and gonorrhoea frequently appear together ; but where this is the case, there can exist but little doubt that the two poisons were communicated either at the same impure venereal inter- course, or at distinct connexions. I have lately seen an in- stance illustrative of this fact. The patient laboured under gonorrhoea of about six weeks' standing : before it was cured he had connexion with a woman ; and in six days afterwards a genuine excavated syphilitic chancre made its appearance. Gonorrhoea generally comes on in three or four days after an impure connexion ; hut in some instances it appears within the first forty-eight hours, and occasionally not until the ex- piration of eight or ten days after the application of the virus. At first, a disagreeable itching or prickling sensation is felt in the point of the urethra, passing a short distance up from the orifice, which on examination will be found slightly reddened and somewhat tender. After this sensation has continued for ten or twelve hours, the mouth of the urethra becomes sensibly in- flamed and swollen, and a limpid or yellowish matter begins to ooze from it. The stinging and itching now increase, and the emission of urine occasions a severe smarting and burning pain in the anterior portion of the urethra. The pain now extends more or less speedily inwards along the urethra; the glans penis becomes swollen, dark red, and tender to the touch, and the discharge acquires a yellow-greenish colour, resembling diluted pus. Frequent and very painful erections harass the patient— more especially after he has been some time in bed; and on passing water the pain, in some instances, is exceedingly smart- ing. In many cases the inflammation extends from the mu- cous membrane of the urethra to the corpus spongiosum, giv- ing rise to much tenderness and hardness of this part, and par- ticularly to a most painful affection called chordee, which con- sists in strong and protracted erections, whilst, from the inflamed and unyielding state of the corpus spongiosum, the penis is thrown into a curved form, with the frenum drawn down and the body forced upwards. At this stage small por- tions of blood are often mixed with the gonorrhoeal discharge; and the prepuce sometimes becomes much inflamed, tumid, and slightly excoriated at the edges and in spots on its internal surface. In some instances one or more of the inguinal glands become inflamed and swollen, and a knotted cord of inflamed lymphatic 486 CONORRHGSA. vessels is felt along the dorsum of the penis. Many patients experience a constant aching pain in the glans and body of the penis; and occasionally one or both testicles become tender, inflamed, and much swollen, attended with pain along the whole course of the spermatic cord. Considerable symptomatic fever always attends, when the inflammation becomes thus extended from the urethra to the neighbouring structures. Not unfre- quently the whole tract of the urethra becomes inflamed, giving rise to harassing sensations of burning and titilation in the neck of the bladder and anus, and very severe cutting pains in the perineum on making water. The patient, under these cir- cumstances, feels a continual urgency to make water, but from the great tenderness of the neck of the bladder and urethra, only a few scalding drops are voided at a time. When the testicles become inflamed, the gonorrhoeal discharge is always sensibly diminished, and in many cases entirely suppressed. Sometimes some of the engorged capillaries of the mucous mem- brane burst, and more or less of pure blood passes off. After an uncertain period these inflammatory symptoms begin to subside. The scalding pain in making water gradually ceases; the erections become less frequent and painful; and the gonorr- hoeal matter acquires a greater consistence, and becomes white and ropy. The specific inflammation of gonorrhoea, is primarily seated in the mucous membrane of the urethra, a short distance above its orifice in thefossa navacularis, and chiefly affects the lacu- nae mucosae of Morgagni, and their excretory ducts. From this point, however, it often extends higher up the urethra to the membranous portion, the veru montanum, and neck of the bladder. Sometimes the gonorrhoeal matter, in the first instance, does not penetrate the urethra, during impure venereal connexion; but being applied to the glans penis, it gives rise to irritation and a discharge of thin purulent matter from the sebaceous glands situated around the corona glandis. Much more com- monly, however, the matter discharged from the urethra comes in contact with the internal surface of the prepuce and the glans, and causes excoriations of these parts, from which a thin whi- tish or whey like fluid is discharged. These excoriations usu- ally appear in the form of irregular patches, leaving interstices of sound skin between them. It would seem too that the virus of gonorrhoea when brought to act on the glans and internal aspect of the prepuce, often produces a peculiar variety of ve- nereal ulcer of a mild character, exhibiting a smooth surface, slightly raised above the surrounding skin, having a healthy colour, but without granulations, and exhibiting somewhat of a fungous appearance. (Carmichael.) These ulcerations are generally connected with more or less phymosis. In some GONORRHOEA. 487 instances, gonorrhoeal discharge from the urethra is accompa- nied both by excoriations and ulcers of the kind just mentioned; but more frequently the disease is attended with simple excoria- tions of the prepuce and glans. Gonorrhoea is, in some rare instances, succeeded by constitutional symptoms—and this is most apt to be the case in those instances of the disease that are attended with the primary excoriations or ulcers just mentioned. These constitutional symptoms consist in minute papular erup- tions, varying from a pale red to a deep crimson colour, which are ushered, in by pyrexia and redness, pain and swelling of the joints. These papulae do not come out together, but follow each other in succession. Some of them are simply pimples, while others are almost advanced to the pustular form. These are most numerous, and in some instances almost altogether confined to the parts about the shoulders, arms, and back. The febrile symptoms are transient, and the papular affection usu- ally disappears without difficulty under the use of purgatives, a simple and unirritating diet, antimonials, and an equable and dry air. In women, gonorrhoea is very rarely attended with the painful symptoms that accompany the disease in men. Indeed, in many instances there is so little uneasiness and pain expe- rienced by females from this disease, that the discharge is often regarded as simple fluor albus. It is very remarkable, that gon- orrhoeal inflammation in females is exceedingly seldom, if ever extended to the urethra. Swediaur asserts, that he has " never seen a woman in whom the disease was seated in the urethra." The orifice of this canal, however, is generally more or less ir- ritated, and in some instances it becomes so very sensible, that the urine in passing off gives rise to extremely severe pains. The seat of the disease is usually either in the clitoris, round the orifice of the urethra, and on the nymphae in the cavity of the vagina, or at the inferior commissure of the labia and rapha. (Swediaur.) Women affected with gonorrhoea, generally experience a dis- agreeable itching and titilation about the orifice of the vagina, and at the rapha. In severe cases, the labia, nymphae, and clitoris become swollen and extremely tender; and there is generally a severe burning and stinging pain felt in voiding the urine. In violent instances of the disease, there is a con- stant aching pain experienced in the bladder, womb, groins, and back ; and the upper and inner surface of the thighs often becomes inflamed, excoriated, or covered with an inflamed pus- tular eruption, from the irritation occasioned by the gonorr- hoeal discharge. In general, the mucous surface from which the gonorrhoeal matter proceeds, is entirely free from ulceration or excoriation. But this does not appear to be always the case, as is usually 488 GONORRHOEA. asserted by writers; for, according to the observations of Whately, irregular patches of excoriation, similar to those which appear on the prepuce and glans, sometimes occur on the lining membrane of the urethra. It must be observed, how- ever, that excoriations or ulcers of the mucous membrane of the urethra in this affection are altogether accidental, and by no means essential conditions of the disease. Treatment.—Gonorrhoea appears to have a natural tendency, if left to itself, to terminate spontaneously. At first, as has already been stated, the matter is thin, and communicates a greenish stain to the linen ; but as the inflammation gradually subsides, the discharge becomes thicker, cream-like, and less abundant; and if the general habit is not phlogistic or irrita- ble, and the patient avoids the influence of stimulating causes, the secretion of the gonorrhoeal fluid often gradually diminishes, until in the course of six or eight weeks it ceases entirely. There are few individuals, however, who are willing to delay the use of remedial measures, or who are sufficiently prudent to abstain from stimulating ingesta and other causes calculated to keep up the phlogistic habit of the system, to obtain such a favourable result ; and in most instances, either from injudicious attempts to arrest the discharge, or from a general inflammatory and irritable diathesis, favoured by stimulating diet and drink, the disease, if it is not subdued by an appropriate treatment, degenerates into a chronic ure- thral discharge, consisting of a milky fluid, usually called gleet. During the inflammatory stage of the complaint, it should be treated strictly as a local inflammatory affection, without any regard to the peculiar nature of the inflammation, or the muco-purulent discharge which attends. In plethoric habits, and particularly where the pulse is hard and active, blood should be freely drawn ; and the inflammatory state of the sys- tem must be reduced by the use of internal antiphlogistic re- medies. For this purpose, the saline .purgatives, nitre, and tartarized antimony, are decidedly the most useful remedies we possess. Dr. Carmichael is particularly partial to the use of the tartarized antimony, dissolved in a solution of sul- phate of magnesia ; and when given so as to keep up a slight degree of nausea, and to procure four or five alvine evacuations during the day, this combination is in fact a highly efficient remedy during the inflammatory period of this complaint.* Nitre and antimony dissolved in a large proportion of some mucilaginous fluid, as a solution of gum arabic, barley-water, * R. Sulphat. magnesi* ?ii. Tart antimonii gr. ii. M. Take a table-spoon- ful every two or three hours. GONORRHOEA. 489 or flaxseed-tea, will in general prove very serviceable, both as a means of lessening the scalding of the urine, and the general and local inflammatory action.* In conjunction with these re- medics, the patient should drink freely of some bland, mucila- ginous fluid. For the relief of the painful erections and chordee, which usually harass the patient—particularly at night in bed, cold applications may be tried ; but although oc- casionally beneficial, they much more frequently procure but very little relief. Indeed, warm fomentations, or emollient cataplasms, are more frequently servicable in this respect, than cold applications to the part. Opium, given in full doses, is in general a very useful remedy for this purpose ; and its good effects are often considerably enhanced by giving it in union with camphor. From one to two grains of the former, to eight or ten grains of camphor, taken an hour before going to bed, will generally prevent the occurrence of the painful af- fections during the night. Mr. B. Bell strongly recommends the use of camphor and hyoscyamus as a means for alleviating the sufferings occasioned by chordee. These articles, he says, should be given in large doses. In general, half a drachm of the former, with a scruple of the latter, given in the course of twenty-four hours, will be found sufficient to allay this af- fection ; but in some instances, he gave it to twice this extent in the same period of time.f If bleeding takes place from the urethra, it ought not to be arrested unless, it becomes too co- pious, which very rarely happens. When it is desired to stop the haemorrhage, pressure made upon the urethra with the hand for twenty or twenty-five minutes, will almost always be suffi- cient to arrest it. Rest, and a mild and unirritating diet, always contribute very materially to the reduction of the inflammatory symptoms. Much advantage may also, in general, he obtain- ed from the application of warm fomentations to the penis, during the inflammatory stage of the complaint. Nothing is more common than the employment of as- tringent injections, almost as soon as the disease commences ; and although the discharge may sometimes be speedily arrest- ed in this way, yet, the consequences are often extremely inju- rious. " This practice," says Mr. Carmichael, " is attended with such risk of exciting inflammation of the entire urethra and bladder, and all the immediate, as well as the secondary train of evils attendant upon this calamity, that I have no • R. G. arab. ?iss. Nitrat. potassae %i- Tart, antimonii gr. i. Infus. sem. lini. fxvi. Of this a wine-glassful may be taken every hour. X Edinb. Med. Journal of Medical Science, No. I. January, 1826. vol. II.—62 490 GONORRHOEA. hesitation in saying, that it is a practice that cannot be too strongly deprecated." As soon as the general and local inflammatory symptoms have been in some degree reduced, and the discharge becomes thick and more purulent, balsam copaiva, cubebs, or what are called terebinthinate remedies, must be resorted to. Almost all writers agree in giving a preference to the balsam copaiva as a remedy in this affection ; and when given in large doses, it will, in fact, more frequently put a stop to the disease than any other article we possess. To obtain the full advantages which it is capable of affording, it should be given in as large doses as the stomach will bear. The following is an excellent formula for administering this article:* The balsam copaiva may be safely and beneficially admi- nistered in this affection where the general habit is not very irritable or phlogistic, although the local inflammation may Btill remain in an active state. I have often given this article in the beginning of the disease, as soon as the bowels were freely evacuated by a saline cathartic, with complete success. Indeed, many eminent practitioners do not hesitate to ad- minister it in large doses soon after the commencement of the disease, and where the inflammation is not particularly violent, and the general arterial system does not sympathize with the local affection, it may be employed with advantage. Dr. John- son observes that, according to his experience, this article " may be safely administered in drachm doses, during the in- flammatory state of the disease, and with palpable success. Under such a treatment incipient gonorrhoea has ceased in two or three days." Cubebs, also, are an excellent remedy in gonorrhoea. They are, however, much more stimulating than the preceding arti- cle, and must be given with more caution during the inflamma- tory stage of the disease. Mr. Jefferies states, that the good effects of cubebs, where it is servicable, usually begins to manifest its beneficial influence within forty-eight hours after the first dose; and where no material relief is obtained in the course of five or six days, its further use will rarely be attend- ed with advantage.! This remedy appears to be most apt to prove serviceable in relaxed and leuco-phlegmatic habits ; and in order to derive the full advantage which it is capable of affording, it should be given in large doses. From six to * R. Bals. copaiv. |i. Spir. nit. dulc. zss. Tinct. opii Spirit, camphorae aa 3i« M. Of this a tea-spoonful should be taken four times daily. t Practical Observations on the Use of Cubebs in the Cure of Go- norrhoea, p. 18. GONORRHOEA. 491 eight drachms of the powdered cubebs may be given in the course of twenty-four hours, where the inflammatory action of the affected parts has been in a great degree reduced. The tincture, also, is an excellent mode of administering the cu- bebs. 1 usually direct a large tea-spoonful of it every four hours. Much more commonly, however, I have given it in combination with balsam copaiva, according to the following formula.* In cases entirely free from general irritation and inclining to a chronic character, I have often united the balsam copaiva, cubebs, and spirits of turpentine with peculiar advantage; and in gleet, I know of no remedy which so frequently succeeds in making a decidedly favourable impression on the disease, as the tincture of cubebs in union with the spirits of turpentine, in the proportion of two parts of the former to one of the latter, given in tea-spoonful doses three or four times daily. It is proper to observe, that the use of medicines of this kind ought always to be continued four or five days after the dis- charge has been arrested by them ; for when they are discon- tinued as soon as the running ceases, it very frequently returns in the course of five or six days ; and when this happens, we rarely find the medicine to produce the same beneficial effect as it did in the first instance. Many of the obstinate cases I have met with, were relapses of this kind after the discharge had been suspended by the use of terebinthinate remedies. When, notwithstanding the free employment of medicines of this kind the discharge continues, recourse should be had to -astringent injections. Under judicious management, and after the inflammatory stage has passed off, local astringent applica- tions may be used without the least risk of injury, and very generally with speedy success. A great variety of articles have been recommended for this purpose; but in general tho sulphate of zinc will prove more promptly beneficial than any other astringent remedy we possess. The injections should at first be weak—not above a grain and a half of this article to an ounce of water—but in proportion as the disease assumes a chronic character, the quantity of the zinc should be increased to eight and even ten grains to the ounce. It is a very com- mon practice to unite the sulphate of zinc and acetate of lead * R. Bals. copaiv. Tinct. cubebae aa 2ji. Spir. nit. dulc. |ss. Tinct. opii 3i. Sacch. alb. 5i. P. g. arab. 3'" Aq. fontanse Sv"'" M. Take a table-spoonful three or four times daily. 492 GONORRHOEA. in injections for this complaint; but it has never appeared to me that any peculiar advantages are to be derived from such a combination. It must, nevertheless, be observed, that there occurs much diversity in different cases with regard to the utility of different astringent injections. We sometimes find a variety of injections wholly ineffectual in this complaint, when at last some particular combination or article will speedily put a stop to the discharge. This, no doubt, generally depends on the peculiar grade of the irritation in the mucous membrane of the urethra. In the atonic stage of the disease, I have often employed the diluted sulphuric acid with complete success, after the zinc ami other articles of a similar character had failed to arrest the disease. A drop, or a drop and a half of the oil of vitriol to an ounce of water, forms an injection of the proper strength. The sulphate of copper, too, may be advantageously used for this purpose. Two grains of this article to an ounce of water form an injection of the medium strength ; but it will in general be better to commence with a grain to the ounce, and afterwards increase it to three or four grains, according as the disease assumes a chronic character. In some instances the nitrate of silver, in the proportion of two grains to an ounce of water, will succeed very speedily; and in gleet or atonic gonorrhoea, the proportion of the silver may be increased to three or four grains to the ounce. 1 have in a few instances of very obstinate gonorrhoea, succeeded with an injection pre- pared from the balsam copaiva in the following manner. Two drachms of the balsam are to be triturated in a mortar with a drachm of carbonate of magnesia. After they have been rubbed together, eight ounces of warm water must be added, and well mixed with the magnesia and balsam. It must then be suffer- ed to stand until the water becomes clear, when it must be poured off, and used as an injection. Mr. Foot, in a work on the venereal disease, published in London about ten years ago, strongly recommends the following solution as an injection in gonorrhoea, after the inflammation has subsided. Dissolve some sulphate of copper in a sufficient quantity of water; preci- pitate the solution with lixivium of tartar; suffer it to separate, then pour off the clear liquor. Wash the precipitate until the water becomes insipid ; then make a saturated solution of car- bonate of ammonia in water, and mix as much of the preci- pitate with the filtered solution of the ammonia as it will dis- solve, which reserve for use. Six drops of this ammoniated copper to an ounce of water form an injection of the proper strength. Six or eight years ago I used this injection in vari- ous instances, and generally with benefit. In obstinate cases of gleet, the long continued use of the tinc- ture of cantharides in conjunction with astringent injections, particularly a solution of the nitrate of silver, will sometimes GONORRHOEA. 493 succeed better than any other remedy. The cantharides should be given in gradually increasing doses—commencing with about thirty drops three times daily, until symptoms of stran- gury ensue, when it must be discontinued, and resumed after the ardor urinae is disappeared. I have often succeeded'with the internal us ■•■ the spirits of turpentine, in conjunction with injections; bui s article is much more offensive to the sto- mach than the cantharides, and patients will seldom continue it a sufficient length of time to obtain the full advantages which it is capable of affording. The direct application of astringent and exciting applications by means of a bougie, will sometimes succeed after all other remedies have failed. I have in several instances removed the disease by introducing a bougie, ipon which some citrine ointment was smeared ; and in one very obstinate and protracted case, I lately succeeded in effecting a cure, by applying in this manner the lunar caustic rubbed up with lard. Twenty grains of the caustic may be triturated with half an ounce of lard, as an application for this purpose. A ^leety discharge is, however, very frequently dependant on the irritation of stricture of the urethra; and when this is the case, nothing but the removal of the stricture by the judicious employment of bougies will effect a cure. Whenever a thin milky discharge continues obstinately after the use of the fore- going means, we may suspect the existence ot stricture ; and on being consulted for aid in a long-standing case of this kind, it is always proper, before any remedial measures are adopted, to make the proper examination, in order to ascertain the state of the urethra in this respect. It may be proper again to say, that where there is much ir- ritability or active inflammation of the urethra present, all astringent or irritating injections are highly improper. When used under circumstances of this kind, they are apt to give rise to various distressing affections—particularly to obstinate chordee, inflammation of the body of the penis, of the neck of the bladder, and of the testes, and to strictures in the ure- thra. In relation to the formation of strictures, however, Mr. Carmichael makes the following observations, which are en- tirely accordant with my own views. " Strictures," he says, " are more generally attributed to the use of injections than any other attendant of gonorrhoea; but I have so often witnessed their occurrence where injections have never been used, that I am more inclined to ascribe these affections to the irritation of gonorrhoea than to any other cause. The sooner such irrita- tion is removed, the more likely is the patient to avoid those unpleasant visitations which are far more to be dreaded than the original disease. I have, therefore, no hesitation in putting as speedy a stop to the discharge as I can, by the use of astrin- gent injections, if the internal remedies mentioned disappoint my expectations." 494 GONORRHOEA. The observations made above, in relation to the propriety of continuing the internal terebinthinate remedies for se- veral days after the disappearance of the gonorrhoeal dis- charge, are entirely applicable also to the employment of injec- tions. In using injections, it will be proper to prevent the passage of the fluid into the neck of the bladder, which may be readily done by making pressure over the posterior part of the urethra near the margin of the anus. SYPHILIS. The origin of syphilitic diseases is still involved in much ob- scurity. The general opinion of its having been introduced into Europe from South America by the sailors who accompa- nied Columbus, admits of a great deal of doubt. Dr. Thomson, who has investigated this subject with much learning and dis- crimination, observes, that it "is extremely improbable that sailors, after a long and successful voyage, landing on the northern coast of Spain, objects of curiosity, ready to embark again to reap the fruits of their discoveries, and the wealth the new countries wTere supposed to abound with, should have been sent off to act as soldiers at the siege of Naples, labouring under a new and horrid disease, which must have been of some months' duration, and have incapacitated them for every kind of exertion. That neither Columbus himself, nor his brother, who left such accurate narratives of his voyage, should not make the least mention of such disease being discovered among the natives, or prevailing among the crews of their vessels, is certainly still more difficult to be reconciled with reason, and afford strong presumption of error."* He thinks it probable that the disease has existed more or less, and under different grades of severity, in all ages, and that "it has been thou- sands of times generated de novo by impure sexual intercourse." The circumstance which especially attracted the attention of physicians to the disease about the period of its supposed im- portation into Europe, was probably its having assumed at that time an extraordinary degree of violence; for it is very evident from the records of medicine, that the disease has va- ried very much since the first accounts that were given of its phenomena and character; and it is certainly very far from possessing the terrible severity now, which it manifested dur- ing a long period after it was first particularly noticed. It is not improbable, too, that the connexion between primary ul- cers on the genitals, and what we now call the secondary con- * Medico-Chirurg. Review, December, 1821, p. 617. SYPHILIS. 495 stitutional symptoms, were overlooked by the ancients; for as the former would very generally heal before the latter could make their appearance, and more especially as these constitu- tional affections were free from the power of infecting the healthy, they might very readily have been regarded as acci- dental diseases, wholly independent of primary sores on the organs of generation. Besides, although ulcers were abun- dantly noticed and described on these parts, their origin from impure venereal intercourse may have escaped detection. It is certain, at least, that Celsus describes various species of ulcers on the genitals; and it appears to me difficult to read his sec- tions De cancro qui in cole nascitur; De phagedena in cole nas- cent e ; and De carbunculo qui in cole nascitur, without being impressed with the conviction, that he had reference to the va- rious species of sores now known under the name of syphilitic chancre. The opinion that syphilis is an ancient disease, but that it has been subject to various modifications from the influence of some occult cause in different ages, is strongly illustrated by the following account of a " new syphilitic disease which has lately appeared in Canada," in the last edition of Swedeaur's valuable work on this syphilis: " A new disease," says this wri- ter, '* broke out some time ago in Canada, especially in St. Paul's Bay. This disease has made rapid progress within these few years among the inhabitants of Canada. The parents transmit it to their children. It is communicated by eating, drinking, &c. If it once enters a family, rarely any one escapes catching it. Some habits seem to absorb the virus, and then sometimes it remains concealed or dormant for years, and then breaks out at last with all the symptoms of the third stage. The patients, often dragging out a miserable existence to old age, lose by degrees, eyes, nose, cheeks, velum pendulum, andthe whole ba- sis of the skull, &c. They call it mal Anglois, (the English disease) because they think the English brought it first amongst them." This accords with the violent and exceedingly conta- gious character which syphilis is said to have had during the first century of its ravages in Europe. It was communicated " by lying in the same bed, by the clothes, gloves, or money of the patient;" and even the breath was thought to be sufficient to communicate the disease; for it is stated that cardinal Wol- sey was indicted "for whispering in the king's ear while sup- fiosed to be labouring under the venereal disease." (Thomson, oc. cit.) Finally, it must be observed that some of the earliest writers did not consider this affection in Europe as of trans- atlantic origin. Fracastorius ascribed it "to the different constitutions of heaven and stars, which hut seldom happen, but may effect great matters when they do coincide ;"* and he, * Aphrodisiac, p. 202, as quoted by Van Sweiten. 496 SYPHILIS. as well as others, believed that it was one of those diseases which rise, cease, and again return at long intervals of ages.* But although inquiries into the origin of the disease are highly interesting, and not altogether useless, the immediate scope of this work does not admit of an extended discussion on this point, and 1 proceed, therefore, to the more practical details of the phenomena and modes of remedial management of this malady. Syphilis, when suffered to proceed in its course, passes through two distinct stages or series of phenomena :—the first or primary, which is altogether local;—and the second, or constitutional, in which the system generally becomes impli- cated in the disease. Primary ulcers, or chancres.—At an uncertain period, vary- ing from a few days to several weeks after an impure venereal intercourse, one or more small pimples, excoriations or ulcers, preceded, usually, with an itching in the part, appear on some part of the genital organs, most commonly on the internal sur- face of the prepuce, the corona gland is, the glans, or on the frenum ; and occasionally on the external surface of the pre- puce, skin of the penis, scrotum or thighs in men; and in fe- males, on the internal or external surface of the labia pudendi, on the clitoris, the nymphae, in the vagina, or on the thighs. Authors have of late years distinguished with great minute- ness the primary venereal ulcers; and some have arranged them under distinct heads, ascribing to them specific differ- ences, with the view, principally, of establishing certain indi- cations in relation to the propriety of administering or with- holding mercurial remedies for the prevention and cure of the secondary constitutional symptoms which may ensue. That there are divers local affections of this kind, is indeed unques- tionable. The observations of Hunter, have long ago esta- blished this fact very conclusively; but it may be greatly d iubted, whether the classifications and hair-splitting distinc- tions which have been announced as absolute and essential differences in the various ulcers of this kind, are entitled to our confidence, at least to the full extent to which they have been carried by some writers. Carmichael asserts, that there is but one of the four classes of the primary ulcers he describes; namely, the indurated and excavated chancre of Hunter, that is capable of giving rise to the true secondary symptoms of lues. This assertion, however, is by no means established on • Quam tamen (seternum quoniam dilabitur aevum,) Non semel in terris visam, sed saepe fuisse, Uucendam est: quanquam nobis nee nomine nota Hactenus ilia fuit: quoniam longaeva vetustas Cuncta situ involvens et res, et nomina delet: Nee monumenta patium seri riders nepotes. SYPHILIS. 497 incontrovertible observations; for it may be affirmed on the authority of competent testimony, that constitutional symptoms, differing in no material point from those which are regarded as truly syphilitic, may arise from various primary venereal pores, distinct from the excavated and indurated chancre. One thing at least is certain, that it is often extremely difficult, and sometimes impossible to determine from the appearances of tho chancre, to which of the species, usually described, it may belong ; for in their external characters they sometimes pass into each other so insensibly—and the varieties of appearance met with in practice are so multifarious, that it will often baffle all our attempts to form a satisfactory diagnosis on this point. Even the unquestionably syphilitic chancre, so accurately de- scribed by Hunter, is liable to be confounded with other vene- real sores, from these latter occasionally assuming the appear- ance of the excavated and indolent chancre. Dr. Hennen, whose opportunities for carefully observing these affections were very extensive, confesses his inability to point out •'any invariable characteristic symptoms, by which to discriminate the real nature of the primary sore." " It would," he observes, " be by no means difficult to show, that the high round edge, the scoped or excavated sore, the preceding pimple, the loss of substance, the hardened base and edge, whether circum- scribed or diffused, and the tenaciously adhesive discharge of a very fetid odour, are all observable in certain states and va- rieties of sores unconnected with a venereal origin. The hard- ened edge and base, particularly, can be produced artificially, by the application of escharotics to the glans or penis of a sound person ; and if any ulceration or warty excrescence previously exists on these parts, this effect is still more easily produced."* Indeed, when we take into consideration the variety of textures which compose the parts upon which these primary sores occur —the diversity which exists in individual constitutions, and the various influences which are continually modifying tho general habit of the body, we can readily conceive that sores, even from the same virus, must be liable to very different as- pects in different individuals. In making these remarks, I would by no means wish to ho understood as regarding all distinctions of this kind as un- founded or nugatory ; but to attempt to classify these primary venereal sores as fixed and essential diversities, merely from their external characters, and to propose them as indications for the employment or rejection of particular remedies, appears to me obnoxious to very serious objections.! * Principles of Military Surgery, &c. p. 517. f " It is not," says Swediaur, " by the external characters alone, that we can discover the nature, and distinguish the different kinds of ulcers vol. ii.—63 49S SYPHILIS. In relation to the diversities which occur in the primary as well as the secondary venereal affections, it must, in the first place, he observed, that there are two distinct classes of these maladies, namely : 1, genuine lues, or syphilis, for the cure of which mercury is indispensable; and 2, venereal affections, often closely resembling, though differing essentially from the former, and which may in general be cured without mercury. I. The true syphilitic chancre is thus described by Mr. Hun- ter—"The sore is somewhat of a circular form, excavated, without granulations, with matter adhering to the surface, and with a thickened edge and base. This hardness and thickening is very circumscribed ; not diffusing itself gradually and im- perceptibly into the surrounding parts, hut terminating rather abruptly." When examined, by pressing the chancre between the fingers, it will be found that the whole excavated surface of the ulcer is surrounded by a hard or indurated basis. In some instances, a small indolent ulcer is seated as it were in an indu- rated knob on the glans; and occasionally indurated tubercles passing deep beneath the surface, with scarcely any visible ulceration, will be followed by constitutional symptoms of syphilis—but in cases of this kind " we will probably learn, a small ulcer existed at first on the callous part, which healed under the use of some local application." (Carmichael.) When the syphilitic chancre is situated on the body of the penis, it presents a dark livid colour, without being scooped out or ex- cavated, and the surrounding parts are less indurated than when it occurs on the glans penis. True syphilitic chancre is always of an indolent character—very slow in its progress. The excavated and circumscribed state of the ulcer, its indu- rated edges and base, and its slow progress, constitute the characteristic marks of the syphilitic chancre ; but it must not be forgotten, that almost any sore situated on the glans penis is apt to acquire a more or less indurated condition from being frequently irritated by improper applications; and hence, "in forming a diagnosis, we should always take into consideration the previous management of the ulcer." (Carmichael.) The constitutional symptoms which proceed from the true syphilitic chancre appear first upon the skin, the throat and mouth; and finally upon the periosteum, bones, and deep-seated parts. The true syphilitic eruption appears in distinct circular patches, from a few lines to half an inch in diameter. They arc slightly raised and covered with thin, whitish, hard scales, easily separated, leaving smooth, shining, copper-coloured spots somewhat elevated above the surrounding skin. In some in- alluded to; to inspection and practical knowledge, we must join a profound acquaintance with the diseases, an attentive examination into the actual state of the patient, his constitution, and the remedies and re- gimen which he has adopted." SYPHILIS. 499 stances a small white band encircles the base of each disk; and occasionally several of the spots unite, forming large irregular copper-coloured patches, with portions of scales adhering to them. These scaly copper-coloured spots are sometimes in a great measure confined to the forehead, neck, breast, forearms, legs, and anterior part of the abdomen. Syphilitic eruptions occasionally appear in the palms of the hands and soles of tho feet, presenting a very peculiar aspect—namely; masses of dry friable scales, very easily removed, and exposing spots of a livid colour, with an indurated state of the skin and subjacent structure. When the syphilitic patches are situated on parts opposed by another skin—as between the nates, under the arms, between the thighs and scrotum, &c, they do not present a dry and scaly appearance; but an elevated, soft, moist, and flat sur- face, discharging a thin whitish matter. Sometimes the upper part of the extremities of the fingers and toes become affected, and the nails are gradually separated. If the disease is not opposed by the employment of mercury, "every succeeding scurf which is formed becomes thicker than the preceding, till at length it forms a crust, under which matter collects, and it becomes a true ulcer. These ulcerations spread very slowly. After the eruption has made more or less progress, the throat also becomes ulcerated, generally about the tonsils and soft pa- late. These ulcerations arc not preceded by much inflamma- tion or swelling, and the tonsils exhibit ulcerated cavities with well defined edges, similar to the primary syphilitic ulcers on the glans penis. As the disease proceeds, the periosteum, the fasciae, ligaments, and bones become affected ; and of the bones, those nearest the surface, as the cranium, clavicle, and sternum, arc most liable to become the seat of its destructive ravages. "The true syphilitic node is a solid enlargement of the bone," unaccompanied during the earlier periods of its progress by any discolouration of the skin, nor is there much pain, until it has arrived at a considerably advanced state. II. Of the non-syphilitic venereal sores, and in which mer- curial remedies are in general unnecessary and often highly injurious, the following arc the principal varieties:— 1. Venerola vulgaris*—or the simple primary venereal ulcer of Carmichael. This is by far the most common variety of venereal ulcerations. The'simple venereal ulcer commences from three to seven or eight days after the impure sexual con- nexion, by an itching or redness, which is speedily succeeded by a small pustule surrounded with a red margin. In a few * Pathological and Practical Remarks on Ulcerations of the Genital Organs. 13y James Evans, Surgeon, &c. &c. 500 SYPHILIS. days the pustule becomes converted into a thin crust, under which more or less matter collects and gives rise to considera- ble pain. The scab gradually enlarges and acquires a trian- gular or circular shape, varying in colour from yellow to dark brown. This scab soon separates, and exposes an excavated, round, or oval ulcer, with a glossy reddish or dirty yellow colour, surrounded by a narrow red areola. The bottom of the sore now begins to fill up; it rises above the level of the surrounding parts, and exhibits a smooth surface, seated on a fungoid basis, without granulations, and of the colour of a healthy sore, the base and edge being usually darker red than the disk of the sore. Between the fourteenth and fifteenth day, the ulcer generally has risen to its greatest height; but the process of ulceration, as well as the surrounding efflorescence, generally cease as soon as the fungoid stage commences. In some instances, the top of the elevated sore extends beyond its base over the surrounding sound skin, giving it the appearance as if a ligature were tied about it beneath the surface. In this state the sore remains stationary for some time, and then gra- dually and usually slowly declines and heals, the average pe- riod from the commencement to the termination of the ulcer occupying from four to six weeks. " Wherever may be the seat of these ulcers, on the inner part of the prepuce, their characters are seldom doubtful after the ninth day; for by drawing the skin well back and making allowance for the form of the parts, the raised edge and surface cannot escape discovery, for although these may not be plainly discernible all around, they will be so on some one side." (Evans.) These ulcers are particularly apt to excite phymosis, and are frequently accom- panied with patchy excoriations on the glans and prepuce, and occasionally with a profuse gonorrhoeal discharge. The causes oivenerola vulgaris consist of gonorrhoeal matter and of other morbid vaginal secretions communicated by the sexual intercourse. With this variety of venereal ulcerations, we may place the ilpalchy excoriations'* already mentioned, for they proceed from the same cause, and may exist either conjointly or separately. Secondary, or constitutional symptoms sometimes succeed or attend this variety of primary venereal ulcers ; hut these are always mild, and readily disappear under mild aperient and diaphoretic treatment. These symptoms consist in slight fe- brile excitement, attended with headach, and aching pains in the joints, and occasionally also in the chest, succeeded by a papular eruption on the forehead, chest, and back, and scatter- ed more thinly over the extremities. Fresh crops of these pa- pulse appear, at the same time that the slight febrile irritation, and nocturnal pains in some of the joints continue. " The papulse vary from a palc-rcd to a deep crimson colour," some SYPHILIS. 501 of them preserving the character of pimples, whilst others are more of a pustular form. They may appear from five weeks to three or four months after the infection. When they are about declining they become paler, and often assume a copper tint, " while the exfoliation of the cuticle gives them an appear- ance of scaliness"—a state in which they may be confounded with the scaly eruption of true syphilis. "But they may be readily distinguished from each other ; for when the papular eruption is on the decline, and has assumed a pale-red or copper colour, on examining the patient we shall find other spots in their pa- pular or pustular form, which will at once point out the charac- ter of the eruption." (Carmichael.) The fauces generally become affected, hut not with excavated or spreading ulcers. The patient complains of soreness on swallowing, and on looking into the fauces, the entire cavity exhibits a red and ©edematous appearance, with swollen tonsils. 2. Venerola superficialis of Mr. Evans, or the primary ulcer of the pustular syphilitic eruptions of Carmichael.—This va- riety begins with a small pustule, which soon breaks, and forms a crust, under which the cuticle ulcerates in a circular or oval form. When the crust separates, it exposes an ulcer of a reddish-brown surface, on a level with, or somewhat elevated above the surrounding skin, with raised and well de- fined edges. It is free from marginal or surrounding indura- tion, of a granulated appearance, and seldom attended with considerable pain. It varies from the size of a pea to that of a shilling; but when neglected or improperly managed, it sometimes increases to a much greater extent. It occurs most frequently on the external surface of the prepuce and body of the penis, and is sometimes met with on the anterior aspect of the scrotum. In some instances this variety of ulcer surrounds the orifice of the prepuce, and occasions, when the ulcer heals, a permanent phymosis. It is generally tedious in its progress, and does not manifest any tendency to spread. This ulcer has not the smooth fungus appearance of the former variety, and is strictly defined in its circumference. Venerola superficialis, when left to itself, is almost invariably followed by constitu- tional symptoms. These consist usually of a pustular erup- tion coming out in succession, and terminating speedily in scabs and superficial sores, so that, "at the same time, on the same individual, there will appear some new formed pustules, and others in their scabbing stage, with an intermixture of small ulcers, whose crusts have fallen off, and of discoloured patches of the skin, where they have healed." Considerable inflammation and ulceration of the tonsils and pharynx, attend- ed with pains resembling acute rheumatism, are particularly apt to follow this variety of primary ulcer. Mr. Evans asserts, that he never met with an instance that was not followed by 502 SYPHILIS. secondary symptoms. Mr. Carmichael thinks that this variety of venereal disease forms " the natural link between the simple ulcer and its consequences, and the phagedenic venereal dis- ease." 3. Venerola indurata, or the induratedsloughingprimary ul- cer.—This variety of venereal ulcer is characterized by great derangement of the general health, much inflammation of the part, local pain, a strong tendency to sloughing or destruction of the parts, and by a cartilaginous induration of the base, unless seated on the glans. The situation of this sore is fre- quently at the duplication of the prepuce behind the corona glans, in which case the ulcer generally burrows deep between the skin and body of the penis. When it is situated on the in- ternal surface of the prepuce, which is very common, the pe- culiar hardness of the base is very remarkable; and the sur- face of the sore, whether seated on the prepuce or glans, pre- sents a dark, liver-coloured slough, " which falls off, and is succeeded rapidly by other sloughs, destroying the parts ra- ther in depth than in breadth." (Bacot.)* When the general and local inflammatory action is very severe, mortification to a greater or less extent is by no means uncommon. Mr. Evans says, that he has " known gangrene to take place as early as twenty-four hours after the appearance of the disease, and in less than seventy-two hours after the venereal connexion. When these sores heal, they are apt to leave indurated spots, which are peculiarly disposed to ulcerate again from irri- tation, or want of cleanliness. (Evans.) This variety of sloughing ulcer is distinguished from the phagedenic ulcer by the presence of the indurated base. The constitutional symp- toms commonly show themselves at a very early period, even before the active progress of the ulcer is completely ar- rested, and do not differ materially from those which succeed the next variety—namely : 4. The phagedenic primary ulcer of Carmichael.—This ulcer exhibits an irregular, corroded appearance, without gra- nulations and surrounding induration. It sometimes spreads rapidly, and causes extensive destruction of the parts in a few days. Sometimes it " creeps on slowly, healing in one part and making progress in another." The internal use of mercu- ry very generally renders its course more rapid and destructive. It is usually seated on the glans near the prepuce, which "it often entirely consumes, and continuing its depredations on the, corona and glans, at last effects their total destruction. When this event takes place, the ulceration usually receives a sudden and permanent check ; but in some instances, profuse haemorr- * Observations on Syphilis, principally with Reference to the Use of Mercury in that Disease. By John Bacot, Member of the Royal Col- lege of Surgeons, &c. SYPHILIS. 503 hage occurs before the glans is entirely destroyed, and a favour- able change occurs in the ulcer. Occasionally, though indeed rarely, the disease slowly proceeds until the whole penis is destroyed. (Carmichael.) It is highly probable, as Dr. Emerson observes,* that the two last varieties of venereal ulcer owe their characteristic phenomena u more to circumstances of climate, constitution, and habits of the patient, than to a peculiar or distinct specific virus." Of this, indeed, I do not in the least doubt. "A southern climate predisposes most to these forms of primary syphilis, which are comparatively rare in the more northern and tem- perate latitudes. In the south of Europe the predisposing causes seem to be far more active, and particularly so in their operation upon northern visiters. The crews of our men of war and merchantmen have occasionally suffered very much from this form of syphilis in the Mediterranean, especially on their visits to the Italian and Spanish ports." Persons of a scorbutic and irritable habit—and especially those whose con^ stitutions have been impaired by breathing an unhcalthful at- mosphere, or by a spare and unwholesome diet, or finally, by long residence in hot climates, are most liable to the slough- ing and phagedenic varieties of venereal ulcerations. (Evans, I. cit. 109.) According to Carmichael,the secondary constitutional symp- toms of the last two varieties of primary ulcer are : tubercles, pustules or spots of a pustular tendency—degenerating quickly into ulcers, with thick scabs, healing usually from the centre, while the ulceration spreads along the circumference. Strong fever often ushers in this eruption ; but in many cases a general feeling of indisposition, of listlessness, palid countenance, languid eye, and broken rest, precede for several days, the ap- pearance of the eruption, unaccompanied by distinct febrile movements. In other instances, "nocturnal headachs, tender- ness of the scalp, slight dyspnoea, with soreness of the sternum and of the breast, generally occur previous to the appearance of the constitutional symptoms." Phagedenic ulcerations in the throat, tending to destroy the pharynx ; the spongy bones of the nose ; soft palate and tonsils ; severe and obstinate pains in the joints—particularly of the knees and wrists ; and obsti- nate enlargement of the testes, are among the most common con- stitutional affections from primary ulcers of this kind. When the ulcers in the throat extend into the larynx, which is not very uncommon, "there is but little chance of saving the pa- tient's life." This occurrence is announced by " a whispering stridulous voice, constant cough, and copious expectoration of * See his edition of Carmichael's work on Venereal Diseases. Phila- delphia, 1825, p. 164. 504 SYPHILIS. viscid matter; restlessless, great anxiety of countenance, ema- ciation, night sweats, rapid pulse, and all the concomitants of phthisis." Treatment.—In perusing the various writers of acknow- ledged authority on this subject, it would seem almost impos- sible to come to any satisfactory conclusion, as to the proper mode of treating both the local and general symptoms of this malady. All indeed agree, that in genuine syphilis, mercury is indispensable to the removal of the disease; hut this forms but a small portion of the great number of venereal cases met with in practice, and it is moreover admitted, and very justly too, that it is frequently almost impossible to determine, from the external character of the disease, whether it is true lues, or only one of the various venereal affections which have been de- scribed. Some writers condemn the use of mercury, without exception, in the various non-syphilitic venereal affections ; others admit its utility in certain varieties and under certain conditions, but they disagree among each other, as to the par- ticular varieties and circumstances which call for its employ- ment. Others, again, less scrupulous in the use of mercury, affirm that, with very few exceptions, and under cautious ma- nagement, it may not only be safely, but very beneficially, used in almost every variety of primary and secondary venereal affections. The result of all this disparity of opinion would seem to be, that there is a " proper medium," in relation to the employ- ment of mercury in affections of this kind ; and that the entire rejection of its aid is just as apt to lead to disastrous conse- quences, as its indiscriminate and universal employment. Mr. Bacot observes, that " with the exception of the sloughing and phagedenic venereal sores, the exhibition of mercury, in the majority of primary ulcers, is so safe and so generally bene- ficial, that where a sore of this kind continues for a certain time to pursue its course, and to resist all those mild methods of cure, both external and internal, which influence the pro- gress of sores in other parts, I should not hesitate to have re- course to its exhibition." In reference to the late discussions concerning the non-mercurial treatment of venereal affections. this experienced writer makes the following observations, to the correctness of which I am entirely disposed to subscribe. " It is assumed, therefore, as an established fact, that all ulcers upon the parts of generation are curable without the use of mercury ; but I cannot concede that, generally speaking, they are cured with equal celerity : they require more strict con- finement ; more attention to the state of the general health and to regimen, than is found necessary under a mercurial treat- ment carefully conducted ; and in some instances, the length of time requisite for their complete cicatrization, is alone a sc- SYPHILIS. 505 nous evil. It may also he added, that under the non-mercurial treatment, they frequently heal with hardened and elevated cicatrices." It must be admitted, moreover, that a much greater proportion of cases are followed by constitutional symptoms, when the primary stage is treated without mercury, than where a cautious exhibition of this mineral is resorted to. "From these circumstances, therefore," says Mr. Bacot, "I would advocate the moderate and gentle use of mercury in all those cases of primary sore, where a mild mode of local and general treatment is productive of no beneficial change in the course of a reasonable period ; at the same time being perfectly prepared to do without it in all those cases, and in those con- stitutions, where its employment appears to he pernicious, be- ing convinced that it is both much wiser and more safe to post- pone the exhibition of this remedy where the habit is irritable, and it appears to operate upon the system as a poison only, calling into action that peculiar and anomalous class of symp- toms usually called cachexia syphiloida.,> (Loc. cit. p. 35.) Mr. Hennen also observes: "In every primary ulcer I would give up the idea of using mercury at first, treating it as if it were a simple ulceration, by cleanliness, rest, and absti- nence, and applying to it the most simple and mildest dress- ings. If the sore did not put on a healing appearance in a reasonable time, the extent of which must depend on the cir- cumstances of the patient, I should make use of more active dressings. But if beyond all calculation it remained open, I should certainly not sacrifice every dislike to mercury, know- ing how many persons have been seriously benefited by a judi- cious and mild administration of that remedy." These senti- ments appear to me unexceptionable, as general precepts, and I have for five or six years uniformly treated the cases that have come under my care in conformity with them. It will be proper, however, to give a more particular detail of the ma- nagement of the various primary ulcers. The simple venereal ulcer—venerola vulgaris, usually runs its course in spite of re- medial applications ; and where the irritation is not consider- able, nothing but the lightest emollient dressings are neces- sary, so long as the scab has not separated and exposed the fungoid and raised surface of the ulcer. Warm emollient poul- tices should be applied until the crust comes away, when the ulcer is on the external part of the penis; when the ulcer is seated on the inner surface of the prepuce, apiece of linen kept constantly moist with a weak solution of lead should be laid over the part; and when phymosis attends, the same liquid should be frequently injected with a syringe between the pre- puce and glans. When the scab separates and exposes a rais- ed and fungous ulcerated surface, nothing in general answers better than the application of a weak solution of the sulphate of vol.. ii.—64 506 SYPHILIS. copper (in the proportion of about four grains to an ounce of water), two or three times daily ; and in the advanced stage of the complaint, the same may be injected under the prepuce, if phymosis attends. I have derived much benefit in the fun- goid state of this variety of venereal sores, from the application of citrine ointment softened down with an equal proportion of lard. The aquae phagedenica—made by dissolving eight grains of corrosive sublimate in four ounces of lime water, or a very weak solution of lunar caustic, may also he usefully employed. All such applications, however, should be weak, for the object is not to destroy the raised surface of the ulcer by an escarotic, but simply to stimulate it. Mr. Carmichael recommends the zinc ointment, either alone or mixed with a third or fourth part of the citrine ointment. During the early stage, the patient should use a light unirritating diet; remain quiet, take mild aperients ; and where the constitutional irritation is consider- able, venesection and perfect quietude in bed are proper. When phymosis attends, emollient poultices, an efficient blood-letting, and nauseating doses of antimony should be re- sorted to. Sometimes the violent attendant inflammation ter- minates in the formation of matter under the ligament of the penis. In this case the tension and pain are excessive and ob- stinate—the skin becomes discoloured, but from the extreme tension of the part no fluctuation can be felt The excessive pain, induration, tension, and obstinacy of the affection, are the only circumstances by which the formation of pus under the ligament can be discovered. If the matter is not evacuated by a free incision into the dorsum penis, it usually makes its way up the dorsum, and escapes by an ulcer near the pubis. Venerola superficialis, or the primary superficial ulcers with elevated and perfectly defined edges, are seldom benefited by stimulating and caustic applications ; and they often do manifest harm. Moderately astringent and soothing applications arc in general beneficial—such as weak solutions of sulphate of zinc, sugar of lead, althea or tutty ointment. When the con- stitutional irritation is very considerable, the lancet, purga- tives, antimonials, and other refrigerant diaphoretics, with lo- cal, emollient, and sedative applications, will be necessary. The internal use of mercury generally renders the progress of pri- mory ulcers, with elevated edges, extremely obstinate. "I have frequently." says Mr. Carmichael, "seen mercury exhi- bited in full doses, maintaining a strong mercurial action in the system for several months, without inducing ulcers of this kind to heal." In the indurated sloughing ulcer, where there is much sur- rounding hardness, and the surface of the sore covered with a dark liver-coloured slough, from which a thin dark-coloured ichorous fluid issues, merairy, according to the cxprience of SYPHILIS. 507 Mr. Bacot, is decidedly beneficial, until the hardness of the surrounding parts disappears; but it does not appear that the most careful administration of this medicine is capable of pre- venting the constitution from the secondary symptoms ; but when the copper-coloured eruption has once made its appear- ance, " it is as much under the influence of mercury as the pri- mary sore"—disappearing in general without difficulty, under the moderate employment of this remedy. When the constitution- al irritation is high, and a disposition to gangrene manifested, at- tended with great anxiety, heat, and dryness of the skin, furred tongue, and much pain and swelling of the prepuce, vigorous antiphlogistic measures must be adopted—the lancet, cathar- tics, antimonials in nauseating doses, cold applications, and a rigorous antiphlogistic treatment arc indispensable in such ca- ses ; and the patient should remain in bed. After the local and general inflammatory action is moderated, and the system is much debilitated, recourse should be had to tonics—particular- ly quinine and opium ; and the separation of the sloughs may be promoted by warm emollient poultices. Mercury can only be safely employed where the surrounding inflammation and pain are moderate. The sores must be dressed with mild ap- plications—such as weak solutions of acetate of lead, or a so- lution of sulphate of copjier, in the proportion of two grains of the sulphate to an ounce of water, or the black lotion, (calo- mel 9i., limewater 3V1.) The phagedenic, soft, sloughing primary ulcer, and which is wholly free from the very conspicuous surrounding hardness, is often especially unmanageable. The most prompt and vigorous antiphlogistic measures are necessary to arrest the progress of the ulceration ; but the employment of mercury, in this variety of primary ulcer, is almost invariably pernicious, ♦' and often productive of the worst consequences" (Bacot.) The measures to be confided in during the inflammatory stage are : rest in a recumbent posture ; venesection ; nauseating antimo- nials ; warm fomentations injected under the prepuce, or ap- plied by steeping ; warm emollient poultices ; together with tho internal use of opium, hyoscyamus, and cicuta. When the vio- lence of the inflammation and the active progress of the ulcera- tion has been moderated, and the ulcer " creeps slowly along," healing in one place while it advances in another, a weak so- lution of (hp nitrate of silver (one, two, or three grains to an ounce of water), "or the black or yellow mercurial washes, agree well in some cases, while in others no applications seem to he capable of checking the progress of the ulceration." (Carmichael.) If sjiontanemis haemon'l age ensues in such obsti- nate cases, an immediate check to the progress of the disease is usually the result. Mr. Carmichael states, that he has in soma instances derived the most decided advantage from "paring off 508 SYPHILIS. the irregular and jagged superficies of the ulcer, and encourag- ing the bleeding afterwards by immersing the part in warm water." When a band or strip of integument connects one portion of the ulcer with another, or the ulcer has separated the frenum from the glans, and the disease has assumed a chronic state, it will be proper to divide it by an incision. In sloughing ulcers, without indurated bases, we may often derive much benefit from stimulating applications. Carmichael particularly recommends Venice turpentine, or balsam co- paiva, mixed with one or two parts of olive oil. I have known very prompt advantage derived in sloughing ulcers of this kind, from the application of poultices made of crumbs of bread and a strong decoction of oak-bark. A lotion of one part of the tincture of myrrh to seven parts of camphorated mixture, may also be very beneficially applied where the sloughs are extensive. (Carmichael.) A pure air is all-im- portant in the management of this variety of venereal sores. The true syphilitic chancre.—When early resorted to. the excision or destruction of the chancre with caustic will not unfrequently succeed in arresting the further progress of the local affection, as well as in preventing the occurrence of the secondary constitutional symptoms. This practice is, how- ever, not always free from unpleasant consequences, for although the sore may thus be speedily healed, buboes will occasionally appear ; and at other times " the virus, confined under the eschar produced by the cautic, corrodes the parts underneath, and forms a deep ulcer." In irritable and de- praved constitutions, too, the irritation produced by the caus- tic is apt to give rise to very injurious consequences. Swe- diaur asserts, that he has seen " the most dreadful symptoms produced by this application." Although mercury is unques- tionably our only means for counteracting the formation of secondary affections, it does not appear that it possesses any especial controlling power over the primary local affection. Nevertheless, as it is of much importance to protect the system against the occurrence of a general syphilitic taint, it will be proper to put the patient at once under the use of a gentle mercurial course, in conjunction with proper local applica- tions to the chancre, unless the primary sore be irritable, and the general system inflammatory, or of a manifestly depraved or scorbutic habit. When these latter contra-in- dicating conditions to the employment of this remedy exist, measures must be previously taken to remove the irrita- ble and phlogistic state of the system, by pure air, diaphore- tics, opium, and laxatives. Most of the recent writers recom- mend the mildest local applications—simple ablution to keep the parts clean, and dressing the chancre with dry lint, or the most soothing ointments ; and in the majority of instances, these will be found better than the irritating applications for- SYPHILIS. 509 merly so much employed. Swediaur, however, is a strenuous advocate for the employment of the red oxide of mercury mixed with lard, as a local remedy for syphilitic chancre. He also speaks very favourably of the effects of " finely powdered corrosive sublimate, mixed with a little saliva, and rubbed for five or six minutes, once or twice a day on the ulcers. These remedies, he asserts, are generally highly useful, notwithstand- ing the assertion of modern writers." To sum up all, he says, " I am of opinion that mercury topically applied, is never in- jurious in syphilitic ulcers ; but on the contrary, that it is extremely serviceable, and almost sufficient to effect a cure, when the ulcers are local, and arise from a primary disease ; lastly, that it is always necessary when the progress of the disease is rapid and alarming." I have repeatedly resorted to applications of this kind with very satisfactory results, although, in general, I have abstained from them until the system was put under a moderate mercurial influence. My usual mode of proceeding, is to destroy the chancre with lunar caustic, when I am consulted during the first five or six days after its appearance ; but where the chancre has already made considerable progress, I, at first, simply keep the parts clean by frequent ablution, and direct it to be dressed with simple cerate; as soon, however, as the system is moderately im- pregnated with mercury, I destroy the callous edges of the chancre with caustic, and direct the sore to be dressed with red precipitate ointment; or to touch it frequently during the day w itli a solution of the sulphate of copper (four grains to an ounce of water;) or finally to wash it repeatedly with the black mercurial lotion. The mercurial impression should be kept up for six or eight weeks ; but it is of the utmost im- portance that the patieut avoid a damp and cold atmosphere, and he should be particularly cautious to keep up an equable action of the skin by warm clothing; and to use mild and unirritating diet, and to abstain wholly from the use of stimulat- ing drinks. During damp and variable weather there is great risk of receiving injury from cold, while the system is under the mercurial influence; and to avoid this accident, the pa- tient should, if possible, remain within doors. The treatment proper for the removal of the constitutional venereal symptoms, has been particularly a field of much con- tention—all turning upon the point, how far mercurial remedies may be necessary or injurious in the management of these af- fections. It is now, however, very generally admitted, that in what are termed the pseudo-syphilitic symptoms, the employ- ment of this potent remedy may often be very properly dis- pensed with—that it is calculated under certain circumstances to do much injury, and that in no instance is it necessary to carry its employment to the great extent which was formerly so indiscriminately and generally practised. Nevertheless, we 510 SYPHILIS. may upon good grounds, I think, refuse to join in the hue and cry set up against the employment of mercury in venereal cases —for there is much reason to believe that many of the baneful consequences which have occurred from its administration, have proceeded rather from its abuse than its use, or from ac- cidental influences contravening its salutary influence. The most violent declaimers against mercury, are those who have practised in hot climates—and in military and other hospitals, and generally among patients whose previous modes of living were such as to deprave the general constitutional habit—all of which circumstances are certainly very well calculated to interfere with the salutary operation of this remedy, and to convert it often into a decidedly deleterious agent. It must indeed be admitted, that the various forms of consti- tutional venereal affections may in general be ultimately re- moved by a long course of the usual diaphoretic ptisans, proper regimen, and other simple measures, calculated to improve the general health of the system. This is more especially practi- cable so long as the secondary symptoms are confined to the skin and throat; but even in this stage of the progress of such affections, the moderate and gentle use of mercury will almost always greatly expedite the cure, and in some instances will be found indispensable to the entire eradication of the malady. Although very generally a mild mercurial influence regularly sustained, will be sufficient to procure all the benefits that may be derived from this remedy, yet instances do sometimes occur, which after a long course of gentle mercurial action, without any permanent advantage, will readily yield to a full saliva- tion. About four years ago, I met with a striking illustration of this fact. The patient had for three years laboured under secondary venereal symptoms, which were the consequence of a phagedenic primary ulcer. He had undergone three mode- rate, but long continued mercurial courses, with only very tem- porary benefit, and during the eight months immediately before I saw him, be daily took the sarsaparilla decoction and syrup—of the latter of* which he had already taken above forty bottles. His nose and internal fauces were much ulcerated, and various painful swellings on the ulnse, tibia;, and cranium, had reduced him to a most distressing condition. I put him immediately upon the use of large and repeated doses of calomel, and confined him to his bed. In five days very profuse ptya- lism was induced, vvhich was kept up for two weeks, and then left to subside gradually, under the use of sarsaparilla infusion. In six weeks he was entirely cured, and he has since enjoyed, apparently, a perfect state of health. The papular form of venereal eruptions, will very generally disappear under the use of antimonials and sarsaparilla, with a mild and unirritating regimen, aperients, the warm bath, SYPHILIS. 511 and an avoidence of a variable, damp, and cold atmosphere. Nevertheless, where this eruption continues obstinately, and the patient's strength declines, recourse should be had to mer- curial remedies; which will rarely fail in a short time to mani- fest a most beneficial effect. The tubercular eruptions which usually appear on the eye- brows, forearms, back, and hairy scalp, and which at last become converted into irregular crusts, leaving ragged, ill looking ulcers of a glassy, shining, and level surface when they separate, are in general decidedly benefited by a mild mercu- rial course, after the general phlogistic symptoms which usu- ally usher in the eruption have been reduced by venesection, antimonials, aperients, diluent drinks, &c. Carmichael recom- mends the free use of the decoction of sarsaparilla and antimo- nials in this variety of the disease; and where the secondary ulcers are extensive and irritable, with phagedenic edges, the use of free doses of cicuta, in conjunction with the compound decoc- tion of sarsaparilla, is often highly beneficial. The internal use of the nitrous acid too, is sometimes very efficacious, where the tubercles spread in foul and irregular ulcers ; and it may be very conveniently given in union with the sarsaparilla. Although Mr. Carmichael advocates the non-mercurial mode of treat- ing this and some other varieties of secondary venereal affections, he "does not wish to be understood as wishing to exclude the use of mercury altogether, for the cure of this most formidable of venereal comnlaints. It is against the abuse not the use of this remedy I contend." The fact appears to be, that where from idiosyncracy, or a peculiar, irritable, and scorbutic condi- tion of the system, the operation of this remedy is not diverted from its ordinary salutary effects, it may in general be employed with as much advantage in this as in any of the other forms of secondary venereal affections. Mr. Bacot asserts it as his conviction, that the tubercular variety of eruptions, with its consequent ulcerations, is in general "strikingly benefited by the mild employment of meicury." Without, however, extending these observations as to the particular circumstances under which the employment of mer- cury may be proper or improper, it will be sufficient to observe, in a general way, that in all instances where the cutaneous and other seconda.v symptoms do not yield in a reasonable course of time to the use of sarsaparilla, the compound decoctions of the woods, antimonials, rest, an equable temperature, and sim- ple and unirritating diet, recourse should unquestionably be had to a more or less active course of mercury. Where the constitutional symptoms are attended with much general irri- tation or febrile excitement, the use of mercury ought to be delaved until the general phlogistic and irritable habit ot the body has been moderated by the use of the measures just nidi- 51S SYPHILIS. cated. It should also he particularly borne in mind, that where the ulcerations in the throat are attended with high inflamma- tion and swelling, mercury cannot in general be safely ad- ministered until this local inflammatory condition has been moderated by general antiphlogistics, emollient gargles, the inhalation of aqueous vapour, perfect rest, low diet, and nau- seating antimonials. In instances attended with an irritable habit of body, much advantage will usually result from the employment of opium or hyoscyamus in conjunction with mercurials. This combination is more especially necessary in cases attended with much pain in the extremities or bones, and where the mercury seems to augment the general irritation. So far as my own limited experience has enabled me to judge, I am well satisfied that the regular employment of full doses of Dover's powder will in general very materially enhance the good effects of mercury, under almost every variety and circumstance of the disease. One of the most important observances in the employment of this remedy, is the rigid avoidance of a cold, damp, and varia- ble atmosphere. If the patient can be induced to remain in his room, which should, however, be kept perfectly clean and well ventilated, and at a uniform temperature, the beneficial influence of the mercury will be much more certainly obtained than when he walks about in the open air, unless the weather be warm and dry. The diet too should be of the lightest and least irritating kind, and every sort of stimulating drink must be especially interdicted. It has already been stated that in the commencement of the constitutional symptoms, it often becomes necessary to employ measures for the reduction of the general phlogistic habit, be- fore mercurial remedies can be with propriety resorted to. It may also he observed, that even in inveterate cases, the use of aperients, the warm bath, and especially the compound decoc- tion of sarsaparilla, continued for three or four weeks, are often decidedly useful preliminary measures to the employment of mercury. With regard to the extent to which the mercurial action is to be carried, no precise rules can be laid down, for the manage- ment of secondary venereal affections. It is admitted, neverthe- less, that it seldom becomes necessary to induce full ptyalism— a moderate and equable action, maintained for a considerable length of time, being commonly sufficient to procure all the advantages that can be derived from this remedy. To this, however, exceptions will occur; and where the disease does not yield under the combined influence of an alterative course of this medicine, and the usual diaphoretic or depurative ptisans, we ought certainly to push the mercury to the full extent of SYPHILIS. 513 its influence, where no symptoms or circumstances exist which seem to contraindicate its vigorous employment. Some difference of opinion prevails as to the preparation of mercury most eligible for the treatment of venereal affections. In recent cases the blue pill, with or without ipecacuanha, is ge- nerally preferred. In chronic syphilitic affections of every form, I have scarcely ever employed any other mercurial than the corrosive sublimate in doses of from one-eighth to one-sixth of a grain, with two grains of the extract of cicuta, three times daily. Professor Zondi has, within a few years, published a new mode of using mercury in chronic venereal complaints, which I have known employed in two instances with extraordinary success. He makes one hundred and twenty pills out of twelve grains of corrosive sublimate, and directs them to be taken in the following way : On the first day one is taken; on the se- cond none; on the third two; on the fourth none ; on the fifth three pills ; and so on, increasing the dose by one pill every other day, and omitting them on the intervening days, until they are all taken, by vvhich time the cure is completed. During the treatment, infusion of senna is to be taken, so as to keep up a regular action of the bowels, and the patient is restricted to half the ordinary quantity of his food, and is permitted to leave his house only during very fine weather. About two years ago I saw this plan of treatment put in practice with complete success. The patient was affected with venereal nodes and ca- ries, with ulcers on different parts of his body, and had been long wholly unfit for any kind of employment. I had him un- der treatment for six months; three of which he used the compound decoction of sarsaparilla, and the three last months he was under an alterative course of mercury, without deriving any particular benefit from all I prescribed. He was then admit- ted into the Pennsylvania Hospital, and underwent two full mercurial courses, but he came away without being in the least relieved. My friend, Dr. Moering, had expressed to me a wish for a proper subject to put Zondi's mode of treatment to a fair trial. I took him to this patient: he prescribed the cor- rosive sublimate in the above way, and in five weeks the pa- tient was relieved of all his symptoms ; and he is now perfectly healthy, and has made several long voyag s since he underwent the treatment. Sarsaparilla and guaiacum in the form of a ptisan, are, with- out doubt, highly valuable remedies in the treatment of venereal affections ; and in conjunction with antimonials, a simple diet, warm bathing, and aperients, will often remove the milder forms of the disease without the aid of mercury. Although I should not be disposed to depend solely on these means, yet the sarsapa- rilla decoctions, in common use, can hardly be omitted with VOL. IT.—65 514 SYPHILIS. propriety, in conjunction with mercurials, in the cure of such affections. A great variety of formulae have been proposed for preparing these ptisans ; but the following are acknowledged to be among the most effectual.* An excellent mode of adminis- tering mercury, is to give it in solution in a ptisan of this kind. As a local application to the chronic and foul ulcers which occur in some instances on different parts of the body, as well as to those which are seated in the fauces, the black or yellow mercurial washes, or a weak solution of blue vitriol, will in general answer a very good purpose. BUBOES Buboes are often extremely troublesome affections; and in irritable and scorbutic habits, or from an abuse of mercury and * Rad. sarsaparil. ?ii. Flor. barag. officin. Petal, ros. gall. Fol. sennas Sem. sem. anis. aa ?ii. Sacch. communis. Mel. despumat. aa f^ii. Boil in a sufficient quantity of water to extract the virtues of the sar- saparilla. Strain, and add the sugar and honey; and boil it down to the consistence of a syrup. To each pound of the syrup may be added one grain of corrosive sublimate. The dose is from one to twa ounces twice or thrice daily. This is the Sirop de Cuissinier. R. Rad. sarsaparillae Liq. guaiac. offic. aa f^i, Fol. senn. G. arab. aa £i. Rad. zingiberis 5ss. Aq. fontanae Jfsx. Boil the two first ingredients in water for one hour; strain, and add to the residuum the same quantity of water as before, and boil it for two hours, and towards the end of the boiling add the other ingredients: strain, and to both decoctions add— Sacch. communis. Mel. opt. aa J^iH. Boil the whole to the consistence of a syrup. The dose is 5ii. twice or thrice daily. This is the rob antisyphilitic of Laffecteur. I have used the following syrup with peculiar advantage: R. Rad. sarsaparilla? ^iii. Fol. chimaphyllae umbel. 5ii. Sulphuret. antimonii enclosed' in a linen cloth, ?i. Aq. bullient. fh"i- Boil it down to three half pints; then add— Mel. despumat. 5viii. Dose—a wine-glassful four times daily. BUBOES. SI5 improper exposure, often give rise to the most destructive and unmanageable ulcerations. Buboes may arise either from mere sympathetic irritation, or from absorption of the venereal virus. The former variety of buboes is not uncommon in virulent gonorrhoea, and they arise often from the superficial ulcerations and patchy excoriations which occur on the internal surface of the prepuce and glans penis. Sympathetic buboes often disappear as soon as the primary local irritation upon which they depend is removed. They, however, sometimes be- come indolent, and remain stationary for a long time. In instances of this kind, mercurial frictions, blistering, or simple emollient poultices, will either dispose them to disperse or to proceed to suppuration, after which they readily heal. I have lately used frictions with the hydriodate ointment, in a case of indolent sympathetic bubo, with marked benefit. Swediaur divides buboes into the tonic and atonic; a dis- tinction which is frequently verified in practice. The former are attended with symptoms of active inflammation in the tumour, and with an evident phlogistic state of the general system. The pulse is full, hard, and quick, and the local pain violent and constant. The atonic bubo is accompanied with the reverse conditions—the symptoms being indicative of ge- neral debility. So long as the inflammation is not very high, or signs of com- mencing suppuration have not yet made their appearance, efforts should be made to disperse the tumour as speedily as possible. It is a common opinion among people, that the disper- sion of a bubo without bringing it to suppuration, is apt to be followed by dangerous consequences, from a supposition, that the venereal poison may be retained in the system, and give rise to subsequent unpleasant affections. For this apprehen- sion, however, there is not the least foundation. Many practitioners are in the habit of depending chiefly on mercurial frictions on the tumour, or on the inner surface of the thighs for the purpose of discussing buboes ; but this prac- tice is very rarely followed with success, unless active anti- phlogistic means, both local and general, be employed at the same time. The most efficient means for the reduction of inflamed buboes, where the general habit is phlogistic, are : local and general bleeding, saline purgatives, nauseating doses of tart, antimony, a very simple and unirritating diet, perfect rest, together with cold astringent lotions—particularly lead- water to the tumour, and mercurial frictions on the inner sur- face of the thighs. When the general irritation or phlogistic excitement is not considerable, venesection may be dispensed with ; but in instances attended with a bright red erysipela- tous appearance of the skin over the tumour, in robust and ple- thoric habits, scarcely any thing will avert suppuration, except 516 BUBOES. very efficient general blood-letting. When these measures do not arrest the progress of the bubo, and its tendency to suppu- ration is uncontrollable, means should be used to promote the suppurative process ; and for this purpose, I know of nothing better than emollient poultices. In atonic buboes, advancing slowly, and remaining for weeks in nearly a stationary condition, without manifesting a ten- dency either to suppuration or to resolution, the application of blisters to the tumour will often succeed in dispersing it, or at all events expedite its termination in suppuration. Both Mr. Carmichael and Mr. Bacot recommend blisters as in ge- neral decidedly the best applications to indolent buboes. The former observes that, " in such cases, (hard and indolent buboes,) the greatest advantage may be derived from the re- peated application of blisters to the indurated bubo, which soon either causes the dispersion or suppuration of the tumour ; and Mr. Bacot says it is a practice which he has pursued for near- ly fifteen years, with the most satisfactory results. (Loc. cit. p. 24.) When buboes of this kind occur in persons of a languid and feeble state of the body, much benefit will sometimes be deriv- ed from a generous diet, and the use of tonics and wine. When we fail to disperse the tumour, and it has? been brought to sup- purate, the matter should not be suffered to ulcerate an opening through the integuments. A free incision, with a common abscess lancet, should be made into the cavity and the matter evacuat- ed. When the buboes advance to suppuration, while their in- teguments are firm, and but little discoloured, Mr. Bacot ad- vises the passing a small seton through the base of the tumour. Mr. Swediaur and some other writers, however, think it much better to suffer suppurated buboes to open sponta- neously by ulceration ; for the artificial opening, he says, "is often made too early, before the abscess is fully matu- rated. This, however, is an argument rather against the improper, than the judicious use of the lancet; for it is not impro- bable that an incision made before the tumour is fully suppu- rated, may give rise to unpleasant consequences. It is un- doubtedly proper to delay making an incision until the ab- scess appears to be matured, but after this has been brought about, it is difficult to conceive any advantage from suffering the matter to remain some days longer confined. When the abscess is laid open, it will generally heal under the use of gently stimulating ointments and emollient poul- tices ; but in some instances the ulcerative process continues ; or the abscess acquires an indolent and unfavourable character, which prevents it from healing. In syphilitic bubo, mercury will be indispensable; but where there is a scrofulous or a scor- butic habit, and in instances where the general system is BUBOES. 517 enfeebled and irritable, the worst consequences will sometimes follow the active employment of mercurials. When a bubo assumes a more unfavourable aspect under the use of mercury, it should be immediately discontinued, and the sarsaparilla decoction freely used ; and in feeble habits, recourse must be had to cinchona, the mineral acids—particularly the nitrous acid, with a generous diet and pure air. When the opened abscess remains stationary, soft, and flabby, discharging a co- pious thin ichorous fluid, we may inject a weak solution of sulphate of copper, or of the yellow mercurial lotion (corrosive sublimate gr. x., lime-water §viii.) into the cavity, and apply stimulating cataplasms—such as a common poultice with a few drachms of cinchona mixed with it; or pieces of linen moistened with the tincture of gal ban u in over the sore. The internal use of opium or cicuta in full doses will also be parti- cularly serviceable in cases of this kind. The regular use of the latter narcotic is especially valuable in cases attended with symptoms of scrofula. When the bubo opens while a portion of it remains indu- rated, Mr. Swediaur recommends repeated cathartics, and the application of irritating remedies, such as the mercurial oint- ment, weak solutions of corrosive sublimate, &c. The solution of sulphate of copper, or the black mercurial wash, will often answer well in such cases. Sometimes the ulcers formed by suppurated buboes become surrounded with projecting, indolent, and undermined edges; "and if these edges are not removed by art, the ulcer will re- main for months, and perhaps years, without healing." In such cases, says Carmichael, "caustic, however powerful, is so slow in its operation upon the extensive and undermined edges of the buboes, that I always make use of the scalpel for their removal ; and this treatment has caused many of them to heal in five or six weeks, which would have resisted any other mode of practice as many months. Full courses of mercury always increase their tendency to burrow, and to extend their circum- ference." In foul and sanious ulcers of this kind, without the elevated and indurated edges just mentioned, much benefit will some- times result from charcoal or carrot poultices ; and where the surface is spongy and indolent, the application of nitric acid by strips of linen moistened with it, often produces a very excellent effect. 518 CHAPTER XXXIII. AMENORRHEA. This is one of the most common forms of menstrual disease, which, though sometimes borne without any material inconve- nience, seldom fails ultimately to derange the general health, and unless remedied, often leads to the most distressing and dangerous consequences. The exciting causes of amenorrhea are exceedingly various. Every thing which is capable of deranging the general health, has a tendency to excite irregularities or suppression of the catamenial discharge. Organic and inflammatory visceral affections—more especially pulmonary consumption—chronic hepatitis, and gastro-intestinal phlogosis or irritation, are rarely unaccompanied by menstrual irregularities, and often by a total and obstinate suppression of this evacuation. Men- tal emotions, particularly protracted grief and despondency, and sudden terror or violent anger have a powerful tendency to arrest the catamenial discharge. Metastasis of rheumatism— of erysipelas—and of chronic cutaneous affections; habitual hsemorrhoidal discharges, as well as other varieties of haemorr- hage, leucorrhoea, and deficient and unwholesome nourishment may also give rise to this affection. But by far the most com- mon cause of amenorrhoea is cold, operating on the system either during the interval of the menstrual periods, or imme- diately before the menses are about to appear, or finally during the actual flow of the evacuation. When the exciting cause acts during the interval of the cata- menial periods, the menses will either not make their appear- ance at the next period, or they will, perhaps, begin to flow sparingly for a few hours, and then cease. In general, no ma- terial inconvenience is felt from the absence of the evacuation, and in some instances it returns spontaneously at the succeeding period. Occasionally, however, considerable uneasiness in the pelvic region, pain in the loins, irregular determinations of blood to the head or chest, and in nervous subjects, various hysterical symptoms, are the immediate consequences of the suppression. But although the system frequently bears the suppression of this evacuation without any material unfavour- able consequences during the first six or eight weeks, more or less derangement of the general health invariably ensues, if the menses fail to make their appearance after the second or third period. The usual symptoms which ultimately arise from this affection are : languor and debility; a pale and sickly expres- sion of the countenance; swellings of the ankles; various AMENORRHEA. 619 nervous affections, such as paroxysms of palpitation of the heart and dyspnoea; flatulent and spasmodic pains in the bowels; loss of appetite; and in relaxed and leucophlcgmatic habits leucorrhoea. In subjects predisposed to phthisis pulmonalis, or to some other local or general disease, protracted suppres- sion of the catamenial evacuation is always particularly dan- gerous, from its strong tendency to develope such affections. When the menses are suddenly suppressed, whilst they are flowing ; or when the remote cause of the obstruction is applied immediately before the impending appearance of the evacua- tion, the consequences are much more violent and sudden. In such cases, the most alarming symptoms sometimes almost im- mediately follow the suppression of the discharge. In some cases paroxysms of violent spasmodic pains occur in the bowels and stomach, attended occasionally with severe retching. In other instances, strong determinations of blood take place to the brain, giving rise to raving delirium, hysteric mania, con- vulsions, or a temporary loss of sensation and voluntary motion. Sometimes extremely alarming palpitations of the the heart, with great difficulty of breathing occur ; and in some cases the irritation passes at once upon the sanguineous sys- tem, occasioning high febrile reaction, and local inflammatory affections. Treatment.—When one or more of the violent affections just mentioned succeed the sudden suppression of the menses, the first object must be to allay the alarming and painful symp- toms, without any immediate attention to the restoration of the evacuation. The attempt, indeed, to reinstate the catamenial secretion, at the period when it becomes arrested, is almost always abortive; yet the remedies which may be proper to palliate or remove the present symptoms, will occasionally have the effect of bringing back the suppressed evacuation. In young and plethoric subjects, or where strong determi- nations of blood take place to the head or lungs, efficient vene- section should be promptly resorted to. We can, indeed, seldom allay the violent spasmodic and painful symptoms very mate- rially by this measure alone ; but in the habits just mentioned, it constitutes an essential preliminary to the successful employ- ment of other remedies—particularly opium and ether, which in most instances afford more speedy relief than any other re- medies we possess. Active cathartics and purgative enemata, sinapisms to the inferior extremities, warm pediluvium, and antispasmodics, are the principal means to be relied on. In weak and nervous females, it will not be necessary, and often improper to bleed. In cases of this kind, warm pediluvium, with a few full doses of laudanum and camphor, will in general speedily allay the alarming and painful symptoms which often accompany this accident. Dr. Dewees states, that he hasTound 520 AMENORRHEA. nothing to answer so well where the pain in the stomach or lower part of the abdomen is severe, "as an injection com- posed of a gill of thin starch, a tea-spoonful of laudanum, and thirty grains of finely powdered camphor; and if it be compli- cated with hysteria, the addition of three tea-spoonfuls of the tincture of assafoetida. instead of the camphor, may be useful." I have in several alarming instances known very complete relief obtained from the injection of laudanum into the bowels ; but where the stomach will retain the inedicine.it will act more promptly when administered by the mouth. Liitle or no benefit, however, will result from an ordinary dose of this narcotic in cases of this kind. From two to three grains of opium, with ten or fifteen grains of camphor, should be given at once. It should be particularly recollected that where the tendency to cephalic congestion is strong, or in full, young, and vigorous subjects, an efficient abstraction of blood must be premised to the use of these remedies. In one case of suddenly suppressed menses, attended with wild raving and paroxysms of extreme pain in the stomach, half an ounce of tbetincture of secale cornutum completely allayed all the symptoms in less than fifteen minutes. A vast variety of remedies have been recommended for the purpose of restoring the suppressed catamenial evacuation ; but we may safely affirm that the amount of injury which has been done by the indiscriminate and unseasonable exhibition of medicines of this kind, {emmenagogues) is incomparably greater than that of all the advantages which have as yet re- sulted from their employment. I do not wish to be understood as condemning, unqualifiedly, the use of such remedies ; for under judicious management, they are not only often decidedly useful, but in some cases, indispensable to success. The prac- tice, however, of resorting to active emmenagogues in the be- ginning of the treatment, without an especial regard to the ge- neral state of the system, and the peculiar circumstances of the case, under an idea that they possess a direct or specific power of restoring this secretion, has been, and no doubt will continue to he, the source of various and irremediable mischief. Ainenorrhoea in young subjects is at first almost invariably accompanied by a manifest phlogistic habit of body. In instan- ces of this kind, moderate abstractions of blood, aided by a sim- ple and unirritating diet, laxatives, and regular exercise in the open air, are all-important remediate measures. Where the dis- ease has developed local inflammations, or sustains irregular de- terminations to internal organs, especial means should be used, in conjunction with the general remedies just mentioned, to coun- teract the local affection, before any direct attempt is made to excite the uterine vessels. Blisters, rubefacients, the warm hath, antimonials, &c. may all be beneficially employed under circumstances of this kind. AMENORRHEA. 521 When the suppression occurs in relaxed and debilitated fe- males, with a small, feeble, and languid pulse, the first object should be to invigorate the general system, and to improve the digestive and alvine functions. Iron ;* mild tonic bitters; a sim- ple, but nourishing diet; exercise by gestation, and gentle aloetic aperients ;f are especially indicated in such cases. I have de- rived much advantage in amenorrhoea, attended with languor and debility, from the black sulphuret of iron, in union with small portions of ipecacuanha. Five grains of the former, with one of the latter, may be given three times daily. It is proper to observe, howrever, that even in cases attended with much lan- guor and weakness, mild aperients are sometimes important remedies, preliminary to the employment of tonics; for it is not uncommon to find the bowels exceedingly loaded in such cases, and there can be but little advantage derived from invi- gorating measures, so long as this condition of the intestinal canal continues. Sometimes cases that come on slowiy, and apparently without any direct exciting cause, will be found, on close examination, to be connected with chronic irritation, or phlogosis of the mu- cous membrane of the bowels, from a remora of fecal matter in the bowels, or from the habitual use of a superabundance of coarse, irritating, or indigestible aliment. I have recently seen a remarkable instance of this kind. The patient, a labouring wo- man, about twenty-five years of age, had suffered a long time un- der amenorrhoea, and the usual attending nervous symptoms. When I first saw her, she was debilitated, and considerably emaciated, but stated that her appetite was very craving. As she ascribed all her complaints to the absence of the menstrual discharge, she had taken a great deal of medicine, obtained from one of our public charitable institutions, for the purpose of " bringing on her courses." On examination I found her ab- domen tumid and hard, the tongue like a piece of raw flesh along the edges and point, and the appetite voracious—in short, * R. Ferri. phosphat. $i. Pulv. zingiberis 3"1 _^__aloes soccot. £r. v. M Divide into ten equal parts. S. Take one twice or thrice daily. Or, R. Extract, gentian. 51. Sulphas, ferri. gr. iv. G. aloes socc. gr. v. M. Divide into twenty pills. S. take one every morning, noon and evening. X R. Pulv. rhaei. 91V. G. aloes 9j- Pulv. capsici. i- Muc £T arab. q. s. JVI. Divide into twenty pills. Tuke two at night on going to bed. vol. 11.—66 522 AMENORRHEA. with all the symptoms of high irritation of the mucous mem- brane of the stomach and bowels. I ordered her a few doses of castor oil, and put her on the exclusive use of rye-mush and milk for her diet, with which she faithfully complied. In four weeks the tension and fulness of the abdomen had subsided, and the tongue presented a much better appearance. The diet was continued, with the addition of a little weak animal broth at noon, and I prescribed an emulsion of balsam copaiva, in small doses, to be repeated thrice daily. This she continued for four weeks, at the end of which time she thought herself quite well, although the menses had not yet returned. She was now put on the use of the following pills,* which in two weeks restored the long suppressed catamenia. By thus pursuing a general treatment adapted to the parti- cular circumstances of the case, we may often restore the men- strual evacuation; and should we even fail in effecting this purpose, we shall, nevertheless, gain some advantage, by placing the system in a condition favourable to the operation of the remedies more directly calculated to act upon the uterine system, f Dr. Dewees speaks in the highest terms of praise of the tincture of guaiacum as an emmenagogue. " I have for more than eight and thirty years," he says, " almost daily used this medicine in suppressed catamenia; and more especially in those of long standing, without its having failed in any case proper for its use,—that is, where the suppression was not the consequence of disease of the uterus or of pregnancy." This is, indeed, great praise ; for Dr. Dewees must have treated per- haps several thousand cases of this affection during the long pe- riod he mentions. That Dr. Dewees hasbeen eminently successful with the employment of this remedy is unquestionable; yet it may be mentioned as a singular circumstance, that although I have employed it in no small number of cases of this affection, and, as I thought, in a vigorous and persevering manner, I have never known it to procure the least apparent benefit, ex- * R. Sulphat. ferri. gr. v. G. myrrh G. aloes aa gr. x. M. Divide into twenty pills. S. Take one every morning, noon, and evening. X These remedies appear to promote the menstrual evacuation, solely by their tendency to determine the blood to the pelvic viscera, or more parti- cularly to the uterus ; and it is hence obvious, that where symptoms of high irritation or chronic inflammation of the uterine system are pre- sent, all medicines of this kind are highly improper. When, for in- stance, a puruloid leucorrhoeal discharge attends, with other signs of vaginal irritation, purgatives, low diet, rest, emollient injections into the vagina, and, perhaps, local bleeding, are indispensable preliminary measures. AMENORRHEA. 523 cept i n one case only. It must be observed, too, that although the doctor's mode of employing this remedy has been for many years well known to the practitioners of this city, I have, as yet, met with none who has been even moderately successful with it Dr. Dewees himself notices this fact. " I have learn- ed," he observes, " that some of my brother practitioners have not been equally successful with it—but I think I can readily account for their failure; first, from their not placing the system in a proper situation for its use; and, second, by not properly persevering in the remedy." The medicine in which I have hitherto most confided as an emmenagogue, after the system was duly prepared by general treatment, is aloes, in small doses, in combination with the extract of savin and ipecacuanha, according to the following formula.* I have, indeed, often failed with this medicine ; but, upon the whole, I have more frequently succeeded with its employment than with any other article or combination. The tincture of melampodium, too, has occasionally succeeded well in my hands; and within the last few years, I have employed the spirits of turpentine with success in several cases. Where hysterical symptoms attend, peculiar advantage may sometimes be obtained from the following pills.f The tincture of cantha- rides too, has been highly recommended as a remedy in this affection. Dr. Joseph Klapp, of this city, has published an account of his experience with this article, from which it would appear, that under judicious management, it will often operate very beneficially:):. It should be given in gradually increased doses, beginning with twenty or twenty-five drops three times daily, until a slight degree of strangury is produced, when it must be omitted, and resumed when the urinary affection has subsided. This article is certainly worthy of particular atten- tion as an emmenagogue, after proper evacuations have been made. I have but seldom prescribed it; but in one of the few instances in which I employed it, the menses were very speedi- ly restored after it was carried to the extent of causing slight strangury. This remedy is especially adapted to cases that are attended with leucorrhoea—but in such instances, it is particu- * R. G. aloes sacc gr. xv. Extract, sabin. 9ii- Pulv. ipecac. 9i- Mucilag. g. arab. q. s. M. Divide into forty pills. Take two pills three times daily t R. G. aloes 5}}- — asafoetid. 3"- — myrrh. 3SS- ,_..... , ... Sulph. ferri. 3ss. M. Divide into three grain pills. Take two twice daily. X Med. Recorder, vol. i. 514 AMENORRHEA. larly important to reduce the local inflammatory action of the vigina, by proper local and general remedies, previous to the employment of the cantharides. There is, indeed, scarcely an end to the number of articles and combinations that have been boasted as remedies for exciting the menstrual secretion ; hut so far as my experience enables me to judge, they are all much more apt to fail than to succeed in restoring the sup- pressed catamenial function. Dr. Lavagna within the last five or six years, has published an interesting statement of the good effects of injections of the aqua ammonia, diluted with water, into the vagina, as a remedy for the suppression of the menses. Dr. Hosack also has reported a case of ten years' duration, which yielded to the employment of the ammonia in this way. Ten or twelve drops of the aqua ammoniae purae, mixed with an ounce of milk or wrater, is to be thrown into the vagina by means of a syringe four or five times daily. If this does not produce a very perceptible sensation in the part, a few drops more of the ammonia must be added to the subse- quent injections ; but if the irritation be excessive, the quantity must be diminished. Dr. Hosack diluted a draxhrn of the am- monia with a pint of rain-water, of which a syringe full was thrown into the vagina three times daily. The cure was accomplished in five weeks.* I have heard of but one instance of the employment of this remedy in this city ; and in this case it failed in doing good. The testimony, however, that has been published in its favour is respectable, and well worthy of atten- tion. DYSMENORRHCEA. Painful and imperfect Menstruation. Dysmenorrhea is a common, and generally an extremely harassing affection. It may occur at every period during the menstruating stage of life; but it appears to be most common between the twentieth and thirtieth years of age, and in sub- jects of an irritable and sanguineous temperament. In many instances severe pains are experienced in the back, loins, and lower part of the abdomen, for five or six hours pre- vious to the appearance of the menstruous evacuation. This however, soon ceases, and an immediate aggravation of the torturing pain follows. Sometimes the catamenia begin to flow moderately with little or no previous pains ; hut in an hour or two they become suddenly arrested, at the same time • New-York, Med. and Phys. Jour. DYSMENORRHEA. 525 that violent pains come on in the hips, hypogastrium, loins, back, and thighs, with a distressing sensation of forcing or bearing down in the pelvis. Occasionally a very slight men- strual discharge continues uninterruptedly for three or four days, accompanied throughout with extremely severe pains in the pelvis and lower portion of the abdomen ; and in some rare instances, the catamenial evacuation, although attended with great suffering, is sufficiently copious and prolonged in its course, and may even exceed the regular duration and quanti- ty of an ordinary healthy menstruation. (Jahn, Burns.) In by far the greater number of cases, however, the evacuation as has just been stated, begins to flow moderately, and after an hour or two ceases again, under great sufferings. Some pa- tients are much harassed by severe headach or nausea, and paroxysms of violent retching and vomiting during the first few hours of the complaint. These pains continue for a period, varying from two or three hours to several days, terminating commonly in the discharge of a pseudo-membraneous substance from the vagina, similar in appearance to the decidua. Females labouring under pain- ful menstruation generally experience two distinct kinds of pain ; namely : the intermitting expulsive pains resembling those of labour or abortion ; and the constant menstrual pains in the back, pelvis, loins, and thighs, which occur often in regu- lar menstruation, shortly before the appearance of the evacua- tion. (Dewees.") Dr. Dewees observes, that there are two distinct states of this affection, which in a prognostic point of view are worthy of attention. Thus, in some cases the mammae sympathize strongly with the uterus—becoming tumid, and often very painful and tender to the touch ; whilst in other cases the breasts remain wholly free from any affections of this kind. The former variety of cases, says Dr. Dewees, are much more manageable than the latter—an observation which I believe to be well founded, however inexplicable it may be. Some writers seem to think that the formation of a pseudo- membraneous substance upon the internal surface of the uterus is alwrays present in this affection, and constitutes in all in- stances, the immediate cause of the difficult and painful men- struation. This, however, does not appear to be founded on correct observation. I have known females to suffer very painful and incomplete menstruatiou for two, three, or four pe- riods in succession, and afterwards menstruate regularly with- out any particular difficulty, where no membraneous matter whatever was at any time discharged. It must moreover be observed, that painful menstruation is not universally attended with a scanty flow of the catamenial fluid. I have met with several instances where, in point of quantity and duration, 526 DYSMENORRHEA. there was nothing irregular in the menstruation, but where notwithstanding extreme suffering attended each menstrual pe- riod. This, we may reasonably presume, could not take place, if the internal surface of the womb were coated with false mem- braneous matter. It may indeed be supposed that the bloody secretion in such cases is furnished by the vessels of the mouth of the womb, or even by those of the vagina; hut this assump- tion is, I think, extremely improbable. It cannot, however, be denied, that in very many cases such membraneous concre- tions are present, and exercise a direct agency in the produc- tion of the difficulties which occur in this affection. It is never- theless certain, that these masses of concreted lymph are them- selves the product of a morbid action of the secreting vessels of the uterus; and there can scarcely exist a doubt, that this diseased vascular action may of itself produce the difficulty and pain in question, independent of the formation of pseudo-mem- braneous matter. I cannot accord with Dr. Dewees, in his notions concerning the etiology of this affection, or rather " of the membraneous productions so often yielded in dysmenorrhea." "Before I attempt an explanation of the formation of this membrane," he says, "I must direct the attention to a very remarkable circumstance in the character of the menstrual blood, namely, its not possessing the property of coagulation. From this it appears that the blood, or a part of it, has suffered some change by the action of the uterine vessels ; and that this change has been imposed upon the coagulating lymph by the process of secretion. Now, it is not difficult to suppose that the uterus, like every other organ, may have its functions im- paired; in consequence of which the texture of the coagulating lymph, instead of being subdued as it is wont to be when the uterine secretory action is perfect, remains nearly the same as when it entered this viscus; except that it may be attenuated, as in some inflammatory diseases: and it will, from this imperfect elaboration, be thrown into the cavity of the uterus, without being dispossessed of the power of separation and of coagulation. It is poured into the uterus in a very gradual manner; and from this circumstance may tarry there suffi- ciently long to separate into its constituent parts; the coloured part or red globules, from their greater weight, will leave the imperfectly subdued lymph, and fall to the bottom of the uterus, and sooner or later be discharged ; while the coagulating lymph, either in part or altogether, will be left to spread itself over the internal surface of the uterus, and there quickly assume, as is usual with it when in contact with living parts, the appearance of a membrane."* * A Treatise on the Diseases of Females, second edition, p. 91. DYSMENORRHEA. 527 These sentiments appear to me not only contrary to well established pathological principles, but most unquestionably, also, to the phenomena of dysmenorrhea. That the menstrual action of the uterus is morbid or deranged, is, indeed, suffi- ciently obvious ; but so far from this derangement consisting in an impaired or enfeebled action of the uterine vessels, every phenomenon clearly indicates that the vessels of the uterus are in a state of increased excitement, amounting perhaps in many cases to a sub-inflammatory action. The sense of fulness, ten- sion, and pain in the pelvis, loins, and back; the accelerated, quick, and tense pulse; the hot and feverish skin, are strong manifestations of inordinate excitement and sanguineous con- gestion in the uterine system. Lymph is never thrown out in such a state as to form mem- braneous matter, except from inflamed, or at least highly irri- tated surfaces. The formation of such concretions is, indeed, one of the most certain evidences of previous inflammatory action in a part. Most assuredly Dr. Dewees will not contend that the decidua, which strongly resembles the membraneous masses thrown off in dysmenorrhea, is formed by an impaired action of the uterine vessels, and in the manner stated in the above quotation. It may he observed too, that if incrustations of lymph arise from the gradual separation of blood retaining its coagulability, in consequence of impaired or deficient action of the uterine vessels, we should, no doubt, frequently meet with these pseudo-membraneous formations in the slow and pro- tracted uterine menorrhagia, which are apt to occur about the period of the final cessation of the menses—which, so far as I know, has never been observed. From an attentive estimate of the phenomena of this affection, as well as from analogy and certain established principles in pathology, we may, I think, conclude, that in dysmenorrhcea generally, whether attended with the formation of membraneous structures, or devoid of such concretions, the uterus is in a state of much sanguineous con- gestion, attended with an irritable and highly irritated condi- tion of its vessels. The discharge at first flows moderately for a short time; but the action of the vessels appears soon to transcend the grade of menstrual secretion, and, instead of the catamenial fluid, lymph is often secreted by the irritated ves- sels, which concretes on the internal surface into the form of a membraneous substance. This opinion of the pathology of dys- menorrhcea is much strengthened by the fact, that all medicines that have a tendency to excite the uterine vessels, as the usual emmenagogues, are uniformly pernicious. Would this be the case if the disease were the result of an impaired action of these vessels ? From much close attention to this disease for the last six or seven years, I have been led to believe that it is very frequently 528 DYSMENORRHEA. dependent on a rheumatic affection of the uterus. In a case which I attended some time ago, the connexion of rheumatism and this affection was strikingly illustrated. The patient, of an irritable and sanguineous habit, was very subject to rheuma- tic pains in the left, and sometimes in the right ankle joint, which often continued for several weeks. For more than five years, she observed that whenever she felt the pain in the joint at the menstrual period, she menstruated with little or no diffi- culty ; but when the period returned while the ankle was free from pain, she invariably suffered excruciatingly during the very sparing and transient flow of the menses. Treatment.—The treatment of dysmenorrhea is divided into palliative and radical; the former to allay the extreme suffer- ing during the presence of the affection ; and the latter, to pre- vent its recurrence, by means employed during the interval of the attacks. I have already observed that all emmenagogue remedies, or such as are calculated to determine the circulation to the pel- vic organs, are always highly improper. Dr. Dewees consi- ders camphor in large doses as decidedly the best palliative remedy we possess in this painful affection. He recommends the administration often grains of this article every hour, until the pains are in a great degree allayed; and when the stomach will not bear it, he advises its use in the form of an enemata. I have used this remedy with much benefit in some cases ; but I have almost invariably prescribed it in union with Dover's powder, in the proportion of six or eight grains of the former to four grains of the latter, every hour. If we can early in- duce a general perspiration, the painful symptoms almost al- ways speedily decline. To promote this intention, it will be proper to confine the patient to bed, and to direct the use of warm, diaphoretic diluents—particularly elder blossom, oreu- patorium perfoliatum tea. Opium, given in full doses, with small portions of ipecacuanha, so as to excite nausea, but not vomiting, is, perhaps upon the whole, the best palliative, where the patient is capable of taking this narcotic without the disagreeable effects which, in some habits, it is apt to produce. It may be advantageously given in combination with camphor, in the proportion of a grain of the former to eight of the latter, every hour until the symptoms are mitigated. Dr. Dewees mentions a case, which was cured by the use of secale cornutum ; but this case does not appear to me to merit the title of dysme- norrhoza. It would seem to have been an instance of menorr- hagia, accompanied by frequent severe pains occasioned by the contractions of the womb to expel the coagula. The warm- bath will occasionally afford considerable relief in dysmenorr- hea, more especially when it is used in conjunction with cam- phor or opium. Bleeding is often decidedly indicated, and al- DYSMENORRHEA. 52$ though it does not appear to be capable of exerting any direct influence over the symptoms, it is an important auxiliary, or preliminary measure, where the pulse indicates its use, to tho employment of the means already mentioned. In instituting a course of treatment for the radical cure of dysmenorrheea, particular attention must, in the first place, be paid to the general state of the system. In plethoric and phlo- gistic habits a mild vegetable diet must be enjoined, and it is especially important to attend to the state of the digestive and intestinal functions. When there are signs of a loaded and torpid state of the bowels, it will be highly important to adopt a course of mild aperient treatment, before recourse is had to remedies more immediately directed to the uterine system. An occasional dose of blue pill in the evening, with a gentle purga- tive on the following morning, should be used until the bowels are put in a healthy condition. Jahn asserts, that the occasion- al employment of ipecacuanha emetic will sometimes afford very considerable advantages in this affection. When the dia- thesis is manifestly phlngistic, and the pulse tense or active. during the intervals of the attacks, small abstractions of blood, and even antimonials, in conjunction with a vegetable diet and aperients, are obviously proper. When the disease is accom- panied with a rheumatic or arthritic diathesis, the warm bath, gentle diaphoretics, particularly decoctions of lignum guaiacum, and small doses of the flowers of sulphur, will often be found especially useful. Among the various remedies that have been recommended as particularly calculated to prevent the recurrence of the affec- tion, the tincture of guaiacum is at present most generally re- lied on by the practitioners of this city. Dr. Dewees. who in- troduced this article to the notice of the profession as a remedy in dysmenorrheea, regards it as incomparably the most efficient means we possess for counteracting this affection. It should be given in as large doses as the stomach will bear, and its uso persisted in for three or four months, and even longer, if its good effects are not previously obtained. Dr. D. observes, that it is not uncommon to find the first return of the menstrual period, after commencing the use of this remedy, attended with unusu- ally severe symptoms : and he considers this as a favourable symptom. I have employed it occasionally, but with very in- different success. The remedy with which I have most fre- quently succeeded in effecting a cure, is the extract of stramo- nium. It is now about six years since I first resorted to this article for the cure of this affection, and I have on record a considerable number of cases that yielded to its powers. My mode of employing it is to give the one-eighth of a grain of the extract (Clutterbuck's preparation) three times daily, com- mencing about four days before tuc exp«rt«d return tf the .it- voi.. 11.-—67 530 DYSMENORRHEA. taCk. I am persuaded, from what I have witnessed1 of its poW-» crs in this way, that we possess no other article which can, at all, be compared to it as a remedy in this affection. Immedi- ately previous to commencing with its use, the bowels should be freely opened by a purgative, and the patient ought to ab- stain from all kinds of stimulating food and drink. The decoction of poly gala senega has been recommended as a means for curing this affection. Dr. Chapman has expressed his confidence in its powers; but it does not appear that his experience on this head has been sufficiently confirmed by others, to have gained it any reputation in this respect. For- merly I employed it freely in five or six cases, but in no in- stance with success. I have known an instance where a salivation, accidentally caused by a mercurial purge, removed the complaint effectually. What would the tincture of colchicum do in cases of this kind? If my notions concerning the rheumatic nature of this affection: be correct, it would seem reasonable to expect advantage from this remedy. LEUCORRHOEA. Fluor Albus. This affection consists in a morbid secretion and discharge' of a mucus, or muco-purulent fluid from the vagina; and is, perhaps, the most common disease to which females are subject. It may occur at every period of life, from infancy to old age, but its appearance between puberty and the final cessation of the menses is by far the most common. The causes of leucorrhoea are very various. In general, what- ever is capable of relaxing the system, as a luxurious, indolent, and sedentary manner of living ; habitual exposure to a humid atmosphere, and want of pure air and wholesome nourishment, are especially calculated to predispose to the occurrence of this disease. Females of a relaxed, leucophlegmatic, and nervous habit of hotly are particularly liable to leucorrhoeal discharges; whereas those of a rigid fibre, and a robust and muscular structure, are comparatively but rarely affected with this dis- ease. Every thing which is capable of causing irritation in the mucous membrane of the vagina, and of establishing a pre- ternatural determination: of blood to the genital organs, may excite leucorrhcea. But the tendency of causes of this kind to give rise to the disease, depends nevertheless in a great degree on the previous constitutional predisposition to this affection ; Jfor in many healthy, robust, and active females, scarcely any EEUCORRIKEA. 531 vaginal irritation, from accidental causes, will produce more than a temporary increase of the mucous secretion. In indivi- duals, on the contrary, of an opposite habit of body—particu- larly when favoured by luxurious living and indolence, the slightest additional irritation of the mucous membrane of tl e vagina will be apt to excite a more or less permanent mor- bid secretion from this membrane. The following are the most common and powerful exciting causes of this disease. 1. Excessive venereal indulgence. Prostitutes, even though pre- viously unaffected with gonorrhoea, are rarely free from mor- bid vaginal secretions of a leucorrhoeal character. 2. Difficult parturition, or the irritation caused by the employment of ob- stetrical instruments. 3. Frequent and profuse menorrhagia is frequently followed by leucorrhoea, being usually sustained by the same causes or circumstances that gave rise to the he- morrhagic discharge. 4. Prolapsus uteri is almost invariably attended with more or less leucorrhoeal discharge, in conse- quence of the continued vaginal irritation by the dislocated uterus. 5. Ascarides, by keeping up a constant irritation in the rectum and neighbouring parts, or by passing into the vagi- na, is no unfrcquent exciting cause of leucorrhoea in young girls and children. 6. The abuse of emmenagogues, particu- larly when unseasonably employed for bringing on what is often injuriously supposed and treated as tardy menstruation about the age of puberty, often gives rise to obstinate leucorr- hoea. 7. A loaded and torpid state of the bowels, is a common cause of this complaint in young females. 8. Tight lacing or dressing about the waist, by pressing the viscera down upon the uterus, and causing prolapsus, or a descent of this organ from its natural position into the vagina, as well as by imped- ing the free circulation of the blood in the portal vessels, is a fertile source of leucorrhoea among young and fashionable fe- males. I will venture to say that of late years, since the pre- posterous custom of pressing the w aist into as narrow a space as cords and steel springs can bring it, has been so general, there are more instances of prolapsus and leucorrhoea among young females than at any other former period, when the abdo- men was a little better accommodated with room. 9. The de- pressing menial emotions, by debilitating the general system and favouring a sluggish circulation in the portal system of vessels, may give rise to the disease. 10. Metastasis of rheu- matism, &c. is, I conceive, much more frequently concerned in the production of this affection than is generally supposed. It is by no means uncommon to find females affected with leu- corrhcea to complain of more or less pain in the joints, and I have satisfied myself that the vaginal disease is not unfre- quently a purely rheumatic affection. 11. Self-pollution is by many of the German writers regarded as one of the most fie- \ 5&2 LEUCORRHtEA. quent sources of this disagreeable affection in young females* 1-2. Atmospheric influences, particularly vicissitudes of tempe- rature, and a warm anil humid atmosphere. It is said that in Holland, where the air is always loaded with much moisture, leucorrhoea is a very common affection. 13. Suppressed hae- morrhoids; diseases of the uterus; tumours pressing upon the vagina; mechanical injuries; the intemperate use of spirituous liquors, &c. may all give rise to the disease. Some females are invariably affected with a more or less pro- fuse leucorrhoeal discharge for five or six days immediately after the completion of each menstrual evacuation ; and others experience the disease only some days previous to each appear- ance of the menses, remaining in a great measure, or wholly free from it during the remainder of the menstrual intervals. Symptoms.—In some instances, the discharge has the appear- ance of the common vaginal mucus. In others it is white, resembling pulverized starch mixed with a mucilaginous fluid. Sometimes it presents the appearance of pus, possessing an acrid and corroding quality. These differences in tlieajipear- ance of the discharge, indicate the relative degrees of violence of the affection. In point of quantity also, great diversity occurs in different cases. In some instances it is so moderate as hardly to occa- sion any inconvenience, whilst in other cases the evacuation is extremely copious. When the discharge is \ery profuse and of an acrid quality, the external parts of the genital organs be- come red, swollen, and painful, and this state of irritation usually extends into the vagina and even to the mouth of the uterus, rendering the whole passage and especially the os tincse very tender to the touch. When the disease is suffered to continue, it scldoms fails at last to make an injurious impression upon the whole system. The countenance at length becomes pallid and sickly ; the eyes dull, languid, and surrouuded by a bluish or lead-coloured circle; the eyelids tumid ; the mind dejected, discontented, and fretful; the whole system debilitated and sluggish ; the extre- mities cold ; the pulse small and feeble, or small, frequent, and somewhat corded : the digestive functions deranged, attended with arid eructations, gastralgia, pains in the back, loins, and lower extremities; colic pains in the lower part of the ab- domen, constipation or diarrhea, and pain in voiding the urine. By decrees the discharge usually becomes more and more copious and purulent ; the relaxation and languor of the mus- cular system increase, whilst the pulse becomes more frequent and irritated. At length, in aggravated cases, the slightest bo- dily exertions give rise to hurried respiration and palpitation of the heart; and in instances of great severity, the powers of digestion at last become exceedingly weak ; nausea and romit- LEUC0RRH03A. 533 ing frequently come on, and finally hectic and rapid emacia- tions arise. Fortunately, however, cases of this violent cha- racter are by no means common ; the great majority of instances being much less severe, though sufficiently annoying and de- bilitating, to become a source of much uneasiness and anxiety. Women who are habitually affected with leucorrhoea, very rarely become pregnant; and where the leucorrhoeal discharge is profuse, it may be doubted whether conception can at all take place. In most instances of severe leucorrhoea, the men- ses are entirely suppressed ; and in all cases th vy are more or less irregular, both in time and quantity. Sometimes they occur at irregular intervals in the form of inenorrhagia, but more frequently they appear very sparingly for a day or two, succeeded by an increased flow of the leucorrhoeal discharge. Much discussion has taken place on the question, whether leu- corrhoea isa disease of relaxation or debility, or connected essen- tially with an irritated or iuflain iatory excitement in the affected parts. It appears to me, however, that it cannot, be properly said to be either a disease of debility and relaxation, nor one of irri- tation or subinflammation. in an exclusive sense. That the mucous membrane of the vagina and mouth of the uterus, is in a state of irritation and even sobinfiatnm..tion in this ;«ff