STUDY OF MEDICINE. WITH A 9>lE78K0E«®(BI[aAL S7SSSI NOSOLOGY. BY; JOHN MASON G#OD, M.D. F.R.S. MEM. AM. PHIL. SOC. AND F.L.S. OF PHILADELPHIA. IN FIVE VOLUMES VOL. IV. ( <" SECOND AMERICAN EDITION Piaatteljriifa: BENNETT & WALTON, A. SMALL, URIAH HUNT, MAROT & WALTER; J. GRIGG, E. PARKER, AND T. DESILVER. AND COLLINS & HANNAY, COLLINS & Co. BLISS & WHITE, AND J. V. SEAMAN, NEW-YORK. 1S24. ANNEX G64^s ■ v. 4 x_ $fjilaDetphia, Printed by William Brown, i:;lass v^ CLASS V. GENETICA. DISEASES OF THE SEXUAL FUNCTION. ORDER I. CENOTICA. AFFECTING THE FLUIDS. II. ORGASTICA. AFFECTING THE ORGASM. III. CARPOTICA. AFFECTING THE IMPREGNATION CLASS V. PHYSIOLOGICAL PROEM. We now enter upon the maladies of that important function by Which animal life is extended beyond the individual that possesses it, and propagated from generation to generation. To this division of diseases the author has given the classic name of genetic a, from yfivoftxi, " gignor," whence genesis (yever^) " origo," " ortus." In almost every preceding system of nosology the diseases of this function are scattered through every division of the classification, and are rather to be found by accident, an index, or the aid of the memory, than by any clear methodical clue. Dr. Macbride's clas- sification forms the only exception I am acquainted with; which, however, is rather an attempt at what may be accomplished, than the accomplishment itself. His division is into four orders; gene- ral, and local as proper to men, and general, and local as proper to women; thus giving us in the ordinal name little or no leading idea of the nature of the diseases which each subdivision is to include, or any strict line of division between them; for it must be obvious that many diseases commencing locally very soon become general, and affect the entire system, as obstructed menstruation; while others, as abortion, or morbid pregnancy, may be both general and local. Under the present system, therefore, a different arrangement is chosen, and one which will perhaps be found not only more strict to the limits of the respective orders, but more explanatory of the leading features, of the various genera or species that are included under them. These orders are three: the first embracing those diseases that affect the sexual fluids; the second those that affect the orgasm; and the third those that affect the impregnation. To the first order is applied the term cenotica (kcvutikx) from xevarts "evacuatio," " exinanitio," to the second orgastic a (o^yx, " to flow," is apparently of modern origin ; as it is not to be found in either the Greek or Roman writers ; and seems first to have been met with in Sonet and Castellus. This is the menorrhagia alba of Dr. Cullen, so denominated be- cause he conceives the evacuation to flow from the same vessels as the catamenia; as also that it is often joined with menorrhagia, or succeeds to it. Its source, however, is yet a point of dispute.* Stoll,| Pinseus, and various other distinguished writers have ascrib- ed it, like Cullen, to the uterus. But as it occurs often in great abundance in pregnant women, in girls of seven, eight, and nine years of age,| and even in infants, it has been supposed by Wedel,§ and most writers of the present day, to flow from the internal sur- * Rat. Med. P. VII. p. 155. f De Notis Virginitatis. Lib. I. Prob. 3. * Heister, Wahrnemungen, B. II. N. 128. Hoechstatter, Obs. Med. Dec. IV. Cas. I. Schol. § Diss. De Fluore albo. Jen. 1743. GE. n.—SP. I.] SEXUAL FUNCTION. 49 face of the vagina, or at the utmost, from the vagina jointly with the cervix of the uterus. Morgagni is, perhaps, most correct, who conceives, and appears, indeed, to have proved by dissections, that, in different cases, the morbid secretion issues from both organs; for wh^l?nKetimeS **"*$ thC UterUS exhibi^S in its internal surface whitish tubercles, tumid vessels, or some other diseased indication, and sometimes the vagina, during the prevalence of this maladv.* In the case narrated by Mr. Hill of Dumfries, and noticed under the preceding genus, it was evidently confined to the vagina alone.t *rom its frequency in Sweden, Riedlin conjectures it to be en- demic there :i but this can hardly be allowed, and there are more obvious causes to which such frequency may be referred. When first secreted it is bland and whitish, but differs in colour and quality under different circumstances, and hence affords the three following species: 1. LEUCORRHCEA COMMUNIS. COMMON WHITES. 2*--------------NABOTHI. LABOUR-SHOW. 3'--------------SENESCENTIUM. WHITES OF ADVANCED LIFE. SPECIES I. LEUCORRHCEA COMMUNIS. Common SUnftea. THE DISCHARGE OF A YELLOWISH-WHITE COLOUR, VERGING TO GREKN This species is the fluor albus of most writers. It is found in girls antecedently to menstruation, or on any simple local irritation in the middle of life, and hence also, as just observed, during preg- nancy. It is said in the Berlin Transactions to be occasionally con tagious :§ and I have met with various cases which seem to justify this remark. It has occurred as the result of suppressed menstruation : as it is said also to have done on a suppressed catarrh ;|| and chillness or sup- pressed perspiration of the feet.f Local irritations moreover are • De Sed. et Caus. Morb. Ep. XLVII. Art. 12, 14. 16, 17, 18, 19.27, Ep. LXVII. Art. 14. r f Edinb. Med. Comment. IV. p. 91. * Lin. Med. 1695. p. 164. c Act. Med. Berol. Dec. I. Vol. V. p. 85 | Act. Erud. Lips. 1709, p. 376. ltaulin, Sur les Fleurs blanches, p. 329. 1 Act. Nat. Cur. Vol. VIIL Obs. 38 VOL. iv.—7 50 GENETIC A. [CX- V.—OR. I. frequent causes. And hence one reason of its being an occasional concomitant of pregnancy; as also of its being produced by pes- saries injudiciously employed, by voluptuous excitements, and un- cleanlincss. It is said at times to exist as a metastasis, and parti- cularly to appear on a sudden failure of milk during the period of lactation; a failure which may be set down to the list of suppressed discharges.* Jensen gives a singular case of leucorrhcea that alternated with a pituitous cough.f It is usually accompanied with a sense of languor, and a weak- ness or pain in the back. And if it become chronic, or of long continuance, the countenance looks pale and unhealthy, the stomach is troubled with symptoms of indigestion, the skin is dry and fe- verish, and the feet edematous. The discharge, in its mildest form, is slimy, nearly colourless, or of an opaline hue, and unaccompanied with local irritation. It afterwards becomes more opake and muculent, and is accompanied with a sense of heat, and itching or smarting ; in this stage it is of a yellowish-white. But as the disease advances in degree it ap- pears greenish, thinner, more acrid, and highly offensive, and is apt to excoriate the whole surface of the vagina: while there is often a considerable degree of pain in the uterus itself and even in the loins. Among novices there is some difficulty in distinguishing the dis- charge of whites from that of blenorrhoea, which we shall describe presently. But though the appearance of the two fluids is often similar, they may easily be known by their accompanying signs. In blenorrhoea there is local irritation from the first, and this irri- tation extends through a considerable part of the meatus urinarius, so as to produce a considerable pain in making water; symptoms which are not found in leucorrhcea. There is also from the first in the former a swelling of the labia, a more regular though a smaller secretion, and of a more purulent appearance. When the disease is violent, or of long continuance, it leads to great general as well as local debility, so as in some instances to make sad inroads on the strength of the constitution. It has some- times been followed by a prolapse of the uterus or vagina ;| by abortion or miscarriage, where there is pregnancy; and by barren- ness, where no pregnancy has occurred. When it acts on the sys- tem at large, it has given rise to cutaneous eruptions of various kinds ;§ and is said to have introduced tabes and hectic fever,[l scirrhus, and cancer.lf The cure is often difficult: but it is of no small importance to be, * Astruc, De Morb. Mulier. Lib. I. cap. 10. f Prod. Act. Havn. p. 160. * Boehman, Diss.de Prolapsu et Inversione Uteri. Hal. 1745 § Klein, Interpres Clinicus. p. 112. |j Hippocr. Aph. Sect. v. K Raulin, Sur les Fleurs blanches. Tom. I. passim GE. |[._SP. I.] SEXUAL FUNCTION. 51 from the first, fully acquainted with the nature of its cause and cha- racter, for the proper means to be pursued will mainly depend upon this. And hence it will often be necessary to examine the organs themselves, or to entrust the examination to a nurse on whose judgment we can fully depend. If the cause be uncleanliness, a lodgment of some portion of a late menstrual flux, or any other actuating material in the vagina, nothing more may be necessary than frequent injections of warm water: or if the vagina itself be much irritated, injections of the diluted solution of the acetate of lead : which last will often indeed be found highly serviceable where the discharge proceeds from debility and relaxation produced by a severe labour or miscarriage, forming no uncommon causes: as they are also no uncommon ef- fects. Other astringent injections have often been tried, as green tea, a solution of alum, or sulphate of zinc, a decoction of pomegranate bark, or a solution of catechu. All these are sure to be of service as tending to wash away the discharge, and keep the parts clean; and in many cases they will also succeed as astringents: nor is it always easy to determine which is to be preferred, for in some cases one answers the purpose best, and in others another. Sir Kenelm Digby recommended a local application of the fume of sulphur,* which may be communicated in various ways; and so far as this has a tendency to change the nature of the morbid ac- tion, by originating a new excitement, it is worthy of attention; but perhaps the diluted aqua-regia bath, of which we have spoken under spasmodic jaundice,! may prove more advantageous. The disease, however, is often highly troublesome and obstinate, and hence it has been necessary to employ constitutional as well as local means. The general remedies that have been had recourse to are almost innumerable. Acids have been taken internally in as concentrated a state as possible, but rarely with much success. The sulphuric acid has been chiefly depended upon : and, in the form of the eau de Rabel, which is that of digesting one part to three of spirit of wine, it was at one period supposed to be almost a specific. The compound, however, has not been able to maintain its reputation, and has long sunk into disuse. Emetics have been found more useful, as operating by revulsion and stimulating the system generally: and on this ground a sea- voyage accompanied with sea-sickness has often effected a cure. Stimulating the bowels, and particularly in the commencement of the disease, and where the general strength has not been much encroached upon, has for the same reason been frequently found useful, as transferring the irritation to a neighbouring organ, and under a more manageable form. And one of the best stimulants for * Medic. Experiment, p. 65. f Medic. Experiment, Vol 52 GENETIC A. [CL. V.—OR. I this purpose is sulphate of magnesia. Small doses of calomel have been given daily with the same view, but they have not succeeded in general. Hcister, however, recommended mercury in this dis- ease, even to the extent of salivation ;* yet this is a very doubtful remedy, and even under the best issue purchases success at a very dear rate. A spontaneous salivation has sometimes indeed effected a cure ;t but this is a very different affair, for here the blood is not broken down into a dilute state, nor the general strength interfered with. Mr. John Hunter, with a view of changing the nature of the morbid action in its own field, advised mercurial inunctions in the vagina itself. Other stimulants have been recommended that operate more generally, and have a peculiar tendency to influence the secretion of mucous membranes, as the terebinthinate preparations, particu- larly camphor, balsam of copaiva, and turpentine itself: and there is reason to believe that the second of these has often been useful. It has sometimes been employed in combination with tincture of cantharides: but the latter is, in most instances, too irritating, whether made use of alone, or with any other medicine. As the acids have not succeeded, neither have other astringents to any great extent. The argentina or wild tansy (Potentilla anserina, Linn.) was at one time in high favour; it was particularly recommended by M. Tournefoot, and, upon his recommendation, very generally adopted. Alum has been supported by a still greater number of advocates for its use; and kino has, perhaps, been employed quite as extensively. Dr. Cullen asserts that he has tried all these alone without success, but that by uniting kino and alum, as in the pulvis stypticus of the Edinburgh College, he obtained not only a most powerful astringent, but one that had occasionally proved serviceable in the present disease. The anserina has justly sunk into oblivion. Upon the whole, the best general treatment we can recommend is a use of the metallic tonics, and especially zinc and iron, in con- junction with a generous but temperate diet, exercise that produces no fatigue, pure air, and change of air, cold bathing, regular and early hours, and especially a course of the mineral waters of Tun- bridge or Cheltenham. * Wahrnemungen. Band. II. f Eph. Nat. Cur. Dec. m. Ann. IX. X. Obs. 140. GE. II.--SP. II.] SEXUAL FUNCTION. 53 SPECIES II. LEUCORRHCEA NABOTHI. &aoour=sfioto. THE DISCHARGE SLIMY, AND MOSTLY TINGED WITH BLOOB. In this species the fluid is secreted by the glandulse Nabothi situate on the mouth of the uterus, whence this specific name. It is the leucorrhcea Nabothi of Sauvages, and the haemorrhagia JYabothi of Cullen. It is most usually found as the harbinger of labour: and indicates that the irritation which stimulates the uterus to spasmo- dic and expulsory contractions, when the full term of pregnancy has been completed, or some accident has hurried forward the pro- cess, has now commenced, and that the pains of child-birth may be expected soon. It is probably nothing more than the usual fluid secreted by the glands from which it flows, augmented in quantity in consequence of temporary excitement, and mixed with a small quantity of blood thrown forth at the same time, and from the same cause, by the mouths of the exhalants, which gives it, soon after its first appearance, a sanguineous hue. It is hardly entitled to the name of a haemorrhage, as given by Dr. Cullen, though blood from the uterus often succeeds to it, apparently thrown forth by anasto- mosis, in consequence of the violence of the pains. In its ordinary occurrence it is only worthy of notice, as a devia- tion from the common secretions of health, and is rather to be hailed than to become a subject of cure or removal. But there is a state of irritation to which these glands are sometimes subject that produces the same discharge, and in considerable abundance, for many weeks or months before labour, and which, for the comfort of the patient, requires a little medical advice and attention. The irritation may proceed from plethora and distention, or from a weak or relaxed state of the constitution. If from the former, venesection and gentle laxatives will prove the best course we can pursue : if from the latter, a reclined position, easy intestinal eva- cuations, and such sedatives as may sit most pleasantly on the stomach, and produce less disturbance to the head. H GENET1CA CL. V.-OB. 1 SPECIES 111. LEUCORRHCEA SENESCENTIUM samites of atffowcetr Uitc. THE DISCHARGE THIN, ACRID, FREQUENTLY EXCORIATING AND FETIU. This is usually, but not always connected with a morbid state of the uterus. It commonly shows itself on the cessation of the menses: and is often chronic and obstinate. The more common diseases of the uterus with which the discharge is combined are an incipient cancer, or a polypous fungus. But I have occasionally met with it unconnected with either, and appa- rently dependent upon a peculiar and chronic irritability of the uterus, or rather perhaps of those glands which secrete the fluid that is poured forth during the act of sexual intercourse. A lady about forty years of age, not long ago applied to me, who had for more than a twelve month been labouring under a very distressing case of this kind. She had been married from an early period of life, but had never been pregnant. Her general health was good, her temper easy, her imagination peculiarly warm and vivid. She had no local pain, and had ceased to menstruate at the age of about thirty-eight. The discharge at the time I first saw her consisted of at least from a quarter tohalf-a-pint daily ;—thick, slimy, brownish, and highly offensive. Every external and internal remedy that could be thought of appeared to be of only temporary avail, and sometimes of no avail whatever, though she certainly derived relief from injections of the punica Granatum, with a fourth part port wine, which for some time checked the discharge, and diminished the fetor. In the mean time, the general strength was preyed upon, the loins became full of pain, the appetite failed, and the sleep was disturbed. Accidental circumstances compelled her, even in this debilitated state, to undertake a voyage to India. During its pro- gress she suffered severely from sea-sickness; but the change hereby produced, or effected by the warmth of the climate, proved peculiarly salutary: for she gradually lost the complaint, and reco- vered her usual health. Emetics, change of climate, and the tonic plan already recom- mended under the first species, seem, hence, to be the best course we can pursue in the species before us. GE. III.] SEXUAL FUNCTION. 55 GENUS III. BLENORRHCEA. ©fonorrhoca. MUCULENT DISBHARGE FROM THE URETHRA, OR VAGINA ; GENERALLY WITH LOCAL IRRITATION AND DYSURY ; NOT DISAPPEARING DURING MENSTRUATION. Blenorrhcea is a Greek compound of modern writers, derived from Qxenx, " mucus," and ptu, " to flow." Sauvages, and after him Cullen, have employed gonorrhoea from yo»«?, " semen," and feu, as a common term for this and spermorrhcea constituting the ensuing genus, and consisting in an evacuation of semen. Cullen, indeed, has extended the term still further in his First Lines, and hence morbid secretion of mucus, all kinds of venereal contagion, and se- minal flux, are equally arranged as species of the same generic dis- ease; and this too under a word which imports the last alone. While, to add to the confusion, this very word, in its vulgar sense, is restrained to venereal contagion, which, in its strict meaning, that of seminal flux, it signifies just as much as it does abortion or stone in the bladder. It is high time to make a distinction, and to di- vide the list of Sauvages into two genera. Blenorrhoea has, indeed, been already employed of late by various writers to denote the first of these genera, and there is no necessity for changing the term. The genus under Miilier,* is subdivided into numerous spe- cies : but the three following include the whole that fairly belong to it: 1. BLENORRHOEA simplex. simple urethral running. 2.----------- LUODES. CLAP. 3. ------.-----CHRONICA. GLEET. * Miilier, Medic. Wochenblatt, 1784. N. 51, plures species. 5b GENETICA. |CL. V.—OK. I. SPECIES I. BLENORRHCEA SIMPLEX. StmjJlc Urethral JXunntiio. SIMPLE INCREASED SECRETION FROM THE MUCOUS GLANDS OF THl URETHRA. This definition is given in the words of Dr. Fordyce, and is suffi- ciently clear and expressive. In effect, the efflux proceeds from mere local irritation, unaccompanied by contagion, or virulence of any kind, and is chiefly found in persons in whom the affected or- gan is in a state of debility; the occasional causes of irritation be- ing venereal excess, too large an indulgence in spirituous liquors, eold, topical inflammation, too frequent purging, violent exercise on horseback, to which various authors add transferred rheumatic action ;* and occasionally, according to Mr. John Hunter, transfer- red irritation of the teeth. \ The matter discharged is whitish and mild, producing no exco- riation, pain in micturition, or other disquiet. It is the mild go- norrhoea of many writers, the gonorrhoea fiura of Dr. Cullen; and usually yields without difficulty to rest, emollient injections, and very gentle and cooling purgatives. SPECIES II. BLENORRH(EA LUODES. GUV. MUCULENT DISCHARGE FROM THE URETHRA OR VAGINA, INTERMIX- ED WITH SPECIFIC VIRUS: BURNING PAIN IN MICTURITION: PRO- DUCED BY IMPURE COITION : INFECTIOUS. This is a disorder of far greater mischief and violence than the preceding, and in contradistinction to it has been very generally denominated the virulent or malignant gonorrhoea. It is the gonor- rhoea imfiura of Cullen. * De Plaigne, Journal de Med. Tom. LXXIV. Richter, Chir. Bibl. B. IV. p. 508. Ponteau, Oeuvres Posthumes. I, f Natural History of the teeth. LE. III.—SP: II.] SEXUAL FUNCTION. 51 The disease was for many years supposed to be a local effect of that poison, which when communicated to the system, produces syphilis. It is in truth received in the same manner, and by the same organs—its medium of conveyance being that of cohabitation with an infected person. We are chiefly indebted to Mr. John Hunter for having pointed out the distinction : and there is now scarcely an individual who has any doubt upon the subject, though there are several who conjecture that it has been derived from the syphilitic venom changed and softened in its virulence by an introduction into different constitutions. These conjectures are harmless, but they have little ground for support. That it is a disease specifically dif- ferent from 6yphilis, is clear from the following facts. Its appear- ance did not commence till more than a hundred years after that of syphilis; it will continue for months without any syphilitic symp* toms, which are rarely, indeed, found connected with it; and where such symptoms have shown themselves, there has been full evi- dence of a new and different infection or strong ground for suspi- cion : the matter of chancre, the pathognomic symptom of syphilis, when introduced into the urethra has been found not to produce clap, and the matter of clap inserted under the skin, has been prov- ed not to produce syphilis; the common course of mercury which is the only specific cure for the latter, is a very inconvenient, and dilatory way of treating the former ; while the local plan by which the former is conquered witli great speed and ease, produces no effect on the latter. Some of these facts were known to physiologists and reasoned from even before the time of Mr. John Hunter; and hence Baglivi contended that virulent gonorrhoea, as it was then called, may be produced by other acrimonies than the syphilitic,* while Zeller, towards the close of the seventeenth century, affirmed, that it may originate in either sex without contact ;t and Stoll in the middle of the eighteenth, that it proceeds from various causes of which syphilitic contagion is one.I It is not easy to account for the primary appearance of this or of any other specific poison: but we see daily that most, perhaps all, mucous membranes, under a stafe of some peculiar morbid action, have a tendency to secrete a virulent and even contagious material of some kind or other; the particles of which are in some instances highly volatile, and capable of communicating their specific effect to organs of a like kind; and of propagating their power by assimu- lation, after having been diffused to some distance through the atmosphere, which does not at all times readily dissolve them ; though, agreeably to a general law we have formerly pointed out, the more readily, the purer the constitution of the atmosphere.§ We * De Fibra Motice, &c. f Diss, de Gonorrhoea virulenta in utroque sexu, Tubing. 1700, t Prxlect. p. 104. § Vol. II. Sect. 9. p. 76. vol. iv.—-8 58 LENETICA. [CL. V.—OR. 1. have a manifest proof of this in the muculent discharge of dysentery, in canine catarrh of the muculent affection in the nostrils of dogs, which is vulgarly called distemper, and in the glanders, possibly also in the farcy, of horses. And although that species of catarrh which we name influenza, is probably a miasm rather dependent on some intemperament of the atmosphere itself in its origin, than on the temperament of the individual who suffers from it; yet thia also becomes a contagion in its progress, and is communicable in consequence of such new property, from individual to individual, after a removal into fresh and very remote atmospheres by travelling;* whilst nothing can be more highly contagious than the discharge from the mucous glands of the tunica conjunctiva in purulent ophthalmy, although possibly the matter of this contagion dissolves rapidly in the atmosphere, or it is not sufficiently volatile to float in it; whence a direct contact is necessary for the production of its effect. In like manner, leucorrhcea,' as we have already observed, has sometimes seemed to be contagious ; for I have occasionally found a kind of blenorrhoea produced in men, accompanied with a slight pain in the urethra, and some difficulty in making water, upon cohabitation with women who upon inspection, had no marks what- ever of luodic blenorrhoea, or clap ; and, in some instances, indeed, were wives and matrons of an unimpeachable character. The disease before us, however, has symptoms peculiar to itself, and undoubtedly depends upon a specific virus. The chief of these symptoms are described in the definition. They are generally preceded by a troublesome itching in the'glans penis, and a general sense of soreness up the whole course of the urethra: soon after which the discharge appears, on pressing the glans, in the form of a whitish pus oozing from its orifice. In a day or two it increases in quantity, and becomes yellowish ; and, as the inflammation aug- / ments, and the disorder grows more virulent, the yellow is convert-' ed into a greenish hue, and the matter loses its purulent appearance, and is thinner and more irritant. The burning or scalding pain that takes place on making water is usually seated about half an inch within the orifice of the urethra, at which part the passage feels peculiarly straitened or contracted, whence the urine flows in a small, interrupted stream : the lips of the urethra are thickened and inflamed, and a general tension is felt up the course of the penis This last symptom is sometimes extremely violent, and accompanied with involuntary erections ; at which time, as the frsenum, in conse- quence of the inflammation, has lost its freedom of motion, the penis is incurvated with intolerable pain. It is to this state of the penis in which it bears some resemblance to a hard, twisted cord, that the trench have given the name of chordee. Under these circum- stances we often meet with a troublesome phimosis, either of the strangulating or incarcerating kind ; in consequence of the in- creased spread of the inflammation. Sometimes it extends to one • See Catarrhus epidemicus, of this work, Vol. II. p. 295, 296 GE. IIL—SP. II.] SEXUAL FUNCTION. 59 or both groins, in which case the glands swell and buboes are often formed ; sometimes it reaches to the bladder, the surface of which pours forth a cheesy or wheyey fluid instead of its proper lubricous secretion, which is communicated to the urine ; and sometimes the testes participate in the inflammation, become swollen and painful, and excite a considerable degree of fever. In women, the chief seat of affection is the vagina; but as this is a less sensible part than the urethra, the pain is seldom so pun- gent, except when the meatus urinarius and the nymphae associate and participate in the inflammation. The disease appears at very different intervals after infection, according to the irritability of the constitution. The usual .time is about the fourth or fifth day- But it has shewn itself within the first twenty-four hours, and has sometimes continued dormant for a fortnight. Domeier lays down the time from the fourth to the fourteenth day.* Plenciz fixes it after the tenth.f Sometimes by the violence of the irritation the secretion is absorbed as fast as it is effused; so that only a very small discharge takes place, while the other symptoms are peculiarly exasperated. To this state of the disease some practitioners have applied the very absurd name of gonorrhaa sicca. It was at one time imagined that the puriform fluid which is usu- ally poured forth in considerable abundance, proceeds from an ulcer in the urethra; but it is now well known, as we have already had occasion to observe frequently, that it is not necessary for an ulcer or an abscess to exist for the formation of pus, and the dissection of persons who have died while labouring under this disease, have sufficiently shown that the secretion is thrown forth from the internal membrane of the urethra, chiefly at the lacunae, without the least appearance of ulceration, or even, in most instances, of excoriation. The cure, in the present day, is simple; for the venereal clap, like the venereal pox, appears to have lost much of that virulence and severity of character, by passing from one constitution to an- other, which it evinced on its first detection. Rest, diluent drinks, and an antiphlogistic regimen will often effect a cure alone. But it may be expedited by cooling laxatives, and topical applications. The remedies employed are of two kinds, and of very opposite characters ; stimulant, and sedative. Both, also, are used generally and locally ; with a view of taking off the irritation indirectly by exciting a new action ; or directly, by rendering the parts affected torpid to the existing action, and thus allowing it to die away of its own accord. Many of these medicines, indeed, as well the local as the general, were, at one time, supposed to be natural antidotes, and to cure by a specific power : an idea, however, which has been long banished from the minds of most practitioners. The general sedatives that have hitherto been principally em- • Fragmente iiber die Erkenntnis venerischer Krankheiten, Hanov. 1790. f Aeta, et Observationes, Med. p. 139. GO GENETIC A. [CL. V.—OIL I ployed are opium, conium, nitre, oily emulsions, and mucilages. The first has often succeeded, but with considerable and very un- necessary inconvenience to the constitution : the others are not much to be depended upon. They may have co-operated with a rigidly reducent diet, but have seldom answered alone. Employed locally, some of them, and particularly opium, have proved far more beneficial. The best form of this last is that ot an injection rendered somewhat viscid by oil or mucilage, both which have a greater chance of acting as demulcents, and sheathing, 01 inviscating the acrimonious corpuscles in this case, than on the irritable surface of the lungs in catarrhs, and asthma, when given by the mouth. The stimulant process has, however, been found to answer so much more rapidly and more effectually, that it has almost super- seded the use of sedatives in modern practice. Formerly this process, also, was employed generally, and it was supposed, and, in many cases, sufficiently ascertained, that by strong- ly irritating some other part, the morbid excitement of the urethra would subside, and the organ have time to recover its natural ac- tion. And hence the intestines were daily stimulated by cathartics, as neutral salts, mercury, and colocynth, which last was at one time regarded as a specific; or terebinthinates, as camphor, balsam of copaiba, and turpentine itself. And sometimes the bladder was treated in the same manner, with diuretics of all kinds, and espe- cially with cantharides. This plan is still continued in many parts of the East, and par- ticularly in Bengal and Java; where, as we are informed by Mr. Crawfurd, the common remedy, and one to which the disease, in those hot regions, yields very easily is that of cubebs, the piper cubeba of Linneus. This pepper, well pounded, is exhibited in a little water, five or six times a day, in the quantity of a dessert- spoonful, or about three drachms, as well in the ensuing as in the present species, during which time all heating aliments are to be carefully abstained from. The cure, we are told, is entirely com- pleted in two or three days, the ardor urinae first ceasing, and the discharge again becomes viscid. A slight diarrhoea is sometimes produced, with a flushing in the face, and a sense of heat in the palms of the hands, and the soles of the feet. In a few instances, Mr. Crawfurd tells us, inflamed testicles have supervened, an affec- tion which yields easily to the common treatment.* There is no necessity, however, for subjecting the constitution to so severe a discipline : for the stimulant process, and particular- ly that of astringept stimulants, when employed locally, succeeds ordinarily in a few days without any trouble. These consist chiefly of metallic salts in solutionis the muriate, and sub-muriate of mer- cury, the former in the proportion of three or four grains to eight ounces of water:—sulphate of zinc, sulphate of copper, ammoniacal * Account of the Piper Cubeba, &c. Edinb. Med. and Surg. Journ. No. LIII. p. 32. GE. III.—SP.1I.] SEXUAL FUNCTION. 61 copper, and sub-acetated solution of lead. The astringent property of most of these, under due management, instead of being found mischievous, gives a check to the morbid secretion, at the same time that it acts as a direct tonic and rapidly restores the irritated mouths of the exhalants to their healthy and proper action ; and this, too, without the inconvenience of a secondary inflammation. A slight solution of alum alone, indeed, in the proportion of one or two grains to an ounce of water, has, for this purpose, been often employed with sufficient efficacy; though the present author has reason to prefer the sulphate of zinc, which he has usually combined with bole armenic in the proportion of one scruple of the former and two of the latter to half a pint of water. And he can venture to say that through a pretty extensive course of practice, for up- wards of thirty years, he has never known this composition to fail; and has never perceived it produce any of the inconveniences of stricture or swelled testicle which were so much but so ground- lessly apprehended when the stimulating and astringent practice was first introduced. The addition of the bole may to some practitioners appear trifling, but it adds to the power of the zinc, probably by giving an in- creased body to the solution without diminishing its stimulant effect, which would certainly follow by using oil or mucilage in its stead. The sulphate of copper is more irritating than that of zinc, and, in a strong solution, is more likely to produce inflammation; and it is on this account chiefly that the author has confined himself to the latter. It is in effect, by an analogous practice,that several modi- fications of purulent opthalmy, and particularly that of infancy, is most successfully subdued, as wre observed when treating of this disease. It is almost unnecessary to add that the utmost cleanliness by frequent washing should be maintained from the first appearance of the disease. Where the complaint, however, is improperly treated with sti- mulants, and particularly astringent stimulants, or where it has con- tinued too long before application for medical assistance, the whole range of the urethra, or some particular parts of it, are apt to be- come so irritable as to excite spasmodic contractions, which com- monly pass under the name of strictures, without being so in reality; and, as we have already observed, this irritation in some cases, ex- tends to the interior surface of the bladder, and even thickens it. We have often had occasion to remark that in fibrous structures and canals the most sensible parts are their extremities; and this remark is particularly applicable to blenorrhoea, for the portions of the urethra which suffer most from irritation are the interior mem- brane of the glans and the prostate, particularly the latter, in con- sequence of its direct connection with the bladder as well as the urethral canal. On this account, when a patient once labours under spasmodic constrictions from the disease before us, whatever other parts these 02 GENETICA. CL. V. OR. I. may exist in, the introduction of a bougie will be almost sure to prove that there is also a constriction in the prostate. Generally speaking it will be found to originate here, and to occur in other parts of the canal from sympathy. But the case will often be re- versed, and while the irritation originates in some other part, or in the bladder, it is by sympathy with these that the prostate itself is affected. Mr. Abernethy has pointed out this double source of spas- modic constriction in the prostate, in the clearest manner possible;* and the remarks he has offered upon the propriety of employing or withholding the bougie as an instrument of cure cannot be too deeply imprinted on every student's mind: the general principle of which is to persevere in its use wherever it appears to blunt the sensibility ; and to pass it as high up the urethra as can be accom- plished with this effect, if possible indeed through the prostate into the bladder; but in every instance to desist where a second or third trial of the instrument gives more pain than the first, or to content ourselves with passing it as high as can be done without any such symptoms of increased irritation, and there stopping short: and only making an occasional trial when-we have reason to hope that the morbid sensibility has still further subsided. SPECIES IN. BLENORRHOEA CHRONICA. mm. ^LIMY DISCHARGE FROM THE MUCOUS GLANDS OF THE URETHRA, WITHOUT SPECIFIC VENOM OR INFECTION ' SLIGHTLY IRRITATING : CHRONIC. This species is a frequent sequel upon a clap that has been ill-ma- naged, or has lasted long, and produced an obstinate local debility. But it exists also independently of clap, and is occasioned by strains, excess of venery, and other causes of weakness. The discharge is, for the most part, a bland and slimy mucus not accompanied with inflammation, apparently proceeding from a morbid relaxation of the mucous glands of the urethra, and at times, like other dis- charges from debilitated organs, accompanied with and kept up by irritation and especially irritation produced by a stricture in the urethra properly so called, or a diseased state of the prostrate gland. In common causes, the disease yields to the local tonics and as- tringents recommended under the preceding species, but it is some- * Surgical Observations on Diseases of the Urethra, p. 194,8vo. 1810. GE. m.~SP. HI.] SEXUAL FUNCTION. 63 times peculiarly irritable, and bids defiance to all the ingenuity of the medical art. A Castro gives an instance of its having conti- nued for eighteen years.* The stimulants ordinarily employed have consisted of copaiba or some terebinthinate or resinous balsam in the form of injection; tincture of ipecacuanha, as recommended by Schwediauer; infusion of cantharides, a favourite remedy with Bartholin; or a blister ap- plied to the urethra, as advised by Mr. John Hunter and several other writers. The bougie may here be used, for the most part more fearlessly than in the preceding species. Its own simple stimulus, if employ- ed regularly once or twice a-day, has often proved sufficient: and where this fails it may be rendered more active by being smeared with turpentine, mercurial ointment, or camphorated liniment; or armed with nitrate of silver, where there are strictures that require it. Even in this species, however, it is a valuable remark of Mr. John Hunter, that, before we have recourse to any powerful acuants, we should well weigh the degree of irritability of the patient's constitution: for we may otherwise run a risk of exciting a violent local inflammation, or of extending the irritation to the testes or the bladder. Should such an issue unfortunately occur, one of the most salutary injections we can employ is a solution of the extract of hyoscyamus in water. Even in chordees, which resisted the in- fluence of opium, Mr. Bell asserts that he has found this medicine advantageous in the quantity of from one to three grains at a time, and repeated three times a-day or oftener? Or we may have re- course to a warm hemlock poultice, applied every night, and made sufficiently large to cover the whole of the perinaeum, testes, and pe- nis. I have known this succeed in taking off an habitual irritation, and with it effectually suppressing the discharge, on the third appli- cation, in two instances of more than a twelvemonth's standing: and this after stimulants of all kinds, and narcotics of many kinds, and particularly opium, had been tried in succession. The leaves were here employed in a fresh state. Nisbet gives an instance of cure, produced by a fresh infection: but this is not a remedy to be recommended either medically or morally. In women this disease is often mistaken for leucorrhcea ; we have pointed out the distinctive character under the last species. Yet the mistake is not of essential consequence, as the same treatment will often effect a cure in both. As the vagina, however, is less irritable than the urethra, gleet in females is a less frequent and a less troublesome complaint than in males. * De Morb. Mul. p. 68 64 GENET1CA. ^L. V.—OR. I. GENUS IV. SPERMORRHCEA Seminal JHuj:. INVOLUNTARY EMISSION OF SEMINAL FLUID WITHOUT COPULA- TION. The generic name is derived from maga, " sero" "semino; whence aspermus, "void of seed," gymnospermus, "having the seed naked,"—a term well known in botany ; and hence also nume- rous other derivatives of the same kind. Gonorrhoea, which is a direct synonym, would have been retained as the name for this ge- nus, but from the confused signification in which it has been em- ployed by Sauvages and Gullen ; and from its being usually, though most improperly applied in the present day to blenorrhoea luodes. The genus offers two varieties as follow: 1. SPERMORRHffiA ENTONICA. ENTONIC SEMINAL FLUX. 2. .______.------■ ATONICA. ATONIC SEMINAL FLUX. SPECIES I. SPERMORRHCEA ENTONICA. Syntonic Seminal iFlup. INVOLUNTARY EMISSION OF PROPER SEMEN WITH ERECTION J MOSTLY. FROM AN INDULGENCE OF LIBIDINOUS IDEAS. The usual cause is assigned in the definition, and it very strikingly points out the influence which the mind bears upon the body, and the necessity of subjecting the passions to the discipline of a chaste and virtuous deportment; since, as there is no passion more debas- ing than that of gross lust, there is. none more mischievous to the general health of the body. It leads the besotted slave straight forward to every other sensuality, and, by becoming at length an established and chronic disease, stupefies the mind, debilitates the body, and is apt to terminate in hectic fever and tabes. This affection sometimes originates in the body itself: in a local and urgent erethism, produced, as Forestes conjectures,* by a su- • Lib. XXVI. Obs. 11 GE. IV—SP. II.] SEXUAL FUNCTION. 65 perabundant secretion of seminal fluid in a constitution of entonic health and vigour. And, as in the former case, the body is to be chastised through the mind, in the present the mind is to be chastis- ed through the body : particularly by purgatives and venesection, a low diet and severe exercise. If, however, the patient be single, as is commonly the case, the pleasantest as well as the most effec- tnal remedy is to be sought for in marriage. SPECIES II. SPERRMORRHCEA ATONICA. 3(tomc Seminal ipluj:. kNVOLUNTARY EMISSION OF A DILUTE AND NEARLY PELLUCID SEMINAL FLUID J WITH LIBIDINOUS PROPENSITY BUT WITHOUT ERECTION. Of this species Sauvages gives us two curious examples: one from Deidier, in which the patient was an exemplary monk, who shrunk with horror at the idea of this involuntary self-pollution, as he re- garded it: the other a case in his own practice, in which the pa- tient a most religious young female, was, as he affirms, driven al- most to madness under the same erroneous contemplation of the disease. From his having included a female under this genus, it should seem that Sauvages inclined to the theory of epigenesis, or that which supposes the male and female to contribute equally a seminal fluid in the act of procreation. It is probable that some local irritation is the usual cause. Professor Deidier himself sus- spected this in the first of the above cases; and referred it rather to a calculus in the bladder, sympathetically affecting the prostate gland, than to any idiopalhetic disease of the vesiculae seminales, or the testes. The pious monk found himself most relieved by scourg- ing his legs: a blister applied to the perinaeum would probably have relieved him still more effectually. The fluid is a thin degenerate secretion, apparently from the vesiculae seminales, rather than se- men itself. It is sometimes found intermixed with blood ; and in this case we have the further irritation of a wound or ruptured ves- sel. The most common cause of this miserable disorder is a pre- vious life of unrestrained concupiscence: and under this debility, hereby produced, the morbid discharge is peculiarly apt to flow Upon the mere muscular excitement that takes place on evacuating the rectum; and hence follows hard upon a stool.* Art. Med. Berol. Dec. I. Vol. IV. p. 70. Wichmann De Pollutione, &c. Goett, 1712. Vol. iv.—9 66 GENETICA. [CL. V.—OR. I. sea A cure should be attempted by the daily use of a bidet of cold ota-water, or of early bathing in the sea, and the internal use ot metallic tonics. The bowels should be kept lax, but the warm and irritating purgatives should be carefully abstained from. Blistering the perinaeum, or making a seton in it has occasionally been found serviceable; as has also a local use of electricity. GENUS Y. GALACTIA. ^Wislactation. MORRIP FLOW OR DEFICIENCY OF MILK. This includes the greater part of those affections, treated of by Dioscorides, under the name of sparganosis, which, however, in his arrangement embraced, as we observed under phlegmone mamm*,* many complaints that have little or no connection with each other, and particularly one of the species of bucnemia, or tumid-leg : so that it has been necessary to break up the division and allot to its different members their proper positions. Galactia is a Greek term, from yxXx, " lac," whence yxXxx.rix.os, "lacteus." It occurs in Linneus and Vogel for the genus now before us, which by Sauvages and Sagar is written galactirrhoea, literally " milk-flux," in a morbid sense of the term. The author has preferred galactia as more comprehensive than galactirrhoea, so as to allow the idea of a depraved or defective, as well as of a superabundant secretion of milk: all which are equally entitled to be comprized under one common head, as excess, deficiency, or other irregularity of arterial action in fever. Hitherto, however, from an opposite fault to that of Dioscorides, these affections have been separated from each other by many nosologists, and carried to different heads, sometimes to different orders, and occasionally to different classes ; whence the student has had to hunt for them through every section of the nosological arrangement. It has al- ready been necessary to make the same remark respecting many of the species of paramenia!'and various other instances will occur to us in the ensuing orders of the class we are now explaining. The flow of milk may become a source of disease as being out of season, defective in quantity, vitiated in quality, transferred to an improper organ, and as discharged from the proper organ but in Vol. II. p. 187. GE. V—SP. I.) SEXUAL FUNCTION. 67 the male sex. These differences will furnish the present genua with five distinct species as follow: premature milk-flow. deficient milk-flow. depraved milk-flow. erratic milk-flow. milk-flow in males. SPECIES I. GALACTIA PREMATURA. premature 3*&ilfc=floto. EFFLUX OF MILK DURING PREGNANCY. The mammae, which maintain the closest sympathy with the ovariaj and uterus, and in most animals possessing them are placed in their direct vicinity, and which in truth are as much entitled to the character of a sexual organ as any organ of the entire frame, par- ticipate in the development of the generative function from the first- stimulus of puberty. It is then that the breasts assume a globose plumpness, and the catamenial flux commences; when pregnancy takes place, and the uterus enlarges, the breasts exhibit a corre- spondent increase of swell; and when, shortly after child-birth, the lochial discharge ceases, and the uterus takes real, the lacteal dis- charge is secreted and poured forth in immediate succession. The sympathy continues, however, even'after this rest has commenced, for one of the most effectual means of increasing the flow of milk from the breasts is a slight excitement of the uterus as soon as it has recovered its tone; and hence the mother of an infant living with her" husband, and herself in good health, makes a far better nurse and even requires a less stimulant regimen than a stranger brought from her own family, and secluded from her husband's visits. Of this, indeed, many of the rudest and most barbarous na- tions, but who are not always inattentive to the voice of nature, have the fullest conviction; insomuch that the Scythians, according to Herodotus, and the Hottentots in our own day, irritate the va- gina to increase the flow of milk in their cows and mares. It sometimes happens, however, that this stimulus of sympathy is carried to excess even during pregnancy, and that the lactiferous ducts of the mammae secrete milk from the ultimate branches of the arteries sooner than it is wanted. If the quantity thus separat- ed be small it is of no moment; but if it be considerable, some de- gree of debility is usually produced with restlessness and pyrexy. 1. GALACTIA PREMATURA. 2. ————— DEFECTIVA. 3.---------DEPRAVATA. 4. .--------- ERRATICA. 5. , YIRORUM. 68 GENETICA. [CL. V.—OR. 1 And hence Galen observes, that a premature flow of milk indicates a weakly child ;* and the collections of medical curiosities contain various cases, in which it has appeared to be injurious.! Sauvages gives an instance in which a pint and a half was poured forth daily, as early as the fifth month. Where the constitution is peculiarly robust, even this may for some time be borne with as little mis- chief as menstruation during pregnancy; but in ordinary cases the system must be weakened by so excessive and unprofitable a dis- charge. There is an instance noticed in the volume of Nosology, in which a pint and a half was poured forth daily at the fifth month. The morbid irritation, however, may generally be taken off by venesection, and, if this should not succeed, by a few doses of ape- rient medicines, which have the double advantage of lowering the action in the affected organ, and exciting a new and revulsive ac- tion in an organ that is usually more manageable. It has sometimes happened that a like precocity has occurred in young virgins, and that these also have secreted and discharged milk from the proper organ. In many cases this has occurred as a substitute for the catamenial flux which has been retained or sup- pressed at the time,}: but more generally it has proceeded from en- tonic plethora, or a morbid erethism of the sexual organs at the period of puberty ;§ and is to be removed by a reducent regimen, bleeding and purgatives, as just pointed out. On the other hand we have occasional instances of a supply of milk, in women considerably advanced in life, and who have long ceased to bear children, and even to menstruate. Thus a woman of sixty-eight, is stated by Dr. Stack, in the Philosophical Transac- tions, to have given suck to two of her grand-children ;|| and an- other of eighty in a Swedish Journal, is said to have performed the same office.1T In most of these cases the antiquated nurses have consisted of married women, who had many years before reared families of their own, and whose lactiferous organs were therefore more easily re-excited to the renewed action, than if they had never suckled, the cause has been some peculiar irritation originating in the radicles of the lactiferous ducts, or excited by a transfer of action from the uterus or ovaria in consequence of a cessation of the menses. * Fragm. ex Aphor. Rab. Mois. p. 34. f Act. Nat. Cur. Vol. IV. Obs. 66. pote? ttSwa£B° Virff°' men9trUiS deficientibus> Ia° i" mammis habere § Hippocr. Aph. Sect. V. § 39. Vega, Comment, in Hippocr. Aph. V. § 39. H Vol. XLI, year 1739. 141. K See also Phil. Trans. Vol. IX. year 1674. 6E. V.-SP. II.) SEXUAL FUNCTION. 69 SPECIES II. GALACTIA DEFECTIVA. Efficient i*Wfe=fl0to. INABILITY TO SUCKLE UPON CHILD-BIRTH. This is the agalaxis or agalactatio of preceding nosologists • and may proceed from two causes, accompanied with symptoms pro- ducing the two following varieties : x Atonica. From want of secretion. Atonic inability to suckle. C Organica. From imperfect nipple or other Urganic inability to suckle. organic defect. To every feeling and considerate mother, inability to suckle is a serious evil: and, generally speaking, it is an evil of as great a mag- nitude to the mother herself as to the child ; for a free secretion of milk prevents many present and not a few eventual mischiefs. The health of women during suckling is, in most instances, better than at any period of their lives. Their appetite is excellent, their sleep sound and refreshing, their spirits free, their temper cheerful. But to every conscientious mother there is, superadded to all this, a pleasurable feeling of a still higher and nobler kind: it is a sense of consciously discharging the maternal duty: it is the gratifica- tion of beholding the lovely babe to whom she has given birth saved from the cold caresses of a hireling, to lie in the warm em- braces of her own bosom : to grow from the sweet fountain which she furnishes from her own veins, rich, ample, and untainted: to swell with the tender thrill that shoots through the heart at every little draught which is drawn away from her; to see the cheeks dimple and the eyes brighten, and the limbs play, and the features open; and to trace, in every fresh lineament, a softened image of herself or one dearer to her than herself. This is the luxury that awaits the mother, whose unseduced ear still listens to the voice of Nature, and estimates the endearments of domestic life at a higher value than the intoxicating charm of fashionable amusements and midnight revels. Though transported with the present, her com- forts do not end with the present: for she has yet to look forward to a term of life in which, when those who have made a sacrifice of maternal duty at the altar of pleasure, are wasting with decline, trembling with palsy, or tormented with the dread of cancer, she will still enjoy the blessing of unbroken health, and sink as on a downy pilly into a tranquil old age. But though these remarks apply to the greater number of those 70 GENETICA. [CL. V.—OR. I. who, in the career of fashion, abstain from the duty of a mother, it by no means applies to all. There are many excellent mothers who would undergo the severest discipline of pain to accomplish this ob- ject, but after all are not able. There are some who from the want of a proper nipple, or perhaps the want or undevelopment of lac- tiferous ducts, are naturally disqualified for the office : as there are others whose constitutional debility renders them incapable of se- creting their milk in sufficient abundance, or with a sufficient ela- boration for healthy food. And in all such cases it is expedient, wherever the means will allow, to seek carefully for the substitute of a foster mother. But let not the natural office be abandoned too soon, and parti- cularly where the child is strong aud hearty. If the nipple be at fault much may be done to remedy it. If it be buried in the breast, it may often be drawn out by exciting a vacuum with the ordinary1 glass tube invented for the purpose, if dexterously applied; or, which will often succeed better, by the suction of a woman who is well skilled in the art: or an artificial nipple may be employed if these do not succeed. And if the breasts be hard and lumpy, and a considerable degree of symptomatic fever supervene, the same kind of suction must be had recourse to twice a-day, while the breasts are kept in a constant state of relaxation by gentle friction with warm-oil, large cataplasms of bread and water, and a suspensory bandage of flannel passed un- der the arms and drawn as tight as may be borne without incon- venience. Even where the milk is not very promising, either in respect to /quantity or quality, let not the unhappy mother despair for the first week or two. As her own strength increases, the strength of the milk will often be found to increase also: the milk vessels will yield with more facility, and the symptomatic pain in the back will subside. Added to which the matrimonial excitement to which I have alluded in the preceding species, will in due time be called in to bear its beneficial part; and the woman who had a hopeless prospect before her may in due time reap the full harvest of her labours. UE. V.—SP. III.] SEXUAL FUNCTION. 71 SPECIES III. GALACTIA DEPRAVATA. 23ejirafoe& iftilfc=floto. EFFLUX OF A DILUTE OR VITIATED MILK. Here also we have two varieties: x Serosa. Weakened by too large a proportion Serous Milk-flow. of serum. £ Contaminata. Deteriorated by intermixture with Contaminated Milk-flow. some foreign material. To the first variety we have alluded under the preceding spe- cies : for it sometimes happens that milk, when deficient in quanti- ty, is also of a more dilute quality than it ought to be. But more frequently, as local irritation is a result or concomitant of debility, there is in weakly habits a very large flow of a thin, slightly blue, and almost pellucid milk, containing little sugar,and still less cream. The properties of a sound woman's milk we have already given under consumption, and to save an unnecessary repetition, the rea- der may turn to the passage, at his leisure, and compare it with the defective character before us.* Tonics, and a generous diet, afford in this case the best chance of success, and are often employed with full effect. Under the second variety the assimilation is imperfect, and the milk has the taste or smell of beer, or wine, or some other fluid that has been introduced into the stomach : proving that the digestive power is weak, and requires correction and invigoration. In other cases we have examples of black, green, or yellow milk : probably discoloured by an union with effused blood. All violent exertions, whether of body or mind, and hence vio- lent passion, as rage and terror, have a peculiar influence in changing the natural character of milk; and the depressing pas- sions frequently drive it away entirely, f It is hence, of no small moment that a wet nurse be of an easy and even temper, and not disposed to mental disturbance. * Marasmus Phthisis, Vol. II. p. 494. f Starch, Archiv. fur Geburtshelfer. B. III. 12. B. II. p. 3. 12 GENETICA. [CL. V. OR. I. SPECIES IV. GALACTIA ERRATICA. Erratic itttlfc^floto. milk transferred to, and discharged or accumulated at some remote organs, often under a different form. Like the menstrual flux, there is scarcely an organ to which the flow of milk has not been transferred under different circumstances, or in different constitutions. And hence the author has adverted in the volume of Nosology to examples of its translation to the fauces, where it has been discharged in the form of a ptyalism : to the general surface of the mammae, where it has been evacuated in the form of sweat: to the navel, where it has assumed an ichorous appearance : to the kidneys, which have thrown it off in an increas- ed flow of urine : to the eyes, whence it has been discharged as a milky epiphora : to the veins, which it has overloaded, so as to de- mand the use of the lancet: and to the vagina, where it has excited a copious leucorrhcea. It is also said to be frequently translated to the thighs, so as to produce the disease we have already described under the name of bucnemia spargan sis, but which is clearly unconnected with the state of the milk or of the breasts. The causes are chiefly a sudden exposure of the breasts to cold; cold-water drunk improvidently when in a state of perspiration, spirituous potation, and sudden emotion of mind. The irregular action is best subdued by gentle laxatives, dia- phoretics, and perfect quiet in a warm bed. Where ardent spirits have been the cause, the aperients should be more stimulant, and bleeding will often be necessary. The blood itself, however, during the time of suckling is often loaded with milk from resorption, and evinces a milky appearance, as are likewise several of the fluids secreted from the blood: and hence, also, one cause of many of the above peculiarities. GE. V.~SP. V.] SEXUAL FUNCTION. 73 SPECIES V. GALACTIA VIRORUM. if*lilfc=floto in Wales. MILK SECRETED IN MALES AND DISCHARGED FROM THE PROPER EMUNCTORY. A milky serum, and sometime sgenuine milk has been found to distil from the nipples of new-born infants, of both sexes, and sometimes from boys of a later age. But various authors, as Schbik, P. Bo- relli, and Lauremberg have given cases of genuine milk discharged in like manner by adult males; occasionally continuing for a long time ; and, in some instances, enabling them to perform the office of nurses. In the Commentaries of the St. Petersburg Academy,* a flow of milk from the breasts of males, is said to be very common in Russia ; and Blumenbach has noticed the same peculiarity in the males of various other mammals.t Among men, indeed, the dis- charge appears occasionally to have occurred even in advanced life; for Paullini gives the case of a man, who was able to suckle at the age of sixty 4 Why man should, in every instance, possess the same organiza- tion as woman for secreting and conveying milk, is among the many mysteries of physiology that yet remain to be solved. But as there is little or no sympathy between the mammae in man and any of the proper organs of generation, as in woman, we are at no loss to ac- count for their general sterility and want of action. Occasionally, however, the lacteal glands in man, or the minute tubes which emerge from them are more than ordinarily irritable, and throw forth some portion of their proper fluid. And if this irritation be encouraged and supported, there is no reason why such persons may not become wet-nurses as well as females. And hence Dr. Parr inquires, with some degree of quaintness, whether this organization is allotted to both sexes, in order that " in cases of necessity men should be able to supply the office of the woman V Under these circumstances, the discharge, though unquestionably a deviation from the ordinary law of nature, can scarcely be regarded as a dis- ease. * Tom. III. p. 278. f Hanoversich Magazin, 1787. t Cent. II. Obs. 93. Shacker, Diss, de lacte Virorum et Virginum. vol. IV.—10 CLASS V. GENETICA. ORDER II. ORGASTICA. diseases affecting tne ©rjjasm. ORGANIC OR CONSTITUTIONAL INFIRMITY, DISORDERING THE POWER, OR THE DESIRE OF PROCREATING. The ordinal term orgastica, is derived from opyxa "appeto impatienter; proprie de animantibus dicitur, quae turgent libidine. Scafiul. Orgasmus is, hence, used by most writers for salacity in general; though by Linn6us it is employed in a very different sense, being restrained to subsultus arteriarum. The following are the genera which appertain to this order: I. CHLOROSIS. GREEN-SICKNESS. II. PRCEOTIA. GENITAL PRECOCITY. Ill LAGNESIS. LUST. IV. AGENESIA. MALE STERILITY. V. APHORIA. FEMALE STERILITY. BARRENNESS. VI. JEDOPTOSIS. GENITAL PROLAPSE. GENUS I. CHLOROSIS. @frertt=&icfctiess. PALE, CHLORID COMPLEXION ; LANGUOR ; LISTLESSNESS ; DEPRAVED APPETITE AND DIGESTION : THE SEXUAL SECRETIONS DEPRAVED OR INERT, ESPECIALLY AT THEIR COMMENCEMENT. Chlorosis is a derivative from #Aa* or %2mi " herba virens;" whence} among the Greeks, %*M$xtrpx and %*»§tao-ts " viror," " pal- GE. I.] SEXUAL FUNCTION. 75 lor;" evidently applied to the disease, like our own term green- sickness, from the pale, lurid, and greenish cast of the skin. The causes of this disorder are numerous: one of the most fre- quent is menostra' on, retained or suppressed catamenia; another is excessive menstruation; a third, inability of obtaining the object of desire, in popular terms love-sickness : a fourth is dyspepsy, or any other source of general debility about the age of puberty, by which the natural development of the sexual system and the energy of its secretions is at this time interfered with. Dr. Parr makes it a question whether love-sickness or an ungratified longing for an object of desire is ever a cause; but the examples are too numerous to give countenance to any doubts upon the subject ;* and pining, eager, ungratified desire for any object whatever, in a particular state of constitution, whether for an individual or for a particular circle of society, for home or for country, is well known in many cases to break down the general health, and to lay a foun- dation for chlorosis, as well as many other complaints even of a severer kind. We have already noticed it as producing suppressed menstruation ; as we have also the opposite state of disappointment overcome, renewed hope, and a prospect of connubial happiness, as one of the best and speediest means of cure. Perhaps retained menses, and dyspepsy at the period of puberty, are the most common causes ; and hence chlorosis makes so near an approach to both these complaints, that sortie nosologists have merg- ed it altogether in the first, and others in the second. Dr. Cullen so far as relates to his ofiinion, is an example of the former. Dr. Young, so far as relates to his arrangement, of the latter. It is necessary to attend to this limitation: for while Dr. Cullen, in the later editions of his Synopsis, asserts " nullam chlorosis speciem veram, praeter illam quae retentionem menstruorum comitatur, ag- noscere vellem"—he still continues chlorosis in all the editions of this work as a distinct genus from amenorrhcea, or paramenia sbstructionis, of which upon this view of the subject it should be only a species of variety. In the same manner, Dr. Young, while he makes chlorosis a mere species of dyspepsia in his classifica- tion, observes, as though dissatisfied with its arrangement, " I have followed a prevalent opinion, but there are various reasons for thinking it is quite as naturally connected with amenorrhoea." Chlorosis is often, indeed, not only connected with amenorrhcea, but a consequence of it. Yet few writers have felt themselves able to adopt Dr. Cullen's views upon the subject, and to believe it in every instance a modification of this disease. Sauvages asserts that there are daily cases of chlorosis occurring among children from their cradles; and he has hence, among his chloroses ver^, set down one species under the name of chlorosis infantum. This, however, is to generalize the term too widely, and to make it * Panarol. Jatrolog. Pentech. III. Obs. 14. Ephem. Nat. Cur. Dec. II. Ann. IX. Obs. 114. 76 GENETICA. [CL. V.—OR. II. include all cases marked by indigestion, and a chlorid countenance. Yet I cannot but concur with those authors who contend that chlorosis is by no means uncommon among females who have no wtrrrufition of the menstrual flux ; though a derangement of some kind or other in quantity, quality, or consritutent principles appears to be always connected with it; and is for the most part the cause or leading symptom. There is even ground for carrying the term, with other authors, still further, and applying it to green sick boys as well as green-sick girls, for reasons which will be offered in their proper place. For the present, it is sufficient to characterize chlorosis as a dysthesisor cachexy, produced by a diseased condition of the sexual functions operating upon the system at large, and hence most com- mon to the age of puberty, in which this function is first called forth by the complete elaboration of organs that have hitherto been inert and undeveloped. " A certain state of the genitals," says Dr. Cullen, " and the remark will apply to both sexes equally, is ne- cessary to give tone and tension to the whole system; and there- fore, that if the stimulus arising from the genitals be wanting, the whole system may fall into a torpid and flaccid state, and from thence chlorosis may arise." The genus chlorsis offers the two following species : 1. CHLOROSIS ENTONICA. ENTONIC GREEN-SICKNESS. 2. » ■-----ATONICA. ATONIC GREEN-SICKNESS. SPECIES I. CHLOROSIS ENTONICA. ISntonic €ffmn=relaxed habit; the plethora of the first or entonic variety would produce the best and most effectual cure ; but as this is rarely to be accomplished in a constitution of ibis kind, tonics, a plain but nutritous diet, especially light suppers, and, more especially still, a bidet of cold water before retiring to bed, form the most effectual means of subduing this precession of generative power. In some cases, the afflux has been so quick as to take place even before the vagina has been fairly entered. The fourth or retarding variety forms a perfect contrast to the preceding. It imports a sluggishness either of constitution or of local erethism, in consequence of which the seminal flow does not * Vol. III. Syspasia, Epilepsia, p. 358. f Borelli. Amalth. Med. Hist. p. 161. \ De sed. et Caus. Morb. Ep. XXVI. Art. 13. § Geneanthropia, p. 794. | Init. Biblioth. Tom. iv. p. 61. 4to. Tubing, 1795. \ Observ. Lib. IV. Obs. 46. 94 GENETICA. [CL. V.—OR. IT. take place till the orgasms of the female has subsided, and fatigue, perhaps disgust has succeeded to desire. Here too, general tonics and local stimulants offer the fairest chance of success; and both sting-nettles* and flagellations,t as in some cases of organic impo- tency, are said to have worked wonders. The variety is generally described under the name of bradyspermatismus. The refluent variety is chiefly introduced upon the authority of M. Petit,$ whose description has been copied by Sauvages. "It consists," he tells us, " in a reflux of the semen into the bladder or vesiculae seminales, on account of the narrowness of the urethra, in consequence of which there is no semination during the mter- union, and the semen is afterwards discharged with the urine. This narrowness is common to those who have suffered from fre- quent blenorrhoeas, and have hence contracted strictures or scirrhous indurations in the course of the urethral passage, or have the pas- sage blocked up with indurated mucus. Deidier gives a case not very unlike, consisting of a patient who laboured under a fistula opening from the vesiculae seminales into the rectum: in conse- quence of which, though sound in every other respect, whenever he embraced his wife scarcely any of the semen escaped from the penis, nearly the whole passing into the intestine, intermixed with a small quantity of urine ; and hence his marriage was sterile.§ In all these cases the cure of the impotency must depend upon a cure of the local cause of constriction. The dyspermatismus, ure- thralis, nodosus and mucosua of Sauvages and Cullen, who has co- pied from him, are all resolvable in this variety, as proceeding from like causes, and producing a like effect. SPECIES III. AGENESIA INCONGRUA. <£ojmlatfte Jtncongvuitg. IHE SEMINAL FLUID INACCORDANT IN ITS CONSTITUENT PRINCIPLES, WITH THE CONSTITUTIONAL DEMAND OF THE RESPECTIVE FEMALE. All the species of this genus are closely connected; yet it is only the first two that have hitherto been noticed by nosologists; nor is there any preceding system that I am aware of, under which * Eph. Nat. Cur. Dec. II. Ann. V. App. p. 55. f Meibom, and Reidlin, loc. citat * Memoirs de l'Academie de Chirurgie, I. p. 434. § Tom. III. Consult. I. GE. IV.-SP. III.] SEXUAL FUNCTION. 95 even these two have been introduced into the same subdivision. In a most every instance, indeed, they have been regarded as d£ aneenuh%i:°ngl?Kt0,diStant °rderS or even clLes, and ar- ranged with diseases that have little or no relation to them. Thus eco^XoT16"^' Y Mm ?aUed a-Ph^isia, occu" I the thi, s?" !nH « a S1Xrth C-laSS' United with such dise*ses as " loss of hitst and "desire of eating;" while dysspermia, or dyssoerma- CuTlen r'h "T* ^^ * *« third °"»er °f «- ninth caTsTn nrni " theS* dlseases <*cur, indeed, in the same class, a very ira" proper one, that of locales, but under different orders of this clasT- impotentia being arranged under the second order, with the m^ bid cravings of the alimentary canal, and some of those of the mind U?iSTg!a\and dysspermia being placed under the fifth order entitled efnscheses or suppressions. The present species is, for the first time, so far as the author knows, introduced into a nosological system ; and is derived from personal observation in full accordance with the scattered remarks of several other writers and practitioners. The principle upon which the species is found belongs, strictly, to the general doctrine of conception, and has been already explained in the Physiological Proem to the present class. It will hence be sufficient to throw out a few additional hints for the purpose of bringing the principle more immediately home to the disease before us, and supporting the propriety of its introduction into the general register. Every one must have noticed occasional instances in which a husband and wife, apparently in sound health and vigour of life have no increase while together; either of whom, nevertheless! upon the death of the other, has become the parent of a numerous family ; and both of whom, in one or two curious instances of di- vorce, upon a second marriage. In various instances, indeed, the latent cause of sterility, whatever it consist in, seems gradually to diminish, and the pair that for years was childless, is at length endowed with a progeny. In all this there seems to be an incon- gruity, inaccordancy, or want of adaptation in the constitutent principles of the seminal fluid of the male to the sexual organization of the respective female; or, upon the hypothesis of the epigenesis, which we have already illustrated, to the seminal fluid of the fe- male. Writers, strictly medical, have not often adverted to this subject, though it is appealed to, and for the most part with appro- bation, by physiologists of all ages and countries. Sauvages, how- ever, evidently alludes to and admits such a cause in his definition of dysspermatismus serosus, which is as follows:" Ejaculatio seminis aquosioris, adeoque ad genesim inepti, quae species est frequentis- simum sterilitatis virilis principium." He illustrates his definition by a case which occurred to Haguenotand Chaptal, who attributed it to the cause in question, and refers for other examples to Etmuller. Cullen expresses himself doubtfully upon this species," De dyssper- matismo seroso Sauvagesii," says he, « mihi non satis constat. Yet his own gonorrhoea iaxorum, in the present system spermorrhoea 9G GENETICA. [CL. V.—OR. II. atcnica, and which he explains "humor plerumque pellucidusr sine penis erectione, sed cum libidine, in vigilance, ex urethra fluit," makes so near an approach to it, that the physiologist who admits the one can find little difficulty in admitting the other. The resem- blance is, indeed, close and striking ; in the latter disease the indi- vidual labouring under it, emits involuntarily, and without coitim, or even erection, but with a libidinous sensation, a pellucid fluid, apparently of a seminal character, affirmed positively by Sauvages, from whom Cullen derives his species, and to whom he refers, to be an "effluxus seminis;" while, in the former, the same dilute and effete semen, with difficult, and imperfect erection, is poured forth during coition In like manner, Forestus speaks of a proper gonorrhoea, or invo- luntary emission of seminal fluid, produced ex aouositate,* from too watery a condition of the secretion: Timaeus, of the same disease occasioned ex semine acri,\ by a secretion of an acrimonious semen : and Hornung, of hysterics occasioned in married women who are sterile from an " immissio/rt£-trfi seminis :"\ an expression adopted from, or at least employed by, Ballonius,§ and supported by Schurig,|| and Ab Heer.t The explanation, however, now offered, takes a more compre- hensive view of the subject, by supposing that the seminal fluid may be secreted, not merely in a state of morbid diluteness, but, under various modifications, even in a state of health, of such a condition as to render it inadequate to the purposes of generation in female idiosyncrasies of certain kinds, while it may be perfectly adequate in those of other kinds. In agricultural language it supposes that the respective seed may not be adapted to the respective soil, how- ever sound in itself. So, Parr tells us, on another occasion that, " In some instances the semen itself seems defective in its essential qualities-"** Here again, the mode of treatment must be regulated by a close attention to the nature of the cause. In most cases, whatever will tend to invigorate the system generally will best tend to cure the sterility : as a generous diet, exercise, the cold-bath, and particu- larly the use of the bidet or local cold-bath. With these may be combined the warm and stimulant resins and balsams, as guiacum, turpentine, copaiba; and the oxydes of iron, zinc, and silver. Abstinence by consent, for many months, has, however, proved a * Lib. XXVI. Obs. 12. f Cas. p. 188. i Cista. p 487. § Opp. I. p. 120. Ii Spermatologia, p. 21. 1 Observ. Rar. N. 10. " Diss. Art. Anaphrodisia. ge. rv.—SP. III.] SEXUAL FUNCTION. 91 more frequept remedy than any other, and especially where the intercourse has been so incessantly repeated as to break down the staminal strength : and hence the separation produced by a voyage to India has often proved successful. GENUS V, APHORIA. jpemale SbtertUtg. Barrenness. INABILITY TO CONCEIVE OFFSPRING. Aphoria (xpogia) " sterilitas" " infecunditas" from * negative, Qiq*> " fero," " pario," is the term in common use among the Greek writers. It is singular that the morbid condition it imports has no distinct place in any of our most esteemed nosologists. It may possibly be intended under the anaphrodisia of several of them, though in none of them has the genus any one species, that expressly applies to female barrenness. The proper species belonging to it are the following : 1. APHORIA IMPOTENS. BARRENNESS OF IMPOTENCY. 2.--------■ PARAMENICA. BARRENNESS OF MISMENSTRUATION. 3. —-----1MPERCITA. BARRENNESS OF IRRKSPONDENCE. 4. , 1NCONGRUA. BARRENNESS OF INCONGRUITY. SPECIES I. APHORIA IMPOTENS. Barrenness trf XnLpotencg. IMPERFECTION OR ABOLITION OF CONCEPTIVE POWER. This species runs precisely parallel with the same disease in males already described under agenesia impotent, and consequently offers us the two following varieties : a Atonica. Atonic barrenness. £ Organica. Organic barrenness. In atonic barrenness there is a direct imbecility or want of tone, vol. iv.—13 98 genetica; [CL. v.—or. ir. Tather than a want of desire: and the ordinary causes are a life of intemperance of any kind, and especially of intemperate indulgence in sexual pleasures, a chronic leucorrhoea, or paralytic affection of the generative organs. It has also been occasioned by violent con- tusions in the loins, or the hypogastric region, and by over-exertion in walking. The plan of treatment is to be the same as already laid down under atonic sterility or impotency in males, yet it is seldom that any treatment has afforded success under this variety. Organic barrenness is produced by pome structural hindrance or defect, whether natural or accidental. And this may be of various kinds : for the vagina may be imperforate, and prohibit not only all intermission of semen, but an entrance of the penis itself. The ovaria may be defective, or even altogether wanting, or not duly developed, or destitute of ovula; or the fimbriae may be defective, and incapable of grasping the uterus ; or the Fallopian tube maybe obstructed, or impervious, or wanting : in all which cases barren- ness must necessarily ensue. In the case of an impervious vagina, however, unless there be a total occlusion, conception will some- times follow: for it has occurred where the passage has been so narrow as not to admit the penis; and occasionally indeed, when, with the same impediment, a rigid and unbroken hymen has offered an additional obstacle, of which the medical records contain abundant examples. Ruyset gives us a singular case of a hymen found un- broken at the time of labour. In all these instances the hymen seems to have been placed high up in the passage, so as to allow the penis to obtain a curtailed en- trance, and to produce its shock; when the occlusion not being complete, a part of the semen has passed through the aperture, and effected its ordinary result. These, however, are rare instances: for the impediment before us is, in common cases, a sufficient bar not only to conception, but to copulation. The author was lately consulted by a very amiable young couple in an instance of this kind, to whom the want of a family was felt as a very grievous affliction. The hymen had a small aperture, but was tense and firm, and the ordinary force of an em- brace was not sufficient to break it. He explained the nature of the operation to be performed, and added that he had no doubt of a suc- cessful issue. The lady was reluctant to submit herself to the hands of a surgeon, and hence with equal courage and judgment be- came her own operator. The impediment was completely removed, and she has since had several children. In a few instances, however, this will not answer, for there is a natural narrowness or stricture, sometimes found in the vagina, which cannot be overcome, at least without a severer operation than most women could be induced to submit to : that I mean of lay- ing it open through the whole length of the contraction. A sponge tent, however, gradually enlarged, has sometimes succeeded. Surig GE. V—SP. II.] SEXUAL FUNCTION. 99 gives an account of a dissolution of marridge in- consequence of an impediment of this kind.* SPECIES II. APHORIA PARAMENICA. barrenness of ifHtsmenstrttatton. CATAMENIAL DISCHARGE MORBIDLY RETAINED, SECRETED WITH DIF- FICULTY, OR IN PROFUSION. It is not always necessary to impregnation that a female should menstruate : for we have already observed! that a retention of men- ses, or rather a want of menstruation, is not always a disease; but only where symptoms occur which indicate a disordered state of some part or other of the body, and which experience teaches us is apt to arise in consequence of such retention. In some cases, there is great torpitude or sluggishness in the growth or develop- ment, or proper erethism of the ovaries, and menstruation is de- layed on this account, and in a few rare instances we have remarked that it has occurred for the first time after sixty years of age. It may hence easily happen, and we shall presently have occasion to show that it often has done so, that a woman becomes married who has never been subject to this periodical flux : and although it is little to be expected that she should breed till the sexual organs are in a condition to elaborate this secretion, yet if such condition take place after marriage, impregnation may instantly succeed and prohibit or postpone the efflux which would otherwise take place.| But where there is a manifest retention of the catamenial flux. producing the general symptoms of disorder which we noticed when describing this disease, it is rarely that conception takes place,, in consequence of the morbid condition of the organs that form its seat For the same reason it seldom occurs where the periodical flow is accompanied with great and spasmodic pain, is small in quantity, and often deteriorated in quality. And, if during any intermediate term, conception accidentally commence, the very next paroxysm of distressing pain puts a total end to all hope by separating the germ from the uterus. * Gynxcolog1. p. 223. f Vol. IV. Paramenia obstructionis, p. 33. i Class V. Order HI. Carpotica, Introductory remarks. 100 GENETICA. [<-L. V.—OR. II. But there must be a healthy degree of tone and energy in the conceptive organs, as well as of ease and quiet, in order that they should prove fruitful, and hence, wherever the menstrual flux is more frequently repeated than in its natural course, or is thrown forth, even at its proper time, in great profusion, and, as is gene- rally the case, intermixed with genuine blood, there is as little chance of conception as in difficult menstruation. The organs are too debilitated for the new process; and not unfrequently there is as little desire as there is elasticity. Having thus pointed out the general causes and physiology of barrenness when a result of mismenstruation, it will be obvious that the cure must depend upon a cure of the particular kind of morbid affection that operates at the time and lays a foundation for the dis- ease, of all which we have already treated under the different spe- cies of the genus paramenia, and need not repeat what is there laid down. SPECIES III. APHORIA IMPERCITA barrenness of Krrespontrenee. STERILITY PRODUCED BY PERSONAL AVERSION OR WANT OF APPETENCY, It is not perhaps'altogether impossible, that impregnation should take j) uct; n the case of a rape, or where there is a great repug- nancy on the part of the female, for there may be so high a tone of (institutional orgasm as to be beyond the control of the individual xv. o is thus forced, and not to be repressed even by a virtuous recoil, and a sense of horror at the time. But this is a possible rather than an -ciual case, and though the remark may be sufficient to suspend a charge of ciminulity, the infamy can only be completely wiped aw-iv' by collateral circumstances. Inordinary instances, rude, brutal force is never found to succeed against the consent of the violated person. And for the same reason, wherever there is a personal aversion, a coldness, or reserve, instead of an appetency and pleasure, an irrespondence in the feelings of the female to those of the male, we have as little reason to hope for a parturient issue. There must be an orgastic shock, or pei r ulsion suffit ient to shoot off an ivulum from its bed, and to urge the fine and irritable fimbriae of the Fallopian tube to lay hold of the uterus and grasp it tight, by which alone a communication can be opened between this last orgc.n and the ovarium, or the seed cannot reach home to its proper soil, and produce a harvest. GE. V.—SP. in.] SEXUAL FUNCTION. 101 So observes the first didactic poet of ancient Rome, addressing himself to the Generative Power, in the language not of the volup- tuary but of the physiologist : — per maria, ac monteis, fluviosque rapaceis Frundiferasque domos avium, camposque virenteis, Omnibus incutiens blandum per pectura araorem, Ecficis, ut cupide generatim secla propagent.* So through the seas, the mountains, and the floods, The verdant meads, and woodlands fil I'd with song, Spuhii'd bt jiesibe each palpitating tribe Hastes, at thy shrine, to plant the future race. The cause is clear, and the effect certain, but it is a disease immedicable by the healing art, and can only be attacked by a kind, assiduous, and winning attention, which, however slighted at first, will imperceptibly work into the cold and stony heart, as the drops of rain work into the pavement. It should teach us, how- ever, the folly of forming family connexions and endeavouring to keep up a family name, where the feelings of affection are not en- gaged on both sides. SPECIES IV. APHORIA INCONGRUA. barrenness of Xnronsruftg. THE CONCEPTIVE POWER INACOORDANT WITH THE CONSTITUENT PRINCIPLES OF THE SEMINAL FLUID RECEIVED ON THE PART OF THE MALE. This species runs precisely parallel with the third under the preceding genus agenesia incongrua, and the physiological and therapeutic remarks there offered will equally apply to the present place. • De Rer. Nat. I. 17. 102 GENETIC A. L^L« V.—OR. IL GENUS VI. .EDOPTOSIS. (Genital prolapse. PROTRUSION OF ONE OR MORE OF THE GENITAL ORGANS, OR OF EX- CRESCENCES ISSUING FROM THEM, INTO THE GENITAL PASSAGE J IM- PAIRING OR OBSTRUCTING ITS COURSE. JUdoptosis is a compound term from xtfoiov, « inguen," pi. xihtx " pudenda," whence xt^ag « pudor," and ^t«o-/S " lapsus." In like manner Sauvages and Sagar use ^Edopsophia, applying the term to the meatus urinarins, as well as to the uterus. Sauvages, however, expresses the present disease, but less correctly, by hysteroptosis, for this, with strict propriety, can denote only one of the species that fall within its range, namely displacement of the uterus. The genus embraces the five following species:— 1. -ffiDOPTOSIS UTERI. FALLING DOWN OF THE WOMB. 2.----------VAGINAE. PROLAPSE OF THE VAGINA. 3. ---------- VESICAE. PROLAPSE OF THE BLADDER. •i.----------COMPLICATA. COMPLICATED GENITAL PROLAPSE. 5.----------POLYPOSA. GENITAL EXCRESCENCE. SPECIES I. ^DOPTOSIS UTERI. jFalitng fcoton of tile Womfc. PROTRUSION OF THE UTERUS INTO THE VAGINA. This may take place in several ways, and hence offers the following varieties: « Simplex. Simple descent of the womb. £ Retroversa. Retroverted womb. "/ Inversa. Inverted womb. In the first variety, or that consisting of a simple descent of the uterus, the organ retains its proper posture and figure. Different names are frequently given to different degrees of this varietv CE. VI.—SP. I.] SEXUAL FUNCTION. 103 If the descent be only to the middle of the vagina, it is called relaxatio uteri; if to the labiae, procidentia; if lower than the labiae, prolapsus. The distinction is of trifling importance ; the causes are the same in all, which are those of debility or violence. The disease is hence most common to women who have had nume- rous families ; but is occasionally met with in virgins after straining, using violent exercise in dancing, or running, and hence sometimes in girls of a very early age. Professor Monro gives an example of its occurring in an infant of not more than three years old, pre- ceded by a regular menstruation, or more probably a discharge of blood, every three weeks or month, from the vagina, accompanied with considerable pain in the belly, loins, and thighs. The case was too long neglected as being supposed of little importance; and the uterus, which at first appeared to be a very small body just peeping out of the vagina, descended lower and lower, continually increasing in size, till at length it became as big as a hand-ball, and entirely blocked up the passage of the pudendum. At this time the sanguineous discharge had ceased its returns; but a con- siderable secretion of leucorrhcea supervened. The uterus seems at last to have been strangulated, gangrene ensued, and was soon succeeded by death.* The disease first shows itself by what is called a bearing down of the womb, which is a slight descent produced by a relaxed state of its' ligaments, and its own weight when in an upright position. There is, at this time, an uneasy sensation in the loins, as well as in the inguinal regions, often extending to the labia, and particularly in walking or standing. There is also an augmented flow of the natural mucous secretion in consequence of the local irritation, which by degrees becomes acrimonious, and excoriates the sur- rounding parts, and is accompanied with an obstinate leucorrhcea. The stomach sympathises with the morbid state of the womb, the appetite fails, the bowels become irregular and flatulent, and the animal spirits are dejected. In attempting a cure we must first restore the prolapsed organ to its proper position, and then retain it there, by a support introduced into the vagina, which should be continued till the ligaments of the womb have recovered their proper tone. Various pessaries have been invented for this purpose, but that made of the caoutchouc or elastic gum, with a ligature to withdraw it at option, appears to be one of the most commodious. Astringent injections, as a solution of alum or sulphate of zinc, or even of cold-water, will generally be found useful ; as will also spunging the body with cold-water, or using a hip-bath of sea-water. New and rough port-wine, diluted with an equal quantity of cold-water, has proved one of the most valuable injections to which the author has ever had recourse. Dr. Berchelmann in a foreign journal, has recommended a far bolder and more decisive cure, derived from the rash, but successful * Edin. Med, Essays, Vol. III. Art. XVII. p. 282. 104 GENETICA. GL. V.—OR. II. practice of a woman upon herself. This courageous sufferer having long laboured under a prolapse of the womb, and tried every method in vain, tired out with the continuance of her complaint, cut into the depending substance of the womb with a common kitchen- knife. A considerable hemorrhage ensued; after which, the ves- sels collapsing, the organ gradually contracted, and ascended into its proper site ; and she was radically cured of the disease. Having boasted of her success, the writer informs us that many other women in the neighbourhood, afflicted with the same complaint, applied for her assistance, and derived a like cure from the same operation.* In cases where the prolapse depends upon a loose and relaxed condition of the uterus, it is highly probable that this bold practice may often be found to succeed, but it must be useless where the relaxation is seated in the ligaments: and the knife, if employed at all, should be applied to an extirpation of the entire organ, which has lately taken place with success in various cases. In the retroverted womb, the fundus falls down, and becomes the lower part, sometimes from a morbid weight and enlargement, but more usually from a neglected distension of the bladder be- tween the third and fourth month of pregnancy, at which period the fundus is just heavy enough to fall forward, whenever the cer- vix is pressed upon and elevated by such distension ; though after this period the cervix itself is too heavy to be affected by the blad- der in this way, and the entire uterus too much enlarged to fall down in any way. The bladder, in this case, must be carefully evacuated, and kept evacuated by a free use of the catheter, which will give the uterus an opportunity of righting itself. But if this should not take place in two or three days, the obstetric practi- tioner should endeavour to restore the organ to its proper position by introducing the fingers of one hand into the vagina and two fingers of the other hand into the rectum. The womb is inverted when at the same time that it is dis- placed or has fallen down, it is turned inside out. This mis- chievous condition is most commonly produced by unskilfully and violently pulling away the placenta after delivery: and is only to be remedied by a restoration of the uterus to its proper state before it contracts, without which perpetual barrenness must necessarily ensue, and the patient be subject for life to a difficulty of walking, leucorrhcea, ulceration, and the chance of a scirrhus or cancer. * Acta Philosophico-Medica Soc. Acad. Scient. Prir.c, Hassiaese 4to. Giessa Cattorum. «E. Vl.-SP. II.] SEXUAL FUNCTION. 106 SPECIES II. ^DOPTOSIS VAGINJE. ftroiajise of the Vagina. PROTRUSION OF THE UPPER PART OF THE VAGINA INTO THE LOWER* This, like the descent of the uterus, may, according to the degree of the disease, be a relaxation, prpcidence, prolapse, or complete inversion of the organ. Under all which modifications it has a considerable resemblance to a prolapse of the anus. It appears in the form of a fleshy substance protruding at the back part of the vulva, with an opening in the centre or on one side. At first it is soft, but by continued exposure and irritation, it becomes inflamed, indurated and ulcerated. The urethra is necessarily turned out of its course : and if the catheter be required it should be employed with its point directed backwards and downwards. Its ordinary causes are those of a prolapse of the womb, and it is to be treated by a like plan of astringent injections and general tonics. Pregnane^ commonly performs the best cure : and where this fails, Dr. Ber- chelmann, from the success which has accompanied incision in the case of prolapsed uteri, has recommended scarification, which appears well worthy of trial, though the author has not known h put into practice. SPECIES III. iEDOPTOSIS VESICAE. Jlrolajise of the Blatrtrer- PROTRUSION OF THE BLADDER INTO THE URINARY PASSAGE. This species is introduced chiefly upon the authority of Sauvages, who gives us two modifications or varieties of it; one in which there is a protrusion of the inner or nervous membrane, in conse- quence of its separating from the general substance of the blad- der, visible in the meatus urinarius, of the size of a hen's egg, subdiaphonous and filled with urine ; and the other in which there is a protrusion of the inner membrane of the neck of the bladder into the same passage. He gives a case of the former variety from Noel, who met with it in a virgin, who was from th«* vol. iv.—14 106 GENETICA. [CL. V.—OR.H, first peculiarly troubled with a retention of urine, accompanied with frequent convulsive movements. She soon fell a sacrifice to it, and it was on dissection that the nature of the tunic was clearly proved. M. de Sauvages queries whether on a recurrence of this case it would be most advisable to make an opening into the protruding sac, or to extirpate it altogether. The second variety he tells us is chiefly found among women who have borne many children, or have been injured by blows or other violence on the lower belly. The protruding cyst produced by an inversion of the membrane, drops down into the urinary passage to about the length of the little finger, and is sufficiently conspicuous between the labia. Solingen, who met with a case of this kind, returned it by a probe, armed at the upper end with a piece of sponge moistened with an astringent lotion ; and afterwards endea- voured to retain it in its proper position by a bandage. species iv. jEDOPTOSIS complicata. <&oroi)lteatetr <2&enttal prolapse. PROTRUSION OF DIFFERENT ORGANS COMPLICATED WITH EACH OTHER. From the connexion of the uterus and the vagina with the bladder, a prolapse of either of the two former is often complicated with that of the latter, giving us the two following varieties: a. Utero-vesicalis. Prolapse of the uterus dragging Utero vesical Prolapse. the bladder along with it. Q Vagino-vesicalis. Prolapse of the vagina dragging Vagino-vesical Prolapse. , the bladder along with it. Under either of these conditions the bladder, being deprived of the expulsory aid of the abdominal muscles, in consequence of its dropping below their action, is incapable of contracting itself suffi- ciently to evacuate the water it contains : and hence the patient is obliged to squeeze it with her hands or between her thighs. The causes and mode of treatment have been already described under the two preceding species. The present is the hysteroptosis composica of Sauvages. •E. VI.—SP. V.] SEXUAL FUNCTION. 107 species v. jEDOPTOSIS polyposa. (Bfenttal ISrcrescence. POLYPUS OR OTHER CARUNCULAR EXCRESCENCE IN THE COURSE OF THE GENITAL AVENUE. This is the polypus uteri, and polypus vagina of authors : but, strictly speaking, they are less polypi than polypous concretions, since the proper polypus is the fleshy excrescence of the nostrils, as already observed in the first volume.* The excrescences before us issue both from the uterus and the vagina, and hence form two distinct modifications as follow : x Uteri. Issuing with a slender root mostly Polypus of the womb. from the fundus of the uterus, and more or less elongating into the vagina. b Vaginae. Issuing from the sides of the vagina Polypus of the vagina. broad and bulbous. The latter excrescenses in an incipient state, and particularly when loose and flabby, are sometimes dispersed by stimulant and astringent applications, or a hard compress of sponge or any other elastic material: and, if this cannot be accomplished, they must be destroyed by excision or caustics. It is rarely that they have a neck narrow enough for the application of a ligature. polypous excrescences of the womb, are, however, a disease ot much greater severity; since the stomach suffers, in most cases, from sympathy, and consequently the general health, producing all the symptoms we have already noticed under ^edoptosis uteri: which last is not unfrequently a result, if the excrescence be of long continuance, and of considerable weight and magnitude. They are of all sizes, and of various degrees of hardness, from that of a soft and yielding sponge to that of firm and substantial leather. Though they commonly grow from the fundus ot the uterus, they have sometimes been found to sprout from its sides, and even its cervix, shooting down to different depths of the vagina, and occupying it more or less completely according to their extent. They are generally round in shape and compact in structure, inter- sected by membranes, running in different directions. Sometimes, however, they are oblong, in which case they usually consist of a loose irregular texture with numerous interstitial cavities. Dr. • Vol. I. p. 313. 108 GENETIC A. [CL. V.—OR. W. Baillie has given various examples of this diseased production in his tables of Morbid Anatomy.* They have been attempted to be removed in different ways, as by caustics, excision, laceration, and ligature. The last, however, is the only method unaccompanied with danger or uncertainty. Yet even this can rarely be had recourse to while the excrescence continues in the womb; and hence, the usual method is to defer the operation till, from its increase of size and weight, it has descended into the vagina, when the removal cannot be attempted too soon. They have sometimes dropped off spontaneously, the peduncle having probably decayed or shrivelled away. • See especially Facie, c. IX. Plate IV- 1= CLASS V. GENETICA ORDER III. CARPOTICA. diseases affeettns the XttLpreflnatiou. The ordinal term carpotica, is derived from «««•.«. « fructus," whence nxf-irua-n, « fruitio." In the Physiological Proem to the present Class, we have taken a brief survey of the laws and general process of generation so far as we are acquainted with them. Impregnation constitutes a part, and the most important part, of this wonderful economy, and, from the changes that the body undergoes during its action, it can never be surprising that it should often give rise to various diseases. These diseases maybe arranged under four genera; including those which occur during the progress of pregnancy : those which occur during the progress of labour; conceptions misplaced : and spurious attempts at conception ; the whole of which may be thus expressed; ' 1. PARACYESIS. MORBID PREGNANCY. II. PARODYNIA. MORBID LABOUR. HI. ECCYESIS. EXTRA-UTERINE FETATION. IV. PSEUDOCYESIS. SPURIOUS PREGNANCY. In the preceding Physiological Proem, we have shown that, in order for impregnation to take place, it is necessary the semen of the male should pass from the vagina to the one or other of the ovaries by means of the Fallopian tubes which lay hold of the uterus by their very fine and sensible fimbriae, or fringed extremities, with a sort of spastic grasp during the high-wrought shock of the em- brace, and thus alone open a path-way for the semen to travel in. The two ovaries are not merely intended to supply the place of each other, in the event of one being wanting or defective, but like the testes in men, they seem to increase the extent of the pro- ductive power, and enable a female to bear a larger offspring than she would do, if she were possessed of one ovary alone, Mr John HO GENETICA. [CL. V.—OR. 111. Hunter has put this to the test-by comparing the number of young produced by a perfect sow with those of a sow spayed of one ovary, both of the same farrow, and impregnated by a boar of the same farrow also. The spayed sow continued to breed for four years, during which period she had eight farrows producing a total of seventy-six young. The perfect sow continued to breed for six years; during the first four of which she also had eight farrows producing a total of eighty-seven young: and during the two ensuing years she had five more farrows producing a total of seventy- five young, in addition to those of the first four years.* So that, if we may judge from this single experiment, the use of two ovaries, in equal health and activity, enables an animal to breed both more numerously, and for a longer period of time, than the possession of one alone. Among women, however, the extent of fecundation does not seem to be much interfered with by the defect of a single ovarium, or its means of communication with the uterus, according to a paper of Dr. Granville read before the Royal Society, April 16, 1813, con- taining the case of a female whose uterus was found after death to have had but one set of the lateral appendages, and, consequently, a connexion with but one ovarium, and who, nevertheless, had been the mother of eleven children, several of each sex, with twins on one occasion. After impregnation has taken place, the membranes produced in the uterus form a complete septum, and, consequently, a bar to the ascent of any subsequent flow of semen, so as to prohibit the pos- sibility of two or more successive impregnations co-existing in any part of the uterus during the period of a determined gravidity. Children, indeed, have been born within a few weeks, or even months, of each other, and hence a colour has been given to the hypothesis that they may be conceived at different periods of a com- mon parturition, and such births have, in consequence, been distin- guished by thenameofsupERFETATioNs; but we shall have occasion hereafter, when treating of a plurality of children, to show that fetuses thus born in succession, however they may vary in size or maturity, are real twins, conceived at one and the same time, from the descent of a plurality of ovula into the uterus, instead of a single one, and that the difference of size or maturity depends upon some unknown cause in the dead or puny fetus, which has killed it or prevented its keeping pace with the other. Women are in general capable of breeding as soon as they begin to menstruate, which is the ordinary proof that the organs of con- ception are fully developed and perfected: and since this discharge, as we have remarked in the Proem just referred to, commences sometimes in very early life, and particularly in hot climates, where it has occured in girls of not more than nine years of age, so we have instances of conception and pregnancy having commenced as * Animal Economy, p. 157. CL. V.—OR. HI.] SEXUAL FUNCTION. 111 early. Baron Haller* and professor Schmidt,t concur in examples of pregnancy at nine years old: and the medical records confirm these singular histories by numerous instances of a like kind.| Yet, though menstruation is the ordinary proof that the concep- tive powers have acquired a sufficient finish and vigour for their proper function, menstruation itself is not absolutely necessary for impregnation. Ab there are circumstances that hurry on this secre- tion before its ordinary term of appearance, there are others that delay it, insomuch that some women pass through a long life with- out menstruating at all, while others only begin after reaching an adult age, and others again not till the period in which it usually ceases. Now, it may happen that a woman whose peculiar habit produces a peculiar retardation of menstruation, may marry before this secretion takes place for the first time; and, as we have just observed that she is able to breed as soon as ever she is able to menstruate, the former process may anticipate the latter, and post- pone it till the term of pregnancy has been completed. " A young woman," says Sir Everard Home, " was married before she was seventeen, and, although she had never menstruated, became preg- nant ; four months after her delivery she became pregnant a second time, and four months after the second delivery she was a third time pregnant, but miscarried; after this she menstruated for the, first time, and continued to do so for several periods, and again be- came pregnant."§ There is much difference of opinion as to the period of pregnancy in the human female; for while other animals seem to observe great punctuality upon this subject, we meet with so many and such considerable varieties in women, that legislators, as well as physi- cians, have not agreed in assigning a common term. Hippocrates rules it that we should admit the possibility of a child being born at ten months, but not later, which is the common term assigned in the book of the Apocrypha entitled Wisdom of Solomon ;|| while Haller gives references to women who are said to have gone not only ten but eleven, twelve, thirteen, and even fourteen months; most of which, however, are of a suspicious kind. Twelve months, nevertheless, is a term allowed by many physicians, as what may take place under peculiar weakness or delicacy of health ;1f and yet it is most probable that in all these the mother is mistaken as to the * Vide Blumenbach, Bibl. I. p. 558. X Act. Helvet. IV. 162. t Eph. Nat. Cur. Dec. III. Ann. II. Obs. 172. § Phil. Trans. 1H17, p. 258. | Chap. VII. 2. j Btichner, Miscell. 1727, p. 170. Enguin, Journ. de Med. Tom. LXI. Brambilla, Abbandl. der Joseph Acad. Band. I. p. 102. Telmout de St. Journ. de Med. lorn. XXVII. Ploucquet, Von den phvsichen Erfordernifsen der Erbfahigheit dpi Kinder, p. 69. Treb. 112 GENETIC A. [CL. V.—OB. lH. proper time of her conception, and imagines herself to have commenced pregnancy for some weeks or even months before it actually takes place. The state of menstruation affords no full proof; for as conception may occur without its appearance, so it may continue for many months or even during the whole term of pregnancy, though most commonly in a smaller quantity than usual. There is a singular case in the Histoire de l'Academie des Sciences, of a living child born after what is said to have been three years of pregnancy.* Few reports of this kind are worth attending to, or entitled to any kind of explanation : but it has sometimes happened, and probably did so in this last case that a woman conceits herself to be in a state of pregnancy, and has various symptoms that simulate it, for a twelvemonth or considerably more than a twelve- month, and particularly towards the cessation of the catamenia, instances of which we shall have occasion to notice under the fourth genus of the present order, entitled pseudocyesis or spu- rious pregnancy: and if, after such a simulation continued for a year or two, the woman should fall into a state of real pregnancy, she may persuade herself at the close of the process that she has been pregnant for the whole of this time. By the code Napoleon, the legitimacy of a child born three hundred days after a dissolution of marriage may be questioned. In our own country the law is to this hour in an unsettled state; and much nicety of argument has frequently taken place ; of which an example was afforded in the famous question of the Banbury peerage, upon a new raised distinction of access and generative access. There can be no doubt, however, that a considerable dif- ference in duration may ensue from the state of the mother's health: for as the fetus receives its nourishment from the mother, there is a probability that various deviations from health may retard the maturity of the fetus. And it is probably on this account that different legislators have assigned different periods of legitimacy; one of the shortest of which is that determined upon by the faculty of Leipsic, who have been complaisant enough to decide, that a child born five months and eight days after the return of the husband, may be considered as legitimate; and that a fetus at five months is often a perfect and healthy child. In the ordinary calculation of our own country, the allowed term does not essentially differ from that in the code Napoleon, for it extends to nine calendar months or forty weeks : but as there is often much difficulty in determining the exact day between any two periods of menstruation in which semination has taken effect, it is usual to count the forty weeks from the middle of the interval before it ceases; or, in other words, to give a date of forty-two weeks from the last appearance of the menses : and at the expira- tion ol this term, within a few days before or after, the labour may confidently be expected. * Hist, de l'Academie des Sciences, 1753, p. 206. GE. I.J SEXUAL FUNCTION, 113 In the progress of pregnancy the figure of the uterus, as well as its position, changes considerably. Before the end of the third month it has a tendency to dip towards the pelvis, at which period it may be felt to ascend: during the seventh month it forms a line with the navel; in the eighth month it ascends .still higher, reach- ing mid-way between this organ and the sternum ; and in the ninth it almost touches the ensiform cartilage ; at the close of which, as though overwhelmed by its own bulk, it begins again to descend, and shortly afterwards, from the irritation produced by the weight of the child, or, more probably, from the simple law of instinct, it becomes attacked with a series of spasmodic contractions extending to the surrounding organs, which constitute the pains of labour, gradually increase in strength, enlarge the mouth of the organ,and protrude the child into the world. In natural pregnancy, a strong hearty woman suffers little consi- dering the great change which many of the most important organs of both the thorax and abdomen are sustaining; and in natural labour, though the returning pains are violent for several hours, there is little or no danger. But numerous unforeseen circum- stances may arise from the constitution of the mother, the shape of the pelvis, the figure or position of the child, to produce diffi- culty, danger, and even death. In describing the diseases which appertain to the whole of this period, it is not the author's design to do more than to take a gene- ral pathological survey, so as to communicate that kind of know- ledge upon the subject which every practitioner of the healing art should be acquainted with, even though he may not engage in the obstetric branch of his profession. The minuter and more practi- cal parts, and especially those which relate to the application of instruments and the mechanical means of assistance, must be sought for in books and lectures expressly appropriated to this purpose, with which it is not his intention to interfere. GENUS I. PARACYESIS. Jfcorfritr ^refinance. THE PROGRESS OF PREGNANCY DISTURBED OR ENDANGERED BY THE SUPERVENTION OF GENERAL OR LOCAL DISORDER. The generic term is derived from tcx^x, " male," and xv«e-i$,» gravi- ditas." The genus will conveniently embrace the three following species, according as the general system, or organs distinct from vol. iv.—15 114 GENETICA. [CL. V.—OK. III. those immediately concerned, are disturbed; as the sexual organs themselves are disturbed ; or as the fruit itself is disturbed and ex- tended prematurely : 1. PARACYESIS IRRITATIVA. 2. 3. UTERINA. ABORTUS. CONSTITUTIONAL DERANGEMENT OF PREGNANCY. LOCAL DERANGEMENT OF PREGNANCY. MISCARRIAGE. ABORTION. SPECIES I. PARACYESIS IRRITATIVA. (Eonstttttttonal Heransement of ^reflnaneg. PREGNANCY EXCITING DISTRESS OR DISTURBANCE IN OTHER ORGANS OR FUNCTIONS THAN THOSE PRIMARILY CONCERNED. The new condition of the womb operates upon the whole or differ- ent parts of the system in various ways. We have frequently had occasion to observe that there is no organ whatever which exercises a more extensive control over the entire fabric than the uterus, with the exception of the stomach, and hence many parts are af- fected by sympathy during its new action, and particularly the brain and the whole of the nervous function. But its change of shape, bulk, and position, operates mechanically on other organs and frequently produces serious mischief by pressure or irritation; these organs are chiefly the stomach itself, the lungs, the intestinal canal, and the veins of the legs. And hence the evils resulting from these causes, may be contemplated under the following va- rieties : * Systatica. Accompanied with faintings, palpitations, convulsions, or other direct affections of the nervous system. f Dyspeptica. Accompanied with indigestion, sickness, and head-ache. y Dyspnoica. Accompanied with difficult breathing and occasionally a cough. ^ Alvina. Accompanied with derangement of the alvine canal, as costiveness, diarrhoea, or hemorrhoids. t Varicosa. Accompanied with venous dilatation of the lower extremities. ^ That the nervous system should often suffer severely and in va- rious ways during pregnancy, will not appear singular to those who GE. L—SP. L] SEXUAL FUNCTION. 115 have attended to the remarks we have already made concerning the close chain of sympathy that prevails between the brain and the sexual organs, from the time of the first development of the latter to their becoming torpid and superannuated on the cessation of the catamenia. But in delicate habits, in which these nervous affec- tions chiefly occur, there is another cause, which is even more powerful than the preceding; and that is the demand of an addition- al supply of sensorial power in support of the new process, and, consequently, an additional excitement and exhaustion of the senso- rium, persevered in without intermission, and increasing from day to day. This excitement and exhaustion necessarily produce weak- ness ; and of course an irregularity in the flow, and particularly in the alternating pauses, of the sensorial current; hereby predispos- ing alike to palpitation of the heart, clonic spasms,and convulsions, according to the law of physiology laid down under the genus clonus,* to which the reader may return at his leisure. Fainting, as has also been previously shown under the genus syncope,! is dependent upon the same deficiency of action, rendered more com- plete, or more protracted in duration. Palpitation, in the case before us, is rarely attended with dan- ger, but is often a most distressing symptom. It returns irregularly in the course of the day or night, but particularly after a meal, and very frequently on first lying down in bed. In the capricious state of the nervous system at this time, its return after meals does not seem to be so much dependent upon the nature of the food as upon the state of the stomach at the moment: it has recurred after a light and plain dinner, and been quiet after a more stimulant dinner ; and then for a few days has been most severe after the latter, and least so after the former; for a short time the digestion has gone on tran- quilly under both, and then again excited palpitation, and perhaps in an equal degree under both: nor has a total abstinence from so- lid animal food afforded any relief. The pulsatory action is some- times confined to the heart, sometimes alternates with the coeliac or some other arterial trunk in the abdomen, and sometimes with the temporal arteries. While writing this sheet, the author is oc- casionally consulted by a lady now in her sixth month, who has been most grievously afflicted with this affection from the time of her beginning to breed, and who will probably be subject to it till her confinement. None of the antispasmodics afford much, if any relief; camphor, in large doses, is found the best palliative ; the narcotics have all been tried in vain ; opium maddens the head and throws out a most distressing lichenous rash. The paroxysms usually continue from two to six or eight hours. Other irritations produce it, as well as those of the stqmach, and especially any sud- den emotion of the mind. Syncope or fainting occurs during any period of pregnancy, but * Vol. HI. p. 265. t Vol. III. p. 337. 116 GENETIC A. [CL. V.—OR. HI. chiefly in the stage of the first three months, and especially about the time of quickening. After this period the general frame ac- quires a habit of accommodation to the change that has taken place, and is less easily affected. It is ordinarily produced by more than usual exertion, exposure to heat or any sudden excitement of the mind. It is sometimes of short duration, and the patient does not lose her recollection ; but in other instances it continues for an hour or upwards. A recumbent position, pungent volatiles, sprinkling the face with cold water, and a free exposure to air, with a mode- rate use of cordials, offer the speediest means of recovery. The extremities, however, should be kept warm, and the friction of a warm hand applied to the feet. One of the worst ailments that ever accompanies the process of gestation is that of convulsions. They may occur at any period of this process, and their exciting causes are not always manifest. The predisposing causes are general weakness or irritability of the nervous system, a constitutional tendency to epilepsy, or any other clonic spasm, and entonic plethora. In all these cases there is a double danger; for we have to dread apoplexy from a rupture of blood-vessels in the head; and abortion or premature labour from an extension of the spasmodic action to the uterus. No time, therefore, is to be lost, and the remedial process must be as active as it is instant. Bleeding must be had recourse to immediately, as well in the ato- nic as in the entonic form of the disease. In the first, indeed, it is of itself an evil, for it will add to the general weakness; but as there is already, or, by a repetition of the fit, will unquestionably be, a considerable determination to the head, and more especially as the vessels in an atonic and relaxed frame yield easily as well to anastomosis as to rupture, it will be a far greater evil to omit it. The quantity of blood, however, that it may be advisable to ab- stract, must be determined by the concomitant symptoms so far as they relate to the head. Generally speaking, in weakly habits, the head is only affected secondarily, or by sympathy with the irritation of the uterus, where convulsions make their appearance ; and hence bleeding, in such cases, is to be employed rather as a prophylactic than as an antidote : and it may be sufficient to confine ourselves to the operation of cupping ; at the same time opening the bowels by a sufficient repetition of some laxative. After this opium must be chiefly trusted to, if the spasms still continue : and, on their subsi- dence, or in their interval, the metallic tonics should be introduced with the warmer bitters. Where, however, the constitution is robust, and the convulsions have been preceded, as is often the fact in this case, by a tensive or even heavy pain in the head, vertigo, illusory corruscations be- fore the eyes, or illusory sounds in the ears, the encephalon is it- self the immediate seat of disease, and the bleeding even in the first instance should be followed up to fainting, or at least till twenty ounces are drawn away, which it will frequently be necessary to GE. I.—SP. I] SEXUAL FUNCTION. 117 repeat within twenty-four hours afterwards; and, if the practition- er be a skilful operator, it will be better to abstract the blood from the jugular vein, as the good effect will be sooner felt. The hair should be shaved from the head and ice-water or other frigid lotions be applied, and very frequently renewed. The bowels must at the same time be purged vigorously, and dilute farinaceous food con- stitute the whole of the diet. Opium should be abstained from, at least till-the general strength is reduced to an atonic state, when if the paroxysms should still return, it may be had recourse to in conjunction with antimonial powder or some other relaxant. When, in despite of all this treatment, apoplexy has taken place, and is followed by a palsy of a particular organ, or of an entire side, it will often be found that the paralytic affection will often continue through the whole course of the pregnancy, and entirely disappear afterwards. Sickness, heart-burn,and other symptoms of indigestion are still more common affections than those of the nervous system we have first noticed. These are chiefly troublesome in the commence- ment of pregnancy, and evidently prove that they proceed not from any mechanical pressure, either direct or indirect, against the coats of the stomach, but from mere sympathy with the new and irritable state of the uterus : for, as the novelty of this state wears away and the stomach becomes accustomed to it, the sickness and other dyspeptic symptoms subside gradually, and are rarely troublesome even when in the latter months of pregnancy the uterus has swol- len to its utmost extent, from a length of three inches to that of twelve, and has risen nearly as high as the sternum. The head-ache, which occurs as a dyspeptic symptom, is of a very different kind from that we have just noticed, and is rarely re- lieved by very copious bleedings, though the whole of these symp- toms are occasionally mitigated by a loss of eight or nine ounces of blood from the arm, or the application of leeches to the epigastric region as recommended by Dr. Sims, and M. Lorentz. Cloths wetted with laudanum and applied to the pit of the stomach have also been found serviceable in various cases: but the most effica- cious means consist in the employment of gentle laxatives, and a very light diet, to which may be added the use of the aerated alka- line waters or saline draughts, in a state of effervescence. The fluid discharged from the stomach on these occasions is . usually limpid, thin, and watery : but where there is much straining a little bile is thrown up at the same time. It is rarely that this kind of vomiting produces any serious evil; though when it has become very obstinate, as well as very severe, it has sometimes en- dangered a miscarriage. The other symptoms of dyspepsy usually cease with this and are rather disquieting than sources of any de- gree of alarm. They may often be palliated by some of the means already recommended under limosis,cardialgia,* and dyspepsia.t * Vol. I. p. 86. f Vol. I. p. 105. llb GENETIC A. [CL. V.-OB. III. The chief symptoms of dyspnoea that become troublesome during pregnancy are occasional fits of spasmodic anhelation. These are mostly common to those, whose respiratory organs are naturally weak, or who are predisposed to hysteria. The paroxysms are of short duration and usually yield with ease to the warmer sedatives and antispasmodics. A dry and troublesome cough, however, is sometimes combined with this state of the chest, that, if violent, endangers abortion, and has occasionally produced it. Bleeding will here also be advisable as the first step in the curativeprocess. Eight ounces of blood will suffice, but the depletion must be repeat- ed at distinct intervals if the cough should continue unabated. Gentle laxatives should succeed to the bleeding and be persevered in as the bowels may require. And to these may be added the mucilagi- nous demulcents already recommended in idiopathic cough, united with such doses of hyoscyamus, conium, or opium as are found best to agree with the state of the constitution.* There is little danger, however, of this cough terminating in consumption however trou- blesome and obstinate it may be in itself, for it is rarely that two superadded actions go forward in the constitution at the same time : and hence, as we already have had occasion to observe, whenever pregnancy takes place in a patient labouring under phthisis, the progress of the latter disease is arrested, till the new process has run its course.f Derangements of the alvine canal under some modifica- tion or other, accompany most cases of pregnancy, are often very- distressing, and by their irritation sometimes hasten on labour pains before their time. These affections are of two very opposite kinds. In some in- stances the intestines participate in the irritability of the uterus, the peristaltic action is morbidly increased, and there is a trouble- some diarrhoea. In others the larger intestines appear to be ren- dered torbid partly by the share of sensorial power which is taken from them in support of the new action, and partly by the pressure of the expanding uterus on their coats. In both cases piles are a frequent attendant, but particularly in the last. The diarrhoea varies in different individuals from a looser flow of proper feces to a muculent secretion, or a dejection of dark co- loured offensive stools, accompanied with a foul tongue and loss of . appetite. The first modification requires no remedy, and may be safely left to itself The second and third import a morbid action of the excretories of the intestines, and are best relieved by small and repeated doses of rhubarb with two grains of epicacuan to each,}: and afterwards by infusions of cascarilla, orange-peel, or any other light aromatic bitter. The costiveness must be carefully guarded against by such ape- * Vol. T. p, 346. 352. f Vol. II. p. 505. * Burns, Principles of Midwifery, p. 154. GE. I.—SP. I.] SEXUAL FUNCTION. 119 rients, as are found upon trial to agree best with the bowels. Where acidity in the stomach is suspected, magnesia may be employed, and will often prove sufficient: but where this does not exist, the senna electuary, Epsom salts, or castor oil, will be found to answer much better. The piles will usually disappear as soon as the bowels are restored to a current state : and, if not, they should be treated according to the plan already laid down under proctica marisca.* Varicose dilatations of the veins of the lower extremities are a frequent, though not often a very troublesome accompaniment of pregnancy. They are chiefly found in women whose occupation obliges them to be much on their feet. Where the affected veins are first perceived to enlarge, the varicose knots may generally be prevented by exchanging the accustomed erect position for a re- cumbent one, and using the legs but little. Where the varices are actually formed, the legs may be supported with a bandage drawn only with such moderate pressure as to afford sustentation ; for if carried beyond this we shall only endanger a worse congestion in some other part not equally guarded against. For the rest the reader may turn to exangia varix, in a preceding part of this work.f SPECIES II. PARACYESIS UTERINA. Soeal Berangement of pregnanes. PREGNANCY DISTURBED OR ENDANGERED BY SOME DISEASED AFFEC- TION OF THE UTERUS. In the progress of this work, we have seen that on the commence- ment and through the course of impregnation the periodical secre- tion of the uterus is suspended ; that the organ gradually enlarges from its ordinary size till, in the ninth month, it measures ten or twelve inches from top to bottom, and that, in the course of this enlargement, it changes its position according to a law that is never departed from in a state of health. In a state of morbid action, however, or from some accidental in- jury, the uterus does not always maintain its proper position, nor abstain from throwing forth not only its ordinary and natural secre- tions, but other fluids of a morbid character; and hence becomes * Vol. I. p. 233. t Vpl. II. p. 598. 120 GENETICA. [CL. V.—OR. III. subject to several varieties of affection of which it may be sufficient to notice the following : x Retroversa. Retroversion of the uterus. Q Leucorrhoica. The uterus secreting, or exciting in the vagina a secretion of, leucorrhcea, so as to produce debility. y Catamenica. The catamenia continuing to recur. ^ Hemorrhagica. Accompanied with hemorrhage. A retroversion of the uterus may be produced in various ways, though it is seldom found except in pregnancy, and between the third and fourth month of this state. This organ, notwithstand- ing its appendages of broad and round ligaments, is still left pendu- lous in the hypogastrium: and hence, if the fundus or broad and upper part happen, by a scirrhous induration, or pregnancy, or any other means, to acquire a certain bulk and weight, and if at the same time the cervix, or lower and narrow part, be pushed on one side by any accidental force, as that of the bladder when distended, the broad and upper part will tumble downward, while the narrower part ascends and takes its place. It is this which constitutes a re- tro verted uterus ; but as it occasionally occurs under other states than that of pregnancy, we have treated of it already, under the genus ^edoptosis uteri, where we have stated the mode of treat- ment to be adopted in the case before us. Leucorrhcea is a result of the increased action excited in every part of the uterus, or of the upper part of the vagina which is in- flamed by continuous sympathy. We have already observed that the mucous discharge denominated leucorrhcea, or whites, appears to be secreted from the lower part of the uterus, and the upper part of the latter organ :* and hence any excitement operating on the fundus of the womb may be easily conceived under a particular condition of the cervix of the uterus and the vagina, or of the sys- tem generally, capable of producing this secretion in considerable abundance. When treating of leucorrhoea as an idiopathic affection we re- marked that where the discharge is excessive it produces considera- ble debility of the system generally, and of the sexual and lumbar region more particularly : and that when it becomes chronic, it of- ten degenerates into an acrimonious condition and occasions great disquiet by excoriating the cuticle to a considerable extent. Both these evils are consequent upon its occurrence in pregnan- cy, and the first has, occasionally, threatened abortion. They are to be relieved by the remedial process already pointed out under the genus leucorrhcea in the first order of the present class.f A continuance of the catamenial discharge at the regular * Vol. IV. Class V. Ord. I. Gen. II. t Vol. IV. p. 51. GE. I.—SP. II.] SEXUAL FUNCTION. 121 periods, is also, in many cases of delicate habits, a source of great weakness and discomfort, and sometimes endangers miscarriage or premature labour: in all which instances it ought to be checked by a recumbent position, and particularly a little before the time in which it may be expected, and by the other means already enume- rated under paramenia superflua in the present class.* It has sometimes continued, however, in strong and vigorous habits through the whole period of pregnancy without any serious mischief;! though, even here, it has usually been found to produce general debility, and many troublesome dyspeptic symptoms. Hemmani and several other writers give cases of women who have never menstruated except when in a state of pregnancy : such is the degree of irritation which the secrctories of the uterus, in some instances, demand, in order to be roused into a due perform- ance of their function. So, some persons can only see on a full ex- posure to a meridian Hght,§ and others can only hear when the tympanum is irritated by the noise of a drum or of a carriage, sufficient to deafen all the world around them.U Hemorrhage from the uterus is sometimes connected with this irregular return of the periodical discharge, as we have already observed it is not unfrequently in an unimpregnated state of the organ. In both cases this is usually a consequence of great general debility, and it is hence the more alarming in any period of partu- rition, as risking the loss of the uterine fruit. In the delicacy of habit we are now contemplating, bleeding would only add to the debility or predisponent cause : and we must content ourselves with the plan already recommended under atonic hemorrhage of the uterus in*a prior class and volume.If Where the discharge has been induced by external violence, or a sudden emotion of the mind, venesection will be the best remedy we can have recourse to, and* afterwards thirty or five and thirty drops of laudanum in a saline draught with two or three grains of ipecacuan. • Vol. IV. p. 44. t Hagedorn, Cent. II. Obs. 94. * Medicinisch-Chirurgche Aufaaze. Berl. 1778. Hopfergartner, iiber menfchliche Entwiklungen. p. 71. Sturtg. 1792. § Vol. HI. Paropsis noctifuga. p. 138. H Vol. III. Paracusis perversa, p. 138. 1 Vol. II. Class III. Ord. IV. pp. 469, 470. VOL. iv.—16 m GENETIC A [CL. v.-oit. m SPECIES III. PARACYESIS ABORTUS. miscarriage. Sfoortfon. PREMATURE EXCLUSION OF A DEAD FETUS FROM THE UTERUS. We have stated in the introductory remarks to the present order that the usual term of pregnancy is forty weeks, or nine calendar months. Within this period, however, the fetus may be morbidly expelled at any time. If the exclusion take place within six weeks after conception it is usually called miscarriage ; if between six weeks and six months, abortion ; if during any part of the last three months before the completion of the natural term, prema- ture labour. Among some writers, however, abortion and mis- carriage are used synonymously and both are made to express an exclusion of the fetus at any time before the commencement oft he seventh month. At seven months the fetus will often live. It has been born alive, in a few rare instances, at four months ;* and has as rarely continued alive when born between five and six months.-)- The process of gestation may be checked, however, from its earliest period : for many of the causes of abortion, which can ope- rate afterwards, may operate throughout the entire term, and hence a miscarriage occurs not unfrequently within three weeks after impregnation, or before the ovum has descended into the uterus. In this case the pains very much resemble those of difficult men- struation ; and with a considerable discharge of clotted or coagu- lated blood the tunica decidua passes away alone, having also some resemblance to that imperfect form of it which we have already noticed as being produced in some cases of difficult menstruation, but exhibiting a more completely membranous structure. And here the ovulum escapes unperceived at some subsequent period, and is probably decomposed and incapable of being traced. In subsequent periods of pregnancy abortion consists of two parts or stages, the separation of the ovum from the fundus of the womb, and its expulsion from the mouth. Sometimes these take place very nearly simultaneously, but sometimes several days or even weeks intervene ; so that the process of abortion may considerably vary in its duration, and become exceedingly tedious. In several cases I have known the ovum remain undischarged for upwards of six weeks, and, in one case, for three months after its separation, and consequently after the death of the fetus, comparing its size and appearance with the ascertained term of gestation. * A. Reyes, Campus Elys. Quaest. 9j. p. 1164. f Brouzet, sur l'Education medicinale des Enfans. I. p. 37. GE. I.—SP. III.] SEXUAL FUNCTION. 123 Through the whole of this period there is an occasional discharge from the vagina, and often temporary disquietudes, and even con- tractile pains in the uterus. But both are of a very different kind from those which occur antecedently to the separation of the ovum. The first pains are usually sharp and expulsory, with a free dis- charge of clotting arterial blood ; sometimes, indeed, in an alarm- ing, though rarely a dangerous profusion ; in the last they are dull and heavy, and the discharge is smaller in quantity, dark and fetid. We may also judge of the detachment of the ovum, and consequently the death of the fetus, by the cessation of those sympathetic symp- toms which have hitherto connected the stomach and the mammse with the action of the uterus, as the morning sickness, and the increasing plumpness of the breasts, which, not unfrequently, are so stimulated as to secrete already a small quantity of milk. On the separation of the ovum from the fundus of the uterus all these dis- appear ; the stomach may be dyspeptic, but without the usual sick- ness, and the breasts become more than ordinarily flaccid. The .ovum, when at length discharged, comes away very differ- ently in different cases. Sometimes the whole ovum is expelled at once; but more generally it is discharged in detached parts, the fetus first escaping with the liquor amnii, or descending with its own proportion of the placenta, the maternal proportion following some hours, or even days, afterwards. And, where there are twins, one of the fetuses, naked or surrounded with its membranes, is usually expelled alone, and the other not till an interval of several hours, or even a day or two ; the discharge of blood ceasing, and the patient appearing to be in a state of recovery: so that it is diffi- cult to determine whether or not there are twins in cases of early abortion. The causes of abortion are very numerous; and some of them are rather to be conjectured, than fully ascertained. They may depend upon the ovum itself, upon the uterus itself, or upon the uterus as affected by the nature of the maternal constitution, or accidental lesions. " The imperfections observable in ova," remarks Dr. Denman, " are of different kinds, and found occasionally in every part; and there is usually a consent between the fetus and the shell of the ovum, as the placental part and membranes may be called, but not always. For examples have occurred in which the fetus has died before the termination of the third month, yet the shell, being healthy, has increased to a certain size, has remained till the expi- ration of the ninth month and then been expelled, according to the genius and constitution of the uterus, though frequently it has been found to have undergone great changes, as, for instance, in many cases of hydatids."* " It is remarkable," says the same author, " that women who are in the habit of miscarrying, go on in a very promising way to a cer- tain time, and then miscarry, not once, but for a number of times, * Practice of Midwifery, Edit, 5. p. 508. 8vo. 124 GENETIC A. [CL. V.-OR. Ill in spite of all the methods that can be contrived, and all the methods that can be given: so that,besides the force of habit, there is some- times reason to suspect that the uterus is incapable of distending beyond such size, before it assumes its disposition to act, and that it cannot be quieted till it has excluded the ovum. What I am about to say, will not, I hope, be construed as giving a licence to irregularity of conduct which may often be justly assigned as the immediate cause of abortion, or lead to the negligent use of those means, that are likely to prevent it But from the examination ot many ova after their expulsion, it has appeared that their longer retention could not have produced any advantage, the fetus being decayed, or having ceased to grow long before it was expelled. Or the ovum has been in such a state as to become wholly unfit for the purpose it was assigned to answer: so that if we could believe there was a distinct intelligence existing in every part of the body, we should say it was concluded in council that thisovum can never come to perfection and shall be expelled."* The causes of abortion of a constitutional or accidental kind are more obvious. They may be internal and depend upon a relaxed or debilitated state of the system generally, and consequently of the uterus as a part of it; or external, and depend on adventitious circumstances. Violent pressure, as that of tight stays, by preventing the uterus from duly enlarging, is an obvious cause, as is also that of a sudden shock by a fall, or a blow on the abdomen : violent ex- ertion of every kind is a cause not less obvious, as that of immoderate exercise in dancing, riding, or even walking ; lifting heavy weights; great straining to evacuate the feces, or two frequent evacuations from a powerful purgative. Violent excitement of the passions, as of terror, anxiety, sorrow or joy. Violent excitement of the external senses by objects of disgust—whether of sight, sound, taste, or even smell; or whatever else tends to disturb or check the circulation suddenly, and hereby to produce fainting, will often prove a cause of abortion. And when once this affection has been produced, the organs with difficulty recover their elasticity, and it is extremely apt to recur upon the slightest causes. Plater gives us an account of fourteen miscarriages in succession ;t Werlhoff, of five within two years ;| and Werloschnig,of not less than eight in a single year.§ Wolfius relates the history of a woman, who, in the whole course of her life, suffered twenty-two distinct abortions :|| and Schultz, that of another, who, in spite of every remedy, miscarried twenty- three times, and uniformly in the third month, probably from an indisposition in the uterus to become distended further, as suggested * Denman, ubi supra, p. 508. f Observationes, Lib. II. p. 467. * Opp. III. p. 718. § De Curationibus Verno-autumn, p. 496. 8 Lection. Memorab. p. 418. GE. I.—SP. m.] SEXUAL FUNCTION. 125 in similar cases by Dr. Denman in the passage just quoted from him. Another, and a very frequent cause, is plethora, and this, whether it be from entony or atony. « The uterus," observes Mr. Burns, " being a large vascular organ, is obedient to the laws of vascular action, whilst the ovum is more influenced by those regulating new formed parts ; with fhis difference, however, that new formed parts or tumours are united firmly to the part from which they grow by all kinds of vessels, and generally by fibrous or cellular substance, whilst the ovum is connected to the uterus only by very tender and fragile arteries and veins. If, therefore, more blood be sent to the maternal part of the ovum than it can easily receive, and circulate and act under, a rupture of the vessels will take place, and an extravasation and consequent separation be produced : or even where no rupture is occasioned, the action of the ovum may be so oppressed and disordered as to unfit it for continuing the process of gestation."* Now in atonic plethora, or that commonly existing in high and fashionable life, among those who use little exercise, live luxurious- ly, and sleep in soft warm beds, although the action that accom- panies the pressure is feeble compared with what occurs in the op- posite state, the vessels themselves are feeble also, and their mouths and tunics are exceedingly apt to give way to even a slight im- petus: and hence plethora becomes a frequent cause of abortion in women of a delicate habit and unrestrained indulgence. Among the robust and the vigorous, however, its mode of opera- tion i6 still more obvious and direct. An increased flow of blood is here forced urgently on the uterus, which participates irresistibly in the vehemence of the aciion ; so that if the vessels do not sud- denly give way, and hemorrhage instantly occur, the patient feels a tensive weight in the region of the uterus, and shootin» pains about the pelvis. " This cause," observes Mr. Burns, " is especial- ly apt to operate in those who are newly married, and who are of a salacious disposition, as the action of the uterus is thus much in- creased, and the existence of plethora rendered doubly dangerous. In these cases, whenever the menses have become obstructed, all causes tending to increase the circulation must be avoided, and often a temporary separation from the husband is indispensable."! The general treatment of abortion consists of two intentions, that of preventing it when it threatens; and that of safely leading the patient through it when there is little doubt that it has taken place. The chief symptoms menacing abortion are transitory pains in the back or hypogastric region, or a sudden hemorrhage from the vagina. In all these cases the first step to be taken is a recumbent position, and when the patient is once placed in this state we should deliberately examine into the nature of the cause. If there be * Principles of Midwifery, 3d Edit, 8yo. p, 191. t Burns, ut supra, p. 192. 126 GENETIC A. [CL. V.—OR. III. symptoms of plethora, or oppression, if an accident, or a sudden emotion of, the mind, or severe exercise, as of dancing, riding, or even walking, have produced them by disturbing the equilibrium of the circulating system, blood should be immediately taken trom the arm, and all irritation removed from the bowels by a genVe laxative or injection. In plethora, indeed, we may go beyond this, and empty the bowels more freely; yet even here our object should be to reduce without weakening. In every instance, except where plethora prevails, after abstracting blood, the next best remedy is a full dose of opium consisting of thirty or forty drops of laudanum, or more if the symptoms be urgent, and repeated every three or four hours till the object is obtained.* And where the system is so feeble or emaciated that bleeding is countenndi- cated, we must content ourselves with giving sulphuric acid with small doses of digitalis, unless, indeed, there be much tendency to sinking at the stomach, and, in this case, we must limit our practise to the mineral acid and opium, and gently relieving the bowels. By this plan the pains originating from incidental causes are often checked, and the partial separation of the ovum that has commenced is put a stop to. But the remedial process is thus far merely begun: the patient, for some weeks, must be peculiarly attentive to her diet, which should be light and sparing, and if exercise of any kind be allowed, it should be that of swinging, or of an easy carriage. Cold bathing, and especially cold sea-bathing, is of great importance ; and where these cannot conveniently be had, a cold hip or shower-bath may be employed in their stead; and if there should still be the slightest issue of blood from the vagina, injections of cold water, or of a solution of alum, or sulphate of zinc, should be thrown up the passage two or three times a day : or an icicle or a snow ball be employed as a pessary. If the habit be peculiarly vigorous and robust, stimulants and softness of bed-clothes must be carefully avoided, and the downy couch be exchanged for a hard mattress. But if the constitution be delicate and emaciated, two or three glassy of wine may be al- lowed daily, and a course of angustura, columbo, or some other bitter tonic should be entered upon. In either case, however, it is absolutely necessary that sexual connexion should be abstained from for ten days or a fortnight. It has of late been very much the custom to confine women of a very delicate frame, and especially after they have once miscar- ried, to a recumbent position from the first symptom of conception through the whole term of gestation. In a few cases this may be a right and advantageous practice, but in the present day it is em- ployed far too indiscriminately. Among the causes of abortion we have just enumerated there are many it can never touch, as where the ovum itself is at fault, or there is a natural indisposition in the uterus to expand beyond a certain diameter. In this last case, if * Aaskow, Act, Soc, Med, Hafn, Tom, I, GE. 1.—SP. m.] SEXUAL FUNCTION. 127 we could be sure of it, a tepid hip-bath employed every evening about the time the abortion is expected would be a far more likely means of preventing it: for we should act here as in all other affec- tions where our object is to relax and take off tension, in which states we uniformly employ warmth and moisture, commonly, in- deed, a bread and water poultice. And hence, in the instance before us, one of the best applications we could have recourse to would be a broad swathe of flannel moistened with warm water and applied round the loins and lower belly every night on going to bed, surrounded externally with a dry swathe of folded linen. This should be worn through the whole night, and continued for a fort- night about the time we have reason to expect a periodical return of abortion from the cause now alluded to. I was lately requested to join in consultation with an obstetric physician upon the state of a young married lady of a highly ner- vous and irritable frame united with great energy and activity both of mind and body, who had hitherto miscarried about the third month of gestation, by braving all risks, taking walks of many miles at a stretch, or riding on horseback for half the day at a time. She was now once more in the family way, and had just commenced the discipline of only quitting her bed for the sofa to which she was carried, and on which she was ordered to repose with her head quite flat and in a line with her body, and without moving her arms otherwise than to feed herself: and to continue in this motionless state for the ensuing eight months. Without entering into the im- mediate cause of her former miscarriages, I ventured to express my doubts whether so sudden and extreme a change would not rather hurry on than prevent abortion, by accumulating such a degree of sensorial power as should produce an insupportable dys- phoria or restlessness, which would peculiarly vent itself on the organ of greatest irritation. But I recommended that all exertion of body and mind should be moderated, that the diet should be plain, the hours regular, that the position should be generally recumbent, and strictly so for a fortnight about the time in which abortion might be expected. It was overruled, however, to persevere in the plan already adopted from the moment, and every sedentary relief and amusement that could be devised was put in requisition to support the patient's spirits. She went on well for a week, but at the end of this period became irritable, fatigued, and dispirited; and miscarried at about six weeks from conception, instead of ad- vancing to three months as she had hitherto done. Even in the case of a delicate and relaxed frame, and of a mind that has no objection to confinement, it is well worth consideration whether the ordinary means of augmenting the general strength and elasticity by such tonics as are found best to agree with the system, and such exercises as may be taken without fatigue; par- ticularly any of those kinds of motion which the Greeks denominat- ed aeora, as swinging or sailing, riding in a palanquin, or in a car- riage with a sofa-bed or hammock, which, as we observed on a 128 GENETIC A. [CL. v.—OR. m. former occasion,* instead of exhausting, tranquillize and prove se- dative, retard the pulse, produce sleep, and calm the irregularities of every irritable organ,—may not be far more likely to carry the patient forward than a life of unchanging indolence, and undisturbed rest, which cannot fail to add to the general weakness, how much soever the posture it inculcates may favour the quiet of the uterus itself. We have thus far supposed that there is a mere danger of abor- tion, and that the symptoms are capable of being suppressed. But if the pains, instead of being local and irregular, should have be- come regular and contractile before medical assistance is sought for, or should have extended round the body, and been accompanied with strong expulsory efforts, and particularly if, in conjunction with those, there should have been a considerable degree of he- morrhage, our preventive plan will be in vain, a separation has un- questionably taken place, and to check the descent of the detached ovum would be useless if not mischievous. Even though the pains should have ceased we can give no encouragement, for such a ces- sation only affords a stronger proof that the effect is concluded. If the discharge continue but in small quaritity, it is best to let it take its course; to confine the patient to a bed lightly covered with clothing, and give her five and twenty or thirty drops of laudanum. Bleeding is often had recourse to with a view of effecting a revul- sion : it is uncalled for, however, and may do mischief by augment- ing the weakness. But the practitioner often arrives when the discharge is in great abundance and amounts to a flooding; and the patient is faint and sinking, and appears ready to expire. To the inexperienced these symptoms are truly alarming, and, in a few instances, sudden death appears to have ensued from the exhaustion that accompanies them. But these are very uncommon cases, for it rarely happens that the patient does not recover in an hour or two from the deliquium: and even the syncope itself is one of the most effectual means of putting a check to the discharge by the sudden interruption it gives to all vascular action. Cold, both external and internal, is here of the utmost importance; the bed-curtains should be undrawn, the windows thrown open, and a sheet alone flung over the patient; while linen wrung out in cold water, or ice-water should be applied to the lower parts of the body and renewed as its temperature becomes warm : holding the appli- cation, however, as soon as the hemorrhage ceases. Injections should, in this case, be desisted from; for the formation of clots of blood around the bleeding vessels should be encouraged as much as possible, instead of being washed away. And for this reason it is now a common practice to plug the vagina as tight as possible with sponge or folds of linen, or what is better, a silk. * Marasmus Phthijis, Vol. II. p. 519. GE. I.—SP. in.] SEXUAL FUNCTION. 129 handkerchief, smeared over with oil that they may be introduced the more easily, and afterwards to confine the plug with a T ban- dage. This plan has been long recommended by Dr Hamilton, and has been extensively followed with considerable success. Here, also, Dr. Hamilton prescribes large doses of opium as an auxiliary, beginning with five grains, and continuing it in doses of three grains every three hours, till the hemorrhage has entirely ceased. Opium, however, is given with most advantage where the flooding takes place after the expulsion of the ovum ; for if this have not occurred its advantage may be questioned, since it has a direct ten- dency to interrupt that muscular contraction without which the ovum cannot be expelled. And it should be farther observed that where opium is had recourse to in such large doses as are above produced, it must not be dropped suddenly, for the most mischiev- ous consequences would ensue ; but must be continued in doses gra- dually diminishing till it can at length be omitted with prudence. If the flooding occur after the sixth or seventh month, and the debility be extreme, the hand should be introduced into the uterus as soon as its mouth is sufficiently dilated, and the child turned and brought away. And if, before this time, a considerable degree of irritation be kept up in the womb from a retention of the fetus or any considerable part of the ovum after its separation, one or two fingers should also be introduced for the purpose of hooking hold of what remains, and bring it away at once. Such a retention is often exceedingly distressing, the dead parts continuing to drop away in membranous or filmy patches for several weeks intermix- ed with a bloody and offensive mucus. And not unfrequently some danger of a typhus fever is incurred from the corrupt state of the unexpelled mass. In this case, the strength must be supported with a nutritious diet, a liberal allowance of wine, and the use of the warm bitters, with mineral acids. It is also of great importance that the uterus itself be well and frequently washed with stimulant and antiseptic injections, as a solution of alum or sulphate of zinc, a decoction of cinchona or pomegranate bark, a solution of myrrh or benzoin, or, what is better than any of them, negus made with rough port wine. The injection must not be wasted in the vagina, but pass directly into the uterus ; and, on this account, the syringe must be armed with a pipe made for the purpose and of sufficient length. The application of cold then, plugging the vagina, opium, and perfect quiet, and, where the pulse is full, venesection, are the chief remedies to be employed in abortions, or threatenings of abortion, accompanied with profuse hemorrhage; and where these do not succeed, and especially after the sixth month, immediate de- livery should be resorted to. The process, however, of applying cold should not be continued longer than the hemorrhage demands ; for cold itself, when in extreme, is one of the most powerful sources of sensorial exhaustion we are acquainted with. And hence, where the system is constitutionally weak, and particularly where vol. iv.—17 130 GENETICA. [CL. V.—OR. Ill it has been weakened by recurrence of the same discharge it may be a question well worth weighing whether any thing below a moderately cool temperature be allowable even on the first attack ? as also whether the application of warm clothes to the stomach and extremities might not be of more advantage ? for unless the extre- mities of the ruptured vessels possess some degree of power they cannot possibly contract, and the flow of blood must continue. And 'it is in these cases that benefit has sometimes been found by a still wider departure from the ordinary rules of practice, and the allow- ance of a little cold negus. So that the utmost degree of judgment is necessary on this occasion, not only how far to carry the estab- lished plan, but on peculiar emergences how far to deviate from, and even oppose it. We have said that the hemorrhage which takes place in abor- tions, however profuse, is rarely accompanied with serious effects. This, however, must be limited to the first time of their taking place : for if they recur frequently in the course of a single gesta- tion, or form a habit of recurrence in subsequent pregnancies, the blood, from such frequent discharges, loses its proper crasis ; the strength of the constitution is broken down ; the sensorial fluid is secreted in less abundance, perhaps in less energy ; and all the func- tions of the system are of consequence performed with a consider- able degree of languor. The increasing sensorial weakness pro- duces increasing irritability : and hence slighter external impres- sions occasion severer mischief and the patient becomes subject to frequent fits of hysteria, and other spasmodic affections. Nor is this all: for the stomach cannot digest its food, the intestines are sluggish, the bile is irregularly secreted, the heart acts feebly ; and the whole of this miserable train of symptoms is apt to terminate in dropsy. GENUS II. PARODYNIA. JHorotu- SLaoour. THE PROGRESS OF LABOUR DISTURBED OR ENDANGERED BY IRRE- GULARITY OF SYMPTOMS, PRESENTATION OR STRUCTURE. The generic term is a Greek compound from *•«£«, male, and uh» or uhs, ives, " dolor paturientis." All the different species of vivi- parous animals have a term of uterogestation peculiar to them- selves, and to which they adhere with a wounderful precision. Among women we have already said that this term is forty weeks, being nine calendar or ten lunar months. Occasionally the expulso- GE. II.] SEXUAL FUNCTION. 131 ry process commences a little within this period, and occasionally extends a little beyond it: but, upon the whole, it is so true to this exact time as clearly to show it to be under the influence of some particular agency, though the nature of such agency has never been satisfactorily pointed out. Sometimes the weight of the child has been supposed to force it downwards at this precise period, and sometimes the uterus has been supposed to contract, from its ina- bility of expanding any farther, and hence from an irritable excite- ment produced by the pressure of the growing fetus. By other phy- siologists it has been prescribed in the increasingactivity of the child, and the uneasiness occasioned by its movements. But it is a suffi- cient answer to all these hopotheses to remark that a like punctua- lity is observed whether the child be small or large, alive or dead ; unless, indeed, the death took place at a premature period of the pregnancy : for " No fact," says Dr. Denman, " is more incontes- tably proved than that a dead child, even though it may have be- come putrid, is commonly born after a labour as regular and natural in every part of the process as a living one :"* and hence we can only resolve it into the ordinary law of instinct or of nature, like that which regulates the term of menstruation, or assert still more intelligibly with Avicenna that, " at the appointed time labour comes on by the command of God." In natural labour, which consists in a gradual enlargement of the mouth of the womb, and the diameter of the vagina, so as to suffer the child to pass away when urged from above by a repetition of expulsatory contractions of the uterus and all the surrounding mus- cles, there is little or no danger, however painful or distressing to the mother. These contractions, or labour-pains, continue with a greater or less irregularity of interval and recurrence from two hours to twelve, the process rarely terminating sooner than the former period, or later than the latter: the ordinary term being about six hours. But unhappily labours do not always proceed in a natural course ; for sometimes there is a feebleness or irregularity in the muscular action that greatly retards their progress ; or a derangement of some remote organ that sympathizes with the actual state of the uterus, and produces the same effect; or the mouth of the uterus itself is peculiarly rigid and unyielding: or the natural presentation of the child's head may be exchanged for some other position ; or the ma- ternal pelvis may be misshappen, and not afford convenient room for the descent of the child ; or there may be a plurality of children ; or even after the birth of the child the placenta may not follow with its ordinary regularity, or an alarming hemorrhage may supersede : each of which conditions becomes a distinct species of disease in the progress of morbid labour, and the whole of which may be ar- ranged as follow: * Pract. of Midwifery, 8yo. Edit 5. p. 255. 132 GENETICA. [CL. V.—OR. Ill 1. PARODYNIA ATONICA. ATONIC LABOUR. 2. ----------■ IMPLASTICA. UNPLIANT LABOUR. 3.----------SYMPATHETICA. COMPLICATED LABOUR. 4. ______ PERVERSA. PRETERNATURAL PRESENTATION. CROSS-BIRTH. 5.----------AMORPHICA. IMPRACTICABLE LABOUR. 6. ---------- PLURALIS. MULTIPLICATE LABOUR. 7. ---------- SECUNDARIA. SEQUENTIAL LABOUR. SPECIES I. PARODYNIA ATONICA. atonic aaoour. LABOUR PROTRACTED BY GENERAL OR LOCAL DEBILITY, OR HEBETUDE OF ACTION. It often happens in various affections of the system that a general law is incapable of being carried into effect with promptness and punctuality from weakness or indolence of the organs that are chiefly concerned in its execution. Thus, when vaccine or variolous fluid is properly inserted under the cuticle, it remains there in many cases for several days beyond its proper period, in a dormant state from inirritability or indolence in the cutaneous absorbents : and, in the case of small pox, even where the fluid has been receiv- ed into the system, whether naturally or by inoculation, and has excited febrile action, this action is, in many instances, very consi- derably augmented froma like indolence or'inirritability of the secer- nents of the skin which do not throw off the morbid matter suffi- ciently on the surface. A like want of harmonious action very frequently occurs in parturition. The full time has expired—the uterus feels uneasy, and the uneasiness is communicated to the adjoining organs, and there are occasional pains in the back or in the lower belly, but either from a weakness, or hebetude, or both, in the uterus itself, or in the muscles that are to co-operate with it in expelling the child, the pains are not effective and the labour makes little pro- gress. It often happens, also, in debilitated habits that while in some part of its progress the labour advances kindly and even rapidly, the little strength the patient possesses is worn out, and her pains suddenly cease ; or, what is worse, still continue, but without their expulsory or effective power, and, consequently, do nothing more than tease her, and add to the weakness. This exhaustion will GE. II.—SP. I.] SEXUAL FUNCTION. 133 sometimes occur soon after the commencement of the labour, or in its first stage, before the os uteri has dilated and while the water is slowly accumulating over it; but in this stage it is more likely to occur if the membranes should have prematurely given way, and the water have been already evacuated. Yet it occurs also, occa- sionally, towards the close even of the last stage, and when the head of the child has completely cleared itself of the uterus, and is so broadly resting on the perineum that a single effective pain or two would be sufficient to send it without any assistance into the world. In the greater number of these cases, to wait with a quiet com- mand of mind, and soothe the patient's desponding spirits by a thousand little insinuating attentions, and a confident assurance that she will do well at last, is the best if not the only duty to be per- formed. A stimulant injection, however, of dissolved soap or mu- riate of soda will often re-excite the contractions where they flag- or change the nature of the pains where they are ineffective. Aftlr this it is often useful to give thirty or five and thirty drops of laudanum, and to let the patient remain perfectly quiet. It is not certain in what way the laudanum may act, for it sometimes proves a local stimulant, and sometimes a general sedative, but in either way it will be serviceable and nearly equally so; for it will either shorten the labour by re-exciting and invigorating the pains, or increase the general strength by producing sleep and quiet If the pulse should be quick and feeble with languor and a sense ot taintness at the stomach, a little mulled wine or some other cordial may be allowed. If the mouth of the womb be lax and dilatable, and the water have accumulated largely and protrude upon it as in a bag, advantage is often gained by breaking the membranes and evacuating the fluid, for a new action is hereby given to the uterus, and while it contracts with more force it meets with less resistance, and its mouth is more rapidly expanded But unless the labour should have advanced to this stage, the membranes should never be interfered with; for their plasticity, and the gradual increase and pressure of their protruding sac against the edges of the os uteri, form the easiest and surest means of enlarging it, whilst the retention of the fluid in this early stage of parturition lubricates the inner surface of the womb, and tends to keep off heat and irritation. For the same reason, if the mouth of the womb be narrow and have hitherto scarcely given way, the application of the finger can be of no advantage. Every attempt to dilate it must be in vain, and only produce irritation, and an increased thickening in its edges: but if it have opened to a diameter of two inches, and be at the" same time soft and expansile, advantage should be taken of the pains to dilate it by the introduction of one or two fingers still fur- ther, which should only, however, co-operate with the pains, and be employed while they are acting; and by these conjoint means the 134 GENETIC A. [CL. V.—OR. ni. head of the child sometimes passes rapidly and completely out of the uterus into the vagina, or outer mouth as it is called on these occasions. We have said that it is sometimes apt to lodge here in conse- sequence of the patient's exhaustion, and an utter cessation of all pains, or of all that are of any avail. She should again therefore be suffered to rest, and, if faint, be again recruited with some cor- dial support. Generally speaking, time alone is here wanting, and the practitioner must consent to wait: and it will be better for him to retire from his patient and to wait at a little distance. But if several hours should pass away without any return of expulsory efforts, if there should be frequent or continual pains without any benefit, if the patient's strength should sink, her pulse become weak and frequent, if the mind should show unsteadiness, and there be a^, tendency to syncope, and if, at the same time, the head be lying clear on the perineum, the vectis or forceps should be had recourse to, and the woman be delivered by artificial means. This situation forms a general warrant: but for the peculiar circumstances in which such or any other instruments should be employed, the manner of employing them and the nature of the instruments them- selves, the reader must consult such books as are expressly written upon the subject, and should sedulously attend the lectures and the introductory practice which are so usefully offered to him in this metropolis. SPECIES II. PARODYNIA IMPLASTICA. ElnjjUaiu aafcour. LABOUR DELAYED OR INJURED FROM IMPLASTICITY OR UNKINDLY DILA. TATION OF THE SOFT PARTS. The tediousness and difficulty of the preceding species of labour proceed chiefly from atony or hebetude of the system generally, or of the instrumental organs particularly. But it often happens that the parts dilate and the labour proceeds as slowly from an implas- ticity, or rigid resistance to the expansion and expulsory efforts which should take place, according to the law of nature, at the fulness of time which we are now supposing to be accomplished, and which is sometimes productive of other evils than that of pro- tracted suffering, offering us indeed the four following varieties :— 6E.II.—SP.H.] SEXUAL FUNCTION. 135 « Rigiditatis. The delay confined to a simple rigidity of the uterus or outer mouth. Q Prolapsa. Accompanied with prolapse. y Hemorrhagica. Accompanied with hemorrhage. & Lacerans. Accompanied with laceration of the uterus or perinaeum. Rigidity of the uterus may extend to the entire organ, or be limited to the cervix, or os uteri as it is called after the cervix has lost its natural form, and partakes of the sphaeroidal shape of the fundus. Where the former occurs the practitioner meets with severe pains in the loins, shooting round to the lower belly and producing great contractile efforts of the muscles surrounding the uterus, so as to throw the patient from the violence of her exertions into a profuse perspiration, and induce the attendants to believe that the labour is advancing with great speed, while the practitioner himself finds, on examination, that there is no progress whatever; that the uterus itself does not unite in the expulsory force, the fluid of the amnios does not accumulate over the os uteri, nor the head of the child bear down upon it. f In other cases, he finds that the general organ of the uterus does participate in the common action, and force the head of the child downward, but that the mouth of the womb does not dilate or become thinner in consequence hereof; appearing on the contrary, in some cases, from a peculiar tenderness and irritation, to grow thicker and tenser, and more intractable. And he not unfrequently finds even where both the body and mouth of the womb are sufficiently pliable and co-operative with the common intention, and the head of the child has become easily cleared of this organ, that a like rigidity and implasticity exist in the os externum, and that the child having readily worked its way thus far, is fast locked from this circumstance, and cannot get any further.* In all cases of this kind the same means of relaxation should be resorted to as in an irritable or inflammatory tenseness and rigidity of other organs. Blood should be freely abstracted, active purga- tives be given by the mouth, and copious emollient injections be administered without much aperient virtue, so that they may for some time remain in the rectum and act as a fomentation. And here also it may be advantageous to apply round the loin$ and lower belly, a broad swathe of flannel wrung out in hot water, and to encircle it with an equally broad band of folded linen, in the manner already recommended in paramenia difficilis. In several cases of rigidity, if no njeans be adopted to subdue the tension, the protrusive force of the surrounding muscles is some- times so considerable that, as it cannot expel the child by itself, it goes far to expel the child and the uterus conjointly, the latter being thrust downward into the outward passage and its mouth pro- jecting out of the vulva, thus constituting a parturient prolapse. 136 GENETICA. [CL: V.—OR. IIL While the uterus is thus forcibly descending, the attendant should support it, or the head of the child, with two fingers: if the pro- lapse be complete, the uterus should be returned into its proper place as quickly as possible ; and if this cannot be done, the child must be turned, and delivery take place as speedily as may be. In the violence of this struggle, it sometimes happens moreover, and particularly where the water has escaped, that some of the vessels give way, or the placenta is partly detached, and there is the additional evil of a profuse hemorrhage to contend with. If this occur in the commencement of labour, venesection should generally be had recourse to, the patient be kept cool and quiet, and take thirty drops of laudanum. If the labour have advanced and is advancing rapidly, and the hemorrhage not be very consider- able, we may safely trust to nature to complete the process before any serious mischief ensues. But if the patient be debilitated, or much exhausted, or the labour advance slowly, the woman should be delivered by turning the child, or having recourse to the forceps according to the progress of the labour, and the position of the child at the time. But there is a far worse evil than any of these, which results from the implasticity we are now considering: and that is a rupture or laceration either of the vagina or of the uterus. The causes of laceration are said to be numerous, and it often occurs suddenly and without any known cause : but if we examine into their general nature, we shall find that except in the case of brutal force or want of skill, they are almost always dependent on a certain degree of implasticity in the part of the lacerated organ which prevents it from yielding with -the uniformity of the other parts, or, from a peculiar degree of irritability that renders it more liable to irregular action or spasm: though there can be no question that in a very few instances the laceration has commenced from a cut produced by an occasional sharpness of the edge of the, ilium. " Those women," observes Mr. Burns, " are most liable to.rupture of the uterus who are very irritable, and subject to cramp ; or who have the pelvis contracted, or its brim very sharp, or who have the os uteri very rigid, or any part of the womb indurated. Schulzius relates a case where it was produced by scirrhus of the fundus; and Friedius one where it was owing to a carneo-cartilaginous state of the os uteri."* Laceration of the fundus of the womb may take place during any part of the labour when the pains are violent, and the walls of the organ do not act in unison in every part; but the mischief more commonly commences in the cervix, when the head, or the shoul- ders, or any other part, is passing through, and the whole of its cir- cumference does not yield equally. Where the accident occurs in the vagina or perinseum, it must necessarily take place after the head has^descended from the womb, and is pressing upon the • Principles of Midwifery, 8vo. 3d. edit. p. 361. GE. Il.—SP. II.] SEXUAL FUNCTION. 137 substance of these organs that, like the lacerating os uteri, does not yield equally in every point. In most cases of an implastic rigidity, whether in the body of the uterus itself, or in its cervix, or in the os externum, there is a con- siderable degree of local irritation, and, in very many of them, of firm and vigorous action. The parts are not only rigid, but dry, and hot, and tender, and the pulse is generally full, with restlessness, and a heated skin. And hence venesection is imperatively called for from an early period of the labour; and there are few cases in which the uterus has not acted afterwards with more freedom, and its mouth been rendered laxer, softer, and more compilable. In all such cases also an emollient injection several times repeated, will considerably co-operate in taking off the tension, and increasing the expansibility. Here opium should be avoided, but general relax- ants as antimony and ipecacuan, given in the neutral effervescing draught, may add to the general benefit. The operator must be abstinent till the parts have yielded and the tension and irritation subsided, for before this, every application of the fingers will only increase the morbid tendency. The only case in which the use of opium is here to be justified, is where, from the violence of the contractile pains, a considerable and an alarming hemorrhage has ensued, and the state of the os uteri will not allow of the introduction of the hand for the purpose of turning and delivering immediately. In this instance, after ve- nesection and a due administration of emollient and aperient injec- tions, our last dependence must be upon a powerful opiate for the purpose of allaying the irritation and taking off the pains. And if the force of the expulsory power thrust down the uterus so as to give danger of producing a prolapse, the practitioner must support the organ during the recurrence of the pains, by introducing two fingers into the vagina for this purpose, and the patient must be kept in a recumbent position without moving from it; and must be instructed to avoid as much as possible every expulsory or bearing- down exertion, while the pain is upon her. If the uterus have actually protruded into the vagina, a reduction must be instantly attempted; and if this cannot be done, no time should be lost in passing the hand through the cervix, as soon as, without force, it can be sufficiently dilated for this purpose, and delivering the child by turning. Laceration generally takes place suddenly, though, in irritable habits, cramps or other spasmodic affections are often previously complained of in different parts of the body. Mr. Burns has well described the symptoms that succeed: " When this accident does happen the woman feels something give way within her, and usually suffers at that time an increase of pain. The presentation disappears more or less speedily, unless the head have fully entered the pelvis, or the uterus contract spasmodically on part of the child, as happen- vol. iv.—18 138 GENETICA. L^L. V.—OR. ed in Bechling's patient.* The pains go off as soon as the child passes through the rent into the abdomen : or if the presentation be fixed in the pelvis, they become irregular and gradually decline. The passage of the child into the abdominal cavity is attended with a sensation of strong motion of the belly, and is sometimes produc- tive of convulsions."f It is not necessary to make a distinction between the parts in which the laceration takes place: for whether it be in the fundus or cervix of the womb, or in the vagina, except where, as just ob- served, the position is fixed in the pelvis, the part presented in- stantly disappears, and the child slips imperceptibly through the chasm into the hollow of the abdomen, sometimes with a hemor- rhage that threatens life instantly, but sometimes with little or even no hemorrhage whatever. This accident will not unfrequently occur towards the close of a labour that promises fair. It is not many years ago, when the pre- sent author, at that time engaged in this branch of the prolcssion, was requested with all speed to attend, in consultation, upon a lady in Wigmore Street, who was then under the hands of a practitioner of considerable skill and eminence. She had for about eight hours been in labour of her first child, herself about thirty-eight years of age, had had natural pains, and been cheered throughout with the prospect of doing well, and even more rapidly than usual under the circumstances of the case. In fact the head had completely cleared the os uteri and was resting on the perinaeum, and the obstetric practitioner was flattering himself that in a quarter of an hour at the farthest, he should be released from his confinement, when he was surprised by a sudden retreat of the child during a pain which he expected would have afforded her great relief, accompanied with an alarming flooding: and it was in this emergency the author of this work was requested to attend. On examination, it was ascer- tained that a large laceration had taken place in the uterus com- mencing at the cervix and apparently on the passing of the shoulders, but why any part of it should have torn at this time rather than antecedently there were no means of determining. It is usual, under these circumstances, to follow up the child with the hand through the rupture into the abdomen, and to endeavour to lay hold of the feet, and withdraw it by turning. The hemorrhage had alarmed the practitioner, and this had not been attempted ; and at the time of the author's arrival, which was about an hour and a half after- wards, the attempt was too late, for the pulse was rapidly sinking, the breathing interrupted, and the countenance ghastly, yet the patient had not totally lost her self-possession, and being informed of her situation, begged earnestly to be let alone, and to be suffered to die in quiet. Where there is little or no hemorrhage, the life usually conti- • Haller, Disput. Tom. III. p. 477. t Burns, ut supra, p. 362. GE. II.—SP. II.] SEXUAL FUNCTION. 139 nues much longer whether the child be extracted or not; mostly about twenty-four hours; though in some cases considerably longer still. Dr. Garthshore attended a patient who lived till the twenty- sixth day, and the Copenhagen Transactions* contain the case of a woman, who after being delivered, lingered for three months: and a few marvellous histories are given in the public collections, of a natural healing of the uterus while the child continued as a foreign and extra-fetal substance in the cavity of the abdomen for many years. Haller has reported a case in which it continued in this state for nine years ;t and others relate examples of its remaining for sixteen,| and even twenty-six years,§ or through the entire term of the mother's natural life. The only rational hope of saving both the mother and the child is by following up the latter through the rupture, and delivering it by the feet: but where this cannot be done from the smallness of the dilatation of the os uteri, or from a violent contraction of the uterus between the os uteri and the rent, we have nothing to pro- pose but to leave the event to nature, or to extract the child by the Cesarian operation. We have just seen that in a few rare instances the vis Medicatrix Naturae* or instinctive tendency to health has succeeded in healing the wound and restoring the patient with the fetus still inhabiting the belly. But this result is so little to be ex- pected that an incision into the cavity of the abdomen has not un- frequently been tried, and in some instances unquestionably with success.|| SPECIES III. PARODYNIA SYMPATHETICA. (EomjrttcateTr Hatour. labour retarded or harassed by sympathetic derangement of some remote organ or function. We have often had occasion to observe that, with the exception of the stomach, there is no organ that holds such numerous ramifica- tions of sympathy with other organs as the womb : and we hence • Tom. II. p. 326. \ Mem. de Paris. 1773. \ Eph. Nat. Cur. Dec. I. Ann. VIII. Obs. 12. % Id. Dec. II. Ann. VIII. Obs. 134. H Progres de la Medicine, 1698. 12mo. Abhandlung der K nigl. Schwed. Acad. 1744. Hist, de l'Acad. Hovale des Sciences, 1714. p. 29. 1716, p. 32. 140 GENETIC A. (CL. V.-OR. Ill find the progress of parturition disturbed, and what would other- wise be a natural, converted into a morbid labour by the interfer- ence of various other parts of the body or the faculties which ap- pertain to them. The whole family of varieties which issue from this source are extremely numerous: but the three following are the chief: x Pathematica. Acompanied with terror or other mental emotion. f Syncopalis. Accompanied with fainting. y Convulsiva. Accompanied with convulsions. In the pathematic variety, the joint emotions which are usually operative upon a patient's mind, and especially on the first labour, are bashfulness on the presence of her medical attendant, and ap- prehension for her own safety. There is not a practitioner in the world but must have had numerous instances of a total suspension of pains on his first making his appearance in the chamber. And in some cases the pains have been completely driven away for four and twenty hours, or even a longer term. There is nothing extraordinary in this, for two powerful morbid actions are seldom found to proceed in the animal frame simulta- neously ; and hence pregnancy is well known to put by phthisis, and the severest pain of a decayed tooth to yield to the dread of having it extracted, while the patient is on his way to the operator's house. It is hence of great importance that the bespoken attendant should familiarise himself to his patient before his assistance is re- quired, and endeavour to obtain her entire confidence: and it is better, when he is first ushered into her presence, in his professional capacity, that he should say little upon the subject of his visit, direct the conversation to some other topic of general interest, and then withdraw till he is wanted. And if the idea alone of his ap- proach be peculiarly harassing, it is best for him to be in a remote part of the house in readiness, and not to see his patient, till her pains have taken so strong a hold as to be beyond the control of the fancy. If her apprehensions, however, be very active, and if there be any particular ground for them it is most reasonable to enter can- didly on the question, and to afford her all the consolation that can be administered. Syncope in labour proceeds commonly from a peculiar partici- pation of the stomach in the irritation of the womb, and is hence often connected with a sense of nausea, or with vomiting. Occa- sionally it occurs also from the exhaustion produced by the violence of the pains; and particularly in relaxed and debilitated habits, in which case the fainting fits sometimes follow up each other in very rapid succession, and require very close attention on the part of the practitioner and the patient's friends. The usual remedies should here be had recourse to in the first GE. II.—SP. Ill] SEXUAL FUNCTION. 141 instance: pungent volatiles should be applied to the nostrils, the patient be in a recumbent position, with the curtains undrawn, and, unless the season of year prohibit, with the windows open ; the face, and especially the forehead and temples, should be sprinkled with cold water or ether ; and the usual volatile fetids, aromatics, and terebinthinates, as camphor, should be given by the mouth: and to these, if necessary, and particularly where the pulse is feeble and fluttering, should be added a glass or two of Madeira, or any other cordial wine, with twenty drops of laudanum. If this plan should not answer, and especially if the fainting fits should increase in duration and approximation to each other, the patient niust be delivered by the process of turning as soon as ever the os uteri is sufficiently dilated to let the hand pass without force. One of the worst and most alarming of the associated symptoms in labour, is that of convulsions, and these are often connected with fainting-fits and alternate with each other. We have already glanced at them generally under syspasia convulsio,* but must dwell a little more at large upon the present modification. Convulsions may occuf during any period of gestation, but we are now to consider therri as an accompaniment of labour and as interrupting its progress. Their proximate cause is a peculiar ir- ritation of the nervous system as participating in the irritation of the womb : and hence it is obvious that the radical and specific cure is a termination of the labour. We cannot always trace the link of this peculiar influence of the womb upon the nervous system: though, where there is a predis- position to clonic spasm of any kind, we can readily account for its excitement, and may be under less apprehension than where it occurs without any such tendency. The occasional causes of faint- ing are the occasional causes of convulsions; and hence they are apt to follow, and particularly in delicate or debilitated constitu- tions, on the fatigue and exhaustion of violent and protracted pains, great depression of the animal spirits, and profuse hemorrhage. Sometimes, however, they occur where none of these are present, and where the patient is of a strong plethoric habit of body, and especially if it be her first time of pregnancy: and are accompanied with, or even preceded by a sense of dizziness and oppression in the head, ringing in the ears, or imperfect vision: the plethora it- self thus forming the occasional cause. The attendant symptoms are peculiarly violent, sometimes re- sembling those of hysteria, sometimes those of epilepsy, but more vehement thanin either of these. Nothing can restrain the spastic force of a woman when in parturient convulsions, whatever be her natural weakness. The distortion of the countenance is more hide- ous than the most extravagant imagination can conceive: and the rapidity with which the eyes open and shut, the sudden twirlings of the mouth, the foam that collects about the lips, the peculiar * Vol. III. p. 346. 142 GENETICA. [CL. V.—OR. in hiss that issues from them, the stertor, the insensibility, and the jactitating struggle of the limbs, form a picture of agony that can- not be beheld without horror. The exciting cause is the irritable state of the womb ; and, what- ever be the predisponent or occasional cause, whether a debilitated and mobile condition of the nervous system, or a robust and entonic fulness of the blood-vessels, it is obvious that such violence of action cannot take place under any circumstances without endangering a rupture of the vessels in the head, and consequently all the mis- chiefs of apoplexy. It is against this, indeed, that all practitioners, how much soever they may disagree upon other points, most cor- dially endeavour to guard, though it rarely happens that effusion in the brain, and some of its results, do not take place in spite of all their exertions. The first step is to open a vein and bleed copiously, from a large orifice, till the patient faints: and if the operator be expert, the best vein to make choice of is the jugular : the hair should be im- mediately removed from the head, and lotions of cold water, pound- ed ice, or the freezing mixture, produced by dissolving three or four different sorts of neutral salts in water at the same time, be applied all over it by wetted napkins changed for others as soon as they acquire the least degree of warmth. At the same time a pur- gative injection should be thrown up the rectum, and five or six, grains of calomel be given by the mouth with a draught of sulphate of magnesia in infusion of senna. The paroxysms must, if possi- ble, be put a stop to, the fatal effects they threaten must be antici- pated, and not a moment is to be lost. This is the general plan ; and it is to be pursued under all cir- cumstances, though its extent, and particularly in regard to blood- letting, must be regulated by the strength and energy of the patient. The local mode of treatment seems to be somewhat less decided. It may happen that at the attack of the fits, theos uteri is merely beginning to open, or that it is of the diameter of a crown piece, but peculiarly rigid and undilatable. There are practitioners who, in this case, confine themselves to the depleting plan, and only wait for the advance of the labour : but, in the state of the uterus we are now contemplating, they may have to wait for some hours be- fore the labour is so far advanced as to render them capable of affording any manual assistance whatever, while the fits are, per- haps, recurring every quarter of an hour, and threatening fatal mischief to the brain. And in this case I cannot but warmly ap- prove of the bolder, or rather the more judicious advice of Dr. Bland, who, after a due degree of depiction, recommends a full dose of opium, for the purpose of allaying the nervous irritation ge- nerally, and particularly that of the uterus, which is the punctum saliens of the whole. A few hours rest may set all to rights, if no vessel have thus far given way in the head : for when the next tide of pains returns, it will commence under very different circumstan- ces in consequence of the reducent course of medicine that has been GE. I[.—SP. III.] SEXUAL FUNCTION. 143 pursued : and it will rarely be found that the whole body of the uterus is not rendered more lax and plastic, and consequently its cervix, and even the os externum, more yielding and dilatable. But this is not the common course which the uterus takes under these circumstances ; for, in by far the greater number of cases, the whole of this organ, the cervix as well as the fundus, is so exhaust- ed in the general contest, as to be more than ordinarily relaxed and flaccid, and dilatable with considerable ease : insomuch that if the muscular power of the system were now concentrated in a com- mon expulsory effort, as in natural labours, the whole process would terminate in a few minutes. But unfortunately this muscular exer- tion, instead of being concentrated, is distracted and erratic, and wandering over all the muscles and organs of the system, produc- ing general mischief instead of local benefit: so that whatever pains there may be they are of far less use than in a state of harmonious action. This may be easily ascertained by introducing the hand on a return of the paroxysm, when the uterus will be found to con- tract, indeed, but with a tremulous undetermined sort of force, per- fectly different from what it does at any other time. The necessary practice in this case should seem to be obvious and without doubt: the medical attendant seems imperatively called upon to introduce his hand into the os uteri, as soon as it is suffi- ciently open for him to do so without force, to break the membranes if not broken already, lay hold of the child's feet, deliver by turn- ing, and thus put an end to the convulsions at once, and, conse- quently to the fatal effects which seemed to await the mother as well as the child. Such was the practice recommended by Mauriceau, upwards of a century since : La convulsion, says he, fait souvent perir la mere etl'enfant, si la femmen'est pas promptement secourue par I'accouche- ment, qui est le meilleur remede, qu'on puisse apporter & l'une et a I'autre.* This recommendation was adopted ^generally, and in our own country successively by Smellie, W. Hunter, and Lowder. And although, in circumstances of so much danger, it was not and could not be always successful, yet it was supposed, and with rea- son, to be the means of saving the life as well of the mother as of the child, in very numerous instances in which that of one or of both would otherwise have unquestionably perished. Some forty years after the publications of M. Mauriceau's work, Professor Roederer of Goettingen called this practice in question, and recommended that the patient be left to the natural course of the labour :f and we are told by Dr. Denman that in our own country Dr. Ross, toward the close of last century, " was the first person of late years, who had courage to declare his doubt of the propriety of speedy delivery in all cases of puerperal convulsions. The observation," continues Dr. Denman, " on which these doubts were founded, was merely practi- • Traite des Maladies des Femmes grosses. Tom. I. 23. 4to. Paris, 1721. t Elements Artis Obstetric*. Aph. 679. Goet. 1769. 8vo. 144 GENETICA. [CL. V.—OR. III. cal, and the event of very many cases has since confirmed the jus- tice of his observation, both with respect to mothers and children."* The sweeping extent of this censure seems to show that the prac- tice has often been had recourse to indiscriminately, and without a correct limitation. And the apparent concurrence of Dr. Denman in Dr. Ross's opinion, together with the undecided manner in which he treats of the question in his subsequent pages, has raised up amongst the most celebrated obstetric physicians of our own day various advocates for leaving in general to nature the case of la- bour accompanied with convulsions, or at least till the natural efforts of the mother are found completely to fail; and in this last case, as the child's head may be supposed to have cleared the uterus, to have recourse to the perforator or the forceps, according to the na- ture of the position. The chief grounds for this proposed delay, as far as I have been able to collect them, are, that the introduction of the hand into the os internum, in the irritable state of the organ we are now contem- plating, is more calculated to renew the convulsions than to put an end to them : that a repetition of them after due depletion has been employed is not so dangerous as is generally apprehended, and consequently that immediate delivery is by no means essential to the patient's safety : and lastly, that we are not sure of putting an end to the convulsions, even after delivery is effected ; since it is well known that they have occasionally continued, and sometimes have not commenced till the process of labour has been long com- pleted. In reply to this, it may be observed, that if a repetition of the convulsive fits be not so dangerous as is commonly apprehended, a practitioner should feel less reluctance in introducing the hand even though he were sure of exciting a single fit by so doing : and the more so as this single fit might perhaps be the means of terminating the whole, and, consequently, would be a risk bought at a cheap rate. At the same time it should be observed that general experience does not seem to justify the remark that a cautious and scientific use of the hand, where the mouth of the womb is sufficiently dilated, be- comes a necessary or even a frequent excitement of fresh parox- ysms; and the prediction of such an effect is therefore without suf- ficient foundation. And if there be a considerable chance, as seems to be admitted, that instrumental assistance will be requisite at last, and that the forceps, or what, in the probability of the child's being still alive is ten times worse, the perforator must be called into ac- tion, how much more humane is it, as well as scientific, to employ instrumental aid at first, and thus save the pain and the peril of per- haps many hours of suffering—and particularly when the soft, and supple, and plastic instrument of the hand, may supersede the use of the ruder, and rougher, and less manageable tools of art. But the most important part of the question is as to the actual de- * Practise of Midwifery, p. 586. 8vo.3d. edit. 1816. GE. II.—SP. III.] SEXUAL FUNCTION. 145 gree of danger which is induced by convulsions; and to determine: this, nothing more seems necessary than to put the whole upon the footing of an impending apoplexy. It is possible that no effusion in the brain may have taken place at the time when the depleting plan has been carried into execution, but if the paroxysms should still re- cur, surely few men can look at the violence of the struggle which tbey induce, at the bloated and distended state of the vessels of the face and of the temples, at the force with which the current of blood is determined to the head, at the stertor and comatose state of the patient during the continuance of the fit, without feeling the greatest alarm at every return. And that he does not feel in vain is clear, because in various instances the insensibility continues after the paroxysm is over, accompanies her through the remain- der of her labour, and is the harbinger of her death. Regarding puerperal convulsions then as a case of impending apoplexy produced by an exciting cause which it is often in our power to remove, it should seem to follow as a necessary and in- contestible result, that in this, as in every other case in which the same disease is threatened, our first and unwearied attempt should be to remove such cause as far as it may be in our power, and whenever it is so. It is not long since that the present author's opinion was request- ed upon a case of this very kind; but it was by the connexions of the patient who had already fallen a victim to her sufferings. She had been attacked with natural labour-pains and was attended by a female, who, alarmed by the sudden incursion of a convulsion-fit, sent immediately for male assistance. The practitioner arrived, and a consultation was soon held with several others : the os uteri is admitted to have been at this time open to the size of a crown- piece, soft, lubricous, and dilatable. The depleting and refrigerant plan was, however, confided in alone, and the labour was suffer- ed to take its course. Expulsory pains followed at intervals, but the convulsions followed also, and became more frequent and more aggravated: in about six hours from the time of venesection, the patient became permanently insensible, and as the child's head, completely cleared of the uterus, had now descended into the pel- vis, it was determined to deliver her by the forceps, which was applied accordingly; and in about an hour afterwards a dead child was brought into tjie world, whose appearance sufficiently proved that it had not been dead long. The source of irritation had now ceased, and with it the convul- sions, but the patient continued comatose still: yet even this effect went off in seven hours afterwards, and she revived, and gave con- siderable hopes of recovery. On the second day, however, in con- sequence of the accession of milk-fever, the convulsions returned, immediately followed with stertor and insensibility, and on the en- suing day she died apoplectic. To reason from a single instance, whether successful or unsuc- cessful, is often to reason wrong. Yet it is difficult to avoid con- VOL. iv.—19 146 GENETICA. LCL. V.—OR. III. jecturing that if immediate delivery had here taken place as soon as the sanguiferous system had been duly emptied, and when the state* of the uterus,was so favourable for a trial, two lives might have been spared, both of which were lost under the course pur- sued. It is true the fits returned with the milk-fever, but had the brain been less injured, there would have been far less danger of such return. The cases of Dr. Smellie and of Dr. Perfect concur in justifying such a conjecture; and the following passage of Mr. Burns should be committed to memory by every student, and every practitioner. " But this is not all," adverting to the necessity of a free depletion, " for the patient is suffering from a disease connect- ed with the state of the uterus, and the state is got rid of by termi- nating the labour. Even when convulsions take place very early in labour, the os uteri is generally opened to a certain degree, and the detraction of blood which has been resorted to on the first at- tack of the disease, renders the os uteri usually lax and dilatable. In this case, although we have no distinct labour pains, we must introduce the hand, and slowly dilate it, and deliver the child. I entirely agree with those who are against forcibly opening the os uteri: but I also agree with those who advise the woman to be de- livered as soon as we can possibly do it without violence. There is, I am convinced, no rule of practice more plain or beneficial. Delivery does not, indeed, always save the patient, or even prevent the recurrence of the fits, but it does not thence follow that it ought not to be adopted."* SPECIES IV. PARODYNIA PERVERSA. LABOUR IMPEDED BY PRETERNATURAL PRESENTATION OF THE FETUS OR ITS MEMBRANES. In the ordinary course of gestation the fetus is rolled up into as small a compass as possible with the breast uppermost, and the head dependent, the legs incurvated and the arms folded : the pla- centa rises from some part of the fundus, and the umbilical cord hangs at perfect ease in loose folds, or is sometimes turned loosely round the body • thus forming an ellipse whose longer axis corres- ponds to the longer axis of the uterus. Why the head rather than the breast, or indeed any other part of the fetus should so uniformly * Principles of Midwifery, p. 359. 3d edit. 8vo. 1811. GE. II.—SP. IV.] SEXUAL FUNCTION. 147 constitute the point of presentation, we know not, excepting that it is by far the most commodious point for delivery: and we can hence only resolve it into one of those striking laws of nature which are ever aiming at accomplishing the best ends by the best means, and afford an unvarying and unequivocal proof of design united with benevolence and power. Here, however, as in every other part of the animal economy, we meet with occasional deviations from the ordinary course of na- ture, and deviations which are always productive of evil. For it sometimes happens, from incidental causes that are totally conceal- ed from us, that some other part of the child is lowermost or pre- sents itself instead of the head : or that the placenta rises in an un- favourable part of the womb, or that the navel-string hangs down below the head and is constantly in danger of being strangled as the child passes through the sharp bones of the pelvis: and hence we have the following varieties of morbid condition offering themselves to us under the present species : x Faciei. Presentation of the face. £ Natium. Presentation of the breech. y Pedis. Presentation of one or both feet. ^ Brachialis. Presentation of one or both arms. t Transversalis. Presentation of the shoulder. £ Funis prolapsi. Prolapsed navel-string. 7) Placentae. Presentation of the placenta. As it is by no means the object of the present work to instruct in the manual or artificial operations of the obstetric art, the author must limit himself to pointing out the different morbid conditions in which such operations will be found necessary. Their nature, mode of accomplishment, and effective instruments are only to be learnt by works written professedly on this subject, or, which is in- finitely better, by an attendance on lectures, and such initiatory practice as the obstetric schools afford. A few general or inciden- tal remarks are all that the author can undertake to add to the above table of morbid presentations. There is no mode of determining what may be the presentation of a child before the commencement of labour, and even at that time it is most prudent for a practitioner to speak with some hesi- tation on the subject till the membranes have actually broken, and the position is fully decided. For though the real presentation is often sufficiently ascertainable through the membranes themselves, and particularly on the natural descent of the head, yet it has oc- casionally happened that, on the breaking of the membranes, the head has receded and the shoulder or some other part taken its place ; and there are cases in which the opposite and more fortu- nate change has occurred of a recession of a presenting shoulder and a descent of the head in its stead* Joerg, Hist. Part. p. 90. Burns, ut supra, p. 292. 148 GENETICA. [CL. V.—OR. IH. There is hence no foundation for those apprehensions which are often entertained by pregnant women respecting the misposition of the child drawn from some peculiar symptom or feeling which she has never been conscious of on former times, as a singularity in the shape of the abdomen, a sense of the child's rising suddenly to- wards the stomach, or a numb or painful uneasiness in one leg more than in another. These, and hundreds of other anomalous sensa- tions have occurred in cases where the presentation has at last been found natural, and the labour has proved highly favourable ; while on the contrary it is very rarely, when a cross birth is detected, that it has been particularly apprehended by any precursive tokens whatever. And the mind of the timid may hence be comforted in the midst of all the peculiarities on which they are accustomed to hang with daily alarm. It will rarely be found necessary to have recourse to any mecha- nical instrument in any of the varieties we have enumerated above : and in some of them, as the breech and foot-presentations, the ex- pulsory powers.of nature alone are found sufficient, at least till the head descends into the pelvis : at which time it will be found ne- cessary, whenever the arms lie over the head, to introduce a finger or two and gently draw them down. Where the face presents, or any other part of the head than the vertex, it was formerly the custom to deliver by turning, but a skilful practitioner of the present day is commonly able, by a dex- trous pressure of one or two fingers against particular parts of the head, and particularly, if attempted in an early stage of labour, to give the organ a right direction without introducing the hand. On the presentation,however, of a shoulder or of one or both arms, it will be expedient to turn as soon as possible ; or, in other words, as soon as the mouth of the womb is sufficiently dilated for this pur- pose. It is singular that, while under the old practice, delivery by the feet was often endeavoured in face-cases, attempts were made in arm and shoulder-cases to bring down the head and reduce the labour to a natural course. This it seems has been done, and may be done, but with so much fatigue and exhaustion to the patient as to run the risk of incapacitating her for any subsequent efforts, if she do even not fall a sacrifice to a flooding as in a case related by Dr. Smellie. It is to the successful exertions of Par6 and Mauri- ceau that the better practice of the present day has obtained a triumph over all Europe. Yet, in-justice to the obstetric practi- tioners of ancient Greece, it should be observed, that the modern method is little more than a revival of their own which unaccountably sunk into disfavour ; for we are told by JEtius, that Philomeles dis- covered the method, at that time in common use, of turning and delivering children by the feet in all unnatural presentations. Where, however, the child is small or of premature birth, it may sometimes be taken away without changing the presentation : for the obstetric writers abound in examples of delivery effected under GE. II.—SP. IV.] SEXUAL FUNCTION. 149 such circumstances by pulling down the arm and drawing the head into the vagina.* It sometimes happens that the shoulder is so far advanced into the pelvis before the arrival of the practitioner, or from the vehe- ment force of the uterus, that it is impossible to raise or move the child by the utmost power of the operator: and the state of the case seems to leave the woman without any hope of relief. At this very moment, however, and by these very means the wise and benevolent law of instinct or of nature is interposing to the relief that is despaired of. This wonderful process, though occasionally noticed by earlier writers, and foremost of all perhaps by Schoen- heider, in the Copenhagen Transactions,! was first fully illustrated and explained by Dr. Denman, who distinguished it by the name of a spontaneous evolution. His explanation is best given in his own words : " As to the manner in which this evolution takes place, I presume that after the long continued action of the uterus, the body of the child is brought into such a compacted state, as to receive the full force of every returning action. The body in its doubled state being too large to pass through the pelvis, and the uterus pressing upon its inferior extremities, which are the only parts capable of being moved, the latter are forced gradually lower, making room, as they are pressed down, for the reception of some other part into the cavity of the uterus which they have evacuated, till, the body turning as it were upon its own axis, the breech of the child is expelled, as in an original presentation of that part: and consequently is delivered by nature at the time she least ex- pected it." Dr. J. Hamilton, however, has justly observed that this evolution can only take place where the action of the uterus can produce no exertion on the presenting part, or where chat part is so shaped that it cannot be wedged in the pelvis: and he might have added where the woman is in full strength and the uterus is capable of exercising a strong expulsory power. And hence, it is a chance that should never be trusted to or suffered to interfere with the common practice of delivering by the feet, wherever this can be accomplished. In all the above cases it is a general rule and one of great im- portance, to suffer the water of the amnios to accumulate towards the neck of the womb as largely as possible, and to leave the mem- branes unbroken as long as may be. A presentation of, the funis is another difficulty often of consider- able moment in the progress of labour: for it is obvious that by a check to the pulsation, either actually taking place or being greatly endangered in every pain by the violent pressure of the head or of any other part against the mouth of the uterus, or afterwards against * Gardner, Med. Comment. Vol. V. 307. Bandelocque, Sect. 1530. Burns, ut supra, 303. f Act. Havn. Tom. II. Art. XXIII. ISO GENETIC A. [CL. V.—OR. HI. the sides of the pelvis, and consequently against the funis itself, the life of the child is in imminent hazard, and without the exercise of considerable skill, may inevitably be lost. If it be possible to return the prolapsed part of the funis round the head as it is descending, or to hook it against the hand or some other part so as to keep it clear of pressure, this ought to be done by all means. But if this be possible the child must be turned, as soon as turning be practi- cable from the dilated state of the os internum : or if the head should have reached the pelvis before the accident takes place, the labour must be accelerated by the patient's using her utmost efforts dur- ing every pain; and, if she be too, much exhausted for concentrat- ing her strength, it must be quickened by the use of the forceps. But if the pulsation in the chord have already ceased, and we have hereby a proof that the child is dead already, the labour is to be suffered to take its natural course. It sometimes happens, however, that after the child is turned and the head does not follow the body so speedily as could be wished from the patient's being greatly exhausted,—and the same fre- quently occurs in breech cases, in consequence of the protracted length of the labour in this presentation—there is still a consider- able danger to the navel string, from its pressure between the child's head and the-pelvis. This should be remedied as much as possible by giving the funis full play between the pains. But it frequently occurs, in spite of the utmost caution, that the pulsation is sus- pended, and the child is born in a state of^sphyxy, and apparently lifeless. The common practice in this case is to tie the naval-string as quickly as possible, remove the child from the mother to the warmth of the fire-place, and endeavour to stimulate the lungs into action by breathing forcibly into the mouth while the nostrils are closed. Friction with a warm hand, and with a conjoint aid of some pungent volatile is at th£ same time applied actively to the chest; and if this do not succeed the nostrils are attempted to be roused with ammonia, or the fauces with a tea-spoonful of brandy and hot water, to excite sneezing or coughing. All this is well; but there is a great and, I,am afraid, not unfrequently a fatal error in thus separating the navel string and removing the child from the mother. While it continues united it has two chances of recovery, that of the action of the lungs and that of the re-action of the umbilical artery. By removing it from the mother we allow it but one chance, and that, in my opinion, the feeblest. The expansion of the lungs is alto- gether a new process, and, like other new processes, does not always take place with great promptness, even-where the child is in full life and vigour, and the umbilical artery in regular pulsation ; for it is sometimes half a minute or double this time before the child begins to cry, which is the first proof of its respiring. But the flow of the blood through the umbilical artery is an established habit, and like all other habits, has a powerful tendency to recur if we give it time and favour; and must derive an additional tendency GE II—SP. IV.] SEXUAL FUNCTION. 151 from the stimulus of the posterior placental vessels which are still pulsating and operating with a vis a tergo. Of the various cases of asphyxy on birth which I have witnessed, by far the greater num- ber have nroved fatal when treated in the former way, and success- ful when treated in the latter : and the explanation here given will readily account for the difference. The placenta itself may, also, form a preternatural presentation and add much to the difficulty, and the danger of labour. We have said that this rises ordinarily from some part of the fundus of the uterus, though it may originate from its sides, or from some other quarter, for there is no quarter of the womb which may not become its source. Hence it occasionally takes its rise more or less over the mouth of the womb ; and while this part of the womb continues quiescent, it produces no more inconvenience there than any where else. But the moment labour commences, or even, in the latter months of parturition, when any cause whatever irritates the mouth of the womb, and in any degree puts it upon the stretch, some of the placental vessels must necessarily become ruptured and a he- morrhage ensue. So long as this is small in quantity, and does not frequently return, it will be sufficient to enjoin quiet, a recumbent position, and that the bed be not heated with a profusion of blankets. But if the hemorrhage be considerable, whether before the full time of labour, or on its accession or in any part of it, there is no perfect safety but in delivery, and hereby giving the ruptured vessels an opportunity of closing their mouths. The difficulty is less than a young practitioner might at first expect: for he may be sure, from the hemorrhage itself, that the os4iteri is both dilated and dilatable, for if this did not give way neither would the vessels which pro- duce the hemdrrhage. SPECIES V. PARODYNIA AMORPHICA. Xtnpvattimblt Sabour. LABOUR IMPEDED BY MIS-CONFIGURATION OF THE FETUS, OR, OF THK MATERNAL PELVIS. In natural labour the size of the head is adapted to the diameter of the pelvis it has to pass through: in some children, indeed, the head is rather larger than in others, or has a difference of shape ; and we meet with a like difference in the area of the pelvis: and these circumstances may prolong the labour, though the expulsory powers of the mother will ultimately triumph over the resistance. But it unfortunately happens that the head is sometimes so en- 152 GENETIC A. [CL. V.—OR. Ilf larged by monstrosity of structure, hydrops capitis, or some other disease, or that the maternal pelvis is so deformed in its make, that the child cannot pass through the passage, and delivery becomes altogether impracticable. - There is, however, an intermediate state between the natural size of the pelvis with a head of a natural size applied to it, and that of absolute impracticability from the utter inaccordance of the head to the opening; in which, though the most violent and best directed pains of the mother may not be sufficient to produce ex- pulsion, this object may be effected by the assistance of instruments co-operating with the natural efforts. What space of pelvis is absolutely necessary to enable a living child, at its full time, to pass through it, has not been very accu- rately settled by obstetric writers, some maintaining that this cannot take place where the conjugate diameter is less than two inches and a half, though it may till we reach this degree of narrowness; and others that it cannot take effect under three inches. The difference in the size of the head in different children on their birth, and of the thickness of the soft parts within the pelvis in different women may easily account for this variation in the rule laid down. It is, clear, however, from the acknowledgment of both parties, that if the dimensions of the pelvis be much under three inches, delivery cannot be accomplished without the loss of the child : and it is also clear that if the head be much enlarged beyond the natural size from any cause whatever, it cannot pass even through the ordinary dimensions, thus giving us the two following sources or varieties of dimcult labour from an amorphous cause. x A fetu. The fetus deformed by a preternatural magni- tude of head, or some other morbid protu- berance. £ Pelvica. The pelvis contracted in its diameter by natural deformity, or subsequent disease or injury. ' It is by no means easy to determine what is the actual measure- ment of the hollow of the pelvis in a living woman, and particularly during the time of labour: and hence, how useful soever it may be to be acquainted with what ought to be its precise capacity as taken under other circumstances, the judgment must chiefly determine as to the practicability or impracticability of the passage from a culm attention to the individual case at the time, and particularly where the difficulty proceeds from the form of the child rather than from that of the mother. If, in well weighing the circumstances, the question remain doubtful, the patient should be allowed to proceed with her natural exertions alone, or such only in addition as the hands may be able to afford, till the strength is considerably exhausted, and the mind participates in the depression of the body. And if at this time, as will probably be the case, the head has descended so low as to be in contact with the perinaeum, and an ear can be felt, it would be imprudent to delay any longer assisting her with the vectis or the forceps. GE. II.—SP. V.] SEXUAL FUNCTION. 153 But the case may not be doubtful, and the passage may be so much contracted as to render all attempts to accomplish the deli- very by the hands or the ordinary instruments totally ineffectual from the first. In this situation other means must be resorted to, or the mother and the child must both perish, worn out by fatigue and perhaps rendered gangrenous in the points of contact from ir- ritation and inflammation. The means that present themselves to the practitioner on this occasion are the three following: He may reduce the head of the child by the crotchet or perforator. He may, in a small degree, enlarge the diameter of the pelvis by dividing the symphysis pubis. Or, he may make a section through the abdomen into the uterus. The first of these methods is designed to save the mother by a voluntary sacrifice of the child. The two last give a chance to the child, but at an imminent hazard of the mother. Where the difficulty proceeds from a morbid enlargement of the child's head, the question as to which of these three methods of treatment should be adopted, ought not to admit of a moment's debate. The child is, perhaps, dead already, or, if not, it is not likely that it would long survive the deformity it labours under, or live so as to render life a blessing: and the life of a sound woman must not be risked, and still less sacrificed, for the chance of saving an unsound child. The head, therefore, ought to be diminished, and consequently the perforator to be had recourse to. But there are instances of a deformity of the pelvis so consider- able as that the perforator cannot be employed to any advantage : for how much soever the cranium may have been broken down, there may not be breadth enough to extract the child in any way. And this will always be the case where the range of the pelvis is under an inch and a half from the pubis to the sacrum, or on either side. Dr Osborn asserts that he once succeeded in removing a child by means of the crotchet in a case where the widest side of the pelvis was only an inch and three quarters broad, and not more than two inches long;* which is a capacity so narrow as to throw some doubt upon the accuracy of the measurement in the minds of many prac- titioners,! and certainly so narrow as to form an unparalleled case in the annals of the obstetric art. In situations, therefore, of this kind, some other plan must be pursued even to save the life of the mother; and the only plans that can even be thought of are that of diving the symphysis of the pubis, and that bf the Cesarean section. Towards the latter months of pregnancy there seems to be a dis- position in the bones of the pelvis to separate at their symphysis, insomuch that some pregnant women are sensible of a motion at the junction of the bones, especially at that of the ossa pubis.f * Osborn's Essays, p. 203. f Bum's Princ. of* Midwifery, p. 351. * Denman. Pract. of Midwifery, p. 46. 446. VOL. iv.—20 154 GENETICA. [CL. V.-OR. 111. This has been known to anatomists for some centuries, and about seventy years ago, for the first time, gave rise to a question whether advantage might not be taken of this tendency in cases of pelvic contractions, to enlarge the space by dividing the ossa pubis at their symphysis, and thus obtain the same end as is answered by the Cesarean section, with a considerable diminution of risk. The operation seems first of all to have been proposed by M. Louis of the French Academy of Surgery to Professor Camper of Gromngen, who tried it first on a dead female body, and found it would afford space, and next on a living pig, which for some days afterwards, was incapable either of walking or standing, but in a few weeks per- fectly recovered. He was then desirous of trying it upon a young woman condemned to death at Groningen, but did not succeed in his request. Not long afterwards, however, it was performed with complete success by M. Sigault of Paris upon the wife of a soldier who had hitherto borne four children, each of which from the mother's misformation, was obliged to be extracted piece-meal. The section of the cartilage connecting the ossa pubis enabled the bones to be separated, according to his account, by a chasm of two inches and a half; and yielded a free passage to the child in four minutes and a half. The wife, with her husband and child, a few weeks afterwards, presented themselves to the members of the faculty assembled in their hall. The patient walked steadily and was found to be perfectly recovered.* Mr. Le Roy, who was requested to attend on the occasion, tells us that the same operation was afterwards performed by two other practitioners on two other women, and in both cases with an equal happy termination. He also observes that although, in an unimpregnated state, the bones of the pelvis cannot be made to separate upon a division of the symphysis to a space of more than an inch, which would be insuffi- cient for the purpose proposed, the additional softness and flaccidity which take place during pregnancy, as well in the bones and car- tilages as in the muscles, is so considerable, that a separation of two inches and a half maybe easily effected in labour and was effected in the above cases, while the same bistoury that divided the soft parts, easily also divided the cartilage.f In various other parts of the Continent, and especially at Moiis and in Holland it has been re- peated with Complete emancipation both to the child and mother. Dr. J. H. Myers, who witnessed it at Paris, speaks of it in the highest terms of commendation. He says that the length of the incision does not exceed three inches, and that the whole operation is over in less than five minutes : while in the Cesarean operation the wound is necessarily more than nine inches long, the uterus is divided, and the surrounding viscera are uncovered. " I have seen," says Dr. Myers, "the operation twice performed in this * Med. Comm. Edin. Vol. V. p. 214. | Recherches Historiques et Partiques sur la Section de la Symphyse du Pubis, &c. Paris. 8vo. 1778. GE. II.—SP. V.] SEXUAL FUNCTION. 155 capital with every possible success. The last patient, while I am writing, is in the room, coming to show herself in justice to her operator. It is only eighteen days since the operation was perform- ed, and she is in perfect health, and by no means injured by it."* The operation, however, has been decried, and, in some instan- ces, has certainly failed ; but there appears to be some .doubt whether, in several of these cases at least, if not in all, it was con- ducted with a sufficient degree of dexterity and skill: for when we are told by one operator that, after the division of the symphysis he could not effect an opening of much more than a finger's breadth, and by another that the utmost extent of the hiatus was not more than an inch and a half, and compare these remarks with the fol- lowing assertion of Dr. Myers upon this very point, it is difficult to come to any other conclusion. " The moment," says he, " the division is made, there is an enlargement of the pelvis, I venture to say, to any extent desired ; the last I saw was three inches, ac- curately measured by an instrument called fielvimetre contrived by Mr. Trainel." To which we may add that M. de Lambon perform- ed the operation twice on the same patient; in the first instance without injury to the mother, and in the second with success to both mother and childf ! After these decisive facts in its favour, to which the reader may add others from the volume of Nosology, I cannot but conceive that the prejudice against it, in our own country, has been carried too far. One experiment alone has been made amongst ourselves, and that Avith an unsuccessful issue. But the chief opposition to it seems to have proceeded from the discountenance of Dr. Denman, added to certain experiments made in relation to it by Dr. William Hunter, which do not seem to have been conducted under circumstances that can fairly call in question the truth of the preceding state- ments. "Immediately," says Dr. Denman, "after the accounts of the operation were brought into this country, wishing, as a matter of duty, to understand the ground of the subject, I had a conference with the late Mr. John Hunter, in which we considered its first principle, its safety ; and after the most serious consideration it was agreed that, if the utility could be proved, there appeared from the structure of the parts, or from the injury they were likely to sustain by the mere section of the symphysis, no sufficient objection against performing it. Of its real utility it was, however, impossible to decide before many experiments had been made an the dead body, to ascertain the degree of enlargement of the capacity of the pelvis, well-formed or distorted, which would be thereby obtained. Such experiments were soon made: and their result published by the late Dr. Hunter, and these proved on the whole that, in extreme or great degrees of distortion of the pelvis, the advantage to be • Edin. Med. Comment. Vol. VII. p. 453. | Leake's Tracheal Observations on the acute Diseases of Women, Svo 156 GENETIC A. [CL. V.—OR. III. gained was wholly insufficient to allow the head of a child to pass without lessening its bulk : and in small degrees of distortion that the operation was unnecessary, such cases admitting of relief by less desperate methods. They proved, moreover, that irreparable injury would be done by attempts to increase the common advan- tages gained by the section of the symphysis by straining or tear- ing asunder the ligaments which connect the ossa innominata to the sacrum, and to the soft parts contained in the pelvis, particu- larly to the bladder."* Now it did not require these experiments to prove that this ope- ration, or almost any other, would become mischievous if unskil- fully performed, but surely it was something too much to endeavour to set aside the facts and results known to have taken place in very numerous instances in the living body, and to call in question the veracity of those who made them and those who witnessed them, by tacts and results made merely on the dead body, without one single experiment on the body while alive and in the peculiar cir- cumstances under which alone it is admitted that the facts and re- sults contended for could possibly take place. Upon the whole it is allowed in the passage just quoted, as the concurrent opinion of Dr. Denman himself, Mr. John Hunter, and apparently Dr. William Hunter, and this too after " the most seri- ous consideration,"—that "there appears from the structure ,of the parts or from the injury they are likely to sustain, by the mere section of the symphysis, no sufficient objection against perform- ing the operation." That it will answer in every degree of a con- tracted pelvis was never asserted by its most sanguine advocates, but only in cases where the constriction was somewhat too consi- derable to allow of the extraction of the child by the forceps. And lastly, it is after all admitted by Dr. Denman himself, that where the life of a child is of more than ordinary importance from public or other considerations, and the mother who is in labour with it possesses a pehis so deformed and contracted, that it can- not pass through the passage in its present state, " there the sec- tion of the symphysis of the ossa pubis might be proposed and performed,—being less horrid to the woman than the Cesarean operation, and instead of adding to the danger, giving some chance of" preserving the life of the child."! It is perfectly clear, however, that, be the advantages of dividing the symphysis what they may when the pelvis is under certain stales of deformity, it is an operation that can never be of any avail where the passage is so narrow that the child cannot be brought away piece-meal even by the use of the perforator. And in such circumstances the only alternative is to leave the patient to nature, in the slender and desperate hope that the pains may gradually wear away as the parts become habituated to the irritation, and the child, as in many cases of extra-uterine fetation, be thrown out in * Denman's Practice, &c. 447. f Denman, ut supr. 449. GE. II.—SP. V.] SEXUAL FUNCTION. 157 detached fragments by an abscess; or to have recourse to what has been called the Cesarean operation, and deliver by making a sec- tion into the uterus through the abdomen. The love of offspring, or a sense of duty, has been so prevalent in some women as to induce them to submit to this severe trial in cases where the pelvis has by no means been so straitened as we are now contemplating. And these motives not being confined to any particular age, the operation is of considerable antiquity, and is particularly noticed by the elder Pliny, who tells us that the elder Scipio Africanus, and the first of the Cesars were brought into the world in this manner, and adds, that the name of Cesar was hence derived "a caso matris utero."* In recent times, one of the ear- liest cases in which it was submitted to was that of the wife of a cattle-gelder at Siegen-hausen in Geimany in the beginning of the sixteenth century. The child it seems was. from its size, supposed to be incapable of being expelled in the natural way, and the ope- ration was performed by the cattle gelder himself. Barehin, in his Appendix to Rousset, who was a warm supporter of the practice, and wrote in favour of it in 1581, tells us that this woman did well and bore several children afterwards in the natural way. There are a few other instances related of its having been execut- ed by lay hands, and with equal success; particularly one perform- ed in Ireland by an uninstructed midwife w'hose instrument was a razor. The case is related by Mr. Duncan Stewart in the Edin- burgh Medical Essays,f who saw the woman a few days after the operation. She was well in about a month. Among regular prac- titioners, however, it has been generally opposed on account of its very doubtful result, from the time of Pare and Guillemeau, who warmly resisted its employment. Dr. Hull not long since made a collection of all the cases in which the operation had been performed both at home and abroad, and calculated them at 231, of which 139, being considerably more than half, had proved successful.| The German collections, indeed, give various examples of its having been repeated several times on the same person : and M. Trestan narrates the extraordinary history of one woman who had submit- ted to it not fewer than seven times.§ One of the latest examples is, I believe, the case furnished by Dr. Locker of Zurich, and pub- lished in a late volume of the Transactions of the Medico-Chirurgi- cal Society; in which the mother and child were both happily preserved.|| Under this view of the subject it is singular to observe the gene- ral fatality, at least to the mother, with which the Cesarean section * Hist. Nat. Lib. VII. cap. ix. f Vol. V. p. 360. i Translation of M. Bandeloque's Memoir, p. 23". § Journ. de Medicine, Tom. XXXVI. p. 69. ", Vol. IX. p. 11. 158 GENETICA. [CL. V.—OR. III. has been followed in our own country. lt There are, I think," says Mr. Burns, " histories of twenty cases where this operation has been performed in Britain : out of these only one woman has been saved, but ten children have been preserved."* At Edinburgh, Mr. Hamilton remarks,! that it had been perform- ed five times at the date of his publication . and that in no instance had the patient the good fortune to survive it many days. Ot the last case he was an eye-witness, and it was only resorted to after every other means had proved ineffectual: the child was saved but the mother survived only six and twenty hours. This ingenious writer enters with great pertinence into the question to what cause so general a failure is to be ascribed. And while he admits that nervous or uterine irritation from cutting, internal hemorrhage, or an extravasation into the cavity of the abdomen may each have an influence; he is disposed to think that its unsuccess is principally to be imputed to the effect which access of air is well known to have on viscera exposed and in a state of irritation. Dr. Monro repeat- edly found that, in making even a large aperture by incision into the abdomen of animals, if the wound be quickly closed the animal readily recovers: but that if the viscera be exposed for only a few minutes to the air, severe pains and fatal convulsions ensue. And hence Mr. Hamilton most warmly exhorts that, in performing the Cesarean operation, the* bowels be denuded as little as possible, and the wound be closed with the utmost expedition. This answer, however, is hardly satisfactory : and I am rather in- clined to think that the comparative want of success at home, is owing to the greater reluctance in performing the operation than seems to be manifested in France and Germany, in consequence of which it is rarely determined upon till the woman is too far ex- hausted, and has an insufficiency of vigour to enable the wounded parts to assume a healing condition. In most of the cases recorded, there does not seem to have been any deficiency of skill; and par- ticularly in that which occurred about five and thirty years since, and was attented by Mr. John Hunter and Dr. Ford,| and hence the unfavourable issue must be resolved into some other cause. It is happy for the world, and peculiarly so for those who are possessed of a contracted pelvis, and in many cases without knowing it till they are in labour, that a far safer, and less painful operation may be had recourse to, where the deformity is known in due time, I mean that of a premature delivery. "A great number of in- stances have occurred," says Dr. Denman "of women so formed that it was not possible for them to bring forth a living child at the termi- nation of nine months who have, in my own practice, been blessed with living children by the accidental coming on of labour, when they were only seven months advanced in their pregnancy, or se- • Princip. ut supr. p. 348. f Elements of the Practice of Midwifery, 8vo. ± Denman, ut supr. p. 463. GE. n.—SP. V.] SEXUAL FUNCTION. 159 vend weeks before their due time. But the first account of any ar- tificial method of bringing on premature labour was given to me by Dr. C. Kelly. He informed me that about the year 1756, there was a consultation of the most eminent men at that time in London to consider of the moral rectitude of, and advantages which might be expected from, this practice ; which met with their general ap- probation. The first case in which it was deemed necessary and proper fell under the care of the late Dr. Macaulay, and it termi- nated successfully. The patient was the wife of a linen-draper in the Strand. Dr. Kelly informed me that he himself had practised it; and, among other instances, mentioned that he had performed this operation three times upon the same woman, and twice the children had been born living. " A lady of rank," continues the same writer, « who had been married many years, was soon after her marriage delivered of a living child in the beginning of the eighth month of her pregnancy. She had afterwards tour children at the full time, all of which were, after very difficult labours, born dead. She applied in her next pregnancy to Dr. Savage, whom I met in consultation. By some accounts she had received she was prepared for this operation, to which she submitted with great resolution. The membranes were according ruptured, and the waters discharged, early in the eighth month ot her pregnancy. On the following day she had a rigor, succeeded by heat and other symptoms of fever which very much alarmed us for the event. On the third day, however, the pains of labour came on, and she was, after a short time, delivered, to the great comfort and satisfaction of herself and friends, of a small but perfectly healthy child, which is at this time nearly of the same size it would have been had it been born at the full period of utero-ges- tation ; and it has lived to the state of manhood. In a subsequent pregnancy the same method was pursued, but whether the child was of larger size, or the pelvis was become smaller, whether there was any mistake in the reckoning, or whether the child fell into any untoward position, I could not discover, but it was still- born though the labour did not continue longer than six hours. Yet in a third trial the child was born living and healthy, and she re- covered without any unusual inconvenience or trouble."* It is only necessary to add, that the time in which labour-pains will come on after thus rupturing the membranes and discharging the waters, is uncertain, and appears to depend much on the irrita- bility ot the uterus. It is sometimes delayed, as in the first trial in the cast just noticed, for three days, but the labour has sometimes, also, been found to commence within a few hours. • Epist. App. ad Strauss de fcetu. Mussipont. p. 298. 160 GENETICA. [CL. V.—OR. III. SPECIES VI. PARODYNIA PLURALIS. iHttlttyifcate ILubouv. LABOUR COMPLICATED BY A PLURALITY OF CHILDREN. The fertility of women seems to depend upon various circumstan- ces, partly, perhaps, the extent or resources of the ovaria, partly constitutional warmth of orgasm, and partly the adaptation of the male semen to the organization of the respective female. Eisen- menger gives us the history of a woman who produced fifty-one children :* and sometimes the fertility seems to pass from genera- tion to generation, in both sexes, though it must be always liable to some variation from the constitution of the family that is mar- ried into I have in my own family at the time of writing, a young female servant whose mother bore twenty-three children, and brought them up with so much success, that at the time of her mother's death, she was the youngest of nineteen then living: and her eldest brother has fourteen children at present, all of whom I believe are in health. But while some women produce thus rapidly in single succes- sion, there are others that are multiparient, and bring forth occa- sionally two or even three at a time, more than one ovum being detached by the orgastic shock. Three at a time is not common: I have met with but one instance of it in which the children were all alive and likely to live ; and one instance only occurred to Dr. Denman in the course of upwards of thirty years practice. Four have occasionally but very rarely been brought forth together, and there are a few wonderful stories of five, but which rest on no well- authenticated testimony. • Twins are mostly produced at a common birth, but, owing to the incidental death of one of them while the other continues to live, there is sometimes a material difference in the time of their expul- sion, and consequently therefore in their bulk or degree of maturi- ty, giving us the two following varieties : x Congruens, Of equal or nearly equal growth, Congruous twinning. and produced at a common birth. £ Incongruens. Of unequal growth, and produc- Incongruous twinning. ed at different births. In congruous tavinni ng or ordinary twin cases, in which there is • Epist. App. ad Strauss de foetu. Mussipont. p. 228. GE. II.—SP. VI.J SEXUAL FUNCTION. 161 no great disparity of size between the two, on the birth of the one, it can be pretty easily ascertained that another is still in the womb by applying the hand to the abdomen ; for the limbs, and, if the child be alive, its movements, may generally be felt very distinctly, except, indeed, when an ascites is present, and the practitioner must then have recourse to other tokens. There are no precise signs by which a woman or her attendant can determine whether she be pregnant of twins or not. Inequali- ties in the prominence of the abdomen, peculiarities of internal sensation or motion, slowness in the progress of a labour, have been advanced as signs; but they belong as frequently to the uniparient as to the multiparient, and hence are not entitled to attention. The claim to priority of birth in a twin case is dependent, not on Superiority of strength, or any other endowment, but on a closer proximity to the mouth of the uterus alone, and, consequently, on a greater convenience of position. Though when, on the birth of twins, one is found small and emaciated, and the other plump and strong, we have some ground for apprehending that the vigorous child has absorbed the greater part of the nutriment afforded by the mother, as we find not unfrequently in plants shooting from the same spot of earth. The general rules that govern in morbid labour of individual children, govern equally in morbid labour of twins. The second child is usually delivered with comparatively few pains and little inconvenience, as the parts have been sufficiently dilated by the passage of the first; and, although there is commonly some interval between the termination of the one and the commencement of the other struggle, it is not often that this interval exceeds half an hour or an hour. It has, indeed, in a few instances extended to whole days; in one instance to ten,* and in another to seventeen days.t But these are very uncommon cases: and as mischief may possibly happen to the womb, and to the system at large from a long pro- traction of uterine irritation, it is now the practice to deliver the second child by art, after having waited four or five hours in vain for a return of expulsory exertions. In incongruous twinning we meet in different cases with every possible diversity in perfection of form, and term of expulsion between the co-offspring. Nor is this to be wondered at in either respect. We have already seen that a single fetus may die during any period of parturition from a variety of causes: and hence we may readily conjecture that one of the twins may die at any period, while the other still thrives and remains unaffected. This twin may remain in the womb, and both be expelled together at the full time. But it may happen, also, from the peculiar irritation of the uterus generally, or the peculiar position of the dead fetus near the cervix, that this organ may be so far stimulated by the death, * Hist, de l'Acad. des Sciences, 1751, p. 107. f De Boset in Verhendelingen van Harlem, XII. App. No. 6. yoL. iv.—21 16g GENETICA. [CL.9.— OR. HI. and corrupt state of the fetal corse and its membranes, as to expel it from the body, while the living child receives no injury, and con- tinues to thrive, and is maturely delivered at its proper time. In the latter case, where the dead fetus has been discharged in the second or third month of pregnancy, the mother, not knowing herself to have been pregnant with twins, has been erroneously conceived, on the arrival of the second birth, to have produced a perfect child within the short term of six or seven months. In the former case, or that in which the dead fetus remains quiet in the womb through the remaining term of pregnancy and both are discharged at a common birth, an opinion equally erroneous was formerly entertained in order to account for the apparent dif- ference of the two in growth and size : for it was supposed that the dead and puny, and apparently premature fetus, was conceived some months subsequently to the perfect and vigorous child, and hence had not time to reach it in size and perfection : and to this supposed subsequent conception was given the name of superfe^* tation. We have reason to believe that such a process does occasionally take place in some quadrupeds whose wombs are so formed as to allow of it: but we have already observed in the preliminary Proem to thepresent Class, as also in the introductory observations to the present Order, that, in women, from the moment of conception, an efflorescent membrane is formed which lines the whole cavity of the uterus, and acts as a septum to the ascent of any subsequent tide of male semen ; not to say further that theos uteri itself is so plug- ged up by the secretion of a viscid mucus at the time as to prevent any communication between this organ and the vagina till the period of pregnancy is completed. And hence the doctrine of superfeta- tion in women has deservedly sunk into general disrepute.* The cases of this kind, and formerly ascribed to this cause, are by no means uncommon. Dr. Maton has given a very decided one in the Medical Transactions, containing the history of a lady de- livered at Palermo of a male child in November 1807, and again, scaicely three months afterwards, in February 1808, of another male infant, " completely formed."t The proportion or powers of the first child are not sufficiently noticed: but we are told that both were born alive; that the elder died when nine days old " without any apparent cause ;" and that the younger died also, but after a longer term. In Henchel we have an account of a minute^ and a mature fetus born at the same time: and in the Transactions of the Medico- Chirurgical Society, a similar account by Mr. Chapman with the exception of the time, which varied considerably: the dead and mi- nute fetus, apparently not more than three or four months old, hav- * Waldschmied, Dissert, de Superfoetatione falso praetens a Hanb. 1727, f Vol. IV. Art. XII. $ Neue Medicinische und Chirurgische Anmerkungen, B. II. GE. II.—SP. VI.] SEXUAL FUNCTION. 163 ing in this case been born in October 1816, and the twin, a full- grown child, not till December, just two months afterwards.* In this last instance, however, there can be no doubt that the aborted fetus had remained quiet in the uterus for some months af- ter its death before it was expelled; which in truth is the only way of reconciling its apparent age and size of not more than three or four months at the time of its expulsion, with the full time or nine months of the mother, completed only two months afterwards. Nor is a quiet and undisturbing continuance in the uterus after the death of the fetus by any means uncommon, whether the off- spring be single or double. We have already given examples of an interval of ten, and even seventeen days, in the case of twins born equally of full size. But where the growth has been discre- pant, and the dead fetus has remained behind unsuspected, it has sometimes been several months before expulsion has taken place. Ruyset gives a case in which it was delayed a twelvemonth, after the apparent term of its death, and even then discharged without corruption :f and some of the foreign collections have instances that more than double this time.} The present author was lately engaged in consultation upon the case of a lady in Bedford Row, who had miscarried of a fetus under three months old, which there was every reason to believe died four months antecedently; as at that time the mother had been at- tacked with a flooding and rigors, had had various subsequent ute- rine hemorrhages, and had never been able to quit a recumbent position without producing some return of the bleeding. SPECIES VII. PARODYNIA SECUNDARIA. Sequential 2Uf>our diseased action, or disturbance succeeding delivery. In ordinary child-birth the pains of labour may be said to cease with the expulsion of the fetus : since though sequential, or after-pains, as they are ordinarily called, are not uncommon for a day or two, and are useful in expelling the placenta and its membranes, and a few large coagula of blood that have formed in the uterus, these • Vol. IX. p. 195. f Tbesaur. omnium max. + Nene Samml, Wahrnekmunjjen. Band. IV. p. 241. 104 GENETICA. [CL. V.—OR. III. last are neither violent nor by any means frequent. It sometimes happens, however, that there is almost as much trouble, and as much pain, and as much danger after the birth of the child as an- tecedently, so that the labour itself may be fairly said to be pro- tracted into this secondary stage, which offers the following varie- ties of morbid affection : x Retentiva. Retention of the secundines. £ Dolorosa. Violent after-pains. y Hemorrhagica. Violent hemorrhage or flooding. r or fiernitu* its real mean- ing in parenchyma; and, consequently, the double signification would trench upon that simplicity and uniformity which it is the direct object of the present nomenclature to maintain. The second objection is, that the term parenchyma (™?eyXvnx) is formed upon a talse hypothesis invented by Erasistratus, who first employed the term, and held that the common mass or interior substance of a viscus is produced by concreted blood, strained off through the pores of the blood-vessels which enter into its general structure or membranes. The order embraces the five following genera: I. POLYSARCIA. CORPULENCY. II. EMFHYMA. TUMOUR. III. PAROSTIA, MIS-OSSIFICATION. IV. CYRTOSIS. CONTORTION OF THE BONES. V. OSTHEXIA. OSTHEXY. 200 ECCRITICA. [CL. VI.—OB. I. GENUS I. POLYSARCIA. Cfonmlrnci). FIRM AND UNWIELDY BULKINESS OF THE BODY OR ITS MEMBERS, FROM AN ENLARGEMENT OF NATURAL PARIS. Polysarcia from vaXvTxgKw, " carnosus," " carne abundans." im- ports bulkiness from any morbid increase of natural parts, whether fleshy or adipose : and the present genus is co-extensive with this latitude of interpretation. In medical history, however, we know of no morbid increase of this kind except from an accumulation of fat; and hence the genus is at present limited to a single species, as follows: I. ADII'OSA. OBESITY. SPECIES I. POLYSARCIA ADIPOSA. ©urmtn. BULKINESS FROM A SUPERABUNDANT ACCUMULATION OF FAT. This species admits of two varieties. For it may be a Generalis. Extending over the body and limbs. General obesity. £ Splanchnica. Confined to the organs or integu- Splanchnic obesity. ments of the trunk. In man and other animals fat is collected in the follicles of the cellular membrane, accumulated in the groin, axilla, omentum, around the kidneys, and the blood-vessels. It is likewise secreted on the surface of the skin, which it protects from acrid substances, and where it sometime^ concretes, often from want of cleanliness, or being inu rmixed with hardened mucus, in the shape of minute worms, forming the varus fiunctar> s, or maggot-pimple, of the third Order of the presem CLss. Whtn the perspiration becomes pro- fuse in consequence of nard walking or o>her exercise, a certain portion of animal oil is dissolved in this fluid which makes the chief, 6E. L—SP. I.] EXCERNENT FUNCTION. 201 perhaps the only difference between the matter of perspiration and that ot 5weat. Fat is, hence, accumulated by diminished perspira- tion ; as it is also by the nature of the aliments fed on, and from idiosyncrasy. It is the basis of steatomatous tumours, and contains and Iron"0 *** ^^ °n many metals' aS lead' C0PPer' In many fishes, as the salmon and herring, it is disused over the whole body, as though the body were steeped in it. In other gene- ra of fishes, as the ray, it is found in the liver alone. In some few, as the whale, it appears in the form of Hakes, and is called blubber! which sometimes amounts to the enormous quantity of three tons m an individual. Fat is a bad conductor of heat; and hence, one of its uses is that ot keeping the body warm ; on which account those who are in- cumbered with fat perspire with but a small quantity of exercise, and are almost always too hot. We may hence also see why the warmth of the body is retained by oiling the surface, or wearing oiled skin over it. Fat is also of considerable use in lubricating the solids, and facilitating their movements; in preventing exces- sive sensibility ; while by equally distending ihe skin, it contributes, when not in excess, to the beauty of the person. In cases of ex- treme hunger, or of abstinence from food, fat is re-absorbed and carried to the biood-vessels ; and from an experiment of Dr. Sark,* it appears to be more capable of supplying the waste of the body than any sort of ordinary food. And hence, there is much proba- bility in the conjecture of Lyonet that insects, destitute of blood, deiive their chief nourishment from the fat in which they abound f With the exception, however, ot the earth of the bones, it is the least animalized of all the substances that enter into the composi- tion of the animal frame. Chemically examined pure fat contains no azote, which is the peculiar characteristic of animalization ; it has also little oxygene, consisting chiefly, indeed, of hydrogene and carbone. " I do not consider," says Mr. John Hunter, "either the fat or the earth of bones, as a part of the animal: they are not ani- mal matter: they have no action within themselves: they have not the principle of life."f It is of late formation in the fetus : scarce- ly any trace of its existence is discoverable before the fifth month from conception. The mode of its production is still a matter of controversy. By some it has been supposed to be secreted by peculiar glands, by others merely to transude from exhalant arteries of a peculiar kind. Sir Everard Home has lately started another hypothesis, which is at least highly ingenious and plausibly supported He has attempt- ed to prove thai the fat of animals is produced in the larger intes- tines, (especially the colon,) out of the recrement of the food and * Hewson, II. p. 151. f Tr. Anat. de la chenille qui rouge le bois de saule, pp. 428. 483, et sen ♦ On Blood, p 440. l' vol. iv.—26 202 ECCRITICA. [CL. VI.—OR. I. the bile, and afterwards conveyed into the system generally by channels yet undiscovered to contribute towards the common growth of the system, especially in early life.* And some arguments in favour of this opinion may be drawn from the nature of that species of enterolithus, to which in the present system is given the name of scybalum, and from the observations with which it has been illus- trated, f In general obesity, or the variety of adipose polysarcia imme- diately before us, the bulk of the body has sometimes been enor- mous. It has amounted to five hundred, and nearly six hundred pounds in many instances. > Bright, of Maldon, weighed seven hundred and twenty eight pounds; Lambert of Leicester, seven hundred and thirty nine pounds a little before his death, which was in the fortieth year of his age. The German journals give us ex- amples of men who weighed eight hundred pounds Yet the Phi- losophical Transactions furnish perhaps a still more extraordinary example of this disease in a girl that weighed two hundred and fifty-six pounds though only four years old.:}: Where a powerful adipose diathesis prevails, fat is often produc- ed whatever be the food fed upon. Ale and porter drank to excess, are, perhaps, the most ordinary means ; Akermann gives proof of the same effect from spirits :§ and in the Ephemera of Natural Curiosities is the case of an individual who generated fat faster, and in larger quantities, upon bread than upon a meat diet.|| Indo- lence and indulgence in sleep seem necessary, however, in every instance. In these cases the animal oil is sometimes secreted and deposited in the cellular membrane almost as rapidly as water in anasarca : on which account obesity has by some writers been Called, and cor- rectly enough, a dropsy of fat. It is in fact under particular circum- stances the soonest formed and deposited, and the soonest absorbed of all the animal secretions. For its formation, however, ease of body and mind are indispensable, and perhaps a slight increase in the flow of sensorial power beyond the common standard, or what has hitherto been the standard of an individual. It is on this ac- count those are apt to become fat who suddenly relinquish a habit of hard exercise either of body or mind for a life of quiet enjoy- ment, provided the change be not sufficient to interfere with the general health. And for the same reason, as we have already ob- served, animals which are castrated, and females that do not breed, or who have just ceased to breed, grow fat and corpulent with equal ease; the sensorial power intended for the use of the sexual organs, and to be expended at a particular outlet, being hereby thrown • Phil. Trans, for 1813. p. 158. and 1816. p. 301. f Vol. I. p. 191. * N. 185. § Baldinger N. Mag. B. VI. p. 489. II Dec. III. Ann. VII. VIII. p. 138. GE. I.—SP. I.] EXCERNENT FUNCTION. 203 back upon the system generally, and transferred to the adipose se- cernents. And hence, also, the cause of that increase of bulk which most persons experience about the middle of life, when the mus- cles have attained their utmost firmness, the stature its full height, and the sexual economy its perfection, there is a less demand for the ordinary supply of sensorial power than has hitherto been made, and the surplus is expended in broadening and rounding the gene- ral frame by filling up the cells of the adipose membrane with animal oil, instead of elongating it. For all this, however, there must be an ease of body and mind approaching to cheerfulness; on which account plumpness, and cheerfulness, or good humour, are commonly associated in our ideas : for pain and anxiety, that wear away the corporeal substance generally, make their first inroad on the animal oil, and empty the cells of the adipose membrane before they produce any manifest effect on the muscular fibres, or, as these are collectively termed, the flesh; upon which subject we have already touched in discuss- ing several of the species of the genus marasmus.* Hence the fat becomes absorbed or carried off, as it is secerned and deposited more readily than any other animal substance. By sweating, horse-riding, and a spare diet, a Newmarket jockey has not unfrequently reduced himself a stone and a half in a week or ten days:f and a plump widow has, by weeping, become a skeleton in a month or two. A moderate increase in the secretion of animal oil rather adds to the facility of motion, and improves the beauty of the person. But if it much exceed, the play of these different organs upon each other is impeded, the pulse is oppressed, the breathing laborious, there is an accumulation of blood in the head, a general tendency to drowsiness, and a perpetual danger of apoplexy. In splanchnic obesity, the encumbered viscera are more or less buried in beds of fat, and usually accompanied with scirrhous affections; making an approach to some species or other of para- B ysm A, as described in the first Class and second Order of the present system.| We have observed that general obesity may be regarded as a dropsy of animal oil instead of a dropsy of water. And, as the latter disease is sometimes universal and runs through the whole of the cellular substance, and at others local, and confined to parti- cular cavities, the former also exhibits both these modifications ; and in the variety before us, is confined to individual organs. It most generally overloads the omentum, and gives that project- ing rotundity to the abdomen which is vulgarly distinguished by the name of pot-belly, and is well described by Prince Henry in his * Vol. II. p. 494. ■J- Code of Health, by Sir John Sinclair, &c. f. Vol. I. p. 273. 204 ECCRITICA. [CL. VL—OR. I. address to Falstaff, as « hu^e hill of flesh,"*—" a globe of sinful continents "t Animal oil is more apt to accumulate in the abdominal viscera than on the surface, and hence while these organs always partici- pate in a general obesity, it is not to be wondered at that they should sometimes be loaded alone As it has been stated that freedom from pain is necessary to its accumulation, it may, perhaps, be a matter of surprise that schirrosities should be a concomitant. But this morbid condition takes place so slowly as to produce little or no local disquiet ; while the small degree of increased irritability that accompanies their formation, for a reason already assigned, tends rather to promote the morbid deposit than to prevent it. In attempting a cure of the general disease, the first step is to avoid all 'he common and more obvious causes as much as possible. Hence, as a life of indolence and indulgence in eating and drinking is highly contributory to obesity, the remedial treatment should consis in tne use of severe, regular, and habitual exercise, a hard bed, little sieep, and dry and scanty food, derived from vegetables alone, except where, from a singularity of constitution, farinaceous food is found to be a chief source of obesiiy. And where these are in-mhcient, we muiy have recourse to frequent venesection and such medicines as freely evacuate the fluids whether by the bowels or the skin. And, for the same reason, sialogogues, as chewed tobac- co,! ^d mercuiy, have occasionally been used with success.§ Generally speaking, however, the diet and regimen just recom- mended with a spare allowance of water will be sufficient to bring down the highest degree of adipose corpulency. Ol this we have a striking examp.e of the history of Mr Wood, the noted miller of Billericay in Essex. Born of intemperate parents, he was accus- tomed to indulge himself in excessive eating, drinking, and indolence, tili, in the forty-iourth year of his age, he became unwieidy fr in his bulk, was almost suffocated, laboured under very ill health from indigestion, and was subject to fits of gout and epilepsy. Fortunately a friend pointed out to him the Life of Cornaro : and he instantly de- termined to take Cornaro for his model, and if necessary to surpass his abridgments With great prudence, however, he made his change from a highly superfluous to a very spare diet gradually : first dimi- nishing his ale to a pint a day, and using a much smaller portion of animal food ; till, at length, finding the plan work wonders as well in his renewed vigour of mind as of body, he limited himself to a diet of simple pudding made of sea biscuit, flour, and skimmed milk, of which he allowed himself a pound and a half about four or five o'clock in the morning for his breakfast, and the same quantity at * Henry IV. Part I. Act. II. f Id. Hart II. Act II. * Borelli, Cent. II. Obs. 11. § Bartholin. Act. Hafn. I. Obs. 74. Bonet, Sepulchr. Lib. II. Sect. ii. Obs. 36. Appx. GE. I.—SP. I.] EXCERNENT FUNCTION. 205 noon for his dinner. Besides this he took nothing either of solids or fluids, for he had at length brought himself to abstain, even from Water ; and found himself easier without it. He went to bed about eight or nine o'clock, rarely slept for more than five or six hours, and hence rose usually at one or two in the morning, and employed himself in laborious exercise of some kind or other, till the time ol his breakfast. And by this regimen he reduced himself to the condition of a middle sized man of firm flesh, well coloured com- plexion and sound health.* A like plan, or rather something ap- proaching it, the present author once recommended to Mr. Lambert of Leicester on being consulted concerning the state of his health. But either he had not courage enough to enter upon it, or did not chuse to relinguish the profit obtained by making a show of him- self in this metropolis. He made his choice, but it was a fatal one, for he fell a sacrifice to it in less than three years afterwards. The local disease is for the most part far less manageable: but it has sometimes yielded to a steady perseverance in the above plan, in connection with active purgatives, and the application of mercu- rial ointment to the vicinity of the organ affected; or a free use of calomel in the form of pills. GENUS II. EMPHYMA. Stunour. GLOMERATION IN THE SUBSTANCE OF ORGANS FROM THE PRODUCTION OF NEW AND ADSCITITIOUS MATTER : SENSATION DULL, GROWTH SLUGGISH. Phyma, in the present system, is limited to cutaneous tumours ac- companied with inflammation, as already explained in Class III. Order II | Emphyma imports, in contradistinction to phyma, a tumour originating beiow the integuments, and accompanied with inflammation, at least in its commencement: while ecphyma in Order III. of the present Class, imports, in contradiction to both, mere superficial extuberances, confined to the integuments alone. The term gtomt ration, or " heaping into a ball," in the generic de- finition is preferred to the more common terms firotuberanct or exniberanc', because some tumours or emphymata lie so deeply seated below the integuments as to produce no prominence what- ever, and are only discoverable by the touch. • Med. Trans. Vol. II. Art. XVII. t Vol. II. p. 19Q. 206 ECCRITICA. [CL. VI.—OR. I' The species of this Order, and much of their general character and arrangement, are taken with a few variations from Mr. Aber- nethy's valuable Tract on Tumours. The subject, indeed, though of a mixed description, is commonly regarded as appertaining rather to the province of surgery than of medicine, from the tendency which most tumours seated on or near the surface have to open externally, or to call for some manual operation. In a general system of the healing art, however, it is necessary to notice them, though it is not the author's intention to dwell upon them at length : but rather Jo refer the reader, from the few hints he is about to pursue, to Mr. Abernethy's work, as the best comment upon them which he can consult. The species embraced by the genus phyma are the following : 1. emphyma sarcoma. sarcomatous tumour. 2. ■ encystis. encysted tumour. wen. 3. ■. exostosis. bony tumour. SPECIES I. EMPHYMA SARCOMA. Sarcomatous humour. TUMOUR IMMOVEABLE; FLESHY AND FIRM TO THE TOUCH. The varieties of this species, modified in respect to structure and situation, are very numerous The following, distinguished by the former quality, are chiefly worthy of notice: x Carnosum. Vascular throughout: texture simple: Fleshy tumour. when bulky mapped on the surface with arborescent veins. Found over the body and limbs generally. £ Adiposum. Suetty throughout: inclosed in a thin Adipose tumour. capsule of condensed cellular sub- stance : connected by minute vessels. Found chiefly in the fore and back part of the trunk. y Pancreaticum. Tumour in irregular masses ; connect- Pancreatic tumour ed by a loose fibrous substance, like the irregular masses of the pancreas. Found occasionally in the cellular substance, but more usually in con- voluted glands: chiefly in the female breast. GE. II.—SP. I.] EXCERNENT FUNCTION. 207 ^ Cellulosum. Cystose tumour. Derbyshire-neck. t- Scirrhosum. Scirrhous tumour. VOL. IV.—-29 220 ECCRITICA. [CL. VI.-OR. I- judge that it originates more frequently from mothers than from fathers. So far as I can refer the disease of the children to the state of the parents, it has appeared to me most commonly to arise from some weakness, and pretty frequently from a scrophulous habit in the mother."—" I must remark, however," continues Dr. Cullen, «< that in many cases I have not been able to discern the condition of the parents to which I could refer it."* Rickets seldom appears earlier than the ninth month of infancy, and not often later than the second year, being preceded, according to Dr. Strack, by a paleness and swelling of the countenance, and a yellow, sulphur hue in that part of the cheeks which should natu- rally be red.! In some instances it seems to have originated later; in every stage, indeed, of a child's growth, till the bones have ac- quired their full size and firmness -,\ and it is said to have occurred even after this. But in these late appearances we are generally capable of tracing the disease to some local injury, which acts as an exciting cause, and, for the most part, unites it with parostia flexilis. Rhachia, in its ordinary course, commences imperceptibly and advances slowly : the body becomes gradually emaciated, the flesh flaccid, and the cheeks wan or sallow, with a slight degree of tume- faction. As the flesh diminishes in bulk, the head is found to in- crease, the sutures gape, and the forehead grows prominent. The' spine bends and is incapable of supporting the weight it has to car- ry : the ribs and sternum partake of the distortion, the former lose their convexity, and the latter projects into a ridge. The same deficiency of bony earth runs through the entire ske- leton, and affects not only those parts that are composed chiefly of lime and phosphoric acid, as the flat bones and the middle of the long bones, but the extreme knobs or epiphyses, in which lime is combined as largely with carbonic as with phosphoric acid. And hence, the joints are loose and spongy, and in swelling keep pace with the head. In many instances the lime appears to be elabo- rated but without its correspondent acids, and consequently, with- out compactness, and to no purpose: for we can occasionally trace it loose in the urine, in which it forms a calcareous deposite, as though carried off from the blood as a recrement. All the assimilating powers participate in the debility in a great- er or less degree : the process of dentition is slow and imperfect. and, while the cellular membrane is without animal oil, the muscu- lar fibres are tabid, without energy, and almost inirritable. It does not seem, however, that the secretion of sensorial power is so much interfered with as the other secretions of the system. Some part, indeed, of what should be sent over the frame at large, appears to * Pract. of Phys. Vol. IV. Book II. Ch. IV. § MDCCXXII. ! Act. Philosophico-Medico Soc. Acad. Princ. Hassiae, &c. 4to. Giesss. Cathorum. t. Thomasio, Journ. de Med. Tom, XLUI. p. 222. GE. IV.—SP. I.] EXCERNENT FUNCTION. 22Tf be concentrated in the sensorium : so that its equipoise is disturbed, but the general average is not perhaps much diminished. And we are hence able to account for the curious and interesting fact that while the body is generally failing, the mind in many instances ad- vances in its faculties, insomuch that a very slight recapitulation of the names of those who have been pre-eminently gifted with mental talents in every age and nation, and have immortalized them- selves as poets, philosophers, and even leaders in the field, will put before the eye of those who have not much attended to this sub- ject, a far greater proportion of the hump-backed, and the ricketty, than they may hitherto have had any conception of. We had occa- sion to make a like remark when treating of scrophula, and the same fact occurs almost as strikingly in hectic fever. The progress of the mind does not necessarily depend upon the general progress of the body : in the ordinary course of things the one runs parallel with the other; but, in the great field of pathology, where this course is departed from, we are perpetually called to behold proofs that these powers are by no means one and indivisible, and that, even before the hour of death, the spirit gives token of an advance towards perfection, while the body in its general crasis is imbecile, or, perhaps, sinking gradually into ruins. At the commencement of rickets there is rarely any degree of fever, but, as the disease advances, irritability, as in scrophula, suc- ceeds to inirritability, and a hectic is produced. • Or it may happen that the sensorium at last participates in a greater degree with the disease of the rest of the frame, and the mind itself becomes en- feebled, and torpid, or fatuous. In the treatment of rickets, the eye should be directed to the two following intentions: that of strengthening the system general- ly : and that of facilitating a supply of phosphate of lime to the or- gans that form the chief seat of disease. For the former purpose, a pure, dry, and temperate atmosphere, a wholesome and somewhat generous diet, regular exercise, of such kind as can be indulged in with the least inconvenience, clean- liness, and cold-bathing are of essential importance, and have often worked a cure alone. And it is possibly owing to a more general conviction of the advantage of such a regimen in the present en- lightened age, that rickets is a complaint far less common now than it was a century or even half a century ago. A tonic plan of medicines, however, ought to be interposed, and will effectually co-operate with a tonic regimen. As in infancy we can employ those remedies only which are neither very bulky nor very disgustful, we should, for the purpose immediately before us, make choice of the metallic salts. Mr. Boyle is said to have em- ployed, long ago, with very great success, some kind of ens veneris ; and various preparations of copper have since been made use of, and been highly extolled for their virtues in the present disease, especially by Benevoli, and Biichner. Dr. Cullen, however, is per- suaded that the ens veneris of Boyle was a preparation not of cop- 228 ECCRITICA. [CL. VI.—OR. I. per, but of iron, in fact the flores martialea of the old dispensatories, and there is no doubt that this conjecture is right. From the ge- neral irritability of the system, iron, indeed, seems to be more ad- viseable on the present occasion than any other metal. And its stimulant property is a recommendation to its use, rather than a dissuasive. If the appetite fail, which is not common, and the stomach evince acidity and other dyspeptic symptoms, an occasional emetic will be highly serviceable. The bowels must be kept open with rhubarb, or neutral salts; and, if the abdomen be tumid, or there be any other symptoms of an affection of the mesenteric glands, mercury in small doses may be advantageously had recourse to, and combin- ed with the tonic plan. The means of carrying into execution the second intention, or that of producing a direct supply of osseous matter, is accompanied with more difficulty, nor is it certain that we are in possession of any remedy whatever by which this can be accomplished, though it has often been attempted. Bone may be regarded as a cancellated fabric of gluten whose cells are filled up with the earth of lime and a combination of car- bonic and phosphoric acid, of which the former bears the larger proportion. In all cases of rhachia, there seems to be a deficiency of these acids, but particularly of the phosphoric, and, in many cases, a deficiency of thcearth as well as of the acids. Acids, however, of every kind, when in excess, have a tendency to dissolve calcareous earth instead of concreting it into a solid mass : and hence one of the most effectual means of preventing that tendency to the separation or production of a morbid super- abundance of calcareous earth in osthexia and lithia, is a free use of acids as a solvent. A hint has been taken from this effect, and, as the disease before us is of an opposite kind, and evinces a deficiency of lime, and es- specially of phosphate of lime, instead of an excess it has been in- geniously proposed to pursue an opposite practice, and to have recourse to a free use of alkalies and alkalescent earths, especially lime united with phosphoric acid, with a view of obtaining the de- ficient materials. Baron Haller and De Haen employed, for this purpose, prepared oyster-shells; but these consist of lime with car- bonic acid, and do not, therefore, offer a proper supply for the basis of bones. M. Bonhomme has of late improved upon this practice by substituting the phosphate of lime, or the powder of bones for its carbonate, and uniting it in equal parts with phosphate of 6oda: of which compound the dose is a scruple for an infant given twice a day. And he recommends that the body should also be bathed morning and night with an alkaline solution, consisting of half an ounce of common potass in a pound of spring water. Abil- gaard has carried the alkaline plans still farther, and has employed. GE. IV.—SP. I.] EXCEBNENT FUNCTION. 229 the fixed alkali internally.* And, as acidity of the stomach in in- fants seems to be one cause of the disease, and a principal cause, as conjectured by Cappel! and Zeviani,J where the digestion is evi- dently at fault, wc may, in such circumstances, reasonably expect benefit from alkaline preparations or magnesia. How far any preparation of lime introduced into the stomach may be able to find its way without decomposition through the sanguiferous system to the assimilating vessels, and be secerned in the parts affected, has not been exactly determined. Vauquelin made various experiments upon fowls, to decide the question, and M. Bonhomme has since attempted others. To themselves these experiments appeared satisfactory; but they are open to some ob- jections which have not been entirely removed. Yet we see every day, in a thousand instances, with what facility substances, of almost every kind, introduced into the stomach, are diffused with little other change than that of minute division over every part of the system. Emetics do not act till they reach the circulating system: the colouring matter of the madder-root is conveyed to and tinges the most solid bones : prussiate of potash, turpentine and various other balsams enter without change into the bladder. It is hence that rape-seed communicates an intolerable taste to hares that feed upon it, and that the flesh of sheep feeding upon wormwood ac- quires the bitter flavour of this plant. So, the buck-thorn gives a cathartic property to the flesh of thrushes that have swallowed it, and scammony to goat's milk. Partridges that have feasted harm- lessly on hellebore,often occasion sickness when employed as food; and when oxen have grazed in a pasture abounding with alliaceous plants the beef they produce possessess the same taste and smell. And hence, phosphate of lime may, in like manner, be conveyed from the stomach to the secernents of the bones, and reach them without chemical decomposition. As rhachia is peculiarly distinguished by a great inirritability and want of action, rubefacients and other cutaneous stimulants have often been employed, and proved serviceable, as well from the friction that accompanies their use as their own actuating pow- er. These have sometimes been so far heightened as purposely to excite some degree of fever, with a view of carrying off the dis- ease by this means, as dyspepsy, cephalaea, and chronic rheumatism have often been carried off by a smart attack of a tertian intermit- tent. We are told that a practice of this kind prevails very gene- rally in the Western Isles, and is productive of great success. The heating oil of the skate-fish is rubbed every evening first upon the wrists and ancles of the patient, which raises a fever of several hour's duration : and when the inunction upon these parts has lost • Collect. Soc. Med. Havn. I. Art. I. t Versuch einen vollerstandigen Abhandlung iiber die Englische krankheit c. ' t Delia cura di Bambini, attacatidella Rhachitide. Cap. II. p. 80. 230 ECCRITICA. [CL. VI.—OR. I. its effect, it is then applied, in like manner, to the knees and elbows; and afterwards, in like manner, to the spine; so that a certain de- gree of pyrexy may be daily maintained. And when friction, on all these organs, is found to fail, as fail it will by degrees, a flannel shirt dipped in the oil is finally had recourse to, and worn on the body, which produces a higher degree of fever than has yet existed; and continues to be worn, after fresh illinations, till a cure is ob- tained, which is said to be certain, and usually in a short time. Many ingenious devices have been executed by surgical instru- ment makers for giving support to the limbs that seem mostly to suffer, and for removing the weight of the body from one part to another. In infancy, however, all these are of little avail, and where the disease pervades the entire skeleton, they will always do as much mischief as good, by aiding one part at the expense of another. The best mechanical instruments are a hard incompres- sible couch, and a level floor on which the infant may lie at full length, and stretch his limbs as he pleases. The couch should be made light and moveable, so that he may be carried upon it in the open air for exercise. Moderate warmth is of great service, but a downy bed that gives way to the pressure of the body and sinks in- to unequal hollows cannot fail to increase the incurvation. SPECIES II. CYRTOSIS CRETINISMUS. Qtvninium CHIEFLY AFFECTING THE HEAD AND NECK; COUNTENANCE VACANI AND STUPID; MENTAL FACULTIES FEEBLE OR IDIOTIC : SENSIBILITY OB- TUSE : MOSTLY WITH ENLARGEMENT OF THE TliYROlD GLAND. Cretinism makes a very close approach to rickets in its general symptoms. It differs principally in the tendency to the peculiar enlargement of the thyroid gland, which, in France, is denominated goitre, and with us, Derbyshire-neck, and in the mental imbecility which accompanies it from the first. In treating of rhachitis we observed, that, while all the functions of the general frame are here in a state of great debility, with the exception of the mental, these last exhibited, in many instances, a precocity and a vigour rarely found in firm health. And we endeavoured to account for it by supposing that the flow of sensorial fluid instead of being in deficiency, like all the other secretions, is only disturbed in its balance; and that much of the proportion GE. IV.—SP. II.] EXCERNENT FUNCTION. 231 of this, which should be distributed among the motory fibres of the frame, and prevent that inirritability and muscular inertness by which rickets is so peculiarly distinguished, is transferred under a different modification, to the sensorium, and gives to the mental faculties a more than ordinary degree of quickness. In cretinism the organ of the brain seems to follow the fate of the rest of the body, and, in many cases, even to take the lead, so that the chief imbecility is to be fou.-.d in this region. For the peculiar symptom of goitre it is not so easy to account. We know so little of the purpose, and even of the fabric of this gland, as to be incapable of assigning its use in the animal economy, and hence, it is not much to be wondered at that its peculiar tendency to asso- ciate, in the present disease, with the morbid condition of the bones and of the intellect, should not hitherto have been ascertained. It does not always, however, accompany the other symptoms, though it is, for the most part, an associate. We have already observed that cretinism was first distinctly noticed and described by Plater about the middle of the seventeenth century, as occurring among the poor in Carinthia and the Valais ; and that it was afterwards found in a still severer degree in other vallies of Switzerland and the Alps generally ; as it has since been detected in very distant regions where the country exhibits a simi- larity of features, as among a miserable race called Caggets, inha- biting the hollows of the Pyrennees, whose district and history have been given us by M. Raymond, and as far off as Chinese Tartary, where it is represented as existing by Sir George Staunton. On the first discovery of cretinism it was ascribed by some to the use of snow-water, and by others to the use of water impregnated with calcareous earth : both which opinions are entirely without foundation. The first is sufficiently disproved by observing that persons born in places contiguous to the glaciers, and who drink no other water than what flows from the melting of ice and snow, are not subject to the disorder ; and contrarywise, that the disorder is observed in places where snow is unknown. The second is con- tradicted by the fact that the common waters of Switzerland*, in- stead of being impregnated with calcareous matter, excel those of most other countries in Europe in purity and flavour. « There is not," observes Dr. Reeve, " a village, nor a valley, but what is en- livened by rivulets, or streams gushing from the rocks. The water usually drunk at La Batia and Martigny is from the river Dranse, which flows from the glacier of St. Bernard, and falls into the Rhone; it is remarkably free from earthy matter, and well tasted. At Berne the water is extremely pure, yet, as Haller remarks, swellings of the throat are not uncommon in both sexes, though cretinism is rare. As comfortable and genial warmth form one of the best auxiliaries in attempting the cure of both cretinism and rickets, there can be no doubt that the chill of snow-water, if taken as such, must consi- derably add to the general debility of the system when labouring 232 ECCRIT1CA. [CL. VI.—OR. I. under either of these diseases, though there seems no reason for supposing that it would originate either. It is not difficult to ex- plain why water impregnated with calcareous earth should have been regarded as a cause: for in cretinism, as in rhachia, the cal- careous earth designed by nature for building up the bones, is often separated and floats loose in various fluids of the body for want of a sufficiency of phosphoric acid to convert it into a phosphate of lime, and give it solidity. And as it is, in consequence hereof, pretty freely discharged by the urine, it seems to have given rise to the opinion that such calcareous earth was introduced into the system with the common beverage of the lakes or rivers, and pro- duced the morbid symptoms. M. de Saussure has assigned a far more probable, and unquestion- ably the real cause of the disease in referring us to a few other physical features of the Alpine districts in which it makes its ap- pearance chiefly. The vallies, he tells us, are surrounded by very high mountains, sheltered from currents of fresh air, and exposed to the direct, and, what is worse, the reflected rays of the sun. They are marshy, and the atmosphere is hence humid, close, and oppressive. And when to these chorographical causes we add the domestic ones, which are also ,well known to prevail very generally among the poor of these regions, such as meagre, innutritious food, indolence and uncleanliness, with a predisposition to the disease from an hereditary taint of many generations, we can sufficiently account for the prevalence of cretinism in such places, and for the most humiliating characters it is ever found to assume* The general symptoms of cretinism are those of rhachia; but the disease shows itself earlier, often at birth, and not unfrequently before this period, apparently commencing with the procreation of the fetus, and affording the most evident proofs of ancestral conta- mination. The child, if not deformed and cachectic at birth, soon becomes so; the body is stinted in its growth, and the organs in their development; the abdomen swells, the skin is wrinkled, the mus- cles are loose and flabby, the throat is covered with a monstrous prominence, the complexion wan, and the countenance vacant and stupid. The cranium bulges out to an enormous size, and parti- cularly towards the occiput, for it is sometimes depressed on the crown, and at the temples ; insomuch that to a front Yiew the head, in some cases, appears even diminutive. The blunted sensibility of these wretched beings renders them indifferent to the action of cold and heat, and even to blows or wounds. " They are, gene- rally," observes M. Pinel, "both deaf and dumb. The strongest and most pungent odours scarcely affect them. I know a Cretin who devours raw onions and even charcoal with great avidity. A striking proof of the coarseness and imperfect development of the organ of taste. Their organs of sight and feeling are equally limited in their operation. Of moral affections they seem wholly destitute; discovering no signs of gratitude for kindness shown to them, nor attachment to their nearest relations." GE. IV.—SP. II.] EXCERNENT FUNCTION. 233 The medical treatment, if medicine can ever be of any avail, should be conducted upon the principles and consist of the process laid down under the preceding species. GENUS V. OSTHEXIA. ©sthejrg. SOFT PARTS MORE OR LESS INDURATED BY A SUPERFLUOUS SECRETION AND DEPOSITE OF OSSIFIC MATTER. Osthexia is derived from oo-Tufos, "osseous or bony," and «f/«, " habitus or habit,"—" ossific diathesis or idiosyncrasy." This morbid affection, though repeatedly alluded to and described by miscellaneous writers, has seldom been attended to in nosological arrangements. It does not occur in Dr. Cullen's Classification ; but he alludes to it in his " Catalogue of omitted Diseases" as one of those which he thinks ought not to have been omitted. We have had various occasions for remarking that as the calca- reous earth, which gives compactness and solidity to the skeleton of the animal frame, becomes waste, and is consequently absorbed and carried off, it is necessary that there should be an equal and regular supply of the same material. This is partly obtained from the lime which enters, in some proportion or other, into almost every kind of nutriment on which we feed : but it seems to be obtained also, and perhaps in a larger proportion, by some chemical elabora- tion out of the constituent principles of the blood itself: for a healthy animal of any kind appears to supply itself with the requisite quantity of bony earth whatever be the nature of its food, and though the soil on which it is grown contains no lime whatever, as is the case in several of the Polynesian islands, and throughout the whole of New South Wales, on the hither side of the Blue Mountains. In several of the preceding genera we have seen that this material is produced or secreted in deficiency : in the species appertaining to the present genus, it is, on the contrary, produced or secreted in excess : and deposited, sometimes in single organs for which it is not naturally intended, and sometimes throughout the system at large, occasionally in the parenchyma or general sub- stance of organs, and occasionally in the membranes or tunics by which they are covered and protected, or in the vessels by which they are furnished with their proper stores. We see much of this irregularity in old age, the cause of which we have already endeavoured to explain. The excernent vessels VOL. IV.—30 234 ECCR1TICA. {CL. VI.—OR. 1 of both sets, absorbents and secretories, partake of the common debility and torpitude of this advanced period. There is hence, in all probability, a smaller quantity of lime, as of every other secerned material, formed at this period than in the earlier and more vigor- ous stages: but however small the quantity, it is carried off, on account of the grossness of its corpuscles, less freely by the debilitat- ed absorbents than the finer and more attenuate fluids, and is hence apt to stagnate first in the bones themselves, which, as we have al- ready observed, are hereby rendered unduly impacted and brittle, and next in the lymphatics of every part of the system, and espe- cially those that enter into the tunics of the sanguiferous vessels, which are hereby often rendered rigid or even ossific. This is a natural consequence of the debility of advancing years. But we not unfrequently meet with a like effect in the earlier stages of life, and in persons of the fullest and most vigorous health, in which case there can be no question that the lime thus profusely and erratically deposited is produced and secreted in excess, and consequently by a state of action the very reverse of that we have thus far contemplated. The mischief thus originating,—as it appears in the parenchyma, and in the membranes or vessels of organs, and thus lays a founda- tion for two very distinct trains of symptoms,—may be contemplat- ed under the two following species : 1. OSTHEXIA INFARCIENS. PARENCHYMATOUS OSTHEXY. 2.-------- IMPLEXA. VASCULAR OSTHEXY. SPECIES I. OSTHEXIA INFARCIENS. $arencugmatotts (©stnerg. OSSIFIC MATTER DEPOSITED IN NODULES OR AMORPHOUS MASSES, IN THE PARENCHYMA OF ORGANS. The most common organs in which calculous concretions are found, are the kidneys and the bladder ; but, as in these they form detach- ed and unconnected balls, and are intimately united with local symp- toms or a morbid state of these organs and constitute only one of various kinds of concretions, it will be most convenient to consider them when treating of the particular diseases to which they give rise, or of which they are prominent symptoms. The organ in whose interior fabric the present concretions are most usually found, seems to be the pineal gland ; of which almost all the medical and physiological journals, as well domestic as GE. V. SP. I.] EXCERNENT FUNCTION. 235 foreign, give numerous examples, as do likewise D.iemerbroek, De Graaf, Schrader, and other monographists. In this gland they have also been found in other animals than man, chiefly those of the deer kind. Such deposits are also frequently found in various other parts of the substance of the brain; in the lungs :* in the substance of the heart, in one instance weighing two ounces ;! in the thymus gland ;$ in the thyroid ;§ in the parotid ;|| the sublingual, and most other glands ;1f in the deltoid and most other muscles: nor is there an or- gan in which it has not been traced on different occasions. Paulli- ni records one instance of an ossified penis, and in the Ephemera of Natural Curiosities, we meet with another.** The general pathology we have already given : the symptoms and effects vary to infinity. Most of the above cases seem to have occurred after the meridian of life ; and in many instances to have been connected with atonic gout, which, by adding to the debility of advancing age, adds to its tendenpy to form such deposits. SPECIES II. OSTHEXIA IMPLEXA. Vascular ©stueyg. OSSIFIC MATTER DEPOSITED IN CONCENTRIC LAYERS IN THE TUNICS OF VESSELS OR MEMBRANES, RENDERING THEM RIGID AND UNIM- PRESSIBLE. All the vessels and membranes as well as the more massy or com- plicated organs of the body, are subject to deposites of phosphate or carbonate of lime, from the causes already pointed out: some of which are those of weak and others of entonic action ; the former operating upon the debilitated and the aged, the latter upon the young and vigorous, who labour under a peculiar diathesis or pre- disposition to the formation of bony earth. The chief modifications appertaining to this species may be contemplated under the follow- ing varieties: • Baillie, Morb. Anat. Fasc. II. PI. 6. f Burnet, Thesaur. Med. Pract. III. 254. % Act. Med. Berol. Tom. L Dec iii. 28. § Contuli, De Lapid. &c. B Plater, Observ. Lib. III. 707. 1 Haller, Pr. de induratis corp. hum. partibus Goett. 1753. Pranser, Diss, de induratione corp, in specie ossium. Leips. 1705. ** Dec. n. Ann. V. 236 ECCRITICA. [CL. VI.—OR. 1. x Arterialis. Ossification of the aorta or other Arterial osthexy. large arteries. 5 Membranacea. Ossification of membranous or Membranous osthexy. connecting parts. y Complicata. Os>ification of different parts Complicated osthexy. . simultaneously. Where the deposite takes place in the aorta, it is rarely confined to this artery alone, but spreads to some parts of the heart, and, perhaps, of the pulmonary, or some other large artery as well. Dr. Baillie gives an instance in which a considerable portion of the right ventricle and right auricle of the heart were affected at the same time ;* and Morgagnt another in which the ossification extend- ed to the valves, and this too without having produced in the patient either palpitation or dyspnoea.! So wonderfully is the instinctive or remedial power of nature capable, in various instances, of ac- commodating the general system to morbid changes. We have other examples of the trunk of the aorta being wholly ossified,^ and in one case so rigidly, both in its ascending and de- scending branches, as to compel the sufferer to maintain an erect position.^ The most troublesome of the membranous ossifications are those of the pleura, of which an example is given by Dr. Baillie in his Morbid Anatomy :|| though the trachea affords at times severe and even fatal examples of this affection,1I in consequence of the stric- ture which is hereby occasionally produced. Mr. Chester gives a singular case of a spread of this disease over the thoracic duct, the ileum, and other abdominal viscera. Yet, in the structure of the arteries, ossification is found more frequently than in any other organ with the exception of the pineal gland: the cause of which seems to have been first glanced at by Dr. Hunter, and was afterwards followed up with much patient in- vestigation and accuracy of research by Mr. Cruickshank. The for- mer used to send round at his lectures a preparation of the patella, in which he demonstrated that the ossification of that bone began in the arteries running through the centre of the cartilage which, in young subjects, supplies the place of a bony patella. Mr. Cruick- shank on prosecuting the subject, discovered that all other bones os- sify in the same manner, and made preparations in proof cf this fact; distinctly showing that the ossification of bones is not only be- gun, but carried on and completed by the ossification of their ar- teries : and, consequently, that the arteries have a natural tendency • Morb. Anat. Fasc. V. PI. 2. t De Sed.et Cause. Ep. XX1II.11. * Buckner, Miscel. 1727, p. 305. § Guattani, De Aneurism, &c. I Fascic. II. PI. I. j Kirkring, Specileg. Anat. Obs. 27. 6E. V.—SP. II.] EXCERNENT FUNCTION. 237 to become ossific above that of all other parts of the system what- ever One of the most extensive appearances of this habit acting mor- bidly on the tunics of vessels, is related by Dr Heberden* in the Medical Transactions, in the case of a very old man who at last died suddenly, as well indeed he might, since almost the only viscus that was found, on examination, to be in a healthy state was the liver. The internal carotid and basilary arteries with many of their primary branches were ossified. Through the substance of the lungs, which firmly adhered to their walls, were scattered small calculous tumours. In the heart the valves of the left auriculo- ventricular opening were partially ossified,, those of the aorta com- pletely so, and small depositions of bony matter were found in the tendinous portions of the carneje columns. The coronary artery was ossified through its whole extent. The descending thoracic and abdominal aorta, with all their primary branches, were convert- ed into cylinders of bone, as were the external and internal lliacs. It is not necessary to pursue the description into the morbid ap- pearances of almost every other organ: and I shall only observe farther that though the substance of the brain was healthy, the ven- tricles contained about eight ounces of water. And yet with all this extent of diseased structure, the patient appeared almost to the last to be of a sound constitution and free from the usual infirmities of advanced age, with the exception of ah habitual deafness; and attained upwards of fourscore years of age before he ditd. Where this diathesis prevails very decidedly, it sometimes con- verts not merely the vessels but the whole of the tendons and the muscles into rigid bones, and Benders the entire frame as stiff and Immovable as the trunk of a tree. There is a striking illustration of this remark in a case communicated to the Royal Society by Dr. Henry of Enniskillen.! The patient was a day labourer who had enjoyed good health till the time of his being attacked with this dis- ease. It commenced with a pain and swelling in the right wrist, which gradually assumed a bony hardness, and extended up the course of the muscles as high as the elbow, the whole of which were converted into a bony hardness, and were of double their natu- ral size. The left wrist and arm followed the fate of the right: and the line of ossification next shot down to the extremities of the fin- gers on both sides, and afterwards up to the shoulders, so that the joints were completely ancylosed, and the man was pinioned. At the time of communicating this history, the same ossific mischief had attacked the right ancle with a like degree of pain, swelling. and bony induration up the course of the muscles: in which state the man was discharged from the hospital as incurable, after sali- vation had been tried to no purpose. Salivation has, indeed, often been tried, probably from its suc- * Med. Trans. Vol. V. Art. XIII. f Phil. Trans. Vol. LI. year 1759. 238 ECCRITICA. [CL. VI.—OR. I. cess in removing venereal nodes, but it doos not seem to have been of much more avail in any instance than in the present. We have pointed out two opposite causes, or rather states of bo- dy, in which a tendency to ossification chiefly shows itself. One is that of general debility, and the other of an entonic action in the assimilating organs which are chiefly concerned in the fabrication or separation of lime: and in laying down any plan for relief, it seems necessary to attend to this distinction. Where debility be- comes a predisponent of morbid ossification, it is mostly a result or concomitant of old age, a scrophulous diathesis or atonic gout: and in all these cases warmth, a generous diet, and tonic course of medi- cines will form the most reasonable curative plan that can be pur- sued ; and that which will tend most effectually to stimulate the absorbents, and prevent that retardation of bony earth in the lym- phatics and vasa vasorum, on which we have already shown the dis- ease to depend in this modification of it. On the contrary, where it occurs in the middle and vigour of life, and we have reason to believe in the existence of too much action in vessels which we cannot very accurately follow up, a reducent plan will be far more likely to prove successful. We should bleed and move the bowels freely, and restrain the patient to a low diet with a copious allowance of diluent drinks. And in both cases with a view of dissolving, as far as we are able, the calcareous matter that may morbidly exist in the system already, or be on the point of entering into it, we should prescribe a free use of the mineral or vegetable acids, as already recommend- ed under parostia fragilia. CLASS VI ECCRITICA. ORDER II. CATOTICA. BCseases affectttifl internal Surfaces. PRAVITY OF THE FLUIDS, OR EMUNCTORIES THAT OPEN INTO THE IN- TERNAL SURFACES OF ORGANS. Catotica is derived from kxtu, «infra," whence Kxrunpt^ and xxTurctrof, " inferior," and " infimus." The order includes four genera as follows, some of which will be found of extensive range: I. HYDROPS. DROPSY. II. EMPHYSEMA. INFLATION. WIND-DROPSY. III. PARURIA. MISMICTURITION. IV. LITHXA. URINARY CALCULUS. GENUS I. HYDROPS. Wvopag- PALE, INDOLENT, AND INELASTIC DISTENTION OF THE BODY, OR ITS MEMBERS, FROM ACCUMULATION OF A WATRY FLUID IN NATURAL CAVITIES. Hydrops is a Greek term (i^po^) importing an accumulation of water: and in nosology there is no genus of disease that has been more awkwardly handled. The term hydrops does not occur in Sauvages, Linneus, or Sagar, and only once in Vogel in the com- 240 ECCRITICA. [CL. VI.—OR. IL pound hydrops scroti. Linneus connects anasarca and ascites, its chief species, with tympanites, polysarcia, or corpulency and gra- viditas or pregnancy, into one ordinal division, which he names tumidom, and of which these constitute distinct genera. Sagar ar- ranges all the same under the ordinal division cachexia. Vogel pursues the same plan with the omission of graviditas or pregnancy, which he does not chuse to regard as a cachexy. Sauvages em- ploys the term hydropes, but only in connexion with fiarcales, in order to restrain it to local dropsies : so that with him ascites is a hydrops, but anasarca is not a hydrops, and does not even belong to the same order; it is an intumescentia, under which, as in the ar- rangement of Linneus, it is united with corpulency, and pregnancy ; while hydrops thoracis is an anhelatio, and occurs in a distinct place and volume. Dr. Cullen has certainly, and very considerably, improved upon his predecessors in this range of diseases. After Sauvages he takes intumescentije for the name of his order; but divides it into the four sections of adiposse, flatuosae,aquosae vel hydropes, and solidae ; while under the third section (the aquosae vel hydropes) he intro- duces all the family of dropsies, whether general or local, instead of sending them with those who preceded him, to different quar- ters. It would, however, have been a much greater improvement, and have added to the simplicity he aimed at, to have employed hydrops as a generic, instead of hydropes as a tribual or family term. It is to Boerhaave we are indebted for the first use of hy- drops as employed in the present method ; and he has been follow- ed by Dr. Macbride and Dr. Young with a just appreciation of his correctness. The species of this genus, which extend over the body generally or almost all the different parts of it, are the following : 1. HYDROPS CELLULARIS. CELLULAR DROPSY. 2. -------- CAPITIS. DROPSY OF THE HEAD. 3.--------SPIN.*. ------------- SPINE. 4. ■ THORACIS. ■ CHKST. 5.--------ABDOMINIS. ------------- BELLY. 6. ——— OVARII. —---' OVARY. 7. -------- TUBALIS. _________ FALLOPIAN TUBE. 8. -------- UTERI. ■ ---- WOMB. 9. ———- SCROTI. ■■ SCROTUM. Before we enter upon a distinct view of the history and treat- ment of these several species, it may be convenient to give a glance at the general pathological principles which apply to the whole. All dropsies proceed from similar causes, which, as they are general or local, produce a general or local disease. The common predisponent cause is debility. The remote causes are very nu- merous, and most of them apply to every form under which the disease makes its appearance; for the accumulation of watery fluid GE. L] EXCERNENT fUNCTION. 241 which constitutes the most prominent symptom of the malady, may be produced by a profuse halitus from the terminal arteries occa- sioning too large a supply of that fine lubricating fluid which, as we have observed in the Physiological Proem to the present Class, flows from the surface of all internal organs and enables them to play with ease and without attrition upon each other; it may be produced by a torpid or inactive condition of the correspondent absorbents occasioning too small a removal of this fluid, when it has answered its purpose and is become waste matter; or it may be produced by each of these diseased conditions of both sets of ves- sels, operating at the same time; and it is to this double deviation from healthy action that Dr. Cullen applies the name of an hydropic diathesis. Want of action on the part of the absorbents is, in every instance, the result of debility. Profuse exhalation on the part of the secern- ents or terminal arteries, in most cases, proceeds from alike cause, for it takes place from a relaxed state of these vessels, which open their mouths too widely, and suffer the serum or other aqueous fluid to escape with too much freedom. Dropsy is, in most instances, therefore, a disease of debility; and, if we minutely attend to the histories of those who are suffering from this disease, we shall generally find that they have for some time antecedently, been labouring under debility either general or local: that they are weakened by protracted fevers; or languishing under the effects of an unkindly lying-in ; that they have unstrung their frames by a long exposure to a cold and moist atmosphere ; or have worn themselves out by hard labour ; or, which is still worse, by hard eating and drinking ; or that they are suffering from habi- tual dyspepsy or some other malady of the stomach or chylopoetic organs, especially the liver, which destroys or deranges the diges- tive process, and hence lays a foundation for atrophy. And for the same reason, innutritious or indigestible food is a frequent cause of some species of this disease :* as is also great loss of blood from any organ, and especially when such discharge becomes periodi- cal. Where the digestive organs are in a very morbid state dropsy may take place as a result of general debility ; but it more common- ly occurs from that peculiar sympathy which prevails so strikingly between the two ends of the extensive chain of the nutritive, or,in other words, the digestive and assimilating powers, which we had occasion to explain when treating of marasmus :! the inertness and relaxation of the excernent vessels being, in this case, produced by the torpitude of the chyloppetic viscera; and the usual forms of dropsy being those of the cellular membrane or of the abdomen. Hence a single indulgence in large draughts of cold drinks, and especially of cold water when the system is generally heated and * Obererzg'ebiirgisches Journ. IV. St. ! Vol. IT. p. 475. 482. VOL. IV.—31 X»42 ECCRITICA. [CL. VI.—OR. II exhausted has occasionally proved sufficient to produce dropsy in one of these forms; of which we have a striking example in the army of Charles V. during its expedition against Tunis, the greater part of it, as we are told by De Haen, having fallen into this disease in consequence of having freely quenched their thirst with cold water in the midst of great fatigue and perspiration.* A like sympathy not unfrequently takes place between several other organs and the mouths of the excernents : as the skin and the uterus : the former as loaded with an extension of the same termi- nal vessels, and the latter as maintaining an influence over almost every part of the frame. It was partly perhaps from sympathy with the skin, and as participating in the chill and consequent coir lapse of its capillaries produced by the coldness of the beverage, that the excernent system became affected in the extensive dropsy just alluded to in the army of Charles V. And we frequently per- ceive a similar effect on a sudden suppression or repulsion of cuta- neous eruptions, the mouths of the excernent vessels opening into internal cavities partaking of the torpitude of the cutaneous capil- laries. The sympathetic influence exercised over the same ves- sels by a morbid state of the uterus is not less manifest; for in chlorosis the abdomen becomes tumid, and the lower limbs edema- tous ; and, on the cessation of the catamenia, cellular or abdominal dropsy are by no means uncommon. Such are the general causes of cellular dropsy as well proximate as predisponent. But there are a few other causes which it is ne- cessary to enumerate as acting occasionally, though the effects pro- duced by some of them can hardly be called dropsy in the proper and idiopathic sense of the term. In the first place, the absorbents are supposed by some patholo- gists, as M. Mezler! and Dr. Darwin, to be at times affected with a retrograde action, and hence to pour forth into various cavities of the body a considerable mass of fluid instead of imbibing and car- rying it off. Next, the exhalants of an organ, though themselves in a state of health, may throw forth an undue proportion of fluid in consequence of some stimulus applied to them. The most common stimulus to which they are exposed is distention and that by a re- tardation of the blood in the veins, and a consequent accumulation in the arteries. This retardation or interruption of the flow of venous blood may arise from diseases of the right ventricle of the heart or its valves; from various affections of the lungs or their surrounding muscles ; from an upright posture continued without intermission for many days and nights, as is often the case in month- ly nurses; from a gravid uterus, whence the edematous ancles of pregnant women ; from scirrhous or other obstructions in the liver or spleen; from polypous concretions in the veins, aneurisms in the * Rat. Med. Part V. 38. 90. ! Von der Wassersucht. UE. L] EXCERNENT FUNCTION. 243 arteries, or steatomatous or other hard tumours in the vicinity of the larger arterial trunks. In some cases inflammation succeeds to distention, and th« quan- tity of fluid poured forth is still more considerable. It is from this double source of stimulus, distention and inflammatory action, that the ventricles of the brain become filled in meningic cephalitis, aud the cavity of the pericardium occasionally in carditis. Thirdly, the aqueous fluid of a cavity may be unduly augmented, and consequently dropsy ensue, from a rupture of the thoracic duct, or of a large branch of the lacteal vessels. These, however, are not common causes ; the lymphatics of the kidneys may, perhaps, most frequently have produced the disease when ruptured by acci- dent or idiopathic affection in the case of renal ischury; during which the watery parts of the blood that should pass off by the kid- neys have been thrown back into the system, and lodged in some cavity. And it is probable that when dropsy follows upon long ex- posure to a cold damp atmosphere, it is produced, in some instan- ces, in the same manner ; the fluid that should pass off by the ex- halants of the skin, but which cannot in consequence of having lost their power; being, in like manner thrown back into the blood and transferred to and accumulated in improper channels. Fourthly, the skin is said, at times, to be in a condition to absorb moisture too freely from the atmosphere ;* the stomach is said, as m the case of dipsosis avens, to demand too large a quantity of li- quids to quench its insatiable thirst ;f and the blood is said to be in a state of preternatural tenuity from saline acrimony ;| and each of these conditions it is affirmed has occasionally proved a source of dropsy. The first of these unquestionably occurs at times during dropsy, and all of them may have operated as causes: but preterna- tural tenuity of blood, adequate to and producing such an effect is very uncommon from any cause ; and the remedial power of na- ture is at no loss for means to carry off a superabundance of fluidity introduced by any means into the system, provided the excernent function itself be not diseased. From this diversity of causes we may reasonably expect that the dropsical fluid discharged upon tapping should exhibit different properties, not only in different organs, but in different cases in the same organ. And hence, it is sometimes found nearly as thin as water, incapable of coagulating when exposed to heat, which only renders it turbid; while, at other times, it flows in a ropy state, and accords, upon exposure to heat, with the natural serum of the blood. A similar discrepancy is discoverable in its colour or some • Erastus, Disp. IV. p. 206. De Haen, Rat. Med. P. IV. p. 125. seq. ! Buchner, Miscell. 1730. p. 888. Mondschien, p. 12. i Galen, Oe Lymph. Caus. Lib. III. cap. 8. Van Swieten ad Sect. 1229. 244 ECCRITICA. [CL. VI.—OR. If, other condition > for it has sometimes been found black and fetid,* bloody, sanious, milky,! green,| yellowish, or peculiarly acrid.§ In some instances it has resembled the glairy ichor of sores in a languid constitution or degenerated habit; and according to Gua- thani and Steidele it has at times appeared oily.|j It has been oc- casionally so urinous or ammoniacal as to turn syrup of red poppies green :t and, according to Dr. M'Lacklan, has sometimes contain- ed so much soda as by the addition of sulphuric acid to produce Glauber's salt** with little or no trouble. From the nature of the fluid itself, therefore, we have a clear proof that the causes of dropsy must be different in different cases. In augmented secretion, impeded absorption, or the rupture of a lymphatic vessel, the accumulated fluid should contain nothing more than the ordinary constituents of the halitus that naturally moistens the cavity into which it is discharged. A relaxed state of the ex- halants may admit particles of greater bulk, and even red blood: in which case the fluid may differ both in viscidity and colour. While, on the other hand, morbid collections of water must proceed from a cause of a very different nature ; probably from the exhalant arteries being themselves so altered by disease as to change the properties of the fluid which passes through them: or the general mass of blood being so attenuate or otherwise vitiated as to affect the secretion. In the last case, dropsy is not a primary disease, but the consequence of some other, generally perhaps of a morbid liver, spleen, or lungs.!! SPECIES I. HYDROPS CELLULARIS. (Ecllular Bvopus. COLD AND DIFFUSIVE INTUMESCENCE OF THE SKIN, PITTING BENEATH THE PRESSURE OF THE FINGERS. This species includes three varieties, as it is general to the cel- • Galeazzi, in Com. Bonon. Tom. VI. f Willis, Pharmaceutice Kationalis. Med. Com. of Edinb. Vol. V. * RGcker, Comm. Lib. Nor. 1736. S Du Verney, Memoirs de Paris, 1701. p. 193. II Guat. De Aneurismatibus. Steid. Chirurg. Beobacht. B. I. 1 De Haen, Rat. Med. P. XI. p. 214. •* Med. Comm. Edinb. IX. II. f[ Hewson Descript. of the Lymph. Syst. Ch. XII. f.E. I.—SP. I.} FXCERNENT function. 245 lular membrane, limited to the limbs, or accompanied with a com- bination of very peculiar symptoms, and especially severe, and in most cases fatal, dyspnoea : « Generalis. Extending through the cellular mem- General dropsy. brane of the whole body. Z A^uum. Limited to the cellular membrane of Edema. the limbs, chiefly of the feet and ancles; and mostly appearing in the evening. y Dyspnoica. Edematous swelling of the feet, stiff- Dyspnetic Dropsy. ness and numbness of the joints ; the swelling rapidly ascending to the belly, with severe and mostly fatal dyspnoea. It is under the first of these varieties that cellular dropsy usually appears as an idiopathic affection. Where the intumescence is confined to the limbs, it is usually a symptom or result of some other affection, as chlorosis, suppressed catamenia or any other habitual discharge ; a disordered state of the habit produced by a cessation of the catamenial flux ; repelled eruptions ; or the weak- ness incident upon protracted fevers, or any other exhausting ma- lady. The third variety is introduced upon the authority of Mr. W. Hunter, and taken from his Essay, published at Bengal in 1804. The disease appeared with great frequency among the Lascars in the Company's service in 1801. Its attack was sudden and its progress so rapid that it frequently destroyed the patient in two days. From the description it does not seem to have been connected with a scorbutic diathesis : and Mr. Hunter ascribed it to the concurrent causes of breathing an impure atmosphere, suppressed perspiration, want of exercise, and a previous life of intemperance. All or any of these may have been auxiliaries, but the exciting cause does not seem to have been detected. The second and third varieties, however, may be regarded as the opening and concluding stages of cellular dropsy : for before the disease becomes general it ordinarily shows itself in the lower limbs, and in its closing scene the respiration is peculiarly difficult and forms one of its most distressing symptoms. General or local, debility is its predisposing cause, ordinarily brought on by hard labour, intemperance, innutritious food, fevers of various kinds, exhausting discharges, or some morbid enlarge- ment of the visceral or thoracic organs that impedes the circulation of the blood, and produces congestion and distension. The disease is hence common to all ages though most frequently found in advanced life; the edema of the feet and ancles, with which symptoms it opens, appears at first only in the evening, and yields to the recumbent position of the night. By degrees it becomes more permanent and ascends higher, till not only the thighs 246 ECCRITICA. [CL. IV—OR. II. and hips, but the body at large is affected, the face and eye-lids are surcharged and bloated, and the complexion, instead of the ruddy hue of health, is sallow and waxy. A general inactivity pervades all the organs, and consequently all their respective functions. The pulse is slow, often oppressed, and always inelastic: the bowels are costive, the urine for the most part small in quantity, and conse- quently of a deeper hue than usual: the respiration is troublesome and wheezy, and accompanied with a cough that brings up a little dilute mucus which affords no relief to the sense of weight and oppression. The appetite fails, the muscles become weak and flaccid, and the general frame emaciated. Exertion of every kind is a fatigue, and the mind, partaking of the hebetude of the body, engages in study with reluctance, and is overpowered with drowsi- ness and stupor. An unquenchable thirst is a common symptom; and where this is the case the general irritation that is connected with it sometimes excites a perpetual feverishness that adds greatly to the general debility. In some parts the skin gives way more readily than in others, and the confined fluid accumulates in bags. At other times the cuticle cracks, or its pores become an outlet for the escape of the fluid, which trickles down in a perpetual ooze. The difficulty of breathing increases partly from the overloaded state of the lungs, and partly from the growing weakness of the muscles of respiration: the pulse becomes feebler and more irregular, slight clonic spasms occasionally ensue, and death puts a termination to the series of suffering. Yet the progress is slow, and the disease sometimes continues for many years. In attempting a cure of cellular dropsy, and indeed of dropsy in general, for it will be convenient to concentrate the treatment, we should first direct our attention to the nature of its cause with a view of palliating or removing it. We are next to unload the sys- tem of the weight that oppresses it. And lastly to re-establish the frame in health and vigour. Simple edema, or swelling of the extremities is often, as we have already observed, a symptom or result of some other complaint, as chlorosis or pregnancy, or some other cause of distention. In the two last cases it may be palliated by bleeding, a recumbent position, and other means adapted to take off the pressure. In chlorosis it can only be relieved by a cure of the primary affection. In like manner, general dropsy may be dependent upon a habit of intem- perance, or a sedentary life, or innutritious food, or an obstinate fit of jaundice; and till these are corrected no medicinal plan for evacuating the accumulated water can be of any avail. For, if we could even succeed in carrying it off, it would again collect, so long as the occasional cause continues to operate. The occasional cause, however, may no longer exist, as where it has been produced by a fever or an exanthem that has at length ceased though it has left the constitution an entire wreck. Or it may exist and be itself incurable, as where it proceeds from a GE.L—SP.L] EXCERNENT FUNCTION. 247 scirrhous induration or some other obstruction of one of the larger viscera of the thorax or abdomen : and in this case our object should be to remove with all speed the mischievous effects, and palliate the organic cause, as far as we are able, according to its peculiar nature, so that it may be less operative hereafter. A removal of the accumulated fluid from the cellular membrane generally has been attempted by internal and external means, as hydragogues of various kinds, and scarification or other cutaneous drains. The hydragogues or expellents of water, embrace medicines of all kinds that act powerfully on any of the excretories, though the term has sometimes been limited to those that operate on the excretories of the intestines alone. And it becomes us therefore to contemplate them under the character of purgatives, emetics, diaphoretics, and diuretics. The purgatives that have been had recourse to are of two kinds, those of general use, and those that have been supposed to act with some specific or peculiar virtue in the removal of the dropsi- cal fluid. Among the first we may rank calomel, colocynth, gamboge, scammony, jalap, and several other species of convolvulus, as the greater white bind-weed (convolvulus Sefiium, Linn) : the turbeth plant (c. Turfiethum, Linn.): and the brassica marina, as it is called in the dispensatories (c. Soldanella, Linn.). These may be employ- ed as drastic purgatives almost indiscriminately, and their compara- tive merit will depend upon their comparative effect, for one will often be found to agree best with one constitution and another with another. We need not here except calomel, unless indeed, where given for the purpose of resolving visceral infarctions ; since in any other case it can only be employed in reference to its.influence upon the excretories generally, and particularly those of the intestinal canal. The purgatives that have been supposed to operate with a specific effect in dropsies are almost innumerable. We must con- tent ourselves with taking a glance at the following, grana Tiglia, or bastard ricinus ; elaterium ; elder, and dwarf elder; black helle- bore ; senega; and chrystals of tartar. The croton Tiglium, or bastard ricinus, affording the grana Tiglia of the pharmacopoeias, is an acrid and powerful drastic in all its parts, root, seeds, and expressed oil. The oil is of the same character as the oil of castor, but a severer and more acrimonious purge ; insomuch, indeed, that a single drop prepared from the dry seeds is often a sufficient dose; while a larger quantity proves cathartic when rubbed on the navel. In India the seeds themselves have long been given as a hydragogue; two being sufficient for a robuster constitution, one for a weaklier; and four proving some- times fatal. From the uncertainty and violence of the action of this plant, the elaterium or inspissated juice of the wild cucumber, is a far 248 ECCRITICA. [CL. VI.—OR. II. preferable medicine. Elaterium, however, has been objected to as unduly stimulant; and both Hoffman and Lister observe that its ef- fect in increasing the pulse is perceivable even in the extremities of the fingers. It is on this account that it seems chiefly to have been neglected by Dr. Cullen ; who admits that he never tried it by itself, or otherwise than in the proportion of a grain or two in com- position with other purgatives. And it is hence, also, that attempts have been made to obtain a milder cathartic from the roots of the plant by infusion in wine or water,* than from the dried fecula of the juice, which is the part ordinarily employed. Admitting the stimulant power here objected to, it would only become still more serviceable in cold and indolent cases from local or general atony ; but even in irritable habits in cellular dropsy, I have found it high- ly serviceable in a simple and uncombined state, produced, as it ultimately appeared, and especially in one instance, from a thicken- ing of the walls of the heart, in a young lady of only thirteen years of age. It is best administered in doses of from half a grain or a grain to two grains, repeated every two or three hours for five or six times in succession according to the extent of its action. Evacuation by the alvine canal is the most effectual of any ; nor can we depend upon any other evacuation unless this is combined with it. The elder tree, and dwarf elder (Sambucus nigra, and s. Ebulus) have been in high estimation as hydragogues by many practitioners. Every part of both the plants has been used ; but the liber or inner bark of the first, and the rob or inspissated juice of the berries of the last, have been chiefly confided in. Dr. Boerhaave asserts that the expressed juice of the former given from a drachm to half an ounce at a dose, is the most valuable of all the medicines of this class, where the viscera are sound ; and that it so powerfully dis- solves the crasis of the different fluids, and excites such abundant discharges that the patient is ready to faint from sudden inanition. Dr. Sydenham confirms this statement,asserts that it operates both upwards and downwards, and in no less degree by urine, and adds, that in his hands it has proved successful in a multitude of hydropic cases.! Dr. Brocklesby preferred the interior bark of the dwarf elder,! as Sydenham and Boerhaave did that of the black, or com- mon elder. Dr. Cullen seems to have been prejudiced against both, though he admits that he never tried either, notwithstanding that he had often thought of doing so :§ and it is chiefly, perhaps, from his unfavourable opinion of their virtues, that they may seem in our own day to have sunk into an almost total disuse. Chesneau employed indifferently the seeds, and their expressed oil, the root • Bondluc, Hist, de l'Acad. Royal de Sciences de Paris. ! Opp. p. 627, 768. * tEconom. and Med. Observ. p. 278. § Mat. Med. Vol. I. p. 534. UE. I.—SP. I.] EXCERNENT FUNCTION. 249 and the inspissated juice of the root: though he preferred the s. Ebulus to the s. nigra.* The melampodium or black hellebore, was at one time a favour- ite cathartic in dropsies, and has the testimony of high authorities for having very generally proved efficacious and salutary. The ancients found the plant which they employed under this name so severe in its purgatives qualities, that they were obliged to use it with great caution ; but we have reason to believe that the black hellebore of the present day is a different production,.as it is mild- er in its effects than the hellebore of Dioscorides, and different in some of its external characters. Its root was the part selected, and the fibres of the roots, or their cortical part rather than the inter- nal. These were employed either in a watery infusion or extract. Mondschein! preferred on all occasions, the latter; Quarin used either indifferently.! Bacher invented a pill which was once in very high reputation, and sold under his own name all over Europe, for the cure of dropsy, in which an extract of this root, obtained, in the first instance, by spirit, formed the chief ingredient; the other^ being preparations of myrrh and carduus benedictus. These pills were said to produce a copious evacuation both by stool and urine ; and by this combined effect to carry off the disease. They have however had their day, and are gone by, apparently with too little consideration upon the subject: for the experiments of Daig- nau and De Home, and especially the successful trials in the French Military Hospitals, as related by M. Richard§ to say nothing of Dr. Bacher himself, do not seem to have excited sufficient attention. In our own country, since the days of Dr. Mead, the black helle- bore has been limited to the list of*emmenagogus, and even in this view is rarely employed at present. Whether this plant prove pur- gative, as has been asserted, when applied to the body externally in the form of fomentations or cataplasms like the croton I have never tried. Ferrara, employed as hydragogues, the black' and white hellebore indiscriminately. The seneka or senega (polygala Senega, Linn.) was another me- dicine much in use about a century ago, and reputed to be of very great importance in dropsy, Irom its combined action upon the kid- neys and intestines, and, indeed, all the excretories. It reached Europe from America, where it had been immemorially employed by the Senegal Indians, from whom it derives its specific name, as an antidote against the bite of the rattle-snake. The root of the plant is the part chiefly, if not entirely, trusted to, and this is given in powder, decoction, or infusion. M. Bouvart found it highly ser- viceable as a hydragogue, but observes that, notwithstanding this • Lib. III. Cap. iii. Obs. 8. ! Von der Wassersucht, &c. \ Animadversiones, &c. § Recueil des Observations de Medicine des H&spitaux Militaires, &c. Tom, II. 4to. Paris. vol. IV.—32 350 ECCRITICA. [CL. VI.—OR. II. effect, it does not of itself carry off the induration or enlargement of infarcted viscera, and ought to be combined with other means. It was very generally employed by Dr., afterwards Sir Francis Mil- man, in the Middlesex Hospital, and has again found a place in the Materia Medicain the London College. There are unquestionable instances of its efficacy in the removal of dropsy when it has been carried so far as to operate both by the bowels and the kidneys. It has, however, often failed; and, as Dr. Cullen observes, is a nause- ous medicine which the stomach does not easily bear in a quantity requisite for success. A far more agreeable, if not more effectual medicine in the case of dropsy, is the super-tartrate of potass, in vernacular lan- guage the cream or crystals of tartar. In small quantities and very largely diluted with water, or some farinaceous fluid, it quenches the thirst most pleasantly, and, at the same time, in most cases, proves powerfully diuretic. But it is as a purgative we are to con- template it at present: and to give it this effect it must be taken in a much larger quantity, never less than an ounce at a dose, and ot- ten considerably above this weight. Thus administered it proves powerfully cathartic, and excites the action of the absorbents in every part of the system far more effectually than is done by the influence of any entirely neutral salts. " I need hardly say," ob- serves Dr. Cullen, " that upon this operation of exciting the absor- bents, is chiefly founded the late frequent use of the crystals of tartar in the cure of dropsy."* Dr. Cullen, in this passage, appa- rently alludes to the practice of his friend Dr. Home, who was pe- culiarly friendly to its use, and in his Clinical Experiments relates twenty cases in which he tried it, and completed a radical cure in fourteen of them, no relapse occurring notwithstanding the frequen- cy ol such regressions. The practice, however, is of much earlier date than Dr. Cullen seems to imagine ; for Hildanus represents the physicians of his day as at length flying to it as their sheet anchor, and deriving from it no common benefit.! On the Continent it has generally, but very unnecessarily, been united with other and more active materials, as jalap, gamboge, or some of the neutral salts, chiefly vitriolated tartar, or common sea-salt; the latter in the proportion of from three to eight drachms of each daily, largely diluted with some common drink-! Another powerful source of evacuation that has often been had recourse to for the cure of dropsy, is emetics : and, though, little in use in the present day they have weighty testimonies in their fa- vour among earlier physicians. Their mode of action has a resem- blance to that of the drastic purgatives ; for, by exciting the sto- mach to a greater degree of secretion, they excite the system gene- rally ; and, in fact, far more extensively and more powerfully than * Mat. Med. 11. 513. 4to. Edit. ! Cent. IV. Obs.4.\ i Medicinisches Wochenblatt, 1781. N. 40. GE. L—SP. I.] EXCERNENT FUNCTION. 251 can be accomplished by mere purgatives, in some degree from the greater labour exerted in the act of vomiting, but chiefly from the closer sympathy which the stomach exercises over every other part of the system than the alvine canal, or, perhaps, any other organ, can pretend to. In cases of great debility, however, it must be ob- vious that such exertion would be too considerable and would only add to the general weakness; and it is on this account chiefly that the prac- tice has been of late years very much discontinued in our own country. It is in consequence of this extensive sympathy of the stomach with every part of the system that emetics have often proved peculiarly serviceable in various local dropsies, especially that of the scrotum when limited to the vaginal sheath, and that of the ovarium, when discovered in an early stage. And from this cause, in combination with powerful muscular pressure, they have often acted with prompt and peculiar efficacy on ascites or dropsy of the abdomen : while Withering, Perceival, and many of the foreign journals* abound with cases of the cure of ascites by a spontaneous vomiting Diaphoretics have also been resorted to as very actively pro- moting the evacuation of morbid fluids; and many instances are related by Bartholet,! Quarint and others, of the complete success of perspiration when spontaneously excited. Tissot tells us that it was by this means Count Ostermann was cured, a very copious sweat having suddenly burst forth from his feet, which continued for a long time without intermission. In the Medical Transactions there is a very interesting case of an equal cure effected by the same means, in a letter from Mr. Mudge to Sir George Baker. The form of the disease was, indeed, an ascites, but it will be more convenient to notice it here, while discussing the treatment of dropsy generally than reserve it for the place to which it more immediately belongs. The patient, a fe- male of about forty years old, had laboured under the disease for twenty years : *he abdomen was so extremely hard as well as en- larged, that it was doubtful whether the complaint was not a para- bysma complicatum, or physcony of various abdominal organs, and tapping was not thought adviseable. She was extremely emaciat- ed : had a quick, small pulse, and insatiable thirst; voided little urine, breathed with difficulty, and could not lie down in her bed for fear of suffocation. For an accidental rheumatism in her limbs she had four doses of Dover's powder prescribed for her, of two scruples in each dose, one dose of which she was to take every night. The first dose relieved the pain in her limbs, but did nothing more. An hour or two after taking the second dose on the ensuing night she began to void urine in large quantities, which she con- tinued to do through the whole night, and as fast as she discharged * Sammlung Medicinischen Wahrnemungen, B. VIII. p. 220. N. Sammlung, &c. B. VIII. p. 114. Schulz. Schwed. Abhundlungen, B. XXI. p. 102. T Apud. Bonet. Polyalth. IV. 47. ± Animadversiones, &c. 252 ECCRITICA. [CL. VI.—OR. II the water her belly softened and sunk. The third dose completed the evacuation ; and " thus," observes Mr. Mudge,"was this formi- dable ascites, which had subsisted near twenty years, by a fortu- nate accident carried off in eight and forty hours." The cure, too, was radical : for the constitution wholly recovered itself, and the patient was restored to permanent health. We may observe from this case that the viscera are not neces- sarily injured by being surrounded or even pressed upon by a very large accumulation of water for almost any length of time. It should be noticed, also, in connection with this remark, that the patient before us was not much more than in the middle of life, even at the date of her cure : at which period we have more reason to hope for a retention of constitutional health in the midst of a chronic and severe local disease, than at a later age. And there can be no question that sudorifics will be found more generally successful in establishing a harmony of action between the surface and the kidneys, and produce less relaxation of the system at this than at a more advanced term of life. But except where there is such a concurrence of favourable points sudorifics can be but little relied upon in the treatment of dropsy, and are rather of use as auxiliaries than as radical remedies. They are also open to the same objection as emetics: they are apt, as Buchner has well observed, to do mischief by relaxing and debi- litating ;* and instances are not wanting in which they have very seriously augmented the evil-! Diuretics are a far more valuable class of medicines, and there are few of them that operate by the kidneys alone; the intestines, the lungs, and oftentimes the whole surface of the body, internal as well as external, usually participating in their action. Of diuretics, the most powerful, if not the most useful, is fox-glove. It was in high estimation with Dr. Withering, and Dr. Darwin regards it almost as a specific in dropsies of every kind ; though he admits that it does not succeed so certainly in evacdating the fluid from the abdomen, as from the thorax and limbs. The preparation usually employed by the latter was a decoction of the fresh green leaves, which, as the plant is a biennial, may be procured at all seasons of the year. Of these he boiled four ounces in two pints of water till only one pint remained ; and added two ounces of vinous spirit after the decoction was strained off Half an ounce of this decoction constituted an ordinary dose, which was given early in the morning and repeated every hour from three to eight or nine doses, or till sickness or some other disagreeable sensation was induced. In the hands of Sir George Baker, even when used in the form recommended by Dr. Darwin, its success was occasionally, very doubtful; while in some cases it was highly injurious without * Diss, de diversa Hydropi Medendi Methodo. Hal. 1766. ! Piso, de Morb. ex serosa Coll. Obs. 1. GE. I.—SP. I.] EXCERNENT FUNCTION. 253 the slightest benefit whatever.* Even where it acts very power- fully as a diuretic} and carries off five or six quarts of water a day, it often excites such incessant nausea, sinking, giddiness, and dim- ness of sight, and such a retardation and intermission of the pulse, that the increased evacuation by no means compensates for the in- creased debility. And by a repetition it is often found to lose even its diuretic effects. In the powder made into pills it seems to operate with an equal uncertainty. It has sometimes produced a radical cure without any superinduced mischief: but in other cases it has been almost or altogether inert. Sir George Baker gives an instance of this inert- ness both in the decoction and in pills. In a trial with the former the dose was six drachms every hour for five successive hours during two days, through the whole of which it had not the least efficacy, not even exciting nausea. In a trial with the latter, three pills, containing a grain of the powder in each, were given twice a day for several days in succession. They gave no relief whatever ; nor produced any other effect than giddiness and dimness of sight. It is not wonderful, therefore, that the fortune of fox-glove should have been various: that at one time it should have been esteemed a powerful remedy, and at another time been rejected as a plant totd substantia venenosa. Its roots have been tried as well as its leaves; and apparently with effects as variable but less active. It seems to have been first introduced into the London Pharmaco- poeia in 1721—folia, flores, semen ; was discarded in the ensuing edition of 1746, and has since been restored in its folia alone: hav- ing encountered a like alternation of favour and proscription in the Edinburgh College. It is greatly to be wished that some mode or management could be contrived, by which its power of promoting absorption might be exerted without the usual accompaniment of its depressive effects. When recommended so strenuously by such characters as Dr. Darwin, and more particularly Dr. Withering, from a large number of successful cases, it is a medicine which ought not lightly to be rejected from practice, and should rather stimulate our industry to a separation of its medicinal from its mischievous qualities. Upon the whole, the singular fact first noticed by Dr. Withering seems to be sufficiently established, that in all its forms it is less injurious to weakly and delicate habits than to .those of firmer and tenser fibres.! The most useful of the diuretic class of medicines is the siliquose and alliaceous tribes; particularly the latter, comprising leeks, onions, garlic, and especially the squill. The last is always a valuable and important article, and Sydenham asserts that he has cured dropsies by this alone. It has the great advantage of acting generally on the secernent system, and consequently of stimulating the excretories of the alvine canal as well as those of the kidneys. * Medical Transactions, Vol. III. Art. XVII. ! Essay on Digitalis, p. 189. 254 ECCRITICA. [CL. VI.—OR. II. It sometimes, indeed, proves a powerful purgative by itself; but is always an able associate with any of the cathartics just enumerat- ed. It may be given in any form, yet its disgusting taste points out that of pills as the least incommodious. When intended to act by the kidneys alone, Dr. Cullen advises that it should be combined with a neutral salt; or, if a mercurial adjunct be preferred, with a solution of corrosive sublimate, which seems to urge its course to the kidneys quicker and more complete- ly than any other preparation of mercury.* It may, also, be observ- ed that the dried squill answers better as a diuretic than the fresh ; the latter as being more acrimonious, usually stimulating the sto- mach into an increased excitement, which throws it off by stool or vomiting, too soon for it to enter into the circulating system. The colchicum autumnale, or meadow-saffron, ranks next, per- haps, in point of power as a diuretic, and is much entitled to atten- tion. It is to the enterprising spirit of Dr. Stoerckthat we are chief- ly indebted for a knowledge of the virtues of this plant, whose experiments were made principally on his own person. The fresh roots, which is the part he preferred, are highly acrid and stimu- lating ; a single grain wrapped in a crumb of bread and taken into the stomach, excites a burning heat and pain both in the stomach and bowels, stranguary, tenesmus, thirst, and total loss of appetite. And even while cutting the roots, the acrid vapour that escapes, irritates the nostrils and fauces; and the substance held in the fingers, or applied to the tip of the tongue, so completely exhausts the sensorial power, that a numbness or torpitude is produced in either org&n, and continues for a long time afterwards. According to Stoerck's experiments this acrimony is best corrected by infusion in vinegar; to which he afterwards added twice the quantity of honey.! In the form of an acetum, and of the strength be proposed, it is given as a preparation in the extant London Pharmacopoeia, while most of the other colleges have preferred his oxymel. Stoerck used it under both forms, but, perhaps, the best preparation is the wine, as recommended by Sir Everard Home in cases of gout, depurated from all sediment, as already noticed under the latter disease. Stoerck began with a drachm of this twice a-day, and gradually increased it to an ounce or upwards. Hautesierk asserts that it is less efficacious than the oxymel of squills \ The other diuretics, in common use, are of less importance; though many of them may be found serviceable auxiliaries as they may easily enter into the dietetic regimen. These are the sal diureti- cus, or acetate of potash, which very slightly answers to its name, unless given in a quantity sufficient to act at the same time as an aperient; nitrous ether ; juniper berries, broom-leaves, and which is far better, broom-ashes ; or either of the fixed alkalies ; and the * Mat. Med. Vol. II. Part II, Ch. xxi. ! Libellus de Radice Colchice autumnali. Vindob. 1763. 8vo % Recueil. II. GE. I.—SP. 1.] EXCERNENT FUNCTION. 255 green lettuce, lactuca virosa, strongly recommended by Dr. Collin of Vienna, but as far as it has been tried in this country far beyond its merits. Dr. Collin, however, asserts that out of twenty-four dropsical patients he cured by this medicine all but one. To this class of remedies we have yet to add dandelion (Leonto- don taraxacum, Linn.) and tobacco. The former of these was at one time supposed to act so powerfully and specifically on the kid- nies as to obtain the name of lectimitiga ; and is said by some writers to have effected a cure in ascites after every other medicine had failed. It is truly wonderful to see how very little of this virtue it retains in the present day, so as to be scarcely worthy of atten- tion: while with respect to tobacco, notwithstanding the strenuous recommendation of Dr. Fowler, it is liable to many of the objections already started against fox-glove. The gratiola officinalis or hedge-hyssop, w.as once extensively employed, both in a recent state of its leaves and in their extract, and like many other simples, it appears to have been injudiciously banished from the Materia Medica. In both forms it is a power- ful diuretic, and often a sudorific; and in the quantity of half a drachm of the dry herb, or a drachm of infusion, whether in wine or water, it becomes an active emetic and purgative. It is said to have been peculiarly useful in dropsies consequent upon parabysma, or infarc- tion of the abdominal viscera; and in such cases seems still entitled to our attention. As a strong bitter, it may, like the lactuca virosa, which is also a strong bitter, possess some degree of tonic power, in connection with its diuretic tendency. The bitter, however, is of a disagreeable and nauseating kind, which it is not easy to cor- rect. The external means of evacuating the fluid of cellular dropsy are blisters, setons, or issues, punctures, and scarification. The last is as much less troublesome as it is usually most effectual. It is, however, commonly postponed to too late a period, under an idea that sloughing wounds may be produced by the operation, difficult of cure, and tending to gangrene. In blistering this has often happen- ed, but in scarifying the fear is unfounded, while any degree of vital energy remains: and it should never be forgotten that the longer this simple operation is delayed, the more the danger, what- ever it may be, is increased. I have never experienced the slight- est inconvenience from the practice; and have rarely tried it with- out some advantage; seldom indeed without very great benefit. The wound should be limited to a small crucial incision, resembling the letter T on the outside of each knee, as the most dependent organ, a little below the joint. The cut thus shaped, and very slightly pene- trating into the cellular membrane will not easily close, and conse- quently the discharge will continue without interruption. In a young lady about twelve years of age, whom the author lately attended, appa- rently labouring under an affection of the liver, but whose enormous bulk of body as well as of limbs, prevented all accuracy of examina- tion, a common jack-towel applied to each leg after the incision was 256 ECCRITICA. [CL. VI.—OR. II. made, was completely wetted through and obliged to be changed every three or four hours, for as many days. She was also purged with small and frequently repeated doses of elaterium: and the quantity of fluid hereby drawn oil at the same time by the intestines is scarcely credible. The whole system was evacuated in ...bout a week, and the entire figure re-acquired as much elegance of shape and elasticity, as before the attack. She was of a li\ ely disposition and fond of dancing; in which exercise she engaged with as much energy and vivacity as ever. Nearly a twelvemonth afterwards the disease returned: but the same means were not successful. The breathing was now affected, and there was great palpitation of the heart; so frequent and distressing indeed as to render her incapa- ble of sleeping for a moment unless in an upright position. The patient in a few weeks fell a victim to the disorder; and on examin- ing the body, the liver and lungs were found perfectly sound: but the heart was enlarged to nearly double its natural size, and parti- cularly on the right side. During the progress of hydropic accumulation there is great dryness of the tongue, and, as already observed, an almost intolera- ble thirst. And the question has often been agitated, whether under these circumstances the patient's strong desire to drink should be gratified. In a state of health it is well known, that whatever be the quantity of fluid thrown into the blood it remains there but a short time, and passes off by the kidneys, so that the balance is easily restored: and hence it is obvious that one of the most powerful, as well as one of the simplest diuretics in such a state, is a large por- tion of diluent drink. But dropsy is a state very far removed from that of health; and in many cases a state in which there is a pecu- liar irritability in the secernents of a particular cavity, or of the cellular membrane generally, which detracts the aqueous fluid of the blood from its other constituents and pours it forth into the cavity of the morbid organ. And hence it has been very generally concluded that the greater the quantity of fluid taken into the sys- tem, the greater will be the dropsical accumulation: and conse- quently that a rigid abstinence from drinking is of imperative ne- necessity. Sir Francis Milman, however, has very satisfactorily shown, that if this discipline be rigidly enforced a much greater mischief will follow than by perhaps the utmost latitude of indulgence. For, in the first place, whatever solid food is given, unless a due proportion of diluent drink be allowed, it will remain in an hydropic patient, a hard, dry, and indigested mass in the stomach, and oniy add a second disease to a first. And next, without diluting fluids, the power of the most active diuretics will remain dormant: or rather they will irritate and excite pyrexy instead of taking their proper course to the kidneys. And, once more, as the thirst and general irritation and pyrectic symptoms increase, the surface of the body, harsh, heated, and acrid, will imbibe a much larger quantity of fluid from the atmosphere than the patient is asking for his stomach; for it GE. I.—SP. I.] EXCERNENT FUNCTION. 25T has been sufficiently proved, that, under the most resolute determi- nation not to drink, a hundred pounds of fluid have in this manner been absorbed by the inhalants of the skin, and introduced into the system in a few days, and the patient has become bulkier to such an extent in spite of his abstinence. Even in a state of health or where no dropsy exists we are in all probability perpetually absorbing moisture by the lymphatics of the skin. Professor Home found himself heavier in the morning than he was just before he went to bed in the preceding evening, though he had been perspiring all night, and had received nothing either by the mouth or in any other sensible way. " That the surface of the skin," says Mr. Cruickshank, "absorbs fluids that come in contact with it, I have not the least doubt. A patient of mine, with a stric- ture in the oesophagus, received nothing either solid or liquid into the stomach for two months: he was exeedingly thirsty, and com- plained of making no water. I ordered him the warm-bath for an hour morning and evening, for a month: his thirst vanished, and he made water in the same manner as when he used to drink by the mouth, and when the fluid descended readily into the stomach "* Under these circumstances, therefore, our first object should be to determine by measurement whether the quantity of fluid dis- charged by the bladder holds a fair balance with that which is re- ceived by the mouth: and if we find this to be a fact, and so long as it continues to be a fact, we may fearlessly indulge the patient in drinking whatever diluents he may please, and to whatever extent. In some cases, indeed, water alone, when drunk in large abundance, has proved a most powerful diuretic, and has carried off the dis- ease without any other assistance, of which a striking instance oc- curs in Panarolus ;! and hence PouteauJ: occasionally advised it in the place of all other aliment whatever: as does also Sir George Baker, in a valuable article upon this subject in the Medical Trans- actions^ in which he forcibly illustrates the advantage of a free use of diluent drinks, by various cases transmitted to him, in which it operated a radical cure, not only without the assistance of any other remedy, but, in one or two instances, after every medicine that could be thought of had been tried to no purpose. But the fluid discharged from the kidneys may not be equal, nor indeed bear any proportion to what is introduced into the mouth, and we may thus have a manifest proof that a considerable quantity of the latter is drained off into the morbid cavity. Still we must not entirely interdict the use of ordinary diluents, nor suffer the patient to be tormented with a continued and feverish thirst. If simple diluent drinks will not pass to the kidneys of themselves, it will then be our duty to combine them with some of the saline or aci- • Anat of Absorb. Vessels, p. 108. 4to. 1790. f Pentec. II. Obs 24. $ Oeuvres Posthumes I. § Vol. II. Art. xvi.i. vol. iv.—33 258 ECCRITICA. [CL. VI.-r-OR. II dulous diuretics, we have already noticed, which have a peculiar tendency to this organ; and we shall generally find, that in this state of union they will accompany the diuretic ingredients, and take the desired course. Of these, one of the most effectual, as well as the most pleasant, is creme of tartar; and hence this ought to form a part of the ordinary beverage in all extensive dropsies, and especially the cellular and abdominal. Any of the vegetable acids however may be employed for the same purpose: as may also rennet-way, and butter-milk, and the more acid their taste the bet- ter will they answer their end. A decoction of sorrel-leaves makes also a pleasant diet drink for an hydropic patient; as does likewise an aqueous infusion of sage leaves with lemon-juice : both sweeten- ed to the taste. Small stale table-beer, and weak cyder, or cyder intern ixed with water, may in like manner be allowed, with little regard to measure. And it was by the one or other of these that most of the cures just referred to, as related by Sir George Baker, were effected. In one instance the cyder was new, yet it proved equally salutary under the heaviest prognostics. The patient was in his fiftieth year; his legs and thighs had increased to such a magnitude that the cuticle cracked in various places; he was ex- tremely emaciated, and so enfeebled as not to be able to quit his bed, or return to it without assistance. His thirst was extreme, his desire for new cyder inextinguishable, and his case being regarded as desperate it was allowed him mixed with water. He drank it most greedily, seldom in a less quantity than five or six quarts a- day ; and by this indulgence discharged sixteen or eighteen quarts of urine every twenty-four hours till the water was totally drained off; and he obtained a radical cure without any other means what- ever. Even ardent spirits, if largely diluted, and joined with a por- tion of vegetable acid, have been found to stimulate the kidneys; and in the opinion of Dr. Cullen may make a part of the ordinary drink.* And it is chiefly owing to the tendency which the neutral salts have to the kidneys, as their proper emunctory, and the sym- pathy which the secernents of these organs maintain with those of all others, that the cure of dropsy has sometimes been effected by large draughts of sea-water alone; though sometimes this has also acted upon the bowels, and produced the same salutary result, by exciting a very copious diarrhoea, of which a striking example is givenby Zacutus Lusitanus ! It should never, however, be forgotten, that dropsy is a disease of debility, and that the plan of evacuating will rarely of itself effect a cure ; and never, perhaps, except in recent cases, and where little inroad has been made upon the constitution. In all other cases it should be regarded as a preparatory step alone ; a mere palliative ; and an evil in itself; though an evil of a less kind to surmount an evil of a greater. And it is for want of due attention to this fact, * Mat. Med. II. 549. t Prax. Hist. Lib. VIII. Obs. 53. CE. I.—SP. I.j EXCERNENT FUNCTION. 253 that the plan of evacuating, and particularly by drastic purgatives, has by many practitioners been carried to a dangerous and even a fatal extreme. Every purgative that does not diminish the general bulk, adds to the general disease by inci easing the debility : and if upon a very few trials the plan be not found to answer this salutary purpose it cannot too soon be desisted from. The radical cure must, afier all, depend upon invigorating the constitution, or the organs particularly affected: for even a total removal of the water affords nothing more than a palliative and present relief. Such an intention may often, indeed, be combined with that of evacuating the fluid ; and hence Mondschein with great reason ad- vises us to employ bitters with diuretics,* as Martius does with purgatives.! Bitters, indeed, where the debility does not depend upon visce- ral obstructions, form one of the most efficacious tonics we can em ploy. They are peculiarly adapted to that general loss of clastici ty in the whole system and that laxity of the exhalants which consti lutes the hydropic diathesis. «It has been alleged," says Dr. Cul- len, " that bitters sometimes act as diuretics. And as the matter of them appears to be often carried to the kidneys, and to change the state of the urine, so it is possible that in some cases they may in- crease the secretion : but in many trials we have never found their operation in this way to be manifest, or at least to be any ways con- siderable. In one situation, however, it may have appeared to be so. When in dropsy bitters moderate that exhalation into the ca- vities which forms the disease, there must necessarily be a greater proportion of serum carried to the kidneys : and thereby bitters may, without increasing the action of the kidneys, seem to increase the secretion of urine."! To bitters have been added the warmer balsamics and aromatics, and by many physicians the metallic oxydes; chiefly the different preparations of copper ; though Willis, Boerhaave, Bonet, and Dig- by, have occasionally preferred those of silver. Iron has generally been abstained from as too heating, though recommended by Grieve,§ Richard,|| and Rhumelius.lf Where the disease is evidently dependant upon some visceral ob- struction, mercury offers a fairer chance of success than any other metal; and in this case has often been pushed to salivation with the most salutary result. Du Verney employed it to this extent in an ascitic patient, whom at the same time he tapped ; and by tnis dou- * Mondschein, p. 82. ! Martius, Obs. 54. $ Mat. Med. II. p. 58. § Med. Com. Edinb. IX. 11.75. || Journ. de Med. XXIX. 140. T Medic. Spagyr. tripart. p. 168. 260 ECCRITICA. [CL, VI.—OR. n ble plan effected a cure ; allowing a regimen of wine and stimulant meals during the process.* And Rahn assures us, that in one case, the disease, though it several times recurred, was in every instance put to flight by a ptyalism excited by mercurial inunction.! But where the system is in a state of great general debility, such a so- lution of the fluids will only add to the weakness and increase the disease. Small dos6s of calomel steadily persisted in will be here our safest course, with a nutritious and generous diet of flesh-meat two or even three times a day; shell-fish ; eggs; spice, and the acrid vegetables, as celery, water-cresses, raw red cabbage shred fine, and eaten as sallad. I have dwelt the longer on this species because the general ob- servations which it suggests, as well in respect to its causes and history as to its mode of treatment, apply in a very considerable de- gree to all the rest; concerning which we shall now have little more to do than to enumerate them and point out their distinctive characters. SPECIES II. HYDROPS CAPITIS. Uroysg ot the f^eafc. SSJater in the l^eatr. EDEMATOUS INTUMESCENCE OF THE HEAD : THE SUTURES OF THE SCULL GAPING. This disease has been strangely confounded by nosologists and prac- tical writers with that inflammation of the brain which apparently commences in its substance or lower part, and, producing effusion into the ventricles, distends them, and thus unites the symptoms of fever and great irritability with those of heaviness, and at length of stupor. The accumulation of fluid is here only an effect, and follows upon inflammation of the brain as in any other part, and is only to be removed by removing the inflammation. It is ordinarily denominated, however, acute or internal hydrocephalus ; but Dr. Cullen has correctly distinguished it from proper hydrocephalus or dropsy of the head by placing it in a different part of his classifica- tion, and assigning it a different name. In his view it is an apo- plexy, and he has hence called it apoplexia hydrocephalica. In the present work it occurs under the name of cephalitis profunda, and in treating of it as a cephalitis the author has submitted his reasons for not regarding it as an apoplectic affection. * Mem. de Paris, 1703, p. 174. t Medic. Briefwechsel, B. I. 365. GE. L—SP. II.] EXCERNENT FUNCTION. 261 The disease before us is common to children. A few singular cases are, indeed, recorded of its commencing in adult age,* and producing an enlargement of the scull by a morbid separation of the sutures, but these are very rare. That it does, however, occur without such separation and enlargement, and that too occasionally in every period of life, has been proved by a multitude of exami- nations after death, that have shown the ventricles of the brain dis- tended with fluid, and producing a considerable pressure upon the brain. Yet where no such enlargement of the scull takes place, we may sometimes strongly suspect the disease from the symptoms, but cannot during the life of a patient speak with certainty upon the subject. Dropsy of the head, like that of every other organ, is a disease of debility, and as we have already observed in the introductory re- marks to the present genus, may proceed from a relaxed condition of the secernents of the brain, a torpitude of its absorbents, or from both. The causes of this morbid state we are rarely able to ascertain : yet in some families there seems to be a peculiar pre- disposition to it, since it occurs in many of the children born in succession: and it may sometimes be connected with a schrophu- lous diathesis. The immediate seat of the dropsy varies considerably: for some- times the fluid accumulates between the bones of the cranium and the dura mater; sometimes between the dura mater or the other membranes and the brain, and sometimes in the ventricles or con- volutions of the organ. With the deficiency of tone there is also not unfrequently some deficiency of structure or substance : and it is in consequence of this that the fluid when morbidly secreted or collected in one part, spreads without resistance to another. A de- ficiency of structure or substance is sometimes found in the brain itself and sometimes in the cranium. If it occur in the former a path may be immediately opened for the morbid fluid, accumulated in the ventricles or in any other interior part, to reach the mem- branes and distend the scull: and if in the latter, it may even pass beyond the scull, and separate and distend the integuments. I have seen instances of large perforations produced in different parts of the bones by a morbid absorption of the bony earth, as though the trephine had been repeatedly applied, and this too in adult age : and in some instances there has been a total absence of the calvaria.! Generally speaking, there is some deficiency of bony earth, as though it were impossible for this secretion to keep pace with the enlargement of the cranium : and hence the bones of the cranium have occasionally been so thin as to be pellucid and transmit the light of a candle, of which Van Swieten gives an instance,! from • Hildan. Cent. III. Obs. 17. 19. ! Act. Helvet. I. 1. t Comment. inHydrop. Sect. 1217. 2G2 ECCRITICA. [CL. VI.-—OR. II. Betbeder;* or have had their place supplied by a membrane co- vering the entire range of the sinciput, an example of which will be found in Vesalius.-j- The dropsical fluid is also said by many writers of high authority to originate in some cases between the integuments and the bone, and to be confined to this quarter : and hence, the disease has been divided into external and internal dropsy of the head. It is possi- ble, indeed, as Van Swieten has justly observed, that since water may be collected in the cellular membrane of the whole body, such an accumulation may take place in the integuments of the head \ But the pretended cases are so rare that Van Swieten himself, Pe- tit,§ and many other writers of high credit, have doubled whether such a form of the disease has ever actually occurred. Yet, should it occasionally take place, there can, I think, be no question that it ought rather to be regarded as a variety of anasarca or cellular dropsy, than hydrocephalus or dropsy of the head, properly so call- ed. Celsus has been quoted upon the occasion as confirming the existence of this external modification, and applying to it the name of hydrocephalus: but this is to misunderstand him egregiously. In the passage referred to he is speaking of internal diseases of the head alone, of cephalaea, and other aches produced by wine, or indigestion, by cold, or heat, or the rays of the sun, sometimes ac- companied with fever, and sometimes without; sometimes affect- ing the whole of its interior, and sometimes only a part:—" modo in toto CAPiTE,modo in parte." And he then adds, "praeter haec etiamnum invenitur genus, quod potest longum esse : ubi humor cutem inflat, eaque itumescit,et, prementi digito, cedit: ofyox,t$x*.oi Graeci appellant."|| It is manifest, therefore, that the hydrocepha- lus here noticed, like the other diseases with which it is associated, is an internal affection of the head : and this idea is still farther confirmed by the treatment which he shortly afterwards proceeds to prescribe for it. It is hence highly probable that the cases which have been called external dropsies of the head, have consisted of internal accumula- tions spreading to and distending the integuments through channels that were not ascertained, and on this account not supposed, to exist. Were the distinctions of external and internal dropsy of the head necessary to be preserved, it would be far more accurate to limit the former to those modes of the disease in which the water is con- fined between the calvaria and the membranes, and the latter to those in which it originates in the cavities of the brain : but as we * Histoire de l'Hydrocephale de Begle, p. 35. ! De Corp. human, fabnea. Lib. I. cap. 5. * Comment, loc.citat. 1718. § Acadeni. des Sciences, Mem. p. 121. i De Medicin. Lib. IV. cap. II. GE. I.—SP. II.] EXCERNENT FUNCTION. 263 can rarely, if ever, determine the limits of the collection by the symptoms, it is a distinction which cannot be supported, and would often lead us into error. Hydrops capitis frequently commences in the fetus, and some- times renders the head so large as to retard the labour, and greatly harass the delivery. Blanchard gives a case in which four pounds of water were evacuated from the head of a fetus after its birth. At other times it does not show itself till some months, or even two or three years, after birth. In most cases the whole head enlarges gradually by a gradual separation of the sutures ; but in a few cases the first symptom has been a small, elastic tumour on the upper part of the head, produced by an inequality of the dura mater, and its yielding more readily at the part that presents, than in any other quarter. This tumour sometimes grows to a size as large as the he.id itself. It is seldom, however, that the walls of the tumour burst; for the uniform pressure to which they are exposed, has a tendency to thicken and harden them. And hence, as the resist- ance increases, the sutures give way generally, and the tumour frequently disappears and is lost in the general swell. The brain often exhibits,as we have already observed, some misformation or defect, which of itself may constitute a remote cause : but the proximate cause is a debility of the local secernents, absorbents, or both. If the debility be confined to these, or the defect in structure do not interfere with the proper development of the mental or corporeal powers of the sensorium, the infant may live and even thrive in every other part, while the water continues to accumulate and the head to become more monstrous, and even insupportable from its own weight: for, provided the pressure ap- plied be very gradual, and unaccompanied with inflammation, the brain, like the stomach and intestines in dropsy of the belly, may be drowned in water for even,twenty or thirty years without serious mischief. Michaelis relates the case of a patient twenty-nine years old, whose appetite and memory were good, and the pupils of the eyes natural, though the disease had continued from birth.* And in treating of vascular osthexy I had occasion to notice, from Dr. Heberden, the history of a patient who, with about eight ounces of water in the ventricles of the brain, as appeared on opening him, —and which there was good reason for believing had existed there for many years,—and with scarcely an organ free ftom disease in his whole body, with the exception of the brain itself, which was found healthy in its substance, was enabled to attain the good old age of Upwards of fourscore years with an apparently sound consti- tution, and free from all the usual infirmities of advancing years, saving the inconvenience of an habitual deafness. But the torpitude or imbecility of the excernent vessels may ex- tend to the other parts of the brain, and to parts that are immediate- ly connected with the mental faculties; or the defects of structure * Medical Communications, Vol. I. Art. XXV. 264 ECCRITICA. [CL. VI.—OR. If. that are so often combined with dropsy of the head may extend to the same : and in such cases the hearing, sight, or speech may be affected : there may be loss of memory or stupidity, vertigo, epi- lepsy, or convulsion fits. The brain has sometimes been found in a spongy or fungous state ;* or otherwise disorganized :! and some- times tense and slender with nerves like mucus-! The fluid, more- over, may accumulate with rapidity, instead of slowly, as soon as the exciting cause, whatever it may be, is in operation, and the suddenness of the pressure may impede the action of the sanguifer- ous vessels; and we shall then perceive symptoms of compression, as a heavy pain in the head, stupor, occasional vomiting, quick pulse, and other febrile concomitants, a perpetual flow of tears from the eyes, or of mucus from the nostrils. And hence it is that drop- sy of the head is so frequently a symptom or a sequel of inflamma- tion of the brain, and particularly of parenchymatic inflammation. Yet even here we have, sometimes, striking and most singular proofs, that the remedial power of nature Is interfering either to obtain a cure, or to render the disease compatible with life, and with the general faculties of the sensorium. There is an interest- ing illustration of this remark in a case, related by Dr. Donald Monro, in the Medical Transactions. It is that of a child which at the age of a year and a half, was brought into St. George's Hospital with a head much enlarged from the disease before us. She was feverish and had a slight stupor. The complaint was peculiarly obstinate, and resisted the use of purges, blisters, issues, bandages, and other remedies The enlargement proceeded and became chronic, though the fever and stupor gradually diminished and at length ceased ; yet the head continued to*enlarge and kept an equal proportion with the child's growth: so that when in her eighth year, it measured two feet four inches round, which is nearly a foot more than it ought to have done, and the forehead alone was half the entire length of the face, or four inches out of eight, which is double the proportion it ought to have held,—yet the child was at this time as lively and sensible as most children of her age, and had a strong and peculiarly retentive memory. It was long before she could walk, on account of the vast weight of head she had to carry, and the difficulty of preserving a balance ; but at length she learn- ed to walk also with tolerable ease.§ In the following case the efforts of the remedial power were less successful: but it is peculiarly worthy of notice, as much from the lateness of the age in which the disease commenced, and the sutures were separated, as from the natural struggle there seems to have been "to obtain a triumph over it. It is related by Dr. Baillie, in another volume of the same valuable work. The patient was a * Conrad, Diss, de Hydrocephalo. Argent. 1778. f lionet, Sepukhr. Lib. I. Sect. XVI. Obs. 9. t Buttner Btschreibung des innern Wasserkopfs, &c. Konigs. 1773. § Medical Transactions, Vol. 11. p. 359. C.E I.—.SP. II.] EXCERNENT FUNCTION. 265 boy, not less than seven years of age when he first became affected. The pupils, from an early stage, were considerably dilated, and the pulse was somewhat irregular; he complained of pain towards the back of his head, and was often in a state of stupor. His under- standing, however, was clear, and his sight very little impaired almost to the last. He had twice intervals of great promise, for a few weeks, with Considerable abatement of all the symptoms, and' an appearance of doing well. But in both instances he relapsed, and at the distance of ten months from the commencement, fell under daily attacks of convulsion fits. It is remarkable that, though his intellect continued unimpaired, the frontal and parietal bones, from the force of the accumulated fluid in every direction, were separated from each other, to a distance of from half to three quar- ters of an inch, notwithstanding that they had been firmly united at their respective sutures before the commencement of the disease. Nearly a pint of water was found in the ventricles upon examina- tion. We have observed, that in many cases the bones of the scull be- come peculiarly thin and pellucid, or are altogether deprived of their calcareous earth, and reduced to cartilages. But where the instinctive or remedial power of nature, which is always labouring to restore morbid parts to a state of health, or to enable them in their altered condition to fulfil their proper functions, has succeed- ed in rendering the diseased brain still capable of exercising some of its faculties, a supply of phosphate of lime, is, in various instan- ces, also provided for the bony membrane; which not only re-as- sumes its ordinary firmness, but has sometimes exhibited a density far beyond the usual proportion and commensurate with the magni- tude of the scull; while the cervical vertebrae have been equally strengthened for the purpose of bearing so enormous a load. Hil- danus gives a case of this kind in a youth eighteen years old, who had laboured under a dropsy of the head from his third year. The scull was of an immense magnitude {immense magnitudinis) as well as peculiarly hard and solid. The patient spoke distinctly, but his mind was not equal to his articulation, and he suffered greatly from violent epileptic attacks.* " If sculls of this kind," says the Ba- ron Van Swieten, " should be disinhumed in their burial-ground by posterity, there would certainly not be wanting persons who would ascribe them to some gigantic family. If, indeed, the calvaria should be dug up entire the error may be corrected, by observing the size of the upper jaw-bones, which would be found of the ordi- nary proportion : but if the bones should be separated and single, there could be no appeal to this distinctive mark.! The disease is always dangerous from the difficulty of determin- ing its extent, and what degree of cerebral disorganization may ac- company it. Where, however, it is limited to a weak condition of the • Observ. Chirurg. Cent. III. Obs. XIX. p. 199. ! Comment. Tom. IV. Sect. 1217. p. 123. vol. iv.—34 366 ECCRITICA. [CL. VI.—OR. H, excernents of the brain it is often remediable and admits of a radi- cal cure. But where, on the contrary, no favourable impression can be made upon it, the general frame partakes by degrees of the de- bility, the vital powers flag, the limbs become emaciated, and death ensues at an uncertain period: or the patient survives, a miserable spectacle io the world and burden to himself; rarely reaching old age, but sometimes enduring life for twenty or even thirty years* before he is released from his sufferings. On opening the head twelve or fifteen pints of fluid have often been evacuated ; and oc- casionally not less than twenty-four or twenty-five pints,! which have the singular property of not jellying even on exposure to heat.! The water has sometimes been found lodged in a cyst, and in a few instances the cerebrum itself has formed a sack for containing it. Morgagni asserts that the disease is more common to girls than to boys.§ I do not know that the remark has been confirmed by any collateral authority. The cure, as in the preceding species, must be attempted by evacuating the water by internal or external means, and by giving tone to the debilitated organs. Drastic purges can rarely, in this form of the disease, be carried to such an extent as to be of essential service, on account of the early period of life in which it commonly shows itself. For the same reason diaphoretics haye not been generally recommend- ed, or often found serviceable when ventured upon. Diuretics have been more frequently had recourse to ; and particularly the digitalis. Dr. Withering was favourable to its use, but it has com- monly, as in other forms of dropsy, proved more injurious than be- neficial. The best internal medicine is calomel, in small doses, in union with some carminative, for the purpose of keeping up the action of the stomach, a healthy state of which is of great importance. The calomel, however, should be employed rather as a stimulant or tonic, so as to excite the mouths of the torpid vessels to a return of healthy action, than as a purgative, or with a view of producing salivation ; except indeed, where symptoms of inflammation are present, in which case it cannot be given too freely as already ob> served under parenchymatic cephalitis.|| Where the disease has been unaccompanied with inflammatory symptoms, but nevertheless has been attended with a feverish irritation, and great heaviness, as well as considerable enlargement of the head, the author has found half a grain of calomel, given three times a day, in the man- * Van Swieten, Comment, loc. citat. ! Bonet, Sepulchr. Lib. I. Sect. XVI. Obs. I. Eph. Nat. Cur. Dec. III. Ann. I. Obs. 10. * Hewson, on Lymph. Syst. Part II. p. 193. § De Sed. et Cause. Mor. Ep. XII. Art. 6. 9 Vol. II. p. 224. GE. L—SP. II.] EXCERNENT FUNCTION. 267 ner above proposed, and continued three times a day for a month, of essential service : and particularly in a case that occurred to him, many years ago, of a little boy who was four years old when the disease first appeared ; which, however, had made its attack so insidiously as to escape the observation of the parents till the in- creased bulk of the head attracted their notice, which was soon af- terwards succeeded by the symptoms just adverted to. The com- plaint had increased, the symptoms were more aggravated, and the scull, within six months, had become as large as that of an adult, when the mercurial process was commenced, accompanied with a free fomentation of the head with the solution of the acetate of am- monia, and an occasional use of purgatives. In ten daystthere was an evident improvement: the child was less languid, and feverish, and showed less desire to rest his head perpetually on a chair. The scull no longer augmented; the mental faculties which began to discover hebetude regained vigour, and the patient, now in his twentieth year, is an unjder-graduate in one of our universities, ex- hibiting a development of talents that has already obtained for him various prizes, and gives a promise of considerable success hereafter. The bulk of his head is at this moment very little larger than it was at six years of age: a curious fact in pathology, though by no means uncommon: since where the disease forms space enough for a perfect growth of the brain, the calvaria ceases to expand, and the head becomes oncc~ mure proportioned to the rest of the body. The external means employed for diminishing the contained fluid have consisted in local stimulants, as different preparations of ammonia, blisters, and cauteries, and puncturing the integu- ments. All local stimulants have a chance of being useful where the dis- ease is seated near the surface, or between the membranes and the cranium, for they tend to excite the absorbents to an increased degree of tone and action, and consequently to a diminution of tho general mass. But they do not seem to have much effect when the fluid issues from the convolutions or ventricles of the brain. Blis- tering the whole of the sinciput has unquestionably been found ser- viceable, and is perhaps the most effectual external stimulant we can employ. The water has also been evacuated in many instances, with full success by a lancet: and, where the sutures gape very wide, and the integuments are^considerably distended, this remedy ought al- ways to be tried. The brain, however, like every other organ, when it has been long accustomed to the stimulus of pressure, can- not suddenly lose such a stimulus without a total loss of energy; and hence, as it is necessary in many cases of dropsy of the belly, to stop as soon as we have drawn off a certain portion of water, in order to avoid faintness, it is found equally necessary to evacuate the water from the brain with caution and by separate stages; for where the whole has been discharged at once, the sensorial ex- 268 ECCRITICA. [CL. VL—OR. n haustion has been so complete as to produce deliquium and sudden death. Hence six or eight ounces are as much as it may be pru- dent to let loose at a time in an infant of three or four years of age; when the orifice should be covered with a piece of adhesive plaster, and an interval of a day or two be allowed. The operation, indeed, is very far from succeeding in every instance: for in some cases there is so much internal disease or even disorganization, that suc- cess is not to be obtained by any means. And next, a fresh tide of water will not unfrequently accumulate, and the head become as much distended as before. Still, however, the attempt should be made, and even repeated and repeated again if a fresh flow of fluid should demand it: for the disease has occasionally been found to yield to a second or third evacuation, where it has triumphed over the first. Dr. Vose of Liverpool, has published an instructive case of this kind in the ninth volume of the Medico-Chirurgical Transactions. The patient was seven months old, and the head between two and three times its natural size when the operation was first performed. On this occasion a couching needle was made use of, and the ori- fice was closed when three ounces and five drachms of fluid were evacuated : about an equal quantity was conjectured to dribble from the orifice after the operation, at which time the infant became ex- tremely faint, and the integuments of the head had shrivelled into the shape of a pciwruluuo bag-. He revived, lu/wcver, with the aid of a little cordial medicine ; and, the water accumulating afresh, a second operation was performed by a history about six weeks af- ter, when eight ounces of fluid were drawn off with little constitu- tional disturbance; which was succeeded only nine days later by a third operation, that yielded, by the introduction of a groved direc- tor, twelve ounces, without any interference with the general health whatever. A copious and vicarious discharge of serum from the rectum took place shortly after this third puncture of the integu- ments, which was succeeded by some degree of deliquium; but from this also, the patient soon recovered; the head gradually di- minished in size, and a complete cure was at length effected. Formey,* Pitschel,! and several other writers have recommend- ed compression, with a view of stimulating the torpid mouths of the absorbents to a resumption of their proper action. But no com- pression can be made on these, whatever they may consist in (for absorbents have not hitherto been detected in the brain) without compressing, at the same time, parts that are injured by pressure already. Advantage, however, may be taken of the recommenda- tion after the brain has been evacuated ; and a proper compress abqut the shrivelled head, may be of as much use in preventing deliquium, and perhaps, by its excitement, in stimulating the tor- * Ad. Riverii, Observ. Medic. Cent. V. ! Anat. and Chir. Anmtrk. Dresd, 1784. GE. I.—SP. II.] EXCERNENT FUNCTION. 269 pid vessels to a return of their proper function, as it is well known to be of when applied around the abdomen after the use of the trocar. SPECIES III. HYDROPS SPIN^E. Eropsg of the Sa>tue. SOFT FLUCTUATING EXTUBERANCE ON THE SPINE } GAPING VERTEHR.fi. This is the spina bifida of authors, so called from the double chan- nel which is often produced by it through a considerable length of the vertebral column: a natural channel for the spinal marrow, and a morbid channel running in a parallel line, and equally descending from the brain, and filled with the fluid which constitutes the dis- ease. It is sometimes local, but in most instances is connected with a morbid state of the brain, and directly communicates with it. In this last form it may be regarded as a compound dropsy of this or- gan, the accumulating water working its way down towards the fo- ramen ovale in consequence of its dependent position, or a deficien- cy in the substance of the brain in this quarter, instead of up to- wards the fontanel. In both cases the surrounding dura mater gives way, and, in the last, forms a sinus, which, as it descends, winds it- self through any accidental opening that may exist in or between the bones of the vertebrae, and distends the superincumbent inte- guments into the same kind of tumour that we have already noticed as sometimes existing on the crown of the head, when the fluid is pressed in an upper direction. Dropsy of the spine is mostly congenital, and consequently a dis- ease of fetal life; in many instances, however, the tumour does not show itself till some weeks, or even months after the birth of the child. The degree of danger must depend upon the structural de- fect, or other mischief that exists in the brain or the substance of the spinal marrow. It has sometimes appeared as a local affection in adult age, and has admitted of a cure ; but, from its usually oc- curring in the earliest and feeblest stage of life, and often before the sensorium is fully developed, so as, indeed to prevent its develop- ment in a perfect form, it is rarely remediable. We observed in the last species that the bones of the cranium are often found im- perfect ; and it is hence not to be wondered at that the bones of the vertebrae should exhibit a like imperfection in the present, and al- low a protrusion externally. Fieliz gives a case in which the whole 270 ECCRITICA. [CL. VI.—OR. II. of the spinous processes were deficient, and the dropsy extended through the entire length of the spine.* The integuments are here thinner and more disposed to burst than in the head, and hence, if the tumour be left to its natural course, it commonly continues to enlarge till it bursts ; while, if it be opened, the child, in most cases, dies from exhaustion and deli- quium, as in dropsy of the head, provided the water be evacuated entirely; and if it be discharged gradually, an inflammation of the spinal marrow is apt to ensue, which proves as fatal. Hence there is much reason in the advice of Mr. Warner merely to support the tumour, but not to touch it otherwise, and, in the mean while, to see how far we can give the remedial power of nature an opportu- nity of exerting itself by invigorating the frame generally. Some- thing, however, beyond support may be safely ventured upon, for a gentle compression may be tried with propriety, and if found to do no mischief, it should be gradually increased. If the disease ex- tend to the ventricles it will probably be of little.use, but if it be local, it may ultimately prove successful. This form of dropsy is mostly fatal; but there are a few cases on record of a successful termination upon the employment of different methods. Thus, Heister, who in his day also recommended com- pression, gives an example of its having radically yielded to this plan, in union with spirituous liniments;! and Fantoni,! and Heil- mann,§ describe, each of them, an instance of a perfect cure upon opening and evacuating the cavity. In all which instances, how- ever, it seems probable that there was no such communication with the brain, or that the brain, or spinal marrow, was less affected than they ordinarily appear to be. A few singular cases have occurred of young persons protracting a miserable existence under this disease to the age of adolescence. Martini mentions a youth who lived till eleven years old; and Ar- crel notices others who survived till seventeen,|| but with paralytic sphincters of the anus and bladder. * In Richter, Chir. Bibl. Band. IX. p. 185. ! Wahrnehmung. B. II. t In Pacchioni Animadvers. cit. Morgagni De Sed. et Caus. § Prodrom. Act. Havn. p. 136. B Schwed. Abhandl. B^X. p. 291. seq. GE. L—SP. IV. EXCERNENT FUNCTION. 271 SPECIES IV. HYDROPS THORACIS. SBropsg ot the Qthm. sense of oppression in the chest ; dyspn02a on exercise, or de- cumbiture; livid countenance ; urine red and spare ; pulse irregular; edematous extremities; palpitation,and start- ings during sleep. This is the hydrothorax of authors ; and the secreted fluid, in direct opposition to that of hydrocephalus, commonly, perhaps always, jellies upon exposure to heat. Sauvages, who has made this disease a genus, gives a considera- ble number of species under it, derived from the particular part or cavity of the thorax which is occupied, or the peculiar nature of the effusion ; as hydrops mediastini, pleurae, pericardii, hydatido- sus; to which he might have added pulmonalis, as the water is, perhaps, sometimes effused into the cellular texture of the lungs. But as these can never, with any degree of certainty, be distin- guished from each other till after death, and as such distinction could make no essential difference in the mode of treatment, it is unnecessary to notice them, and is scarcely consistent with an ar- rangement founded upon symptoms alone. Those who are desi- rous of examining into the curious, and often contradictory signs by which these several forms of pectoral dropsy have been attempted to be discriminated by various writers, may turn with advantage to Sir L. Maclean's work upon the subject, where he will find them selected with much patient study, and accompanied with many judi- cious remarks.* In the present place it may be sufficient to ob- serve that the disease is, in fact, sometimes limited to any one of those parts, and sometimes extends to several of them : and that when it occurs as a consequence of cellular dropsy, it is in a great- er or less degree common to the whole. The complaint originates with little or no observation, and con- tinues its course imperceptibly ; there is at length found to be some difficulty of breathing, particularly on exertion or motion of any kind, or when the body is in a recumbent position, usually accompanied with a dry and troublesome cough, and an edema of the ankles to- wards the evening. Then follow, in quick succession, the symp- toms enumerated in the definition, several of which I have drawn directly from my friend Sir L. Maclean's very accurate arrange- ment of them. The difficulty of breathing becomes, at length, pe- • Inquiry into the Nature, Causes, and Cure of Hydrothorax, p. 52, 70.8vo. 7 810, 272 ECCRITICA. [CL. VI.—OR. II culiarly distressing, and the patient can obtain no rest but in an erect posture; while even in this condition he often starts suddenly in his sleep, calls vehemently for the windows to be opened, and feels in danger of suffocation. His eyes stare about in great anxie- ty, the livid hue of his cheeks is intermixed with a deadly paleness, his pulse is weak and irregular, and as soon as the constrictive spasm of the chest is over, he relapses into a state of drowsiness and in- sensibility. By applying the hand to the sides and using a slight degree of percussion, we shall sometimes be able to trace a slight degree of fluctuation. The disease, contrary to the preceding species, is mostly to be found in advanced life, and its duration chiefly depends upon the strength and habit of the patient at the time of its incursion. It is hence, in some cases, of long continuance, while in others the pa- tient is suddenly cut off, during one of the violent spasms, which at length attack him as well awake as in the midst of sleep. The causes are those of dropsy in general, upon which we have already enlarged, acting more immediately upon the organs of the chest, and inducing some organic affection of the heart, lungs, or the larger arteries. We also frequently find, upon dissection, that the disease has been produced, or considerably augmented by a number of hydatids (taenia hydatis, Linn.) some of which appear to be floating loosely in the effused fluid, and others to adhere to particular parts of the internal surface of the pleura, constituting the hydro- thorax hydatidosus of Sauvages. They consist of spherical vesicles containing a watery fluid, whose circular membrane is possessed of a living power and a peculiar organization that enables them to attach themselves to the internal surface of a cavity, and to suck up the more attenuate and limpid humours from the neighbouring parts. The only decisive symptom in this disease is the fluctuation of water in the chest, whenever it can be ascertained ; for several of the other signs are often wanting, or, in a separate state, are to be found in other complaints of the chesj; as well as in dropsy, more particularly in asthma and empyema. And hence, in determining the presence of this disorder, we are to look for them conjointly, and not to depend upon any one when alone. Even when asso- ciated, we are sometimes in obscurity : and the difficulty of indi- cating the disease by any set of symptoms has been sufficiently pointed out by De Haen;* while Lentin,! Stoerck! and Rufus§have given instances of its existence without any symptoms whatever: and Morgagni with few or none||; Bonet observes that dyspnoea!! * Rat. Med. P. v. p. 97. \ In Blumenbach Biblioth. III. \ Ann. Med. II. p. 266. § Ad River. Observ. Med. H De Sed. et Caus. Morb. Ep. XVI. Art. 2. 4. 6. 8. 11. 1 Ep. cit. Art. 28. 30. GE. I.—SP. IV.) FXCERNENT FUNCTION. 275 is not an indication common to all cases,* and Morgagni, that start- ings during sleep or on waking, do not always accompany the dis- ease, and may certainly exist without it. Hoffmann and Baglivi have given, as an additional symptom, intumescence and torpitude of the left hand and arm ; but even this affection, or the more ordinary one of laborious respiration, has existed without water in the chest. De Rueff relates a singular case in a man who was attacked with most of the symptoms jointly, at the age of about sixty, and was supposed to be in the last stage of this disease. He recovered by an ordinary course of medicine, and died at the age of eighty with his chest perfectly sound to the last.! The general principles to be attended to in the mode of treatment, are the same as have already been laid down under hydrops cellula- ris : for, as already observed, the causes are similar, and only varied by an accidental deposition of the morbid fluid in the chest, in con- sequence of a peculiar debility in the thoracic viscera, or of some organic misaffection. The squill is here a more valuable medicine than in most other species ; as, independently of its diuretic virtue, it affords great relief to the dry and teasing cough, and in some degree, perhaps, to the pressure of the fluid itself, by exciting the excretories of the lungs to an increased discharge of mucus. Digitalis, as in other species of the same genus, is a doubtful remedy ; its diuretic effects are considerable, but, however cautious- ly administered, it too often sinks the pulse, and diminishes the vital energy generally ; and is particularly distressing from its producing nausea, and endangering deliquium ; results which ought more especially to be guarded against in dropsy of the chest, as it is, in most cases, not merely a disease of debility but of enfeebled age. Sir L. Maclean is a firm friend to its use in almost every case: but even he is obliged to admit that the state of the pulse, the stomach, the bowels, and the sensorial function, should be atten- tively observed by every one who prescribes it. And under the following provision, which he immediately lays down, there can be no difficulty in consenting.to employ it. " if these be carefully watched, and the medicine -withdrawn a,v soon as a?>y of them are materially affected, I hesitate not to affirm that no serious inconve- nience will ever ensue from it, and that it may be administered with as much safety as any of the more active medicines in daily use."! Blisters are, in many cases, of considerable avail; they act more directly, and therefore more rapidly and effectually than in most other modes of dropsy, and should be among the first remedies we have recourse to. The strong symptoms of congestion under which the heart seems, in some instances, to labour, has, occasionally induced practitioners • Sepulchr. Lib. 11. Sect I. Obs. 72. 84. ! Nov. Act. Acad. Nat. Cur. Tom. IV. 4to. Norimb. \ Inquiry into the Nature, 8cc. of Hydrothorax, p. 171. *OL. IV.—35 274 ECCRITICA. [CL. VI.—OR. II. to try the effect of venesection: and there are cases in which it has unquestionably been found serviceable : as that more especially related by Dr. Home, in which he employed it seven times in the course of eighteen days, and hereby produced a cure.* I am induced to think, however, that in this instance the dropsy was an effect of the obstruction under which the heart laboured, rather than that the obstruction was an effect of the dropsy. And in all instances of this kind no practice can be more prudent. But where the drop- sy is primary and idiopathic, all such obstructions will be more safely and even more effectually relieved by a quick and drastic purge than by venesection. Opium is a medicine that seems peculiarly adapted to many of the symptoms : but by itself it succeeds very rarely, heating the skin and exciting stupor rather than refreshing sleep. When mixed, however, with tne squill pill, or with small doses of ipecacuan, and, if the bowels be confined, with two or three grains of calomel, it often succeeds in charming the spasmodic struggle of the night and obtaining for the patient a few hours of pleasant oblivion. Besides blisters as external revellents, setons and caustics have sometimes been made use of, and especially in the arms or legs. Baglivi preferred the cautery and applied it to the latter.! Zacutus Lusitanus to both, and employed it in connexion with diuretics and tonics.! Tapping is another external mean of evacuating the water. The practice is of ancient date, and is described by most of the Greek writers. To avoid the effect of a dangerous deliquium from a sudden removal of the pressure, Hippocrates allowed, in many instances, thirteen days before the fluid was entirely drawn off. And to prevent the inconvenience resulting from a collapse of the integuments, and the necessity of afresh opening or the retention of a canula in the orifice through the whole of this period, he advised that a small perforation should be made in one of the ribs, and that the trocar should enter through this foramen.§ There are two very powerful objections, however, to the use of the trocar. The first is common to most dropsies, and consists in its offering, in most instances, nothing more than a palliative. The second is peculiar to the present species, and consists in the uncertainty of drawing off any water whatever, from the obscurity or complicated nature of the complaint, upon which we have touch- ed already. If the fluid be lodged in the p'ericardium, the duplica- ture of the mediastinum, or the cellular texture of the lungs, it is ob- vious that the operation must be to no purpose. And yet, with the rare exception of a palpable fluctuation in the chest, we have no set of symptoms that will certainly discriminate these different forms of * Clinical Experiments, p. 346. ! Opp. p. 103. * Prax. Admir.Lib.I. Obs. 112. § rii$> s8voc Ttudm, Lib. LIU. p. 544. GE. I.—SP.IV.] EXCERNENT FUNCTION. 275 the disease. It must be also equally in vain if the fluid be confined in a cyst, as has occasionally proved a fact, unless the operator should have the good fortune to pierce the cyst by accident. And, in a few instances, again, the fluid, which has at all times a striking tendency to become inspissated, has been found so viscid as not to flow: of which Saviard has given us a striking example.* A considerable pause is necessary, therefore, before tapping is decided upon : nor ought it ever to be employed till the ordinary internal means have been tried to no purpose. But where these have been tried and without avail; and more especially where we have reason to ascribe the disease to local debility or some local obstruction rather than to a general decline of the constitution; and more especially still, where we have the satisfaction of ascer- taining a fluctuation, or of noticing, as has sometimes occurred, that the ribs bulge out on the affected side, the operation may be ventured upon, and will often be found serviceable. The ordinary place forantroducing the instrument is between the fourth and fifth of the false ribs, about four fingers' breadth from the spine. Du Verney, however, recommends between the second and third of the false ribs : and, in different cases, there may be reason for even a greater latitude than this. On the Continent the operation of tapping is far more frequently tried than in our own country: and the German Miscellanies are full of cases of a successful event. In the volume of Nosology I have given an account of many of these ; in several of which the quantity of water evacuated appears to have been very considerable. Thus in one instance, a hundred and fifty pounds were discharged at a single time : in others between four and five hundred pounds by different tappings within the year: and in a single example near- ly seven thousand pints, in eighty operations, during a period of twenty five years through which the patient laboured under this complaint; having hereby prolonged a miserable existence, which doubtless would have terminated without it much earlier, but which, perhaps, was hardly worth prolonging at such an expense. In the Berlin Medical Transactions there is a case of a cure effected by an accidental wound made into the thorax by which the whole of the water escaped at once.! In a few rare instances we have reason to believe that the dis- ease has ceased spontaneously, judging from the trifling remedies that were employed at.the time : as, for example, the specific of eighteen ounces of dandelion-juice taken daily, which, according to Hautesierk, succeeded radically in one patient, ot the use of small doses of squills alone, which, in the hands of Tissot, was equally fortunate in another. r-# Recueil d'Observationes Chirurgiques, &c. Paris, 1784. f Act. Med. Berol. Vol. X. Dec. L p. 44. 276 ECCRITICA. [CL. VI.—OR. It SPECIES V. HfDROPS ABDOMINIS. ISroBSg of tlie Uellg. 1'ENSE, HEAVY, AND EQUABLE INTUMESCENCE OF THE WHOLE BELLY J DISTINCTLY FLUCTUATING TO THE HAND UPON A SLIGHT STROKE BEING GIVEN TO THE OPPOSITE SIDE. This is the ascites of nosologists. It is sometimes a result of ge- neral debility operating chiefly on the exhalants that open on the internal surface of the sack of the peritonaeum and the abdominal muscles : sometimes occasioned by local debility or some other disease of one or more of the abdominal organs considerably in- farcted and enlarged, and sometimes a metastasis or secondary disease produced by repelled gout, exanthems or other cutaneous eruptions: examples of all which are to be found in Morgagni,* and offer the three following varieties, which may not unfrequently be applied to the preceding species: x Atonica. Preceded by general debility Atonic dropsy of the belly. of the constitution. £ Parabysmica. Preceded by or accompanied Parabysmic dropsy of the with oppilation or indurated belly. enlargement of one or more of the abdominal viscera. y Metastatica. From repelled gout, exanthems Metastatic dropsy of the or other cutaneous eruptions. belly. In the first variety, the fluid is found in the cavity of the> ab- domen, or between the peritonaeum and the abdominal muscles. It is produced by any of the causes of general debility, operating on an hydropic diathesis ; and is frequently a result of scurvy, or va- rious fevers. In the second variety, the organ most commonly affected is the liver, which is occasionally loaded with hydatids, and has sometimes weighed twelve pounds. The gall-bladder is often proportionally enlarged and turgid, and has occasionally been found with an oblite- rated meatus, full, of a coffee-like fluid, and together with its con- tents has weighed upwards of ten pounds. The accumulation has also sometimes been discovered in the omentum,! or sides of the intestines.! In this second variety the disease is often denominated • De Sed. et Caus. Morb. Ep. XXXVIH. Art. 49. ! De Haen. Rat. Med. P. IV. p. 95. Senberlich, Pr. de Hydrope omenti saccato. Fr. 1752. i Frank, in Commentation. Goetting, VIL 74. GE. I.—SP. V.] EXCERNENT FUNCTION. 277 an encysted dropsy; a term, however, which will quite as well apply to dropsies of the ovaria, the Fallopian tube, and even the uterus and scrotum, as to that of the liver. In the third variety the fluid is commonly deposited in the cavity of the abdomen; and is far more easily removed than in either of the others; often yielding, indeed, to a few drastic purges alone: except where, as sometimes happens in metastatic dropsy from repelled gout, the constitution has been broken down by a long succession of previous paroxysms. Under the veil of dropsy, pregnancy has often been purposely disguised; and, sometimes, on the contrary, where pregnancy has been ardently wished for and has actually taken place, it has been mistaken for a case of ascites: while, in a few instances, both have co-existed : Mauriceau, indeed, mentions a case of pregnancy re- curring a second time along with dropsy :* and in an hydropic dia- thesis there is a general tendency to the latter whenever the former makes its appearance ; for the exhalants of the abdomen are easily thrown into a morbid condition, and the pressure of the uterus, as it enlarges, weakens and torpefies their action. If dropsy occur at a period of life when the catamenia are on the point of naturally taking their leave, and where the patient has been married for many years without ever having been impregnated, it is not always easy, from the collateral signs, to distinguish between the two. A lady under these circumstances was a few years, ago attended for several months by three or four of the most celebrated physicians of this metropolis, one of whom was a practitioner in midwifery, and concurred with the rest in affirming that her disease was an en- cysted dropsy of the abdomen. She was in consequence put under a very active series of different evacuants; a fresh plan being had recourse to as soon as a preceding had failed ; and was successively purged, blistered, salivated, treated with powerful diuretics, and the warm-bath, but equally to no purpose: for the swelling still increased and became firmer; the face and the general form were emaciated, the breathing was laborious, the discharge of urine small, and the appetite intractable; till at length these threatening symptoms were followed by a succession of sudden and excruciat- ing pains, that by the domestics, who were not prepared for their appearance, were supposed to be the forerunners of a speedy disso- lution, but which fortunately terminated before the arrival of a single medical attendant, in giving birth to an infant that, like its mother had wonderfully withstood the whole of the preceding medical warfare without injury. In all common cases, the best means we can take to guard against deception, are to inquire into the slate of the menses, of the mam- mae, and of the swelling itself. If the menses continue regular, if the mammae appear flat or shrivelled with a contracted and light- * Traite des Maladies des Femmes grosses, n. p. 59, 204. 278 ECCRITICA. [CL. VT.—OR. II. coloured areola; and if the intumescence fluctuate to a tap of the fingers, there can be no doubt of its being a case of dropsy : but if, on the contrary, the mammae appear plump and globular with a broad and deep-coloured areola; if we can learn, which in cases where pregnancy is wished to be concealed, we often cannot do, that the catamenia have for some time been obstructed ; and if the swelling appear uniformly hard and solid, and more especially if it be seated chiefly just above the symphysis of the pubes, or, provided it be higher, if it be round, and circumscribed,—though we may occasionally err, there can be little or no doubt, in most instances, of the existence of pregnancy. The most difficult of all cases is that in which dropsy and pregnancy take place simultane- ously. It is a most distressing combination for the patient; and can only be treated with palliatives till the time of child-birth. The ordinary causes of dropsy of the abdomen are those of cel- lular dropsy, of which we have treated at considerable length al- ready, and to which the reader may therefore refer himself: the only difference being, as in dropsy of the chest, that the excernents of these cavities, are, from particular circumstances, more open at the time to the influence of whatever may happen to be the cause than the excernents of the cellular membrane, or of any other part of the system. From the extent, however, of the abdominal region, and the connexion of its cavity with so many large and important viscera, and especially with the liver, we can be at no loss in ac- counting for a more frequent appearance of dropsy under this species than under any other. The general symptoms, moreover, are those of cellular dropsy. The appetite flags, there is the same aversion to motion and slug- gishness when engaged in it, the same intolerable thirst, dryness of the skin, and diminution of all the natural discharges. The pecu- liar symptoms, as distinct from cellular dropsy, are the gradual swelling of the belly, and, as a consequence of this, a dry, irritable cough and difficulty of respiration. It is often as difficult to determine whether the water be seated in the cavity of the abdomen or in the liver, omentum, or any other cyst, as in making a like distinction in dropsy of the chest. But, generally speaking, if we have previously had reason to sus- pect a diseased condition of any of these organs, if the abdominal swelling be local or unequal, and the constitution do not seem to enter readily into the morbid action, and the remaining functions retain a healthy vigour, we may suspect the dropsy to be of the encysted form. While, on the contrary, if the animal frame evince general weakness, if the limbs be edematous, the appetite fail, and the secretions be concurrently small and restricted, there is good reason for believing that the fluid is effused into the cavity of the peritonaeum. The treatment of ascites, as to its general principles and plan, muSt be the same as that already laid down for anasarca or cellular dropsy: but here, instead of evacuating the water by scarification, ftb. i.—-ar. v.) EXCERNENT FUNCTION. 279 we can often very advantageously, and more easily than in any of the preceding species, draw it off at once by tapping. Where, in- deed, the dropsy is of the encysted kind, our efforts will often prove in vain ; for we may either miss the proper viscus, or the fluid lodged in the separate vesicles of a vast aggregation of hydatids, amounting sometimes to seven, eight, or nine thousand at a time,* cannot be set free. But where it lies in the peritonxal sac alone, or on the outside of this sac alone, we can often afford very great relief by this simple process, and sometimes an effectual cure. It ought, therefore, by no means to be delayed as it often is till the debility from being local has become general, nor can the operation be too soon performed after a fluctuation is distinctly felt, and the swelling from its bulk has become troublesome to the breathing, and interferes with the night's rest. Nor should we be deterred if the first evacuation do not fully succeed. On the contrary, if the general strength seem to augment for some time after the opera- tion, the appetite to improve, and the usual symptoms of the disease to diminish, we may take courage from our first success, and augur still more favourably from a second or even a third attempt if it should be necessary. Various cases have fallen to the lot of the author in which a radical cure has only been completed in this man- ner : nor are instances wanting in which the patient has only reco- vered after the twelfth time of operating. Hautesierk gives an instance of cure after sixty tappings within two years and a half, in conjunction with a steady use of aperients and tonics :! and Martin, in the Swedish Transactions, relates another instance of an infant of four years old restored after a second use of the trocar, in con- junction with a like course of medicines. Internal evacuants, therefore, as far as the strength will allow, and tonic restoratives generally, should be called to our aid through the entire process of cure, as already recommended under hydrops cfllularis. The thirst, which is often unconquerable, and the most distressing of all the symptoms, may be allayed, as we have already pointed out, by a free use of subacid drinks, the desire for which is by no means to be repressed, as the absorbents of the skin are al- ways stimulated by the irritation of an ungratified desire to imbibe far more fluid from the atmosphere than any indulgence in drink- ing can amount to: as ordinary food, the alliaceous plants which give an agreeable excitement to the stomach., and at the same time quicken the action of the kidneys, will be found highly useful: and asparagus, which in an inferior degree answers the last of these purposes, may make a pleasant change in its season. After all it must be confessed that tapping, is often employed without radical success, for the disease, under all its modifications, is too often incurable. Yet even in the worst of cases it has its ad- vantage as a palliative ; and it is no small consolation to be able to * Commerc. Nor. 1731. p. 271, ! Recueil, II. 280 ECCRITICA. (CL. VI.—OR. If. procure temporary ease and comfort in the long progress of a chronic but fatal disease. The quantityevacuated by the operation of tapping has, in some instanres, been enormous. It has often amounted to eight gallons at a time, and Dr. Stoerck gives an instance of twelve gallons and a half* Guattani relates a case in which thirty pints of an oily fluid were, in like manner, evacuated by a single paracentesis. This disease was produced by an aneurismal affection,! and it shows great irregularity of action in the absorbent system : for while the absorbents of the peritonaeal sac were in the utmost degree dull and torpid, those of the surface were in a like degree irritable, and drunk up all the animal oil from the cellular membrane, as well as all the moisture they came in contact with from the atmosphere. The operation has frequently been repeated forty or fifty times upon the same patient; and sometimes much oftener. In the Edin- burgh Medical Communications is a case in which it occurred nine- ty-eight times within three years.! And in a foreign Journal of re- pute is another case in which the operation was repeated a hun- dred and forty-three times, though the total quantity evacuated is not given.§ Dr. Scott of Harwich performed the operation twenty- four times in only fifteen months, and drew off a hundred and six- teen gallons in the whole.|| Occasionally, both abdominal and cellular dropsy have been car- ried off by a spontaneous flow of water from some organ or other. In the latter species most frequently by a natural fontanel in some one of the extremities, as the hand, foot, or scrotum.f In the for- mer by a spontaneous rupture of the protuberant umbilicus, of which the instances in the medical records are very numerous :** And hence many operators, taking a hint from this spontaneous mode of cure, have preferred making an incision into the umbili- cus with a lancet to the use of the trocar. Paullini relates a sin- gular mode of operation, and which, though it completely succeed- ed, is not likely to be had recourse to very often. The patient, not submitting to the use of the trocar, had the good fortune to be gored in the belly by a bull; the opening proved effectual and he recovered.!! There are also a few instances of a subsidence of the accumula- » Ann. Med. I p. 149. ! De Aneurismatibus. * Vol. IV. p. 378. § N. Samml. Med. Wahrnemungen, B. III. p. 94. || Edinb. Med. Comment. Vol. VI p. 441. 1 R< idlin, Linn. Med. 1696. p. 258. Schenrk, Lib. ill. Sect. II. Obs. 136. ex Hollerio. Obs. 140.141. •* Desportes, Hist, de Malad. de St. Dominiques, 11.122. Schenck, Lib. III. Sect. II. Obs. 147. Forest us, Lib. XIX. Obs. 33. ft Cent. II. Obs. 10. GE. I.—SP. V.] EXCERNENT FUNCTION. 281 tion upon a spontaneous efflux of some other kind ; especially of Wood, and chiefly from the hemorrhoidal vessels.* SPECIES VI. HYDROPS OVARII. Brojisj) ot the #barg. HEAVY intumescence of the iliac region on one or both sides : GRADUALLY SPREADING OVER THE BELLY J WITH OBSCURE FLUCTUA- TION. There is the same difficulty in distinguishing this disease from pregnancy as in dropsy of the belly : and, consequently, the same mistakes have occasionally been made. There is also quite as much difficulty in distinguishing it from the parabysmic variety of abdomi- nal dropsy, especially when the liver is the organ enlarged and filled with hydatids. Yet in this last case, the confusion is of less conse- quence as the general mode of treatment will not essentially vary. Pregnancy, when it first alters the shape, produces an enlargement immediately over the pubes, which progressively ascends, and when it reaches the umbilicus assumes a definite boundary. In the atonic or common variety of abdominal dropsy, the swelling of the belly is general and undefined from the first. And in dropsy of the ova- ry or ovaries, it commences laterally, on one or both sides, accord- ing as one or both ovaries are affected. And it is hence of the ut- most importance to attend to the patient's own statement of the ori- gin of the disease and the progressive increase of the swelling. It is generally moveable when the patient is laid on her back; and as the orifice of the uterus moves also with the motion of the tumour, by passing the finger up the vagina, we may thus obtain another distinctive symptom. Where there are several cysts in the ovary, we may perceive irregularities in the external tumour resembling, to the touch, those of schirrhus. This disease is sometimes found in pregnant women, but far more commonly in the unimpregnated and the barren. It is also met with in the young and those who regularly menstruate, as well as in those whose term of menstruation has just ceased. The accumu- lation of fluid is often here also very considerable. Morand drew off four hundred and twenty-seven pints, within ten months ;! and Martineau four hundred and ninety-five within a year: and from * Saviard, Observ. Chir. Engalenus, p. 150. ! Mem. de l'Acad. de Chir. II. 44£. vol. iv.—36 282 ECCRITICA. [CL. VI.—OR. H. the same patient six thousand six hundred and thirty-one pints by eighty punctures within twenty-five years.* The disease commences, and indeed often continues for years, without much affection of the general health ; yet it is insidious, and the constitution at length suffers and falls a prey to it. Internal medicines have been rarely found efficacious, and when tried must consist of those already noticed in the treatment of cel- lular dropsy. Tapping affords the same ease as in abdominal dropsy, and the operation is to be performed in the same manner. I had lately a lady under my care for six or seven years, who required the operation to be performed at first every six months, afterwards every three months, and at length every month or six weeks. She rose from it extremely refreshed, and in good spirits ; and often on the same evening joined a party of friends, and was sometimes present at a musical entertainment. In about six years, however, her health completely gave way, and she sunk under the disease. So little, however, is the general health interfered with for the first year or two, that the patient occasionally becomes pregnant, while the accumulation continues to increase, and often produces a living offspring. Sir L. Maclean, has given an interesting case of this kind, in which there was not only an extensive dropsy, but an abscess of the ovary, and a discharge of pus as well as of water on tapping which was performed five times during a single pregnancy. The patient passed easily through her labour, but died within five months afterwards upon a bursting of the abscess into the peritonaeal sac. On examining the body, two pints of " a thick, brown, well digested pus were found to have escaped into the cavity of the ab- domen, and three pints more in the ovarian sac. The opening was large enough to admit of three fingers ; and the external sur- face of both the large and small intestines was found inflamed, and verging in some places on gangrene." This my learned friend ascribes to the influence of the pus that had escaped and was in contact with them :! but as this is said to have been " well digested pus," the inflammation is, I think, more probably to be attributed to sympathy with the lacerated ovarium in its actual state of irrita- tion from so large a rent, and so much larger an inflamed surface in its interior. The fluid is in this species also, sometimes lodged in a cyst, oc- casionally in many cysts, or perhaps hydatids, and there is great difficulty in ascertaining its exact situation, and consequently in puncturing it. A distinguished and skilful friend of the author's not long since made an attempt on a lady, who had been affected with the disease for some years ; yet unfortunately not a drop of serum ensued, but instead of it a pint of blood. The swelling of the abdomen has since increased to an enormous size; internal me- dicines have proved of little avail, and she has not consented to * Phil. Trans. 1784. p. 471- | Enquiry into the Nature, &c. of Hydrothorax. Appx. p. 1. 8vo. 1810. GE. I.—SP. VI.) EXCERNENT FUNCTION. 383 another trial of the trocar. It was probably from an equal want of success that Tozzetti long since declared the operation to be of no avail ;* and that Morgagni denounced it not only as useless but mis- chievous.! A more radical mode has been proposed, but so far as I know only proposed, that of extirpating the ovarium ; which, how- ever, for various reasons is! not likely to be brought into practice; De Haen regards such an operation as doubtful,§ and Morgagni as- serts it to be impossible.il Dr. Perceval relates a case of cure pro- duced by vomiting.lf Port-wine has been injected after evacuating the water, but a general inflammation is apt to succeed, and some- times death.** SPECIES VII. HYDROPS TUBALIS. mtom ot the iFallojJtau Euur. HEAVY ELONGATED INTUMESCENCE OF THE ILIAC REGION, SPREADING TRANSVERSELY; WITH OBSCURE FLUCTUATION. This species is not common. Dr. Baillie, however, among others, has particularly noticed and described it in his morbid anatomy, in a case referred to in the volume of Nosology. Its mode of treat- ment is that of dropsy of the ovary. Tapping may be attempted, but as the water lies frequently in the hydatid-vesicles or distinct sacs, success is doubtful. The quantity collected is for the most part larger than in the ovarium. Munnik mentions a case in which the distended tube contained a hundred and ten pints of fluid ;!! Harder one in which the fluid measured a hundred and forty pints ;!! and Cypriani an- other that afforded a hundred and fifty pints at a single tapping.§§ * Osservazioni, &c. ! De Sed. et Caus. Morb. Ep. XXXVIII. Art. 68, 69. $ N. Act. Nat. Cur. Vol. V Obs. 49. § Rat. Med. P. IV. c. iii. § 3. H De Sed. et Caus. Morb. Ep. XXXVIII. Art. 69, 70. 1 Ep. II. p. 156. ** Denman, Introductto the Pract. of Midwifery. Ch. III. Sect XII. If Apud Manget. tt Apiar. Obs. 87, 88. §§ Epistola historiam exhibens fcetus humani ex Tuba excisi Leid. 1700. 284 ECCRITICA. [CL. VI.—OR. II Weiss describes a case of complicated dropsy distending both the ovarium and the Fallopian tube.* The causes, and progress as well as general mode of treatment are those of dropsy of the ovary. Its chief distinctive symptom is the elongated line which the swelling assumes and the direction it takes towards the iliac region on the one side or on the other. SPECIES VIII. HYDROPS UTERI. Bvop$2 of the OTomb. HEAVY, CIRCUMSCRIBED PROTUBERANCE IN THE HYPOGASTRIUM, WITH OBSCURE FLUCTUATION ; PROGRESSIVELY ENLARGING, WITHOUT ISCHURY, OR PREGNANCY ; MOUTH OF THE WOMB THIN AND YIELDING TO THE TOUCH. Sauvages makes not less than seven species of this disease, which he calls hydrometra, and which with him occurs as a genus. The distinctions, however, are of too little account to call for such sub- division ; and one or two of the species is doubtful: particularly .the hydrometra gravidarum, or dropsy of the womb during preg- nancy. Dr. Cullen regards it as altogether unfounded, and hence makes the symptom of citra graviditatem a pathognomic character of the complaint. The disease is rarely to be met with in the cavity of the uterus, and when this is the case the orifice is perfectly closed. It is much more frequently to be found in a particular cyst, or the walls of an hydatid, or a cluster of hydatids, or between the tunics of the or- gan. Carron ascribes it in various cases to a debility of the uterus produced by a chronic leucorrhoea.! Other writers to the stimulus of pent-up, coagulated blood, sometimes assuming an encysted structure.! It is for the most part the result of a scirrhous or some other morbid change in the organ, producing debility and occa- sionally fever. A membranous or cellular dropsy is the variety most commonly assumed, in which the uterus is sometimes distend- ed to an enormous size, and the abdomen seems to be labouring under an anasarca. The water when in the cavity of the uterus, may often be eva- cuated by a canula introduced into the mouth of the organ ; and if this should be prevented by a scirrhus, cicatrix, or tubercle lying over its mouth, a rupture of the sac in which the fluid is lodged * Abhandl. einer ungewohnlichen Krankheit, &c. Rastadt. 1785. f In Blegny, Zodiac, 1781. * Act. Nat. Cur. Vol. VII. Obs. 61. GE. L—SP. VHL3 EXCERNENT FUNCTION. 285 may sometimes be produced by a violent shock of electricity passed through the hypogastric region, hard exercise or emetics. A sudden fall has often had the same effect. Tozzetti relates a case of cellular dropsy of the womb which extended down the thigh and leg on one side; and disappeared by a spontaneous discharge of the water from the cuticle of the leg affected.* The uterus has also been said to be sometimes affected with dropsy in consequence of a conveyance of the water accumulated in the cavity of the abdomen in dropsy of the belly, into the uterine cavity by means of the fringy termination of the Fallopian tubes. Of this cause, however, there does not appear to be any satisfactory proof. " Yet I must confess," says Dr. Denman, «I have seen some cases of water collected, and repeatedly discharged from the uterus in the state of child-bed, which I was unable to explain on any other principle."! The internal treatment is that of the preceding species. SPECIES IX. HYDROPS SCROTI. Brnjjsg ot the Scrotum. SOFT TRANSPARENT, PYR1FORM INTUMESCENCE OF THE SCROTUM ; PRO- GRESSIVELY ENLARGING, WITHOUT PAIN. This is the hydrocele of Heister, and other writers : and offers the two following varieties: x Vaginalis. The fluid contained in the tunica Vaginal dropsy of the vaginalis or surrounding sheath scrotum. of the testis. 5 Cellularis. The fluid contained in the cellular Cellular dropsy of the membrane of the scrotum. scrotum. The ordinary causes of the first variety are organic atony, and organic violence as a contusion, and perhaps repelled buboes. Van der Harr asserts that it occurs more frequently on the left than on the right side ;! and Jonston that is never found on the latter.§ Delattre describes a case of congenital affection.|| * Osservazioni, Mediche, Pirenz. 1752. f Introduct.to the Pract. of Midwifery, Ch. III. Sect. IX. i Waarneeminge. § IV. 72. !| Journ. de Med. Tom. XXXII. 286 ECCRITICA. (CL. VI.—OR. II. The second variety takes easily the pressure of the finger, and is mostly an accompaniment of general cellular dropsy, or a prelude to it. If it be an idiopathic affection it may be removed by scarifi- cation. The vaginal dropsy of the scrotum is the proper disease and is elastic to the touch. It sometimes takes place with great rapidity, and sometimes very slowly. The tunic is, in some cases, extreme- ly distended, and the whole scrotum rendered transparent, so that a candle may be seen through its contents. On the Malabar coast, Koempfer asserts, that the disease is ende- mic ;* and the scrotum has been sometimes found to weigh sixty pounds! In recent cases, emetics have appeared peculiarly serviceable: and astringents and stimulants may be tried in the form of cata- plasms or fomentations ; as vinegar, with or without a solution of muriate of ammonia, or neutralized with volatile alkali. Though where there is much pain leeches should be previously applied. If this do not succeed the sac must be opened, and the fluid be eva- cuated by a lancet or the trocar. But the water soon re-accumu- lates, and the same palliative must usually be had recourse to three or four times a year. Van Swieten mentiens the case of a dignified ecclesiastic who was obliged to have the operation performed every three months for twenty years in succession.! And I had lately a patient who submitted to it as often, for many years of the latter part of his life, though he did not live so long as Van Swieten's patient. The only radical cure we are acquainted with is that of obliterat- ing the cavity, by exciting an inflammation in the vaginal and albugineous tunics, or in the latter alone. By the first of these operations the two tunics adhere together, and, the cavity being destroyed, there can be no subsequent accumulation. Thus inflam- mation may be excited by a seton, a caustic, the introduction of an irritating fluid by means of a syringe, as brandy, diluted spirits of wine, or a solution of corrosive sublimate ; or by incision. This was the ordinary plan pursued till of late years, and the particular modes of carrying it into effect were equally countenanced by sur- geons of reputation. For the latter and simpler process, or that which consists in con- fining the inflammation to the tunica albuginea, we have been chiefly indebted of late years to Mr. Ramsden, and Mr. Kinder Wood. The last, after evacuating the fluid, draws forward with a small hook " that portion of the tunica vaginalis presenting at the external opening, and cuts it away with a pair of scissors, imme- diately closing the external opening with adhesive plaster. By which means a moderate inflammation of the membrane will be * Amoenitat. Exotic. f Memoires de Paris, 1711. p. 30. * Comment, ad § 252. GE. I.—SP. IX.] EXCERNENT FUNCTION. 287 insured, and I am led to hope," says the ingenious writer, "that the success will be frequent."* In effect, Mr. Wood gives various instances of complete success. The piece snipped off is very small, and very little inconvenience is suffered. The inflammation under this mode of operating is so inconsiderable as to be confined to the tunica vaginalis alone, and consequently the cavity between the two tunics is not obliterated as is obvious by the testis being still able to roll to a considerable extent within the scrotum. This plan, therefore, is best adapted for dropsies of recent standing, and where the sac is not much thickened and indurated. In old and obdurate cases it will mostly be found necessary to carry the in- flammation so far as to obliterate the cavity. Mr. Wood does not seem to be aware that Mr. John Douglas em- ployed a similar remedy as a radical cure in the cellular dropsy of the scrotum, and recommended it in his Treatise on Hydrocele, published in this metropolis in 1755. Celsus appears also to have glanced at the same in both kinds of dropsy.f In a case on which the author was consulted some few years ago, the patient, a gentleman far advanced in life, and who had been re- gularly tapped about once in three months for five or six years antecedently, found a considerable hemorrhage ensue shortly after the last operation, but which yielded on immersing the scrotum into water chilled to the freezing point. The hemorrhage, however, returned within two days, and the scrotum was again as much dis- tended, though manifestly with blood, as before the trocar had been applied. It was clear that a pretty large artery had been ac- cidentally wounded, or that the internal parts were in a very mor- bid condition. To ascertain the real fact, and put a stop to the dis- charge, the scrotal and vaginal tunics were immediately laid open from the top to the bottom, and a pretty strong pressure made between the testicle and the sides of the latter tunic with folds of lint which effectually restrained the hemorrhage, without the ne- cessity of pausing to take up any vessel. On examining the organ more closely on the ensuing day, a foul and spongy ulcer was detected on the tunica albuginea, from which the hemorrhage had proceeded : by a course of warm digestive dressing, however, both the wound and the ulcer healed, and a radical cure of the dropsy was completely accomplished-! The clitoris has sometimes been found affected with the second or cellular variety, and acquired a considerable size. The earliest writer who seems to have noticed this sort of dropsy is Aetms;§ and it has since been described or adverted to by Van Swieten,|| • Trans, of the Medico-Chir. Soc. Vol. IX. 49. ! De Medicin. Lib. Vll. cap. 21. t See, for a case somewhat similar, Edin. Med. Ess. II. Art. XIV. by Mr Jamieson. § Tetrab. IV. Serm. II. c. 22. Serm. IV. c. 100. D Comment, ad. § 1227. 288 ECCRITICA. [CL. VI.—OR. II. Saviard,* Menoury,! and various others under the name of hydro- cele muliebris or faeminina. GENUS II. EMPHYSEMA. Xnflatton. 3&titiMB);o]>S2. ELASTIC AND SONOROUS DISTENTION OF THE BODY OR ITS MEMBERS, FROM AIR ACCUMULATED IN NATURAL CAVITIES, IN WHICH IT IS NOT COMMONLY PRESENT. The term emphysema is derived from ei* or ev and m, a coagulum of blood, or any other viscid material. And hence, in all the cases of this disease which have descended to us, we find such a closure described as existing whenever the organ has been examined. Thus, in the instance related by Eisenmen- gei'4 we are told that the uterus was completely impervious; and a like account is given of a similar instance recorded in the Ephe- mera of Natural Curiosities. Palfin§ gives a case in which the ob- struction proceeded from an hydatid cyst that had fixed at the mouth of the uterus, and Fernelius|| another in which the obstruction, * Introduction to the practice of Midwifery, Chap. III. Sect. X. f Animal Economy, p 406, 4to. 1792 t Collect. Historia foetus Mussi-pontani, &c. § Description des parties de la femme qui servant a la generation. Leid. 1708. 0 Patholog. Lib. IV. Cap. XV. GE. II. SP.—III.] EXCERNENT FUNCTION. 297 and consequently the inflation, returned periodically. Dr. Den- man intimates that this affection is sometimes accompanied with spasmodic pains, resembling those of labour ; and the same remark will apply to dropsy of the womb which so much resembles it. The fact is that the uterus, when once enlarged by whatever means, and stimulated, has a natural tendency to run into a series of expul- sory exertions in order to free itself from its burthen, and to ex- cite all the surrounding muscles into the same train of action ; and hence, natural labour, false conception, uterine dropsy and inflation produce the same effect, though, perhaps, in different degrees. Emphysemas, like dropsies, are, in all cases, disorders of debili- ty ; and hence the mode of treatment in the disease before us is ob- vious. As an occasional discharge of wind from the vagina affords temporary ease, we should take a hint from this effect: and endea- vour, first, to evacuate the confined air entirely, by a canula in- troduced into the os tincae; and secondly, to invigorate the weak- ened organ by the use of some tonic injection, as a solution of ca- techu, alum, white vitriol, or diluted port wine. GENUS III. PARURIA. Sttfemfrtuntfon. MORBID SECRETION OR DISCHARGE OF URINE. The term paruria is a Greek derivation from tx^x, perperam, and •vgto, « mingo." The genus is intended to include the ischuria, dysuria, pyuria, enuresis, diabetes, and several other divisions and subdivisions of authors, which, like the different species of the pre- ceding genus, lie scattered, in most of the nosologies through wide- ly different parts of the general arrangement. Thus, in Cullen, diabetes occurs in the second class of his system; enuresis in the fourth order of his fourth class; and ischuria, and dysuria, in the fifth order of the same class. All these, however, form a natural group ; and several of them have characters scarcely diversified enough for distinct species, instead of forming distinct genera. Dysuria might have been employed instead of paruria, as a ge- neric term for the whole; but as it has been usually limited to the third species in the present arrangement, it has been thought better to propose a new term than to run the risk of confusion by retain- ing the old term in a new sense. The species that justly belong to the present genus appear to be the following : vol. iv.—38 298 ECCRITICA. [CL. VI.—OR. If 1. PARURIA INOPS. DESTITUTION OF URINE. 2. RETENTIONIS. STILLATITIA. STOPPAGE OF URINE. STRANGURY. 4. MELLITA. SACCHARINE URINE. 5. INCONTINENS. INCONTINENCE OF URINE 6. INCOCTA. UNASSIMILATED URINE. 7. ——-- ERRATICA. ERRATIC URINE. From this group of family diseases we may perceive that the urine is sometimes deranged in its quantity, sometimes in its quali- ty, and sometimes in its outlet: and that in its quality it is deranged in two ways, by being made a medium for foreign materials, and by being imperfectly elaborated. The most important principle which it seems to carry off from the constitution is the urea or that of the uric acid: and it has been ingeniously remarked by M. Berard, in his Analysis of Animal Substances, " That, as this is the most azo- tised of all the animal principles, the secretion of urine appears to have for its object a separation of the excess of azote from the blood, as respiration separates from it the excess of carbone." SPECIES I. PARURIA INOPS. Destitution of ©frme. URINE UNSECRETED BY THE KIDNEYS : NO DESIRE TO MAKE WATER, NOR SENSE OF FULNESS IN ANY PART OF THE URINARY TRACK. A deficient secretion of urine is often a result of renal inflam- mation, in which case, however, there is necessarily a considerable degree of pain and tenderness in the lumbar region. But the pre- sent species occurs occasionally as an idiopathic affection, some- times followed rapidly by great danger to the general fabric, some- times assuming a chronic form, and running on for a considerable period of time without danger, and sometimes existing as a consti- tutional affection coeval with the birth of the individual. Dr. Parr relates a case that occurred in his own practice in which no urine was apparently secreted for six weeks,* and Haller gives a similar case that lasted twenty-two weeks.f In the Philosophical Transactions! we meet with various instances of a similar deficien- cy ; among the most singular of which is the case of a youth of * Diet, in verb. Ischuria. t Bibl. Med. Pr. II. p. 200. i Vol. XXVIII. year 1783. liE. III.—SP. I.] EXCERNENT FUNCTION. 299 seventeen years of age described by Dr. Richardson, who had never made water from his birth, nor had felt the least uneasiness on this account, being healthy, vigorous, and active. Let it not be supposed, however, that so important a recrement as the urine is, can have its constituent principles remain behind, and load the blood without danger. The outlet at which these are separated and discharged is not always manifest, and hence they sometimes appear not to be separated and discharged at all; though if the state of the patient be critically examined into by an accurate pathologist, the vicarious channel will generally be detected, and most of the cases that must at present range under the species be- fore us, would be transferred to that of paruria erratica. The two most common emunctories that supply the place of the kidneys are the skin and the bowels. In Dr. Parr's case, he states that there was no vicarious evacuation,' except a profuse sweat for a day or two, and he adds that there was no suspicion of imposture, as the patient was in a hospital and constantly watched. But we have no account of the state of the bowels. In Dr. Richardson's case of a natural destitution of urine, the patient is admitted to hav1? laboured under an habitual diarrhoea, though with little uneasiness, and the discharge of the urinary elements is very correctly ascribed to the intestinal flux. The effects that result from a retention of the urinary elements in the system, are a loss of energy and a growing torpitude in every function, proving that the sensorium is directly debilitated, and rendered incapable of secreting its proper fluid. It is, hence, to be expected that the brain should evince torpitude in a greater de- gree than any other organ, and become oppressed and comatose, as though in a state of apoplexy. Nor is it difficult to account for these effects, since they naturally follow from having the blood sur- charged with that excess of azote which, as we have just observed, it appears to be the office of the urine to carry'off. The destruc- tive power of azotic gas to animal life is known to every one, as is also its further power of increasing the coagulability of the blood. I do not know, however, that the great and pressing danger of having the constituent principles of the urine thrown back into the blood, have been distinctly pointed out by any physician before the appearance of Sir Henry Halford's valuable article in a late volume of the Medical Transactions, which contains the following interest- ing case: "Avery corpulent robust farmer, of about fifty five years of age, was seized with a rigor which induced him to send for his apothecary. He had not made water, it appeared, for twenty-four hours ; but there was no pain, no sense of weight in the loins, no distention in any part of the abdomen, and therefore no alarm was taken till the following morning, when it was thought proper to as- certain whether there was any water in the bladder, by the intro- duction of the catheter; and none was found. I was then called, and another inquiry was made, some few hours afterwards, by one 300 ECCRITICA. [CL. VI.—OR. II. of the most experienced surgeons in London, whether the bladder contained any urine or not, when it appeared clearly that there was none. The patient sat up in bed and conversed as usual, complain- ing of some nausea, but of nothing material in his own view ; and I remember that his friends expressed their surprise that so much importance should be attached to so little apparent illness. The patient's pulse was somewhat slower than usual, and sometimes he was heavy and oppressed. I ventured to state that if we should not succeed in making the kidneys act, the patient would soon be- come comatose and would probably die the following night; for this was the course of the malady in every other instance which I had seen. It happened so ; he died in thirty hours after this, in a state of stupefaction."* To this short history, Sir Henry has added the following remarks, which are of too much importance to be omitted. " All the pa- tients who have fallen under my care were fat corpulent men be- tween fifty and sixty years of age : and in three of them there was observed a strong urinous smell in the perspiration twenty-lour Htturs before death;" evidently proving that in these cases the in- stinctive or remedial power of nature, aided by the constitutional vigour of the respective patients, was endeavouring to convert the exhalants of the skin into a substitute for the palsied kidneys, but was not able completely to succeed. In attempting a cure of paruria inops we ought, in the first in- stance, whatever be its cause, to take a hint from the light of na- ture which is thus thrown upon us: and, as the excretories of the skin and of the kidneys are so perpetually assisting each other in almost every way, excite the former by active diaphoretics to take upon themselves for a time the office of the latter, and carry off the urea that should be discharged by the kidneys. We should next endeavour to restore the kidneys to their natural action by gentle stimulants or diuretics, as the alliaceous and sili- quose plants, especially horse-radish and mustard, the aromatic resins and balsams, especially those of turpentine, copaiba, and the essential oil of juniper. Digitalis is of little avail, and in idiopathic diseases of the kidneys does not often exhibit a diuretic effect. If given at all it should be in conjunction with tincture of lytta, or the spirit of nitric ether. Stimulants may, at the same time, be applied externally as the hot-bath, or strokes of the electric or voltaic fluid passed through the loins; to which may succeed rubefacients and blisters. In the mean while the alvine canal should be gently excited by neutral salts; and juniper-tea, broom-tea, or imperial, may alter- nately form the common drink. The juice of the birch-tree (be- tula alba) will often, however, prove a better diuretic than any of these. It is easily obtained by wounding the trunk, and when fresh is a sweetish and limpid fluid, in its concrete state affording a brown- M " "" ' * Med. Trans. Vol. VI. p. 410. GE. ID.—SP. I.] EXCERNENT FUNCTION. SOI ish manna. It has the advantage of being slightly aperient as well as powerfully diuretic. From its stimulating the intestines it was at one time supposed to be a good vermifuge, and to have various other properties of which, in the present day, we know nothing : whence it has unjustly fallen into discredit even for properties to which it has a fair claim. SPECIES II. PARURIA RETENTIONS. Storage of S&rfttc. URINE TOTALLY OBSTRUCTED IN ITS FLOW : WITH A SENSE OF WEIGHT OR UNEASINESS IN SOME PART OF THE URINARY'TRACK. This is the ischuria of many writers, and though, like the preced- ing species, it is equally without a flow of urine, it differs very widely from it in other circumstances. In paruria inops the ex- cretories of the kidneys are inactive, and, consequently, no urine is produced. In the species before us the secernents possess an ade- quate power, but the secretion is obstructed in its passage. And as it may be obstructed in different organs and in numerous ways in each organ, we have the following varieties: * Renalis. Pain and sense of weight in the region of Renal stoppage of the kidneys, without any swelling in urine. the hypogastrium. fe Ureterica. With pain or sense of weight in the re- Ureteric stoppage gion of the ureters. of urine. y Vesicalis. With protuberance in the hypogastrium; Vesical stoppage frequent desire to make water; and of urine. pain at the neck of the bladder. £ Urethralis. With protuberance in the hypogastrium; Urethral stoppage frequent desire to make water; and a of urine. sense of obstruction in the urethra, re- sisting the introduction of a catheter. Obstruction of urine may take place in the kidneys from a variety of causes, as spasm, calculous concretions, inflammation or abscess; and the tumour or swelling which occurs in any of these states, may be so considerable as to prevent the fluid from flowing into the pelvis of the kidneys as it becomes secreted by the tubules, or out of the pelvis when it has collected there. The kidneys, however, lie so deep, and from their minuteness 302 ECCRITICA. [CL. VI.—OR. 11. are so completely buried in the loins that the intumescence which produces the obstruction is often imperceptible to the eye, or even to the touch. At times, however, the organ becomes wonderfully augmented as the process of inflammation proceeds. Cabrohus gives us the history of a purulent kidney that weighed fourteen pounds.* And where the enlargement is accompanied with but little inflammation, proceeds gradually, and does not enter into a suppurative state, the organ not unfrequently becomes much more enormous, and has sometimes been found to weigh from thirty-five to forty pounds.f In this condition there is no difficulty in conceiving a total ob- struction to the flow of the urine even when elaborated in sufficient abundance. But the kidney, on the contrary, sometimes wastes away, instead of enlarges, and this so much as to become a shri- velled sack, and not exceed a drachm in weight; and as the sinus of the kidney contracts with its body, the organ at its extreme point is sometimes found imperforate: and hence how small soever may be the quantity of fluid which in this morbid condition may be se- parated from the blood, none whatever can pass into the ureter; and if both the kidneys concur in the same emaciation, this also must form as effectual a cause of the disease before us as any other. When the stoppage of urine exists in the ureters, the causes may be as numerous and nearly of the same kind as when the kid- neys are at fault: for here also we occasionally meet with calculous concretions, inflammations, and spasm: to which we may add gru- mous blood, viscid mucus, and a closed orifice in consequence of ulceration. Vesical retention of urine is produced by inflammation, pressure upon the neck of the bladder, irritation, or paresis. Pres- sure of the neck of the bladder may be occasioned by distention of the rectum from scybala, or other enterolithic concretions, flatus, inflammation, or piles; or by distention of the vagina from inflam- mation, or a lodgement of the menstrual flux in consequence of an imperforate hymen. Irritation may be excited by a calculus, or too long a voluntary retention of urine, as often happens on our being so closely impacted in large assemblies or public courts, or so powerfully arrested by the interests or eloquence of a subject dis- cussed in such places, that we cannot consent to retire so soon as we ought: whence the sphincter of the bladder from being volun- tarily, becomes at length spasmodically, constricted, and the urine cannot escape. It sometimes happens under the last circumstance that, from the pressure of the urine against the sides of the bladder, the absorbents are stimulated to an increased degree of action, and a considerable portion of the surplus is thus carried back into the vessels, and perhaps thrown off by perspiration, so that we are able to remain for a very long term of time after the bladder has be- come painful from over-distention. * Cabrol. Observ. p. 28. f Commerc. Liter. Nor. 1731. p. 32.1737. p. 326. UE. III.—SP. II.] EXCERNENT FUNCTION. 308 Atony or paralysis of the bladder by which its propulsive power is destroyed, is a frequent cause ; whence, as Saviard has observed, it is often met with in paraplegia :* and as Morand remarks, on in- juries to the spine.t And hence, I have occasionally found it an at- tendant upon severe and long protracted attacks of lumbar rheuma- tism :t as most practitioners have probably done on injuries to the kidneys, ureters, urethra, prostate gland, or penis. It is said more- over, to be a result of repelled eruptions of various kinds, chiefly of scabies§ and scalled head ;|| but it has not occurred to me from these causes: though I have not witnessed it in infancy from the irritation of teething where dentition has been attended with diffi- culty. In urethral retention of urine, the causes do not essential- ly vary from those already noticed; such as inflammation, the lodgement of a calculus ; viscid mucus ; and grumous blood. To which are to be added the ligature of a strangulating phimosis ; ir- ritation from a blennorrhoea or clap; strictures; an ulceration of the urethra producing an opening into the scrotum, or rendering the canal altogether imperforate. There is always danger from a retention of urine when it has continued so long as to distend and prove painful to the bladder : and the danger is of two kinds, first, that of an inflammation of the distressed organ, and next, that of resorption, and a refluence of the urea, and other constituent parts of the urine, as noticed under the preceding species. The retention, however, has occasionally continued for a consi- derable period without mischief. It has lasted from a week to a fortnight.! Marcellus Donatus gives a case of six months stand- ing ;** and Paullini another of habitual retention.ft But in all these an observant practitioner will perceive the two following accom- paniments : firstly, a constitutional or superinduced hebetude of the muscular coat of the bladder so as to indispose it to inflamma- tion ; and secondly, a resorption of the urinary fluid, and its evacu- ation by some vicarious channel, as already remarked under paruria inops. We have there stated that the two most commonly substi- tuted outlets are the excretories of the bowels and of the skin. Dr. Percival gives an instance of the latter in which the perspira- ble matter was so much supersaturated with the ammoniacal salt of * Observ. Chirurgiques. f Vermichte Schriften, B. II. i See also Snowden, in the London Medical Journal. § Morgagni, de Sed. et Caus. Morb. Ep. XLI. Art. 4. H Nov. Act. Nat. Cur. Vol. V. Art. 68. 1 Eph. Nat. Cur. passim. Cornar. Obs. N. 21. •• Lib. IV. cap. 27, 28, +t Cent. II. Obs. 26. 304 ECCRITICA. [CL- VI.—OR. II. the refluent urine, as to crystallize on the surface of the body, and this to such an extent that the skin was covered all over with a white saline powder.* Sometimes it has been thrown out from the stomach intermixed with blood, in the form of a ha?matemesis ;t and sometimes from the nostrils with the same intermixture in the form of an epistaxis.J And where the absorbents of the bladder have been too torpid for action, it has regurgitated through the ureters of these organs instead of by those of the former.§ The quantity retained, and afterwards discharged, or found in the bladder on dissection, has often been very considerable. It has oc- casionally amounted to eight or nine pints; and there is a case given by M. Vilde in the Journal de Medicine, in which it equalled sixteen pints. In all the varieties thus pointed out the mode of management must be regulated by the cause as far as we are able to ascertain it. If we have reason to believe the suppression is strictly renal from the symptoms just adverted to, and particularly from ascer- taining that there is no water in the bladder or ureters, in most cases, whether it proceeds from inflammation or stone, we shall do right to employ relaxants, and mild aperients : and, where the pain is violent, venesection succeeded by anodynes. But it sometimes happens that the obstruction is produced by a parabysmic enlarge- ment or coacervation of the substance of the kidney without inflam- mation. If this should occur in both kidneys at the same time, which is rarely the case, we have little chance of success by any plan that can be laid down. If it be confined to one, the sound kid- ney will often become a substitute for the diseased, and perform double duty ; and we may here attempt a resolution of the enlarge- ment by minute doses of mercury continued for some weeks, unless salivation should ensue, and render it necesssary to intermit our practice. A mercurial plaster with ammoniacum should also be worn constantly over the region of the affected organ. The same plan must be pursued if we have reason to suspect the obstruction is confined to the ureters. The passage of a calculus is the chief cause of this variety of retained urine : and, indepen- dently of the sense of pain and weight in the region of the ureters which an impacted calculus produces, we have commonly also a feeling of numbness in either leg, and a retraction of one of the testicles in men, as the calculus in its passage presses upon the nerves which descend from the spermatic vessels. Opium and relax- ants are here the chief, if not the only means, we can rationally em- ploy; though the ononis npicata, or rest-harrow of our fieids, is said, both in the form of powder, and of decoction, to be useful in this and • Edin. Med. Comm. Vol. V. 437. f Act. Nat. Cur. III. Obs. 6. t Eph. Nat. Cur. Dec. II. Ann. IV. Obs. 63. § Petit. Traits, &c. OSuvres Posthumes. Tom. III. p. 2. GE. HI.—SP. II.] EXCERNENT FUNCTION. 305 various other diseases of the bladder accompanied with severe pain : on which account it holds a place in the Materia Medica of Bergius. The asplenium Ceterach and athamanta Oreoselinum,ov mountain-parsley were formerly in vogue for the same purpose, but seem to be of feeble efficacy. The seeds of the athamanta cre- tensis or wild-carrot, had a wider and better founded fame, both as a diuretic and lithontriptic. Dr. Cullen employed them for the lat- ter purpose but without success. The suppression is seldom total; for the opposite ureter is rarely so much affected by sympathy as to be spasmodically contracted, and equally to oppose the flow of the urine. The most common variety of this disease is that of vesical reten- tion, or a retention of the water in the bladder. This is usually pro- duced by inflammation or spasm, by which the sphincter of the bladder becomes contracted, and rigidly closed. Inflammation is to be relieved by the ordinary means ; and, in addition to these, by anodyne clysters, and fomentations, a warm bath, warm liniments, and blisters to the perinseum. Spasm is excited by various causes : a stone in the bladder will do it, an ulcer about the neck of the blad- der will do it, as will also too long a voluntary retention of urine. Spasm is for the most part to be treated, and will in most cases be subdued, by the method just proposed for inflammation , to which we may add camphor and opium by the mouth, and bladders of warm water applied to the pubes and perineum, or, which is bet- ter, the warm-bath itself. Camphor has the double advantage of being a sedative as well as an active diuretic; but combined with opium we obtain a much more powerful medicine than either af- fords when employed singly. If the retention proceed from Spa- nish flies camphor alone will often answer : though in this case it is far better to combine with it mucilaginous diluents, as gum-arabic dissolved in barley water. Several of the terebinthinate oils have also been employed with great advantage, as the oil of juniper; the balsamum carpathicum, as it was called by C. Ab Hortis, who first introduced it into practice, and recommended it for a mul- titude of other complaints as well; concerning which there was at ©ne time a great secret, but which is, in fact, nothing more than an essential oil very carefully distilled from the fresh cones of the trees which yield the common turpentine; and the balsamum hun- garicum which is an exudation from the tops of the pinus silvestris, and proves sudorific as well as diuretic. Another remedy, of early origin, and which has preserved its reputation to our own day, is the dandelion, the leontodon Taraxacum of Linneus. It was at one time regarded as a panacea, and prescribed for almost every disease by which the system is invaded, as gout, jaundice, hypo- chondrias, dropsy, consumption, parabysmas of every species, as well as gravel and other diseases of the bladder: and was equally employed in its roots, stalks, and leaves. It is now chiefly used as a deobstruent; but it possesses unquestionably diuretic powers, and hence, indeed, its vulgar name of piss-a-bed. vol. iv.—39 306* ECCRITICA. [CL. VI.—OR. II. If the joint use of these means should fail, the water must be evacuated by the introduction of a bougie or catheter, though the irritation is sometimes increased by the use of these instruments ; and the spasm or the thickening at the prostate or about the heck of the bladder is so considerable, as to prevent an introduction of even the smallest of them. In this case, if the inflammation in- crease, and the distress be alarming, nothing remains but to punc- ture the bladder, either above the pubes, in the perinccum, laterally, or posteriorly through the rectum, for the operation has been per- formed in all these ways and each has had its advocates. The urethral retention, as already pointed out, arises also from inflammation, which is to be treated in the ordinary way; or from a calculus or a stricture; both which are best removed by the ap- plication of a bougie. In the last case the bougie, if it pass with- out much pain, should be continued daily, and progressively en- larged in its size. It has often been employed with a tip of lunar or alkaline caustic : and in many instances with perfect success : but very great caution is requisite in the use of a caustic bougie; and even in the hands of the most skilful it has sometimes proved highly mischievous. When a simple bougie is employed, Ferrand* advises that, if the water do not flow immediately, it should be re- introduced and left in the urethra ; and I have myself advised such a retention of the bougie catheter through an entire night with con- siderable advantage; for the water which would not flow at first has gradually trickled, and given some relief to the over distended bladder, which has hereby progressively recovered its tone and propulsive power ; so that the water before morning has been pro- pelled in a stream. But this is a plan only to be pursued where the organ has too little instead of too much irritability, and conse- quently where there is no danger of inflammation. SPECIES III. PARURIA STILLATITIA. Stratiflurg. PAINFUL AND STILLATTTIOUS EMISSION OF URINE. This is the dysuria of Sauvages and later writers. In the preceding species there is an entire stoppage of the urine ; in the present it flows, but with pain and by drops. Several of the causes are those of paruria retentionis; but others are peculiar to the species itself; • Blegny Zod. Ann. 1681. GE III.—sp. m] EXCERNENT FUNCTION. SO'! and, as they are accompanied with some diversity in the symptoms, they lay a foundation for the following varieties: x Spasmodica. Spasmodic strangury. € Ardens. Scalding strangury. y Callosa. Callous strangury. ^ Mucosa. Mucous strangury. c Helminthica. Vermiculous strangury. £ Polyposa. Polypose strangury. The first variety is characterised by a spasmodic constriction of the sphincter, or some other part of the urinary canal, catenat- ing with spasmodic action in some adjoining part. The spasmo- dic actions of which this variety is a concomitant are chiefly those of hysteria, colic, and spasm in the kidneys. It is hence a secon- dary affection, and the cure must depend on curing the diseases which have occasioned it. Opium and the digitalis will often af- ford speedy relief when given in combination. In the second variety there is also a spasmodic constriction, but of a different kind, and making it more of a primary affection ; whence Sauvages and others have distinguished it by the name of dysuria primaria. It is excited by an external or internal use of various stimulants as acrid foods, or cantharides taken internally; and is accompanied with a sense of scalding as the urine is dis- charged. This is also a frequent result of blisters: and to avoid it in this case the patient should be always advised to drink freely of warm diluents in a mucilaginous form. Gum-arabic, marsh-mallows root, the jelly of the orchis or salep, infusion of quince-seed, lint-seed, or decoction of oatmeal or barley may be employed with equal advan- tage ; for they do not essentially differ, and the only preference is to be given to that which affords the largest proportion of mucilage. Formerly the winter-cherry (physalis Alkekengi, Linn.) was in much repute, and was supposed to produce speedy relief.* It is unquestionably sedative and diuretic, and possesses these properties without heating or irritating : and seems to be worthy of farther trial. As a sedative, indeed, Hoffman employed it in haemoptysis; and as a diuretic it has been still more generally made use of in dropsy. About five or six cherries or an ounce of the juice forms a dose; the pericarp is bitter, yet the fruit within possesses but little of this property, and has an acidulous and not unpleasant taste. Camphor has also been employed with great advantage for the same purpose, and acts on the same double principle of being a diuretic and a sedative. It is often found to act in the same manner when applied externally, and even when intermixed with the blister plaster itself, as though in some constitutions it possesses a specific influence over the bladder: upon which subject Dr. Perceval has penned the following note in his Commentary to the volume of • Manardus, Epist. Libr. XIII. N. 12 308 ECCRITICA. [CL. VI.—OR. II Nosology ; " In three instances blisters sprinkled with camphor were repeatedly applied without strangury, and as uniformly, when the camphor was omitted with the concurrence of that symptom. I will not say that in all constitutions, camphor will obviate stran- gury ; nor in all constitutions will cantharides without camphor produce it." It will commonly be found useful, and sometimes absolutely ne- cessary, in this variety, from whatever cause produced, to employ neutral aperients: and with them the means just recommended in cases of cantharides will rarely fail to succeed in most other cases. If not, the practitioner should have recourse to a decisive dose of opium. Strangury is also occasioned by a callous thickening of the membrane of the urethra producing a permanent stricture. Some interesting examples of this may be seen in Dr. Baillie's Plates of Morbid Anatomy.* We have already had occasion to observe that the most common situation of a stricture is in its bulb or the prostate gland that lies immediately above,f though it may take place in any other part. A stricture of this kind " consists," says Dr. Baillie, u of an approxi- mation for a short extent, of the sides of the canal to each other. Sometimes there is a mere line of approximation, and not uncom- monly the sides of the urethra approach to each other from some considerable length, as, for instance, nearly an inch. The surface of the urethra at the stricture is often sound, but not unfrequently it is more or less thickened." It is this thickening which produces the variety of strangury before us. The sides of the urethra have sometimes approximated so nearly by its increase that the stricture will only allow a bristle to pass through it: and hence ulcers are occasionally formed in the prostate gland, and fistulae in the perinae- um : and the cavity of the prostate is enlarged from distention, in consequence of the accumulation of urine behind the ulcer; of all which Dr. Baillie has also given examples. When the prostate, or urethra, is highly irritable, palliation only can be resorted to; but where the thickening is recent and there is little irritation, a skilful use of a bougie will sometimes afford tem- porary relief; after which, by gradually employing those of larger diameter, the stricture will often give way and the canal widen so as to allow the water to flow with considerable comfort. I have at this moment a patient under my care, who was so grievously afflict- ed with this variety of strangury about six years ago, from two dis- tinct strictures, as never to make water otherwise than by drops: the smallest cat-gut bougie could with difficulty be made to pass through the thickened parts; and he was entirely debarred from going into company. By gradually accustoming himself to bougies of increasing diameter he can now bear the introduction of a * Fascic. VIII. PI IV. V. f Vol. IV. Blenorrhoea luodes, p. 58. CE. III. SP. Ill] EXCERNENT FUNCTION. 309 moderately sized one with ease ; the water flows freely, though in a small stream, and he is able to go into company and travel with- out inconvenience. He still finds it necessary, however, that the bougie should occasionally be continued, and it is introduced into the urethra every week or fortnight. In the variety which we have called mucous strangury,the urine is intermixed with a secretion of acrimonious mucus, of a whitish or greenish hue, which is frequently a sequel of gout, lues, or blenor- rhoea. It is often, however, produced by cold, and in this last case forms the catarrhus*r.v/ca of various authors : so denominated from its being conceived that the bladder and urethra are affected in the same manner as the nostrils in a coryza. The constriction therefore depends upon an excoriated or irritable state of the urethra, or neck of the bladder. And hence the warm-bath, or sitting in a bidet of warm-water, is often of considerable service. Warm and diluent injections have also frequently been found, as well as diluent and demujcent drinks, of great advantage. If this variety continue long it is apt to produce an obstinate and very narrow stricture, of which ulceration and fistulae in perinaeo are frequent results. Strangury is also sometimes accompanied with a discharge of worms ot a peculiar kind, and proceeds from the irritation they excite. Of this we have various instances in the Ephemerides of Natural Curiosities,* in some of which the worms were found in the bladder after death, and in others discharged by the urethra during life. They are described as of different forms in different cases, sometimes resembling the larves of insects: sometimes dis- tinctly cucurbitinous, of the fasciola, fluke, or gourd-kind. Dr. Barry of Dublin has given us the case of a solitary worm discharg- ed by the urethra of a man aged fifty, " above an inch in length, of the thickness of the smallest sort of eel, and not unlike it in shape, ending in a sharp-pointed tail." It was dead, but did not seem to have been dead long. The patient had for several years been in the habit of discharging urine mixed with blood, but unaccompani- ed with pain either in the bladder or urethra. During the whole of this time he had been feverish ; and gradually lost his appetite, found his strength decay, and had become turbid and hectic ; from all which he speedily recovered as soon as this cause of irritation was removed.f We have also an example of a like vermicule, highly gregarious, and of much longer dimensions in an interesting paper of Mr. Lawrence, inserted in the second volume of the Medico-Chirurgi- cal Transactions. The patient was a female aged twenty-four, and had long laboured under a severe irritation of the bladder, which was ascribed to a calculus. She at length discharged three or four worms of a non-descript kind, and continued to discharge more, * Dec. I. Ann. IX. X. Obs. 113. Dec. II. Ann. I. Obs. 104. Ann. VI Obs 31. Dec. III. Ann. I. Obs. 82. Ann. II. Obs. 203. f Edin. Med. Ess. Vol. V. Part. II. Art. LXXII. p. 289. 310 ECCRITICA. [CL. VI.—OR. II. especially when their removal was aided by injections into the bladder, or the catheter had remained in the urethra for the night. The evacuation of these animals continued for at least a twelve- month. Twenty-two were once passed at a time ; and the whole number could not be less than from eight hundred to a thousand. A smaller kind was occasionally evacuated. The larger were usually four to six inches in length; one of them measured eight. For the most part they were discharged dead. The subject is obscure, but it may be observed that the ova of worms, and even worms themselves, are occasionally found in many animal fluids, and have been especially detected in the blood-ves- sels, where they have been hatched into grubs or vermicules, for the most part of an undecided character; though some, observed in the mesenteric arteries of asses, have been referred to the genus strongylus.* Dr. Barry supposes his isolated worm to have travel- led in the form of an ovum as far as to the extremity of an exhaling artery opening into the bladder; to have found, in this place, a pro- per nidus and nourishment for the purpose of being hatched into a larve or grub, and of growing to the size it had assumed when thrown out of the urethra; and, in consequence of this progressive growth and the proportional dilatation of the vessel in which it was lodged, he accounts for the discharge of blood without pain. If a worm reach the bladder alive and full of eggs, we have no difficul- ty in accounting for a succession of progenies. Strangury is also sometimes produced in consequence of the bladder or urethra, or both, being obstructed by the formation of a polypous excrescence which has occasionally shot down to. the ex- ternal extremity. Dr. Baillie's Morbid Anatomy furnishes several examples of this -* variety ; which, in most cases, is only to be radically cured by an extirpation of the substance which produces the obstruction,! wher- ever it can be laid hold of. When small, however, and in the form of caruncles, these excrescences have sometimes separated spon- taneously, and been thrown out by the urethra with very great re- lief to the sufferer, and have been followed by a perfect cure.f Upon this variety my venerable friend Dr. Percival has added the following note in his manuscript Commentary on the Nosology, from which the present work has been so often enriched: *' It might not be amiss to insist on a case which sometimes deceives young practitioners : ischuria cum stranguria. A copious draining of urine took place for several days in a patient with a swelled belly Death supervening, the bladder was found distended to an enormous bulk, and the parietes of the abdomen wasted. Two excrescences near the neck of the bladder internally had almost closed its outlet, and interfered with the action of the sphincter." « * Hodgson on the Diseases of Arteries. f Fascir. IX. PI. III. * Fabric. Hildan. Cent. IV. Obs. LID. Art. Nat. Cur. Vol. I. Obs. XIII. GE, in.—SP. IV.] EXCERNENT FUNCTION. 311 SPECIES IV. PARURIA MELLITA. Saccharine mvint. URINE DISCHARGED FREELY, FOR THE MOST PART PROFUSELY ; OF A VIOLET SMELL AND SWEET TASTE ; WITH GREAT THIRST, AND GE NERAL DERILITV. This is the diabetes, diabetes Anglicus, or diabetes mellitus of au- thors ; from foxGqTm. importing " a siphon," or rather from hxGxnu, " transeo." Diabetes among the Greek and Roman, and, indeed, among modern physicians till the time of Willis, imported simply a flux of urine, either crude or aqueous, for no distinction was made between the two, and both were named indifferently diabetes, dip- sacus, from the accompanying thirst, urinary diarrhoea, urinal dropsy, and hyderus (yhp«s,) or water-flux.* The writers among the an- cients who seem chiefly to have noticed it are Galen, Aretaeus, and Trallian; and the reader who is desirous of knowing what they say, and is not in possession of the original authors, may turn to Dr. Latham's Treatise upon the diseasef who has translated the whole with very great clearness and fidelity. The form of diabetes, to which we are now directing our attention, Galen describes as hav- ing a resemblance to lientery, from the rapidity with which the solids and fluids of the body seem to be converted into a crude and liquid mass, and hurried forward to the kidneys; and to canine appetite, from the voracity and thirst which are its peculiar symp- toms. He supposes a high degree of appetency or irritation to exist in the substance of the kidneys, in consequence of which it attracts the matter of urine with great vehemence from the vena cava; and an equal degree of atony and relaxation to exist in its orifices or pores, so that the same matter flows off unchanged as soon as it reaches them.f This general view of the subject was adopted with a few additions by Aretaeus, and without any by Trallian; and seems to have de- scended with little variation, as we have just observed, till the time of Willis, who first called the attention of practioners to the curi- ous and important fact that the urine of diabetic patients, seemed in many cases, to contain a saccharine principle. These cases, however, were not, at that time, duly distinguished, and hence, in Sauvages, who was well acquainted with Willis's discovery, diabetes * Galen, de Crisibus, Lib. I. Cap. XH. X Facts and Opinions concerning Diabetes, 8vo. 1811. * De Loc. Affect. Lib. VI. Cap. iii. iv., compared with De Crisibus, Lib. I, Cap. xii. 312 ECCRITICA. [CL. VI.—OR. II. signifies equally an immoderate flux of urine from hysteria, gout, fever, spirituous potation, as well as urine combined with saccha- rine matter: though the only relation which the last has to the rest is that of its being usually secreted in a preternatural quantity : but as even this last quality, though mostly, is not always, the case, it should be distinguished by some other name than that of diabetes, and form a distinct division : or, if the name of diabetes be applied to it, it should be given to it exclusively. Dr. Young, who retains the name in the latter sense, and employs it as that of a genus, justly allows but one species to the genus, the diabetes miltuu-, of Culien, and describes the diabetes insipidus under the genus and species of hyperuresis ayuosus. There is great doubt whether this last ever exists as an idiopathic affection. Cullen himself, indeed, candidly expresses the uncertainty of his mind upon the subject: " Almost all the cases of diabetes of late times," he observes, '• exhibit saccha- rine urine, ita ut dubium sit, an alia diabetis idiopathicae et perma- nentis species revera detur." If such be found it will probably be nothing more than a variety of the next species in the present ar- rangement, paruria incontinent :* while the honeyed diabetes or saccharine urine ought to be studied as a distinct affection. The pathology of this disease is still involved in a considerable degree of obscurity : for though anatomy has pointed out a few morbid changes that exists more or less extensively in the urinary or digestive organs, and chemistry has sufficiently explained to us the morbid character of the discharge, they have thrown less light upon its origin than could be wished for, and have hitherto led to no satisfactory opinion upon the subject. Even the seat of the disorder is, to the present hour, a point of controversy; and as its seat, together with the nature of its cause, can only be collected from its symptoms, we will first lay down its general history and afterwards glance at a few of the leading hypotheses which have been started in respect to its pathology. Saccharine or honeyed paruria is rarely, though sometimes,! found in early life, but is often a sequel to a life of intemperance, on which account it is occasionally connected with a morbid state of the liver. It makes its approach insidiously, and often arises to a considerable degree and exists for some weeks without being particularly attended to If the urinary symptoms take the lead it is without the patient's noticing them, for the first morbid change he is sensible of is in the siomach. At this time, to adopt the description of Dr. Latham, " It is attended, for the most part with a very voracious appetite, and with an insatiable thirst; with a dry harsh skin, and clammy, not parched, but sometimes reddish tongue; and with a frequent excreation of very white saliva, not inspissated, but yet scarcely fluid As the disease proceeds it is accompanied often with a hay-like scent or odour issuing from the * Spec. V. t Latham's Facts and Opinions, p. 176. GE. III.--SP. IV.] EXCERNENT FUNCTION. 313 body, with a similar sort of halitus exhaling from the lungs, and with a state of mind dubious and forgetful: tie patient being dis- satisfied, fretful, and distrusting, ever anxious indeed for relief, but wavering and unsteady in the means advised for the purpose of procuring it."* _ In the mean time the kidneys discharge a fluid usually very limpid and large in quantity, though sometimes slightly tinged with green, like a diluted mixture of honey and water, and possess- ing a saccharine taste more or less powerful. The pulse varies in different individuals, but, for the most part, is quicker than in health; and not unfrequently there is a sense of weight or even acute pain in the loins occasionally spreading to the hypochondria, a symptom which Areta:us notices as one of the earliest that ap- pears ; the uneasiness extending still lower till, as the same writer remarks, a sympathetic smarting is felt at the extremity of the penis whenever the patient makes water. The flesh wastes rapidly; and, as the emaciation advances, "cramps," says Dr. Latham, "or spasms of the extremities some- times supervene, the pulse is more quick and feeble, and the saliva more glutinous." And when the strength is almost exhausted in a still more advanced stage of the disease, the lower extremities often become edematous, and the skin cold and damp : the diabetic discharge is then frequently much diminished, and is sometimes even found to become more urinous for a few hours before death closes the distressing scene." A pulmonic affection occasionally accompanies or precedes the attack ; Dr. Bardsley, indeed, affirms that he does not recollect a case that was entirely free from this symptom. And it is probably on this account, as also from the feverish state of the pulse, which by some writers has been supposed to partake of a hectic character, that by M.M. Nicolas and Gueudeville the disease has been deno- minated Phthisurie sucree.X The state of the bowels is extremely variable, though there is commonly a troublesome costiveness; sometimes, indeed, so much so, that the feces are peculiarly hard- ened and scybalous: which is well described by a patient of Dr. Latham's, in a letter of consultation; " The heat of my body," says he, " I suppose arises from a most determined costiveness that I cannot find means to conquer, and which occasions me great pain and misery, frequently feeling an inclination without the ability of discharging: and when, after much difficulty, the excrement is ejected, it has almost the solidity of lead."| In a few instances the disease seems o be connected with family predisposition. Mr. Storer has noticed a case of this kind in his communication with * Facts and Opinions concerntng Diabetes, &c. p. 1. •J- R^cherches et Experiences M£dicaleset Chimiques sur la Diabe'te sucrle. ou la Phthisie sucre'e. 8vo. Paris, 1803. \ facts and Opinions, &c. p. 185. VOL. IV.—40 314 ECCRITICA. [CL. VI__OR. II. Dr. Rollo; and M. Isenflamm has given the history of seven chil- dren of the same parents who fell victims to it in succession.* The real nature of the fluid evacuated has been very sufficiently determined both in our own country and on the Continent by chem- ists of the first authority, who have concurrently ascertained that, whilst it is destitute of its proper animal salt, it is loaded with the new ingredient of saccharine matter. Dr. Dobson from a pound of urine collected an ounce of sac- charine substance ; and Mr. Cruickshank, from thirty-six ounces Troy, obtained, in like manner, by evaporation, not less than three ounces and a quarter: which, from the quantity discharged by the patient, would have amounted to not less than twenty-nine ounces every twenty-four hours. Chevreul has shown that by concentrat- ing this morbid urine and setting it aside we may obtain a deposit of sugar in a crystallized state. The absence of animal salts has been ascertained not less satis- factorily. M.M. Nicolas and Gueudeville showed, by a series of experiments in 1802, that the saccharine urine contains no urea, nor uric or benzoic acid; that the phosphoric salts exist in a very small proportion : and that in consequence of its sugar it will enter into the vinous and acetous fermentation, and yield an alcohol of a disagreeable odour.f The same results have since been obtained by M.M. Dupuytren and Thenard by experiments still more satis- factory. They also found an albuminous substance in the urine which is always discharged in a sensible form when the disease be- gins to take a favourable change, and is the constant harbinger of a return of the proper animal salts; for after having appeared for a little while it gradually diminishes and yields its place to the urea and uric acid. In an excellent paper of Dr. Henry's inserted in the Transactions of the Medico-Chirurgical Society,^ he appears to have arrived at many of the same conclusions though by a some- what different process. Dissection has also been had recourse to for collateral informa- tion on this complicated malady: but its researches have been less successful than those of the chemists. The only organ in which any morbid structure has been clearly ascertained is the kidneys. Mr. Cruickshank affirms generally that the arteries of the kidneys are, on these occasions, preternaturally enlarged, particularly those of the cryptse or minute glands which secrete the urine."§ And this state of inflammation or morbid activity is confirmed by Dr. Baillie in his ' Account of a case of diabetes, with an examination of the appearances after death,'|| in which he tells us that " The * Versuct einiger practicher Anmerkungen iiber die Eingeweide, &c. Er- lang, 1784. ■J- Rdcherches et Experiences, ut supra citat. $ Transact, of Medico-Chirurg. Soc. Vol. X. § On the Lacteals and Lymphatics, p. 69. U Transactions of a Society for the Improvement of Medical and Chirurgical Knowledge, &c. GE. III.—SP. IV.] EXCERNENT FUNCTION. 315 veins upon the surface were much fuller of blood than usual, put- ting on an arborescent appearance. When the substance of both kidneys was cut into it was observed to be every where much more crowded with blood-vessels than in a natural state, so as, in some parts, to approach to the appearance of inflammation. Both kid- neys had the same degree of firmness to the touch as when healthy : but I think, were hardly so firm as kidneys usually are, the vessels of which are so much filled with blood. It is difficult to speak very accurately about nice differences in degrees of sensation un- less they can be brought into immediate comparison. A very small quantity of a whitish fluid, a good deal resembling pus, was squeez- ed out from one or two infundibula in both kidneys, but there was no appearance of ulceration in either. These premises, taken conjointly or separately, according to the light in which they may be viewed by different persons, open an abundant field for speculation concerning the nature of the malady : and hence, an infinity of hypotheses have been offered of which the fullowing are the chief: I. The disease is dependent upon a morbid action of the stomach, or some of the chylifacient viscera, which necessarily, therefore, constitute its seat. II. The disease is dependent upon a dyscrasy or intemperament of the blood, produced by a morbid action of the assimilating pow- ers. III. The disease is dependent upon a retrograde motion of the lacteals, and is consequently seated in the lacteal vessels. IV. The disease is dependent upon a morbid condition of the kidneys, and seated in these organs. I. The first of these hypotheses, though not the most ancient, has been by far the most commonly received, and is, perhaps, the most prevalent in the present day. It is derived from observing the increased action which exists in the stomach, and probably also in the collatitious viscera, in conjunction with the untempered fluid which is discharged by the kidneys, whose morbid crasis is refer- red to these organs. But even here there has been much difficulty in determining which of the digestive viscera is principally at fault. Dr. Mead having remarked that the disease is frequently to be traced amongst those who have lived intemperately, and particular- ly who have indulged in an excess of spirits and other fermented liquors, ascribed it to the liver, and the idea was very generally re- ceived in his day. Dr Rollo has since, and certainly with more plausibility, fixed the seat of the disease in the stomach, and confin- ed it to this organ : conceiving it to consist" in an increased action and secretion with a vitiation of the gastric fluid, and probably too active a state of the lacteal absorbents :—while the kidneys, and other parts of the system, as the head and skin, are only affected secondarily." According to this hypothesis the blood is formed imperfectly 316 ECCRITICA. [CL. VI.—OR. II. from the first, and the morbid ch«nge of animal salts for sugar is the work of the stomach or its auxiliary organs, which are immediate- ly influenced by it. It is a strong if not a fatal objection to this view of the subject, that the blood before it reaches the kidneys, is found, upon the most accurate experiments to which it has hitherto been submitted, « to contain the salts of the blood, but no trace whatever of sugar." The experiments I allude to are those of Dr. VVollasion, and Dr. Marcet, detailed in the Philosophical Trans- actions.* Prior experiments had, indeed, been made under the supei attendance of Dr. Rollo, which induced those engaged in them to conjecture that some small portion of sugar might exist in the blood; but these trials led to no definite conclusion, and did not satisfy the experimenters themselves. The results of Wollaston have since been confirmed by other experiments of Nicolas, Sorg, Thenard, and Bostock. II. The second hypothesis, or that which regards the disease as dependent upon a dyscrasy or intemperament of the blood, produc- ed by a morbid action of the assimilating powers, is of parallel date with the preceding, and has had the successive support of many of the ablest and most distinguished pathologists from its origin to our own day. It was first started by Dr. Willis and immediately fol- lowed upon his discovery of the saccharine property of dLbetic urine, who thus expresses his opinion of the seat and nature of the disease in his treatise upon this malady :—" Diabetes is rather an immediate affection of the blood than of the kidneys, and thence de- rives its origin ; for the mass of the blood becomes, so to speak, melted down, and is too copiously dissolved into a state of serosity : which is sufficiently manifest from the prodigious increase of the quantity of urine which cannot arise from any other cause than from this solution and waste of blood." He admits, however, that the orifices of the kidneys are at this time peculiarly relaxed and patulous, in consequence of which tfie untempered fluid passes off with a greater ease and rapidity. This hypothesis of Willis wa3 readily embraced by his distin- guished cotemporary Sydenham, who fortified himself in the same by observing, that those who have long laboured under an intermit- tent, and have been unskilfully treated, and especially old persons, sometimes fall into a diabetes, from a crude or debilitated condition of the blood. And nence, he tells us in his letter to Dr. Brady, Re- gius Professor of Physic in the University of Cambridge, that "the curative indication must be completely directed towards the invi- gorating and strengthening the blood, as well as restraining the preternatural flux of urine." Thus advanced and advocated by two of the brightest luminaries that have ever enlightened the medical world, it cannot be a mat- ter of surprize that this opinion should have been extensively adopted. In truth it was espoused on the continent as well as at * Vol. CI. 1811. p. 96. GE. III.—SP. IV.] EXCERNENT FUNCTION. 317 home, and, in 1784, gave birth to M. Place's able dissertation at Gdningen :* and continued to be the prevailing opinion till the ap- pearance of Dr Rollo's work, to which we have just adverted ; and even since the appearance of this work, it has been still warmly and ably maintained by Dr. Latham, who, while he pays all the homage to Dr. Rollo's labours and abilities to which they are enti- tled, and scrupulously adopts the general principles of his practice, opposes his doctrine of a morbid condition of the stomach,! which, as well as the kidneys,± he believes to be perfectly sound in its ac- tion « I must take leave," says Dr. Latham, " to differ in opinion most materially from Dr. Rollo, who seems to consider this most enormous appetite as such an evil in diabetes, as to endeavour, by every possible means, to repress it, having founded his theory principally on the idea that on this action of the stomach depends the evolution of sugar with the whole train of consequent symp- toms : whereas, I consider the appetite, however great it may be and which I would never check by medicines, as a natural sensation calling into its full exercise that organ through which the constant waste of the body must be directly supplied, and without which the patient must soon inevitably perish : and I look upon the more mo- derate appetite which takes place usually in a few days after a strict conformity to animal diet, as the surest sign of convalescence, inas- much as I hold it in proof that the blood being thereby rendered firmer in its crasis, there is less disposition in it to be decomposed, and, consequently, (as is the fact) that there must soon be a dimi- nished discharge of nutritious matter from the kidneys " An opinion promulgated and maintained in succession by autho- rities so high, and names so deservedly dear to the healing art, ought not to be lightly called in question: but it is as difficult to reconcile the present notion as the preceding with the existence of the ordinary salts and the non-existence of sugar in the blood of diabetic patients. Dr. Latham, however, has argued the point with great and elaborate ingenuity, and has endeavored to show, by a train of reasoning which is worthy of attention, that the sugar, in respect to its elements, may exist in the blood, though the substance itself be not discoverable in it, being " so weakly and loosely oxyge- nated as to be again readily evolved by the secretory action of the kidneys, not from any fault in the kidneys themselves, but from the regular and natural exercise of their function, in separating from the imperfect blood such matters as are not properly combined with it."§ III. A bold and plausible effort was made, between forty and fifty years ago, to get rid of the stumbling-block of the absence of sugar • Dis. de Vera Diabetis caussa in defectuassimilationis qusrenda. Goett 84. f Facts and Observations, &c. n, 230. * Id. p. 110. $ Ut supra, p. 97. 31b ECCRITICA. [CL. VI.—OR. It from the blood by showing that provided it were once formed by the digestive organs, there is no necessity for its travelling in this direction. This hypothesis was brought forward by that very acute and ingenious physiologist, Mr. Charles Darwin, in an essay pre- sented to the jEsculapian Society of Edinburgh in 1778, that ob- tained for him an unanimous grant of the prize-medal for the year: an honour dearly earned, as almost immediately afterwards, he fell a martyr to his indefatigable pursuits, while on the verge of gra- duating. In this essay he endeavoured to account for the disease of saccharine urine by a retrograde motion of the lymphatics of the kidneys. Having endeavoured to establish the general principle of a retrograde lymphatic action, he proceeds to remark, that all the branches of the lymphatic system have a certain symphathy with each other, insomuch that when one branch is stimulated into any unusual motion, some other branch has its motions either increased, or decreased, or inverted, at the same time: thus, when a man drinks a moderate quantity of vinous spirit, the whole system acts with more energy by concert with the stomach and intestines, as is seen from the glow on the skin, and the increase of strength and activity: but when, says he, a greater quantity of this inebri- ating material is drunk, at the same time that the lacteals are quick- ened in their power of absorbing it, the urinary branches of the absorbents which are connected with the lacteals by many anasto- moses, have their motions inverted, and a large quantity of pale, unanimalized urine is hereby discharged. Where, continues Mr. Darwin, this ingurgitation of too much vinous spirit occurs often, the urinary branches of absorbents at length gain a habit of invert- ing their motions whenever the lacteals are much stimulated: and the whole or a great part of the chyle, is thus carried to the blad- der without entering the circulation, and the body becomes ema- ciated: while the urine is necessarily sweet and of the colour of whey. And on this account Mr. Darwin proposed to denominate the species before us a chyliferous diabetes. This hypothesis, for, ingenious as it is, it has never been entitled to a higher character, became at one time also very popular, and was supported by the talents of the celebrated author of Zoonomia, the father of its ingenious inventor. A few singular facts which have occurred since the decease of both these writers, seem at first sight to give it a little colourable support: such as the rapid passage of certain substances from the stomach to the bladder ap- parently, according to the experiments of Dr. Wollaston and Dr. Marcet, without their taking the course of the circulation : and M. Magendie's experiments upon the lymphatic system, and the doctrine he has founded upon them. These, however, the author has ex- amined with some attention in the Physiological Proem to the pre- sent Class, and has endeavoured to reconcile them with the ascer- tained and admitted structure and laws of the animal frame : so that they can add but little to the speculation before us. And in truth, how much soever it may have been caught up hastily by men of GE. in.—SP. IV.J EXCERNENT FUNCTION. 319 warm imagination, or those who are fond of novelty, the soberer physiologists have never been made converts to it. " In the dia- betes," says Mr. Cruickshank, " it has' been supposed that the chyle flows retrograde from the thoracic duct into the lymphatics of the kidney, from them into the cryptae, so into the tubuli uriniferi, thence into the infundibula, pelvis, ureter, and so into the bladder. This opinion is mere supposition, depending on no experiments. And, besides that all such opinions should be rejected, why should the chyle flow retrograde into the lymphatics of the kidney and not in the lacteals themselves ? and why are not the feces fraught with a similar fluid as well as the urine ? The arteries of the kidneys are, on these occasions, preternaturally enlarged, particularly those of the cryptae or minute glands which secrete the urine. And it is infinitely more probable that the fluid of the diabetes arises from some remarkable change in the vessels usually secreting the urine, than from any imaginary retrograde motion of the chyle through the lymphatics of the kidneys."* Even Dr. Wollaston prefers a state of doubt concerning the course pursued by the above-men- tioned substances to an adoption of this conjecture, notwithstanding the ready solution it offers to his experiments. " With respect," says he, " to Dr. Darwin's conception of a retrograde action of the absorbents, it is so strongly opposed by the known structure of that system of vessels, that I believe few persons will admit it to be in any degree probable."f IV. We come now to the fourth hypothesis to which the disease before us has given rise, and which places it in the kidneys. These form, indeed, the most ostensible seat, and hence, as we have al- ready seen, they were the first suspected, and were supposed by the Greek writers to be in a state of great relaxation and debility, and hence also of great irritability. To this irritability was ascrib- ed their morbid activity, and the accumulation of blood with which they were overloaded : while their weakened and relaxed condition allowed the serous or more liquid parts of the blood to pass off through the patulous mouths of the excretories without restraint or change, and, consequently, in a crude and inelaborated form like the food in a lientery. Such was the explanation of Galen: and of all the hypotheses before us there is no one that seems to be so fully confirmed, as well by the symptoms of the disease during its progress, as by the appearances it offers upon dissection. The anatomists have hence generally adopted this opinion, which is to be found in Bonet,{ Ruysch§ and Cruickshank ;|| and in proof that it has of late been gaining additional ground among physicians and medical practition- * On the Lacteals and Lymphatics, p. 69. f Phil Trans, ut supra. 1811. p. 105. * Sepulchr. Lib. HI. Sect. XXVI. Obs. 1. § Observ. Anat. Chir. N. 13. I| On the Lacteals and Lymphatics, p. 69. 320 ECCRITICA. [CL. VI.—OR. II ers in general, as well on the Continent as in our own country, it may be sufficient to refer to the writings of Richter, the works of M.M. Nicolas and Gueudeville, and M.M. Dupuytren and The- nard, already quoted from, and the communications of Mr. Watt, Dr. Henry, and, still more lately, of Dr. Satterley; several of whom, however, conceive the stomach or some other chylifactive organ to be affected at the same time secondarily or sympatheti- cally. By far the greater number of these writers regard the irritation of the kidneys as connected with inflammation : though several of them ascribe it to a spasm. They seem to reason from the pain found occasionally in the region of the loins, and the limpidity and enormous quantity of the fluid that is discharged, which in their opinion is analogous to that evacuated in hysteria or hypochondri- as ; such was the opinion of Camerarius upwards of a century ago,* and of Richter and Gueudeville in our own day : " la phthisurie," says the last, for under this name he describes saccharine urine, " est une consomption entretenue per une deviation spasmodique et continuelle des sues nutritifs non animalises sur l'organe uri- naire."t There seems after all but little to support this doctrine, and yet it was adopted by Cullen, and that so completely as to induce him to arrange diabetes in his Class Neuroses, and Order Spasmi, im- mediately before hysteria, and hydrophobia. His reason for doing so is c. t.tained in the following passage in his First Lines : " As hard- ly any secretion 6an be increased without an increased action of the vessels concerned in it, and as some instances of this disease are attended with affections manifestly spasmodic, I have had no doubt of arranging the diabetes under the orde* of spasmi":}: A more unsatisfactory reason has, perhaps, never been offered, nor does the author himself seem satisfied with it, for we find him, shortly afterwards, not indeed, like M. Gifeudeville, uniting it with another cause to give it potency, but abandoning it for this auxiliary cause which seems to be adopted exclusively for he adds within a few aphorisms, " I think it probable that, in most cases, the proxi- mate cause is some fault in the assimilatory powers, or those em- ployed in converting alimentary matter into the proper animal fluids."§ But admitting the kidneys to be in a morbid and highly irritable state, which is the oldest, and apparently the best supported doc- trine upon the subject, and that this state is connected with an in- flammatory action of a peculiar kind, what necessity is there for supposing an idiopathic affection of any other part, whether the stomach or the nerves,the chylifacient or the assimilating powers? And why may not every other derangement that marks the progress * Diss de Diabete Hypochondriacorum periodico, IVj. 1696. \ Recherches et Expediences Medicates, &c. 8vo. Paris, 1803. * Pract. of Phys. Aph. MDIV. § Pract. Phys. Aph. MDXII. GE. III.—SP. IV.] EXCERNENT FUNCTION. 321 of the disease be regarded as consequent upon the renal mischief? I ask the question with all the deference that is due to the distin- guished authorities that have passed in review before us, the value of whose writings, and the extent of whose talents no man is more sensible of than myself: but I ask it also, after having studiously at- tended .o the nature of these derangements both in theory and in all the practice which has fallen to my own lot, and with a strong disposition to believe that the whole can be. traced and resolved in- to this single and original source, and consequently that diabetes is a far less complicated disease than has hitherto been imagined. That an inordinate excitement of the kidneys is capable of aug- menting the urinary secretion, whatever be the cause of such ex- citement, is obvious to every one who has attended to the stimulant effects of spirits drunk to excess, hysteria, and several other irregu- lar actions of the nervous system, and the whole tribe of diuretics. In all these cases, however, the excitement is only secondary, and follows upon a previous affection of some other organ or part of the system. But in the disease before us, we are contemplating a primary excitement, a morbid action originating and seated in the kidneys themselves. And surely when we reflect upon the pro- digious quantity of serum the excretories of the cellular membrane are capable of separating and carrying off from the blood in cellular dropsy, and those of the more limited range of the pleura or the peritoneum in dropsy of the chest or of the belly, there can be no difficulty in conceiving that the emunctory of the kidneys, whose function, when in health consists in eliminating a very large portion of the more attenuate parts of the blood, should, when in a state of morbid and increased action, be capable of secreting quite as pro- digious an excess of fluid as is found secreted in any kind of dropsy whatever. And hence, from a morbid irritation of the kidneys alone, we may, I think, satisfactorily account for the largest quantity of vvater that is ever discharged in the disease before us, and see with what peculiar force it was denominated by the Greeks hyde- rus (ufopos ) or water-flux, as also hydrops mat ell a or urinal dropsy. This analogy will be still more obvious from our following up the common forms of dropsy to their ordinary consequences, and comparing them with the consequences of diabetes. As the watery parts of the blood in cellular or abdominal dropsy are drawn off with great rapidity and profusion to a single organ, every other organ becomes necessarily desiccated and exhausted; the skin is harsh and dry, the muscles lean and rigid, the blood-vessels collaps- ed, the bowels costive, and the adipose cells emptied of their oil. Every part of the system is faint, and languishes for a supply, and hence that intolerable thirst which oppresses the fauces and sto- mach, and urges them by an increased action to satisfy the general demand. This is a necessary effect of so profuse a depletion, be the cause what it may: and we have reason, therefore, to augur a priori that such an effect must follow in this form of the Greek hyderls, or water-flux. That it does follow we have already seen ; vol. iv.—41 322 ECCRITICA. [CL. VI.—OR. It. and we are hence led almost insensibly to adopt, in its fullest lati- tude, the correct doctrine of Dr. Latham, that " the increased ap- petite in this last disease, however great it may be, is a natural sen- sation, calling into its full exercise that organ through which the constant waste of the body must be directly supplied, and without which the patient must soon inevitably perish."* From a morbid excitement then, a weak and irritable inflamma- tion, if I may be allowed the expression, of the kidneys alone, we are able to account, not only for all the local symptoms of an enor- mous flux of water, lumbar, or hypochondriac pains, and occasion- ally fulness, and the post-obit appearances of distended or " preter- naturally enlarged arteries," as observed by Mr. Cruickshank, " blood-vessels more crowded than in a natural state, so as in some parts to approach to the appearance of inflammation," as observed by Dr. Baillie, " ossified arteries," as observed by Mr. Gooch, and " a glutinous infarction of the parenchyma of the kidneys," as ob- served in other cases by Pienciz ;f but also for all the constitutional symptoms of a dry, harsh, and heated skin, general emaciation, and sense of exhaustion, depression of animal spirits, great thirst and voracious appetite. In dropsy, indeed, the appetite is not uniformly voracious, nor is it always so in diabetes : but that inanition of al- most every kind has a tendency to produce this system, where the tone of the stomach is not interfered with or has re-established it- self, is manifest from its occurring so commonly after severe fa- tigue, long fasting, protracted fevers, or any other exhausting state of body. And hence the very existence of the symptom in diabetes is a direct proof that the action of the stomach, instead of being morbid, is perfectly sound though inordinately excited. But the grand question, it may, perhaps, be said, still remains untouched. How are we to account for that crude, fused, or dis- solved state of the blood, which appears so conspicuously in dia- betes, and which reduces it from an annualized to a vegetable cra- sis ? Now upon this point, let us fairly put to ourselves this previ- ous question : Does such a state of the blood appear at all ? and is it in fact reduced or changed in any respect from its anamalized character antecedently to its arrival at the morbid organ of the kid- neys ? So far as we have been able to obtain information from che- mical experiments, the blood of a diabetic patient continues in full possession of its anamalized qualities, and evinces no approach to- wards those of vegetable fluids : and so far as we can judge from its being drawn from the arm during life, instead of evincing a thin, dis- solved, and colourless state, it discovers that very condition which we should anticipate as a natural consequence of a very copious ab- straction of its serous or more liquid, principles. For we are told, without a dissentient voice, by those who have drawn blood freely and repeatedly during the disease, that it has the general appear- * Practical Treatise, &e. I. p. 417. t Acta et Observationes Med. p. 153. 6E. m.—SP. IV.J [EXCERNENT FUNCTION. 323 ance of the treacle ; thicker than natural from the drain of its finer parts, and darker from a closer approximation of its red co> puscles, little capable of coagulability from its loss of coagulable lymph, and hence not separating by rest into a proper serum and crassament. And we are told farther that wherever venesection has been ser- viceable, and the renal flux has dimished, the latter instantly as- sumes a greater disposition to coagulate, and loses the darkness of its hue. The grand reason, after all, for supposing that this change from an animalized to a vegetable, or rather from an uric to an oxalic character, takes place in the blood itself, is from the difficulty of conceiving how it can take place in the kidneys : the difficulty of explaining how an organ whose common function is to secern alka- lies, and an acid strictly animal, should be brought to secern an acid directly vegetable. But, in the first place, is the difficulty one which is diminished by transferring this wonderful change of action to the assimilating powers, or to the stomach, or to any other or- gan ? For let us lay the fault where we will, we are still involved in the dilemma of supposing, that an animal structure whose healthy function consists in the formation of ammonia, has its action so per- verted by the disease before us, as to produce sugar in its stead. And hence, by enlisting the assimilating powers into service upon the present occasion, we only gain two levers instead of one. We place the globe upon the elephant instead of upon the tortoise, but we have still to inquire what it is that supports the latter. There are, however, if I mistake not, various pathological and physiological facts perpetually occurring before your eyes, which if properly applied, may at least reconcile us to this supposed anoma- ly, if they do not explain its nature : a very few of which I will briefly advert to. We see a tendency in most animal organs to produce sugar un- der particular circumstances, whatever be the character of their ordinary secretion; and this both in cases of health, where we have no ground for supposing an imperfectly animalized fluid; and in cases of disease where such a change may perhaps be contended for and supported: and we see this also, and equally, under an animal and under a vegetable diet; in some instances, indeed, most so where the former predominates. No one, if he did not know the fact, would predict that the breast of a healthy woman, which forms no sugar at any other time, would become a saccharine fountain immediately after child birth: and still less so that an animal diet, or a mixed diet of animal and vegetable food, would produce a larger abundance than a vegetable diet alone : and least of all, that woman's milk produced by animal food would yield more sugar in a given quantity than ass's,goat's, sheep's,or cow's; and less case- ous matter than any of these quadrupeds,* though this last is the * Experimens des M. M. Stirpriaan, Liviscius, et Dc Bondt, in Mem. de la Societe de Med. a Paris. 1788. 324 ECCRITICA. [CL. VI.—OR. II. only matter of a strictly~animalized quality which milk of any kind contains. This, however, is a natural process. Yet under the action of a morbid influence sugar is often produced in other organs, while what should be sugar in the mammae is changed to some other sub- stance. Under the genus Ptyalismus, we have observed, that the saliva is sometimes so impregnated with a saccharine principle as to acquire the name of p. mellitus :* it is indeed by some authors represented as having the sweetness of honey. Pus, under various circumstances, evinces a sweetish taste, and hence the occasional sweetness of the sputum in consumptive patients. So in fevers of various kinds, as wc have already had several occasions to observe, and particularly in hectic fever, the sweat throws forth a vapour strongly impregnated with acetous acid. Even the ceramen some- times both smells and tastes sweet; a fact noticed by Hippocrates, who at the same time remarks that it is a fatal symptom. As an animal product it might be reasonable to expect that the gastric juice would be alkaline, and it is so in some animals : yet those who have paid but little attention to animal chemistry will be surprised to learn that while it is for the most part neutral in animals that feed jointly on flesh and vegetables, it is alkaline in ruminating and graminivorous animals, or those that feed on grass, and acid in carnivorous animals, as the falcon, hawk, and heron. Upon which points the experiments of Brugnatelli,f coincide with those of Carminati and Macquart. It is unnecessary to pursue these illustrations any further. Can- didly reflected upon they cannot fail, I think, to diminish in a con- siderable degree, the repugnance which the mind at first feels in admitting a secretion of sugar by an organ, whose common function is so inaccordant with such a production: and consequently they co-operate in leading us to the conclusion which it has been the design of these remarks to arrive at, that paruria mellita, or diabetes, is a disease seated in the kidneys alone, and dependent upon a pe- culiar irritability or inflammation of the renal organ. Of the predisposing or occasional causes of this disease, however, we are still involved in considerable darkness; with the exception that whatever debilitates the system seems at times to become a predisponent, and only requires some peculiar local excitement to give birth to the disease, without which it is in vain to expect that it should take place. Hence it occurs to us, in some instances, as a consequence of old age, in others of a constitution broken down by intemperance or other illicit gratifications; in others again of a diseased liver, or diseased lungs,|: of atonic gout, or suppressed eruptions: and particularly of chronic carbuncles, or ill-conditioned » Vol. I. p. 55. f Saggio d'un Analisa Chemica di Succi gastrici. Vide Crell, Beitrag. zu dem Chem. Annal. 1787. * See Case in Latham's Tracts, &c. p. 142, as alao the remarks already ed from Dr. Bardsley. * GE. ill.—SP. IV.] EXCERNENT FUNCTION. 325 sores approaching to their nature, and showing like themselves a considerable degree of constitutional debility. I am greatly obliged to Dr. Latham for calling my attention to this last fact while drawing up the present history of the disease, and for referring me in support of his own opinion upon this sub- ject to the following passage in Cheselden : " There is sometimes a large kind of boil or carbuncle in this membrane, which first makes a large slough and a number of small holes through the skin which in time mortifies and casts off, but the longer the slough is suffered to remain the more it discharges, and the more advan- tage to the patient: at the latter end of which case the matter has a bloody tincture, and a bilious smell, exactly like what comes from ulcers in the liver; and both these cases are attended with SWEET URINE as in DIABETES."* In concurrence with this remark of Cheselden, Dr. Latham in- forms me in a letter as follows : " I have a patient at this moment, whose diabetes was first observed after a long confinement from carbuncle : he is upwards of seventy, and is moreover afflicted with a mucous discharge from the internal coats of the bladder." Not dissimilar to which, is the following case, whish is well worthy of notice, and occurs among the earliest, in Dr. Latham's treatise on this disease. " About the year 1789 there was a most remarkable case of diabetes in St. Bartholomew's hospital, under the imme- diate care of the late greatly to be lamented Dr. David Pitcairn. The patient's history of himself was this : that a rat had bitten him between the finger and thumb, that his arm had swelled'violently, and that boils and abscesses had formed, not only in that arm but in other parts of the body: that his health from that time had decay- ed, and emaciation followed. His urine had then the true diabetic character both in quantity and quality: the saccharine part was in very great proportion, constantly oozing through the common earth- ern pot over the glazing, and affording an infinity of pure saccha- rine crystals, adhering like hoar frost to the outside of the utensil, and which were collected by myself and by every medical pupil daily, in great abundance."f How far the grand agent in this change of renal action, admit- ting the disease to be seated in the kidneys, is to be ascribed to a change in the quality or intensity of the nervous power transmitted to it, or, as the chemists call it, in the state of the animal electrici- ty of the organ, to which power Dr. Wollaston has referred the production and distinction of all the secretions, I am not prepared to say : but the subject ought not to be concluded without noticing this conjecture, which at the same time imports, on the part of those who hold it, an admission of the general principle of the disease which I have endeavoured to support. " Since," says Dr. Wollas- ton, il we have become acquainted with the surprising chemical • Anatomy, 8vo. p. 139. f Facts and Opinions, p. 134. 326 ECCRITICA. [CL. VI.—OR. II. effects of the lowest states of electricity, I have been inclined to hope that we might from that source derive some explanation of such phenomena. But though I have referred secretion in general to the agency of the electric power with which the nerves appear to be indued, and am thereby reconciled to the secretion of acid urine from blood that is known to be alkaline, which, before that time, seemed highly paradoxical, and although the transfer of the prus- siate of potash, of sugar, or of other substances may equally be ef- fected by the same power as acting cause, still the channel through which they are conveyed remains to be discovered by direct expe- riment."* Whilst such is the diversity of opinions which have been held concerning the pathology of honeyed paruria it cannot be a matter of much surpiise that the proposed plans of treatment should also exhibit a very great discrepancy. On a first glance, indeed, and without keeping the grounds of these distinct opinions in view, nothing can be more discordant or chaotic than the remedial process proposed by different individuals. Tonics, cardiacs, astringents, and the fullest indulgence of the vora- cious appetite in meals of animal food, with a total prohibition of vegetable nutriment on the one side, and emetics, diaphoretics, and venesections to deliquium, and again and again repeated, on the other: while opium in large doses takes a middle stand, as though equally offering a truce to the patient and the practitioner. It is easy, however, to redeem the therapeusia of the present day from the charge of inconsistency and confusion, to which at first sight it may possibly lie open. Different views of the disease have led to different intentions: but so long as these intentions have been clearly adhered to, how much soever they may vary in their respective courses, they are free from the imputation of absurdity. These intentions have been chiefly the following: I. To invigorate the debilitated organs whether locator general, and to give firmness and coagulability to the blood. This was the object of all the Greek physicians, and it regulated the practice to a very late period in the history of the disease. « The vital intention," says Dr. Willis," is performed by an incras- sating and moderately cooling diet; by refreshing cordials, and by proper and seasonable hypnotics." Hence agglutinants of all kinds were called into use, as tragacanth, gum arabic, and the albumen of eggs; and these were united with astringents as rhubarb, cinnamon, and lime-water, with or without an anodyne draught at evening as might be thought prudent. Sydenham carried the tonic and cardiac part of this plan considerably further than Willis: for while the lat- ter chiefly limited his patients to milk or a farinaceous diet, the for- mer allowed them an animal diet, with a vinous beverage. "Let the patient," says he, " eat food of easy digestion, such as veal, mut- • Phil. Trans. 1811. p. 105. GE. in.—SP. IV.] EXCERNENT FUNCTION. 327 ton, and the like, and abstain from all sorts of fruit and garden-stuff, and at all his meals drink Spanish wine." This plan continued in force with little variation, except as to the proportionate allowance of animal and vegetable food, till with- in the last thirty years. The chief tonic medicines being the warm gums, or resins, astringents and bitters. Alum and alum-whey ap- pear to have been in particular estimation with most practitioners. They were especially recommended by Dr. Dover and Dr. Brock- lesby in our own country, and Dr. Herz* on the Continent. Dr. Brisbane and Dr. Oostendyk,t on the contrary, assert, that in their hands they were of no use whatever. Sir Clifton Wintringham ap- plied alum dissolved in vinegar, as a lotion, to the loins. The other astringents that have been chiefly htid*recourse to are lime-water, as noticed already, chalybeate waters, kino and catechu in tincture, powder, and decoction; none of which, however, seem to have been eminently serviceable. While cantharides as a local astrin- gent has been exposed to a very extensive range of experiment both at home and abroad. Dr. Morgan gave it in the tincture, Dr. Herz in the form of powder, and both esteemed it salutary. Dr. Bribsane tried it in the first of these ways, giving from twenty to thirty drops, twice a-day : but appears to have been as dissatisfied with cantharides as with alum, and declares that all astringents are hurtful, as Amatus Lusitanus} asserted long before, that they are of no use. II. A second intention of pathologists in the present disease has been that of adding to the deficient animal salts, and resisting the secretion of sugar, by confining the patient to a course of diet and medicines calculated to yield the former, and to counteract the lat- ter. This intention may have been indirectly acted upon by some part of the process we have just noticed, and particularly by the dietetic plan of Sydenham : but it is to Dr. Rollo that the medical world is immediately indebted for its full illustration, and the means of carrying it directly into effect, which consists in enforcing upon the patient an entire abstinence from every species of vegetable matter, and consequently limiting him to a diet of animal food alone : some form of hepatized ammonia being employed as an auxi- liary in the mean time. . Narcotics, as under the preceding inten- tion, are also occasionally prescribed by Dr. Rollo : and, in accord- ance with his doctrine that the stomach is the chief seat of morbid action, and that the thirst and voracity are indications of such action, the aid of an emetic is occasionally called in to allay the high-wrought excitement. From this last part of Dr. Rollo's curative method Dr. Latham appears to dissent upon the ground, and in the present author's opi- * Sell Neuc Beitrage. 1.124. + Samml. auserl. Abbandl. fur. Pract. aerzte. B. I. 179 t Cent. V. Cur. 33. 326 ECCRITICA. [CL. VI.—OR. II. niona correct ground, that the increased action of the stomach pro- ceeds from a sound instead of from a morbid appetency : but to the injunction of an exclusive use of animal food, and a total abstinence from fermented and fermentable liquors, he accedes, with a full conviction of its importance, and without permitting the smallest deviation. And as Dr Rollo, with a view of completing the inten- tion of supplying the readiest means for a recruit of the deficient animal salts, prescribed hepatized ammonia as an auxiliary, Dr. Latham, for the same pupose, prescribes phosphoric acid, having observed in various cases of the disease an evident deficiency in the supply of phosphate of lime ; whence, indeed, the destruction that is occasionally met with of the fangs of the teeth together with their alveolar processes. 4fr ♦ Some severe remarks, which I am at a loss to account for, have occasionally been thrown upon this last recommendation since the publication of Dr. Latham's very candid and ingenuous work. The idea is in perfect accordance with his own view of the gene- ral nature of the disease : and, in every view of it, is more likely to be of service, than Dr. Rollo's hepatized ammonia, or, perhaps, than alkalies of any kind. For while, like the last, it has been sug- gested upon the principle of supplying to the kidneys the deficient materials upon which they are to work, it has a claim to attention as a very valuable tonic and astringent, even by those who may abjure this principle as incorrect, and particularly by the advocates for the mineral acids. I ought not indeed, while upon this subject, to conceal the following paragraph of a letter in direct allusion to it, addressed to me by Dr. Latham, so lately as May 26 of the cur- rent year, in which he communicates with much candour, his pre- sent opinion upon the general line of practice he thus undertook to recommend to the public, little less than twelve years ago. " The experience," says he," which I have had in diabetes since the pub- lication of my observations on that disease, does not excite, in any degree, a wish to alter the opinions which I had then formed con- cerning it: and I am more and more convinced that although my theory may be wrong, the practice has been successful. As to the theory about the phosphoric acid, I cannot help thinking that there is more in it than I ever suspected : be that however as it may, I urge my patients to persevere in its use, and am certain that it may do something more than produce a mitigation of the thirst, which circumstance of itself would be sufficient to maintain it as a reme- dy even if it went no further in effecting a cure." III. Some of the indications of the disease, however, have given rise to a much bolder intention. We have already seen that, from a few of its symptoms, and the appearances discoverable on dissec- tion, there is reason to apprehend an irritable and inflammatory State of the kidneys; and it has hence been attempted to cut short the complaint, and, so to speak, to strangle this condition at its birth, by copious and repeated bleedings. Le Fevre appears to have adopted and acted upon this principle almost as early as the GE. m.—SP. IV.] EXCERNENT FUNCTION. 329 beginning of the preceding century :* but he does not seem to have obtained any considerable number of converts to his opinion; and it is to Dr. Watt of Glasgow that we are principally indebted for whatever advantages may have resulted from this mode of practice in our own day ; and particularly for trusting to it mainly or exclu- sively, and carrying it to a very formidable extent. The plan pur- sued by Dr. Watt, has since been pursued by Dr. Satterley, and the success obtained by the former has apparently been more than equalled by the latter, in the course of various trials, of which a very interesting account is detailed in a late volume of the Medical Transactions.! These trials embrace four distinct cases, the first of which is given most at length. The patient was thirty-two years of age: and had been in a state of progressive debility for nearly six months, brought on in the first instance, as was appre- hended, by his having drunk copiously of cold water when over- heated. He fell under Dr. Satterley's care in consequence of being taken to the Middlesex Hospital; the symptoms were strongly marked, and the disease unequivocal: the pulse was quick, small, and hard Fourteen ounces of blood were taken from the arm on the day after his admission, which was Feb. 19, 1808 : he was put upon a meat diet, with an allowance of drink sufficient to allay, though not to satiate, his distressing thirst. The abstraction of blood appearing to afford relief, eighteen ounces more were taken from him the next day, the 20th; twenty ounces more on the 23d ; the same quantity on the 25th ; and eighteen ounces successively on the 28th, on March the 3d, and March 11th : making a total of a hun- dred and twenty-six ounces in twenty days. On the day and night of admission, he had evacuated sixteen quarts of urine ; after the first use of the lancet, the quantity was reduced to eleven quarts in twenty-four hours ; after the second, to "six quarts ; after the third it varied from five to seven quarts ; after the fourth, it stood at six; after the fifth, it varied from five to six; after the sixth, it sunk below five ; and at the time of the seventh, was calculated at three, and had sometimes been not more than two : at which time his mor- bid thirst had entirely left him, he was in tolerably good health, and increased in strength and size. In consequence of some pneu- monic symptoms, he was afterwards blooded once or twice, and de- tained in the hospital for a long period of time, though the term is not stated. He was, however, at length discharged cured, and was found several years afterwards to have kept free from any return of the complaint. The regimen and accompanying course of medicines are not very accurately stated. He seems to have been limited to a diet of ani- mal food ; to have used alternately as a part of his beverage, alum- whey and lime-water ; to have taken occasionally calomel, and cas- tor oil, and for a part, if not the whole period, a grain of calomel * Opera, p. 134. Verunt. 1737.4to. f Vol. V. Art. I. vol. iv.—42 330 ECCRITICA. [CL. VI.—OR. U and a dose of compound powder of ipecac uan every night, the quan- tities of which are not given. But it was the depleting plan that was altogether depended upon, and no very minute attention was paid to any thing else. The two next cases admitted of easier cure under the same treatment. The patients were both males. The fourth case breaks off incompletely, for, in consequence of a removal of the patient, the termination was not known. In each of these there was the local symptom of great pain in the loins, which in the first is described as having been " always severe but at times excessively acute." Here also the testicles were occasionally retracted ; and in one of two female cases there was a distressing itching in the pudendum : so that there is reason to conclude that these instances were accompanied with a more than ordinary degree of irritability or inflammation. " This," says Dr. Satterley, " is the extent of my experience respecting bleeding in diabetes: an experience that fully warrants my asserting the safety, and I think the efficacy, of the practice, in some species of this com- plaint." IV. It has, however, been thought possible by other practitioners, to subdue the irritation whether local or general, and which is often strikingly conspicuous, by powerful narcotics repeated in quick succession ; and thus to obtain a cure without that increase of de- bility which, in many cases, must necessarily ensue upon an active plan of depletion—and this has constituted a fourth intention. Anodynes, though of no great potency, were occasionally admi- nisted by Willis and Sydenham; and their benefit was expressly insisted upon by Buckwald.* The ordinary form has been that of Dover's powder, thus aiming at a diaphoretic as well as a sedative effect: and in this form it has sometimes been found successful, particularly in a case published by Dr. M'Cormick in the Edinburgh Medical Commentaries :f but I am not aware that narcotics alone have been relied upon, or their effects completely ascertained be- fore the late experiments of Dr. P. Warren, an interesting state- ment of which he has communicated in the same work that con- tains Dr. Satterley's practice in venesection.^ These experiments embrace the progress of two cases that occured under Dr. Warren's care in St. George's Hospital. In the first he directed his attention, like Dr. M'Cormick, to opium, in conjunction with some relaxant; and hence made choice of the compound powder of ipecacuan. So far as the present cases go, however, they prove very satisfac- torily that whatever benefit is derivable from the use of this va- luable medicine, depends far more upon its sedative than its sudo- rific power. Dr. Warren, indeed, seems rather to have found the latter a clog upon his exertions, as he could not carry the opium * Dissert, de Diabetis curatione, &c. f Vol. IX. Art. II. p. 56. t Vide supra. GE. m.—SP. IV.] EXCERNENT FUNCTION. 331 far enough to produce a permanent effect on account of the nausea or vomiting occasioned by the ipecacuan, from which symptoms no benefit whatever appeared to be derived. In his first case, there- fore, he soon trusted himself to opium alone, and persevered in the same practice through the second. These patients also were in the prime or middle of life : the one aged twenty-two, the other thirty-eight: and both had been declin- ing for some months antecedently to their applying to St. Georges' Hospital for relief. The first seems to have been worn down by the fatigue of journeying, and was considerably disordered, before the attack of diabetes, in his stomach and bowels. When received into the hospital, however, with this last complaint upon him, he had a considerable pain in his back and loins. Of the origin of the second case no account is given. To ascertain whether an animal diet would succeed by itself, or whether it be of any collateral advantage, the patients were sometimes restricted to animal food alone, to opium alone, and to opium with a mixed diet of animal and vegetable food. It appears to me from the tables that the animal regimen was of advantage, but certainly not alone capable of effecting a cure, for in every instance the quantity of urine in- creased and became sweeter, whatever the diet employed, as soon as the opium was diminished. Dr. Warren, however, is inclined to think that it was of no avail whatever; and, consequently, the second patient had no restriction upon his food, whether animal or vegetable. The quantity of opium given was considerable. When Dover's powder was employed it was gradually increased from a scruple to a drachm twice a-day. And when opium was employed alone, or with kino, with which it was for a short time mixed, but without any perceptible advantage, it was augmented from four grains to six grains and a half twice a-day in one patient: and to five grains four times a-day in the other. It is singular that the opium seldom produced constipation. Few other medicines were employed.* The disease in both cases was as decided as in the preceding treated by venesection : but the flow of urine was much less, the maximum in the one patient being only fifteen, and in the other only eight pints in the twenty four hours: and the cure occupied a much longer period of time; running on to nearly four months in the first instance, and to more than six in the second. The sum of the whole appears to be, that paruria mellita attacks persons of very different ages, constitutions, and habits, and hence, in different cases, demands a different mode of treatment :and that the morbid action is seated in the kidneys; with the irritable, and, often, inflammatory, state of which all the parts of the system mor^ or less sympathize. It appears that under a diet of animal food strictly adhered to, the tendency to an excessive secretion, and particularly to a secretion of saccharine matter, is much less than under any other kind of regimen, though, from idiosyncrasy or some • Med. Transact. Vol. IV. Art. XVI. p. 188. 332 ECCRITICA. [CL. VI.—OR. H, other cause, this rule occasionally admits nf evreptinns. It appears also that the irritation is in some instances capable of being allayed, and at length completely subdued by a perseverance in copious doses of opium, probably by an exhaustion of the general excita- bility ; and in others by a free use of the lancet, leading more ra- pidly to a like effect The skin, through the progress of this com- plaint, does not seem to catenate in the action of the kidneys s© much as in many others, except in a few individuals; and hence diaphoretics are rarely of advantage. As the irritability of the affected organ is connected with debility and relaxation, tonics are frequently found serviceable, and particularly the astringents ; those mostly so, that are conveyed to the kidneys with the least degree of decomposition. And hence the advantage that has been so often found to result from an use of lime-water, alum-whey, and many of the mineral springs. The mineral acids are, on this account, a medicine of very great importance, and in some instances have been found to effect a cure alone ; of which Mr. Earnest has given a striking proof in a professional journal of reputation.* Their seda- tive virtue is nearly equcd to their tonic, and they surpass every other remedy in their power of quenching the distressing symptom of intolerable thirst. Cinchona and various other bitters have been tried, but have rarely proved successful. Some benefit has occa- sionally been derived from irritants applied to the loins, and espe- cially from caustics; but these have also failed. How advantageous soever the plan of sanguineous depletion may be found occasionally, it is clear that it cannot be had recourse to generally, for the present disease, is, for the most part, though by no means always, a result of advanced years and of a debilitated constitution. Under such circumstances, indeed, it has uniformly occurred to the present writer, in the few instances he has been called upon to superintend it, in which, while the thirst was intense, the appetite by no means kept pace with it, and was sometimes found to fail completely. Where, on the contrary the constitution does not seem seriously affected, and the soundness and, indeed, vigour of the stomach and collatitious viscera are sufficiently proved by the perpetual desire of food to supply the waste that is taking place, a free use of the lancet may probably be allowed as offering what may be called a royal road to the object of our wishes: but the practice should, I think, be limited to this state of the animal frame; since, while this favourable condition of the digestive organs re- mains, whatever be the prostration of strength induced by the lancet, it will soon be recovered from. By what means an animal diet effects the beneficial change that so generally follows from its use, has never, that I know of, been distinctly pointed out: but there is a fact of a very singular kind that has lately been discovered in animal chemistry which is, I think, capable of throwing a considerable light upon the subject. * Medical Journal, Vol. XIII. GE. HI.—SP. IV.] EXCERNENT FUNCTION. 333 In healthy urine, the predominant principle is that of uric acid, in diabetic, that of saccharine or oxalic. The uric acid, indeed, exists so largely in sound urine as to be always in excess, as we shall have occasion to observe under lithia or urinary calculus. It is not only a strictly animal acid, but till of late years was supposed to exist in no other urine than that of man; though it has since been found, but in a smaller proportion, in the urine of various other animals. Whatever then has a tendency to reverse the nature of the acid secretion in the disease before us, to produce uric instead of oxalic acid, and in this respect to restore to the urine its natural principle, must go far towards a cure of the disease, as well by taking off from the kidneys a source of irritation, and hereby di- minishing the quantity of the secretion, as by contributing to the soundness of the urine itself. Now the physiological fact I refer to is, that animal food has a direct tendency to induce this effect: for Dr. Wollaston has satisfactorily ascertained that a greater quan- tity of uric acid is produced in the dung of birds in proportion as they feed on animal food: and he has hence ingeniously suggested, that where there is an opposite tendency in the system to that we are now contemplating, a tendency to the secretion of an excess of uric acid, as in the formation of uric calculi and gouty concretions, this evil may possibly be obviated by a vegetable diet. SPECIES V. PARURIA INCONTINENS. Xttcontfnence ot Witint. KREQ.UENT OR PERPETUAL DISCHARGE OF URINE, WITH DIFFICULTY OP RETAINING IT. This is the enuresis of most of the nosologists, and admits of four varieties from diversity of cause and mode of treatment, with often a slight diversity in some of the symptoms. x Acris. From a peculiar acrimony in the Acrimonious incontinence fluid secreted. of urine. Q Irritata. From a peculiar irritation in some Irritative incontinence of part of the urinary channel. urine. y Atonica. From atony of the sphincter of Atonic incontinence of the bladder. urine. ^ Aquosa. From superabundant secretion : Flux of aqueous urine. the fluid limpid and dilute. -A ECCRITICA. [CL. VI.—OR. II. In the first variety, proceeding from a peculiar acrimony of the secreted fluid, the cause and effect are mostly temporary; as too large a portion of spirits combined with certain essential oils as that of the juniper-berry. Diluents and cooling laxatives offer the best cure. In the second variety, the irritation usually proceeds from sand or gravel, or some foreign substance, as hairs, accidentally intro- duced into the urethra. We have some accounts, however, of a discharge of hairs, in such quantities that it is not possible to ascribe the affection to an accidental cause; and we should rather, per- haps, resolve them into a preternatural growth of hair in the blad- der itself, an idea the more tenable as we shall have to observe, in due time, that calculi of the bladder have occasionally oeen dis- charged or found after death surmounted with down. In this case the disease may be regarded as a species of triehosis, under which name it is described by Goelicke,* as it is under that of trichiasis by Scultetus.f But at present we are in want of decisive informa- tion upon the subject. If the last view be correct, filling the blad- der with injections of lime-water or any other depilatory liquid of as much acrimony as the bladder will bear without injuring its in- ternal and mucous surface, will be the best mode of cure. Frequently, however, the irritation is that of simple debility : and hence, tonics and stimulants, as the terebinthinates or even the tincture of cantharides, may be employed internally with success, while externally we prescribe blisters to the perinscum, or the cold water of a bidet. Pressure is also of great service in many instan- ces. In the sixth volume of the Medico-Chirurgical Transactions, Mr. Hyslop gives a case of nine years' standing, in which a cure was effected in three days by binding a bougie tightly to the urethra through its course by means of adhesive plaster. And Mr. Burns gives another case, in the same volume, in which great benefit was derived from a similar plan : which is also in many instances equally adapted to the next variety. In incontinence of urine from an atony of the sphincter of the bladder, the same means maybe had recourse to, though with less hope of success. Stoll recommends the use of an acetum armoracium, which, from combining a stimulant with a tonic and astringent power, may possibly be found serviceable, and is certainly worthy of trial.f Small shocks of electricity passed from the pubes to the perinaeum seem also to have succeeded in a few cases. As the perpetual dribbling of the urine in this, and evep the preceding variety, is always troublesome, and often produces ex- coriation, the patient will find it very convenient to be provided with a light urinary receptacle. This, for males, may consist of a • Dissert, de Trichosi. Frankf. 1724. f Trichiasis admiranda, seu Morbus Pilaris, &c. Norib. 1658. * Praelect. p. 287. •E. DX— SP. V.] EXCERNENT FUNCTION. 335 small bag of oiled-silk worn as a glove for the penis, with a small piece of sponge placed in it as an absorbent. The simplest contri- vance for females is a larger piece of soft sponge loosely attached to the pudendum. The fourth variety, or fluxof aqueous urine, is often a nervous affection, as in hysteria, or hypochondrias; but it more generally proceeds from a relaxation of the mouths of the cryptse or tubuli uriniferi, which in consequence suffer a much larger quantity of fluid, and with too little elaboration, to pass through them than they should do. In treating of paruria mellita, we observed that antecedently to the discovery of the singular secretion of sugar in the genuine form of this disease, the term diabetes, by which it was commonly ex- pressed, imported any extraordinary or profuse flow of urine, whether watry or saccharine : -whence the term was made to em- brace at least two affections of the kidneys, of very different kinds: as a simple relaxation of the mouths of the urinary tubules from debility ; and vehement excitement and a morbid change of action ; the former expressed by diabetes insipidus, and the latter by d. mellitus. The variety we are now contemplating constitutes the first of these ; as the second runs parallel with the preceding spe- cies. It is the urina aguosa* of Galen, which was also by himself, as well as the Greek writers in general, blended with the urina mellita, from their not having been acquainted with the difference of their constituent principles, and of the state of the kidneys in the one case and in the other; and hence both were equally described by them under the names of hyderus or water-flux, and hydrops matellse or urinal dropsy. As this variety, like the preceding, is dependent on a debilitated state of the organ, it should be attacked with the same remedies, and particularly with astringent tonics and stimulants both local and general. Blisters applied to the loins will be found often useful, as may also tincture of cantharides in doses of from twenty drops to half a drachm or even a drachm. The warm and resinous balsams will moreover frequently afford aid, as turpentine and balsam of copaiva, or the essential oil of juniper. The quantity discharged under this variety of the disease has occasionally been enormous : amounting to from thirty to forty pints a-day and sometimes more, for one, two or even three months with- out intermission ; a variety of examples of which are offered in the volume of Nosology. Fonseca mentions a case of two hundred pints evacuated daily, but for what term of time is uncertain.! * De Crisibus, Lib. I. Cap. XII. X De Natura Artisque Miraculis, p. 538. 336 ECCRITICA. [CL. VI.—OR. II. SPECIES VI. PARURIA INCOCTA. SUmuiiSimflcite) WLvint. URINE impregnated with fluids taken into the stomach, and excreted without change. The Greek pathologists evidently allude to this morbid state of the urinary organs in comparing some varieties of their diabetes, or urinary diarrhoea, to a lientery or laevitas intestinorum, under which last the food is described by .them as evacuated in a crude and undigested state, with very little alteration from the condition in which it was introduced into the stomach. The experiments of Sir Everard Home, and those of Dr. Wollas- ton, and Dr. Marcet, both contained in the Philosophical Transac- tions for the year 1811, show that rhubarb and prussiate of potash, may pass from the stomach into the bladder, without undergoing any decomposition ; and, in these cases, apparently without taking the course of the blood-vessels. By what other path it is possible for them to have travelled is to this moment a subject of mere con- jecture, upon which, however, the author has offered a few hints in the Physiological Proem to the present class. Oil of almonds has frequently reached the bladder with an equal destitution of change and has been discharged in the form of oil by the urethra:* and oil of turpentine and juniper pass off in the same manner daily. Actuarius mentions a discharge of urine of a blue colour, in a boy who had taken a bitter pill designed for another patient, but does not state the materials. Urine containing a sediment resembling Prussian blue was discharged copiously by a patient in a low fever about three days before his death: it afterwards became greenish, and possessed a strong ammoniacal smell. Another case is related by the same author of a discharge of blue urine in a woman of sixty without mischief. We do not know, however, that either of these two last cases were connected with any thing introduced into the stomach, and the blue or dark-coloured matter consisted proba- bly of extravasated and venous blood, intermixed with the yellow or other tinge of the urine. Copious diluents, mucilaginous or farinaceous, will at all times afford the best means of deterging the kidneys of any such untem- pered materials as those we are now contemplating; and if the co- lour should appear to proceed from a rupture of blood-vessels in * liachotoni, Comment. Bonon. Tom. II. Part. I. 6E HI.—SP. VII.] EXCERNENT FUNCTION. 337 the same organs, the affection will become a variety of .hematuria, and should be treated accordingly.* SPECIES VII. PARURIA ERRATICA. Erratic Witinc. URINE DISCHARGED AT SOME FOREIGN OUTLET. Under the preceding species, we have seen that certain substances introduced into the stomach, will find their way unchanged to the kidneys. The present species presents to us a singularity of dif- ferent and almost opposite kind, by showing us that the urine itself, in a certain condition of the organ that secretes it, or of the system generally, may travel from the kidneys to other regions in a form equally unchanged. We know nothing of the means by whicii all this is accomplished, but we can sometimes avail ourselves of the fact itself, by employing a variety of medicines, which, in con- sequence of their being able, in this manner, to arrive at a definite organ without being decomposed in the general current of the blood, are supposed to have a specific influence upon such quarter, and have often been denominated specifics for such an effect; as cantharides in respect to the bladder, demulcents in respect to the lungs, and cinchona in respect to the irritable fibre. This disease has often been described under the name of uropla- nia, which is nothing more than a Greek compound for "erratic urine" as it is here denominated, but it has seldom been introduced into nosological arrangements. The cases, however, are so numer- ous and distinct, in writers of good authority, ihd it ought not to be rejected. In most instances it is not a vicarious discharge ; or, in other words, a secretion of a different kind compensating for a destitution of urine, but a discharge of an urinous fluid apparently absorbed after its secretion by the kidneys, and conveyed to the outlet from which it issues by a path or under a protection that has hitherto never been explained. We sometimes meet with it while there is a free secretion of urine by the kidneys, and a free passage by the bladder and urethra, in which case alone it can be called a disease. On other occasions we find it, as already observed under paruria inopn, performing a remedial part, and travelling in the new direction to carry off recrementoiy matter that cannot be • See Vol. n. p. 468. vol.. iv.—43 338 ECCRITICA. [CL. VI.—OR. II. discharged at its proper outlet, nor retained in the blood without mischief. It has in different persons been evacuated by the salivary glands, the skin, at the navel, and by a fistulous opening into the perinaeum. The volume of Nosology gives a reference to cases and autho- rities illustrating each of these forms of discharge : and others are probably to be met with in other writings. GENUS IV. LITHIA. mvinat£ (talznlm. MORBID SECRETION OR ACCUMULATION OF CALCULOUS MATTER IN IN- TERNAL CAVITIES. Lithia is a Greek term from Aide?, whence Xiitua" calculo laboro." It has often been written lithiasis, which is here exchanged for lithia, since iasis, in the present arrangement, is limited, as a ter- mination, to words indicating diseases affecting the skin or cuticle, and that for reasons which will be explained presently. The name of lithus or lithiasis, as used by Aretaeus and Aure- lianus, and that of calculus or sabulum, as employed by Celsus and Pliny, sufficiently evince the elementary principles of which the Greeks and Romans conceived urinary calculi to consist. The mistake is not to be wondered at when we reflect, that it is not till about thirty years ago that these principles were detected with any degree of accuracy; and that we are indebted to the minute and elaborate experiments of Fourcroy and Vauguelin for an analysis that till their time, though successively pursued by Hales, Boyle, Boerhaave, and Slare, had been left in a very unsatisfactory state ; and which even since this period has required the further correc- tions of Wollaston, Marcet, Cruickshank, Berzelius, Brande, and various other animal chemists to produce ail the success we could desire. So generally was the belief that the calculi of the bladder were formed in the same manner and consisted of the same mate- rials as the stones of the mineral kingdom, that Dr. Shirley pub- lished a learned book as late as 1671, which is now become ex- tremely scarce, entitled "Of the causes of stones in the greater world in order to find out the causes and cure of the stones in man." The urinary secretion in a state of health is one of the most com- pound fluids of the animal system : and consists of various acids, and alkalies, the former, however, bearing a preponderancy, with a certain proportion of calcareous earth, and other materials which GE. IV.] EXCERNENT FUNCTION. 339 it is not necessary to dwell upon at present. The acid first dis- covered in it was the phosphoric, which was traced by Brandt and Kunckel, whence the experiments of Boyle from which he obtain- ed phosphorus. The important discovery of uric acid was reserv- ed for Scheele, who detected it in 1776: as he did also benzoic acid, chiefly confined to the urine of children. Proust has since proved that it contains also carbonic acid, and a peculiar resin like that of bile; and other acids, in smaller proportion, have more lately been ascertained by Thenard and Berzelius. Hence the calcare- ous earth that is separated by the kidneys, as we have had occa- sion to observe that it is also by most other organs of the body in a state of health or of disease, is productive of numerous compounds, as carbonate ot lime, phosphate of lime, oxalate of lime: together with compounds still more complicated by an intermixture of the lime with the urinary alkalies. But as, in a state of health, the urine is always found to contain calcareous earth under some form or other, in a morbid stale it is also found to contain magnesian earth more or less united with the other materials, both acid and alkaline. In many cases moreover, the natural acids, or the natural alkalies are secreted in excess, in others in deficiency. And from all these circumstances it is easy to conceive that a very great variety of concretions, or calculi may at times take place either in the kidneys or in the bladder. How far these varieties extend, has, perhaps, not fully been determined to the present day, but the num- ber which has been detected and analyzed is now very considerable and has been increasing ever since Dr. Wollaston's valuable essay on this subject, which appeared in the Philosophical Transactions for the year 1797, and laid a foundation for the arrangement. Among those which have been subsequently ascertained, a few, and especially the cystic oxyde, have been discovered by himself; and the whole are thus enumerated by Dr. Marcet in a still later pro- duction of highly distinguished merit.* 1. Lithic calculus, com- posed chiefly of lithic or uric acid. 2. Earth-bone calculus, con- sisting chiefly of phosphate of lime. 3. Ammoniaco-magnesian phosphate or calculus, iri which this triple salt obviously prevails. 4. Fusible calculus, consisting of a mixture of the two former. 5. Mulberry calculus, or oxalate of lime. 6. Cystic calculus, consist- ing of the substance called by Dr. Wollaston cystic oxyde. 7. Alter- nating calculus, or a concretion composed of two or more different species arranged in alternate layers. 8. Compound calculus, the ingredients of which are so intimately mixed as not to be separable without chemical analysis. 9. Calculus from the prostate gland, of a peculiar kind, and consisting, according to Dr. Wollaston, " of phosphate of lime not distinctly stratified, and tinged by the secre- tion of the prostate gland." The two not hitherto described are. 10. Xanthic oxyde, making an approach to the cystic calculus, but • Essay on the Chemical History and Medical Treatment of Calculous Dis- orders. 346 ECCRITICA. [CL. VI.—OR. H giving, which that does not, a bright lemon residuum on evaporat- ing its nitric solution. And 11. Fibrinous calculus, so called from its possessing properties exactly similar to those of the fibrina of the blood, and no doubt formed by a deposit from this fluid. Of these a few only are commonly found in the kidneys, though most of those which are found in the kidneys are found also in the bladder, and in reality constitute the common nuclei of the calcu- lous concretions of this last organ ; the augmentation resulting from other constituent principles of the urine, gradually separating, and encrusting them as they lie in the bladder in an undisturbed state. The symptoms, moreover, of renal and vesical calculi differ as widely as their component parts, and hence point out the necessity of subdividing the genus into the two following species: 1. LITHIA RENALIS. RENAL CALCULUS. 2.-----VESICALIS. VESICAL CALCULUS. SPECIES I. LITHIA RENALIS. itmal <£alctiUt8. PAIN IN THE LOINS, SHOOTING DOWN TOWARDS THE TESTES OR THIGHS, INCREASED ON EXERCISE ; URINE OFTEN DEPOSITING A SABULOUS SEDIMENT. The calculous matter of the kidneys sometimes passes off in minute and imperceptible grains with the urine, which are only noticed by their concreting or crystallizing about the sides of the vessel that receives it; and sometimes collects and forms very troublesome spherules or nodules in the substance or pelvis of the kidneys : thus offering the two following varieties : * Arenosa. Urinary sand. £ Calculosa. Urinary gravel. Pain slight, and unfrequent: free discharge of sabulous granules. Pain mostly severe and constant: sabulous discharge small and seldom or never: calculus vary- ing in size, often large and ob- structing the pelvis or ureter of the kidney. Urinary sand, or the sabulous matter deposited on the sides or bottom of a receiving vessel, is of two kinds, white and red : and it GE. IV.—SP. I.] EXCERNENT FUNCTION. 341 is of great importance to distinguish the one from the other as they proceed from very different causes, and require a different, and, in- deed, opposite mode of treatment. Mr. Brande has published an excellent treatise upon this subject in his Quarterly Journal; and in the remarks about to be offered upon this ipecies, I shall avail my- self in no small degree of the benefit of his labours in connexion with those of Dr. Marcet to which I have already referred. The urine, in a healthy state, is always an acid secretion, and it is the excess of its acid that holds the earthy salts in solution. If, from any cause, it be deprived of this excess, or, in other words, the secretion of its acid be morbidly diminished, the earthy parts are no longer held in solution, and a tendency to form a white sand or calcareous deposite immediately commences. And that this is the real source of its production is manifest from the simple ex- periment of mixing a little alkali with recently voided urine; for the alkali has no sooner exercised its affinity for the acid than the urine throws down a white powder. And hence a like deposit will not unfrequently take place upon using magnesia too freely. A knowledge of the cause of this modification of urinary sand puts us at once into an easy mode of curing it, a mode however which was first pointed out to the world by Dr. Wollaston. It con- sists in introducing into the system some other acid as a substitute for that which is wanting to the kidneys. All the acids seem to answer this purpose, but as the sulphuric usually sits easier on the stomach than any other of the mineral acids it is entitled to a pre- ference ; and the more so on account of its superior tonic powers, and consequently its better adaptation to the chylifactive organs, a debility of which is no unfrequent cause of the complaint. The vegetable acids, nevertheless, may be interposed with the sulphu- ric, or, where the stomach is very delicate, entirely supersede their use. Of these the citric is the pleasantest and can be persevered in for the longest period of time, especially in the case of children. The tartaric, however, and especially in the form of creme of tar- tar, has the advantage of gently operating upon the bowels which is always a beneficial effect. Carbonic acid, whether taken in the form of effervescing saline draughts, or simply dissolved in water by means of Nooth's apparatus will a^so De found a useful and pleas- ant auxiliary. The general diet should be of the same description, and be as largely as possible intermixed with salads, acids, fruits, and especially oranges. Malt liquor should be abstained from ; and, if the habit of the patient require that he should continue the use of wine, Champagne or claret should be preferred to Madeira or port. It is possible, however that this modification may be a result of too large a secretion of calcareous earth, instead of too small, a se- cretion of acid ; yet the effect being the same, the same mode of treatment will be adviseable. But the acid may be in excess instead of in deficiency, or, which is nearly the same thing, the natural secretion of calcareous earth 342 ECCRITICA. [CL. VI.—OR. II. may itself be deficient while the acid retains its usual measure: and in this case the acid itself has a tendency to form a deposit by crystallizing into minute and red spiculae,—and hence the modifi- cation of red sand that is so frequently found coating the sides and bottoms of chamber-utensils. This, like the preceding, is sometimes voided in a concrete or crystallized state, or the urine may be voided clear, and the depo- sit not take place till some hours afterwards. The last is ordina- rily the result of some temporary cause, and is of no importance as it disappears with the cause that produces it. The first is of more serious consideration as it indicates a lithic diathesis that may lead to a formation of large and mischievous calculi, and is a pretty cer- tain bai binger of the variety we shall have to notice under the name of gravel. As acids form the best preventive and cure in the preceding case, alkalies present an equal, or nearly equal remedy in the pre- sent, with the exception that the tendency to produce urinary red sand is more likely to run into a habit, and is hence less easily ex- tirpated, than that to produce white. It has. in fact, been long known that concrete uric acid is soluble in the caustic fixed alkalies, and these were, in consequence here- of, the earliest forms of alkali adverted to for this deposit. But it has since been ascertained that the alkaline carbonates and sub-car- bonates are equally effectual. And, as the latter are far less apt to disagree with the stomach than the former, they have very gene- rally taken their place. Of the alkalies and alkaline carbonates soda has commonly been found to answer the purpose best. It is, indeed, chiefly effectual in its pure state, but it is most convenient to use it in a milder form ; and of all the forms it offers that of so- da-water is the pleasantest, and may be persevered in for the long- est period of time. Nevertheless there are some constitutions in which potash and its carbonate prove more effectual than soda, a remark for which we are indebted to Sir Gilbert Blane, who, on this account, has occasionally given it the preference, and for the sake of rendering it more palatable has sometimes partly saturated it with lemon juice or citric acid ; and where there has been severe or protracted pain, producing considerable irritation, has united it with opium.* A drachm of the carbonate of either of the fixed al- kalies will form a moderate dose for an adult, and may be repeated two or three times a-day, taken during the effervescence produced by the addition of half an ounce of lemon-juice to the menstruum, which may consist of two ounces of water sweetened with honey. Ammonia and its sub-carbonate have been had recourse to, and with great advantage, where symptoms of indigestion have been brought on by the fixed alkalies ; and particularly in cases in which red gravel is connected with gout, and the two diseases show a dis- position to alternate. * Transactions of a Society for improving Medical and Chirurgical Know- ledge, Vol. III. p. 358. GE. IV. SP.—I.J EXCERNENT FUNCTION. 343 Magnesia is also of considerable use, as has been lately shown by Mr. Brande in two excellent papers upon this subject, published in the Philosophical Transactions.* Taken in free and frequent doses it has often succeeded in checking the tendency to a formation of sand and gravel, and has kept many individuals free from this com- plaint for very long periods of time who have been constitutionally predisposed to it. Nevertheless it is not calculated to supersede the use of the alkalies, but may be employed as a convenient adjunct, or supply their place for a time, when the patient has become tired of using them. There is some doubt as to the manner in which the acids em- ployed to a correct secretion of white sand, and the alkalies hat of red, fulfil their object: whether indirectly by a peculiar action on the chylifacient organs so as to render the fresh supply of nutriment more easily disposed to yield an acid in the one case, and iess easi- ly in the other ; or directly by passing unchanged along the current of the blood and arriving at the kidneys in their proper forms. There is a difficulty attending both these views; but as uric acid, though soluble in the caustic alkalies, is found not to be solu- ble in their carbonates and sub-carbonates, the benefit of alkaline medicines does not seem referable to their solvent powers. And hence it is, on the whole, more probable that both acids and alkalies produce an indirect influence on the kidneys, as we have already had occasion to observe that animal food does in saccharine urine, by a peculiar influence on the chylifacient viscera, or the nutritive materials during their subaction. There is also another class of medicines which have long stood the test, and been proved to possess a truly remedial power in all urinary concretions of the kind before us—I mean astringents. So considerable is their efficacy that De Heucher ascribes to them an expulsory power, in his treatise entitled " Calculus per astringentia pellendus." Their real mode of action has prohably been pointed out by Dr. Cullen in a passage in which he has anticipated much of the reasoning of the present day concerning the benefit of alkalies, and has hereby given an additional proof of the strength of his judg- ment. Speaking of the leaves of the uva ursi, he says, that this medi- cine, "Not only from the experiments of the late De Haen, but also from my own, I have found to be often powerful in relieving the symptoms of calculus. This plant is manifestly a powerful astrin- gent : and in what manner this and other astringents arc useful in the cases mentioned may be difficult to explain : but I shall offer a con- jecture upon the subject. Their powerful attraction of acid wc have mentioned above, and that thereby they may be useful in cal- culous cases is rendered probable by this, that the medicines which of late have been found the most powerful in relieving the symptoms of calculus are a variety of alkalies, which are known to do this * Phil. Trans. Year 1810, p. 136; 1813, p. 213, 344 ECCRITICA. [CL. VI.—OR. II. without their acting at all ni dissolving the stone."* Their virtue as a stomachic tonic ought also to be taken into consideration as weli as theii absorbent power. The second vakiety of the lithic concretion we are now con- tern plating, and which, from its tendency to form larger masses is usually denominated gravel, is of far greater importance than the preceding, from the actual pain that is suffered in most cases, and the danger there always exists of the conversion of such nodules into calculi of the bladder. Of the eleven classes of urinary calculi enumerated by Dr. Mar- cet, there are rarely more than three that are found passing through the natural passages of the kidneys, though others are traced occa- sionally as imbedded in the pelvis or substance of the kidneys. These three are the uric, oxalic, and cystic : and of these the two last are very rare productions in comparison with the first. " Out of fifty-eight cases of kidney calculi," says Mr. Brande, "fifty-one were uric, six oxalic, and one cystic." The phosphates seem never to concrete so as to form calculi in the kidneys, for which it seems difficult to assign a reason. The uric calculi as voided immediately from the kidneys, are of a yellowish or reddish-brown colour, somewhat hard, and soluble in caustic potash. They exhale the smell of burnt horn before the blow-pipe, and when heated with nitric acid, produce the peculiar red compound which Dr. Prout has called rosacic acid. The oxalic calculi vary considerably in appearance. They are generally of a grayish-brown colour, and made up of numerous small cohering spherules, and have sometimes a polished surface and resemble hempseeds. They are easily recognised by their insolubility in di- lute muriatic acid : and by swelling up under the blow-pipe, and burning into a white ash consisting of pure lime. The cystic cal- culi have a yellowish colour, and a crystallized appearance; they are soluble in dilute muriatic acid, and in diluted solution of potash. Dr. Wollaston has remarked that when heated in the flame of a lamp, spirit or by the blow-pipe, they exhale a peculiar fetid smell by which they may readily be characterized.f The usual symptoms by which this variety is marked are those of pressure and irritation: as a fixed pain in the region of the affect- ed kidney, with a numbness of the thigh on the same side, the pain alternating with a sense of weight. The pain is sometimes very acute and accompanied with nausea and deliquium, proving that the calculus has entered the ureter, and is working its way down into the bladder, after which the pain ceases till it reaches the ure- thra, or by remaining in the bladder, it becomes incrusted with other materials, and forms a vesicular calculus. During the whole of the passage from the kidneys the urine is usually high-coloured, and deposits a reddish or reddish-brown sediment, occasionally not • Mat. Med. Part. II. Chap. I. p. 13. t Brande, Journal, &c„ Vol. VUI. p. 6f. GE. IV.—SP. I.] EXCERNENT FUNCTION. 345 unlike the grounds of coffee, and evidently giving proof of the lace- ration of blood-vessels by the angular points of the calculus. It is a very singular fact, and has been properly noticed by Dr. Heberden, that during the most violent pain at any time endured from this cause there is rarely an acceleration of the pulse : in the same man- ner as the torture sustained by the passage of a gall-stone through the gall-ducts produces as little effect upon it. If, however, the flow of the urine be obstructed by the calculus, as sometimes hap- pens, the ordinary constitutional symptoms take place which cha- racterize that affection, as a general sense of uneasiness, heat, thirst, a quickened pulse, and other pyrectic concomitants : sick- ness at the stomach, costiveness, sleepless nights, and at length coma, intermitting pulse, convulsions, and death: and all this even where the pain or weight in the loins is not peculiarly dis- tressing. We have often had occasion to observe that where a morbid change takes place in an organ very gradually, it may proceed to almost any extent without any acute suffering on the part of the patient, and sometimes without any suffering whatever. The same fact not unfrequently occurs in the disease before us, of which a re- markable instance is related by Dr. Marcet, in a patient who died of a dropsy in the chest, without having made any complaint of the state of his urinary organs, though one of his kidneys was found, on dissection, to be distended by a large collection of calculi. The proximate cause of the formation of uric calGuli we have already shown to be an excess of uric acid ; that of the oxalic and cystic is not quite so obvious,—a point however, of less importance from the infrequency of their occurrence. The predisposing and occasional causes of all of them are too often involved in obscurity. In many persons there is an hereditary tendency to this complaint; general indolence or a sedentary life becomes a predisponent in others; too large an indulgence in fermented liquors, and the luxu- ries of the table generally, forms a predisponent in a third class; but the chief cause of this kind we are'acquainted with is a want of constitutional vigour, and especially in the digestive organs; and hence the periods of life in which this disease occurs most fre- quently are from infancy to the age of puberty, and in declining years : while it is rarely found during the busy and restless term of mature virility. The process of treatment must, for the most part, be derived from these causes. As a preventive of that modification of caiculus which is by far the most frequent, we have already advised the use of alkalies and alkaline carbonates. Where the digestive organs are weak the diet should be light but generous; warm and bitter tonics will always be found serviceable; the bowels should never be suffered to become costive, and should occasionally be stimulated by brisk purgatives, which tend equally to remove acidiiies from the stomach, and to stimulate the kidneys to a more healthy action. vol. iv.—44 346 ECCRITICA. tOL. VI.—OR. II. Indolence and a sedative life must give way lo exercise, and espe- cially equitation, which is by far the best kind of exercise for the present purpose, and whatever will tend to promote an increased determination towards the surface, and a frequent glow on the skin will prove a valuable auxiliary: for the skin itself becomes, in this affection, though rarely in paruria mellita, an outlet for the dis- charge of a redundancy of acid, as may be observed by the simple experiment of tyeing a piece of paper stained with litmus about the neck; which even in a state of common health, will often be changed to a red colour by the acid thrown off in the ordinary course of perspiration. Of the mischievous effects of a luxurious diet, and the advantage of abstinence M. Magendie has given a very striking example in the case of a merchant of one of the Hanseatic towns who was habitually afflicted with the complaint before us. " In the year 1814, this gentleman," he tells us, " was possessedof a considerable fortune, lived in an appropriate style, and kept a very good table, of which he himself made no very sparing use. He was at this time troubled with the gravel. Some political measure unexpectedly took place which caused him the loss of his whole fortune, and obliged him to take refuge in England, where he passed nearly a year in a state bordering upon extreme distress, which obliged him to submit to numberless privations; but his gravel disappeared. By degrees he succeeded in re-establishing his affairs; he resumed his old habits, and the gravel very shortly began to return. A second reverse occasioned him once more the loss of all he had acquired. He went to France almost without the means of subsistence, when his diet being in proportion to his exhausted resources, the gravel again a second time vanished. Again his industry restored him to comfortable circumstances; again he indulged in the pleasures of the table, and had to pay the tax of his old complaint."* It may at first sight appear a singular fact, but the remarks just offered will tend to explain it, that mariners are rarely subject to stone or gravel. Mr. Hutchison has published a valuable article upon this subject in one of the volumes of the Medico-Chirurgical Transactions,! from which it appears that out of ninety-six thousand six hundred and ninety-seven patients admitted in the course of sixteen years into the three grand coast hospitals of Plymouth, Haslar, and Deal, not more than eight had laboured under either species of lithia. Whence it appears that the occupation, diet, activity and regimen of a maritime life are the best preservatives against all such affections : such as an animal aliment largely combin- ed with the alkaline stimulus of muriate of soda; a farinaceous, for the most part, instead of any other vegetable diet; great exercise, and that free exhalation from the skin at night which is so well known * Recherches Physiologiques et Medicales sur les Causes, les Symptomes et la Traitment de la Gravelle. 8vo. Paris, 1818. f Trans, of the Medico-Chirurg. Soc. Vol. IX. GE. IV.—SP. I.] EXCERNENT FUNCTION. 347 to take place among sailors in the royal navy, in consequence of their being compelled to sleep closely together. And, as the disease appears to be equally uncommon in tropical climates, we have here an easy explanation of the cause of its infrequency. In our own country it appears from the tables of the Norwich hospital to be more frequent in Norfolk than in any other county of the same po- pulation. It only remains to be observed that during the paroxysm of pain produced by the passage of a calculus through the ureter, our chief object should be to allay the irritation and mitigate the distress. The warm-bath is here a very valuable remedy, friction on the loins with rubefacient irritants combined with narcotics often afford relief: but the present author has found most benefit from a flannel- swathe wrung out in hot water and folded about the loins; being suffered to remain theie for hours, wrapped round, to confine the moisture, with an outer swathe of calico or linen. If these do not answer, opium, and in free doses, must be had recourse to. SPECIES II. LITHIA VESICALIS. Stone in the Elartfaer. FREQUENT DESIRE OF MAKING WATER, WITH A DIFFICULTY OF DIS- CHARGE ; PENIS RIGID, WITH ACUTE PAIN AT THE GLANS : SONOROUS RESISTANCE TO THE SOUND WHEN SEARCHING THE BLADDER. The substances, vulgarly called stones in the bladder, are, for the most part, of a very composite structure. They originate from a nucleus which may consist of any morbid or foreign material that can accidentally obtain an entrance and a lodgment in the bladder; the body of the calculus being formed out of such constituent parts of the urine as are most easily detached and attracted: which gra- dually encrust around it, and concrete into a mass for the most part far too large to pass through the urethra. The most common of these nuclei is a kidney-calculus itself, and consequently a crystallized spherule or nodule of uric acid; and, where the acid is habitually in excess, the coating of the vesicular calculus may consist of this alone or chiefly : but, from the great variety of materials, as earths, alkalies, and other acids besides uric, and sometimes blood and mucus, which enter into the composition of the urine at this time, it is not often that a calculus of the bladder is a crystallization of uric acid alone. In the introductory remarks upon the present genus we observed that the different kinds of calculi discovered in the human bladder 345 ECCRITICA. [CL. VI.—OR. II. had been treated of by Dr. Wollaston, as far as they were then known, in a very masterly essay upon this subject, published in the Philosophical Transactions for the year 1797: he has since enume- rated them as follows: 1. Uric acid calculus. 2. Fusible, triple, or ammonio-magnesian phosphate. 3. Bone-earth calculus, or phosphate of lime. 4. Mulberry calculus, or oxalate of lime. 5. Cystic oxyde. The cystic oxyde is not contained in the article above referred to, as not having been discovered at the time : but it has since been detected by the same excellent chemist, and named as above. We have also observed that various other calculous masses have stili more lately been ascertained by the analyses of other experi- menters, and that the whole number, as arranged by Dr. Marcet, amounts, in the present day, to eleven or twelve. Their names we have already given, nor is it worth while, in a work devoted to practical medicine, to notice them any further, as they are rarely to be met with in comparison with the five arranged above, and when met with will not call for any essential difference in the mode of treatment. In effect, they have been found equally different in composition, form, size and colour ; from the weight of half a drachm to that of several pounds ; purple, jasper-hued, red, brown, crystalline, cine- ritious, versicoloured: in one or two instances covered with down.* apparently produced from the surface of the bladder, from which, as we have already had to observe, hairs are occasionally dis- charged with the urine.f They have also been found solid, perfo- rated, hollow, compact, crumbling, glabrous, rough, and spinous,^ and, in a few instances, combined with iron.§ They seem sometimes to form very rapidly ; and, where the patient has already discharged one or two, and the urethra has in consequence become more than ordinarily dilated, they occasionally pass off in great numbers in a short space of time. We have hence, in different professional journals and transactions, accounts of a hundred and twenty voided in the course of three days ;|| two thousand in the course of two years ;f and three hundred of a pret- ty large size within the same term.** The largest discharged in this manner, which has ever occurred to me in reading, weighed five • Blegny, Zodiac. Ann. IV. Febr. Obs. 4. \ Gen. III. Spec. V. part, in cont. * Bartholin. Act. Hafn. Tom. II. Obs. 85. § Act. Erudit. Leips. 1627. p. 332. Dotsus, Ep. ad Waldschmidt. p. 253. || Eph. Nat. Cur. Dec. III. Ann. V. VI. p. 99. 1 Griindlicher Bericht, von Blatterstein. •• Hildan. Fabric. Cent. I. Obs. 89. GE. IV.—SP. II.] EXCERNENT FUNCTION. 349 ounces. Dr. Huxham describes one instance of such a fact ;* and another is given in a distinguished foreign miscellany.t By females they have often been discharged of the weight of two ounces and a half; and my excellent friend Dr. Yellowly mentions a calculus of nearly three ounces and a half ;| in one case we are told of a stone thus evacuated that weighed twelve ounces § The general character of the uric calculus has been given al- ready. Its texture when formed in the bladder is commonly lami- nated ; and, when cut into halves, a distinct nucleus of uric acid is almost always perceptible. Its exterior is generally smoother than that of other calculi, except the calculus of bone-earth, or phosphate of lime.|| The appearance of the second or fusible calculus is generally white, and often resembles chalk in its texture. Strongly heated before the blow-pipe this substance evolves ammonia, and readily fuses ; whence the name assigned to it. It often breaks into layers, and exhibits a glittering appearance when broken. The third division, consisting of the bone-earth calculus, or phosphate of ljme unmixed with any other substance, has a pale brown, smooth surface; and when sawn through is found of a lami- nated texture, and easily separates into concentric crusts. This calculus is peculiarly difficult of fusion. The fourth division embracing the mulberry calculus, or oxalate of lime, is of a rough and tuberculated exterior, and of a deep reddish-brown or mulberry colour, probably produced by a mixture of blood that has escaped from some lacerated vessel, whence the name assigned to it. The nucleus is generally oxalic, and of renal origin ; but it is sometimes uric. It is also frequently enveloped by the fusible calculus. The fifth, or cystic calculus has a crystalline appearance, but of a peculiar greasy lustre, and is somewhat tough when cut. Its colour is a pale fawn bordering upon straw-yellow. It is very rarely to be met with. Such are the calculi which are principally found in the bladder; and we may readily conceive with what facility they are formed there, when an accidental tendency is given to their formation by a lodgment of any thing that may serve as a nucleus, by noticing the deposites of phosphates of lime and other materials that are perpe- tually encrusting every substance over which a current of urine is frequently passing; as the public drains in our streets, which are daily exhibiting them in regular crystals. The ordinary causes of renal calculi are necessarily those of ve- sical calculi, but any local injury or infirmity, which prevents the • Huxh. Vol.m. p. 42. X Sammlung. Med. Wahrnemung. Band. VIII. p. 258. + Trans, of the Medico-Chir. Soc. Vol. VI. § Eph. Nat. Cur. Dec. II. Ann. V. Obs. 71. | Brande'* Journal, Vol. VIII. p. 207. 350 ECCRITICA. [CL. VI.—OR. II. urine from passing off freely from the bladder, accelerates their formation and enlargement, not only by the confinement it causes, but by the decomposition which rest soon produces, in which case it becomes ammoniacal, and a larger portion of the phosphates will be precipitated. And hence, an obstruction in the urethra of any kind, but particularly a diseased prostate becomes a frequent auxi- liary, and sometimes even a primary cause of the formation of a stone without any mischief in the kidneys, or any disordered secre- tion of urine.* « The bladder," says Sir Everard Home, " never being completely emptied, the dregs of the urine, if I may be al- lowed the expression, being never evacuated, a calculus formed on a nucleus of the ammoniaco-magnesian phosphate and mucus is produced, when it would not have been produced under other cir- cumstances. This species of stone, or a stone upon such a necleus, can only be produced where the bladder is unable to empty itself. It may therefore be arranged among the consequences of the en- largement of the middle lobe of the prostate gland."f It does not appear from the experiments or observations of Dr. Marcet, that a difference in the waters of different places is much, if at all concerned in the production of calculous disorders: nor have we any satisfactory evidence of their being more prevalent in cider than in other countries, notwithstanding the general opinion that they are so. But we are yet in want of sufficient data upon this subject to speak with much decision. As the disease of stone in the bladder is very generally a sequel of calculi in the kidneys, the symptoms indicative of the preceding species form, in most instances, the first symptoms of the present. Yet occasionally, from causes we have just pointed out, the concre- tion commences in the bladder, and the symptoms of an affected kidney are not experienced. One of the first signs of a stone in the bladder is an uneasy sensation at the point of the urethra occurr- ing in conjunction with a discharge of urine that deposits red or white sand, or after having occasionally voided small calculi or frag- ments of a larger. This pain is sympathetic, and proceeds from the irritation of the prostate or the neck of the bladder, agreeably to a law of nature we have often found it necessary to recur to, which ordains that the extremities of nerves which enter into the fabric of an organ, and particularly of mucous canals, should possess a keener reciprocity of feeling than any intermediate part, and consequently participate with more acuteness in any diseased action. This un- easy sensation at the point of the urethra, is at first only perceived on using any violent or jolting exercise ; or in a frequent desire to make water, which is often voided by drops or in small quantities, or, if in a stream, the current stops suddenly while the patient is still conscious that the bladder is not fully emptied, and has still an inclination to evacuate more, but without a power of doing so. • Brande's Journal, &c. Vol. VIII. p. 210. f On the Diseases of the Prostate Gland, VoL I. p. 40. GE.IV.—SP. H] EXCERNENT FUNCTION. 351 As the stone increases in size there is also a dull pain about the neck of the bladder, the rectum partakes of the irritation, and produces a troublesome tenesmus, or frequent desire to go to stool. Where the pain is trifling the urine is often limpid, as the saline or earthy materials from their confinement in the bladder arrange themselves around the growing calculus, and enlarge it by a new coating; but where the irritation is considerable, there is often a mucous sedi- ment in the water, and sometimes a discolouration from blood. The region of uneasiness extends its boundary, the stomach partici- pates in the disquiet, sleepless nights ensue, with pyrexy, anxiety, and dejection of spirits : all which symptoms are increased by exer- cise of every kind and particularly by equitation. Several of these signs may indicate a primary disease of the prostate or neck of the bladder, but the occasional discharge of calculous fragments or deposite of urine loaded with uric acid or phosphate of lime, are sufficiently pathognomic. It is usual, however, in all such cases, to examine the bladder by a sound, which commonly puts the question beyond all dispute : though if the calculus be lodged in a peculiar sac or the fasciculi of the bladder, or lurk behind some morbid enlargement of the prostate gland, the sound may not detect it, and the experimenter may deceive himself and the patient in re- spect to the nature of the disease. The treatment of this disease offers two indications, a palliative and a radical. The palliative may be applied to relieve the actual symptoms, and to prevent a further enlargement of the calculus. The symptoms vary greatly in different cases: partly, indeed, from the size of the calculus itself, but quite as much from the con- stitutional irritability of the bladder and the particular quarter of it in which it is seated. In a few persons, the bladder has possess- edjso little morbid excitement that stones of considerable magnitude have been found in this organ after death without having produced any very serious inconvenience during life. If the calculus be im- mediately seated on the neck of the bladder it is, however, almost impossible for the most impassive not to suffer severely at times. But the stone has sometimes found a fortunate lodgement between the muscular fascicles of the bladder, where it has become imbedded as in a pouch, and a train of morbid symptoms, which have antece- dently shown themselves, have gradually disappeared in proportion as this change has been affected. Mr. Nourse showed to the Royal Society the bladder of a man in which not less than six sacs or bags were in this manner produced by a protrusion of the internal coat of the bladder through the mus- cular, and which contained altogether nine stones.* The stones are sometimes fixed so firmly that it is impossible to separate them by the forceps in performing the operation of lithotomy, without tearing the bladder or cutting one side of the sac; which last me- • Mem. 462. Sect. 3. 352 ECCRITICA. [CL. VI.—OR. II. thod M. Garangeot informs us he once tried with success. In seve- ral other cases, however, that he has described, the vessels of the bladder had spread luxuriantly over the stone, and apparently grown into it; and the extraction was followed by a mortal hemorrhage.* Generally speaking, calculi, when seated in pouches of this kind, continue without much disturbance for years,and sometimes for the whole of a man's natural life, of which Dr. Marcet has given various striking examples in his treatise. Art cannot scoop out such convenient receptacles, but it may do something to allay the irritability of the bladder when severely ex- cited, and in this manner palliate the distressing pain that is often endured. This may frequently be accomplished by the warm-bath ; by rubefacients impregnated with opium applied to the region of the pubes, and in the course of the perinaeum ; by cooling aperients and a steady.use of sedatives, and particularly of conium. If these do not answer we must have recourse to opium, which will often succeed best, and with least inconvenience to the constitution if introduced into the anus in the form of a suppository. Our next intention should be to prevent, as far as possible, an augmentation of the calculus already existing in the bladder. In order to accomplish this, it will be necessary to inform our- selves of its chemical constituents, for otherwise any method we may propose will probably do harm. From the remarks already made, it is obvious that the chief constituent principles of the cal- culi in the bladder, like those in the kidneys, are uric acid and bone earth, or phosphate of lime. If the former predominate the urine will often throw down a precipitate or incrustation of red sand, if the latter, of white sand: and in the former case, as there is an excess of uric acid, our remedial forces must be derived from the alkalies and alkaline preparations to which we have already advert- ed under the preceding species : in the latter case, as there is, in all probability, a deficiency of acid, we must have recourse to an opposite mode of treatment, and employ the mineral and vegetable acids, with a diet chiefly composed of vegetables as recommended above under renal calculus. But the calculus may consist of both, for it may exhibit, and often does, a nucleus of crystallized uric acid with laminae of phosphate of lime, magnesia, or some other substance : or, by carrying either of the above processes to an extreme, we may convert one morbid action into another. For if, by the use of alkalies, we diminish too much the secretion of uric acid, we may let loose the calcareous earth, which, in a healthy proportion, it always holds in solution, and hereby increase the vesical calculus by supplying it with this material; while, on the contrary, by an undue use of acids where ihese are required to a certain extent, we may obtain a secretion of uric acid in a morbid excess, and augment the stone in the blad- der by a crystallization of an opposite kind. Hence a very consi- * Mem. de l'Acad. de Chirurg. Tom. I. GE. IV.—SP. II.] EXCERNENT FUNCTION. 353 derablc degree of skill and caution is requisite in the mode of treat- ment, and the character of the urine should be watched perpetual- ly. Nor, where the calculus is of a still more composite kind, can either of these plans be attended with all the success they seem to ensure, so that the augmentation will sometimes be found to proceed in spite of the best directed efforts. From the success that has attended the use of the colchicum autumvale in many cases of gout, and the tendency there is in many cases of this disease to form calculi in the joints, Mr. Brande has ingeniously thrown out the idea of trying the virtue of the colchi- cum in the disease before us, and hints that he has received from one quarter a very flattering account of its success, though not suffi- ciently precise for publication. If the reasoning pursued in examin- ing the powers and effects of the colchicum in that part of the present work which is allotted to the history of gout be correct, we can have little hope of any permanent advantage from its use in respect to the lithic concretions before us. It has there appear- ed that the colchicum does not act as a preventive but as an anti- dote, during the prevalence of a paroxysm. Nor does it act in this last way in all paroxysms, but chiefly, if not solely, in those of the regular form of gout, in which the general state of the con- stitution is sound and vigorous, while in atonic gout, it seems from the violence of its effects, not unfrequently to add to the evil. Y"et it is in this last modification of gout that calculi are only found to concrete in the joints: the deposit, rarely, if ever, taking place, till the constitution has been seriously shaken by a series of at- tacks, evidencing, as in the case of similar deposits in the coats of the vessels and the parenchyma of various organs in old people, a general torpitude and debility of the excernent system. Upon which subject the reader may turn to the genus osthexia* in a pre- ceding Order of the present Class. There is something perhaps more plausible in the remedial regi- men proposed by M. Magendie, who, on reflecting that azote is an essential constituent of urea and uric acid, advises that the patient be confined to food that possesses no sensible portion of azote, as sugar, gum, oil-olive, butter, and a vegetable diet generally :t thus treating it with a dietetic course directly the reverse of what is now generally proposed for paruria mellita, or diabetes. From the whole that has been advanced not only under the pre- sent genus, but also under much of the preceding, it is obvious that the soundness of the urine keeps pace, in a considerable degree, with the soundness of the stomach and its auxiliary organs, and is dependent upon them : and hence in calculous concretions of every kind it is of the utmost importance that the chylifacient viscera, and the whole course of the intestinal canal, should be kept in as healthy a state as possible. * Supra, p. 233. f Recherches Physiologiques et Medicales, &c. ut supra V«L. IV.—-45 351 ECCRITICA. [CL. VI.—OR. II Astringents and bitters offer to us the best remedies for this purpose. From the supposed absorbent power of the former, Dr. Cullen, as we have already seen, ascribes to them much of the pe- culiar benefit resulting from the use of alkalies and magnesia, in- dependently of their decided virtue as a tonic : nor ought we, while upon this subject, to overlook the advantage which, in calculi of uric acid at least, the same distinguished writer asserts that he derived from the use of soap, which he ascribes entirely to its correcting acidity in the stomach ;* thus acting the same part as magnesia, and in many cases with greater potency. If such be the difficulty of preventing a calculus already formed in the bladder from enlarging, we may readily see how hopeless must be every attempt at dissolving the matter that has already be- come crystallized or concreted. Calculi of uric acid will dissolve in caustic alkalies, but in no alkalies of less power : nor can those of the phosphates be acted upon by acids of any kind, except in a state far too concentrated for medical use. " These considerations," says Mr. Brande, " independently of more urgent reasons, show the futility of attempting the solution of a stone of the bladder by the injection of acid and alkaline solutions. In respect to the al- kalies, if sufficiently strong to act upon the uric crust of the calcu- lus, they would certainly injure the coats of the bladder : they would also become inactive by combination with the acids of the urine. and they would form a dangerous precipitate from the same cause. The acids, even when very largely diluted, and qualified with opi- um, always excite great irritation. They cannot, therefore, be applied strong enough to dissolve any appretiable portion of the stone, and the uric nucleus always remains as an ultimate obstacle to success."t The greatest impediment of all, however, consists in the difficulty of ascertaining the nature of the surface of the stone that is to be acted upon, and the diversity of substances of which its various laminae very frequently consist: insomuch that had we glasses that could give us an insight into the bladder and unfold to us the nature of the first layer, and could we even remove this superficial crust by a solvent of one kind, we should be per- petually meeting with other crusts that would require other li- thontriptics ; while the very means we employ to dissolve them, by decomposing the principles of the urine, would build up fresh layers faster than we could hope to destroy those that have already concreted. In truth if we examine the most famous lithontriptics that have had their day, we shall find that by far the greater number of them were calculated to deceive either their own inventors, or the public, by a palliative rather than a solvent power. Some*of them were oleaginous or mucilaginous ; others, that contained a considerable portion of alkali, contained also some narcotic preparation: • Mat. Med. Part. II. Chap. X. p. 403. f Journal, Vol. VIII. p. 215. CE. IV—SP. II.] EXCERNENT FUNCTION. 355 while a third sort seem to have acted by a diluent power alone, in consequence of being taken into the stomach or injected into the bladder in a very large quantity ; and by these means all had a tendency to appease the irritation. Even Mrs. Stephen's rude and operose preparations which exercised so much of the analytical skill of Dr. Hales, and Dr. Hartley, and Dr. Lobb, and Dr. Jurin, and many other celebrated characters of their day, were combined with opium when the patient was in pain, and with aperients when he was costive ; and through their entire use, with an abstinence from port wines and other fermented liquors, salt meats, and heat- ing condiments, and with rest and a reclined position instead of ex- ercise ; and with these auxiliaries there is no great difficulty in sup- posing she might often succeed in allaying a painful fit of stone or irritation of the bladder, whatever may be the talismanic virtue of her egg shells, and pounded snails, and best Alicant soap, and cresses, and burdock, and parsley, and fennel, and hips, and haws, and the twenty or thirty other materials that held a seat in the ge- neral council.* How far filling the bladder with sedative or demulcent injections may succeed in diminishing irritation and alleviating pain, has not perhaps been sufficiently tried : but from the supposed success of many of the old lithontriptics employed in this way, and whose vir- tue can be ascribed to no other cause, it is a practice worth adven- turing upon in the present age of physiological experiments. When, however, there is much disease of the prostate or bulb of the ure- thra, the attempt should be desisted from, but wherever the sound can enter without much pain, we need not be afraid of increasing the irritation. This operation is of very ancient date, and of equally extensive range, as appears from a brief account, published in a professional journal of considerable merit, of the manner in which it is performed in the present era, and has been from time imme- morial in the dominions of Muscat, beyond the mountains of So- hair in Arabia. The instrument employed is a catheter of gold made long enough to pass directly into the bladder, so as to avoid injuring any part of the urethra with such solvent as might be had recourse to. The usual form it appears, and I notice it for the purpose of confirming the remark I have made upon the nature of such lithontriptics as have been most in vogue in every age, con- sisted of a weak ley of alkali or alkaline ashes, united with a cer- tain proportion of mutton suet and opium.f And when we are gravely told that this preparation never fails to dissolve the stone, we are at no loss to settle the account upon this subject, and can trace the real cause of whatever degree of ease may have been derived from such an injection, and can allow that even the alkali itself, if not in too concentrated a stale, may have been of occasion- al advantage._____________________________________ * See a full account of thorn in the Edin. Med. Essays, Vol. V. Part II. A>-t. LXIX. t Edin. Med. Comm. Vol. HI. p. 334. 356 ECCRITICA. [CL. VI.—OR. II, When, however, all these means of relief fail, and the general health is worn out by a long succession of pain and anxiety, no- thing remains but the operation of extraction. The shortness and expansibility of the urethra in women which allows, as we have already seen, a passage for calculi, of a considerable calibre to pass naturally, has suggested an idea of the possibility of introducing a stone forceps into the female bladder so as to supply the place of lithotomy. The first hint of this kind that has occurred to me, is to be found in the Gallicinium Medico-practicum of Gockel, pub- lished at Ulm in 1700. It was afterwards taken up, perhaps, origi- nally started, by Mr. Bloomfield, who ingeniously advised that the urethra should, for this purpose, be dilated by forcing water through the gut of a fowl introduced into the urethra as an expansile canula. Mr. Thomas has since, by the use of a sponge-tent gradually en- larged for the purpose, succeeded in introducing his finger into the bladder, and bringing away an ivory ear-pick which had been incautiously used as a catheter, and had slipped into the cavity of this organ.* This, however, is a method that can never be applied to males, nor even successfully to females, except where the calculus is com- paratively of small dimensions, or the meatus is so far dilated by the passage of former calculi as to render it unnecessary. In all other cases lithotomy offers the only means of removing the indis- soluble stone from the bladder ; and for the various modes in which this is performed, the reader must consult the writers on practical surgery. Calculi thus extracted have been found of all weights and bulks. A stone from a quarter of a pound to half a pound may, perhaps, be regarded as the ordinary average : but they have sometimes grown to a much larger size, and have still been safely extracted. The largest for which lithotomy seems at any time to have been per- formed in this country, weighed forty-four ounces, and was sixteen inches in length. The operation was performed by Mr. Cline, but the stone could not be brought away, and the patient died a few days after.f In a foreign journal of high reputation, we have an account of a calculous found in the bladder after death, that weighed four pound and a half or seventy two ounces, and seems to have filled nearly the whole of its cavity 4 * Transactions of the Medico-Chir. Soc. Vol. I. p. 124. X Phil. Trans, year 1809. $ Bresl. Sammlung. Band. II. 1724. 434. 11. CLASS VI. ECCRITICA. ORDER III. ACROTICA. fflmant n affecting tne External Surface. FRAVITY OF THE FLUIDS OR EMUNCTORIES THAT OPEN ON THE EXTER- NAL SURFACE ; WITHOUT FEVER, OR OTHER INTERNAL AFFECTION, AS A NECESSARY ACCOMPANIMENT. Acrotica is a Greek term, from «xfa«," summus," whence axgerjjf- rlTei, " summitas," " cacumen." The excretories of the skin form a most important outlet of the system, and although the fluid they secrete, is, in a state of health, less complicated than that of the kidneys, under a variety of circumstances it becomes more so. It is to this quarter that all the deleterious or poisonous ferments pro- duced by eruptive fevers are directed by the remedial power of nature, as that in which they can be thrown off with least evil to the constitution. By the close sympathy which the surface of the body holds with the stomach, the heart, the lungs, and the kidneys, its excretories are almost perpetually varying in their action, and still more so from their direct exposure to the changeable state of the atmosphere : in consequence of which they are one moment chilled, torpid, and collapsed, and perhaps the next violently excit- ed and irritated : now dry and contracted, now relaxed and stream- ing with moisture ; now secreting their natural fluid alone, and now charged with acrimonies of every kind, acid, alkaline, and saburral: and sometimes with a load of gluten or calcareous earth that har- dens into horn or shell. But the mouths of the cutaneous exhalants are in their own na- ture peculiarly delicate and tender; and hence the necessity of their being covered by the epithelium of a fine cuticle, which defends them in a considerable degree from the rudeness of external im- 358 ECCRITICA. [CL. VI.—OR. HI. pressions or irritants with which the air is impregnated. This de- fence, however, they frequently lose ; often from external violence, and often also from the acrimony or roughness of the materials that arc thus transmitted to them, and which excoriate as effectually as friction, a keen frosty north-east wind, or the direct rays of a tropi- cal sun. And at times the absorbents of the skin are torpid or weak in their action ; and the finer parts only of the fluids that are se- cerned are imbibed and carried off, while the grosser parts remain and accumulate in the cutaneous follicles, and become acrimonious from decomposition. And hence a great variety of superficial erup- tions, papulous, pustulous, and ichorous, squammose, or furfura- ceous. And not unfrequently there is a constitutional irritability of the skin which not only renders it peculiarly liable to be excited by small causes in every part, but to sympathize in the morbid ac- tion through its whole extent in whatever part it may commence : and hence the spread of eruptions to a greater or less extent, sometimes, indeed, over the entire surface. From these sources of affection a variety of complaints must ne- cessarily take their rise, none of them perhaps fatal to life, but many of them peculiarly troublesome and obstinate. They may be arranged under the following genera: I. EPHIDROSIS. MORBID SWEAT. II. EXANTHESIS. CUTANEOUS BLUSH. III. EXORMIA. PAPULOUS-SKIN. IV. LEPIDOSIS. SCALE-SKIN V. ECPHLYSIS. BLAINS. VI. ECPYESIS. SCALL. TETTER. VII. MALIS. CUTANEOUS VERMINATION. VIII. ECPHYMA. CUTANEOUS EXCRESCENCE. IX. TRICHOSIS. MORBID HAIR. X. EPICHROSIS. MACULAR SKIN. Most of these genera contain numerous species, many of which, though by no means all, form a part of Dr. Willan's arrangement, and have been described by himself or my late excellent friend Dr. Bateman, of whose labours I shall avail myself as far as they may answer the present purpose. GE. I.] EXCERNENT FUNCTION. 359 GENUS I. EPHIDROSIS. aJHorufir Stoeat. PRETERNATURAL SECRETION OF CUTANEOUS PERSPIRATION. Ephidrosis (eQifyarii) is a Greek term for " sudor." The matter of sweat and that of insensible perspiration are nearly the same; the former consisting of the latter with a small intermixture of animal oil. It is affirmed by some writers that there are persons who never perspire. This demands ample proof; for experience teaches us that all warm-blooded animals either perspire by the skin, or have some vicarious evacuation that supplies its place, as in the case of the dog kind, in which an increased discharge of saliva seems to answer the purpose ; though in violent agony, I have known a New- foundland dog thrown into a sweat that has drenched the whole of his thick and wavy hair. In cold-blooded animals we sometimes find partial secretions, as in the lizards, the exudation from some of which, particularly the lacerta Geitja of the Cape of Good Hope, is highly acrid; and as it touches the hand and feet of men occa- sionally produces dangerous gangrenes Generally speaking, how- ever, cold-blooded animals secrete but a small quantity of fluid from the surface, and consequently suffer but little exhaustion or dimi- nution of weight, and can live long without nourishment: and it is hence probable that, among mankind, those who throw off but a small quantity of halitus may exist upon a very spare supply of food, which may afford a solution to many of the wonderful stories of fasting persons, most of whom seem to have passed sedentary and inactive lives, recorded in the scientific journals of different countries, a subject we have already discussed :* for the matter of insensible perspiration is calculated, upon an average, as being daily equal in weight to half the food introduced into the stomach in the course of the day. Thus if a man of good health and middle age, weighing about 146 pounds avoirdupois, eat and drink at the rate of fifty-six ounces in twenty-four hours, he will commonly be found to lose about twenty-eight ounces within the same period by in- sensible perspiration : sixteen ounces during the two thirds df this period allotted to wakefulness, and twelve ounces during the re- maining third allotted to sleep. It sometimes happens that this evacuation is secreted in excess, and becomes sensible, so as to render the whole, or various parts of the body, and especially the palms of the hands covered with mois- * Vol. I. Class. I. Ord. I. Limosis expers, p. 76. 360 ECCRITICA. [CL. VI.—OR. III. ture, without any misaffection of the system. It is to this species that the term ephidrosis has been usually applied and limited by nosologists. Sauvages, however, has employed it in a wider signi- fication, so as to include various other species, and perhaps cor- rectly ; though Cullen inclines to regard all but the first as mere- ly symptomatic of some other complaint. The following appear to be those which are chiefly entitled to a specific rank: 1. EPHIDROSIS PROFUSA. PROFUSE SWEAT. 2. ---------- CRUENTA. BLOODY SWEAT. 3. ---------- PARTIALIS. PARTIAL SWEAT. 4. ---------- DISCOLOR. COLOURED SWEAT. 5. ————— OLENS. SCENTED SWEAT. 6. 1 ARENOSA. SANDY SWEAT. SPECIES r. EPHIDROSIS PROFUSA. Urofuse Stoeat CUTANEOUS PERSPIRATION SECRETED PROFUSELY. This is commonly a result of relaxed fibres: the mouths of the cu- taneous exhalants being too loose and patulous, and the perspirable fluid flowing forth copiously and rapidly upon very slight exertions, sometimes without any exertion at all; as we have already seen the urine flows in paruria aquosa, and the serum in various species of dropsy. There is here, generally speaking, less solution of animal oil than in perspiration produced by exercise or hard labour :* but from the drain that is perpetually taking place, no animal oil accumulates, and the frame is usually slender. Corpulent persons also perspire much, but this is altogether from a different cause, being that of the weight they have to carry, and the labour with which breathing and every other function is performed in consequence of the gene- ral oppression of the system. Here also an extenuation of the frame would soon follow, but that from the peculiar diathesis which so readily predisposes to the formation of fat the supply is always equal to, and for the most part continues to exceed the waste, un- less a more than ordinary course of exertion be engaged in. In persons of relaxed fibres, but whose general health is sound, I have frequently perceived that there is no particular liability to * Biichner, Diss, de Sudore colliquative Hal. 1757. • GE. I.—SP. I.] EXCERNENT FUNCTION. 361 catch cold, notwithstanding this tendency to perspiration, and have very often seen it suddenly checked without any evil: such is the wonderful effect of an established habit. But the moment the ge- neral health suffers, or the system becomes seriously weakened by its continuance, the sweat is apt to become colliquative, and to ter- minate in a tabes or decline.* Tulpius gives a case of its continuing for seven years.t Astrin- gents of all kinds have been tried, but with variable effects. Dr. Percival relied chiefly on bark ; De Haen employed the white agaric,| and in the Journal de Medicine,§ the same medicine is re- commended under the name of fungus laricis ; it is the boletus la- ricis of the present day. It was given in the form of troches and pills. Cold sea-bathing, and the mineral acids, with temperate exercise, light animal food, and the use of a hair mattrass instead of a down bed at night, have proved successful on many occasions, and form the best plan we can adopt. SPECIES II. EPHIDROSIS CRUENTA. Blootts Stoeat CUTANEOUS PERSPIRATION INTERMIXED WITH BLOOD. This species has not been very commonly described by nosologists ; but the cases of idiopathic affection are so numerous and so clearly marked by other writers that it ought not to be passed over.|| We have noticed a sympathetic and vicarious affection of this kind under the genus mismenstruation,! and have there observed that the cutaneous exhalants, in such instances, become enlarged in their diameter, and suffer red blood or a fluid of the appearance of red blood to pass through them. In cases of extreme debility from other causes, as in the last and fatal stage of atonic fevers, or in sea or land scurvy** blood has been known to flow from the cutaneous exhalants in like manner, evidently from weakness, and a relaxation of their extremities, in connexion perhaps with a thinner or more * See Vol. II. p. 474. f Lib. HI. Cap. 42. * Rat Med. P. Xll. Cap. vi. § G. § Tom.XLVII. || Ploucq. Init. VII. 316. 1 Vol.111, p. 45. ** N. Act. Nat. Cur. Vol. IV. Obs. 41 Bresl. Samml. 1725, I. p. 183 vol. iv.—46 369 ECCRITICA. [CL. VI.—OR. III. dissolved state of the blood itself. None of these, however, are idiopathic affections. When the discharge shows itself as a pri- mary disease, the cause has generally been some violent commotion of the nervous system forcing the red particles into the cutaneous excretories, rather than a simple influx from a relaxed state of their fibres. And hence it has taken place occasionally during coition ,* sometimes during vehement terror ; and not unfrequently during the agony of hanging or the torture.t It is said also to have oc- curred in some instances in new-born infants,} probably from the additional force given to the circulation, in consequence of a full inflation of the lungs accompanied with violent crying. SPECIES III. EPHIDROSIS PARTIALIS. iJarttal Sfoeat. CUTANEOUS PERSPIRATION LIMITED TO A PARTICULAR PART OR ORGAN. There are some persons who rarely perspire, others who perspire far more freely from one organ than another, as the head, or the feet, or the body. Such abnormities rather predispose to morbid affections, than are morbid affections themselves. Sauvages, in il- lustration of the present species, quotes a case from Hartmann, of a woman who was never capable of being thrown into a sweat either by nature or art in any part of her body except when she was preg- nant, at which time she perspired on the left side alone.§ Schmidt has noticed a like anomaIy.|| In this last case it is probable that the kidneys became a substi- tute for the action of the cutaneous exhalants, as we see they do on various occasions, as when their mouths become collapsed from the chilly spasm that shoots over them on plunging into a cold bath, or in a fit of hysterics. The sweat thus discharged from a partial outlet, is frequently fetid, as under the fifth species of the present genus; and where it is constitutional, it is often repelled with great danger to some more important organ. • Paulini, Cent. HI. Obs. 46. Eph. Nat. Dec. II. Ann. VI. Appx. pp. 4. 45.55. f Bartholinus, Epist. I. p. 718. * Eph. Nat. Cur. Dec. II. Ann. X. Obs. 65. 4 Hartmanni, De Sudore unius lateris, 4to. 1740. II Collect. Acad. Vol. III. p. 577. GE. I.—SP. IV.] EXCERNENT FUNCTION. 363 SPECIES IV. EPHIDROSIS DISCOLOR. <£oloure& Sbtoeat CUTANEOUS PERSPIRATION POSSESSING A DEPRAVED TINGE. Sweat is often tinged with a deeper yellow than is natural to it from a resorption of bile into the blood-vessels : and, as we have already seen, it is sometimes intermixed with blood from violence, or a relaxed state of the cutaneous exhalants. And where these, or causes like these, co-operate, we can readily account for the va- rious colours it has sometimes exhibited as green, black,*blue, saffron, or ruby : examples of all which are referred to in the vo- lume of Nosology. We see, indeed, the whole of these hues pro- duced daily under the cuticle from the extravasation of blood, ac- cording as the effused fluid is more or less impregnated with the colouring matter of the blood, and the finer and more limpid parts are first absorbed and carried off. It is possible also that in some of the cases referred to, the stain may have been produced by in- haling a vapour impregnated with metallic corpuscles or some other pigment; and especially when working in metallurgical trades or quicksilver mines. SPECIES V. EPHIDROSIS OLENS. Scentetr Stoeat CUTANEOUS TERSPIRATION POSSESSING A DEPRAVED SMELL. The varieties that have been chiefly noticed are those of a sulphu- reous scent; of a sour scent; of a rank or fetid scent; of a violet,* and of a musky scent.t The rank or fetid scent is sometimes par- tial ; being only evacuated from particular organs as the feet and axilla. De Monteaux, however, has found the same thrown off generally :{ and as a symptom in atonic fevers it must have been * Paullini, Cent. I. Obs 21. Eph. Nat. Cur. Dec. II. Ann. V. Appx. p. 9. fid. Dec. III. Ann. IX. X. Obs. 96. i Maladies de Femmes, Tom. n. 364 ECCRITICA. [CL. VI.—OR. III. witnessed by most practitioners, as also in several sordid cutaneous eruptions. In fevers, moreover, we frequently meet with a secre- tion of sour perspiration, which, in a few instances, has had the pungency of vinegar. When such smells accompany diseases they usually cease on the cessation of the disease which gives rise to them. Where they are habitual they often depend upon amor- bid state of the stomach, or of the cutaneous excretories ; and will often yield to a course of aperients or alterants, a frequent use of the warm, and, when the constitution will allow, of the cold-bath, and such exercise as shall call forth a copious discharge of per- spirable matter, and free the cutaneous follicles or orifices of what- ever olid materials may lurk there. Many of these, however, are often dependent upon the diet or manner of life. Thus the food of garlic yields a perspiration pos- sessing a garlic smell: that of peas a leguminous smell, which is the cause*of this peculiar odour among the inhabitants of Greenland; and acids a smell of acidity. Among glass-blowers, from the large quantity of sea-salt that enters into the materials of their manufac- ture, the sweat is sometimes so highly impregnated that the salt they employ and imbibe by the skin and lungs, has been seen to collect in crystals upon their faces. A musky scent is not often thrown forth from the human body, but it is perhaps the most com- mon of all odours that escape from the skin of other animals. We discover it in many of the ape kind, and especially the simia Jacchus ; still more profusely in the opossum, and occasionally in hedge-hogs, hares, serpents, and crocodiles. The odour of civet is the production of the civet-cat alone; the viverra Zibetha, and viverra Civetta of Linneus, though we meet with faint traces of it in some varieties of the domestic cat. Among insects, however, such odours are considerably more common, and by far the greater number of them are of an agreeable kind, and of very high excel- lence ; for the musk scent of the cerambix moschatus, the apis fragrans, and the tipula moschifera, is much more delicate than that of the musk quadrupeds : while the cerambix suaveolens, and several species of the ichneumon yield the sweetest perfume of the rose ; and the petiolated sphex a balsamic, ether highly fragrant, but peculiar to itself. GE. I.—SP. VI.] EXCERNENT FUNCTION. 365 SPECIES VI. EPHIDROSIS ARENOSA. Sairtrg Stoeat CUTANEOUS PERSPIRATION CONTAINING A DISCHARGE OF SANDY OR OTHER GRANULAR MOLECULES. As the odorous particles of both animal and vegetable food are sometimes absorbed by the lacteals and impregnate the matter of perspiration, so at times are the more solid particles of the mate- rials employed in handicraft trades absorbed by the lungs, and equally thrown forth upon the surface. This, as observed under the last species, is particularly the case with glass-blowers, upon whose forehead and arms salt is often seen to collect and crystal- lize in great abundance, from the quantity of this material which they employ in the manufacture of glass, and its diffusion through the heated atmosphere of the workshop in minute and impercepti- ble particles. But a reddish sandy material is occasionally found to concrete on the surface of the body under other circumstances and which can- not be charged to any material volatilized in the course of business. Bartholin, Schurig,* Mollenbroek,t and various other writers have given instances of this kind of crystallization, which seems to con- sist in an excess of free uric acid, translated from the kidneys to the skin by an idiopathic sympathy, and forming red sand on the sur- face, as it probably would otherwise have done in the bladder or the urinal. It is possible, indeed, that a man may hereby escape from the fabrication of an urinary calculus, or stone in the bladder : and were such a transfer at all times, in our power, we should gladly avail ourselves of it in many cases of a lithic diathesis, and employ it as a preventive of urinary concretions. When the sand is trou- blesome from the quantity collected the alkaline and other medi- cines recommended under lithia renalis% will easily remove it.§ * Litholog. p. 235. f De Vasis, Cap. XIII. $ Hist. Anat. Cent. 1.34. § Supra, p. 346. ECCRITICA. [GL. VI.—OR. IK GENUS II. EXANTHESIS. Cutaneous Mush. SIMPLE, CUTANEOUS, ROSE-COLOURED EFFLORESCENCE, IN CIRCUM- SCRIBED PLOTS, WITH LITTLE OR NO ELEVATION. Exanthesis is a Greek compound from ff " extra" and xv6s» « flo- reo," superficial or cutaneous efflorescence, in contradistinction to enantiiesis in Class III. Order IV. rash-fever or " efflorescence springing from within." This genus affords but one known species, the specific name for which is taken from Dr. Willan: 1. EXANTHESIS ROSEOLA. ROSE-RASH. SPECIES I. EXANTHESIS ROSEOLA ftosc-ftasli. EFFLORESCENCE IN BLUSHING PATCHES, GRADUALLY DEEPENING TO A ROSf.-COI.OUR, MOSTLY CIRCULAR, OR OVAL J OFTEN ALTERNATELY FADING AND REVIVING; SOMETIMES WITH A COLOURLESS UMBO; CHIEFLY ON THE CHEEKS, NECK, OR ARMS. Roseola was sometimes employed by the older writers, though in a very h use sense, to signify scariet-fever, measles, and one or two other exctn'hcms that were often confounded : but as it is :«ow no longer used for these it may stand well enough as a nan • or the present species, which Fuller has described as a flushing ail over the body like fine crimson, which is void of danger, and " rather a ludicrous spectacle than an ill symptom."* As a symptom this rash is frequently met wi.h in various mala- dies. Thus in the dentition of infancy it appears on the cheeks ; in the inoculated cow-pox, around the vesicle ; in dyspepsy, and various levers, in different parts of the body, constituting varieties, several of which by Dr. Willan are named, according to the disease • Exanthematologia, p. 128. Bateman's Synops. 95. GE. II.—SP. I.] EXCERNENT FUNCTION. 367 they accompany, Roseola infantilis, R. variolosa, R. vaccina, and R. miliaris : but which, as mere symptoms of other disorders, are to be sought for in the diseases of which they occasionally form a part. In the spring and autumn it often appears to be idiopathic espe- cially in irritable constitutions The occasional causes are fatigue, sudden alterations of heal and cold, or the drinking of very cold water after violent exercise. Dr. Willan mentions one instance of its occurring after sleeping in a damp bed. It has sometimes been mistaken for an eruption of the measles, and still oftener for that of a mild rosalia or scarlet-fever, of which last error the same author gives an example in a child that was extensively affected with it, about Midsummer, for several years in succession, and whose attendant physician informed the parents that the scarlet fe- ver had recurred in their child, seven times ; and hence one reason why the same name was formerly applied to all these. The attack is sometimes preceded during the heat of summer, by a slight febrile indisposition. It appears first on thelface and neck, and, in the course of a day or two, is distributed over the rest of the body. The eruption spreads in small patches of various fi- gures but usually larger than those of measles, often as large as a shilling, at first of abrightish red, and soon settled into the deeper hue of the damask rose. It sometimes assumes an annular form, and appears over the body in rose-coloured rings with central areas or umbos of the usual colour of the skin : the rings being at first small, but gradually dilating to the diameter of half an inch. This rash is troublesome, but of little importance otherwise. In the medical treatment of it the state of the stomach and bowels should be particularly inquired into, and, for the most part, will be found to require correction. Acidulated drinks, with occasional and gentle laxatives generally remove the disease, unless it be con- nected with any constitutional or visceral affection, when it some- times proves very obstinate, and can only be cured by curing the primary malady. GtiNUS III. EXORMIA #apulcms Stun. SMALL ACUMINATED ELEVATIONS OF THE CUTICLE ; NOT CONTAINING A FLUID, NOR TENDING TO SUPPURATION ; COMMONLY TERMINATING IN SCURF. For the acuminated elevation of the cuticle, which the Latins call papula, the Greeks had two synonymous terms, ecthyma, (e>c6v{*x) 368 ECCRITICA. [CL. VI.—OR. HI. and exormia {t%o^ix.) The first was used most frequently in this sense; but as this has by some unaccountable means been employed very generally to import a very different eruption, a crop of large pustulous, rather than of small solid pimples, forming a species of ECPYESis,or the sixth genus of the present order, 1 have chosen the second term for the present purpose. The common terminating diminutive (ula or ilia) is probably de- rived from the Greek cJajj (ule or ile,) " materia," " materies"— of the matter, make, or nature of; " thus papula or papilla," of the matter or nature of pappus ; " lupula," of the matter or nature of the lupus; " pustula," of the matter or nature of pus; and so of many others. Papula and pustula, which by Sauvages are degraded into mere symptoms of diseases, and not allowed to constitute diseases of themselves, are raised to the rank of genera by Celsus, Linneus, and Sagar, and, under a plural form (papulae and pustulae,) to that of order! by Willan. In the present system exormia and ecphlysis, intended to supply their place, are employed as generic terms, and run parallel with those papulae and pustulae by Willan, which are not essentially connected with internal disease ; and are only made use of instead of papula and pustula, first as being more immediate- ly Greek, and next, in order to prevent confusion from the variety of senses assigned to the latter terms by different writers. Exormia and ecphlysis, therefore, as distinct genera under the present ar- rangement, import eruptions of pimples and pustules in their sim- plest state, affecting the cuticle, or at the utmost the superficial in- tegument alone, and consequently without fever, or other internal complaint as a necessary or essential symptom ; although some part or other of the system may occasionally catenate or sympathize with the efflorescence. It is difficult, indeed, to draw a line of se- paration, and perhaps impossible to draw it exactly, between efflo- rescences strictly cutaneous and strictly constitutional, from the numerous examples we meet with of the one description combining with or passing into the other. But a like difficulty belongs to every other branch of physiology in the widest sense of the term, as well as to nosology ; and all we can do in any division of the sci- ence, is to lay down the boundary with as much nicety and caution as possible, and to correct it, as corrections may afterwards be call- ed for. The species which belong to this genus, or which, in other words, are characterized by a papulous skin not necessarily crn!M~^iL with an internal affection are the following : 1. EXORMIA STROPHULUS. GUM-RASH. 2.-------LICHEN. LICHENOUS RASH. 3.-------PRURIGO. PRURIGINOUS RASH. 4. ——— MILIUM. MILLET-RASH. GE. III.—SP. I] EXCERNENT FUNCTION. 396 SPECIES I. EXORMIA STROPHULUS. tiSfum^Haffh. ERUPTION OF RED PIMPLES IN EARLY INFANCY, CHIEFLY ABOUT THE FACE, NECK, AND ARMS, SURROUNDED BY A REDDISH HALO ; OR IN- TERRUPTED BY IRREGULAR PLOTS OF CUTANEOUS BLUSH. Dr. Willan has observed, that the colloquial name of Red-gum, applied to the common form of this disease, is a corruption of Red- gown, under which the disease was known in former times, and by which it still continues to be called in various districts; as though supposed, from its variegated plots of red upon a pale ground to resemble a piece of red printed linen. In effect it is written Red- gown in most of the old dictionaries: in Littleton's as late as 1684, and I believe to the present day. The varieties in Willan are the following, whose descriptions are large and somewhat loose. We may extract from them, however, the subjoined distinctions of character: x Intertinctus. Pimples bright red ; distinct; inter- Red-gum. mixed with stigmata, and red patch- es; sometimes spreading over the body. S Albidus. Pimples minute, hard, whitish; sur- White-gum. rounded by a reddish halo. y Confertus. Pimples red, of different sizes, crowd- Tooth-rash. ing or in clusters ; the larger sur- rounded by a red halo; occasionally succeeded by a red crop. ^ Volaticus. Pimples deep-red, in circular patches, Wild- fire-rash or clusters; clusters sometimes soli- tary on each arm or cheek; more generally flying from part to part. e Candidus. Pimples large, glabrous, shining; of a Pallid gum-rash. lighter hue than the skin: without halo or blush. Generally speaking none of these varieties are of serious import- ance ; and all of them being consistent with a healthy state of all the functions of ihe body, they require but little attention from me- dical practitioners. Several of them are occasionally connected with acidity or some other morbid symptom of the stomach and bowels, and, hence, particular attention should be paid to the primae viae. The system, also, suffers generally, in many cases, if the vol. iv.—47 370 ECCRITICA. [CL. VI.—OR. III. efflorescence be suddenly driven inwards by exposure to currents of cold air or by the use of cold-bathing. Both these, therefore, should be avoided while the efflorescence continues; and if such an acci- dent should occur, the infant should be immediately plunged into a warm-bath, which commonly succeeds in reproducing the eruption, when the constitutional illness ceases.* In every variety, indeed, the nurse should be directed to keep the child's skin clean, and to promote an equable perspiration by daily ablutions with tepid water, which are useful in most cutaneous disorders ; and will be found in other respects of material importance to the health of children. In the tooth-rash, strophulus confertus, there is no difficulty in tracing the ordinary cause, Yet this also has often been ascribed to a state of indigestion or some feverish complaint in the mother or nurse. "I have, however," says Dr. Willan, "frequently seen the eruption, where no such cause for it was evident. It may with more propriety be ranked among the numerous symptoms of irrita- tion arising from the inflamed and painful state of the gums in denti- tion, since it always occurs during the process, and disappears soon after the first teeth have cut through the gums." It may, however, like the red-gum, *. intertinctus, be occasionally connected with a weak and irritable state of the bowels: though the tender and deli- cate state of the skin, and the strong determination of blood to the surface, which evidently takes place in early infancy, and is the common proximate cause of the red-gum, is probably the common remote cause of the tooth-rash. The tooth-rash is the severest form in which strophulus shows itself. Instead of being confined to the face and breast, it oftentimes spreads widely over the body, though it appears chiefly, in a diffused state, on the fore-arm. Dr. Willan notices a very obstinate and painful modification of this disorder which sometimes takes place on the lower extremities. "The papulae spread from the calves of the legs to the thighs, nates, loins, and round the body, as high as the navel; being very numerous and close together, they produce a continuous redness over aW the parts above mentioned. The cu- ticle presently becomes shrivelled, cracks in various places, and finally separates from the skin in large pieces." It has some re- semblance to the intertrigo, which however may be distinguished by having an uniform red, shining surface without papulae, and being limited to the nates and thighs. In like manner, those children are most liable to the scrophulus volaiicus or wild-fire rash, who have a fair and irritable skin, though this also occasionally catenates with a morbid state of the stomach and bowels. It appears sometimes as early as between the third and sixth month, but more frequently later. This last is the erythema volaticum of Sauvages,the aestus vola- iicus of many earlier writers : whence the French name of feu vo- lage. All these terms, have however, been often used in a very * Uronzet, sur l'Education des Enfans, p. 187 fcE. HI.—SP. I] EXCERNENT FUNCTION. 371 indefinite sense, and hence, also applied to one or two species of porrigo, and especially porrigo Crustacea or crusta lactea.* And hence, Dr. Armstrong has described this last disease as a strophulus or tooth-rash.f The strophulus albidus, and strophulus Candidas, are the two slightest varieties of this species of indisposition. The first is chiefly limited to the face, neck, and breast, and often continues in the form of numerous, hard, whitish specks for along time, which on the removal of their tops do not discharge any fluid, though it is probable they were originally formed by a deposition of fluid, which afterwards concreted under the cuticle. The pimples in the scro- phulus candidus are larger and diffused over a wider space; often distributed over the loins, shoulders and upper part of the arms; though it is rarely that they descend lower. Several of the varie- ties occasionally co-exist and Km into each other, particularly the first two.f SPECIES II. EXORMIA LICHEN. acchcnous Hash. ERUPTION DIFFUSE ; PIMPLES RED ; TROUBLESOME SENSE OF TINGLING OR PRICKING. Lichen (tew* -*«) is a term common to the Greek phytologistsj as well as the Greek pathologists. By the former it is applied to that extensive genus of the algae, or rather to many of its species, which still retains the name of lichen in the Linnean system : and it is conjectured by Pliny that the physicians applied the same name to the species of disease before us from the resemblance it produces on the surface of the body to many of the spotty and minutely tubercular lichens, which are found wild upon stones, walls, and the bark of trees or shrubs. Gorrxus, however, gives two other origins of the term; one of which he does not approve, from the eruption being supposed to be cured by its being licked with the human tongue ; and the other, to which he inclines, from its creeping in a lambent or tongue-like form, over different parts of the body. The derivation in both these cases being *«»£• " lambo,' " lingo. It is a far more troublesome rash than the preceding; from the severest modifications of which, however, it chiefly differs by the • Astruc, De Morb. Infant, p. 44. f On the Diseases of Children, p. 34. \ Underwood, on the Diseases of Children, Vol. I. passim. 372 ECCRITICA. [CL. VI.—OR. Ill intolerable tingling or pricking which accompanies, and peculiarly characterises it. The following are its chief varieties : x Simplex. Simple Lichen. C Pilaris. Hair-Lichen. y Circumscriptus. Clustering Lichen. $ Lividus. Livid Lichen. Tropicus. Summer-rash. Prickly-heat. £ Ferus. Wild Lichen. » Urticosus. Nettle-Lichen. General irritation; sometimes a few febrile symptoms at the commencement; tingling ag- gravated during the night; pim- ples scattered over the body; which fade and desquammate in about a week. Pimples limited to the roots of the hair; desquammate after ten days ; often alternating with complaints of the head or sto- mach. Pimples in clusters or patches of irregular forms, appearing in succession over the trunk and limbs : sometimes coalescing: and occasionally reviving in successive crops, and persever- ing for six or eight weeks. Pimples dark-red or livid ; chiefly scattered over the extremities; desquammation at uncertain pe- riods, succeeded by fresh crops, often persevering for several months. Pimples bright red, size of a small pin's head ; heat, itching, and needle-like pricking; sometimes suddenly disappearing, and pro- ducing sickness or other inter- nal affection; relieved by the re- turn of a fresh crop. Pimples in clusters or patches, surrounded by a red halo; the cuticle growing gradually harsh, thickened, and chappy: often preceded by general irritation. Pimples very minute, slightly ele- vated, reddish : intolerably itch- ing, especially at night; irregu- larly subsiding, and reappear- ing ; chiefly spotting the limbs ; qccasionally spreading over the body with gnat-bite-shaped wheals: from the violence of the irritation, at times accom- GE. III.—Sl\ II.] EXCERNENT FUNCTION. 373 panied with vesicles or blisters, and succeeded by an extensive exfoliation of the cuticle. Under this species, as under the last, we may observe that all the varieties are in their purest state simple affections of the skin, though occasionally, probably from peculiarity of habit, or some ac- cidental disorder of the digestive function, connected v\ ith the state of the constitution or of the stomach or bowels. Dr. Willan, indeed, makes it a part of his specific character, that lichen is " connected with internal disorder:" but his description is at variance with his definition ; for with respect to the first variety, or simple lichen, he expressly asserts,* that it " sometimes appears suddenly without any manifest disorder of the constitution ;" while in regard to the tropical lichen or prickly heat, one of the severest modifications under which the disease appears, he states, and with apparent ap- probation, from Winterbottom, Hillary, Clark, and Cleghorn, that it is considered as salutary ; that even, " a vivid eruption of the prickly heat is a proof that the person affected with it is in a good state of health;"—that " its appearance on the skin of persons in a state of convalescence from fevers, &c. is always a favourable sign, indicating the return of health and vigour ;'"t that " it seldom causes any sickness or disorder except the troublesome itching and pricking :"t that it is not attended with any febrile commotion whilst it continues out ;"§ and that « it is looked upon as a sign of health, and, indeed, while it continues fresh on the skin, no inconvenience arises from it except a frequent itching."|j And, in like manner, Dr. Heberden observes that some patients have found themselves well on the appearance of the eruption, but troubled with pains of the head and stomach during the time of its spread ; but by far the greater number experience no other evil from it besides the in- tolerable anguish produced by the itching, which sometimes makes them fall away by breaking their rest, and is often so tormenting as to make them almost weary of their lives. Most of these re- marks apply equally to the urticose variety, one of its severest forms, as I shall have occasion to observe presently. The simple lichen shows itself first of all by an appearance of distinct red papulae about the cheeks and chin or on the arms, with but little inflammation round their base : in the course of three or four days the eruption spreads diffusely over the neck, body, and lower extremities, attended with an unpleasant sensation of tingling which is sometimes aggravated during the night. In about a week the colour of the eruption fades, and the cuticle separates in scurf. * Willan, p. 39. f Id. p. 35, from Winterbottom. t Id. p. 59, from Hillary, § Id. p. 61, from Clark. B Id. p. 63, from Cleghorn. 374 ECCRITICA. [CL. VI.—OR. III. All the surface of the body, indeed, remains scurfy for a long time, but particularly the flexures of the joints. The duration of the complaint varies; and hence, in different cases, a term of from fourteen to thirty days intervenes between the eruption and a reno- vation of the cuticle. " The eruption sometimes appears suddenly without any manifest disorder of the constitution :"* and some- times there is a febrile state or rather a state of irritation at the beginning of the disorder though " seldom considerable enough to confine the patient to the house"f—and which is relieved by the appearance of the eruption. It has occasionally been mistaken for measles or scarlatina: but its progress, and, indeed, the general nature of its symptoms from the first are sufficiently marked to dis- tinguish it from either of these. The causes are not distinctly pointed out by any of the writers, and it is singular that they should have been passed by both by Willan and Bateman. So far as I have seen, this and all the va- rieties depend upon a peculiar irritability of the skin as its remote cause, and some accidental stimulus as its exciting cause. The ir- ritability of the skin is sometimes constitutional, in which case the patient is subject to frequent returns of the complaint; but it has occasionally been induced by various internal and external sources of irritation : as a diet too luxurious or too meagre; the debility occasioned by a protracted chronic disease, or an exacerbated state of the mind; an improper use of mercury, or of other preparations that have disagreed either with the stomach, or the chylifacient viscera. Under any of which circumstances, a slight occasional cause is sufficient for the purpose, as exposure to the burning rays of a summer sun, a sudden chill on the surface, cold water drunk during great heat or perspiration ; a dose of opium or any other narcoctic, or substance that disagrees with the stomach or the idiosyncrasy. Dr. Heberden has suggested another cause, as per- haps operating in various cases, and inquires whether it may not be produced by some irritant floating in the atmosphere of so fine a structure as to be invisible to the naked eye, as the down of va- rious plants or insects; and he particularly alludes to the delicate hairs of the dolichos pruriens or cowhage as occasioning the dis- ease in the West Indies, from their attacking the skin in this man- ner imperceptibly. But since general ablutions afford little or no relief, and all medicated lotions are even more ineffectual; and as we can often trace it to other causes in our own country, and are at no less for a different cause in the West Indies, the present can hardly be allowed to be the ordinary cause, though it may become an occasional excitement. The remedial process should consist in keeping the bowels cool and free by neutral salts; a mixed diet of vegetables, ripe fruits, * Willan, ut supra, p. 39. f Id. p. 37. GE. III.—SP. II.] EXCERNENT FUNCTION. 375 especially of the acescent kind, as oranges and lemons, and fresh animal food; with an abstinence from fermented liquors,alight and cool dress, an open exposure to pure air, and an occasional use of the tepid-bath. The mineral acids have sometimes proved service- able, but not always; and the red or black hydrargyrussulphuratus, has been thought useful by many. Where the system is evidently in an impoverished state from previous sickness, innutritive food, or any mesenteric affection, bark, the mineral acids, or the metallic tonics afford a reasonable hope of relief, and especially such prepa- rations of iron as may sit easy on the stomach. The hair lichen, and clustering lichen differ from the preceding in little more than a difference of station or of form. Their causes or mode of treatment run parallel, and it is not need- ful to enlarge on them farther. The livid lichen is evidently connected with a weak and debi- litated habit. Its papulae are often interspersed with petecchiae, sometimes, indeed, with purple patches or vibices, and manifest a state of constitution bordering on that of scurvy or porphyra. Here the diet regimen and medical treatment should be altogether tonic and cordial, and may be taken from the plan already proposed for this last malady.* The tropical lichen, or prickly heat, is a" disease of high antiquity .and is equally described by the Greek and Arabian writers. The latter denominate it eshera, which is the plural of sheri, lite- rally papule, and hence the PAPUL^E,^or papulous disorder, by way of emphasis. And this term, softened or corrupted into essera, has been adopted and employed as the name of the disease by many European writers ofgreat reputation, as Bartholin, Hillary, and Ploucquet. The term, however, has sometimes been used both in the East and among Europeans in a looser sense, so as oc- casionally, but most improperly, to embrace urticaria, and some other febrile rashes as well. The symptoms of the disease I shall give in the words of my valued friend Dr. James Johnson, whose excellent work on the In- fluence of Tropical Climates, I lament that I was not in possession of so early in the progress of the present undertaking as I could wish to have been. Dr. Johnson delineates the disease as he has felt it, and as, in recollection, he seems almost to feel it still, and hence his description flows Warm from the heart and faithful to its fires. "From mosquittoes," says he, "cock-roaches, ants,and the nume- rous other tribes of depredators on our personal property, we have some defence by night, and, in general, a respite by day; but this unwelcome guest assails us at all, and particularly the most unsea- sonable hours. Many a time have I been forced to spring from ta- ble and abandon the repast, which I had scarcely touched, to writhe * Vol. II, p. 582 376 ECCRITICA. [CL. VI.—OR. IIL about in the open air, for a quarter of an hour: and often have I returned to the charge with no better success, against my ignoble opponent! The night affords no asylum. For some weeks after arriving in India, I seldom could obtain more than an hour's sleep at one time, before I was compelled to quit my couch, with no small precipitation, and if there were any water at hand, to sluice it over me, for the purpose of allaying the inexpressible irritation ! But this was productive of temporary relief only; and what was worse, a more violent paroxysm frequently succeeded. " The sensations arising from prickly heat are perfectly inde- scribable ; being compounded of pricking, itching, tingling, and many other feelings, for which I have no appropriate appellation. " It is usually, but not invariably accompanied by an eruption of vivid red pimples, not larger in general, than a pin's head, which spread over the breast, arms, thighs, neck, and occasionally along the forehead, close to the hair. This eruption often disappears, in a great measure, when we are sitting quiet, and the skin is cool; but no sooner do we use any exercise that brings out a perspiration, or swallow any warm or stimulating fluid, such as tea, soup, or wine, than the pimples become elevated, so as to be distinctly seen, and but too sensibly felt! " Prickly heat, being merely a symptom, not a cause of good health, its disappearance has been erroneously accused of produc- ing much mischief; hence the early writers on tropical diseases, harping on the old string of*" humoral pathology," speak very se- riously of the danger of repelling, and the advantage of" encourag- ing the eruption, by taking small warm liquors, as tea, coffees, wine whey, broth, and nourishing meats." "Indeed, I never saw it even repelled by a cold bath; and in my own case, as well as in many others, it rather seemed to aggra- vate the eruption and disagreeable sensations, especially during the glow which succeeded the immersion. It certainly disappears suddenly sometimes on the accession of other diseases, but I never had reason to suppose, that its disappearance occasioned them. I have tried lime juice, hair powder, and a variety of external appli- cations, with little or no benefit. In short, the only means which I ever saw productive of any good effect in mitigating its violence, till the constitution got assimilated to the climate, were—light clothing—temperance in eating and drinking-t-avoiding all exer- cise in the heat of the day—open bowels—and last, not least, a de- termined resolution to resist with stoical apathy its first attacks." The wild lichen, or lichen ferus, is particularly noticed by Cel- sus under the name of agri a, as applied to it by the Greeks from the violence with which it rages. It occurs in him after a brief de- scription of a variety of papula of a milder kind, which Willan sup- poses, and with some reason, to be the clustering. " Altera autem est, quam 'Ayftxv Graeci appellant: in qua similiter quidem, sed ma- gis cutis exasperatur, exulceraturque, ac vehementius et roditur, et rubet, et interdum inter pilos remittit. Quae minos rotunda est, diffi- GE. m.—SP. II.] EXCERNENT FUNCTION. 377 cilius sanescit: nisi sublata est, in impetiginem vertitur."* This variety, however, in its general range, its vehemence, and protract- ed duration, approaches nearer to the nettle-lichen than to any other : yet the pimples are larger, more clustered, and more apt to run into a pustular inflammation, so as often to produce cutaneous exulcerations and black scabs ; and hence the remark of Celsus that it is disposed to terminate in an impetigo, or, as others have it, in psora or lepra. The urticose or nettle lic hen is, perhaps, the most distressing form of all the varieties, if we except the tropical: and like the tro- pical, notwithstanding its violence, it is often totally independent of any constitutional affection. I can distinctly say from various cases that have occurred to me, that even where the patient has been worked up to such a degree of madness as to force him against his own will into a perpetual scratching, which greatly exasperates it, still the constitution has remained unaffected, the pulse regular, the appetite good, and the head clear. In most of the cases, the author alludes to, however, there was an established or idiopathic irritability of the system, and especially of the skin ; and in one or two of them it was unfortunate that opium, under every form and in every quantity always increased the irritability; while no other narcotic was of any avail. I freely confess that I have been more perplexed with this obstinate and intractable variety, which has in some cases, irregularly subsided for a few days or weeks, and then re-appeared with more violence than ever, than I have been with almost any other complaint that has ever occurred to me. A tepid bath and es- pecially of sea-water has sometimes been serviceable, but I have often found even this fail; and have uniformly observed the bath mis- chievous when made hot; for the skin will not bear stimulation. From the alterant apozems of sarsaparilla, elm-bark, juniper-tops, and snake-root, no benefit has accrued ; and as little from sulphur, sulphurated quick-silver, nitre, the mineral acids, and the mineral oxydes and salts. I once tried the arsenic solution, but the stomach would not bear it. Sea-bathing, however, in connexion with sea-air, has rarely failed ; and I am hence in the habiuof prescribing it to a delicate young lady who has been several times most grievously afflicted with this distressing malady, as soon as it re-appears; as well from the known inefficacy of every other remedy, a long list of which she has tried with great resolution, as from the benefit which this has almost uniformly produced. I have said that the wild lichen in its severity and duration offers a near resemblance to this. The former, however, is more apt to run into a pustular inflammation, though in the nettle-lichen we sometimes find a few of the vesicles filled with a straw-coloured fluid, but which are not permanent. There is also a greater tendency to some constitutional affection in the wild than in the nettle-modification, and particularly to a sickness or some other * De Medicina, Lib. V. Cap. XXVIIL vol. iv.—48 378 ECCRITICA. [CL. VI.—OR. III. disorder of the stomach upon repulsion by cold. Under the nettle- lichen the patient seldom finds the stomach or any other organ give way, and will endure exposure to a sharp current of air, with a full feeling of refreshment, without any danger of subsequent mischief. There is a singular modification of this disease described in a letter from Dr. Monsey, of Chelsea College, to Dr. Heberden, in which the cause was exposure of the skin to a bright sun in the open air. The patient was a man thirty years of age, of a thin, spare, habit; and his skin as soon as the solar rays fell upon it, became instantly almost as thick as leather, and as red as vermilion, with an intolerable itching: the whole of which abated about a quarter of an hour after he went into the shade. Dr. Monsey adds that this was not owing to the heat of the sun, for the sun in winter affected him full as much, if not more, and the heat of the fire had not such an affect. He was, in consequence, thrown into a state of " confinement for near ten years. It may not be amiss," continues Dr. Monsey, " to mention one particular, which is, that one hot day having a mind to try if he were at all benefitted by his immersions," (he seems to have used a salt-bath under cover, for many weeks) "he undressed himself and went into the sea, in the middle of the day: but he paid very dearly for the experiment,the heat diffusing itself so violently over his whole body by the time he had put on his clothes, that his eye-sight began to fail, and he was compelled to lie down upon the ground to save himself from falling. The moment he lay down the faintness went off; upon this he got up, but instantly found himself in the former condition: he, therefore, lay down, and immediately recovered. He continued alternately getting up and lying clown till the disorder began to be exhausted, which was in about half an hour, and so gradually went off. He had frequently been obliged to use the same practice at other times, when he was attacked with this disorder." That this case is to be regarded as a peculiar form of the present species, the extraordinary irritation and intolerable itching of the skin seem to vouch for sufficiently. It discovers, however, a cuta- neous excitement of, an idiopathic and most singular kind : and, keeping this idea in mind, it is not difficult to account for the ten- dency to deliquium related in the latter part of the account. The patient, it seems, could endure cold bathing under cover, or in the shade, and was not rendered faint by the re-active glow that ensued upon his quitting the water; but when to this reactive glow was united, in consequence of his bathing in the open air and in the middle of the day, the pungent heat of the sun, he was incapable of enduring both, till, by a certain length of exposure to this con- joint stimulus, the cutaneous nerves became torpid, which it seems they did in about half an hour; when the affection we are told « gradually went oft'." A daily exposure to the same exhausting power would in all probability, soon have rendered the torpitude habitual, or at least have reduced the cutaneous sensibility to its proper balance, which, GE. III.—SP. II] EXCERNENT FUNCTION. 379 after all, forms the real cure in the West Indies, and in most of the chronic cases of our own country. This, however, does not seem to have been thought of: but, after having tried a long list of different series of medicines in hospital and in private practice to no purpose, the patient was at length fortunate enough, when under the care of Dr. Monsey, to be put, as a forlorn hope, upon a brisk course of calomel, of which he took five grains every nightwitha purge of rhubarb or cathartic extract the ensuing morning for nearly a fortnight in succession; and having thus transferred the morbid irritability of the skin to the intestinal canal, the disease left him. SPECIES III. EXORMIA PRURIGO. $run'swous Jfcash. liRUPTION DIFFUSE : PIMPLES NEARLY OF THE COLOUR OF THE CUTICLE ; • WHEN ABRADED BY SCRATCHING OOZING A FLUID THAT CONCRETES INTO MINUTE BLACK SCABS; INTOLERABLE ITCHING, INCREASED BV SUDDEN EXPOSURE TO HEAT. In the symptoms of a papular eruption, and an intolerable itching, this species bears an approach towards the preceding : but it differs from it essentially in the colour of the papulae, and in the nature of the itching, which is often far more simple; and, when combined with a sense of stinging, gives a feeling peculiar to itself, like that of a nest of ants creeping over the body and stinging at the same time. It offers the three following varieties, the last of which chiefly differs from the second in being more inveterate :— * Mitis. Pimples soft and smooth : itching Mild Prurigo. at times subsiding; chiefly com- mon to the young and in spring time. b Formicans. Pimples varying from larger to Emmet-prurigo. more obscure than in the last; itching incessant, and accom- panied with a sense of pricking or stinging, or of the creeping of ants over the body; duration from two months to two or three years, with occasional but short intermissions : chiefly common to adults. 380 ECCRITICA. [CL. VI.—OR. III. y Senilis. Pimples mostly larger than in Inveterate prurigo. either of the above, sometimes indistinct, giving the surface a shining and granulated appear- ance ; itching incessant: common to advanced years, and nearly in- veterate. In all the varieties the itching differs in its extent: being some- times limited to a part only of the body, and sometimes spreading over the entire frame.* Courmette relates a case in which it al- ternated from side to side :f and in many instances it appears peri- odically. Hence, in Willan we have not only an account of the three preceding varieties, but of several others, which chiefly, if not entirely, differ from them in being limited to particular parts ; as prurigo podicis, p. praeputii, p. urethralis, p. pubis, p. pudendi muliebris. A common cause of this species in all its varieties, though by no means the only cause, is want of proper cleanliness of the skin and of apparel; and hence it is found most frequently in the hovels of the poor, the squalid, and the miserable. Yet as it is not always found under these circumstances even where there is the grossest uncleanliness, some other cause jointly operating in such situations, some idiopathic condition of the skin by which the sordes thus col- lected and obstructing the mouths of the cutaneous exhalants be- comes an active irritant, must be admitted. One of these conditions appears to be a skin peculiarly delicate and sensible, which is most- ly to be found in early life ; and another, a skin peculiarly dry and scurfy, which is a common condition of old age ; on which account repelled perspiration is correctly set down as a cause by Riedlin. Even in the cleanliest habits, these peculiarities of the skin often become causes of themselves, and of a more intractable kind than mere sordes, as they are far more difficult of removal. A diet of fish alone has sometimes excited such a habit: and an habitual ad- diction to spirituous drinks, whether wine, ale, or alcohol, produces also, in many persons, a like sensibility of the surface, and lays a foundation for the disease in its most obstinate form. Where the rash continues long and becomes pertinacious, the papulae form minute exulcerations, degenerating, in the first varie- ty, into a species of contagious itch, and in the second, into a run- ning scall; which last, in the third or inveterate variety, sometimes forms nests for various parasitic insects,}: and especially for several species of the. acarus and pediculus, to which Dr. Willan adds the pulex. In treating of intestinal animalcules, we had occasion to observe that " they appear, from the luxuriance of their haunts and * Sitonu9, Tr. 34, Loescher. \ Journ. Med. Tom. LXXXV. $ Sommer, Diss, de affectibus pruriginosis Senum. Loescher, Diss, de pruritu senili totius corporis. Witeb. 1728. GE. III.—SP. III.] EXCERNENT FUNCTION. 381 repasts, to be, in various instances, peculiarly enlarged and altered from the structure they exhibit out of the body; whence a difficul- ty in determining, in many cases, the exact external species to which a larve, worm, or animalcule found within the body may belong."* This remark applies with peculiar force to the parasites detected in the diseases before us, some of which grow to such an enormous size, and with such altered characters from rioting on so plentiful a supply of juice, that it is by no means easy to recognize them. Dr. Willan describes an insect of this kind found in great abundance on the body of a patient suffering under the inveterate prurigo, which he at first took for a pediculus, though from the nimhleness of its motions, as well as from other characters, he at length ascer- tained it to be a pulex, not described by Linneus : more probably, from the causes just stated, so altered in its form, as not to be ea- sily referred to the species to which it really belongs. Thorough and regular ablution and cleanliness are here, there- fore, peculiarly necessary, and these will often succeed alone, espe- cially in the first variety. If they should not, sulphur and the sul- phureous waters, as that of Harrowgate, taken internally and ap- plied to the skin itself, have sometimes been found serviceable. Fossile alkali combind with sulphur and taken internally with in- fusion of sassafras or juniper drops is peculiarly recommended by Dr. Willan. If the constitution have suffered from a meagre diet, or be otherwise exhausted, general tonics and a nutritive food must necessarily form a part of the plan. In many cases, however, of the second variety, and in still more of the third, this pertinacious and distressing complaint bids defi- ance to all the forms of medicine, or the ingenuity of man: and I cannot adduce a stronger illustration of this remark than by refer- ring to an attack which it has lately made on one of the brightest ornaments of medical science in our own day, whose friendship allows me to give the present reference to himself. It is now con- siderably more than a year and a half since he was first visited with this formicative but colourless rash which affected the entire sur- face, but chiefly the legs : and he has since tried every mean that the resources of his own mind or the skill of his medical friends could suggest, yet for the most part without any thing beyond a palliative or temporary relief. The tepid bath produced more harm than good, though several times repeated : Harrowgate water internally and externally had recourse to has been of as little avail: acids and alkalies, separate or conjoined, in whatever way made use of, have failed equally : nor have purgatives or diaphoretics or any of the alterative diet drinks, or the alterative metallic prepara- tions answered better. The coldest spring water employed as a bath or lotion, and free doses of opium as a sedative, are the only medicines from which he has at any time derived any decided re- lief, and these have constantly afforded it for a short time. In the * Vol. I. Helminthia erratica. p. 208. 382 ECCRITICA. [CL. VI.—OR. III. middle of the coldest nights of last winter, and the still colder nights of the winter before, he was repeatedly obliged to rise and have recourse to sponging with cold water, often when on the point of freezing. The opium he has taken never effected real sleep, nor abated the complaint but generally threw him into a quiet kind of a revery which produced all the refreshment of sleep: and to ob- tain this happy aphelxia or abstraction of mind he has been com- pelled to use the opium in large doses, often to an extent of ten grains every twenty-four hours, for weeks together, and rarely jp less quantity than five or six grains a day and night for many months in succession. The change operated on the general habit by this peculiar sensibility of the skin is not a little singular ; for first, in the midst of the distraction produced by so perpetual a harassment, and the necessary restlessness of nights, neither his animal spirits nor his appetite have in any degree flagged, but, upon the whole, rather increased in energy, and his pulse has held true to its pro- per standard. And next, though opium was wont to disagree with him in various ways antecedently, it has proved a cordial to him through the whole of his tedious affection without a single unkind- ly concomitant, and has never rendered his bowels constipated. From the long continued excess of action there was at length an evident deficiency in the restorative power of the skin : for two ex- coriations arising from the eruption, degenerated into sloughing ulcers. At the present period, forming a distance of nineteen or twenty months from the first attack, he is apparently getting well; the skin which has been so long in a state of excitement is loosing its morbid sensibility, and becoming torpid: he has rarely occasion to have recourse to cold ablutions, but dares not trust himself through the day without a dose of opium, as an exhilarant, though the quantity is considerably reduced. He has also, for many months been taking the bark and soda as a general tonic. Perhaps the most instructive part of this case is the great advantage and safety of the external application of cold water, as a refrigerant and tonic in cutaneous eruptions accompanied with intolerable heat and irri- tation. And it is possible that half the wells, which in times of superstition were dedicated to some favourite saint, and still retain his proper name, derive their virtue from this quality rather than from any chemical ingredient they contain, which has often as little to do with the cure as the special interposition of the preternatural patron. GE. HI.—SP. IV.] EXCERNENT FUNCTION. 383 SPECIES IV. EXORMIA MILIUM. JWfllet*»asn. PIMPLES VERY MINUTE ; TUBERCULAR ; CONFINED TO THE FACE ; DIS- TINCT ; milk-white; hard; glabrous; resembling millet SEEDS. This species is taken from Plenck who denominates it grutum sive milium. It is a very common form of simple pimple or exormia, and must have been seen repeatedly by every one, though, with the exception of Plenck, I do not know that it has hitherth been de- scribed by any nosologists. It has a near resemblance to the white- gum of children, as described by Dr. Underwood, the strophulus albidus of Willan, and the present system. But the pimples in the milium are totally unattended with any kind of inflammatory halo or surrounding redness: and are wholly insensible. They are sometimes solitary, but more frequently gregarious. It is a blemish of small importance and rarely requires medical interposition: but as it proceeds from a torpid state of the cutaneous excretories, or rather of their mouths or extremities which are balled up by hard- ened mucus, stimulant and tonic applications have often been found serviceable, as lotions of brandy, spirit of wine, or tincture of myrrh, or a solution of sulphate of zinc with a little brandy added to it. When this species becomes inflamed it lays a foundation for a varus or stone-pock, which we have already described under the order of inflammations in the third class of the present system.* GENUS IV. LEPIDOSIS. Scale=<£fctu. EFFLORESCENCE OF SCALES OVER DIFFERENT PARTS OF THE BODV, OFTEN THICKENING INTO CRUSTS. Lepidosis is a derivative fromA**™? -fa, " squamma." The Greek is preferred to the Latin term, in concurrence with the general • Vol. II. p. 196. 384 ECCRITICA. [CL. VI.—OR. Ill rule adopted in the present system in regard to the names of the classes, orders, and genera. The genus includes those diseases which consist in an exfoliation of the cuticle in scales or crusts of different thickness, and with a more or less defined outline, in ma- ny cases owing to a morbid state or secretion of the rete mucosum or adipose layer of the part immediately beneath, which is some- times too dry, or deficient in quantity; sometimes perhaps absent altogether; sometimes charged with a material that changes its natural colour; and sometimes loaded with an enormous abundance of a glutinous fluid, occasionally combined with calcareous earth. In the severer cases the true skin participates in the change. As this colorific substance,forming the intermediate of the three lamellae that constitute the cutaneous integument, is only a little lighter in hue than the true skin among Europeans, it is not often that we have an opportunity in this part of the world of noticing , the changes effected upon it by different diseases : but as among ne- groes it contains the black pigment by which they are distinguished, such changes are very obvious and frequent: for the individual is sometimes hereby, as we shall see presently, rendered pye-balled, or spotted black and white, and there are instances in which the whole of this substance, or rather of its colouring part, being car- ried off by a fever, a black man has suddenly been transformed into a white. Changes of this kind often occur without any separation of the cuticle from the cutis, but if the fever be violent such separation takes place over the entire body, and the cuticle is thrown off in the shapie of scurf, or scales, or a continuous sheath. And some- times the desquammation from a hand has been so perfect that the sheath has formed an entire glove. The same effect has followed occasionally from other causes than fever, as on an improper use of arsenic* or other mineral poisons, on being bitten by a viper,f and sometimes on a severe fright.}: There are various instances in which the nails have been exfoliated with the cuticle,§ and others in which the hair has followed the same course. Sometimes, in- deed, a habit of recurrence has been established and the whole has been thrown off and renewed at regular periods,|| in one instance once a month.II In the genus before us the exfoliations are of a more limited kind, and in some instances very minute and comparatively insig- nificant. In the severer forms, however, the true skin participates in the morbid action, and the result is far more troublesome. * De Haen, Rat. Med. Part. x. Cap. II. f Eph. Nat. Cur. Dec. 1. Ann. IV. V. Obs. 38. * Act. Nat. Cor. Vol. VII. Obs. 43. § Eph. Nat. Cur. Dec. III. An. II. Obs. 124. J Gooch, Phil. Trans. 1769. U Eph. N»t. Cur. Dec. in. Ann. I. Obs. 1"4. GE. IV.—SP. I.) EXCERNENT FUNCTION. 385 The species it presents to us are the following : 1. LEPIDOSIS PITYRIASIS. DANDR1FF. 2. --------- LEPRIASIS. LEPROSY. C DRY SCALL. I SCALY TETTER. 4. . ICTHYIASIS FISH-SKIN 3. ■ PSORIASIS. SPECIES 1. LEPIDOSIS PITYRIASIS ISaufcrtff. PATCHES OF FINE BRANNY SCALES EXFOLIATING WITHOUT CUTICULAR TENDERNESS. This species is the slightest of the whole: its varieties are as fol- low : x Capitis. Scales minute and delicate : con- Dandriff of the head. fined to the head ; easily sepa- rable. Chiefly common to in- fancy and advanced years. (8 Rubra. Scaliness common to the body ge- Red dandriff. nerally ; preceded by redness, roughness, and scurfiness of the surface. y Versicolor. Scaliness in diffuse maps of irre- Motley dandriff. gular outline, and diverse co- lours, chiefly brown and yellow; for the most part confined to the trunk. Pityriasis is a term common to the Greek Physicians, who con- cur in describing it, to adopt the words of Paulusof J£gina,as "the separation of slight furfura matters (VfrvgwAtw a-e>iMtrm,) from the surface of the head, or other parts of the body without ulceration." The same character is given by the Arabian writers, and especially by Avicenna and Ali Abbas. But several writers, both Greek and Arabian, who have thus described it generally, limit its extent to the head, which is the ordinary seat of the porrigo or scabby scall, characterized by ulceration, and a purulent discharge, covered by minute scabs : and hence in some writers, pityriasis has been con- founded with porrigo ; or, in other words, the dry and branny scale with the pustular scab ; which, however, there is no difficulty in accounting for, since the first variety, whose seat is also in the head, has a tendency, if neglected, and the minute and scurfy scales grow VOL. IV.—49 3S6 ECCRITICA. [CL. VI.—OR. III. thicker and broader, and crustaceous, to degenerate into porriginous pustules. The first variety, or dandriff of the head, when it attacks in- fants, exhibits minute scales, and when it appears in advanced age, scales of larger diameter. It shows itself at the upper edge of the forehead and temples as a slight whitish scurf, set in the form of a horse-shoe ; on other parts of the head there are also cuticular ex- foliations, somewhat larger, flat and semipellucid. Sometimes, however, they cover nearly the whole of the hairy acalp, imbricate in position, or with an overlap, as in tiling. Little attention is necessary to this complaint beyond that of clean- liness, and frequent ablution; where, however, the hairy scalp is attacked it is better to shave the head, when the scales may be re- moved by a careful use of soap and warm water, or by an alkaline lotion. This is the more expedient because the scales in this situa- tion are often intermixed with sordes, and pustules containing an acrimonious lymph are formed under the incrustations ; and in this way pityriasis, as we have already observed, may, and occasionally does, degenerate into porrigo. The second variety, or red dandriff, sometimes affects the gene- ral health in a perceptible degree from the suppression which takes place in the perspiration, and the consequent dryness, stiffness, and soreness of the skin ; and the general itching which hence ensues, is often productive of much restlessness and languor. This, which is the severest modification of the disease, appears chiefly at an advanced period of life, though it is not limited to old age. A tepid bath of sea-water is, perhaps, the most useful application, as serving 10 soften the skin, and produce a gentle diapnoe. With this external remedy Dr. Willan advises we should unite the compound decoction of sarsaparilla, and antimonials, which operate towards a like ef- fect. The tinctura hellebori nigri in small doses has also some- times been found useful; and, where the irritability of the skin is not very great, Dr. Bateman was in the habit of using a gently re- stringent lotion or ointment, consisting of the superacetate of lead with a certain proportion of borax or alum. The variegated or motley dandriff, pityriasis versicolor, often branches out over the arms, back, breast, or abomen, but rarely in the face, like many foliaceous lichens growing on the bark of trees; and sometimes, where the discoloration is not continuous, suggests the idea of a map of continents, islands, and peninsulas, distributed over the skin. We have a more distinct proof of a morbid condition of the rete mucosum, or adipose colorific layer of the skin in this than in any other affection belonging to the entire genus.* The morbid action, indeed, seems confined to this quarter and consists in the secretion of a tarnished pigment, though possibly, in some instances, it may be only discoloured by a mixture with a small portion of extrava- sated blood. And were it not for the furfuraceous scales which determine its real nature, this affection would belong to the genus GE. IV.—SP. I.] EXCERNENT FUNCTION. 381 epichrosis of the present order. There is no elevation ; and the staining rarely extends over the whole body. Dr. Willan tells us that it seldom appears over the sternum or along the spine of the back. I had lately a patient, however, in a gentleman about forty years old, who was suddenly attacked with a discoloration and bran- ny efflorescence of this kind, which extended directly across the spine over the loins, and very nearly girded the body. It continued upon him for about three years without any constitutional indis- position, or even local disquietude, except a slight occasional itch- ing, and then went away as suddenly as it made its appearance. The hue was a fawn-colour : and, as the patient was anxious to lose it, he tried acids, alkalies, and other detergents of various kinds, but without any effect whatever. This variety of dandriff gene- rally continues for many months, and not unfrequently, as in the present case, for several years. Being altogether harmless, it re- quires no medical treatment. The pityriasis nigra of Willan, referred to by Bateman, but only glanced at by either of them, so far as I have seen it, is rather a modification of the genus epichrosis, and species Poecilia, under which it will be noticed. It is a cuticular discoloration, but with- out cuticular exfoliation. SPECIES II. LEPROSIS LEPRIASIS. aqirosg. This genus constitutes the vitiligo ofCelsus. The termLEPRiAsis is a derivative from Xen-poi " scaber, vel asper, ex squammulis dece- dentibus;" with a termination appropriated by a sort of common consent, to the squammose tribe of diseases.* Lepra, which is the more common term, is derived from the same root: but lepriasis is preferred to lepra as a more general term, and hence better calcu- lated to comprise the general varieties of this species so generally described or referred to by the Greek and Oriental writers, but whose descriptions, not very definite when first written, at least with a few exceptions, have been rendered altogether indefinite and incongruous in modern times, from a misunderstanding or confu- sion of the names under which the descriptions are given. The embarrassment which Dr. Bateman felt upon this subject, when writing on the genus elephantiasis, and which has been noticed already,! he was equally sensible of when he came to lepra, * See the Author's volume of Nosology. Prelim. Diss. p. 51. f Vol. II. p. 567. 388 ECCRITICA. [CL. VI.—OR. Ill and the researches of Dr. Willan gave him little or no assistance. I could not then find time to render him ihe aid he stood in need of, but I have since directed my attention to the subject, and will now give the reader its results as briefly as possible. In the admirable and exact description of the cutaneous efflores- cences and desquammations, to which the Hebrew tribes were sub- ject on their quilting Egypt, and which they seem to have derived from the Egyptians, drawn up by Moses, and form a part of the Levitical law,* there are three that distinctly belong to the present species, all of them distinguished by the name of berat (mru) or " bright spot ;" one called boak (pm) which also imports brightness, but in a subordinate degree, being " a dull white berus," not contagious, or, in other words, not rendering a person unclean, or making it necessary for him to be confined; and two called tsorat (r\p¥) " venom or malignity :" the one a berat lebena or " bright-white berat,"f and the other a berat cecha, " dark or dusky berat,"| spreading in the skin ; both of which are contagious, or, in other words, render the person affected with it unclean, and exclude him from society.§ The Arabic and Greek writers have in fact taken notice of and described all these, but with so much confusion of terms and symp- toms, from causes I will presently point out, that without thus turn- ing back to the primary source it is difficult to unravel them or understand what they mean. The boak, or slighter and uncontaminating berat, is still denomi- nated by the same name among the Arabians, boak, and is the Xengx AXtpog or "dull-white leprosy" of the Greeks: while the bright- white and dusky berats of the Hebrews, which the latter distinguish- ed on account of their malignity by the name of npy (tsorat,) are still called among the Arabians by the Hebrew generic term with a very slight alteration; for the berat lebena (jvih mro) or bright- white berat of the Hebrew tongue, is the beras bejas of the Arabic, and the berat cecha (nriD mro) or dusky berat, its beras asved : the former of these two constituting the Xm^x Atvx.^ or " bright- white" leprosy of the Greeks, and the latter their Xvrgx piXus " dusky or nigrescent leprosy." So far the whole seems to run in perfect harmony: but as many of the Arabians, in process of time, used boak and beras indiscrimi- nately, the different species of the disease as well as their qualities became immediately confounded, and we are told sometimes that leprosy is, and at other times that it is not unclean or contagious. And what increased the confusion is, that the Arabians employed * Levit. Cap. XIII. t Id. Cap. XIII. 38, 39. * Id. V. 3. $ Id. V. 6. 8. GE. IV.—SP. II.] EXCERNENT FUNCTION. 389 also another term of still wider import than either of these, being, kuba or kouba, which imported scaly eruptions of every kind, run- ning not merely parallel with the entire genus lepidosis before us, but something beyond, so as to includethe humid as well as the dry scall; and consequently diseases of very different qualities and de- grees of malignancy, contagious and uncontagious, cuticular and ulcerative. It is a term peculiarly common to the writings ofAvi- cenna and Serapion. And as kouba, or with the article alkouba was also frequently applied to all the species of beras or leprosy, the real characters of the latter were rendered doubly doubtful and intricate. And hence a very obvious source of confusion upon thi9 subject originating among the Arabians. But while the Arabian writers borrowed two terms appropriated to the disease before us from the Hebrew tongue, beras and boak, and employed both of them in a loose and indefinite manner, the Greeks themselves borrowed one and employed it still more indetermi- nately : for from the Hebrew npi* (tsorat) they obtained their -^w^x (psora)—as our own language has since the word sore. Tsorat, as we have already seen, is restrained by the Hebrew legislator to the two forms of beras or leprosy which were contagious or ren- dered a man unclean :»and as the Greeks introduced this term into their own tongue it would have been better to have restrained it to the same import, and to have used psora as the translation of tsorat. But the Greeks had the word lepra already by them, as significa- tive of the same disease generally, or a synonym of berat or beras ; and hence instead of psora they employed lepra which is the word made use of in the Greek, as well as in the Latin versions. As lepra, however, is a gen2ric term and runs parallel with berat, so as to include the boak or unconlaminating, as well as the conta- minating forms of the disease, the clearness, if not the entire sense, of the Hebrew is greatly diminished in the Greek version. When we are told by Moses, in the language of the Hebrew bible, that the priest shall examine the berat, or bright spot, accurately, and if it have the specific marks, it is a tsorat, (which the berat is not ne- cessarily,) we readily understand what he means. But when he tells us in the language of the Greek bible, that the priest shall look at the berat or tnXxvym (which is itself necessarily a lepra) and if it have the specific marks it is a lepra, the meaning, to say the least of it, is obscure and doubtful. It is probable, however, that psora, when first introduced into the Greek tongue, imported the very same idea as in the Hebrew : but it soon gave way to the older term of lepra, and having thus lost its primitive and restricted sig- nification, it seems to have wandered in search of a meaning, and had at different times, and by different persons, various meanings attributed to it; being sometimes used to express scaly eruptions generally, sometimes the scales of leprosy ; but at last and with a pretty common assent the far slighter efflorescence of scaly tetters or scalls, denominated in the Levitical code saphat (nnao): and 390 ECCRITICA. [CL. VI.—OR. III. by the Latins scabies or impetigo sicca : constituting the psoriasis, or ensuing species of the present classification. So that whilst in Hebrew, or under its primitive sense, tsorat or psora denoted the most malignant form of lepidosis, in Greek or under its secondary sense, it denoted one of the mildest forms of the same. And hence, another source of confusion upon the subject before us originating among tRe Greek writers, as the preceding originated among the Arabian. And when to these two sources of perplexity we add that the Greek term lepra was, from a cause I have formerly explained, employed equally to express elephantiasis, we shall easily be able to account for the indefinite and incoherent descriptions of all these diseases which are given by many of the Greek and Arabian writers, and the inaccuracy with which the symptoms of one specific disease are run into another. Actuarius endeavoured to throw something of order into the midst of this confusion by contemplating all these maladies, in conjunction with lichen, as different forms of a com- mon genus, and dividing them into four separate species : " A less violent disease," says he, '' than elephantiasis is lepra; lepra is, however, more violent than psora, and psora than the lichenes. But lepra penetrates deep, forms circular eruptions and certain funguses or deliquesceuces of flesh (rivx$ o-vyr^tn o-*f*e$) and throws off scales from which also it derives its name : while psora is more superficial, assumes indeterminate shapes, and only casts off furfu- raceous corpuscles. A roughness and itching of the skin is com- mon to both."* And to the same effect Paulus of ./Egina. The real fact is, that the two last are nearly connected in nature, and in the present work follow in immediate succession, while both are widely remote from the first; and though it is possible they « have occasionally terminated in it, are by no means naturally con- nected with it, or form a necessary harbinger. Lepra or lepriasis in Celsus occurs under the name of vitiligo, and like the berat of the Hebrew legislator, is made to include three modifications; the ordinary forms of it, indeed, that have descend- ed to us, though delineated with much error and incongruity. The description of Celsus is drawn up with peculiar accuracy and con- cinnity, and makes the nearest approach to that of Moses of any I am acquainted with : and by uniting them and combining a few well ascertained symptoms from other authors, we shall be able to obtain a pretty clear insight into the genuine characters of these modifi- cations, freed from the extraneous concomitants that have so often bewildered us. * Actuar. De Meth. Medend. II. 11. And compare Paul -Egin. IV. 2. Serajnon Breviar. Tr. V. Cap. IV. Avicenn. Lib. I. Hi. 1. GE. IV.—SP. II.} EXCERNENT FUNCTION. 391 « Albida. Scales glabrous, dull-white, circular and Boak (pm). Hebr. definite; preceded by reddish, and Boak. Arab. glossy elevations of the skin; sur- Alphos. ('AA^ej) Auct. rounded by a dry, red, and slightly Gr. Cels. elevated border: scattered; some- Common or dull-white times confluent; irregularly exfoliat- leprosy. ing and reproduced : rarely found on the face : not contagious. £ Nigricans. Scales glabrous, dusky or livid, without Berat cecha ; Hebr. central depression, patches increas- (nro mni) ing in size; scattered, or confluent. Beras asved, Arab. Contagious. Melas (MeXxs) Auct. Gr. Cels. Dusky or black leprosy. */ Candida. Scales on an elevated base glossy-white, Berat lebena. Hebr. with a deep central depression; en- (jtilh mn^) circled with a red border ; patches Beras bejas. Arab. increasing in size : hairs on the Leuce (Aevx.*).) Auct. patches white or hoary ; diffused over Gr. Cels. the body. Contagious. Bright-white leprosy. All these, at least in their origin, are strictly cutaneous affec- tions : though we shall presently have to observe that the last two when they become inveterate, sometimes seem to affect the habit; and it is hence possible that the first may do so in a long course of time if neglected. It is on this account that the boak, common or dull-white le- prosy has been regarded as in every instance a constitutional ma- lady by many writers of recent times; but it was not so regarded either by the best Greek and Arabian physicians, who also duly distinguished it from elephantiasis and other complaints with which it has been confounded by later writers; nor is it so regarded by Dr. Willan, who ascribes it chiefly to cold, moisture, and the accu- mulation of sordes on the skin, especially in persons of a slow pulse, languid circulation, and a harsh, dry, and impermeable cuti- cle : or whose diet is meagre and precarious. It is hence found chiefly in this metropolis among bakers and bricklayers' labourers : coal-heavers, dust-men, laboratory-men, and others who work among dry, powdery substances, and are rarely sufficiently atten- tive to cleanliness of person. In the common, and, perhaps, in all the varieties, the scaly patches commence where the bone is nearest to the surface, as along the skin about the elbow, and upon the ulna in the fore arm, on the scalp, and along the spine, os ilium, and shoulder-blades. They rarely appear on the calf of the leg, on the fleshy part of the arms, or within the flexures of the joints. Both sides of the body are usually affected at the same time and in the same manner; but, con- 392 ECCRITICA. [CL. VI.—OR. ill trary to the erysipelatous erythema and some other maladies of the skin, the parts first affected do not run through their action and heal as other parts become diseased, but continue with little alteration, till, from medical application or the natural vigour of the constitu- tion, returning health commences; when all the patches assume a like favourable appearance at the same time, those nearest the ex- tremities, and where the disease, perhaps, first showed itself going off somewhat later than the rest. The scaly incrustations some- times extend to the scalp, and a little encroach on the forehead and temples; but it is very rarely that they spread to the cheeks, chin, nose, or eyebrows. The eruption is seldom attended with pain or uneasiness of any kind, except a slight degree of itching when the patient is warm in bed, or of tingling on a sudden change of tem- perature in the atmosphere. We have said that this variety is strictly a cutaneous eruption, and rarely, if ever, affects the constitution. It is in consequence regarded as of but little importance in the Levitical code, which contemplates it as not penetrating below the skin of the flesh, and not demanding a separation from society. " If a man or a woman," says the Jewish law, " have in the skin of their flesh a berat, a white berat, then the priest (who after the manner of the Egyptians united the character of a physician with his own,) shall look -r and, behold, if the berat in the skin of the flesh be dull, it is a boak growing in the skin : he is clean."* Not essentially different Celsus, " the viti- ligo, though it brings no danger, is, nevertheless, offensive, and springs from a bad habit of body. The dull-white and the dusky forms in many persons spring up and disappear at uncertain pe- riods. The bright-white when it has once made its attack, does not so easily quit its hold. The cure of the two former is not diffi- cult : the last scarcely ever heals."t We may hence distinctly affirm that the variety of the dull-white or common leprosy, is not contagious: and had it been so among the Jews, Moses would have condemned the patient to a quarantine under this form, as well as under the two ensuing. Dr. Willan, in- deed, yielding to the general opinion upon this subject, derived from a proper want of discriminating one form of the disease from another, inclines to believe that it may occasionally become in time so interwoven with the habit as to be propagable, but still rejects the idea of its being contagious. In reality, although in most coun- tries where leprosy is a common malady, places of separate resi- dence are usually allotted to those who are affected with it under whatever modification it may appear, this has rather been from an erroneous interpretation of the Jewish law, and an ignorance of the exceptions that are introduced into it. The lepers of Haha, a pro- vince in the Barbary states, though banished from the towns, are seen in parties of ten or twenty together, infesting the roads, and * Levit. Cap. X1I1. 38, 39. f De Medicina. Lib. v. Cap. XXVHI. Sect. 19. GE. IV.—SP. ILj EXCERNENT FUNCTION. 393 approach travellers to beg charity. In Morocco they are confined to a separate quarter, or banished to the outside of the walls. They are, according to Mr. Jackson, but little disfigured by the dis- ease, except in the loss of their eye-brows, which the females en- deavour to supply by the use of lead-ore ; while they give an addi- tional colour to their complexion by the assistance of al akken or rouge. In like manner, Niebuhr asserts that one of the species of leprosy to which the Arabs are subject, is by them still called Boak ; but that it is neither contagious nor fatal. Upon which remark his annotator M. Forskal adds, ** the Arabs, call a sort of leprosy in which various spots are scattered over the the body Behaq ; which is without doubt the same as is named pm (bohak or behaq) in Lev. xiiL They believe it to be so far from contagious that one may lie with the person affected without danger.—On May 15, 1763," says he, « I saw at Mokha a Jew who had the leprosy bohak.' The spots are of unequal size : they do not appear glossy ; they are but little raised above the skin, and do not change the colour of the hair: the spots are of a dull-white inclining to red."* The nigrescent leprosy ; forming a second variety, is impro- perly called black, though it was so named by the Greeks. The colour, as repeatedly described by the Jewish legislator, is rather obscure, darkling, or dusky. The term is nn3 (cecha), whence the Latin caecus : and it immediately imports obfuscous, or overcast with shade or smoke. The character in Celsus is in perfect accord- ance with this, as he explains to us that pcXxs, or niger, in its appli- cation to this variety imports "umbrae siinilis," " shade like," or "shadowed." The hue is tolerably represented in Dr. Willan's plate, but better in Dr. Bateman's in which it has been retouched. The natural colour of the hair, which in Egypt and Palestine is black, is not changed, as we are repeatedly told in the Hebrew code, nor is there any depression in the dusky spot; while the patches, instead of keeping stationary to their first size, are perpetually en- larging their boundary. The patient labouring under this form was pronounced unclean by the Hebrew priest or physician, and thereby sentenced to a separation from his family and friends: and hence there is no doubt of its having proved contagious. Though a much severer malady than the common leprosy, it is far less so than the leuce or third variety : and on this account is described more briefly in the Hebrew canon. In our own quarter of the world the exfoliated surface in the nigrescent or dusky leprosy remains longer without new scales, discharges lymph, often intermixed with blood, and is very sore. When it covers the scalp it is particularly troublesome. With us it is chiefly found among soldiers, sailors, sculler-men, stage-coachmen, brewers' labourers, and others, whose occupations are attended with much fatigue, and * Reisebeschreibung nach Arabienund andern unlfegeden Landern. Band. L Kopenhag. 4to. 1774. VOL. IV.—50 394 ECCRITICA. [CL. VI.—OR. II,' expose them to cold and damp, and to a precarious or improper mode of diet. For the same reason, women habituated to poor living, and constant hard labour, are also liable to this form of the disease. In consequence of the increased excitement and irritability of the skin in the hot and sandy regions of Egypt and Palestine, there is, however, a far greater predisposition to leprosy of all kinds, than in the cooler temperature of Europe. And hence, under the next variety, we shall have occasion to observe, from the Levitical account, that all of them were apt to follow upon various cracks, or blotches, inflammations or even contusions of the skin. The bright-white leprosy, is by far the most serious and obsti- nate of all the forms which the disease assumes. The pathognomic characters dwelt upon by the Hebrew legislator in deciding it are, " a glossy white and spreading scale upon an elevated base, the elevation depressed in the middle but without a change of colour, the black hair on the patches which is the natural colour of the hair in Palestine, participating in the whiteness, and the patches themselves perpetually widening their outline." Several of these characters taken separately belong to other lesions or blemishes of the skin as well, and therefore none of them were to be taken alone : and it was only when the whole of them concurred, that the Jewish priest, in his capacity of physician, was to pronounce the disease a tsorat (njnx) or malignant leprosy. We have said that in lepriasis, the rete mucosum, or colorific adipose layer of the skin, is peculiarly affected, and we have here a still more distinct proof of this assertion in the change of the hair, the colour of which is derived from this material. This change is produced by the barter of a black for a white colouring material, probably a phosphate of lime, which gives also the bright glossy colour, not hoary or dull, to the scaly patches ; and which in ichthyiasis, forming the fourth species of the present genus, we shall find is occasionally deposited on the surface in prodigious abundance. Common as this form of leprosy was among the Hebrews, during and subsequent to their residence in Egypt, we have no reason to believe it was a family complaint, or even known amongst them antecedently ; and there is hence little doubt, notwithstanding the confident assertions of Manetho to the contrary, that they received the infection from the Egyptians instead of communicating it to them. Their subjugated and distressed state, however, and the peculiar nature of their employment, musthave rendered them very liable to this as well as to various other blemishes and misaffections of the skin: in the production of which there are no causes more active or powerful than a depressed state, of body or mind, hard labour under a burning sun, the body constantly covered with the excoriating dust of brick-fields and an impoverished diet: to all of which the Israelites were exposed whilst under the Egyptian bondage. It appears also, from the Mosaic account, that in consequence of these hardships, there was, even after they had left Egypt, a general GE. IV.—SP. II.] EXCERNENT FUNCTION. 395 predisposition to the tsorat or contagious forms of leprosy, so that it often occurred as a consequence of various other cutaneous affec- tions; sometimes appearing as a berat lebena (nJ^S mm,) or bright-white leprosy, and sometimes as a berat cecha (nro mm,) dusky leprosy, according to the peculiar habit or idiosyncrasy. The cutaneous blemishes or blains which had a tendency to termi- nate in leprosy, and whicii were consequently watched with a suspicious eye from the first, are stated by Moses to have been the following : 1. Saat (nxty).* 2. Saphat (nnSD).t 3. Netek (pnj)4 4. Berat (nnia).§ 5. Boak (pru).ll 6. Nega (yn)-% 7. Shechin (frit?).** 8. Mecutash (utx niDD).ft Herpes, or tetter, evXtt, Sept. an irritated cicatrix. Psoriasis, or dry scall___Dry sa- hafata. Arab. Porrigo, or humid scall. Porrigo. Lat. vers. Jun. et Tremel. Moist sahafata. Arab. Leuce, bright-white scale: the critical sign of contagious le- prosy. Alphos, dull-white scale.: the critical sign of uncontagious leprosy. Ictus, blow or bruise : *5, 8vo. 1822. X Iceland; or, the Journal of a residence in that Island. 398 ECCRITICA. [CL. VI.—OR. 111. of the cure will generally, in such case, depend upon a better regi- men, and general tonics In the other varieties, when they occur among ourselves, the sulphureous waters of Harrowgate, Croft, and Moffat, whether applied externally or internally, seem frequently to prove more efficacious. As external applications, most benefit appears to be derived from the tar-ointment, as employed by Dr. Willis, and a dilute solution of sublimate, or the unguentum hy- drargyrinitrati, as recommended by Dr. Willan. These medicines should be applied to the skin, and the former of them be well rub- bed in upon the parts affected every night, and carefully washed off the next morning with warm water, or a slight alkaline lotion. As internal medicines the most useful seem to have been the sola- num Dulcamara, and ledum palustre, in decoction or infusion. Dr. Crichton strongly recommends the former, and speaks in high,terms of its success. I have not been so fortunate in the trials I have given it. The ledum in Sweden,* and, indeed, over most parts of the north of Europe, as high up as Kamschatka, has long maintained a very popular character, and the form of using it is given by Odhelsus in the Stockholm Transactions for 1774. Infuse four ounces of the ledum in a quart of hot water ; strain off when cold; the dose from half a pint to a quart daily. The bark of the ulmus campestris or elm-tree, has also been warmly recommended by various writers, for this as well as nume- rous other cutaneous eruptions ; and, in connexion with more active medicines, appears to have been of some use, but it is feeble in its effect when trusted to alone. Its form is that of a decoction, two ounces to a quart of. water: the dose half a pint morning and evening.f The cenanthe crocata, or hemlock drop-wort, is another plant that has been recommended in obstinate and habitual cases of this kind; and there are unquestionable examples of it having produced a beneficial effect. Dr. Pulteney has especially noticed its success in a letter to Sir William Watson. The herb, however, is one of the most violent poisons we possess in our fields, and when mistaken for wild cellery, water-parsnip, or various other herbs, has fre- quently proved fatal a few hours after being swallowed, exciting convulsions, giddiness, lock-jaw, violent heat in the throat and stomach, and sometimes sickness, and purging: and where the patient has been fortunate enough to recover, it has often been with a loss of his nails and hair. Goats, however, eat it with impunity, though it is injurious to most other quadrupeds. As a medicine,it is given in the form of an infusion of the leaves: though sometimes the juice of the roots has taken the place of the leaves. Three tea-spoonfuls of the juice is an ordinary dose, which is repeated every morning. * Linnaeus, Diss, de Ledo palustri. Upsal, 1775. Abhandl. der Konigl. Schwed. Academie der Wissenchaffen. Band. XLI. p. 194. \ Medical Transactions, Vol. II. p. 203. GE. IV.—SP. II.] EXCERNENT FUNCTION. 399 But by far the most active and salutary medicine for every form of leprosy, in Europe as well as in Asia, is arsenic. I have al- ready adverted to its common use in the latter quarter, and at home, in the form of the College solution, it has often been found to suc- ceed, when every other medicine has been abandoned in despair. The ordinary dose is five minims twice or even three times a-day, increased as the stomach will allow. SPECIES III. LEPIDOSIS PSORIASIS ©rg Scall. PATCHES OF ROUGH, AMORPHOUS SCALES ; CONTINUOUS, OR OF INDE- TERMINATE OUTLINE; SKIN OFTEN CHAPPY. Psoriasis is a derivation of -^u^x, " scabies, asperitas," with a ter- minal s. •.KUPTION OE BLEBS, CONTAINING A REDDISH, TRANSPARENT FLUID J MOSTLY DISTINCT; BREAKING AND HEALING WITHOUT SCALE OR CRUST. Pompholyx or pomphus, was used amongst the Greek writers in the same sense as pemphix, of which we have treated already,* and equally imported a bladdery tumour of the skin, distended with a fluid : the Latins denominated it bulla, of which our own term water-bleb is an apt and exact representative. Pemphix in the modern use of the term, is necessarily accompanied with fever, and hence under the present arrangement is an emphlysis as pompho- lyx, being without fever or other constitutional affection necessarily connected with it, is an ecphlysis. The latter is hence denominat- ed Pemphigus apyretos by Plenck, and Pemphigus sine pyrexia by Sauvages. It has, however, been properly separated from pemphi- gus by Dr. Willan, who has arranged it as it stands in the present work. It offers the four following varieties : x Benignus. Blebs pea-sized, or filbert-sized; Mild water-blebs. appearing successively on various parts of the body ; bursting in three or four days, and healing readily. 3 Diutinus. Blebs gradually growing from small Lingering water-blebs. vesicles to the size of walnuts ; yellowish: often spreading in suc- cession over the whole body, and interior of the mouth ; occasion- ally reproduced, and forming an excoriated surface with ulcera- tion. Often preceded by languor, or other general indisposition for several weeks. Duration from two to four or five days. y Quotidianus. Blebs with a dark red base, appear- Quotidian water-blebs. ing at night and disappearing in the morning, or appearing in the morning and disappearing at night. Found chiefly on the hands and legs. * Vol. II. 402. Emphlysis Pemphigus. 408 ECCRITICA. ICL. VI.—OR. HI ^ Solitarius. Bleb solitary; but reproductive in Solitary water-bleb. an adjoining part; very large, and containing a tea-cup-full of lymph. Preceded by tingling: of- ten accompanied with languor. The third, or quotidian variety, is here introduced upon the authority of Sauvages, for it does not occur in Willan, who seems to have overlooked it: and hence it is not noticed by Bateman. Sauvages, from the time of its more usual appearance, calls it cpinyctis ; but as Vandermonde has given a case of an opposite kind, in which the bulla showed itself daily and subsided nightly, this name will not properly apply. Under whatever form, however, the pompholyx appears, its causes seem to be debility and irritability either general or confined to the cutaneous exhalants. The benign variety has hence been found in infancy during teething and bowel complaints, and occa- sionally immediately after vaccination. The quotidian has evidently succeeded to great anxiety, fatigue, watching, and low diet. It appears also chiefly in persons of advanced age, or who have been unduly addicted to spirituous liquors. It is by far the most severe of all the forms of the disease, as being painful as well as tedious. The other varieties are to be referred to like sauses. In early or middle life, Peruvian bark given freely, with an im- proved diet, where necessary, has formed the most successful remedy. In old age, softening the skin, and gently exciting the cutaneous exhalants, has been equally useful: but while the bark is less serviceable in old age, warm bathing has proved rather inju- rious in earlier life. SPECIES II ECPHLYSIS HERPES Setter. eruption of vesicles in small, distinct clusters; with a red margin ; AT first pellucid, afterwards opake : accompanied WITH ITCHING OR TINGLING,; CONCRETING INTO SCABS : DURATION FROM FOURTEEN TO TWENTY-ONE DAYS. Herpes from tgiru," serpo," " repo," has been used in very different senses by different writers : being sometimes restricted to one or two of the modifications of the present classification, and by others extended so widely as to include both tire preceding and the ensu- ing genus—or, in other words, cutaneous eruptions, dry, vesicular. GE. V.—SP. II,] EXCERNENT FUNCTION. 409 and postular, and in this latitudinarian sense of the term it is em- ployed by Mr. B. Bell, who gives us a herpes farinosus, and postu- losus, as well as a herpes miliaris and exedens. In the present arrangement the term is limited to minute and clustering cutaneous vesicular eruptions alone, which forms a clear and distinctive indication. The fluid contained in the vesicles is for the most part highly acrimonious and excoriating; and hence the terms ^ ... 390 Lethargy, 5 m> °yU varieties W, iii. 391 Leucasmus, iv. 458 Leuce, iv. 391 Leucorrhcea, iv. 48 communis, iv. 49 Nabothi, iv. 53 senescentium, iv. 54 Libellula or dragon-fly, singular posi- tion of sexual organs, iv. 10 Lichen (in botany) caninus, iii. 248 terrestris cinereus, iii. 248 ' in pathology, iv. 371 Lientery, i. 159 Life, various hypotheses concerning, iii. 27 weariness of, iii. 103 Lign-aloes in indigestion, i. 113 Limosis, i. 71 avens, i. 72 Cardialgia, i. 83 Dyspepsia, i. 100 Emesis, i. 94 expers, i. 76 Flatus, i. 89 Pica, i. 80 Lippitude, ii. 288 Lippitudo, ii. 288 Lisping, i. 340 Lithia, iv. 338 renalis, iv. 340 vesicalis, iv. 347 Lithiasis, iv. 338 Lithic calculus, iv. 339 Lithontriptics, iv. 354 Stephens's, iv. 355 Lithopcedion, iv. 175 Lithotomy, iv. 356 Lithus, iv. 338 Liver, organ of, i. 5 how affected by summer heat. i. 155 use of, i>. 244 found in most animals of everv rank, i. 244 inflammation of, ii. 260 Living principle, various hypotheses concerning, iii. 28 Loathii^, i. 96 Lobelia syphilitica, ii. 557 Lochial discharge profuse, iv. 164.167 Locked jaw, iii. 213 variefie.s iii. 215 GENERAL INDEX. 483 Locke, tribute to his Essay on Human Understanding, iii. 33 Lodgement of matter in the chest, ii. 178 Long-sight, iii. 140 Looseness, i. 152 Lopezia Mexicana, or lopez-root, i. 160 Love, ungovernable, iii. 86 Love-sickness, iii. ib. Lousiness, iv. 485 Loxia, iii. 208 Lowness of spirits, iii. 99 its varieties, iii. 101 Ludibria fauni, i. 392 Lues, ii. 547 Syphilis, ii. 549 syphilodes, ii. 563 history of, ii. 549 Ostiacks said to be insusceptive of, ii. 556 Lullaby-speech, i. 338 Lumbago, ii. 326. 331 Lumbricus cucurbitinus, i. 209 Luna fixata, iii. 295 Lungs, structure of, i. 297 Lupus, ii. 620 Lust, iv. 82 Lysta, iii. 228 canina, iii. 255. 238 felina, iii. 235, 236 M. Macular-shin, iv. 458 Madness, iii. 64 varieties, iii. 64 lascivious, iv. 86 Madwort, iii. 252 Magendie, his hypothesis concerning the living principle, iii. 28 of the absorb- ent system, iv. 191 his azotic regimen of, in calculus, iv. 353 Maggots, intestinal, i. 207 Magnesia, its use in indigestion, i. 108 Malabar nut, i. 106 Malaria of the Campagna, ii. 90 Mal de la Rosa, ii. 367. 576 Mal de Siam, ii. 99 del Sole, ii. 574 Maliasmus, iv. 434 Malis, iv. ib. pediculi, iv. 435 pulicis, iv. 487 acari, iv. 438 filiariae, iv. 439 Malis, gordii, iv, 441 oestri, iv. 440 Malleatio, iii. 292 Malum pilare, iv. 446 Mama-pian, ii. 448 Manducation, i. 5 Mange, iv. Mania, iii. 64 varieties, iii. 64 the illusion often unconnected with the caiise of the disease, iii. 69 Mania, most easily cured when pro- duced by accidental causes, iii. 70 heat and cold in the cure ap- plied at the same time, iii. 74 attendance on religious ser- vices, how far advisable, iii. 74 moral treatment of, iii. 74 Manie sans delire, iii. 92 Marasmus, ii. 472 Atrophia, ii. 475 climactericus, ii. 480 Tabes, ii. 487 I Phthisis, ii. 494 Marcus, his doctrines of fever, ii. 30 Mare's milk as a vermifuge, i. 219 Marsh effluvium, ii. 42 principles, ii. 46 laws of, ii. 52 Masques a louchette, iii. 160 Materialism, hypotheses in support of, iii. 28 Matter, lodgement of in the chest, ii. 178 of the world, its essence not known, iu^26 wheroer extension be a dis- tinct property, iii. 26 whether solidity, iii. ib- Maw-worm, i. 203 Meal-bark, i. 3 Measles, ii. 379 black, ii. 379 Medicine gymnastic, ii. 520 pneumatic, ii. 521 Megrim, iii. 323 Melcena, i. 262 choloea, i. 263 cruenta, i. 266 Melaleuca Leucodendron, i. 57 | Melampodium, iv. 249 i Melanaema, iii. 367 ; Melancholia, iii. 56 1 its varieties, iii. 56 Melancholy, iii. ib. how distinguished patho- ( gnomically from mania, iii. 58 why mistaken at times fiai hypochondrism, iii. 58 484 GENERAL INDEX. Melancholy, exciting causes, iii. 59 tendency to violence and abusive language accounted for, iii. 62 Melas, iv. 391 Melasma, iv. 429 Melliceris, iv. 212 Memory, retention of, how differs from*quickness, iii. 126 failure of, iii..126 Menorrhagia, iv. 43 Menstruation obstructed, iv. 31 by retention, iv. 31 by suppres- sion, iv. 35 laborious, iv. 36 superfluous, iv. 43 vicarious, iv. 45 irregular cessation of, iv. 46 Mental extravagance, iii. 94 Mephytic suffocation, iii. 376 Merganser, i. 294 Mergus, i. ib. Mesotica, iv. 199 Metamorphopsia, iii. 144 Miasm, febrile, what, ii. 43 laws of, ii. 52 powers of in typhus, ii. 124 identity with contagion,ii. 296 Mildew mortification, ii. 608 Miliary fever, ii. 386 Milium, iv. 383 Milk, artificial, ii. 516 . Milks, analysis of in diff^pent animals, ii. 516 Milk-teeth, i. 21 Milk-flow, premature, iv. 67 deficient, iv. 69 depraved, iv. 71 erratic, iv. 71 in males, iv. 73 Millepes, i. 255 Millet-rash, iv. 383 Mind, its nature but little known, iii. 25 whether in its essence material or immaterial, iii. 25 real character deducible from natural and revealed evidence, but its essence not known, iii. 27 by what means it maintains an intercourse with the surrounding world, iii. 31 various hypotheses examined, iii. 32 the difficulty felt by Locke, iii. 33 its faculties to itself what or- gans are to the body, iii. 37 Mind, feelings of, hi. 38 subject to diseases as well as the body, iii. 38 Misanthropy, iii. 103 Miscarriage, iv. 122 Misemission, seminal, iv. 91 Misenunciation, i. 334 Mislactation, iv. 66 Mismenstruation, iv. 29 barrenness of, iv. y9 Mismicturition, iv. 297 See Paruria Misossification, iv. 216 fragile, iv. 217 flexile, iv. 219 Mole uterine, iv. 176 cutaneous, iv. 459 Mollities ossium, iv. 219 Monorchids, whether natural, iv. 10 Morbus niger, i. 262 4 comitialis, iii. 356 pilaris, iv. 441 puerorum, iv. 79 Moria, iii 123 imbecilis, iii. 124 demens, iii. 130 Mordekie, Mordechie (Arab.), i. 174 Morpio, iv. Mort de chien (cholera,) i. 174 Mortification, ii. 604 Moss, Iceland, i. 353 Mountain-parsley as a diuretic, iv. 305 Mouth-watering, i. 51 Mulberry calculus of the bladder, iv. 339 Mumps, ii. 225 Mungo radix, iii. 246 Musca, larves of, intestinal, i. 207 carnaria, i. 207 vomitoria, i. 207 Muscles, diseases affecting tbe, iii. 202 fibres of, iii. 7 in mass, iii. 202 voluntary and involuntary, iii. 204 See muscular fibres Muscular fibres, what and how pro- duced, iii. 7 contraction, laws of, iii 203 See Muscles Musk in rabies, iii. 249 artificial, how prepared, i. 357 Myrrh in hectic fever, ii. 116 N. Nausea, i. 96 Necrosis, ii. 610 Necrosis ustilaginea, ii. 60& GENERAL INDEX 485 Negroes, pye-balled or spotted, iv. 464,465 Nephritis, ii. 269 Nerium antidysentericum, ii. 315 Nerve-ache, iii. 192 of the face, iii. 193 foot, iii. 192. 198 breast, iii. 192. 200 Nerves, number and general charac- ter, iii. 8 Nerves, whether solid chords or hol- low cylinders, iii. 18 Nervous function, its extent and im- portance, iii. 5 fluid, iii. 21 both sensific and mo- tory, iii. 22 Netek (Hebrew) Scall, iv. 395 Nettle-lichen, iv. 372. 377 rash, ii. 384 .Neuralgia, iii. 192 faciei, iii. 193 mistaken for tooth- ache, i. 38 pedis, iii. 192. 198 mammae, iii. 192. 200 Neurotica, iii. 41 Nictitatio, iii. 281 Night-mare, i. 392 Night pollution, iii. 114 Night-sight, iii. 135 Nirles, iv. Nisus formativus, what, iv. 18 Noli me tangere, ii. 619 Numbness, iii. 189 Nutmeg, hypnotic quality of, i. 92 iii. 311 Nux vomica, i. 88. 114 in intermittents, ii. 87 dysentery, ii. 313 palsy, iii. 432 Nictalopia, iii. 135. 137 Nymphaea Nelumbo, ii. 559 Nymphomania furibunda, iv. 86. 88 O. Obesity, iv. 200 general, iv. ib. splanchnic, iv. 203 Oblivion, iii. 125 Obstipation, i. 151 Ocular spectres, iii. 144 Qdontia, i. 17 dentitionis, i. 18 dolorosa, i. 27 stuporis, i. 39 deformis, i. 41 edentula, i. 43 Odontia, incrustans, i. 45 excrcscens, i. 47 (Estrus, (larves of, or) bots, intestinal, i. 203 cuticular, iv. 440 Oil, train, in chronic rheumatism, ii. 334 Oleum templinum, i 213 jecoris aselli, ii. 334 Olives, singular mode of rearing, i. 7 Omentum, organ of, i. 13 Oneirodynia, iii. 114 Ononis spicata, as a diuretic, iv. 304 Opacity, humoral, iii. 147 Ophiasis, iv. 456 Ophiorrhiza Mungos, iii. 246 Ophthalmia, ii. 273 Taraxis, ii. 275 iridis, ii. 278 purulenta, ii. 280 glutinosa, ii. 287 chronica, ii. 429 metastatica, ii. 283 epidemica, ii. 280 gohorrhoica, ii. 284 catarrhalis, ii. ib. intermittens, ii. 284 Lippitudo, ii. 2b8 Ophthalmy, ii. 273 lachrymose, ii. 275 purulent, ii. 280 of infants, ii. 284 Egyptian, ii. 280 epidemic, ii. 280 glutinous, ii. 287 Opisthonia, iii. vll Opisthotonos, m.'2il. 221 Orange-skin, iv. 463 Orban, his practice of using acids in consumption, ii. 513 Orchitis, ii. Organic molecules, what, iv. 16 Orgasm, diseases affecting the, iv. 74 Orgastica, iv. ib. Ormskirk medicine, iii. 251 Ornithorhynchus paradoxus, or platy- pus, i. 5 Orthopncea, i. 363 Osmundia regalis, i. 217 Osteopoedion, iv. 175 Osthexia, Osthexy, iv. 233 infarciens, iv. 234 implexa, iv. 235 varieties, iv. 236 Otaheite, vowel-softness of many pas- sages in this and other savage tongues, i. 339 Ova, human, iv. 14 Ovaria, human, iv. ib. 186 GENERAL INDEX. P. Painter's cholic, i. 127 Palpitatio, iii. 272 cordis, iii. ib. arteriosa, iii. 275 complicata, iii. 278 Palpitation, iii. 272 in the epigastric region, iii. 277 Palsy, iii. 414 varieties, iii. 417 shaking, iii. 297 Pandiculatio, Pandiculation, iii. 284 Papula, iv. 367 Papulous skin, iv. ib. Parabysma, i. 273 hepaticum, i. 274 complicatum, i. 288 intestinale, i. 285 mesentericum, i. 282 omentale, i. 287 pancreaticum, i. 281 splenicum, i. 279 Paracentesis in dropsy of the chest, of early origin, iv. 274 Paracusis, iii. 162 acris, iii. 164 obtusa, iii 165 perversa, iii. 166 duplicata, iii. 168 illusoria, iii. ib. varieties, iii. 169 Surditas, iii. 169 Paracyesis, iv. 113 irritativa, iv. 114 uterina, iv. 119 Abortus iv. 122 Parageusis, iii. 178 acuta, iii. 181 obtusa, iii. 180. 182 expers, iii. ib. 183 Paralysis, iii 414 varieties of, iii. 417 whether likely to be bene- fited by tertian ague, iii. 435 Paramenia, iv. 29 obstructionis, iv. 31 difficilis, iv. 36 superflua, iv. 43 erroris, iv. 45 cessatonis, iv. 46 Paraphimosis, ii. 189 Paraplegia, iii. 417. 422 Parapsis, iii. 183 acris, iii. 184 expers, iii. 189 illusoria, iii. 190 Parenchyma of organs, iv. 183 Parenchyma, diseasf.s affcting the, iv. 199 Paristhmitis, ii. 227 varieties, ii. 227 Parodynia, iv. 130 atonica, iv. 132 implastica, iv. 134 sympathetica, iv. 139 perversa, iv. 146 amorphica, iv. 151 pluralis, iv. 160 secundaria, iv. 163 Paroniria, iii. 114 ambulans, iii. 115, 116 loquens, iii. 115 118 salax, iii. 115. 119 Paronychia, ii. 199 Paropsis, iii. 134 lucifuga, iii. 135 noctifuga, iii. 137 longinqua, iii. 140 propinqua, iii. 141 lateralis, iii. 142 illusoria, iii. 143 Caligo, iii. 146 Glaucosis, iii. 147 Catarracta, iii. 148 Synizesis, iii. 152 Amaurosis, iii. 154 Staphyloma, iii. 158 Strabismus, iii. 160 Parosmis, iii. 172 acris, iii. ib. obtusa, iii. 176 expers, iii. 177 Parostia, iv 216 fragilis, iv. 217 flexilis, iv. 219 Parotid phlegmon, ii. 185 Parotitis, ii. '225 Paruria, iv. 297 inops, iv. 298 retentionis, iy. 301 stillatitia, iv. 306 mellita, iv 311 incontinens, iv. 333 incocta, iv. 336 erratica, iv. 337 Passio bovina, iv. Passion ungovernable, iii. 77 Passions of the mind, as liable to dis- ease, as its intellectual faculties, iii. 77 Pearl-ash, in indigestion, i. 110 f,e!^ra' li\.573 Pellagra, 5 Pemphigus, ii. 402 Peripneumonia, ii. 239 Peripneudrony, ii. 239 GENERAL INDEX. 487 Peripneumony, varieties, ii. 239 Peritoneal fever, ii. 148 Peritoneum, inflammation of, ii. 249 Peritonitis, ii. 249 propria, ii 250 omentalis, ii. 251 mesenterica, ii. 251 Pernio, ii. 210 Pestis, ii. 426 varieties, ii. 426 Phacia, iv. 460 Phalaena pinguinaHs, larves of, intesti nal, i. 207 Phasianus, mot-mot, i. 294 Pheasant, mot-mot, i. 294 Philautia, iii. 82 Phimosis, ii. 189 Phimotic phlegmon, ii. 189 Phlegmasiae, ii. 153 Phlegmatia dolens, ii. 317 Phlegmone, Phlegmon, ii 182 Parulis, ii. 184 communis, ii. 183 auris, ii. 184 parotidea, ii. 185 mammae, ii. 187 Bubo, ii. 188 phimotica, ii. 189 Thlogistica, ii. 153 Phlogotica, ii. 153 Phlyctaenr, ii. 209 Phlysis, ii. 198 Phonica, i. 310 Phosphorus in typhus, ii. 143 gout, ii. 350 Phrenica, iii. 41 Phrensy, ii. 219 Phryganea grandis, larves of, intesti- nal, i. 207 Phthiriasis, iv. 434 Phthisis, ii. 494 varieties, ii. 495 dyspeptic, ii. ib. Phyma, ii. 190 Hordeolum, ii. 191 i Furunculus, ii. 192 Sycosis, ii. 192 Anthrax, ii. 193 Physalis Alkekengi, or winter-cherry, iv. 307 Physometra, iv. 295 Pian, ii. 445 Piles, i. 233 Pin of the eye, iii. 146. 155 Pin-eye, iii 146. 155 ; Placenta, retention of, iv. 164 Plague, ii. 426 varieties, ii. 426 of Athens, ii. 427. 429 of London, ii. 429 leuriy lq/rost Plague, of Morocco, ip31 of British artf in Egypt, u. 433 / inoculation f>r> "• 432 exposure "< diminishes its power, ii. 440 ; influence/by state of the at- mosphere, ii. f} Platalea Leucor^ia (spoon-bill,) i. 294 Plethora, ii. 45/ ento/ca or sanguine, n. 453 atof^a or serous, ii. 454 Pleuralgia, 'A01 fcuta, i. 402 hronica, iv. 403 Pleurisy,/- 245 /spurious, ii. 331 Pleurit/. ». -i45 vera, ii. 245 mediastina, ii. 247 diaphragmatica, ii. 247 Ple/rosthotonus, iii. 221 Pljta, iv. 449 P/ieumatic medicine, ii. 521 PNEUMATICA, i. 309 Pneumatosis, iv. 290 Pneumonica, i. 342 Pneumonitis, ii. 239 vera, ii 239 maligna, ii. 243 notha, ii. 244 Podagra, ii. 335 its varieties, ii. 337 toecilia, iv. 464 Poison of viper as an antilyssic, iii. 259 Poliosis, iv. 453 Ptlyglottus, mocking-bird, i. 295 Polypus, i. 313 elasticus, i. 314 coriaceus, i. ib. I uteri, iv. 107 S vaginae, iv. ib. sarcia, iv. 200 adiposa, iv. ib. pholyx, Pomphus, iv. 407 ine marshes, insalubrity of, ii. 90 ihyra, ii. 578 simplex, ii. 580 haemorrhagica, ii. 581 nautica, ii. 585 Pofrigo, iv. 421, 422 Portland powder, ii. 352 P.jie, ii. 335 Putver, nervous, iii. 21 ■sensific and motiiic, ii. 22 f motific, or irritation (if a lower description than sensific, Iii. 23 Pjx, ii. 549 / 48b GENERAL INDEX. Pox, bastard,,. 563 Precocity, gen.aI, iv. 79 Pregnancy, moiid, iv. 113 from constitutional derangement, 114 from local de- rangement, iv. 19 rom miscarriage, ii. 122 iv. Ill Poper period of, utn>gt extent al- lowed, iv. 112 Premature delivery, its advantages at times, iv. 158 Priapus, iii. 207 Pricking, general feeling of,iii. 186 Prickly-heat, iv. 372. 375 Pride ungovernable, iii. 82 Proctica, i. 220 simplex, i. 220 spasmodica, i. 221 callosa, i. 227 Exania, i. 240 Marisca, i. 233 Tenesmus, i. 232 Prceotia, iv. 79 foeminia, iv. 81 masculina, iv. 80 Prolapse, genital, iv. 102 of the bladder, iv. 105 vagina, iv. 105 womb, iv. 102 Protuberant eye, iii. 158 Prunus Lauro-cerasus, i. 394 in fevers, ii. 87 Prurigo, iv. 379 Pruritus, iii. 186 Prussic acid, i. 278 Psellismus, i, 332 Bambalia, i. 332 Blaesitas, i. 334 Pseudocyesis, iv. 176 molaris, iv. 176 inanis, iv. 178 Psoas abscess, ii. 175 Psora, iv. 389. 399 Psoriasis, iv. 399 Psorophthalmia, ii. 287 Ptyalism, i. 49 Ptyalismus, i. ib. acutus, i. 50 chronicus, i. 57 iners, i. 57 | Pubis symphysis ossa, division of, in impracticable labour, iv. 153 Puerperal fever, ii. 148 epidemic, ii. 148 contagious, ii. 149 , mania, iii. 65 Puerperal convulsions, iii. 346 Pulex (Daphnia,) iv. 7 (Monoculus,) iv. ib. Pulex, iv. Pulsatilla nigricans, iii. 146 Pulse, doctrine of, ii. 16 Pulse, why different in different ages, ii. 9 standard in adult life, ii. 16 infancy, ii. 17 advanced life, ii. 17 different kinds of, ii. 19 of Solano, ii. 20 of Bordeu, ii. 20 Pulselessness, iii. 260 Pulvis, antilyssus, iii. 249 Cobbii, iii. 251 Pupil, closed, iii. 132 double, iii. 153 five-fold, iii. ib. Purpura (.Miliaria,) ii. 386 Purulent ophthalmy, ii. 280 Pus, a secretion, ii. 167, 168 Hewson's view, ii. 167 Hunter's, ii. 168. 171 use of, ii. 170. 173 Push, ii. 183 Pye-balled skin, iv. 464 Pyrectica, ii. 27 Quartan ague, ii. 71 double, 73 treble, ib. duplicate, 74 triplicate, ib. Quas, Russian, ii. 591 Quinsy, ii. 227 varieties, ii. ib. nervous, i. 63 R. Rabid blood, as an antilyssic, iii. 25f. Rabies, iii. 228 canine, iii. 235. 238 feline, iii. 235, 236 Rainbow worm, iv. 412 Raphania, iii. 300 Raptus nervorum, iii. 211 Rash exanthem, ii. 366 ' rose, iv. ib. gum, iv. 369 lichenous, iv. 371 pallid, iv. 371 pruriginous, iv. 379 millet, iv. 383 rainbow, iv. tooth, iv. 369, 370 GENERAL INDEX. 489 Rash, wildfire, iv. 369, 370 Rattling in the throat, i. 316 Rectum, stricture of, spasmodic, i. 221 callous, i. 227 Red-gum, iv. 369 Remittent fever, ii. 91 mild, ii. 91 malignant, ii. 93 autumnal, ii. 94 yellow, ii. 98 burning, ii. 108 asthentic, ii. 110 of Breslaw, ii. ib. Renal calculus, iv. 340 Respiration, effect of, on the blood, i. 300 Ellis's hypothesis, i. 301 quantity of air expired and inspired in, i. 304 Rest-harrow as a diuretic, iv. ib. Restlessness, iii. 312 Retching, i. 96 Retension of the menses, iv. 31 secundines, iv. 164 Revery, iii. 107 of mind, iii. 108 abstraction of mind, iii. 107. Ill brown-study, iii. 107. 112 Rachialgia, i. 127 Rhachitis, iv. 223 % origin of the name, iv. ib. Rheuma, how used formerly, ii. 335 Rheumatism, acute, ii. 326 whether co-exists with gout, ii. 325 articular, iii. 326 lumbar, ii. 330 of the hip-joint, ii. ib. pleura, ii. 331 chronic, ii. 332 Rhonchus, i. 316 stertor, i ib. Cerchnus, i. 317 Rhus vernix, i. 358.—iii. 432 toxicodendrum, iii. 432 Rhypia, iv. 414 Richerand, his hypothesis concerning a living principle, iii. 28 Rickets, iv. 223 Ringing in the ears, in. 169 Rine-worm, iv. 409. 412 * scall, iv. 421. 424 Rosalia, ii. 366 Rose-rash, iv. ib. Rose-wood, i. 93 Roseola, iv. 366 Rosy-drop, ii. 197 Rot in sheep, cause ot, l. 110 Rotacismus, i. 338 vol. IV.—62 Rubeola, ii. 366 Rubia tinctorum, iv. 39 Rubula, ii. 445 Rubus Chamaemorus, ii. 590 Rumbling of the bowels, i. 89 Rumination, instances of in man, i. 94 Running at the nose, i. 309 Rye, spurred, iv. 40 Saat (Hebr.), iv. 395 Sahafata (Arab.) Scall, iv. 399 Salacitas, ~) . go Salacity, 5 Saliva, analysis of, i. 49 Salivation, i. 50 Salmon, fecundity of, iv. 9 Sambucus Ebulus, iv. 248 nigra, iv. 248 Sancti Viti chorea, iii. 289 Sand, urinary, iv. 340 white, iv. 341 urinary red, iv. 342 Sanguiferous system, machinery of, ii. 5 moving powers of, «• H fluids of, in. 21 Santonica, i. 215 ___ Saphat (Hebr.) Scall. iv. 389. 395.399 Sarcocele, iv. 208 Satyriasis furens, iv. 86 Scabies, iv. 429, 430 Scabiosa Indica, i. 211 Scale-skin, iv. 384 Scall, dry, iv. 399 humid, iv. 416 scabby, iv. 421 milky, iv. 422 honey-comb, iv. 423 Scalled head, iv. 422 . Scandix cerefolium, i. 237 Scarabaeus, (beetle-grubs) intestinal, i. 203 Scarlatina, ii. 366 Scarlet-fever, ii. ib. with sore throat, u. 368. 371 Scelotyrbe, iii. 290. 297 Scented odours issuing from the bo- dies of animals, iv. 364 Sciatica, ii. 331 Scotodinus, iii. 334 Scotoma, iii. 334. 336 Scott's acid bath, in jaundice, i. 257 lues, ii. 558 Scrophula, ii. 525 Scurvy, ii. 578 land, ii. 581 49U GENERAL INDEX. Scurvy, petecchial, ii. 580 sea, ii. 585 Scybalum, i. 191 Sea-bear, i. 3 calf, i. 3 sickness, how produced, i. 99 worms, feed harmlessly on cop- per-bottomed ships, i. 139 Seasoning fever of hot climates, ii. 100 Secale cornutum, or spurred rye, i. 141 Secernent System, diseases of, iv. 184 Secretions, furnished by different ani- mals, and often the same animal in different parts, iv. 197 sugar sulphur lime milk urine bile yi97 honey wax silk phosphorescent light ] air J electricity ) furnished by plants, C198 equally diversified, j Secundines, retention of, iv. 164 Self-conceit, ungovernable, iii. 82 Seminal fluid, how secreted, iv. 10 powerful influence of, on the animal economy, iv. 12 flux, iv. 64 entonic, iv. 64 atonic, iv. 65 misemission, iv. 91 Senega, iv. 249 Seneka-root, i. 384 Sensation, diseases affecting the, iii. 133 Sensation and motion, principle of, iii. iy whether a com- mon power, or from distinct sources, iii. 22 Senses, external, in different animals, iii. 13 whether any animal possesses more than five, iii. 17 Sensorial powers, diseases affect- ing jointly, ii. 307 Sentimentalisro, iii. 94 Serpigo, iv Seta equina, intestinal, i. 205 Seville prange Tree, iii. 295 Sex and features, how accounted for, iv. 14. 17 Sexual fluids, diseases affecting, iv. 29 Shaking palsy, iii. 297 Shark, procreation of, iv. 8 Shingles, iv. 409, 410 Short-breath, i. 364 Sibbens, or Sivens, ii. 564 Sick head-ache, iii. 325 Sickness of the stomach, i. 94 Sighing, how produced, i. 300 Sight, in different animals, ii. Sight, morbid, iii. 134 night, iii. 135 day, iii. 137 long, iii. 140 of age, iii. 141 short, iii. 141 skew, iii. 142 false, iii. 143 Silliness, iii. 130 Silver, nitrate of, in epHepsy, iii. 365 power of producing a dark co- lour on the skin, iii. 365 Simarouba, ii. 315 Singing-birds, vocal avenue of, i. 294 bull-finch, i. 294 nightingale, i. ib. thrush, i. 294 tuneful manakin, i. 294 mocking-bird, i. 295 Singultus, iii. 268 Sisymbrium, iii. 351 Skin papulous, iv. 367 Slaughter-houses, exhalation of, in consumption, ii. 522 Slavering, i. 57 Sleeplessness, iii. 308 Sleep-disturbance, iii- 114 sleep-walking, iii. 116 sleep-talking, iii. 115. 117 night-pollution, iii. 115 Small-pox, ii. 411 varieties, ii. 417 Smell, morbid, iii. 172 acrid, iii. ib. sex, age, and other qualities discoverable by it, iii. 174 obtuse, iii. 176 want of, iii. 177 illusory, whence, iii. 333 how far it exists in different animals, iii. 14 Snaffles, ii. 296 Snail, procreation of, iv. 10 Sneezing, iii. 270 Snivelling, i. 311 Snuff-taking, why injurious, i. 106 GENERAL INDEX. 491 inuffles, ii. 296 Snuffling, i. 311 Soap, i. 256 Soins, ii. 591 Sol-lunar influence, Balfour's hypothe- sis of, ii. 56 Solid parts of organs, of what com- posed, iv. 183 Solvents, biliary, i. 273 Somnambulism, iii. 116 Sore-throat, ii. 227 « ulcerated or malignant, ii. 228 Soreness, general feeling of, iii. 184 Sounds, vocal, i. 337 guttural, i. 340 nasal, i. 338 lingual, i. ib. dental, i. 340 labial, i. 337. 339 imaginary in the ears, iii. 169 Sparganosis, ii. 317 Spasm, doctrine of, as applicable to fevers, ii. 33 Spasm, constrictive, iii. 207 its species, in. 207 clonic, iii. 265 its species, iii. 267 synclonic, iii. 287 its species, iii. ib. comatose, iii. 342 its species, iii. 342 Spawn, or hard roe, what, iv. 8 Speech, how produced, i. 292 inability of, i. 318 may be produced without a tongue, i. 319 Speechlessness, i. 318 Sperm, or soft roe, what, iv. 8 Spermorrhaea, iv. 64 Spider discharged from the anus, i. 208 Spigelia, i. 211. 219 Spignel, iv. 40 Spilosis, iv. 459 Spilus, iv. 459 Spina ventosa, what, ii. 614 Spine, dropsy of, iv. 269 Spirit of animation, of Darwin, n. 3M Spitting of blood, ii. 462 Splanchnica, i. 243 Spleen, office not known, i. 13 not found below the class o fishes, i. 13 iii. 103 Splenalgia, ii. 267 Splenitis, ii. ib. Spoon-bill, i. 294 Spurred-rye, i. 141 iv. 40 Spurzheim, his hypothesis upon tho nature of the mind, iii. 29 Squalus, procreation of, iv. 8 Squinting, iii. 160 varieties, iii. 161 St. Anthony's fire, ii. 406 varieties, ii. 407 St. Guy, Dance de, iii. 289 St. Vitus's Dance, iii. 89 Stahl, his doctrine of fevers, ii. 30 Stammering, i. 332 Staphyloma, iii. 158 varieties, iii. ib. Stays, tight, their mischievous effects, i. 404 Sterility, male, iv. 88 female, iv. 97 Sternalgia, i. 393 ambulantium, i. 394 chronica, i. 400 Sternutatio, iii. 270 Stertor, i. 316 Stiff-joint, muscular, iii. 210 its varieties, m. 210 Stitch, i. 402 Stomach, organ of, i. 4 omnivorous power of, i. 3 self-digesting power of, i. 11 seat of universal sympathy, i. 14 inflammation of, ii. 25~ Stone in the bladder, iv. 347 Stone-pock, ii. 196 Stoppage of urine, iv. 301 Strabismus, iii. 160 Stramonium, iii. 249 Strangury, iv. 306 spasmodic, iv. 307 scalding, iv. ib. callous, iv. 308 vermiculous, iv. 309 polypous, iv. 310 mucous, iv. 309 Stricture of the rectum, spasmodic, i. 221 Strophulus, iv. 369 Struma, ii. 525 vulgaris, ii. 527 Studium inane, iii. 112 Stupidity, iii. 124 # Sturgeon, mode of procreation, iv. 9 f Stuttering, i. 332 Sty, ii. 191 Subsultus, iii. 283 i Sudor anglicus, ii. 62 | Suffoeatio stridula, ii. 233 Suffocation from asphyxy, iii. 368 from hanging or drown- ing, iii. 368 492 GENERAL INDEX. Suffocation, mephytic, iii. 376 electrical, iii. 379 from severe cold, iii. 380 Suffusio, iii. 149 scintillans, iii. 143 reticularis, iii. 143 Sugar in saccahrine urine, the propor- tion, iv. 314 Summer-rash, iv. 372. 375 Sun-burn, iv. 461 Superannuation, iii. 130, 131 Superfetation, iv. 162 Suppression of the menses, iv. 35 Suppurative inflammation, ii. 165 Surditas, iii. 169 SunFACES, INTERNAL, DISEASES AFFECT- ING, iv. 239 Surface, external, diseases affect- ing the, iv. 357 Surfeit, i. 135 Suspended animation, iii. 367 Susurrus, iii. 169 Sweat, morbid, iv. 359 profuse, iv. 360 bloody, iv. 361 partial, iv. 362 coloured, iv. 363 scented, iv. ib. sandy, iv. 365 Swan, dumb, i. 294 musical, i. 294 Sweating-fever, ii. 62 whether Englishmen only subject to it, ii. 64 Sweet-spittle, i. 55. 59 Swimming of the head, iii. 336 Swine pox, ii. 400 Swooning, iii. 337 varieties, iii. 339 Sycosis, ii. 192 Sympathies and antipathies, how formed in the mind, iii. 37 Synclonvs, iii. 287 Tremor, iii 287 Chorea, iii. 289 Ballismus, iii. 297 Raphania, iii. 300 Beriberia, iii. 303 Syncope, iii. 336 simplex, iii. 337 varieties, iii. 339 recurrens, iii. 341 Synizesis, iii. 152 Synocha, ii. 118 Synochal fever, ii. 145 Synochus, ii. 145 its varieties, ii. 146 Syrigmus, iii. 169 Syspusia, iii. 342 Convulsio, iii, 345 Syspasia, Hysteria, iii. 352 Epilepsia, iii. 356 Systatica, iii. 307 Systremma, iii. 211 T. Tabes, ii. 487 varieties, ii. 487 dorsalis, ii. 490 Tabor or Talbor, his early use of the bark in agues, ii. 84 Taedium vitae, iii. 103 Taenia Solium, i. 200 vulgaris, i. ib. generation of, iv. 10 Tarantismus, iii. 290 ' Tar, fumigation with, ii. 521 Tar-water, useful in indigestion, i. 109 Taraxacum, i. 256 iv. 305 Taraxis, ii 275 Taste, how far it exists in differen animals, iii. 14. 178 Taste, morbid, iii. 178 acute, iii. 181 obtuse, iii. 180. 182 want of, iii. 180. 183 illusory,whence, iii. 333 Teats in the mare, inguinal, iv. 10 Teeth, tartar of, i. 45 transplantation of, i. 43 whether an extraneous body, i. 32 whether injured by sugar, i. 34 pretended, reproduced by jug- glers, i. 27 carious, i. 30 deformity of, i. 44 Teething, i. 18 in adults, i. 25 in old age, i. ib. Tenderness, general external feeling of, how produced, iii. 184 Teneritudo, iii. 184 Tenesmus, i. 232 Tertian ague, ii. 70 double, ~) triple, C ii. 73 duplicate, j Testes, diminish in the winter in man* animals, iv. 10 where seated in the cock, i* ih. Testudo, iv. 213 Tetanus, iii. 221 anticus, iii. 221 dorsalis, iii. 221, 222 lateralis, iii. 221 erectus, iii. 221. 223 GENERAL INDEX. 49S Tetter, iv. 408 Therioma, iv. 410 Thirst, morbid, i. 67 immoderate, i. 69 sensation of, how accounted for, i. 67 Thirstlessness, i. 70 Throbbing of the arteries, iii. 275 heart, iii. 272 Thrush, ii. 390 its varieties, ii. 390 Tic, meaning of the term, iii. 194. 213 ! doloureux, iii. 193 Tick-bite, iv. 438 Tiglium seeds as a hydragogue, iv. 247 Tinea, iv. 42^. 423 Toads, suckling in cancer, ii. 545 Tongue, speech not necessarily de- pendent upon it, i. 542 Tonquin powder, iii. 251 Tooth, derangement of, i. 17 wise, i. 25 Tooth-ache, i. 27 Tooth-edge, i. 39 Toothlessness, i. 43 Torpor, iii. 366 Touch, morbid, iii. 183 acute sense of, iii. 184 insensibility of, iii. 189 illusory, iii. 190 Trance, iii. 385 Transudation in dead animal matter, iv. 190 Trembling, iii. 287 Tremor, iii. 287 Trichechus Dudong, i. 3 Trichoma, iv. Trichocephalus, i. 200 Trichosis, iv. 446 setosa, iv. 448 Plica, iv. 449 Hirsuties, iv. 451 distrix, iv. 452 Poliosis, iv. 453 athrix, iv. 454 Area, iv. 455 decolor, iv. 456 Tripudatio, iii. 297 Trismus (entasia) iii. 213 varieties, iii. 215 maxillaris, iii. 193 dolorificus, iii. 193 Triton palustris, intestinal, i. 208 Tsorat of the Jews, what, iv. 388, 389 394. 399 Tubba, ii. 447 Tubercle, ii. 190 Tumid-leg, puerperal, ii. 317 of West-Indies, ii. 320 Tumour, iv. 205 Tumour, sarcomatous, iv. 206 fleshy, iv. ib. adipose, iv. ib. pancreatic, iv. ib. cellulose, iv. 207 cystose,iv. ib. scirrhous, iv. 207, 208 mammary, iv. 207 tuberculous, iv. ib. medullary, iv. ib. encysted, iv. 212 steatomatous, iv. ib. atheromatous, iv. ib. honied, iv. ib ganglionic, iv. ib. horny,iv. 213 bony, iv. 214 osteous, iv. 215 periosteous, iv. ib- pendulous, iv. ib. exotic, iv. ib. Turgescence visceral, i. 273 Tussis, i. 342 Twinkling of the eye-lids, iii. 281 Twinning, congruous, iv. 160 incongruous, iv. 161 Twins, iv. 160 Twitchings of the tendons, iii. 283 Tympanites, iv. 292 Tympany, iv. ib. whether ever an idiopathic affection, iv. 293 Typhomania, ii. 219.—iii. 392 Typhus, how far approximates yellow fever, ii. 50. 124 described, ii. 123 causes, ii. 124 how becomes contagious, ii. 124 extent and intensity of conta- gion, ii. 125 mild, ii. 127 malignant or putrid, ii. 128 specific properties of its mi- asm, ii. 124. 132 septic power, distinct from its debilitating, ii. 132 copious bleeding, how far advisable, ii. 134 U& V. Vaccinia, ii. 394 its varieties, ii. 395 Vagina, prolapse of, iv. 102 Vapours, iii. 101 Variola, ii. 411 Varix, ii. 598 Varus, ii. 196 494 GENERAL INDEX. Vegetation promoted by animal de- jections, i. 8 Veins and arteries, ii. 7 Vena Medinenses, iv. 440 Venereal disease, ii. 547 Ventriloquism, what, i. 295 Vermifuges, 211 Vermis Medinensis, iv. 440 Vermination, cutaneous, iv. 434 Vertigo, iii. 331 origin of, iii. 332 Verruca, iv. 444 Vesicul* seminales, iv. 11 differ in different animals, iv. 11 Vesicular inflammation, ii. 207 fever, ii. 402 its varieties, ii. ib. Viper, poison of, as an anltilyssic, iii. 259 Vis insita, iii. 20 nervea, iii. ib. a tergo, hypothesis of, ii. 13 Viscus quernus, iii. 351 Vitiligo, iv. 387 Ulcer, ii. 615 depraved, ii. 616 callous, ii. ib. fungous, ii. ib. cancerous, ii. ib. sinuous, ii. 618 carious, ii. 620 Ulcus, ii. 615 incarnans, ii. 615 vitiosum, ii. 616 sinuosum, ii. 617 tuberculosum, ii. 619 cariosum, ii. 620 Vocal avenue, i. 291 Voice, how produced, i. 292 imitative, seat of, i. 295 whispering, i. 327 of puberty, i. 329 rough, i. 331 harsh, i. ib. nasal, i. ib. squeaking, i. ib. whizzing, i. ib. guttural, i. ib. palatine, or through the nose, i. 331 immelodious, i. ib. Vomica, ii. 181 occult, ii. ib. open, ii. ib. Vomiting and purging, i. 167 of blood, ii. 464 i. 96 Vomito prieto, ii. 99 Vomituritio, i. 96 Vomitus, i. 96 Voracity, i. 72 Uric calculus, iv. 344 Urinal dropsy, iv. 311. 335 Urinary^ calculus, iv. 338 Urinary sand, iv. 340 gravel, iv. 340. 344 Urine, earths, salts, and other princi- ples of, iv. 339 bloody, ii. 464 destitution of, iv. 298 stoppage of, iv. 301 saccharine, iv. 311 honeyed, iv. ib. incontinence of, iv. 333 unassimilated, iv. 336, erratic, iv. 337 Uroplania, iv. 337 Urticaria, ii. 384 Uteri procidentia, iv. 103 prolapsus, iv. ib. relaxatio, iv. ib. Uterine hemorrhage, ii. 465. 468 W. Wakefulness, iii. 308 irritative, iii. 308 chronic, iii. 310 Walrus, i. 3 Wart, iv 444 Water in the head, iv. 260 Water-blebs, iv. 407 Water-flux, iv. 311 Water-brash, i. 84 Water-pox, ii. 400 Water-hemlock, i. 141 Web of the eye, iii. 146 Weeping, how produced, i. 30(r Wen, iv. 212 adipose, iv. ib. honied, iv. ib. horny, iv. 213 Wheal-worm, iv 439 Whelk, ii. 195 White-gum, iv. 369. 371 White-swelling, ii. 358 Whites, iv. 48 Whitlow, ii. 199 Whizzing in the ears, iii. 169 W ild carrot, as a diuretic, iv. 30- Wind-cholera, i. 171 cholic, i. 142 dropsy, iv. 288 Winking, iii. 281 Winter-cherry, iv. 307 Wit, how it may exist without judg- ment, and hence in insanity, iii. 57 crack-brained, iii. 94. 96 Witlessness, iii. 130 GENERAL INDEX. 495 Womb, inflammation of, ii. 270 falling down of, iv. 102 retroverted, iv. 104 Worm-grass, i. 219 Worm, goose-foot, i. 215 Wormwood, i. 114 Worms, intestinal, their ability to re- sist digestion, i. 11 various species, i. 195 long round, i. 200 thread, i. 200, 201 tape, i. 201 broad tape, i. 202 maw, i. 203 erratic, i. 205 hepatic, i. 275 vesical, iv. 309 Worm-seed, i. 211 Wry-neck, iii. 208 Xanthic oxyde of the bladder, iv. 339 Y. Yam, i. 3 Yawning, iii. 286 Yaws, iii. 445 Yellow fever, how far approaches ty- phus, ii. 50 description of, ii. 98 Z. Zaruthan, ii. 543 Zona, iv. 410 ignea, iv ib. Zoster, iv. 409, 410 k^«JB>.OF vol. HfW national library of NLfl 03277^3 7 NLM032779237