9t' ANAIYTICAI COMPENDIUM MEDICAL SCIENCE. •^ t- v J ANALYTICAL COMPENDIUM VARIOUS BRANCHES MEDICAL SCIENCE, USE AND EXAMINATION OF STUDENTS. JOHN NEILL, M.D., DEMONSTRATOR OF ANATOMY IN THE UNIVERSITY OF PENNSYLVANIA, LECTURER ON ANATOMY IN THE MEDICAL INSTITUTES OF PHILADELPHIA, ETC., FRANCIS GURNEY SMITH, M.D., LECTURER ON PHYSIOLOGY IN THE PHILADELPHIA ASSOCIATION FOR MEDICAL INSTRUCTION, FELLOW OF THE COLLEGE OF PHYSICIANS, ETC. ^n\ -11839 J PHILADELPHIA: LEA AND BLANCHARD. 1848. Vi 4 \ 2 CK, \%4 1 Entered, sceording 10 Act of Congress, in the year IMS, By Lea &, Blanchard, In the Clerk's Office of the District Court for the Eastern District of Pennsylvania. C. SHERMAN, PRINTER, 19 St. James Street. CONTENTS. PAGES. IIXUSTKATIONS. ANATOMY,........180 157 PHYSIOLOGY,........134 40 SURGERY,.........122 51 OBSTETRICS,........114 37 MATERIA MEDICA AND THERAPEUTICS, - 116 29 CHEMISTRY,........94 19 PRACTICE OF MEDICINE,.....152 PREFACE. The great progress of the Medical Sciences, and the increasing number and size of the standard text-books in the various depart- ments of Medicine and Surgery, have created a necessity for " Com- pends," or " Manuals," to assist the student in the prosecution of his labours, and the practitioner in refreshing his recollection of former studies. The present work has been prepared solely to meet this want. No one could pretend to compress into so limited a space all the information necessary to the student or practitioner: but we hope to have succeeded in embodying in its pages the elements of medical science; as much, indeed, as is compatible with its character as an analysis. While, therefore, the volume is not offered as a substitute for the ordinary text-books, or to lessen the necessity of regular attendance on lectures, or close office study, we trust that it may be found of practical use in facilitating the acquisition of knowledge by the student. The very plan of the work excludes all pretensions to originality of matter. As an Analytical Compendium, its highest claim is to be considered a faithful digest of recorded facts and opinions. We ask for it nothing more, and, to obtain this, we have freely used the standard text-books of the day, gleaning from them whatever seemed useful to our purposes, even in some instances to the use of language as well as ideas, and to them we own our indebted- ness. We also acknowledge with pleasure the valuable assistance afforded us, in the departments of Materia Medica and Chemistry, by Dr. Reese, Lecturer in the Medical Institute of Philadelphia. In preparing this compendium, the ordinary form of question and answer has been avoided, as incompatible with the character designed for the volume, and as occupying, with meagre questions, space that might be more advantageously employed. It is hoped that the arrangement adopted will be found at once concise and intelligible, while we feel assured that the mechanical execution of the work, its copious illustration, and neat, cheap, and convenient form will prove all that can be desired by the student and prac- titioner. Philadelphia, August 1848. HANDBOOK or ANATOMY. THE OTHER PORTIONS OP THIS SERIES ARE PHYSIOLOGY, WITH FORTY ILLUSTRATIONS. SURGERY, WITH FIFTY ILLUSTRATIONS. OBSTETRICS, WITH THIRTY-SEVEN ILLUSTRATIONS. MATERIA MEDICA AND THERAPEUTICS, WITH TWENTY-NINE ILLUSTRATIONS. CHEMISTRY, WITH NINETEEN ILLUSTRATIONS, AN D PRACTICE OF MEDICINE. ANY ONE OF WHICH MAY BE HAD SEPARATELY, DONE UP IN A WRAPPER FOR MAILING. HANDBOOK OF ANATOMY: WITH ONE HUNDRED AND FIFTY-SEVEN ILLUSTRATIONS. BEING A PORTION OF AN ANALYTICAL COMPEND OF THE VARIOUS BRANCHES OE MEDICINE. BY JOHN NELLL, M.D., DEMONSTRATOR OF ANATOMY IN THE UNIVERSITY OF PENNSYLVANIA, LECTURER ON ANATOMY IN THE PHILADELPHIA MEDICAL INSTITUTE, ETC. AND FRANCIS GURNEY SMITH, M.D., LECTURER ON PHYSIOLOGY IN THE PHILADELPHIA ASSOCIATION FOR MEDICAL INSTRUCTION, ETC. PHILADELPHIA: LEA AND BLANCHARD, 1848. Entered, according to Act of Congress, in the year 1848, By Lea & Blanchard, In the Clerk's Office of the District Court for the Eastern District of Pennsylvania. C SHERMAN, PRINTER, 19 St. James Street. CONTENTS. Definition of Anatomy ... SECTION I. BONES. General anatomy of bone—Composition of bone Periosteum ..... Marrow ..... Formation and growth of bone Callus..... Cervical vertebrae .... Dorsal vertebra? .... Lumbar vertebras .... Sacrum ..... Coccyx ..... Innominatum .... Sternum ..... Ribs ..... Bones of the cranium - ... Bones of the face .... Hyoid bone ..... Scapula ..... Clavicle ..... Humerus ..... Ulna -..... Radius ..... Carpus ..... Metacarpus .... Phalanges of the fingers ... Femur ..... Patella ..... Tibia ..... Fibula...... Tarsus ..... Metatarsus ..... Phalanges of the toes Vi CONTENTS. SECTION II. ARTICULATIONS. Of ligaments generally Ligaments of the lower jaw Ligaments of the vertebrre Ligaments of the pelvis ... Ligaments of the ribs - - - - Ligaments of the shoulder Ligaments of the elbow ... Ligaments of the wrist ... Ligaments of the fingers - Ligaments of the hip Ligaments of the knee Ligaments of the ankle . . - Teeth ------ Cellular tissue - Fat ----- - Skin ..... Nails...... Hair - SECTION III. MUSCLES. General anatomy of - Muscles of the head and face Muscles of the neck .... Muscles of the chest Muscles of the abdomen Anatomy of inguinal hernia Muscles of the back - Muscles of the shoulder and arm - Muscles of the forearm Muscles of the hand Anatomy of femoral hernia ... Muscles of hip and thigh - Muscles of the leg .... Muscles of the foot SECTION IV. VISCERA. Mouth ..... Tongue ..... Muscles of tongue - ' UUWfENTS. Palate Salivary glands of the mouth - Pharynx and oesophagus - Regions of abdomen . ♦Peritoneum Mesentery . Stomach ... Small intestines Liver Gall bladder Pancreas ... Spleen Kidneys ... Supra-renal capsules - Bladder ... Vesiculas seminales Prostate gland Scrotum and testicles - Spermatic cord Muscles of perineum and anus- Larynx - Trachea Thyroid gland Lungs .... Pleura Mediastinum ... Thymus gland Heart - Pericardium Vll 98 99 100 102 ib. 104 105 108 111 113 114 115 ib. 116 117 119 120 ib. 122 123 124 127 128 129 130 ib. ib. ib. 133 Structure of arteries Aorta External carotid artery Internal carotid artery Arteries of the brain . Subclavian artery . Axillary artery Brachial artery Thoracic aorta Abdominal aorta - Cceliac axis Superior mesenteric artery SECTION V. VESSELS. 133 134 ib. 136 137 ib. 138 139 140 141 ib. ib. V1I1 CONTENTS. Renal artery . Inferior mesenteric artery Internal iliac artery - External iliac artery - Femoral - - - - Anterior and posterior tibia! Veins ..---" Veins of the head and neck Sinuses of the dura mater « Veins of the upper extremity Ascending cava • Descending cava .... Vena azygos - Portal vein .... Veins of the lower extremity ... Lymphatics .... SECTION VI. NERVOUS SYSTEM. General anatomy of - Membranes of the spinal marrow - Spinal marrow .... Membranes of the brain ... Brain ...... Cranial nerves .... Spinal nerves ..... Cervical nerves .... Dorsal nerves ..... Lumbar nerves .... Sacral nerves ..... Sympathetic nerve Cervical ganglia .... Thoracic ganglia .... Lumbar and sacral ganglia SECTION VII. ORGANS OF SENSE. Nose ---.._ Eye and its appendages ... Ear - ANATOMY. Anatomy is the science which investigates the structure and organization of living beings. By the term Special Anatomy or Descriptive Anatomy is meant the consideration of each organ or part of the human body, including its size, weight, colour, shape, &c. General Anatomy investigates the different tissues or structures out of which organs are formed, independently of the particular organs. Surgical Anatomy or Regional Anatomy is the study of the re- lation of one part to another, and is one of the most important applications of anatomy to the practice of medicine and surgery. Physiological Anatomy considers the uses and functions of organs in a healthy state. Pathological Anatomy regards the different parts and organs as altered by disease. This is a compendium principally of special anatomy; and is divided into seven sections : 1. Bones. 2. Ligaments. 3. Muscles. 4. Viscera. 5. Vessels. 6. Nerves. 7. Special Senses. 2 14 SECTION I. BONES. GENERAL CONSIDERATIONS OF BONE. The bones of the skeleton are two hundred and eleven in number, of which twenty-two belong to the head, fifty-six to the trunk, sixty- nine to the superior and sixty-four to the inferior extremity; when held together by ligaments and cartilages they form a natural skeleton, when by other means an artificial skeleton. They are hard, white, and inflexible; and more numerous in childhood than in old age. They are classified into long, thick, and flat bones. The body or shaft of a long bone is called Diaphysis ; its articulating extremities, Epiphyses; its processes and projections are called Apophyses. The small foramina on the surface of bones are for the transmission of nutritious vessels, the largest of which enters about the middle. Bones are composed of two structures, compact and cellular, which are external and internal. The cells communicate with each other and contain marrow. The compact structure consists of small fibres arranged in laminae ; each of these fibres has a canal running through its length called the canal of Havers, transmitting vessels; it commu- nicates with small lenticular excavations called corpuscles of Purlcinje, by radiating tubes. The cellular structure increases the strength without increasing the weight, and also diminishes the effect of con- cussion. Composition of Bones.—Bones are chemically composed of animal and earthy matters, united in the proportion of two parts of earthy to one of animal, or, more accurately, consist of thirty-two parts of gelatine, one part of insoluble animal matter, fifty-one parts of phos- phate of lime, eleven of carbonate of lime, two of fluate of lime, one of phosphate of magnesia, and one of soda and muriate of soda ; the earthy matter is most abundant in bones of the cranium; the ani- mal matter in the cellular structure. Combustion will remove the animal matter, and dilute acids will remove the earthy matter The Periosteum is a fibrous membrane investing the external sur- face, adhering less firmly in infancy, and becoming ossified in old age. It is vascular, insensible in health, assists in the secretion of the external laminse, restrains ossification within proper limits re- ceives the insertion of muscles, tendons, &c. &c., and protects'the bone from suppuration in the vicinity. BONES OF THE TRUNK. je Marrow is contained in a fine vascular membrane, lining the me- dullary canals and cells of bones called the Internal Periosteum Lnsvt ! ' bKUt CK°TStS, °f finer §ranuleS' in consumption dropsy, &c, it is absorbed and its place is supplied with serum PormaUon and growth of bones.—There are three stages of ossifi- cation in the embryo. The first is the mucous or pulpyf which con- inues for one month ; the second is the cartilaginous, and the third the osseous, commencing at the third month. The colour of the cartilage deepens and then a vessel conveys red blood to a central point, which first receives calcareous particles and is called punctum osstficationis. Bones increase in length by continued deposit at their extremities between the Diaphysis and the Epiphyses, as is proved by Hunter's experiment of placing two shot in the tibia of a young pig; after the animal had reached full size, the shot were found at their origmal distance from each other. Bones increase in thickness by external deposit and by secretion from the periosteum, which is proved by disease and the experiment of feeding a young pig with food coloured with madder. Various lamina? of white and coloured bone can be produced by suspending and resuming this mode of feeding. While deposit is taking place upon the surface of a bone, absorption is going on internally ; this is proved by Duhamel's experiment of surrounding a long bone of a young animal with a metallic ring; after the animal is fully grown, the ring was found in the medullary canal, which increases in size by this constant de- posit and absorption. Callus.—When bones are fractured, the process of reparation resembles that of the formation of a bone. Blood is effused, lymph is thrown out, causing a swelling; the blood is absorbed, lymph coagulates and ossifies in the form of a ring, surrounding the seat of fracture, and also in the form of a pin in the medullary canal The fractured extremities begin to unite and coalesce, after which the wu6, uUS nng and pin °f bone which acted as sPlints are absorbed Whilst this process is going on, it is important that the parts should be maintained at rest, else the process of ossification is arrested, and a false joint results. BONES OF THE TRUNK. The trunk consists of the Spine, Pelvis, and Thorax. SPINE. It extends from the head to the coccyx at the posterior part of the trunk, having several curvatures in its extent. In the neck it is convex anteriorly, in the thorax concave, in the loins convex, and in the pelvis concave. It contains an osseous canal for the spinal marrow, and is formed of 28 or 29 separate bones called vertebra?, 16 BONES OF THE TRUNK. 24 of which are classified as true vertebra, on account of then bility, and the 5 remaining are called false vertebra Th« ™ vertebra, are divided into 7 cervical, 12 dorsal, and 5 lumbar the false vertebra consist of the sacrum, and 3 or 4 eoccygea bones A vertebra consists of a body, 7 processes, and a spinal 1°™™"' The body is in front and is the thickest part; its upper and lower surfaces articulate with a contiguous vertebra by meansiot^a earn. lage; it is convex anteriorly from side to side. The P™cesses are« one spinous, of a triangular shape, and situated behind for the at- tachment of muscles ; two transverse, one projecting horizontally on either side for the attachment of muscles and ligaments; and lour oblique processes, two of which are superior and two inferior, wnicn are for the purpose of articulation. The spinal foramen is in the middle, and constitutes a portion of the spinal canal. 1 he interver- tebral foramen is formed on each side by a groove upon the upper and lower surface of each vertebra, and transmits a spinal nerve. CERVICAL VERTEBRAE. l The bodies are small and flattened in front; the superior surfaces1 are con- cave laterally, the inferior, are concave antero-superiorly ; they gradually in- crease in size. The spinous processes* are short, thick, horizontal, and bifid. The oblique processes are flat, oval, and short; the superior7 look upwards and backwards, and the inferior* down- wards and forwards at an angle of forty- five degrees. The transverse processes* are broad, perforated at their base by a foramen9 for the transmission of the vertebral artery. The spinal foramen2 is very large. The first cervical vertebra is called the a/las ; it has no body, and resembles a ring. In place of a body, there is an arch which has a tubercle in the middle of its anterior surface ; in the correspond- ing part of its posterior surface is an articular fossa for the processus dentatus of the second vertebra. The posterior arch has a tubercle instead of the spinous process. The superior oblique processes are large, oblong, and concave, adapted to the condyloid processes of the occiput; and admit of flexion and extension. The inferior oh- lique processes are round, flat, and horizontal, adapted to the rotatory motion of the head. The transverse process is extremely long. On the inner side of the oblique processes is a tubercle for the attachment of the transverse ligament. The spinal foramen is the largest. The second is called dentata, from its tooth-like process projecting from the upper surface of the body ; the tip of which is rough for V ' vfe BONES OPTHE TRUNK. 17 the middle straight ligament, and on the sides of the tip there is a flatness for the attachment of the moderator ligaments. This pro- cess is smooth in front where it touches the arch of the atlas and also behind where the transverse ligament plays. Upon this process the head rotates. The superior oblique process is circular and slightly convex. The spinous process is long and bifid. The sixth has a long and pointed spinous process. The seventh is the largest and resembles a dorsal. The spinous process is the longest and tuberculated. The foramen at the base of the transverse process does not transmit the vessels. DORSAL VERTEBRAE. These are twelve in number. The bodies* are cylindrical, and their transverse diameter decreases from the first to the third and then increases. The upper and lower surfaces are flat, and the sides have articular marks3 for the heads of the ribs. Each fossa is formed by two contiguous vertebra. The oblique processes Fig. 2. are vertical, the superior8 looking backwards and the inferior8 looking forwards. The transverse processes7 are long, and their extremities are enlarged; in front there is an arti- cular face for the tubercle of the rib. The spinous processes6 are long and triangular, broad at the base, sharp-pointed and overlap each other. The spinal foramen is small and round. The first has a complete fossa for the head of the rib upon its side. The eleventh and twelfth have also complete fossa? for the heads of the ribs. Their transverse processes are short, directed backwards, and do not articulate with the ribs. LUMBAR VERTEBRAE. Their number is five. The bodies are large and oval, the transverse diameter being the longest. The spinal foramen is FlS- 3. triangular and large. The groove forming the intervertebral fora- men is also large. The oblique processes are vertical; the supe- rior7 looking inwards and the inferior8 looking outwards; the transverse processes6 are long and at right angles,rare short, thick, quadrangular, and horizontal. 2* 4- J*"*^. 18 BONES OF THE TRUNK. Fig. 4. The first is the smallest ; the third has the longest transverse process; the fifth has a wedge-shaped body. SACRUM. Is triangular, and originally consisted of five pieces; its an- terior surface is concave, and has four funnel-shaped holes5 8 on each side transmitting the anterior branches of the sacral nerves. Its posterior surface is rough and convex, and contains the representations of spinous and oblique processes. A fis- sure usually exists in place of the fourth and fifth spinous pro- cesses. There are four fora- mina on each side, smaller than those in front, for the transmis- sion of the posterior branches of the nerves. The base has a large oval articular mark1 upon which rests the last lumbar ver- tebra, two grooves completing the intervertebral foramina ; and has also two oblique processes.9 The apex2 is blunt and has a transverse articular surface9 for the coccyx. The sides are rough, broader above than below, having a large articular mark for the innominata ; behind this surface arise muscles of the back, and below it the sacro- iliac ligaments. The sacral canal runs through the length of the sacrum. It is triangular and larger above than below ;6 is continuous with the spinal canal and contains the cauda equina ; with it com- municate the foramina transmitting the nerves. coccyx is flat and triangular, having its base upwards. It consists of three or four bones united usually in the same curve as that of the sacrum. The pieces are frequently united with each other and the sacrum. The first piece is the largest, and has two articular marks; behind, it has two cornua ;2,3 on its side are grooves4,5 which with the sacrum complete the canal for the fifth sacral nerve. The last piece® is a mere tu- The sides of the coccyx give origin to muscles and ligaments. PELVIS. The pelvis consists of the sacrum, coccyx, and the two innominata or hip bones. bercle. BONES OF THE TRUNK. 19 INNOMINATUM. This is a large flat bone forming the haunch or hip of common language, resembling in some measure the figure 8. In youth it consists of three different parts, united in the acetabulum, viz. the ilium, ischium, and p.ubes. Ilium.—This is the largest piece, and forms the wall of the upper pelvis. Its external surface is convex and rough, with a semicircular ridge crossing it; above this ridge arises the gluteus medius,and below it the gluteus minimus muscle; the posterior part of this sur- face is the roughest, and gives origin to the gluteus maximus. The internal surface* or costa, is concave ; the anterior portion is smooth, and gives origin to the iliacus internus; the posterior is rough and has a large articular mark for the sacrum, behind which arise muscles and ligaments. The edge or crista is arched and curved like the italic/. In front there are two eminences, one of which is called the anterior superior spinous process? giving origin to the sartorius and tensor vagina? muscles and Poupart's ligament; the other is the anterior inferior spinous8 process, and gives origin to the rectus muscle; the space between the two gives orio-in to the gluteus medius. Below these processes is a large prominence" called ilio-pectineal; in the groove above this passes the iliacus internus and psoas magnus muscles. Behind these are the posterior superior and inferior spinous processes. The crista has three lips, from the internal of which arises the transversalis muscle, from the middle arises the internal oblique, and into the external is inserted the external oblique. The inferior border of the ilium presents a notch,? called sciatic. 20 BONES OF THE TRUNK. Ischium.—This is the most inferior part of the innominatum. It consists of a body and branch ; the external surface of the body is rough ; the internal surface is smooth, and is called the plane of the ischium. The posterior border presents a projection called the spine, into which is inserted the lesser sacro-sciatic ligament, and beneath the spine is a groove in which plays the tendon of the obturator in- ternus muscle. The inferior portion of the body is called the tuber. osity,c from which arise the semi-membranosus, semi-tendinosus, bi- ceps, and adductor muscles; in front there is a ridge into which is inserted the greater sacro-sciatic ligament. The ramus or branch is short and thick, and ascends forward and inward, joining the ramus of the pubes, and forming a portion of the pubic arch ;a externally it is rough, and internally it is smooth, whence arises the crus of the penis. Pubes.—It forms the anterior boundary of the pelvis,0 and con- sists of a body and descending ramus or branch. The body articulates with its fellow by a vertical surface/ called the symphysis. The superior portion of the body at right angles with the symphysis is horizontal^ and limited externally by a pro- jection' called the spinous process ; from this process there diverge two ridges ; the posterior,* is called the crista of the pubes, or linea pectinea, and to it is attached a portion of Poupart's ligament; the anterior is sometimes called linea innominata. Between these ridges is included a triangular space," the base being the ilio-pectineal emi- nence," and the apex the spinous process; from this space arises the pectineus muscle, and over it pass the femoral vessels. The ramus descends to join that of the ischium, and form a part of the pelvic arch ; externally it is rough for the origin of the ab- ductor muscles; internally it is smooth, and from it arises the crus of the penis. The acetabulum,9 is a deep hemispherical concavity upon the outer side of the bone for the articulation of the head of the femur. The brim of this cavity is notched on the lower edge. In the bottom of the cavity is a rough depression occupied by a mass of fat, commonly called a gland of Havers. Immediately beneath the acetabulum is a groove, in which plays the tendon of the external obturator muscle. The obturator or thyroid foramen, is that large opening in the front and lower part of the bone, which is filled up by a mem- branous ligament, with the exception of a groove at its upper part, through which pass the obturator vessels and nerve. . Its shape is oval, but rather triangular in males. THORAX. This cavity is formed by the dorsal vertebra?, ribs, and sternum; its figure is conoidal, flattened in front, and concave behind • the BONES OF THE TRUNK. 21 apex presents a cordiform opening, and the opening at the base has a large notch in front. STERNUM. Is an oblong, slightly curved bone, placed in front of the thorax. Usually it consists of three pieces, but in advanced life of but one. The first or superior bone,1 is the thickest, and resembles in shape a trian- gle with the corners cut off, the base being upwards; on the superior edge is a concavity for the benefit of the movements of the tra- chea ; on each side is a large concavity for the ar- ticulation of the clavicle, and below are two smaller ones for the articulation of the first, and part of the second rib. The second bone3 is longer and narrower than the first, increasing in breadth in its lower extremity ; its sides present pits for the articulation of part of the second, the third, fourth, fifth, sixth, and part of the seventh ribs. The third bone,3 is very frequently cartilaginous, and called xyphoid or ensiform; its shape varies ; sometimes being pointed, and sometimes bifurcated ; upon its side is a depression for a portion of the seventh rib. RIBS. These are twenty-four in number, twelve on either side; those that articulate with the sternum are called true ribs, and are seven in number; the five below them are called fcdse ribs : in some rare instances there have been thirteen or eleven ribs on one side. They are parallel, and directed obliquely downwards and forwards ; each having a parabolic curve, and gradually increasing in size until the eighth, afterwards gradually diminishing. The anterior or sternal extremity is larger and flatter than the posterior ; the posterior or vertebral extremity presents a spherical head, having two articular surfaces separated by a ridge ; surrounding the head, the rib is very narrow and called the neck, the upper edge of which is sharp for the insertion of the internal transverse liga- 22 EONES OF THE HEAD. ment; about one inch from the head is the tubercle, a prominence with an articular face, for the transverse process of the vertebra; just beyond this is a smaller tubercle, for the insertion of the external transverse ligament. Each rib is twisted and bent; this bend constitutes the angle of the rib; upon the external surface is a mark, showing the insertion of the sacro-lumbalis muscle. The lower edge of the rib is thin and cutting, and just within it is a groove,13 running two-thirds of its length, and containing the intercostal vessels and nerve. The upper edge is rounded for the insertion of the intercostal muscles. The first rib is small and semicircular, its surfaces looking superiorly and inferiorly; the superior surface has upon its middle a slight fossa, for the subclavian artery ; in front of this is a roughnes3 for the insertion of the scalenus anticus muscle, behind it another for the insertion of the scalenus medius ; the head has a single articular surface, its angle is at the tubercle, and it has no intercostal groove. The eleventh and twelfth,™ are called floating ribs, because they are not connected with the others; they have no tubercles, and their heads have but a single articular surface; the twelfth is very short, but slightly curved, and has no intercostal groove. BONES OF THE HEAD. These are twenty-two in number, and are divided into those of the cranium, which are eight in number; and those of the face, which are fourteen. CRANIUM. FRONTAL BONE. forms the forehead of common language; it is usually a single, symmetrical bone, This Fig. 8. though occasionally divided by a suture into two parts; its shape resembles that of a shell. The external surface is convex, and about the middle upon each side there is the frontal protuberance,1 being the original centre of ossifi- cation; below this and nearer the median line is an oblique ridge, called the nasal or superciliary protuberance? The inferior edge of the bone is formed on either side by the orhitary ridge,2 forming the anterior boun- BONES OF THE HEAD. 23 dary of the orbit of the eye; this ridge is terminated outwardly by the external angular process,4 just within which is a depression for the lachrymal gland, and inwardly by the internal angular6 process; between the internal angular processes is a prominence called the nasal spine,9 which serves as an abutment for the nasal bones. Upon this orbitary ridge, half an inch distant from the internal angular process, a small depression exists, upon which plays the tendon of the superior oblique muscle ; to the outside of this depres- sion is a notch or foramen, for the transmission of the supra-orbital artery and nerve.8 The frontal sinus opens near the internal angular process, and is formed by the separation of the tables over the orbitary ridge ; its capacity varies and there are no means of determining it in the living being ; it empties into the infundibulum of the ethmoid. The internal surface is c6ncave and has numerous depressions corresponding with the convolutions of the brain; in the middle is a fossa for a superior longitudinal sinus, and a ridge for the attachment of the dura mater ; at the bottom of this ridge is the foramen ccecum, transmitting a vein, which forms the commencement of the sinus. The orbitar processes are two horizontal plates, forming the roofs of the orbits, separated by a large space, which is occupied by the ethmoid bone. The internal edges of these processes have two grooves, which are converted into foramina, called ethmoidal or orbi- tary, by the articulation of the ethmoid. The anterior transmits the internal nasal nerve. Laterally the bone articulates with the parietal and sphenoid, in- feriorly with the bones of the faoe^nd the ethmoid. PARIETAL BONES. These occur in pairs, and form the middle and lateral portions of the Fig. 9. cranium; they are quadran- gular and flat, externally con- vex and internally concave. The external surface has in its middle the parietal pro- tuberance, the centre of ossi- fication ; below this is the se- micircular ridge indicating the attachments of the temporal fascia and muscle. The internalsurfaceis con- cave, with numerous depres- sions for the convolutions of the brain, and is also tra- versed by furrows showing the course of the middle artery of the dura mater. The superior edge1 is the thickest and much dentated; 24 BONES OF THE HEAD. when adjusted with its fellow, it forms a deep groove for the longitu- dinal sinus.5 The parietal foramen,6 transmitting an emissary of Santorini, opens in this groove. The inferior edge is short, con- cave, and squamous, articulating with the temporal. The anterior inferior angle7 is long and pointed; the posterior inferior8 angle is very obtuse, and deeply grooved on its internal surface for the lateral sinus. OCCIPITAL BONE. Placed at the posterior and inferior part of the head, is of an oval or trapezoidal shape. The external surface is convex and rough in some parts ; near its middle is a prominence called the external occipital cross,3 from which there proceeds on each side a semicircular ridge,1 to which is inserted the sterno-cleido mastoideus muscle, and from which arise the trapezius and occipital frontalis. About one inch below is an- other semicircular ridge4 for the insertion of the superior oblique muscle. Between this ridge and the foramen magnum, the space is occupied by the recti postici muscles. Reaching from the external occipital cross is a vertical ridge3 extending to the foramen magnum, into which is inserted the ligamentum nucha?. A space between the superior and inferior semicircular ridges is occupied by the insertion of the splenius and complexus muscles. The foramen magnum5 is oval, its antero-posterior diameter being the largest; it transmits the medulla oblongata, spinal accessory nerves, and vertebral vessels. On either side of the foramen is the condyloid process,6 an oblong convex surface converging towards its fellow, by which the head articulates with the atlas. The anterior condyloid foramen9 transmits the hypoglossal or ninth nerve, the posterior condyloid foramen7 a vein to the lateral sinus. In front of the foramen mag- num is the basilar process,11 the extremity of which articulates with the sphenoid; the inferior surface receives the insertion of the recti postici and superior con- strictor muscle of the pharynx; the superior surface is concave and contains the medulla oblon- gata. The internal surface is con- cave and about its middle has ar\internaloccipitalcross,which is more prominent than the ex- ternal ; from it there diverge three grooves, containing the two lateral and the superior longitu- BONES OF THE HEAD. 25 dinal sinuses; inferiorly there proceeds a ridge to the foramen mag- num to which is attached the falx cerebelli. The concavity is thus divided into^our; the two superior, containing the posterior lobes of the cerebrum, and the two inferior the hemispheres of the cerebellum. The two superior edges are deeply dentated and articulate with the parietal; the two inferior articulate with the temporal. On each edge is a prominence called the jugular eminence? in front of which is a fossa converted into the posterior foramen lacerum10 by articulation, through which pass the internal jugular vein and the eighth pair of nerves. Upon the inferior surface of this eminence is inserted the rectus capitis lateralis. SPHENOID. Position. In the middle and anterior part of the base of the cra- nium. Shape. Resembles a bat; consists of a body and four wings ; a large and small one being placed on each side, besides two vertical processes directed downwards. The body is in the centre and cuboidal in its shape. On its supe- rior surface is a deep pit called sella turcica,16 which contains the the pituitary gland. This depression is overhung posteriorly by the posterior clinoid process ;6 on either side are two grooves called sulci carotid, for the carotid arteries, and in front there is a promi- nence called processus olivaris, upon which is a transverse groove indicating the position of the chiasm of the optic nerves. On the anterior view of the body are the orifices of the two sphe- noidal cells, separated by a ridge, upon which articulates the nasal lamella of the ethmoid bone; they empty into the post. eth. cells and do not exist in infancy. The inferior surface of the body has an ele- vation in the middle line called the processus azygos, by which it ar- ticulates with the lower two projections. Posteriorly, the surface is Fig. 11. 3 26 BONES OF THE HEAD. rough for articulating with the cuneiform process of the occipital bone. The small wings' are placed in front of the large. 1 hey are triangular, flat, and narrow. Their posterior extremities constitute the anterior clinoid processes, which are perforated by the optic jora- mina* through which pass the optic nerve and ophthalmic artery. They articulate in front with the frontal bone. The great wings are separated from the small by the sphenoidal fis- sure or foramen,7 which transmits the third, fourth, first branch of the fifth, and the sixth nerves. This wing has three surfaces. The cerebral is concave and has numerous depressions for the convolutions of the middle lobe of the cerebrum which lodge in this concavity. It has three foramina. The foramen rotundum8 transmits the second branch of the fifth pair. Behind it, is the foramen ovale,9 through which passes the third branch of the fifth pair. The posterior angle of this surface is the spinous process, which is perforated by the foramen spinale,10 by which the middle artery of the dura mater enters the cranium. Pro- jecting from the inferior surface of this process is another called sty- loid,11 which gives origin to muscles. The external surface is the temporal, which is divided by a ridge, and has a process in front; it is covered by the temporal and external pterygoid muscles. The anterior surface is called the orbital, form- ing a large portion of the orbit of the eye. On the superior surface is a large, triangular, serrated surface, for articulating with the frontal bone ; laterally it articulates with the temporal. Pterygoid processes.—These project downwards on either side, and articulate with the palate bones in front. Posteriorly, there is a fossa called pterygoid, which terminates in a notch, and divides the < process into an external and internal plate. The external1* is the broader, and gives origin to the external pterygoid muscle ; the inter- i nalt3 is the longer, and terminates in a hook-like process, called the hamulus, over which plays the tendon of the circumflexus palati muscle. The internal plate gives origin to the internal pterygoid muscle, which occupies a portion of the fossa. The base of the pterygoid process has a groove upon it, showing the course and connexion of the cartilaginous portion of the Eustachian tube. The pterygoid foramen14 perforates the base of the process, and transmits the vidian or recurrent nerve. TEMPORAL BONES. These are placed on either side of the cranium below the parietal bone. They consist of three portions, squamous, petrous, and mastoid. The squamous1 is thin and shell-like. The external surface is slightly convex, has grooves for the deep temporal artery and is covered by the temporal muscle. Projecting from the lower part of BONES OF THE HEAD. 27 this surface is the zygomatic process,6 which forms a part of the zygo- matic arch. The base of this process is triangular, and has beneath it a cavity called glenoid for the articulation of the lower jaw. This cavity is separated by the Glaserian fissure from another behind it, containing a portion of the parotid gland. Through this fissure pass the chorda tympani nerve and the laxator tympani muscle, attached to the processus gracilis of the malleus. The internal surface has a distinct groove4 for the middle artery of the dura mater. The edge is thin and cutting and has flat serrations5 for the parietal bone. The mastoid* portion is behind, and nipple-like. It is thick and cellular ; the cells being lined by a thin membrane. Ex- ternally it is rough, and has a large process called mastoid, into which are inserted the sterno-cleido-mastoid and tra- chelo-mastoid muscles. Be- neath this process is the di- gastric fossa,7 which gives ori- gin to the digastric muscle. Internally is a deep sulcus8 containing a part of the lateral sinus. The edges are thick and dentate. Near the upper edge is the mastoid foramen, which transmits a vein, one of the emissaries of Santorini. The petrous3 portion is pyramidal and directed obliquely forwards and inwards. Its structure is extremely dense and brittle. The base has a large oval opening externally, betweeen the zygo- matic and mastoid, called the external meatus, which is surrounded by a rim called the auditory process, to which is attached the carti- laginous portion of the ear. In the foetus it is a ring. The apex is obtuse and is perforated by the carotid canal and foramen lacerum. In the angle between the apex and squamous portion, is the bony por- tion of the Eustachian tube, and above it a canal for the tensor tympani muscle. The inferior surface presents a large process, styloid1* projecting from a ridge called vaginal process. Behind it, is the stylo-mastoid foramen,16 the orifice of the Fallopian canal, which transmits the facial nerve and stylo-mastoid artery. Inwards from the styloid process is the jugular fossa, which is converted into the posterior foramen lacerum by the articulation of the occipital bone; this foramen transmits the internal jugular vein and the eighth pair of nerves. The tympanic canal, containing Jacobson's nerve, opens in this fossa; its other orifice is near the Eustachian tube. Before the jugular fossa is the opening of the carotid canal,16 which contains Fig. 12. 28 BONES OF THE HEAD. the carotid artery and the ganglion of Laumonier. Upon the septum between the jugular fossa and carotid canal, is the entrance to the aqueduct of the cochlea. The anterior surface presents a groove leading to a foramen called hiatus Fallopii, which transmits the superficial petrous nerve, a branch of the vidian; behind this is the eminentia arcuata, made by the prominence of the labyrinth. At the edge is a groove for the superior petrosal sinus, and near the apex a semilunar depression for the ganglion of Casser. The posterior surface has a large opening near the middle, in- ternal meatus auditorius; it is not deep, and the base is cribriform. Immediately above it, is a foramen or fissure for the dura mater and a small vessel; behind it is a ridge produced by the inferior semi- circular canal, and half an inch behind it is the aqueduct of the vestibule, concealed by an osseous lamella. ETHMOID. Is so called from its resemblance to a sieve. It is placed in the median line, at the base of the skull, in front of the sphenoid bone, and between the orbitar processes of the frontal. Is cuboidal in shape and cellular in structure. The superior surface is called the cribriform plate,* which is per- forated with holes for the transmission of filaments of the olfactory nerve ; the most anterior hole is the largest, and transmits the internal nasal nerve. From the median line is a narrow, triangular, hollow process called the crista galli,3 and to it is attached the falx cerebri, In front of this is sometimes the foramen or groove called foramen ca?cum, which admits of the passage of a small vein from the nose. The bone is divided longitudinally into two halves by the vertical plate of bone called the nasal lamella y1 this can best be seen by ex- amining the inferior surface. It articulates below with the vomer, and behind with the crista sphenoidalis. The lateral surfaces of the bone are called the ossa plana.3 The Fig, 13. os planum is extremely thin and papy- raceous, forming a large part of the orbit of the eye. On its upper edge are two grooves, which are converted into two foramina, called internal orbitary or ethmoidal ,• the anterior transmits an artery, vein, and the internal nasal nerve; and the posterior transmits an artery and vein. The inferior edge articulates with the superior maxillary bone. When the bone is viewed from behind, there will be seen two scrolls or shells on either side of the nasal la- BONES OF THE FACE. 29 mella, but attached to the internal face of the os planum. They are the superior6 and middle turbinated bones7 placed one above the other, and separated by a fissure. This fissure is the superior meatus6 of the nose. The middle meatus is a space observed in an articulated head between the middle and inferior turbinated bones. The anterior cells of the ethmoid bone empty into the middle mea- tus; the most anterior of these cells is funnel-shaped {infundulum), and receives the fluid from the frontal sinus; from the inferior part of these cells there proceeds a hook-like process. The posterior eth- moidal cells and the sphenoidal sinus empty in the superior meatus. In children there is attached to the ethmoid bone, on each side, a hollow triangular process, called the pyramid of Wistar, or cor- nu Bertini. The base is connected with the superior turbinated bone, the posterior edge of the cribriform plate, and the posterior edge of nasal lamella. The apex lies under the body of the sphenoid bone, on each side of the processus azygos. These pyramids are de- tached from the ethmoid in afterlife, and become the sphenoidal sinuses. The ethmoid articulates with the frontal, sphenoid, inferior turbi- nate, upper jaw, nasal, lachrymal, palate bones, and vomer. BONES OF THE FACE. These are fourteen in number, and exist in pairs with the exception of two, the lower jaw and the vomer. SUPERIOR MAXILLARY BONE. This with its fellow constitutes the upper jaw. It articulates with all the bones of the face with F- the exception of the lower jaw. It has an irregular cubical body and four processes. The body is hollow and has four surfaces. The anterior or facial sur- face is bounded above by the inferior margin of the orbit, be- neath which is the infra-orbital foramen, transmitting the infra- orbital nerve, artery, and vein. Contiguous to this foramen is a depression, called the canine fossa, which gives origin to the levator anguli oris muscle. The posterior or temporal surface is rounded. The most prominent part is called the tuber,13 which is rough and perforated by several small foramina which transmit the posterior dental nerve, artery, and vein, to the floor of the antrum. The superior or orbital surface is triangular, and traversed bv the 3* J 30 BONES OF THE FACE. infra-orbital groove leading to the foramen of that nama The in- ternal or nasal surface has a large opening of the .znlrum^H*gH monanum,1 which is a pyramidal cavity with thin walls the walk are grooved, indicating the passage of the den a nerve The £*n- ing is diminished by the articulation of the Palate, infei or turbinate and unguiform bone to a small orifice which opens into the middle meatus of the nose. . „„j anterinr nnrt nf The nasal process* arises from the superior and anterior part of the bone. It is broad and thin below; externally it gives origin to the levator labii superioris ala?que nasi muscle, internally is a transverse ridge for the inferior turbinated bone. The anterior edge articulates with the nasal bone, the superior with the frontal, and the posterior edcre has a deep groove, which is converted into a bony canal by the articulation of the os unguis, to contain the lachrymal sac. The malar process is a rough process upon the external and supe- rior part of the bone for articulation with the malar bone The alveolar process contains the sockets for eight teeth which are larger behind. The anterior nasal spine is best seen when the bone is articulated with its fellow ; immediately behind this is the foramen incisivum for the naso-palatine nerve and ganglion. The palate process7 is the horizontal roof of the mouth and floor of the nose ; uniting behind with the horizontal part of the palate bone,10 and on the side with its fellow, from which latter junction or suture there arises the nasal crista, for.the articulation of the vomer. The anterior extremity8 is the anterior nasal spine. PALATE BONE. Situated on each side between the superior maxillary and the sphenoid bone; the figure is irregular and consists of three parts. The horizontal part1 is quadrilateral in its shape and assists in forming the floor of the nostril and roof of the mouth. The suture between it and its fellow forms a part of the nasal crista for the arti- culation of the vomer, and posteriorly is elongated into the posterior nasal spine; from which arises the azygos uvula? muscle. The ascending or vertical portion* is divided in its internal or nasal face by a ridge,8 for the articulation of the inferior turbinated bone ; externally it has a rough. articular surface for the maxillary bone ; upon this surface is a groove, converted into the posterior palatine foramen or canal by this articulation, which transmits the palatine nerve and artery. Posteriorly there is an elongated triangular process called pterygoid? this process has three grooves, the middle of which forms a part of the pterygoid fossa, and those on each side receive the external10 an.' internal11 plates of the pterygoid process. BONES OF THE FACE. 31 The upper extremity of this vertical or nasal portion is formed by two processes separated by a notch which is converted into a foramen, called spheno-palatine,7 by articulation with the sphenoid bone, and transmits the sphenopalatine artery and nerve. The anterior pro- cess is called orbital? forming a small part of the orbit between the ethmoid and superior maxillary. The posterior is the pterygoid apophysis? extremely thin, in- clines inwards and fits upon the Fl£- 16- base of the body of the sphenoid. MALAR BONE. Is quadrangular in shape, and forms the prominence of the cheek. It consists of a body and processes. The body has three surfaces, the external or facial of which, has numerous small perforations for ar- teries7 and nerves ; the internal or orbital is smooth and has a notch which limits the spheno-maxillary fissure or foramen lacerum inferius of the orbit; the posterior forms the anterior boundary of the temporal or zygomatic fossa. The superior process is the frontal,3 for articulating with the exter- nal angular process of the frontal bone. The temporal process* pro- jects backwards to unite in forming the zygomatic arch. The maxillary? 6 is triangular and rough for articulating with the malar process of the superior maxillary bone. The bone has also three edges. The superior3 is curved and continuous with the orbital ridge, the inferior gives origin to the zygomatic and mas- seter muscles, and the posterior has the temporal fascia connected with it. The malar bone sometimes contains a cavity called the sinus jugalis, especially in Mongolians and Malays. NASAL BONE. These bones unite with each other2 and are placed between the nasal processes of the superior maxillary bones. The shape is a long quadrangle. The superior extremity is narrow and thick, articulating with the frontal bone. The inferior is thinner and broader, having the cartilage of the nose attached ; the internal edge articulales with its fellow, and the external has a spiral groove, whereby it is overlapped by the nasal process of the superior maxil- lary above, and overlaps the process below. The anterior surface has numerous foramina for nutritious vessels; the posterior contains a groove for the internal nasal nerve. 32 BONES OF THE FACE. UNGUIFORM BONE. Called so from its resemblance to a finger nail («nguis);val~^ lachrymal. It is quadrangular, flat, and- small, «tr«mely thm and often cribriform. The external surface1 forms a portonotlteort* Fi„ 17 of the eye, and has a groove in front,2 which completes * * "■ the canal for the lachrymal sac. From its inferior edge there projects a triangular process7 which art.cuates with inferior turbinated bone. The edge4 s "articulates with the frontal, ethmoid, and superior maxillary bone. INFERIOR TURBINATED BONE. This is a porous scroll, placed at the inferior ~ rJ part of the nasal cavity below the ethmoid. Its posterior e'nd is the more pointed. Its internal surface is convex and looks towards the nose; the external surfaceTias a broad hook, processus maxillaris," which enters the antrum Highmonanum, and partly closes it. The superior edge has a triangular process called lachrymal, which articulates with the unguis. The portions of the edge in front and behind this process rest upon ridges of nasal process of the superior maxillary and palate bone ; there is frequently a process upon this edge which unites with the ethmoid bone. VOMER. \ single bone, forming a large portion of the nasal septum, consisting of two plates of compact structure. It is a flat bone with four edges. The superior is the thickest, having a deep groove between two lips (ala?) for the reception of the processus azygos of the sphenoid. The inferior is the longest, articulating with the nasal crista of the palate suture. The anterior unites with the nasal la- mella of the ethmoid, and the posterior is thin, sharp, and concave, separating the posterior openings of the nose. INFERIOR MAXILLARY. Is also single, having a parabolic curve; placed at the inferior portion of the face. It consists of a body and two rami. The body is convex in front and presents in its middle the anterior mental tubercle or spine, which in youthful life is a suture. On either side of this is a large hole, called the anterior mental5 foramen, trans- mitting a part of the inferior alveolar artery and nerve. The pos- terior is concave and has the posterior mental tubercle in its middle, upon which are two marks on each side, for the genio-hyoglossus and genio-hyoid muscles; on either side of this tubercle or spine is a fossa for the insertion of the digastricus. Extending backwards from this is a ridge8 called mylo-hyoid, for the muscles of that name; above this ridge in front, is a shallow fossa for the sublingual gland; OF THE HEAD IN GENERAL. 33 below it and behind, a larger one for the submaxillary gland. The upper edge is the alveolar pro- cess, with sockets for sixteen teeth. The inferior edge is the base, thicker in front, with two corners in front giving a squareness to the chin, which is that portion included between the anterior mental fora- mina. The ramus2 is square, and at right angles to the body in man- hood, in youth and old age oblique; externally it is rough for the mas- seter muscle, anterior to which is a groove for the facial artery.7 The internal face has a foramen, posterior mental,13 for the entrance of the inferior alveolar artery and nerve. To the edge of this foramen is attached the internal lateral ligament; near it is a groove14 trans- mitting the mylo-hyoidean nerve ; below, is the surface for the inser- tion of the internal pterygoid muscle. The angle8 is rough, has attached to it the stylo-maxillary ligament. The anterior edge of the ramus is continued into the external oblique ridge.6 The supe- rior part of the ramus has two processes separated by13 the sigmoid notch. The coronoid process is in front,10 triangular and thin; it has inserted into its apex the temporal muscle; in front there is a groove for the buccinator muscle. The posterior is the condyle11 arti- culating in the glenoid cavity of the temporal bone. The neck is narrow, and on the inside of it is a fossa for the insertion of the ex- ternal pterygoid muscle. OF THE HEAD IN GENERAL. Sutures.—The principal sutures of the head are the coronal, which unites the parietal and frontal bones ; saggital, which unites the two parietal bones in the adult, and in a child extends to the root of the nose; occipital, which joins the parietal and occipital bones; squamous, uniting the squamous part of temporal and parietal. Besides these there are others uniting the bones of the face. That part of the suture between the mastoid and parietal bones, is called additamen- tum sutura? squamosa? ; and that suture between the mastoid and oc- cipital, called additamentum sutura? occipitalis. Fontanels.—These are the deficiencies in the bones peculiar to the foetal head. The anterior is large and quadrangular, situated at the junction of the coronal and saggital sutures. The anterior angle is the most elongated. The posterior is small and triangular, situ- ated at the junction of the lambdoidal and sagittal sutures. Besides 34 OF THE HEAD IN GENERAL. these there are two smaller fontanels on either side; one is in the angle of the temporal, parietal, and occipital bones, and the other is at the junction of the temporal, parietal, and sphenoid bones. Ossa Wormiana or Triquetra, are small, irregular in shape and number, sometimes found in the sutures, particularly about the middle of the lambdoidal. They have a distinct point of ossification. The diploe is the cellular bony structure between the external and internal or vitreous tables; it is traversed by channels lined by a venous lining which empty into the emissaries of Santonni. The cavity of the cranium is about six and a half inches in length, five in breadth and five in height. When the calvaria or arch of the cranium is removed, three deep fossa? are ob- served at the base on each side. The anterior is formed by the frontal, sphenoid and ethmoid bones, and contains the anterior lobes of the brain; the middle, formed by the sphenoid and temporal bones, lodges the middle lobe; the posterior, formed by the occipital and temporal bones, is for the cerebellum. Orbital cavity.—Is formed on each side by seven bones repre- sented in this manner Frontal Sphenoid (lesser wing). M , Lachrymal. c u •j, , • v Orbit. Ethmoid (os planum), Sphenoid (greater wing). Sphenoid (body). Malar. Superior maxillary. Palate. The cavity is conical, the apex being formed by the optic foramen, the base looks outwards and is somewhat quadrangular. The sphe- noidal foramen or fissure opens into the orbit, and is also called fora- men lacerum superius ; a slit or fissure between the sphenoid and, maxillary bones being the foramen lacerum inferius. Besides these there are other openings into the orbit already mentioned in the de- scription of each bone. Nasal Cavity.—This is an irregular cavity, separated from its fellow by the nasal septum. It has three distinct passages or mea- tuses. The superior is between the superior and middle turbinated bones, and has opening into it the posterior ethmoidal cells, the sphe- noidal cells, and the sphenopalatine foramen : the middle is between the middle and inferior turbinated bones, and has opening into it the frontal sinus, anterior ethmoidal cells, and the antrum, usually. The inferior is the largest, and between the inferior turbinated bone and the floor of the cavity. Into it opens the nasal duct. The opening into the nasal cavity in front is called the anterior nares ; the open- ing behind posterior nares or clivance. UPPER EXTREMITY. 35 Zygomatic fossa, also called temporal, is the large fossa on either side of the head, formed by the parietal, sphenoid, temporal, and frontal bones, and bounded externally by the zygoma. The tem- poral muscle occupies nearly the whole. Plerygo Maxillary Fossa or Fissure.—This is at the bottom of the zygomatic fossa, and formed by the sphenoid, palate, and supe- rior maxillary bones. It is triangular, and the base is upwards. The ganglion of Meckel is contained in it, which gives off branches going through the foramina which open upon this fossa. It is con- tinuous with the foramen lacerum inferius or spheno-maxillary slit. Facial Angle.—This is formed by drawing a straight line from the lower part of the frontal bone to the anterior nasal spine, and in- tersecting at this latter point by another drawn through the externa*! meatus auditorius. It establishes a relation between the cranium and the face. The smaller the angle the more inferior is the con- formation. By comparing the heads of the great races of the world, it is found to be 80° to 85° in Europeans, 75° in the copper-coloured or Mongolians, and 70° in Negroes. HYOID BONE. This bone is isolated in the neck, connected with the root of the tongue and upper part of the larynx. It is shaped like the Greek u, the convexity being in front. It consists of a body and four cornua. The body1 is quadrilateral, convex in front, and concave behind. The front surface gives origin and insertion to muscles, and has a well-marked projection. The great cornua2 are about an inch in length, and generally united to the body by means of cartilage-and ligaments; they are flattened, project backwards, and terminate in a head or tubercle. They give origin and insertion to muscles. The lesser cornua? are attached at the junction of the body and great cornu ; it is cartilaginous usually, and of a few lines in length. To it is attached the stylo-hyoid ligament. UPPER EXTREMITY. The upper extremity may be divided into the shoulder, arm, and forearm. The shoulder consists of two bones, the scapula and the clavicle. Scapula.—The shoulder blade of common language. Placed on the back part of the thorax between the second and seventh ribs. It is thin, flat, and triangular; has two surfaces, three edges, and three angles. 36 CLAVICLE. Fig. 20. The anterior face ^^^^^^ZT^t^ ridges, and giving origin to the subscapular mu*cle. i F face is the dorsum, divided by the spine into two fossa, the io supra-spinata, containing the supra-spinatus muscle, and the tossa infra-suinata for the infra-spinatus muscle. ThePspine is a rough ridge running obliquely across the dorsum, and terminating in the acromion process, which is flat an1 tnanguar has a small articular mark in front for the clavicle. The edge of the spine gives origin to the deltoid, and insertion to the trapezius muscles ; near the base of the scapula the spine has a small triangular surface,11 over which plays the trapezius tendon Internal edge or base.—Is the longest, and nearly parallel" with the vertebral column, has an external lip for the insertion of the rhom- boid muscles, and an internal one for the serratus anticus. External edge.—Is thick,' and contains a fossa giving origin to the teres minor muscle. At the upper part of this fossa is the origin8 of the long head of the triceps. Superior edge.—Is thin and small,3 has a notch called coracoid,4 which is converted into a foramen by a ligament, and transmits the supra-scapular artery and nerve, Near this notch arises the omo- hyoid muscle. Superior angle.—Almost a right angle, and has the levator anguli muscle inserted into it. Inferior angle.—Most pointed,' and gives origin by its posterior surface to the teres major muscle and is connected with the latissimus dorsi. External angle.—Presents a large articular cavity6 called glenoid upon a narrow neck. This cavity is oval and shallow, and at its summit is a mark showing the origin of the long head of the biceps muscle. Coracoid process.—This projects forwards and outwards from the neck,14 in a curved manner. Its tip has marks for the pectoralis minor, coraco-brachialis and short head of the biceps. Its base has a tubercle for the conoid ligament. CLAVICLE. A long bone placed transversely at the upper and anterior part of the thorax, resembling in shape the italic / It articulates HUMERUS. 37 with the sternum and scapula. The sternal two-thirds is convex anteriorly, and the humeral third concave anteriorly. The upper surface has a depression near the sternal extremity showing the origin of the sterno-cleido-mastoid muscle. The inferior surface has a roughness near the sternal extremity for the rhomboid or costo-clavicular ligament, and near the humeral extremity a tubercle and ridge for the coraco-clavicular ligament; the space between these two marks is for the subclavius muscle. The anterior edge gives origin by its sternal two-thirds to the pectoralis major, and by its humeral third to the deltoid. The posterior edge has a foramen for the nutritious artery. The sternal extremity is thick and triangular, with a surface for articulations with the sternum; the posterior and inferior corner of it is elongated, which contributes to the strength of the articulation. The humeral extremity is fiat and spongy with an articular face for the acromion process of the scapula. In the male the bone is shorter, thicker, and more curved than in the female. HUMERUS. The arm-bone is cylindrical, and reaches from the shoulder to the elbow. The superior ex- tremity presents a hemispherical head* for articu- lation with the glenoid cavity of the scapula, separated by a deep groove, the anatomical neck3 from the shaft of the bone. Below this groove are two tuberosities, the greater,4 is the external, and has three facets for the inser- tion of supra and infra-spinatus, and teres minor muscles ; the lesser on the inner side6 is for the insertion of the subscapularis. These tuberosi- ties are separated from each other by a groove,8 called bicipital, in which plays the tendon of the long head of the biceps muscle. The anterior or external edge7 of this groove has the pectoralis major muscle inserted into it, and the posterior8 receives the latissimus and teres major muscles. The surgical neck is between the insertion of these muscles and the anatomical neck of the humerus. About the middle of the shaft, and upon its outer side, is a triangular roughness9 for the insertion of the deltoid; on the inner side and a little below is a ridge for the coraco- brachialis :10 below this ridge is the nutritious 4 Fig. 21. 38 ULNA. foramen, and above it is a shallow spiral groove for the musculo- spiral nerve and profunda major artery. The inferior extremity is flat and broad ; anteriorly it is covered by the brachialis anticus muscle, and posteriorly by the triceps. Externally, there is a ridge1" leading to the external condyle,1* rom which arise the supinator and extensor muscles. Internally a ridge'6 leads to the internal condyle?* which is more prominent than the external, and from which arise the flexor muscles of the forearm. The articular surface for the elbow consists of a hemispherical head11 for the radius, and an irregular cylinder13 for the ulna. Above this articular surface, and in front, is a fossa,17 called the lesser sig- moid cavity, which receives the coronoid process of the ulna in extreme flexion; behind is a larger fossa, the greater sigmoid, for the olecranon in extreme extension. Fig. 22. The forearm consists of two bones—Radius and Ulna. The ulna is the longer and is placed on the inner side, reaching from the elbow to the wrist. The upper extremity is the larger, and has a hook-like process behind4 called olecranon, to which is inserted the triceps extensor cubiti. In front, is the coronoid process? the base of which has a roughness for the insertion of the brachialis anticus muscle. Be- tween the olecranon and coronoid processes, is the greater sigmoid cavity,3 for articulation with the humerus; continuous with this is the lesser sig- moid cavity,3 upon the outside of the coronoid pro- cess, for the articulation of the head of the radius. Behind the lesser sigmoid cavity, is a triangular, uneven surface, for the insertion of the anconeus muscle. This surface is limited by a ridge giving origin to the supinator radii brevis muscle. The body is prismatic; the anterior surface1 is occupied in its upper three-fourths by the flexor profundus, and in the lowest fourth, by the pro- nator quadratus muscle. The posterior surface is occupied by the extensors of the thumb and the indicator muscle. The external edge7 is the sharpest, for the at- tachment of the interosseous ligament. The lower extremity, has a small rounded head,8 the outer side of "which has a smooth articular sur- face for the radius. From the inner side, there projects<> the styloid process, to which is attached the internal lateral ligament; behind this process is a groove in which glides the tendon of the extensor carpi ulnaris muscle. CARPUS. 39 RADIUS, Placed on the outer side of the ulna, is slightly curved and pris- matic. The superior extremity has a rounded head?1 the rim of which is smooth, and partly plays in the lesser sigmoid cavity. The upper surface of the head has a cup-like depression for articulation with the humerus. Beneath the head is the neck?* the narrowest part of the bone. Below the neck, and on the inner side, is the tubercle?3 a prominence, rough below and smooth above, for the insertion of the biceps muscle. The body is prismatic; anteriorly, the surface gradually increases in breadth,10 giving origin to the flexor longus pollicis, and receiving the insertion of the pronator quadratus muscle. The posterior sur- face is occupied by the extensor major of the thumb and the indicator muscle. The external surface is curved, and has a roughness about the middle for the insertion of the pronator radii teres muscle, above which and-below the tubercle is the space occupied by the insertion of the supinator radii brevis muscle. The inferior extremity is thick and triangular. The surface of the extremity15 is concave and divided by a ridge. It articulates with the scaphoid and lunare. Continuous with this articular surface, is a smaller one on the internal aspect of the extremity for articulation of the ulna. Externally there is a styloid process?6 for the connexion of the external lateral ligament. Into a ridge contiguous to the palmar surface of the bone is in- serted the supinator radii longus. Upon the dorsal view of this extremity, are three large grooves, each divided into smaller ones. The groove near the supinator ridge transmits the tendons of the extensor ossis metacarpi pollicis and the extensor minor pollicis; the groove in the middle is the broadest and most shallow, transmitting the tendons of the radial extensors ; and the groove nearest the ulna transmits the tendons of the extensor communis, indicator, and exten- sor major pollicis. The portion of the groove occupied by the latter is very deep. HAND. The hand consists of the carpus, metacarpus, and digiti. The carpus or wrist is oblong, the greatest diameter being trans- verse. The dorsal surface is convex, and the palmar surface is concave with four prominences. This concavity transmits the flexor tendon. It consists of eight bones arrayed in two rows. The bones of the superior row are the scaphoid, lunare, cuneiform, and pisiform. Those of the inferior row are the trapezium, trapezoides, mag- num, and unciform. 40 metacarpus. Fig. 23. Scaphoid, is on the radial side, and resembles a boat; has a large convex surface superiorly for the ra- dius, and inferiorly a deep concavity for the magnum. It articulates in front with the trapezium and trape- zoides, and on the inside with the lunare. Lunare, of a crescentic figure, has a convex surface superiorly for the radius, and a concavity in front for the magnum, articulates on the inside with the cuneiform. Cuneiform. — Wedge-shaped, or pyramidal. Inferiorly it articulates with the unciform. Distinguished by a circular facet on its palmar surface for the pisiform. Pisiform.—Pea-like bone, forms one of the prominences in the palm of the hand, has the flexor carpi ulnaris muscle inserted into it, and has but one articular mark, which is for the cuneiform. It is the smallest bone of the carpus. Trapezium, has the most surfaces and angles. The largest articular surface is for the thumb; two others, joining each other, are for the scaphoid and trapezoides. On the palmar surface is a ridge and a deep groove for the flexor carpi radialis tendon. Trapezoides, is the smallest bone of this row—is a four-sided pyramid with its apex towards the palm ; its dorsal surface is the base and inclines inwards. Magnum.—The largest bone of the wrist. Has a rounded head looking backwards; the body is quadrilateral. Unciform.—Distinguished by a hook-like process resembling a nail on its palmar surface, which gives origin to the flexor brevis minimi di«iti. METACARPUS Consists of five bones, each having a head, shaft, and base. The head is rounded, articulating with the phalanx ; a roughness on each side indicates the attachment of the lateral ligament. The base is the superior extremity, rough, and quadrilateral, having articular marks on the extremity and either side. The body or shaft is prismoid, having impressions on its sides for the interossei muscles. First, is short and thick, for the thumb. Its base has but one articular surface, and that is for the trapezium. Its head is not very spherical, its palmar surface articulates with the sesamoid bones. DIG1TI. 41 Second, is the longest, for the index finger; has a notch at its base for articulating with the trape- zoid ; a lateral articular mark upon one side only, and a mark upon its dorsal surface for the extensor carpi radialis longior. Third, has a triangular base, with an articular mark on each side, and on its dorsum, one for the extensor carpi radialis brevior. Fourth, is much smaller. The ex- ternal lateral surface of its base is double. Fifth, the smallest. Its base has but one lateral surface, and that is ex- ternal and single. Internally a tuber- cle at the base for the extensor carpi ulnaris. DIGITI. The fingers contain three bones call- ed phalanges: the thumb has but two. First row.—The phalanges of this row are the largest, convex on their dorsal, and flat on the palmar surface. The superior extremity has a single concavity for the head of the metacarpal bone. The inferior has two convexities separated by a groove. A roughness on either side of this extremity, indicates the attachment of the late- ral ligament. The ridges extending from one extremity to the other, are for the theca of the flexor tendons. Second row.—These are smaller. The superior extremity has two concavities, separated by a ridge ; the inferior two convexities, separated by a groove. The ridge on either side of the body has the theca and tendon of the flexor sublimis attached to it. Third row.—These are the smallest, and differ much from the other rows, having but one articular extremity, which is the superior, having two concavities and a ridge. The inferior extremity is flat- tened, thin, and rough. The middle finger (impudicus) is the longest. The ring finder (annularis) is the next in size. The forefinger (indicator) is thicker than the last. . The little finger (auricularis) is the smallest. Sesamoid bones.—These are four in number—two being placed upon the palmar side of the lower extremity of the metacarpal bone of the thumb, in connexion with the short flexor tendon. Fig. 24. 4* 42 FEMUR. LOWER EXTREMITY. FEMUR. The femur is the longest bone in the body, reaching from the acetabulum to the knee. , ,-..,. The superior extremity presents a spherical head? which has a de- pression upon it for the ligamentum teres. The part between the head and shaft is the neck? which is shorter and Fig. 25. more horizontal in old persons and in females. Externally is the trochanter major, a large process having an oval mark in front for the gluteus minimus; and above a double mark for the gluteus medius; the tip has the pyriformis inserted into it, and behind the tip is the digital fossa, into which are inserted the gemelli and ob- turator muscles. Below and on the inner side is the lesser trochanter, into which is inserted the psoas magnus, and iliacus internus muscles. A ridge between the trochanters behind, indicates the insertion of the quadratus femoris, and a corresponding one in front, which is less distinct, serves for the connexion of the capsular ligament. The inferior extremity is broader than the up- per, and is divided by a fossa in front, and a notch behind, into two condyles. The internal condyle seems to be the longer ;8 its internal and posterior surfaces11 give origin to the internal lateral ligament and gastrocnemius muscles; its external surface assists in forming the notch, and has a roughness in front for the posterior crucial ligament. The external condyle contributes by its internal surface to form the notch, and has a roughness be- hind for the anterior crucial ligament. Its external and posterior surfaces give origin to popliteus, plantaris, and gastrocnemius muscles, and external lateral ligament. The fossa in front, is unequally divided between the condyles, the larger and flatter portion belonging to the ex- ternal. The shaft of the bone is curved anteriorly, and is covered in front by the origin of crura?us muscle. Posteriorly there is a rough ridge called linea aspera (Fig. 26), which consists of two lips having a tendency to separate above and below. The inner lip shows the insertion of the pectineus muscle,P of the adductor brevisab TIBIA. 43 and of the adductor magnus.am This last insertion occupies this inner lip in nearly its whole length, so also does the origin of the vastus internus. The Fig. 26. outer lip has inserted into it the gluteus maximusgm and also gives origin to the vastus externus, and the short head of the biceps flexor cruris.b PA T E LL A. The patella is the largest sesamoid bone in the body, and commonly called the knee-pan. It is flat and triangular; thick and broad above, and thin and pointed below. The anterior surface is covered by integument ; the posterior is a smooth articular surface divided by a ridge unequally— the external portion is the larger and flatter, adapted to a corresponding surface of the femur. The superior edge is thick, and has the tendon of the rectus inserted into it. The inferior is pointed, and to it is attached the ligament of the patella. TIBIA. The tibia is longer and thicker than the fibula, and placed on the inside of the leg, and commonly called the shin-bone. The superior extremity, or head, is large and thick, presenting an oval arti- cular surface for the femur. This surface is divided by a pyramidal eminence, the spinous process? into two, both of which are oval, but the internal is longer and deeper; to the base of this spinous process are attached anteriorly and posteriorly the crucial ligaments; in a depression upon its summit is fastened the posterior end of the external semilunar cartilage. (Fig 26 ) An enlargement upon either side of the head are called tuberosi- ties or condyles ; upon the posterior part of the external condyle* is a small articular face, looking downwards, for the head of the fibula ; upon the posterior part of the internal condyle3 is a depression for the insertion of the semi-membranosus tendon. Below the head, and in front, is a prominent tubercle" for the in- sertion of the ligament of the patella, and above it a smoothness corresponding with its bursa ; below the head, and behind, is a tri- angular surface, occupied by the popliteeus muscle, limited by an oblique ridge- (Fig. 28), which gives origin to the soleus muscle. Ihe body is prismatic. Its internal surface- (Fig. 27) is smooth and covered by the skin; the external surface gives origin to the 44 FIBULA. tibialis anticus and extensor communis digitorum ; from the posterior surface arise the tibialis anticus, and flexor communis dlfto™™; The anterior edge* (Fig. 27) is sharp and superficial, generally curved with some resemblance to the italic/; the external has a for the attachment of the interosseous ligament, and the xn- Fig.27. Fi^-28- ridge ternal is rounded, having the sartorius, gracilis, and semi-tendinosus inserted into it at its upper part. The inferior extremity is smaller than the superior, and four- sided. Over the anterior surface pass the extensor tendons; poste- riorly is a slight fossa9 (Fig. 28) for the tendon of the flexor longus pollicis ; externally, is a rough triangular fossa for the articulation of the fibula; and internally is a large process, called the inter- nal malleolus8 (Fig. 28), behind which is an oblique fossa, trans- mitting the tendons of the tibialis posticus. The inferior extre- mity of the malleolus is notched for the attachment of the internal lateral ligament; its internal surface is superficial; its external sur- face is continuous with the quadrangular concavity at the extremity of the bone, for the articulation of the astragalus. FIBULA. The fibula is a long thin bone placed upon the outside of the lee FOOT. 45 and somewhat posteriorly at the upper part (Fig. 279, Fig. 2810). It is somewhat twisted in its appearance, and has a slight convexity backwards. The superior extremity or head is thick and large, and depressed upon the upper part by a concave surface, which ar- ticulates with the external condyle of the tibia. External to this surface, is a mark for the attachment of the external lateral liga- ment of the knee-joint, terminated behind by a styloid process, for the insertion of the tendon of the biceps. The body is prismatic, and has three surfaces, the external of which is the broadest, and commencing upon the anterior part of the bone above, curves around it, so as to terminate upon its posterior side below. The upper two-thirds of this surface gives origin to the peroneus longus and brevis; the lower third terminates in a groove, which indicates the course of the tendons of these muscles. The internal face looks towards the tibia, and is divided longitudinally by a ridge, to which is attached the interosseous ligament, the space in front of which gives origin to the extensor proprius pollicis, and the extensor communis digitorum ; and the space behind gives origin to the tibialis posticus. The posterior surface is also spiral, and gives origin to the soleus, and the flexor longus pollicis muscles. The inferior extremity terminates in the external malleolus, which is longer and flatter than the internal. Its external surface is super- ficial and triangular; its internal has a smooth articular surface for the astragalus. The extremity is pointed, and often called the coronoid process, immediately within which is a rough depression for the external lateral ligament. FOOT. It consists of the tarsus, metatarsus, and pha- langes. The tarsus consists of seven bones. Os Calcis.—This is the largest of the tar- sal bones, and constitutes the heel of common language. Its figure is longitudinal. The superior surface has two articular convexities for the astragalus, separated by a deep groove, in which is fastened the interosseous ligament. The posterior is the larger of the two. The internal surface has a deep concavity, called the sinuosity, for the tendons, vessels, and nerves of the sole of the foot. The ex- ternal surface is covered by the skin, and has two grooves for the tendons of the peroneus longus and brevis. The inferior surface has two tuberosities behind, of which (he internal is the broader and larger; and also one in front. 46 FOOT. These tuberosities give origin to muscles and ligaments. The pos- terior extremity3 is rough and prominent in its inferior hall, into which is inserted the tendo-achillis; the superior half is smooth, corresponding with the bursa. The anterior extremity presents two processes, called the greater and lesser apophyses ; the greater is external and below, and has a flat triangular articular surface for the cuboid bone, surmounted by a rough projection, which is a surgical guide in Chopart's amputation of the foot. The lesser apophysis (sus- tentaculum tali), is a blunt hook projecting forwards and upwards, having an articular concavity above, constituting a portion of the superior surface of the bone, which articulates, with the astragalus; upon its inferior surface is a groove for the tendon of the flexor longus pollicis. Astragalus.1—Is next in size to the os calcis. It consists of a body and a head. The superior surface of the body presents a large articular convexity for the tibia ; continuous with this, on either side, is an articular surface for the malleoli; inferiorly is a concavity, divided by a deep rough groove for the interosseous liga- ment ; posteriorly, is a slight groove for the flexor longus pollicis. The head is upon the anterior portion of the bone. It presents a large anterior convexity, the horizontal diameter of which is the greatest. On the internal side of the head is a small triangular sur- face, which rests upon the calcaneo-scaphoid ligament. The head is united to the body by a narrow portion called the neck, which has a depression superiorly and inferiorly. Scaphoid*—Is oval, thicker above than it is below ; posteriorly, it has a deep concavity for the head of the astragalus ; anteriorly, an articular convexity, divided by ridges into three triangular facets for the cuneiform bones. Internally, is a tubercle for the insertion of the tibialis posticus tendon ; and externally, there is sometimes a small articular face for the cuboid. Internal Cuneiform.5—Is the largest of the three cuneiform bones. It is wedge-shaped, and is placed upon the inner side of the foot. The small extremity of the wedge looks upwards. Its internal sur- face is convex, and immediately beneath the skin ; its external sur- face is concave, and has articular marks for the second cuneiform and the second metatarsal bones ; anteriorl//, is the largest arti- cular surface, for the metatarsal bone of the big toe ; posteriorly, is a triangular articular cavity, with the base downwards. The in- ferior surface of the bone, or the base of the wedge, is rounded into a tuberosity ; upon the inner side, is inserted the tendon of the tibialis anticus. Middle Cuneiform?—Is the smallest of the three, and placed with the base of the wedge upwards; anteriorly, it articulates with the second metatarsal bone; posteriorly, it is slightly concave and arti- METATARSUS. 47 culates with the scaphoid; internally, it articulates with the internal cuneiform, and externally, with the external cuneiform bone. External Cuneiform.7—Intermediate in size between the two last. It is wedge-shaped and base upwards. Anteriorly it articu- lates with the third metatarsal bone; posteriorly there is a quadran- gular facet for the scaphoid ; internally it has two articular surfaces, the posterior of which is the larger, and for the internal cuneiform bone; the anterior is for the second metatarsal. Externally is an angular projection, in front of which is a small facet for the front metatarsal bone, and behind which is an articular surface for the cuboid bone. Cuboid.8— Placed at the outer portion of the foot, is somewhat cuboidal in shape; superiorly, it is rough and convex; inferiorly, is a prominent ridge for the calcaneo-cuboid ligament, and in front of this ridge is a groove, commencing at the external edge, and running obliquely forward, in which plays the tendon of the peroneus longus* internally, it articulates with the external cuneiform; anteriorly, with the fourth and fifth metatarsal bones; posteriorly, is a semi- spiral surface for the greater apophysis of the os calcis. M ETAT ARS U S, Consists of five parallel long bones," whose heads articulate with the toes rough on each side, and whose bases articulate with each of the three cuneiform and cuboid bones. The necks are narrow Fcrst On the inside of the foot; easily recognised, being the shorter and thickest of the set. Its base is large and articulates with the in- ernal cuneiform bone, and has a tubercle below for the peroneus longus. The head is spherical, articulating with the first phalanx in front, and below with the sesamoid bones. Second Is the longest. Its base articuiates with the middle cunei- T^nl0ni mSlde Wkh the internal cuneiform, and on the outside with the third metatarsal and external cuneiform Third. Is distinguished by the external surface of its base, having two articular facets for the fourth metatarsal. The base articulate! also with the external cuneiform and second metatarsal Fourth. Its base articulates with the cuboid, and on either side with the contiguous metatarsal bone. The internal lateral face of the bone is distinguished by having two articular marks *ijth. Is the smallest and readily recognised by the large tubercle projecting backwards and outwards from the base, into thl upe for part of which is inserted the. peroneus tertius, and into the extremftv the peroneus brevis. This process is a surgical guide n Hev's^m metalTsatthG ** **" ^ ^^ -^thLu^SfourTh 48 LIGAMENTS. TOES. There are five on each foot. Each consists of three phalanges, with the exception of the first or great toe, which, like the thumb, has but two. Theirs* row1* of phalanges are smaller than those of the fingers, and readily distinguished by the narrowness of their bodies. The bases have a single concavity; the anterior extremities have two convexities, separated by a groove. The second row.13—These phalanges have hardly any body ; the posterior extremities have two concavities, separated by a ridge; and the anterior, two convexities separated by a groove. The third row.1*—These phalanges are very small; their bases have two concavities and a ridge. The anterior extremity is flat and rough. Sesamoid Bones.—These are two small sections of a sphere of bone, imbedded in the tendon of the flexor brevis pollicis of each foot. The flat surface plays on the inferior part of the head of the meta- tarsal bone of the great toe. SECTION II. ARTICULATIONS. LIGAMENTS. An articulation or joint is the connexion of one bone with another. If motion be intended, it is necessary that cartilage, ligaments, and synovial membranes should be employed in the mechanism. Cartilage.—Is white, flexible, elastic and hard. Its chemical composition is, gelatine 44*5; water 55 ; phosphate of lime 0*5, By boiling it becomes yellow, swells, and the gelatine is dissolved. It resists mortification and putrefaction longer than any tissue except bone. When dried it becomes hard and contracted, and semi-trans- parent, resembling common glue. Soaking in water restores its appearance. It contains no red blood-vessels, nor can nerves nor lymphatics be traced in it. Old age disposes it to ossify, particularly in the ribs and larynx. Perichondrium is the fibrous investing membrane of cartilage corresponding to the periosteum of bone. Articular cartilages.—These cover the extremities of bone and obviate or equalize pressure. Those lining the cavity are thicker on the edges ; those covering a convexity are thicker in the middle. Inter-articular cartilages are free and movable in the joint, not covering a bony surface, and held in their places by connexion'with ligaments: they are called menisci, from their shape. Fibro-cartilage.—Is stronger and tougher than cartilao-e • it is ARTICULATION OF THE LOWER JAW. 49 partly ligament and partly cartilage ; found in the ear, at the sym- physis pubis, and between the vertebra?. Ligaments consist of fibrous tissue, of which there are two kinds, white and yellow ; an example of the white is found in tendons, fascia?, and most of the ligaments ; the yellow is found in the liga- mentum nucha?, and in many vessels and ducts. It is elastic. Ligaments are called capsular when they are bag-like, as at the shoulder and hip ; funicular, when cord-like, and membranous when like a riband. Synovial membranes are thin, transparent, closed serous sacs, lining capsular ligaments, and secreting an albuminous fluid called synovia, which resembles in appearance the white of an egg. It lubricates the joints, and prevents attrition. Masses of fat outside of the synovial membranes are usually called glands of Havers. They do not secrete, however, but serve a mechanidal purpose in the mechanism, filling up spaces which would otherwise be formed in many articulations during the performance of certain movements. The synovial fringes are nothing but folds of this membrane in- cluding small portions of fat. The principal kind of articulations are termed : Synarthrosis, implying immobility, and including Sutura.—Bones of the skull. Harmonia.—Superior maxillary bones. Schindylesis.—Vomer with processus azygos. Gomphosis.—Teeth with alveoli. Amphiarthrosis implies partial motion, and is exemplified in the symphyses and bodies of vertebra?. Diarthrosis is a movable articulation, and includes— Arthrodia.—Tarsal and carpal bones. Ginglymus.—Elbow—wrist—hinge-like. Enarthrodia.—Hip, shoulder, ball and socket. ARTICULATION OF LOWER JAW. Capsular Ligament.—Extends from the border of the glenoid ca- vity of the temporal bone, and surrounds the neck of the con- dyloid process of the lower jaw. External Lateral Ligament? —Is broad and triangular, cover- ing the outside of the joint, ex- tending from the tubercle at the root of the zygoma to the outside of the neck of the condyle— (Fig. 30). Internal Lateral Ligament.— Properly speaking, not a liga- ment but a fibrous band or sheath Fig.,30. 50 LIGAMENTS OF THE VERTEBRA- for the protection of vessels or nerves from the ucontractl°" ^ *e pterygoid muscles, between which it passes from the spinous pioces of the sphenoid to the spine at the margin of the posterior mental foramen.4 (Ficr. 31.) , . „. , , Stylo Maxillary? (Fig. 31), is an extremely thin fibrous band ex- tending from the styloid process of the temporal bone to the angle of the lower jaw. Fig. 31. Fig. 32. Internal Articular Cartilage3 is a thin oval plate, dividing the joint into two cavities. It is partly concave above and below, thick at the edges. (Fig. 32.) The Two Synovial Membranes? * (Fig. 32.) One is reflected between the glenoid cavity and the interarticular cartilage ; the other between the cartilage and the condyle of the jaw. When the cartilage is perforate, the two cavities are lined by one synovial membrane. LIGAMENTS OF THE VERTEBRAE. BODIES. Intervertebral Substance.—The bodies of the vertebra? are united by fibro-cartilaginous disks, which are twenty-three in number, con- sisting of concentric rings ; toward the centre there is a yellow jelly- like mass, in a state of compression; it is whiter and more abun- dant in infancy. On this account persons are stiffer in old age, and are shorter in the evening than they are in the morning. Anterior Vertebral Ligament1 is in front of the bodies of the ver- tebra? (Fig. 351) ; extending from the second vertebra? of the neck to the first of the sacrum ; it is thin and gradually increases in breadth. Posterior Vertebral Ligament.—It lies upon the posterior sur- face of the bodies of the vertebra?, and extends from the occiput to the os-coccygis ; it is narrow and thick in the thorax, adheres closely to the intervertebral substance, and its edges present a ser- rated appearance. Processes.—Oblique.—These are surrounded by capsular liga- ment, lined by a synovial membrane. ATLAS AND DENTATA. 51 Spinous.—The spaces between the processes are filled by the inter-spinal ligaments. In the back they are triangular, in the loins quadrangular, and in the neck deficient or wanting. The free edge of the ligament is thick and cord-like.1 Ligamentum Nucha.—Continuation of the last, reaching from the seventh cervical vertebra to the vertical ridge on the occiput. Yellow Ligaments are between the bony bridges of the vertebra? —twenty-three pairs; the first is between the second and third vertebra?. They are remarkable for their elasticity and colour. ATLAS AND OCCIPUT. Anterior Ligament is a strong, broad ligament, extending from the superior edge of the anterior arch of the atlas to the basilar pro- cess of the occiput. The middle portion connected with the tubercle of the atlas is thick. Posterior Ligament, is thin, broad and loose, extending from the posterior arch of the atlas to the corresponding edge of the foramen magnum occipitis. It is perforated by the vertebral artery. Capsular Ligament surrounds the superior oblique process of the atlas and the condyloid process of the occiput. Thicker and stronger in front. ATLAS AND DENTATA. Transverse Ligament stretches across the atlas from one tubercle to the other, dividing it into two rings,3 (Fig. 33), and has an ap- pendix above,3 connecting it with the occiput, and one below,4 con- necting it with the dentata. Moderator Ligaments are short and thick; extending from the sides of the apex of the processus den- tatus5 to a fossa on the inner side of each condyle. They limit ro- tation of the head. Middle or Straight Ligament, reaches from the tip of the apex of the processus dentatus to the an- terior edge of the foramen magnum. Capsular Ligament of the oblique process of the atlas and den- tata is very loose. La^erti Ligamentosi are ligamentous bands extending from the occiput to the posterior part of the body of the dentata. LIGAMENTS OF THE PELVIS. Sacro-Iliac Symphysis.—The articular surfaces are covered by cartilage and united by short, thick, strong fibres, which are with dif- 52 LIGAMENTS OF THE PELVIS. Fig. 34. ficulty divided. A yellow fluid is sometimes interposed, and in children and pregnant women a synovial membrane. v 5 Anterior Sacro-Iliac Li- gament; short ligamentous fibres passing from bone to bone in front of the joint. Posterior Sacro - Spin- ous Ligament; numerous strong fibres, passing from the superior and inferior spinous processes to the transverse processes of the third and fourth sacral ver- tebra?. Greater Sacro - Sciatic Ligament, extends from the posterior inferior spin- ous process of the ilium, margin of the sacrum and of the first bone of the coc- cyx, to the inner margin of the tuberosity and ramus of the ischium. front of last; arises from coccyx; inserted into the Lesser Sacro-Sciatic Ligament; in the side of the sacrum3 (Fig. 34), and spine of the ischium. Fig. 35. These two ligaments form the posterior and lateral boundaries of the pelvis, converting the sacro- sciatic notch, into two foramina,4' (Fig. 34). Ilio-Lumbar Ligament, passes from the transverse process of the last lumbar vertebra to the poste- rior part of the crest of the ilium.3 (Fig. 35). Lumbo-Sacral Ligament, arises from the transverse process of last lumbar vertebra, and is inserted into the upper part of the sacrum.3 (Fig. 35). Anterior Coccygeal Ligament, —Its fibres are indistinct, often wanting—runs in front of the whole length of coccyx from the last bone of the sacrum. RIB WITH STERNUM. 53 Posterior Coccygeal Ligament, arises from the inferior margin of the sacral canal, and terminating at the second bone of the coccyx. Obturator Ligament5 (Fig. 35).—Fills up the thyroid foramen; is membranous and thin, perforated at its upper part for the trans- mission of the obturator vessels. Sub-Pubic Ligament.—A thick, triangular ligament, rounding the apex of the circle of the pubis; reaching from one bone to the other. Symphysis Pubis.—The bones are connected by fibro-cartilage, resembling intervertebral substance; sometimes there is a synovial membrane. A few transverse fibres in front and behind are some- times called anterior and posterior ligaments. THORAX. VERTEBRA WITH THE RIBS. Anterior or Radiated Ligament.—Short fibres radiating from the head of the rib, to the two contiguous vertebra? and the sub- stance between them. Capsular Ligament.—Surrounds the head of the rib ; thickest above and below. Inter-articular Ligament.—A thin Ig' " band passing from the ridge on the head of a rib to the intervertebral substance, dividing the cavity into two parts, each of which has a distinct synovial mem- brane. The first, eleventh and twelfth are exceptions to this rule. The tubercle of the rib is connected to the transverse processes by a capsu- lar ligament, and also the internal costo- transverse ligament3 passes from the inferior edge of the transverse process, and is inserted in the sharp edge of the neck of the rib below. External costotransverse Ligament? —Is quadrangular, extending between the transverse process and the contiguous rib. Middle costo-transverse Ligament.—A collection of short irre- gular fibres mixed with reddish adipose tissue, passing directly from the transverse process to the rib. RIB WITH STERNUM. Anterior extremity of ribs. Anterior radiated Ligament6 (fig. 37).—Consists of a number of fibres, reaching from the cartilage of the true ribs to the sternum, and blending itself with the periosteum. Posterior radiated Ligament.—Not so distinct as the last, passing in the same direction. 5* 54 CLAVICLE AND SCAPULA. Costo-xiphoid Ligament.—Reaches from the cartilages of the sixth and seventh ribs, to the ensiform cartilage. w„,™ A synovial membrane and ligamentous fibres are found between the sixth and seventh, and eighth and ninth, sometimes. UPPER EXTREMITY. SHOULDE R. The clavicle and sternum have interposed a wedge-shaped infer- articular cartilage, dividing the joint into cavities, and the whole is surrounded by a strong capsular ligament1- (Fig. 37), which is fibrous and thick, looser before than it is behind. Inter-clavicular Ligament} —A ligamentous cord stretch- ing from the end of one clavi- cle to the other. Rhomboid Ligament?— A strong, thick ligament, proceed- ing from the upper surface of the cartilage of the first rib obliquely upwards and outwards to the inferior and sternal end of the clavicle. Fig. 37. CLAVICLE AND SCAPULA. Capsular Ligament.1—Surrounds the acromion process of the sca- pula, and the external extremity of the clavicle. The fibres upon the upper and lower surface are very distinct. Coraco-clavicular Ligament* (Fig. 38).—Consists of two parts, one of which is called conoid; it is triangular, vertical, commencing at the root of the coracoid process, and expanding as it ascends, is fastened to the tubercle at the inferior extremity of the clavicle; the other is called trapezoid; it is in front of the last, arises at the in- ternal edge of the coracoid process, and proceeds obliqifely upwards to a ridge on the lower surface of the external end of the clavicle. Bifid Ligament.—Is an aponeurotic expansion, commencing at the coracoid process, terminating upon the inferior surface of the clavicle, and also upon the cartilage of the first rib. It protects the inferior portion of the subclavius muscle. Coraco-acromial Ligament3 (Fig. 38).—Is thick and triangular; the base commences upon the outer edge of the coracoid process, and the apex is fastened to the acromion ; it prevents a dislocation of the humerus upwards. Coracoid Ligament* (Fig. 38).—Is a small transverse fasciculus, ELBOW JOINT. 55 stretched across the coracoid notch, and converting it into a fora- men for the supra-scapular artery and nerve. HUMERUS AND SCAPULA. Fig. 38. Capsular Ligament5 (Fig. 36).— Surrounds the glenoid cavity and the neck of the humerus; it is loose and perforated by the tendon of the long head of the biceps.7 It is deficient behind ; this deficiency is supplied by the tendons of the surrounding muscles, particularly the sub-scapu- laris. Coraco-humeral Ligament? — Is sometimes called adscititium; is a thick fasciculus of the capsular ligament, proceeding from the coracoid pro- cess, which holds the head of the bone on a level with the glenoid cavity. Glenoid Ligament.—A prismatic ring of fibro-cartilage, attached to the edge of the glenoid cavity, and in- creasing its depth. The synovial membrane is very extensive, and communicates with the bursa? of tendons. ELBOW JOINT. Capsular Ligament.—It surrounds the extremities of the humerus, radius, and ulna. It is strengthened by the Internal lateral Ligament* (Fig. 39), which, commencing at the internal condyle, has two insertions, one into the coronoid, and the other into the olecranon process of the ulna. External lateral Ligament* (Fig. 40). —Is triangular, com- mencing at the external condyle, and terminating in the annular ligament. Coronary or annular Ligament5 (Fig. 41).—Is strong and dense surrounding three-fourths of the head of the radius ; its extremities are fastened on either side of the lesser sigmoid cavity. Interosseous Ligament5 (Fig. 39).—Is a ligamentous membrane, filling up the space between the radius and ulna throughout their length. It is perforated at its upper part, for the transmission of the posterior interosseal artery; this deficiency is compensated for by the hgamentum teres* (Fig. 39), whose fibres are oblique and 56 WRIST JOINT. in an opposite direction to those of ^ ^^^^\I commences at the coronoid process, and terminates oeiu cle of the radius. Fig. 39. Fig. 40. Fig. 41. Sacciform Ligament.—Is a loose capsular ligament, proceeding from the lower extremity of the ulna with the lesser sigmoid cavity of the radius. This is strengthened by the anterior radio-ulnar ligament2 (Fig. 42), which passes obliquely between the two bones, and the posterior radio-ulnar ligament. WRIST JOINT. This joint is formed by the greater sigmoid cavity of the radius, and the scaphoid, semilunar, and cuneiform bones ; and is surrounded by the capsular ligament, which is strengthened by an anterior ligament3 (Fig. 42), a broad membranous layer; an internal lateral ligament? reaching from the styloid process of the ulna to the cuneiform and pisiform bone ; an external lateral ligament? reach- ing from the styloid process of the radius to the scaphoid bone; and a posterior ligament, which is thin and loose, passing be- tween the posterior surface of the radius, semilunar, and cuneiform bones. LOWER EXTREMITY. 57 Fig. 42; Fig. 43. The bases of the metacarpal bones are secured to the second row of the carpal bones by fibrous bands called dorsal and palmar liga- ments. That of the thumb has a true capsular ligament. FINGER JOINTS. The joint between the metacarpal bones and the first row of pha- langes, is a ball-and-socket joint. It is secured by an internal and external lateral ligament13 (Fig. 40), which are very thick in pro- portion to the size of the bone; anterior or palmar ligament?2 the extensor tendon taking the place of a posterior ligament. The heads of the metacarpal bones are also connected by transverse liga- ments.14 The second and third joints of the finger18 are arranged upon the same principle as the first, with the exception of the transverse liga- ment. LOWER EXTREMITY. HIP JOINT. Capsular Ligament8 (Fig. 35).—Is the largest and strongest cap- sule in the body, surrounding the acetabulum and the neck of the 58 KNEE JOINT. femur. It is thicker and longer in front than it is behind, and is strengthened by a bundle of fibres,* called iho-femoral. Cotyloid Ligament6 (Fig. 34).—Is a thick prismatic ring of fibre cartilage, surrounding and deepening the acetabulum. Ligamentum teres* (Fig. 34).-Is attached to a pit upon the head of the femur, and divides into two fasciculi, which are inserted into the corners of the notch of the acetabulum and the cotyloid ligament. The synovial membrane is extensive, and the Haversian mass is large. KNEE JOINT. This joint is surrounded by an expansion of the fascia lata of the thigh, called the involucrum generale. Anterior Ligament.—-Is the ligament of the patella3 (Fig. 44); it is the strongest ligament of the body. It is a continuation of the tendon of the quadriceps muscle,1 in which the patella" is developed, previous to its insertion into the tubercle of the tibia. Posterior Ligament.—-Is the ligament of Winslow1 (Fig. 45). It is a broad ligament passing obliquely from the external condyle of the femur to the posterior part Fig. 44. Fig. 45. of the internal tuberosity of the tibia. Its strongest fasciculi are derived from thesemi-membranosus ten- don.3 Internal Lateral Liga- ment.—Is broad, thin, and membranous, extending from the external condyle of the femur to the lower part of the internal tubero- sity of the tibia.5 External lateral Liga- ment.—Is a strong cord- like ligament8 reaching from the external condyle to the superior extremity of the fibula. Semilunar Cartilages.—Are two prismatic rings of fibro-carti- lage, deepening the articular surfaces of the tibia. The external7 (Fig. 46) is the smaller and more circular. The internal8 is the larger and a semicircle. The extremities are attached to the spine of the tibia. A small transverse ligament* connects them behind. Crucial Ligaments. — These cross each other. The anterior'1 ANKLE JOINT. 59 Fig. 46. (Fig. 46), arises from a roughness in front of the spine of the tibia, and is inserted into the posterior part of the internal face of the ex- ternal condyle. The posterior? commences at a roughness behind the spine of the tibia, and is inserted at the anterior part of the external face of the internal condyle of the femur. The synovial membrane is the most exten- sive in the skeleton; it forms folds in the in- terior of the joint, one of which is called the ligamentum mucosum, which is triangular in shape, passing from the condyloid notch to a mass of fat in front of the tibia. The alar ligaments are fringed folds of the synovial membrane, containing masses of fat on each side of the patella. The tibia and fibula are connected above by the Anterior Superior Ligament7 (Fig. 44).—A short, strong liga- ment, extending obliquely between the heads of the two bones in front. Posterior Superior Ligament9 (Fig. 45).—Passes obliquely be- tween the heads of the two bones behind. The synovial membrane of this articulation is generally distinct from that of the knee-joint. Interosseous Ligament11 (Fig. 46).—Is stretched between the tibia and fibula throughout their entire length, and opening at its up- per part, transmits the anterior tibial artery. Anterior Inferior Ligament (Fig. 48). — Is a broad band pass- ing obliquely between the two bones in front, and at their lower extremity. Posterior Inferior Ligament.—Is somewhat similar, passing ob- liquely between the lower extremities of the two bones. Besides these, the tibia and fibula are united by short strong fibres, passing from the contiguous surface of the two bones. ANKLE JOINT. It is the most perfect hinge in the body. Internal Lateral or Deltoid Ligament6 (Fig. 47).—Is triangular; its apex is attached to the internal malleolus, and its base to the os calcis, astragalus and calcaneo-scaphoid ligament. The tibialis posticis runs in a trochlea upon it. External Lateral Ligament678 (Fig. 48). — Consists of three parts, which arise from the external malleolus; the anterior passes forwards, and is inserted into the astragalus ; the middle descends, and is inserted into the os calcis; the posterior passes backwards, and is fastened to the astragalus. The synovial membrane is large 60 ARTICULATIONS OF THE FOOT. and loose, and is reflected upon some condensed cellular ti front, which is sometimes called the anterior ligament. Fig. 47. FiS- 48- ARTICULATIONS OF THE FOOT. The astragalus and os calcis are united by a strong, thick, inter- osseous ligament, passing from the groove on the upper surface of the os calcis to the corresponding one of the astragalus.—Poste- riorly there is a short ligament, called the posterior ligament, upon which plays the tendon of the flexor longus pollicis muscle. The 05 calcis and scaphoid are united by the superior calcaneo- scaphoid ligament, which passes from the inside of the greater apo- physis of the os calcis to the outside of the scaphoid and the in- ferior calcaneo-scaphoid, which occupies the triangular interval be- tween the lesser apophysis of the os calcis and the tubercle of the scaphoid. Upon this rests a portion of the head of the astragalus. The os calcis and cuboid are united by the superior calcaneo- cuboid ligament, which is a very thin flat band of fibres extending directly forwards from the os calcis to the cuboid and the inferior calcaneo-cuboid, which consists of two planes of fibres, of which the superficial or inferior layer is a strong band of pearly-white fibres, extending from all the under surface of the os calcis to the groove of the cuboid. The deeper-seated or superior layer, extends from the anterior tuberosity of the os calcis obliquely to the rid»e of the cuboid. The astragalus and scaphoid are united by a thin semicircular ligament, consisting of parallel fibres, extending from the neck of the astragalus to the margin of the concavity of the scaphoid. Cuneiform Bones.—-They are united to each other and the sca- phoid, by dorsal, plantar, and interosseal ligaments. The Bases of the Metatarsal Bones.—That of the first is united by a strong capsular ligament with the internal cuneiform bone, having a distinct synovial membrane. Those of the second and third are united with the middle and external cuneiform bone, by dorsal and TEETH. 61 plantar ligaments; those of the fourth and fifth by dorsal and plantar ligaments with the cuboid. The heads of the metatarsal bones are united to each other by a strong transverse ligament: and to the phalanges by two lateral, the plantar, and an expansion of the extensor tendon. The phalanges.—Their ligaments are arranged similarly to those of the hand. TEETH. The teeth are placed in the alveolar processes of the upper and lower jaw, and are the hardest portion of the human body. The permanent teeth are thirty-two in number, sixteen in each jaw; they are divisible into four classes. On each side of each jaw there are two incisors, one cuspid, two bi-cuspid and three molars ; each tooth consists of a body or crown, which is the part exposed above the gum; the neck, a narrow portion surrounded by the gum ; and a root or fang which is contained within the alveolus. The roots are surrounded by a periosteum, and perforated at their extremities by a foramen for the transmission of an artery and nerve. Fig. 49. Incisors.—Are next to the median line; their edge is bevelled, and in early life serrated; the root is single and conoidal; those of" the upper jaw are larger than those of the lower jaw. Cuspid, or Canine.—Is next to incisors. Its body is conoidal, and it has the longest root. Those of the upper jaw are sometimes called eye-teeth, those of the lower jaw stomach-teeth. Bi-cuspid.—Are next in size to the molars. The body has two grinding points, of which the external is the larger. The root is sometimes bifid and grooved upon either side. The anterior is the smaller. Molars.—They have large quadrilateral bodies, with four or five 6 62 TEETH. grinding points. In the upper jaw they have three divergent roots, two of which are external, and one is internal. In the lower jaw they have but two roots, which are anterior and posterior. 1 he third molar or wisdom-tooth is smaller, and less perfectly developed than the other two, and does not appear until manhood. Structure.—Each tooth has three textures, the ivory or bony por- tion, the enamel, and the cementum. The ivory forms the largest portion of the body, neck, and root; it consists of radiating fibres, the particles of which are not absorbed as in bone. It contains no vessels or nerves, and consists of phosphate of lime, gelatin, and water. The enamel is the hardest portion ; it encrusts the body; it is white, brittle, and semi-transparent, thicker upon the grinding sur- face, and terminates by a thin edge at the neck. Its structure consists of radiating fibres, and it possesses neither vessels nor nerves. The cementum forms a thin coating over the root of the tooth, from the apex to the enamel. It resembles bone in structure. It increases with the advance in age, making the teeth of old persons appear to project. A cavity exists in the roots of the teeth, which is filled by a pulp, principally composed of an artery, vein, and nerve, which enter at the small orifice at the point. Fig. 50. An infant gum contains the rudiments of fifty-two teeth, in sepa- rate cavities; twenty of them appear between the sixth month and second year of age, and fall out between the sixth and twelfth year; they are therefore called the deciduous or milk teeth, of which there are two incisors, one cuspid, and two molars on either side of ejch jaw. The order of the eruption is irregular, but the average is as follows : seventh month, two middle incisors; ninth month, two late- ral; twelfth month, first molar; eighteenth month, canine; twenty- fourth, two last molars. The teeth of the lower jaw precede those of the upper by a short interval. SKIN. 63 INTEGUMENTS, ETC. CELLULAR TISSUE. The cellular or areolar tissue is that substance found so universally distributed throughout the body. It serves for the purpose of con- necting muscles and organs, and forming a protection, being parti- cularly abundant beneath the skin. When parts are torn in a sub- ject it is very distinct, and its characters can then be best observed. It will be found to be white in colour usually, and to consist of a num- ber of cells which freely communicate, as is manifested in anasarca, emphysema, and ecchymosis. It is elastic and tough when fresh, when dried it is opaque and crisp ; long boiling converts most of it into gelatine. Its toughness is due to one set of fibres, which are white, inelastic, and straight; of such most ligaments are formed. Its elasticity is due to another set of fibres, which are yellow, elastic, and curling; of such the ligamentum nucha? and middle coat of arteries are composed. It is very vascular, though most of its vessels do not contain red blood in health, as may be seen in inflammation produced by the air or any other stimulus. Its moisture is due to serum. FAT. Fat is found in almost every part of the body, with the exception of the penis, ear, eyelid, and ball, interior of cranium, &c. &c, but in great abundance under the skin around the serous membranes. It is of a yellowish colour, and in life is in a semi-fluid condition. It consists of three elements, stearine, margarine, and elaine, which are contained in vesicles aggregated in lobules. In women fat is more abundant; and in infants it is upon the surface of the body, rather than in the cavities. It is of use in diminishing pressure upon the hands and feet; retains heat, being a bad conductor, and assists in nutrition, as is manifested in hibernating animals. SKIN. The skin is an external covering and protection, as well as an organ of touch and excretion. Its colour and thickness vary in different persons and in different parts of the same person. At the orifices of cavities it is converted into mucous membranes. The largest wrinkles are produced by the contractions of muscles, and by the flexion of joints ; others of an angular variety, owing to the con- tractile character of the skin, are seen upon the back of the hand ; the third variety is spiral. The skin is, perforated by hairs, perspiratory ducts, pits containing sebaceous glands and follicles; these are considered as appendages. 64 SKIN. Fig. 51. The skin consists of two layers, the true skin, also called cutis vera or chorion, and the cuticle or epidermis. The cutis vera" is the thicker and deeper of the two: is white, and semi-transparent in all persons; its internal or inferior surface is much blended with the subjacent cellu- lar tissue, and contains a number of pits or depressions ; the external surface has a number of conical projections called papilla tactus* which are particularly numerous in those parts where there is much motion. On the hands and feet they are arranged in spiral and semicircular rows, which occasion a similar wrinkle of the cuticle. They consist of an artery, vein and nerve; the sensibility of a part is in ratio to their number. The skin itself is formed of con- densed cellular tissue, the yellow fibrous element predominating where great elasti- city is required, as in the armpit; the white element, where resistance is de- manded, as in the sole of the foot. Between the interstices of these fibres, pass innu- merable vessels, ducts, &c, &c. It is thickened by pressure ; boiling reduces it to gelatine; and tannin converts it into leather. The cuticle or epidermis* affords pro- tection to parts most exposed to pressure or friction ; its thickness varies with the amount of pressure to which it is sub- jected ; compare the hand of an artisan with that of a delicate female. It is rot per- meated by vessels or nerves, but consists of particles arranged in different lamina?; those that are deepest are granular, those of the next layer are more compressed, whilst those upon the surface are mere scales. These superficial scales, which are horny, are constantly being shed, and new particles constantly supplied by the moist granules, which are below. The laminated condition makes it easy to divide into different layers, and the in- ferior layer was formerly called by a dis- tinct name,rete mucosum; but it is nothing more than the deepest or most recently formed part of the cuticle, which also con- tains the colouring matter, very abundan- dant in moles, freckles, and the skin of negroes. NAILS--HAIRS. 65 NAILS. The nails are modifications of the epidermis. Their appearance is too familiar to every one to demand description. That portion which is concealed is called the root, that which is free or projecting the edge, that attached to the surface of the cutis is the body. The matrix is that portion of the cutis under the root and body, which produces the nail. The lunula is that crescentic, white portion of the matrix near the root, and is owing to a want of vascularity. The Fig. 52. nail firmly adheres to the matrix, and is moulded upon it like the epi- dermis in other situations. The epi- dermis or cuticle is continuous with the nail, and neither passes over or under it; being essentially of the same structure. By maceration the epidermis and nailnn can readily be removed from the cutis vera.mm The border of the root of the nail is jagged, thin, and soft, and consists of newly- formed substance; the deep surface of the body is also soft, and marked by longitudinal grooves corre- sponding to the papillary ridges on the surface of the matrix; but the edge and superficial portion of the nail is composed of scales more dense and fibrous. HAIRS. Hairs are found on all parts of the surface, except the palms of the hands, and soles of the feet; and vary in length, thickness, shape, and colour, according to situation, age, sex, or race. The shaft is that portion projecting beyond the surface ; the bulb is that extremity contained in a follicle of the skin. The cuticular lining of this follicle is continuous with the bulb itself, there being a gradual change in the scales, as they pass from the follicle into the hair; the hair itself grows from the bottom of the follicle, like the nail from the matrix, or the epidermis from the cutis. If the hair is to be coloured, pigment grains are here also developed. The human hair is a rod, and not as commonly supposed, a tube. The scales in the axis of the hair are softer, and not so closely con- densed as those of the surface, and thus they contain a larger amount of pigment in the interstices, which produces that dark ap- pearance which is mistaken for a tube ; this loose, porous structure in the middle, is sometimes called the medulla, and the condensed, fibrous exterior is termed the cortex ; the scales of which are im- bricated, that is, overlap each other like the shingles of a roof. 6* 66 SWEAT GLANDS. Where the hairs are large, and especially where they serve as tactile organs, there may be a papilla furnished with nerves and vessels, in the bottom of the follicle, which projects into the bulb, as in the whiskers of a cat, and the quills of a porcupine ; an approach to this papillary projection may be seen in some of the hairs of man, but their size is much overrated. The hairs maintain a vital, though not a vascular connexion with the body; the moisture is partly due to the sebaceous glands, whose secretion passes through them by capillary attraction. Mental emotion has occasioned the hair to become white in a single night; some account for this by a secretion of fluid acid which percolates the tissue of the hair, and chemically destroys the colour. Ordinary gray hairs resemble other hair in every respect, save that of colour. The disease called Plica Polonica, is a matting together of the hairs by a glutinous matter, probably from the cutaneous glands; the hairs so affected bleed if cut close to the skin, owing to a morbid elongation of the vascular papilla? at their roots. SWEAT GLANDS. These are found in great number upon the inferior surface of the cutis vera generally. In the axilla they form a layer, an eighth of an inch thick, which is mammillated,and of a reddish colour. They are about the size of a pin's head, are soft, and often compressed and surrounded by a network of capillary blood-vessels. They are distinguishable from pellets of fat by their pink colour, and semi- transparent texture. When highly magnified, it is seen to consist of a solitary tube, intricately ravelled, one end of which is closed, and buried within the gland, and the other opens upon the skin. The duct at first meanders through the interstices of the cutis vera, becomes straight between the papilla?, then assumes a spiral course in perfo- rating the .cuticle. (Fig. 51.) The secretion varies in odour in different por- tions of the body, and in different races. SEBACEOUS GLANDS. The sebaceous glands are found in most parts of the skin, except in the palms and soles ; they are most abundant on the scalp and face, especially about the nose. The orifices open into hair follicles, or upon MUSCLES. 67 the general surface. They consist of a duct, terminating in a blind, pouch-like extremity, lined by an epithelium, in the particles of which are included granules of sebaceous matter. The secretion is sub- servient for the lubrication of the hair and the skin. There are gene- rally found in their ducts, parasites, of which two specimens are given in b and c, fig. 53. These animals are found in almost every indi- vidual, especially in those possessing a torpid skin; and they multiply in sickness. The ceruminous glands of the ear resemble the sebaceous glands. SECTION III. MUSCLES. Muscles are formed of that substance usually called flesh, which has a peculiar contractile power, producing motion ; they consist, independently of the cellular tissue, vessels, and nerves, which enter into their formation, of a special tissue, resembling the middle coat of the arteries. Every muscle is composed of a number of bundles of fibres, each of which consists of filaments ; each fila- ment is divisible into fasciculi, and each fasciculus consists of a num- ber of primitive particles or sarcous elements, held together by a tough, delicate, and elastic membrane called sarcolemma. The fibres of the voluntary muscles, as well as the fibres of the heart and some 68 MUSCLES. of those of the oesophagus, are striped; that is, have their fibres arranged in parallel lines; while all other muscles, including those of the alimentary canal, the uterus and the bladder, all of which are involuntary, are unstriped, that is, the fibres cross each other and interlace, and always form the walls of a cavity. The red colour of muscles is not dependent upon the capillary vessels, but upon a peculiarity of colouring matter united with them. After death they become stiff, as the fibrin coagulates, which rigidity is the rigor mortis. They are well supplied with vessels and nerves, and can be made to contract by external irritation after death, such as galvanism, &c, Every muscle has a belly and two extremities ; that which is fixed is called the origin or head, that which is movable, the in- sertion. Those which have neither origin nor insertion, and sur- round orifices, are called sphincters. A tendon is formed of condensed white fibrous tissue, reaching from the end of a muscular fibre to some structure which it is in- tended to move. MUSCLES OF THE HEAD AND NECK. Occipito frontalis.1*3—Has four bellies. Origin, from the superior semicircular ridges of the occiput. Insertion, into the superior margin of the orbicularis oculi, and cor- rugator supercilii, and into the Fig. 55. internal angular process of the os frontis and os nasi. Use; elevates the eyebrows making transverse wrinkles. Compressor Naris?—Origin, from the root of the ala nasi. Insertion, tendinously into its fellow on the dorsum of the nose, and into the lower part of the os nasi. Use; it either compresses or dilates the nostril. Orbicularis palpebrarum.* ;—This is a sphincter surround- ing the orbits of the eyelids. Origin, from the nasal pro- cess of the superior maxillary, the os unguis, the internal an- and the internal pa,pebra, ligMnenf 'S^t^ £& MUSCLES OF THE HEAD AND NECK. 69 Corrugator supercillii.—A narrow, small, and pointed muscle, be- neath the occipito-frontalis. Origin; internal angular process of the os frontis.—Insertion, into the occipito frontalis and orbicularis. Use; makes vertical wrinkles of the forehead. Levator Labii superioris alceque Nasi.8 — On the side of the nose. Origin, from the nasal and orbitar processes of the superior maxillary bone. Insertion, into the upper lip and wing of the nose. Use; it elevates the wing and sides of the nose. Levator anguli Oris?—Small and concealed by the last. Origin, from the superior maxillary bone, below the infra orbitar foramen. Insertion: corner of the mouth. Use; elevates the angle of the mouth. Zygomaticus minor.10—Origin, from the malar bone. Inser- tion, into the upper lip. Use; raises the upper lip outwardly. Zygomaticus major.11—Origin, from the malar bone, behind the last. Insertion, into the corner of the mouth. Use; draws the mouth obliquely upwards and outwards. Depressor Labii superioris al&que Nasi.—Very much concealed. Origin, from the alveolar processes of the incisor and canine teeth. Insertion, into the wing of the nose and upper lip. Use; depresses the upper lip and wing of the nose. Depressor anguli oris?3—Origin, from the base of the lower jaw, outside of the chin. Insertion, into the corner of the mouth. Use; draws the mouth downwards. Depressor Labii Inferioris?2—Origin, from the base of the lower jaw, beneath and in front of the last. Insertion, into the whole side of the lower lip. Use; draws the lip downwards. Levator Menti.1*—Is much concealed, and best viewed from the inside of the lip. Origin, from the alveolar processes of the lateral incisor and canine teeth. Insertion, into the lower lip. Use; ele- vates the lip. Buccinator.18—Origin, from the coronoid process of the lower jaw, from the tuber of the upper jaw, and alveolar processes of both jaws. Insertion, corner of the mouth and lips. Use; draws the mouth backwards, and presses the food between the teeth. Orl/icularis oris?—Is a circular muscle surrounding the mouth, has neither bony origin nor insertion, but is much connected with other muscles of the mouth. Masseter.1618—Origin, from the superior maxillary and malar bones, and also from the zygoma of the temporal bone. Insertion, into the angle and external surface of the lower jaw. Use; draws the jaw upwards and backwards ; is very strong, and consists of two planes of fibres. Temporalis.—Origin, from the temporal fascia, and sides of the temporal, frontal, and parietal bones. Insertion, into the coronoid process of the lower jaw. Use; draws the jaw upwards. 70 NECK. Pterygoideus externus.1- Fig. 56. Origin, from the pterygoid, spinous and temporal processes of the sphenoid, and from the tuber of the upper max- illary bone. Insertion, into the neck of the lower jaw. Use; draws the . jaw forwards. Pterygoideus internus? — Ori gin, from the internal pterygoid process, pterygoid fossa of the sphenoid, and from the Eustachian tube. Insertion, into the internal surface of the angle of the jaw, Use; draws the jaw upwards and inwards. MUSCLES OF THE NECK. Fascia;.—There are two fascia? for the neck ; the superficial and deep. The superficial fascia is continuous with that which covers the whole body. It consists of two lamina?, between which are en- closed the platysma myoides muscle. The deep fascia is formed of more condensed cellular tissue, and extends from the ligamentum nucha? to the larynx in front, including between its lamina? the sterno-cleido-mastoid muscles, and vessels of the neck. A strong process of it exists between the styloid pro- cess of the temporal bone and the angle of the jaw, and is called the stylo-maxillary liga- F'g-57- ment. Inferiorly, it forms a loop, which acts as a pulley to the omo-hyoid muscle, and thence is con- tinued down behind the subclavius muscle into the ligamentum bicorne, forming a por- tion of the boundary of the thorax. Platysma myoides, is included between two lamina? of the superficial fasciaof the neck, is a broad, thin muscle, and not al- ways well developed in man. Origin, from the condensed cellu- NECK. 7J lar tissue below the clavicle. Insertion, into the muscles upon the side of the face and lower jaw. Use; draws the skin of the neck and lower jaw downwards. Sterno-cleido-mastoideus?1 forms the most prominent feature on the outside of the neck. Origin, from the upper part of the sternum, and sternal end of the clavicle. Insertion, into the mastoid process of the temporal and into the superior semicircular ridge of the oc- cipital bone. Use; acting with its fellow, draws the chin towards the breast. Sterno-hyoideus.1*—Origin, from the sternum, clavicle, and car- tilage of the first rib. Insertion, into the inferior edge of the os hyoides. Use; draws the hyoid bone towards the sternum. Sterno-thyroideus.15—Origin, from the sternum and cartilage of the first rib. Insertion, into the side of the thyroid cartilage. Use; draws the cartilage downwards. Thyreo-hyoideus.16—Origin, from the side of the thyroid carti- lage. Insertion, into the body and cornua of the os hyoides. Use; it approximates the hyoid bone and thyroid cartilage. Omo-hyoideus?7 ls—Origin, from the superior edge of the sca- pula, near the coracoid notch. Insertion, into the base of the hyoid bone. Use; draws the hyoid bone downwards. It is tendinous in its middle. Digastricus,.12—Origin, from the fossa, behind the mastoid pro- cess of the temporal bone. Insertion, into the base of the lower jaw, at the side of its symphysis ; its middle is tendinous, and per- forates the stylo-hyoid muscle near its insertion. Use; elevates the hyoid bone, and opens the mouth, even when the lower jaw is fixed. Stylo-hyoideus? *—Origin, from the middle and inferior part of the styloid processes of the temporal bone. Insertion, being per- forated : into the junction of the body and cornua of the hyoid bone. Use; draws the hyoid bone upwards and backwards. Stylo-glossus?—Origin, from the upper and internal part of the styloid process. Insertion, into the side of the root of the tongue. Use; draws the tongue backwards. Stylo-pharyngeus.10—Origin, from the inner side of the styloid process near its root. Insertion, into the side of the pharynx, be- tween the superior and middle constrictor muscles. Use; raises and widens the pharynx. Mylo-hyoideus? forms the floor of the mouth. Origin, from the mylo-hyoidean ridge of the inside of the lower jaw. Insertion, into a white tendinous line, between it and its fellow, and hyoid bone. Use; draws the hyoid bone upwards, and projects the tongue. Genio-hyoideus?—Origin, from the posterior tubercle, inside of the chin. Insertion, into the body of the hyoid bone. Use; draws it upwards and forwards. Longus colli?58—Origin, from the bodies of the three superior 72 MUSCLES OF THE CHEST. Fig. 58. «*#■' dorsal vertebra?, and the transverse processes of the five lower cer- vical. Insertion, into the bodies of all the cervical vertebra?. Use; bends the neck forwards and to one side. Rectus capitis anticus major.1— (See Fig. 58.) Origin, from the transverse processes of the third, fourth, and fifth cervical yer- tebra?. Insertion, into the basilar or cuneiform process of the occiput. Use; bends the head forwards. Rectus capitis anticus minor?— Origin, from the atlas near its trans- verse process. Insertion, into the basilar process of the occiput. Use; bends the head forwards. Rectus capitis lateralis.10—On- gin, from the transverse process of the atlas. Insertion, between the V} condyle and jugular eminence of the occipital bone. Use; draws the head to one side. Scalenus anticus?—Origin, from the transverse processes of the fourth, fifth, and sixth cervical vertebra?, tendinously. Insertion, into the upper surface of the first rib in front of the groove for the subclavian artery. Use; bends the neck forwards, or raises the first rib. Scalenus medius?—Origin, from the transverse processes of all the cervical vertebra? tendinously. Insertion, into the upper surface of the first rib, behind the groove for the artery. Use; same as last. Scalenus posticus?—Origin, from the transverse processes of the fifth and sixth cervical vertebra?. Insertion, into the upper face of the second rib beyond the tubercle. Use; bends the neck, and raises the second rib. MUSCLES OF THE CHEST. Pectoralis major.—Forms the cushion of the chest. Origin, from the two upper bones of the sternum, the sternal two-thirds of the clavicle, the cartilages of the fifth and sixth ribs, and from the tendon of the ex- ternal oblique muscle. Insertion, into the outer edge of the bicipital groove of the humerus. Use; draws the arm inwards and forwards. Pectoralis minor?—Origin, from the third, fourth, and fifth ribs. Insertion, into the inner face of the coracoid process of the scapula. Use ; draws the scapula inwards and downwards. MUSCLES OF THE CHEST. 73 Fig. 59. Subclavius.'—Or. from the cartilage of the first rib. In. into the inferior face of the clavicle. Use. Draws the clavicle down- wards. Serratus magnus, or anticus.1 in—Or. from the nine upper ribs, five of its heads interdigitating with the external oblique muscle. In. into the whole length of the base of the scapula. Use. Draws the scapula forwards. Intercostales externi.11—There are eleven on each side. Or. from the transverse process of the vertebra, and the inferior sharp edge of the rib. In. into the superior rounded edge of the rib below. The fibres pass obliquely downwards and forwards. Intercostales interni.—A\so eleven on each side. Or. from the inferior edge of the rib, and costal cartilages. In. into the superior rounded edge of the rib below, the fibres passing downwards and backwards. Use. To approximate the ribs. Triangularis sterni.—Situated on the inner wall of the front of 7 74 MUSCLES OF THE ABDOMEN. the chest. Or. from the ensiform cartilage, and second bone of the sternum. In. into the third, fourth, fifth, and sixth ribs. Use. To depress the ribs. MUSCLES OF THE ABDOMEN. Beneath the skin of the abdomen is the fascia superficialis abdo- minis, a layer of condensed cellular substance, varying in thickness in different individuals, and containing more or less fat. Its lami- nated character admits of its being dissected into several layers. In the groin it incloses the lymphatic glands, and is traversed at its lower part by the arteria ad cutem abdominis; it is thickened over the symphysis pubis, and constitutes the mons veneris. Obliquus externus.1*—Origin from the eight inferior ribs, the first head being covered by the pectoralis major; five superior heads interdigitate with those of the serratus anticus, and three inferior, with those of the latissimus dorsi. The fibres pass obliquely down- wards and forwards. Insertion, into the whole length of the linea alba, tendinously ; into the anterior half or two-thirds of the crest of the ilium, by muscular and tendinous fibres; and into the body and crest of the pubis, forming thereby Poupart's ligament. As the ten- dinous fibres approach the pubes, they split, forming a triangular opening called the external abdominal ring ;16 through which passes in the male the spermatic cord, and in the female the round ligament of the uterus; a portion of the tendon being inserted into the spinous process and body of the pubes; the external or posterior edge of this part constitutes the anterior or internal column of the ring. The other portion is inserted into the crest of the pubes; the internal , edge of which constitutes the external or posterior column of the ring. The external edge of this portion of the tendon is called Gim- bernat's ligament. This ring is prevented from splitting still further, by some transverse tendinous fibres.14 (Fig. 59.) Use.—It compresses the viscera of the abdomen, and approximates the pelvis and thorax. Obliquus internus.18—Origin, from the three inferior spinous pro- cesses of the lumbar vertebra?, and from all those of the sacrum, the whole length of the crest of the ilium, and from the outer half of Poupart's ligament. Insertion, into the six inferior ribs, into the ensiform cartilage, into the whole length of the linea alba, and also tendinously into the pubes behind the external abdominal ring. At the linea semilunaris, the tendon splits into two lamina?, which thereby form a sheath for the rectus muscle; in the lower third or fourth of the muscle, both lamina?, however, pass in front, and include between them the pyramidalis. Transversalis abdominis.—Is beneath the last. Orioin from the transverse processes of the last dorsal and four upper lumbar vertebra?, from the crest of the ilium, and from the external half of INGUINAL HERNIA. 75 Poupart's ligament; it also arises from the cartilages of the six in- ferior ribs. Insertion, into the ensiform cartilage, linea alba, and pubes, in common with the internal oblique tendon behind the exter- nal abdominal ring. Rectus abdominis.16—Origin, from the symphysis and body of the pubes, gradually increasing in breadth. Insertion, into the ensi- form cartilage, and into the cartilages of the fifth, sixth and seventh ribs. This muscle has several tendinous intersections called linea transversa, which are three or four in number. Pyramidalis?7—Is in front of the lower part of the rectus, about three inches in length, not always present. Origin, from the body of the pubes. Insertion, into the linea alba. Cremaster.—This muscle forms a muscular sheath for the cord and upper part of the testicle; before the descent of the testicle, it constitutes the inferior edge of the internal oblique and transversalis muscles, which are much blended at this part; hence its origin may be said to be the muscular portion of the lower edge of these muscles, and that its insertion is into the conjoined tendon of these muscles. Fascia, transversalis.—This fascia covers the abdomen, and lies under the muscles and in front of the peritoneum; it is continuous with the iliac fascia, which surrounds the posterior part of the peritoneum, and the pelvic, fascia, which surrounds that portion of peritoneum in the cavity of the pelvis. It is thin and tough, and near the groin possesses greater density. This fascia is an object of study, particularly on account of the internal abdominal ring being situated in it. This point is usually much misunderstood, partly from the use of the term ring, which gives rise to the idea that it is a hole or opening like the external ring, and partly from the variety and confusion of terms employed in its description. It may be said to be that portion of the fascia tran- versalis where it ceases to cover the abdomen and commences to cover the cord; here it is very thin, and an artificial or false dis- section readily can form a ring or hole with a well-defined edge. But such does not exist in nature, for the fascia is continued from the abdomen upon the cord. INGUINAL HERNIA. Inguinal hernia is of two kinds; oblique or indirect, and direct or ventro-inguinal hernia. Oblique is by far the most common ; and in order to understand the anatomy of it, it will be necessary to bear in mind the arrangement of the parts previous to the descent of the testicle, the subsequent and natural condition, and also the state of things as altered by the affection. 76 INGUINAL HERNIA. Oblique inguinal hernia is a protrusion of intestine through a passage originally made by the escape of the testicle from the loins to the scrotum, and afterwards occupied by the spermatic cord. Until the seventh month of foetal life the testicle reposes in the lumbar region beneath the kidney, but not within the cavity of the perito- neum. As yet there is no spermatic cord formed, the constituents, to wit, the artery, vein, duct, &c, each approaching the testicle separately. About this period the testicle ordinarily descends, by means of a contractile structure attached to its inferior extremity, until it is enveloped in the scrotum. In its passage it must come in contact with the various structures forming the parietes of the abdo- men, viz., the peritoneum, fascia transversalis, the transversalis, internal and external oblique muscles, the superficial fascia, and the skin. Now each of these structures, with the exception of the ex- ternal oblique muscle, will be found to form a covering for the testicle and cord, because it does not perforate them, but pushes them before it; although this covering may be modified in some degree, nevertheless there is a representation of every layer of the walls of the abdomen; and this is the case not only in the covering of the testicle and cord, but also in the covering of a hernial protrusion ; hence, if a student understands the changes which take place in the descent of the testicle, he must necessarily understand the mode by which a hernial protrusion obtains its coverings. Here we must caution students from attaching too much impor- tance to words or terms used in description, for they vary with diffe- rent writers; but let him keep constantly before his mind the thing itself, as if he were making a dissection ; for by actual dissection he can understand it thoroughly, although he may not know the name of a single point. In the first place, by the contraction of the gubernaculum testis, the testicle is brought in contact with the peritoneum, and since it is not in the peritoneal cavity, it must necessarily push before it a doubled lamina of peritoneum. Thus the testicle gets a covering of serous membrane arranged as serous membranes always are; that is, one lamina covers the testicle, and the other lines the cavity in which it is contained, and it is called the peritestis or tunica vaginalis testis. The communication between the peritoneum and peritestis is oblite- rated, otherwise the bowel could readily pass down; and when this does occur, it constitutes a variety of hernia, termed congenital. As the testicle descends, the spermatic artery, vein, and vas deferens descend with it, and thus the cord is formed ; the components are held together by means of cellular tissue, formerly the canal of peritoneum, connecting the peritoneum and peritestis. Oroans that have been of use in the system are never entirely absorbed but converted into another which serves a different purpose—as in the case of an artery when tied for aneurism, it becomes a cord • the urn- bilical vein becomes the ligamentum teres. INGUINAL HERNIA. 77 Fig. 60. Now, the next structure with which the testicle comes in contact, is the fascia transversalis; let us follow this in its descent with the testicle, and observe the changes which it undergoes. It is not per- forated as most pictures represent, but pushed before the testicle, covering it and the cord. The point where this protrusion takes place, is midway between the anterior superior spinous process of the ilium and the pubes, and about an inch and a half above Pou- part's ligament, and is called the internal abdominal ring; but there is no hole or opening unless made with a scalpel. The fascia is continuous from the abdomen upon the cord, although that portion covering the abdomen is tougher and thicker than that of the cord. If the cord is stretched, this portion of the fascia will resemble a funnel, and hence some call it the infundibiliform fascia. That portion which covers the testicle, assists in forming its cellular coat, which is termed by some tunica vaginalis communis testis, by others, fascia propria. Terms are matters of minor importance; the truth to be taught is, that the testicle, cord, and abdomen are invested by the same fascia, having different names and dif- ferent thicknesses in different parts. The next layer of the abdominal wall with which the testicle comes in con- tact is the transversalis muscle. At the lower part of the abdomen, the in- ternal oblique is so much blended with the transversalis, that the two may be considered as having the same relation to the testicle in its descent, and also to hernia. At the internal abdominal ring, the testicle, already covered by the peritoneum and fascia transver- salis, comes in contact with these muscles; it does not perforate them, but pushes their conjoined lower ed«re before it, obtains for itself and cord a muscular covering, which is the cremaster muscle ; and this accounts for that looped appearance which the fibres of this muscle have upon the testicle; also, for the muscle being thicker upon the anterior part of the cord. These muscular fibres are very pale, and very scattered upon the lower part of the testicle, and form an imperfect covering for the testicle. When the cremaster is cut away from the transversalis and internal oblique, their inferior edge presents an arched appear- ance. The tendon of the external oblique is the next structure opposing its descent, and since this is very tough, it is not pushed before the 7* 78 INGUINAL HERNIA. testicle; but the testicle passes obliquely downwards and inwards for an inch and a half, until it gets opposite the external abdominal ring, which is a hole, and at which, it emerges between its columns or pillars. The fact, that in health these two rings are not opposite, contributes much to the strength of the arrangement, and preventing the more frequent occurrence of hernia, which is much favoured by a deficiency in the fibrous character of the tendon of the external oblique. The space between these two rings, is called the inguinal, abdo- minal, or spermatic canal. It is bounded anteriorly by the inferior edge of the internal oblique and transversalis muscles, the tendon of the external oblique, the superficial fascia, and skin ; posteriorly by the transversalis fascia, and the conjoined tendon of the transversalis and internal oblique muscles; inferiorly, by Poupart's ligament. When the hernia does not emerge from this canal, it is called a concealed inguinal hernia. At the external abdominal ring, the testicle, with its covering, comes in contact with the superficial fascia, which has already been described as consisting of numerous lamina?, one of which can readily be shown to extend between the columns of the ring, and hence it is called the intercolumnar fascia by some, by others, the external spermatic, &c. This fascia, pushed before the testicle, assists in forming that covering already alluded to, the fascia pro- pria, or tunica vaginalis communis. That portion of the fascia transversalis engaged in forming this cellular coat of the testicle, is actually blended with the superficial fascia of the testicle, on account of the intervening muscular structure, that of the cremaster being deficient in some parts, and very spare in others. Hence a confu- sion in authors and terms, some attributing this covering of the tes- ticle to the transversalis fascia, and some to the superficial fascia, whereas in fact it is formed partly by both. The skin is, of course, readily traced from the abdomen to the scrotum, although in the scrotum it is modified by the dartos, which, according to some, is an expansion of the gubernaculum testis. We have seen the changes which take place in the descent of the testicle, and are now prepared to consider the escape of the intestine. The convolution or knuckle of intestine first presses against the peritoneum, and being contained within the cavity, can only push before it a single lamina. This portion of the' peritoneum always forms the hernial sac, which gradually increases in size and thickness. In this variety of hernia, (oblique inguinal), the protru- sion takes place at the internal ring; the sac must then necessarily be covered by the transversalis fascia and cremaster muscle and after passing down the inguinal canal, emerges at the external abdo- minal ring, where it receives an additional investment of superficial fascia and skin. v INGUINAL HERNIA. 79 Hence, in the operation for hernia, the following layers are cut through:— Skin, superficial fascia, cremaster muscle, transversalis fascia, and the hernial sac. In the dissection of a hernial sac, we will find alterations in thick- ness and colour, the consideration of which properly belongs to the surgical part of this work. Direct or ventro-inguinal hernia consists of a protrusion directly at the external abdominal ring, and of course does not pass through the canal. The coverings are the skin, superficial fascia, the com- mon tendon of the internal oblique and transversalis muscles, trans- versalis fascia, and hernial sac. This variety is not of so frequent occurrence, on account of the insertion of the tendon of the internal oblique and transversalis into the pubes immediately behind the external abdominal ring, which protects this opening, and therefore it must be ruptured or expanded when a protrusion takes place at this ring ; when it is ruptured, of course this covering of the sac does not exist. Diaphragma.—This muscle forms the septum between the thorax and abdomen ; it consists of two parts, a greater and lesser muscle* The greater1*3 muscle arises from the ensi- Fig. 61. form cartilage, and from six inferior ribs ; the fibres converge to the cordiform tendon, which is in the cen- tre. The lesser8 10 muscle consists of two bellies, which are called crura, the right of which is the larger. Origin, from the second, third, and fourth lumbar verte- bra?. Insertion, into the cordiform tendon. There are three openings in the dia- phragm ; - one in the tendinous centre,13 called foramen quadratum, which transmits the ascending vena cava; another, an erliptical muscular opening,12 called foramen gcso- phageum, through which passes the oesophagus and the par vagum nerves; and the third, the hiatus aorticus,11 which is between the crura, and in front of the vertebra; through it passes the aorta, the 80 MUSCLES OF THE BACK. thoracic duct, the azygous vein, and the great splanchnic nerve. Use ; widens the thoracic, and diminishes the abdominal cavity. Quadratus lumborum.—Origin,15 from the crest of the ilium. Insertion, into the transverse processes of the last dorsal and all the lumbar vertebra?, and also into the last rib beneath the ligamen- turn arcuatum. Use ; bends the loins to one side. Psoas parvus.—Not always present. Origin, from the last dorsal and first lumbar vertebra?. Insertion, by a long tendon, into the crest of the pulses and fascia iliaca. Psoas magnus.1*—Origin, from the transverse processes of all the lumbar vertebra?, and from the bodies of the four upper lumbar and last dorsal vertebra?. Insertion, into the lesser trochanter of the femur, and into one inch below it. Iliacus internus.—Origin, from the transverse process of the last lumbar vertebra, from the costa and crest of the ilium, and from the capsule of the hip joint. Insertion, into the tendon of the psoas magnus. Use ; the action of the last two muscles is the same, to bend the body forwards and draw the thigh upwards. MUSCLES OF THE BACK. Trapezius?—Origin, from the superior semicircular ridge of the occiput, from all the spinous processes of the neck, by means of the ligamentum nucha?, and from all those of the back. Inser- tion, into the external third of the clavicle, into the acromion pro- cess, and spine of the scapula. Use ; draws the scapula towards the spine. Latissimus dorsi?—Origin, from the seven inferior spinous pro- cesses of the back, and from all those of the loins and sacrum, also from four inferior ribs, which heads interdigitate with those of the external oblique. Insertion, by a thick flat tendon, in common with the teres major, into the posterior ridge of the bicipital groove. Use; draws the humerus downwards and backwards. Serratus posticus inferior.16—Origin, from the two inferior spi- nous processes of the back, and the three superior of the loins. In- sertion, into the last four ribs. Use ; draws the ribs downwards. Rhomboideus minor.11—Origin, from the three inferior spinous processes of the neck. Insertion, into the base of the scapula oppo- site the spine. Rhomboideus major.13—Origin, from the spinous processes of the last cervical, and of the four superior dorsal vertebra?. Insertion, into the base of the scapula below the spine. Use; the last two draw the scapula upwards and backwards. Serratus posticus superior.—Origin, from fhe three inferior spi- nous processes of the neck, and the two superior of the back. In- sertion, into the second, third, and fourth ribs. Use ; it draws the ribs upwards. m MUSCLES OF THE BACK. 81 Levator anguli scapula.10—Origin, from the transverse pro- cesses of the three, four, or five superior cervical vertebra?. Inser- tion, into the angle of the scapula, and base above the spine. Use; draws the scapula upwards. Fig. 62. Splenius.13 14—It consists of two parts : splenius capitis and sple- nitis colli. Origin, from the spinous processes of the five inferior cervical and the four superior dorsal vertebra?. Insertion, into the occipital bone, between the two semicircular ridges, and into the transverse processes of the two superior cervical vertebra?. Use ; draws the head and neck backwards. Sacro-lumbalis and longissimus dorsi.—These two muscles arise in common. Origin, from the spinous and transverse processes of the loins and sacrum, and from the crest of the ilium. The first3 is on the outer side. Insertion, into the angles of the rib. The 82 MUSCLES OF THE BACK. latter3 is nearest the spine. Insertion, Fig. 63. into all the transverse processes of the back except the first, and into all the ribs beyond their tubercles, except the two last. Use; to keep the spine erect, and draw down the ribs. Spinalis dor si?—Origin, from the three inferior spinous processes of the back, and two superior of the loins. Insertion, into the nine superior spinous processes of the back, except the first. Use; to keep the spine erect. Cervicalis descendens.* — Origin, from the four superior ribs. Insertion, into the fourth, fifth, and sixth trans- verse processes of the neck. Transversalis cervicis? °—Origin, from the five superior transverse pro- cesses of the back. Insertion, into the five middle transverse processes of the neck. Use ; the two last draw the neck backward. Trachelo-masloid?— Origin, from the three superior transverse processes of the back. Insertion, into the mas- toid process. Complexus? — Origin, from the transverse processes of the four inferior cervical, and from the spinous process of the first dorsal vertebra?. Insertion, into the occiput between its semicircular ridges. Use; the two last draw the head backward. Semi-spinalis cervicis.11—Origin, from the six superior trans- verse processes of the back. Insertion, into the spinous process of the five middle cervical vertebra?. Semi-spinalis dorsi.10—Origin, from the transverse processes of the seventh, eighth, ninth, and tenth dorsal vertebra?. Insertion, into the spinous processes of the two lower cervical, and five upper dorsal vertebra?. Multifidus spina?6—Origin, from the oblique and transverse processes of all the vertebra? of the sacrum, loins and back, and of the four inferior of the neck. Insertion, into the spinous processes of all the vertebra? of the loins and back, and of the five inferior of the neck. Use ; the three last twist the spine. Rectus capitis posticus major.—Origin, from the spinous pro- cess of the dentata. Insertion, into the occiput at its superior semi- circular ridge, and below it. Use ; it turns the head. 1 MUSCLES OF THE SHOULDER AND ARM. 83 Rectus capitis posticus minor.—Origin, from the tubercle of the atlas. Insertion, into the occiput, at the inferior semicircular ridge, and below it. Obliquus superior.—Origin, from the transverse process of the atlas. Insertion, into the outer end of the inferior semicircular ridge of the occiput. Obliquus inferior.—Origin, from the spinous process of the den- tata. Insertion, into the transverse of the atlas. Interspinales.—Between the spinous processes of all the vertebra?. In the neck they are double : in the back, tendinous ; in the loins single and well-marked. Inter-transversarii?8—Between all the transverse processes. In the neck, double; in the back, tendinous ; in the loins fleshy and single. Use ; to approximate these processes. Levatores costarum?7—Origin, from the transverse processes of the last cervical and eleven upper dorsal vertebra?. Insertion, into the upper edge of the two ribs below. Use ; to elevate the ribs. MUSCLES OF THE SHOULDER AND ARM. FASCIA. The brachial fascia covers the muscles of the upper extremity, commencing at the spine of the scapula and clavicle. Upon the deltoid it is thin. At the elbow it sends several processes to the bone, which serve for the origin of muscles, and in front it receives a portion of tendon from the biceps muscle, which renders it tense. At the wrist it forms the anterior and posterior annular ligaments, which bind down the tendons of the hand, and in the hand it forms the palmar aponeurosis. Deltoid?—Origin, from the spine of the scapula, the acromion process, and the external third of the clavicle. Insertion, into a triangular roughness near the middle of the humerus. Use; it raises the humerus. (Fig. 62.) Supra-spinatus?7—Origin, from the whole of the fossa supra- spinata. Insertion, into the inner facet of the greater tuberosity of the humerus. Use ; it raises the arm and turns it outwards. Infraspinatus.18—Origin, from the whole of the fossa infra- spinata. Insertion, into the middle facet of the greater tuberosity of the humerus. Use ; it rotates the humerus outwards and back- wards. Teres minor.19—Origin, from the lesser costa of the scapula. Insertion, into the outer facet of the greater tuberosity of the humerus. Use ; it rotates the humerus outwards, and draws it downwards and backwards. Teres major.20—Origin, from the posterior surface of the angle of the scapula, and a part of its lesser costa. Insertion, into the posterior edge of the bicipital groove of the humerus in common 84 MUSCLES OF THE FORE-ARM. Fig. 64. with the tendon of the latissimus dorsi. Use ; it rotates the hu- merus inwards and draws it downwards and backwards. Subscapulars? (Fig. 64.) Origin, from the whole of the costa of the scapula. Insertion, into the lower tuberosity of the humerus. Use ; it rotates the humerus inwards, and draws it downwards. Biceps flexor cubiti?—Origin, by a long tendon from the superior extremity of the glenoid cavity, which passes through the joint and bicipital groove, and by a short head from the coracoid process of the scapula. Insertion, into the posterior and inferior parts of the tubercle of the radius, and into the brachial fascia. Use; it flexes the fore-arm. Coraco-brachialis?—Origin, from the middle facet of the coracoid process of the scapula, in common with the short head of the biceps. Insertion, into the middle of the os humeri by a rough ridge on its in- ternal side. Use; it draws the arm up- wards and forwards. Brachialis Internus?—Origin, from the anterior and lower half of the os humeri. Insertion, in front of the root of the coro- noid process of the ulna. Use; it flexes the fore-arm. Triceps extensor cubiti.10—Origin, by three heads ; the first or longus, is from the inferior part of the glenoid cavity. The second or brevis, is from a ridge from the back part of the os humeri, just below its head ; and the third, or brachialis externus, is from the inner side of the os humeri, near the bicipital groove. Insertion, into the olecranon process of the ulna. Use ; it extends the fore-arm. Anconeus.11 (Fig. 67.)—Origin, from the external condyle of the humerus. Insertion, into the ulna below the olecranon. Use; it extends the fore-arm. MUSCLES OF THE FORE-ARM. These are eighteen in number, eight of which are on the front of the arm, and are flexors, and for the most part arise from the internal condyle. The remaining ten are extensors, and arise for the most part from the external condyle. Pronator radii teres. (Fig. 65.) — Origin, from the internal condyle of the humerus, and the coronoid process of the ulna. Insertion, into the middle and back portion of the radius. Use ; it rotates the hand inwards. MUSCLES OF THE FORE-ARM. 85 Flexor carpi radialis.—Origin, from the internal condyle of the humerus, the brachial fascia, and the upper part of the ulna. Inser- tion, into the base of the metacarpal bone of the index finger. Use ; it flexes the hand at the wrist. (Fig! 65.) Palmaris longus?—Is sometimes deficient. Origin, from the internal condyle. Insertion, into the annular ligament and palmar aponeurosis. Use ; it bends the hand. Fig. 65. Fig. 66. Flexor carpi ulnaris?—Origin, from the internal condyle, and from the ridge at the inner side of the ulna. Insertion, into the pisiform bone and sometimes into the base of the metacarpal bone of the little finger. Use-; it flexes the hand. Flexor sublimus digitorumperforatus?—Origin, from the internal condyle of the humerus, the coronoid process of the ulna, and the tu- bercle of the radius. Insertion, by four split tendons into the second phalanges of the fingers. Use ; it bends the hand and fingers. Flexor profundus digitorum perforans? (Fig. 66.)—Origin, from the ulna by its anterior flat surface, from its coronoid process, 8 86 MUSCLES OF THE FORE-ARM. Fig. 67. and from the interosseous ligament. Insertion, the tendons are four in number, which, passing through the perforations in the tendons of the flexor sublimus, are inserted into the third phalanges of the fingers. Flexor longus pollicis.6—Origin, from the internal condyle of the humerus, and the middle two-thirds of the radius, and a part of the interosseous ligament. Insertion, into the base of the second phalanx of the thumb. (Fig. 66.) Pronator quadratus?—Origin, from the inner surface of the ulna, near its lower ex- tremityl Insertion, into the corresponding surface of the radius. Use; it rotates the radius inwards. Supinator radii longus.™ (Fig. 67.)— Origin, from the ridge leading to the ex- ternal condyle of the humerus. Insertion into a ridge of the radius just above its styloid process. Use ; it rotates the radius outwards. Extensor carpi radialis longus?—(Fig. 66.) Origin, From the ridge of the external condyle of the humerus. Insertion, into the posterior part of the base of the metacarpal bone of the forefinger. Use; it extends the hand. Extensor carpi radialis brevis?—Origin, from the external condyle of the humerus, and from the external lateral ligament. In- sertion, into the posterior part of the base of the metacarpal bone of the middle finger. Use; as the last. Extensor carpi ulnar is.10—Origin, from the external condyle and the brachial fascia. Insertion, into the base of the metacarpal bone of the little finger. Use; as the last. Extensor digitorum communis?—Origin, from the external condyle. Insertion, by four tendons which are connected by slips previous to their being spread out, into a membranous insertion, into all the phalanges of the fingers. Use; it extends the joints of the fingers. Supinator radii brevis.—Origin, from the external condyle, and from a ridge of the ulna on its, posterior surface. Insertion, into the radius between its tubercle and the insertion of the pronator. Use ; it rotates the radius outwards. Extensor ossis metacarpi pollicis manus.—Origin, from the posterior surface of the ulna, from the interosseous ligament, and a part of the radius. Insertion, into the base of the metacarpal bone of the thumb, and into the trapezium. Extensor minor pollicis manus.13—Origin, from the back of the MUSCLES OF THE HAND. 87 ulna below its middle, and from the interosseous ligament. Inser- tion, into the first phalanx of the thumb. Extensor major pollicis manus.1*—Origin, from the back of the ulna above its middle, from the interosseous ligament, and from the back of the radius. Insertion, into the base of the second phalanx of the thumb. Use; these last three extend the thumb. Indicator.—Origin, from the back of the ulna, and interosseous ligament. Insertion, into the base of the first phalanx of the index finger. Use; it extends the fore-finger. MUSCLES OF THE HAND. Palmaris brevis.—Origin, from the anterior ligament of the wrist, and palmar aponeurosis. Insertion, into the skin at the inner edge of the hand. Use; it contracts the skin. Lumbricales?—These are four in number, and resemble earth- worms. Origin, from the ten- dons of the flexor profundus. Insertion, into the radial side of the base of the first phalanx of each finger. Use; they assist in bending the fingers. (Fig. 68.) Abductor pollicis manus*— Origin, from the annular liga- ment, trapezium, and scaphoid bones. Insertion, into the base of the first phalanx of the thumb. Use; draws the thumb from the fingers. Opponens pollicis?—Origin, from the trapezium and annular ligament. Insertion, into the ra- dial edge of the metacarpal bone, from its base to its head. Use; it draws the metacarpal bone in- wards. Flexor brevis pollicis manus? B—It consists of two bellies. The external arises from the trapezium and trapezoides, and the annular ligament, and is inserted into the outer side of the first phalanx of the thumb. The internal head arises from the magnum and unci- form, and the metacarpal bone of the little finger, and is inserted into the inner side of the base of the first phalanx of the thumb. The sesamoid bones are included in these tendons. Adductor pollicis manus?—Origin, from the metacarpal bone of the middle finger between its base and its head. Insertion, into the base of the first phalanx of the thumb. Use; it draws the thumb towards the fingers. 88 MUSCLES OF THE HAND. Abductor minimi digiti manus.10—Origin, from the pisiform bone, and annular ligament. Insertion, into the ulnar side of the base of the first phalanx of the little finger. Use; it draws the little finger from the rest. Flexor parvus minimi digiti.11—Origin, from the unciform pro- cess of the unciform bone, and annular ligament. Insertion, into the ulnar side of the base of the first phalanx of the little finger. Use; it bends the little finger. Adductor metacarpi minimi digiti.—Origin, from the unciform process and annular ligament. Insertion, into the metacarpal bone of the little finger, from its base to its head. Use; it brings the metacarpal bone towards the wrist. Interosseous muscles.—These are seven in number ; three of which are on the palmar side, and four on the dorsal side. The palmar interossei are adductors, the dorsal are abductors. Fig. 69. Fig. 70. The palmar interosseous muscles. (Fig. 69.)—These arise from the base of the metacarpal bone of one finger, and are inserted into the base of the first phalanx of the same finger. The first belongs to the index finger,1 the second to the ring finger,3 and the third to the little finger.3 The dorsal interosseous are penniform, arising by two heads from ad- joining sides of the metacarpal bones. (Fig. 70.) They are inserted into the bases of the first phalanges ; the first into the index finger,1 the second and third into the middle finger,23 compensating its exclu- sion from the palmar group; the fourth into the ring finger.4 The diversified and confused description of these muscles by dif- ferent authors, is owing to the use of terms that are not significant, a want of proper classification, and the dividing of one muscle in two; thus, some enumerate four palmar and three dorsal interossei, FEMORAL HERNIA. 89 together with the muscle called abductor indicis; others, again, enumerate four palmar and four dorsal. The principle of classifi- cation should be with regard to their action. Whether they are abductors or adductors, with reference to an axis passing through the middle finger. If you split the first dorsal interosseous into two muscles, and call that portion arising from the metacarpal bone of the thumb, the abductor indium; and enumerate the remaining por- tion among the palmar interossei, you can reconcile the various modes of counting these muscles. MUSCLES OF THE LOWER EXTREMITY. The lower extremity is covered by a dense fascia called fascia lata, which commences at the crest of the ilium, and extending over the glutei muscles, reaches the foot. In the front of the thigh it is termed iliac and pubic, with reference to its proximity to these bones. At the knee, it forms a general covering, called the involucrum ; in the leg it is termed the crural fascia ; in front of the ankle it con- stitutes the annular ligament, which binds down the extensor ten- dons ; under the sinuosity of the os calcis, it binds down the flexor tendon in the form of the ligamentum laciniatum, or plaited liga- ment; finally, it terminates in the plantar fascia, that firm aponeu- rosis upon the sole of the foot. From it are formed numerous sheaths for muscles. ANATOMY OF FEMORAL HERNIA. This variety of hernia is a protrusion of intestine at an opening near the passage of the large vessels to and from the thigh. We shall at first describe the parts as they occur upon dissection, and / then the descent of the gut. Upon the removal of the skin from the upper portion of the thigh the superficial fascia is brought into view. This fascia is a continua- tion of the superficial fascia of the abdomen, and like it is capable of being dissected in lamina?. In the groin it contains numerous lymphatic glands. It is traversed by the saphena vein, which en- ters the femoral vein, through the saphenous opening about an inch below Poupart's ligament. Having removed this fascia we bring into view the fascia lata of the thigh. This fascia is of a pearly white colour and very dense structure. It consists of two portions, the sartorial and pectineal. The sartorial portion1 is upon the iliac side, and is connected at its upper part with Poupart's ligament. It passes in front of the sheath of the vessels and has a crescentic edge on its inner side, called the falciform process. This process limits the saphenous opening on its outer side; and in order that this edge should, be distinctly seen, a layer of superficial fascia with which it is continuous must be care- fully removed ; this portion of superficial fascia which fills up the saphenous opening is often called cribriform fascia. (See Fig. 60.) 90 FEMORAL HERNIA. The superior horn of this crescentic process is twisted and in- serted in the crest of the pubes external to, but continuous with, Gimbernat's ligament, and is called Hey's ligament. The pectineal portion of the fascia lata is upon the pubic side ; it is thinner than the sartorial and passes behind the sheath of the vessels. The sheath of the vessels is formed of condensed cellular tissue, and may be considered a prolongation^ the fascia transversalis and fascia iliaca. It is usually compared to the tubular portion of a funnel; the abdominal portions of these fascia? constituting the larger part of the funnel. Numerous perforations exist in the sheath of the vessels for the passage of veins and absorbents, which renders it cribriform. One of these perforations can be seen where the sheath is laid open, and also the saphena vein entering the femoral vein.13 Since the artery and vein are cylinders, it must be evident that there must be some structure filling up the intervening spaces, and also the space1* be- tween the vein and Gimbernat's ligament,16 or else there would be a deficiency of structure. Now this space is the crural ring16 and is fill- ed up with loose cellular tissue and a lymphatic gland. This cellular tissue is called by some the crural septum, by others fascia propria. A weakness of this sep- tum between the cavity and tube of the funnel predisposes to hernia. The crural or femoral ring is bounded in front by Poupart's ligament; behind, by the bone ; on the inside, by Hey's and Gimbernat's liga- ment; on the outside by the vein. The femoral vessels,11 ia with their sheath, together with the iliacus internus7 and psoas magnus9 muscles, pass out under Poupart's ligament, and thus fill the crural arch. The intestine in femoral hernia pursues the following course. The peritoneum, as in all other instances, is at first distended and forms the hernial sac ; this distension takes place at the crural ring, this being the only spot where it can occur under the crural arch; the crural septum or fascia propria is now stretched and thickened; gradually yielding, it forms the next covering of the gut. With these it descends the sheath of the vessels, and when it gets below the fal- ciform process, emerges at one of. the foramina for veins or absor- bents ; then it comes in contact with the cribriform and superficial fascia, which in fact are the same structure ; these form another covering, and the skin forms the last. MUSCLES OF THE HIP AND THIGH. 91 In reaching the intestine by an operation for hernia, the order of coverings would be the skin, superficial fascia, fascia propria, and hernial sac. Much alteration of structure would of course exist by the parts becoming thicker and more laminated. In some in- stances the foramen of the sheath is not sufficiently large, and then the sheath is distended and consolidated with the other coverings. Many restrict the term fascia propria to this consolidated covering. A femoral hernia may be concealed either above or below the saphenous opening; then of course the fascia lata will also form one of its coverings. MUSCLES OF THE HIP AND THIGH. Gluteus maximus? (Fig. 62.)—Origin. From the crest of the ilium, from a portion of the dorsum of the ilium, from the sides of the sacrum and coccyx, and from the greater sacro-sciatic ligament. Insertion. Into the upper third of the linea aspera, and into the fascia femoris. Use. It draws the thigh backwards and keeps the trunk erect. Gluteus medius.8 (Fig. 62.)—Origin. From the dorsum of the ilium between the crest and semicircular ridge, from between the anterior spinous processes, and from the fascia femoris. Inser- tion. Into the upper surface of the trochanter major, and into that portion of the shaft just in front of it. Use. It draws the thigh backwards and outwards. Gluteus minimus? (Fig. 72.)—Origin. From the dorsum of the ilium, between the semicircular ridge and the capsular ligament. Fig. 72. Insertion. Into the trochanter ma- jor, within that of the last. Use. It abducts and rotates the thigh in- wards. Pyriformis?—Origin. From the second, third and fourth bones of the sacrum. Insertion. Into top of the trochanter major. Use. It ro- tates the limb outwards, Gemini.10 u—These are two in number; the superior arises from the spinous process of the ischium, and the inferior from the tuberosity of the ischium ; both are inserted in common with the tendon of the obturator internus. Obturator internus.11—Origin. From the margin of the thyroid foramen and the thyroid ligament, and fascia iliaca. Insertion. Into he digital fossa of the femur. 92 MUSCLES OF THE HIP AND THIGH. Quadratus femoris.13—Origin. From the tuberosity of the ischium. Insertion. Into the femur between the two trochanters. Obturator externus.—Origin. From the anterior margin of the thyroid foramen, and ligament. Insertion. Into the digital fossa at the root of the trochanter major. Use. The last four rotate the thigh outwards. Biceps flexor cruris.16—Origin. By a long head in common with the semi-tendinosus from the tuberosity of the ischium, and by a short fleshy one from the lower part of the linea aspera. Insertion. Into the head of the tibia. « • * -l -' . -,.- fix-. . - ,;n ■■• -• --> -^ - Semi-tendinosus.18—Origin. From the tuberosity of the ischium. Insertion. Into the side of the tibia just below its tubercle. Semi-membranosus.—Origin. From the external part of the tuberosity of the ischium. Insertion. Into the inner side of the head of the tibia and into the external condyle of the femur. Tensor vagina femoris.*—(Fig. 73.) Origin. From the anterior p- »3 superior spinous process of the ilium. Insertion. Into the fascia or sheath of the thigh. Sartorius? — Origin. From the anterior superior spinous process of the ilium. Inser- tion. Into the inner side of the head of the tibia. Use. It bends the leg and draws it inwards. It is the longest muscle of the body. Rectus femoris?—Origin. From the anterior inferior spinous process of the ilium. Inser- tion. Into the upper surface of the patella. Vastus externus?—Origin. From the linea aspera, and trochanter major. Insertion. Into the upper and external part of the patella. Vastus internus.8—Origin. From the linea aspera in its whole length, covering the inside of the thigh. Insertion. Into the common tendon of the patella. Cruraus.—Origin. From the anterior part of the femur as well as from the linea aspera. Insertion. Into the patella. These four last muscles form a common ten- don in which is placed the patella, before it is inserted into the tubercle of the tibia. They are often called the quadriceps femoris, and extend the leg. Gracilis.16—Origin. From the body and ramus of the pubes. Insertion. Into the inside of the head of the tibia. PectineusJ*—Origin. From the crest of the pubis, and the triangular face in front of it. Insertion. Into the linea aspera below the trochanter minor. MUSCLES OF THE LEG. 93 Adductor longus.™—Origin. From the body of the pubes. Inser- tion. Into the middle third of the linea aspera. Adductor brevis.—Origin. From the body and ramus of the pubes. Insertion. Into the upper third of the linea aspera. Adductor magnus.1*—Origin. From the body and ramus of the pubis, and from the ramus of the ischium. Insertion. Into the whole length of the linea aspera. It is perforated by the femoral artery, at its insertion near its middle third. Use. These four last draw the thigh forwards and inwards. MUSCLES OF THE LEG. Tibialis anticus3 (Fig. 74).— Origin, from the outer side and head of the tibia and from the interosseous ligament. Insertion, into the base of the internal cuneiform bone, and base of the meta- tarsal bone of the big toe. Fig. 74. Fig. 75. 94 MUSCLES OF THE LEG. Extensor Longus Digit or urn Pedis.*—Origin, from the head of the fibula, from the head of the tibia, and from a portion of the interosseous ligament, and edge of the fibula. Insertion, by four tendons -into the phalanges of the toes. Peroneus Tertius?—Origin, from the anterior angle of the fibula, below its middle. Insertion, into the upper surface of the base of the metatarsal bone of the little toe. It looks like a portion of the last-named muscle. Extensor Proprius Pollicis Pedis.5—Origin, from the lower two- thirds of the fibula and interosseous ligament. Insertion, into the bases of the first and second phalanges of the great toe. Use ; it extends the great toe. Peroneus Longus?—Origin, from the head and upper third of the outer side of the fibula. Insertion, into the base of the meta- tarsal bone of the great toe. Use ; it extends the foot and inclines the sole outwards. Peroneus Brevis.8—Origin, from the lower two-thirds of the outer surface of the fibula. Insertion, into the base of the meta- tarsal bone of the little toe. Use ; it extends the foot. Gastrocnemius.—Origin, by two heads from the condyles of the femur. Insertion, by the tendo Achillis into the tuberosity of the os calcis. Soleus.—Origin, from two-thirds of the posterior part of the fibula, and the middle third of the tibia. Insertion, into the tendo Achillis. Plantaris.—This muscle has the longest tendon in the body. Origin, just above the external condyle of the femur. Insertion, into the os calcis before the tendo Achillis. These last three muscles form the calf of the leg, and are called the triceps sura. Popliteus6 (Fig. 75).—Origin, from behind the external condyle of the femur. Insertion, into an oblique ridge of the tibia, below its head. Use ; it bends the leg and rolls it inwards. Flexor Longus Digitorum Pedis Perforans7—Origin, from the back of the tibia below its oblique ridge. Insertion, by four tendons, which perforate the split tendons of the flexor brevis, into the bases of the 'third phalanges of the four lesser toes. Use ; it flexes the toes. Flexor Longus Pollicis Pedis?—Origin, from the lower two- thirds of the posterior face of the fibula. Insertion, into the second phalanx of the great toe. Use ; it flexes the great toe. libialis Posticus.8—Origin, by two heads from the tibia and fibula, and from the interosseous ligament. Insertion, into the tuberosity of the scaphoid bone. Use ; it extends the foot. MUSCLES OF THE FOOT. 95 MUSCLES OF THE FOOT. Extensor Brevis Digitorum Pedis11 (Fig. 74).—Origin, from the greater apophysis of the os calcis. Insertion, by four tendons into the backs of the four greater toes. Use ; it extends the toes. Flexor Brevis Digitorum Pedis6 (Fig. 76.)—Origin, from the tuberosity of the os calcis and plantar fascia. Insertion, by four small tendons, which are Fig. 76. perforated by those of the flexor longus, into the second phalanges of the four smaller toes. Flexor Accessorius.— Origin, from the in- side of the sinuosity of the os calcis in front of its tuberosities. Insertion, into the out- side of the tendon of the flexor longus, at its division. Use ; assists in flexion. Lumbricales Pedis.7—Origin, from the tendon of the flexor longus. Insertion, into the inside of the first phalanx of each toe. Use ; assist in flexion. Abductor Pollicis Pedis?—Origin, from the internal tuberosity of the os calcis, the plantar fascia, and internal cuneiform bone. Insertion, into the inner side of the base of the first phalanx of the great toe, including the internal sesamoid bone. Use; it draws this toe from the others. Flexor Brevis Pollicis Pedis.—It consists of tWo bellies, which arise from the calcaneo- cuboid ligament and external cuneiform bone. Insertion, by two tendons into the base of the first phalanx of the great toe, including the sesamoid bones. Use ; it flexes this toe. Abductor Pollicis Pedis.—Origin, from the calcaneo-cuboid liga- ment, from the bases of the second, third, and fourth metatarsal bones of the lesser toes. Insertion, into the tendon of the flexor brevis and external sesamoid bone. Use ; to draw this toe towards the rest. Abductor Minimi Digiti Pedis?—Origin, from the outer tube- rosity of the os calcis and the metatarsal bone of the little toe. Insertion, into the base of the first phalanx of the little toe. Use ; it draws this toe from the others. Flexor Brevis Minimi Digiti Pedis.—Origin, from the calca- neo-cuboid ligament, and from the fifth metatarsal bone. Insertion, into the base of the first phalanx of the little toe, and into the head of its metatarsal bone. Use ; it bends the little toe. Transversalis Pedis.—Origin, from the capsular ligaments of the 96 MOUTH. first joint of the fourth and fifth toes. Insertion, into the external sesamoid bone. Use ; it approximates the heads of the metatarsal SECTION IV. VISCERA. ORGANS OF DIGESTION. MOUTH. The Mouth is separated from the nose by the hard and soft palate, communicating behind with the fauces ; it is bounded in front by the lips, while its floor is formed by the mylo-hyoid muscles; and its sides by the cheeks; the space between the lips and the teeth is called the vestibule ; it is lined by a mucous membrane, which has a variable degree of thickness. This membrane is thrown into folds, which are called frena ; there is one beneath the tongue, one beneath the epiglottis cartilage at the root of the tongue, and one THE PALATE. 97 ; at the inner surface of each of the lips. This membrane is covered with numerous glands, some of which are mucous and some salivary. The upper lip is longer and thicker than the lower, and has a vertical depression on the middle of its front surface called philtrum, internally the lips are composed of muscular fibres and fat, externally of skin. The Gums are formed of the lining membrane of the mouth, much thickened; they have great hardness and vascularity, but little sensibility. They include the neck of the tooth, and adhere firmly to the periosteum. TONGUE. The Tongue is an oblong, flattened, muscular body, which varies in size and shape; it is the organ of taste, and also of im- * *S- 79- portance in speech and masti- cation. Its posterior extre- mity or root arises from the hyoid bone, to which it is at- tached by yellow fibrous tis- sue. Its anterior extremity is called its point or tip ; its intervening portion its body. The mucous covering of the tongue is very thick upon its upper surface, and very thin upon its under surface. Upon its upper surface are a num- ber of projections or papilla of various sizes and shapes ; the largest are eight or nine in number, called papilla? maxi- ma, and are situated at the posterior portion of the tongue, in two convergent lines ; they are surrounded by fossa?, the largest of which is in the middle, and called the fora- men cacum. The smallest papilla? are fine and pointed, and are found near the middle of the tongue, and are termed filiform. The intermediate papilla? are most abundant, some of them are conical, others fungiform. Different functions are attributed by some to these different papilla?. Muscles of the Tongue.—Hyo-glossus?—Origin, from the base 9 98 THE PALATE. and corner of the hyoid bone. Insertion, into the side of the tongue, some of the fibres reaching Fig. 80. its tip. Genio-hyo- glossus? — Origin, by a tubercle behind the symphysis of the lower jaw. Insertion, into the hyoid bone, and into the whole length of the tongue. Lingualis?—Origin, from the yellow tissue at the root of the tongue. Insertion, into the tip, be- tween the two last mentioned mus- cles. Superficialis lingua.—An indis- tinct layer of muscular fibres on the dorsum of the tongue under the mucous membrane. It seems to curl the tip upwards. Transversales lingua.10 — Are scattered fibres which pass from the middle line to the edge of the tongue; they extend from the tip to the root, and their contractions lengthen the tongue. Verlicales lingua.—These are fibres which extend from the up- per to the lower surface of the tongue. THE PALATE. The palate separates the back portion of the nose from the mouth, and is divided into two parts : the hard palate consists of the palate processes of the superior maxillary and palate bones, covered by mucous membrane, which is continuous with that of the mouth, but is not so vascular or sensitive as that of other parts. It very frequently presents transverse ridges, as well as a ridge in the median line. The soft palate is the membranous separation between the back portion of the mouth and nose, and consists of a fold of mucous membrane stretched transversely. From its middle there projects the uvula, about three quarters of an inch in length; from each side of the uvula there are two divergent crescentic folds of mucous membrane, which are called lateral half-arches ; the space between which constitutes the fauces. Between the anterior and posterior arches of each side is the tonsil gland. The tonsil is about the size of an almond, and con- sists of a collection of large mucous follicles. Muscles of the palate.—Constrictor isthmi faucium.—A small muscle placed in each anterior half-arch, arising from the middle of the soft palate, and inserted into the side of the root of the tongue. It diminishes the opening into the pharynx. SALIVARY GLANDS OF THE MOUTH. 99 Palato-pharyngeus.—Another small muscle, included in the pos- terior half-arch, arising from the soft palate, and inserted into the side of the pharynx. It draws the palate down and the pharynx up. Circumflexus or Tensor palati.—Origin, from the spinous pro- cess of the sphenoid bone, and the contiguous portion of the Eusta- chian tube. Insertion, by a tendon, which winds around the hamulus or hook of the internal pterygoid process, into the posterior and crescentic edge of the palate bone. Use; to extend the soft palate transversely. Levator palati.—Origin, from the petrous portion of the tem- poral bone and Eustachian tube. Insertion, into the soft palate. Use ; it draws the palate upwards. Azygos uvula.—Is in the middle of the uvula and soft palate. Its contractions shorten the uvula. SALIVARY GLANDS OF THE MOUTH. The salivary glands are of a light pink colour, and their secretion is of great service in mastication and digestion. They are three in number—the parotid, submaxillary, and sublingual. Fig. 81. The parotid is the largest of the three, its shape is irregular ; it has no capsule, and is merely covered by the superficial fascia of the neck. The position it occupies1 is in the space behind the ramus of the lower jaw and the mastoid process. It extends in front, so as to cover a portion of the masseter muscle ; in depth it reaches towards the styloid process, and superficially it is covered.by the skin; its structure is lobulated, and its duct, called the duct of 100 THE PHARYNX AND ffiSOPHAGUS. Steno? traverses the outer face of the masseter muscle m a line drawn from the lobe of the ear to the end of the nose. It is white and hard, about the size of a crow-quill, and perforates the cheek through a pad of fat by a very small orifice opposite the second molar tooth of the upper jaw. The external carotid artery passes through the deeper portion of the gland, and it is also traversed by the portio dura nerve. There is sometimes found in front of the gland an accessory portion called socius or accessorius parotidis, whose duct empties into that of Steno. The submaxillary gland3 is much smaller than the parotid, is irregularly oblong in figure and lobulated in structure. It is situated in a depression on the internal face of the inferior maxillary bone, being covered externally by the skin, superficial fascia, and platysma muscle. Its duct4 is called the duct of Wharton, which empties at the side of the fra?num under the tongue by a very small orifice on the summit of a papilla; the coats of this duct are very thin, the gland is traversed by the facial artery as it mounts the lower jaw. Sometimes there is an additional gland and duct, called after Bar- tolin. The sublingual gland5 is the smallest of the three ;' its shape is also oblong, and its structure lobulated ; it is situated under the tongue, between the mucous membrane of the mouth and the mylo- hyoid muscle. Its duct or ducts (for they are frequently numerous) are called after Rivinus, and empty into or near the duct of Wharton. THE PHARYNX AND OESOPHAGUS. The pharynx is a muscular and membranous sac, communicating with the mouth, nose, oesophagus, larynx, and Eustachian tube. It is situated in front of the vertebral column, and extends from the basilar process of the occiput to the fourth or fifth cervical vertebra. It is funnel-shaped, being larger above than it is below. Its length is about five inches, although this varies by contraction and disten- sion ; it is never collapsed, but its walls are always kept distended by its muscular origins. It consists of three coats, muscular, cel- lular, and mucous. The inferior constrictor muscle9 arises from the cricoid and thy- roid muscles. The fibres terminate in those of its fellow, along the posterior median line ; those of the upper part are oblique, those of the lower horizontal. The middle constrictor muscle10 arises from the cornu of the os hyoides, and the lateral thyreo-hyoid ligament, and is inserted into its fellow in the posterior median line. Its upper fibres ascend ob- liquely to the basilar process of the occiput, and overlap the supe- rior constrictor, while its lower fibres are horizontal or descending, and are overlapped by the inferior constrictor. THE PHARYNX AND OESOPHAGUS. 101 Fig. 82. The superior constrictor muscle is quadrilateral, and arising from the pterygoid process of the sphenoid bone, from the upper and lower jaw, the buccinator muscles, and the root of the tongue; is inserted into its fellow behind, and also into the basilar process of the occiput. The stylo-pharyngeus muscle1* has been described before. The cellular coat is thin, and merely serves for a transmission of vessels and nerves, and the connexion of the external and internal coats. The internal or mucous coat is a continuation of that of the mouth, nose, and Eustachian tube, and it is covered by a thin epithelium, and studded with mucous follicles and glands. It is supplied by the pha- ryngeal and palatine arteries, and by the sympathetic, and eighth pair of nerves. Its uses are for deglutition, respiration, and modulation of the voice. The ozsophagus is a canal which conveys the food from the pharynx to the stomach. It is situated in the median line, in front of the vertebral column, and passing through the posterior mediastinum, and inclin- ed somewhat to the left side in its lower part, where it passes through the diaphragm. Its length is about nine or ten inches, and its diameter is not uniform, gradually in- creasing as it descends. Its upper portion is the narrowest part of the alimentary canal, and hence foreign bodies which are too large to pass through the alimentary canal, are generally arrested in the neck; its shape is cylindrical, although its walls when at rest, are in contact, never containing air. It consists of three coats, the ex- ternal of which is muscular, and thicker than any other portion of the canal; it consists of two layers, the external consists of longi- tudinal fibres, and the internal of circular fibres. The cellular coat attaches the muscular and mucous, and serves for the passage of vessels and nerves. The internal or mucous coat is continuous with that of the pharynx, and has a number of longitudinal folds when in a state of quiet. It has a thick epithelium, and numerous mucous glands and follicles. It is supplied by the oesophageal ar- teries, proceeding from the inferior thyroid, aorta, coronary, and phrenic arteries ; its nerves are derived from the eighth pair, and from the sympathetic. Deglutition is performed by the contraction of its longitudinal 9# 102 PERITONEUM. fibres which shorten the passage, and by the contraction of its cir- cular fibres successively from above downwards; vomiting is pro- duced by the contraction taking place from below upwards. VISCERA OF THE ABDOMEN. The cavity of the abdomen is divided into nine different regions, by the drawing of parallel lines Fig. 83. vertically,3 3 through the anterior inferior spinous processes, and intersect- ing them with two other parallel lines drawn transversely1 * over the crests of the ilia, and over the most prominent part of the costal carti- lages. We thus have three regions arranged above, three in the mid- dle, and three below. Those of the upper row are termed the epi- gastric? in which are the left lobe of the liver, and a portion of the sto- mach ; the right hypo- chondriac5 contains with- in it the right lobe of the liver, while the left con- tains the spleen, a portion of the stomach, and the liver. The middle row contains the umbilical? in which are the small intestines, and on either side the lumbar regions ;8 the right lumbar region contains the right kidney, and ascending colon ; while the left contains the left kidney and descending colon. The lower row contains the hypogastric region,9 1J in which is a portion of the small intestines and bladder, and on either side the iliac fossa;10 the right of which contains the ccecum or caput coli, and the left contains the sigmoid flexure. PERITONEUM. The peritoneum is a thin, transparent membrane, lining the cavity PERITONEUM. 103 Fig. 84. of the abdomen, and covering most of the viscera that are contained therein; it is a se- rous membrane, and there- fore a shut sac, following the general rule of lining the cavity, and covering the or- gans contained within. It se- cretes a small quantity of fluid in health, which lubri- cates the surfaces of the vis- cera, so that they readily move upon each other and the walls of the cavity. It also forms ligaments and con- nexions whereby the viscera are held in their places. That portion of the perito- neum, which passes between one viscus and another, or a viscus and the wall of the cavity, usually consists of two lamina?, and is called an omentum. There are four principal omenta, viz. the gastro-hepatic, or lesser omen- tum, which reaches from the lesser curvature of the sto- mach to the liver; the gastro- splenic, reaching from the left extremity of the stomach to the spleen; the colic-omentum or meso- colon, which holds the large intestine to the posterior wall of the abdomen; and lastly, the gastro-colic or great omentum or caul which passes between the stomach and colon ; the last is the largest, and covers the intestines like an apron ; it appears to consist of four layers, whereas, like the rest, it consists but of two. Owing to its great size and the proximity of the colon to the stomach, it must necessarily be folded or doubled, and thus presents a quadruple appearance. Since the peritoneum is a continuous membrane, its whole surface can be traced in a male subject with the point of a finger, otherwise it would not be a single sac. In the female there is a deficiency at the extremity of the Fallopian tube. Commencing at the umbilicus to trace the peritoneum, it will be found to line the anterior wall of the abdomen and under surface of the diaphragm, thence to cover the upper and a part of the lower 104 PERITONEUM. surface of the liver,L thence to pass to the stomach,s forming thus' the upper lamina of the gastro-hepatic or lesser omentum; having covered the anterior face of the stomachs» it passes down to form one of the lamina of the apparently quadruple omentum—the gastro- colic ; ascending again it forms another lamina, and surrounding the inferior semi-circumference of the colon,c it passes to the verte- bral column, forming at7 the inferior lamina of the colic omentum; then we find it including the small intestine forming at10 the mesen- tery ; from the vertebral column it can be traced over the upper and anterior part of the rectum,R and over the posterior and superior por- tion of the bladder,8 forming at ' the vesico-rectal pouch, and again13 we traced it to the umbilicus, the point whence we started. But in thus tracing it will be found, by the diagram, that we have not traced the peritoneum covering some portions of the viscera and abdomen. In the dead subject it is very easy to introduce the finger through a narrow passage which is called the foramen of Winslow, although there is no hole or tearing of the peritoneum. By looking for the posterior end of the gall-bladder and passing the finger under the vessels of the liver it will be easy to touch the peritoneum covering the posterior surface of the stomach. This cannot be demonstrated very clearly from a drawing alone, which represents merely a longi- tudinal section of the abdominal cavity ; and without explanation it gives the false idea of there being two sacs instead of one. In the subject, however, by placing the finger upon the under surface of the liver, we trace the peritoneum in the foramen of Winslow; there it forms the inferior lamina of the lesser omentum,' thence it covers the inferior surface of the stomach; descending it forms the third and ascending at6 it forms the fourth lamina of the great omentum; then it covers the superior convexity of the colon, and forming the superior lamina of the colic omentum at7 it ascends in front of the duodenum and pancreas,1" D and passing out at the foramen of Wins- low we can trace upon the posterior and inferior portion of the liver, the point of starting. The mesentery is formed of two lamina? of peritoneum, and serves to connect the small intestine to the parietes of the abdomen. Its root is about six inches wide, and its inferior edge equals in breadth the whole length of the small intestine. Between these two lamina? of peritoneum are the superior mesenteric artery and vein, lym- phatic glands and vessels, and branches of the sympathetic nerve, together with a portion of fat and cellular tissue. The meso-colon is also formed of two lamina? of peritoneum, and holds the large intestine in its place. The transverse portion is long and loose, but on each side in the iliac regions it is short, and binds the intestine down very tightly; it also contains between its lamina? vessels and nerves, together with some fat and cellular tissue; that portion which is attached to the rectum is called the meso-rectum. THE STOMACH. 105 Fig. 85. THE STOMACH. The stomach is a conoidal sac, somewhat bent or curved, and is situated in the left hypochondriac and epigastric regions. It is some- what flattened anteriorly and posteriorly, and thus presents an an- terior and posterior face; its direction is oblique from above down- wards, and from left to right. The left3 extremity is much the larger, and terminates in a rounded cul-de-sac; at the superior por- tion of this extremity is the Cardiac orifice, where the oesophagus is continued into the stomach immediately below the diaphragm. The right extremity gradually diminishes in size, and its orifice is called Pyloric9, which is continuous with the small intestine. The structure of the pylorus is much thicker than that of any other portion. The upper and lower curvature of the sto- mach are called the greater and lesser cur- vatures58, near the pyloric extremity of the stomach, is a slight dilatation7 called an- trum pylori. The di- mensions of the sto- mach are variable, de- pending upon the mode of life. It consists of four coats; peritoneal, muscular, cellular, and mucous. The Peritoneal coat completely covers the stomach, except at the curvatures, where are attached the omentum ; the looseness of which adhesion at these points admits of the distension of these remaining coats. The Muscular coat is not so thick as that of the oesophagus, and its fibres pass both in a circular7 and longitudinal8 direction, (see Fig. 86.) Some of the muscular fibres which pass obliquely round the left extremity, constitutes the muscle of Gavard. The circu- lar fibres are most numerous near the pyloric orifice, and the longi - tudinal fibres are most distinct upon the lesser curvature. The Cellular coat connects the muscular and mucous; it serves for the transmission of vessels and nerves, and can readily be in- flated ; when dried, it resembles cotton. 106 INTESTINES. The Mucous or Villous coat, is a continuation of the oesophagus; it is soft and thick, of a light pink colour, and is thrown into a num- Fig. 86. ber of longitudinal ruga or folds, which are particularly numerous at the greater curvature, and nearer the pyloric orifice.8 (See Fig. 86.) The epithelium of the mucous membrane of the stomach is thinner than that of the oesophagus. The surface of the stomach is covered by numerous pits or cells, into which enter several small tubes, which are supposed to secrete the gastric juice, and hence called gastric glands. At the pyloric orifice, the mucous membrane is thrown into a cir- cular or semi-circular fold, which is called the pyloric valve. The lesser curvature is supplied by the gastric artery, the greater by the right and left gastro-epiploics, and the greater extremity by the vasa brevia. The nerves are derived from the par vagum and sympathetic. INTESTINES. The intestinal canal is from thirty to thirty-five feet in length, and is divided into large and small intestine. SMALL INTESTINE. The small intestine is four-fifths of the length of the whole canal, reaching from the pylorus to the large intestine; it is cylindrical, and about one inch in diameter, although there is a gradual diminu- tion in diameter as it descends. It consists of four coats. INTESTINES. 107 The Peritoneal coat is the external, being included in the lower edge of the mesentery. The Muscular coat is thin, and consists of pale fibres ; the super- ficial and longitudinal8 are not distinct; the remainder are cir- Fig. 87. cular3 4. The Cellular coat connects the muscular and mucous, and con- tains the vessels and nerves; when inflated with air and dried, it appears like cotton, as is the case in the stomach. The Mucous coat is longer than any other, and hence must be thrown into numerous folds, which are called valvula conniv'entes; these are circular and over- lapping, and more numerous" and larger1 in the upper portion of the intestine, than in the lower. The surface of the mucous membrane is covered with a number of papillary projections called villi, many of which are conical in shape. Each villus consists of an artery, vein, and lacteal. This lacteal does not open directly upon the surface of the mucous membrane, but the chyle is conveyed into the intestine by the intervention of cells. Fig. 88. Fig. 89. Brunner's Glands are a number of small solitary glands, which are with difficulty perceived by the naked eye. They are most abun- dant near the duodenum, but exist in a scattered manner throughout the intestine. Peyer's Glands are larger, and exist principally in the lower part of the small intestine. They are flat and elliptical, and vary in size, 108 LARGE INTESTINE. from a few lines to a few Fig- 90. inches. They consist of a cous layer. They are seen in the interstices of the villi. (Fig. 91.) In fa urine Fibrine. > Compounds of proteine. Uric or lithic acid. ( Caseine. } Cholesterine ; in the bile. Gelatine. Biliary matters. Chondrine. Pepsine; in the gastric juice. Elaine. Sugar of milk. Stearine. Lactic acid. Margarine. Hffimatosine. Globuline. (Todd and Bowman.) Albumen.—Exists in two forms, fluid and concrete. In the latter form, when pure, it is perfectly white; hence its name (albus, white) ; it is found solid in the brain, spinal cord and nerves, and in the mu- cous membranes, which are thence called albuminous tissues. It is fiuid in the serum of the blood, the lymph and chyle, and in many of the secretions. It is coagulable by heat, acids, and corrosive sub- limate, but not spontaneously. Fibrine is found in solution in the chyle, lymph, and blood. It is the basis of the muscles, in which it is found in a solid form. It is one of the most abundant of the animal substances. It may be 20 PHYSIOLOGY. obtained by stirring blood as it is flowing, or by washing a clot in clean water so as to dissolve out the colouring matter. Fibrine is white, solid, flexible, and slightly elastic; insoluble in water, alcohol, and acids, but soluble in caustic potassa. Chemically speaking, fibrine does not differ essentially from albumen. Phy- siologically, the great variation lies in the spontaneous coagulation of the fibrine, and when coagulated it is found to possess a definite fibrous arrangement, the fibres crossing each other in every direction. Fibrine is the plastic element of the blood, and with the serum constitutes the liq. sanguinis; it forms the buffy coat of the blood, and is found in those exudations which take place either in inflam- mation, or from a peculiar Fig. 2. formative action, destined to repair an old tissue, or pro- duce a new one ; under these circumstances, it is often called coagulable lymph. (Fig. 2.) Caustic potassa, carb. potass., chloride of sodium, and many neutral salts, when mixed with blood, will prevent the coagu- lation of fibrine. Caseine has many proper- ties in common with albumen and fibrine. It exists in great- est abundance in milk, and is the basis of cheese. Its occurrence in other fluids has not been positively detected. It may be obtained by allowing milk to remain at rest till it is coagulated, skimming off the cream, then washing and drying the clot. Caseine is very perfectly coagulated by the action of rennet. This coagulating power is not due to the acid of the stomach, but to the pepsine resident in it. It is not coagulable by heat, but is readily precipitated by the addition of an acid. It contains sulphur, but no phosphorus. Proteine.—If albumen, fibrine, or caseine, be dissolved in caustic potassa, and acetic acid be added to the solution, a precipitate takes place of a translucent, gelatinous material. This substance was called proteine by Mulder, the discoverer, because it was supposed to be the starting point or basis of all the tissues (from irjwrsuw, I take the first place). The precipitate is the same no matter which of the substances above named be taken, be it animal or vegetable. They are looked upon therefore as modifications of proteine by the addition of certain proportions of phosphorus or sulphur, or both. Dried proteine is a hard, brownish-yellow substance, without taste, ELEMENTARY PARTS OF ANIMAL STRUCTURE. 21 and insoluble in water and alcohol. It unites with oxygen in defi- nite proportions, so as to form a binoxide and tritoxide. These are formed in the lungs from fibrin, which, in a moist state, possesses the property of absorbing oxygen. The tritoxide, especially, is formed every time that the blood passes through the lungs, and given out again when it returns to the system. A much larger quantity is formed also during the inflammatory condition, constituting the buffy coat. Pepsine and Pyin are also included under the head of proteine compounds by some authors, although the existence of this substance in them is denied by many others. The first is a peculiar substance thrown off from the mucous lining of the stomach, and the second is also a peculiar substance found in pus. Mulder regards it as a protoxide of proteine. Proteine undergoes decomposition very readily when acted on by other chemical substances, especially by alkalies. This is a property which must be continually acting in the living body ; since the blood is known to have an alkaline reaction. Gelatine is the chief constituent of the cellular, or areolar tissue, skin, tendons, ligaments, and cartilages : it is also contained in large quantities in bones. It is obtained by boiling any of the above sub- stances, and allowing the solution to cool. Glue is an example of impure gelatine. It contains no proteine, hence it has been concluded that it cannot yield albumen, fibrine, or caseine. It is insoluble in cold water, alcohol, and ether, and has a strong affinity for tannin. The process of tanning leather results from this affinity. Proteine cannot be obtained from gelatine, but it is probable that it or its com- pounds have yielded gelatine, for the gelatine of the chick must be produced from a compound of proteine. Chondrine resembles gelatine in many respects, except that it is not precipitated by tannin, and yields a precipitate to acetic acid, alum, acetate of lead, and protosulphate of iron, which do not dis- turb solutions of gelatine. It is obtained by boiling the permanent and temporary cartilages ; also from the cornea, and gelatinizes when cool. Elaine, stearine, and margarine are proximate principles of fat. The first gives fluidity, the second is the solid ingredient, and the third is of medium consistency. Stearine is but sparingly present in human fat. Hamatosine is the red colouring matter of the blood contained in a capsule which is composed of globuline. The latter is regarded by some chemists, as a proteine compound. In regard to the secondary organic compounds, they are trans- formed by some unknown chemical agency, from the elements of the tissues, to be excreted from the system by particular organs. There is reason also to believe, that, at least with respect to some of them, 22 PHYSIOLOGY. the elements of the food contribute immediately to their formation. Of this latter hypothesis the bile is supposed to be an example. Further, in regard to the particular tissues from which these com- pounds are formed, Dr. Prout suggests that urea is derived from the gelatinous, and uric acid from the albuminous tissues, whilst the fatty materials are supposed to form some of the constituents of the bile. The particular compounds will be treated of under the head of secretions. CLASSIFICATION OF THE TISSUES. From the proximate principles described above, are developed the various tissues of the body. In combining to form the different structures the solids are arranged in a variety of ways. Of these the chief are in filaments, or elementary fibres, tissues, organs, apparatus, and systems. By filament, is meant the elementary solid. A fibre consists of a number of filaments united together. By the union of tissues, organs are formed. A number of different organs united to accomplish one end constitute an apparatus. When a number of organs of similar or analogous structure are united for one end, they form a system. Schwann advanced the doctrine that all the tissues of the body were formed from cells. It has been shown, however, by subsequent research, that this assertion was rather too hasty ; that although many tissues retain their original cellular type throughout life, and many more are formed from cells which are afterwards metamorphosed, there are some in which no other cell-agency is employed than that concerned in the elaboration of the plastic ma- terial. This is the case in certain forms of the very delicate struc- tureless lamella known by the name of basement membrane, found beneath the epidermis and epithelium, in which no vestige of cell structure can be seen, but which appears rather to resemble that of which the cell walls are themselves constituted. At other times it seems to be composed of the coalesced nuclei of cells whose deve- lopment has been arrested. In regard to the fibrous tissues a doubt also exists as to whether they are developed by a metamorphosis of cells, or whether they are not, like basement membrane, produced by a consolidation of a plastic fluid which has been elaborated by cells. The following arrangement of the human tissues, is that adopted by Dr. Carpenter, and expresses their fundamental relation to the elements above alluded to, viz.: membrane, fibres, and cells. a. Simple membranous tissues.—Of these there are scarcely any examples in the human body except in the capsule of the lens, and the posterior layer of the cornea. The walls of the primary organic cells are also composed of it; and it is employed in forming muscle, nerve, and the adipose and tegumentary tissues. Its principal cha- CLASSIFICATION OF THE TISSUES. 23 racter is extension, but its ultimate arrangement defies the highest powers of the microscope. b. Simple fibrous tissues.—Under this head are included the white and yellow fibrous tissue and the areolar tissue. These are extensively used for connecting different parts, or for associating the elements of other tissues. The ligaments of joints are composed of the white, or yellow fibrous tissues; and areolar tissue surrounds and connects the component parts of nerves, muscles, vessels, &c. c. Simple cells floating separately and freely in the fluids, as corpuscles of the blood, lymph, and chyle. d. Simple cells developed on the free surfaces of the body, as epidermis and epithelium. e. Compound membrano-fibrous tissues, composed of a layer of simple membrane, developing cells on its free surface, and united on the other to a fibrous or areolar structure, as the skin, mucous mem- branes, serous and synovial membranes, lining membrane of blood- vessels, &c. /. Simple isolated cells, forming solid tissues by their aggregation, as fat cells, the vesicles of gray nervous matter, absorbent cells of the villi, the cellular parenchyma of the spleen; the cells being held together in all these cases by the blood-vessels and areolar tissue which pass in between them. In cartilage, and certain tissues allied to it in structure, the cells are united by intercellular substance, either homogeneous, or of a fibrous character. g. Sclerous or hard tissues, in which the cells have been more or less consolidated by internal deposit, and more or less completely coalesced with each other, as the hair, nails, &c. These may be more properly ranked under the epidermic tissues, but the result is more characteristically seen in bones and teeth. The sclerous tissue contains a large proportion of inorganic material to which it owes its hardness. It differs from all the other tissues except cartilage and fibro-cartilage, which for hardness might be classed with it. h. Simple tubular tissues, formed by the coalescence of the cavi- ties of cells, without secondary internal deposit, as the capillary blood-vessels and smallest lacteals and lymphatics. i. Compound tubular tissues, in which, subsequently to the coa- lescence of the original cells, a new deposit has taken place within their cavities. In the tubuli of the white nervous matter, and in those of the least perfect form of muscular fibre, the secondary de- posit has only a granular or amorphous character; but in the striated muscular fibre it is composed of minute cells. Other classifications of the tissues have been adopted by different physiologists and general anatomists, among these Haller described only three,the nervous, the muscular, and the cellular ; from these all the organs are formed by the association of the first two tissues, or by the last alone. The limits of a work like this will not admit of an 24 PHYSIOLOGY. examination of all these different classifications. That one has been adopted which seems to be most generally received. The elementary membrane was alluded to and described, as far as seemed requisite, in the commencement of this article ; we proceed at once, therefore, to the consideration of the second group of tissues, the fibrous. OF THE SIMPLE FIBROUS TISSUES. Under this head are included two kinds of texture, resembling each other only in the fact that they present to the eye a fibrout aspect. They differ in their ultimate structure, colour, and physical properties. They are both used in connexion with the skeleton, and are concerned in the mechanism of animal motion and locomotion. They are known as the white and yellow fibrous tissues. It will be remembered that there is reason to doubt whether they are generated by a metamorphosis of cells, or whether they are not produced by the consolidation of a plastic fluid which has been elaborated by cells; the latter is the more probable hypothesis. The white fibrous tissue is found in textures requiring great flexi- bility, strength, and an unyielding firmness; such as ligaments, tendons, fibrous membranes, aponeuroses, &c. It presents itself in the form of inelastic bands, somewhat wavy in their direction, some- times arranged side by side, at others, disposed on different planes, and interlacing and crossing in various directions. (Fig. 3.) It is inelastic, and under ordinary circumstances, inexlensible; con- tains but few vessels, and no nerves, at least they have never been satisfactorily disco- vered. It seems entirely destitute of any vital properties; and its chemical nature is such that it needs very little interstitial change to maintain its normal composition.4 It yields gelatine in considerable quantityr by boiling. When treated with acetic acid* it immediately swells up and becomes trans- parent. When a solution of continuity takes place in this tissue it is readily repaired by the in- terposition of a new substance, in every re- spect resembling the original, save, that it wants the peculiar glistening aspect, and is more bulky. Yellow fibrous tissue, differs from the last in colour, and in the possession of great elasticity. It consists of bundles of fibres covered * 2. Straight appearance of the tissue when stretched. 1, 3. 4, 5. Various wavy appear- ances which the tissue exhibits when not stretched. Fig. 3.« OF THE SIMPLE FIBROUS TISSUES. 25 Fig. 4. Fig. 5. by a thin sheet of areolar tissue; the fibres are either round or flat- tened, brittle,and disposed to curl at the end. (Fig. 4.) It is found in the middle coat of the arteries, in the chordae vocales, the ligamentum nuchas, the liga- menta subflava, in the crico-thyroid membrane, and in the longitudinal bands of the trachea and its branches. It.undergoes little or no change by boil- ing, and is unaffected by acetic acid; it resists putrefaction, and preserves its elasticity during a long period. Both these varieties may be detected in the tissue now generally designated as areolar, formerly cellu- lar. This is formed by the crossing and interlacing of minute fibres and bands interwoven in every di- rection, so as to leave innumerable interstices which communicate with each other: this may be proved by filling them with air or water, as occasionally happens in the living body in anasarca and traumatic emphysema. (Fig. 5.) These interstices are not cavities possessed of definite limits, be- cause they are open on all sides. The application of the term cell to them, is, therefore, inappropriate. The term cellular is more applicable to those tissues which consist of a congeries of distinct cells. The areolar tissue is one of the most' extensively diffused of all the ele- ments of organization, being found in every part of the fabric, except in the compact portion of bone, teeth, and cartilage. It does not exist in the brain either, except around the minute vessels. Its great use is to connect together organs, and parts of organs which require a certain degree of motion upon each other. To do this, it is placed in their interstices, and is more or less lax, and more or less abundant, according to the par- ticular exigency of the part. It has scarcely any vital properties, but possesses the physical properties of extensibility and elasticity. It has neither contracti- lity nor sensibility, the nerves which it contains, being merely dis- tributed in it in their route to other organs. Areolar tissue is readily regenerated when destroyed, and yields gelatine very readily by boiling. The interstices are filled during 3 26 PHYSIOLOGY. life with a fluid resembling dilute serum, which soaks out of the blood-vessels by the mere physical process of transudation; a mor- bid increase of this fluid occasions the condition called anasarca, which is recognised by the skin pitting under the pressure of the finger. SIMPLE CELLS FLOATING IN THE ANIMAL FLUIDS. OT these we have examples in the corpuscles of the blood, chyle, and lymph. The corpuscles of the blood consist of an investing capsule composed of globuline, and a contained fluid, secreted in the interior of the cell, of a red colour, called hamatosin or hamatin. In shape they are somewhat disc-like, the sides are concave, and there is a bright spot in the centre, which by many has been re- garded as a nucleus. The form of the disc is readily altered by rea- gents, the membrane of the cell-wall being readily permeable by liquids either inwards or outwards, as the relative density of the contents of the cell and the surrounding fluids may direct. It is supposed that these cells contain a nucleus, though it cannot be distinctly brought into view in the corpuscles of human blood, as it can in that of the oviparous vertebrata. Dr. G. O. Rees states that he could distinguish a nucleus on the ruptwred cell-walls, al- though they escape observation when within the corpuscles in con- sequence of their high refractive power. Their size varies in the same individual, and they bear no con- stant relation to the size of the animal. In man their average dia- meter is about l-3200ths of an inch. Chemical composition.—Globuline is a proteine compound, and does not differ essentially from other substances that result from the organization of the proteine compounds. Hamatine, when sepa- rated from albuminous matter, is of a dark brown hue, its formula is C. 44, H. 22, N. 3, 0. 6, F. 1. The red colour is not due to the presence of iron, since, as Scherer has shown, it may be entirely dissolved out without destroying the colour. In regard to the origin of the red corpuscles there is considerable difference of opinion. Most physiologists look upon them as nu- cleated cells, having the power of reproducing themselves, either by splitting up the disc and nucleus into six or seven segments, or, as Dr. Rees has observed, by an hour-glass contraction of the cor- puscle, by which two unequal-sized circular bodies were eventually produced from each. In the formation of the embryo, they have an origin common to that of all the other tissues. In the embryo of the bird, they are formed in that portion of the germinal membrane known as the vascular layer; this consists of delicate cells very uniformly dis- posed, and whilst capillary vessels are formed by the union of the SIMPLE CELLS FLOATING IN THE ANIMAL FLUIDS. 27 cavities of these cells, their walls being absorbed at the points of contact, the blood discs seem to be developed from the granules or cell-germs they contain. These corpuscles are larger in the em- bryo than in the adult, which fact is an argument in favour of the independent circulation in the fcetus. According to Dr. Carpenter, the uses of the red corpuscles are now definitely settled. Since they are confined nearly entirely to the vertebrata, and are absent in the embryo of higher animals at an early period of their development, the inference appears highly probable, that they are not essential to growth or nutrition. On the other hand, as they are found most abundant in those classes of vertebrata which possess the highest temperature, and are known to undergo important changes in the pulmonic and systemic capilla- ries,—it seems highly probable that their office is, to convey oxygen into the system, and carbonic acid out of it; serving, in fact, as the medium for bringing the tissues into relation with the air, the influ- ence of which is necessary for the maintenance of their vital activity. Besides the cells which have been described as floating in the blood, viz., the red corpuscles, there are also found both in this fluid and in the chyle and lymph, certain colourless corpuscles which are observed to be present in the blood, both of the vertebrata and inver- tebrata. From the latter fact it would not be wrong to infer that the function of the latter must be of a general character, and imme- diately connected with the nutritious properties of the circulating fluid, whilst the function of the red corpuscles must be of a limited character, being required only in a portion of the animal kingdom. The dimensions of these corpuscles are nearly constant throughout the different classes of vertebrata ; their diameter being seldom more than l-3000th of an inch; hence it would seem improbable that the one would ever be converted into the other. They have no distinct nucleus, but are studded with minute granules which may occa- sionally be seen in active motion within them, and which are dis- charged when the corpuscles are treated with liq. potassse. In the circulating blood, they are always found on the outside of the cur- rent where the motion of the fluid is slow. The function of these colourless corpuscles, both in the blood and in the chyle and lymph, seems to be, the elaboration of plastic fibrine from unorganizable albumen. They are always found most abundant where these processes are going on, in the fluids in which they are contained, and their number is always in proportion to the amount of fibrine. They are looked upon as cells of a transitional character, precisely such as those developed in the germinal vesicle for the elaboration of its contents. They are not in themselves des- tined to form an integral part in any permanent structure, but, after attaining a certain maturity, reproduce themselves and disappear, 28 PHYSIOLOGY. successive generations thus following each other until the end is ac- complished for which they were first produced. OF CELLS DEVELOPED ON FREE SURFACES. Of these we have examples in the cells composing the epidermis and epithelium, two structures which are essentially alike in their origin, mode of development, situation, and individual history; they differ, however, in the purposes which they respectively serve in the economy. The epidermis is the cellular covering of the external surface, the epithelium is the corresponding covering of the internal cavities. They both consist of cells, which are developed from the subjacent membrane, which are nourished by its vessels, and which are, after a time, cast off from its free surface, to be replaced by a succeeding generation. The epidermis is not permeated by either vessels or nerves, but consists solely in a congeries of nucleated particles arranged in laminas. Those that lie deepest and rest immediately on the cutis are small granules scattered in a homogeneous matrix. Those of the next layer are rounded cells of transparent membrane, in which similar granules can be seen. In the succeeding layers these cells are more and more compressed as they are nearer to the surface; and on the surface they are mere flattened scales. The superficial scales are being constantly shed ; and new ones are as constantly formed below from germs, which are supplied by the basement membrane. The soft layer immediately in contact with the true skin was formerly called rete mucosum, but it is now proved to consist of the same elements with the ordinary epidermis. The epidermis varies in thickness in different parts, according to the amount of pressure or friction to which it is subjected. The use of the epidermis is to protect the true skin from mecha- nical injury, and from the irritating effects of exposure to atmo- spheric vicissitudes. Mixed up with the epidermic cells, we find the Pigment cetts, or those which contain the peculiar colouring matter of the races. The black colour is caused by the presence within them of a number of flat or oval granules, which are transparent, and exhibit an active movement when set free from the cell. The chemical nature of this pigment is unknown; it includes, however, a larger proportion of carbon than most other organic substances—every 100 parts con- taining 58^ of carbon. Exposure to light increases the development of these pigment cells, as is seen in freckles, tan, and the swarthy hue obtained by expo- sure in tropical climates. The latter is doubtless the cause of the blackness of the negro's skin, operating through successive gene- rations. OF CELLS DEVELOPED ON FREE SURFACES. 29 The nails and hairs are also modifications of epidermic cells— for description of which see Anatomy. The epithelium is the layer of cells which covers the internal free surfaces of the body. In some instances it serves, as the epidermis, to protect the subjacent membranes ; in others, it takes an important part in some of the organic functions. In the arrangement of the epithelial cells, two principal forms are seen, viz.: the tessellated or pavement-like epithelium; and the cylindrical, or cylinder epithelium. The tessellated, covers the serous and synovial membranes, the lining membrane of blood-vessels, and the ultimate follicles or tubuli of the glands connected with the skin or mucous membranes. It is called tessellated, from the fact, that the cells which compose it are polygonal, and arrange themselves like the pieces of marble in a tessellated pavement. Sometimes, however, the cells retain their rounded form, and are separated by considerable intervals. The cylinder epithelium is so called because the component cells are cylinders, and arrange themselves side by side^ one extremity resting on the basement membrane, while the other forms part of the free surface. It is found in the mucous membrane of the alimentary canal, from the cardiac orifice downwards; in the larger ducts of the glands which open into it; or, upon the external surface. Both these forms of epithelium are frequently seen to be fringed at their free extremities with delicate filaments, termed cilia, from their resemblance to an eyelash. These, although exceedingly minute, are of great importance in the economy, through the ex- traordinary motor power with which they are endowed (Fig. 6). In form the cilise are usually a little flattened, and tapering gra- dually from base to point. Their size is variable, ranging from 1-5000th to 1-13000th of an inch in length. When in motion they present the appearance of a field of wheat over which the wind is blowing, first depressed, and then returning to its original state. The direction of this motion is towards the outlets. The cause of ciliary motion is unknown, it is not dependent on muscular action, since it continues after separation, and contains not even a fibrilla of muscle. It seems to be entirely molecular and in- dependent of muscular influence, and of both the vascular and nervous systems. It continues many hours after separation from the rest of the system has taken place, and when all supply of blood to the parts endowed with it has been cut off. It resists the action of * o. Nucleated cells resting on their smaller extremities; b. Cilia. 3* Fig. 6.* 30 PHYSIOLOGY. narcotics, which affect powerfully the nervous system; and even electricity, which destroys muscular contractility, does not affect the action of cilia?. It continues much longer in cold-blooded than in warm-blooded animals. The function of the ciliae seems to be, to propel the secretions, which would otherwise accumulate on these membranes, towards the outlets. The epithelium cells, like the epidermic, are being constantly cast off and renewed from the subjacent surface; but the rapidity of this renewing process varies according to the particular function of the part. OF THE COMPOUND MEMBRANO-FIBROUS TISSUES. This division includes the structures made up of the elementary components of the body, viz. : membranes, fibres, and cells, in their simplest forms. These are the serous, synovial, and mucous mem- branes. The serous and synovial membranes are essentially alike in their minute structure. On their free surface is a single layer of epithe- lium, the particles of which are polygonal in shape, and of trans- parent texture. This rests upon a continous transparent basement membrane of extreme tenuity. Beneath this is a layer of areolar tissue, which constitutes the chief thickness of the membrane, and gives it its strength and elasticity. This areolar tissue is traversed by a network of capillary vessels, lymphatics, and nervous filaments in varying number; and is the bond of union with the tissues beneath. It is commonly known as the subserous tissue. The physical and vital properties of serous membranes are pre- cisely those of areolar tissue. They are elastic, but not contractile, and have very little sensibility, except when inflamed. They are bedewed with a secretion which resembles the serum of the blood. That of the synovial membranes and bursa? mucosa? has from 6 to 10 per cent of additional albumen. It escapes from the blood-ves- sels by simple transudation. Serous membranes are recognised by the fact, that they always form shut sacs. The peritoneum of the female is the only excep- tion to this rule. At two points this membrane is open, where it communicates with the canal of each Fallopian tube at its dilated extremity. The mucous membranes may be said to consist of the three parts described in the serous, viz.: epithelium, basement membrane, and the submucous areolar tissue. The mucous membrane is continuous with the external skin, and by some is considered as identical. It is recognised by the fact that it lines the outlets, and never occurs as a shut sac. It is abundantly supplied with blood-vessels, absorbents, and nerves. The first two are very numerous, the last not so much so, hence the sensibility of this structure is usually low. The areolar tissue of mucous membranes usually makes up the OF SIMPLE ISOLATED CELLS FORMING SOLID TISSUES. 31 greater part of their thickness; and is so distinct from the subjacent layers as to be readily separated from them. The elasticity of these membranes is dependent upon the presence of the yellow fibrous tissue in the areolar tissue. Mucous membranes are very speedily regenerated whenever they have been destroyed either by injury or disease. They constitute the medium through which all the changes are effected that take place between the living organism and the external world. The character of the secretions of mucous membranes varies in almost every part, and is dependent upon the properties of the epithelial cells which cover them. In the ultimate tubuli of glands, these cells are found to contain the peculiar substances which cha- racterize the secretion. They are not mere protective agents, as the epidermic cells are, but, in the case of the glands, they are con- cerned in elaborating their peculiar secretions, and in the mucous membrane of the small intestine, in effecting the absorption of nu- trient materials. In the bronchio-pulmonary and gastro-intestinal mucous membrane, we meet with the peculiar secretion called mucus, which is intended to lubricate the parts on which it is thrown out, and to protect them from the action of irritating substances. It is also found in the ducts of glands, and in the urinary and gall-bladders, but is gene- rally mixed with the secretions of these parts. Mucus is a viscid, colourless, or slightly yellow fluid, not miscible with water, and containing a substance called mucin, upon which its characteristic properties depend. This appears to be an albuminous compound, altered by the presence of an alkali. Mucus contains, also, a small proportion of solid matter, and some salts, resembling those of the blood, and epithelial scales, together with peculiar cor- puscles called mucus corpuscles. OF SIMPLE ISOLATED CELLS, FORMING SOLID TISSUES BY THEIR AGGREGATION. The cells of this class begin and end their lives as such without undergoing any transformation, but instead of lying upon free sur- faces, or being cast off from them, they form part of the substance of the fabric. Two examples of this kind are found in the cells de- veloped at the extremities of the intestinal villi, and those which exist at the terminal extremities of the hepatic ducts. Both these sets of cells seem to have the power of selecting from the fluids pre- sented to them certain materials which they deliver up, to the absorbents in one case, and the hepatic duct in the other. An ana- logous set of cells are found at the extremities of the foetal tufts in the placenta, which have a like power of selecting nutritious materials from the maternal blood for the nourishment of the foetus. The fat-cells, of which adipose tissue is composed, also perma- nently exhibit the original type of structure in its simplest form. 32 PHYSIOLOGY. This tissue is usually diffused over the whole body, either in the areolar tissue, or in small clusters covered by the common envelope; and even in cases of great emaciation there is some fat always left, especially at the base of the heart, around the great vessels, &c. Fat-cells are spherical or spheroidal; when closely pressed to- gether they assume a polyhedral form. (Fig. 7.) Large masses of fat are often formed by their aggregation, the com- ponent parts being held together by areolar tissue, and also by the blood- vessels which ramify minutely among them, forming a capillary network upon the smallest lobules, and even between the individual cells. This tissue contains neither lymphatics nor nerves. The fat is contained in the interior of these cells, where it is deposited from the blood-vessels. Its con- sistence varies according to the proportion of the organic elements entering into its composition. These are elaine or oleine, stearine, and margarine; the last two, which are solid when separated, being dissolved in the former at the ordinary temperature of the body. The oil thus formed in the interior of the cells is prevented from escaping, by the moistening of the cell-walls by the watery fluid circulating through the vessels. All the substances above named are regarded by chemists as salts, being compounds of the oleic, stearic, and margaric acids with a base, called from its sweet taste, glycerine. The fat is analogous to the starch of vegetables, and has a like use, viz.: to supply elements of nutrition, when other sources are cut off. It also answers the important purpose of retaining the animal temperature by its non-conducting properties; and the still more important object of serving as a kind of reservoir of combusti- ble matter against the time of need. Fat appears to be deposited only when an excess of non-azotized alimentary matter is introduced into the body, over and above the wants of the system. Cartilage in its simplest form consists merely of nucleated cells, and greatly resembles the cellular tissue of plants. In other forms, however, the cells are imbedded in an intercellular substance, or matrix, called chondrine. This substance bears a strong resem- blance to gelatine, but requires longer boiling in water to effect its solution. It is not precipitated by tannic acid, but is, by acetic acid, alum, acetate of lead and proto-sulphate of iron. It agrees more nearly with the proteine compounds, in composition, than gelatine, and may be considered as an intermediate stage between the two. Cartilage, in general terms, may be considered a non-vascular. substance, considerable masses of it existing unpenetrated by a single Fig. 7. OF SIMPLE ISOLATED CELLS FORMING TISSUES. 33 vessel. They are, however, surrounded by numerous blood-vessels, which form large ampulla, or dilatations at their edges, or on their surfaces, from which they derive their nourishment by imbibition. Cartilage is insensible; neither nerves nor lymphatics can be traced into its substance, and it is doubtful whether it is ever replaced by a similar structure when once destroyed. Fibro-cartilage is a compound of white fibrous tissue and carti- lage in varying proportions. When the intercellular substance as- sumes a fibrous arrangement, surrounding the cells, it is known by this name. In some instances the fibrous structure is developed so much at the expense of the cells, that the latter disappear altogether, and the whole structure becomes fibrous. This structure is seen in all those cartilages which unite the bones by synchondrosis, as in the vertebral column and pelvis. The reticular structure is seen in the concha auris and in the epiglottis. The cornea, according to the researches of Messrs. Todd and Bowman, is a peculiar modification of the white fibrous tissue, in which the fibres, which in the sclerotic have been densely interlaced, flatten out into a membranous form, so as to follow the curvatures of the cornea, and constitute a series of more than sixty lamella united to one another by delicate processes extending from one to the other. The resulting areola? lie in superposed planes, the conti- guous ones of the same plane be- ing for the most part parallel, but crossing those of the neighbouring planes at an an- gle, and seldom communicating with them. (Fig. 8.) The crystalline lens has long been known to be fibrous. The fibres are united into lamina? by means of numerous teeth or sinuosi- ties at their edges which lock into one another. They originate in cells, several of which coalesce to form one. After the lens is fully formed it is not permeated by blood-vessels; these being confined to the capsule. It consists chiefly of albumen in its soluble form, and is coagulated by heat. The latest analyses represent the substance of the lens as consisting of that modification of albumen called globuline. The vitreous humour is an example of a very loose form of cellular tissue. The cells have no open communication with each other, and contain a fluid holding a small quantity of albumen and saline matter in solution. It is nourished by the vessels which are minutely distributed upon its general surface, there being none dis- tributed through its substance for this purpose. 34 PHYSIOLOGY. TISSUES CONSOLIDATED BY EARTHY DEPOSIT.--BONES AND TEETH. For a full description of these tissues, see Anatomy. Articles Bone, Teeth. SIMPLE TUBULAR TISSUES. Of these we have examples in the smaller capillary vessels, and probably also in the smallest lymphatics and lacteals. They seem to be formed by the coalescence of the cavities of the cells, produced by the absorption of the cell-walls at the point of contact. In all the higher animals, in their adult condition at least, the ca- pillary circulation is carried on through tubes having distinct mem- branous walls. These tubes are formed from cells, like the straight and anastomosing ducts of plants. In the walls of these tubes cell- nuclei may be constantly found; and these are too far apart to war- rant the idea, that they are the nuclei of epithelial cells, such as line the larger vessels. These vessels have a claim to be regarded among the elementary parts of the fabric, since they are formed independently of the larger trunks, and have little in common with them in function. All those changes which take place between the blood and surrounding parts, by which nutrition, secretion, and respiration are accomplished, occur during the movement of the blood through these vessels, the larger vessels merely bringing to them a constant supply of fresh blood, and conveying from them that which has been impoverished in the foregoing processes. The diameter of the capillaries varies in different animals accord- ing to the size of the blood-corpuscles. Thus, they are larger in the frog than in man, in whom they average from l-3700th to l-2500th of an inch. In the living subject, it may be stated, they may be seen to vary their diameter at different times, so as to accommodate themselves to the varying supply of blood. They seem to have a distributive power of their own, entirely independent of the heart's action, but influenced by the attraction existing between the tissues and the constituents of the blood. The capillary vessels are first formed in the vascular layer of the germinal membrane, entirely by the coalescence of cells, which send off prolongations in various directions, like the radii from a star. By the junction of these pro- longations a network of tubes is formed, at first, irregular in size, but afterwards becoming more equalized. In newly-forming tissues, much the same arrangement takes place, the prolongations coming in contact with the vessels of the surround- ing parts. The opinion, that the white tissues are nourished by vessels con- veying white blood is no longer tenable. Some of the white tissues, such as cartilage, are entirely destitute of vessels; and in others the supply of blood is so scanty, as not to communicate to them any. decided hue. What have been considered as white vessels, are COMPOUND TUBULAR TISSUES. 35 merely those of very minute size, which, admitting only a single row of blood corpuscles, do not contain a sufficient amount of colour- ing matter to affect the light transmitted through them. COMPOUND TUBULAR TISSUES. Examples of these are seen in the muscular and nervous tissues, in which, after tubes have been formed by the coalescence of the cells, their interiors are filled up with a secondary deposit. The functions of these two tissues are widely different. The muscular is that by which all the sensible movements of the body are effected. The nervous is that by which sensations are received; and by which the instincts, emotions, or volitions excited by these sensations, act upon the muscles. The ultimate structure of these two tissues is alike ; both consist of tubes formed by the coalescence of cells. The difference between them exists in the nature of the internal deposit. There are two forms of muscular tissue,—in one the ultimate fibrils are marked by transverse stria?, or bands; in the other, they are plain, or unstriped. The former, or the striped fibres, are found in all the voluntary muscles, or, as they are sometimes called, the mus- cles of animal life. The latter are seen in those muscles which are concerned in the organic or vegetative functions. They are not so readily called into action through the agency of the nervous system, as the striped muscles, but are more readily excited by stimuli applied directly to themselves. An ordinary muscle is seen, even by the naked eye, to consist of bundles of fibres, arranged with great regularity, in the direction in which the muscle is to act. These fibres are arranged in fasciculi, or bundles, connected together by means of areolar tissue. Each fibre presents two sets of markings, or stria?, one set longitudinal, the other transverse. By close examination the individual fibre may be separated into fib- rilla? by the splitting of Fig. 9.* its contents in a longi- tudinal direction. (Fig. 9.) These fibrilla? pre- sent a beaded appear- ance, caused by the pe- culiar arrangement of the contents of the tube. It frequently happens, ^^ that when force is ap- mi plied to a fibre, its con- \§i|f tents separate in the direction of the trans- * 1. Longitudinal cleavage. 2, 3, 4. Transverse cleavage forming disks. 5. A detached disk showing the sarcous elements. 7, &. Separated fibrillse showing the beaded enlarge- ments. 36 PHYSIOLOGY. verse stria?, quite as frequently as in the longitudinal direction, thus forming a series of discs as seen in fig. 9. If a general disintegration took place along all the lines in both directions, there would result a series of particles, which have been called primitive particles, or sarcous elements, the union of which constitutes the mass of the fibre. According to the opinion of Messrs. Todd and Bowman, (in which they are supported by Muller, Lauth, and Schwann, the cross-stripes of the fibres are formed by the apposition side by side of the dark points seen on the separated fibrilla?. The elements of the muscular fibre are held together by a tubular sheath adapted to its surface and adhering to it; this is called the sarcolemma, or myolemma. It is a transparent, very delicate, but tough and elastic membrane, which isolates the fibre from all other tissues. It has nothing to do with the production of the transverse stria?. Neither is it perforated by either nerves or blood-vessels. Muscular fibres are rather polygonal than cylindrical, owing to the pressure to which they are subjected by juxtaposition. Their average diameter in man is about 1-400th of an inch, being rather larger in the male than in the female. The fibrilla?, when examined, are found to present an alternation of dark and light spots, corresponding with the transverse stria? of the fibre, and the lighter intervals between them. Each dark spot is surrounded by a pellucid border ; the whole constitutes a complete, though minute cell, and the entire fibrilla may be considered as made up of a linear aggregation of such cells. The dark spot within the bright border is the cavity of the cell, filled with a refracting sub- stance. When the fibrilla is relaxed, the longitudinal diameter of these cells is greatest; when contracted, the transverse. Thus the act of muscular contraction seems to consist in a change of form in the cells of the ultimate fibrilla?, consequent upon an attraction between the walls of their two extremities or their nuclei. This corresponds with the contraction of certain vegetable tissues, the component cells of which change their form when irritated, and thus produce a movement. When muscular fibre contracts therefore, it is not thrown into zigzag lines, since fibres in this state, cannot be supposed to exercise any force of traction, but it is shortened in length by the approxima- tion of its elements, at the same time that the transverse diameter is increased. Muscles grow by an increase, not of the number, but of the bulk of their elementary fibres; the number of fibres probably remains the same through life, as it was in the foetus. Notwithstanding the energy of its growth, and the constant interstitial changes, it is doubtful whether muscular tissue is ever regenerated where loss of substance has taken place. It is generally replaced by areolar tissue, which gradually becomes condensed, but never contractile. The great property of muscular tissue is that of contractility, by COMPOUND TUBULAR TISSUES. 37 which is meant, the power of moving responsive to irritation. It is not the mere mechanical power by which elastic substances shorten themselves on the removal of a distending force, but it is an endow- ment responsive to appropriate stimuli, and diminishing or disap- pearing with the healthy state of the tissue. Elasticity is a mere physical property. Contractility is a vital property. Whatever is capable of inducing contraction in muscles, when applied to them, is called a stimulus. Chemical agents, mechanical applications, and irritating substances are included under this head. In the living body the ordinary stimulus exciting contraction is the nervous influence. Muscular contraction, however, is not dependent on this influence, since it can be excited after all connexion with the nervous centres has been destroyed, and even in a single isolated fibrilla. The contractility of a muscle may be exhausted by repeated exer- cise, as well as by the continued application of any of the above stimuli, but it may be recovered again, provided sufficient interval of rest be afforded to it. " In regarding contractility, therefore, as a property of living muscular fibre in general, it is meant that it resides in it as a property, without which it would not be muscle; and in such a manner, that no particle, however microscopic, can be de- tached from a muscle which does not of itself, and independently of the rest, possess this property as long as it possesses vitality." Muscles are abundantly supplied with blood-vessels and nerves. The capillary vessels ramify in the spaces between the fibres, but never penetrate the sarcolemma, the nutritive materials being proba- bly supplied by the selecting power of cells. The nerves are motor nerves, and they are exceedingly abundant, terminating in the sub- stance of the muscle in loops. The muscles of organic life are but little influenced by nervous power, but depend for their stimulation upon the presence of substances brought immediately into contact with them. The muscles therefore have but little sensibility. Every fibre of the striated muscles is attached by its extremities to white fibrous tissue; through the medium of which it exerts its contractile power on the bone, or other substance to be moved: the union of all these white fibres constitutes the tendon. The muscular fibre ends by a perfect disc, and with the whole surface of this disc the tendon is connected and continuous, with it and the sarcolemma. Muscular contraction is accompanied by the production of sound and heat, both of which are probably produced by the movements of the neighbouring fibres upon each other. The heat may also be produced by the chemical changes resulting from the disintegration of the muscular tissue consequent upon its use. This elevation of temperature is sometimes as high as 2° Fahr. The rigor mortis, or the stiffening of the body after death, is due to the contraction of the muscles, and, like the coagulation of the blood, is the last act of their vitality. Where the individual has died of a wasting disease, it comes on early, and lasts but a short time, 4 38 PHYSIOLOGY. Fig. 10. and the reverse obtains where death has occurred during full health. As the rigor mortis comes on the contractility of the muscle departs, Its cause is obscure, and may be complex, but its resemblance to the contraction of fibrine after recent coagulation is strongly marked. The muscular fibres of organic life are very different, not only in structure, but alsoin function, from those already described. They con- sist of a series of tubes, which are not marked by transverse lines, and in which the longitudinal stria? are very faint. These tubes are usually much flattened, and cannot be shown to contain distinct fibrilla?. They are generally smaller than those of animal life, and sometimes present markings indica- tive of a granular deposit. The nodosities upon their surface are the nuclei of their original components. (Fig. 10.) The peculiarity of these fibres is, that they are very little subjected to nervous influence, and that when stimulated to contraction by an irritant, they per- form a series of vermicular movements gradually de- creasing in intensity till perfect rest takes place. They are found in the intestinal canal, ducts of glands, middle coat of the arteries and bronchial tubes, &c. In every case muscular action must alternate with intervals of rest. It is in these intervals that the re- paration of the disintegrated tissue takes place, and that the muscle recovers its contractility. The mechanical arrangement of the muscles upon the skeleton is usually accompanied with a loss of power, but with a gain of velocity. The locomotive framework may be regarded as a series of levers, of which the fulcrum is generally a joint. In most cases the muscles are attached near the fulcrum, as in the biceps. By this arrange- ment a contraction of a single inch in the muscle, moves the hand through the extent of a foot, but then the hand moves only with one twelfth of the power exerted by the muscle. The nervous structure as it appears in the nervous trunks is an- other example of the tubes with a secondary deposit. This is seen in the white or fibrous matter, wherever it occurs in the body, and also in the fibres of the great sympathetic. In the ganglia we find the other form of nervous substance, known by the name of the gray or vesicular. Wherever these two kinds are united together, they constitute a nervous centre. The ultimate nerve fibre—such as is seen in the spinal nerves—is distinctly tubular. It consists of an external thin and delicate mem- brane, which is nearly or quite homogeneous. It forms one complete sheath, isolating the contained matter in its whole course from its central to its peripheral extremity. This is called by Todd and Bow- man the tubular membrane. * 4. A muscular fibre of organic life with two of its nuclei (from the bladder). 5. The same from the stomach. COMPOUND TUBULAR TISSUES. 39 Within the tubular mem- brane lies a more opaque sub- stance known as the white substance of Schwann, and within this again is a transpa- rent material which has been called the axis cylinder. The whole of the contained sub- stance is exceedingly soft, and may be made to pass from one part of the tube to another. A bundle of nerve-fibres, sur- rounded and connected by are- olar tissue, constitutes a nerve. The other form of fibrous matter is that which is seen in the great sympathetic system, and which is known as the gelatinous nervousfibre. These fibres contain nothing analo- gous to the white substance of Schwann, and are devoid of the whiteness which charac- terizes the tubular fibre. The gray colour of certain nerves depends upon the presence of a large proportion of gelatinous fibres Hence, they are sometimes called gray fibres. They are smaller in diameter than the tubular fibres, ranging from g^W to TTfoT of an inch- (Fig; 1 l •) The remaining element of the nervous structure is what is called the gray or vesicular. This is found in the nervous centres, but never in the nerves, properly so called. It consists of cells or vesicles containing nuclei and nucleoli. The walls of each vesicle are ex- tremely thin and delicate, and contain a soft but tenacious granular mass. In some vesicles we find a number of pigment granules ex- terior to the nucleus, giving a dark colour to a portion of the vesicle. Another form of nerve vesicle, is that called the caudate, which is characterized by one or more tail-like processes extending from it. They contain nuclei and nucleoli, and pigment granules. These caudate processes either serve to connect other vesicles, or else they become continuous with the axis cylinder of the tubular fibres. * a. Diagram of tubular fibre of a spinal nerve :—a. Axis cylinder. 6. Inner border of white substance, c. c Outer border of white substance, d. d. Tubular membrane, b. Tu- bular fibres ; e, in a natural state, showing the parts as in a. /. The white substance and axis cylinder interrupted by pressure, while the tubular membrane remains, g. The same, with varicosities, g'. Varicose fibres of various sizes, from the cerebellum, c. Gelatinous fibres from the solar plexus, treated with acetic acid to exhibit their cell-nuclei. 40 PHYSIOLOGY. The fibrous matter is produced as the muscular fibre, by the coalescence of cells, in which a secondary deposit takes place. The vesicular by a succession of cells like those of epithelium. The chemical constitution of nervous matter is as follows: Albumen, ..... 7'00 Ce,eb„>f.., J*™' $3} • ■ M3 Phosphorus ..... 1*50 Osmazome, ..... T12 Acids, salts, sulphur . . . . 5 '15 Water......80.00 10000 (Vauquelin.) The amount of phosphorus varies at different times of life, and is exceedingly small in idiotcy. According to L'Heritier's analysis, the minimum is found in infancy, old age, and idiotcy; and the maxi- mum of water in infancy. The nervous structure, like the muscular, is constantly under- going the process of disintegration and renewal, every exercise of this system being accompanied by a loss of its substance, re- quiring new material to compensate for it. This renewal takes place in the intervals of rest. As in the muscular system, its waste is represented by the amount of urea in the urine, so in the nervous system, is its waste represented by the amount of phos- phatic depositions ; the latter being always increased under mental exercise. Persons, therefore, whose mental faculties are much excited, require as nutritious a diet as those who gain their "living" by the sweat of their brows. In regard to the regeneration of nervous structure when it has been destroyed, it is now believed, on the authority of Schwann, Steinruch, and Nasse, that the white or tubular matter may be re- stored, they having discovered, that in the uniting substance between the ends of a divided nerve, true nerve-fibres may be developed. Perfect restoration, however, does not always take place, owing most probably to the fact, that the central and peripheral portions of the same fibres do not always meet again. In regard to the gray or vesicular matter we are not so well in- formed. When a portion of the brain is removed in animals, its place is supplied by new matter; but whether this becomes true cerebral substance remains to be proved; from the great activity of its nutritive processes, there seems reason to believe that its loss is repaired by similar matter. Those nerve-fibres which originate in the brain, and are distributed to the muscles, have no proper termination, they form loops, which either return into themselves, or join others formed by the ultimate ramifications of the main trunks. They never anastomose with each DEVELOPMENT OF TISSUES FROM CEtLS. 41 other, but each runs a separate and distinct course. Those fibres which originate on the periphery and run towards the brain and spinal cord, also form loops in these centres. Wherever the vesicular matter is found, it is looked upon as a generator or originator of nervous influence; whilst the white or tubular, is the carrier of that influence to the various parts of the system. The former, having the higher set of functions, receives by far the larger quantity of blood. Plexuses are formed by the free interchange of fibres from several neighbouring nerves. Four or five nerves, for instance, proceed from the spinal cord and are plaited up together like the strands of a coach whip. From the plexus thus formed, certain nerves emerge which are composed of fibres from several of the original trunks. The advantage of this arrangement is, that not only are nerves of different endowments joined together, but the injurious effects which would otherwise result from lesion of the spinal cord, are obviated ; for the nerves which come off below the injured part, all receiving filaments from those which are above, the nervous influence is thus transmitted unimpaired to all those parts supplied by filaments from below the point of lesion. OF THE DEVELOPMENT OF TISSUES FROM CELLS. It has been seen that there is reason to doubt whether cells are concerned in the development of all the tissues, further than in the part which they take in elaborating the fluid from which the tissues are derived, some of the structures seeming to be produced by a consolidation of the plastic fluid which has been elaborated by their agency. Many of the component structures, however, owe their development to the agency of cells, and of these we shall now speak. Cells are formed in two ways, either in a previously existing, structureless fluid called a blastema, or within the interior of pre- viously existing cells. In the first method, when a plastic fluid is in contact with a living structure it is seen to become opalescent; this change in colour is owing to the deposition within it of a number of small granules called nucleoli ; several of these aggregate themselves together and form what is called the nucleus, within the interior of which the nucleolus can still be seen. This nucleus is also called the cytoblast, (from xuros, a vesicle, and f3\a?og, a germ,) or cell-germ. From the side of this nucleus a thin transparent membrane is next seen to project in the manner of a watch-crystal from the dial; this gradually enlarges till at last the nucleus is seen only as a spot on its wall. The whole is then called a nucleated cell, or germinal cell. The fluid in which the granules are first deposited is called the cytoblaslema. In the second method, or the endogenous development as it is called, the nucleus seems to perform an important office. Each granule of which it has been shown to consist, has the power of 4* 42 PHYSIOLOGY. developing a cell, so that the parent cell becomes filled with one or more generations of new cells, which may either disappear entirely, as in the case of the ovum, or by the rupture of the original cells the contents may be scattered and undergo an independent develop. ment. Sometimes several nucleoli are seen within one nucleus; and sometimes several nuclei within one cell. Cells are concerned not only in the function of nutrition in the development and restoration of parts, but also in several other organic processes; for instance in absorption and secretion, the elaborating and selecting processes of which, we shall hereafter see, are per- formed by their agency. Each cell is an independent organ; it lives Jor itself and by itself, and is dependent upon nothing but a due supply of nutriment and of the appropriate stimuli for the continuance of its growth and for the due performance of its functions, until its term of life is expired. The nucleus and cell-wall differ from each other in chemical compo- sition, though both seem to be concerned in the development of tissues. The cell-wall is a proteine compound. In the formation of tissues, the cells undergo changes which may be described under two heads: first, Those affecting the cell-mem- brane ; and secondly, Those in which the nucleus is concerned. In the fibrous tissues, the cell-membranes become elongated, and so folded and divided as to give the appearance of subdivision into minute threads or fibres. In the compound tubular tissues, as muscle and nerve, the cells are joined end to end, and the partitions at each extremity being removed, a tube is formed, in which the proper deposit of muscular or nervous matter takes place. In the simple tubular tissues, as in the capillaries, the tubes are also formed by the coalescence of the walls of the cells at several points owing to their elongation, here and there into pointed pro- cesses, which unite and form the ramifications of the vessels. The metamorphoses of the nucleus, although equally important, are much less numerous. In some cases it sends out radiating pro- longations causing it to assume a stellate form, which is the case in bone cells. In other cases it appears to resolve itself into a fasciculus of fibres; and this, according to Henle, is the origin of yellow fibrous tissue. The tubuli of the dental structure are formed by its separa- tion into a number of distinct fibres, each composed of a linear aggregation of granules. Lastly, according to Dr. Carpenter, it may disperse itself still more completely into its component granules, by whose reunion, certain peculiar vibrating filaments (the so-called spermatozoa,) may be formed, possessing motor powers and destined to perform most important offices in the function of reproduction. The development of cells goes on during the life of the organism at every period of its existence. They are found floating in immense numbers in the blood, chyle and lymph; and even in diseased PHYSICAL AND VITAL PROPERTIES OF TISSUES. 43 secretions as pus. In the inflammatory process they are developed in great quantities; and even the malignant growths, such as cancer and fungus ha?matodes which infest the body, owe their development to the same agencies. In short, the nucleated cell is the agent of most of the organic processes, both in the plant and animal, from the time of their earliest development, to their full maturation and decline. PHYSICAL AND VITAL PROPERTIES OF THE TISSUES. The tissues present manifest differences among themselves, not only in their anatomical structure, but in their properties. These pro- perties may be divided into physical and vital. The physical are those which are dependent solely on the peculiar arrangement or mode of cohesion of the constituent particles of the tissues as well as upon their chemical constitution, and are found as distinctly in the dead as in the living texture. The vital properties are those which exist only during the life of the organism, and which cease whenever molecular life departs. The most striking of the physical properties, are elasticity, flexi- bility, extensibility, and porosity. Elasticity is that property by which a tissue reacts, after a stretch- ing or compressing force has been withdrawn. It is strongly marked in the yellow ligament constituting the ligamenta subflava, which is as elastic as India rubber. It is also seen in the middle coat of the arteries, and in the cartilage of the ribs, and on the articular faces of the bones. Extensibility is implied in elasticity ; but there are some tissues which are extensible, but not elastic; such yield only to a long-con- tinued distending force; of this, we have an example in the resist- ance offered by a fibrous membrane to the growth of a tumour. Flexibility is seen in the white fibrous tissues, which are flexible, without being either extensible or elastic. We have examples of this property in the tendons. Porosity. The property of permeability by fluids, is possessed by the tissues even after death, and is termed porosity, or imbibition. Animal tissues owe their softness to the watery fluids which they contain, and which fill their pores. If a solution of any salt, or of sugar, is poured into a glass tube closed below by a piece of bladder, the particles of the solution per- meate the pores of the bladder, but do not pass through it. If the tube thus filled is placed in a vessel containing distilled water, the fluid gradually rises within the tube, and sometimes to the extent of several inches, while, at the same time, it is found that a portion of the solution has passed from the interior of the tube to the water external to it. Dutrochet has named the phenomena above described, endosmose and exosmose. The term endosmose, or imbibition, being applied 44 PHYSIOLOGY. to the current from without to within, while exosmose, or transuda- tion, signifies the passage of the fluid from within to without. In order that these phenomena may present themselves, the fluids must be of different densities, and miscible with each other; and under these circumstances the current is most rapid, as a general rule, from the rarer to the denser fluid, and it continues until the fluids are of equal density on both sides. There must also be an affinity between the membrane and the fluid, otherwise no current will take place. It is not membranes only which are endowed with this property; very thin plates of slate, or of baked clay, produce the same effect, though in a more feeble degree. Calcareous and siliceous lamina? have no effect of this kind. In membranes, endosmose is produced till they begin to putrefy, when the phenomenon entirely ceases, and the liquid which had risen in the tube descends, and filters through the membrane. Of all the organic substances soluble in water, albumen produces endosmose with the greatest force. It has also been proved by Dutrochet, that, all other things being equal, the force which pro- duces endosmose is proportional to the excess of the density of the interior liquid over that of the water. Various theories have been produced to account for these phenomena. Dutrochet's hypothesis, that electric action is concerned with these phenomena, has not been confirmed. The theory of Poisson, that endosmose depended on capillary attraction, is, according to Matteuchi, inadmissible. " Pois- son supposed that the least dense liquid entered the capillary tubes of the membrane, and that this capillary thread, drawn down by the pure water, and up by the denser liquid, must be elevated in virtue of molecular attraction. But this explanation is inadmissi- ble, when we consider that alcohol, which is lighter than water, pro- duces endosmose; and that certain calcareous and siliceous stones, placed under the same conditions as membranes and plates of clay, do not give rise to the same effects."* According to the same author, up to the present time there is no satisfactory theory of endosmose, though many physiologists accept that of cafoUary attraction. " Experiment proves that the current of endosmose is not pro- duced by the least dense liquid, nor by the most viscid one, nor by that which is endowed with the greatest force of ascent in capil- lary tubes. The current is in general determined by the liquid which has the greatest affinity for the interposed substance, and by which it is imbibed with the greatest rapidity. In fact, it is evident that the membrane imbibes the two liquids unequally; and that the one which is imbibed with the greatest facility, ought to mix with, and augment the volume of the other."f * Matteuchi's Lectures, p. 39. t Op. cit., p. 39. PHYSICAL AND VITAL PROPERTIES OF TISSUES. 45 Poisseuille found by experiment, that there was endosmose through animal tissues, from the serum of the blood to Seidlitz water, and to solutions of sulphate of soda and common salt. This is precisely what happens when these substances are used internally as medi- cines : the rejected excrements contain large quantities of albumen. In this case, it must be admitted that endosmose takes place through the capillary vessels of the intestine, from the serum of the blood to the saline solution introduced into the intestinal canal. The ex- periments of Poisseuille have been confirmed by Bachetti, who also proved that the rapidity of endosmose is considerably increased, when one of the fluids is in motion and constantly renewed, as is the case with the blood circulating through the capillaries. The most remarkable fact discovered by Poisseuille, is that of the influ- ence exercised by the muriate of morphia. When this substance is added to saline solutions, it very considerably weakens the en- dosmose from the serum to the solution, and ultimately changes the direction of the current. This has also been confirmed by Bachetti, and upon this is based an hypothesis as to the modus operandi of morphia, and of the preparations of opium in diarrhoea, as well as of the constipation they produce. The animal membranes exercise the property of porosity, or im- bibition, in reference to gases as well as fluids; and the tendency of dissimilar gases to become diffused among each other, manifests it- self even through compound textures. As was shown to be the case with liquids, there is a double current, when two dissimilar gases are separated by a porous septum, and the predominant cur- rent is that which has the greatest attraction for the septum. In respiration, this phenomenon occurs at every inspiration through the walls of the pulmonary air-cells and the plexus of capillaries dis- tributed upon them. It was said that all gases were not equally transmissible. The experiments of Professor Mitchell have demonstrated this fact: and the following list shows their comparative transmissibility, beginning with the most powerful: Ammonia, sulphuretted hydrogen, cyano- gen, carbonic acid, nitrous oxide, arsenuretted hydrogen, oleflant gas, hydrogen, oxygen, carbonic acid, and nitrogen. The experiments of Brunner and Valentin have led to the inte- resting result, that when two gases are placed on opposite sides of an animal membrane, the relative proportions absorbed and exhaled, will be inversely as the square roots of their specific gravities. Thus, if we have oxygen on one side, and carbonic acid on the other of an animal membrane, the volume of oxygen that passes inwards will exceed that of the carbonic acid that passes outwards, in the proportion of 1174 to 1000. The application of this to respiration is easy. Endosmose does not explain all the phenomena of absorption, but 46 PHYSIOLOGY. merely that of those fluids which require no change or elaboration; when elaboration is demanded, a vital action becomes necessary. Vital properties of the tissues. — The vital properties are those which belong only to living organized products, and they manifest themselves by a change in their molecules, resulting from a stimulus applied. This change may be evident from a visible alteration in the tissue stimulated, or it may show itself through a secondary in- fluence exerted upon some other texture or organ, with which the stimulated tissue may be in connexion. These properties exist in two tissues, viz., in muscle, and in nerve. When seated in muscle, it is called contractility, and is characteris- tic of that tissue. When in nerves, it is manifested in three ways: first, by its inducing contraction in the muscle supplied by it; se- condly, by exciting contractions in muscles not supplied by it, through a change effected in the nervous centre with which it is connected; thirdly, by its exciting sensation. The same stimuli which are capable of developing muscular con- tractility, will produce these effects in nerves, and the parts well supplied with nerves are said to be highly endowed with sensibility, while the nerves concerned in ministering to sensation are called sensitive. From these it will be seen that two vital properties are described by Physiologists, to wit, sensibility and contractility. The first being resident in nervous tissue, the second in muscular. A vital property, however, is one possessed by every living organized being, vegetable as well as animal. As vegetables have no nervous system, they cannot possess sensibility, and as this latter is a function of one particular part of the nervous system, viz., the brain, the term irri- tability or excitability will, perhaps, better express the property. Plants are irritable, but not sensible, inasmuch as they have no con- sciousness. Muscles, also, when separated from the body, are irri- table, but not sensible. Hence irritability, excitability, contractility, or incitability, as the property has been variously termed, may be considered as the only vital property that is possessed by all living organized beings. These properties are entirely dependent on the nutrition of their respective tissues; they quickly vary with the state of that function, and when it ceases in death, they vanish with it. SPECIAL PHYSIOLOGY. GENERAL CONSIDERATION AND CLASSIFICATION OF THE FUNCTIONS. In every living structure of a complex nature, we see a great va- riety of actions resulting from the exercise of the different properties of its several component parts. A general survey of these, with reference to their mutual relations to each other, will show that they may be associated into groups, each consisting of a set of actions, which, though different in themselves, concur in effecting some posi- tive and determined purpose. These groups and actions are termed functions. A function may be defined the action of an organ or system of organs. Thus respiration is a function ; its object is the conversion of venous into arterial blood, and its instrument is the lungs. On further examination of these functions, we find that they are susceptible of some degree of classification. There is a set which is found to be possessed by all living organized beings, vegetable as well as animal; these are called the organic or vegetative. These may be again subdivided into those concerned in the maintenance of the structure of the individual, or the nutritive, and those to which the preservation of the species is due, or the reproductive. There is then a set which is possessed by animals alone, in addition to those belonging to vegetables, these are called the animal functions, or the functions of relation, and are dependent for their exercise upon the existence of a nervous system, t/u? presence of which latter in an organized being marks the distinction between an animal and a vegetable. The animal functions render the individual con- scious of external impressions, and capable of executing spontaneous movements. These two sets of functions, the organic and animal, are mutually dependent on each other, the organic supplying the material neces- sary for the repair of the instruments of the animal; whilst the animal functions, in which are included sensation and voluntary motion, are essential to enable the individual to obtain that material which the plant, from the different provision made for its support, can obtain without any such assistance. In the animal body, all the functions are so completely bound up together, that none can be suspended without the cessation of the rest. 48 PHYSIOLOGY. TABLE OF FUNCTIONS. ORGANIC. ANIMAL, OR OF RELATION. / 1. Digestion. 1. Sensation. \ 2. Absorption. 2. Muscular motion. J 3. Respiration. 3. Mental manifestation. Nutritive. / 4. Circulation. \ 5. Nutrition. J 6. Secretion. ^ 7. Calorification. Reproductive. < 8. Generation. Three of these have been called the vital functions, viz., inner- vation, circulation, and respiration; these constitute the vital tripod, the maintenance of which, is essential to life. ORGANIC FUNCTIONS. DIGESTION. The first of the organic functions may be defined as that by which the food or aliment is "reduced to such a condition that the nutri- tive 'material can be separated from it.'''' In animals, the food being for the most part in a solid form, requires to be brought to a fluid state before it can be inservient to nutrition, hence the necessity for a digestive process. In the animal body, aliment is demanded for four different pur- poses. First, for the original construction or building up of the organism. Second, to supply the loss occasioned by the continual decay, even when in repose. Third, to compensate for the waste occasioned by the active exercise of the nervous and muscular sys- tems. Fourth, to supply the materials for the heat-producing pro- cess, by which the temperature of the body is kept up. The amount required for these several purposes, varies according to the condition of the body as regards exercise or repose, external heat and cold, and the age of the individual, a larger quantity being demanded in youth in proportion to the size of the body, than in manhood. Any drain upon the system also increases the demand. There can be no universal law laid down as to the amount re- quired, so much depending upon the external conditions in which the individual may be placed. The diet scale in the British navy allows to each man from 31 to 35^ ounces of dry nutritious matter daily; of this 26 oz. are vegetable, and the rest animal, 9 oz. of salt meat, or 4^ of fresh meat, being the allowance of the latter. A mixed diet seems to be absolutely indispensable, where such a variety of tissues have to be repaired. The disastrous effects resulting from the long- continued use of one kind of food, are to be attributed not so much DIGESTION. *v to the quality or quantity, as to the absence of variety in the aliment supplied. Aliments have been variously classified ; Prout divides them into the following groups. Aqueous, including water, either alone, or holding important elements in suspension or solution. Saccharine, including sugars, starch, gums, and vinegar. Oily or oleaginous, including the various fats, oil, and alcohol. Albuminous, including all those substances which contain nitrogen—such as fibrine, gela- tine, albumen, caseine, and vegetable gluten. All the materials which make up this group are derived generally from the animal kingdom, with the exception of the last, which is contained in great abundance in wheat. Similar, if not identical, principles exist in vegetables. In milk we find a natural combination of all the various sub- stances which contain nitrogen, and this is the only instance in which nature has provided a single article of food for the support of the animal body in which such an union exists. Liebit* divides aliments into two classes. Azotised, and non- azotised. The azotised products are for the nutrition and reparation of the animal tissues, hence he calls them '■'■plastic elements of nutrition." The non-azotised substances are designed chiefly, ac- cording to him, to supply the materials for animal heat and respira- tion, hence he calls them " elements of respiration.'''' The uncon- sumed material being deposited as fat. Dr. R. D. Thomson proposes to call the azotised, nutritive ele- ments, and the non-nitrogenised, calorifacient. The organic compounds enumerated would be of little service without the admixture of certain inorganic substances, which also form a part of the animal frame, and which are constantly being voided by the excretions. These are chloride of sodium, which enters into the composition of the gastric juice, and the bile; phos- phorus, which is found in the osseous and nervous tissues ; sulphur, found in the albuminous tissues; lime, which is required for the consolidation of bone; and lastly, iron, which will hereafter be shown to be an essential constituent of hasmatosine. The digestive apparatus varies greatly with the habits of the animal, and with the nature of the aliment with which it is supplied; thus in carnivorous animals it is exceedingly simple, because the food requires to undergo little change before it is fitted for nutrition. In the ruminantia the food is macerated in a complex stomach, prior to, as well as after it has been subjected to a more complete masti- cation than is employed in other animals, because the aliment con- tains but little nutritive matter, which is with difficulty separated from it. In the omnivorous animal the digestive apparatus is mid- way between those above described. Modifications also occur in the masticatory process; the vegetable 5 50 PHYSIOLOGY. feeder requiring a more complicated dental apparatus; the carni. vora being provided with teeth of a simpler construction, but more fitted for seizing and tearing their prey. In the omnivorous animal we find both the cutting and grinding teeth. In birds there are no teeth ; and mastication, properly so called, is effected in the stomach, a portion of which (the gizzard) acquires a great increase of mus- cular power, and is lined by a dense cuticle, and thus becomes a powerful organ for triturating the food, the bird swallowing pieces of flint or other hard substances to aid in the mechanical reduction. Hunger and thirst. The want of solid aliment is indicated by the sensation of hunger ; and that of liquid by thirst. The former of these sensations is referred to the stomach, and the latter to the fauces; but, although these sensations may be caused by the condi- tion of the parts mentioned, they are really indicative of the wants of the system at large. The nerve which is instrumental in the sensation is probably the vagus by its gastric branches, but there is no reason for denying to the sympathetic nerve distributed to the stomach, some share in this phenomenon; the latter probably conveys the wants of the system to the stomach, while the former is the medium by which those wants are expressed. Section of the vagus abates, if it does not entirely arrest the sensation of hunger. The same is true of the introduction of matters not alimentary into the cavity of the organ. Thirst results from a peculiar state of the mucous membrane of the digestive tube, but more especially of the mucous membrane of the mouth and fauces, caused by the imperfect supply of liquid. Thirst is perhaps more immediately connected with the wants of the general system than hunger, since the relief that is afforded by the introduction of liquid into the stomach is immediate, and may be fully accounted for by the instantaneous absorption of the fluid into the veins. Any excess in the amount of fluid excretions will in- crease this sensation, as is also the case when stimulating or irri- tating articles of food have been used ; the purpose of this increase is obviously to cause ingestion of fluid, by which they may be diluted. The process of digestion may be divided into the following stages: 1st. Prehension of food; 2d. Mastication and insalivation; 3d. Deglutition; 4th. Chymification ; 5th. Action of small intestine; 6th. Defecation. Prehension, or the taking of food into the mouth, is performed mainly by the hand, assisted by the lips and cheeks, as well as the anterior teeth and the tongue. Mastication has for its object the comminution of the food so that it can be readily acted upon by the solvent juices of the stomach. The contact of the solid food with the interior of the mouth excites the act of mastication, performed by alternating contractions of the muscles which pull the lower jaw upward, downward, backward, DIGESTION. 51 forward, and laterally by acting on the bone in which they are im- planted. By the motion of the lower teeth upon the upper the food is comminuted. During mastication the food is mixed with the saliva and fluids of the mouth, which latter cavity is closed ante- riorly and posteriorly during the process. The disintegration of the food by mechanical reduction, is mani- festly aided by insalivation; and the admixture of saliva appears further, to have the effect of commencing the transformation of the starchy particles of the food into sugar. From experiments of Ber- nard and Barreswil, it appears that saliva, when acidulated, possesses the same power of acting on azotised compounds as that which cha- racterizes gastric juice ; consequently when introduced into the sto- mach, the saliva may afford important aid in the digestive process. Deglutition.—The food, comminuted and moistened in the mouth by the means above mentioned, is prepared for the action of deglu- tion. In this there are three stages. In the first, the particles of the food, collected to a bolus, glide between the surface of the tongue and the palatine arch, till they have passed the anterior arch of the fauces. This is a purely voluntary movement. In the second, the bolus is carried past the constrictors of the pharynx. In the third, it reaches the stomach through the oesophagus. These three acts follow each other with extreme rapidity. During the second stage of deglutition, the tongue, the muscles of the anterior and posterior half arches, the superior muscles of the soft palate, and the constrictors of the pharynx, are all in action. In this stage, by the retraction of the tongue, and the elevation of the larynx, the epiglottis is pressed over the rima glottidis, which is also closed during this process. The communication between the fauces and posterior nares is cut off by the muscles of the posterior palatine arches, which contract in such a manner, as to cause the sides of the arch to approach each other like a pair of curtains, and to the cleft between the to/o sides, the uvula is applied like a valve. Some of these acts may be per- formed voluntarily, but the combination of the whole is automatic, and under the presidency of the reflex system of nerves. In the third act, in which the food passes through the oesophagus, every part of that tube as it receives the bolus, and is dilated by it, is stimulated to contract. The movements of the oesophagus are entirely involuntary and rhythmical in their character; in the act of vomiting they are in- verted. At the point where the oesophagus enters the stomach,—the cardiac orifice of the latter,—there is a sort of sphincter. This opens when there is sufficient pressure made upon it by the accumu- lated food, and afterwards closes so as to retain the food in the stomach. The opening of the cardiac orifice is one of the first acts 52 PHYSIOLOGY. in vomiting. When the sphincter is paralysed by division of the pneumogastric nerve, the food regurgitates into the oesophagus. Chymification.—As soon as the bolus has entered the stomach it is subjected to several agencies, all of which are more or less con- cerned in effecting its solution. It is exposed in the first place, to the movements of the stomach, which have for their object to produce the thorough intermixture of the gastric juice with the alimentary mass. The fibres of the muscular coat of the stomach are so arranged, as to shorten its diameter in every direction ; by the alternate contrac- tion and relaxation of these bands, a great variety of motion is induced. This contraction is due to the stimulus of the food; and when the aliment is difficult of digestion, the muscular coat is pro- portionately stimulated. These movements are also increased by the action of the respiratory muscles. The contraction of the muscular fibres extends also to those of the two orifices of the stomach so as to prevent the escape of the food. This is particularly the case as regards the pyloric orifice in the first period of digestion. The bolus, in the next place, is exposed to the action of the gastric juice, a pure colourless and slightly viscid fluid, having a distinctly acid reaction, which has been observed to distil from the surface of the mucous membrane and mingle with the food. The exudation of this fluid is always excited by the contact of any foreign substance, but it is never present in the organ when empty, the sole contents being then a little viscid mucus. According to the analysis of Pro- fessor Dunglison, the gastric juice contains free muriatic and acetic acids, phosphates and muriates of potassa, soda, magnesia, and lime. According to the experiments of Blondlot, its acid reaction is due to the presence of the super-phosphate of lime, while Professor Thomson and MM. Bernard and Barreswil attribute it to the presence of lactic acid, the existence of which in the healthy stomach has been positively denied by Liebig. The gastric juice is secreted through cell agency, by follicles of a tubular srTape, resting upon the sub-mucous tissue, having their open ends towards the cavity of the stomach. But diluted acids, of themselves, have no power in chymifying alimentary substances, although their presence in the gastric fluid is essential to its action. The active agent is an organic compound obtained from the mucous membrane of the stomach, to which the name of pepsine has been given. It is a proteine compound in a state of change, and it seems to act in precisely the same manner as the diastase does in the conversion of starch into sugar. In so doing, it acts as a sort of ferment, having the power of exciting change in another substance, in which it does not itself participate. Pepsine undergoes no change itself, and forms no combinations with the sub- stances on which it acts, but merely disposes them to solution in DIGESTION. 53 the acids of the stomach, with which they form definite chemical compounds. The quantity of gastric juice prepared, is regulated by the wants of the system, and not by the amount of food taken; hence all that is taken over and above these wants will act as a source of irritation. All substances are not equally soluble in the juices of the stomach; in general terms it may be said, that animal food is more soluble than vegetable, though there are exceptions to this rule. Of the saccharine group, sugar is generally converted into lactic acid during its passage along the intestinal tube, and is probably absorbed in this form unless it have been administered for a long time. The particles of starch, when their envelopes have been ruptured, are converted into dex- trine and grape sugar; and this is gradually converted into lactic acid, in which state it is absorbed. It is now certain that the sub- stances of this class may be converted into oleaginous compounds, though the mode and situation in which this change occurs is not cer- , tainly known; probably it is by the action of the bile, the long-con- tinued contact of which with saccharine matter occasions the conver- sion of part of it into an adipose compound. The substances of the oleaginous class do not undergo much change in the stomach, except a minute subdivision of their particles in the form of an emulsion. When the bile is mixed with them they form a saponaceous compound which is more readily absorbed by the chyliferous vessels. The albuminous and gelatinous articles undergo no other change than one of simple solution. Lastly, the bolus is exposed to the temperature of the stomach, which is about 100° Fahr. It was found by the'experiments of Dr. Beaumont that the gastric juice had very little effect in dissolving alimentary matters, when the temperature was below this. Hence the taking of cold drinks during digestion is extremely prejudicial to this act. - The fluids taken into the stomach are for the most part absorbed from it, and do not even pass the pylorus. The solids, with the exception of the insoluble parts, are reduced to a substance called chyme, the consistence of which will of course vary with the amount of fluids taken. In general it is grayish, semifluid, and homogeneous, with a slightly acid taste and smell. When the food has been of a rich character it resembles cream; when of a farinaceous order, it resembles thin gruel. The time occupied in the reduction varies, according to the nature of the food, from three to five hours; and it is now generally con- ceded that this reduction is a true chemical solution, and not a pro- cess of putrefaction, trituration, ox fermentation. The gas contained in the stomach during digestion is generally very small in quantity. Magendie and Chevreul obtained some from 5* 54 PHYSIOLOGY. the stomach of an executed criminal, and found it to consist of Oxygen, 11-03, Carbonic acid, 14-00, Hydrogen, 3-55, Nitrogen. 71-45. Action of the small intestine.—The passage of the chyme through the pyloric orifice is at first slow; but when the digestive process is nearly completed, it is transmitted in larger quantities. The move- ments by which this passage is effected are of a peristaltic charac- ter, each one being preceded by a series of slighter movements in the opposite direction. The chyme is mingled in the duodenum with the biliary and pancreatic secretions, which effect an immediate alteration in its sensible and chemical properties. When mingled out of the body, as was done by Dr. Beaumont, the chyme is sepa- rated into three parts; a reddish-brown sediment,—a whey-coloured fluid in the centre,—and a creamy pellicle on the top. The central portion, and the creamy pellicle, seem to constitute the materials from which the chyle is elaborated; the creamy matter consisting of the oleaginous particles, and the whey-like fluid containing proteine compounds, saccharine, and saline matters in solution; while the sediment, consisting of the insoluble matter of the food and of biliary matter, is probably excrementitious. The contents of the alimentary canal become more consistent, and obtain more of the fa?cal character as they pass down the intes- tinal tube; during which time there is also mixed with them, the secretions of the various follicles; of Brunner, in the duodenum; Lieberkuhn, in the whole route; and Peyer, at the termination of the ilium. The last have no excretory orifice, but discharge their secre- tion by cell agency. In the neighbourhood of these glands the fa?cal matter obtains its characteristic odour, probably from their secretion, which is depuratory. The movements of the intestinal canal are dependent upon the contraction of its muscular coat, and are directly excited by the con- tact, either of the fa?cal matter, or of the secretions poured into it. This movement is called the peristaltic action of the bowels. It is not dependent on nervous influence, as is seen from the fact, that it will continue after all nervous communication has been cut off. The influence of the emotions upon this movement is probably due to the sympathetic nerve which is distributed to the whole intestinal tract. Defecation.—The large intestines act as a reservoir and excretory canal for the faeces. And as the passage through them is not so rapid as in the small intestine, the fa?cal matter accumulates until the desire to expel it arises. The contractions of the muscular coat of the large intestines are wholly without, the domain of the will; but the involuntary escape of the faoces is prevented by the action of the sphincter ani muscle, which is partly under the influence of the reflex system of nerves. The concurrence of the voluntary muscles with the action of the intestines, is necessary to overcome the contraction ABSORPTION. 55 of the sphincter. The act is finally accomplished, principally by a contraction of the diaphragm and abdominal muscles upon a full and sustained inspiration, the glottis being closed so as to prevent the escape of the air contained in the lungs. ABSORPTION. Absorption is that function, by which nutritive, or other matters, are taken up and carried into the circulation. There are two great divisions of this function: 1st. External absorption, ox the absorption of composition, which obtains from without the organs the materials intended for their composition. 2d. Internal absorption, or, the absoiption of decomposition, which takes up from the organs the old, or effete matter that has to be replaced by new. By external absorption is meant that which takes place from the external surface of the body, including the skin, and the mucous membranes of the digestive and respiratory passages. By internal, or interstitial absorption, is meant that which takes place from the component tissues of the organs themselves, and from the interior of shut sacs. The great agents of external absorption are the veins and chyli- ferous vessels; of internal absorption, the lymphatics. In the chyli- ferous and lymphatic vessels the fluid is always found to possess the same general properties. In them, therefore, an action of elabora- tion or selection must have taken place; and the vital agents that are concerned in this elaboration are cells. The veins, on the other hand, exert no selecting power, but receive into their interior by imbibition, any fluid that possesses the proper degree of tenuity, which is then carried along with the current of the circulation. Watery fluids when taken into the stomach, in this man- ner enter the circulation. Matters which find their way from the stomach or intestines into the circulation, by permeating the coats of the capillaries, do not pass directly from the intestinal veins into the vena cava; they circulate through the liver before reaching the gene- ral circulation. Magendie has observed, that in their transit through the liver the properties of many substances are altered, at all events they become so thoroughly mixed with the blood in their route through the portal system, that their possibly injurious influence upon the centre of the circulation is in a great measure, obviated. Substances that require digestion, on the other hand, must pass through the chyliferous vessels and thoracic duct before being mixed with the blood. Alimentary, or digestive absorption, which is included under the head of external absorption, is executed in the small intestines, and is exercised upon the food after it has been subjected to the digestive process. The vessels that are concerned in it are the lacteals, or absorbents of the intestinal walls. These are engaged almost exclu- 56 PHYSIOLOGY. sively in the absorption of nutritious materials ; other articles find- ing their way into the circulation through the veins. The lacteals commence in the villi of the mucous lining of the intestinal tube, below the point where the ductus communis choledochus and pan- creatic duct open into the duodenum. Each lacteal tube commences in a sino-le villus, by a closed extremity, and the trunk that issues from each villus is formed by the confluence of several smaller branches which anastamose freely with each other, forming loops, so that there is no proper free extremity in any case, nor do the lacteals ever commence by open orifices upon the surface of the intestinal canal. (Fig. 12.) These loops are imbedded in a mass of cells at the extremity of each villus which select the nutritive elements from the materials of the intestinal canal and when full, yield their con- tents to the absorbent vessels either by burst- ing, or deliquescence. Their place is then sup- plied by fresh cells, and the process is continued so long as there is any nutritive material pre- sent. After this the villi, which were then turgid, become flaccid, and the epithelium, which was removed dur- ing the process of absorption, is again renewed, and the lacteal ves- sels become the lymphatics of the intestinal canal, to effect its inter- stitial absorption. (Fig. 13.) * Fig. 13. t- The villi are also abundantly supplied with blood-vessels, which are supposed to afford the materials for the development of the cells, ♦Diagram of mucous membrane during digestion and absorption of chyle; a, a villus, turgid and erect; its protective epithelium cast off from its free extremity ; its absorbent vesicles, its lacteals, and its blood-vessels turgid ; 6, a follicle discharging its secreting epi- thelial cells. f Diagram of mucous membrane of jejunum, when absorption is not going on ; a, protec- tive epithelium of a villus; 4, secreting epithelium of a follicle ; c, c, c, primary membrane, with its germinal spots or nuclei, d, d; e, germs of absorbent vesicles; /, vessels and lac- teals of villus. ABSORPTION. 57 as well as to be concerned in the absorption of those fluids which require no elaboration. The fluid that is found in the lacteals is called chyle, and is almost invariably the same in composition, no matter how great the diversity of food from which it is obtained. From this fact the inference is drawn, that the lacteals (or rather the absorbent cells amongst which they originate) have the power of selecting the particles of which the chyle is composed; while they reject any other ingredients which may be contained in the fluid of the intestines. The milky colour of the chyle is owing to the presence of minute corpuscles called chyle globules. It also contains fat, albumen, fibrine, and salts in varying quantities. The course of the chyle, after leaving the intestinal canal, is through the chyliferous vessels and ganglia of the mesentery, into the receptaculum chyli or commencement of the thoracic duct, along which it passes to enter the circulation at the point where the left internal jugular and subclavian veins unite. During this passage it undergoes several marked changes in its physical and vital properties. When it first leaves the intestine its principal constituent is fat; if examined in the lacteal vessels of the mesentery, at a point between the mesenteric ganglia and the receptaculum chyli, the fat will be found to have diminished in quantity, while albumen will be in maxi- mum quantity and fibrine in medium quantity ; and a slight coagula- bility will also be manifested. The chyle taken from the thoracic duct contains little or no fat, a medium quantity of albumen, and a maximum quantity of fibrine, and is now distinctly coagulable, and has a slight rosy tint. These circumstances have given rise to the belief that the chyle, as it proceeds, becomes more and more anima- lised, or transformed into the nature of the being to be nourished. MM. Tiedmann and Gmelin infer that it is to the action of the mesenteric glands, that the chyle owes these important changes in its nature;—the fluid in its passage through them, obtaining from the blood circulating in them, the new elements which animalise it. The chyle corpuscles are supposed by Dr. Carpenter to originate in the mesenteric ganglia and to be the altered epithelium cells which line the lacteals in their course through these bodies. Their function is, according to this author, to convert the albumen into fibrine, since they are found to be most abundant where this process is going on. Internal, or interstitial absorption, is effected by agents strongly resembling those concerned in the absorption of chyle. One part of the apparatus, the thoracic duct, is common to both. The lymphatics are distributed through the greater part of the body, especially upon the skin. They have never been found to commence by closed or open extremities ; but seem to form a network from which the trunks arise. In their course they pass through glands, called lymphatic glands, which exactly resemble in structure and function those of the mesentery. The same agents,—cells,—are probably concerned 58 PHYSIOLOGY. in the elaboration of the lymph, as of the chyle, and the fluid thus formed is likewise a nutritive flirid, being mingled with the chyle in the thoracic duct. So that what is true of chylosis, is also true of lymphosis, both forming a part of the nutritive operations. The lymphatics, however, sometimes take up materials that are not inservient to nutrition, as bile, pus, the venereal and other virus that may be brought in contact with them. But these facts merely prove that the walls of the lymphatics are permeable by such sub- stances, for thin fluids will always enter those vessels that present the thinnest walls and the greatest surface. As this is the case with the lymphatics upon the surface of the body, it explains the phenomena of absorption through that surface. In the lungs and in the intestinal canal, the veins are most numerous, hence these are the recipientrof the thin fluids. In both cases the fluids soak in by imbibition. In the case of the absorption of pus, the probability is that the absorb- ents must have been laid open themselves by the ulcerative process, since the pus-globule is too large to have gained admittance in any other way. It is difficult to speak with certainty of the source of the matters absorbed by the lymphatics. Their contents bear a close resemblance to the fluid element of the blood, or " liquor sanguinis " in a state of dilution. Dr. Carpenter supposes them to consist of the residual fluid, which, having escaped from the blood vessels into the tissues for their nutrition, is now to be returned to the former. They may also include those particles of the solid frame-work which have lost their vital powers, and are therefore not fit to be retained as compo- nents of the living system, but are not yet so far decayed as to pre- vent their serving as materials for reconstruction after being again subjected to the organizing process. The same author says further, that if this view of the function of the lymphatics be correct, it follows that we must attribute to the blood-vessels the absorption of the truly effete particles ; and in this there would seem to be no improbability, since we know that the venous blood contains the elements of two important excretions, that of the liver and that of the lungs, in far greater proportion than arterial blood ; and there is also in the former fluid a certain amount of "ill-defined animal principles " that seem ready to be thus thrown off. The lymph very closely resembles the chyle, the main difference being in their colour, the lymph being nearly colourless. Both con- tain the same ingredients, but not in the same proportions, the chyle abounding most in organic elements. Both contain peculiar corpus- cles, and are capable of self-coagulation, in fact each may be looked upon as imperfectly elaborated blood. The movements of the chyle and lymph in their respective vessels is due partly to vis a tergo, but mainly to the contractility of the middle coat. Both sets of vessels are supplied with valves which prevent a retrogade movement. RESPIRATION. 59 The absorption that takes place through the skin, or accidental absorption, as it is called, is effecteo>by the agency of the lymphatics also, which are here very, abundantly distributed. In this case there is no selection, the fluids passing in by simple imbibition. In the pulmonary mucous membrane, as in the digestive, thin fluids are taken up by the veins. In general, wherever a thin fluid is placed in contact with an extended surface, it will be taken up by those vessels that present the largest surface and the thinnest walls. The rapidity of this absorption through the skin and mucous membrane, is greatly influenced by the condition of the blood-vessels; being very great when the vessels are drained of their contents, and proportionately small when they are full. The presence, or absence of the epider- mis affects it as might be readily inferred. The external integument, so long as it is covered with the epidermis, absorbs with extreme slow- ness ; the epidermis removed, however,—by means of a blister,— and the vascular lamina of the corium exposed, absorption goes on with extreme rapidity. It is upon this fact that what is called the endermic method of exhibiting medicines depends. In regard to the absorption of fluids from serous cavities it is remarked, that imbibition does not explain all the phenomena ; the probability is that the lymphatics under certain circumstances are also concerned. If the fluid in the veins be more concentrated than those to be absorbed, then imbibition is sufficient. But, if, on the contrary, the external fluid is equally concentrated with that con- tained in the interior of the vessels, the two fluids ought to pass through the membrane in both directions with equal rapidity. And if the fluid in the vessels be less concentrated of the two, it will exude in greater quantity so as to increase the amount of the effused fluid. A collection of fluids in the pleura, or peritoneum, containing albu- men and salts in the same state of concentration as these substances exist in the blood, would not be diminished in quantity by imbibition alone ; there would be merely an interchange of the saline matters contained in the external fluid and in the blood, while the bulk of the former would remain the same. The probability is, therefore, that in this case there would be other agents than the blood-vessels con- cerned in the absorption, viz: the lymphatics. It is possible that the process of endosmosis may be modified by a peculiar attraction exerted by the tissues on the fluids circulating in them ; an attraction, by the agency of which the fluids in the tissues may be retained while the external fluid is absorbed, so that merely absorption, and not an interchange of fluids, as is the case under ordinary circum- stances, is the result. RESPIRATION. Respiration is that function by which venous blood is converted 60 PHYSIOLOGY. into arterial; carbonic acid, given off from, and oxygen taken into the system. In the higher classes of animals the whole of the cir- culating fluid is sent through special organs formed on the same general principle as the secreting glands, which fulfil incessantly an office the most essential to life; these organs are the lungs. In the lungs, the mass of the circulating fluid, which had been changed in the periphery of the body into venous blood, mixed with the lymph from all parts, and the newly-elaborated chyle, is brought into intimate contact with the air of the atmosphere, the effect of which is to restore to the blood its bright colour, and to give to it the arterial character which is alone competent to minister to nutrition, and to impart to the nervous system and locomotive apparatus their proper stimulus. The arterial blood, thus changed, also supplies to the secretory apparatus the material for the exercise of its function. All that is necessary then for these purposes is, that the blood should be exposed to the influence of the atmospheric air, or air dissolved in water, through the medium of a membrane that shall permit the diffusion of gases; an interchange then takes place between the gaseous matters on the two sides,—carbonic acid being exhaled from the blood and replaced by oxygen. The extrication of carbonic acid is effected in a manner that renders it subservient to the introduction of oxygen, which is required for all the most active manifestations of vital power; and it is in these two actions conjointly, not in either alone, that the function of respiration essentially consists. It will be remembered that the carbonic acid passes out through the animal membrane by exosmose, and the oxygen passes in by endosmose. The sources of the carbonic acid given off in respiration are three- fold, 1st. The continual decay of the tissues; which is common to all organized bodies; which is diminished by cold and dryness, and increased by warmth and moisture ; which takes place with increased rapidity at the approach of death; whether this affects the body at large, or only an individual part; and which goes on unchecked when the actions of nutrition have ceased altogether. 2d. The metamorphosis, which is peculiar to the nervous and muscular tissues; which is the very condition of their activity, and which therefore bears a direct relation to the degree in which they are exerted. 3d. The direct conversion of the carbon of the food into carbonic acid; which is peculiar to warm-blooded animals; and which seems to vary in quantity in accordance with the amount of heat to be generated.* The organs of respiration are always formed upon the same * For a more detailed account of these sources of carbonic acid, of which the above is merely a recapitulation, see Carpenter's Principles of Human Physiol- ogy, 3d American Edition, p. 570 and seq. RESPIRATION. 61 general plan, being essentially membranous prolongations of the external surface, adapted by its permeability and vascularity to bring the blood into close relation with the surrounding medium. As this medium may be either air or water, we find two principal forms of respiratory organs, one of which is adapted for each. In aquatic animals the membrane is usually prolonged externally into tufts or fringes, each one of which is supplied with arteries and veins, during the circulation through which the aeration is accomplished. These organs are called gills. In air-breathing animals the aerating surface is reflected inwardly, forming passages or chambers in which the air is received, and on which the capillary vessels are distributed. In insects we find a series of tubes called trachea, ramifying through the body and carrying air to every part of it. In regard to the human lung, according to the observations of Mr. Rainey, a bronchus, when traced from its commencement to its termination, is seen in the first part of its course, to be more or less cartilaginous; it then becomes destitute of cartilage, retaining, how- ever, a perfectly circular form and having no air-cells opening into it; farther on, being still circular, numerous air-cells open into it; lastly, the air-cells increase so much in number, and open into the bronchus so closely to one another, that the tube can no longer retain its circular form, but becomes reduced to an irregular passage running between the cells, and ultimately reaching the surface of the lobule, ends by forming a terminal air-cell. The air-cells are small irregularly shaped cavities, having usually four or- five unequal sides ; those which are situated close to the small bronchial passages open into them by well-defined circular aper- tures, while those at a distance from these passages open one into the other, as in the lung of the frog and serpent; in fact each lobule of the lung of the mammal and man, with its bronchial passages and appended cells, may be regarded as a repetition of the whole lung of the frog. The sides or walls of the air-cells are formed of a thin transparent membrane, and the capillary vessels are so placed between the walls of two adjacent cells as to be exposed on their two sides to the action of the air. The number of capillary plexuses is not the same as that of the air-cells, one network passing between and supplying several cells ; or in other words, one terminal branch of the pulmonary artery supplies the plexites of several cells. It has been calculated by M. Rochoux that as many as 17,990 air-cells are clustered around each terminal bronchus, and that their total number amounts to 600 millions. The foetal lungs, according to Mr. Rainey, prior to respiration are distinctly seen, when injected, to possess air-cells fully formed, and 6 62 PHYSIOLOGY. surrounded, as in the animal which has respired, by plexuses of blood-vessels. The chemical process of respiration is not essentially dependent on the respiratory movements. They merely serve to expel the air, (or water) which has undergone the change induced by the chemical process constantly carried on between it and the blood, and to renew the supply of fresh air or water. The lungs, by their internal surface, offer an immense expansion for the action of the blood and air on each other; and, as they are never completely emptied by the act of expiration, this action is con- stant. By the contraction and dilatation of the chest, the motions of which the lungs follow, a portion of the altered contents of the pul- monary reservoir is first expelled, and then a new supply introduced, to undergo change in its turn. According to the inquiries of M. Bourgery the development of the air-cells continues up to the age of thirty, at which time the capacity of respiration is greatest; it subsequently decreases, especially in persons who suffer from cough. The violence of such expiratory efforts frequently causing rupture of the air-cells, thus gradually producing that emphysematous condition of the lungs so common in elderly people. The power of increasing the volume of air by a forced inspiration is much greater in young than in old persons, and is twice as great in males as in females of the same age, a circum- stance which is evidently connected with the extent to which mus- cular efforts can be carried in these classes respectively. Movements of respiration. — These may be divided into two classes, those of inspiration and those of expiration. By the first is meant the action by which air enters the lungs; by the latter, the act of expelling from the lungs the air received in inspiration. In mammalia generally, as well as in man, inspiration and expi- ration are performed by the dilatation and contraction of the cavity of the thorax. As soon as the walls of the chest are drawn wide asunder, and the thorax dilated, the external air rushes through the trachea and its branches into the air-cells, distending them in pro- portion to the dilatation of the thorax, thus keeping the surface of the lung accurately in contact with the thoracic walls in all their movements. This contact, however, can only take place while the thoracic cavity is closed on all sides, so that the air cannot exert any pressure on the outer surface of the lung, by which that upon the inner would be balanced. Hence it is, that in penetrating wounds of the chest, the lungs cannot be fully distended by inspiration, be- cause the air entering through the wound into the cavity of the pleura balances the pressure of the air on their inner surface; the lungs, in such a case, remain collapsed, although the thoracic parietes dilate. Inspiration.—The diaphragm contributes the principal share to RESPIRATION. 63 Fig. 14. the dilatation of the chest during in- spiration. In its relaxed state this muscle is arched; by contracting it becomes more plane; and by this flattening of its arch, the capacity of the thorax is increased, at the same time that the abdominal viscera are pressed upon from above, so as to produce the protrusion of the abdo- men observed during inspiration. (Fig. 14.) In a natural, tranquil inspiration, the dilatation of the chest is effected almost entirely by the diaphragm. The lateral dilatation, as in deep in- spiration, is performed principally by the action of the intercostal muscles, assisted also by the sca- led, the levatores costarum, the serratus posticus inferior, and the thoracic muscles generally. In the old, inspiration is mainly accom- plished by the diaphragm, in conse- quence of the ossification of the car- tilages of the ribs. The number of inspiratory movements vary greatly under diffe- rent circumstances. In general it may be stated from 14 to 18 usually occur in a minute; of these the ordinary inspiration involves but little movement of the thorax; but a greater exertion is made at about every fifth recurrence. The average numerical proportion of the respiratory movements to the pulsations of the heart, is about 1 to 5 or 4£, and when this proportion is widely departed from, there is reason to suspect some disorder of the respiratory apparatus or the nervous system. Expiration, when perfectly tranquil, may be the result of the mere collapse or elastic reaction of the parts recovering their na- tural state, after the active dilatation they have undergone; in fact, tranquil respiration seems to consist more in the periodic action of the muscles of inspiration, than in the alternate action of antago- nising muscles. Among the elastic components of the respiratory organs may be mentioned the cartilages of the ribs, the cartilages of the bronchial tubes, and the capsule of elastic tissue described by M. Bazin, which invests the lungs, and sends prolongations inwards, and the elasticity of the air-cells themselves. The muscles which are concerned in expiration are the abdominal, which draw down the * Section of thorax and abdomen, a. Thorax, b. Abdomen, c. Relaxed diaphragm. d. Contracted diaphragm. 64 PHYSIOLOGY. ribs, and by compressing the abdomen force the viscera up against the relaxed diaphragm, and thus diminish the cavity of the thorax from below. These are the recti, obliqui, and transversi abdominis, the quadratus lumborum, the serratus posticus inferior, the sacro- lumbalis, and the longissimus dorsi. If the whole time occupied by a respiratory act, from the begin. ning of one inspiration to the beginning of the next, be represented by 10, the inspiratory movement may be estimated at 5; the expi- ratory at 4 ; while the remaining 1 will be occupied by the period of repose which succeeds expiration. The capacity of the lungs varies very much in different indivi- duals. According to Mr. Hutchinson, by this term is meant "that quantity of air which an individual can force out of his chest by the greatest voluntary expiration, after the greatest voluntary inspira- tion." This author has shown that in health, this capacity bears a very constant relation to the height of the individual. Thus the mean " capacity" of 172 males under the height of 5 ft. 8 in. is 220 cubic inches, whilst that of 82 males from 5 ft. 11. to 6 ft. is 255 cubic inches. For every additional inch of height (from 5 to 6 ft.), 8 additional cubic inches are given out by a forced expiration. The exceptions to this occur among stout and corpulent individuals, whose capacity stands lowest. The size of the chest, therefore, is not always a criterion as to the capacity of expiration. Mr. Hutchinson also found that the full expiratory force of a healthy man is commonly one-third greater than his inspiratory force. According to the experiments of Mr. Coathupe, about 266J cubic feet, or 460,224 cubic inches of air, pass through the lungs of a middle-sized man in 24 hours; reckoning the average number of inspirations at 16 per minute, this would give 20 cubic inches as the amount inhaled at each. Residuary air.—According to the calculation of Sir H. Davy, the human lung, after the strongest expiration, still contains 35 cubic inches of air, and after an ordinary expiration, 108 cubic inches. This (air) is called the residuary air, and upon it depends the light- ness of the lungs, which enables them to float upon water; in fact, when once these organs have been distended by a full inspiration, no mechanical, or other power can dislodge the air so as to cause them to sink in water. Upon this circumstance was based the hydro- static test of infanticide. The residuary air also gives rise to the tympanitic resonance on percussion. In the act of inspiration the air within the lungs is alternately in- creased and diminished in amount; and thus a regular exchange is secured. This exchange, however, affects only a portion of the con- tained air at a time, and this proportion appears to vary according to the frequency of the respiration. Indeed, if it were not for the tendency of gases to mutual diffusion, the air in the remote cells might never be changed. Probably about one-eighth of the whole RESPIRATION. 65 contents is changed at each inspiration. As long as the residuary air contains any oxygen, aeration of the blood will take place, pro- vided always the heart continues to act; but as soon as the contained oxygen is consumed, asphyxia begins to occur, unless a fresh supply is obtained. The residuary air will probably support life about three minutes. Influence of the nerves on respiration.—The source of the ner- vous influence on which the different respiratory movements depend, is one and the same, although the nerves implicated in these move- ments are very various. The medulla oblongata is the source from which the nervous influence for the respiratory motions is derived, and the spinal cord is, as it were, the trunk of the nerves which arise from it. If the spinal cord is divided above the point where the dorsal nerves are given off, the motions of the ribs and abdo- minal muscles are paralysed, while the other respiratory movements continue. If it is cut above the origin of the phrenic nerve, then the diaphragm is paralysed, while the nerves given off from the medulla oblongata itself still continue to exert their function. In- jury of the medulla oblongata arrests instantly all the respiratory movements, both those dependent on the par vagum, and those on the spinal nerves. The respiratory movements are partly voluntary, partly invo- luntary. Partly voluntary, in order that they may be inservient to the production of vocal sounds, and to the actions of speech, sing- ing, &c. Partly involuntary, lest in sleep, or in moments of forget- fulness, the movements of respiration should be suspended, and fatal results ensue. The combined action of the respiratory muscles is under the in- fluence of that portion of the nervous system called the reflex; a part which does not involve the will, or even sensation, and which may continue to transmit its influence when all the other parts of the nervous centres have been removed. The principal excitor, or afferent nerves, are the par vagum, and the sensory branches of the fifth pair, the former conveying impressions from the lungs, the latter from the general surface. If the par vagum be divided on both sides, the movements of respiration are greatly diminished in frequency. Chemical phenomena.—The prominent phenomena in respiration are, the removal of a certain quantity of oxygen from the air, and its replacement by carbonic acid; and the change in colour of the blood from a dark venous hue, to a bright scarlet or arterial. The relative proportions of oxygen inhaled and of carbonic acid exhaled, are to each other inversely as the square roots of their specific gra- vities ; that is, the quantity of oxygen absorbed will exceed that of carbonic acid given off in the proportion of 1174 to 1000. Carbonic acid contains precisely its own volume of oxygen ; consequently, of 66 PHYSIOLOGY. the 1174 parts of oxygen absorbed, 1000 are again excreted as car- bonic acid, leaving 174 parts, or nearly 15 percent, to be accounted for. Some of this unites with the sulphur and phosphorusof the ori- ginal components of the body ; the remainder most probably enters into combination with the hydrogen of the fatty matter, thus forming part of the water exhaled by the lungs. Of the nitrogen which enters so largely into the composition of atmospheric air, a small portion only is absorbed, in consequence of the difficulty with which it passes through animal membranes; its main use in the atmosphere being to dilute the oxygen. The exha- lation and absorption of nitrogen appear usually to balance each other, so that the amount of this gas in the respired air undergoes little or no change. The quantity of carbonic acid exhaled varies at different times, and under different circumstances. The mean of a great number of observations gives about 160 grains of carbon per hour as the quantity set free by an adult; this would give 8 oz. Troy in the 24 hours. The amount varies with the development of the body, and with the sex. In males, the quantity increases from eight years of age till thirty, it remains stationary till forty, and then decreases till old age, when it little exceeds that at ten. An extraordinary de- velopment of the muscular system is always accompanied by the extrication of a larger quantity; the reverse is also true. In females there is the same proportional increase till puberty, from which time it remains stationary during the menstrual life; after which it increases. After fifty, it decreases as in men. Du- ring pregnancy the amount of exhalation is increased, and the same takes place whenever the menses are temporarily arrested. The quantity exhaled is also increased by cold, exercise, or a full meal, and by many of the exanthemata. It is diminished in typhus fever, in chronic diseases of the respiratory organs, and in sleep. Independently of these variations, there is a difference in amount in accordance with the time of day, being least at midnight, gradu- ally increasing till midday, then again declining till midnight. The sources of the carbonic acid have been already adverted to. It is not formed in the lungs as was originally supposed, but in the tissues themselves, as is shown by the facts that venous blood con- tains a larger amount of this gas than arterial; and that an animal placed in hydrogen, or nitrogen, still continues to evolve carbonic acid. In regard to the change of colour effected by respiration, it must be regarded as a purely physico-chemical phenomenon, inasmuch as the same changes will take place in blood exposed to the air out of the body, even through the medium of a thick membrane, such as a bladder. The precise cause of the change of colour is as yet un- settled. By Liebig it is supposed that the iron in the red corpuscles RESPIRATION. 67 is the real agent in the respiratory process, and that the corpuscles are the carriers of oxygen into the system, and of carbonic acid out of it. He supposes the iron to exist in the form of protoxide in venous blood, united with carbonic acid, forming a carbonate of the pro- toxide of iron; in the lungs, the carbonic acid is- given off, leaving the protoxide, which by union with half an equivalent of oxygen, is converted into the peroxide, at the same time that the colour is changed to arterial. In the systemic capillaries the reverse takes place,—the oxygen being imparted to the tissues, and replaced by the carbonic acid, which is given up by them to be conveyed out of the system. Mulder, Scherer, and others, account for the change of colour, by a change of form in the red corpuscles, which are supposed to be bi-concave, and reflecting bodies in arterial blood, and bi-convex, and refracting bodies in venous blood. Mulder shows that the colour is not dependent on the presence of iron, since it is retained when all the iron has been entirely removed. The presence of a certain amount of saline matters appears, from the experiment of Dr. Stevens, to be essential for the due influence of oxygen upon the colour of the blood ; since, if they be deficient, the contact of oxygen will not produce its usual effect. The blood parts with a considerable amount of water in the lungs, amounting to 16 or 20 ounces in 24 hours. It also absorbs volatile matters from the air. The water contains some animal matters, and has its source, according to Dr. Prout, in the chyle which has just been poured into the blood; probably also it escapes by evaporation through the thin animal membrane. Asphyxia.—If from any cause the supply of oxygen be cut off, a condition ensues to which the name of asphyxia has been given ; the essential character of which, is the cessation of muscular move- ment, and shortly afterwards of the circulation, with an accumula- tion of blood in the venous system. The time necessary for the production of this state is inversely proportionate to the development of the respiratory function; thus, warm-blooded animals are much sooner asphyxiated than reptiles. In the former, deprivation of air for two minutes is sufficient to produce insensibility and loss of mus- cular power. The circulation generally fails within ten minutes. The first effect of non-arterialization of the blood in the lungs, is the retardation of the fluid in their capillaries, an accumulation in the venous system, and a deficient supply to the arterial. The ope- ration of these two causes arrests the action of the heart, although the effect on the two sides is different; the right side ceases to act from over-distention; the left, from deficiency of stimulus to excite the movement. If the stoppage have not been too long, the heart's action may be renewed by artificial respiration ; for the replacement of oxygen in the air cells, restores the pulmonary circulation, 68 PHYSIOLOGY. and thus, at the same time, relieves the distended right ventricle, and conveys to the left the due stimulus to its action. In conclusion, it may be stated, that the post-mortem appearances are always the same in asphyxiated individuals, no matter what may have been the mode of death. CIRCULATION. By this term is understood that function by which the nutritive fluid is conveyed to every part of the body through appropriate channels. This distribution is spoken of under the general title of The circulation of the blood; the organs and canals by means of which and through which it is accomplished constitute the vascular system. The greater circulation was discovered in the higher animals by William Harvey in 1619, and although it cannot be asserted to be an universal character of all animals, yet at every advance of obser- vation, new traces of vessels are discovered in the most simple beings. There is a circulation in plants as well as in animals, and its ob- ject is the same. There is no central organ, however; the elaborated sap is distributed partly by vis a tergo, partly by capillary action, and the influence of light and air upon the leaves, but mainly by the affinity between the elaborated sap and the tissues of the plant. In the higher orders of animals, there are two distinct circulations, with a heart for each. Thes,e two circulations are entirely separate and distinct from each other in the perfect adult, as are also the hearts belonging to each, being merely brought together for economy of material and space. They are called the greater and the lesser; or the systemic and pulmonic. The course of the blood through these two circuits, may be likened to the figure 8 ; and the heart is placed at the junction of these. Each system has its own set of arteries or efferent trunks, and veins or afferent trunks; these communicate at their central extremity by the heart; and at their peripheral extremity by the capillary vcs- sels, by which are meant the minutest ramifications of the two sys- tems inosculating into a plexus. The route of the circulation is as follows: the venous blood is collected in the right auricle, thence it passes through the tricuspid orifice into the right ventricle; thence it is distributed to the lungs through the pulmonary artery to be aerated, after which it is collected by the pulmonary veins and carried to the left auricle, from which it passes through the mitral orifice into the left ventricle, and from thence through the aorta to the system. The chief impelling power of the circulation, is the rhythmic mo- tion of the heart. This organ is endowed in a remarkable degree with the property of irritability or contractility; by which is meant CIRCULATION. 69 " the capability of being easily excited to movements of contraction alternating with relaxation." This property is an endowment strictly belonging to the heart, and is not derived from any connexion with the nervous sj^stem, since it has been shown to continue after all connexion has been severed. It is retained much longer in the cold- blooded than in the warm-blooded animals ; and in the very young animals than in the old. This movement of the heart cannot be accounted for by the sti- mulus of the blood, since it will continue when the heart is empty; nor yet by the stimulus of air, since it persists even in vacuo; and it has been shown above that they are independent of the nervous system; they must therefore depend on the vis insita, though the exciting cause cannot be positively determined. If the heart of a living mammiferous animal or bird is laid bare, the two ventricles are seen to contract together, and the two auricles, with the commencement of the pulmonary veins and of the vena? cava? also simultaneously, the contraction of the auricles and that of the ventricles not being synchronous. The contraction of all the cavities is followed by their dilatation; the contraction is called the systole; the dilatation, the diastole. The auricles are but little concerned in the propulsion of the blood, they being mere sinuses or receptacles. The systole of the ventricle corresponds with the projection of the blood into the arteries, causing the pulse; whilst the diastole, coincides with the collapse of these vessels. When the ventricles contract, the blood is prevented from return- ing into the auricles by the tricuspid valve, on the right side; and by the mitral valve on the left. When they dilate, the blood is prevented from re-entering their cavities, by the semilunar valves at the mouth of the aorta and pulmonary artery. The dilatation of the ventricles may be distinguished into two stages: the first immediately succeeds their systole, and manifests itself in the recession of the heart's apex from the walls of the chest; the second stage is attended with the enlargement of the heart in all directions, and is synchronous with the auricular contractions. It is between these two stages that the interval of repose takes place. The diastole of the heart, according to Cruveilhier, is an active force, but of its cause no precise account is given. It is supposed to be owing to the presence of the yellow fibrous tissue, interwoven with the muscular substance, upon whose elasticity the first stage of the ventricular diastole is supposed to depend; the second stage being caused by the ingress of blood produced by the auricular systole. The impulse of the heart must not be confounded with the arterial pulse. The heart's impulse is the shock communicated by its apex to the walls of the thorax in the neighbourhood of the fifth and sixth ribs. 70 PHYSIOLOGY. Sounds of the heart.—When the ear is placed over the precordial region, two sounds are heard, following each other in quick suc- cession, at each beat of the heart. These sounds are followed by a short interval of repose, after which they recur, again fol- lowed by repose, and so on. The sounds are of different lengths; the first being the longest. If the whole interval, from the beginning of one pulsation to the beginning of the next, be divided into four j equal spaces of time, the first two will be occupied by the first sound, the third by the second sound, while the fourth will represent the period of repose. The first sound coincides with the systole of the ventricles, the pulse ' in the arteries, and the impulse against the walls of the chest. The second, with the first stage of the diastole of the ventricles. The first is a dull, prolonged sound, the second is short and sharp, and follows so immediately upon the first, that it can hardly be imagined to occur during the systole of the auricles, as has been supposed. The causes of these sounds have given rise to much discussion. The first is evidently complex, having several elements in its com- position. The principal cause of it is found at the orifices of the aorta and pulmonary artery, and is produced by the rush of the blood through these comparatively narrow outlets. Another element is found in the passage of the blood over the rough internal surface of the heart; a third element, in the sound of muscular contraction accompanying the systole of the ventricles; and a fourth in the im- pulse of the heart against the walls of the chest; for when the impulse is prevented, the sound is much diminished. In regard to the second sound, which accompanies the first stage of the diastole of the ventricles, there is not so much doubt. It is produced by the sudden shutting down of the semilunar valves at the orifices of the aorta and pulmonary artery, the function of which valves is, to prevent the reflux of the blood into the ventricles during their dilatation. To sum up, the causes of the first sound, are : 1st. The rush of blood through the narrow orifices of the aorta and pulmonary artery; 2d. The passage of the blood over the rough internal surface of the ventricles; 3d. The sound of muscular contraction; 4th. The im- pulse against the chest. The cause of the second sound is, the sud- den shutting down of the semilunar valves at the orifices of the aorta and pulmonary artery. The following table from Dr. Carpenter's Human Physiology, will perhaps assist the student in connecting the sounds of the heart with its movements: First Sound. Ventricular systole, and auricular diastole. Impulse against the chest. Pulso in arteries. Second Sound. First stage of ventricular diastole. Interval. Short repose; then auricular systole, and second stage of ven- tricular diastole. CIRCULATION. 71 The capacities of the different cavities of the heart are said to vary slightly, as well as the thickness of the walls; the right auricle and ventricle are said to be most capacious, while the left auricle and ventricle have the advantage in thickness of their walls; the left ventricle having its parietes nearly three times as thick as the right, since it has to exercise more force in sending the blood to the distant parts of the system. Each cavity will hold about two fluidounces, but it is probable that the ventricles do not entirely empty themselves at each stroke; they will therefore discharge about l£ ounces at each pulsation. Reckoning 75 pulsations in a minute, there will pass through the heart in this time, 112 oz., or 7 lbs. of blood. The whole quan- tity of blood in the human body is equal to about -^th of its weight, or 28 lbs. in a person weighing 140 lbs. This quantity would there- fore pass through the heart once in four minutes, and would circu- late about fifteen or twenty times in an hour. Recent experiments would seem to show that this is below the esti- mate, since substances introduced into the venous circulation have been detected in the remotest parts of the arterial system in less than 30 seconds. The force with which the heart propels its blood has been variously stated. According to Hales, the usual force of a man's heart would sustain a column of blood 1\ feet high, the weight of which would be about 4 lbs. 6 oz. According to Poisseuille, who caused the blood to act upon a column of mercury, the force of the heart is equal to 4 lbs. 3 oz. The true estimate of this force is found by multiplying the pressure of blood in the aorta into the surface of a plane passing through the base and apex of the left ventricle; according to which it is found to be about 13 lbs. The number of contractions of the heart in a minute, is about 70 or 75. The frequency of its action gradually diminishes from the commencement to the end of life. Just after birth, it ranges from 140 to 130; in old age, 65 to 50. Age, sex, muscular exertion, emotions, and temperament, exert a controlling influence over the heart's action. In persons of sanguine temperament, the heart beats more frequently than in those of the phlegmatic, and in the female sex more frequently than in the male. Its action is also increased after a meal, and by rising from a recumbent, to a sitting or stand- ing posture. The time of day also affects it; the pulse is more fre- quent in the morning, and becomes gradually slower as the day advances. In inflammations and ft&ers, the pulse is much more frequent than during health. When the vital powers decline, it becomes frequent and feeble. In nervous affections, with more oppression than ex- haustion of the forces, the pulse is often remarkably slow. Movement of the blood in the arteries and capillaries.—By the 72 PHYSIOLOGY. action of the left ventricle, the blood is forced onwards and distri- buted throughout the whole body, with the exception of the lungs, and passes through the capillaries into the veins. The pressure of the column of blood against the elastic walls of the arteries, at every contraction of the ventricle, produces what is called the pulse. The sensible pulse of the arteries is synchronous, or nearly so, with the contraction of the ventricle; it is somewhat later than the heart's beat, especially in the distant vessels, but the difference of time is scarcely perceptible. In the capillaries and veins, the pulse is no longer perceived. There is found to be a very close correspondence between the areas of the branches and that of the trunk from which they spring. According to a well-known geometrical law, the areas of circles are as the squares of their diameters. Now, if we add together the squares of the diameters of the branches of a given vessel, we will find that their sum is about equal to the square of the diameter of the parent trunk, showing that the conjoint size of the branches is not greater than that of the main trunk, and that the vascular system cannot be compared to a cone whose apex is at the heart, and whose base is at the circumference of the body, with a regularly increas- ing surface; but rather to a cylinder, whose diameter is equal through- out, and the pressure upon whose walls is at every point the same. The arteries are possessed of three coats, an external, cellular; a middle, composed of muscular fibres and yellow fibrous tissue; and an internal, which is serous. Upon the elasticity of the yellow fibrous tissue is dependent the property by which the interrupted force of the heart is made equable and continuous, and which is seen most in the large vessels connected with that organ. The contrac- tility of the muscular fibres, which they have been shown to pos- sess, is concerned in regulating the flow of blood towards particular organs. Their contractility is most plainly seen at a distance from the heart, where the impelling power of this organ becomes almost null. Under these circumstances, the muscular coat becomes an important adjuvant. The muscular coat has also another function, that of regulating the diameters of the tubes in accordance with the quantity of blood to be conducted through them to any part; this is seen in the enlargement of the uterine and mammary arteries, during preg- nancy and lactation, and in their return to their normal size after these periods are over. These changes are due to the contractility of the muscular fibres of the middle coat, probably regulated by the sympathetic nerve, which is minutely distributed upon the vessels. In the permanent dilatation of arteries, however, in parts that are undergoing enlargement, their nutrition is also increased, the walls being thickened as well as extended. In addition to the elasticity and contractility already described, CIRCULATION. 73 experiment indicates the existence of that power of slow contraction in the arteries to which the name of Tonicity has been given; this, however, does not seem to be anything else than a particular mani- festation of the general property of vital contractility, and is quite distinct from ordinary elasticity. The manifestation of this property is seen when a ligature is applied to an artery, the part beyond the ligature becoming gradually smaller, and emptied to a greater or less degree of the blood which it contained. The empty condition of the arteries after death is due to the same cause. It is to the moderate action of the Tonicity of arteries, that these contractions upon the stream of blood passing through them, is due. If the tonicity be excessive, the pulse is hard and wiry ; but if it be deficient, the pulse is very compressible, though bounding, and the flow of blood through the arteries is retarded. The smaller arteries in every organ of the body, before they be- come capillary, are connected by repeated anastomoses with each other, the object of which arrangement is, to supply the circulation to any part, when an important vessel leading to that part is either compressed or obliterated. The capillary system of all connected parts being continuous, all the vessels, whether arteries or veins, are united through its medium. Capillaries.—It has been shown that in all organic textures the transmission of the blood from the minute branches of the arteries to the minute veins is effected by a network of microscopic vessels, in Fig. 15.* the blood-vesBels and their anastomoses. 1, l. Veins. 2,2,2. Arteries. 74 PHYSIOLOGY. the meshes of which the proper substance of the tissues lies. These minute vessels are called capillaries from their small size, and they may be seen by the aid of the microscope in the web of the frog's foot, (fig. 15,) in the tail of the tadpole, and the lungs, urinary bladder, or tongue of the frog. The size of the capillaries is proportioned to that of the red par- ticles of the blood, and can be measured in parts finely injected. Their diameter varies from yxfcrjth to Tnt)Utn or TTn>t>tn °f an inch. When filled with blood they are not so much distended as when in- jected, and have seldom been measured when so filled. No other elementary tissues are much more minute than the capillaries. Microscopic observations and minute injections have shown that the capillary vessels are merely the fine tubes which form the medium of transition from arteries to veins, and that no other kind of vessels arise from them; that the minute arteries have no other mode of termination than the communication with the veins by means of capillaries ; in a word, that there are no vessels terminating by open extremities. (Muller.) Serous vessels, that is, branches of the blood-vessels too minute to allow the passage of red particles, and consequently traversed merely by the lymph of the blood, may pos- sibly exist, though they have not been demonstrated. What have probably been mistaken for them, are vessels which are so small as to admit only a single row of blood-corpuscles, the amount of colour- ing matter in which is not sufficient to tinge the light transmitted through them. The existence of vessels in the substance of the cor- nea, which were supposed to be serous or white vessels, is, according to Muller, very doubtful; they have never been injected. The existence of membranous parietes in the capillary system has been doubted by many physiologists, but more accurate research seems to establish the fact that such is the case. The fact that fluids injected into the arteries pass into the veins without extravasa- tion, and that currents cross above and below each other without mixing, have been adduced as arguments for the existence of mem- branous walls. Besides which, Windischmann has dissolved away the other tissues in a delicate membrane found in the ear of birds, leaving the beautiful vascular network, with the meshes empty. Schwann has also discovered by the microscope, that the capillaries have not merely membranous parietes, but a coat in which circular fibres can be distinguished as in the arteries. The capillary circulation seems to be in a great, degree indepen- dent of the heart's action, since it has been seen to continue in cold- blooded animals after complete excision of the heart. The emptiness of the arterial system after death, although partly owing to the toni- city of the arteries themselves, is commonly more complete than could be thus accounted for, and must therefore be partly due to the capillary circulation. Farther, the process of secretion has also CIRCULATION. 75 been seen to continue after death, which could not take place unless the capillary circulation were still continued. In the embryo, the blood circulates before the heart is formed ; and instances are not wanting in which the heart is entirely absent during embryonic life, and yet the greater part of the organs were well developed. In the latter case the circulation must be due to capillary power. The local determination that takes place whenever the processes of nutri- tion and secretion are carried on, and the increased rapidity of the movement without corresponding increase of the heart's action, also go to support the idea of an independent capillary power. These facts, and others to prove that the circulation in a part may be arrested, while the heart is still acting, and the vessels pervious, seem to be favourable to the support of the belief in the existence of such a power. In regard to the nature of the power, it cannot be mechanical, since no movement, of contraction or dilatation has ever been seen. The conditions under which the power in question uniformly operates, may be thus expressed :—" Whilst the injection of blood into the capillary vessels of every part of the system is due to the action of the heart, its rate of progress through those vessels is greatly modified by the degree of activity in the processes to which it should be normally sub- servient in them;—the current being rendered more rapid by an in- crease in their activity, and being stagnated by their depression or total cessation. " Thus the capillaries seem to have a distributive power over the blood, regulating the local circulation independently of the heart's action, and in obedience to the necessities of each part."* The views of Prof. Draper in relation to the dependence of the circulation of the sap in plants upon chemical changes in the cir- culating fluid, assist to explain very satisfactorily the capillary cir- culation in animals. A brief and modified summary of these views is here given. Experiments on inorganic bodies show, that if two liquids communicate with each other through a capillary tube, for the walls of which they have an unequal affinity, the liquid which has the greater affinity will be absorbed most energetically, and drive the other before it. This is what seems to take place in the organ- ized tissues, permeated by nutritious fluid. The particles of this fluid, and the solid matter through which it is distributed, have a certain affinity for each other, which is exercised in the nutritive changes, to which the fluid becomes subservient during the course of its circulation. Certain matters are drawn from it in one part to carry on the nutritive process; in another, to accomplish the func- tion of secretion. The fluid, which has given up to one tissue some of its materials, has no longer the same affinity for that tissue; it is * Carpenter's Princip. p. 564. 76 /■ PHYSIOLOGY. consequently driven from it by the superior attraction then possessed by the tissue for another portion of the fluid containing the required ingredients; this in its turn is rejected for a fresh supply. But the fluid, thus repelled from one part, may still be attracted towards another ; because that portion of its contents which the latter requires may not yet have been abstracted ; and thus the flow of the blood is maintained through the capillary network until it is alto- gether exhausted of its nutritive matter. Although the circulation is not dependent upon nervous power, its influence is nevertheless manifest, as is occasionally seen in the functions of nutrition and secretion, by the control it exerts over the diameter of the blood-vessels. The phenomena of blushing, pallor, and the erection of certain tissues, are also examples of a modified condition of the blood-vessels through the agency of this system. The venous system arises in the small trunks formed by the union of the capillaries ; and it returns the blood to the heart. These ves- sels are possessed of the same number of coats and the same proper- ties as the arteries, only not so strongly developed. The internal membrane is thrown into valves or folds to prevent the reflux of the blood. The capacity of the venous system is said to be consider- ably greater than the arterial, holding two or three times as much blood as the latter. The venous circulation is mainly due to vis a tergo; it is assisted, however, by a vis a fronte, in the suction power of the heart. The inspiration of venous blood is also said to assist it. By this is meant the rush of blood towards the chest, in order to supply the vacuum created there by the descent of the diaphragm. That it has some influence is seen in the partial emptying of the veins in inspiration, and their turgidity in expiration. But that it can have no general influence over the venous circulation, will perhaps be seen from the fact that the pulmonary circulation, being entirely within the chest, cannot be affected by atmospheric pressure, and also that the circu- lation of the foetus in utero cannot be affected by any such agency. Muscular movements are among the most important adjuvants to the venous circulation, every contraction being accompanied by a pressure upon the veins of the part; and as the blood is prevented by the valves from flowing back into the small vessels, it must be driven on towards the heart. This is familiarly seen in bloodletting, every movement of the hand increasing the flow of blood from the orifice. A few of the peculiarities of the circulation may be mentioned in conclusion. These are first, in the pulmonary circulation, in which venous blood is sent from the heart, and through a tube which is arte- rial in its structure; whilst arterial blood is delivered to the heart through several venous trunks. The portal circulation is also peculiar in its arrangements, the NUTRITION. 77 venous blood ramifying through vessels disposed like arteries, and having to overcome the resistance of an additional capillary system in the liver, before reaching the heart. The erectile tissues appear essentially to consist of a plexus of varicose veins, enclosed in a fibrous envelope, which plexus, ac- cording to Gerber, is traversed by numerous contractile fibres, to the contraction of which is probably to be attributed that obstruction to the return of blood by the veins, which is the occasion of their turgescence. In the penis, according to Muller, there are two sets of arteries, one destined for the nutrition of the organ, the other, by communicating with venous cells, for its erection. In all the erectile tissues, erection may ensue either from local irritation, or as a result of certain emotional conditions of the mind, the influence of which is probably transmitted through the sympathetic nerve. NUTRITION. According to the definition of Adelon, nutrition is the action by which every part of the body, on the one hand, appropriates or assi- milates to itself a portion of the blood distributed to it, and, on the other hand, yields to the absorbing vessels a portion of the materials that previously composed it. The process of nutrition is not an ob- ject of microscopic observation; the precise mode, therefore, in which it is accomplished is not accurately known. The source of all nutrition and of all growth is the blood, from which materials are shed or separated, to be employed in the renovation and repara- tion of the tissues. This is obviously only to be accomplished by the parenchyma selecting from the capillaries and intermediate ves- sels those ingredients that can become inservient to this process. The structure composing every separate portion of the body has, what may be called, an elective affinity for some particular consti- tuents of the blood; causing it to abstract from that fluid, and to convert into its own substance, certain of its elements. This selecting power, possessed by the component cells of every tissue, is exercised not only upon the materials required for their development, but even upon substances abnormally present in the blood; thus, arsenic will produce irritation of the mucous membranes of the body; and the continued introduction of lead into the circulating system modifies the nutrition of the extensor muscles of the fore-arm, producing the phe- nomena of lead palsy; the existence of this modification is proved by chemical analysis, which reveals the existence of lead in the palsied muscles. Substances thus introduced into the blood affect the symmetrical portions of the body; thus the extensor muscles in both arms are paralysed; and the cutaneous eruptions produced by the internal exhibition of certain remedies, are found to be almost precisely symmetrical; the presence of the medicine in the blood 7* 78 PHYSIOLOGY. being the occasion of a disordered nutrition of certain parts of the skin; and the selecting power of particular spots being evinced by the exact correspondence of the parts affected on the two sides. In the process of nutrition is exemplified the fundamental principle of organic assimilation. Each elementary particle of an organ attracts similar particles from the blood; and by the changes it produces in them, causes them to participate in the vital principle of the organ itself. Nutrition does not consist merely in the component particles of the organs attracting the fibrin, albumen, and other materials of the blood which flow through them, adding to themselves the matters similar to their own proximate principles, and changing the compo- sition of those which are dissimilar; but the assimilating particles must infuse into those newly added to them their own vital proper- ties. Mere increased size is not nutrition ; parts may be increased in size by the deposition of fibrin, as in inflammation, but this fibrine is unassimilated, and not endowed with the vital properties of the tissue in which it is deposited, and in this consists the difference be- tween increased nutrition and increased size. It was said that the source of all nutrition was the blood: a short account of this fluid may be necessary here. The chyle and the lymph, which are also generally considered as nutritive fluids, have been already described under the head of absorption. The blood, whilst circulating in the living vessels, consists of two parts,—a thin, transparent, nearly colourless liquid, termed liquor sanguinis ; and a number of small bodies called the red corpuscles, from which the colour of the blood of vertebrated animals derives its peculiar hue; in addition to which are found some white, or colour- less corpuscles. When the blood has been drawn from the body and allowed to stand, a spontaneous coagulation takes place, dividing it into crassa- mentum and serum. The crassamentum, or clot, is formed by the union of the fibrine and red corpuscles, by the entanglement of the latter in the meshes of the former. Whilst the serum is merely the liquor sanguinis deprived of its fibrine. From the fact that the serum coagulates by the addition of heat we know that it contains albumen; by exposure to a high temperature, the animal matter is decomposed, and a considerable quantity of earthy and alkaline salts remain. The distribution of these constituents in living and dead blood may be seen in the following table. r Fibrine, J Living Blood. < A,l)umen» ( *n solution, forming Liquor Sanguinis. 1 Oil llS, 1 Corpuscles.—Suspended in Liquor Sanguinis. Corpusdes. ( Crassamentum, or clot Albumen, ( T ... _ Salts. \ solution, forming serum. Dead Blood. NUTRITION. 79 The mean proportion of these different ingredients in a thousand parts of blood may be thus stated: Fibrine, 3 parts; Albumen, 80 parts; Red Corpuscles, 127 parts; Water and Salts, 790 parts. These proportions are subject to considerable variations within the limits of health. There is also a small amount of fatty matteus and extractive. The following is the analysis of Simon made upon the blood of males: Water, 791-9; Fibrine, 2-0 ; Corpuscles, 114-3 Albumen, 75-6; Extractive Matters and Salts, 14-2; Fatty Blat- ters, 2-0. There is a greater amount of solid matter in the blood of the male than of the female, except in the case of albumen, which is in larger quantity in the female. Each of the prominent constituents of the blood has been already described in the earlier pages of these divisions, to which the reader is referred. When the blood is examined shortly after a meal the serum is found to present a milky appearance. According to Drs. Buchanan and R. D. Thompson this appearance is due to the admixture of the chyle. The period at which the discoloration is greatest, however, and the length of time during which it continues, vary according to the kind and quality of the food, and the state of the digestive functions. The milkiness seems to be entirely due to the presence of oleaginous matter in the food. The crassamentum of such blood often exhibits a pellucid fibrinous crust, sometimes interspersed with white dots; and this seems to consist of an imperfectly assimilated proteine compound, analagous to that found in the serum. A small quantity of sugar is occasionally found, even in healthy blood, when large quantities of it are taken as food. But commonly it is trans- formed into lactic acid, or into fatty matter, before it is received into the circulating current. By some high authorities the coagulation of the blood is looked upon as a mere physical process, dependent upon the exposure of the fluid to the air, precisely as some chemical substances are known to solidify under similar circumstances; and the long delay of the coagulation after death is mentioned as confirmatory. By others it is contended that the coagulation is the last act of vitality of the blood, which is evident from the incipient organization which may be detected even in an ordinary clot; and still more from the fact, that if the effusion of fibrine take place upon a living surface, its coagulation in the first act of its conversion into solid tissues posses- sing a high degree of vitality. If not within the influence of a living surface, it soon passes into a state of decomposition. The rapidity of the coagulation depends very much upon the circumstances in which the blood is placed. It is accelerated by moderate heat, and retarded, though not prevented by cold. The blood that flows last from a vessel coagulates more rapidly, but less firmly, than that first drawn; and in inflammatory blood, in which the fibrine is increased, coagulation is unusually slow. 80 PHYSIOLOGY. In certain disordered conditions of the blood the surface of the clot is not unfrequently covered with a layer of fibrine nearly free from colour, and known as the buffy coat. This is commonly looked upon as positive evidence of the existence of inflammation. Such is not really the case, however, since it is seen in very opposite conditions of the system, as in chlorosis. In inflammation the amount of fibrine is really increased, and the coagulation of the blood is much retarded. This allows the corpuscles time to sink to the bottom, leaving the upper part of the clot composed of fibrine alone, which is nearly destitute of colour and very tenacious in its character, while the lower part obtains its deep red colour from the presence of the red particles. The layer of fibrine in its slow coagulation undergoes contraction of its edges, thus giving rise to the cupped appearance of inflammatory blood. The buffy coat is also seen in the blood of pregnant females; and also in that of chlorotic patients, in whom the fibrine is relatively in excess over the red corpuscles. In idiopathic fever the amount of fibrine is lessened; should inflammation supervene, however, the fibrine is increased. The increase here is not due to the febrile condition, but to the local inflam- mation, which, according to Andral, is always accompanied by an increment in the amount of fibrine. The corpuscles of the blood, in coagulating, apply themselves to each other so as to resemble piles of money. It is said that in inflammatory blood they are more closely applied, and the areola? between the piles are larger than in healthy blood. Fig. 16 represents this arrangement, and the shape of the corpuscles. , The materials of the nutri- Fig. 16.* tive process being prepared in a , the blood, every tissue and a?jf) ^,B every organ attracts from it *......S^ a02 fftf^A Part'c'es similar to itself, or .jjJp) ||F 10* metamorphoses the proximate ^ principles of the blood into its -j* own elements. The blood is w @ distributed to the tissues by the capillary system of vessels, with a degree of minuteness varying with the activity of the nutritive operations taking place in the individual parts. It is in the capillary system that all nutri- tion takes place, the plastic material being selected, as before de- scribed, by the component cells of the tissue to be nourished. The mode in which the tissues are developed by cells, has already been explained. It was then shown that in the production of any * A. Blood-corpuscles seen on their flat surface, and edge. B. Congeries of blood corpm- cles in columns. NUTRITION. 81 given form of tissue, nature does not at once unite the organic molecules in that form, but that she first creates in a structureless fluid, or in previously existing cells by a definite process, round vesicles or cells, and subsequently transforms these into the various elements of the organic textures. The process of nutrition varies greatly according to age, consti- tution, idiosyncrasy, state of health, &c. It is most rapid in youth, during the growth of the body; it is greatly less in old age; but differs widely with reference to particular organs. Morbid condi- tions, excessive bodily and mental efforts, the depressing emotions, such as care and sorrow, are all incompatible with perfect and pow- erful nutrition, and induce wasting of the several organs. As a general rule it may be stated, that the greater the demand for the functional activity of the organ or tissue, the more energetic is its nutrition, and vice versa. Whenever the amount of nutritive mate- rial deposited in a tissue or organ is more than sufficient to supply the waste, the part becomes hypertrophied or over-nourished. The term hypertrophy signifies excessive nutrition. It differs from healthy nutrition only in degree. It consists in the augmentation of one or more of the natural constituents of an organ, in such a man- ner that the newly formed parts are continuous with those already existing, and cannot be anatomically distinguished from them. Hy- pertrophy is never known to affect the whole body, to a degree suf- ficient to constitute disease. But examples of hypertrophy of parti- cular organs or tissues are very common. Atrophy, or diminished nutrition, is exactly the reverse of the condition just described, but is more generally a morbid operation, and may affect either the whole body or individual parts. It takes place whenever the waste of the tissues is more rapid than their replacement by nutrition. The nutritive operations, by which lost parts are repaired, take place with great activity. In its most perfect form, this process is analogous to that of the first development of the corresponding parts, and its results are as complete in the one case as in the other. The reparative process was formerly thought to depend on the existence of inflammation; it can be shown, however, that in the majority of instances inflammation is injurious rather than beneficial. • " That the powers of reparation and reproduction are in proportion to the indisposition or incapacity for inflammation; that inflamma- tion is so far from being necessary for the reparation of parts, that in proportion as it exists, the latter is impeded, retarded, or prevented; that, when inflammation does not exist, the reparative power is equal to the original tendency to produce and maintain organic form and structure; and that it then becomes a natural function, like the growth of the individual, or the reproduction of the species."* Treatise on Inflammation, p. 7, by Dr. Macartney. 82 PHYSIOLOGY. The continual death, or destruction of the individual cells which enter into the composition of the organs or tissues, constitutes what is called, molecular death, to distinguish it from somatic death, or the death of the whole body, which follows upon the cessation of the respiratory and circulatory functions. Molecular death, however, is not always an immediate result of somatic death, since it is known that the lives of individual parts may be prolonged after the suspen- sion of the regular series of their combined operations; so on the other hand, molecular death may take place to a considerable extent, if the function of the part have no immediate relation to the indis- pensable actions just alluded to, without somatic death necessarily resulting. | There is no valid reason for believing that the processes of nutri- tion are dependent upon nervous influence, although, as before stated, it is known that they may be influenced by it. These processes go on with great regularity and rapidity in the vegetable kingdom, in which nothing approaching to a nervous system exists; and in the animal kingdom they take place long before any nervous system be- gins to be developed; the conversion of the primary cells into mus- cular tissue, bone, and mucous membrane takes place in virtue of the inherent properties of the primary tissue itself, since no nervous influence can be supposed to operate, before nerves are called into existence. SECRETION. Nearly allied to the function last considered (nutrition) is that of secretion, which means literally separation. In both certain materials are separated from the blood; in nutrition the object of the separa- tion is to build up the living body; in secretion, to get rid of certain useless substances, or to supply certain other combinations that may either directly or indirectly be essential to the economy. The essential character of the true secreting process seems to con- sist not so much in the nature of the action itself, for this is identical with that of nutrition, both being effected by a process of cell-growth, but in the position in which the cells are developed, and the manner in which their products are disposed of. In secretion the product of the action of the cells is delivered upon a free surface, communicating, more or less directly, with an external outlet, or into cavities pro- vided with orifices that lead to them. The organs by which the latter operations are effected, are called secreting organs, and the matters separated are spoken of as secreted fluids, or simply as secretions. A distinction has been made between those secretions that are produced with an ulterior view as means to other functions in the economy, such as the saliva, gastric juice, &c, and those that are immediately rejected from the organism, as useless, as for example, SECRETION. 83 the urine, &c. The first are regarded more peculiarly as secretions; the latter, as excretions. Of the reason why one organ should separate bile, another milk, and another sperm, no other account can be given than that which refers them to the special endowments of the cells, the real instru- ments in the process. That the particular modification of structure which the organ may present, has no essential connexion with the character of the secretion is evident, from the fact that almost every gland may be found under a variety of forms in different parts of the animal series; and for every gland there is a part of the animal scale below which it does not exist, and when it makes its first appearance it almost always presents a character nearly as simple, as that of the least complex glandular structures in the higher or- ders. The simplest form of secreting organ is that of the simple animal membrane, well supplied with blood-vessels and covered with an epi- thelium; of such a membrane we have an example in the serous and synovial membranes. The next is that of the follicle, a depression, or inversion of the animal membrane, lined with epithelium cells, and abundantly supplied with blood-vessels from which are elaborated their peculiar secretions. (Figure 13, page 56, already referred to.) The third and last form of secreting organs is the gland, which is nothing but an aggregation of follicles, closely packed together, so as to present a large secreting Fig. 17. surface in as small a bulk as possible. In some glands the sacs or follicles, are prolonged into ca?ca, or blind tubes, as in the kidney and testis ; these are called tubular glands; or else they are very greatly multiplied, and clustered together (like currants on a stalk) upon efferent ducts common to several of them. (Fig. 17.) In all secreting organs the important agents are the cells which are developed upon the lining mem- brane of the follicles and tubes, and which select and elaborate the materials from the blood and discharge their contents into the excretory duct. These cells are being constantly cast off and re- placed by a new growth, having their origin in the basement mem- brane of the mucous membrane which lines the ducts or follicles. The simplest condition of a secreting cell in the animal body is that of the adipose tissue, every cell of which has the power of selecting its materials from the blood. The contents of these, how- ever, are not discharged, but remain stored as a reservoir in time of need. The adipose tissue has already been described. There is a difference between the processes of secretion and exhala- tion; the former is a vital process, the latter a physical. Wherever a fluid requires to be elaborated, it is done by a process of secretion, and the agents are cells ; but where no such process is necessary, 84 PHYSIOLOGY. the fluid pre-existing in the blood, it soaks out by the physical pro- cess of exosmose. The exhalations do not require much notice after what has been said of their mode of separation. Under this head are included those from serous and synovial membranes, which are destined to lubricate them ; the fluid of the areolar tissue, giving softness and suppleness to that tissue; the watery exhalations from the skin and mucous membranes, a mere physical evaporation ; and the exhala- tion of the aqueous and vitreous humours of the eye, two of its transmitting and refracting media. The follicular secretions are divided into two classes, the mucous and cutaneous. In the first division, besides the ordinary follicles which secrete the lubricating mucus, and which are seen generally existing in mucous membranes, there are included the numerous glandula? of the intestinal canal. In the stomach are the simple and compound gastric follicles, opening into little pits or depressions in the mucous membrane ; these follicles secrete the gastric juice. In the duodenum are the glands of Brunner, seated in the sub-mucous tissue; these consist of numerous minute lobules, with a common excretory duct. The nature of their secretion is unknown. In the jejunum, and more particularly in the ilium, are the agminated glands of Peyer, which consist of a cavity covered over with an extremely thin membrane, and having no excretory duct; their secretion probably escapes through the medium of cells developed in this membrane. These glands or follicles are supposed to secrete the putrescent elements of the fa?ces. Throughout the whole intes- tinal tract, especially in the small intestines, are found the follicles of Lieberkuhn, which secrete the thick, tenacious mucus to lubricate these parts. In the ccecum and lower part of the rectum, arc a number of simple and large follicles, producing slight elevations on the surface of the mucous membrane. These are always most abundant where most mucus is required. The glands of Duvergny and Nabothi, in the vagina and cervix uteri are also lubricating mucous follicles: as are also the glands of Cowper, and the prostate in the male. The tonsil glands are considered by some anatomists and physiologists as composed of numerous mucous follicles having the same function, viz., to lubricate the parts on which they are placed. The cutaneous follicular secretions include the meibomian, ceru- minous, sebaceous, and sudoriferous. The meibomian follicles are seated in the substance of the tarsal cartilage, and secrete a gummy fluid to lubricate the edges of the lids. The ceruminous, are seated beneath the skin of the auditory meatus, and consist of a tube con- voluted upon itself. They secrete a resinous substance, nearly solid, and intended to lubricate the external meatus. The sebaceous matter of the skin is secreted by innumerable minute, branched follicles opening by a narrow orifice. These sebaceous glands generally open into the follicles of the hairs. By these an adipose secretion SECRETION. 85 is poured out upon the skin destined to protect it from the action of the sun and air. They are sometimes the seat of a minute parasite called the demodex folliculorum. 19.t The perspiration is formed by small tubes of peculiar conformation, very much convoluted, and seated just be- neath the cutis vera, and pouring out their secretion by minute pores upon the epidermis. The ducts pass through the epidermis and cutis vera in a spiral di- rection, and their openings upon the epidermis, which are seen along the ele- vated lines of the skin of the palm and sole, are called pores. (Fig. 19.) Ac- cording to Mr. E. Wilson, the number of these sweat glands in the whole sur-, face of the body is about seven millions, and the conjoined length of the perspi- ratory tube 28 miles. The secretion from these glands is continually taking place, but as it is usually evaporated as fast as it is formed it does not become sensible. If, however, from excessive secretion, or a moist condi- * Fig. 18. a a. Sebaceous follicles, b. A hair with its follicle c, surrounded by fat cells, t Fig. 19. a. Epidermis, b. Upper layer of cutis vera. c. Cutis vera. d. Sweat eland surrounded by fat cells, with its duct running spirally through the layers of the skin. 8 86 PHYSIOLOGY. tion of the atmosphere, it is not carried off as fast as formed, it ac- cumulates upon the surface, constituting the sensible perspiration. It has usually an acid reaction, which is due to the presence either of acetic or lactic acid. It contains also a small amount of animal matter, and some salts, principally chlorides. The entire amount of fluid insensibly lost from the cutaneous and pulmonary surface is estimated at 18 grs. per minute ; of these 11 pass off by the skin, the remainder by the lungs. The maximum loss from both sources during 24 hours is equal to about 5 lbs., the minimum 1% lb.- The perspiratory secretion is depuratory and vicarious with that of the kidney, both separating the superfluous azotizcd matters. The amount of solid matter thrown off from the skin in 24 hours is about 100 grains. The amount of fluid thrown off is influenced greatly by external temperature, being greatest when it is elevated, the object of which increase is to keep down the temperature of the body by evaporation. It is also influenced by general conditions of the vascular and nervous system, though the manner is not yet well understood. A peculiar glandule, resembling the sudoriferous, but larger, has lately been described as existing in the axilla? ; these are called the odoriferous or miliary, and probably serve to secrete the character- istic odour of those parts. The odorous principle may be detected in blood which has been dried, by treating it with sulphuric acid: and it is said to differ so much in different animals as to afford a test by which their blood can be recognised. It has even been said that the blood of the female can by this means be distinguished from that of the male. GLANDULAR SECRETIONS. The lachrymal secretion is formed by the gland of that name, whose seat and structure are described in the anatomical division. It is one of the granular glands, and pours its secretion upon the surface of the conjunctiva to cleanse and lubricate. The lachrymal fluid resembles dilute serum deprived of a great part of its albumen. It is a constant secretion, and is absorbed by the open orifices of the nasal ducts, and carried into the nose as fast as it is poured out. The cause of this absorption is probably capillary attraction, assisted by the syphon-like action of the nasal duct. This secretion is greatly influenced by the emotions. The salivary secretion is formed by the Parotids, Submaxillaries, Sublinguals, and Pancreas, the latter is sometimes called the ab- dominal salivary gland. These glands also come under the division of the granular glands, being composed of aggregated follicles, dis- charging into an excretory duct. GLANDULAR SECRETIONS. 87 The salivary secretion is not necessarily constant, it takes place during the movements of mastication, and when any irritant is taken into the mouth. It is alkaline in its reaction, and contains among other ingredients, a peculiar animal principle, analogous to pepsine, called ptyaline, which seems to act as a ferment, since by it starch may be converted into sugar, and sugar into lactic acid. A consider- able proportion of saline and earthy matter exists in the solid residue of the saliva; this is nearly the same as that the blood contains. The tasjtar of the teeth consists principally of one of these, the earthy phosphates, held together by a little animal matter. If the alkalinity of the saliva be destroyed, it loses its converting power on starch ; and if acidulated, it has a solvent power for caseine, animal flesh, and other albuminous substances. The specific gravity varies from 1-006 to 1-009. The quantity secreted during 24 hours has been estimated at about 15 or 20 ounces. The pancreatic secretion con- tains a larger proportion of solid matter than the saliva. The Mammary Secretion is peculiar to the mammalia, and is one of those which are destined for special uses in the economy. The gland is found in both sexes, and presents but little difference in them till the period of puberty. It consists of numerous lobules held together by areolar tissue. Each lobule consists of a series of ducts passing inwards from their termination in the nipple, and then rami- fying like the roots of a tree, their ultimate subdivisions terminating in minute follicles. The mammillary tubes are ten or twelve in num- ber ; they are straight ducts terminating in the nipple, and having a slight dilatation just before their termination, which acts as a reservoir to receive the secreted milk. The secretion, as in the other glands, takes place in the ultimate follicles, by means of cells, which dis- charge themselves into the ducts. (Fig. 20.) The mammary gland of the male is a minia- ture of that of the female, but it does not undergo any marked increase in size at any particular period, its evolution going on pari passu with that of the body. There are some instances on record (one by Dr. Dunglison,) of its secreting milk; in Dr. Dunglison's case, the secretion was induced by the individual applying the children entrusted to his care, to the breasts during the night. The milk consists of water holding in solution sugar, various saline ingredients, and a peculiar albuminous substance called caseine, and having oleaginous particles suspended in it. By allow- ing the milk to stand, the oil-globules will come iJt$JTiC?1 s.ecti°n °|[the Mammary Gland, showing its thickness and the origins of the Lu,S < th %■'■ t8, 3' lts.Pectoral SUI-fece; 4. section of the skin on the surface of the ™ \??™ thl" sk,n covering the nipple; 6, the lobules and lobes composing the gland ; 7, the lactiferous tubes coming from the lobules; 8, the same tubes collected in the nipple. Fig. 20.* 88 PHYSIOLOGY. to the top, constituting the cream ; this includes also a considerable amount of caseine, with the sugar and salts of the milk. By agitating the cream the envelopes of the oil-globules are ruptured, and it is separated into butter and butter-milk, the latter containing the caseine, sugar, &c. A small quantity of caseine, however, is generally en- tangled with the butter, which has a tendency to render it rancid, and should be removed by heat. After the removal of the cream the milk still contains the greatest part of the caseine and sugar; if kept long enough the sugar is con- verted into lactic acid, which coagulates the caseine, precipitating it in small flakes. The same precipitation may be accomplished by other acids; the most effectual is that contained in the rennet, or dried calf's stomach, the active principle of which will coagulate 30,000 times its weight of milk. The sugar may be obtained by evaporating the whey. The proportion of the solid ingredients of the milk is about 110 parts in 1000, varying according to constitution, the amount and character of ingesta, and the time which has elapsed since parturition. The first milk is called the Protogala, or Colostrum, and has a purgative effect upon the child, owing to the presence in it of numer- ous yellow granulated corpuscles, called colostrum corpuscles. This property soon disappears, however, though occasionally it returns after the expiration of twelve months, seeming to indicate that the flow should be no longer encouraged. Human milk contains more sugar and less caseine than that of the cow, a fact to be remembered in substituting the latter for the former. The milk of carnivorous animals, fed exclusively on animal diet, con- tains scarcely a trace of sugar, while the caseine and butter are abundant. The quantity of milk that can be squeezed from either breast at one time is about two ounces. It is not always the largest breasts that secrete most milk, since their great size is often owing to the presence of adipose matter. The secretion is often materially affected by emotions, &c, so as to become poisonous to the child; and it is often rendered medicinal by substances administered to the mother. The instances of vicarious secretion of milk are not numerous; and in no instance is there any proof that the elements of the fluid were pre-existent in the blood. The secretion sometimes occurs in undoubted virgins, widows, and women past the child-bearing period, as well as in males. Secretion of Bile.—The Liver is perhaps more universally pre- sent throughout the animal scale than any other gland. It is the largest gland in the body, weighing from three to four pounds. The entire organ is made up of a vast number of minute lobules, of irre- gular form, of about the average size of a millet seed. Each of these GLANDULAR SECRETIONS. 89 lobules is a miniature gland, containing all the component elements of which the gland is made up, viz.: branches of the hepatic artery and vein, branches of the portal vein, branches of the hepatic ducts and secreting cells. These lobules are connected together by means of areolar tissue and anastomoses of blood-vessels. The hepatio artery is distributed in a capillary form upon the walls of the hepatic ducts, and upon the trunks ^ and branches of the portal and hepatic veins; it is therefore probably destined for the nutrition of the or- gan and not to supply ma- terials for the biliary secre- tion, at least until it has be- come venous by traversing the capillary system. From the capillary network the blood passes into branches of the portal vein, and thence into the hepatic veins; for when fine injection was thrown by Mr. Kiernan into the hepatic artery, the por- tal veins became filled, but not the hepatic. The vena porta ramifies in a capillary form between the lobules, and hence is called the interlobular vein, sending capillary twigs inwards, which converge towards the centre of the lobule, to form the hepatic or intralobular vein. (Fig. 21.) These Fig. 22.t latter terminate in the larger trunks,which pass along the bases of the lobules, collecting from them their venous blood; a these are called by Mr. Kiernan sublobular veins. The main trunk of the hepatic vein ter- 2i minates in the ascend- ing vena cava. The he- patic ducts also form a plexus, which surrounds * Horizontal section of three superficial lobules, showing the two principal systems of blood-vessels; 1, 1, intra-lobular veins, proceeding from the hepatic veins; 2, 2, interlobular plexus, formed by branches of the portal veins. t Horizontal section of two superficial tobules, showing the interlobular plexus of biliary ducts; 1,1, intra-lobular veins; 2, 2, trunks of biliary ducts, proceeding from the plexus which traverses the lobules; 3, interlobular tissue ; 4, parenchyma of the lobules. 90 PHYSIOLOGY. the lobules, connecting them together, and sending branches towards the interior of each. Their mode of termination, and their relation to the hepatic cells forming the parenchyma of the gland, areas yet un- explained. These cells of the liver, which are the real agents in the secreting process, are of a flattened spheroidal form, lying in piles, which seem to be directed from the circumference to the centre of each lobule. Their diameter is from l-1500th to l-2000th of an inch ; they have a distinct nucleus, and a well-marked biliary tinge, and contain a granular amorphous matter with a few small adipose granules. They are easily obtained in a separate condition by scraping a piece of fresh liver. The secretion of bile is probably a constant operation, although it may vary in quantity at different times. It may be discharged at once into the intestine, or it may regurgitate into the gall-bladder, as it probably does when the intestine is empty and there is no stimulus there to provoke the flow. In the gall-bladder the bile undergoes a concentration by the absorption of its watery parts; it is also mixed with the mucus secreted from its walls. The chemical composition of the bile is unsettled. It is of a yel- lowish green colour, viscid, and slightly bitter. It combines readily with water, mixes freely with oil or fat; and foams, when stirred, like soapy water. The proportion of solid matter is usually from 9 to 12 per cent; nearly the whole of this consists of substances pe- culiar to the bile. Three distinct substances are found in the biliary matter:—Clio- lesterine, or bile fat, resembling spermaceti, and consisting princi- pally of carbon and hydrogen. Bilic acid, a compound of soda with a peculiar organic body,.now regarded in the light of a fatty acid, and described by some chemists as choleic acid, bilin, picromel, &c, and a colouring matter called biliverdin, a substance identical with the chlorophyl of plants. In addition to these the bile contains some earthy salts. Uses of the bile.—A portion unquestionably passes off with the fa?ces; this, which includes the colouring matter, is that which would be injurious if retained in the blood, and is probably excrementilious. The soapy portion seems to act by rendering the fatty matters solu- ble, and thus enabling them to be absorbed by the lacteals. The importance of the bile, (probably the soapy portion of it,) has been shown by Schwann, who prevented it from passing into the in- testine, and found that the animals wasted, and at last died in a state of emaciation. The bile may also perform another function, as before stated,—the transformation of sugar into fatty matter. It is not improbable that this change may take place in the liver; since in animals fed upon grape sugar, trys substance has been found in the portal vein but not in the hepatic. The fatty matter of the bile, when reabsorbed with that of the newly'ingested food, is probably GLANDULAR SECRETIONS. 91 carried off in the respiratory process, to assist in the calorifying func- tion. The bile, therefore, seems to be partly excrementitial, partly recrementitial. . The sources of the bile may be found in the disintegration of the fibrinous and nervous tissues when the amount of food is just suf- ficient to supply the waste of the system, the liver removing such products as are rich in carbon and hydrogen; and in any excess m the non-azotised compounds derived from the food, beyond the amount that is requisite for the supply of the respiratory process, or that can be deposited as fat. In this elimination of hydro-carbon the liver is subsidiary to the lungs. In the fcetus it is the great decar- bonizing agent. In regard to the kind of blood from which the bile is secreted, analogy would point to the hepatic artery, although the experiments of Kiernan seem to fix it upon that of the vena porta?. Both have their supporters. Those who embrace the supposition of the secre- tion from the hepatic artery, assign to the vena porta? the office of mixing thoroughly with the blood heterogeneous substances absorbed from the stomach and intestines, before transmitting them to the heart. Those who contend for the secretion from the vena porta? assign to the hepatic artery the office of nourishing the liver, which from its small size, in comparison with the vena porta?, seems more justly to be its function. Secretion of urine.—This secretion is purely excrementitial, being destined to removed certain effete substances from the blood, whose retention would be positively injurious. As it is the function of the liver to remove the superfluous carbon, so it is of the kidney to get rid of the excess of nitrogen in the blood. The kidney is a tubular gland, being formed of uriniferous tubes, both convoluted and straight, the convoluted being found in the cortical portion, the straight in the me- dullary. The cortical portion is the most vascular, and it is probably the seat of the greater part of the secreting process, whilst the medullary is concerned in carrying the secreted matter; the two parts being in this respect analogous to the cortical and me- dullary portions of the brain. In the cortical portion of the kidney are seen a number of small dark points, called corpora malpighiana; each of these is com- posed of a mass of minute blood-vessels very * Distribution of the renal vessels; from kidney of horse ; o, branch of renal artery, a/, afferent vessel; m, n», Malpighian tufts; ef, ef, efferent vessels; p, vascular plexus sur- rounding the tube; st, straight tube ; ct, convoluted tube. Magnified about 30 diam. Fig. 23.* 92 PHYSIOLOGY. much convoluted upon themselves, like a ball of twine, into which a small afferent branch of the renal artery is seen to enter, and an efferent venous twig to emerge, the points of im mergence and emer- gence being very near to each other. Each of these Malpighian cor- puscles is included in a flask-like expansion of one of the tubuli uriniferi which is dilated to receive it. It is at this point, and from the arterial blood of the corpuscle, that the watery parts of the urine are separated by soaking through the walls of the blood-vessels and tubes, the blood being detained in the corpuscles for this purpose. The venous twig after leaving the corpuscle of Malpighi, becomes again capillary, and interlaces with the uriniferous tubes at another point; and at this point, and from venous blood, as in the vena porta?, the solid matters of the urine are separated by the agency of cells developed in the walls of the tube. (Fig. 23.) It would thus seem that the function of the Malpighian corpuscles is to get rid of the superfluous water in the blood, which, from their peculiar arrangement, they are well calculated to do. In this respect they assist the skin, which is very liable to great variations in the amount of fluid it exhales from the temperature of the air around. The quantity of solid matter eliminated by the kidney has no reference to the amount of water to be got rid of; being dependent upon the amount of waste in the system, and upon the quantity of surplus azotised aliment which has to be discharged through this channel. The average quantity of urine voided in twenty-four hours, by adults who do not drink more than the wants of nature require, is from 30 to 40 oz. Its average specific gravity is 1020. The amount voided is less in summer than in winter, on account of the large exhalations from the skin in the former season. The quantity of solid matter varies in health from 3-6 to 6-7 per cent. About one- third of the solid matter is made up of alkaline and earthy salts; the rest consists of organic compounds. The urine in health usually presents an acid reaction; this de- pends, however, upon certain conditions furnished by the aliment, and may be altered by a change in the ingesta. The most important constituent of the solid matters is urea, a transparent crystalline substance, soluble in water, and combining with acids without neutralising them. In chemical composition it is identical with cyanate of ammonia, viz.: 2 carb., 2 ox., 2 nit., 4 hyd. The amount of urea excreted may serve as a measure of the waste of the system, especially of the muscular system. The average amount of urea is about 30 parts in 1000 of urine. The amount excreted by children is much greater in proportion to their bulk than in old men. This corresponds precisely with the rapidity of interstitial change at different periods of life. Uric or lithic acid is another important ingredient. It exists in GLANDULAR SECRETIONS. 93 larger proportions in the urine of the lower vertebrata than in mamma- lia, in whom there exists only about one part in a thousand of urine. It is crystalizable, tasteless, inodorous, and nearly insoluble in water. It exists in healthy urine in combination with a base, either am- monia or soda, which latter, according to Liebig, is derived from the bibagic phosphate of soda, which by yielding up a part of its base gives the acid reaction to the urine that characterizes its healthy state. Its affinity for the base, however, is so feeble, that it is readily thrown down by any other acid in the urine. According to Keller, uric acid is not replaced by Hippuric in the urine on the adminis- tration of Benzoic acid. The amount of uric acid is not dependent on waste or diet; but often on disease, as gout, in which it is often deposited from the blood, in combination with soda, around the affected joints, forming chalky concretions. The urates are com- monly red. The presence of lactic acid as a constituent of healthy urine is denied by Liebig. The urine contains also various saline matters, such as muriates, sulphates, and phosphates; the latter supposed to be derived from the waste of the nervous tissue, into whose composition phosphorus enters. The phosphates are commonly yellowish white in colour. The quantity of salts in the urine is never the same in the same individual in like FiS- 24«* spaces of time; the urine of men, however, generally contains a relatively larger por- tion of salts than that of women. The total suspension of the urinary se- cretion is attended with rapidly fatal re- sults, the patient dying with symptoms re- sembling those of narcotic poisoning. Besides the essential constituents already mentioned, the urine often contains acci- dentally mixed substances, such as articles of food, of drink, or of medicine, which pass into it unchanged or changed, and can sometimes be detected in it in an in- conceivably short time after administration. The spermatic secretion is formed by the testes, another tubular gland consisting of lobules formed of convoluted seminiferous tubes. The number of lobules is about 450 in each testis, and that of tubules about 840. The different parts may be seen in Fig. 24. The diameter of the tubes is generally very uniform; they anastomose freely with each * A view of the minute structure of the testis; 1, 1, tunica albuginea ; 2, 2, corpus high- morianum ; 3, 3, tubuli seminiferi convoluted into lobules; 4, vasa recta ; 5, rete testis ; 6, vasa efferentia ; 7, coni vasculosi constituting the globus major of the epididymis ; 8, body of the epididymis; 9, its globus minor ; 10, vas deferens ; 1, vasculum aberransor blind duct, 94 PHYSIOLOGY. other without increasing in size. The testes originate in the lower part of the corpora woolfiana, in the embryo, while the kidneys spring from the upper and outer parts. They begin to descend into the scro- tum about the middle of pregnancy ; at the seventh month they reach the inner ring ; in the eighth they enter the passage ; and in the ninth they descend into the scrotum. Sometimes one or both remain in the abdomen, without, however, interfering with their function. The sperm is a thick, tenacious, grayish fluid, having a peculiar odour called spermatic, probably dependent on the secretions mixed with it. It is difficult to analyze it in consequence of its admixture with the secretions of the prostate and Cowper's glands. It is alka- line in its reaction, and contains albumen and a peculiar principle called spermatin. The so-called spermatozoa are most probably cells of the ciliated epithelium of the mucous membrane lining the genito-urinary apparatus. They are supposed to correspond with the pollen tubes of plants, and are probably the agents by which the fecundating materials of the male are brought into contact with the elements supplied by the female. They seem to be essential to the reproductive process. The sperm also contains seminal gra- nules, the mode of production of which corresponds with that of other glands. The salts that are found in the sperm are muriates and phosphates, especially the latter. The secretion takes place about the 14th or 15th year and continues till about 60 or 65, and during the whole of this time is much under the influence of the nervous system. The spleen, thymus and thyroid glands, and supra-renal capsules, are called glandiform ganglia, sometimes vascular glands. They all act as diverticula to the circulation in their neighbourhood; the spleen to the portal circulation, the thymus to the lungs in foetal life, the thyroid to the cerebral circulation, and the supra-renal capsules to the kidney. They all seem to share likewise in the pre- paration of the nutritive materials of the blood, assisting in this respect the lymphatic system, to which they seem to be appendages. CALORIFICATION • Is that function by which the heat of organized beings is generated. The source of this heat has long been a disputed question among physiologists. From the fact that plants are capable of generating an amount of heat, sometimes far above that of the surrounding medium, an unequivocal indication is given that we are to look for its source in the organic functions and not in those of animal life. In examining the phenomena in plants which present any relation to this source, we at once perceive that an absorption of oxygen and extri- cation of carbonic acid is continually taking place, (constituting the respiration of plants,) and that these processes occur with great CALORIFICATION. 95 activity at the time when the evolution of heat is most remarkable— that of germination and flowering. In animals an exact conformity may be perceived between the amount of oxygen consumed and of carbonic acid given off, and the amount of heat liberated. Some physiologists have thought that this carbonic acid was formed in the lungs, and the resulting heat distributed to the system by the arterial vessels, they having a greater capacity for heat than the veins; but it has already been shown that the carbonic acid is formed in the tissues and not in the lungs ; as the latter, therefore, cannot be the point at which the heat is generated, it must be evolved throughout the system. Exercise, or any increase in the nutritive operations of a part, is always attended with an elevation of temperature, as well as an increase in the extrication of carbonic acid. The formation of carbonic acid by the union of the oxygen absorbed from the air with the carbon set free from the body, is the main source of the heat generated within the animal system. The amount of carbon consumed in 24 hours is not sufficient, however, to account for all the heat liberated ; we must therefore look to other sources. That it is not dependent on nervous influence is evident from the fact that the process occurs in vegetables. Perhaps the formation of the various secretions,—fluids having a less capacity for heat than arterial blood,—may be accompanied with the elimina- tion of some latent heat. It is also suggested that the union of oxygen with hydrogen, phosphorus and sulphur, and the conversion of the plastic fluids into solids may likewise explain the source of some of the heat that is unaccounted for. That the cutaneous respiration is subservient to the maintenance of the heat is evident from the- fact that if the hair of rabbits be shaved off, and the surface covered with varnish, the temperature instantly/a//s. Diseases that involve an accelerated pulse and augmented respira- tion are generally accompanied with elevation of the temperature. The converse is also true. The ordinary temperature of the human body ranges from 98° to 100° Fahr., varying but a few degrees above or below when the temperature of the surrounding medium is elevated or depressed. Man is able to resist high degrees of temperature, (provided the surrounding air be dry,) by the evaporation of .the perspiratory secretion from the surface of his body. The less the age of the individual, the less is his ability to maintain an independenttempera- ture; the human infant in this respect resembles a cold-blooded animal. REPRODUCTION. See Obstetrics, in which this function is treated of. 96 PHYSIOLOGY. ANIMAL FUNCTIONS, OR FUNCTIONS OF RELATION. The animal functions are so called because they are peculiar to that class of organized beings. They render the individual conscious of external impressions, and capable of executing spontaneous move- ments, and are dependent for their exercise on the existence of a nervous system. They are thus classified : 1st. Sensation. 2d. Muscular Motion. 3d. Mental Manifestation. It has been shown (pages 38, 39) that into the composition of the nervous structure two distinct kinds of matter enter, viz.: the gray or vesicular, and the white, or tubular; that these two kinds differ not only in structure and colour, but also in function, the gray, or vesi- cular, being a generator of nervous influence, and the white the carrier of this influence to the various parts of the body. A union of these two kinds of matter constitutes a ganglion, or nervous centre. Our fundamental idea of a nervous system consists of a ganglion, or centre, thus composed, and a set of trunks composed of the white or tubular matter, connecting the central organ with the different parts of the fabric. These trunks or branches are distributed to the sensory surfaces or organs, and to the 'muscles or motor organs. The first receive and convey impressions^om the periphery to the centre, and are hence called afferent. The latter convey motor influence from the centre to the periphery, and are hence called efferent. The first are sometimes called sensory, from their connexion with sensa- tion ; the latter are likewise sometimes designated motory, from their connexion with muscular contraction. The functional activity of the nervous system is mainly depen- dent upon the due supply of oxygenated blood; this is especially necessary at the points at which changes originate, not seeming so necessary for the mere conduction of impressions. In accordance with this, we find the centres, and the peripheral extremities of affe- rent nerves always duly supplied with arterial blood; any interrup- tion to its supply being attended with an immediate arrest of their ANIMAL FUNCTIONS. 97 functions. On the other hand any increase in the supply of a part is attended with an exaltation of its function, as is seen m active con- sestion of the brain and spinal cord. It is now a generally received physiological truth, that the functional activity of the nervous system is mainly dependent, not only upon the due supply of arterial blood, but also upon the combination of its oxygen with the elements of the nervous structure. For physiological consideration the nervous system may be divided into three great divisions, the cerebrospinal; the reflex, or true spinal; and the great sympathetic. The cerebrospinal includes the cerebrum and cerebellum, with the sentient and motor nerves, that run to and proceed from them along the base of the brain, or along the spinal marrow to every part of the system. It presides over sensation and voluntary motion. The reflex, or true spinal, includes the gray matter of the medulla oblongata and spinalis as its centre, and a peculiar set of fibres running to and proceeding from these centres, called afferent, or excitor, and efferent, or motor. It presides over involuntary or ex- cited movements. The great sympathetic, or ganglionic, consists of a series of gan- glia on each side of the vertebral column, extending from the base of the cranium to the os coccygis, and communicating both with the spinal and encephalic nerves, sending its branches along the arteries, and particularly to the organs of involuntary functions. Its office is supposed to be to bring the functions of organic life into relation or sympathy with those of animal life. The changes which take place in a nerve of any of the above di- visions, when it is in action, are known to us only by the effects they produce on the sentient mind, or on muscular parts. There is no alteration in the physical appearance of the nerve or its fibres, which can be detected by our aided or unaided vision, and yet, from the in- stantaneous effect produced by stimuli, and its as sudden cessation on their withdrawal, we can refer the phenomena to nothing so readily as to a molecular change, rapidly propagated along the course of a nerve from the point of application of the stimulus. According to Bowman, a state of polarity is induced in the particles of the nerve by the action of the stimulus, which is capable of exciting an analogous change in other particles, whether muscular or nervous; whence results the peculiar effects of the nerve's influence. If this doctrine be tenable, the inference results that the nerves are not mere passive conductors, but that the whole extent of the fibre between the stimulated point and the peripheral extremity, or central termination, is the seat of change. The organic changes produced in a nerve by either mental or physical stimuli, develope that remarkable power known as the ner- vous force, or vis nervosa. Of the nature of this power we know 9 98 PHYSIOLOGY. nothing. That it is not identical with electricity or galvanism, as was once supposed, is now established. The following experiments prove this. If a ligature be placed upon a nerve its power of con- ducting nervous influence is lost, while it still continues to transmit electrical currents. Again, if a section of a nerve be removed, and its place be supplied by an electric conductor, electricity will still pass along the nerve, but no nervous force will be propagated through the conductor to the parts beyond. Lastly, the conducting power of nerve for electricity, according to Matteucci, is not more than one- fourth that of muscle; hence, if the nervous force were electric, it would leave the nerve, and follow the muscle in preference. It seems to be a peculiar power developed in the nervous structure under the influence of appropriate stimuli; just as contractility is developed in a muscle under similar influence. The functions of particular nerves may be discovered by examin- ing the anatomical distribution. If a nerve is discovered to lose itself entirely in the substance of muscles it may be inferred to be chiefly or entirely motor, or efferent. If, on the contrary, it can be traced to a membranous expansion, cutaneous, mucous, or otherwise, there is equal reason to believe it an afferent, or sensory nerve. If a nerve is entirely distributed upon a surface adapted to receive impressions of a special kind, it may be inferred that it is incapable of receiving or transmitting any others. Such a nerve is said to be one of special sensibility, to distinguish it from those that transmit impression of a general character, and which are called nerves of general sensibility. In considering the functions of the various parts of the nervous system, it is best to begin with the spinal marrow, which, with its cranial prolongation, the medulla oblongata, may be regarded as the essential part of the nervous system of vertebrata. OF THE MEDULLA SPINALIS. The spinal cord is to be considered in a two-fold light. First. As a conveyor of nervous agency to and from the brain. Second. As an originator of nervous influence. All the cerebral nerves are sub- ject to the influence of the brain, and all the spinal nerves are subject to the same influence through the medium of the spinal cord. As soon as the transmission of this influence is interrupted by division, or wounds inflicted upon the cord, impressions on sensitive nerves cease to be propagated to the sensorium, and the brain loses the power of voluntarily exciting the action of the motor nerves which are given off below the injured point. All the nerves above this point, however, still transmit impressions and are subject to the influ- ence of the brain. The white fibrous matter of the cord is to be regarded as the common trunk of all the nerves of the body. It must not be sup- MEDULLA SPINALIS. 99 posed, however, that they are all fused into one common trunk, for each individual filament of every nerve runs a separate and distinct course from its starting point to its termination. It will hence be understood, that it is the white or fibrous matter of the cord that is connected with the cerebro-spinal division, and which is concerned in sensation and voluntary motion, or in other words, in the transmis- sion of nervous influence to and from the brain. The spinal cord is traversed by an anterior and a posterior fissure dividing it into two lateral halves, each of these also is marked by two furrows on each side, subdividing it into three columns. There are, therefore, upon each half of the cord, an an- terior, middle or lateral, and posterior column. Each spinal nerve arises by two roots, an anterior and a posterior. The anterior root joins the spinal cord near the anterior furrow, and the posterior near the posterior furrow. (Fig. 25.) The functions of these two roots are now esta- blished. The posterior, which is distinguished by having a ganglion upon it, is the afferent root. Part of its fibres run on to the brain, conveying impressions to this organ; part terminate in the gray matter of the spinal cord, in like manner convey- ing impressions to the latter. In a word, the posterior root is the sen- sory root. The anterior is the efferent or motor root. Part of its fibres come from the brain con- veying voluntary motion; part have their origin in the gray matter of the spinal cord, and are conveyors of excited motion from that centre. Those fibres of both roots which are unconnected with the brain, constitute the system to which reflex actions are due, and with the gray matter of the spinal cord, constitute a distinct nervous circle. Each spinal nerve, then, contains at least four sets of fibres, I. A sensory bundle, passing upwards to the brain. II. A motor set, conveying the influence of volition and emotion downwards from the brain. * Transverse section of human spinal cord, close to the third and fourth cervical nerves. / Posterior columns. 1 i. Gelatinous substance of the posterior horn. k. Posterior root. t. Supposed anterior root. a. Anterior fissure, e. Posterior fissure, g. Anterior horn of gray matter, e. Anterolateral column, (from k to a.) 100 PHYSIOLOGY. III. A set of excitor, or centripetal fibres, terminating in the true spinal cord, or ganglion, and conveying impressions to it. IV. A motor, or centrifugal set, arising from the same ganglionic centre (or true spinal marrow) and conveying the motor influence reflected from it to the muscles. Of these, the first and third are united in the posterior, or affe- rent root; the second and fourth, in the anterior or efferent roots. The functions of the I. and II. bundles have been treated of, when speaking of the spinal cord, as a conveyor of nervous influence to and from the brain. The III. and IV. are now to be considered, in connexion with the cord, as an originator of nervous influence. These latter, with the gray matter in the centre of the cord, consti- tute the reflex system. The spinal cord has, in virtue of the gray matter in its composi- tion, or the ganglionic cells collected in its interior, certain proper- ties which characterize it as a central organ. It has a proper inherent motory power, which it communicates to its nerves inde- pendently of the brain, a fact which is proclaimed by the state of permanent contraction of those muscles, the sphincter for example, which depend most immediately on the spinal cord. If an animal be stunned by a blow upon the head, or even decapitated in some instances, it will still retain for some hours the power of moving the extremities, when the integument is pinched, but without the least consciousness, or anything like volition; the motions are automatic, and proceed directly from the spinal cord, in consequence of an excitement or stimulation of its substance effected through the fibres of the spinal nerves that terminate in its gray substance; the mo- tions are pure reflex motions; in other words, motions which arise from stimuli conveyed to the spinal cord by centripetal or afferent nerves, which stimuli are reflected from the cord by centrifugal or efferent nerves. These movements will also continue if the spinal cord be cut across, so as to make two segments, one for the upper and one for the lower extremity; each pair of members may be excited to move- ment by stimuli applied directly to themselves. The same phenomena are witnessed in the human subject when the spinal cord has suffered injury, or disease in the middle of the back, provided the lower seg- ment remain sound, and its nervous connexions with the limbs are uninjured. These facts prove that sensation is not a necessary link in the chain of reflex actions, all that is required being an afferent fibre capable of receiving the impression, and conveying it to the centre; a ganglionic centre, composed of vesicular nervous sub- stance into which the afferent fibre passes; and an efferent fibre, capable of transmitting the motor impulse from the ganglionic cen- tre to the muscle which is to be thrown into contraction (Fig. 26). MEDULLA SPINALIS. 101 There is scarcely any evidence of a disposition to reflwx move- ments of the limbs of the human body during health, or in the waking condition, these move- ments being restrained by the controlling influence of the brain. But when the spinal cord is in a state of unnatural excitability, as in tetanus and hydrophobia, or during the presence of strychnine in the system, or when the com- e 8(??^T\~ ^iST" .r 2~~*"*%]H II«- munication of cerebral influence CD «1 to the limbs is cut off by disease ™ of the spinal cord or brain itself, spasms may be excited in the extremities often by the slightest touch. It is to be understood in this explanation of the reflex system, that the spinal cord has the power of reflecting the action of sensitive nerves upon the motor nerves, without itself perceiving the impres- sion, in other words, without possessing sensation, that being a func- tion exclusively of the brain. It is probable that all convulsive movements are produced through the agency of the spinal cord and medulla oblongata, either by irri- tation seated in the cord itself, (centric irritation;) or.by causes seated at a distance, the irritation of which is transmitted to the spinal cord, (eccentric irritation.) The ganglionic system of the lower orders of animals does not correspond with the great sympathetic or ganglionic of the higher, (the latter system existing only in those of most perfect develop- ment,) but with the reflex or true spinal. In the lower orders, the ganglia are scattered over various parts of the body, in the leech around the mouth; in the higher they are collected into one common centre, the spinal cord. In regard to the functions of the columns of the cord, nothing definite is settled. In the opinion of some physiologists (Bellinger and Valentin), besides being concerned in sensation and motion, when the posterior column is irritated, at the point where the nerves of either extremity are given off, that extremity is extended; and that when the anterior is irri- tated, the extremity is flexed. According to others, (Todd and Bow- man), if it could be proved that the anterior roots were exclusively connected with the antero-lateral columns, and the posterior roots * Diagram of the origins and terminations of the different groups of nervous fibres: aa. Vesi- cular substance of spinal cord. bb. Vesicular substance of brain, e. Vesicular substance at commencement of afferent nerve, which consists of c 1 The sensory nerve passing to the brain, and s1 The spinal division, or excitor nerve, which terminates in the vesicular sub- stance of the spinal cord. On the other side is the efferent or motor nerve, consisting of two divisions. cs The cerebral portion conveying voluntary motion, and*2 The spinal division conveying the reflex power. 9* 102 PHYSIOLOGY. with the posterior columns, then there would be ground for the belief that the functions of the columns corresponded with those of the roots; but nothing is more certain than that both roots are connected with the antero-lateral columns; and there is a doubt as to whether the posterior roots have any connexion at all with the posterior column. Hence they are disposed to believe that the antero-lateral columns are both motor and sensitive. They are also disposed to believe that the posterior columns have a function different from that usually assigned to them. They may be in part commissural between the various segments of the cord, and in part subservient to the function of the cerebellum in co-ordinating and regulating the movement ne- cessary for perfect locomotion. FUNCTIONS OF THE MEDULLA OBLONGATA. The brain and spinal cord act on each other through the medium of the medulla oblongata; hence the importance of a knowledge of the course of the different columns or bundles of fibres of these parts. It consists of four principal parts. 1st. The Anterior Pyramids, or Fig. 28. t Corpora Pyramidalia; 2d. The Olivary Bodies, or Corpora OH- varia ; 3d. Restiform Bodies, or Corpora Resliformia ; sometimes called Processus a Cerebello ad Medullam Oblongatam ; 4th. The * Front view of medulla oblongata, pp. Pyramidal bodies, decussating at d. oo. Olivary bodies, rr. Restiform bodies, aa. Arciform fibres. ' t Posterior view of medulla oblongata, pp. Posterior pyramids rr Restiform bodies composed of ce. posterior columns, and dd. lateral part of anterolateral' columns a« Oli- varycolumns,as seen on the floor of the fourth ventricle, n™ Fibres of seventh pair of FUNCTIONS OF THE MEDULLA OBLONGATA. 103 Posterior Pyramids, or Corpora Pyramidalia Posterior a. (Figs. 27 and 28.) ... In considering the functions of these parts it is impossible to sepa- rate them completely, they are so closely connected with each other, and the functions of one part are so readily affected by any change in those of the others. In tracing upwards the four divisions of the medulla oblongata, the following are found to be their connexion with the brain. 1. The fibres of the anterior pyramids for the most part enter the crura cerebri, passing through the pons Varolii, and traversing the optic thalami, (which, it must be remembered, have scarcely any connexion with the optic nerves, or with the sense of sight;) after which they diverge and become mingled with gray matter, thus forming the corpora striata, and finally radiate to the convolutions of the cerebrum. 2. The fibres of the olivary body also pass into the pons Varolii, and there divide into two bands; one of which proceeds upwards and forwards to join the crura cerebri, thence to pass to the optic thalami; the other passes upwards and backwards into the corpora quadrigemina. 3. The fibres of the true restiform bodies pass entirely into the cerebellum. 4. The fibres of the posterior pyramids pass directly onwards through the crura cerebri into the thalami, whence they radiate to the convolutions. The anterior pyramids may be said to connect the motor fibres of the cerebral hemispheres, with the antero-lateral columns of the spinal cord. Part of its fibres decussate, a large portion of those that proceed from the right hemisphere passing over into the left side of the cord ; and those from the left hemisphere into the right side of the cord,—an arrangement which fully explains the frequent oc- currence of paralytic affections on the opposite side from that affected in the brain. The olivary bodies probably constitute the essential portion or nucleus of the medulla oblongata, that on which its power as an in- dependent centre depends. This opinion seems supported by the fact, that these bodies and the central portion of the medulla oblongata contain that intermixture of vesicular and fibrous matter which con- stitutes the main character of a nervous centre. It is probably the centre of the respiratory nerves. The olivary bodies are connected above with the cerebral hemispheres and corpora quadrigemina, and below with the antero-lateral columns of the spinal cord. The restiform bodies are probably associated in function with the hemispheres of the cerebellum, and the posterior columns of the spinal cord. The posterior pyramids are supposed by some to have the func- 104 PHYSIOLOGY. lion of connecting the different segments of the cord with each other. By Mr. Solly they are regarded as the ganglia of the sense of hearing. The medulla oblongata has the general properties of the spinal cord. It has the same property of reflection, indeed in a higher de- gree than any other part of the nervous system; and the nerves which arise from it are more prone than any others to reflex action. It belongs also to the motor apparatus, and no other part has so great an influence on the production of motion, irritation of it exciting convulsions in the whole trunk. The most important motory influ- ences of the medulla oblongata, however, are those that subserve respiration and deglutition, both of which, respiration more espe- cially, depend upon it. All the rhythmical motions of respiration. such as laughing, yawning, sighing, &c, depend upon it. The faculty of the power of volition seems also to have its probable seat in the medulla oblongata, according to some physiologists, for many animals, after complete removal of the brain and cerebellum, still retain the power of performing voluntary motions. (Flourens.) It is doubtful how far the medulla oblongata participates in sensation, (as alleged by Desmoulins, Magendie, Flourens.) Any conclusion in this direction from experiments must be unsatisfactory, inasmuch as all the phenomena that have been noted are readily referred to reflex actions. All the psychological excitements or faculties,—affections, pas- sions, &c, are realised, or made manifest by means of the medulla oblongata ; and in those diseases which mental emotion is apt to give rise to, many of the symptoms are referable to affections of the medulla oblongata. The chief excitor nerve of the respiratory movements, is the affe- rent portion of the par vagum ; the afferent portion of the fifth is, also a powerful excitor. The chief motor nerves are the phrenic and in- tercostals, which probably originate in the medulla oblongata, though they issue from the cord at a point lower down. Several other spinal nerves are concerned in the motor portion of the respi- ratory process, as are also the facial nerve, the motor portion of the par vagum, and the spinal accessory. In the movements of deglutition, which are purely reflex, the chief excitor is the afferent portion of the glosso-pharyngeal, assisted by the branches of the fifth, distributed upon the fauces. The motor nerves are the pharyngeal branches of the par vagum, assisted by the facial, hypoglossal, motor portion of the fifth, and, perhaps, also, the motor portions of some of the cervical nerves. The medulla ob- longata is also concerned, in its reflex action, in governing the aper- ture of the glottis, which it does through the agency of the superior laryngeal branch of the par vagum, the afferent nerve, and the infe- rior or recurrent laryngeal, the efferent or motor nerve. The medulla oblongata is connected, in its upward prolongations, FUNCTIONS OF THE MEDULLA OBLONGATA. 105 with certain gangliform bodies, which have also their proper func- tions. These are the corpora striata, the optic thalami, and the tubercula quadrigemina. The corpora striata, and the optic tha- lami, whilst both extensively connected with the cerebral hemis- pheres, are, in the most marked way, connected inferiorly with separate and distinct portions of the medulla oblongata ; the corpora striata, with the inferior planes of the crura cerebri, and their con- tinuations, the anterior pyramids, and the optic thalami with the olivary columns, the central and probably fundamental portions of the medulla oblongata. Thus along the tract that passes from the anterior pyramids to the corpora striata, we have none but motor nerves: whilst along the tract that connects the olivary columns with the thalami, there are none but sensory nerves. The thalami then may be regarded as the ganglionic centres of common sensa- tion, standing in the same relation to the sensory nerves, converging from the various parts of the body to the encephalon, as do the optic and other ganglia to their nerves of special sensation. On the other hand, the corpora striata are implanted on the motor tracts of the crura cerebri, which descend into the anterior pyramidal columns; and their connexion with the motor function is very generally ad- mitted, from the constancy with which paralysis is observed to ac- company lesions of these bodies. According to the views above expressed, the corpora striata and optic thalami bear to each other a relation analogous to that of the anterior to the posterior horn of the spinal gray matter. The cor- pora striata and anterior horns are centres of motion; the optic thalami and posterior horns, centres of sensation. The tubercula quadrigemina are the true optic ganglia, the ence- phalic recipients of the impressions necessary to vision, which, ac- cording to Bowman, are doubtless simultaneously felt by means of the optic thalami; they are also the centres of those movements of the iris which contribute largely not only to protect the retina, but likewise to increase the perfection of vision. Irritation of an optic tubercle on one side causes contraction of both irides. This is quite in accordance with the fact, that if light be admitted to one eye so as to cause contraction of its pupil, the other pupil will contract at the same time. Whatever other functions the tubercula quadragemina may perform, they have a sufficiently obvious relation to the optic nerves, the eye, and the sense of vision. They may therefore be justly reckoned as special ganglia of vision. At the base of the brain are found other ganglionic masses, which are in direct connexion with the nerves of sensation, and appear to have functions quite independent of those of the other components of the encephalon. Anteriorly are found the olfaclive ganglia, in what are commonly termed the bulbous expansions of the olfactory nerve. That these are real ganglia is proved by their structure, 106 PHYSIOLOGY. (containing gray or vesicular matter,) their relation to the olfactory nerves, their direct proportion of bulk to that of these nerves, and to the development of the olfactory apparatus. The auditory ganglia are not so clearly made out. In higher animals, and man, the auditory nerve can be traced into a small mass of vesicular matter which lies on each side of the fourth ventricle, which may be consi- dered as having a character of its own, and that it is really the gan- glionic centre of the auditory nerve. The ganglia of the sense of touch may be considered as existing in the ganglia on the posterior roots of the spinal nerves, and of the fifth pair. As this sense is diffused over the whole body, it would seem to need ganglia in con- nexion with those nerves which receive the tactile impressions. The gustatory ganglion is a collection of gray or vesicular matter, im- bedded in the medulla oblongata, which is considered by Stilling to be the nucleus of the glosso-pharyngeal nerve, and to which a por- tion of the sensory root of the fifth pair may be traced. FUNCTIONS OF THE CEREBELLUM. On this point there has been, and is still, much discussion. Some regarding it as the organ of the sexual impulse; others, as being connected with the function of motion. The development of the cerebellum in the scale of animals bears no relation to the energy of the sexual impulse. In the amphibia (as frogs and toads) this organ is extremely small, constituting a mere band lying over the fourth ventricle, and nevertheless the sexual instinct of these animals is proverbial, although they have no erectile organ. The same thing is true of the monkey and the kan- garoo, both remarkably salacious, and yet with an inconsiderable development of the cerebellum. Pathological evidence is also against the phrenological doctrine; instances are on record of partial, and even total absence of the organ, without the destruction of the sexual passion. In the first case the individual was married, and the father of several children. In the other there was a tendency to mastur- bation. The experiments of Flourens, Hertwig, Rolando, and others, show that after removal of the cerebellum the animals lost the power of executing the movements necessary for locomotion; stupor in these instances was never produced, nor the sensibility of any part of the body destroyed; the power of muscular movements only was lost; neither were convulsions ever produced. By the time the last portions of the organ were removed the animals had lost entirely the power of springing, flying, walking, standing, and preserving their equili- brium. All these mutilations were performed without the animal's evincing any sensibility in the cerebellum while it was being re- moved. There was no loss of volition or sensation, but merely of the faculty of combining the action of the muscles in groups. These FUNCTIONS OF THE CEREBRAL HEMISPHERES. 107 facts have led physiologists mostly to adopt the opinion that the ce- rebellum has for its function, the regulation and harmonisation, or co-ordination of muscular movements, especially those of a volun- tary character. This opinion is further substantiated by the observations of Leuret and Lassaigne, which show conclusively that the cerebellum is larger in geldings, which are commonly used for draught purposes, and in whom the number of muscles employed is consequently great, than it is either in the mare or stallion, the latter of which is kept espe- cially for the purpose of propagation, and is much less applied to occupations which call forth their motor faculties. The cerebellum is connected with the medulla oblongata and spinal cord by the resti- form bodies, and the posterior columns of the cord, and with the mesocephale by the fibres of the pons. Thus this organ is brought into union with each segment of the great nervous centre, upon which all the movements and sensation of the body depend. FUNCTIONS OF THE CEREBRAL HEMISPHERES. The fact of the cerebral hemispheres having a more perfect deve- lopment in proportion as the animals in which we examine them are higher in the scale of vertebrata, from fishes up to man, and the coincidence of atrophy, and the absence of the convolutions on their surface with idiocy, are alone sufficient to indicate that the seat of the higher intellectual faculties must be sought for in this part of the encephalon. The primitive fibres which go to the constitution of the cerebral hemispheres have least of all to do with the simple motory and sensitive operations of the nervous substance. All inquirers agree in representing the hemispheres as altogether insensible; they may be cut, pricked, and either partially or entirely removed without any feeling of pain being excited. Wounds of this part of the en- cephalon, moreover, give rise to no convulsions; the only constant effect of a deep incision is blindness of the eye of the opposite side, and a state of stupidity. These investigations, while they render more precise the functions of the cerebrum, have also tended to limit them. It has also been shown that this organ is not essential to life, that it must be considered as an organ superadded for particular pur- poses ; that it has no representative in the lowest classes of animals, and that when it first makes its appearance in fishes it evidently per- forms a subordinate part in the general actions of the nervous sys- tem. Hence, whatever be its function, it should be remembered that it does not deprive other parts of their independent powers, although it may keep them in check, and considerably modify their manifes- tation. The experiments instituted by the same physiologists above men- tioned, go to prove that the cerebrum is the organ of intelligence. 108 PHYSIOLOGY. Animals from whom the hemispheres were removed, had constantly the appearance of deep sleep, and when irritated resembled in their motions an animal just awaking. M. Flourens likens them to an animal condemned to perpetual sleep, but deprived even of the faculty of dreaming. A hen, in which Hertwig had cut away the hemi- spheres nearly to the base of the brain, was found to be deprived of sight, hearing, taste, and smell; it sat constantly in one spot, and was as if dead, until strongly roused, when it moved a few steps; it neither fed itself, nor drank, nor attempted to avoid danger. It is evident from these experiments, and from the effects of pressure on the cerebral hemispheres in man, that they are the seat of the mental functions ; that in them resides the power of directing the mind to particular sensorial impressions,—the faculty of attention. The portions of the cerebral hemispheres that possess these elevated functions are the convolutions. The complexity of the convolutions in the animal scale is in the direct ratio of the advance of intelligence. In infancy they are imperfectly developed, and their increase in size goes on simultaneously with the advance of mental power. If their growth be arrested, the mental powers are of the feeblest kind. In idiots the brain is not only small, but the convolutions are exceedingly limited. The object of these convolu- tions is to afford as extensive a surface of the gray or vesicular matter, in as small a space as possible. By this arrangement also, a more ready access is permitted to the blood-vessels on the one side, and a more free communication on the other with the vast number of fibres by which its influence is to be propagated. It is evident, that if the surface of the gray did not exceed that of the white matter, folds or convolutions would not be necessary, but a simple expanse of the former would suffice to cover the surface of the latter. The existence of convolutions on the surface of the hemispheres affords evidence of a large relative amount of the dynamic or vesicular nervous matter, and their number or com- plexity is a measure of the extent to which the vesicular surface is increased. Of two brains, equal in bulk, the one that has most con- volutions has most vesicular matter, and is, physiologically, the more potential. It has been calculated that the entire surface of the human cerebrum, when the convolutions are unfolded, is equal-to about 670 square inches. The weight of the entire encephalon in the adult male usually ranges between 46 and 53 ounces ; in the female, from 41 to 47 ounces. The maximum is about 64 ounces or four pounds ; the minimum about 31 ounces, or rather less than two pounds. In the idiot it is often much below this, as for instance 20 ounces. The cerebral hemispheres alone weigh about four times as much as the rest of the cerebro-spinal mass. The brain is abundantly supplied with blood by the vertebrals and FUNCTIONS OF THE SYMPATHETIC. 109 carotids, which anastomose very freely with each other, to obviate the effects of pressure upon either of them. Their course is also a tortuous one, that the impulse of the blood upon so delicate an organ may be avoided. A certain amount of regulated pressure upon the walls of the vessels of the brain is essential to the proper exercise of its func- tions. It is known that the amount of blood circulating through the brain varies at different times in accordance with its in- creased or diminished functional activity, and that the cranial case is not an unyielding one, as its contents would then be invariable. A special provision is made to meet this varying amount of fluid, and to keep up the same degree of pressure upon the organ, in the existence of a fluid beneath the arachnoid wherever the pia mater exists. The amount of this fluid averages about 2 ounces, but in cases of atrophy of the brain, as much as 12 ounces may be ob- tained from the cranio-spinal cavity ; whilst in all instances in which the bulk of the brain has undergone an increase, either from the production of additional nervous tissue, or from undue turgescence of the vessels, there is either a diminution, or a total absence of this fluid. It has been shown by Magendie that the withdrawal of this fluid in living animals always causes great disturbance of the cerebral functions, probably by allowing undue distension of the blood-vessels. It is, however, speedily renewed, and its reproduction restores the nervous centres to their normal condition. FUNCTIONS OF THE SYMPATHETIC. This nerve has been variously called the splanchnic, ganglionic, vegetative, and organic. It consists of an uninterrupted chain of ganglia, extending on each side of the vertebral column, from the first cervical vertebra down to the coccyx, and moreover extending upwards beside the cranial vertebra?, and occupying spaces between the bones of the cranium and those of the face. The chains of the opposite sides communicate with each other at various points in the plexuses of nerves that originate from them, and through the gan- glion impar, a single ganglion in front of the coccyx. A cephalic communication is as yet uncertain. Ribes described a ganglion impar situated upon the anterior communicating artery of the circle of Willis, and other anatomists regard the pituitary body in the sella turcica as a ganglion of like description, a common point of union for the right and left chains at their cranial extremities. The peculiarities of the sympathetic fibres were spoken of when describing the development of the nervous system, (page 39.) The sympathetic system contains two sets of nervous fibres,— the ordinary white tubular fibres, which it derives from the cerebro- spinal system ; and the gray or gelatinous fibres, which belong ex- clusively to itself. 10 110 PHYSIOLOGY. Each of these systems thus mingles with the other, the cerebro- spinal transmitting both Fig. 29.* motor and sensitive fibres into the sympathetic; whilst the sympathetic is represented in the cere- bro-spinal system by cer- tain fibres and collections of vesicular matter of its own. (Fig. 29.) Adopting this view of the compound nature of the sympathetic, it seems to be impossible to re- gard it either as inde- pendent of the cerebro- spinal centres, or wholly depending upon them. It is probably indepen- dent of them as regards its gelatinous fibres, but dependent upon them as regards its tubular fibres. It is to be looked upon as a portion of the ner- vous system, peculiar in its composition, having, as regards some of its constituent fibres, a spe- cial relation to the blood-vessels, especially the arteries, but being by its other fibres connected with the cerebro-spinal centres. It is also distributed both to sentient surfaces and to muscles, as to the heart and intestinal canal, movements in which can be excited by stimu- lation of the ganglia connected with them. The well-known occur- rence of pain in parts supplied by it, proves the existence of sensitive fibres. The sympathetic thus appears to exercise a threefold office: first, that of a sensitive nerve to the parts to which it is distributed; secondly, that of a motor nerve for certain muscular parts; and thirdly, that of a nerve to the blood-vessels. By the last arrange- ment it may influence nutrition and secretion by its effect upon the contractility of the coats of the vessels. The effect of the emotions * Fig. 29. Roots of a dorsal spinal nerve, and its union with the sympathetic, c. c. An- terior fissure of the spinal eord. a. p. Anterior and posterior roots, s. Sympathetic, t. Its double junction with the anterior branch of the spinal nerve, by a white and a gray filament. SENSATION. Ill operating through this channel upon the blood-vessels is seen in the act of blushing, and also in the pallor that often accompany them. Dr. Carpenter thinks that as the sympathetic system is not deve- loped in proportion to the predominant activity of the functions of organic life, but in proportion to the development of the higher division of the nervous system, its office is not to preside over the former, but to bring them into relation with the latter; so that the actions of the organs of vegetative life are not dependent upon it, but influenced by it, in accordance with the operations of the system of animal life. SENSATION. By this term is meant the perception of an impression. It is with the brain alone that the mind possesses the relation necessary for the production of sensation. Hence the brain is often called the sensorium. Sensations are of two kinds, external and internal. By the first are meant those that arise from impressions made upon the external surface of the body, as the sense of sight, touch, or hearing. The internal are such as occur within the body, and arise from some alteration in the function of the part, for the time being. Hunger and thirst are internal sensations. With regard to all sensations, it must be remembered that the change of which the mind is informed, is not the change which occurs at the peripheral extremity of the nerves, but the change communicated to the sensorium ; in other words, sensation does not occur at the point impressed, but in the brain. Hence it happens that sensations often occur from impressions upon a nerve some- where in its course. This is of frequent occurrence in the senses of sight and hearing, flashes of light being seen, and ringing sounds being heard, when no external stimuli could have produced such impressions. In such cases they not unfrequently arise from im- pressions made on these nerves in their course from special gan- glia to their peripheral termination. This variety of sensations is termed subjective, to distinguish them from objective, in which the stimuli are derived from without. The most common cause of these subjective sensations is congestion or inflammation in the course of the nerve. Whenever an impression is made upon a nerve in its course, the mind instinctively refers it, not to the point impressed, but to the ordinary termination of the nerve upon the periphery of the body, even although these terminations should not exist, or should be in- capable of receiving impressions. Thus, after amputations, the patients are often troubled with sensations which they refer to the removed extremities ; and in like manner, after the Taliacotian ope- ration, all sensations produced by touching the nose are referred to 112 PHYSIOLOGY. the forehead, from whence the flap was taken, until the new vas- cular and nervous communications are established. An active capillary circulation in a part is essential to its sen- sibility; any cause which retards this, deadens the sensibility of the part, as is well seen in the benumbing influence of cold. Increased vascular action, again, produces a corresponding increase in sensi- bility ; this is seen in the active congestion preceding inflammation. Sensations are divided into general and special. General sensa- tion is distributed over all the body ; by it we feel those impressions made upon our bodies by surrounding objects, which produce the various modifications of pain and pleasure, the sense of contact and resistance, and variations of temperature. Special sensation is that which arises from impressions of a peculiar character, upon nerves which are adapted to receive them alone. The intensity of all sensations is very much blunted by frequent repetition, excepting in the case of those to which the attention is particularly directed; these, so far from losing their acuteness, be- come much more cognizable by the mind. Hence arises the educa- bility of the special senses. Although there are some stimuli which can produce sensory im- pressions on all the nerves of sensation, it will be found that those, to which any one organ is peculiarly fitted to respond, produce little or no effect upon the rest. Thus the ear cannot distinguish luminous rays, nor the eye the undulations of sound ; and the same is true of the other senses. Hence it may be inferred, that no nerve of special sensation can, by any possibility, take on the function of another. But that each requires its own peculiar stimulus to call it into action, light for the eye, and sound for the ear, &c. The nerves of special sensation have in themselves no general sensibility; they may be pricked or torn without the individual suf- fering any pain ; they only experience or give rise to their own peculiar sensations. All the general sensibility that the organs of the senses possess is derived from nerves of general sensibility dis- tributed to them. The special senses are five in number, viz.: touch, taste, smell, hearing, seeing. To these some add a sixth, the mus- cular sense, or that by which the will can produce, check or regulate the amount of contraction in the voluntary muscles ; and also appre- ciate, by certain sensations originating in the muscles, the precise degree of contraction in each. The organs of the special senses consist of two parts, a physical and a vital part. The physical part receives and modifies the impression ; the vital transmits the impression to the brain. The different transparent media of the eye contribute its physical portion; the nerve is the vital portion. SENSE OF TOUCH. 113 SENSE OF TOUCH. Of all the senses, Touch is the most extensively diffused through- out the animal kingdom; it is the simplest and most rudimentary of all the special senses, and may be considered as an exalted form of common sensation, from which it arises by imperceptible gradations till it reaches its highest development in some particular parts. It is also the earliest called into operation, and the least complicated in its impressions and mechanism. The sense of touch is most highly developed in those parts that are most abundantly supplied with sensory nerves. In the lips, the tip of the tongue, and the palmar aspect of the last joints of the fingers, the nerves are both very numerous and superficially dis- tributed, and whilst the epidermic layer is thinner, there is at the same time a greater degree of isolation of the papilla? of the skin between lines and furrows of the epidermis. The number of these lines or furrows is commensurate with the development of the sense. Even in man the acuteness of the sense of touch varies much in different regions of the body, as can be proved by observing the varying distances at which the two points of a pair of compasses can be separately recognised on different parts of the surface; on the points of the fingers they can both be recognised at a distance of 5 of a line, while they require to be separated 30 lines in order that the two points may be recognised over the spine. The nerves of touch are the same as those of general sensation, viz.: the posterior roots of the spinal nerves, and some fibres of the fifth and eighth cerebral nerves. They are distributed to the tactile papilla? of the skin, small elevations enclosing loops of blood-vessels and branches of the sensory nerves, (Fig. 30,) situated on the exterior surface of the cutis vera. The papilla? are covered by the epidermis, lg- which protects them from too violent im- pressions of external bodies upon them. In the sense of touch the body to be ex- amined must be brought into contact with the sensory surface. The only exception to this is in regard to the sense of tempera- ture, for which there would seem to be a distinct set of nerves. The only idea communicated to our minds by the sense of touch, is that of resistance. By the various degrees of resistance which the sensory surface encounters, we obtain a knowledge of the hard- ness or softness of a body. When the sensory surface, and the sub- stance touched are moved upon each other, we obtain a notion of extension or space. At the same time, by the impressions made * Papillae of the palm, the cuticle being detached. 10* 114 PHYSIOLOGY. upon the tactile surface, we discover the roughness or smooth- ness of the substance. The knowledge of form and weight is derived by the additional assistance of the muscular sense. The sense of touch is exceedingly educable, as is seen in the case of the blind, who can be taught to read, and even distinguish colours by its agency. Impressions made upon the organ of touch continue perceptible for some time after the stimulus has been removed; for instance, the stinging of a smart blow does not soon subside, and the simple con- tact of an article of clothing often leaves the impression of its presence after it has been removed. The subjective sensations pertaining to the nerves of this sense are among the best known. The tingling of a limb that is " asleep" which commonly depends on pressure on its trunk, may also result Fig. 31.* from changes in the centre; the same is true of formica- tion, heat, chilliness, itching, and also of pain. SENSE OF TASTE. In the sense of taste, as well as in touch, the substance to be examined must be brought into contact with the organ of the sense, which organ is the mucous membrane of the tongue and fauces. The mu- cous membrane of the tongue is largely supplied with .papilla? of various forms, which are abundantly supplied with nerves and blood-vessels. The papilla? are of three varieties: 1st. The calycifQrm, or cir- cumvallate, situated at the base of the tongue in a V shaped line, a (Fig. 31); the fungiform, on the sides and apex, b ; and the conical, or filiform, the most numerous, and most abundant, in the cen- tral part, d. The latter are supposed to be concerned rather in the sense of touch than of taste. When these papilla? are called into * Upper surface of tongue, a. One of thecircumvallate papillae ; b. one of the fungiform; d. conical papillae.j SENSE OF SMELL OR OLFACTION. 115 action by the contact of substances having a strong savour, they be- come turgid and erect, so as to produce a decided roughness on the surface of the organ. There is no special nerve of taste, the sense seems to be divided between the glosso-pharyngeal and the fifth.—The impressions made upon the front of the tongue are conveyed by the fifth; those upon the back of the organ by the glosso-pharyngeal. The first ministers also to general sensibility ; the latter conveys the impressions that produce nausea. It is also the afferent nerve in the reflex act of swallowing. The ninth pair is also distributed to the tongue, but it is a motor nerve, and not at all concerned in the special sense. A necessary condition for the exercise of this sense, is solubility of the substance to be tasted ; if it be insoluble it merely excites the feeling of contact. The sapid substance should also be moved over the surface of the tongue; by this means the taste is very much heightened. In this respect there is a strong analogy between touch and taste. Taste may also be produced by mechanical irritation or chemical excitation of its nerves. A smart blow of the finger, or galvanism, will often excite a taste, sometimes acid, at others alkaline. A large part of the impression made by sapid substances is received through the sense of smell, as may easily be proved by attempting to taste any substance while holding the nose. In inflammation of the Schneiderian membrane too, we lose the power of appreciating the flavour of bodies through the impairment of the sense of smell. Taste is an educable sense, as is seen in the case of the spirit tasters, but it is not considered an intellectual one. Its subjective phenomena are not so strongly marked as in some of the other senses, and yet we are constantly experiencing pleasant or unpleasant tastes without any apparent cause. Magendie states that dogs, into whose Veins he had injected milk, licked their lips as though they tasted it. The sense of taste is designed to guide us in our search for food ; it is therefore placed at the entrance of the digestive apparatus. Impressions of taste remain longer than those of -other senses; but the after taste itself is not always the same as the original. Cold air deadens the sense of taste, precisely as it is known to do in the sense of touch. SENSE OF SMELL OR OLFACTION. This sense is designed to acquaint us with the odorous qualities of particles suspended or dissolved in the atmosphere. It is seated in the mucous membrane of the nose, and at the commencement of the respiratory passages, that it may protect them against the entrance of deleterious matters. Its principal use, however, is to second the impressions of taste in conveying intelligence of the pro- perties of food. The organ of the sense of smell has no capacity of movement in 116 PHYSIOLOGY. relation to its ordinary stimuli; the odorous particles are brought into contact with it in the act of inspiration. These particles are so small as to elude detection by the most delicate experiments. The whole mucous membrane of the nose is not endowed with the sense of smell; it seems to be limited to that portion expanded over the superior and part of the middle spongy bones. This region is there- fore called the olfactory region. It is to this portion only that the olfactory nerve is distributed. The other portions of the mucous membrane are supplied with branches of the fifth pair, from which they obtain their general sensibility. These branches are derived from the ophthalmic and superior maxillary divisions. When the fifth nerve is diseased, irritating substances may be introduced into the nose without discomfort to the patient. Section of the fifth pair also arrests the secretion from the mucous membrane, and in that way diminishes the acuteness of smell. This nerve is the afferent or excitor nerve in the reflex act of sneezing. The organ of smell is seated high up in the nose, not only to protect it from mechanical injury, but that it may be screened from the contact of air either too cold or too dry. The convoluted ar- rangement of the turbinated bones, with their expansion of mucous membrane, effects this. These parts break the force of the current of air, warm it, and impart that degree of moisture which is best calculated to aid the solution of the odorous particles on the sentient surface to which they are to be applied. The olfactory nerve passes down from the olfactory bulb or gan- glion through the cribriform plate of the ethmoid bone, and is dis- tributed in minute threads having a plexiform arrangement, (Fig. 32.) Their ultimate distribution is probably in loops. The conditions requisite for the exercise of the sense of smell are, in addition to the integrity of the nervous apparatus, a healthy con- dition of the mucous membrane. If it be dry, or in a raw irritable state, with a watery discharge, the sense is lost or impaired. This is familiarly seen in a cold in the head. The substance to be smelt must also be soluble ; insoluble substances cannot be perceived by this sense. When we wish to examine any substance closely, it is drawn up into the nose with some force, in order that the odorous particles may reach the olfactory region. The sense of smell, although not an intellectual sense, is suscep- tible of cultivation ; by it individuals are often capable of recognising others, and even, as in one instance, to discover their own clothes among many others. Subjective phenomena sometimes occur in this sense, arising, as in the others, from irritation by an internal cause. Disease of the olfactory bulb, or of the anterior lobe of the brain, has been known to produce them. Muller relates the case of a man, who ever after a fall from his horse, believed that he smelt a bad odour. Whether HEARING OR AUDITION. 117 Fig. 32.* substances introduced into the circulation would excite the olfactory nerve to the perception of the odour, has not been ascertained ex- perimentally. The cavities that communicate with the nasal passages have no connexion with the sense of smell. HEARING OR AUDITION. By the sense of hearing the mind takes cognizance of the condi- tion of the auditory nerve produced by those oscillations of elastic matter which give rise to the phenomena of sound. The communi- cation of these oscillations to the ear may take place through the air, or through the intervention of some solid conductor, brought into immediate connexion with the organ of hearing. The following condensed account of the organ is from the eighteenth chapter of Todd and Bowman's Physiological Anatomy. The essential part of the organ of hearing is a sac, containing fluid, upon which the nerve of hearing is freely distributed; this sac being in connexion with the cranial parietes. This is represented in the human subject by that small cavity excavated in the petrous portion of the temporal bone called the vestibule. This, and three semicircular canals, with a spirally disposed canal, divided by a partition, constituting the coch- lea, form the labyrinth. External to this, and situate between the squamous and petrous portions of the temporal bone, is a cavity, * a. Olfactory process, b. Olfactory bulb. c. Fifth nerve within the cranium, d It3 superior maxillary division, anastomosing with the olfactory filaments, and with s, branches of the nasal division of the ophthalmic nerve, o. Posterior palatine twigs from Meckel's ganglion, supplying the soft and hard palate. The cut rej resents the outer wall of the nasal fossa, with the three spongy bones and meatus. 118 PHYSIOLOGY. the tympanum, which in front further communicates very freely with the cavity of the throat through an open canal, the Eustachian tube, whereby air has a free access into the tympanum. This cavity is closed on the outside by the membrana tympani, which extends over its external orifice as a drum. A small chain of bones extends from this membrane to another in the inner wall of the tym- panum, (the membrane of the foramen ovale.) These are the ossicles of the ear. These small bones are articulated by movable joints, and are moved by small muscles, which are thus enabled to regulate the tension of the membrana tympani, as well as of the membrane of the vestibule. Externally is an apparatus for collecting sounds and conducting them to the tympanum, called the external ear, com- prising the free expanded part, the auricle and the auditory canal, or meatus externus. (Fig. 33.) Fig. 33.* The auditory nerve is the portio mollis of the seventh pair, which is distributed to the vestibule, cochlea, and semicircular canals. Its mode of termination is unsettled. It will be seen from this descrip- tion of the auditory apparatus that it is divided into three parts. CaVty^mpan^^ 4- 5< 6" Chain of bones. 7. circular ca£aTTc9ch^ 10- Vestibule' * ^ HEARING OR AUDITION. 119 1st. External ear; 2d. The middle ear, or tympanum; 3d. The internal ear. Sounds may be propagated in three ways, by reciprocation ; by resonance ; and by conduction. Vibrations of reciprocation are ex- cited in a sounding body when it is capable of yielding a musical tone of definite pitch, and another body of the same pitch is made to sound near it. Thus, if two strings of equal tension be placed side by side, and one be thrown into vibrations, the other, although un- touched, will be thrown into corresponding vibrations. The same is true of membranes as of strings. If a membrane and a string both capable of yielding the same note, he placed side by side, and one be thrown into vibrations, the other will reciprocate. But no membrane or string will reciprocate any tone that is lower than its own fundamental note, by which is meant, the lowest note which it will yield when the whole of it is in vibration together. Vibrations of resonance occur when a sounding body, as a tuning- fork, is placed in connexion with any other, of which one or more parts may be thrown into reciprocal vibrations, even although the tone of the whole be different, or it be not capable of producing a definite tone at all. If a tuning-fork, whilst vibrating, be placed in contact with a sounding-board, the board will divide itself into a number of parts, each of which will reciprocate the original sound so as greatly to increase its intensity. Vibrations of conduction are the only ones by which sounds can be said to be propagated. If the ear be placed af one extremity of a long board, and the other be lightly struck, the sound will be con- ducted to the ear along the whole length of the board. All media are capable of conducting sound, a vacuum being the only space through which it will not pass. Solids are better conductors than fluids, and fluids than gases. The greatest diminution in the inten- sity of sound is usually perceived, when a change takes place in the medium from which it is propagated, especially from the aeriform to the liquid. The object of the external ear is to receive sonorous vibrations, concentrate and conduct them inwards. The various elevations and depressions of the external ear, adapt it peculiarly to catch the sono- rous waves arising from opposite quarters. The auditory canal— meatus externus — receives the sonorous pulses immediately, and conducts them to the membrana tympani. The sound is at the same time strengthened by reflection from the walls of the meatus, and the resonance of the mass which it incloses; the walls of the passage, moreover, are solid conductors of sound. The use of the membrana tympani is to receive the sonorous un- dulations in such a manner as to be thrown into reciprocal vibra- tion, which is to be communicated to the chain of bones. It cannot, however, reciprocate any sounds that are lower than its own funda- 120 PHYSIOLOGY. mental note, hence, if it be unduly tense from any cause, the indivi- dual will be deaf to low sounds. In its natural condition it is rather lax than tense ; by this means it can reciprocate a greater variety of sounds. The integrity of this membrane does not seem to be essen- tial to hearing, since it may be perforated, or destroyed, without the loss of the sense. The chain of bones is intended to conduct the sonorous undulations across the tympanum to the internal ear. The tensor tympani muscle which is inserted into the handle of the malleus has a pro- tective agency over the organ of hearing, analogous to that of the iris. When this muscle contracts it draws in the handle of the malleus and renders the membrana tympani tense, and thus takes away from it the power of reciprocating low sounds. It is also capable of being excited to reflex action by loud sounds, and thus putting the membrane into such a state of tension as not to recipro- cate them. It may, therefore, be fairly compared to the iris, which contracts ever the more powerfully the stronger the light that im- pinges upon it. The tympanum isolates the chain of bones and allows free vibra- tion to the membrane at either end of it. Moreover the air which it contains reverberates, and the walls and neighbouring spaces and cells reflect sonorous pulses, which thus fall strengthened upon the walls of the labyrinth, and particularly upon the membrane of fene- stra ovalis and fenestra rotunda. The principal use of the Eustachian tube seems to be, to maintain the equilibrium between the air of the tympanum and the external air, so as to prevent undue tension of the membrana tympani. It also serves to conduct away the secre- tions of the middle ear, which it discharges into the cavity of the throat by means of cilia? vibrating upon its surface. In regard to the uses of the different parts of the labyrinth nothing certain is known. The semicircular canals are supposed by their direction to give information as to the direction of sounds. The cochlea, in like manner, is thought to enable us to judge of the pitch of notes, an idea which seems to derive confirmation from the corre- sponding development of this portion in animals, and the variety in the pitch of the sounds, which it is important they should hear dis- tinctly. The vestibule, from its uniform presence,"may be considered as the essentia] part of the organ of hearing. The chain of bones, it was said, connects the external and internal ears. The base of the stapes is attached to the membrane filling up the fenestra ovalis. Immediately beneath this is a circular opening, called the foramen rotundum, which also is filled up with a mem- brane, and is capable of receiving reciprocal vibrations from the air of the middle ear, and transmitting them to the internal ear. The vestibule and semicircular canals have lyin^ within them, a membranous labyrinth, having the same general shape as the cavi- HEARING OR AUDITION. 121 ties in which it lies, only smaller. Between it and the walls of the bony labyrinth lies the fluid called the perilymph, and within it is contained the endolymph, and some small calcareous particles called otolithes or ear-stones. The use of the membranous labyrinth is probably to afford a more extended surface for the expansion of the auditory nerve. The otolithes, by being thrown into vibration, pro- bably increase the impression upon the nerve. The sonorous waves reach the labyrinth from the membrana tympani in three distinct ways. 1st. A portion of the vibrations reflected from the walls of the tympanum reaches the external wall of the vestibule immediately, this being at the same time the inter- nal wall of the tympanum. 2d. Other vibrations are thrown directly upon the fenestra rotunda, and in this way reach the cochlea. 3d. A third set of vibrations travel.along the chain of bones immediately from the membrana tympani to the labyrinth. This is the most powerful of any. The fluid of the labyrinth may also be thrown into vibration, by undulations transmitted through the bones of the head. A single impulse communicated in any of the above ways is suffi- cient to excite the momentary sensation of sound, but a number of them in rapid succession is essential to the production of a musical tone. The acuteness or depth of the tone depends upon the rapidity with which the impulses succeed each other. The acuteness of hearing varies very much in different individuals, and its power may be very much increased by practice. A part of this increase is due to the greater attention which its fainter indica- tions receive; a part also to the increased use of the organ. A want of musical ear is an encephalic defect, and not a deficiency of the organ. The power of appreciating the direction of sounds is for the most part acquired by habit. In some instances we are assisted by the relative intensity of the sensations communicated to the two ears respectively. The idea of distance is another acquired perception depending principally upon the loudness or faintness of the sound. The sensation of sound often lasts longer than the exciting cause of it. It is upon this circumstance that the continuity of a musical tone depends ; a fresh impulse succeeding before the impression of the first has disappeared. The subjective phenomena of hearing generally result from some affection of the brain, or that part of it in which the auditory nerve is implanted. Ringing sounds, or buzzing in the ears, are the most common, and are indicative of either redundancy or deficiency of blood in the brain. They may also be caused by some disturbance of the local nutrition of the brain. U 122 PHYSIOLOGY. SENSE OF VISION. By the sense of sight, we become acquainted with the existence of light; and by the medium of that agent, we take cognizance of the form, size, colour, position, &c. of bodies that transmit or reflect it. A knowledge of the laws of light and optics, is essential to an un- derstanding of the functions of the different parts of the organ of vision; for these the student is referred to the works on natural philosophy. In the globe of the eye we recognise, as the most essential parts, the expansion of the optic nerve, called the retina; and in front of this the transparent refracting media, which transmit the light so as to bring it to a focus upon the nervous expansion. The optic nerve, at its entrance into the eye, splits up into numerous fibrils, which spread themselves out, and inosculate freely with each other, so as to form a net-like plexus. This plexus comes into relation with numerous vessels and a layer of ganglionic cells, like those in the cortical part of the brain. This layer of cells constitutes the internal layer of the true retina. In order to protect the retina, the slightest change in whose form would be attended with injury to its function, the whole is enveloped in a dense tissue called the sclerotic, which is opaque, with the ex- ception of its front, where it becomes modified to allow the light to enter, and is called the cornea. Between the sclerotica and the re- tina is a layer of dark pigment contained in a delicate membrane called the choroid, the use of which is to absorb the rays of light after they have made their impression upon the retina. In the albino it is entirely wanting, and in others it becomes gradually lighter in colour as they advance in life, so as to increase the stimulus applied to the retina, by reflecting the rays again from one part of its sur- face to another. In front of the retina are the transparent media. These are the vitreous humour, the crystalline le?is, and the aqueous humour. The vitreous humour lies immediately within the cup formed by the retina, and seems destined to give it the necessary support inside, which the sclerotic gives outside. In the anterior part of the vitreous humour is imbedded the crystalline lens, which comes nearly up to the cornea in front, leaving a small cavity, however, which contains the aqueous humour. Across this cavity, and divid- ing it into an anterior and posterior chamber, hangs a vertical curtain- like process of the choroid, called the iris. This is perforated in its centre by a circular aperture called the pupil, which is capable of being enlarged or diminished; a condition permitted by the fluidity of the aqueous humour.* The contraction of the pupil under the stimulus of light, seems to be effected by a sphincter muscle sur- rounding the orifice of the pupil, and put in action by the third pair * Todd and Bowman. SENSE OF VISION. 123 of nerves. This seems to be a pure reflex action, in which the optic nerve is the afferent, and the third pair the efferent. The sti- mulus is the presence of light. When the optic nerve is divided, the fifth pair may in some degree convey the requisite stimulus. The dilatation of the pupil probably results from the elasticity of the tissue of the iris after the muscular contraction has ceased. The iris prevents the ingress of too much light, and also shuts off the rays of light from falling on the circumference of the lens. The transparent media so refract and modify the rays of light, as to overcome both spherical and chromatic aberration, and bring them to a perfect focus upon the retina. Fig. 34.* Fig. 35.+ The second pair of nerves is devoted to the sense of sight, and is hence called optic. The greater part of their roots may be traced to the tubercula quadrige- mina, which are regarded as the optic ganglia ; from these they run forwards along the base of the brain, and unite in front of the tuber cinereum and mammillary bodies, form- ing an intimate junction call- ^H§r P ^ps. /// * \\N ed the chiasm. From this point they diverge, and enter the orbits through the optic foramina. Part of the fibres of each nerve pass to the opposite eye, part are commissural, and the re- mainder pass to the eye of the same side. (Fig. 35.) * Longitudinal section of the globe of the eye. 1. Sclerotic. 2. Cornea. 3. Choroid con- nected anteriorly with (4) ciliary ligament; and (5) ciliary processes. 6. Iris. 7. Pupil. b. Retina 9. Canal of Petit. 10. Anterior chamber, containing aqueous humour. 11. Pos- terior chamber. 12. Crystalline lens. 13. Vitreous humour. 14. Neurilemma of the optic nerve. 16. Central artery of retina. t Course of fibres in the chiasm- a. Anterior fibres, commissural between the two retinae. p. Posterior fibres, commissural between the thalami. a'.p'. Diagram of the preceding. 124 PHYSIOLOGY. The eye has six muscles, four straight, the recti; and two oblique, the obliqui. The first are supplied by the third pair of nerves, ex- cept the rectus externus, which has the sixth. Of the latter, the superior oblique receives the fourth pair; the inferior, a branch of the third. When the recti act together, they fix the eyeball; when singly, they turned it towards their respective sides. The oblique antagonise the recti, and in addition, when acting together, draw the globe inwards, and converge the axes of the eye. The superior ob- lique turns the eye downwards and outwards, and the inferior oblique upwards and inwards. There is, however, considerable uncertainty as to their functions. The adaptation of the eye to distances, by which a perfectly dis- tinct image is perceived, whether the object be far or near, is a phe- nomenon as yet not explained. By some it is thought to be entirely educational; by others it is supposed to depend upon a varying length of the focal distances, produced either by altering the shape of the globe of the eye, so as to diminish or increase its convexity, or by altering the position of the lens by muscular agency. It is interesting to remark, that the adjusting power of the eye is lost or greatly impaired by the extraction of the lens, or by paralysing the ciliary and iridial muscles by belladonna. According to Dr. Clay Wallace, the ciliary muscle advances the lens by compressing the veins, and thus causing an erection or lengthening of the ciliary pro- cesses. The contraction of the iris, which takes place when the eyes converge, is supposed to depend on the third pair, which is dis- tributed to it, and the internal recti. The forms of imperfect vision, known as myopia and presbyopia, are to be attributed entirely to defects in the optical adaptation of the eye. In myopia, or nearsightedness, the refractive power of the eye is too great, and the rays of light are brought to a focus before reaching the retina. This defect is to be corrected by a double con- cave lens which shall disperse the rays, and thus overcome the too great convergence. In presbyopia, or far-sightedness, there is the opposite defect, there is not sufficient refracting power, and the rays reach a focus behind the retina. This defect is to be obviated by convex lenses, which increase the refracting power of the eye. Myopia, which commonly occurs in young persons, is not always corrected by age. The presbyopic eye is always present after the operation for cataract. It is known that the rays of light from the opposite points of a luminous object, by reason of the changes they undergo through the successive refractions they experience, cross one another, and thus the image on the retina appears inverted. The question then arises, how do we see objects erect, with an inverted image on the retina? Volkmann has shown, that Sir D. Brewster's law of visible direc- tion, which affirmed that every object is seen in the direction of a SENSE OF VISION. 125 perpendicular to that point of the retina on which the image is formed, and that as all these perpendiculars meet in the centre of the eye, the line of direction is identical with the prolonged radius of the sphere, is not optically correct. Some of these lines cross each other at a point behind, and some before the lens, and they thus fall on the retina at such different angles, that no general law can be laid down respecting them. The notion of erectness, which we form by the combined use of our eyes and hands, is really the result of education and experience. Single vision with two eyes, is explained by the fact that the rays of light proceeding from a luminous object fall upon parts of the retina which are accustomed to act together. It is not necessary that these points should be equi-distant from the optic nerve, as is evi- dent in strabismus. Double vision almost always follows the ope- ration for its cure, till the parts become accustomed to act together. The vanishing of images that fall on particular parts of the re- tina, as shown in Marriotte's experiments, is due to the fact that the rays fall directly upon the centre of the optic nerve, at the point where the middle artery of the retina passes in; and as this has no special sensibility, no impression, of course, is conveyed to the brain. By the association of visual and tactual sensations, we obtain know- ledge of various properties of bodies, such as smoothness and rough- ness, form, and to a certain extent, of distance. In the latter both eyes seem to be required. The distinctness of outline also assists us in the estimate of distances, haziness of outline being generally associated with distance. If we know the real size of an object, we often judge of its distance by its apparent size. Impressions made upon the retina continue for some time after the removal of the stimulus. It is this which causes the appearance of a circle of light when an ignited point is rapidly moved in a circle. It also accounts for the optical delusion in the toy called thauma- trope. The phenomena of accidental colours is thus explained. When the eye is steadily fixed for a length of time upon one particular colour, as for instance, upon a red wafer, the retina becomes fa- tigued and loses its impressibility to that colour; if now the eye be turned to a white ground, a spot having a different colour will be seen; this will be made up of all the colours of the solar spectrum, minus the red, and the resulting one colour is called the comple- mentary or accidental colour. In this case it will be bluish-green. The laws of harmonious colouring in painting, are founded upon the combination of complementary colours. The subjective phenomena of vision are familiar to all. Examples are seen in the flashes of light before the eyes in congestion of the 11* 126 PHYSIOLOGY. brain; and that also result from blows that jar the optic nerve or ganglia. . . The mal-appreciation of colours, like the deficient musical ear, is rather an encephalic defect, than in any way connected with the visual organ itself. THE ENCEPHALIC NERVES. The only encephalic nerves whose functions have not been alluded to, are the fifth; portio dura of the seventh; and the eighth pairs. The fifth and eighth pairs combine the functions of sensitive and motor nerves. The portio dura is entirely motor. The fifth pair presents a remarkable resemblance to the spinal nerves in its mode of origin. It arises by two roots, a larger and a smaller; the larger is involved in a ganglion, and the two are quite distinct until after the formation of the ganglion. The trunk of the nerve separates into three branches, the opthalmic, the superior maxil- lary, and the inferior maxillary. Fig. 36.* The first two consist exclusively of fibres derived from the poste- rior, or larger root, and ganglion; the third is composed of fibres from both roots : it is the only portion that is strictly compound, (Fig. 36.) The ophthalmic and superior maxillary being composed of fibres from the posterior root, are exclusively sensitive. The inferior maxillary is both motor and sensitive. The ophthalmic and superior maxillary are dis- tributed entirely to sentient sur- faces ; division of them, there- fore, destroys the sensibility of those parts, without impairing the muscular action. The inferior maxillary sends some branches and motor filaments to the mus- cles of mastication ; the others go to the integuments of the lower part of the face, and the mucous membrane of the mouth and tongue, which they supply with general sensibility. Division of these last destroys the general sensibility in the parts to which they are distri- * A view of the distribution of the fifth pair. 6. First branch of the fifth pair or ophthal- mic. 7. Second branch or superior maxillary. 8. Third branch or inferior branch. For other references, see Anatomy. THE ENCEPHALIC NERVES. 127 buted, and also puts a stop to the movements FiS' of mastication. Pain- ful affections of the face (neuralgia) have their seat in the sensi- tive branches of this nerve. The portio dura of the seventh pair is the general motor nerve to the face, (Fig. 37.) The muscles supplied by it are chiefly those upon which the aspect of the countenance and the balance of the fea- tures depend. It is sometimes called the nerve of expression. The acts of closing the eyelids and frowning depend on this nerve. Subsequently to its entrance into the canal from which it emerges, it receives sensory filaments from the fifth, and some cervical nerves, which cause irritation of its several branches to produce pain. Section of the nerve, at its emerging from the stylo-mastoid foramen, is followed by paralysis of the muscles of the face and eyelids. It was formerly thought to be the seat of neuralgia, and was upon several occasions cut. The only result was paralysis of that side of the face, total loss of control over the features, of the power of frowning, and of closing the eyelids. The portio dura is also the channel of the reflex movements concerned in respiration, but it is not at all concerned in mastication. The eighth pair of nerves is made up of three others, the glosso- pharyngeal, the par vagum or pneumogastric, and the spinal ac- cessory, (Fig. 38.) The conclusions that have been arrived at by physiologists in relation to these nerves, can alone be stated here. The glosso-pharyngeal is the sensitive nerve of the mucous mem- brane of the fauces and of the root of the tongue, and in the latter situation it ministers to taste and touch, as well as to common sensi- bility ; and being the sensitive nerve of the fauces, it is probably concerned in the feeling of nausea so readily excited by stimulating the mucous membrane of this region. Such are its peripheral or- + Distribution of the facial nerve. 1. Facial nerve escaping from stylo-mastoid foramen. For references, see Anatomy. 128 PHYSIOLOGY. Fig. 38.* ganization, and central connexions, that stimulation of any part of the mucous membrane in which it ramifies, excites instantly to contraction all the faucial muscles supplied by the vagus and the facial nerves, and the permanent irrita- tion of its peripheral ramifications, as in cases of sore throat, will affect other muscles supplied by the facial nerves also. It is, therefore, an excitor of the movements necessary to pharyngeal de- glutition. The par vagum.—The following con- elusions may be adopted respecting the functions of this nerve and its branches. 1. That the vagus nerve contains fila- ments both of sensation and motion. 2. That its pharyngeal branches are motor. 3. That its superior laryngeal branch is the sensitive nerve of the larynx, con- taining a few motor filaments to the crico- thyroid muscle. 4. That the inferior laryngeal is the principal motor nerve of the larynx. 5. That the cardiac branches exert a slight influence on the movements of the heart. 6. That its pulmonary branches con- tain both motor and sensitive filaments, and exercise an important influence upon the respiratory acts, for they cannot be destroyed without retarding materially the respiration, impeding the passage of the blood through the lungs, and causing oedema of these organs. 7. That the oesophageal branches are the channel through which the muscles of that tube are excited, through the medulla oblongata, to contract. 8. That the gastric branches influence the movements of the stomach, and probably in some degree the secretions and the sensi- bility of its mucous membrane; but that their integrity is by no * Origin and distribution of eighth pair of nerves. 6. Origin of the glosso pharyngeal nerve. 8. Trunk of the nerve. 9. Spinal accessory, 10. Ganglion of the pneumogastric. 22. Origin of the spinal accessory. MUSCULAR MOTION. 129 means essential to the continuance of the secretion, or to complete chymification, (Todd and Bowman.) The spinal accessory is so called in consequence of its extensive connexion with the upper part of the spinal cord. Of its two branches, the internal is probably sensitive. The external is dis- tributed to the sterno-cleido-mastoideus and trapezius muscles, some of its filaments inosculating with the cervical plexus, and is motor in its functions. The movements excited by irritating it, are of a direct, and not of a reflex character. MUSCULAR MOTION. The muscular system forms part of the apparatus of animal life, inasmuch as it is the instrument by which nervous energy operates upon external objects. The contractility which it manifests on the application of a stimulus, is an endowment derived from its own structure, and not from the nervous system. The presence of this contractility is connected with the healthy nutrition of the tissue, and with its due supply of arterial blood : the separation of any muscular part from its nervous connexions has none but an indirect influence on its properties. The development of muscles, their physical and vital properties, their mechanical adaptation as moving agents, having been already described, (pages 36, 37,) but little remains to be added. There is one form of contractility which produces a constant ten- dency to contraction in the muscular fibre, but which differs from simple elasticity from the fact that it exists after death and before de- composition takes place. This is called tonicity, and it manifests itself in the separation or retraction that takes place between the divided ends of a living muscle, as in amputation. It also shows itself in the permanent flexure of the joints when the extensors are paralysed, as in lead palsy. In the healthy state the tonicity of the several groups of muscles is counterpoised, but the balance is de- stroyed when the tonicity of one set is lost or impaired. The tonicity is greater in the non-striated than in the striated; it is this property that keeps the walls of the arteries contracted upon their contents. It is increased by cold, and diminished by heat. The rigor mortis, as already described, is probably to be regarded as a manifestation of this property. The energy of muscular contractions is seen in the various feats of strength performed by jugglers, &c. It is very much increased by continued exercise. Much, however, depends upon the mechani- cally advantageous application of the power; persons of ordinary strength may in this way perform feats that would seem incredible. An idea of the rapidity of muscular contractions may be had by estimating the number of letters that can be pronounced in a given time. Some persons can pronounce 1500 in a minute; each of 130 PHYSIOLOGY. these requires a separate contraction of muscular fibres, followed by a relaxation of equal length. Each contraction must therefore have occurred in one-tenth of a second. The production of voice, or vocal sounds, depends upon the appli- cation of muscular power to the vocal instrument, and is therefore properly considered under this head. OF THE VOICE AND SPEECH. The voice is produced when the air is expelled from the lungs; every one knows it is impossible to articulate sounds with the mouth and nose closed. It must be remembered that vocal sounds, and speech are two very different things ; the former may be produced in great perfection, where there is no capability for the latter. The voice is formed in the larynx; the modifications of it by which speech is formed, are effected in the cavity of the mouth. The na- tural voice, or cry, exists in nearly all animals. Man alone, it is believed, has the power of producing articulate sounds or language. The larynx consists of four cartilages. The cricoid, the thyroid, and two arytenoid. The cricoid is the lowest of these ; it surmounts the trachea, and is shaped like a seal-ring, having its deepest portion behind. The thyroid is situated above the cricoid, with which it is articulated by its lower cornua, in such a manner that its lower front margin may be made to approach or recede from the upper margin of the cricoid. The higher the tone, the more nearly do they ap- proximate. The arytenoid cartilages are situated upon the posterior and superior portion of the cricoid, with which they are articulated also in a movable manner. From the tips of the arytenoid carti- lages, to the inner front of the thyroid, are stretched the two pairs of vocal ligaments, composed of yellow elastic tissue, and named the superior and inferior vocal ligaments. The whole interior surface of the larynx is lined by mucous membrane, which is reflected over the vocal cords, dipping down into the spaces between them to form the ventricles of the larynx, or, as they are sometimes called, ventri- cles of Morgagni, or of Galen (Fig. 39). Upon the varying degree of tension of the vocal ligaments depends the variety of tones of which the voice is susceptible. For the production of vocal tones the ligaments of the opposite sides are also required to be brought into approaching parallelism with each other, by the approximation of the points of the arytenoid cartilages, whilst in the intervals they are separated from each other, and the rima glottidis, or fissure between them, assumes the form of the letter V (Fig. 40). The muscles that are concerned in governing the pitch of the notes, by regulating the tension of the cords, and those that govern the aperture of the glottis are the following. (The table is derived from Carpenter's Human Physiology.) MUSCLES THAT GOVERN THE APERTURE OF THE GLOTTIS. 131 Fig. 39. Fig. 40.t GOVERN THE PITCH OF THE VOICE. ^ J Crico-thyroidei, £ ) Sterno-thyroidei, w o 2. J Thyro-arytenoidei £• ( Thyrohyoids, 'I S Depress the front of the thyroid cartilage on the cri- coid, and stretch the vocal ligaments; assisted by the arytenoideus and crico-arytenoidei postici. Elevate the front of the thyroid cartilage, and draw it towards the arytenoid, relaxing the vocal liga- ments. GOVERN THE APERTURE OF THE GLOTTIS. Crico-arytenoidei postici, > CZose th lottis< Arytenoideus, S 6 Crico-arytenodei laterales, \ Open the glottis. The muscles that relax or stretch the vocal ligaments are con- cerned in voice alone. Those that govern the aperture of the glottis are also concerned in respiration, regulating the amount of air re- ceived. They are also the seat of the spasmodic affections of the larynx which so often occur in children. The vocal apparatus has been compared to various instruments, such as stringed instruments, flutes, and reed instruments. It is not justly compared to a stringed instrument, inasmuch as the cords are too short to produce all the varied notes of which the human voice is capable, more especially the lower notes. Besides which they are covered with mucous membrane, which would act effectually as a damper upon them. * Vertical section of the larynx to show its internal surface. 7. Superior vocal ligaments. 8. Section of thyroid cartilage. 9. Ventricle of Galen. 10. Lower vocal ligament. 11. Arytenoid cartilages. 12. Inside of cricoid cartilage. t Larynx from above. G. E. H. Thyroid cartilage. N. F. Arytenoid cartilages. T. V. T. V. Vocal ligaments. N. X. Crico-arytenoideus lateralis. V. k.f. Right thy ro-arytenoideus. N. /. N. /. Crico-arytenoidei postici. B. B. Crico-arytenoid ligaments. 132 PHYSIOLOGY. Neither can they be compared to a flute pipe, in which the sound is produced by the vibration of the column of air contained in the tube, and the pitch of the note determined by the length of the column, slightly modified by its diameter. There is nothing in the form or dimensions of the column of air between the larynx and mouth which can be conceived to render it capable of such vibra- tions as are required to produce the tones of the human voice. The third class of instruments are the reeds, and to these the vocal organ bears more analogy than to any of the others. In the reed instrument, a thin plate or lamina vibrates freely in a frame that allows the air to pass readily round it. In the accordion the variations in the tone are produced by different lengths in the reeds. In the vocal apparatus there are laminae formed by stretching the mucous membrane over the vocal ligaments, and by increasing or diminishing the tension of these, various notes can be produced. In this respect it resembles a reed instrument. In regard to the pro- duction of falsetto notes nothing certain is known. Muller supposes that in them merely the border of the glottis vibrates. The intensity of the voice, or, as it is commonly called, the volume of the voice, results in part from the force with which the air is driven from the lungs, and from the size of the thoracic cavity; and in part from the facility with which the vocal cords of other parts of the larynx are able to vibrate. These modifications explain the difference which exists between the male and female voices. The vocal cords in the male are longer than in the female in the proportion of 3 : 2, and their voices are commonly an octave lower. The power of the will in determining the exact degree of tension necessary to produce a given note, is extremely remarkable. The j natural compass of the voice in most persons is two octaves or 24 semitones. Now a singer can produce ten distinct intervals between each semitone, or 240 intervals. There must, therefore, be 240 different states of tension of the vocal cords all produceable at pleasure when a distinct conception exists as to the tone required. And all these different notes can be produced without a greater varia- tion in the length of the vocal cords than one-fifth of an inch. The peculiar timbre, or quality of the voice which each person possesses, and its imperfections, depend on the smoothness or rough- ness of the cartilages of the larynx, or on the different aptitudes for vibration which the parts of the organ possess. In the production of voice the inferior ligaments are the impor- tant agents. If we remove the superior ligaments, voice continues, though more feeble; but if we divide the inferior ligaments, voice is destroyed. Even the ventricles of the larynx may be cut into and yet voice continue. The use of the ventricles is to allow free vibration of the vocal laminae. All the articulated tones or sounds which form the basis of speech VOCAL SOUNDS. 133 are produced under the conjoint influence of the larynx, fauces, and mouth. In the majority of instances, the whole, or the greater num- ber of the organs included in the mouth co-operate in producing each articulate sound. The vowels alone are primarily formed be- tween the vocal chords, and are continuous sounds, modified by the shape of the aperture through which they pass out. The sound of consonants is formed by some kind of interruption to the voice, so that they cannot be properly expressed unless joined with a vowel. It is the latter which commonly offer the greatest difficulty to the stammerer, especially those which are called explosive. THE END. 0 • HANDBOOK SURGERY. THE OTHER PORTIONS OF THIS SERIES ARE ANATOMY, WITH ONE HUNDRED AND FIFTY-SEVEN ILLUSTRATIONS. PHYSIOLOGY, WITH FORTY ILLUSTRATIONS. OBSTETRICS, WITH THIRTY-SEVEN ILLUSTRATIONS. MATERIA MEDICA AND THERAPEUTICS, WITH TWENTY-NINE ILLUSTRATIONS. CHEMISTRY, WITH NINETEEN ILLUSTRATIONS, AND PRACTICE OF MEDICINE. ANY ONE OF WHICH MAY BE HAD SEPARATELY, DONE UP IN A WRAPPER FOR MAILING. A HANDBOOK OF SURGERY: WITH FIFTY ILLUSTRATIONS. BEING A PORTION OF AN ANALYTICAL COMPEND OF THE VARIOUS BRANCHES OF MEDICINE. BY JOHN NEILL, M.D., DEMONSTRATOR OF ANATOMY IN THE UNIVERSITY OF PENNSYLVANIA, LECTURER ON ANATOMY IN THE PHILADELPHIA MEDICAL INSTITUTE, ETC., AND FRANCIS GURNEY SMITH, M.D., LECTURER ON PHYSIOLOGY IN THE PHILADELPHIA ASSOCIATION FOR MEDICAL INSTRUCTION, ETC. PHILADELPHIA: LEA AND BLANCHARD. 1848. Entered, according to Act of Congress, in the year 1848, By Lea & Blanchard, In the Clerk's Office of the District Court for the Eastern District Pennsylvania. C. SHERMAN, PRINTER, 19 St. James Street. CONTENTS. Inflammation . Results of inflammation Treatment of inflammation Abscess Ulcers . Erysipelas . Furunculus Anthrax, pernio, and frost-bite Burns and scalds Wounds Hydrophobia Gunshot wounds Tetanus Caries Necrosis Exostosis Fragilitas ossium Mollities ossium Rickets . Spina ventosa Osteo-sarcoma . Coxalgia Fractures of the nose of the upper and lower jaw of the spine of the pelvis of the ribs and sternum of the scapula of the clavicle . VI CONTENTS. Fracture of the humerus of the radius and ulna of the carpus and phalanges of the femur of the patella of the tibia and fibula of the tarsus, &c. . Compound fracture Dislocations of the jaw of the spine and ribs of the clavicle of the humerus at the elbow at the wrist of the femur of the knee . of the patella of the ankle of the foot Injuries of the head Concussion . Fractures of the cranium Compression . Trephining Injuries and diseases of the face, nose, and mouth Wounds and affections of the throat , Injuries and surgical affections of the chest Wounds of the abdomen Artificial anus Hernia . Inguinal hernia Femoral hernia Umbilical and other varieties of hernia Fistula in ano Fissure of the anus Hemorrhoids Prolapsus ani Encysted rectum Imperforate anus Urinary calculus Lithotomy . CONTENTS. Lithotrity .... Lithotripsy. ... Venereal disease Gonorrhoea . . . . . Syphilis .... Stricture of the urethra Fistula in perineo Enlarged prostate . Inflammation of the bladder Orchitis . . . . . Hydrocele .... Circocele . . . . . Aneurism .... of the aorta . of the carotid Axillary aneurism Brachial aneurism Inguinal aneurism Popliteal aneurism Varicose aneurism Amputation .... of the thigh . of the hip joint of the leg . of the foot .... of the great toe of the shoulder joint of the arm . of the forearm at the wrist . of the fingers Cancer .... Scirrhus .... Fungus hsematodes * Diseases of the eyelids . . . Hordeolum.... Ophthalmia tarsi Entropion .... Ectropion .... Ptosis . Diseases of the lachrymal apparatus Obstruction of the lachrymal duct . viii CONTENTS. Fistula lachrymalis ■ . 114 115 Conjunctivitis • . 116 Ulcer of the cornea • 116 . 116 117 . 118 119 Sclerotitis . . • • Iritis . Cataract Amaurosis . Strabismus. • . 120 Club-foot • SURG EEY. INFLAMMATION. The immediate or proximate causes of inflammation have been variously ascribed to viscidity of the blood, to enlarged blood-glo- bules obstructing the capillaries, to a spasm of the extreme vessels, to an increased action, to a debility, to a paralysis, to an injury of the nerves, to an attraction of the red globules, to a rapid union of the inflamed parts with oxygen, to abnormal nutrition. The theory which is best substantiated by facts is the following:—The blood circulates with greater rapidity and abundance in the capillaries of an inflamed part; this is followed by exudation of lymph in the in- terstices ; subsequently the blood stagnates in the focus of the inflammation, by the adhesion of the red globules to each other, and to the sides of the capillaries ; finally, the tissues are broken down and disorganized, pus is formed, the blood ceases to circulate, and the parts mortify. The symptoms are redness, swelling, heat, pain, throbbing, in- creased sensibility, disorder of function, arrest and change of se- cretion. Redness.—This is due to an afflux of blood to the part; the ves- sels become distended, and the capillaries convey red blood; the proportion of the red globules is also increased by the exudation of the serum. The degree varies in different tissues, and according to the intensity of the action ; compare, for instance, an inflamed tendon with an inflamed mucous membrane. The tint varies also between a bright scarlet and a deep purple. Permanency is characteristic of inflammatory redness. The redness of blushing is not indicative of inflammation, because it is momentary, and not conjoined with other symptoms. Swelling.—This is occasioned by the increased quantity of blood, and an effusion of serum, pus, &c. The swelling of inflammation must be conjoined with other symptoms also, for in oedema there is swelling, but not inflammation. It must be gradual in its develop. ment: the sudden swelling produced by a hernia or dislocation is not that of inflammation. It must also be recent, not like the tedious growth of a genuine tumour. Swelling may be injurious, as in the brain or orbit of the eye; or it may be useful, as in a fracture, &c, 2 14 SURGERY. It is most remarkable in loose textures; also in the breast, testicles, and lymphatic glands. Heat.—This depends upon a more rapid oxidation of the tissues, which are also supplied with an increased quantity of blood. Heat of inflammation may be partly actual, as ascertained by the touch or the thermometer, and partly the result of a perverted nervous func- tion, estimated only by the patient. It must be permanent, and con- joined with other symptoms to be characteristic, for in hectic therejs burning of the hands and feet, yet no inflammation is there. Pain—is caused partly by the pressure upon the nerves of the in- flamed spot, and the distension of the arteries which are supplied by small nerves; and partly by disordered function. Mechanical pres- sure increases it, for instancey by the hand in peritonitis, or inspira- tion in pleurisy. Pain varies with the natural sensibility of the part affected, hence inflammation of the skin is more painful than that of cellular tissue. It is proportionate to the yielding nature of the struc- ture affected; thus inflammation produces more pain in bones and ligaments, than in mucous membrane. Pain is not always indicative of inflammation—for example, in spasm and neuralgia. In spasm the pain comes on suddenly, and is relieved by pressure; in neuralgia it is intermittent. Not so with in- flammation—in the latter the pain gradually increases from the first; if it suddenly disappears suspicion is excited lest gangrene has su- pervened. Pain may be sympathetic, and referred to a part at a distance : in coxalgia, the pain is at the knee ; in liver disease, in the shoulder ; in disease of the kidney, at the orifice of the urethra. This is a point of practical importance in the application of remedies. Increased sensibility.—This may be illustrated by intolerance of light when the eye is inflamed; the tenderness of the skin in erysi- pelas ; the rejection of food by the stomach, and the constant urina- tion if the bladder is the seat of inflammation. Disorder of function.—The stomach cannot digest, nor the kidney secrete. If the brain or spinal cord be the seat, we may expect con- vulsions, or paralysis. The causes of inflammation may be divided into predisposing and exciting. Predisposing causes.—Include sanguine temperament, excitability; plethora, excess in food, drink, or exercise; debility, miasmata, bad air, food, and clothing; previous disease, &c. These may be con- sidered as constitutional or idiopathic. Exciting causes.—May be direct, such as the chemical effects of acids, salts, &c.; or mechanical effects of wounds, pressure, &c. Indirect, or vital, such as heat and cold, cantharides and turpentine. Specific, as in the instance of vaccine virus. The duration and character of inflammation are modified by the nature, situation, and condition of the part affected, and the tempera- RESULTS OF INFLAMMATION. 15 ment and diathesis of the patient. Age, sex, habit, atmosphere, and season, all exercise an important influence in its progress and type. RESULTS OF INFLAMMATION. 1. Resolution.—This is the most favourable result. It is the re- storation of the part, as regards both structure and function, to its original and normal state. Effusion takes place, the vessels are relieved, the red globules move on, absorption takes place, and the usual symptoms subside. Delitescence is the sudden disappearance of inflammation ; and when it is attended by the establishment of a new one, the term metastasis is used. 2. Excessive deposit.—Either of serum or fibrin, which has ex- uded through the coats of the vessels. When serum is effused into cellular tissue it constitutes cedema, which is characterized by pitting on pressure; when effused and collected in serous membranes, it con- stitutes dropsy. The effusion of fibrin requires a higher degree of inflammation, upon the subsidence of which new structures are formed by the organization of the fibrin, and parts are repaired; hence the term plastic is applied to it. Thus wounds unite, bones knit, and arteries consolidate. 3. Hemorrhage^—Occasioned by the destruction of the coats of the vessels. If it occur in the interior it is termed extravasation. It is usually injurious, by producing pressure and exciting irritation, as for instance, in the humours of the eye, or membranes of the brain. 4. Suppuration.—The formation of a fluid called pus. It is called laudable when it is yellow, creamy, and opaque; insoluble in water, but readily mixing with it. It has no odour, but a slightly sweetish taste. It is not corrosive, but bland and protective to ten- der granulations until covered by cuticle. When confined, it pro- duces disintegration of the textures in contact, by pressure. It is the result of a vital action. It consists of a fluid and globules. The fluid is the liquor sanguinis of blood effused; this separates into serum and fibrin; the fibrin becomes granular by the formation of exudation corpuscles, and these degenerate into pus-globules. When pus is thin and acrid it is termed ichor, consisting mostly of serum. In scrofulous persons it is flaky. When it contains blood it is called sanies. When it is of a leaden colour, thick, coagulated, and very offensive, it is sordes. Sometimes it is mixed with a subtle virus, as the venereal or vaccine ; it is then said to be specific. When mixed in the mucous or serous discharges, it is termed sero-purulent or muco-purulent. When suppuration is profuse and'long continued, in a debilitated frame, it produces a fever called hectic, which is a constitutional irritation different from the inflammatory type. It is remittent, and attended with paleness of surface, except upon the cheeks. The appetite is good, but yet there is great emaciation. The tongue is 16 SURGERY. clean, at first moist, but afterwards dry and glazed or aphthous. The bowels are constipated, or else attended with a diarrhoea, termed colliquative. The palms and soles burn, and there is great thirst. Respiration is rapid and short. The pulse is frequent and small. At noon there is increased fever preceded by a chill; at night there is perspiration, most profuse towards morning. The eyes are bright, though sunk in hollow orbits; and though there may be sleepless- ness,°lassitude, and debility, yet the mind is clear and the spirits are good. 5. Ulceration. — Hunter supposed that it was entirely the re- suit of absorption. It is more properly a vital softening of a texture changed by inflammation and suppuration; becoming disintegrated and fluid, it passes away with the pus. The more violent the inflam- mation, the more rapid is the destruction; the term phagedenic is applied to those ulcerations in which the part is apparently eaten or consumed with unusual rapidity. Congestion is a predisposing cause of ulceration. The skin, mucous membranes, and cellular tissue, yield more rapidly in ulceration than the vascular, nervous, and fibrous tissues. Those of intemperate habit, and of scrofulous or syphilitic taint, are most liable to its ravages. The parts most likely to be affected are those whose circulation is weak and languid, such as the lower extremities, and parts newly formed, such as cica- trices, callus, and tumours. 6. Mortification.—This term includes the dying and death of a part from injury or disease. Gangrene denotes the process of dying, and is recognised by the following signs. Redness is changed into a livid hue; circulation is arrested, so is effusion, and there is less tension. Pain and heat abate, often suddenly. Putrescence commences, and there is an offensive smell. Phlyctense, or vesicles filled with putrid serum, appear over the skin. Sphacelus is the completion of the gangrene. The part is cold and insensible; shrunken, soft, and flaccid ; crepitates distinctly, owing to its con- taining gas, the result of putrescence; vital action has ceased, and the colour becomes black if the parts are exposed to the air. A slough is a small sphacelation. Nature makes an effort to throw off an injurious mass. The living part in contact with the dead in- flames ; and, in consequence, the abrupt livid line is bordered by a diffuse, red, and painful swelling—the line of demarcation; this vesicates, the vesicle bursts, puriform matter is discharged, and an inflamed and ulcerating surface is disclosed—the line of separation. The furrow deepens ; skin and cellular tissue yielding first, the ten- don and arteries resisting for some time. No hemorrhage occurs during gradual division of the parts; the arteries are sealed by the effusion of fibrin during the inflammation. But when the mortifica- tion is rapid, as in acute hospital gangrene, arteries are found playing TREATMENT OF INFLAMMATION. 17 in the dark and putrid mass alive, whilst all is dead around them. At length they yield, and death is hurried on by hemorrhage. The constitutional symptoms are of a typhoid form. The pulse is frequent and small, irregular or intermittent. The countenance is anxious, the face livid, the nose pinched, and the lips contracted. Anxiety is soon changed into stupidity of expression, as if the patient were under the influence of opium or alcohol; sighing, hic- cup, and involuntary movements of the hands and fingers are now observed, such as picking and fumbling with the bedclothes. Appe- tite fails; the tongue is coated with a brown fur, except at the tip and edges. The lips and mouth are dry and incrusted; swallowing is difficult. The mind is stupid, wavering, and subject to illusions; the articulation is thick and broken. Still more marked are the deathlike coldness, the clammy sweat, the small, indistinct, and flickering pulse, and the cadaverous expression. In this state a patient will sometimes lie for hours, and die without a struggle. Mortification may be acute or chronic. The acute comprehends the humid, inflammatory, and traumatic. The chronic—the dry and idiopathic. The cause of mortification is a want of vital power, and may be the result of high inflammation, mechanical injury, pressure, heat, obstruction to the return of venous blood, deprivation of nervous agency, interruption to arterial supply, as by aneurism or tourni- quet, cold, general debility, bed-sores, improper food, spurred rye. TREATMENT OF INFLAMMATION. The first object is always to remove the cause, and afterwards to prevent or diminish the inflammatory action. The chief means are termed antiphlogistic, and consist of General Bloodletting.—This is only required when the inflam- mation is severe, as in erysipelas, and compound fractures, when important organs are involved, such as the lungs, bladder, kidney, eye, and peritoneum. If resorted to unnecessarily, it produces con- gestions, effusions, and atrophy. Syncope, or fainting, is produced when bleeding is pursued to a great extent. It is occasioned by the removal of the natural stimulus of the heart—the blood, and by the sedative influence transmitted from the brain, when deprived of its share of arterial blood. The benefit to be derived from bleeding is not merely the loss of superabundant blood, but also the sedative influence, whereby the emptied capillaries can resume their natural tone. A rapid full stream from a large orifice will soon produce syncope, if the patient be sitting or standing ; whereas the system may be almost drained of blood by a slow stream from a small aperture, before faintness ensues, if the recumbent position is main- tained. Bleeding is not to be regulated by its amount, but by its effects. As a general rule, the blood should flow until there is some 18 SURGERY. paleness of the lips, sighing, nausea, fluttering of the pulse, or relief of pain. The ability to bear bleeding will vary according to age, sex, temperament, and disease. A man in health will faint usually from the loss of fifteen ounces; the same person, with a severe inflammation, particularly of the head, will bear double that amount. Reaction takes place after bleeding, the pulse rises, and pain increases, often to such an extent, as to require a second amount to be taken. A smaller quantity will now produce the same effects as a large one in the first instance. The operation is usually per- formed at the bend of the arm, in the neck, or in the anterior tem- poral artery. Local Bleeding.—This is preferable when the inflammatory action is not high ; when the powers of the system are low, when the inflammatory action on the part has been fully established, and there would be no benefit from a general bleeding, and when extreme age forbids it. Cupping.—By this means blood is obtained more rapidly than by leeches, and we have the advantage of general bleeding combined with local abstraction. Leeching.—Leeches can be applied where cups cannot. In order to apply them, the part should be first washed, and if they will not stick, a little cream or blood should be smeared on it. Their appetite is increased by being dry. If slow to bite, immersion in warm porter will be useful. Their bites are sometimes troublesome from haemorrhage. This is arrested by the mur. tinct. ferri, or a fine point of nitrate of silver. American leeches will draw a 3 or 3iss. of blood ; foreign leeches take an 3 or 3iss. Salt will occasion them to drop off. Purgatives.—They deplete, by causing an increase of mucous exhalation from the bowels. They also act as derivant, prevent assimilation of nutrition, and promote absorption; they are particu- larly useful in diseases of the head, but are contra-indicated in bad fractures, and inflammatory affections of the bowels. Emetics, diaphoretics, and diuretics are useful at the outset, emptying the stomach, and promoting perspiration, particularly the tart. ant. et potassse. Mercury.—Not only as a purge, but gradually introduced into the system, it seems to exert a tonic effect on both the extreme blood- vessels and the lymphatics; that is, in the exhalents and absorbents, thus preventing or limiting impending effusion, and at the same time expediting the removal of that which had already been exuded. Opium.—Particularly useful when combined with calomel, and given after bleeding. Before bleeding it arrests secretion, and stimu- lates,—afterwards, it soothes the nervous system, relieves pain, and prevents reaction. A strict diet must be maintained, and the drink should be refri- ABSCESS. 19 gerant; at the same time both body and mind should be at rest, and there should be a good supply of fresh air. Local Remedies.—Complete rest of the inflamed part. Elevated position, so as to favour the return of blood. Cold applications, ice-water, solution of sugar of lead, and muriate of ammonia— especially in the early stages ; for in high inflammations warmth and moisture are very grateful to some persons—relaxing tension, and assuaging pain. Nitrate of silver has great antiphlogistic powers, as well as caustic properties, especially when applied to the skin and mucous membranes. Iodine also exerts a somewhat similar influence. Counter-irritation.—By means of dry cupping, blisters, setons, issues, caustic, and actual cautery. ABSCESS. An abscess is a collection of pus in a part or cavity, and may be either acute or chronic. Acute Abscess.—Is frequently called phlegmon, when occurring in the subcutaneous cellular tissue. Commencing with all the symp- toms of inflammation,—fever, pain, redness, and swelling. The centre is firm, with oedema surrounding it. The formation of pus is indicated by rigors, an abatement of the fever, and a feeling of weight, tension, and throbbing. The centre softens, which is termed pointing, and fluctuation can be felt. There is a natural tendency to the discharge of pus, which is more apt to be towards the skin. It is less apt to open into serous than into mucous membranes. The matter having been discharged, the pyogenic membrane lining the cavity becomes covered with numerous small, red, vascular emi- nences, called granulations. They are formed by the organization of lymph. The cavity contracts and fills up with granulations. A white pellicle extends from the circumference, gradually covers the whole surface, and becomes organized into a new cutis and cuticle, called a cicatrix. At first the cicatrix is thin, red, and less vascular; it afterwards contracts and becomes paler. The causes of abscess are mostly idiopathic ; it occurs frequently after fevers; it may, however, be caused by blows, foreign bodies, &c. Treatment.—The indications are, in the first stage to produce resolution, and prevent the formation of matter. After it has formed, the indications are to cause its evacuation, and induce granulation and cicatrization. There should be cold applications, and leeches applied to the part, purging, and low diet. When matter is formed, the applications should be warm fomentations and poultices. Poul- tices may be made of bread, Indian meal, or ground flaxseed soft- ened with water; they should be large and light, and renewed 20 SURGERY. frequently : they relax the skin, promote perspiration, soothe the pain, encourage the formation of pus, and hasten its progress to the surface Lint soaked in warm water may answer for a substitute. Abscesses need not be opened if they point, and are pyramidal, and do not enlarge in circumference, but allowed to burst them- selves But they should be opened when they are beneath tendons, fascia, or the thick cuticle ; when caused by the infiltration of urine; when in loose cellular tissue, with a tendency to burrow ; when near a joint, or under the deep fascia of the neck,—where it is desirable to obviate the scar made by the abscess opening spontaneously. The best instrument for the purpose is a straight-pointed, double- edged bistoury, by which the opening can be enlarged to any extent. The matter should not be forcibly squeezed out, but allowed to exude gradually into a poultice. By introducing a tent the edges are prevented from uniting. Abscesses are sometimes absorbed, especially those in glandular structures and venereal cases. This can be promoted by leeches, mercurial ointment, and remedies adapted to increase the general health. Chronic abscess.—Is the result of a low degree of inflammation, and is often unsuspected. It is lined by a cyst, and the pus is serous or curdy. Sometimes the matter is concrete. Is most apt to occur in weak and scrofulous habits, and is usually free from pain, redness, swelling, &c. It may, however, become exceedingly large, and from distension, inflame, ulcerate, and discharge. Treatment.—Improve the general health, and promote absorption by means of mercurial plasters, blisters, and iodine frictions. If it cannot be absorbed, it must be opened with care; a small, super- ficial abscess should be opened freely at once, the cavity injected with a stimulating solution, and pressure applied by means of com- press and bandage. If the matter is not freely evacuated, great in- jury results from the effect of air on the contained pus; putrefying, the product—hydrosulphate of ammonia is absorbed, and the pa- tient becomes typhoid. When the abscess is large, the opening should be small and valvular, so as to prevent the introduction of air ; or, the opening may be healed after a portion of the matter has escaped, and another made ten days afterwards ; or, the part may be kept constantly immersed in water. ULCERS. Ulcers are breaches of continuity of surface, the destruction being caused by disease or unrepaired injury. The following classifica- tion will be found to include the great majority of ulcers. Simple or Healthy Ulcer.—In this we have an exemplification of granulation and cicatrization. The surface is covered with a thick, creamy, yellow pus, not too profuse, and inodorous. The granula- ULCERS. 21 tions are small, pointed, florid, sensitive, and vascular. When they reach the level of the skin, cicatrization commences. The edge swells a little, and then is covered with a white pellicle of lymph, which is converted into cuticle. Treatment.—The plan of the treatment is simply protective. Pus is the natural protection to these granulations ; if, however, it collects, it becomes a source of injury, increasing ulceration. The air acts as a stimulus, and may cause too great inflammation. Hence the propriety of dressing. It should be lint dipped in tepid water or some simple cerate ; water dressings are now preferred. The dress- ing should only be removed for the sake of cleanliness and removing the fluid pus; but care should be taken not to wash the surface too freely, else the progress of cicatrization is delayed by the removal of lymph which may be mistaken for pus. Weak Ulcer.—If the granulations are too luxuriant, becoming pale and flabby and long, they should be treated by an astringent wash, such as a solution of sulphate of zinc or copper ; or they may require an escharotic, such as solid sulphate of copper or nitrate of silver ; or a scab may be formed by exposure to the air, or spreading fine lint upon the surface; at the same time a generous diet will be beneficial. Scrofulous Ulcers.—These occur in debilitated constitutions, and usually in clusters; most frequently upon the neck and joints. They originate in the cellular tissue, beneath the skin. At first, there is hardening, without pain, then swelling, followed by imper- fect and slow suppuration; the skin becomes blue and thin, and the aperture for the discharge has ragged edges, revealing a dirty gray surface, with no granulations ; the integument is soon undermined, and the ulcers communicate. The pain is slight, and the discharge is thin and serous. The system sympathises and the result may be hectic. Treatment.—Constitutional remedies should be steadily perse- vered in. Active measures must be taken to get rid of the soft infil- trated tissue surrounding, by escharotics; caustic potash must first be freely applied, and then a poultice; upon its removal a slough will be found to have separated, and the surface to be firm and vas- cular, covered with healthy granulations. The sore may then be treated as a healthy one, unless a relapse occur, when the applica- tion should be repeated. The constitution must be sustained, and the cicatrix supported by a bandage; otherwise it may ulcerate, es- pecially if it is blue, soft, spongy, and elevated. Indolent Ulcer.—This is the most common of all ulcers, and occurs most frequently in the lower extremity and in old persons. It is owing frequently to a healthy sore having been neglected or badly treated. Its surface is smooth, glassy, concave, and pale. The discharge is thin and serous. Its margin is elevated, round, white, and callous, resembling a cartilaginous ring surrounding a mucous 22 SURGERY. membrane. The surrounding integument is swollen, hard, and ofa dusky red colour. It has little sensibility, and the patient is apt to let it go unnoticed, unless by accident, exposure, or over-exertion, it inflames and be- comes painful. Treatment.—At first a poultice will be serviceable by cleansing the sore and diminishing the inflammation and pain which usually precedes the application for relief, which a purge and rest will assist in producing. The surface should be lightly touched with nitrate of silver or nitric acid, in order that healthy granulations should sprout; or, pressure may be employed to produce the same effect by means of strips of adhesive plaster and bandages. Small doses of opium are also useful in maintaining the capillary circulation. Irritable Ulcer.—This has been defined as possessing an ex- cess of organizing action, with a deficiency of organizable material. It is superficial, having an unequal surface of a dark hue, and often covered with tenacious fibrin. It occurs most frequently near the ankle. The edges are thin, serrated, and everted. The discharge is thin, acrid, and bloody. It is very sensitive, attended with great pain, and produces often peevishness of disposition. Treatment.—Rest, elevation, and relaxation of the part. Nitrate of silver produces a sedative and antiphlogistic effect. This should be followed by a light poultice, or warm-water dressing, or, if there is great pain, fomentations of the infusion of opium, conium, or belladonna. Phagedenic Ulcer.—This is of an irregular form, with ragged, abrupt edges, and uneven brown surface, looking as if gnawed by the teeth of an animal. It is attended with burning pain, and great constitutional disturbance. It frequently assumes a sloughing form, as in hospital gangrene, and cancrum oris, where the discharge is extremely fetid. Treatment.—Should be both constitutional and local. Fresh air and good diet are all-important; the secretions must be corrected and a Dover's powder given at night. Locally, there should be ap- plied active escharotics, such as nitric acid, nitrate of mercury, &c, followed by warm poultices; these may be superseded by warm so- lutions of the chloride of lime or soda. Mercury must never be given, especially in cases of a venereal taint. Varicose Ulcer.—This is dependent upon a varicose condition of the veins, and usually occurs in the leg, just above the ankle. They are oval and superficial, and attended with deep-seated, aching pain. They are indolent, and usually moist upon the surface. Treatment.—The cure must depend upon removing the disease of the veins. Great relief will be found in the constant use of cold water, rest, regular bandaging, or laced stockings. Certain ulcers are not to be healed, for example, when an ulcer FURUNCULUS, OR BOIL. 23 has been stationary for years, when the patient is old, gouty, or a high liver; it may be looked upon as a safety valve, and any ten- dency to unite as'indicative of impaired health. The sudden cessa- tion of a drain of pus might be followed by hemorrhage, apoplexy, or inflammation of some important organ. ERYSIPELAS. - Erysipelas is an inflammation of the skin and subcutaneous cellular tissue, having a tendency to spread. • The cutaneous form is characterized by redness, elevation, and burning pain; compression produces pale dimples, which soon dis- appear, and the cuticle vesicates. It usually terminates in a week or two, but may return to some other part. The phlegmonous or cellulo-cutaneous form is more severe. The swelling is greater, the colour darker, and the pain more severe. Thin, ichorous pus is formed, which infiltrates the cellular tissue, and thus ulcerations and sloughs follow. The constitution sympathizes ; at first the fever is high, then there are signs of hectic, and at last pros- tration and collapse. When it affects the head or throat, producing coma or dyspnoea, and when it occurs in feeble, old, or intemperate persons, there is great danger. The causes may be fatigue, foul air, intemperance, epidemic in- fluence, contagion, and injuries. Treatment.—This must be adapted to the age and constitution of the patient; the young and plethoric will require most active anti- phlogistic treatment constitutionally, whilst the old and broken down will need stimulants and tonics. In most instances, bleeding will be useful, followed by saline purgatives and diaphoretics. In highly inflammatory cases, an emetic administered early will also prove serviceable. Bark will be necessary in the latter stages, if there is debility; opium will allay the restlessness at night. The local measures most useful are leeches, punctures, cold lotions, if the pulse is good; and mercurial ointment, or nitrate of silver applied to the surface. Extension of the disease may be pre- vented by strips of blistering plaster, encircling the part. Deep incisions are to be made in case there is pus collected under the skin. Chronic, or habitual erysipelas, is best treated by alteratives and aperients. FURUNCULUS, OR BOIL. Boils occur most frequently in the young, and in those of plethoric habit, and in those parts where the skin is the thickest. They are 24 SURGERY. usually gregarious, and depend upon derangement of the primae via;, and frequently succeed eruptive diseases. The swelling is of a conical shape, having a hard, red, and painful base, and a yellow apex. If left to itself it bursts and discharges pus, and a core, or slough of cellular tissue. When completely emptied the heat and pain subside. Treatment.—Poultices* and warm fomentations should be applied early ; as soon as pus has formed a free incision must be made; and the granulating wound dressed in the ordinary way. ANTHRAX, OR CARBUNCLE. This is a serious disease; it is a solitary inflammation of the cel- lular tissue and skin, presenting a flat spongy swelling of a livid hue, and attended with dull burning pain. It varies in size, and its progress is slow. The constitutional symptoms are asthenic throughout, and the at- tendant fever is apt to become typhoid; prostration and delirium often terminate the case. It most frequently attacks high livers of an ad- vanced age. Treatment.—A free and early incision will evacuate sanious pus and fetid sloughs; this is to be followed by applications of caustic potash, in order that the dying parts may be thoroughly removed. Poultices and warm fomentations will clean the surface, and give rise to healthy granulations. Tonics and stimuli, such as bark, brandy, ammonia, are early required, particularly if the carbuncle is large, and system debilitated. PERNIO, OR CHILBLAINS. This is an affection of the skin, produced by sudden alternations of cold and heat, most commonly affecting the toes, heels, ears, or fingers. It is attended with itching, swelling, pain, and slight red- ness at first; it may afterwards become of a livid hue, with vesica- tions and ulcerated fissures, which are difficult to heal. Treatment.—There is a great variety of applications in domestic use for this disease, and some of them of the most opposite character. The most serviceable remedy under all circumstances, but particu- larly when there is ulceration, is the nitrate of silver. Temporary and soothing relief is produced by cold applications. FROST BITE. Severe exposure, combined with exhaustion and fatigue, irresist- ably induces sleepiness, which, if yielded to, is followed by coma and death. When a part of the body is frost-bitten it becomes contract- ed, pale and insensible. It may take place without the conscious- ness of the patient; without care it terminates in gangrene. Treatment.—Produce moderate reaction, which will restore cir- WOUNDS. 25 culation and sensibility, taking care that it be not excessive, which would lead to dangerous inflammation. First rub the part with snow, and then with cold water in a room without fire. For the comatose condition of the body produced by cold, also use friction with snow, in a cold room, afterwards substituting fur or flannel; gradually giving warm and stimulating drink, such as wine and water. BURNS AND SCALDS. There are three principal divisions of these injuries, which may be produced by hot fluids, vapour, flame, or solids. 1st. Those which produce mere redness and slight inflammation, terminating in resolution, and perhaps desquamation. 2d. Those causing vesications of the cuticle, which often dry up and heal; but if the cutis has been injured and inflamed, suppura- tion and ulceration result. 3d. Those causing the death of the part, in which there is not much pain, and which are followed by sloughs. Extensive burns, even if superficial, are very dangerous; and those upon the trunk are more fatal than those of the extremities. The symptoms are paleness and shivering, with a feeble, quick pulse; often prostration, coma, and death. The greatest danger is during the first four or five days, from collapse; subsequently from an affection of head, chest, or abdomen, or from prostration. Treatment.—Bathing the part in cold water will mitigate the heat, pain, and inflammation; afterwards it must be protected from the air by cotton, or some bland unctuous substance, care being taken to dis- charge the vesicles without removing the cuticle. Calm the nervous excitement with opium, and prevent sinking with wine and ammonia. Be careful of over stimulation, and promote the separation of sloughs by rest, poultices, and fomentations. Regulate the diet, and encourage granulations by water dressings, saturated with salts of copper, zinc, or silver, or with chloride of lime. Contraction of cicatrices is to be prevented by mechanical means, and the function of joints is to be retained by passive motion. WOUNDS. Wounds are classified into incised, contused, lacerated, punctured, poisoned, and gunshot. Incised.—These are produced by sharp-edged instruments, and bleed freely. They heal in various ways; by adhesion, or union by the first intention, in which there is no suppuration. Fibrin is thrown out, and coagulating, becomes organized; and constitutes a new living structure; incorporated with the cut surfaces, it restores the solution of continuity in the solid parts. Wounds heal by growth, whereby reparation is made, without inflammation and suppuration, as in ordinary nutrition. 26 SURGERY. Wounds heal by the modelling process, which is somewhat simi- lar to the last, the gap gradually filling up with lymph, and restor- ing the deficiency. Wounds heal by granulation, constituting union by the second intention, a process formerly described in treating of abscess. Treatment.—This consists in arresting hemorrhage, removing foreign bodies, bringing the edges together, and promoting adhesion. Hemorrhage is arrested by cold applications, elevated position, and compression, or, if an artery has been cut, by a ligature, or by torsion. Ligatures are usually made of silk or thread, and should be round or twisted, in order to divide the internal and middle coats of the artery. Animal ligatures are sometimes used on account of their speedy decomposition, and separation from the artery ; ligatures of lead have also been used. Compression can be effected by the tourniquet, bandages, and pled- gets of* lint; in lieu of a tourniquet a Spanish windlass may be used, which is made by tying a handkerchief around a limb, and twisting it tightly with a stick. Styptics are also used where the vessels are small, and the actual cautery when the hemorrhage cannot be arrested by other means. Foreign bodies, such as pieces of glass, clots of blood, &c, &c, are to be removed from the wound, and the lips brought together by means of adhesive plaster applied to surfaces cleanly shaved, and free from moisture. Sutures, or stitches, are to be used only when the edges cannot be approximated by other means. An interrupted suture is made by passing a needle, armed with a single ligature, through both lips of the wound, which are then to be drawn together without any great straining, and secured by a double knot. These stitches are to be made at intervals of about an inch, but should not be made in any tendinous structure, or highly inflamed part. A twisted suture is made by transfixing the margins of the wound with a needle or pin, and passing around it a wax ligature in the form of the figure 8, by which means the edges are brought in con- tact ; the point of the pin, or needle, is to be protected with wax, and allowed to remain for several days. The continued, or glover suture, is nothing more than the ordinary mode of sewing cloth or leather. Contused and Lacerated.—These resemble each other; are attended with little hemorrhage, because the arteries are little torn, and do not bleed so much as when cut. They are dangerous, be- cause they are liable to inflammation and sloughing, and are often complicated with foreign bodies ; and they are more apt to produce constitutional disturbance and tetanus. Treatment.—Adhesion is impossible; suppuration must take place, and the dead parts be thrown off; the reparation takes place by WOUNDS. 27 granulation. At first it will be necessary to arrest hemorrhage, re- move foreign bodies, bring the parts in apposition by strips of ad- hesive plaster, and apply water-dressings, or a light poultice, accord- ing to the condition of the patient. Cold and other antiphlogistic means, such as bleeding and purging, must be used cautiously when there has been a great shock upon the system, otherwise the vitality of the parts will be depressed, and the risk of gangrene increased; but after fever and suppuration are established, the usual means of combating inflammation may be employed. When the sloughs are numerous, and the discharge profuse, typhoid symptoms will appear, especially if the patient be much reduced by depletion and rigid diet. Punctured and Penetrating.—These are inflicted by sharp- pointed instruments, and are extremely dangerous, on account of the injury done to important parts, by opening vessels and cavities, and from the diffusion of purulent secretions, and the liability of tetanus. Treatment.—After ascertaining that the wound contains no foreign matter, apposition is effected, and maintained by position, rest, and dressings, and the system placed under antiphlogistic regimen ; adhesion is to be expected, or reparation by granulation. There may be severe secondary symptoms arising from secondary hemor- rhage, or confined purulent secretions; it may be necessary to ap- ply a ligature upon the artery above the ulcerated wound ;. or, to open and dilate it for the exit of pus, or a foreign body before un- discovered. Poisoned.—These include bites and stings of animals, and the effects of dissecting wounds. The stings of ordinary insects are not sufficiently severe to require surgical aid, unless in great number, and in peculiar situa- tions. Children sometimes suffer with fever and headache, when stung in a number of places; and the suffocation produced by a sting in the pharynx is alarming. Treatment.—For the common sting of a wasp or bee, remove the sting of the animal with forceps, should it remain, and apply some stimulating application, such as turpentine, cologne water, or harts- horn. Hartshorn will probably give most relief, especially com- bined with cold applications. If there is faintness or depression, ad- minister wine and opium. If the sting is in the fauces, use leeches internally and externally, stimulating gargles, and, if necessary, open the trachea. Spiders, especially the tarantula, scorpions, and serpents, inflict a most severe injury. The bite of the viper, cobra de capello, and rattlesnake, is attended with great pain, swelling, constitutional dis- turbance, and death. In such wounds great caution must be used to extract the poison from the wound, and to prevent its passing into the circulation. Surrounding the limb with a ligature, bathing the 28 SURGERY. wound with warm water, and sucking it, are all of use; but the ap. plication of cupping glasses, and scarifications, is the most certain method. The prostration of the system is to be treated with brandy and ammonia, and the pain to be relieved by opium. Various remedies are given internally, such as sweet oil and ammonia, but arsenic has a most decided preference ; the celebrated Tanjore pills each con- tain a grain; the proper dose is f3j to f3ij of Fowler's solution. Hydrophobia. — Hydrophobia is a disease brought on by ino- culation with the saliva of a rabid animal, and characterized by in- termitting spasms of the muscles of respiration, together with a pecu- liar irritability of the body and disturbance of the mind. The first symptoms in the dog are shyness, want of appetite, drooping of his tail and ears, a suspicious, haggard look, red and watery eyes, constant snapping at and swallowing straws, and lick- ing cold surfaces, such as stone and iron ; afterwards respiration be- comes difficult, viscid saliva flows rapidly, and there is inflammation of the fauces, and high fever. He is not always furious, nor does he always bite, unless irritated; his gait is staggering, and he dies in convulsions, usually after the fifth day. The symptoms in man vary with constitution and habit, and usu- ally appear between five and ten weeks subsequent to the bite. The wound heals as usual; after a time there is pain and itching in the cicatrix, which gradually increases, and ulceration follows. There is headache, restlessness, fever, and excitement of the nervous system. The mind is particularly clear and active; the memory strong, the imagination vivid, the countenance animated, and the eyes sparkling. This is succeeded by despondency, and the dread of fluids, great agitation, spasms, difficulty of breathing. Every attempt to relieve the burning thirst is followed by convulsive con- tractions of the neck and throat; sleepless despair, change of voice, croupy inspiration, and involuntary biting are the next symptoms. As the disease advances, the brain becomes more affected and death is preceded by delirium. Treatment.—The recent wound should be treated by cupping- glasses and nitrate of silver. In not more than one case out of twenty does hydrophobia follow the bite of a rabid animal. The bite is much less dangerous when through the clothes. After the disease is established, nothing can be done with the prospect of cure; although every remedy and mode of treatment has been recommended. Palliatives and medicines which calm the nervous system and relieve pain may give some temporary relief. Dissecting Wounds.—These are followed by unpleasant results more frequently in those of a scrofulous temperament, or in those whose systems are exhausted by study or dissipation. GUNSHOT WOUNDS. 29 The consequences may be a simple pustule, inflammation of the lymphatics, and typhoid fever, with diffuse abscesses. The pustule has not much elevation, is surrounded by redness, and attended with burning and itching. When opened, it discharges a little thin pus, and is soon refilled, the excavation gradually in- creasing. This may not be followed by constitutional symptoms, unless the health is very bad. The inflammation of the lymphatics is more apt to follow a small scratch or wound from examining recent subjects, especially those dying with peritonitis or any disease of serous membranes. The pain and swelling extend up the arm to the axilla, and there is fever and depression of spirits. The course of the inflammation can be traced along the lymphatics to the axillary glands, which often suppurate. Extensive abscesses and typhoid fever take place when the poison is very violent, and the system much prostrated. Treatment.—The pustule will be managed best by a lye poultice, and then removing the coverings and touching the surface with lunar caustic. A simple incision or puncture for an ordinary pustule will not prevent the renewal of the matter. When the lymphatics are inflamed, the original wound is not always the most tender spot, nor is there the appearance of a pus- tule. Leeches, cold applications, poultices of Indian meal and rye, nitrate of silver, and tincture of iodine are useful local applications. Bleeding may be necessary when the inflammation and fever are very high. Free incisions prevent the formation of a"bscesses, by evacu- ating the serum and depleting the part. Spreading abscess of the cellular tissue is attended with typhoid fever, and very dangerous. The system must be supported by stimulants and tonics, such as brandy and bark; opium will allay pain and restlessness, and the local dressing will resemble that for abscess in general. Fresh air, clean clothes, healthy skin, good diet, and regular habits will be found to be the best prophylactics. GUNSHOT WOUNDS. These include all injuries by fire-arms, and partake of the nature of lacerated and contused wounds. There is usually but little he- morrhage, unless a large vessel is injured. The nature and extent of the injury will vary with the distance, force, and character of the shot or slug producing it, and the part affected ; fracture, contusions, and perforations, may require amputation. The aperture made by the entrance of the bullet often appears smaller than the bullet, and resembles an incised wound with inverted edges; the aperture of its exit is larger, and has ragged and everted edges. The pain of a flesh wound is often so slight that it does not attract attention ; but when a bone is broken or a nerve torn, the pain is severe. The 3 30 SURGERY. shock upon the system is greater than in other wounds, and is partly corporeal and partly mental. Syncope and depression of spirits are very common attendants. The idea of injury resulting from the wind of a ball is erroneous. Injuries may result from spent balls, which, having a rotary motion, may roll over the surface without producing an open wound. The course of bullets is uncertain ; any obstacle, such as a button, a watch, or a bone, may occasion a most devious track. A ball may strike the forehead, and emerge at the occiput, or, striking the ster- num, lodge in the scrotum. A bullet may be divided into two parts by striking a sharp edge of bone; or it may bury itself, and remain concealed for years, being enclosed in a cyst. When there is but one aperture, it is probable that the ball has lodged ; though it may have escaped upon the removal of the cloth- ing, if a portion of the clothing should have been carried before it into the wound ; or, the ball may make a complete circuit, and escape by the aperture of entrance; in this instance the track would be discovered by redness and swelling. When two orifices are in a straight line, it is not always to be inferred that the ball has escaped, for two balls may have entered opposite each other; the character of the orifices will determine this point. A plurality of openings does not always imply a plurality of balls; the same bullet may per- forate and escape, and perforate again. The wound partially sloughs and may produce abscess, erysi- pelas, hemorrhage, disease of the bones, hectic, or tetanus. Treatment.—The general indications are to overcome the shock, remove foreign matters, adjust the parts, and place them in a com- fortable and relaxed position. A simple wound, made by a ball passing through some fleshy part, should at first be sponged clean, and after hemorrhage has ceased, dressed with dry lint, secured by strips of plaster. A little wine and laudanum may be given if the patient is disposed to faint, or suffers much with anxiety and fear. In a few days there is inflam- mation and suppuration. The primary dressings are to be removed with warm water, and a poultice or the water dressing substituted. Care must be taken that the sloughs are readily thrown off, and that no sinuses are formed. The constitutional treatment should be moderately antiphlogistic; consisting of purging, low diet, leeches, and perhaps bleeding; an opiate at bedtime will allay pain and twitching. The presence of bullets and other foreign bodies can be detected by a probe, and they are to be removed by a forceps, the wound having been dilated, if necessary. If they are superficially lodged, they are to be cut down upon, extracted by a counter opening; if they are deep-seated and impacted, wait for the suppurative stage. When lodged in bone, they are to be removed by a chisel or tre- TETANUS. 31 phine, lest they produce caries or necrosis, although in many in- stances they have become encased and occasioned no inconvenience. The question of amputation will be settled by considering the liability of gangrene, the usefulness of the limb if retained, the age, habits, and strength of the patient, and the means at hand for carry- ing out the treatment. The latter consideration will justify more numerous amputations in military and naval than in civil surgery. The following circumstances make amputation necessary. When a limb is completely knocked off by a cannon-ball. If the bone is shattered and the joint endangered it should be amputated above the joint. When the femur is fractured; and the femoral artery or vein, or the sciatic nerve is lacerated. When large joints are injured; but that of the elbow may often be excised. When the main artery is wounded, and gangrene has commenced and is spreading. TETANUS. * Is a disease of the true spinal system and is manifested by spasm and rigidity of voluntary muscles. When the muscles of the neck and face are affected, it is termed Trismus, or locked jaw; when the muscles of the front, Ernpros- thotonos ; when the muscles of the back, Opisthotonos ; bending to either side is termed Pleurothotonos. Tetanus may be either an acute or chronic disease; the former is the most frequent in occurrence, and most formidable to treat; the latter, apt to be partial, milder, and more subject to treatment. Traumatic tetanus follows a wound or injury, and is usually acute; idiopathic tetanus is of spontaneous origin, and usually chronic. Acute traumatic tetanus is more frequent in hot climates, and in military practice, and may follow a slight bruise or puncture, espe- cially if some nerve has been injured. Intestinal irritation and at- mospheric changes predispose to the disease. The symptoms may appear in a few hours, or in as many days; at first there is stiffness and soreness about the neck and face, the contraction of the muscles causing a ghastly smile; swallowing and mastication are difficult, the forehead is wrinkled, eyeballs are dis- torted, nostrils dilated, and the grinning countenance is expressive of horror. Respiration is rapid, the tongue protrudes, and saliva dribbles ; the sphincters are usually contracted, perspiration is pro- fuse and of a peculiar odour ; the pulse at first may be strong and full, but soon becomes weak and indistinct. The mind is clear until just before death, which generally takes place in a few days. Treatment.—The indications are to remove all sources of irrita- 32 SURGERY. tion, and diminish the spasm. The wound is to be cleansed from all foreign bodies, pus to be discharged by a free incision, if necessary, and warm anodyne poultices and fomentations are to be applied. Excision of the wound, or division of the nerve leading to it, has been practised with great benefit. Bleeding should be employed with great care, and purgatives combined with mercury are always of advantage. Opium is almost indispensable, and may be used externally and internally. Camphor, musk, assafoetida, and tobacco are also of use as antispasmodics. Chronic tetanus is seldom fatal, and frequently idiopathic; it lasts several weeks, and should be treated by the shower-bath, tonics, and electricity. DISEASES OF BONES. CARIES. Caries is an unhealthy inflammation of the bone, attended with softening, and leading to suppuration and ulceration. The bone has its cells filled with serous, and often with scrofulous fluids, and when dried has a spongy and worm-eaten appearance, and resembles a lump of sugar after being dipped in hot water. The disease most frequently attacks the thick bones, and the extremities of long bones; and it may result from local injury, or simply from constitutional causes, such as scrofula, or effects of mercury. It is attended with pain and swelling, and after ulceration there is a foetid discharge containing portions of bone. Treatment.—The constitutional treatment consists of fresh air, tonics, and alteratives ; and the local treatment in removing those portions incapable of repair, and endeavouring to establish healthy granulations. Sometimes it may be necessary to remove loose por- tions of bone which are disintegrated, and to apply escharotics to the surface. CARIES OF THE SPINE. This occurs most frequently in children, and in persons of a scrofulous temperament. At first there is a sensation of numbness in the lower extremities, languor, and a stumbling gait. The patient usually sits with his legs drawn up under the chair, has a constric- tion of the chest, and derangement of the digestive organs ; in a short time paralysis ensues, and there may be a pointing of matter at some portion of the spinal column, most frequently about the dorsal vertebrae. The bodies of the vertebrae are softened and com- pressed, and thus a curvature takes place, most generally in a pos- terior direction. Many die from fever and irritation, and recovery is usually attended with deformity. Treatment.—Absolute rest upon a mattrass, attention to the FRAGILITAS OSSIUM. 33 general health, counter-irritations over the tender point, by means of blisters and issues, and in the early stages, leeching. The diet should be light and nutritious, and a laxative administered occa- sionally. NECROSIS. This signifies the death of the bone, which is often enclosed in a case of new bone. When a superficial layer is affected it exfoliates ; the dead portions thrown off are termed sequestra. It occurs at all ages, and most frequently in the compact bones; the immediate cause, is inflammation of the periosteum. It is attended with swell- ing, and a discharge of matter through openings in the case of new bone, which are termed cloaca. The pain is deep-seated, long-con- tinued, and very severe. Treatment.—This is principally local, although constitutional remedies may be given to allay pain. The great object is to faci- litate the escape of pus and the sequestra ; it is often necessary to enlarge the cloacae by a saw or trephine, and to dilate the sinuses with lint. Amputation may be necessary in case the joints are in- volved. EXOSTOSIS. This is a tumour formed by an excessive and irregular growth of bone. The shape varies, being sometimes broad, and sometimes spiculated. The structure is healthy, and it may cause no incon- venience, unless it interferes with an artery, muscle, or joint. Treatment.—The object is to produce absorption, by means of mercury, iodine, blisters, and leeches; but since these usually fail, it is necessary to resort to an operation. This may be performed by a saw or trephine. Scraping off the periosteum is also recom- mended. FRAGIIITAS OSSIUM. This is a brittleness of bones, occurring frequently in youth, but oftener in old age. The proportion of earthy matter is relatively but not actually increased. The cancellated structure is filled by an oily substance, and surrounded by a thin, brittle lamella. This degeneration follows long confinement, intemperate habits, and rheumatic and cancerous affections. A hasty step, turning in bed, or tripping on a carpet, may produce fracture. Treatment.—In old persons all that can be done is to guard against any accident, and to enjoin a nutritious diet and salubrious atmosphere. In children, care should be taken to overcome a scrofulous constitution by tonics and good diet, and to treat the frac- ture as usual. 3* 34 SURGERY. MOLLITIES OSSIUM. This is a deficiency of the earthy matter of bones, and hence they are soft and pliable. This disease occurs in adults, and its course is rapid; the general health is impaired; flesh, spirits, and strength, diminish daily. The bones are light, soft and greasy, and often consist of an external shell, filled with a soft, greasy matter. The cause is obscure; phosphatic deposits are found in the secretions. Treatment.—This is merely palliative, for the disease is in- curable. RICKETS. This is an original defect of the skeleton, peculiar to youth and scrofulous temperaments. The bone is changed in its structure, be- coming soft and pliable, as in mollifies ossium. The cancellated structure predominates, the cells being filled with a reddish oily fluid. The flat bones are often thickened, and the long bones atrophied in the shaft. This disease gradually increases with age, and hence great deformity, and curvatures of limbs must necessarily occur. In adult life, the general health may be regained, and the patient, though a confirmed and unseemly dwarf, weak and puny in his boy- hood, may prove a healthy, muscular, and active man. Treatment.—Improvement of the general system by diet, exercise, proper clothing, and tonics. Mechanical apparatus, properly con- structed, may be of service in preventing permanent deformity. Those articles of diet which are readily converted into lactic acid, such as sugar, starch, gum, milk, &c, should be avoided, and animal food of easy digestion preferred. SPINA VENTOSA. This is a swelling, usually of considerable extent, involving the whole circumference of the bone, and has a regular surface.* In most instances, it is a bony shell, containing one or several cavities, filled with an ichorous fluid, clotted blood, and portions of carious bone. It is preceded by severe pain, and external injuries and constitutional causes may give rise to it. It is difficult to cure, especially in adults. Treatment.—When the tumour is small, the cure is to be effected by means of puncture, satisfactory evacuation, external support, and internal stimulation of the cavity. If the tumour is large, and the general health affected, amputation will be necessary. OSTEO-SARCOMA. This is a tumour, composed partly of bone and partly of flesh, and is usually considered of a malignant nature. A dissection of the tumour presents a dense, pearl-coloured membrane, covering the FRACTURES. 35 surface, and adhering closely to the bone; above this membrane the muscles are thin and spread out, so as to cover an extensive surface, having lost their colour. Upon opening the tumour, it will be found to contain cells divided by spicula of bone, and materials resembling flesh, jelly, and fat. It is attended with deep-seated pain, and at last bursts, assuming a cancer-like ulceration. Treatment.—At first, leeches, cold applications, and anodynes, may give temporary relief, but no permanent benefit can be expected without its removal; and even after amputation, it frequently attacks the stump. COXALGIA. This is a disease of the hip-joint, common to scrofulous children. Symptoms.—At first there is slight pain, referred to the knee ; lameness, and stumbling in walking ; ten- derness in the groin, and pain is produced by pressing the head of the bone sud-, denly against the acetabulum ; apparent lengthening of the limb. This apparent in- crease of length is owing to a depression of the pelvis of the diseased side, the weight of the body being supported on the opposite limb. If the disease is not arrested, destruc- tion of the head of the bone and aceta- bulum results, and the femur is drawn up, constituting a spontaneous luxation. Often an abscess forms, and opens ex- ternally. The toes may be turned in- ward or outward. Treatment.—Perfect rest upon a mat- trass, as in caries of the spine, the limb being confined in a curved splint. Cups and leeches, over the joint, will be useful at first; subsequently, more benefit will be derived from blisters, setons, and issues. Counter-irritation, by purging with jalap and cream of tartar, tonics, and iodine, are the constitutional remedies. It may require months or years to effect a cure. FRACTURES. Fracture is a solution of continuity of a bone, produced by ex- ternal violence, or muscular contraction. Fractures are divided into oblique, transverse, and longitudinal, according to the direction. Simple fracture is a mere separation of the bone into two parts ; com- 36 SURGERY. pound, implies an open wound, communicating with the fracture; comminuted, when the bone is broken into numerous fragments; and complicated, when attended with luxation, laceration of large vessels ($£C* The signs of fractures are deformity, preternatural mobility, ere- pitation, pain, swelling, and helplessness of the part. Old age, and certain diseases of the bones, predispose to fractures ; in cold weather, they are more numerous, on account of the increased muscular ex- ertion necessary in walking, where there is ice. Indirect violence may occasion fracture, when a force is applied to the two extremi- ties of a bone, which gives way between them. Deformity may be produced by an angular derangement, or a derangement in the direc tion of the axis, the diameter, or the circumference of the bone. Bent bones are occasioned by a few of the osseous fibres giving away upon the convexity of the curve. The process of reparation is more rapid in the young, and also takes place sooner in a small than in a large bone. Danger results, according to the site of the injury, the nature of the fracture, and the state of the system. The mode of reparation is attended by the following changes : extravasa- tion of blood; after this is absorbed, the liquor sanguinis is effused, and assumes the position which the blood occupied; this consoli- dates; the serous portion is absorbed; the fibrin remains, and becomes organized. This period of plastic exudation lasts for eight or ten days, and then becomes cartilaginous. This mass contracts, increases in density, and gradually becomes bone. The ossification advances from the periphery. The fractured extremities are now surrounded by a bony case, termed the provisional callus ; after which continuity is truly restored by the formation of what is called definitive callus, which takes place between the fractured extremities; and, finally, the provisional callus is absorbed. Treatment.—This consists of two parts; first, reduction, which is to be effected gradually by extension and counter-extension, over- coming muscular contraction, and coaptating the extremities; se- condly, retention, which is effected by keeping the limb in such a posture as will relax those muscles which would be likely to cause a displacement, and by applying such mechanical means as will prevent motion ; these means consist of splints, which are variously constructed of wood, pasteboard, or metal, and applied by means of bandages or rollers; they should be light, and always of such a length as to command the neighbouring joint; the inner surface should be padded or lined, in order to prevent chafing. After being dressed, the part should be laid upon a pillow, and not disturbed, unless there should be inordinate swelling of the limb, when the bandage should be loosened. Bandages soaked in gum or starch, have recently been used, in place of splints. Under certain circum- stances, this dressing is admirable, but an indiscriminate employ- FRACTURE OF LOWER JAW. 37 ment tends manifestly to injury: on account of the swelling of the limb, it produces pressure, which may occasion ulceration or slough- ing. It is called the immovable apparatus. The diet should be watched, and antiphlogistic means resorted to, if necessary. At the end of three to six weeks, the provisional callus is complete, and the substitutes for this splint of nature can be discontinued; the use of the part must be resumed gradually, especially in the lower limbs. FRACTURE OF THE NOSE. The nasal bones are usually fractured by a fall, a violent blow, or kick of a horse, or some direct application of force. This frac- ture is often attended by injury of the brain, and followed by caries and exfoliation. Treatment. — This consists cf antiphlogistic means, such as leeches, cold applications, and rigid diet, to remove swelling and in- flammation, and the adjustment of the fragments; which can be ac- complished by a catheter, probe, or dressing forceps. The nose should not be plugged with lint, unless to check profuse hemorrhage. FRACTURE OF THE MALAR AND SUPERIOR MAXILLARY BONES. These can only occur by the most direct violence, or gunshot in- juries, and are usually attended with crushing and wounding of the soft parts; severe inflammation and nervous symptoms may come on, and the brain may also be affected. There will be great pain and difficulty in chewing. Treatment.—If there is no displacement, there is nothing to be done but to subdue inflammation, and keep the parts quiet. If the alveolar processes are loosened, they must be pressed into their places, and the mouth kept shut, and the patient nourished by fluids. FRACTURE OF LOWER JAW. This may occur in the middle of the base of the jaw, in the ramus or processes; and in children it may take place at the sym- physis. The most frequent seat of fracture is between the chin and the insertion of the masseter muscle; the longer fragment and the chin are depressed. In double fractures, the chin alone is de- pressed. There is pain, swelling, inability to move the jaw, irregu- larity of the dental arch, crepitus, and frequently hemorrhage and deafness. The diagnosis of fracture of the ramus and condyle is often ob- scured by swelling; the neck of the condyle is drawn forwards by the external pterygoid muscle, and crepitation will be perceived by the patient. Treatment.—The teeth serve as a guide in the adjustment of the fragments, and the upper jaw acts as a splint in the retention. A 38 SURGERY. compress and a pasteboard splint, retained by a suitable bandage, will retain the parts in apposition ; and the patient is to be fed by gruels and soups, through the interstices of the teeth. The union is rapid, and there is usually but little deformity. FRACTURE OF THE SPINE. This is attended with serious injury to the spinal cord, from com- pression, laceration, bruising, concussion, or from subsequent in- flammation and softening. When it occurs above the fourth cervical vertebra, death is almost certain, on account of the origin of the phrenic nerve which supplies the diaphragm. When the lumbar region has suffered, the symptoms are paralysis of the lower limbs, involuntary discharge of faeces, retention of urine, and frequently priapism. When the injury is in the upper dorsal or lower cervical region, there is, in addition to these symptoms, paralysis of the arms, diffi- culty of breathing, sluggishness of the bowels, and distention of the abdomen. In all fractures of the spine, the kidneys suffer, and bed- sores are apt to follow. Treatment. — Absolute rest upon a mattrass, low diet, and anti- phlogistic means, to prevent the formation of pus, and thickening of the membranes. The discharges of the bowels must be regu- lated, and the bladder relieved by the catheter; counter-irritation and frictions will be useful in the latter stages of the case. The use of the trephine in this injury has not met with success, and will pro- bably do more harm than good. FRACTURE OF THE PELVIS. Fracture of the bones of the pelvis can only be produced by the greatest violence. There is but little displacement, although great danger results from injury to the parts within. Treatment. — All that can be done is to place the patient at rest in an easy position, keep a catheter in the bladder, and make inci- sions, if urine or pus is extravasated in the perineum. The appli- cation of a broad bandage around the hips, will assist in preventing motion. When the crest of the ilium or the anterior superior spinous pro- cess is knocked off, the fragment is displaced inwards, and can be readjusted by the fingers. Fracture of the sacrum is longitudinal usually, and there is no displacement. The coccyx may be frac- tured by a kick, and is displaced inwardly : readjustment may be effected by the finger in the rectum. The acetabulum may be split, and injury of the neck of the femur may be simulated, though there is no shortening of the limb, and crepitus is felt by the finger in the rectum, when the pelvis is moved. FRACTURE OF THE SCAPULA. 39 FRACTURE OF THE RIBS. The ribs are very liable to fracture, which usually is in the mid- dle, when occurring from direct force, or force applied at each end. Displacement is seldom great, and is difficult to detect in fat persons. There is pain, swelling, and difficulty in breathing; crepitus is felt, when the hand is placed over the part during respiration or coughing; emphysema appears when the pleura is injured. Treatment.—If there is an angular projection of the extremities, a compress is to be applied over it; if there is a depression, a com- press is to be placed at each extremity ; the chest is to be surrounded by a roller, in order to prevent respiration by the intercostal muscles, and thus to keep the parts at rest. Inflammation and cough are likely to ensue, and must be treated by antiphlogistic means and anodynes. Compound fracture of the ribs is treated of, under the head of Wounds of the Chest. FRACTURE OF THE STERNUM. Fracture of this bone is rare, on account of violence being neces- sary to produce it; injury usually is done to the thoracic viscera. The deformity is generally a depression, and the symptoms are great difficulty of respiration, pain, palpitation of the heart, and perhaps spitting of blood, and cough. Caries, or a pulmonary affection, often results from a fracture of the sternum or ribs in scrofulous habits. Treatment.—The local treatment consists of a compress and a roller, applied upon the same principles as in fracture of the rib. The general treatment must be adapted,to the inflammatory condi- tions of the organs of the chest. Collections of pus and blood be- hind the sternum can be evacuated with a trephine, but the operation* is often attended with unfavourable results. FRACTURE OF THE SCAPULA. The acromion process is sometimes fractured ; the shoulder loses somewhat of its roundness, the head of the humerus falls slightly, and there is a slight depression at the point of fracture. It is distin- guished from dislocation by mobility of the joint, and crepitation can be felt by rotating the head of the humerus. Treatment. — It may unite by bone, but generally it unites by ligament. It is to be kept in its place, by elevating and firmly fix- ing the os humeri; this is effected by placing a cushion between the side and the elbow, and retaining it by a roller, the elbow being car- ried a little backwards. If the pad be placed in the axilla, and the elbow be brought close to the side, the fragments will be separated; but little inflammation follows, and bandages may be removed in 40 SURGERY. three weeks. In many individuals, the tip of the acromion process is slightly movable, being merely united by ligament. The neck of the scapula is rarely fractured, and it is liable to be mistaken for a dislocation ; the shoulder falls ; there is a hollow be- low the acromion, from a sinking of the deltoid muscle; and the head of the humerus can be felt in the axilla. It can be recognised by the facility with which the parts are replaced, the falling of the head of the bone into the axilla, when the extension is removed, and by crepitation. Treatment.—The first point is to carry the head of the humerus outwards, and the second to raise the glenoid cavity and arm. The former is effected by a thick cushion confined in the axilla by a bandage, and the latter by placing the arm in a short sling. Ten or twelve weeks are necessary to procure union, and a still longer time to recover the strength of the arm. The coracoid may be fractured by direct violence; the process is drawn downwards, by the action of the coraco-brachialis, pectoralis minor and biceps muscles. There are pain, swelling, and crepita- tion in the part, and loss of power in the limb. Treatment. — This consists in making the fingers of the injured limb touch the shoulder of the opposite side, the position being secured by bandaging. The body of the scapula may be fractured either vertically or transversely, and there is but little displacement, unless it is near the lower angle of the scapula. When the angle is fractured, it may be drawn forward and upward. Treatment.—This consists of a tight roller around the chest; the arm being placed in a sling. FRACTURE OF THE CLAVICLE. This fracture is frequent, and is usually produced by violence upon the shoulder, arm, and hand. It is generally oblique, and near the middle of the bone; the part is painful and swollen, and every attempt at motion produces pain ; the shoulder is sunken, and drawn towards the sternum, and the acromial fragment is drawn down- ward by the weight of the arm, and forward and inward by the action of the subclavius muscle. The patient usually supports the arm with his other hand, to relieve the pressure upon the axillary plexus of nerves. The indications are plain, viz.: to elevate the shoulder; to keep it outward from the chest; and to draw it slightly backward. Treatment.—The mode of dressing this fracture is extremely various. DessauWs apparatus consists of a compress placed over the fracture, a wedge-shaped pad placed in the axilla, and retained by a roller which surrounds the chest. The elbow is to be brought to the side, and the arm and chest surrounded by circular turns of a FRACTURE OF THE HUMERUS. 41 second roller, whereby the shoulder is elevated and drawn outwards. A third and last roller commences at the armpit of the sound side, and being carried obliquely over the compress, descends the posterior portion of the arm, passes under the elbow, and obliquely upwards across the chest to the armpit, whence it started; then over the back to the shoulder of the affected side, across the compress, down in front of the arm, under the elbow, and across the back to the sound armpit again. This bandage serves to retain the arm and shoulder in its elevated position. Fox's apparatus consists of a wedge-shaped pad, secured by strings to a circular collar which surrounds the shoulder of the sound side, and a sling made of linen, which contains the forearm ; it elevates the shoulder, and, by bringing the elbow to the side, draws the shoulder outwards. Some use merely a pad and two handkerchiefs, which, if properly applied, can be made to fulfil all the indications. Some deformity almost always results. FRACTURE OF THE HUMERUS. The anatomical neck is the seat of fracture in young persons, and sometimes in old. There is little or no flattening of the shoulder, owing to the head of the bone remaining in its place ; the end of the shaft is directed obliquely upwards and forwards, and projects on the coracoid process ; the arm is shortened, and crepitus is distinct after slight extension and coaptation of the Fig. 2. fragments. Treatment.—This requires a pad in the axilla, a splint on the fore and back part of the arm, a roller, and a sling for the hand, the elbow hanging free. The Surgical Neck.—The upper fragment remains in its place, but its low extremity inclines slightly out- wards ; the upper end of the lower fragment is drawn upwards and inwards under the pectoral muscle, and the shoulder is round, the arm shortened, the elbow abducted, and there is crepitation upon adjustment. Treatment.—A pad is placed in the axilla; two splints secured by a roller; the hand supported by a sling, and the elbow free. Fracture at the Neck may be accompanied with dis- location. This is recognised by the tumour in the axilb., formed by the head of the bone, which does not move when the shaft is rotated. Treatment.—An effort should be made to restore the head of the bone, and then to coaptate the extremities: this is often impossible ; then the extremity of the lower fragment should be brought to play in the glenoid ca- 4 42 SURGERY. vity. A pad will be necessary in the axilla, and the same dressing as the last. A new joint is formed, and the motions of the arm are only partial. The shaft may be fractured at any point, and is easily recog. nised by crepitation ; and when the fracture is just below the surgical neck, the lower extremity of the upper fragment is drawn inwards by the muscles inserted into the bicipital ridges, and the upper ex- tremity of the lower fragment is drawn outwards by the deltoid muscle. Treatment.—The reduction is easy, and the extremities may be retained in contact by four small splints placed around the arm, and secured by a roller, which, as in all other instances of its use in the upper extremity, must commence at the hand. The forearm should be suspended in a sling. The condyles are fractured in various ways. Either condyle may be fractured, most frequently the internal; or, there may be a frac- ture between the two condyles, and another separating them from the shaft. These injuries are distinguished from dislocation at the elbow by mobility and crepitation. Treatment.—By a roller and two angular splints, (Physick's,) reaching to the hand from the middle of the arm. The angle of the splints must be changed to prevent anchylosis. Some deformity and stiffness often remain. FRACTURE OF THE RADIUS AND ULNA. When both bones of the forearm are fractured at once, or when either bone is fractured near the middle, there is but little difficulty in the diagnosis, being easily recognised by the ordinary signs of fractures, such as pain, crepitus, swelling, and uselessness of the limb. Treatment.—The great object is to preserve the interosseous space; for, if the fragments unite at an angle, supination and prona- tion will be prevented. The fracture is readily reduced by slight extension, and then the muscles shonld be pressed into the interos- seous space, in order to separate the two bones. Two splints, well padded on the inside, reaching from the elbow to the fingers, should be applied, and retained by a roller. The arm must be kept in a position between supination and pronation, and supported by a sling; after a week or two pasteboard splints, or a starch bandage may be substituted. The radius is more frequently fractured than the ulna, on account of its articulating with the carpus, and thus receiving the weight of the body in falls, &c. When fractured near the middle there is but little deformity, the ulna acting as a splint. The neck of the radius is but rarely fractured, and the accident is difficult to recognise, especially when the muscles covering it are FRACTURE OF THE RADIUS AND ULNA. 43 very large. It is to be discovered by fixing the head of the bone, and rotating the hand and forearm. The loiver extremity of the radius is often fractured, and fre- quently mistaken for a dislocation of the wrist. (Fig. 3.) Fig. 3. Fractures of the radius are to be treated upon the same principles, and by the same means as in other fractures of the forearm, unless the fracture should be through the articular surface of the carpal extre- mity of the radius. This latter fracture gives a peculiar deformity to the wrist, dependent upon a partial luxation of the carpus. In this in- stance, besides the ordinary splints, two small compresses are to be applied, one upon a prominence on the dorsal surface caused by the fragment, the other upon the projecting extremity of the radius on the palmar side. Of course these compresses will not be opposite to each other. Passive motion should be established in a week, for Fig. 4. Fig. 5. 44 SURGERY. fear of anchylosis, and the loss of the pulley-like motion of the ex- tensor tendons on the back of the radius. The ulna is most frequently fractured below the middle of the shaft. The lower fragment approximates the radius by the action of the pronator quadratus, and the other usual symptoms of fracture are evident. The olecranon process is often fractured by sudden violence, or muscular action. The fragment is drawn up upon the back of the arm by the triceps muscle, and the deformity is increased by flexion. The union is usually ligamentous. (Fig. 4.) The coronoid process is rarely fractured, and usually by inordi- nate muscular action of the brachialis anticus muscle, whose tendon is inserted in front of the base of this process. Dislocation back- wards by the action of the triceps may result. The union will be ligamentous. (Fig. 5.) Treatment.—Fractures of the shaft are to be treated by two splints and compresses, as are those of the radius. Fracture of the olecranon is to be treated by extending the elbow, placing a small splint in front of the joint, and securing it by a roller. The coronoid is to be treated by flexing the elbow, applying a roller to relax the muscles and prevent their action, and keeping the forearm in a sling. FRACTURE OF THE CARPUS, METACARPUS, AND PHALANGES. The bones of the carpus are seldom fractured. The injury is usually a compound one, and produced by direct force. The metacarpal bones are subject to simple fracture, which is easily recognised by pain, swelling, crepitus, &c. The treatment consists of coaptation of the fragments, and retaining them by means of two splints and interosseous pads, or compresses. The phalanges are liable to compound and simple fracture. Simple fractures to be treated by two or four small splints, and a narrow bandage; when several fingers are broken, a curved splint will be useful. FRACTURE OF THE FEMUR. The neck may be fractured within the capsule. This occurs most frequently in old persons, and in females, on account of bony tex- ture being more brittle in advanced life, and on account of the anatomical character of the neck of the femur in women. The accident may be produced by a slight fall, muscular contraction, blows, &c. The head of the bone remains in the acetabulum ; the lower fragment is drawn upwards by the muscles of the hip, and the foot is everted, owing to the action of the rotator muscles. The limb is shortened, the trochanter is one or two inches higher, and flatter than its fellow; there is pain, crepitus, and want of voluntary - FRACTURE OF THE FEMUR. 45 motion. The arc which the trochanter, upon rotation, will describe, will be of a much smal- ler circle than that described by the rotation of its fellow. Union is possible, but improbable; on ac- count of the difficulty of coaptating the frag- ments, the want of provisional callus, the frac- tured extremities being bathed in an increased quantity of synovia, and the feeble nutrition of the head of the bone through the round ligament. Yet, in a young person of good constitution, where the periosteum is not com- pletely severed, there may be bony union. Ordinarily there results a false joint, thicken- ing of the capsule, partial absorption of the fragments, and the patient is lame for life, and requires a stick or crutch. Feeble old women may die from the shock of the injury or from the irritation of pain and confine- ment. Treatment.—Extension and splints are un- necessary—the limb should be supported by pillows, and motion restrained. Care should be taken with reference to bedsores, sloughs, ( The neck may be fractured partly within and partly without the capsule, in which case the prospect of union is much more favour- able. Or, the extremity of one fragment may be driven into the cancellated structure of the other, constituting an impacted fracture; in these cases, crepitus is obscure, the displacement is slight, and there is considerable power and motion of the limb, and but little shortening and eversion. They are produced by great direct force, and are attended with great pain, swelling and constitutional dis- turbance. The treatment may be successful in many instances, without the use of splints. The trochanter major may be fractured; the process is drawn upwards by the glutei muscles, and a space can be felt between the fragments. Approximation and retention are difficult, and the union generally ligamentous. The cure is to be effected by rest, position, and relaxing the muscles. Fracture of the condyles is a serious injury, especially when communicating with the joint. After the fragments are somewhat consolidated by rest and position, passive motion must be established to prevent anchylosis. Fracture of the shaft is easily recognised by shortening, crepita- tion, &c. &c. The deformity is greater when it occurs in the upper part, especially when just below the trochanters, the lower end of the 4* Fig. 6. 46 SURGERY. upper fragment being tilted forward by the action of the psoas mag- nus and iliacus internus muscles. Treatment.—The principles of treatment are, as in all fractures, coaptation and retention, but the means to effect it are various. The double inclined plane is a simple contrivance. The leg is secured to one plane, which furnishes the means of counter-extension, and the thigh rests on the other; the weight of the body produces the extension. DessauWs Apparatus.—Consists of an outer splint, three or four inches wide, reaching from the crest of the ilium to four inches beyond the foot, each extremity having a hole in it; an inner splint reaching from the perineum to the sole of the foot, and an upper splint reach- ing to the knee. The counter-extension is made by a band in the perineum, which is secured to the upper end of the outer splint by means of the hole in it. The extension is made by a band or handkerchief applied to the ankle, and secured to the hole in the lower end of the outer splint. Liston uses only the outer splint, as represented in the figure. Fig. 7. Dr. PhysicWs modification consists in an elongation of the outer splint, nearly to the axilla ; by this means counter-extension is made in a line more nearly parallel with the axis of the body, and a block was placed upon the inner side of the lower end of the same splint, below the foot, for the purpose also of preventing the line of exten- sion being oblique, which might produce pain and deformity. Bags of bran are placed on each side of the limb, so as to secure uniform pressure from the splints, and the whole is secured by bandages. Hagedorn's Apparatus consists of one splint reaching from the hip to a foot-board. The counter-extension is made at the acetabulum of the sound side, and the extension by the foot of the injured side. The splint is first applied to the outer side of the sound limb, and the foot secured to the foot-board ; and the extension is made by drawing the foot of the fractured limb down to the foot-board, and securing it. This avoids the necessity of a perineal band, which may excoriate. Dr. Gibson's modification of this apparatus consists in an elon- FRACTURE OF THE LEG. 47 gation of the splint as high as the axilla, which will prevent any lateral inclination of the body ; and the application of a similar splint to the fractured limb. FRACTURE OF THE PATELLA. The accident may result from muscular contraction or direct vio- lence. It is sometimes attended with an audible snap and falling of the patient; the pain is not severe, and a simple fracture is not dan- gerous. The limb is bent partially, and there is no ability to ex- tend it. The direction is usually transverse, and a separation of the frag- ments can be felt. There is no crepitus. Considerable swelling usually follows. Longitudinal fractures are rare, and are not attended by the same symptoms. Treatment.—Leeches and lotions should be applied to reduce swelling and inflammation, and then the limb should be extended, a roller and figure of 8 bandage applied to coaptate the fragments and compress the muscles of the thigh. A long splint, reaching from the ischium to the heel, applied to the back of the limb, will prevent motion. Bony union is not to be expected ; a strong ligamentous connexion is usually formed, which answers the purpose extremely well. Pas- sive motion should be made after five or six weeks. Sixty or seventy will elapse before the limb can be used, and even then caution should be taken that the newly-formed ligament is not broken, or the patella of the opposite side, from increased muscular exertion of the sound limb, and possessing the same structure which disposed to the fracture in the broken limb. v FRACTURE OF THE LEG. A frequent accident, occurring in one or both bones, from a fall or direct violence. The tibia is most frequently fractured, on ac- count of its exposed position, and sustaining the weight of the body. The fracture may occur at any part, but the deformity is greater, as it may be nearer the lower extremity ; if nearer the upper extremity the deformity may be slight and the patient even walk about. The fibula may be fractured by direct or indirect force. Little deformity results, unless the fracture is below its middle. When nearer the ankle, dislocation may be produced. The most frequent seat of fracture is from two to three inches above the malleolus. There is immediate lameness; the foot is turned out; crepitus is distinct, and a depression exists over the fractured part. Both bones are often fractured at once by falls or blows; they 48 SURGERY. occur at the weakest points. The signs are evident: crepitus, pain, want of motion, &c. There is seldom any great shortening, and the deformity is readily reduced. Treatment. — When both bones are fractured, when the tibia alone is fractured, or, when the upper part of the fibula is fractured, the best and most simple apparatus is the fracture-box and pillow. The fracture-box has a foot-board, to which the foot is secured by a bandage, thus preventing any lateral inclination. In lieu of this, two splints of the length of the leg, applied on either side of the pillow, will answer the purpose, care being taken to support the foot by a bandage or handkerchief. Fig. 8. Fractures of the lower end of the fibula are to be treated by Du- puytren's or Physick's apparatus; which consists of a single splint, placed on the inner side of the leg, and reaching beyond the foot. It is provided with a wedge-shaped pad, which reaches only to the ankle, the larger end of which, being applied to the internal malle- olus ; a bandage is carried over the ankle in such a manner as to produce inversion of the foot, making the sole of the foot approxi- mate the splint, and thus fragments are adjusted and the deformity removed. FRACTURES OF THE BONES OF THE FOOT. The os calcis may be fractured by great violence connected with the action of the sural muscles. The tuberosity will be drawn up by the tendo Achillis, and the patient is unable to stand. The treatment consists in overcoming the action of the triceps surse, flexing the leg upon the thigh, and extending the foot upon the leg. The fragments are to be approximated by a figure of 8 bandage. The astragalus is rarely fractured; it may occur at the posterior part where the tendon of the flexor longus pollicis plays over it; or it may occur between the body and the head. In the first instance the foot will be inverted, in the latter but little deformity will occur. It can be treated successfully by a simple fracture-box. Should caries take place it may become necessary to extirpate it. The metatarsal bones and the phalanges are seldom fractured, unless the injury be complicated or compound. DISLOCATIONS. 49 COMPOUND FRACTURE. Unless a wound communicate with the fracture it is not com- pound. The wound may be produced by the means which broke the bone, by the bone protruding, or by subsequent ulceration. Great danger may result from the shock, hemorrhage, tetanus, sup- puration, hectic, or typhoid fever. Primary amputation is necessary if the bone is much shattered; if a joint, especially the knee-joint, is opened ; if large arteries are torn ; if the soft parts are extensively lacerated or bruised, particularly if the patient is old or enfeebled by disease. The treatment, if it be determined to try to save the limb, will be to convert the fracture into a simple one, by arresting bleeding, re- moving pieces of bone, clots, &c, so the wound will heal without suppuration. To reduce the protruding fractured extremities, it may be necessary to saw off a portion; to arrest the hemorrhage, it may be useful to envelope the parts in bran, or stuff the opening with lint, which must be removed as soon as suppuration occurs. The subsequent part of the treatment may require antiphlogistic, but more frequently tonic measures, such as bark, wine, good diet, &c, especially if the discharge is profuse. Secondary amputation may be necessary at last. DISLOCATIONS. Dislocation or luxation, is the removal of a bone from its articu- lating cavity. The ball and socket joints are most liable to the injury. The predisposing causes are the peculiarity of the construction of the joint, weakness or paralysis of muscles, elongation of the ligaments, particular position of the parts, accumulation of fluids in the joint, or diseases and fractures of the bones. The exciting causes are external violence; such as blows, falls, &c, and muscular contraction. The symptoms are deformity, swelling, and a hollow where none should be, shortening or elongation, pain and immobility of the limb. The consequences are rupture of ligaments, effusion of blood and serum ; lymph coagulates, forms new adhesions, and fills up the old socket, and the head of the bone gradually accommodates itself to its new position, there always being some attempt to form a new socket; and thus considerable motion is subsequently acquired by the limb. Dislocation is to be distinguished from fracture by the absence of crepitus, the rigidity of the limb, the peculiarity of the deformity at the articulation, and by the absence of deformity after reduction; whereas in fractures, it will recur without being prevented by dressings. Treatment.—This essentially consists in overcoming the action of the muscles which retain the bone in its unnatural position, and 50 SURGERY. also in bringing the head of the bone into such a situation that the action of the muscles may draw it into its place. Constitutional means are often necessary to effect reduction in the larger joints, such as bloodletting, warm baths, emetics, in order to produce relaxation of the muscles. The local means are ex- tension and counter-extension. The extension must be made gra- dually, in order to overcome the action of the muscles, and to place the head of the bone in such a situation as to be drawn into its place, and the extension must be withdrawn suddenly, in order that the muscles may leave the effect by their contraction. The treatment subsequent to the reduction consists in maintaining the limb at rest, and applying leeches and cold applications to re- move swelling and pain. Afterwards, if any stiffness remains, stimulating friction may be used. Subluxation implies a partial removal of the head of a bone from an articulating surface. Recent and old, are terms applied to luxa- tions with reference to the period which may have elapsed, and the changes which may have occurred by adhesions, &c. Compound Luxation.—This is connected with a wound in the integuments, fracture of bone, laceration of large vessels, &c. The same principles apply as in compound fracture. The same contin- gencies of age, temperament, and constitution, will influence the treatment. The question of amputation is first to be considered, and then the reduction. The after treatment would be that for a wound of the joint: careful closure of the wound,—prevention of inflam- mation by antiphlogistic means ; if possible preventing suppuration, anchylosis, and tetanus. DISLOCATION OF THE JAW. Dislocation of the jaw may be caused by spasm of the pterygoid muscles when yawning, Fig. 9. or by a blow on the chin when the mouth is wide open. The condyles are pushed forwards, and rest in front of the base of the zygomatic process of the temporal bone. Symptoms.—The mouth gapes and cannot be shut, the glenoid cavity is va- cant, and there is a prominence felt beneath the zygoma ;—the saliva trickles, articulation is pre- vented, and there is great pain. DISLOCATION OF THE RIBS. 51 Treatment.—The patient should be seated on a low stool, and the surgeon standing in front, should press his thumbs, properly pro- tected, upon the last molar teeth, at the same time elevating the chin with the fingers. The condyles are thus extricated from their un- natural position, and returned to their socket by the normal action of the muscles, which produces an audible noise. In difficult cases, greater leverage may be obtained by using two forks or strong pieces of wood, connected by a string in such a way that it will elevate the chin, whilst the ends are pressed against the teeth in place of the thumb. When the resistance is great the efforts may be directed first to one side at a time. After reduction, the chin should be confined by a bandage for a week or ten days. DISLOCATION OF THE SPINE. This accident rarely happens unless connected with fracture; although it has occasionally occurred in the cervical vertebrae. It may be produced by the muscular efforts of convulsion and mania, but more frequently is the result of violence; for instance, falls from a height, crushing by wheels, hanging, &c. The chance of life is but small on account of injury done the spinal marrow. The displacement is easily recognised by the deformity, paralysis, &c. Dislocation of the atlas upon the dentata may occasion instant death, by the intrusion of its dentate process into the spinal marrow. Dislocations of the oblique processes simply may terminate with no other inconvenience than contortion of the neck and restricted mo- tion of the head. The action of the diaphragm may be suspended by compression of the phrenic nerve. Dislocations of the bodies of vertebrae of the neck and back, are almost necessarily accompanied by fracture. Treatment.—But little is to be expected. Great care is required in extension and coaptation. In the neck, danger is to be appre- hended from an attempt to reduce the deformity. Contusion of the muscles may produce a deformity which may resemble dislocation. Subluxation or partial dislocation is more common ; and it may terminate without permanent injury to the spinal marrow; provided the antiphlogistic system is pursued in all the details of rest, diet, purging, cups, &c. DISLOCATION OF THE RIBS. The vertebral extremity of the ribs can only be dislocated by severe falls, or blows upon the back ; on account of its double articulation, and its protection by the muscles of the back. The sternal extremity is sometimes loosened from the cartilage by vio- lent bending of the body backwards;—great pain and difficulty of 52 SURGERY. breathing follows. Reduction can be effected by deep inspiration, slightly bending the body backwards and making some pressure on the projecting point. The subsequent treatment is the same aa that for fracture of the rib. DISLOCATION OF THE CLAVICLE. The clavicle may be dislocated at either extremity, and is more rare than fracture. The sternal end may be dislocated upward, backward, and for- ward, fig. 10. When dislocated upward, the sternal extremity approaches its fellow, and is much more elevated than the acromial extremity. When dislocated backward, which is more rare, there is a depression over the articulation, pain and stiffness in the neck, and difficulty of swallowing. When the direction is forward, which is the most frequent, it is produced by force applied at the opposite extremity. It is characterized by a projection over the spot, inclina- tion of the head to the affected side, pain upon moving the arm, and the shoulder is brought near to the chest. The reduction is easy,—by means of extension and counter-ex- tension ; there is more difficulty in preventing a recurrence of the accident. Dessault's apparatus for fractured clavicle should be applied. But even with the greatest care, greater or less deformity commonly remains, which, however, does not interfere with the motions of the arm. The scapular end is generally dislocated upwards. Although sometimes it slides beneath the acromion. It is usually the result of a fall; and is recognised by pain, impeded motion, depression of the shoulder, and the clavicle resting on top of the acromion occa- sions a projection. Reduction is effected by elevating the shoulder and depressing the corresponding end of the clavicle. Dessault's bandage is then to be applied, and the part kept at rest. Some displacement usually re- mains, which does not prevent motion of the shoulder. DISLOCATION OF THE ARM. This is the most frequent dislocation, on account of the mobility of the shoulder joint, its constant exposure to injury, and the shal- lowness of the glenoid cavity, compared to the size of the head of the humerus. It may be displaced in three directions; viz., inwards, downwards, and backwards. In dislocation inwards, the elbow stands out from the body, and is inclined a little backward ; a protuberance is felt beneath the pectoralis major muscle, and there is frequently shorten- ing of the limb. In dislocation downwards, which is the most common displace- ment, the arm is lengthened, and there is great rigidity and DISLOCATION OF THE ARM. 53 immobility; the elbow stands out from the F«• 10- body ; there is a hol- low under the acro- mion process, and a prominence in the axilla. In dslocation back- ward, which is most rare, the elbow is in- clined inward and for- ward, the head of the bone forms a promi- nence beneath the spine of the scapula, and there is a hollow beneath the acromion, together with rigidity and immobility. Violence and con- traction of the mus- cles pectoralis major, latissimus dorsi, teres major, and deltoid, are the causes of disloca- tion of the arm. The immediate injury is a laceration of the capsule, contusion of the muscles, and effusion of blood, and often paraly- sis of the deltoid muscle from compression of the axillary nerve. Unless reduction is effected the parts become united by adhesions,— after which reduction cannot be produced without danger of lacerating the artery. Fig. 11. 54 SURGERY. The reduction is managed in different ways. The ordinary plan is to place the patient on the bed, and then to place a spherical pad in the axilla. The surgeon makes counter-extension with his foot upon the pad, and extension with his hands. If this force is not sufficient, counter-extension may be made by passing a folded towel or sheet under the axilla, and securing the ends to the bed-post; and extension by fastening a folded sheet or long towel to the wrist or elbow by a damp roller; thus several assistants can make exten- sion at once. If this force is not sufficient, pulleys may be employed, taking care that the extension be made very gradually. The elbow has this advantage over the wrist, as a point of appli- cation of the extending band,—the elbow can be bent, and thus a greater rotatory movement of the head of the bone produced. The wrist is preferred by some, on account of there being no muscles compressed, whose contraction might interfere with the reduction. After reduction, which is recognised by cessation of pain, rotun- dity of the shoulder, and mobility of the limb, the arm should be kept in a sling, and not used for several days. Should paralysis of the deltoid continue, it may be relieved by stimulating lotions, blisters, moxas, &c. DISLOCATIONS AT THE ELBOW. When both radius and ulna are dislocated at the elbow, the fore- arm is bent nearly at a right angle, and is immovable. The olecra- non forms a prominence behind, and the articular extremity of the humerus, covered by the brachialis anticus muscle, forms a pro- tuberance in front. The coronoid process of the ulna is received Fig. 12. into the greater sigmoid cavity of the humerus, and tends to main- tain the bones in their unnatural situation. A lateral dislocation inwards may also occur, in which there is a great projection of the external condyle of the humerus, in addition to the symptoms of the first variety. When the ulna alone is dislocated backwards, the olecranon forms a marked projection posteriorly, the elbow is bent at right angles, and the forearm is pronated. DISLOCATIONS AT THE ELBOW. 55 Reduction of the above forms of dislocation is effected by making forcible extension of the forearm over the surgeon's knee, which is to be placed at the elbow, to make counter-extension. The forearm is to be bent while extension is produced. The radius is dislocated at its upper extremity, either forwards or backwards. Backwards is the most frequent displacement. The head of the bone forms a prominence behind, the arm is bent and the hand is prone. When displaced anteriorly, there is a distinct prominence in front, the arm is slightly bent, but cannot be com- pletely flexed, and there is some pronation. The reduction is effected by making forcible extension and pro- nation at the same time, if the displacement be anteriorly; if the displacement be posteriorly, supination is to be produced with exten- sion. In both the head of the bone is to be pressed upon by the surgeon's thumb, in order to facilitate its sliding into its proper place. Dislocation at the elbow occurs but. rarely, on account of the ginglymoid character of the joint, and is generally accompanied by considerable laceration of the soft parts. Rest, cold applications, a sling, are subsequently required and together with general anti- phlogistic means. It is produced, most frequently, by force applied to the wrist, and when complicated with fracture of any of the processes, anchy- losis, gangrene, and other dangerous results may follow, especially if the reduction is delayed, and adhesions have formed. DISLOCATIONS AT THE WRIST. The radius and ulna may be separated from the carpus, either anteriorly or posteriorly. When dislocated forwards there is a great projection in front, and the hand is bent backwards; when back- wards, the projection is behind, and the hand is flexed. It is produced by violent bending of the hand, and is accompanied by rupture of the ligaments and stretching of the tendons. The reduction is easily effected by extension and pressure. Pain, swell- ing, and stiffness of the joint may follow, which are to be obviated by cold applications, rest, lotions, &c.; if there should be a tendency to its reproduction, a light splint may be applied. If the radius alone is dislocated from the carpus, which is gene- rally anteriorly, the hand will be somewhat twisted, the radial side of it being thrown backward. The ulna may be dislocated back- wards upon the radius, rupturing the sacciform ligament, and pro- ducing a projection on the back of the wrist, by which it is easily recognised. It is readily reduced by pressure and extension. A splint and bandage may be necessary to prevent its recurrence. DISLOCATION OF THE BONES OF THE HAND. Displacement of the bones of the carpus rarely occurs. Occa- 56 SURGERY. sionally there is a dislocation of the phalanges of the fingers, but more frequently the dislocation backwards of the first phalanx of the thumb, upon the metacarpal bone. Fig. 13. Reduction is effected by making extension in a curved line, by means of a narrow bandage or tape, firmly applied by a clove-hitch upon the phalangeal extremity. In some instances it may be neces- sary to divide the lateral ligament. DISLOCATIONS OF THE FEMUR. Dislocations of the thigh may occur in five directions:—1st, up. wards and backwards, on the back of the ilium (Fig. 14); 2d, in- Fig. U. Fig. 15. ?//..>!■& DISLOCATION OF THE FEMUR. 57 wards and downwards, into the foramen ovale (Fig. 15); 3d, back- wards and downwards, into the ischiatic notch (Fig. 16); 4th, upwards and forwards, on the horizontal ramus of the pubes (Fig. 17); 5th, downwards, under the tuberosity of the ischium. The first is the most common, the fifth is the most rare. Fig. 16. Fig. 17. In the most frequent displacements upwards and backwards, the limb>is shortened from an inch and a half to two inches and a half; the toes rest on the opposite instep; the knee is turned inwards and slightly bent; the limb may be bent across the other, but cannot be moved outwards; the trochanter is less prominent, and nearer the spine of the ilium ; and if the patient is thin, and there is no swelling, the head of the bone can be felt in its new position, and the rounded form of the hip is lost. It is to be distinguished from a fracture of the neck of the bone by the position of the foot and the rigidity of the limb. The reduction is the most difficult of all dislocations, and must be attempted as soon as possible after the displacement. If it is not produced, the head of the bone will adapt itself to its new position by the formation of a new cavity, and the patient will gradually be 5* 58 SURGERY. able to walk, the toes merely touching the ground. Bleeding, a warm bath, and tartar emetic must be administered, according to the patient's constitution, in order to produce relaxation of the muscles. Counter-extension is to be made by a folded sheet or large towel placed in the perineum, the patient being in the recum- bent position, and secured to a ring or hook firmly fastened in the wall or floor. \ Extension is to be effected by securing a folded towel or sheet above the knee, by means of a damp roller; this towel is to be acted upon gradually, by numerous assistants or by pulleys. The Fig. 18. extension is to be made gradually, in such a direction as to draw the thigh across the opposite one, a little above the knee. A third band or towel is to be passed around the pelvis, in order to fix it more firmly, the ends of which are to be tied on the sound side, which is to be given to an assistant. Dislocations backwards and downwards in the sciatic notch are next in point of frequency. The head of the bone rests on the pyri- formis muscle, between the sacro-sciatic ligaments and the upper part of the notch, a little above the level of the middle of the acetabulum. The shortening and inversion of the foot is not so great as in the first variety; the head of the bone can seldom be felt; the joint is extremely rigid, and motion of the limb almost impossible. In re- ducing this dislocation it is necessary that the head of the bone should first be brought out of the notch, before it can be restored to the acetabulum. Dislocations downwards and inwards are comparatively rare; the limb is elongated nearly two inches; the foot is advanced, though neither inverted or everted; the thigh is abducted, and cannot be brought near to its fellow ; the psoas and iliacus muscles form a ridge which can be seen or felt; the trochanter is flattened and depressed, and the space between it and the anterior superior spinous process of the ilium is much increased. To reduce this form, counter-exten- sion is to be made outwards by a band across the upper and inner DISLOCATIONS OF THE PATELLA. 59 part of the thigh; extension is to be made at the knee, which is gradually to be made to approximate its fellow. In dislocation upwards and inwards, the head of the bone rests upon the horizontal portion of the pubes, under Poupart's ligament, where it forms a tumour. The limb is shortened an inch, and the foot is turned outward, and cannot be rotated. The reduction is effected by extension in the axis of the body. Reduction of the thigh is indicated by an audible noise when the head of the bone returns to its socket, by the natural length and direction of the limb, by the cessation of pain, and the free motion of the joint. . After reduction there is sometimes a slight elongation of the limb, which depends upon the swelling of the ligaments of the joint. The patient should be kept at rest, and may require antiphlogistic treat- ment ; walking should not be attempted for several weeks. DISLOCATIONS OF THE KNEE. Dislocation at this joint is rare on account of its great strength. The displacement may be forwards, backwards, and laterally; is usually incomplete and readily reduced. The reduction is accomplished by extension of the leg and coap- tating the extremities of the bones. Subsequent inflammation and its results, anchylosis, suppuration, &c, are to be avoided by strict antiphlogistic means; sustaining the weakness of the joint by splints or rollers, and removing the stiffness by lotions and frictions. The semilunar cartilages are sometimes displaced by twisting the joint, especially if an unusual relaxation of the ligaments should exist. The limb is immediately rendered stiff, and the pain is severe parts to their position, although the pain and swelling remain for and sickening. Extreme flexion usually is sufficient to restore the some time and require attention. DISLOCATIONS OF THE PATELLA. The patella may be dislocated anteriorly, posteriorly, and late- rally. Outwards is the most frequent displacement, and is charac- terized by the leg being stretched, a prominence externally formed by the patella, and a projection internally of the internal condyle. Reduction is effected by raising the leg and resting the patient's heel on the surgeon's shoulder, thus relaxing the muscles of the thigh ; at the same time the patella is to be forced into its place with the hand. This bone can only be displaced upward by a rupture of its tendon, and downward by a laceration of the rectus muscle. It may be displaced by semi-rotation, one edge resting on the trochlea of the femur, and the other forming a prominent ridge. Extreme flexion and coaptation will reduce it. 60 SURGERY. DISLOCATION AT THE ANKLE. This accident is usually the result of severe force, and accom- panied by fracture of the malleoli. The displacement may be for- ward, backward, inward, and outward. Dislocation of the tibia inward is the most frequent, and owinu to a fracture of the external malleolus, the foot is everted and the internal malleolus greatly projects. Reduction is effected by extension of the foot and flexion of the leg, so as to relax the gastrocnemius muscle. Dislocation of the stibia outward is occasioned by a fracture of the internal malleolus, and the deformity is the reverse of the last. Dislocation backwards may result from a fracture of the posterior extremity of the astra- galus, in which instance the foot is inverted as in varus ; this is more rare than dislocations forward, which result from fractures of the lower end of the fibula. There is danger of suppuration and gangrene, especially if connected with an external wound. Ampu- tation will often be the best resort, particularly when the constitution of the patient is bad. #' DISLOCATION OF THE BONES OF THE FOOT. The astragalus is more frequently dislocated than any bone of the tarsus; and it may either be forward or backward. Unless re- duction can be effected, which is difficult, excision of the bone may be necessary, or amputation at the ankle. Dislocation of the other bones of the tarsus are usually compound injuries, and are to be treated upon general principles. INJURIES OF THE HEAD. THE SCALP. Contusion of the scalp may be very severe, on account of its being stretched over the resisting bony surface of the cranium, and being frequently connected with a lacerated wound. Owing to its vascularity, great swelling will occur from extravasation of serum or blood; in many instances a fluctuating tumour being produced be- neath the integuments. The swelling which results being readily depressed in the middle, may give rise to the idea of a fracture, which is to be carefully diagnosticated. The treatment will require cold applications. In no instance is a coagulum of blood to be evacuated by incision or puncture; but ab- sorption is to be promoted and depended upon, even if slow and tedious. It may be that the clot will produce inflammation and suppuration ; then a free incision should be made, and the exit of the pus favoured. Healthy granulation contracts the cavity, and the wound unites by the formation of a cicatrix. CONCUSSION. 61 The constitutional treatment required may be different in the early stages from the latter, being antiphlogistic or tonic, as the symptoms demand. Wounds of the Scalp.—Simple incised wounds of the scalp give little trouble but that of hemorrhage, which is best arrested by a ligature or torsion; a curved needle will be found more convenient to secure the vessels than the tenaculum. The edges are to be drawn together by adhesive straps, in preference to stitches, on account of the danger of erysipelas. When a large portion of the scalp is lacerated, and hangs like a flap, it is not to be cut, even though it is attached by a very small process ; but, after being care- fully cleaned, it is to be adjusted accurately, and retained in its place by proper bandaging. It thus protects the bone from exposure, and by granulation becomes firmly united to the adjacent parts. Blind- ness may result from a wound upon the forehead injuring the supra- orbital nerve. CONCUSSION. Concussion.—By this is meant a jarring or shaking of the brain without any great lesion, though function is temporarily impaired; inflammation is apt to follow. The force may be directly from a blow upon the head, or indirectly, from alighting upon the feet. The patient is stunned, is somewhat insensible, lies motionless, pale and cold. Insensibility is not complete, for questions will be answered, and pain manifested by pinching; respiration is feeble, the pulse is rapid, small, and fluttering; the pupils are insensible to light, some- times contracted, and sometimes dilated; nausea and vomiting often follow. After reaction, inflammatory symptoms commence, the pulse becomes full and hard, the skin hot and dry, the face flushed, the eyes bloodshot, great pain, especially in the head, restlessness and delirium. Treatment.—In the first stage, that of prostration, the chief care of the surgeon is to prevent some bystander from bleeding the pa- tient, in common with the vulgar notion. No active treatment should be resorted to until reaction has taken place. In the mean- time the patient should be undressed and put to bed, and his limbs carefully examined ; the head should be shaved, wounds dressed, &c. Should the prostration continue, and danger impend from syn- cope, stimulation is to be resorted to in the most gradual and cautious manner; warm frictions are to be employed, small quantities of tea, wine, and water are to be administered with care, lest they pass into the air-passages, and produce asphyxia. After reaction commences, stimulants are to be suspended, lest they increase subsequent inflam- mation. By hurrying on reaction, life is as often endangered as by the too early abstraction of blood. So soon as inflammatory symp- toms fairly manifest themselves, we should endeavour to repress 62 SURGERY. them by excluding all kinds of excitement, especially light and noise, and by the application of ice and evaporating lotions to the head, which should be elevated upon pillows. If great reaction occur, manifesting itself by delirium, convulsive movements, a full and active pulse, pain, &c, local and general bleeding, together with enemata and purgatives, are to be resorted to : opium will also have a beneficial influence if administered judiciously, especially in con- nexion with calomel and tartar emetic. For some time after the violence of the inflammation has subsided, the brain remains weak and requires watchful care ; excitement, both physical and mental, is to be avoided, the diet regulated, and the head kept cool. The me- mory is often impaired, the conversation childish and incoherent, the eye wild and vacant in its expression, the demeanour either most timid and gentle, or entirely the reverse; occasionally one or more of the special senses, such as hearing or smell, is lost; such conse- quences may be temporary or permanent. The treatment most suitable is a mild mercurial course, long-continued counter-irritation, regulated diet, avoidance of all excitement, and exposures to changes of weather, together with the use of the cold shower-bath. FRACTURES OF THE CRANIUM. These occur more frequently in adults than in children, on ac- count of the unyielding and brittle nature of their bones, whereas the bones of a child's head are pliable, and yield to the force without fracture. Fractures of the cranium are classified, by the extent of injury, into simple fissure, stellated, depressed, and camerated frac- tures, fractures of the external or internal table, &c. The dangers attendant are various: there may be concussion, compression, hemorrhage, and inflammation of the brain and its membranes. A simple fissure is of but little importance, even should it be ex- tensive, and traverse a suture, which it often does. The fracture itself requires no treatment, unless accompanied by symptoms of concussion, compression, or inflammation. Fracture at the base of the cranium is a very serious injury, and usually attended with laceration of the membranes, and internal hemorrhage. It is usually suspected, from the early appearance of symptoms of compression, the manner in which the injury was received, escape of blood from the ears, and sometimes from the nose and mouth. This latter symptom, although generally consi- dered a most dangerous one, may be the result of mere laceration of the lining membrane of the ear or the nose. The treatment required will be that for inflammation or compression. A depressed Fracture.—This is to be carefully diagnosticated from a fracture of the external table alone, and from a depression in the middle of a tumour occasioned by the effusion of lymph. It is COMPRESSION. 63 dangerous, from the complications of concussion, compression, ex- travasation of blood, and inflammation. The treatment consists in removing the cause of compression, and combating the effects of inflammation ; the former by the operation of trephining, and the latter by strict antiphlogistic means. COMPRESSION. Compression may be the result of extravasated blood, depression of the bone, or the formation of pus. The symptoms which cha- racterize it are slow, laborious, stertorous respiration ; a full, regular, slow pluse, and complete loss of consciousness and sensibility ; the muscles are relaxed and powerless, pupils dilated and insensible, the skin warm and moist, and the sphincters often relaxed. The patient may perish immediately from coma, or may rapidly recover from the removal of the cause of depression. Extravasation of blood may take place immediately upon the infliction of the injury, or not until reaction has followed; concus- sion often being produced at the same time. The extravasation may be situated between the bone and the dura mater, which is the result of a wound of the meningeal artery. This may be the result either of a direct blow, or of a counter stroke. The symptoms gradually appear, and if urgent, the trephine should be used, and the blood, if fluid, escapes at once. If the symptoms be not severe, the clot may be absorbed, and the brain gradually recover from the compression, provided high inflammatory action is prevented. Blood may be effused within the membranes, or within the ventri- cles; most frequently being the result of injury to the vessels of the pia mater. The clot effused within the membranes is usually larger, and will produce more dangerous symptoms than one external to them. The most dangerous consequences result from a clot at the base of the brain. Treatment. — The objects are to prevent increased effusion and diminish subsequent inflammation, and the removal of the clot. The head should be elevated, cups and cold applications applied, with general bloodletting and purging. The action of the heart is to be diminished, in order to prevent the further extravasation of blood. The removal of the clot is accomplished by trephining, and opening the membranes. If, however, the clot is at the base of the cranium, or it is uncertain where it may be, the membranes are not to be opened, for the chances of inflammation would be much increased by the operation, and the cause of compression not certainly removed. Compression resulting from the formation of pus, does not exhi- bit the ordinary symptoms rapidly, as is the case by the escape of blood, nor do the symptoms subside so readily; because pus is not so amenable to absorption as blood. Tt cannot be discharged but by 64 SURGERY. the exfoliation of the bone, which is a tedious process. The symp. toms denoting the formation of this dangerous abscess, affect the system as well as the part; and the patient would manifest the same restlessness, rigor, and fever, which attend the formation of pus in other parts of the body. TREPHINING. The scalp is first to be cleanly shaved; and if a wound already exist, the cranium may be exposed simply by enlarging it; but if no previous wound exist, an incision is to be made, of a crucial, triangular, or semicircular shape,—the latter being most preferred. The pericranium is then to be detached by a scraper, unless the trephine have an additional means for removing it. That portion of the cranium should be selected which is sufficiently near the injured parts to allow of elevation of the fragments, by the introduction of an elevator, and at the same time to be sufficiently firm to bear the pressure of the trephine. The sinuses of the dura mater, the occi- cipital cross, and the course of the middle artery of the dura mater are to be avoided. The centre pin of the trephine is to be withdrawn, after a groove is made sufficiently deep for the play of the teeth of the instrument; and great care is to be taken, lest the trephine saw through the bone unequally, owing to the want of parallelism of the two tables of the skull. The progress of the operation is to be cautiously watched, and the depth of the groove made by the trephine, ascertained by a toothpick or a small probe. The button- like portion of bone frequently comes away in the trephine; if not, it is to be removed by a forceps or elevator; the rough edges (should any exist) of the internal table, are to be taken away by an instrument called a lenticular. Through the opening thus made, the elevator may be introduced, or the extravasated blood may escape. The opening is subsequently filled up by a dense mem- brane, formed by the pericranium and dura mater. The edge of the opening is somewhat altered by absorption, and some deposit of bone. In some instances of compound fracture of the skull, a promi- nent angle may be sawed off with Hey's saw, and thus an opening be formed sufficiently large for the admission of the elevator, or the exit of the bloody clot. INJURIES AND DISEASES OF THE FACE, NOSE, AND MOUTH. Wounds of the face are usually attended with considerable he- morrhage, which sometimes requires the tying of an artery. Care is required to approximate the edges, in order to prevent deformity and an ugly cicatrix. When the supra-orbital nerve is injured, vision is impaired ; when the portio dura nerve is cut, paralysis of the muscles upon one side of the face results. DISEASES OF THE FACE, NOSE AND MOUTH. 65 Wounds of the External Ear do not affect the hearing; but when the cartilage is cut, a split will remain, unless the integuments are carefully united. Wounds of the Eyeball, produced by great violence, such as gun- shot wounds, of course destroy the sight, and are often followed by a fungous growth, which requires removal and the substitution of a glass eye. Wounds of the Tongue.—Bleed very copiously, and there is some difficulty in arresting hemorrhage. This is to be effected by a liga- ture and styptics ; and, if necessary, by the actual cautery. Sutures are necessary to approximate the edges of the wound. Salivary Fistula. — This results from a wound or ulcer of Steno's duct, by which the discharge of the parotid gland opens ex- ternally on the cheek, occasioning great inconvenience and de- formity, and interfering with the processes of mastication and diges- tion. A cure is to be effected by making an opening through the mucous membrane of the cheek, that the saliva may enter the mouth, and by closing the fistulous orifice. The edges of this orifice will require caustic, or paring with a sharp knife, or the actual cautery, to make them unite, and the internal orifice is to be kept open by a tent. Epislaxis.—This implies hemorrhage from the nostril, produced by injury, plethora, or diseased state of the blood and mucous mem- branes. The treatment will, in a great measure, depend upon the cause. The arrest of hemorrhage by external applications, is only to be made under certain circumstances; it will be effected by an upright position, cold applied to the head and back, astringents thrown up the nostrils, and compression by lint. In some instances, the lint is to be introduced through the posterior nares, by means of Belloque's canula, or by a flexible catheter and a piece of string, where it must be allowed to remain for several days; in many in- stances, constitutional treatment is necessary. Foreign Bodies in the Nostril.—Peas, beads, and such like sub- stances are often inserted by thoughtless children; and by unwise efforts at removal, they are more deeply lodged in the cavity. The surgeon is to inject a stream of warm water into the nose, which will wash away any coagula of blood, and loosen the foreign body; its position is to be discovered by a probe, when it can be extricated by a scooped end of a director or forceps. A pinch of snuff will sometimes dislodge it. Polypus of the Nose.—There are different varieties of polypi: the most common is a gelatinous, pyriform mass, attached to the mucous membrane of the turbinated bones. The patient has a sensation of a cold in the head, which is much increased in damp weather. It in- terferes with respiration, and frequently alters the tone of the voice. The sense of smell is also impaired, and deafness may be produced, 6 66 SURGERY. should it occupy the orifice of the Eustachian tube. It may be removed by twisting it off by the forceps ; and the hemorrhage is to be arrested by astringent injections and lint. A dense fibrous poly- pus is best removed by a ligature or wire, applied by means of a double canula, for the purpose of strangulation. Malignant polypi may be regarded as incurable. Lipoma of the Nose, is a hypertrophied condition of the skin and fat of the apex, and alae of the nose; seldom occurring but in aged free-livers. When the growth is large, it is to be removed by the knife. Ozana.— Is an obstinate, profuse, and foetid discharge from the mucous membrane of the nose, with disease of the bones beneath. The disease often extends to the frontal sinus and antrum. In adults, it is often dependent upon syphilis, or the abuse of mercury; in children, upon scrofula. The treatment will in a great measure be constitutional, although benefit and comfort will be derived from the use of astringents and chlorine washes, and promoting the free discharge of the matter. Abscess of the Antrum. — May result from a blow, or the irrita- tion of a decayed tooth. It is attended with permanent, deep-seated aching of the cheek, the pain often becoming intense,' together with rigors and fever. The cavity bursts, either internally or externally, which gives great relief. The earlier that leeches and emollient poultices are applied, the better; but, after the cavity has become filled with matter, there is necessity for immediate puncture just over the third molar tooth; or, a tooth must be extracted, and a trocar pushed through the socket. The discharge of pus can be facilitated by syringing with warm water. Epulis. — Is a solid tumour of the gum, of a non-inflammatory character. It commences in the form of a seed-like excrescence upon the gums, between the interstices of ihe teeth. Being without sensibility, it may occasion but little inconvenience, except by its size. As it grows, it loses its dense fibrous structure, and may become fungous ; sometimes it becomes malignant. Treatment.—Nothing will suffice but complete extirpation of the adjacent portion of the gum and alveolar process. Several perfectly sound teeth may have to be drawn, in order to apply a fine saw or bone-pliers. The hemorrhage is to be arrested by muriated tincture of iron, and pressure by lint. Parulis.—Is a gum-boil; occasioned usually by a decayed tooth, or a stump, or a tooth whose nervous pulp had been destroyed pre- vious to plugging. The swelling is slow at first, though the pain is intense while the pus is forming. Unless the tooth is extracted, an opening will be formed through the alveolar process and gum, for the discharge of the matter, which may remain fistulous. The treatment will consist of leeches and fomentations, and the WOUNDS AND AFFECTIONS OF THE THROAT. 67 speedy evacuation of the abscess, either by the abstraction of a tooth, or by puncture. Ranula.—Is a sac formed beneath the tongue, by an expansion of Wharton's duct, either from disease or obstruction. Inconve- nience is felt in mastication, deglutition, and articulation. The treatment consists of dilatation of the duct, or making an artificial opening. It is necessary to keep the orifice distended by a tent or loop of wire, until the cyst contracts to its normal size; otherwise it will be refilled. WOUNDS AND AFFECTIONS OF THETHROAT. Tonsils.—Inflammation of the tonsil is characterized by the rapid swelling of the part, great pain in deglutition, and fever. It is to be treated by bleeding, leeches, purging, and gargles. An incision made with a bistoury will unload the vessels, and give exit to any pus which may have been formed. Chronic enlargement of the tonsil may result from inflammation, especially in scrofulous persons; degluti- tion is impeded, the voice is rendered hoarse, respiration is noisy and laborious, and there may be deafness, from the obstruction of the Eustachian tube. The treatment should consist of the internal and external use of iodine, astringent gargles, and the application of nitrate of silver. If these means fail, it should be removed by the knife, or with an instrument constructed for the purpose, such as Physick's or Fahne- stock's. Elongated uvula may be removed simply by a forceps and scissors. (Esophagus. — The oesophagus may have a permanent or spas- modic stricture. A spasmodic stricture comes on suddenly, generally at meals, and is attended with pain, and a choking sensation. It depends on a weakened or hysterical state of the system, or neuralgia. Tonics, antispasmodics, and alteratives are the means of cure, with proper attention to diet, and care to avoid swallowing food that is hot or imperfectly masticated. Permanent stricture is a narrowing produced by inflammation of the mucous and cellular coats, which forms a firm ring generally opposite to the cricoid cartilage. It is most frequent in females, and has these symptoms: difficulty of swallowing, which gradually in- creases, and is never absent; pain in the chest and neck. It is a serious complaint, and may be followed by ulceration, salivation, vomiting of purulent matter, and death from starvation or irritation. The treatment should consist of a mild course of mercury, com- bined with some anodyne, a seton between the shoulders, and the 68 SURGERY. passage of a bougie, together with a weak solution of nitrate of sil- ver* applied to the surface. Foreign bodies in the CEsophagus produce a sense of choking and suffocation, and may prove fatal. Treatment. — The patient should be seated in a chair, with his head thrown back, and his mouth wide open; the surgeon should then introduce his finger, regardless of the attempts to vomit, ascer- tain the position of the substance, and if possible remove it by the finger, or by the assistance of curved forceps. A small sharp body, such as a fish-bone, may be got rid of by swallowing a large mouthful of bread; a large soft mass, such as a piece of meat, may be pushed down into the stomach with a probang ; a rough and angular body, such as a piece of bone or glass, should be brought up, if possible, by long and curved forceps, or with a piece of whalebone, armed with a flat, blunt hook, or with a skein of thread, so as to form a number of loops. If the stomach is full, it should be emptied by an emetic, with the hope that the foreign body may be ejected with the food. It may be necessary to resort to the ope- ration of oesophagotomy, which should be performed by making an incision as nearly opposite the foreign body as possible, through the skin, platysma and fascia, and between the sterno-mastoid muscle and trachea. Care must be taken to avoid the carotid and thyroid arteries, and the recurrent nerve, A small opening should be made in the oesophagus, by cutting it upon a silver catheter, which should be passed down the throat, and made to project into the wound; the opening should be dilated, so as to prevent hemorrhage. Foreign Bodies in the Larynx and Trachea.—Food may get into the rima glottidis, whilst a person is laughing and talking at a meal; and unless immediate relief is afforded, death will result. The sur- geon may sometimes be enabled to remove it with his finger; but if not, the larynx or trachea should be opened, and a probe intro- duced through the wound, so as to push the foreign substance up into the mouth. A foreign body may be impacted in the ventricle of the larynx, or be loose in the trachea, producing spasmodic cough, difficulty of breathing, and pain ; a small body may even pass into the bronchial tube, generally the right one. Laryngotomy, or tra- cheotomy, may be necessary. The larynx is opened by a longi- tudinal incision through the middle crico-thyroid ligament. The trachea is opened in the median line through the skin, fat, and fascia, at the lower portion of the neck. After the tracheal rings are made bare, the patient is directed to swallow; and while the windpipe is thus rendered tense and elongated, the scalpel is made to penetrate the lower part of the wound, with its back towards the sternum, and the rings are to be divided by cutting upwards. Care should be taken, in this operation, to avoid opening large veins, or any part of the thyroid gland. This operation is sometimes necessary for 9 WOUNDS AND AFFECTIONS OF THE THROAT. 69 dyspncea, when a conical curved tube should be introduced for the patient to breathe through. Wounds of the Throat. — Are extremely dangerous, on account of the important parts injured, and are usually the results of at- tempted suicide. The treatment consists in arresting hemorrhage, obviating diffi- culty of breathing, and preventing inflammation. The arteries must be rapidly yet carefully tied, and the hemorrhage of the large veins restrained by pressure. If the larynx or trachea should be wounded, subsequent inconvenience may result from the introduction of cold air, clots of blood, &c.; if the pharynx or oesophagus is wounded, the use of a tube becomes necessary, in order to convey nourish- ment to the stomach. This tube must be introduced through the mouth, and not through the wound, as often as it may be necessary to supply the patient with food. The edges of the wound should be carefully drawn together, and dressed in the most simple manner, and should be protected from unfavourable atmospheric influences by a covering of loose gauze, or of woollen texture thrown lightly over the neck. The patient should be carefully watched, to prevent a recurrence of the injury. A fistulous opening sometimes remains in the trachea or larynx, which is extremely difficult to heal. Bronchocele, or Goitre. — Is a swelling of the thyroid gland, depending for the most part upon hypertrophy, although a cyst may be formed, or calcareous matter deposited. In certain localities, it is an endemic disorder, and often asso- ciated with cretinism. It occurs most fre- Fig. 19. quently in females after the age of puberty. It grows gradually, and without pain, occa- sioning inconvenience merely by its deformity and bulk.—Respiration is sometimes affected, and the venous blood being prevented from returning from the head, produces cerebral disorder. The cause of the disease is ob- scure, but probably connected with climate. The treatment will consist in the use of iodine, internally and externally, with atten- tion to the general health; or it may be necessary under the threatening of suffoca- tion, to perform an operation. The removal of the gland is extremely dangerous, on account of hemorrhage, and does not always produce a cure. Torticollis, or Wryneck.—This is a distortion of the neck to one side, generally the result of spasm of the sterno-cleido-mastoid muscle, or by a paralysis of the muscle of the opposite side. It may also result from tumours, caries of the spine, and cicatrices, espe- cially those from burns. 6* I 70 SURGERY. The treatment will vary with the causes producing it. If it result from spasm ; purgatives, leeches, and fomentations should be used; if from paralysis of the opposite side, general tonic treatment and stimulating friction will be useful. If the contraction be permanent, the muscle must be divided. INJURIES AND SURGICAL AFFECTIONS OF THE CHEST. Wounds of the chest may be inflicted by a sharp instrument, a fractured rib, or a bullet. Danger results from hemorrhage, and subsequent inflammation from air, or clot of blood in the pleura. The intercostal may be the source of the bleeding, and it is some- times difficult to arrest it by the ordinary means. A curved needle, armed with a ligature, is the best means of securing the vessel, when deeply concealed in the intercostal groove. The entrance of air into the chest (pneumothorax) through the wound, is to be pre- vented as much as possible by the early and accurate closure of the wound ; otherwise there may be compression of the lung. The suppuration of the wound may lead to inflammation and suppuration of the pleura. This collection of pus in the chest is called empyema. When the lung is wounded, there is still greater danger from hemor- rhage, inflammation, and the air. It is attended with great prostra- tion, difficult breathing, anxiety of countenance, and expectoration of blood. The danger of bleeding results not only from the direct loss, but from its collecting in the pleura (hsematothorax), and its filling up the bronchial tubes and trachea. The inflammation may subsequently destroy the lung and the life of the patient also by hectic. The air may also more readily enter the cavity of the chest, and not being readily discharged through the external wound, may infiltrate it into the subcutaneous cellular tissue. The hemorrhage is to be controlled by venesection, rest, antiphlo- gistic means, acetate of lead, and opium. A careful examination of the wound should be made, in order that no foreign matters remain; the patient should lie on the wounded side, so as to favour the dis- charge of blood or pus, and it may also be necessary to prevent a closure of the wound. Emphysema may be overcome by compres- sion, or an incision. Paracentesis thoracis.—Puncture of the thorax, may be required for accumulated air, blood, or pus. The opening is most frequently for empyema. The point selected is usually between the sixth and seventh ribs, halfway between the spine and sternum. If made too low, the diaphragm may be wounded; if too high, the fluid will not so readily escape. The opening should be closed with care, to avoid the entrance of air. WOUNDS OF THE ABDOMEN. 71 WOUNDS OF THE ABDOMEN. Wounds of the abdomen are extremely dangerous, on account of the important viscera contained within, and the liability to peritonitis. A simple wound of the parietes must be closed by suture if it is exten- sive, care being taken not to include a portion of the intestine. When complicated with a wound of the liver, fatal hemorrhage must almost necessarily result, on account of the great vascularity of the organ. A patient may survive a small wound, which will be succeeded by great prostration, pain in the liver, yellowness of the skin and urine, and a bilious discharge of the wound. The wounds of the gall bladder, and spleen, and urinary bladder, if communicating with the peritoneum, are almost always fatal. Wounds of the kidney are also exceedingly dangerous from hemor- rhage, violent inflammation, and suppuration, with excessive vomit- ing. Venesection, laxatives, warm bath, avoidance of drinks, with light dressings of the wound, are the proper measures for treatment. Protrusion of the Bowel.—When a portion of the intestine pro- trudes through a parietal wound of the abdomen, it is to be returned with great gentleness and accuracy, so as to avoid inflammation and obscure strangulation. The edges of the wound are to be carefully approximated, by suture if necessary, and by moderate bandaging such pressure is to be made as to prevent reprotrusion. Wound of the Bowel.—A wound of the bowel may be suspected from the passage of blood with the stools, the escape of fseces through the wound, excruciating pain over the whole belly, and a great ten- dency to collapse. Extravasation into the cavity of the peritoneum does not take place from a small wound, owing to the protrusion of the mucous coat through the muscular, and the constant and equable pressure of all the abdominal viscera; lymph is also rapidly effused, and the contiguous edges are thus united. If, therefore, the protruded part be found to have sustained a mere puncture, it is to be returned as if entire. A small incision may be closed by the glover's suture ; the ends are cut short, and the exudation of lymph envelopes the thread, which in time finds its way into the cavity of the bowel, and is thence discharged. If the portion of bowel be bruised and lacerated to such an extent as to render adhesion impossible, and gangrene probable, the wounded part must be retained at the surface, and the peritoneal coat united with the integuments at one or more points; the fseces are thus dis- charged through the external wound, and an artificial anus is thus established. Wounds of the stomach are recognised by vomiting of blood, and the nature of the matters which may escape from the wound. They are much more dangerous than those of the bowel. The edges of the stomach and the edges of the external wound are to be stitched 72 SURGERY. together by the continuous suture. The subsequent treatment should consist of perfect rest, and the prevention of inflammation; venesection and leeches, and large doses of opium, will probably be necessary; nothing but thin arrow-root, or mucilage, should be given as a diet, and it may be necessary to administer this by the rectum ; purgatives should be studiously avoided. ARTIFICIAL ANUS. This is an unnatural opening of the intestine, through which faeces are discharged. It may be the result of a wound, or sloughing con- sequent on strangulated hernia. The orifices of the upper and lower portion of the intestine are united with the abdominal wall. The lower portion of the bowel becomes contracted, and receives but little fseces. The integuments around the artificial opening form a funnel-shaped cavity, the edges of which are red, everted, and exco- riated. The consequences of the affection may be inanition by the escape of chyle, especially if the upper portion of the small intes- tine be engaged ; a patient is liable to hernia, colic, besides the dis- gusting annoyance of the constant escape of fseces and flatus. The treatment will consist of regulating the bowels by diet and medicine, and by supporting the orifice by a compress or truss, which will retard the escape of the discharge, and promote the con- traction and cicatrization of the funnel-shaped cavity. It may be necessary to perform Physick's operation : this consists of introducing a ligature by means of a curved needle into the orifice of the upper intestine, and bringing it out through the orifice of the lower, which ligature is then to be secured with a slip-knot. The object of this ligature is to produce adhesion between the peritoneal surfaces of the upper and lower intestine: this will require several weeks; after- wards, an opening is to be formed through this adhesion by means of a bistoury, through which the fseces will pass from the upper to the lower intestine, the external orifice being firmly compressed with a truss. Dupuytren operated by means of a forceps, one blade of which was inserted into the orifice of each intestine, and the pressure regulated by a screw at the handle. The effect of the pressure of the two blades of the forceps, is first to produce adhesion between the sides of the two intestines, and by still greater pressure, to form an opening between them by ulceration. HERNIA. Hernia signifies a protrusion, but the term is usually limited to the protrusion of the abdominal viscera. The predisposing cause is a weakness of the parietes of the abdomen at the natural openings. This weakness may be increased by injury, disease, or pregnancy, and there may also exist a congenital deficiency. The exciting causes are muscular exertion, jumping, straining, playing on wind instruments, coughing, vomiting, lifting weights, HERNIA. '** tiaht clothes, parturition, straining at stool, &c. Hernia is divided according to the site of the protrusion, into inguinal, ventro-ingui- nal umbilical, ventral, phrenic, perineal, vaginal, pudendal, thy- roideal, and ischiatic. The condition of hernia is also a ground of division into reducible, irreducible, and strangulated; and if the con- tents of the sac be intestine, it is called enterocele, if it contains omentum, it is called epiplocele. The sac is formed of peritoneum, and the different parts are called mouth, neck, and fundus. Reducible Hernia.—Symptoms.—A painful swelling suddenly forms at some part of the abdominal parietes, which is compressible and soft; can be made to disappear by pressure in the proper d.rec tion and which often disappears spontaneously. An enterocele is smooth, elastic, and globular, retires suddenly, and with a gurgling noise. An epiplocele is more irregular in its form, has a doughy feel, and retires slowly without noise. - Treatment —The treatment consists of reduction and retention. Reduction is effected by a manipulation termed taxis, the patient being placed in a recumbent position, and the muscles of the abdomen relaxed; gentle and steady pressure is made by the hand in the direction of the descent. Retention is effected by continued and suitable pressure over the site of the protrusion, by means of a truss. The points of a good truss are, a well made elastic spring and a pad, That can be accurately fitted. The spring is to be applied two inches below the crista of the ilium, and not above it, as is fre- quently done. Care must be taken to prevent excoriation, and also that every portion of intestine or omentum is removed from the sac previous to its application. By constant and careful use of a truss, a radical cure may be effected in a child, but rarely, if ever, in an 3 Irreducible Hernia.—When the contents of the sac cannot be restored to the abdomen, the hernia is called irreducible. It may arise from adhesions between the sac and the intestine contained, or from membranous bands stretching across the sac; from great en- largement of the omentum or intestine, or contraction of the cavity of The abdomen. The patient usually suffers from flatulence, indi- gestion, and constipation, owing to the peristaltic movements of the bowels being partially interrupted. The treatment consists in carefully regulating the bowels, avoid- ing any great exertions, and the wearing of a bag truss to support the tumour, and prevent further protrusion. Strangulated Hernia.—This is an incarceration of the con- tents of the sac with inflammation, and an interruption to the passage of fseces, and the circulation in the part. The inflammation is caused by the constriction, which may be the result of spasm, or sudden enlargement of the intestine by fseces or gas. The symptoms are flatulence, constipation, pain m the part and abdomen, nausea and vomiting; sometimes the matter is stercora- 74 SURGERY. ceous. The countenance is pale and anxious, the skin cold and clammy, and the pulse, which was at first full, now becomes rapid and indistinct; gangrene has taken place, the pain subsides in the tumour, which feels doughy and crepitant upon being handled. The vomiting may cease, and the patient will appear more comfortable, although he is actually sinking. It may be that the integuments and cover- ings of the intestine may inflame and slough with the intestine; and, after a copious feculent discharge, the patient may_recover by artificial anus. When the tumour is small and recent, and the constriction tight, a few hours may produce death, if no relief is afforded; when the hernia is old and large, days may elapse. Many of these symptoms may exist in other diseases, as in colic or ileus, but inquiry or examination should always be made as to hernia. Treatment.—The great object is to relieve the strangulation. In the first place taxis should be resorted to, and an effort made to reduce the contents of the sac. In order to facilitate this object, bleeding, warm bath, purgatives, enemata, opium, and cold applica- tions to the tumour will be found of use. A tobacco injection, made with 3j to Oj of water, may be of use, but requires great caution in its use, on account of its prostrating effect. These remedies may so relax the system that the reduction can be effected; at any rate they will diminish the inflammation if judiciously used. If not successful, the knife must be used. INGUINAL HERNIA. Bubonocele is a common name for this variety of hernia, which consists of a tumour in the groin, made by a descent of the gut or omentum through what are called the rings of the abdomen. These are the weak spots at which the protrusion takes place. Before studying the operation for strangulated inguinal hernia, it will be proper to examine the anatomy of the parts in their natural condition, and then the varieties of the disease. For anatomy of inguinal hernia refer to Anatomy, page 75. Oblique, or indirect inguinal hernia, occurs thus :—The intestine, or omentum, first pressing against the parietal peritoneum, distends it and forms it into a sac; this sac, containing the intestine, then presses against the fascia transversalis at that portion where it is thin, and passes from the abdomen to the cord, which spot is called the in- ternal abdominal ring, although it is not a hole. The sac, covered by the fascia transversalis, which is now thickened by pressure, then descends the inguinal canal, behind the transversalis and in- ternal oblique muscles, and when it reaches the external ring it is covered by the cremaster, which may be considered as a con- tinuation of these muscles; thus covered, it escapes at the ex- INGUINAL HERNIA. 75 ternal rino-, and there receives an investment from the superficial fascia and the skin. We thus see that the intestine is covered by a representation of all the structures forming the parietes of the abdo- men, with the exception of the external oblique muscle. Direct, or ventro-inguinal hernia, is a protrusion at the external abdominal ring, having its coverings formed in very much the same manner as the last, but instead of the cremaster muscle forming a covering, it is covered by the expanded tendon of the internal oblique and transversalis muscles. Sometimes this tendon is split, and there is no covering representing this portion of the parietes of the abdo- men. The tumour in this variety is nearer the symphysis pubis, and is on the inner side of the epigastric artery, whereas, in the direct variety, the tumour is on the other side of the epigastric artery. Concealed inguinal hernia is a term applied to a protrusion which has been detained in the inguinal canal. The operation for relieving the stricture in an indirect inguinal hernia is to be performed by placing the patient upon the edge of a Fig. 20. table, with each foot resting upon a chair; the surgeon sits before him, and makes an incision extending from the upper part of the tumour nearly to its base. The skin having been divided, the su- perficial fascia must next be divided. This will be found to exist in the form of laminae, the most inferior of which is the thickest; having been, in the natural condition of the parts, that portion of the fascia which fills up the space between the columns of the external ring, and which is sometimes called the intercolumnar fascia. After this division the cremaster muscle will be exposed, altered from its natural appearance; the fibres being stretched and separated from each other, and being more pallid than natural. Having divided 76 SURGERY. these fibres, the next covering will be the fascia transversalis, which is continued from the abdomen upon the cord; this being done the hernial sac is then exposed. The sac being formed of peritoneum, has been mistaken by some for the intestine, from which it. is to be distinguished by not having a flexure, or crease, which the intestine always has. The sac is to be opened carefully, pinching up a part and rubbing it between the fingers, in order that no portion of intestine may be included; a small opening is to be made, and into this a director may be intro- duced and the sac divided freely. Bloody serum will escape freely, and the contents of the sac be thus exposed ; the convolution, or knuckle of intestine will vary in its colour, according to the period and intensity of its strangulation, between a light red and a deep chocolate colour; very often the in- testine will exhibit patches upon its surface when the inflammation has been intense. The finger is then to be introduced to examine the point of stricture; if none should exist, an attempt at reduction should be made, if the intestine be in a proper condition. The stricture having been detected, a probe-pointed bistoury with a cut- Fig. 21. ting edge only near the extremity, is introduced flat upon the finger, and a slight cut made directly upwards to the extent of one or two lines. The only danger to be apprehended is the wounding of the epigastric artery, and this is avoided by making a vertical, instead of a lateral incision. The sac may be strictured by the external or internal ring, or in the canal by the lower edge of the transversalis muscle. The stricture being relieved, the gut is to be returned, the edges of the wound are to be carefully approximated, and a compress applied to support the part, and prevent accidental reprotrusion. A mild laxative may be given in a few hours if there is no peristaltic motion of the bowels; sometimes the bowel seems to have been pa- ralysed by the compression, and its peristaltic action is not recovered for several hours. Danger results then from the accumulation of medicines, food, &c, and life may be lost by inflammation of the • FEMORAL HERNIA. 77 bowel subsequent to its reduction. The antiphlogistic treatment will be most serviceable. After cicatrization a truss must be worn to prevent a return of the protrusion, though occasionally the operation produces a radical cure. Such is the course in an ordinary case ; but, it may be found upon opening the sac, that the hernia is irre- ducible, owing to the intestine adhering to the sac; the stricture is to be relieved, and the wound dressed, and no attempt made to restore the intestine, unless the adhesion be recent or slight. Should the intestine be extensively mortified it is not to be re- turned, the only chance of life being through the establishment of an artificial anus; but, if mortified only in a few spots, the spots are to be included with a fine ligature, and the intestine returned; the ligature finds its way into the interior of the gut, and is discharged with the fseces. In case there should be a gangrenous condition of the omentum, the gangrenous part should be cut off, and the vessels secured by fine ligatures; the remainder may then be returned to the abdomen, or be allowed to remain impacted in the outlet, and thus prevent future tendency to protrusion. Some have successfully divided the stricture exteriorly to the sac, the sac being reduced with the hernia. The objection to this opera- tion is the danger of there being a stricture within the sac; and if the gut should be gangrenous it will not be discovered. Usually the cord will be found behind the sac, but sometimes it is split up, and its constituents found lying upon the sac; caution is then required to avoid wounding the artery and duct. The operation for direct or ventro-inguinal hernia, is very much the same. There will be no cremasteric covering, but in place of it an expansion of the conjoined tendon of the internal oblique and transversalis muscles; sometimes this is wanting, owing to the ten- don having been split, especially if the protrusion is sudden, and the result of great violence. In a concealed inguinal hernia, the tendon of the external oblique must be divided, as well as the lower portion of the internal oblique and transversalis muscles. FEMORAL HERNIA. This is most common in women, owing to the natural form of the pelvis. The descent occurs at the crural ring; in order to under- stand which, it will be necessary to refer to the anatomy of the part, (see Anatomy, page 89.) The tumour is more spheroidal usually than in inguinal hernia, and will be found to be beneath Poupart's ligament, instead of above. The fundus of the tumour is bent upon its neck, which curvature must be attended to in producing taxis. Strangulation is more common and more severe than in inguinal hernia. 7 78 SURGERY. Fig. 22. The operation for the relief of stricture is thus performed. The patient being properly placed upon a table, and the parts being shaved, the skin is pinched up and divided by transfixion, in order that there maybe no injury to the important parts beneath. The wound of the skin may be crucial in shape, or resemble an inverted T. After dividing the skin, the superficial fascia is exposed ; this being divided, the fascia propria is brought in view; that fascia is some- times much blended with the sheath of the vessels. Under the fascia propria will be found the hernial sac. It is opened in the same cau- tious manner as before, when a smaller quantity of fluid will escape than in inguinal hernia, and the convolution of intestine be readily recognised. The seat of stricture is then to be sought; it may beat Hey's ligament, at Gimbernat's ligament, or, at the mouth of the sac. The stricture is to be divided with great care, for fear of an irregular origin of the obturator artery, the neck of the sac being surrounded by it. The gut being returned, the after treatment will be the same as in inguinal hernia: the patient is to be kept in a recumbent position, and under antiphlogistic regimen. If there is no movement of the bowels in the course of several hours, a dose of castor oil may be given, or a mild enema may be useful; should there be inflamma- tory symptoms, leeches, calomel, and opium will be serviceable. Occasionally the patient is troubled with tympanites and flatulence, which will be relieved by a carminative, or enema of turpentine. UMBILICAL HERNIA. This is common in infants in whom the umbilicus is not consoli- dated. It is produced by crying; and appears as a soft, compres- sible tumour. OTHER varieties of hernia. 79 It occurs also in women who have borne many children ; though in them the point of the protrusion is not through the navel, but near it. Strangulation does not often take place. The treatment in a child is simple and effective. A small hemi- spherical pad, made of cork, or half of a nutmeg, covered with buckskin, is properly fitted, and there secured by a broad strip of adhesive plaster, which should surround the belly of the child. In the adult the tumour may become very large, and usually contains a large quantity of omentum. Pain, indigestion, and con- stipation are often its accompaniments. The treatment consists of a large truss, adapted to the case. In case it should be strangulated, the operation for relief of the stricture is performed by making an incision through the skin and superficial fascia, which exposes the sac; this is to be opened in the usual manner. The incision for the relief of the stricture is to be made in the linea alba. OTHER VARIETIES OF HERNIA. Scrotal hernia is a term applied to the protrusion when it has descended from the groin into the scrotum. It occasionally entirely obscures the penis, and reaches almost to the knees. Its coverings are those of inguinal hernia. Congenital Hernia.—This depends upon a want of obliteration of the connexion between the peritoneum and tunica vaginalis of the testicle. The intestine descends in the same manner as the testicle. It has no sac or peritoneal covering other than that in which it and the testicle are contained. This is most common in young male children, and is easily cured by a truss; there being a natural tendency to closure in this tubular connexion between the peritoneum and tunica vaginalis. Care should be taken in the application of the truss or compress, not to injure the spermatic cord. In very young children a graduated compress and roller will effect a cure if properly applied. Ventral Hernia, is a protrusion at any part of the belly except the navel and groin ; and it may be the result of a bruise, wounds, and unnatural weakness of the muscles of the abdomen. Vaginal Hernia,, is a protrusion into the vagina; perineal, when the tumour is in the perineum, having descended between the bladder and rectum; phrenic or diaphragmatic, is a protrusion through an opening of the diaphragm. The intestine is sometimes strangulated within the cavity of the abdomen, through an opening in the mesentery, or meso-colon, or some portion of peritoneum, or peritoneal band, resulting from in- flammation. 80 SURGERY. DISEASES OF THE RECTUM. FISTULA IN ANO. A Fistula is said to be complete when a sinus communicating with the bowel, opens upon the nates ; when it does not commu- nicate with the bowel, but opens externally, it is called a blind ex- ternal fistula ; when it opens internally but not externally, it is called a blind internal fistula. If complete, there is discharge of pus, fseces, and wind, and it is attended with heat, uneasiness, and pain. The sinus is sometimes very tortuous, and often multilocular. The internal orifice is usually about an inch and a half above the anus, but sometimes higher. The cause producing it may vary. It may originate in an inflam- mation of the rectum, or by an abscess external to it. It is very frequently connected with phthisis, caused by the constant cough in that disease. The treatment for complete fistula is generally that of the knife, the object being to place the part at rest, and convert the sinus.into an open sore. The bowels having been entirely emptied, the index finger of one hand being oiled, is introduced into the rectum, and a Fig. 23. knife-pointed bistoury is introduced through the sinus into the gut, so that its probe touches the finger ; thus kept in contact, both finger and bistoury are withdrawn, completely laying open the sinus, and dividing the sphincter ani muscle. Any bleeding vessel is to be tied ; hemorrhage by oozing is to be stopped by stuffing with lint; a small portion of lint is to be placed between the lips of the wound, so as to prevent their closure ; the object being to make the whole track inflame, granulate, and heal from the bottom. After the HEMORRHOIDS. 81 operation, a dose of morphia may be given to promote quietness and sleep ; and after 3 or 4 days a dose of castor oil, which will bring away the contents of the bowel, and the dressings of the wound. Subsequently it will only be necessary to attend to clean- liness, and prevent the edges from uniting. If the opening be very high in the rectum, it is better to use the ligature in preference to the knife, on account of the danger of hemorrhage from the hemorrhoidal arteries. The ligature only is to be used in phthisical cases; it gradually cuts itself out, and leaves the part solid behind it. A blind fistula may be readily converted into a complete one by puncturing the intestine should it be an ex- ternal fistula, or the skin in case it should be an internal one. FISSURE OF THE ANUS. This is an ulceration or cracking of the skin and mucous mem- brane, on the verge of the anus; and is attended with intense pain, especially upon going to stool. It results very often from dyspepsia, and this circumstance must materially affect the treatment. Altera- tives and laxatives are necessary to bring the bowels into a healthy condition. The local applications are caustics and anodynes, such as nitrate of silver, which has a soothing as well as antiphlogistic power; opium, in the various forms of ointment, solution, and poultice. Sometimes it is necessary to excise the part, or divide the sphincter ani muscle. HEMORRHOIDS. Piles, or hemorrhoids, are divided into external and internal. They are more common in males than in females, and rarely occur in children. The predisposing causes are whatever tends to deter- mine the blood to the rectum, such as constipation, pregnancy, sedentary habits; and the exciting causes may be purging, diar- rhoea, &c. External Piles are a congeries of varicose veins, surrounded by condensed cellular tissue. In some cases, bleeding occurs from ulceration of the skin or mucous membrane covering them. When they, do not bleed, they are said to be blind. When the blood has coagulated, they become hard. Usually, there is more than one. The palliative treatment consists in the application of astringent and anodyne ointments, made of galls, opium, &c, and the regula- tion of the bowels with laxatives,'such as sulphur, rye mush with molasses, &c. The radical treatment is removal by scissors or bistoury ; arrest- ing the hemorrhage, and producing a healthy ulcer. A recent tense, single pile, may be successfully cured sometimes by freely eva- cuating its contents by a lancet. Internal Piles may be of the same nature as external ones, or of 7* 82 SURGERY. a sarcomatous character; but more frequently they consist of an ab- normal development of the submucous cellular tissue, having the nature of erectile tissue: the tumour has a broad base, and its sur- face resembles a strawberry; at stool they protrude, and are at- tended with hemorrhage. The general health will suffer by emacia- tion, indigestion, pain, and there may result fistula, prolapsus, and disease of the genital organs. Treatment.—In the first place, the stomach and bowels must be regulated by laxatives;—disorder of the liver must also be cor- rected, since any obstruction of the portal circulation in that organ predisposes to hemorrhages, or congestion of all the chylopoietic viscera; there being no valves in the veins forming the portal vein. Great benefit will result from the use of astringent injections, such as solutions of zinc, oak bark, &c.; but the radical cure consists in the removal of them, by strangulating with a ligature or wire ap- plied by means of a double canula. Piles should not always be cured in elderly persons, especially those with tendency to diseases of the head. PROLAPSUS ANI. This is an eversion and protrusion of the rectum beyond the anus, and is dependent upon relaxation. The extent of the protrusion varies very much in different cases; in some instances being confined to a small portion of the mucous membrane; in others the rectum, and perhaps a portion of the sigmoid flexure escape. In children, worms, diarrhoea, straining, and crying may promote the disease. In old persons, it is brought on by enlarged prostate, stone, coughing, 6zc. When the gut ha- bitually descends, the tumour is red and large. The treatment consists in removing the cause ; in regulating the bowels, and carefully replacing the intestine after each protrusion. The evacuation should be made in the recumbent position. The general habit should be invigorated by tonics, and the tumour should be bathed with cold astringent washes. It may be necessary to lubricate the parts before reducing them, and afterwards a T bandage should be worn, to prevent the prolapse. In extreme cases, operations have been performed. A fold of the mucous membrane has been removed, in order to contract the in- testine ; and a portion of the sphincter has been cut out, in order to diminish the orifice of the anus. ENCYSTED RECTUM. This consists of an enlarged and diseased condition of the sac of the mucous membrane of the rectum, just above the anus. The treatment consists in drawing down these sacs with a bent probe, and excising the sac with a pair of scissors. URINARY CALCULUS. 83 IMPERFORATE ANUS. This is a congenital imperfection. The rectum terminates in a cul de sac, at various distances from the ordinary location of the anus; in some instances, it is so near the skin as to form a prominence, by the constant collection of fseces. In such cases, the operation is easy and simple : a free opening being made in the proper direction, with regard to the bladder or vagina, the meconium escapes, and the edces are prevented from uniting, by the interposition of a piece of lint. In other instances, it is impossible to reach the cul de sac; then it is necessary to form an artificial anus. This is done by open- ing the descending colon immediately under the left kidney, making the incision through the skin and fascia, so as to expose the posterior portion of the bowel, which is not covered by peritoneum at this part; a sphincter is said to be formed in the loins, though it is necessary to wear a pad. URINARY CALCULUS. Calculi are generally formed in the kidneys by a precipitation of earthy substances, and when they pass freely and frequently, the disease is termed gravel; when they are retained and become large, the disease is called stone. The symptoms of stone in the kidneys are pain in the loins, irri- tation and retraction of the testicle, bloody urine, and inflammation of the kidney. The passage of the stone through the ureter causes most acute and severe pain in the loins and groin, faintness, and sickness of stomach, which may last for several days, and is only relieved by the stone entering the bladder. The treatment for a fit of the gravel, as these attacks are called, consists in bleeding, warm bath, large doses of opium, soothing enemata, diluent and diuretic drinks, spirits of turpentine, &c. The ordinary result is the passage of the calculus; but sometimes it is retained in the kidney, increasing in size, and assuming the branch- ing f >rm of the pelvis, calices, and infundibula. It does not always produce inconvenience, but generally is attended with wasting of the organ, or suppuration, the abscess bursting into the colon or loins. A small calculus, lodging in the bladder, and not being discharged through the urethra, serves as a nucleus for further deposit; any foreign body, such as a needle, drop of blood, or bullet, may sarve, also, as a nucleus. The symptoms of stone in the bladder are, frequent, sudden, irresistible, unrelieved desire to make water; pain in the glans penis, and elongation of the prepuce; sudden stoppage of the stream in urination, and its re-establishment by change of po- sition—the urine being mixed with mucus and sometimes with blood ; but nothing but a sound can positively prove its existence. Many 84 SURGERY. of the symptoms are simulated by other diseases, such as stricture of the urethra, enlarged prostate, irritable bladder, &c. The rectum sym- pathizes, especially in children, and hemorrhoids or prolapsus ani are apt to occur. Stones vary in their form, size, colour, consis- tence, and chemical composition; some are rough on their surface, others smooth ; they are more frequently of an oval shape. The size may be that of a pea, or that of a goose-egg. The most common colour is a light brown; some, however, are nearly white, others nearly black. Some are soft and friable, and crumble easily; others are flinty, and require great force to fracture them. They are most generally composed of lithic or uric acid, lilhate of ammonia, phosphate of lime and magnesia, oxalate of lime, and carbonate of lime. The lithic acid stones are perhaps the most com- mon : they are oval, flattened, of a fawn-colour, and consist of con- centric laminse; the phosphatic stones are light-coloured and friable, The oxalate of lime forms the mulberry calculus, which is the hardest stone, of a very dark colour and a very rough surface. The number existing in the bladder at once, may vary from one to several hundred. The formation of stone is consequent upon a derangement of health, deficiency of exercise, indulgence in animal food, defective condition of the skin, and dyspepsia. It is also dependent upon climate, age, locality, and hereditary influences. The immediate cause in every case cannot be discovered; some suppose that the character of the water drank influences its production. Stones are sometimes encysted in the prostate gland and urethra. Treatment.—Gravel may be prevented or mitigated by attention to the skin and digestion, the use of acids or alkalies, dependent upon the diathesis of the patient manifesting the disease; but, after stone has been lodged in the bladder, it cannot be removed by medicines: surgical means must be resorted to. Sounding.—This requires great tact and care in its performance, and must only be attempted when the condition of the patient is most favourable ; if performed immediately after a journey, or during a fit of the gravel, the consequences might be serious. A sound is a solid steel instrument, resembling a catheter in shape, but having its curvature much nearer the extremity, and a broad flattened handle, The patient should be placed in a recumbent position, and the urine retained in the bladder for some time previous to sounding. The in- strument being carefully introduced, can be moved about in the bladder, and when the stone is touched, a distinct click will be heard, and a sensible impression of impingement will be felt. There are many sources of error in sounding : the instrument may pass over the stone, when lodged in the inferior fundus of the bladder, or the stone may be small and encysted in the mucous coat; on the other hand we may be deceived by the sound grating against a diseased LITHOTOMY. 85 prostate or sandy matter in the urethra. In case of difficulty in de- tecting a stone, it is better to repeat the operation frequently, the patient being placed in different postures, than to prolong the ex- ploration, at the risk of producing inflammation of the bladder. Having detected the stone, it is possible to form some idea of the size and number by sounding. Some have attempted the disintegration of the stone by injecting various solutions into the bladder; but the most common operations are Lithotomy, Lithotrity, and Lithotripsy. LITHOTOMY. This is an ancient operation, modified and improved in modern times. It is to be performed in children and in old persons, when the stone consists of the oxalate of lime, and when there is stricture, or diseased prostate. The different modes of performing the operation are the lateral, high, and bilateral. The lateral is most common, and is performed in this manner: The patient, having been properly prepared by emptying the bowel and retaining the urine in the bladder, is placed upon a table of convenient height, and firmly bandaged hand to foot, with his knees elevated. A staff as large as the urethra will admit, and deeply grooved on the convex and left side, is then introduced. Two assistants separate the knees, so as to expose the perineum, which ought to be cleanly shaved. The patient is then to be brought to the edge of the table, and the surgeon seats himself in front with his instruments in good order, and conveniently at hand. The staff, being brought in contact with the stone, is well hooked up under the symphysis pubis, and not pressed down upon the rectum, and then given to a third assistant, who is directed to hold it vertically, and also charged with keeping the scrotum out of the way. Fig. 24. 86 SURGERY. An incision is made with a scalpel in the direction of the dotted line of the drawing, (fig. 24,) of about three inches in length, commenc- ing about one inch behind the scrotum, and extending downwards and outwards to a point between the anus and tuberosity of the ischium, and even beyond it. Various measurements are given by different surgeons as to the point at which this is to be commenced. No well- informed surgeon should depend upon an absolute measurement, on account of the difference which exists in different patients, with re- ference to the size and depth of the perineum. He should inform himself of the probable size of the prostate gland by an examination per anum, and then, by his anatomical knowledge, make his inci- sion so as to expose the membranous portion of the urethra, taking care not to cut the bulb of the corpus spongiosum in front and the rectum behind. Having cut through the skin and superficial fascia of the perineum, which is very thick, especially in fat persons, the transversus perinei jmuscle, the transversus perinei artery, the lower edge of the triangular ligament, and it may be a few fibres of the Fig. 25. levator ani muscle, must then be divided. By an examination with the finger, the staff may now be felt in the urethra. By means of the finger and nail this space should be increased, and the urethra opened by a bistoury, which will be indicated by a flow of urine. The gorget should now be introduced into the wound, with its beak securely fixed in the groove; it is then pushed in the direction of the bladder, cutting through its neck and prostate gland. Care must be taken to depress the handle of the gorget whilst making this thrust, for fear of wounding the rectum. Urine gushes out, the gorget is carefully removed, for fear of wounding the internal pudic artery, and the finger introduced into the bladder to discover the stone, its LITHOTRITY. 87 position, and size. A strong pair of forceps are then introduced, and the stone grasped in such a way that its short diameter shall engage in the wound, whence it is to be delivered slowly and gradually. If H be impossible to remove the stone through this opening, it may be enlarged with care, on the same, or, if necessary, the other side. After its removal, the finger must again be introduced, to see if there is another stone. The bladder being freed from all calculus by the forceps or syringe, a tube is introduced into the bladder through the wound, by which the urine is to escape. The patient is then put to bed, with the knees placed together. A small cup or saucer receives the urine from the tube. Severe hemorrhage may result from a wound of the bulb of the corpus spongiosum, or from cutting the urethro- bulbar artery. If a ligature cannot be applied, it must be compressed by the finger as long as may be necessary. There may also be a venous or arterial oozing, which is to be arrested by removing the tube and cramming the wound with lint, a catheter being introduced through the urethra. Should there be no hemorrhage, the tube is to remain until the wound has granulated around it, and the urine has commenced to flow from the urethra. Some prefer to open the bladder with a scalpel, having confidence in their anatomical knowledge, and considering the gorget as a clumsy instrument, a remnant of olden times. Others use a con- cealed bistoury, cutting either upon one or both sides of the urethra. Besides which are various instruments, modifications of the gorget, and scalpels with beaks attached. In four or five weeks the wound is healed. The high operation is performed by making an incision through the linea alba, opening the bladder where it is not covered by peri- toneum. This is only necessary where the stone is of enormous size, the prostate diseased, or the space between the tuberosities of the ischia contracted. Stone in women, is much less frequent than in men, because the renal calculus is more readily passed by the urethra. Should it be retained, and increase in size, it may be removed by dilating the urethra sufficiently, or by the lateral operation, making the incision from the orifice of the urethra, and through the neck of the bladder. Incontinence of urine is apt to follow. The recto-vesical operation consists in cutting into the bladder from the rectum. LITHOTRITY. Lithotrity signifies the boring or drilling the stone, and has been most successfully accomplished by Civiale. His instrument con- sists of a straight canula containing a drill and three claws which 88 SURGERY. can be protruded after its introduction into the bladder. These claws are equally liable to catch the coats of the bladder as well as the stone, and the operation has been superseded by the following. LITHOTRIPSY. This implies the crushing of the stone whilst in the bladder; and it is preferred to all other operations for disintegration. The cases most favourable for this operation are adults, where the urethra is free from stricture, the bladder free from irritability and not contracted, and the prostate not enlarged. A mulberry calculus would be unfavourable for lithotripsy, on account of its hard cha- racter. The instrument most frequently used is that of Heurteloup, or a modification of it. It consists of two blades, which slide one upon Fig. 26. the other, the extremities being slightly bent. It can be introduced into the bladder as a sound or catheter, and afterwards the blades are separated, to grasp the stone. In the original instrument the male blade was struck with a hammer, and thus the stone was broken; now the crushing power is that of a screw, variously adapted,—that of Mr. Weiss being most simple and perfect. The extremities of the instrument have teeth, so as to retain the stone when grasped, and Fig- 27. also fenestrse to allow of the escape of sand or pow- dered stone. The patient must be previously prepared for the operation, by regula- tion of the general health, dilatation of the urethra, and distension of the bladder. The patient lies on a convenient table or bed, with the pelvis ele- vated, so as to throw the stone into the fundus of the bladder ; the bladder must be full, so as to prevent its coats from being entangled in the instrument. If urine cannot be retained, tepid water must be injected. The instrument must be oiled and warm. GONORRHOEA. 89 After encountering the stone and fairly grasping it, an operation which requires tact in manipulation, the stone is crushed by slowly and gradually turning the screw. Then the instrument should be withdrawn, and when the irritation has subsided, subsequently in- troduced, to crush the fragments. Thus many operations may be required to reduce the stone into fragments sufficiently small to pass the urethra. It is not to be expected that fragments will escape at the first urination : the after treatment should consist of diluent drinks, and bland injections to accelerate their passage ; and it may be that the hip-bath, anodyne enemata, and leeches, will be required. The sources of danger are the irritability of the bladder, and urethra ; inflammation often resulting from the irregularity of the fragments, and too frequent introduction of the instrument. Sometimes frag- ments are arrested in their passage through the urethra : a bougie or catheter should be introduced, of large size, and the fragment pushed back into the bladder: should it become impacted, it may require a special instrument for its extraction, or an incision in the perineum. Jacobsoii's instrument is used by many. Its extremities are con- nected by a link : thus a loop is formed to grasp the stone when the blades are separated in the bladder. By the operation of the screw, the female blade is pulled upon the male; whereas in Heurte- ioup's the male is pushed upon the female,—thus there is less danger of fine fragments or sand being caught between the blades of the latter, which would impede the movement. VENEREAL DISEASE, The history of this disease is involved in some obscurity, although it is generally believed to have existed from the earliest ages. It consists of G-onorrhoza and Syphilis, which are usually considered as distinct diseases, although there are high authorities to the con- trary. GONORRHOEA. Gonorrhoea is an acute inflammation of the lining membrane of the urethra, commencing in its anterior portion. It is caused by matter from another, during sexual intercourse. In about five days a discharge appears, although it may occur in a few hours, or not until ten days after coition. Symptoms.—Heat, itching, redness of the glans, and swelling of he orifice of the urethra; the stream of urine is small and at- tended W1th burning and smarting ; the swelling, redness, and pain increase; the discharge is no longer limpid, but turbid, puriform, and profuse, sometimes being mixed with blood; the thighs, loins, testicles, and groins sympathize in a dull pain, and there may be fever 9 90 SURGERY. Chordee may occur, which is an intensely painful erection of the penis, which is bent like a bow, with the convexity upwards: this is owing to the corpus spongiosum being filled with lymph, which prevents its expansion by blood. It is aggravated by the warmth of the bed, and voluptuous dreams. The glans may become excoriated ; the prepuce cedematous, in- ducing phymosis ; a sympathetic bubo may form in the groin, or an abscess in the perineum.. The joints may be painful as in rheumatism ; the testicle swell and inflame, constituting orchitis, especially if the patient is impru- dent in exercise, during which the discharge diminishes. As the orchitis declines, the discharge reappears. Gonorrhoea is capable of self-cure ; the symptoms gradually sub- siding, and the discharge diminishing, and becoming mucous in its character : it is then a gleet, which is without pain, redness, &c, but which is readily rekindled into an inflammatory gonorrhoea by im- prudence in diet or exercise. Treatment.—In the earliest stage, the ectrotic or abortive plan may be pursued, if the discharge has not reached the suppurative crisis. A strong solution of nitrate of silver, used properly with a glass syringe, may cut short the disease at the outset. It should be used but once or twice, and acts by neutralizing the virus, as an antiphlogistic, and also coats the urethra with a film which' protects the villous surface. This treatment often fails, especially in irritable temperaments, and when not used in the earliest stage; and if not succeeding, is followed by an aggravation of symptoms. In the treatment of gonorrhoea, it is to be remembered that the first attack is generally the most severe; hence the importance of rest, which is seldom complied with. Low diet, purging, and tartar emetic as an antiphlogistic and antaphrodisiac; opium and camphor are also useful at night, in preventing painful erections and chordee; a warm bath is most serviceable. Mucilaginous drinks may mitigate the ardor urinse. Leeches and ice to the perineum are sometimes very advantageous. The discharge now must not be suddenly arrested, else by metas- tasis the testicle, bladder, or prostate become involved. Strong in- jections are very injurious, although they may temporarily arrest the discharge. As the inflammatory symptoms subside, weak astrin- gent injections may be used with a glass syringe: sulphate of cop- per, zinc, alum, or iron, in the proportion of half a grain to the ounce of water. Cubebs and copaiba are remedies which seem to exert a specific influence on the urethra: the latter may be given in almost all stages of the disease; but the former should be restricted in its ad- ministration to the latter stage. These medicines often do harm, when persevered in too long, by inducing a chronic disease of the SYPHILIS. 91 bladder, attended by a slight discharge. In the chronic stage of the disease, the discharge may be benefited by weak solutions of nitrate of silver, and a weak solution of chloride of zinc. In a gleet, a lar<*e bougie introduced into the urethra, will often prove of imme- diate service. Spurious gonorrhoea, or balanitis, is a discharge from the prepuce and glans, often induced by want of cleanliness, or gonorrhoea! mat- ter. A solution of nitrate of silver, and frequent application of cold water will cure it. Warts are to be removed by the scissors or knife, and their bases touched with nitrate of silver, or nitric acid. Women suffer less than men, although the vagina is involved as well as the urethra. The symptoms are the discharge, swelling, pain in micturition, sitting, and walking, aching in the back and loins. The treatment is upon the same principles as in men ; stronger in- jections may be used without the danger of stricture; and lint saturated with medicated solutions, retained in the vagina. Young girls suffer from spurious gonorrhoea and leucorrhoea, from which they are to be carefully distinguished. Leucorrhoea is chronic in its character from the first, attended with lassitude, pain in the back, pallor, irregular menstruation, and the urethra is not involved generally. SYPHILIS. This term comprises all diseases resulting from a certain virus. Primary Symptoms.—After one or two days' incubation of the virus, the pustule forms, and the ulcer is established at the sixth day. It is first attended with redness, itching, and heat; then a vesicle appears, becomes purulent, breaks, and an ulcer is formed. This is circular or oval, excavated, and pale, with a bright red areola; the discharge is thin, ichorous, and infectious ; finally, flabby granulations and cicatrization. If the virus touches an abrasion, the sore may appear at once. This sore is not to be mistaken for a common ulcer, or abrasion, or herpes. Most frequently it is situated on the collum behind the corona; the most unfavourable position is the frsenum, which it often destroys. Treatment.—If the ulcer is freely cauterized before the sixth day, the poison is destroyed, the ulcer converted into a simple one, and the system is uncontaminated. After the application of nitrate of silver, water may be used, or water medicated with aromatic wine, or chloride of soda : granulation and cicatrization are treated as in any other case, and thus a simple venereal ulcer heals. Hunterian or True Chancre.—The sore is circular, much ex- cavated, with hardened base and edges; and the surface is of a tawny or brownish hue, covered by a thin pellicle. It occurs most frequently on the glans penis or the skin, and is usually solitary, and has no areola. 92 SURGERY. It is to be treated by the application of lunar caustic, and the in- ternal administration of mercury and iodide of potash. Mercury hastens the cure of the primary sore, and affords security against secondary consequences, especially of the Hunterian chancre; some general constitutional treatment may also be necessary. Blue pill may be given every night and morning, until the gums are slightly sore, and there is a slight increase of saliva: its action should be maintained at this point for several weeks. Phagedenic Chancre. — These are rapid in their progress and painful; their surface yellow, and dotted with red streaks; their shape irregular; edges ragged and undermined; their discharge is thin, profuse, and sanious. These ulcers eat deeply into the skin of the penis and surrounding parts. This chancre is apt to occur in those whose constitution is broken down with drink, debauchery, prostitution, and mercury : mercury usually aggravates it. Treatment. — As a local application, the nitrate of mercury is most beneficial; the chloride of zinc is also calculated to arrest the spread of the disease. The constitution must be supported with tonics, stimulants, and good diet. Bubo. — Bubo is an inflamed lymphatic vessel or gland leading from a venereal ulcer; the glands may inflame from a wound of the foot or from gonorrhoea, but a real syphilitic bubo is the result of absorbed virus. Buboes vary in the rapidity of their development, and some are termed acute, others chronic; the former hastening to sup- puration, whilst the latter are indolent. If one gland only is affected, and that above Poupart's ligament, it is most probably caused by chancre, if one exist; but if many glands are swelled, and they are below this ligament, their swelling is probably the result of irrita- tion. Inoculation is the surest test. Treatment.—An acute bubo will often yield to rest, leeches, fo- mentations, &c, but if the venereal virus shall have created pus in the interior, leeches and cold applications will i*ather retard the cure. Poultices, and early evacuations, are then most to be relied on. Extensive collections of pus, and sinuses, are often the result of delay in eliminating the virus. The opening of a bubo at an early stage with a sharp lancet, even should no pus exist within, empties the congested vessels, and rather promotes a cure. Blisters and iodide of potassium will be found of use in assisting in absorp- tion. In an indolent bubo an alterative course of mercury, and good diet are necessary. Constitutional Symptoms.—These are secondary and tertiary. The secondary symptoms speedily follow the primary, usually during the second month; consisting chiefly of general eruption, affection of the throat, fever, change of complexion, dryness of hair, rheumatic pains in shoulder and knee, headache. Different kinds of eruption follow different kinds of primary sore, although there may STRICTURE OF THE URETHRA. 93 be irregularity in this respect. Periostitis is apt to manifest itself in the shins. Secondary symptoms are transmissible from husband to wife, wife to child, child to nurse. Treatment.—The object is to assist nature in the elimination of the poison; hence we should not suppress the eruption, but act on the skin, kidneys, bowels, and other organs of excretion. The throat should be fomented, and touched with nitrate of silver. Mercury is not to be used if possible, especially in scrofulous, weak temperaments, or when the constitution is broken by dissipation, or the previous abuse of mercury. Small doses of corrosive sublimate, or the protio- dide of mercury, is the best form of administration. But the iodide of potash is the most effective remedy in this disease. It is given in doses of 4 or 5 grains three times a day. Baths are most impor- tant ; sometimes their value is increased by medicating them. Sul- phur, and weak solutions of mercury seem to exercise the best in- fluence upon the local affections of the skin. Tertiary Symptoms.—These seldom occur, except after the worse kinds of sore, unless mercury has been rashly used. The perios- teum and bones are affected by a chronic inflammatory process. Suppuration, caries, and necrosis result; also, stiff joints, tubercular formations of the skin, and condylomatous tumours. Destruction of the gums, cheeks, deafness, and iritis are also among the conse- quences. These symptoms are not transmissible. Treatment.—More dependence is to be placed upon the iodide of potassium, than any single remedy. The general remedies will consist of bathing, regimen, and alteratives. Opium and blisters are necessary to relieve the pain in the bones at night. DISEASES OF THE URIN O - GE N IT A L ORGANS. STRICTURE OF THE URETHRA. Spasmodic stricture depends on spasm of the muscles connected with the membranous portion of the urethra. It generally occurs in persons with some permanent obstruction; exposure to cold, and indulgence in drink also favour an attack, which usually occurs after dinner. Cantharides absorbed from blisters produce the effect. Symptoms.—Sudden retention of urine; great straining and de- sire to urinate; the bladder becomes distended, the countenance anxious, the pulse quick, the skin hot; at last the bladder bursts, and extravasates into the peritoneum, or perineum. The inflammatory stricture is another variety of the above, gene- rally caused by abuse of injections, exposure, or intemperance during acute gonorrhoea. Treatment.—A catheter should be introduced at once. This is managed by introducing as large an instrument as the parts will admit of, and stretching the penis forward on the catheter, whose point at the same time should be directed towards the upper surface 8* 94 SURGERY. of the urethra, and pressed steadily, but gently, against any ob- struction. Relaxation of the spasm may also be produced by bleed- ing, warm bath, Dover's powder, laudanum enemata, and cold water upon the genitals. Should all these means fail, and life be •endangered, the bladder should be punctured from the rectum. Permanent Stricture.—This is a contraction from permanent in- flammation, plastic deposit having taken place in the submucous cellular tissue. The occasion of this inflammation may be clap, venery, kicks or blows, riding on horseback, acrid urine, drinkings, &c. The most frequent sites are at the commencement of the mem- branous portion of the urethra, and also within a few inches of the glans penis. The extent and degree of contraction vary : some- times the stricture is very tight, but limited, as if a thread had been tied around the urethra ; more frequently it is of greater extent, con- tinuing from a quarter of an inch to several inches. Several strictures may exist at once. Behind the stricture the urethra is enlarged, and serves to catch a calculus. Sym,ptoms.—These come on gradually: middle-aged men are most liable. Urination is frequent, tedious, and painful: the stream is thin, twisted, or forked. After urination a few drops pass which had collected behind the stricture. Pain in the perineum, thighs and loins; erection is often painful: semen does not escape in coition, but passes into the bladder, and afterwards is voided with the urine; chill and fever constantly occurring, as in ague: a slight discharge is visible at the end of the penis upon rising in the morning; the testi- cles, rectum, and bowels sympathize, and the general health fails, Treatment.—1st. Dilatation by bougies of flexible metal, sil- ver, or gum elastic, of sufficient size, since small bougies are more apt to be entangled than large ones. The natural structures are not to be mistaken for strictures, viz., an enlarged lacuna in the fossa; spasmodic contraction of the accelerator urinse muscle; the trian- gular ligament, and prostate gland. The operations must be fre- quent and cautious until the cure is complete, and even afterwards, to prevent return of this disease, which is not uncommon; indeed there is no certainty that it will not return. 2d. Caustic applied firmly to the stricture; it destroys irritability, but is more advan- tageous in stricture near the glans than the bladder. 3d. Punctura- tion.—By means of a lanceted stilet, introduced concealed in a silver canula ; after the division, a catheter is to be introduced. 4th. Open- ing the urethra through the perineum, resembling a lithotomy opera- tion; a catheter is then introduced into the bladder, and the wound heals over it. FISTULA IN PERINjEO. This is usually the result of abscess of the perineum, or a wound. The patient has rigors, fever, and an exquisitely painful promi- ORCHITIS. 95 nence in the perineum, which opens and discharges, much to the fcj relief of the sufferer. The opening, h#wever, often remains, and j through it the urine dribbles. This abscess may be caused by a kick, or urinous infiltration from an internal fistula, produced by a stricture. . •/•.•* r Treatment.—This should be directed to the cause; if a stricture v exist, this should be cured first, and then the fistula, by caustic apph- * cation, red-hot wire, or paring the edges. ' ENLARGED PROSTATE. M The gland is enlarged, from chronic inflammation, brought on by fj gleet, stricture, horse exercise, &c.; it is most common in middle life, and disappears upon the removal of the cause. Leeches, rest, counter-irritation, iodide of potash, laxatives, and enemata, are the ^ proper treatment. But the gland is also enlarged in old persons,—a hypertrophy independent of inflammation. This enlargement takes ^ place first in the middle lobe, and the lateral lobes enlarge unequally. . The bladder sympathizes, and becomes irritable ; the urine is fcetid, \ mucous, and stains often retained. Catheterism, opiates, laxatives, J and regimen are the palliatives. ^ INFLAMMATION OF THE BLADDER. JS This is usually a secondary affection, usually resulting from go- <* norrhcea, &c. There is pain in the perineum and sacrum; micturi- tion is frequent, with straining; the urine is mixed with mucus or pus. 0 Treatment.—Bleeding, leeches, hip-bath, opiate enemata, castor oil, &c. L Chronic Inflammation—Catarrhus Vesica.—May result from f the same causes as the acute form ; and also from over-distension of V, the bladder: it is attended with great irritability and incontinence of urine. The irritability and incontinence are sometimes the most prominent symptoms; and for these symptoms the injection of a * solution of sulphate of morphia, or nitrate of silver will be found pi most serviceable. I Swelled Testicle is a common accompaniment of mumps. It is often the result of an injury; but, oftener, of gonorrhoea and its treatment: exercise, wet, and cold, often induce it. Sometimes it is termed hernia humoralis. Symptoms.—There is a great sense of weight, and the swelling constantly increases; the skin, becomes tense, red, glistening; the pain is intense, often producing fever and vomiting. The cord is often swollen and painful. The epididymis is chiefly affected. The urethral discharge diminishes. Treatment.—Bleeding, in a plethoric habit, leeches, purgatives, 96 SURGERY. tartar emetic, and opium; cold or warm lotions, according to the patient's feelings. Low digt, and the recumbent position are essential. The weight of the tumour must be sustained by a suspensory or handkerchief. After the acute symptoms have subsided, friction with mercurial ointment, astringent lotions, and compression by ad- hesive straps will be useful. In discussing the hardness and swelling which generally remain, the iodide of potash has the best effect. Abscess may result, but oftener results from chronic inflammation or sarcocele. Neuralgia of testes causes such severe pain that patients fre- quently apply to be castrated. The cause should be ascertained before treatment is commenced. HYDROCELE. This is a collection of serum in the tunica vaginalis testis; com- mencing at the lower part of the scrotum, and gradually ascending, It is smooth on its surface, fluctuating. The testicle is situated at the posterior part of the sac, near the middle. It is to be distin- guished from hernia by its transparency and progress: there is no impulse upon coughing: it does not retire by recumbency. Treatment.—The palliative treatment consists of evacuation of the serum by a trocar. The radical cure is performed by injecting stimulating fluids, such as port wine and water, or solutions of zinc and iodine into the sac ; or, by introducing a seton. CIRSOCELE. Varicocele or cirsocele is a varicose condition of the veins of the cord. Some restrict the term varicocele to the enlargement of the veins of the scrotum. The causes are such as produce obstruction to the return of blood; constipation, corpulence, tight belts around the abdomen, and warm climate. The left side is more frequently affected than the right, because the left spermatic vein is more likely to be compressed by fseces in the sigmoid flexure, and because it is longer and not so direct in its course. The swelling is pyriform, and feels like a bunch of earth-worms. Treatment.—The disease may be palliated or cured by removing the causes, bathing the testicle in cold water constantly, and sup- porting it with a suspensory. The radical cure often requires an operation for obliteration of the veins,—such as the actual cautery, compression by sutures, wires, spflngs, &c. The scrotum may be diminished with advantage. ANEURISM. An aneurism is a pulsating sac, filled with blood, which commu- nicates with an artery. A true aneurism is the result of disease, and the sac consists of ANEURISM. 97 one or more of the coats of the artery. The artery may be dilated, all the coats being entire, as is usually the case in the aorta; or, the internal and middle coats are ruptured, and the sac is formed of the external coat. The interior of the sac is lined by fibrin in a membranous form. False Aneurism.—Is owing to a complete division of the arterial coats, either from a wound or external ulceration ; the sac is formed in the cellular tissue. Dissecting Aneurism.—Is a sac formed by the infiltration of blood between the coats of an artery. This sac may communicate with an artery at several points. Circumscribed and diffused, are terms used to signify its limits; whether confined to a cyst, or extending by infiltration into the sur- rounding tissues. Symptoms.—The most frequent form of aneurism is the true cir- cumscribed aneurism. The tumour, at first, is small, gradually increasing, soft, and quite compressible, being only filled with fluid blood. It has a distinct pulsation from the beginning, synchronous with the heart's impulse, increased by pressure on the distal side, and diminished or arrested by pressure on the cardiac side, A peculiar thrill is imparted to the hand, which can be heard by application of the ear. At first the pain is slight, and merely owing to interference from the adjoining textures. By pressure upon the nerves a numb- ness is produced; pressure on the veins and lymphatics causes oedema, discoloration, and swelling. The strength of the part is much impaired, as the tumour enlarges; the circulation in the ex- tremity is weaker; the diminished volume of the main artery is com- pensated by enlargement of the side channels, the collateral circu- lation conveying the blood from the cardiac to the distal side of the tumour. The tumour gradually becomes larger by the separation of fibrin, and is less compressible, and pulsates less distinctly. The clot thus filling up the sac, restrains its further dilatation by the force of the heart. Ultimately, it may become smaller by con- tinued absorption. During the progress of an aneurism, adjacent parts are displaced, altered, and absorbed, even bone is rendered carious and absorbed by the constant pressure of the tumour. As the tumour enlarges, pain and numbness increase, and the general health fails. At length the tumour may burst, opening upon the skin or some important ca- vity, and prove fatal, either by hemorrhage, or by pressure on impor- tant parts,—as the trachea, oesophagus, &c, or by suppuration or hectic. The diagnosis from abscesses, glands, and solid tumours is im- portant. An aneurism is soft and compressible from the first, and then becomes hard, whereas an abscess begins with induration and ends with softening. A tumour or other swelling, receiving an impulse from lying over the track of an artery, will no longer pulsate 98 SURGERY. when raised or held to one side. An aneurism expands coincidently with pulsation; a solid tumour will not alter its volume by pressure either upon the distal or cardiac side. Causes.—The disease is more frequent in men than in women, and seldom occurs before puberty; the predisposing cause may be said to be disease of the coats of the arteries; the exciting causes are muscular exertion, mental emotion, and intemperance. Cure.—This may either be spontaneous or surgical—the sponta- neous being owing to pressure on the cardiac side of the tumour, occlusion of the aperture of communication, coagulation and absorp- tion, or by inflammation from sloughing of the cyst; this however is oftener the cause of death, than a means of cure. Medical treat- ment may mitigate the symptoms, such as bleeding, rigid diet, horizontal position, and cold and astringent applications. Compression is a means of cure which is slow, painful, and rarely effectual. The ligature is alone to be relied on. Previous to the time of Hunter, the vessel was tied immediately above the tumour, and the sac opened. Hunter tied the artery at a distance from the sac, in a healthy part, and allowed the sac and its contents to be absorbed; this is the present mode of operating. Abernethy applied two ligatures, and divided the artery between them. Brasdor's operation is directly the opposite to Hunter's, tying the artery immediately beyond the tumour. Wardrop modified this, and tied the artery beyond the tumour and Flg> 28, beyond its first bifurca- tion. The effect of a ligature is to arrest the blood and divide the in- ternal and middle coats; a coagulum or plug is formed up to the first branch, and lymph is effused from the cut edges of these coats, and also surrounds the ligature upon the exte- rior of the artery. The lymph in the artery above the ligature firm- ly consolidates the in- ternal and middle coats; and the cellular coat being compressed by the ligature is subse- quently destroyed, and ANEURISM OF THE CAROTID. 99 thus the ligature is removed with its noose entire; finally the portion of the artery will be found converted into a small cord. The ligature should be round and small, or the coats will not be divided ; inclusion of cellular tissue or a nerve will also prevent this division. Secondary hemorrhage may result from the application of an im- proper ligature, or its premature removal, and also from the artery being too much exposed, or in a diseased condition. ANEURISM OF THE AORTA. The arch of the aorta is especially liable to aneurism, producing difficulty of breathing, pain in the chest, and palpitation of the heart, difficulty of swallowing, and troublesome cough, owing to its pressure upon the trachea, which is sometimes perforated; it should not be mistaken for an enlargement of the bronchial glands, or collections of serum or pus. Aneurism of the abdominal aorta is usually situated just below the diaphragm, producing pressure in the thoracic duct, caries of the vertebra, dropsy, and by its rupture, death. Astley Cooper, James, and Murray have tied it without success; it should be treated only by medical means. ANEURISM OF THE CAROTID. This occurs most frequently in labouring people: it is situated at the angle of the jaw, near the bifurcation of the artery, and pro- duces difficulty of swallowing and breathing; it is to be carefully distinguished from glandu- lar enlargement. It was first Fig. 29. tied by Sir Astley Cooper in 1805. The operation is thus performed: the patient being recumbent, with the head thrown back, and slightly turned to the opposite side, an incision three inches in length is made along the in- ner border of the sterno- mastoid muscle, through the integuments, platysma and superficial fascia, extending from near the angle of the jaw to the cricoid cartilage. The cross veins, descen- dens noni nerve, and the omo-hyoid muscle should be carefully pushed aside, the sheath opened, and the aneurismal needle 100 SURGERY. introduced between the artery and the internal jugular vein, which is upon the outer side; great care should also be taken not to in- clude the par vagum nerve, which is included in the same sheath. AXILLARY ANEURISM. This tumour occupies the arm-pit and sometimes extends above the clavicle, producing pain and numbness in the arm. The ope- ration of tying the artery above the clavicle is thus performed: the patient is placed upon a high table and the shoulder forcibly depress- ed ; an incision (b. fig. 29), is made over the clavicle, through the skin and platysma myoides, reaching from the anterior edge of the trapezius to a little beyond the posterior edge of the mastoid ; the cervical fascia is then divided, the external jugular vein pushed aside, and the omo-hyoid disclosed; in the triangle formed by this muscle and the clavicle, we find the artery at the outer edge of the scalenus muscle, passing over the first rib, with the nerves forming the brachial plexus above it, and the subclavian somewhat in front and below. Great caution should be used in exposing the vessel, on account of the varieties of the arterial distribution in the neck; it should also be recollected the phrenic nerve descends upon the anterior face of the scalenus anticus muscle. The artery is tied also below the clavicle by making a semi- circular incision, with the convexity upwards, from near the sternal end of the clavicle towards the acromial, carefully avoiding the cephalic vein and acromial thoracic artery, which pass between the outer edge of the pectoralis major muscle and the deltoid. After dividing the skin, superficial fascia, and pectoralis major, the pectoralis minor will be exposed, between the upper edge of which and the lower edge of the subclavian muscle, the artery will be found deeply imbedded in cellular tissue and fat; the vein is in front, and the axillary plexus of nerves surround the artery. The arteria innominata has been tied, but without much success where the tumour is large. The patient lying on his back, with his shoulders raised, and head thrown back, an incision two inches in length is made on the inner side of the sterno-cleido-mastoid, reaching to the sternum; another incision is made just above the clavicle and through the sterno-mastoid : thus a flap can be turned up; the sterno-thyroid and sterno-hyoid are then to be divided on a director, and the deep fascia exposed; cautiously opening this fascia, the vein is to be pushed aside, avoiding the par vagum, re- current, and cardiac nerves. BRACHIAL ANEURISM. This is usually the result of violence, and is very often a false aneurism; the tumour is in the bend of the arm, and inconveniences its mobility. BRACHIAL ANEURISM. 101 The brachial or humeral artery is tied by making an incision on the inner edge of the biceps flexor muscle, of two inches in length, Fig. 30. about the middle of the arm. The median nerve will be found first, lvina close to the artery; this and the veins are to be carefully seDarated It must be borne in mind, that the artery may bifurcate 'as high as the axilla. If it be necessary to tie the artery in the upper portion of the arm, an incision is to be made overthepulsating vessel, and it will be found on the inner edge of the coraco-brachialis muscle; the nerves and veins are to be carefully avoided. Deligation of the radial and ulnar arteries is seldom required except for wounds. Often wounds in the palm of the hand require the tying of the humeral artery. The radial may be exposed in the upper part of the fore- arm, by an incision through the skin and superficial fascia. By separating the supinator longus muscle from the pronator teres, the artery will be found as it passes over the ten- don of the pronator. In the lower part of the forearm the radial may be readily exposed by making an incision through the skin and fascia on the outer border of the flexor carpi radialis; and the ulnar by an incision on the radial side of the flexor carpi ulnaris muscle. 9 102 SURGERY. INGUINAL ANEURISM. This is a pulsating tumour in the groin, not to be mistaken for a bubo, hernia, &c. The external iliac is tied by making an incision (a, Fig. 31), about 3J inches in length, commencing on a level with the anterior superior spinous process, and about an inch distant from it; and continued nearly parallel with Poupart's ligament, to a point 1 inch above, and l£ inches to the outside of the pubes. Carefully cut- ting through the skin, superficial fascia, tendon of the external oblique, internal oblique, and transversalis muscles, the fascia transversalis will be exposed, with some danger of wounding the epigastric artery. This fascia should be scratched through, and the peritoneum pushed aside, and held out. of the way by an assistant with a spatula: the artery will be detected by its pulsation on the inner border of the psoas muscle : the vein being on its inner side. The operation for tying the internal iliac or the common iliac is made by making an incision b. The letter c shows the incision of Sir Astley Cooper when he tied the aorta. POPLITEAL ANEURISM. Fig. 32. This is of frequent occurrence, and occupies the space between the hamstrings behind the knee, causing pain, numbness and swelling of the leg, disease of the joint, &c. The operation is to tie the femoral artery. The patient being properly placed, the sar- torius muscle is rendered prominent by raising and adducting the thigh. An in- cision of two or three inches in length is made upon the inner side of the sarto- rius muscle, in the upper part of the thigh, according to Scarpa, where the artery is superficial. The saphena vein is to be re- garded in the dissection of the superficial fascia. After opening the sheath, care must be taken not to injure the vein, nor to include the saphenus nerve. Hunter's operation is somewhat below, and in its performance the sartorius must be divided or pushed aside.—The anterior tibial artery may be tied in several places: at the upper part of the leg, by a free incision, so POPLITEAL ANEURISM. 103 Fig. 33. as to get between the tibi- alis anticus and extensor communis digitorum. After the division of the superficial fascia, a proper allowance should be made for the breadth of the tibialis anti- cus, in order to strike the line of division upon the dense fascia between the two muscles. The artery will be found at the bottom of this space, lying on the interosseous membrane. At the lower part of the leg a less incision is neces- sary, the vessel being more superficial. The wound is made on the fibular side of the extensor proprius polli- cis. The vense comites and anterior tibial nerve are to be avoided. On the instep the artery may be secured by making an incision on the fibular side of the tendon of the extensor proprius pollicis. The posterior tibial may be readily tied near the middle of the leg, upon the inner side; divide the skin, superficial fascia, crural fascia, and some fibres of the soleus, and the leg being flexed, the triceps sura can be pushed aside sufficiently to expose the sheath of the vessels ; the artery is to be carefully ex- cluded from the veins and nerve. At the ankle the operation is simple. A semilunar incision is made, posterior to the internal malleolus, through the skin and superficial fascia, and a thick aponeurosis; this exposes the sheath of the vessels. The veins and nerve are to be excluded. Fig. 34. 104 SURGERY. VARICOSE ANEURISM. This is usually the result of a wound, and occurs most frequently in the elbow after bleeding. An opening remains both in the artery and the vein, and a cyst is formed with this double communication. The arterial blood en- ters the vein, and pro- duces greater or less distension of it. This enlargement of the vein is recognised by a peculiar thrill, resem- bling the purr of a cat: it may exist for some time without any inconvenience, and is to be removed by tying the artery above and below the sac, and oftentimes it is necessary to tie the vein. Aneurismal varix is another variety, occurring under the same circumstances, at the bend of the arm. The vein and artery com- municate, as in the former, but without any cyst interposed; the swelling is less, but more diffused, and varicose distension of the veins is very great. The Fig. 36. limb below the tumour is imperfectly supplied with arterial blood, and, con- sequently, cold, numb and vitally weak, and also liable to congestion and oedema. It is to be treated by pressure, so as to repress the swelling, and moderate the sanguineous mixture: this will palliate the symptoms, and permit the use of the limb. A permanent cure can only be effected by tying the artery above and below the aperture of communication. Aneurism by anastomosis presents itself in various forms: 1. Capillaries of a portion of integument may be equally and perma- nently dilated, producing discoloration and slight elevation of the part. / This is one form of nsevus, or congenital mark, which is attended with no danger, and may be considered as a deformity rather than as a disease. 2d. The structure may consist chiefly of dilated veins fed by arterial branches. This structure is not found in the true skin, but in the adjacent cellular tissue; or it may be submucous, as is exemplified by one variety of hemorrhoid. 3d. The swelling may consist chiefly of dilated and active arteries, supplied with large tortuous veins, which are mere conduits from the tumour; the tumour is erectile, and varies in bulk and tension, AMPUTATION OF THE THIGH. 105 according to the state of the circulation. It often grows rapidly, and brings life into imminent peril. Its removal may require the knife, excision or compression. AMPUTATION. Amputation is not to be resorted to until all other means of cure have failed. In cases of gangrene, large malignant tumours involv- ing a bone or a joint, diseases of the joints causing hectic and threatening life; in case of recent injury, where reparation is im- possible, then amputation must be performed. In case of injury, amputation is either primary or secondary : Primary ; when performed immediately after the patient has re- covered from the shock of the injury, and before febrile excitement. Secondary; after suppuration has commenced, and perhaps sloughing. Secondary amputations are also performed for diseases of the bones or joints. Primary amputations are to be performed when it is impossible to save the injured limb. In military life, limbs are amputated for in- juries, which a surgeon might attempt to save in civil life; there being less opportunity for treatment, and less favourable opportunity for secondary amputation. Instruments and Dressings.—Amputating knives, Catlin's saw, tourniquets, scalpels, tenacula, forceps, needles, ligatures, sponges, bone-nippers, compresses, rollers, retractors, lint spread with cerate, charpie, adhesive strips, and warm water. AMPUTATION OF THE THIGH. The patient having been brought to the edge of the bed, his back is supported by pillows, and his hands held by assistants. The tourniquet is applied over the superficial portion of the artery, about three inches below the groin, so as to interrupt the circulation of blood in the limb. This, like other amputations, may be performed in two ways, either by the circular incision or by the flap operation. Circular Incision.—The surgeon stands so that he may use his left hand to grasp the part which he is to amputate, the leg being firmly supported, in a horizontal position, by an assistant; the sur- geon then carries the amputating knife under the limb, and with one complete sweep round the limb, divides the skin, fat, and fascia. A scalpel is then used to dissect the integuments from the muscles, in order that they may be turned up, for two inches, in the same way that one would turn up the cuff of a coat. With the amputating knife, the muscles are now cut through down to the bone, the edge of the knife being inclined upwards, in order that the stump may present somewhat of a conoidal cavity ; the muscles are to be slightly separated from the bone, and a retractor applied to pull them up- wards. In using the saw, the heel should first be applied on the 9* 106 SURGERY. bone, and a groove made; by steady strokes the bone is divided care being taken to prevent splintering and roughness : in case there should be any, it may be removed by bone-nippers. The large ves- sels can now be tied, and the stump sponged with warm water, in order to detect orifices of smaller ones. After hemorrhage is com- pletely arrested, and the tourniquet somewhat loosened, the end of the bone is to be covered by the muscles and skin, so as to form a rounded stump; the edges are to be retained by adhesive strips, and the ligatures brought out at the corners of the wound. The stump is now covered by lint spread with cerate, and over this a thin pledget of charpie or tow ; the whole is supported and covered by a roller, which should be carried once or twice around the patient's pelvis. Having been carefully placed in bed, the stump is supported upon a pillow, and secured to it by pins; over the stump is placed a frame, to take off the weight of the bedclothes. During the winter, the dress- ings may remain on seven or eight days; in summer only two or three : a poultice previously applied may facilitate their removal. The after dressings may be repeated once in forty-eight hours. About the tenth day the ligatures may come away, and, generally, the wound is healed in three or four weeks. Some suppose that the stump may be better covered by the flap operation, especially should the integument be thin. Flap Opercdion.—The original plan of Vermale was, to introduce a knife perpendicularly to the anterior surface of the thigh, and to Fig. 37. cut a lateral flap on either side. Liston and others prefer an anterior and posterior flap, which prevent the end of the bone rising at the upper angle of the wound, and protruding forwards. These are made by inserting the knife by the side of the thigh, as in Fig. 37, instead of upon its anterior surface. The objections to the flap ope- 9 AMPUTATION AT THE HIP JOINT. 107 ration are the injuries to vessels and nerves, by transfixion and oblique division. AMPUTATION AT THE HIP JOINT. This operation is rarely necessary, and is always severe and dan- gerous ; it should never be performed for disease of the joint. The patient is to be placed on a table, with his pelvis projecting from the edge. The artery is compressed by an assistant, who must be ready to thrust his fingers in the wound formed during the formation Fig. 38. of the anterior flap, so that he can grasp the end of the vessel, as soon as it is cut. The knife is entered about middle way between the trochanter major and the anterior superior spinous process of the ilium. By cutting downwards, the anterior flap is formed. The head of the bone is then disarticulated, and the blade of the knife being then placed behind the bone, is carried downwards and backwards, so as to form a posterior flap ; the vessels are to be rapidly secured, and the flap managed as in all other flap operations. By some the formation of a lateral flap is preferred. Very often the selection of the flap will depend upon the character of the wound which may render the operation necessary. AMPUTATION OF THE LEG. The length of the stump will, in some measure, depend upon the kind of artificial limb to be used. If the patient is to rest upon his knee, the stump should be short, in order to be bent at right angles. Circular method.—The tourniquet having been applied, the in- teguments are to be divided, dissected up, and turned back for two inches; the muscles are to be divided, down to the bone, by a 108 SURGERY. second circular incision. Then a catlin is to be passed between the bones, so as to divide the interosseous ligament and muscles; a three-tailed retractor is then to be applied, and the bones sawn through together. If the spine of the tibia projects much, it can be removed by a fine saw, or bone-nippers. The vessels are to be secured, and the stump treated as in amputation of the thigh, the integuments being brought together in a straight line. Flap Operation.—This is generally preferred, and is thus per- formed. The surgeon first places the heel of the knife on the side Fig. 39. of the limb, farthest from him, and draws it across the front of the limb, in a semicircular direction, making a semilunar flap. When its point has arrived at the opposite side, it is at once made to trans- fix the limb, and then the larger and posterior flap is cut. In trans- fixing the limb, care must be taken not to pass the knife between the bones. This amputation may also be performed near the ankle; but, in this instance, it will be necessary to shorten the tendo Achil- lis after the flap is made. The leg should not be amputated nearer. the knee than the tuberosity of the tibia, or the joint will be opened, and inflammation result. Hence amputation at the knee is rarely performed, although disarticulation may be readily performed with a large scalpel. In this operation the patella should be allowed to remain. AMPUTATION OF THE FOOT. The foot is amputated at two places. - Choparfs Operation.—A flap is made from the upper part of the instep, and the disarticulation commenced immediately behind the tuberosity of the scaphoid bone. The bistoury is passed between the scaphoid and head of the astragalus, and then between the cu- AMPUTATION AT THE SHOULDER JOINT. 109 boid and os calcis: an inferior flap is then made from the sole of the foot. Fig. 40. Hey's Operation.—The disarticulation is commenced immediately behind the tuberosity of the fifth metatarsal bone ; separating the fifth and fourth metatarsal bones from the cuboid, the third and se- cond from the external and middle cuneiform bones. The internal cuneiform is sawed through. The superior flap is made before the disarticulation, and the inferior one subsequently. AMPUTATION OF THE GREAT TOE. The most convenient mode of removing this toe is by incisions represented by dotted lines in this figure. Commencing upon the inner side of the metatarsal bone, and running round the joint obliquely, tak- Fig. 41. ing care not to wound the anterior ti- bial artery. The flap is made from the outer side of the toe. It will cover the head of the metatarsal bone more per- fectly, and can be more readily retained in its position than any other. AMPUTATION AT THE SHOULDER JOINT. Hemorrhage is to be restrained by pressure with the fingers, or the handle of a key well padded, upon the subclavian artery, as it passes over the first rib. The flaps may be cut by transfixion, or in the manner represented in fig. 42. The external flap should be made first, out of the deltoid, and then the head of the bone disarticulated. The internal flap is 110 SURGERY. smaller, and made last, in order that the vessel may be secured im- mediately upon the limb Fig. 42. being severed. In some instances it may be ne- cessary to remove the whole of the scapula, and one half of the clavicle. The extent and character of the injury must often determine the shape of the flaps. AMPUTATION OF THE ARM. The circular operation is most frequently per- formed. The artery is compressed by a tourni- quet or the fingers, and the skin drawn firmly back. One circular in- cision will divide the skin and fascia; another will divide the muscles. If the knife is held so that the edge is directed Fig. 43. slightly toward the shoulder, the end of the bone will be found in a conical cavity, and can be well covered by the muscles and skin. CANCER. Ill The flap operation is sometimes performed. The arm being trans- fixed, the anterior flap is made first; the vessels are divided in the posterior. Amputation at the elbow is performed by making a single flap from the muscles and skin in front of the joint. The head of the radius is disarticulated first: the ulna is then to be sawed, so as to let the olecranon remain. AMPUTATION OF THE FORE-ARM. The tourniquet is applied to the brachial artery as in other opera- tions upon this extremity. Two flaps are formed, one on the dorsal, the other on the palmar aspect. These are best made by transfixion and Fig-44- cutting outwards. The amputation should be performed as near the wrist as circumstances will admit of; although below the middle it is not easy to obtain sufficiency of flaps. But, the general rule is, to remove as little as possible from the organs of prehen- sion : and operations are attended with less risk to life the farther they are removed from the trunk. Amputation at the Wrist.—The disarticula- tion of the radio-carpal joint is readily effected by commencing at the styloid process of the radius. A dorsal and palmar flap is made of the skin. The pisiform bone is to be allowed to remain. Amputation of the Fingers.—The hemorrhage may be con- trolled by an assistant's grasping the wrist tightly. The finger may be amputated at a joint or in the middle of a phalanx, though it is important to save as much as possible. The operation may be circu- lar, or with a flap, which should be made from the palmar aspect of the finger. CANCER. Malignant diseases change the original structure of the part, transform or destroy the surrounding tissues, travel in the course of 112 SURGERY. the lymphatics, contaminate the nearest glands, affect several organs in the same individual, and, if mechanically removed, reappear in or near the cicatrix. Malignant growths contain granules or nucleated cells, imbedded in a fibro-cellular tissue. They are composed almost entirely of albumen. Their development is dependent upon perverted nutrition. The causes are perpetual local irritation, and a morbid state of the constitution, which may be hereditary. In the ordinary sense of the word they are not contagious; but cancer-cells injected into the blood of a dog, produced malignant disease of the lungs. Cancer is a term applied to several kinds of malignant disease. schirrus. This term is applied to the early condition of cancer, and implies a peculiarly hard tumour, usually rounded, and subject to severe lancinating pain. It cuts with the crispness of a potato, and is intersected with dense white bands, the interstices being filled with a semi-fluid dark substance. It may occur anywhere, but most frequently in glands, especially in the female breast. Its progress varies. Generally the tumour is movable at first, and without pain. It may continue thus for a great length of time. After a time the pain increases, and the tumour swells and becomes adherent to the surrounding textures ; fissures form upon the surface, ulceration softens the tumour, and an open sore results, to which the term cancer is most frequently applied. Its edges are jagged, undermined, and inverted. The discharge is thin, sanious, foetid, and irritating. Occasionally a few unhealthy granulations appear; sometimes the whole mass sloughs away. Symptoms.—General bad health, languor, depression of spirits, emaciation, a sallow complexion, bad appetite and imperfect digestion. Hectic is induced by pain, exhaustion, and the absorption of deleteri- ous secretions. Occasionally the bones become fragile. The diagnosis must be guarded. The hardness and situation of the tumour and its lancinating pain, the age and cancerous cachexia will assist in determining the disease. Women are more liable to it than men ; persons over forty than those under it. Treatment.—Various applications have been used, but without success. Caustics and other powerful remedies often aggravate the disease. The only chance of cure is by extirpation when the tumour is hard, movable, and without pain. But even when performed under the most favourable circumstances, the disease most frequently returns. Relief and palliation of symptoms may be obtained often by alteratives and tonics. DISEASES OF THE EYELIDS. 113 FUNGUS H.EMATODES. The tumour is at first rounded, soft, smooth, elastic, free from pain and tenderness : it grows rapidly, and becomes blended with sur- rounded tissues. When the tumour is enlarged, the skin becomes livid, and the veins distinct and tortuous. The pain is aching and throbbing, but not so severe as that of cancer. Ulceration takes place, a grumous fluid discharges, and a rapidly increasing fungus grows from the aperture. This fungus is of a dark red colour, is extremely vascular, and easily bleeds. The constitution is rapidly undermined, and hectic and death soon occur. Upon dissection, the tumour presents different appearances from that of cancer. It consists of a soft pulpy matter resembling brain, which is often termed medullary. In the midst of this are cysts filled with coagulated blood and pus. It is distinguished from cancer by occurring amongst children and young persons, by its consistence, and by its attacking internal organs, such as the brain, liver, kidneys, spleen, &c. Treatment.—There never can be a radical cure: death must be the result, sooner or later. All remedies should be directed to the general health, with a view to palliation of symptoms. AFFECTIONS OF THE EYE. DISEASES OF THE EYELIDS. Hordeolum, or stye, is a small painful boil, originating in the sebaceous follicles at the root of the eyelash. It is caused most frequently by derangement of the stomach: a scrofulous constitution predisposes to them. Treatment.—Cold applications and nitrate of silver may arrest it; generally it requires poultices, and puncturing. Ophthalmia Tarsi.—This is a chronic inflammation of the edges of the eyelids. In adults the form is catarrhal, in children scrofulous. The edges are swollen and red; the eyelashes loaded with meibo- mian secretion; and the lids are glued together in the morning. There is itching, smarting, and a sensation of stiffness. When the disease is of long standing, the eyelashes fall out, and the new ones are misdirected, and irritate the conjunctiva. It may be the result of catarrhal ophthalmia, or be produced by cold and damp air, or in- temperance. In children it may result from eruptive diseases.* Treatment.—Alteratives, laxatives, and tonics. The state of the skin requires attention. Fomentation will remove the incrustations. Loose and misdirected eyelashes are to be removed. An ointment composed of gr. x. of red precip. and an ounce of cerate is to be carefully applied at night; and in the morning the lids are to be bathed with tepid water, and not separated forcibly. In inveterate cases, sulphate of copper and nitrate of silver may be applied to the edges, and blisters placed behind the ears. 10 114 SURGERY. Entropion, which is a permanent inversion of the eyelid, often results from tarsal ophthalmia, and it can only be remedied by an operation, such as dissecting off the edges of the eyelids with the lashes and their bulbs ; or by removing a transverse fold of the skin beyond the eyelid. Ectropion is an eversion of the eyelid, caused often by a thicken- ing of the conjunctiva from long inflammation. This is to be cured by bringing the conjunctiva to a healthy condition, by the applica- tion of nitrate of silver or sulphate of copper. Should these remedies fail, a portion of the conjunctiva is to be excised. Ptosis is a falling of the upper eyelid, from a palsy of the third nerve. It is often connected with congestion of the head, and may be a precursor of apoplexy, and should be treated by bleeding, purgatives, mercury, and blisters. If persistent, it may be obviated by removing a fold of the skin from the upper eyelid. DISEASES OF THE LACHRYMAL APPARATUS. Xerophthalmia is a dryness of the eye, arising either from a want of secretion of the conjunctiva, or, as some suppose, from' a deficiency of tears. It is to be remedied by frequently bathing the eye with mucilage. Epiphora is a superabundance of tears, so that they run over the cheeks : it should be distinguished from stillicidium lachrymarum, which is an overflow in consequence of an obstruction of the chan- nels that convey them to the nose. It arises frequently from scro- fulous inflammation; or from the action of chemical or mechanical agents, cold winds, acrid vapours, &c. The treatment will, of course, vary with the cause. Obstruction of the lachrymal duct, is known by the overflow of the tears, the dryness of the nostril, distension of the sac, and formation of a small tumour. It often leads Fig. 45. to inflammation and abscess. In other instances it results in thicken- ing of the tubes and duct, which may be much benefited by the use of probes. Fistula lachrymalis is an aper- ture at the inner corner of the eye, the result of a bursting of an abscess caused by obstruction. The inflam- mation of the sac is to be treated by leeches and cold applications. If suppuration cannot be obviated, the tumour is to be opened as soon as it has become soft and fluctuating. The opening should be make paral- lel to the margin of the orbit, and below the tendon of the orbicularis. DISEASES OF THE CONJUNCTIVA. 115 The sac should then be fomented and thoroughly cleansed, and after a few days, should any doubt exist with reference to the per- viousness of the tubes and sac, an exploration is to be made by probes. Should the obstruction be firm, the opening into the sac will remain fistulous, and then a style must be introduced. The object of the style Fig. 46. Fig. 47. is to dilate the strictured portion of the sac. The form and size is represented in the cut. They are usually made of lead, silver, or gold, and sometimes of catgut. Some have thought best that there should,be a groove on the style, or that it should be hollow, but this is unnecessary; for although the style may occupy the whole of the calibre of the duct when first introduced, the tears gradually widen it, and flow readily by the side of it. DISEASES OF THE CONJUNCTIVA. Acute Conjunctivitis.— Symptoms.—Smarting, heat, stiffness, with a feeling as if dust had got into the eye. Subsequently the secretion of mucus increases; which becomes puriform. The vessels of the conjunctiva are turgid and numerous, giving it a bright red appearance. There is slight intolerance of light and in- creased flow of tears. Causes.—Cold or damp, bad condition of stomach, or local irri- tation. Treatment.—A dose of calomel followed by a saline cathartic; leeches, cold applications, moderately dark room, and a solution of nitrate of silver. The disease may become chronic ; when blisters behind the ear, and astringent applications to the eye will be useful. Purulent Ophthalmia or conjunctivitis and Egyptian ophthalmia, are more severe forms of the same affection, and are infective. The most severe form of inflammation of the conjunctiva is gonorrheal ophthalmia ; in this variety the eye is often lost. The treatment must be early and active. Scrofulous Conjunctivitis.—Symptoms.—Extreme intolerance of light, the eyelids are spasmodically contracted, the head is turned away from the light, there is no general vascularity of the conjunc- tiva, but a few vessels running towards the cornea, terminate in phlyctenulae, or pustules on the cornea. This disease is most obstinate and liable to perpetual recurrence, often resulting in ulceration of the cornea, or opacity from effusion of lymph between its layers. Treatment.—Local applications are of no avail unless the gene- 116 SURGERY. ral health be improved. A dose of calomel and rhubarb should be followed by tonics and alkalies, and other general remedies for scrofula, such as quinine and salt baths. The nitrate of silver exer- cises a more sedative and antiphlogistic influence than any other local remedy. Granular Conjunctivitis is a thick, rough, fleshy state of the palpebral conjunctiva, dependent upon long-continued inflammation; it causes great pain and disturbance to the motion of the eye, and if it continues will render the cornea opaque by its friction. Treatment.—If the granulations are long, they may be removed by the knife or scissors ; ordinarily they can be cured by scarifica- tion, lunar caustic, and sulphate of copper; at the same time the gene- ral health must be attended to, and blisters may be applied behind the ears. ULCER OF THE CORNEA. This most frequently occurs as a result of conjunctivitis, espe- cially of the scrofulous form, but may arise from mechanical injury; it often penetrates the cornea and leaves an opaque cicatrice. When the ulcer is healthy, its surface is somewhat opaque, owing to the effusion of lymph ; when inflamed, vessels will be found approach- ing it; when indolent, it is clear, and transparent, appearing as if a small piece had been cut out of the cornea. The nitrate of silver is the best application to the inflamed and indolent ulcer of the cornfa. If the acetate of lead be used, a white precipitate is formed, which is liable to become fixed in the cicatrice as a dead white spot. SCLEROTITIS. This disease is often called rheumatic ophthalmia. It is known by redness of the sclerotica, slight intolerance of light, severe aching pain of the eye, and the bone surrounding it, which is aggravated at night. It is distinguished from conjunctivitis by the character of the pain, and redness. In sclerotitis the vessels are deep-seated, of a pale pink colour, and run in straight lines from the circumference of the eye, towards the cornea ; whereas in conjunctivitis, the vessels are tortuous, freely anastomose, superficial, and are of a bright red co- lour. Treatment.—Bleeding, purging, together with the administration of colchicum, warm baths, and anodyne fomentations ; blisters behind the ears, and Dover's powder, are also of great avail. IRITIS. This often is caused by injury or cold, but oftener by scrofulous, syphilitic, or gouty taint. Symptoms.—The iris changes in colour; appears rough or villous; CATARACT. 117 the pupil is contracted, and often filled with lymph ; a pink zone surrounds the cornea, formed by small vessels from the sclerotica ; there is intolerance of light, dimness of vision, a burning pain in the eye, and an aching pain over the brow. Treatment.—The inflammation should be subdued by active an- tiphlogistic means, such as bleeding, purging, and leeching. The absorption of lymph is to be promoted, and its fresh effusion ar- rested by the administration of small doses of calomel and opium every four hours, until the gums become affected. The pupil should be kept well dilated by belladonna or stramonium, and the pain must be relieved by anodyne fomentations and nightly doses of opium. Artificial Pupil.—It is often necessary to form a new aperture in the iris, owing to the pupil having been obliterated by inflammation. CATARACT. Is an opacity of the lens or its capsules. It may be caused by in- flammation or injury, but is more frequently the result of impaired nutrition. There are different varieties of cataract, designated by the terms, hard, soft, radiated, capsular, &c. Symptoms.—The vision becomes gradually impaired, and objects appear as if surrounded by a mist or cloud. The sight is better in the evening, or after the application of belladonna, because the pupil being dilated, more light passes through that part of the lens which may yet be transparent. The pupil is active, and behind it is an opaque body of a grayish-white or amber colour. The catoptric test is the most certain mode of distinguishing it from amaurosis and glaucoma. When a lighted candle is held before the healthy or amaurotic eye, three images of it may be seen: an erect image that moves upwards when the candle is moved upwards, which is produced by reflection from the surface of the cornea ; another erect image, produced by reflection from the anterior surface of the lens, which also moves upwards when the candle moves upwards ; and a very small inverted image, that is reflected from the posterior surface of the crystalline, that moves downwards when the candle is moved upwards. In cataract this inverted image is from the first rendered indistinct, and soon abolished ; and the deep erect one is soon abolished also. Treatment.—There is no cure but by an operation, which should be deferred until the patient is in good health and condition. If the iris moves freely, and there is no tendency to vascular disturb- ance in the eye or head, the chances are favourable.—There are three modes of operating, before performing either of which, the pupil should be dilated by belladonna or stramonium. Extraction.—An incision is made through one half of the circum- ference of the cornea, the capsule of the lens lacerated, and the cataract extracted entire. Couching or Depression.—The object of this operation is to re- 10* 118 SURGERY. move the cataract from the axis of the vision, and is performed by a couching needle passed through the outer side of the sclerotica, about two lines from the margin of the cornea. Producing Absorption.—The needle is introduced in the same manner as in depression, the lens broken up and subjected to the absorbing influence of the aqueous humour. AMAUROSIS. Is an imperfection of vision, arising from some change in the retina, optic nerve, brain, or fifth pair of nerves. Symptoms.—The sight is impaired by degrees; at times vision is more impaired than at others; objects appear double, crooked, or discoloured; black spots or flashes of light, a vacant stare, dilated pupil, and but little motion of the eyelids, indicate amaurosis. There is often a want of the natural colour of the pupil, which may cause it to be mistaken for cataract, from which it is most certain to be distinguished by the catoptric test, as well as by rational signs. The usual causes are circumstances which over-stimulate the retina, such as glaring lights, heats, intemperance, tight neck-cloths; also in- flammation, concussion, extravasations, tumours, &c. Treatment.—Should it be inflammatory, produced by wounds, lightning, or exposure to intense light; or if there are plethora, head- ache, giddiness, turgid countenance, and frequent flashes of light when stooping; or if the complaint has followed a suppression of any accustomed evacuation, or the drying up of an habitual ulcer or eruption, then the antiphlogistic treatment must be adopted,—bleed- ing, cupping, counter-irritants, and purgatives. Should it be atonic, the result of a protracted illness, great loss of blood, over-lactation, leucorrhoea, or other debilitating circumstances, it is attended with pallid lips, dilated pupils, trembling pulse, and despondency of mind. The patient usually sees best after eating, and in a strong light. The discharge or other source of exhaustion should be corrected, and the system strengthened by fresh air, tonics, quinine, steel, good living, &c. The secretions should be well regulated, and the cutaneous and general circulation be promoted by exercise and bathing. Should it be sympathetic, supervening on jHundice, some disorder of the stomach, or worms, the general health must be regulated before a cure can be expected. It may arise from tumours near the eye and carious teeth, which should be removed. If it follow an injury of the fifth pair of nerves, the wound should be dilated; or if it be healed, the cicatrice must be cut out. Should it follow the use of tobacco or opium, it may be relieved by a cold shower-bath, counter-irritation, and electricity. Should it be organic, the treat- ment should be palliative. STRABISMUS. 119 STRABISMUS. Strabismus or Squinting is the want of harmonious action of the muscles of the eyeball. It may be caused by the overaction or the paralysis of a muscle. The or- Fig- 48- dinary varieties are the convergent, looking in- wards, and the divergent, looking outwards: the former is the more frequent. It may be congenital, but usually occurs in childhood. Sometimes it is the result of imitation; or it may be induced by marks or patches on the nose; but oftener it is oc- casioned by gastric or intestinal irritation. Cerebral disturbance is another cause, especially when the squint does not come until adult age. Treatment.—In childhood, where squinting depends on sympathetic disturbance, it is often removed by pur- gatives, alteratives, or anthelmintics. Some cases of squinting may be cured by division of a muscle, but not all; in fact, a deformity sometimes results from the operation. In almost all cases of squinting, there is defective vision in the affected eye; this defect is usually relieved when the operation is properly performed. The patient should be steadied, as for other ophthalmic operations. The eyelids are to be separated by an assistant or speculum, and the eye not to be operated on is carefully to be bandaged. The conjunctiva is to be seized by a small toothed forceps, about midway between the cornea and the ca- runcle, so as to form a horizontal fold, which is to be snipped by the scissors close to the forceps, and between them and the cornea; or, this fold of conjunctiva may be divided by an iris knife. After the division, the con- junctiva is to be separated from the sclerotica for a slight distance. The third step consists in the introduction of a blunt hook, which is curved so as to accommodate it- self exactly to the curvature of the eyeball. The hook is to be passed under the tendon, from above downwards; and the muscle now being secure, it is to be divided by a pair of scissors. If the pupil is now in the centre of the orbit, and if the patient cannot turn the eye hori- zontally inwards, the operation may be considered as complete. Should a portion of the muscle, or some ten- dinous fibres remain undivided, they are to be sought for by the blunt hook, and divided. If the fascia is too extensively divided, the eye will become too prominent, or an external squint will result. 1 120 SURGERY. After the operation, cold water is all that need be applied. The operated eye should be exclusively used for a few days. A fungous granulation often rises from the wound, which may be removed by the knife, scissors, or lunar caustic. CLUB-FOOT. This deformity may either be congenital or acquired. The con- genital form is dependent upon some disturbance of the cerebro- spinal system, that produces irregular contraction of the muscles, by which antagonism is destroyed. The accidental causes by which it may be acquired, are injuries and diseases of the foot or ankle, convulsions, scarlet fever, cica- trices, rickets, die. The principal varieties are three: — 1. Talipes Varus, in which the foot is turned inward, as in figure 49, and rests upon Fig. 49. its outer edge. There are various grades and modifications of varus. The foot is not dislocated, but the bones deviate from their normal direction, and their articular surfaces are partially separated. The astragalus is least altered in position. The liga- ments on the outer side are lengthened, and those on the inner are shortened. The tendons of the tibialis anticus and posticus, and the tendo Achillis, are most contracted; the peronei are re- laxed. 2. Talipes Valgus (fig. 50). The foot is everted, and rests on its inner edge. It is a rare form of club-foot. The ligaments on the inner side are relaxed. The peronei muscles are contracted, and the tibialis anticus and posticus elongated. 3. Talipes Equinus.—In this variety the foot rests upon the ball, or upon the toes. After a person has walked for a number of years the deformity is increased, as is represented in the drawing CLUB-FOOT. 121 Fig. 50. (Fig. 51). The shortening is due to contraction of the triceps tendon, and thickening of the plantar fascia. There are two other varieties; Fig. 5-1. one in which the toes are drawn up by contraction of the extensors, and the patient walks upon the heel; and the other when the dorsum or instep comes in contact with the ground. Besides which there may be various complications of the above. The prognosis will depend upon the degree of contraction, the va- riety of the deformity, the condition of the bones, and the age of the patient. Treatment.—Many cases of con- genital club foot may be rectified by constantly wearing a proper apparatus, especially if the treat- ment be commenced in early child- hood ; but in confirmed cases it is better to resort at once to Stromeyer's operation of division of the tendons. The operation is thus performed. The tendon is put on the stretch, and a narrow sharp-pointed 122 SURGERY. knife is thrust through the skin externally to the tendon; then the edge is directed towards the tendon and the knife withdrawn, cutting the tendon as it escapes. The operation will facilitate the cure in most cases, provided the subsequent treatment be effectually maintained; and this depends as much upon the fidelity of the parent or nurse in the constant application of the apparatus as upon the skill of the surgeon. There may be said to be little or no danger resulting from the operation. Various foot-boards and shoes are to be worn, by which the de- formity is gradually and permanently overcome. The most favourable period for the operation is between six and eighteen months. Great care is required not to produce excoriation and ulceration of the skin in a young child. Oftentimes it is better to remove the apparatus entirely than run the risk of producing fever or convulsions. Till) E.\D. ERRATA. Page 47, line 23, read: Sixty or seventy days will elapse before the limb can be used; and even then, caution should be taken that the newly-formed ligament be not broken. The patella of the oppo- site side is liable to fracture; for it possesses the same structure which predisposed to fracture in the other limb, and there is increased mus- cular exertion of the sound limb. Page 50, line 10, read, for leave, have. I, ii i i i • » i I i I HANDBOOK OF OBSTETRICS. M, ., THE OTHER PORTIONS OF THIS SERIES ARE ANATOMY, WITH ONE HUNDRED AND FIFTY-SEVEN ILLUSTRATIONS. PHYSIOLOGY, WITH FORTY ILLUSTRATIONS. SURGERY, WITH FIFTY ILLUSTRATIONS. MATERIA MEDICA AND THERAPEUTICS, WITH TWENTY-NINE ILLUSTRATIONS. CHEMISTRY, WITH NINETEEN ILLUSTRATIONS. AND PRACTICE OF MEDICINE. ANY ONE OF WHICH MAY BE HAD SEPARATELY, DONE UP IN A WRAPPER FOR MAILING. HANDBOOK OBSTETRICS: WITH THIRTY-SEVEN ILLUSTRATIONS. BEING A PORTION OF AN ANALYTICAL COMPEND VARIOUS BRANCHES OE MEDICINE. BY f JOHN NEILL, M.D., DEMONSTRATOR OF ANATOMY IN THE UNIVERSITY OF PENNSYLVANIA, LECTURER ON ANATOMY IN THE PHILADELPHIA MEDICAL INSTITUTE, ETC. AND / FRANCIS GURNEY SMITH, M.D., LECTURER ON PHYSIOLOGY IN THE PHILADELPHIA ASSOCIATION FOR MEDICAL INSTRUCTION, ETC. PHILADELPHIA: LEA & BLANCHARD. 1848. Entered, according to Act of Congress, in the year 1848, By Lea & Blanchard, In the Clerk's Office of the District Court for the Eastern District of Pennsylvania. C SHERMAN, PRINTER, 19 St. James Street. CONTENTS Bones of the Pelvis—Os innominatum, divisions of - Os ilium, dimensions, &c. - Os ischium ....... Os pubis ....... Os sacrum ....... Os coccygis ....... Dimensions of the pelvis—Divisions into greater and lesser brim Diameters of the pelvis ..... Cavity—Outlet - Planes of the straits . Inclined planes of the pelvis Axes of the pelvis Of the Fcetal Head - Dimensions of the fcetal head - Regions of the head Of the Organs of Generation Of the external organs Of the internal organs Of the uterus Broad ligaments Fallopian tubes • Ovaries Graafian vesicle, ovum, &c. Corpus luteum Menstruation and its Diseases Amenorrhcea— Emansio mensium Suppressio mensium, acute and chronic Dysmenorrhcea ... Menorrhagia ... Vicarious menstruation Leucorrhoea—three forms VI CONTENTS. Hysteralgia, or irritable uterus Prolapsus uteri ...... Generation, mode in which it is effected - Changes in the uterus after conception Deciduous membranes - Pregnancy, its phenomena and diseases ... Measurements of the gravid uterus - Changes in the uterus during gestation - «► Signs of Pregnancy ..... Rational signs ...... Sensible signs- ..... Ballottement—Auscultation .... Tabular view of the signs of pregnancy during gestation Development of the Foetus ..... Germinal membrane ..... Umbilical vesicle ...... Allantois ...... Amnion, formation of - - - r The chorion ------ The placenta, mode of formation and uses The umbilical cord—Battledore placenta Development of different parts of embryo - - - Duration of pregnancy .... Extra-uterine pregnancy, varieties of Foetal circulation ..... Premature Expulsion of the Foetus .... Tampon, construction and mode of application Pathology of the Foetus, and Signs of its Death Retroversion of the Uterus .... Labour, definition of—Cause - . . . . Classification of labours—General features and symptoms Stages of Labour ...... Bag of waters ..... Presentations and Positions - Diagnosis of presentations .... Mechanism of Labour - Vertex presentations - Occipito-anterior—Occipito-posterior positions Cause of greater frequency of vertex presentations Flexion—Rotation - - . . Extension—Restitution .... Mechanism of second position .... third and fourth position fifth and sixth position Conduct of a Labour ..... CONTENTS. Lochia - After pains - - - - - " General directions for the management of the child—Defective vi Asphyxia of child - - - Apoplexy—Caput succedaneum—Hemorrhage from the navel Tedious Labour - Premature rupture of the membranes Excessive quantity of liquor amnii Toughness of the membranes Rigidity of the soft parts Face Presentations - Causes Positions and mechanism - Diagnosis - Treatment - Pelvic Presentations—Causes - Prognosis - Positions - - - - Mechanism - Treatment - Preskntations of the Inferior Extremities - Dingnosis - - - " Positions of feet . - - - Positions of knees - - - - Mechanism - - - - Treatment - Preternatural Labour, or dystocia - - - - Causes - Presentations of Superior Extremities - Causes -----* Diagnosis- ..---- Positions ...---- Treatment—Version by the head—by the breech—by the Kct . Method of procedure ------ Position of patient—Choice of hand Version in cephalic presentations - The Forceps, history and description of - - - Indications for their use - - - - . - Method of application - Which blade to be introduced first . - - - Mode of application in occipito-anterior positions - " " occipito-posterior positions Exception to the general rule of applying left-hand blade first Right occipito-iliac position - Locked or impacted head .... - V1I1 CONTENTS. Vectis or Lever ...... Fillet or Noose, and Blunt Hook .... Craniotomy ....... Object of the operation ..... Mode of operating ...... Instruments—Holmes, Smellie, Davis, Baudelocque, Jr., Meigs After treatment ...... Cesarean Operation ...... Prolapsus of the Cord ...... Prognosis and treatment ..... Uterine Hemorrhage ...... Diagnosis....... Treatment ... .... Unavoidable Hemorrhage—Placenta prtevia; placental presentation Symptoms ....... Diagnosis—Treatment Hemorrhage after delivery Causes .... Treatment .... Puerper a l Convulsions—Hyst erical—Epilept Apoplectic .... Puerperal Fever ... Symptoms—Causes—Treatment Milk Fever .... Treatment .... Inversion of the Womb Causes .... Treatment ... 97 98 99 ib. 100 101 ib. 102 ib. ib. 103 ib. ib. 104 ib. 105 106 ib. ib. 107 109 ib. Ill 112 ib. ib. 113 ib. OBSTETRICS. OF THE BONES OF THE PELVIS. ; The pelvis is an irregular bony cavity, situated at the base of the spinal column, and above the inferior extremities, with which it is connected by muscles and articulations, and for which, as well as for the muscles of the trunk, it constitutes " a point d'appui." When divested of its soft structures, this organ somewhat resem- bles a basin, and hence its name; for the Greeks called it crsXuf, a wooden utensil of bowl-form ; the Latins from them derived the word pelvis, which is the term generally adopted by English and American writers. The French call it le bassin, the Italians el bacino, all which words have the same signification. In the adult, the pelvis consists of four parts, viz.: two ossa inno- minata, the os sacrum, and the os coccygis, but in early life they are more minutely divisible. Each 05 innomina/Mm at an early period of intra-uterine life con- sists of cartilage only. Subsequently bony depositions take place, which at birth have coalesced so as to form three bones separated by cartilage. The process of ossification continues till these three bones meet in the acetabulum, two-fifths of which are formed by the ilium, two-fifths by the ischium, and one-fifth by the pubis. The breadth of each os innominatum, from the anterior superior spinous process to the posterior superior spinous process is six inches, and the height, from the tuber ischii to the crest of the ilium, is seven inches. Os ilium, hip, or haunch bom (Fig. 1), is the largest of the three divisions of the os innominatum, and is uppermost in position. It has an outer and an inner surface; the outer'1) is called dorsum, and is irregularly convex, and marked by eminences and depressions afford- ing attachments for the glutaei muscles, The inner(10) is concave and smooth, and is called venter; it is occupied by the iliacus inter- nus muscle, The lower portion, the base, or body,'6) is the thickest part of the bone, and enters largely into the composition of the ace- tabulum, a cavity for the reception of the head of the femur. Just above the base, the bone narrows into a kind of neck, from which springs the ala or wing. The ala terminates superiorly in a ridge running along its whole extept, called the crista ilii, or crest of the 2 14 OBSTETRICS. Fig. 1. ilium. To different parts of the crest are attached the oblique and transverse abdominal muscles, the latissimus dorsi, the erector spina, and the quadratus lumborum. It terminates anteriorly, in the ante- rior superior spinous process, and anterior inferior spinous pro- cess^*?) and posteriorly in the posterior superior and inferior spinous processes.'6?) The anterior superior spinous process gives attach- ment to one end of Poupart's or Gimbernat's ligament, the tensor vagina femoris, and the sartorius muscles. From the anterior infe- rior arises the longer portion of the rectus femoris. Into the posterior are inserted strong ligaments, which bind this bone very firmly to the sacrum. Below the posterior inferior spinous process there is a deep arch, the sciatic notch, which is divided by ligaments into the two sciatic foramina; through the upper, which is the larger, pass the gluteal, sciatic, and pudic arteries, the sciatic and pudic nerves, and the pyriform muscle; through the inferior, the pudic arteries and nerve re-enter the pelvis, and the obturator internus muscle passes out. The posterior part of the crest is very rough, and marks the connexion between the ilium and sacrum, called the sacro-iliac sym- physis, of which there is one on each side of the sacrum. The body of the bone is divided from the ala internally by a ridge running horizontally^13) forming a portion of the pelvic brim, linea innomi- nata, or linea ilio-pectinea. The ilium is connected with the ischium and pubis in the acetabulum, and posteriorly with the sacrum. Os ischium, is the second in size, and lowest in position of the divi- sions of the innominatum. It is noted for a base or body, a spinous process, its tuberosity, and ascending ramus. The base,or body, (Fig. 2?) forms the inferior portion of the acetabulum, and is the thickest BONES OF THE PELVIS. 15 Fig. 2. part. Below this is a nar- rowed portion called the neck; from this a pyra- midal process juts out called the spine, or spi- nous process, affording at- tachment to part of the sacro-sciatic ligament. It varies in length and direc- tion, and is at times of importance obstetrically. In its descent from the neck, the bone bulges out into a protuberance called tuber ischii,^*) and turn- ing upwards at an acute angle, becomes the as- cending ramus of the ischium.'15) The inter- nal surface of this bone is smooth and even, and forms one of the inclined planes of the pelvic cavity; the external is rough, and gives attachment to the sacro-sciatic ligament, and several muscles. The ischium is connected with the ilium and pubes in the acetabulum, and articulated with the sacrum by ligaments. Os pubis, is the smallest and most anterior of the three divisions. It has a base or body, two rami, a horizontal and a descending, a spinous process, and a symphysis. Its base is the thickest part, and forms the anterior and smaller portion of the acetabulum, beyond which the bone narrows, and proceeding forwards forms the hori- zontal ramus (Fig. 2 lB). This terminates in a wider sheet, and its edge, the point of junction with its fellow bone, is called the sym- physis pubis (Fig. 1 17). From the inferior part of the symphysis, the descending ramus (Fig. 2 18) proceeds downwards to meet the ascending ramus of the ischium, and with it forms one side of the arch of the pubis. On the interior, running along the upper margin of the horizontal ramus, is a ridge, which is part of the linea ilio- pectinea, and at its pubic extremity is a small spinous process, afford- ing an attachment to the pubic end of Poupart's ligament, and near it to the pectineus ; whilst the inner and outer edges of this portion of bone afford insertions to the abdominal muscles. The os pubis is connected with the ilium and ischium in the acetabulum, with the ascending ramus of the ischium, and with its fellow, by the symphy- sis. In the anterior part of the os innominatum is seen the obturator foramen,^) formed by the ischium and pubis, which is nearly filled in the recent state by the obturator ligament; through the hole at the superior part pass the obturator vessels and nerve. The object 16 OBSTETRICS. attained by this arrangement is lightness of structure where strength is not needed. Of the three bones, the ilium forms part of the brim of the pelvis but none of the outlet; the ischium part of the outlet, but none of the brim; whilst the pubis forms part of both brim and outlet. Os sacrum terminates the vertebral column ; in form it is triangu- lar with the apex of the pyramid downwards, and rather backwards. It is the lightest bone in the body when its size is considered, and is spongy in structure. It has four surfaces, an external and internal, and two lateral, is about four and a half inches in length, four inches in width, and its greatest thickness is about two and a half inches. The external surface is convex and rough, and has three or four processes like those of the vertebrae, which may be called the spinous processes of the sacrum ; anterior to these we find a hollow cavity for the reception of the cauda equina, with four holes on each side, which communicate with the cavity for the transmission of nerves. The internal surf ace (Fig. 3 3) is smooth and concave to the depth of half an inch, and crossed by four trans- verse white lines, which mark the former division of its bones by car- tilage. There are also four pairs of holes on this surface, which transmit nervous filaments, which afterwards form part of the great sciatic nerve. The upper edge of this bone completes the brim of the pelvis, and from the projection of the central part it is called the pro- montory of the sacrum.'1) The lateral surfaces'*) are rough and uneven, the irregularities corres- ponding with those on the ilium and forming with them the sacro-iliac symphysis. Os coccygis, is attached to the apex of the sacrum, and is so named from its resemblance to the beak of a cuckoo.(4) It is com- posed of three or four pieces, which play upon each other by separate joints, and is of much importance in obstetrical study. The small sciatic ligament and the ischio-coccygeal muscles are inserted into it. Dimensions of the pelvis.—The pelvis is divided into the true and false ; the upper and the lower; and the greater and the lesser, by the linea ilio-pectinea, all above that line being the upper, the greater, or false pelvis, all below receiving the other denominations. The lower or true pelvis is of most importance to obstetricians, and is divided into brim, cavity or excavation, and outlet. The brim is defined by the linea ilio-pectinea, and is shaped like BONES OF THE PELVIS. 17 the heart on a playing card. It has three diameters, an anteropos- terior, called also, straight or conjugate, from the promontory of the sacrum to the inner edge of the symphysis pubis, which measures about four inches. (Fig. 4, a. p.) The transverse, across the widest part of the brim, and at right angles to the an- teroposterior, is about five inches and Fig. 4. a quarter.(£ t) The oblique, from the sacro-iliac junction on either side to the opposite side of the brim above the acetabulum, five inches.(o o)— These measurements are of course less in the living body in consequence of the presence of the soft structures. The circumference of the brim is about thirteen inches. The cavity or excavation is the space included between the brim and the outlet. It is an inch and a half deep in front, three and a half at the side, and from five to six inches from the sacral promon- tory to the tip of the coccyx. The brim of the pelvis is also called the superior strait. The outlet is of an irregularly oval shape, and its diameters are the reverse of those of the superior strait; thus, the antero-posterior diameter, from the arch of the pubes to the tip of the coccyx is four to four and a half inches. (Fig. 5, a. p.) The transverse, from one tuberosity to the other, is four inches.(Z t) The outlet is bounded by the tip of the coccyx at the back, by the lower edge of the under fasciculus Fig. 5. of the sacro-sciatic ligaments posteri- orly and laterally, by the tubera ischii at the sides, by the rami of the ischia and pubes anteriorly and laterally, and by the symphysis pubis in front. Its circumference is about twelve inches, and it is also called the infe- rior strait. The planes of the straits.—If a piece of card or paper be cut so as to fit within the linea ilio-pec- tinea, it will represent the plane of the superior strait. Now hold the pelvis in the position it occupies when the individual is either sitting or standing, and it will be found that the plane of the strait has an inclination of about thirty-five degrees, which may be increased or diminished at will by extending or flexing the lumbar vertebrae. The plane of the inferior strait may also be described in the same way, viz. : by fitting a card into it. It will be found that they incline towards each other anteriorly, and would meet, if pro- duced, about one and a half inches in front of the pubes. The whole position of the pelvis in regard to the trunk of the body is oblique, so that a line drawn through the trunk in the direction of its axis 2* 18 OBSTETRICS. would, in falling downwards, strike on the centre of the symphysis pubis. The inclined planes of the pelvis.—These are four in number, an anterior and a posterior on the right side, and an anterior and posterior on the left side. To demonstrate them, let two vertical cuts be made through the lesser pelvis and at right angles to each other. The first should be made through the symphysis pubis, and the median line of the sacrum and coccyx, and the second, or transverse, should commence behind the tuberosity of the ischium on either side and run upwards perpendicularly through the apex of the spine of the ischium, up to the linea ilio-pectinea. By these two vertical cuts there will be an anterior and posterior inclined plane demonstrated on each side of the pelvis, of which the anterior will be the longer. Axes of the pelvis.—There are two axes of the pelvis, one of the brim or superior strait, which is a line drawn perpendicular to the plane of that strait, and, if produced, would extend from the coccyx to a little above the umbilicus ; the other, of the outlet or inferior strait, which is a line drawn perpendicular to the plane of that strait, and, if produced, would extend from the promontory of the sacrum to the central space between the tubera ischii. The axes of the upper and lower straits of the pelvis form an obtuse angle with each other. By combining these axes with the inclination of the pelvis we can obtain a correct notion of- the direction of the canal of the pelvis, which, it will be readily seen, is curved. By having a correct know- ledge of the axes of the trunk and pelvic entrance, the obstetrician is enabled to place his patient in the position most favourable to the ready descent of the child's head through the brim into the exca- vation. OF THE F03TAL HEAD. The head is of. an oval shape, and largest at its occipital ex- tremity ; so that in vertex presentations the largest end necessarily descends first, and its smallest circumference, which is about ten and a half inches, will be nearly parallel to the successive planes of the canal. It is the largest part of the child, and its lateral and superior parietes are most compressible. The bones of the head which re- quire our study are the two parietal, the frontal, which is divided into two, the occipital, and the two temporal, for a minute description of which, see the division on Anatomy. The bones of the child's head are not dove-tailed into each other as we find them in the adult, but are separated to some extent by intervening lines and spaces of membranous formation ; the lines are called sutures, the spaces fon- tanelles ; from their having been supposed to distil a moisture, they are also called bregmata, from Pptyu, to moisten. The sutures are the coronal, sagittal, lambdoidal, and squamous. At the two extremities of the sagittal suture are the two fontanelles, the anterior and pos- terior, named from their position. The anterior is the larger, and is ORGANS OF GENERATION. 19 from one parietal , (3 <) ' • 4 in. to 4J in. of a quadrangular shape ; it is formed by the rounding off of the four corners of the two frontal and the two parietal bones. Ihe posterior is triangular, and formed by the union of three bones, the superior posterior angles of the two parietal, and the upper angle of the occipital. A knowledge of these fontanelles is of great im- portance in the practice of midwifery, as they are the chief means of diagnosticating the position of the child's head in labour ihe great advantage gained from this arrangement of the child s head, is that it allows a more uniform growth and development to the brain than could have taken place had the cranium been solid, and what is perhaps of greater importance, it allows the bones to overlap, and thus permits a certain amount of compression, which enables the head to be pushed through a smaller space than if it had been formed of one continuous piece. The dimensions of the foetal head have been variously stated by obstetrical writers, each basing his report upon the result of his own observations. The following table, modified from Churchill's, is the best average. The longitudinal or occipitofrontal diameter, Fig. 6, (' a) is from The transverse or bi-parietal, boss to the opposite, . The occipito mental, or oblique The cervicobregmatic, (5 ") The trachelo-bregmatic, . The inter-auricular, The bi malar, The fronto-mental, (7 8) The transverse diameter of the shoulders, « " " " hips,. In general, it may be observed that all larger in the male than in female children. Regions of the head.—Vertex. A circle of an inch in radius around the posterior fontanelle as a centre. Top of the head. —Sometimes called the breg- matic region ; besides which the terms lateral, chin, face, forehead, base, are used to de- fine .different regions of the head which may present. By the base is understood all the immovable parts of it, viz.: the sphenoid in the centre, the temporal bones laterally, to- gether with the bones of the face 4 54 4 4 5 reducible to 3 5 the measurements are Fig. 6. 20 OBSTETRICS. OF THE ORGANS OF GENERATION. These are generally divided into the external and internal. The external consist of the mons veneris, labia externa, perineum, clitoris, nympha, vestibule, meatus urinarius, hymen in virgins, and carun- cula myrtiformes in matrons. The internal are the vagina, uterus, and uterine appendages, which latter are the broad ligaments, round ligaments, two ovaries, and two Fallopian tubes. The mons veneris (Fig. 7) is placed at the lower part of the abdomen, and upper part of symphysis pubis ; it consists of dense fibro-cellular, and adipous tissue, and is covered, in the adult, with hair, among the roots of which are numerous seba- ceous follicles. The labia externa are two folds of skin and mucous membrane, which commence in front of the symphysis pubis, and ex- tend downwards and backwards to the perineum, where they again meet. The superior junction is called the anterior commissure of the vulva, the posterior, is called the posterior com- missure. Their texture is principally cellular and vascular, and their use is to protect the organs situated between them. The perineum extends from the lower union of the labia externa back- wards towards the anus. It is composed principally of highly dis- tensible cellular tissue, but does not possess a great deal of fat, and the skin is very scantily supplied with hair ; it is somewhat trian- gular in shape, and its medium breadth in women who have not borne children is from an inch to an inch and a half, being narrower, of course, in women who have. It is capable of great distension. The nympha, labia interna vel minora, arise from nearly the same point, at the anterior commissure, and run downwards and backwards about an inch, to the middle of the orifice of the vagina, where they are lost in the general lining of the labia externa. They are covered with mucous membrane, and consist of cellular and erectile vascular tissue, and do not disappear during the distension of the external parts by the escape of the child's head. The clitoris is seated just below the point of junction of the nym- pha?, and is the analogue of the male penis, excepting that it has no corpus spongiosum, and no urethra ; it is erectile, and extremely sensitive. The vestibule is a triangular space, bounded superiorly by the clitoris, and laterally by the nymphoe, it is covered by smooth mucous membrane, and at its lower portion we find the orifice of the urethra, easily recognised by its soft, prominent, circular rim. Fig. 7. INTERNAL ORGANS. 21 The urethra is about an inch and a half long, dilatable, and ex- tends from before backwards and upwards, running under and behind the symphysis pubis. The hymen is a fold of mucous membrane, generally of a crescentic shape, with its concavity upwards, which is found just within the orifice of the vagina ; it is generally ruptured at the first sexual intercourse, and its remains constitute what are known as the caruncula myrtiformes. The space between the hymen and the fourchette is called the fossa navicularis. The external organs in the aggregate are often spoken of under the name pudendum. THE INTERNAL ORGANS. The vagina is a musculo-membranous canal, extending from its origin in the vulva obliquely through the cavity of the pelvis to the uterus, in its progress describing a curve, which is greater even than than that of the sacrum and coccyx, having the neck of the bladder, the urethra, and the symphysis pubis anteriorly, and the rectum pos- teriorly. It is about four or five inches long, and three in circum- ference, being shorter and more capacious in those who have borne children. It has three coats, an external cellular, a middle muscular, and internal mucous. It is well supplied with blood-vessels, which are much multiplied and interlaced at its anterior extremity, consti- tuting what is known as the plexus retiftnmis. Its mucous membrane is of a pink colour, and is arranged in transverse rugse anteriorly and posteriorly, which allow great distension of the vagina. Its orifice Fig. 8. 22 OBSTETRICS. is surrounded by a collection of muscular fibres, called the sphincter vaginae. At its superior and posterior portion, it receives a reflection of peritoneum. (Fig. 8.) The uterus is placed at the upper part of the vagina, and hangs in the centre of the pelvis behind the bladder, and before the rectum with its long diameter parallel to the axis of the superior strait, and its superior edge a little above the brim of the pelvis. As the axis of the vagina is nearly parallel with that of the inferior strait, it meets the axis of the uterus at an obtuse angle; any deviation from which, implies a displacement of the womb. It is a hollow pear-shaped body, rounder posteriorly than anteriorly, about 2£ to 3 inches long, 2 inches wide, and very nearly an inch thick. Anatomists divide it into fundus, body and neck. The fundus is that portion above the Fallopian tubes, the cervix is the inferior, cylindrical portion, and the body is that part between the fundus and cervix. (Fig. 9.) Fig. 9. The uterus has three coats, a serous, a muscular, and a mucous. It is covered anteriorly and posteriorly by peritoneum, which is re- flected laterally to the sides of the pelvis, near the .sacro-iliac sym- physis, forming the broad ligaments, which serve to steady the uterus. The middle coal of the uterus is muscular, and classed among those muscles which are called non-striated, and which are also found in the middle coats of the arteries. There are three sets of fibres, cir- cular, longitudinal, and oblique, which, by their contraction, tend to diminish the cavity and expel the contents of the uterus. The amount of muscular fibres is much increased during pregnancy. The internal coat is generally considered to be a mucous membrane, though there are some obstetrical physiologists who deny it. It extends down into the cervix, whence it is continuous with that of the vagina; it also lines the Fallopian tubes. Its colour is a pale pink except during menstruation. The uterus is supplied with blood by the spermatic and uterine arteries, and with nerves from the aortic INTERNAL ORGANS. 23 plexus, and from the hypogastric nerves and plexus, being a mixture of sacral sympathetic nerves. The cavity of the uterus is triangular, its base being directed upwards, and the superior angle correspond- ing to the points where the Fallopian tubes enter it; in size it is about equal to a split almond, and the internal walls are nearly always in contact. Its inferior angle communicates with the vagina through the canal of the cervix, which is barrel-shaped, and from half to three quarters of an inch long. The contraction at the upper extre- mity of the canal is called the internal os uteri, whilst that at the lower extremity is called the os uteri or os tinea ; the latter name from its supposed resemblance to the mouth of the tench. The shape of the os uteri varies, in some being transverse, and in others cir- cular, or ragged ; the latter especially in women who have borne children. In the mucous membrane of the cervix are found the glandula Nabothi. The broad ligaments of the uterus are two duplicatures of peri- toneum, one on either side, extending from the sides of the uterus to the ilia, in the line which divides the anterior from the posterior in- clined planes of the pelvis ; they act as stays to the uterus, and con- tain the Fallopian tubes, which run along their upper margin, and the ovaries, which are enclosed in a posterior fold. The Fallopian tubes are two cylindrical canals, about four inches long, which arise from the superior angles of the uterus. They open obliquely into the uterus, at which point the canal narrows; it after- wards expands, and again contracts at the point where it opens into the abdomen. In the unimpregnated state it is about the size of a bristle. Externally they are equally thick throughout, except at their terminal extremity, where they expand into a trumpet-shaped enlarge- ment, called fimbria, or morsus diaboli, which applies itself to the ovary. They have three coats, an internal mucous, a middle mus- cular, and an external serous, or peritoneal, and they are looked upon as the excretory ducts of the ovaries. The ovaries are two in number and are the analogues of the male testis. They are situated on the posterior face of the broad liga- ments, and are attached to the uterus by a ligament of their own, called the ligamentum ovarii. They are oval in shape, and have two coats, an external peritoneal, and an internal, the tunica albu- ginea. On removing these we come to the proper tissue of the ovary, called its stroma, which consists of dense cellular tissue, containing within its meshes or areolae, numerous little vesicles, named Graafian vesicles. These vary in number and size, the largest being gene- rally seen near the surface of the ovary; they are found early in life, but are more developed about the period of puberty. The Graafian vesicle has two coats, an external, the tunic of the ovisac, and internal, the ovisac, (Barry.) Within the cavity formed by these membranes is found, floating in an albuminous fluid, the ovum or egg, which is exceedingly small, and resembles in all its 24 OBSTETRICS. details the egg of the chick. The ovum also contains within its capsule or membrane, which is called the yelk membrane, a granular fluid termed the yelk, and in the centre of the yelk a little vesicle, the germinal vesicle, and on the walls of the germinal vesicle its nucleus is seen, named the macula germinativa, or germinal spot. As each Graafian vesicle rises to the surface of the ovary it bursts, and allows the contained ovum to escape, which is seized by the fimbriae of the Fallopian tube, and transmitted to the uterus. The cavity of the Graafian vesicle, (which still remains in the ovary,) be- comes filled up either with a clot of blood, or a new deposit, which, assuming a yellow colour, is called from that circumstance, corpus luteum, or yellow body. There is no correspondence between the number of corpora lutea found in the ovaries of a woman, and the number of children she may have borne, as ova are being constantly discharged irrespective of fecundation, hence the corpus luteum is no evidence of previously existing pregnancy. MENSTRUATION AND ITS DISEASES. By the term menstruation, is understood that function in the female economy by which a certain amount of sanguineous fluid is eliminated by the uterus, and discharged from the vagina every month. This discharge, from its occurring at this regular interval, is called the menses, or catamenia, and the female in whom it so takes place is said to be regular. This function generally commences at the age of puberty, which in this country is about fourteen or fifteen, and lasts till about forty-five, when it disappears; to this latter period is often applied the terms, critical period, change of life, &c. During the whole of a woman's menstrual life she is capable of conceiving; after this, her repro- ductive function ceases. The approach of puberty is announced by other changes than those mentioned. The mammae are developed, the form becomes rounded, the pelvis expands, and the pudendum is covered with a growth of hair. The flow generally returns every twenty-eight days, and lasts from four to six, and the amount dis- charged varies from four to eight ounces, though about this there is no certainty, as every woman is a law to herself; what would be a profuse discharge in some, is merely normal in others. The first menstrual flow is generally preceded by languor, lassitude, pain in the back, headache, chilliness, &c, which generally disappear when the discharge takes place. The after occurrences are often unac- companied by any premonitory or attendant symptoms. The theo- ries that have been brought forward to explain the efficient cause of menstruation are too numerous, and too unsatisfactory to detain us here. The most popular is that which looks upon the maturation and escape of ova as the efficient agent. It is said that every twenty- eight days a Graafian vesicle rises to the surface of the ovary, and MENSTRUATION AND ITS DISEASES. 25 during its development and enlargement puts the tunica albuginea and peritoneal coat upon the stretch, and thus becomes a source of irritation ; in consequence of which there is an afflux of blood to the parts (that is, to the ovaries, tubes, and uterus), which is discharged into the latter organ; the vesicle finally ruptures, the irritation is removed, and the flow ceases. This view is supported by Drs. Lee, Gendin, Negrier, Pouchet, Raciborski, and others; but is denied by Dr. Ritchie and others, who contend that ova may be discharged without menstruation, and the reverse, that the maturation of ova is an effect, and not a cause ; but the whole is yet in a transition state. That the ovaries are concerned seems proved by the fact, that in their absence there is no menstrual flow. The blood that is dis- charged in menstruation is considered by Mad. Boivin to be identical with venous blood, and the opinion is adopted by Prof. Meigs and M. Duges. Although there are many, and the larger number, who look upon it as altered blood, and deficient in fibrin, the first opinion would seem to be supported by the microscopic investigations of M. Donne and others. The uterus is congested during menstruation, so are the Fallopian tubes and ovaries; the vagina is relaxed and distensible, and the os uteri is soft, pulpy, and swollen. All of which conditions disappear when the flow ceases, and the parts return to the normal condition. Amenorrhcea.—By this term is understood an absence of the menstrual flow. There are two varieties : emansio mensium, when they have never appeared; and suppressio mensium, when, having once appeared, they have been arrested from any cause. The first may depend upon several causes, viz.: congenital malformation, as absence of the ovaries, uterus, or vagina, closure of the cervix, im- perforate hymen, &c.; or, it may be dependent upon the health or habits of the patient. The diagnosis is not always easy ; if malfor- mation be suspected, recourse must be had to a per vaginam exami- nation, and the defect, if possible, relieved by an operation. If the retention be dependent on constitutional causes, remove them. If the patient is of a full habit, venesection, mild diet, hip-baths, &c. When the reverse obtains, an opposite plan of treatment must be followed; tonics, as iron and its preparations, a generous diet, ex- ercise, warm clothing, hip and foot baths, always bearing in mind that the woman is not sick because she does not. menstruate, but that she does not menstruate because she is sick, or in other words that arnenorrhoea may be merely a symptom of deranged health. Suppressio mensium, occurs also in two forms : Acute, when the discharge is arrested during the flow; as, by cold, emotions, &c.; and chronic, where it occurs in consequence of the acute, or from gradual failing of the health, disease of ovaries, and critical period, &c. The most important point in the early treatment is not to confound the disease with pregnancy. In the acute form, if there 3 26 OBSTETRICS." is much constitutional disturbance, venesection, or cups to the loins, laxatives, baths, and opium to relieve pains. In the chronic form, if possible, remove the cause: tonics, aloetics, and the means above mentioned ; there being but few direct emmenagogues. Dysmenorrhea.—Painful or difficult menstruation.—This may be dependent on a faulty condition of the system, upon neuralgia of the uterus, or an inflammatory state of that organ, or it may depend on mechanical constriction of the cervix. The discharge is often scanty, accompanied with great pain in the back, loins, fever, &c. and often with the elimination of membranous or shreddy coagula. The treatment during the paroxysm is antiphlogistic, as cups to the loins, revellents, baths, anodyne enemata. In the interval, tonics, if debilitated ; alteratives, if inflammatory ; and dilatation by the bougie, as recommended by Dr. Mackintosh, if there be stricture of the cer- vix. Females afflicted with this disease rarely conceive. Menorrhagia, is an increase of the menstrual flow either in fre- quency or in quantity, and it may be either active or passive, the former occurring in robust plethoric habits, the latter in the reverse. The most common causes are nervous and vascular excitements, fevers, internal congestions, displacements of the uterus, and ap. proach of the critical period, &c. It may be confounded with the hemorrhage arising from abortion, foreign growths, &c, within the uterus. The treatment varies ; in persons of a full habit venesection may be necessary, Test, revulsives, saline laxatives, astringents, &c. In the interval, moderate diet, cold baths, &c. In debilitated cases, rest, tonics and astringents, and opium, good diet, &c. When the hemorrhage occurs about the critical period, it often resists the ordi- nary treatment. Under such circumstances, the ergot of rye often answers a good purpose. It may be given in doses of from 5 to 10 grs. twice or thrice a day. All stimulating and hot drinks should be avoided, and the patient kept in a horizontal position on a hard mat- tress. As soon as the discharge is entirely arrested, a blister should be applied to the sacrum, and kept open, and vaginal injections of cold water, or of a solution of acetate of lead, or other astringents, used two or three times a day. In taking the injections, the patient should assume the horizontal position, and endeavour to retain the fluid for a short time. If displacements exist, rectify them, avoid sexual excitement of all kinds, warm clothing, frictions, &c. Vicarious menstruation.—Seems a provision to obviate the ill effects of suppressed menstruation, by substituting a similar discharge from some other part. It occurs from various parts of the body, sometimes from the gums, nostrils, eyes, lungs, anus, stomach, or even from an amputated stump. The fluid sometimes resembles or- dinary blood, at others, it has the characters of the catamenial fluid. It may occur at any time, and in any constitution. It is not, how- ever, usually attended by any serious consequences. MENSTRUATION AND ITS DISEASES. 27 Treatment.—After once occurring, the patient should be watched, and the system relieved by some other means; venesection, astrin- gents, sedatives, mineral acids, and if debilitated, tonics may be used. Leucorrhoea.—An excessive and altered secretion of the mucus furnished by the membranes lining the vagina and uterus, by the follicles of the interior of the cervix uteri, and by the lacunae of the vestibulum; generally white, or nearly colourless and transparent, sometimes yellow, or green, or slightly sanguineous, and of varying degrees of consistency. The amount of constitutional derangement depending on the severity of the affection, and the susceptibility of the patient (Ashwell). The seat of the discharge may be diagnosticated by examining its characters. If it be of a jelly-like consistence, resembling partly coagulated albumen, and taking place at intervals, and in small quantities at a time, it probably comes from the muciparous follicles of the neck of the uterus. . If, on the contrary, it be of a whey-like or creamy consistence, and varying in colour from white to green, or brown, it probably comes from the mucous membrane of the vagina. In such cases the mucous membrane is commonly found studded over with red points, the inflamed orifices of mucous follicles. There is sometimes an offensive sanious ichor discharged, whose origin is probably in the cavity of the uterus, or the Fallopian tubes themselves. Acute vaginal leucorrhoea is accompanied by a sense of weight, heat and soreness in the vagina, tenesmus, irritation of the bladder, pain in the lower belly and thighs, &c. The discharge, at first thin and acid, becomes whitish, or yellowish, and more consistent. The occurrence of the discharge generally relieves the urgent symptoms. Treatment.—If the patient be plethoric, bleeding should be prac- tised, either general or local. Fomentations, rest, spare diet, and paginal injections should also be used. Chronic vaginal leucorrhoea is one of the most frequent diseases during menstrual life; sometimes, however, it precedes the menses. By most writers it is considered as a local disorder, inflammatory in its nature. It is frequently caused by cold, excessive coition, parturition, pessaries, displacements, and irritating food. There is seldom any pain accompanying it. If the discharge be great, weakness and pain in the back and loins may ensue. The treatment consists in the use of depletory measures if re- quired. The removal of pessaries. Tonics if the patient be weak ; opium if pain be present; and the use of the balsams and astringent injections. The uterine leucorrhoea, which is also often accompanied by con- stitutional symptoms, requires the use of depletory measures at times, with the use of astringent injections, and tonics if the health be feeble, 28 OBSTETRICS. particularly the preparations of iron. A solution of nitrate of silver, applied by means of a speculum to the interior of the cervix uteri, has succeeded when other means have failed. Should there be any suspicion of a syphilitic taint, the remedies proper in such cases should be used. HYSTERALGIA, OR IRRITABLE UTERUS, May be defined, a permanent and painful sensibility of the uterus, especially of its neck ; often accompanied by increased frequency of pulse, a dry hot skin, and generally, in protracted cases, with gastric and renal derangement. The disease commonly occurs in the mid- dle period of life, though it is sometimes met with in early youth. The local symptoms are pain in the small of the back and sacrum, extending down the thigh to the knee, and around the brim of the pelvis to the lowest part of the abdomen. There are also sometimes erratic pains in the thorax and loins. The character of the pain is that of soreness, slight pressure relieves it, but it is aggravated by rough handling. Sometimes it is spasmodic, like those of abortion. Dewees describes the pain as often pulsating. The pain is aggravated by excitement of any kind, by exercise, and sometimes by standing. Straining, either in defecation or urina- tion, constipation, flatulence, and diarrhoea all aggravate it. A per vaginam examination may prove the uterus to be either dis- placed or engorged, but not altered in form, size, or density; extremely painful to the touch, in the body as well as in the neck, the pain is " as if a knife had been plunged into it." Causes.—Among the predisposing causes may be placed, educa- tion, fashionable life, prolonged lactation, and temperament. Among the exciting causes, bodily exertion during menstruation, astringent injections, abortions, prolapsus and sudden arrest of the menses from any cause. Diagnosis.—From neuralgic dysmenorrhoea, by the constancy of the pain. From acute inflammation of the cervix, by the absence of heat, swelling and throbbing; by the absence of discharges, and by the slight change of the cervix compared with the amount of suffering. Pathology.—Gooch considers it a permanently painful condition of the uterus, neither accompanied by, nor tending to produce change in its structure. Ashwell considers it a modified inflammation, or at least, closely allied to inflammation or congestion. Treatment.—Two indications present themselves, viz.: 1. To mitigate local suffering; 2. To sustain and improve the general health. The first indication will be fulfilled by the use of anodynes, either by the mouth, rectum, or applied directly to the uterus itself; by the application of nitrate of silver, by dilating the cervix by PROLAPSUS UTERI. 29 bougies, and by anointing the cervix with anodyne unguents, especially the unguent, aconiti. The second indication, by rest, exer- cise in a recumbent posture, or, if it suits best, on foot or horseback, tonics, nutritious food, cold bath, or the douche, and cheerful society. Scarifications to the neck of the uterus are highly recommended by Dr. Ashwell, especially if there be any congestion. The introduc- tion of the pessary is often followed by marked relief, especially if there be any descent. PROLAPSUS UTERI, Signifies a sinking of the uterus nearly or quite down to the os externum; when it protrudes beyond the vulva it is called prociden- tia uteri. The position of the uterus has been already described. (Page 22.) Causes.—Heaviness of the uterus itself; hence it often occurs in early pregnancy ; congestion of the uterus; ovarian and other abdo- minal tumours ; tympanitis ; distention of the colon ; relaxation of the ligaments, and too early "getting up" after labour; tight lacing; dancing, running, or any severe muscular exercise; leucorrhoea and other exhausting discharges, straining, coughing, &c. Symptoms.—In some cases there is no suffering at all, or merely a sense of fulness. At others, there is pain in the back and groin, extending down the thighs to the knees or toes. The patient suffers great distress in standing or walking, and in voiding the urine and feces. Strangury is sometimes present from the extension of the irritation to the bladder. Sometimes leucorrhoea is present, at others menorrhagia. The stomach and bowels sympathise ; there is ano- rexia, loss of tone in both stomach and bowels, constipation or diarrhoea, and sometimes tympanitis. The patient often becomes morose and irritable. In procidentia the patient often suffers no other inconvenience than that arising from the external presence of the organ, or its acrid discharges. Diagnosis.—In addition to the above symptoms, a per vaginam examination reveals the nature of the disease. The presence of the os uteri, at the lower part of the tumour, felt in the vagina, is almost infallible. From prolapsus of the bladder, rectum, or vagina, it may be distinguished by their greater softness and elasticity, and by the absence of the os uteri. Procidentia may be distinguished from partial inversion, by the presence of the os uteri at the lower portion of the tumour; by the absence of severe floodings, and by the smooth surface of the tumour. Treatment.—Opinions differ much on this point. Nearly all agree as to the necessity of mechanical support in most cases. The difficulty is, as to the mode. In slight cases, rest in a horizontal position, with cold or astringent injections are often sufficient. In 3* 30 OBSTETRICS. prolapsus after confinement it is particularly necessary. Bandages, when they relieve, act by supporting the abdominal muscles, and those of the back, hence they may be useful in women who have borne many children, and in whom these muscles are much relaxed. They can never be regarded as uterine supporters. In decided pro- lapsus, and almost invariably in procidentia, mechanical support by means of pessaries becomes necessary. These differ in shape according to the end to be obtained, and the peculiar views of the practitioner using them. The mode of introduction is as follows: The patient being placed on her side or back, the long diameter of the instrument is to be placed in accordance with the long diameter of the lower outlet; then gently introduced by steady pressure. When fairly introduced it must be partially turned so as to place it transversely across the pelvis and above the tubera ischii. The globe pessary is more easily introduced and requires no turning. In procidentia the uterus should be first returned, and then retained by means of the pessary. In addition to these means the patient should use cold injections, or hip-baths, astringent injections, rest, for a season at least, tonics if her health be enfeebled, laxatives if the bowels are constipated, and astringents if diarrhoea be present. It has been proposed to cure the disease by cutting out part of the vagina, or to produce cicatrices by caustic, which, by their contrac- tion, shall support the uterus. GENERATION. By this term is understood, that function by which the species is reproduced ; and it is effected by the union of the two sexes. There are two principal theories of generation, viz.: that of epigenesis, in which each parent contributes a part to the development of the new being, and that of evolution, in which the mother supplies all the material necessary to the development of the new being, the male merely awakening the plastic powers resident in the female product. The popular belief is that each parent supplies material; the male, the seminal fluid; the female, the ovum; that a union of these two takes place, and from thence results the tertium quid, the new being. A great point of difficulty is, as to where this union takes place; some contending that it is in the ovaries, others, that it occurs in the uterus; the ovum having been previously discharged from the ovary, meeting the male sperm at that place. The only point that seems entirely settled, is the necessity of actual contact, mere aura not being sufficient to effect fecundation. The immediate effect of this contact, or of successful intercourse, is the production of great ex- citement and vascular turgescence of the uterus, ovaries, and Fallo- pian tubes, which lasts for some time. After fecundation has taken place, both ovum and uterus undergo changes, the ovum developing itself by its own plastic action upon the materials it derives from the PREGNANCY. 31 mother, at first by absorption through the villi of the chorion, and afterwards by the placenta, and the uterus increasing in size, and producing upon its interior face a membrane called the caducous, or deciduous, the formation of which has been variously explained. According to Dr. W. Hunter, the whole interior of the uterus becomes coated with a pulpy fluid, which covers over the cervix and Fallopian tubes; this becomes hard, and resembles coagulated lymph, and is called the decidua vera. As the ovum now descends the Fallopian tubes on its way to the uterus, it comes in contact with this mem- brane at the orifice of the Fallopian tubes, and pushes it before it, at the same time that it is reflected over itself, thus forming the decidua refiexa. According to Dr. Carpenter, this is not altogether the true account of it. It appears from the late researches of Dr. Sharpey and Professor Weber, that the decidua is really composed of the inner portion of the mucous membrane of the uterus itself, which undergoes a considerable change in its character. Dr. Reid has described a tubu- lar structure on the free surface of the uterus, which becomes thick- ened and increased in vascularity within a short time after conception ; and when the inner surface of a newly impregnated uterus is ex- amined with a low magnifying power, the orifices of its tubes are very distinctly seen, being lined with a white epithelium.* This is perhaps the more correct view, since the decidua reflexa is found to be different in its structure from that of the vera, which would not be, were they formed as described by Hunter. When an ovum has been thus fecundated, and brought to maturity in the uterus, before extrusion, it is called viviparous generation. This is the variety which occurs in the human female. PREGNANCY, ITS PHENOMENA AND DISEASES. Before entering upon the consideration of the signs by which a woman knows herself to be pregnant, it will be proper to examine what farther changes take place in the uterus itself. It has already been stated that the uterus becomes more vascular, after conception has taken place, and that its interior lining becomes altered; the vessels, arteries, veins, and lymphatics are increased in size, and it has been said by Dr. Robert Lee, that the nerves are also increased in numbers, although this latter change is doubted by many. The proper tissue of the uterus also undergoes great changes. In propor- tion as the ovum is developed, the fibres are separated from each other, and increased in number, leaving spaces between them which are filled by the enlarging vessels (Fig. 10). That the amount of substance is absolutely increased, is shown by the difference of weight between a virgin uterus, and one at full term, just emptied ; the former weighing one ounce, the latter nearly twenty-four. The increase in * Human Physiology, Am. edition, p. 201-2. 32 OBSTETRICS. the development of the womb is not uniform from the first, but com- mences at the fundus, gradually extending to the body, and last of all, about the fifth month, to the cervix. Up to the fourth month the uterus is generally retained entirely within the pelvis ; shortly after Fig. 10. this, its fundus may be felt above the symphysis pubis in thin per- sons ; about the fifth month it reaches midway between the pubes and umbilicus, gradually ascending till the eighth month, when it is as high as the ensiform cartilage. After this, although it increases in capacity, it no longer ascends; on the contrary it rather falls. Its capacity is also greatly increased ; according to Levret's calcula- tions, its superfices may be estimated at 339 inches, and its cavity will contain 408 inches; its length being from 12 to 14 inches, its breadth from 9 to 10, and its depth from front to rear, 8 to 9 inches. The weight of the whole organ and its contents, at full term, is about twelve pounds. The form of the gravid uterus differs also from that of the unimpregnated state, and this difference appears to depend in a great measure upon its increase in size, and the form of the cavities it occupies. In the non-gravid state, when it occupies the cavity of the pelvis, its anterior surface, corresponding to the bladder, is flattened, while its posterior aspect is convex. The reverse, however, obtains during the latter half of pregnancy. The anterior surface is now convex, being merely covered by the yielding anterior wall of the abdomen; whilst posteriorly the uterus is nearly concave, corre- sponding to the prominence of the lumbar vertebrae. This condition of things may be readily ascertained by examining the abdomen of a pregnant female in the last months of gestation, whilst she is lying down. The situation and position of the uterus are also changed; in the PREGNANCY. 33 non-gravid state, the fundus inclines somewhat backwards, the os uteri being nearly in the centre of the pelvic cavity ; the gravid uterus, during the later half of pregnancy, has its fundus inclined forwards, and the os uteri directed backwards towards the upper part of the hollow of the sacrum. During the first month, the changes are not very appreciable, the uterus is larger, softer, and more vascular, the os and cervix are soft, and cushiony, as during the menstrual period, and the transverse fissure is more oval. During the second month, abdomen somewhat flat, cervix in- creased in size, and the os uteri can be felt lower than natural; its shape also is changed, being round and smooth in primiparee, while in multiparae it is larger and irregular in shape. The canal of the cervix is closed by a gelatinous plug. During the third month, slight protrusion of the abdomen, os uteri not so easily reached, and somewhat changed in position; it is no longer in the middle of the pelvic cavity, but inclines towards the hollow of the sacrum, while the fundus approaches more nearly to the anterior parietes of the abdomen. During the fourth month, the fundus may be discovered two or three inches above the symphysis pubis in thin persons by pressure, having first relaxed the abdominal parietes, and emptied the bladder and rectum. During the fifth month, the cervix is drawn out by the expanding uterus and shortened, and the fundus may be felt halfway between symphysis pubis and umbilicus. During the sixth month, the cervix has lost very nearly one-half its length, the fundus is as high as the umbilicus, and the navel de- pression begins to disappear. During the seventh month, the cervix is only half its original length; the fundus rises a little above the umbilicus, which often be- comes pointing. The head may also be felt per vaginam by ballotte- ment, and the movements of the child detected through the abdominal walls. During the eighth month, the cervix is not more than a quarter of an inch long, abdomen increased considerably in size, and the os uteri so high as scarcely to be reached. The fundus is about mid- way between umbilicus and scrobiculus cordis. During the ninth month, the neck is obliterated, so that upon making an examination, we find the vagina closed superiorly by the rounded lower end of the uterus, and in primiparee the fundus is at the scrobiculus cordis. During the last few weeks of pregnancy the fundus sinks a little, the abdomen falls, the os uteri appears only as a little dimple, and its edges are thin and membranous; it occupies now the upper part of the hollow of the sacrum. In women who have borne many children the cervix does not entirely disappear. 34 OBSTETRICS. SIGNS OF PREGNANCY. These are divided into the rational and sensible, the latter of which only can be depended upon, as the former may occur in ab- normal conditions of the uterus, independent of pregnancy. The rational signs occur in the earlier months ; the sensible or physical, after the ovum is somewhat developed. The diagnosis is at all times difficult in the early periods. Rational signs. — Plethoric condition and fibrinous blood; varia- tions in temper and taste; altered functions of stomach, bowels and kidneys ; change in the colour of the skin ; cessation of the menses, though not invariable, is one of the earliest signs ; morning sickness, from the sympathy between the uterus and stomach; salivation, not to be confounded with mercurial ptyalism, from which it may be distinguished by the absence of sponginess of the gums, and the pe- culiar fetor ; enlarged and painful mamma, and in many cases a darkened areola, and enlargement of the follicles situated in it, with a soft and moist state of the integuments; milk in the breasts ; this fluid is sometimes found in the breasts during the latter stages of gestation, but is not invariable, nor always to be depended on when present. Quickening ; this sensation has been variously described, some authors say it is caused by the first movements of the child; others assert that it is caused by the sudden rise of the uterus from the pelvis into the abdominal ca.vity, producing fainting, sickness, &c. As a sign of pregnancy it is almost valueless, since females are very apt to be deceived in this respect by the movements of flatus in the bowels, by occasional spasmodic twitching of the abdominal muscles, &c. Kiesteine.—During pregnancy a peculiar substance, analogous to caseine, is found in the urine, forming a thin pellicle upon its surface when it is allowed to stand, which emits an odour resembling cheese. It is not, however, peculiar to pregnancy, but may occur whenever the lacteal elements are not eliminated by the mammary glands. At the same time the probabilities are as 20 to 1, that the female is pregnant, if the kiesteine be present. Blue colour of the vagina, has also been looked upon by M. Jac- quemiex, and M. Parent Duchatelet, as among the rational signs of pregnancy. The Sensible or physical signs of pregnancy, are those by which the presence of a foetus in utero are detected by an exploration of the organ itself. Enlargement of the abdomen, begins to be perceptible about the end of the second month; before this the abdomen is often flatter than usual. " A ventre plat, enfant y'a." Ballottement, is practised thus : The patient should be in the upright position, or at least in a semi-recumbent posture; now let SIGNS OF PREGNANCY. 35 the operator place the left hand upon the fundus uteri to steady it, and introduce the index finger of the right hand to the cervix uteri, then suddenly but gently jerking the finger upwards, he will feel a sensation as if something had receded from it, and then settled down upon it again. This test is most available about the fifth and sixth months. (Fig. 11.) ,,-,.„_ r Auscultation, was applied to the detection of the presence ot ifatus in utero, first by M. Mayor, of Geneva. Three sounds have been heard by different observers, ^ viz.: that of the foetal heart, that Flg- 1 of the placental circulation, and that of the pulsation in the cord. The first of these is the most cer- tain ; the second may be imi- tated by the pressure of a tumour upon any great vessel, and the last can only be heard under very favourable circumstances, as where the cord lies between the child and the abdomen of the mother. The situation in which the foetal heart is most distinctly heard, is about the middle point between the scrobiculus cordis and symphysis pubis, generally to the left. The frequency of the pulsation is about double that of the adult, ranging from 120 to 140 per minute, and entirely independent of the maternal circulation. The sound resembles very much the ticking of a watch under a pillow. In breech presentations it is usually heard a little higher. This is a most valuable diagnostic sign, and if once heard, une- quivocally, the real nature of the case is established beyond doubt. The placental uterine souffle may usually be detected by the stethoscope low on the sides of the abdomen after the fourth month; it is a peculiar blowing sound, corresponding to the pulse of the mother. The movements of the child may frequently be detected by placing a cold hand on the abdomen of the mother, after the sixth month, but this is not a certain sign, as above stated, since it may be imi- tated by movements of flatus, &c. The following resume of the signs of pregnancy, is taken from the " Elements of the Principles and Practice of Midwifery," by Prof. Tucker:— * A, vertical section of sacrum ; B, rectum; C, uterus and ovum; D, bladder ; E, finger in the vagina with its extremity pressing up the uterus. 36 OBSTETRICS. During the First and Second Months. RATIONAL signs. 1. Suppression of the catamenial dis- charge. 2. Nausea, vomiting, ptyalism, ano- rexia, &c. 3. Unnatural flatness over the hypo- gastrium. 4. Tumefaction and tenderness of the mammae, sensible signs. 1. Increase in the size and weight of the uterus. 2. Slight prolapsus of the uterus. 3. Diminished mobility of the uterus. 4. The cervix uteri is directed to. wards the symphysis pubis. 5. The os uteri, round and regular in primiparee, but in multipara^ irregular in its circumference and more or less open. 6. Ramollissement of the mucous membrane, covering the cervix uteri. The fibres of the neck not yet softened. During the Third and Fourth Months. 1. Suppression of the catamenia. 2. Continuance of nausea, vomiting, anorexia, ptyalism. 3. Slight prominence over hypogas- trium. 4. Depression of the umbilicus. 5. Tumefaction of the breasts in- creased, with increase in the promi- nence of the nipple, and a slight disco- loration of the areola. 6. Kiesteine in the urine. 1. The fundus uteri elevated rather above the pelvic brim, at the end of the third month. At the termination of the fb.urth month, it rises two inches above the pubis. 2. Fulness and dulness over the hy- pogastrium. 3. Existence of a small tumour in hypogastric region. 4. The direction of the long diameter of the uterus is now changed, so as to correspond with the axis of the pelvic brim. The os uteri is considerably ele. vated in the excavation. 5. Ramollissement of the inferior portion of the cervix is more marked; os uteri more open in the multiparas, but still closed in those who have not borne children. During the Fifth and Sixth Months. 1. Suppression of the catamenia. 2. Cessation of nausea, vomiting, &c, now usually takes place, though they may continue throughout preg- nancy. 3. Increased prominence of the um- bilical region. 4. The size of the abdominal tumour is increased, it is round, elastic, and if the abdominal walls be thin, the ine- qualities of the fetus may be felt. 5. The umbilical region more full. 6. Discoloration of the areola? more marked, with an enlargement of the subcutaneous glands. 1. At the end of the fifth month, the fundus uteri is within an inch of the umbilicus. 2. Movement of the fetus is now active. 3. The bruit de souffle and the foetal pulsations may now be distinguished. 4. Ballottement. 5. Between the cervix and the pubis a tumour may now be felt, either soft and fluctuating, or round and hard. 6. Ramollissement of one half of the cervix uteri. 7. In the primiparee, the os uteri is still closed, but in the multiparee, it is SIGNS OF PREGNANCY. 37 RATIONAL SIGNS. 7. Kiestine in the urine. SENSIBLE SIGNS. sufficiently open to admit the half of the first phalangeal bone. During the Seventh and Eighth Months. 1. Suppression of the catamenia. 2. Nausea, vomiting, &c. ordinarily absent. . 3. Abdominal tumour much increas. ed in size. 4. Pouting of the navel. 5. Increased discoloration of the are- oloe, with enlargement of the sebaceous "follicles, and increased prominence of the nipple. 6. The milk may now be pressed from the swollen mammee. 7. Kiestine still exists in the urine. 1. Increase in the size of the abdo- men. 2. The fundus uteri, at the end of the seventh month, has risen two and a half inches above the umbilicus : at the eighth, it is placed within the epigas- tric region. 3. Active movement of the fetus. 4. The fetal pulsations and the bruit de souffle still continue. 5. Ballottement perfectly felt during the seventh month, becomes obscure in the subsequent months of pregnancy, on account of the increase in the size of the fetus. 6. The ramollissement of the cervix is more extensive, and at the end of the eighth month is nearly complete. 7. In the primiparae, the cervix is ovoid and somewhat shortened; the os uteri is still closed. 8. In the multiparee, the os uteri is wide enough open to admit the whole of the first phalangeal bone; the upper orifice is firmly closed. During the first half 1. Re-appearance of vomiting, not from nausea, but from pressure of the gravid uterus against the stomach. 2. The abdominal tumour is increas- ed in size. 3. Respiration difficult. 4. All the other symptoms are aug- mented in intensity. of the JSinth Month. 1. The fundus uteri occupies the epi- gastric region. 2. The movements of the fetus; the pulsation of the fetal heart are still present. At this time, ballottement has disappeared. 3. The whole cervix uteri is softened, except the internal orifice, which re- mains firm and closed. The os uteri in primiparee is slightly opened, though not sufficiently to admit the finger, as is the case in multiparee. During the last half of the Ninth Month. 1. The vomiting ceases, as the abdo- minal tumour sinks from the epigas- trium. 2. Respiration less oppressed. 3. Considerable difficulty exists in walking, owing to the sinking of the presenting part into the pelvic excava. tion. 1. The fundus uteri has sunk lower down in the abdomen. 2. The sensible signs still persist, except ballottement, which is usually, though not always, absent after the fetus has acquired considerable size. 3. In multiparee, the internal orifice of the cervix is softened and dilated, so 38 OBSTETRICS. RATIONAL SIGNS. SENSIBLE SIGNS. 4. Constant desire to evacuate the that the membranes may be felt. In bladder and rectum. the primiparee, the internal orifice is 5. The hemorrhoids, the oedema of soft and dilated, but the external re- the limbs and the varicose condition of mains partially closed. During the last the veins of the inferior extremities are ten or twelve days, owing to the dilata- all increased. tion of the internal orifice of the cervix uteri, the whole cervix becomes en. larged, so as to increase the size of the uterine cavity ; so that in touching, the finger reaches the membranes, in the primiparee, after having passed the thin and even margin of the os uteri. While in the multiparee, the external orifice of the cervix is thick and unequal. DEVELOPMENT OF THE FffiTUS. It has already been stated, that after impregnation, the ovum de- velopes itself by its own plastic power, out of the materials supplied it by the mother. It will be remembered that it was originally con- tained within the Graafian vesicle, and that it contains a yelk similar to that seen in the hen's egg, although much smaller, in the centre of which is found the germinal vesicle, on whose walls is the germinal spot or nucleus, from which all the various parts of the new being are developed. According to some physiologists, impreg- nation takes place in the ovary, and before the rupture of the Graa- fian vesicle; according to others, the Graafian vesicle is ruptured first, the ovum escapes into the Fallopian tubes and meets the male sperm on its way to the uterus. After impregnation, the germinal vesicle becomes filled with cells, which are developed from the nu- cleus, until the whole mass resembles a mulberry, which, from this circumstance is called the germinal or mulberry mass. From this is developed the germinal membrane, by layers of cells, which pass round the yelk of the ovum, so as to enclose it, the whole being still contained within the yelk membrane. The germinal membrane consists of three layers ; the external, which is formed first, is called the serous, the middle is called the vascular, and the internal is called the mucous. The external layer becomes the integument; the middle, the vascular system; and the internal, the digestive apparatus. The umbilical vesicle is formed by the doubling in of the mucous layer under the abdomen of the foetus, so as to enclose a cavity con- taining the yelk, which communicates with the digestive tract. Upon this yelk the embryo subsists as long as it lasts, the umbilical vesicle becoming smaller and smaller as it is absorbed, until finally only a narrow orifice remains, which ultimately closes up and the umbilical vesicle is thrown off; it may, however, be detected upon the umbi- lical cord up to a late period of pregnancy. (Fig. 12.) The Allantois.—After the yelk has been entirely absorbed, it DEVELOPMENT OF THE F03TUS. 39 becomes necessary that the foetus Fig. 12. should have some other means of support, and the following are sup- ,plied. From the inferior or caudal extremity of the foetus there arises at the point where the urinary blad- der is afterwards seated, a delicate membranous sac, which is formed from the mucous layer, and has dis- tributed upon its surface, a number of minute blood-vessels, from the vascular layer; this vesicle gradu- ally extends itself between the am- nion and the chorion, until it comes in contact with that part of the uterine surface, where the villi of the chorion are most abundant; here the vessels which it carries, attach themselves in order to form the placenta, and the allantois having fulfilled its function shrivels up, although traces of it may be found in the cord. In its development the allantois passes out of the ante- rior part of the abdominal cavity, in the region of the umbilicus, which at this time is open. As the cavity is closing, by the gradual de- velopment of its walls towards the median line, it is separated into two portions which communicate; that part which is within the body, forms the urinary bladder, with its urachus or tube of communication. (Fig. 13.) The Amnion.—The outer or serous layer of the germinal mem- brane at the point where the embryo is developing itself, rises up on each side of it in two folds, forming the inner membrane of the ovum, which is called the amnion. These two folds gra- dually approach each other till actual contact takes place, in the space between the general envelope and the embryo, so as to form an additional investment to the latter. As each fold con- tains two layers of membrane, a double envelope is thus formed, of which the outer layer (fig. 12, d, e,) afterwards adheres to the inner surface of the chorion; * o, chorion; b, umbilical vesicle, surrounded by the serous and vascular laminae; c, era- hryn; d, e, and/, external and internal folds of the serous layer, forming the amnion; g, in- cipient allantois. t Diajram representing a Human Ovum iu second month ; a, 1, smooth portion of chorion; a, 2, villous portion of chorion ; k. k, elongated villi, beginning to collect into placenta; 6. yolk-sac or umbilical vesicle; c, embryo;/, amnion (inner layer); g, allantois; A, outer layer of amnion, coalescing with chorion. --^^ 40 OBSTETRICS. whilst the inner one (fig. 12,/,/,) remains as a distinct sac, to which the name amnion is given. "The membrane thus formed embraces the embryo very closely at an early period, and is continuous with the common integument of the foetus, at the open abdominal parietes. At a later period it is dis- tended with fluid, and so separated from the foetus, and after being reflected upon the funis, of which it forms the outer coat, it termi- nates at the umbilicus. It is thin and transparent, but of a firm texture, resisting laceration much more than the other membranes, Its external surface is somewhat flocculent, but internally it is quite smooth, like serous membrane, and like it secretes a bland fluid." This fluid resembles dilute serum, and is called liquor amnii. It varies in amount from half a pint to several quarts, the average quan- tity being about half a pound. It subserves several useful ends. It probably serves as nutriment to the foetus during the early months ; it preserves an equable tem- perature for it while remaining in utero, it protects it from the effects of sudden blows, shocks, &c. It is also useful in dilating the os uteri, by protruding the membranes in the commencement of labour, The Chorion.—The outer membrane of the ovum is called the chorion, and is formed during its passage through the Fallopian tube, by receiving an additional layer of albuminous matter secreted from the walls of the tubes, and this is surrounded by a fibrous membrane. This new formation is one of great importance, as it is through this the whole subsequent nutrition of the embryo is derived ; this is ac- complished at first by means of a number of villous processes, which proceed from the whole surface of the chorion and give it a rough, shaggy appearance ; these villous processes serve as absorbing radi- cles, drawing in the fluids supplied by the mother, until a more per- fect communication is afforded by the placenta. As the ovum ad- vances in age, these villi diminish in number, assume a vesicular appearance, and finally disappear altogether, except at that part of the chorion which is in contact with the uterus, and where the pla- centa is subsequently formed. In some animals, this connexion be- tween the villous coat of the chorion and the uterine surface is the only one that exists, hence they are called non-placental. Tlie Placenta.—The formation of this organ commences by the penetration of the villi of the chorion into the tubuli of the decidua already described; later we find a vascular connexion established between them and the villi, by the agency of the allantois, in the manner above mentioned, the allantois conveying the blood-vessels of the foetus to that portion of the chorion. It must not, however, be understood, that there is any direct communication between the vessels of the foetus and those of the mother, the foetal tufts being merely bathed in the maternal blood and drawing nourishment from it by its own cells, which have the power of selecting, and of elabo- DEVELOPMENT OF THE FCETUS. 41 ratino- their own materials. The foetal portion of the placenta con- sists of the branches of the umbilical vessels, which divide minutely where they enter the organ, and constitute by their ramifications a large portion of its substance, each subdivision terminating in a villus. Each villus contains a capillary vessel, which forms a series of loops, communicating with an artery on one side and with a vein on the other. The vessels of the villi are covered by a layer of cells en- closed in basement membrane. The maternal portion may be con- sidered as a large sac, consisting of a prolongation of the internal coat of the great uterine vessels. Against the foetal surface of this sac the placental tufts push themselves, dipping down into it and carrying before them a portion of its thin wall, so as to constitute a sheath to each tuft. The blood is conveyed into the cavity of the placenta by the "curling arteries," so named from their tortuous course, which Fig-14-* proceed from the arteries of the uterus, and the blood is returned through large uterine veins called sinuses. The placenta per- forms the twofold office of an absorbing and respiratory organ; it begins to be formed about the end of the second month, acquires its peculiar character during the third, and goes on increasing in proportion to the development of the ovum. At full term its diameter is about six or eight inches, its circumference eighteen to twenty-four, and its thickness from one inch to an inch and a half. Its internal or foetal surface is smooth and shining, being covered by the chorion and amnion ; the outer, or uterine sur- face, is level but not so smooth, being djivided by numerous sulci between the lobules of which it is composes. The umbilical cord, called also the funis, or navel-string, is the means of communication between the foetus and placenta. It usually arises from the centre of the placenta, though sometimes from the edge, forming the battledore jjlacentxi. It consists of two umbilical arteries, and one umbilical vein ; besides these it contains the duct of the umbilical vesicle, the omph^lo-mesenteric vessels, the urachus, and sometimes more or less of the intestinal canal, the whole im- bedded in the Whartonian jelly, and invested by a reflection from the amnion. The length varies much; the average, however, is about eighteen inches. Sometimes it is so short as seriously to impede the progress of the labour. To return to the development of the embryo. * Extremity of a placental villus :—a, external membrane of the villus, continuous with the lining membrane of the vascular system of the mother ; ft, external cells of the villus, belonging to the placental decidua; e, c, germinal centres of the external cells ; d, the space between the maternal and fcetal portions of the villus; e, the internal membrane of the vi lus. continuous with the external membrane of the chorion ;/, the internal ceUa of the villus, belonging to the.chorion; g, the loop of umbilical vess«ls. 4# 42 OBSTETRICS. The parts first formed are those which most clearly distinguish the vertebrated animals from all others, viz., the vertebral column and spinal cord. These first make their appearance in the situation of the embryonic cell, and are included under the name of chorda dorsalis, which is found to be composed, wherever it exists, of nu- cleated cells. From cells exterior to this, is developed the vertebral column. Concurrently with this development, appears the vascular system, which is first seen in the middle layer of the germinal mem- brane, called the vascular. Vessels are formed here which serve to take up the nutriment supplied by the yelk, and carry it to the tis- sues of the embryo. These vessels are first seen in that part of ihe vascular lamina of the germinal membrane which immediately sur- rounds the embryo, and they form a delicate network of vessels called the vascular area ; this gradually extends itself till the vessels spread over the whole of the germinal membrane, and it is through their agency that the nutritious matter of the yelk is conveyed to the embryo. The vessels of the yelk-bag terminate in two large trunks called omphalo-mesenteric, meseraic, or vitelline vessels, which enter the embryo at the point which afterwards is known as the umbilicus. The first movement of fluid takes place towards the embryo, and may be discovered before any heart is seen. The heart is formed in the substance of the vascular layer, by a dilatation of the trunk, into which the blood-vessels unite. It is at first a mere excavation, but afterwards its walls become more developed, and it is divided into cavities. Along with the development of the vascular, appears also the permanent digestive cavity ; this originates in the separation of a small portion of the yelk-bag lying immediately beneath the embryo by a doubling in of the mucous layer, so as to enclose a cavity. This, by subsequent prolongation and involution of its walls, is ren- dered more complex, so as to form a stomach and intestinal tube. The digestive cavity communicates for some time with the yelk-bag (from which it has thus been pinched off) by the opening that is left by the imperfect meeting of the folds of the germinal membrane that forms its walls. In the mammalia, this orifice is gradually nar- rowed, and at last completely closed; and the yelk-bag thus sepa- rated is afterwards thrown off; it is then known as the umbilical vesicle, and may be seen upon the umbilical cord up to a late period of pregnancy. At first the body of the embryo is more elongated than afterwards, and the trunk is the first part developed, at the upper extremity of which is a small prominence less thick than the rest, and separated by an indentation, which distinguishes the head. No traces of ex- tremities can yet be discovered, or of any other prominent parts, It is straight, or nearly so, the posterior part being slightly convex, the anterior concave. Afterwards the head becomes more rapidly developed, so that at DEVELOPMENT OF THE FQ3TUS. 43 the beginning of the second month, it nearly equals the half of the whole body. In the fifth week, the extremities become visible, the upper generally appearing first, in the form of small blunt promi- nences. As they develope themselves, the distant points appear first, that is, first the hands, which seem to be fixed to the shoulders, then the fore-arm, then the arm. The same is true of the lower extremi- ties. The external organs of generation appear after the develop- ment of the extremities, as also do the nose, ears, and mouth. Ossi- fication commences in the base of the cranium, and the bones under the scalp are those in which the process is last completed. The length of a full-grown foetus is about eighteen inches, the weight between six and eight pounds as the average. Duration of pregnancy.—On this subject very little can be posi- tively said, the average duration being about ten lunar months, or 280 days. There can be no doubt that many females fall short of this computation, as well as that there are many who go beyond it. Many well-authenticated instances are on record, under the authority of Drs. Merriman, Blundell, Montgomery, Dewees, Meigs, and others, where both these deviations have occurred. The same is true of the lower animals. Dr. Rigby supposes that the duration of pregnancy is much influenced by the time in the intermenstrual period at which conception took place; that there is at every menstrual period an irritability about the uterus, even when gravid, which disposes it to take on contraction. Hence, when impregnation has occurred im- mediately after an appearance of the menses, the uterus will have attained such a dilatation and weight of contents by the time that the ninth period has arrived, that it will not be able to pass through this state of catamenial excitement without contracting, or in other words, labour coming on: hence it is that we find a considerable number of labours fall short of the usual time, so much so, that some authors have even considered the natural term of human ges- tation to be 273 days, or 39 weeks. If, on the other hand, impregnation has occurred just before a menstrual period, the uterus may not have attained such a development as to prevent its passing the ninth period without expelling its con- tents, but may even go on to the next without this process taking place. Under this view of the subject, he further remarks, " the duration of time between each menstrual period should also be taken into account, some women menstruating at very short, others at very long intervals; but although this will affect the number of periods during which the pregnancy will last, it will not influence the actual duration of time, as this will more immediately depend upon the size and weight of contents which the uterus has attained." The method of calculation, is to compute from a fortnight after the last appearance of the menses, and the period so fixed is usually 44 OBSTETRICS. corrected by the time at which quickening occurs, the latter occur. rence usually taking place at four months and a half. Extra-uterine pregnancy. It occasionally happens that the ovum, instead of passing down the Fallopian tube to the uterus, is arrested in its progress, and an effort is made at the point of obstruction to afford space and nutrition for the foetus. When the ovum is de- tained and developed in the ovary, it is called ovarian pregnancy. Of this variety Dr. Granville relates a case in the Lond. Phil, Transactions, part 1, 1820. When the Fallopian tube is the seat of the arrest, it is called tubal pregnancy ; of this variety cases are reported by Dr. R. Lee in the Lond. Med. Gaz., vol. xxvi, p. 436, Also by Dr. Meigs, vide his work, p. 106. It sometimes happens that the ovum enters the parietes of the uterus, constituting a third and rare description called interstitial pregnancy. A fourth variety is called ventral or abdominal pregnancy, where the ovum falls into the abdominal cavity, attaches itself, and is developed there. It is worthy of remark, that in all these varieties, the uterus is lined with a deciduous membrane, as it is in intra-uterine pregnancy. The causes are not well known, and the treatment can be merely palliative. Portions of the foetus are often discharged from fistulous openings in the abdomen, vagina, or rectum. Fatal circulation.—The peculiarities of the foetal circulation, in which it differs from that function in the adult are, 1st. The ductus venosus, a supplementary vein, situated at the thick edge of the liver, and leading from the umbilical vein to the vena cava ascendens. 2d. The aperture between the right and left auricle, effecting a com- munication between them, called the foramen ovale. 3d. The ductus arteriosus, a branch given off from the pulmonary artery soon after its origin, which conducts the venous blood that has arrived at the heart from the head into the aorta just below its arch. The following is the route of the circulation in the foetus, starting from the placenta. The blood, after being aerated in this organ, is collected by the umbilical vein, which carries it to the umbilicus of the child. After entering the cavity of the abdomen, the current divides, part of it being sent through the venae portarum to the liver ; the remainder reaches the vena cava ascendens through the ductus venosus, where it is mixed with the blood from the inferior extremities. The blood that was sent to the liver is collected by the hepatic veins and also emptied into the vena cava ascendens, which finally discharges its contents into the right auricle of the heart. From the right auricle, it is directed by the Eustachian valve through the foramen ovale, into the left auricle, thence it passes into the left ventricle, by which it is distributed through the aorta to the system, a large proportion of it going to the head and upper extremities. The latter blood, (that from the head, &c.,) is DEVELOPMENT OF THE FOETUS. 45 Fig. 15." collected by the vena cava descendens, and emptied also into the right auricle, from whence it passes into the right ventricle, from thence mainly through the ductus arteriosus into the aorta, a small portion only passing into the pulmo- nary artery. From this it will be seen that the liver is the only organ that receives the blood from the placenta unmixed. Every other organ receiving mixed arterial and venous. After birth, the current is entirely changed by the esta- blishment of respiration, and its diversion into the lungs. The ductus venosus, and the ductus arteriosus shrivel up into ligamentous cords; the foramen ovale shortly closes by the apposition of its valve ; the pulmonary artery and vein become dilated to receive the increased current, and the circulation, which before re- sembled that of the higher reptiles, becomes now that of the perfect mammal. It not unfrequently happens, how- ever, that some arrest of de- velopment takes place, and prevents the completion of these changes; * The foetal circulation ; 1, the umbilical cord, consisting of the umbilical vein and two umbilical arteries; proceeding from the placenta (2); 3, the umbilical vein dividing into three branches ; two (4, 4) to be distributed to the liver; and one (5) the ductus venosus, which enters the inferior vena cava (6); 7, the portal vein, returning the blood from the in- testines, and uniting with the right hepatic branch ; 8, the right auricle ; the course of the blood is denoted by the arrow, proceeding from 8 to 9, the left auricle; 10, the left ventricle; the blood following the arrow to the arch of the aorta (11), to be distributed through the branches given off by the arch to the head and upper extremities. The arrows, 12 and 13, represent the return of the blood from the head and upper extremities through the jugular and subclavian veins, to the superior vena cava (14), to the right auricle (8), and in the course of the arrow through the right ventricle (15), to the pulmonary artery (16); 17, the ductus arteriosus, which appears to be a proper continuation of the pulmonary artery—the offsets at each side are the right and left pulmonary artery cut off; these are of extremely small size as compared with the ductus arteriosus The ductus arteriosus joins the descend- ing aorta (18,.18), which divides into the common iliacs, and these into the internal iliacs, which become the umbilical arteries (19), and return the blood along the umbilical cord to the placenta; while the other divisions, the external iliacs (20), are continued into the lower extremities. The arrows at the termination of these vessels mark the return of the venous blood by the veins to the inferior cava. \J \J 46 OBSTETRICS. various malformations hence result, involving an imperfect discharge of the function. It will be borne in mind by the student, that there is, in the foetal circulation, a deviation from the normal function in several of the vessels. The umbilical vein and ductus venosus carry arterial blood ; while the umbilical arteries and ductus arteriosus carry venous blood. (Fig. 15.) PREMATURE EXPULSION OF THE FCETUS. The uterus sometimes expels its contents before the full period of utero-gestation is accomplished. This may occur at any time during gestation, though it appears to be more easily excited at, or previous to, the third month, owing to the frailty of the connexion between the ovum and the decidua. It is also more liable to occur at the commencement of each menstrual return, than in the interval, owing to the increased excitement of the gestative organs at that time. It is called abortion when the fcetus is expelled before it is capable of maintaining an independent existence, that is, before the seventh month. It does sometimes happen that a foetus lives when expelled before this time, but such cases are rare. The child is hardly con- sidered " viable" before this time. Premature labour signifies the expulsion of the ovum before the full term of pregnancy has expired, but after the seventh month ; in other words, after the child has become viable. Causes.—These are infinitely various and numerous, and include almost every agency capable of acting injuriously on the mother, and through her on the fcetus. Mental emotions, fright, anger, joy, or sorrow, when excessive, intense pain, shocks, blows, falls, great fatigue, deficient nourishment, debilitating evacuations, acute and chronic disease, the exanthemata, syphilis, and the habits of life, either extreme, being capable of producing it. To these we may add a peculiar constitutional irritability of some females, by which they abort habitually. Premature expulsion is sometimes produced by circumstances which compromise the life of the child. Thus certain pathological conditions of the amnion, chorion or decidua, malformations of the placenta, or erroneous insertion of the cord. Or it may occur from the administration of drugs exhibited for the purpose, or otherwise, such as ergot, savine, &c. The manner in which these causes act, is either by destroying the child's life, in which method syncope, syphilis, and mercurial saliva- tion seem to act; or by causing the womb to contract; or by par- tial separation of the placenta, causing the effusion of blood between that organ and the womb, and finally its entire separation, thus arresting the nutrition and respiration of the fcetus, and producing its death. Symptoms.—The patient who is about to miscarry, generally PREMATURE EXPULSION OF THE FCETUS. 47 experiences a sense of uneasiness, languor, pain in the back and lower part of the abdomen, accompanied by pains of an expulsive character, and often with hemorrhage. When the ovum itself is ruptured, there is a discharge of water from the vagina, greater or less, according to the age of the fcetus, followed afterwards by pain and discharge of blood. Sometimes the ovum is discharged with little or no pain, at others the pains are described as being more severe than those of labour at the full term. Treatment.—There are two points to be observed in the treatment of these accidents; first, If possible, to prevent the expulsion of the fcetus, and enable the woman to complete her pregnancy ; secondly, Where this is hopeless, to shortenjthe process as much as possible, and prevent further hemorrhage, ^^^r " As we cannot be certain in the first fflsl^rice, whether the child is dead, or not, it behooves us to act under trfe^rojosition of its life, knowing that if the vital relation between the ov'uWand the uterus is compromised it will be discharged. The preventive treatment will consist in moderate bloodletting if the patient be plethoric and the pulse full and bounding, rest in a strictly horizontal posture, on a hard bed, lightly covered with clothes, and in a cool room, cold wet napkins to the vulva, abstinence from stimulants, anodyne enemata, and if necessary, the internal use of astringents, such as infusion of rose leaves, elixir vitriol, alum, ace- tate of lead and opium, &c. ^ If these means fail, and the hemorrhage continues, whilst the ovum is not expelled, there is little or no chance of preventing mis- carriage ; our endeavours must be directed to the suppression of the discharge, knowing it will generally cease as soon as the womb is emptied. The best agent we possess under these circumstances, is the tampon, or plug. This should never be used, however, if inter- nal hemorrhage can take place to such an extent as to destroy life; in other words, not if the uterus be empty, and the patient far advanced in pregnancy. It may be used with safety and advantage, if the uterus be filled with its natural contents, or be only slightly distensible, even though empty. For this purpose some recommend a sponge steeped in vinegar, others a silk handkerchief, others, again, small, square pieces of linen pressed into the vagina till that cavity is entirely filled, the whole being retained in its place by a T bandage, or the hand of an assistant. It should be allowed to remain in situ, from six to twelve, or even twenty-four hours, the patient being still in a horizontal position, and the bladder, if necessary, relieved by the catheter. When withdrawn, the ovum, or fragments of it, will generally be found adherent to its upper part, along with a coagulum. The tampon, it will be remembered, is not to be used under any circumstances where there is a hope of saving the pregnancy. 48 OBSTETRICS. If the ovum is not discharged with the tampon, and cannot be reached with either the finger or hook, it is recommended to leave such occurrences in the hands of nature, rather than use force. The prophylactic treatment consists in the avoidance of all causes of excitement, both mental and bodily. Small bleedings and rest if she be plethoric ; a nutritious diet and tonics if otherwise, together with careful cold sponging. When the abortion is habitual, and the uterus is irritable, an efficient remedy has been found in the adminis- tration of an opiate enema every night, consisting of forty-five drops of tr. opii, in a wineglassful of starch water, rest, tonics, &c. PATHOLOGY OF THE FCETUS, AND SIGNS OF ITS DEATH. The fcetus is liable to many of those diseases that attack the child after its birth. Many of these are entirely independent of the mother, but there are also many with which the child is affected seriously through her. As examples of the latter may be classed, those cases of premature expulsion which occur during the prevalence of epidemic diseases, and where the fcetus appears to have participated in the dis- ease of the mother. Dr. Churchill has observed a considerable quick- ening of the action of the foetal heart, some days after pregnant women have been attacked with fever. Examples are not wanting of cases where children have been born with small pox, or measles; and according to Duettel, Schweig, Zurmeyer, &c, children born of mothers, who were suffering under intermittent fever, have exhibited the same disease immediately after birth. There is scarcely an internal organ that has not been described as the seat of inflammation; the brain and its membranes, the lungs and pleura, the peritoneum, the mucous membranes of the lungs and bowels, may all be the seat of inflammation during uterine life. In addition to these acute diseases, the foetus presents even more numerous cases of chronic affections; general hypertrophy, or atrophy, syphilitic diseases, worms, calculus, dropsy, jaundice, her- nia, &c. Even the bones and joints may be the seat of disease; children are sometimes born with rickets, caries, and necrosis; and it has happened to many practitioners to meet with cases of fractures of some standing in children just born. Unfortunately we possess neither the means of diagnosticating, ' nor of treating these cases of intra-uterine disease. 2%e signs of the death of the foztus, are also obscure and uncer- tain. Absence of the sound of the foetal heart, is a negative sign, and its value will depend much upon the skill of the auscultator. If after repeated and careful auscultation of the abdomen no trace of foetal pulsation can be detected, the death of the fcetus may be asserted on safe grounds. Cessation of the movements of the foztus is no proof of its death, as the movements may be suspended for some days without its death. The sensation of a weight in the abdomen rolling about as she moves, is, with some rare exceptions, RETROVERSION OF THE UTERUS. 49 a sure sign. The subsidence of the abdominal tumour, flaccidity of the breasts, after having been tense, and the general deterioration of the health, are all enumerated among the probable signs. The con- currence of all these render the diagnosis nearly certain, though separately they are of little value. The signs during labour are much more accessible and certain. The loose, flabby scalp, the absence of swelling, occasional emphy- sema of the cellular tissue beneath, the looseness and grating of the cranial bones, and the sharpness of their edges, are enumerated by Dr. Rigby among the certain signs. The absence of pulsations at the great fbntanelles, is admitted to be an important sign. In presentations of the face, the lips of a dead child will be flaccid and the tongue flabby and motionless, and the presenting part slightly swelled. The contrary in a living child. In breech presentations, the sphincter ani, in a dead child is relaxed and insensible to the finger. In a living child it is closed and resists the finger. The presence of meconium is a sign of no value. In arm presentations, when the child is dead, the limb is cold, livid, and flabby, there is no pulsation at the wrist, (the latter is not of much value, as pressure may arrest it,) and the epidermis soon begins to peel off. In a living child, the arm will swell and become livid. In prolapsion of the Junis, the presence or absence of pulsation will decide. There are exceptions to this rule, however, as in the case related by Dr. Kennedy, in which the cord was prolapsed an hour, and during a pain no pulsation was perceptible; when the pain subsided he drew the funis backward towards the sacro-iliac sym- physis, and then detected a faint pulsation. The child was delivered alive by the process. Fetid liquor amnii is not a certain sign of the child's death, neither is the presence of meconium in it, especially in breech cases. RETROVERSION OF THE UTERUS. During the early months of pregnancy the uterus is liable to a pe- culiar species of displacement, known by the above name. It is where the fundus is pushed downwards and backwards into the hollow of the sacrum between the rectum and posterior wall of the vagina, while the os tincae is tilted upwards and forwards behind the symphysis pubis. Most of the instances of retroversion are attributable to a distended bladder; for, as this organ fills, it rises, and pulls the lower portion of the uterus upwards ; at the same time the fundus is pushed back- wards, by the repletion of the bladder; the os uteri therefore presses against the neck of the bladder and produces retention of the urine ; the fundus presses against the rectum and prevents the passage of faeces, which thus accumulate above the point of pressure, and not only prohibit the ascent of the fundus to its normal position, but 5 50 OBSTETRICS. really force it lower. The accident may also happen from falls, shocks, lifting weights, and, according to Churchill, in the early days of menstruation, when the uterus is increased in weight by the afflux of blood. The growth of tumours in the neighbourhood of the fun- dus is also a cause. The symptoms are, violent bearing-down pains, sense of fulness and distention about the loins and hollow of the sacrum, dragging and tension in the groins, and inability to pass fseces or urine. A per vaginam examination reveals the os tineas thrust up behind the symphysis pubis, and the vagina seems to be obstructed by a hard body, which is the fundus turned down into the hollow of the sacrum. The treatment consists in emptying the bladder and rectum, and pressing up the fundus by two fingers in the rectum, assisting them, if necessary, by a finger of the other hand in the vagina, by which the os uteri can be hooked down. Venesection is sometimes necessary to relax the system. Sometimes merely emptying the bladder and rectum are sufficient, the uterus recovering itself through the muscu- larity of the round ligaments. Sometimes it is necessary to rupture the ovum, and let the uterus condense itself. At others, tapping the uterus is required. The after-treatment is, rest in a horizontal pos- ture, and the avoidance of the distention of the bladder and rectum. General treatment of the female before labour.—A woman should be prepared for the perils of childbirth by a course of preliminary treatment, commencing a few weeks before her term. This should consist of an occasional venesection, if she is plethoric or has headache, and the use of a gentle aperient that may serve to secure the regular evacuation of her bowels. The diet should be light and unstimulat- ing, and the female should, as far as possible, take regular exercise either in riding or walking till the end of gestation. LABOUR. By this term is understood, that process by which the contents of the gravid womb are expelled. It should commence, as we have already seen, at or about the two hundredth and eightieth day from the last appearance of the menses, or about one hundred and forty after quickening. The principal agent in affecting this process is the uterus itself, assisted, however, by the action of the diaphragm and abdominal muscles. The cause of labour is not well understood: it has been variously attributed to the inability of the uterus to sustain farther distension, to the struggles of the fcetus in its endeavours to breathe, and to the absence of adequate nourishment. Whatever be the cause, certain it is, that the fcetus contributes nothing to expediting the process, being entirely passive throughout, and the volition of the mother is but little concerned, farther than the assistance afforded by the voluntary contraction of the abdominal muscles and diaphragm, the action of the uterus being entirely involuntary. This action consists in the LABOUR. 51 contraction of the muscular fibres, which enter into the composition of the uterine parietes. By this contraction the cavity of the uterus is diminished in size, propulsion is produced, and eventually expul- sion is effected. The action of the uterus continues even after the child is expelled, for the purpose of extruding the placenta, and closing the orifices of bleeding vessels, which might otherwise give rise to serious hemorrhage. The classification of labours.—Almost every obstetrical writer has a classification in accordance with his own peculiar views, each based upon his definition of a natural labour. Some include under the head of natural labour, all those cases which are terminated by the natural unassisted powers, without reference to the presentation. Among these are Hippocrates, Smellie, Baudelocque, Rigby, &c. Others consider that the presentation should be taken into account, and those only which occur most frequently should be called natural. Denman, Blundell, Davis, Ashwell, Ramsbotham, &c, therefore limit natural labours to head presentations. The simplest classification seems to be that which includes all under two heads, viz.: natural, and preternatural. Natural labour, or eutocia, being that which follows a natural course, and in which the woman is delivered unassisted; preternatural labour, or dysto- cia, signifying faulty or irregular labour, the course of which is unfavourable, and in which the assistance of the obstetrician becomes necessary. The general features of labour are the same in every case, but the details are widely different. It is always attended with suffering, if the patient be conscious ; and is sometimes complicated with irregu- larities and danger. The duration also varies much, as well as the amount of pain, in different women, and in the same women in dif- ferent pregnancies, some expelling their children with a single pain, others requiring many to accomplish the same object. The symptoms of labour may be divided into the premonitory, and those which indicate that the process has already commenced. The premonitory are, the subsidence of the abdominal tumour ; some slight mucous discharge from the vagina, together with relaxation and distensibility of it and the external parts ; and a peculiar irrita- bility and restlessness on the part of the patient. The diminution of the abdominal tumour is produced partly by the subsidence of the uterus into the pelvic cavity, and partly perhaps by the painless contraction of the same organ. It is sometimes very sudden in its approach, the woman finding on rising from her bed that she is much less than on the preceding day. It is generally a good sign, as indicating that she has a roomy pelvis. The increased discharge and relaxation of the external organs is also a good sign, showing that there is a disposition in the passages to facilitate the progress of the labour. 52 OBSTETRICS. The irritability and restlessness is seen also in the lower animals, and is therefore not peculiar to the human female. The symptoms indicative of the commencement of labour are, pain, glairy discharge from the vagina, irritability of the bladder and rectum, nausea and vomiting, and rigours or shivering, without the accompaniment of chilliness. The pain felt in labour is due to the sensibility of the resisting, rather than to that of the expelling organs. The sharp, cutting pains of the commencement, which are technically called grinders, are produced mainly by the stretching of the cervix uteri and the vagina, and are generally referred to the lower part of the abdomen and the back, in a situation corresponding to the position of the os uteri. These generally accompany the dilatation of the os uteri, and are indicated by the cries and gestures of the patient, the former being of a moaning, complaining character, the latter, twisting and writhing. When, however, the dilatation has gone to such an extent as to allow some of the contents of the uterus to be propelled through the opening, the pains become of a forcing, expulsive nature, and the gestures attending them differ from those before mentioned. The breath is held; she no longer cries out, but makes strong expulsive efforts as if straining at stool; she makes use of the muscles of respiration to fix the thorax, and then contracts the abdominal mus- cles upon the womb, at the same time pulling violently upon any- thing within her reach. The gestures and cries are valuable indica- tions of the character of the pains. The characteristic of the uterine pains is, that they are dull, and not very acute in their character; are felt mainly in the back and loins; that under their action the uterus becomes tight and hard; and particularly, that they are regular and intermittent; that is, coming on at tolerably equal in- tervals, and succeeded by an entire relief from suffering. At the commencement, the uterine pains are short, weak, and at long intervals; as labour advances, the interval becomes less, and the pains longer and stronger. It is well known that labour pains may be suspended, by any sudden emotion, particularly those of a depressing character, as well as by opiates, administered either by the mouth, rectum, or rubbed upon the general surface. The mucous discharge which takes place from the vaginal surface, is known commonly by the name of show. It is generally mixed with the gelatinous mucus that blocked up the uterine cervix, and with more or less blood. " The more albuminous it is, the better, and it is always a good sign when lumps of albuminous matter come away from time to time ; the thicker, softer, and more cushiony the os uteri is, the more mucus does it secrete." It is useful not only as a lubricating agent, but also as a topical depletion, for by unloading LABOUR. 53 the congested vessels, they diminish the vascularity and heat of the part, and render it more capable of dilatation. The irritability of the bladder and rectum are among the most prominent signs of commencing labour, and are dependent upon the contiguity between the dilating os uteri and these organs, all de- riving a portion of their nervous influence from the same source. The disposition to urinate exists even when the bladder is empty, arid the tenesmic irritability of the rectum is equally independent of the presence of fiscal matter. Nausea and Vomiting, at the commencement of labour, are looked upon as favourable signs, being indicative of a general relaxation, which favours the dilatation of the os uteri. It must not, however, be confounded with that which sometimes supervenes in lingering labours, which is rather prognostic of great exhaustion, and to be dreaded accordingly. In ordinary cases, vomiting in the early stages requires no treatment, being generally relieved as soon as dilatation takes place. When, however, it is very violent, it may often be checked by an effervescing draught, with a few drops of laudanum. The rigors, which often occur early in labour, are like- wise accompaniments of the dilating os uteri, and although often severe, are not dependent on diminished temperature of the female, or irregular arterial action ; they require little other treatment than an extra covering, and diluent drinks. STAGES OF LABOUR. Some obstetricians divide a labour into three, others into four, five, or six stages, all ending with the expulsion of the placenta. The first division is the one generally adopted, and the three stages are thus enumerated. The first terminates with the dilatation of the os uteri ; the second with the delivery of the child; and the third with the expulsion of the placenta. First stage.—This is generally the longest and most distressing, both to practitioner and patient. The pain, although not so great as in the second stage, is of a more distressing character, and more difficult to bear. The patient is more irritable, uneasy, and alarmed as to the result. The character of the cry, as before mentioned, as well as the gestures, are peculiar to this stage, as well as diagnostic of it. Nausea and vomiting also occur during this stage, and, it is thought, assist in effecting it. By placing the hand upon the abdomen during a pain, the uterus can be felt to contract and harden itself, and at the same time tilt forwards so as to bring its axis into accordance with that of the superior strait. As the pain goes off, the uterus becomes soft again, without, however, returning to its former state of relaxation. The approach of a pain may often be foretold by the practitioner before its access, by auscultation. " The moment a pain begins, and before the patient is herself aware of it, we hear a short rushing 5* «.. 54 OBSTETRICS. sound, which appears to proceed from the liquor amnii, and to be partly produced by the movement of the child, which seems to an- ticipate the coming on of the contraction ; nearly at the same moment all the tones of the uterine pulsations become stronger; other tones which have not been heard before, and which are of a piping, resonant character, now become audible, and seem to vibrate through the stethoscope, like the sound of a string which has been struck and drawn tighter, while in the act of vibrating."* As the pain grows stronger, the pitch rises. By the time the pain has reached its height, the sound has entirely ceased, or become very faint; as it departs, however, the sound again returns as at the beginning of the pain, and finally resumes its former tone, which it had during pregnancy. The noise made by the escape of the blood through the uterine veins during a contraction, is probably an im- portant element in the production of the sound in question. It is remarked also by the author quoted above, that the pulse increases in rapidity in proportion as the pain rises in intensity, subsiding in the same manner with it. As the labour advances, the rapidity of the pulse increases, so that shortly before the child is born, it has attained the maximum that it had during the height of the pains in the commencement. A per vaginam examination at the commencement of labour re- veals to us the condition of the parts through which the child is about to pass. If the vagina is cool, moist, and cushiony, and the os uteri soft and thick, the dilatation will most probably proceed favourably. If, on the contrary, the vagina is hot and-dry, and the os uteri hard and thin, or hard and thick, the first stage will generally be tedious. The time occupied in the first stage varies very much in different women, and in the same women in different labours. In primiparse, it is generally longer than in those who have had several children. Regular and genuine contractions seldom require more than six hours to perfect this stage, and often it is accomplished in much less. The dilatation also proceeds much more slowly at the commencement, than it does later; this is owing to the want of the mechanical dilatation which it afterwards receives by the forma- tion of the bag of waters, which acts as a wedge, and forcibly dis- tends the os uteri. Bag of waters.—As the circle of the os uteri enlarges, the mem- branes of the ovum, containing a portion of the liquor amnii, pro- trude through the opening, forming a tense, elastic, conical bag; this by its mechanical pressure assists in the dilatation of the os uteri. During a pain it can be felt becoming more and more tense, and again relaxing as the pain subsides, so that the presenting part can often be detected through it. Near the end of the first stage streaks of blood will often be * Rigby, p. 159. LABOUR. 55 found mixed with the mucus upon the finger, after an examination. This is commonly denominated in the lying-in rooms " a shoiv," and it is usually an indication that the os uteri is dilated, or nearly so. The hemorrhage proceeds from the slight vascular twigs extending between the uterus and the membranes, which are ruptured by the increasing dilatation. The phenomena which have been described are repeated during every succeeding pain, (the intervals being shorter and the pains longer,) until the dilatation of the os uteri is completed. During the whole period of the first stage, the pains have been acting, not so much for the expulsion of the child, as for preparing it and the pas- sage for that purpose. The more completely the os uteri is oppo- site to the fundus, and the greater the correspondence between the axis of the uterus and that of the superior strait, the more speedily will the dilatation be accomplished. As soon as this has taken place, the first stage is ended. Second stage.—The phenomena that present themselves in this stage differ essentially from those of the preceding. The pains suc- ceed each other with greater frequency, and last longer, and the suffering is increased; but, in consequence of the respiratory muscles being fixed, in order to supply a fulcrum for muscular exertion, the woman rarely cries out during a pain. Hence the character of the cry, as before stated, is a diagnostic sign of this stage. The pains now appear not to be so much confined to the womb; they acquire a more expulsive character, and are attended with strong bearing- down efforts of the abdominal muscles. Upon the approach of each pain, the woman seizes hold of anything within her reach, and brings the muscles of the extremities, back, and abdomen to aid her in the expulsive effort. These are commonly called bearing-down pains. If the membranes have not ruptured previously, they generally give way during one of these pains, and the liquor amnii escapes through the external organs; the fcetus, forced downwards by the same con- traction, immediately fills up the space previously occupied by the bag of waters, and the uterus condenses itself upon the body of the child. This is therefore folded into a smaller space, and is much more com- pressed than previously. Each succeeding contraction pushes on the presenting part; but, as the pain goes off, it again recedes, not, however, to the point it occupied before, as there generally is more or less advance on that gained by the preceding effort. If it were not for this gradual ad- vance and recession, there would be great danger of laceration of the soft parts, from a continued expulsive effort before the passages were sufficiently dilated to receive the presenting parts. It thus not only takes away the danger of pressure, but is in itself a good sign, inas- much as it proves that the cavity of the pelvis is sufficiently capa- cious. The woman during the second stage is much less irritable 56 OBSTETRICS. than in the first. She seems to have recovered her energy and equa- nimity, and, if this stage be prolonged, will often sleep between the pains. The young practitioner should be on his guard, however, in relation to this drowsiness, particularly if it occur in primiparas, and be much protracted, or accompanied with headache, as it is in- dicative of congestion, and may be the precursor of convulsions. During the descent of the presenting part, particularly if it be the head, we are often informed of its progress by the occurrence of an unpleasant symptom, viz., cramp in the lower extremities, pro- duced by pressure upon the internal sacral nerves. Under the in- fluence of another pain the head descends along the vagina and begins to press upon the perineum, the rectum becomes flattened, and its contents are often involuntarily expelled; by the time it has reached the floor of the pelvis it is about to meet with its greatest resistance, viz.: that of the perineum. Here again we observe the gradual advance and recession, until this part is distended to such a degree as to allow the presentation to escape over it. This disten- sion is often so great, and the perineum so thin, that the finger can scarcely distinguish it from the presenting part. Occasionally it happens that from this cause the part is rendered transparent, so Fig. 16. that the presentation is visible through it. Twice Madame Lacha- pelle has seen the hair of the foetal head through the distended peri- neum (Fig. 16). The presenting part has now entered the inferior LABOUR. 57 strait, the coccyx is pushed backwards, and the external orifice is dilated ; the anus projects, and the whole perineum is elongated ; the labia majora, and even the mons veneris,- are put greatly upon the stretch, and the former disappear entirely ; this is not the case, how- ever, with the labia minora, which can be felt even at the moment of the exit, and greatest distension. The sufferings of the patient are now at their height, and the pains are frequently "double" a new one commencing before the former has quite terminated. The force is at length so great, that all resistance is overcome, and with a cry of anguish the exit is effected. There generally succeeds an interval of rest for a few seconds or more, then the pains again re- turn, and the remainder of the child is expelled. The second stage is now completed, and the woman is entirely free from pain. If the hand be placed upon the abdomen, it will be found flabby and relaxed, and the uterus can be felt through the abdominal parietes, large, and moderately contracted. The third stage is occupied by the detachment and expulsion of the placenta; the period occupied in effecting this varies much in duration. Sometimes it is expelled with the body of the child, at others, it is retained for some time after. Usually, after an interval of ten or fifteen minutes, pains of a different character follow; by these the detachment of the placenta is effected, and it is extruded into the vagina. By the voluntary efforts of the woman, assisted by the contraction of the vagina, it is entirely expelled, and the labour is completed. Its expulsion is commonly accompanied by a gush of blood, from which circumstance these pains have been called dolores cruenti. The placenta generally enters the vagina inverted, that is, with its foetal face looking outwards, and the bag of membranes is also turned inside out. Especially is this the case, if traction has been employed upon the cord. After the expulsion, the uterus, now emptied of its contents, contracts into a firm hard ball, which can usually be de- tected for some days above the symphysis pubis. In this state of condensation it is about the size of a foetal head. PRESENTATIONS AND POSITIONS. By the term presentation, we understand that part of the child which offers itself at the superior strait. By position, the relative situation of the presenting part to some point of the superior strait. It will at once be seen that there may be a presentation for every square inch of the child's body. This, however, would lead to end- less confusion ; hence obstetrical writers have diminished the num- ber greatly. Some make only two great presentations, viz.: of the head and breech, looking upon all others as deviations from one of these. Others include the above with their deviations, viz.: 58 OBSTETRICS. Cephalic presentations, including vertex and face. "} Breech or pelvic, including the hips and loins. / Inferior extremities, including the knees and feet. \ Churchill. Superior extremities, including the shoulder, elbow t and hand. J Others, such as the back, belly, and sides, are so exceedingly rare, that it is not considered advisable to burden the student's mind with them, particularly as their treatment is the same as that of shoulder presentations. The diagnosis of these different presentations may be described in general terms, as follows, viz.: Of the head, by its hardness, by the presence of sutures and fon- tanel les, and by its shape. Of the face, by its irregular shape, by the orbits of the eyes, by the nose, mouth, &c. Of the breech, by its softness, by the nates, organs of generation, tubera ischii, and often by the meconium, by the single prominence of the os coccygis, and by the sphincter ani muscle, which con- tracts when irritated by the finger. Of the knee, by its rounded form, and by the condyles of the femur, and perhaps by the patella. Of the foot, by its length, shape, position at right angles to the leg, by the equal length of the toes, the heel, &c. Of the shoulder, by its rounded shape, by the clavicle, the spine of the scapula, the axilla, ribs, &c. Of the elbow, by its sharpness, produced by the olecranon process. Of the hand, by its shortness, the thumb and fingers, palmar and dorsal aspect, &c. In regard to the positions, it is customary to note the relation be- tween some point of the presenting part, and some other point in the brim of the pelvis ; for instance, the first position of the vertex is that in which the posterior fontanelle is found behind the left acetabulum. The different positions will be spoken of in treating of the various presentations. MECHANISM OF LABOUR. " When the long axis of the child's body corresponds with that of the uterus, the child (provided the passages are round) can be born in that position; it matters little, so far as the labour is concerned, which extremity of child presents, so long as this is the case; but where the long axis of the body does not correspond with that of the uterus, the child must evidently lie more or less across, and will pre- sent, with the arm or shoulder, a position in which it cannot be born. Tn stating this, we wish it to be understood, that we merely refer to the full grown living fcetus, and not to one which is premature, or which has been some time dead in the uterus, as these follow no rule MECHANISM OF LABOUR. 59 whatever. Hence the positions of the child, at the commencement of labour, resolve themselves into two divisions, viz.: where the median line of the child's body is parallel with that of the uterus, and where it is not; the first we shall call natural, the second, faulty presen- tations of the child."—Rigby. Vertex presentations.—The vertex may present at the brim of the pelvis in various positions; some obstetrical writers enumerate as many as eight, others only four, whilst a third class take the inter- mediate number of six. The latter is the division of Baudelocque, and the one most generally adopted in the schools. These are as follows, enumerated in the order of their most frequent occurrence. 1st. Vertex at the left acetabulum; Forehead at the right sacro-iliac junction. 2d. " right " " left " " 3d. " symphysis pubis, " promontory of the sacrum. 4th. " right sacro-iliac junction, " left acetabulum. 5th. M left " " " right " 6th. " promontory of sacrum, " symphysis pubis. Naegele and others make four, leaving out the fifth and sixth. Rigby makes only two, viz., the first and second, whilst Ramsbotham, Flamant, &c, make eight, adding to those already enumerated, 1st, the face inclining to the right ilium, the occiput to the left, the right ear behind the symphysis pubis, the left towards the spinal column. 2d, the reverse of the first, face tqjhe left ilium, occiput to the right, right ear towards the promontory of sacrum, left behind symphysis pubis. The remaining six follow in the order given above. According to this table, the first three are called occipitoanterior, the last three occipito-posterior. In regard to the frequency of these positions, it may be stated that Naegele maintains that the fourth position of the vertex is much more common than the second, and that the fifth and sixth are so rare that they fire discarded entirely by many eminent practitioners, they having never met with them. Cranial presentations are by far the most numerous of the varie- ties that offer themselves, and of these, those of the vertex in the first position, occur most frequently. Madame Boivin states, that in supervising twenty thousand five hundred and seventeen labours at the Maternite Lying-in Hospital, at Paris, she found fifteen thousand six hundred and ninety-three cases in which the vertex presented in the first position. The greater frequency of vertex presentations may be readily accounted for. It will be remembered that the fcetus hangs suspended in the liquor amnii by the umbilical cord, which is attracted nearer to its pelvic than cephalic extremity ; the head being the heaviest part, consequently becomes the most dependent. Neither is it difficult to explain why the head in labour more com- 60 OBSTETRICS. monly presents itself in the occipito-anterior, rather than in the con- trary way. The child in utero naturally lies on its back, with the head inclined downwards towards the orifice of the womb. The long diameter of the womb, at the end of pregnancy, and especially at the commencement of labour, dips at an angle of about forty-five degrees towards the horizon in a woman who is sitting or standing up. The child being in a complete state of flexion both as to its body and limbs, would naturally roll, so as to bring that part of its body which is convex, to adapt itself to the concavity of the womb. This will of course be its back. The uterus at the same time rests "upon the abdominal muscles anteriorly, which form a soft cushion for it. The head can only pass the brim of the pelvis, (superior strait,) by the adaptation of certain of its diameters to those of the pelvis. The longitudinal diameter of the child's head is four and a half inches, whilst the antero-posterior diameter of the superior strait is only four; it must therefore adapt itself either to the oblique or the transverse ; of these, the oblique is most common. Suppose it to be a first position, in which the longitudinal diameter corre- sponds with the oblique of the superior strait, the vertex is behind the left acetabulum, and the forehead at the right sacro-iliac junction. The two fontanelles will be at first on a level. The first step in the mechanism of labour is the flexion of the head, or the approach of the chin to the breast. This is produced by the action of the uterus pressing the- head downwards into the cavity. Being pressed from above downwards, the spine causes the head to bend forwards, so that the occiput sinks towards the centre of the pelvis, and the chin is squeezed firmly against the breast. By this movement, the diameters of the child's head are brought into correspondence with such diameters of the pelvis as will allow its ready transmission. The occiput occupies the centre of the superior strait; the occipito-bregmatic diameter corresponds to the oblique diameter of the pelvis, which extends from left to rigbt, and from before backwards; the bi-parietal, represents the other oblique diameter; the occipito-mental is parallel to the axis of the pelvic circle, and the occipito-bregmatic circumference corresponds to the plane of the strait. Next follows rotation, by which is meant, the screw-like move- ment of the head in the excavation by which the vertex is brought to the symphysis pubis. By the continued action of the uterus, the head is pushed into the , .excavation until it reaches the floor of that cavity; here its progress ris arrested and the direction changed by the gliding of the occiput upon the left anterior inclined plane, from behind forwards and from left to right, so as to place itself behind the symphysis pubis. Whilst the vertex is executing this movement, the forehead glides from right to left, and from before backwards, on the right posterior inclined MECHANISM OF LABOUR. 61 plane, so as to fall into the hollow of the sacrum. In executing this rotation, or pivot motion, the head turns upon its long diameter. The third stage is extension, which signifies, the departure of the chin from the breast. This commences as soon as the occiput begins to emerge, and is completed when the child's head is entirely born. Instead of con- tinuing to bend forwards, the head now tends to turn over back- wards, so as to bring the occipito-mental diameter into correspon- dence with the axis of the inferior strait. After the head is fairly engaged in the inferior strait, it is no longer in the same relation to the diameter as before; its great diameter and occipito-bregmatic circumference, however, have not undergone any change, for we find, that at the inferior strait, as well as at the superior, they still represent the plane and axis of that strait. The bi-parietal diameter corresponds to the transverse of the inferior strait, and the occipito-bregmatic to the antero-posterior. The great end of rotation is to produce this relation between the diameters, to effect the exit of the child's head. The last stage is restitution, by which is meant, the turning of the vertex again to that side of the pelvis, towards which it was directed before the labour began, or before rotation took place. As soon as the head is born, all restraint is taken away from it, and as it is incapable of retaining the twist which brought it under the arch of the pubis, it returns to its natural position upon the shoulders, which had been temporarily changed. In the position now under considera- tion, the vertex turns towards the left thigh of the mother, and the chin to the right. A short interval of ease succeeds the birth of the head, after which the shoulders enter the excavation. They also enter obliquely, and perform the rotation as above described. The right shoulder is behind the right acetabulum, and rotates from right to left on the right anterior inclined plane towards the symphysis pubis ; the left is at the left sacro-iliac junction, and rotates from left to right on the left posterior inclined plane into the hollow of the sacrum. The right shoulder generally appears first at the pubic arch, whilst the left escapes over the perineum ; the vertical axis of the child's body is bent, so as to accommodate itself to the axis of the pelvis, which, it will be remembered, is a curved line. After the shoulders emerge, the rest of the body is expelled without anything peculiar to demand description. In the second position of the vertex, the mechanism differs but little from that of the first; the same forces are brought to bear upon the child, and the same diameters offer themselves to the prin- cipal diameters of the pelvis; the head also executes the same move- ments as in the preceding. The vertex, however, in this case, is be- hind the right acetabulum, and rotates from right to left on the right anterior inclined plane, and the forehead on the left posterior inclined 6 62 OBSTETRICS. plane into the hollow of the sacrum. At the inferior strait there is no difference between the two positions; but after the escape of the head, the vertex turns towards the right thigh, the left shoulder comes under the arch of the pubis, and the right falls into the hollow of the sacrum ; but in these changes there is no variation from the proportional relations between the foetal head and the maternal pelvis. This is considered by some obstetricians as not so favourable a position as the first, in consequence of the impediment offered by the rectum to the rotation ; this is not believed to be a valid objection, as the rectum can be easily emptied, and then offers but a slight obstacle. The third position is confessedly so rare that some obstetrical writers have banished it entirely. Baudelocque admitted it rather to fill up his plan, than from any evidence of his senses. Madame Boivin met with it only six times in twenty thousand five hundred and seventeen cases. Velpeau also is sceptical as to its existence. When it does occur, its mechanism is a little different from the preceding; the occiput is at the pubis, and the forehead at the pro- montory of the sacrum. In this case, the occipito-mental diameter corresponds with the axis of the superior strait, and the occipito- bregmatic circumference with the plane of that strait. The bi-parietal diameter, however, is situated transversely, and the occipito-bregmatic from front to rear. There is no rotation ne- cessary in this case, and none occurs, consequently there is no re- stitution. The shoulders commonly enter transversely, although they gene- rally emerge with one at the sacrum, and the other at the pubis, without our being able to tell beforehand which it will be. In the rest of the labour there is nothing peculiar. The fourth position of the vertex is the most common of the occi- pito-posterior varieties. In this position the same diameters corre- spond as in the first; but, the situation of their extremities is re- versed. Engagement takes place more easily, and the head descends into the excavation more readily than in the occipito-anterior posi- tions, until it reaches the floor of the pelvis. Instead of extension occurring readily now, a greater degree of flexion is demanded so as to enable the occiput to rotate into the hollow of the sacrum, which it does, from right to left, upon the right posterior inclined plane, whilst the forehead, or anterior fontanelle, slides forward upon the left anterior inclined plane, from left to right. The vertex is born first, over the perineum, and extension takes place backwards, so that the posterior fontanelle, the sagittal suture, the anterior fontanelle, the parietal protuberances, and the several parts of the face are successively seen in front of the perineum. Immediately after the birth of the chin, restitution takes place; the MECHANISM OF LABOUR. 63 face turns towards the left groin, and the occiput towards the poste- rior part of the right thigh of the mother. The left shoulder rotates to the front under the symphysis pubis, while the right falls into the hollow of the sacrum. M. Naegele states that this position is more common than the second, and that rotation takes place from behind forwards, so as to bring the occiput under the pubis, instead of into the hollow of the sacrum, as already described. In this opinion he is confirmed by Professor Meigs. In the fifth position, the back of the child is directed to the left and backwards, the right shoulder to the left and forwards, and the left, to the right and backwards; the bi-parietal diameter corre- sponds with the left antero-posterior oblique, and the occipito-breg- matic with the right antero-posterior oblique diameter; the lesser circumference of the fcetal head, and the occipito-mental diameter, are parallel with the plane and axis of the strait. Rotation of the vertex takes place upon the left posterior inclined plane, into the hollow of the sacrum, while the forehead, gliding upon the right an- terior inclined plane, is brought to the symphysis pubis. After the birth of the head, restitution takes place, with the occiput to the inside of the mother's left thigh, while the face looks towards the right. This is said to be a more difficult position than the pre- ceding, in consequence of the presence of the rectum, which retards the progress of the occiput. In the sixth position, as in the third, there is neither rotation, nor restitution ; the occipito-bregmatic diameter corresponds with the an- tero-posterior, and the bi-parietal with the transverse. It is less favourable than the corresponding oblique positions, in consequence of the liability of the forehead and face to be turned downwards, and thus permit the long diameter of the head to be brought into parallelism with the short diameter of the pelvis. In all these occipito-posterior positions, there is much greater dis- tension of the perineum than in the occipito-anterior, in consequence of the head having to descend lower ; they are therefore more tedious and painful. It is by no means an easy matter to diagnosticate the positions of the vertex ; it requires great delicacy of touch, and considerable expe- rience. The movements of the child, and the stethoscope, are valu- able assistants to the sense of touch. Naegele observes that when the movements are felt most on the right side, the head is probably in the first position, when on the left, in the second. The stethoscope also informs us of the situation of the fcetal heart, and when this is decidedly known, it becomes an easy matter to de- fine the position of the head. 64 OBSTETRICS. CONDUCT OF A LABOUR. The conduct of a labour includes all that is done for a parturient patient from the beginning of her pains till the uterus is emptied, and the safety of both mother and child secured. It is not to be understood by this, that the accoucheur is to substitute himself for nature ; on the contrary, he really has little to do in most cases, except to receive and protect the child, to deliver the placenta, and watch over the mother and her offspring for some hours after the delivery. Whilst thus he is ready to let nature assist herself, he must be prompt to recognise and avert any danger that may arise. It is well for the practitioner always to be provided with a lancet and an elastic male catheter; and if he live in the country, with a little laudanum. The first duty of the attendant is, to ascertain her present condition, whether in labour or not, and if so, how long she has been in labour, the nature of the presentation, the rate of pro- gress, and probable termination. The first conditions will be readily discovered, by examining the skin, pulse, tongue, &c. ; then directing the attention to the pains, noting their character, frequency, duration, &c, the character of the outcry, the gestures of the patient, and the state of the vaginal dis- charge. By these symptoms he will be enabled to judge of the existence of labour or Fig. 17. not, the stage and rate of progress, and also of the necessity for a more particular ex- amination. One of the first duties of the practi- tioner, after the above inquiries have been attended to, is to dis- cover the condition of things by a per vagi- na m examination; this, it need hardly be said, should al- ways be proposed in the most delicate manner. There is much information to be gained during the first examination (and it should never be CONDUCT OF A LABOUR. 65 needlessly repeated;) first, whether she be really pregnant; second- ly, if she be in labour; thirdly, whether the membranes have ruptured or not; fourthly, the nature of the presentation ; fifthly, the stage and progress of the labour; sixthly, the state of the os uteri, vagina, and perineum ; he is also to take the opportunity of estimating the capacity of the pelvis, and other circumstances which may influence the duration of the labour. (Fig. 17.) It is scarcely necessary to repeat this examination during the first stage, if all is right; but in the second, it should be regulated by the rapidity of the advance, and when once the head has reached the perineum, the finger should be kept upon the head during each pain, so as to regulate the amount of support for the perineum. The finger ought always to be introduced during a pain, but the exami- nation should also extend to the interval. During the first stage, the patient need not be confined to the bed, but may be allowed to sit up, or even to walk about, if she desire it. Neither is it incumbent upon the medical attendant to remain in the lying-in room during the first stage; his presence may be a restraint upon the patient. The condition of the. bowels should always be early attended to, and if they have not been acted upon lately, should be unloaded either by an enema, or an aperient. The bladder should also be emptied, either spontaneously, or by the catheter. The diet of the patient, when the first stage is protracted, should be of a light, un- stimulating character; the object being to sustain nature while under a severe effort, at the same time that we carefully avoid calling that effort in the direction of the digestive organs. There should always be in readiness several strong ligatures for the cord, a pair of sharp scissors, some strong pins, and a " binder," or broad bandage, for the female. It is likewise the duty of the accoucheur to see that the bed is properly prepared for the patient. This is best done by spreading a piece of oiled cloth upon the mattress to protect it at the point the patient is about to occupy ; over this may be placed several blankets or coverlets, folded square, to receive the discharges, &c. These latter can be easily removed after the labour is completed, without disturbing the patient, leaving the bed-linen beneath unsoiled. The second stage is often announced by the rupture of the mem- branes. As soon as this occurs the patient should retire to her bed, and the practitioner make an examination, in order to determine more accurately the position, and inform himself of the advance of the head. In this country and in England, it is usual to place the woman upon her left side, with her hips close to the edge of the bed, and her knees drawn up towards the abdomen. This position enables the practitioner to use his right hand with advantage, and is also sup- 6* 66 OBSTETRICS. posed to favour the engagement of the head in the first position. If the membranes have not ruptured at the commencement of this stage, and the head has passed the circle of the os uteri, they may be broken either by pressing the finger upon them during a pain, or by means of a probe passed along the index-finger, provided always, • that it is not a first labour, and the attendant is satisfied that their usefulness as a dilating agent is at end. When the head has reached the floor of the pelvis, and is begin- ning to distend the perineum, the latter should be supported by the palm of the left hand, (guarded with a soft napkin,) in such a way as to delay the passage of the head slightly, and to bear it towards the pubis, so as to prolong the curve of the sacrum, and make cer- tain of the head being carried forward to the anterior orifice of the vagina, and not allowed to perforate the perineum for want of a just support. As the head escapes from the os externum, it should be received in the hand of the practitioner, and allowed to perform the motions of restitution, carrying it forward as the shoulders are expelled ; he should also be careful to observe whether the cord is twisted about the neck, and if it be to disengage it. The perineum should be supported during the exit of the shoulders, and the whole body car- ried forward in the axis of the pelvic outlet, and not by any means pulled out, in order to relieve the woman from pain, and facilitate the delivery. When the child is entirely born, and respiration is established, or the cord ceased to pulsate, it may be separated from the mother. To do this, one strong ligature should be tightly tied around the cord about two inches from the umbilicus, and another about an inch further on, and the cord cut between them/ The two ligatures are useful in case of twins, which sometimes have a common placenta, and also for the sake of cleanliness. The accoucheur should then place his hand on the abdomen of the mother, for the purpose of ascertaining whether there be a second child or not, and also to discover, from the state of contraction of the uterus, whether the placenta is discharged or not. If the uterus be well contracted, the placenta will probably be found in the vagina ; as soon as it has descended so low that he can feel the insertion of the cord, he may withdraw it by gentle traction in the axis of the vagina. No force should be used in this operation, for fear lest the placenta should be still adherent, and thus the risk of inversion be produced, or the cord torn from its insertion. The pudendum should now be carefully and gently dried, and covered with warm napkins ; after which the binder should be so applied as to extend from the pubes to the ensiform cartilage, and drawn moderately tight, thus affording an adequate support for the uterus and abdominal viscera. CONDUCT OF A LABOUR. 67 The wet sheets, &c, may now be removed from under her, and the patient covered over to prevent chilliness, and then left to have an hour's rest before she is made comfortable in bed. The child should be put to the breast as soon as the mother is sufficiently rested. It is not only useful to the child by supplying it with the early secretion, which is laxative, but it is also beneficial to the mother, inasmuch as it excites contraction of the uterus. The diet of a woman lately delivered should be as light as possi- ble, consisting mainly of the farinaceous articles; and she should be kept in a strictly horizontal position till all danger of hemorrhage has passed. About half an hour after the labour is completed there often occur a succession of painful contractions called after-pains. During their presence, the discharge from the uterus increases and coagula are frequently expelled ; their operation is salutary within certain limits, they prevent hemorrhage, diminish the size of the uterus and expel its contents; they are rare in primiparous women. If very severe they may be diminished by small doses of camphor and opium. The lochia is the name given to the discharge that continues after labour is completed. For some days it retains the character of blood ; but it finally loses its firmer portions and red globules, in conse- quence of the continued contractions of the uterus, and becomes of a greenish tint. It comes from the patulous orifices of the vessels on the uterine surface where the placenta was attached, and disappears as these become compressed by the uterine contractions. It usually lasts three weeks, though sometimes longer. General directions have been given for the management of the child after birth ; it sometimes happens that it requires further atten- tion at the hands of the practitioner, owing to some pathological con- dition into which it may have fallen. For instance, when born it may be in a state of defective vitality, asphyxia, or apoplexy. The first condition may be produced by excessive uterine hemorrhage, by too early a detachment of the placenta, or by defective nutrition. This will be recognised by the feeble efforts at respiration and the weak and irregular action of the heart. Under these circumstances no advantage is gained in preserving the connexion between the mother and child; the cord should be tied and cut and the infant immersed in a warm bath of the temperature of 97° or 98° Fahr. If after a few minutes, the child does not gasp, and we observe that the heart is acting less forcibly, a longer continuance in the bath will do harm ; it should, therefore, be removed, and cold sprinkling tried, or what is better, gentle stimulation by means of frictions over the general surface, and if necessary, artificial respiration. In the second condition, the child is sometimes asphyxiated by pressure upon the cord, or by being delayed in the passage in a tedious labour. Here it would be obviously improper to cut the cord; 68 OBSTETRICS. the practitioner should resort to frictions, cold aspersions, or water poured from a height upon the epigastric region, artificial respiration, &c. Should these means fail, he may try the effeet of bleeding, by cutting the cord and allowing about a table-spoonful of blood to escape ; if this is unsuccessful, the case is probably hopeless. The third condition is most frequently produced by long-continued pressure, or, from an interval elapsing between the birth of the head and that of the body. Under these circumstances, the action of the heart is weak, and the pulsation in the cord feeble and oppressed, the surface is blue and the face livid, and occasionally it happens that the form of the head is altered. Bloodletting is here obviously indicated, and it should be done by cutting the cord and allowing from half an ounce to an ounce to escape; when it will generally be found, that the surface becomes of a natural hue, the pulse quicker and firmer, and attempt is made to respire. If the child does not breathe, a sudden puff into its face, or a slap upon the buttocks, will often establish respiration, or the means above mentioned may be resorted to. The tumour that is often found upon the scalp of new-born chil- dren, called caput succedaneum, and which is produced by the extravasation of blood, or effusion of serum beneath it, generally disappears spontaneously, or by the application of spirit or some stimulating lotion. Hemorrhage from the navel after the separation of the cord is sometimes very troublesome, and may be treated by means of astringents, cautery, compresses, &c; if these means fail, Dr. Churchill recommends to stretch open the navel and fill it with plaster of Paris, either dry or moistened, allowing it to remain till solid. Others propose to cut down upon the vessel and tie it. A less formidable operation has been successfully practised in this city, by passing two needles through the navel parallel with the sur- face of the abdomen and at right angles to each other, and applying a ligature beneath them, as in the operation for aneurism by anas- tomosis. Tedious Labour.—The labour is often prolonged beyond the usual limit by a delay in one of the three stages, and yet may be completed without either manual or instrumental assistance. In the first stage it often depends on an undilated os uteri; this more frequently occurs with first labours, and also in women of advanced age, than under other circumstances. On examination, the os uteri is found in one of two conditions, either thin and hard, or semi-pulpy and cedematous, and but little influenced by the pains, which may be frequent and very severe. It may also be undilatable from the presence of cicatrices. One of the most effectual remedies for this condition is venesection, which may be carried sometimes to a great extent, provided there TEDIOUS LABOUR. 69 be no contraindication. Dr. Dewees once took away as much as two quarts. The blood should be drawn rapidly and from a large orifice ; if the patient becomes faint, so much the better. The bloodletting may be assisted by an opiate enema, by the administra- tion of tartar emetic in nauseating doses, or by the application of belladonna ointment to the cervix. The warm bath has been recommended by some practitioners and disapproved of by others. Moral influences have, at times, a good effect; changing the dress, or the bed, changing the position, &c, are often of service. Some practitioners recommend mucilaginous injections to be thrown into the vagina. There is another condition of the os uteri which is often a cause of delay, where the anterior lip is caught between the head and symphysis pubis and its retraction prevented. This may result either from an obliquity of the uterus, or more probably from an unequal dilatation of the anterior and posterior lips, the latter dilating most rapidly. The remedy is simple and easily applied. During the interval between the pains, when the os uteri is soft and dilatable, the prac- titioner should gently push back the anterior lip over the crown of the head and hold it there during the succeeding pains,—a proceed- ing which, if nicely accomplished, will soon be followed by the expulsive pains of the second stage. Premature rupture of the membranes.—This may occur either through their own weakness, or from violence, either accidental, or from the officious meddling of the accoucheur. The result is, that the os uteri instead of being dilated by the bag of membranes, which is soft and wedge-like, comes at once in contact with the child's head, which is not by any means so good a dilator. The only remedy is patience. An examination should be made early in order to correct the presentation without loss of time, should it be abnormal. Excessive quantity of liquor amnii is sometimes enumerated as a cause of tedious labour; and this is apt to be in excess when the patient is feeble and the child small and ill-nourished. The treat- ment for this is rupture of the membranes; but it should not be practised without due caution, or it may produce tedious labour from the cause mentioned in the preceding paragraph. In the second stage, the labour is often rendered tedious by the feeble and irregular action of the uterus ; when this exists, the interval between the pains is long, and the pains themselves are feeble and short, and have little or no effect on the child. This state of things is not uncommon in delicate women, or in the reverse ; or it may be produced by mental depression, a deranged state of the digestive organs, or, it may arise from hereditary transmission. In the treatment of these cases, it is above all things necessary to keep up the patient's spirits; all causes of irritation should be re- 70 OBSTETRtOS. moved, and she should be allowed to change her position. In some cases it may be right to administer an opiate, so as to recruit her by sleep, and in all cases a stimulating enema will be found of service, especially if the bowels are loaded and the delay depend on this cause. But the most effectual remedy in these cases, is the ergot of rye, a remedy which seems to possess a power of certain, direct, and speedy action on the uterus, causing it to contract almost unremit- tingly till its contents are expelled. Besides the power of strength- ening feeble pains, Dr. Ramsbotham has shown that it is capable of originating uterine action. It may be given either in substance, infusion, or tincture, in the dose of from fifteen to twenty grains of the powder, till a drachm is taken ; half a fluid-drachm to one fluid-drachm of the tincture; or, the same quantity of powder as above directed, mixed in hot milk or coffee. It is, however, to be given with caution, as results fatal both to mother and child hav*e followed its injudicious administration. The indications for giving it are, according to Dr. Churchill, 1st, feeble and inefficient pains without especial cause; 2d, if the os uteri be soft and dilatable; 3d, if there be no other obstacle to a natural delivery; 4th, if the head or breech present, and are suffi- ciently advanced; 5th, if there be no threatening head symptoms, nor excessive general irritability. But, on the other hand, it should not be given, 1st, if the os uteri be hard and rigid ; 2d, if the presentation be beyond reach; 3d, if there be a mal-presentation ; 4th, if the pelvis be deformed; 5th, if there be any serious obstacle to delivery in the soft parts; and, 6th, if there be head symptoms, or much general irritation. Toughness of the membranes, even after the os uteri is dilated, is sometimes a cause of tedious labour; but, when once ascertained, it admits of an easy remedy; if the pains are active, and the os uteri dilated, they may be ruptured without ceremony. The practitioner should cut a notch in his finger nail, and saw through the mem- branes, at the most dependent part, during a pain. Sometimes they protrude unbroken, down to the os externum, and in some few cases, the child has been expelled with the bag of mem- branes and placenta en masse ; under such circumstances it would certainly be drowned in its own liq. amnii if assistance were not at hand to rupture them, and enable the child to breathe. Rigidity of the soft parts is a very common cause of delay in women who have borne children late in life, or who are of a plethoric condition, with a well-developed muscular system. In such, the head makes little or no progress, although the pains be strong and frequent. If this condition of things lasts long, the patient will fall into a state of exhaustion, or constitutional irritation ; or inflamma- FACE PRESENTATIONS. 71 tion and sloughing of the soft parts from long-continued pressure will ensue. The indications in the treatment are, 1st, to gain time; 2d, to counteract inflammation. These will be fulfilled by a moderate bleeding, if the constitution will bear it; by a dose of opium, to * moderate or suspend the uterine action ; and by small doses of tartar emetic, with the hope of relaxing the system. To these means may be added, warm hip-baths, warm mucilaginous fomentations to the parts, and the introduction of unirritating unguents into the vagina. If the rigidity be dependent upon the presence of cicatrices of the os uteri, vagina, or perineum, the result of laceration or sloughing in former tedious labours, or occasioned by the ill use of instru- ments, the same rules for treatment may be adopted. The uterus may acquire an inclination one way or another, during pregnancy, from different causes, and this oblique position of the organ may be a cause of delay in the progress of the labour. In women who have borne many children it is often owing to re- laxation of the abdominal muscles, which permits the uterus to fall forwards, and thus the child's head, instead of being propelled into the brim of the pelvis, is driven back against the upper part of the sacrum. The nature of the obliquity is detected by a per vaginam examination, which reveals the position of the os uteri; if it be lateral, place the patient on the opposite side; if anterior, let her lie on her back, and support and draw up the fundus uteri by means of a towel or napkin passed beneath the pendulous belly and fastened behind the back, until the head shall occupy the inferior strait. There are various other causes that may render a labour tedious, such as an over-distended bladder, or a rectum filled with hardened faeces, a rheumatic condition of the uterus, tumours, and deformities of the pelvis, &c. In the first case, the remedy is found in the in- troduction of the catheter and drawing off the water ; in the second, a stimulating injection should be given, or, if necessary, the hard- ened faeces removed with the handle of a spoon; in rheumatism of the uterus, the patient generally complains of feverishness and rest- lessness, the abdomen is tender, the urine scanty and high-coloured, for some time before labour sets in. The contractions of the uterus are rendered exceedingly painful, and at times inefficient. The treatment consists in bloodletting, warm fomentations, an aperient of mag. sulph. and sodse carb., and alkaline drinks. Tumours and deformities of the pelvis require instrumental aid, and render an otherwise natural labour, preternatural. FACE PRESENTATIONS. Face presentations are deviations from those of the vertex, and are not by any means as danger*ous as they were formerly sup- posed to be. Madame Lachapelle has laid it down as a fixed prin- 72 OBSTETRICS. ciple, that this sort of labour is nearly as easy and as natural as that by the vertex, and affirmed, that out of seventy-two cases of this kind, forty-two were delivered by the unassisted efforts of the female, without danger either to mother or child. They are there- fore included under the head of Natural Labour. The causes of face presentations are obscure, and have been variously described by authors. Some suppose that they are caused by the inclination or obliquity of the fcetus itself, rather than of the organ which contains it. Madame Lachapelle attributes them tolhe circumstance that the anterior obliquity of the womb being very common, the weight of the occiput must in such cases prevent the chin from being applied to the breast; and must bring the mento- bregmatic diameter into parallelism with the sacro-pubic diameter, from the very commencement of the labour. Paul Dubois thinks they are primitive, and probably produced by the active movements of the fcetus itself, and the following is his explanation. " At any time during gestation, the chin may depart from the breast; if the fcetus retains this position till the end of pregnancy, it becomes per- manently fixed in it at the commencement of labour, by the rupture of the membranes, and the contractions of the uterus." By most authors, obliquity of the uterus has been looked upon as the principal cause of face presentations. If at the commencement „. of labour the uterus is so oblique as to throw the fundus far over to the right side, the child presenting by the head and the vertex in the first position, the direc- tion of the expulsive force operating on the infant, will propel its head against the edge or brim of the pelvis, and either -cause it to glance upwards into the iliac fossa and let the shoulder come down, or it will be turned over, so as to let the face fall into the opening,and thus produce a face presentation, in which the chin will be direct- ed to the right side, and the forehead to the left of the pelvis. (Fig. 18.) # FACE PRESENTATIONS. 73 It will therefore be seen, from this explanation, that face presenta- tions are deviations from those of the vertex. From this circumstance some authors make the same number of positions for them as for vertex presentations; others again make four, corresponding to the four oblique positions of the vertex, while some enumerate the same number, disposing them transversely, and from Jront to rear, ad- mitting a right mento-iliac and a left mento-iliac, a mento-pubic and a mentosacral position. These positions having all been esta- blished, it is proper that they should be mentioned. It seems ad- visable, however, to simplify as much as possible, and accordingly the number has been reduced very generally to two. First position.—Forehead to the left ilium, or left acetabulum, and the chin to the right ilium, or right sacro-iliac junction, the bridge of the nose representing the line described^ by the sagittal suture in the first vertex position. (Fig. 18.) The second position.—Forehead to the right acetabulum, or right ilium, and the chin to the left ilium, or left sacro-iliac junction. (Fig. 19.) The first position is a deviation Fig. 19. from either the first or fifth position of the ver- tex ; the second, from the second or fourth. Mechanism.—In the first position the right side of the face is an- terior, and therefore more depressed than the other on entering the brim, and the finger touches the right eye or zygoma first, on making an examina- tion ; if the labour is a long one, this part of the face is swollen and livid. The face comes down transversely, with the bi-malar, or rather the bi-temporal dia- meter, in coincidence with the antero-posterior of the superior strait, and the fronto-mental with the transverse. As the head is forced down into the excava- tion, extension first becomes as great as possible, then the chin rotates upon the right anterior inclined plane until it gets under the arch of the pubes; while the anterior fontanelle glides in an opposite 74 OBSTETRICS. direction upon the left posterior inclined plane, and falls into the hollow of the sacrum. As the chin emerges, it rises up towards the mons veneris, performing in this case the movement of flexion, instead of extension, as in vertex cases ; the forehead, followed by the sagittal suture and occiput, passes gradually down the plane presented to it by the anterior surface of the coccyx and perineum, in front of which all these parts are succes- sively disengaged. (Fie 20.) The second position is merely the reverse of the first; the left side is now turned forwards, and the left eye and zygoma are lowest in the pelvis, and the ec- chymosis is found on this side, if the labour is protracted. The chin rotates upon the left anterior inclined plane, and the anterior fonta- nelle on the right pos- terior one: the same diameters correspond, and the labour is completed as in the first position. It is said that this position is more frequent than the former, and that rotation is more readily effected, as the rectum offers no impediment. In all the various positions that have been described or alluded to, the object is to bring the chin to the pubis, and the mechanism is the same as in the two varieties above described. Should this fail, and the chin rotate into the hollow of the sacrum, it is impossible for this part to be born first (unless the fcetus be an abortion); for the thorax would then be in the pelvis at the same time as the head, and would require assistance to deliver it. These cases will be treated under Preternatural Labour. Diagnosis.—Generally speaking, it is not difficult, although the face has been confounded with the breech. It is generally distin- guished by the prominence and regularity of the features, by the nose, eyes, chin, and mouth ; the latter is distinguished from the anus by the absence of the prominence of the coccyx, and by the sphincter ani; the best means of diagnosticating face presentations is by the bridge of the nose, which from its crossing the os uteri Fig. 20. PELVIC PRESENTATIONS. 75 may be detected at a very early period of labour; it is better than the eye, which may not only be injured, but may mislead; it is better than the malar bones, for these may be mistaken for the tuber ischii, or even for the shoulder. The nose not only tells the pre- sentation, but also the position. After the face has descended, the chin will confirm it. Treatment.—Face presentations require more laborious effort for delivery than others, from the fact that the cephalic extremity is re- moved from the line of direction in which the uterus and accessory powers act. The second stage is also longer, because the bones of the face are incompressible, and there is not the same adaptation to the parts through which it is to pass. In ordinary cases little is required beyond watching the case carefully, cheering and supporting the patient. If called early enough, endeavour to rectify the presentation; if not, to bring the chin to the pubis by the gentlest assistance. In most cases no interference is required; the general rules already given are sufficient. The features of a child born under a face presentation are generally much swollen, turgid, and livid. We must be prepared, therefore, to expect some disfigurement, which, however, will generally dis- appear in a day or two. Other deviations from vertex presentations sometimes occur from the operation of the same or similar causes. The head may descend half turned over, so that the occipito-frontal, or occipito-mental diame- ter corresponds to those of the straits. In this case either the anterior fontanelle or forehead will be the presenting part. Sometimes the head is too much flexed, occasioning a part of the nucha to present with the occiput. Again, it frequently happens that one of the pa- rietal bones, or the ear, or the temple, being nearly parallel with the plane of the superior strait, engages first. Such cases may either correct themselves, or become the cause of preternatural labour. PELVIC PRESENTATIONS. Under the head of pelvic presentations are included those of the knees and feet; it matters but little, so far as the mother is concerned, which end of the fcetal oval presents at the superior strait, since either can be born unassisted. These pelvic presentations are, how- ever, more dangerous to the child than cephalic, either from the fact that the placenta is often detached from the uterine surface before the head is born, or from pressure upon the umbilical cord during the exit of the head, either case being attended by the same result, viz.: asphyxiation of the child. All practitioners agree that the child is oftener born dead in pelvic presentations, than in those in which the vertex descends first. Causes.—Breech labours occur once in about every forty-five or fifty cases; why they occur this often, or why they happen at all, 76 OBSTETRICS. appears to be inexplicable. Madame Lachapelle explains their oc- currence as follows :—During a great part of gestation, and whilst the foetus is still movable in the cavity of the uterus, its long diameter can be readily brought into coincidence with the transverse diameter of that organ ; its position therefore is by no means fixed, and it can, by virtue of its active movements, present any part of its surface at the uterine orifice, but especially the cephalic or pelvic extremities. The latter part may occupy the superior strait at any period of gestation, in consequence of the movements of the fcetus, and may remain in that situation for an indefinite period. It hap- pens then, if the fcetus in this time should have developed itself to any extent, it cannot turn, and it will be apt to retain the attitude it may then acquire till the end of pregnancy, as its length does not readily admit of its passing the transverse diameter of the uterus.* Violent movements on the part of the female, it is thought, may .also be a cause of pelvic presentations, but as before stated, they are in the great majority of cases, inexplicable. Some women, from original conformation or other causes, appear particularly obnoxious to this mischance, bringing all their children into the world by breech labours. Prognosis.—Breech labours are generally more tedious than ce- phalic, inasmuch as the pelvic extremity is not so good a dilator as the cephalic; it never presents the same evenness, the same resist- ance, or the same rounded form as the head to the openings of the pelvis; it consequently acts to much less advantage on the cervix to finish its dilatation. In vertex presentations the most voluminous part, that which is best calculated to bear all kinds of pressure, es- capes first. In pelvic presentations, on the contrary, the point of the cone advances first, so that the fcetus progresses more slowly in proportion as the labour advances. Positions.—The same difficulty occurs in enumerating the various positions of the breech that we have seen obtain in the other presen- tations, every author recording those which seemed to him best es- tablished. Thus some make as many as eight; among these is M. Flamant, who makes one for each extremity of the different diameters of the superior strait, viz.: two for the antero-posterior, two for the transverse, and two for each of the oblique, making eight in all. Others make six, corresponding to the different positions of the vertex, the sacrum taking the place of the vertex. We find again some reducing them to four, viz.: 1st, sacrum to the left acetabu- lum, 2d, to the right acetabulum, 3d, to the pubes, 4th, sacrum of the child to the promontory of sacrum of the mother. Thus the direct positions, either anterior or posterior, are possible, as well as the diagonal ones, and the breech may present in as many ways as the head. » Chailly, Traite Pratique de l'Art des Accouchemens, p. 604. PELVIC PRESENTATIONS. 77 To simplify the matter, however, most of the recent writers reduce them to two, viz.: sacro- anterior, and sacro-pos- Fig. 21. terior, that is, the back of the child towards the belly of the mother, and the back of the child towards the back of the mother. Not that the back of the child is di- rectly anterior or poste- rior, but oblique, the transverse diameter of the child's hips corre- sponding to one or other of the oblique diameters of the superior strait. (Fig. 21.) Mechanism. — The mechanism of the sacro- anterior positions is so much alike, that but one description will be given of them. Naegele, on the mechanism of parturition, says, that " In every case, whether the nates have at first a completely transverse or oblique direction, they will be always found, on pressing lower into the superior aperture of the pelvis, to have taken an oblique position; and that ischium which is directed anteriorly, to stand lowest. In the most common position, where the sacrum of the child is towards the left acetabulum, as the breech descends into the pelvis, it is the left ischium that stands lowest, and is first touched by the finger. The child's left hip rotates forwards upon the right anterior inclined plane under the arch of the pubis, while the right hip slides backwards into the hollow of the sacrum along the left posterior inclined plane. As the shoulders are supposed to remain fixed in the uterus, flexion of the child's body takes place as it is being born, and restitution after the birth of the hips is effected. As the shoulders also engage obliquely, they un- dergo rotation, the left shoulder rotating on the right anterior inclined plane, and appearing under the pubis, while the right falls into the hollow of the sacrum (Fig. 22). " But whilst the shoulders are descending in the above-mentioned oblique position, the head, with the chin resting upon the breast, presses into the superior strait in the direction of the right oblique diameter, that is, with the forehead at the right sacro-iliac junction, the occiput rotates upon the left anterior inclined plane, towards the 7* 78 OBSTETRICS. Fig. 22. pubis, and the forehead on the right posterior, into the hollow of the sacrum, and the head is born in such a manner, that whilst the occiput rests against the os pubis, the point of the chin, followed by the rest of the face, sweeps over the perineum, as the head turns on its lateral axis from below upwards (Fig. 23). Fig. 23. " There is no essential difference in the mechanism of the labour, when the sacrum is at the right acetabulum, except that the rotation is reversed; the right hip and shoulder rotate on the left anterior in- PELVIC PRESENTATIONS. 79 clined plane, and the left hip and shoulder *on the right posterior inclined plane; the occiput on the right anterior, and the forehead on the left posterior inclined plane. As before mentioned, when the sacrum is to the pubes, as it descends it becomes oblique, and then the mechanism is precisely the same as above described. (Figs. 22, 23 describe these.) " As in positions of the cranium, the swelling of the integuments is chiefly met with on that parietal bone which, during the passage of the head, is situated lowest, and on that spot with which it enters the external passage, so in this case, the livid-coloured swelling appears on that part which, directed forwards, was situated lowest during the passage of the nates, and with which the nates were born." In the second chief position, viz.: with the anterior surface of the child corresponding to the anterior abdominal parietes of the mother, or in other words, with the sacrum of the child to the sacrum of the mother, the same effect is produced by the expulsive action as be- fore. The breech descends to the outlet of the pelvis; a slight turn is effected; one of the ilia (and it is generally the left) appears un- der the arch of the pelvis, the other traverses the perineum; the breech and legs escape, the shoulders pass the brim, and descend until they press upon the structures at the outlet; one escapes under the arch of the pubes, the other follows the curve of the sacrum, and the head is propelled into the cavity of the pelvis, with the face looking to one side, and the occiput to the other. It might be supposed, from the position of the head at the com- mencement of labour, with the face looking forwards, that the occiput would fall into the hollow of the sacrum, and the face emerge under the pubes; but this is not the case; for when the shoulders are born, and the head is in the pelvis, the face is directed to one side or the other, exactly as in the sacro-anterior position ; and a precisely similar turn is effected, the face falling into the hollow of the sacrum; so that the fcetus in its exit makes a semicircular rotation, the face being placed forwards at the commencement of labour, and being expelled through the outlet over the sacrum and perineum. Dr. Ramsbotham, from whom the above description is taken, says farther, " I believe that in no instance, if the case were left entirely to nature—provided the child and pelvis were of the common size and form—would the face be expelled under the arch of the pubis." Dr. Collins also confirms it. Dr. Naegele mentions this last as a deviation from the ordinary mechanism of breech cases. He also describes another deviation, in which the chin departs from the breast, and the head enters the pelvis, after the birth of the body, with the occiput pressed against the nape of the neck, and the vertex corresponding to one or other ilium of the mother. As the head presses lower into the cavity, the vertex turns gradually more and 80 OBSTETRICS. more backwards, so that when the trunk is born, the arch of the cranium is directed to the hollow of the sacrum, and the inferior surface of the lower jaw to the symphysis pubis. In the birth of the head, whilst the under jaw presses with its inferior surface against the os pubis, the point of the occiput, with the vertex, followed by the forehead sweeps first over the perineum ; thus bringing the occipito-mental diameter into apposition with the antero-posterior of the outlet. The diagnosis of breech presentations has already been given; it is not usually difficult. It may be confounded with the face, parti- cularly where the labour has continued for some time, and the pre- senting part is tumid. It will be distinguished from the latter by the absence of the bridge of the nose, by the movable, single point of the coccyx, by the contractility of the sphincter ani, by the tubera ischii, by the cleft between the nates, by its roundness and softness, and by the organs of generation. Of these, however, the point of the coccyx and the sacrum are the best, as the others may be so altered by swelling as not to be recognisable. The presence of the meconium is not a certain sign, since it is occasionally met with in cephalic presentation, where the child is subjected to strong pressure, though in the latter case, Dr. Collins says it is more fluid, from being mixed with the discharges from the uterus and vagina. The shape of the bag of waters, is another diagnostic sign, being less hemispherical and more cylindrical than in vertex presentations, and more resembling an intestine in shape. Auscultation, though not a certain test, is a corroborative proof; the sound of the fcetal heart will be heard higher in the abdominal region, if the head be at the fundus uteri, than if it be seated in its more natural position. The same is true of the movements of the fcetus, they being generally felt lower in the abdomen in breech cases, than in those in which the vertex presents. Presentations of the breech, although perfectly natural labours, are generally more tedious for the mother, and more dangerous for the child than those of the head, for reasons already stated, viz.: that when, in pelvic labours, the head enters the pelvis, if every thing be not favourable for its passing rapidly through it, the cord is so long compressed that the child is almost certainly lost. Treatment.—Much more care and attention are required in the treatment of these labours, than in those before described ; not only to protect the soft parts of the mother, but also to preserve the child's life, which is always placed in more or less danger. It is, therefore, of great importance that a correct diagnosis should be made early. Being satisfied that it is the breech which presents, the case requires no interference until the breech shall have been expelled through the external parts, further than to guard the soft parts of the mother, and carefully to support the perineum. Above all things, the atten- PELVIC PRESENTATIONS. 81 dant should not draw down the feet, as the inexperienced are too apt to do, in the hope of facilitating the delivery by having something to pull upon ; this practice always diminishing the size of the dilating part, and thus prolonging the labour. As the breech escapes, it should be supported and carried upwards in the axis of the pelvis, allowing it perfect liberty to change its position or make such turns as the mechanism may require. Mechanical assistance is rarely required in these cases, the child adapting itself to the passages of the mother. When the umbilicus appears at the external organs, the cord should be seized and gently drawn down and pushed down to one side; this will prevent its being torn and pressed upon. The strength of the pulsations in tlie cord, is the best evidence we have of the necessity for any interference. When the thorax has emerged, if the arms have not escaped with it, they should be brought down by passing one or two fingers over the shoulders, as near as possible to the elbow, and then drawing the arm across the face and chest until the elbow arrives at the ex- ternal orifice; having delivered one, the other is easily extracted. It is generally better to deliver the one at the perineum first. The slower the pelvis and body pass out, the quicker will the head pass, and the greater will be the chance of saving the child's life. The body being born, it should be wrapped in warm flannel, and raised upwards on the practitioner's arm, to a height sufficient to enable the longest diameter of the head to become parallel with the axis of the vagina, and the patient urged to bear down. If the head be delayed while in the vagina there is danger of losing the child; the extent of this danger will be estimated by the pulsation in the cord. As in most cases the head will be found with the face in the hollow of the sacrum, the delivery may be hastened by introducing one or two fingers of the left hand into the mouth, and depressing the chin upon the breast, at the same time carrying forward the body of the child. (Fig. 24.) If this fail, the perineum should be pressed back so as to allow the atmospheric air to enter to the respiratory organs. The child, in this way, may be saved till the expulsive efforts effect the delivery. Should these means fail, and the child be in danger, the forceps should be at hand, and the child be delivered by their assistance. If it should happen that the body is expelled with the face ante- riorly, and the chin should lodge upon the pubes, it should be carried backwards, and the chin drawn down by the finger introduced into the mouth. The remainder of the delivery and the after treatment, are the same as in vertex presentations. Presentations of the inferior extremities.—What has been said in relation to the danger of breech presentations, applies with even more force to those of the lower extremities. In this latter case the 82 OBSTETRICS. Fig. 24. child may be compared to a cone, the apex of which presents itself first. Of course, under these circumstances, the pressure upon the child is constantly increasing as it descends, and the external parts not having been thoroughly dilated, when the body is born and the head engages, it is much more liable to prove fatal to the child in consequence of the detention that almost unavoidably ensues; the prognosis, therefore, in such cases is less favourable, than in a simpk breech presentation.—Diagnosis. Presentations of the feet may be readily distinguished. Before the membranes have ruptured, the bag of waters often protrudes in a more cylindrical form, or like the finger of a glove, and we discover that the presenting part is smaller than either the head or breech. At this stage we cannot readily dis- tinguish whether it be the superior or inferior extremity that presents. After the membranes have ruptured, the foot will be recognised by its greater length, by the rounded instep, by the uniform length of the toes, by the absence of a thumb, and by the presence of the heel with the ankle bone on either side. The knee may be dis- tinguished from the elbow, with which it is liable to be confounded, from the fact, that it is thicker, that it has two prominences, and a depression between them; while the elbow, which is thinner, pre- sents between the two prominences, a projection, in which it seems to end. (Fig. 25.) PELVIC PRESENTATIONS. 83 Positions of the feet. Fig. 25. —Most accoucheurs enumerate four posi- tions forfootlingpresen- tations, viz.: 1st. Heels behind the left acetabu- lum, loins in front and to the left. 2d. Heels behind right acetabu- lum, loins forward and to the right. 3d. Heels behind the pubis, loins directly in front. 4th. Heels to the promon- tory of the sacrum. There are others who enumerate six, corre- sponding with vertex positions, and others again as many as eight, corresponding with those of the sacrum mentioned in the beginning of this article. Following the arrange- Fig. 26. ment adopted in relation to breech presentations, we enumerate but two, viz.: a calcaneo-anterior, and a calcaneo-posterior. 1st. When the heel is di- rected forwards and the toes backwards. 2d. When the heel is back- wards and the toes for- wards. The former is the more frequent, and both correspond to the two classes of breech presen- tations. (Fig. 26.) The positions of the knees, have also the same varieties, the anterior parts of the leg corres- ponding to the sacrum and the vertex; and as they are commonly con- verted into footling cases, they do not require a separate description. (Fig. 25.) 84 OBSTETRICS Mechanism.—The feet meeting with no resistance to fix them, are liable to change their position during their descent until the hips enter the brim, which they do precisely as in breech cases; the me- chanism, therefore, is the same, and does not require a further de- scription. Treatment.—The same rules apply to the treatment of presenta- tions of the inferior extremities that were laid down in breech cases, with the additional caution, not to yield to the temptation to pull down the feet; the dilating part is already too small for safety, and if it be diminished by this procedure, the child will almost certainly be lost by pressure upon the cord during the descent of the head. PRETERNATURAL LABOUR. Preternatural labour, or dystocia, signifies a faulty, or irregular labour, the course of which is unfavourable, and in which the assis- tance of the obstetrician becomes necessary. It will be remembered that this definition applies to all cases of labour, without reference either to presentation or position, in which manual assistance becomes necessary. According to Velpeau, the causes that render labour difficult, depend either upon the mother or the child. Some of them are unforeseen, or do not occur till the moment of parturition; the title of accidental may be appropriated to them. Others exist before- hand, and render the labour necessarily difficult; they merit the denomination of pre-existing causes. The accidental causes are : any serious disease, such as inflamma- tion of the brain or its coverings, the lungs, pleura, peritoneum, or uterus, &c, which takes place during labour; any hemorrhage sufficiently abundant to endanger the life of the mother or her offspring; convulsions, syncope, laceration of the womb, the prema- ture escape of the cord, hernia, aneurism, asthma, great debility, &c, and some positions which do not become bad until after the first pains. The pre-existing causes are : deformities of the pelvis, malforma- tion or disease of the organs of generation, calculus in the bladder, fibrous or other tumours in the excavation, deformities in respect to height, transverse positions, monstrous conformation and diseases of the foetus. As these different causes are in reality only complications of labour, it follows that dystocia comprises all cases of complicated labour, as eutocia comprehends all simple labours. From the occurrence of any of the above-mentioned causes, one of the following operations may become necessary, to wit; turning, the application of the forceps, or craniotomy. The first of these most frequently becomes necessary in cases of transverse positions PRESENTATIONS OF THE SUPERIOR EXTREMITIES. 85 of the child, as in presentations of the shoulders. As the mode of proceeding is the same whenever the operation becomes necessary, it will be described only in cases of shoulder presentations. PRESENTATIONS OF THE SUPERIOR EXTREMITIES. In almost all cases of this kind it is the shoulder which presents itself at the superior strait, but it may happen that instead of a shoulder, a hand or elbow may be prolapsed ; still, when they are advanced to a certain degree, it is the shoulder which fills the strait and presents the obstruction. The descent of the arm or hand add nothing to the difficulty ; indeed it is rather serviceable, since it assists us in our diagnosis, and does not at all interfere with the sue cessful termination of the labour. In this respect it differs from breech presentations, in which the descent of the feet is altogether to CIn all cases of shoulder presentation the back of the child either looks forwards toward the abdomen of the mother, or backwards towards the spine; the former is twice as frequent as the latter. It need hardly be said, that in the majority of such cases, the delivery is impracticable except by art, although there are cases reported of what is called spontaneous evolution, in which the child has righted itself, the arm and shoulders receding, and the breech descending in its place, the labour being completed by the unassisted efforts of the mother. # # Although spontaneous evolution may take place, it is more con- formable to the dictates of prudence and humanity to turn the child, and bring down the feet, or restore the head to its proper place. Causes.—There have generally been enumerated but two great presentations, viz., the cephalic and pelvic, all others are but devia- tions from these. As footling and knee presentations are deviations from the breech, so are those of the shoulder from cephalic. Various causes have been enumerated; among them are particular positions of the mother's body, inclination of the womb or of the straits of the pelvis, sudden and irregular movements of the foetus, irregular early contractions of the womb, and irregular distension. Dr. Rigby concludes that the causes of arm or shoulder presentations are of two kinds, viz., when the uterus has been distended by an unusual quantity of liquor amnii, or when, from a faulty condition of the early pains of labour, its form has been altered, and with it the position of the child. Dr. Meigs looks upon obliquity of the womb as the great cause. When the fundus falls over to either side, the action of the uterus is oblique, the head, instead of engaging in the superior strait, strikes against the brim of the pelvis, and glancing off from thence, is 86 OBSTETRICS. turned upwards into the costa of the ilium, while the shoulder de- scends or engages in the superior strait. Diagnosis.—It is only when the labour has commenced, and indeed made some progress, that a shoulder presentation can be positively detected. It may be suspected, if we are unable to reach the presenting part, if the os uteri, though flaccid, opens slowly, if the bag of waters is cylindrical, or like the finger of a glove, and if the uterus ceases to act after the membranes have been ruptured for some time. We can only positively detect the presentation by dis- tinguishing the different parts of the child, as, for instance, the spinous process of the scapula, the clavicle, the round-shaped shoulder, the axilla, the ribs, the arm, and in some eases the hand when prolapsed, distinguished from the foot by the means already pointed out. The aspect of the palm of the hand will mark whether it be the right or left. The diagnosis between the breech and the shoulder will be easy, if the distinguishing marks of the former are remembered. Positions.—There are two positions for the presentation of each shoulder, viz., a first and second for the right shoulder ; and a first and second for the left. In both the first positions the head is on the left of the mother, and in both the second, on the right. As shoulder presentations are deviations from vertex presentations, the first posi- tions are the most common. These positions are called the dorso- pubic and dorso-sacral of the right, and dorso-sacral and dorso-pubic of the left shoulder. Fig. 27. PRESENTATIONS OF THE SUPERIOR EXTREMITIES. 87 Right shoulder.—First position.—The head of the child is to the left of the mother, the back of the child is towards the front of the mother, (dorso-pubic,) and the face of the child with its toes and feet look towards her back. (Fig. 27.) Second position.—The head of the child is to the right of the mother, the back of the child towards the back of the mother, (dorso- sacral,) and the face and front of the child FiS- 28- look towards the front of the mother. (Fig. 28.) Left shoulder. First position.—The head is on the left, the face and front of the child look forwards, and the back is to the back of the mother, (dorso-sa- cral of the left.) Second position.— The head is to the right, the face and front of the child look backwards, and the back is towards the front of the mo- ther, (dorso-pubic of the left.) Treatment.—Hav- ing ascertained that the case is a shoulder presentation, the indications are to deliver by the operation of turning, or version ; by which is understood " the act of turning the child with the hand, and bringing one of the ex- tremities of its great diameter to the superior strait." (Velpeau.) There are three varieties of this operation described by obstetrical writers : First. Version by the head, in which the presenting part is pushed away, and the head substituted for it; the remainder of the labour being left to nature. Second. Version, by the breech.—Where the pelvic extremity of the child is substituted for the presenting part, and the case converted into a breech labour. Third. Version by the feet, in which the hand is introduced into the cavity of the uterus, one or both feet seized and brought down, causing the child to make a complete evolution, and extracting it footling. (Fig. 29.) The first and second methods,although safest for the child, are rare- ly employed, in consequence of the difficulty of seizing and moving 88 OBSTETRICS- Fig. 29. the parts mentioned into • a more favourable condi- tion. The third is the mode of practice gene- rally adopted, and al- though more dangerous to the child, it is safest for the mother, since it gives the attendant more complete control of the case. It is the mode of delivery now almost uni- versally adopted, both in this country and Europe. Method of procedure. —The operation ought never to be attempted till the os uteri is dilated, or dilatable; the fittest moment is when the os uteri is fully dilated and the membranes unrup- tured. If the os uteri is rigid and unyielding, the proper means of relaxing it should be first adopted ; the rectum and bladder should also be thoroughly evacu- ated, and the position carefully ascertained. The patient should be placed in the position most convenient to the operator ; some recommend that on the back, with the hips on the edge of the bed, and the knees supported by assistants; some on the hands and knees ; others prefer the ordinary position on the left side. The choice of the hand depends on the position : the rule is, use that hand w/iose palm, when opened in the cavity of the womb, looks toivards the abdomen.of the child. Some recommend the use of the right or left hand, according as either is most convenient. It should be well oiled on the outside, and introduced in a conical form, into the vagina, during a pain; it will then be ready to enter the os uteri as soon as the pain goes off. The presenting arm is never an impedi- ment, and should not be removed. When the membranes remain unruptured, the hand should be gently insinuated between them and the uterus, until the feet, (or one foot,) are found, always stopping and opening the hand on the accession of a pain. Be certain that it is a foot that is seized. Nno rupture the mem- branes and draw the feet, or foot, with a waving motion, slowly into the pelvis. By this method the liquor amnii is retained, the uterus PRESENTATIONS OF THE SUPERIOR EXTREMITIES. 89 kept distended, and the child turned with as great facility as in a " bucket of water." The act of turning should be accomplished during an interval of pain, thus the danger of rupturing the womb will be avoided. Ex- ternal pressure with the unoccupied hand favours the version very considerably, and should never be neglected. In turning the child, the feet should be brought over the front of the child, and not over the back, thus avoiding dislocation of the spine. The extraction of the child should be accomplished during a pain, always remembering the axis of the pelvis, and being careful not to place the fcetus in a wrong position, but endeavouring to make the face fall into the hollow of the sacrum. The case is now a footling one. When the membranes are ruptured, and the waters drained off, additional care is necessary not to force the uterus, but to endeavour to promote relaxation by the proper means, and above all to use gentleness in overcoming the contractions. It is considered advisable by some practitioners to turn by one foot only, inasmuch as the breech with the thigh turned up, is more bulky than the hips with the thigh extended; the passage will be better prepared to admit the quick transit of the child's head, upon which the safety of the infant depends. After the case has been converted into a footling, it should be treated as though it were so originally, that is, left as far as possible to the natural expulsive powers. Version in cephalic presentations, is accom- plished by ihe same me- thod of proceeding: the same rules applying for the choice of the hand, &c, as in shoulder pre- sentations. This opera- tion sometimes becomes necessary in hemorrhages before delivery, either accidental or un- avoidable ; convulsions ; prolapsus of the cord ; syncope, &c, thus converting, what would otherwise have been a natural, into a pre- ternatural labour. (Fig. 30.) 8* 90 OBSTETRICS. When the operation of turning is entirely impossible, it may be- come necessary to deliver the mother either by exvisceration, or decapitation. THE FORCEPS. It would be manifestly out of place, in a work of this kind, to enter into a detailed history of the forceps. Suffice it to say, that although hinted at by the ancients, we find no record of their dis- covery or application, till the beginning of the seventeenth century, when Dr. Hugh Chamberlayne published a translation of Mauriceau, in the preface of which he declares that his father, brother, and him- self, " have by God's blessing and our industry, attained to, and long practised, a way to deliver women without any prejudice to them or their infants." " By this manual operation, a labour may be de- spatched (in the least difficulty), with fewer pains, and sooner, to the great advantage, and without danger, both of woman and child." The merit of the discovery, therefore, seems to rest with Dr. Paul Chamberlayne, by whom and his sons it was kept a profound secret, till about the year 1715, when it was made public. Since that time, the instrument has undergone various modifications, always, how- ever, retaining the general form originally given to it. The English generally prefer the short forceps, the French and Germans the long. In this country, the long forceps are most generally used. ■ The forceps are intended for the extraction of the child's head, and nothing else. They possess the twofold power of, 1st, grasping and slightly compressing the child's head; 2d, that of acting as a lever of the first kind, and as an extractor. They are to be applied to no other part of the child's body than the head, and are not de- signed to be applied in cases of premature delivery, or where the head is larger than natural from abnormal growth. This instrument consists of two branches or pieces, one intended to be used by the right hand, and the other by the left. The first is called the right hand blade; the second, the left hand blade, or branch. Each branch consists of three parts, viz.: the blade, or clam, the lock, and the handle; in some instruments, the handle ter- minates in a blunt hook. The clam or blade, ought, if possible, to be applied to the side of the child's head, and not to the face or ver- tex, and should extend from the vertex to the chin. It is provided with an open space called the fenestra, which not only renders the instrument lighter, but enables it to be more accurately applied to the sides of the head. The lock consists either in a pivot in one branch, which is called the male blade, and a notch in the other, called thence the female blade, which is the German lock; or a notch in the upper surface of the left, and in the lower surface of the right branch, which is the English lock. The original forceps, (and at this day, many of the English THE FORCEPS. 91 forceps,) were straight in the direction of their length; that is, they had only one curve, that which applied itself to the child's head. Drs. Smellie and Levret, both about the same time, gave to the blades a new curve on the edges, so as to adapt them to the axis of the pelvis. This modification is therefore often spoken of as the " New curve." (Fig. 31.) Fig. 31. SS The " eclectic forceps" as modified by Professor Hodge, of the University of Pennsylvania, combines the advantages of both the long and short forceps. Fig. 32 represents them : a, lock; b, blunt hook at end of handle ; c, d, clam ; e,f, the fenestras. Indications for their Use.—The forceps are indicated, 1st, where nature is unable to expel the child, either from a want of sufficient power, or when the labour is arrested by certain malpositions of the head at the brim, or in the cavity of the pelvis; 2d, whenever the 92 OBSTETRICS. labour becomes dangerous for mother or child, and where the dan- ger can only be removed by hastening the labour. Fig. 32. It is meant, when the forceps are used, to supply with them the insufficiency, or want of labour-pains; but, so long as the pains continue, there is reason to hope they will produce their effect, and therefore justify waiting. The first stage of labour must be completed, that is, the os uteri must be dilated, and the membranes broken, before the attempt is made to apply the forceps. They are never to be used as dilators. Care must be taken, however, that, from an aversion to the employ- ment of instruments, their use is not too long delayed, and thus the benefit to be derived from their application be entirely lost. The most favourable case for their application is, where the head is at the inferior strait; the nearer the head is to the external organs, the more readily may the instrument be adjusted to it, especially if rotation have taken place. It is very rarely, if ever, necessary to apply them, where the head has not yet passed the superior strait. The forceps should always, if possible, be applied over the ears of the child; it is a good rule, therefore, always to find this part, before proceeding to apply them. THE FORCEPS. 93 Method of Application.—Having determined to apply the forceps, the same general rules should be observed as in turning, viz.: eva- cuate the bladder and rectum; draw the patient to the edge, or side of the bed, having previously protected it from injury, and place her either on her back with the feet supported, or as the English prac- titioners prefer, on her left side. The necessity and nature of the operation should always be explained to the patient or her friends, before proceeding to its performance. The instruments should always be warmed and well anointed be- fore using them, and some mild unguent should also be applied to the external organs, and the patient protected from exposure, by a sheet or blanket thrown over her. The great importance of a precise knowledge of the position of the head should be impressed upon the mind of the practitioner, before commencing this operation. Which blade must be introduced first ?—In this country and on the continent, where the long curved forceps are used, very explicit directions are laid down for the choice of the blade. In England, where the short straight forceps are employed, it seems to be a mat- ter of indifference which is applied first, the general directions being to apply that blade first, the lock of which looks forwards. The fol- lowing directions, therefore, apply to the use of the long curved forceps. Let the student remember, in the first place, that the forceps are to be applied perpendicularly to the transverse, parallel with the occipito-mental diameter of the child's head. As a general rule, the left hand, or male blade, should always be introduced first. Occipito-anterior position, where the vertex presents and rotation has taken place. The left hand, or male blade, is to be taken in the left hand as a writing pen is held, two or three fingers of the right hand are to be introduced between the left side of the vagina and the child's head, so that their extremities may touch the os uteri; the handle of the instrument is first raised up high in front of the woman's right groin, so as to bring the other extremity in the line of the axis of the vulva, into which it is next gently and slowly in- troduced in the interval between the pains ; in proportion as it enters, the handle is by degrees brought from above downwards, and from right to left, towards the median line. The point of the instrument must be kept carefully in contact with the child's head, and no force used in the introduction. It is thus moved onwards, making it follow the left posterior inclined plane, gradually depressing the handle until the instrument has been placed by the side of the child's head in the direction of the occipito-mental diameter. The handle is then to be given in charge of an assistant, and the right hand, or female blade, to be taken in the right hand in the same manner as before, while the fingers of the left are to be introduced between the right ■* side of the vagina and the child's head. Upon these, as the guide, the blade is to be introduced as before described, gradually depressing 94 OBSTETRICS. the handle till it comes in contact with and crosses the blade first introduced; the two are then to be locked, and the adjustment is completed. Care should be taken that nothing be entangled in the lock of the forceps, by carrying the finger round it. Should the handles of the forceps, when applied, come close to- gether, probably the bulk of the head is not included between them, and therefore, when we acted with them, they would slip. If the handles, when locked, are at a great distance from each other, they are not accurately applied, and will probably slip. Allowance should be made, however, in these estimates, for the different dimensions of the heads of children. When the instru- ments are thus adjusted, a slight compression, and traction should be made in order to be sure the soft parts of the mother are not in- cluded in the grasp, (which is known by her complaints,) and also to bring the instrument to its proper adjustment on the child's head. As soon as a pain comes on begin the extraction by slowly moving the forceps from handle to handle, thus causing them to act as double levers, exerting at the same time sufficient extractive force to prevent the opposite blade from slipping deeper into the organs, while the handles are moved to the right, or to the left. Great care should be taken to support the perineum as the vertex emerges, and at the same time to carry the handles of the forceps upwards, towards the abdomen of the mother, causing the head to execute the same movements, as though it were expelled by the na- tural pains. The woman should be allowed intervals of rest between the ex- tractive efforts, precisely as in a natural labour, unless there be some pressing exigency for her rapid delivery; at the same time the hold upon the forceps should be relaxed, so as to remove the pressure from the head. When the head is born, the forceps should be removed, and the labour completed by the natural powers of the woman. In the operation just described, that is, after rotation has taken place, when the forceps are adjusted, the lock looks upwards, and the concavity of the new curve is directed towards the symphysis pubis, while the convexity coincides with the hollow of the sacrum. In every application of this instrument, the general rule is that the con- cave edges should look towards the pubes, and the convex towards the hollow of the sacrum. In the first position, before the rotation has taken place, the same general rules are to be observed in the introduction. When the blades are locked they are inclined towards the left thigh, and the lock looks upwards and to the left. The same rule of traction is to be observed as before; the rotation will take place as the head ad- vances. In the second position the adjustment is not so easy, because after THE FORCEPS. 95 the introduction of the first blade, it occupies so much of the anterior commissure of the vulva as to leave insufficient space for the intro- duction of the second. To obviate this, after the first, or male blade is introduced, retract it a little till it is opposite the left ischium, then give it in charge of an assistant, and introduce the female blade to its proper position; now pass the male blade up to its position under the ramus of the left pubis, and lock as before; the handles will point towards the right thigh, and the lock will look upwards and to the right. Make traction as before. In the occipito-posterior positions, the forceps ought to be intro- duced and fixed as in the former positions, only the handles must be much more depressed, and the perineum thrust back, so as to allow them to adapt themselves to the occipito-mental diameter. If rotation has taken place into the hollow of the sacrum, as the vertex must escape first, the first movement in extraction should be to raise the handles up a little, so as to increase flexion ; then as the vertex escapes over the perineum, (which is greatly distended in this operation, and should be carefully guarded,) they should he depressed, so that the head may extend itself backwards, as it always does in these labours. The rest of the process is completed as in natural labour. In the fourth and fifth positions, where rotation has not taken place, the application is more difficult; the blades rather seize the head in its vertical diameter, and are brought into parallelism with the oblique as the extraction proceeds. The introduction must take place as in a first or second position, the fifth corresponding to the first, and the fourth to the second. In these positions the forceps ought to be so placed, that the concave edge may look forwards, and it is allowable to rotate the vertex into the hollow of the sacrum, pro- vided all hope of bringing it to the pubis has failed. There is one position of the child's head in which it is recom- mended to introduce the right hand, or female blade first, viz., the left occipito-iliac, according to Velpeau, where the head is trans- verse, the occiput at the left ilium, and forehead at the right; the right hand blade is to be introduced first, and conducted with care in front of the right sacro-iliac junction, as high up as the forehead; then by the assistance of the fingers of the left hand, placed under its convex edge, and in concert with the right hand, move it from behind forwards, and from right to left, until its concave edge is turned to- wards the left iliac fossa, and the blade has arrived upon the right parietal protuberance. The handle, strongly depressed, is then given to an assistant, who holds it against the woman's left thigh. The left branch is held in the left hand, and passed up along the posterior part of the pelvis, until its point is above the superior strait, and the pivot even with the mortice that is in the other branch. After having joined them, and dislodged the head, if it be still in the 96 OBSTETRICS. superior strait, and forced the occiput to descend into the excavation, provided it were not already there, the concave edges of the instru- ment are gradually brought to the front, and the remainder of the operation is conducted as in the occipito-pubic positions. Dr. Meigs describes a similar operation, when the head is trans- verse, but lower in the pelvis, with the vertex resting on the left ischium, and the forehead on the right. " When the instrument has grasped the head in this position, the handles will project very much towards the left thigh in abduction; but if we introduce the male blade first, inasmuch as its handle will project towards the left thigh, it will occupy all the space on that side, and prevent the insertion of the second branch, for there is no place in which to depress the handle. To avoid this difficulty, take the female blade in the right hand, and introduce it into the posterior and right side of the vagina, causing its point to sweep over the face to the right side of the head, behind the pubis, leaving the handle to project towards the left thigh. Next take the male blade into the right hand, and turning the concave edge of the new curve down- wards, insert the point into the right side of the vagina, below the female branch. Let the foetal face of the clam apply itself to the convexity of the head, and slide it onwards, and in proportion as it enters, make it sweep round the crown of the head towards the back of the pelvis. In effecting this, the handle comes gradually down as the clam gets on the left side of the cranium, and at last the lock is found where it ought to be, viz.: under the upper or female blade, with which it is then locked." Having ascertained that the head is properly grasped, the attempt may be made to rotate it, and the latter stage of the operation will be the same as already described. Right occipito-iliac position.—The only difference between this and the left occipito-iliac position is in the application of the forceps, in doing which the left blade is applied first. The forceps are sometimes necessary in face presentations. In these cases they may be applied to the sides of the head, as in the preceding. In those examples in which the chin comes to the pubis, the method of application is the same as when the vertex is at this point; but in those in which the forehead is at the pubis, the handles must be very much depressed at first, as in the occipito-posterior positions ; as the case proceeds they must be strongly elevated, so as to draw the chin down to the fourchette, over which it must slip. As soon as the chin is free the handles must be allowed to descend again, whilst the traction is continued until the head is born. In cases of locked or impacted head, instead of applying the for- ceps to the sides of the head, one blade is passed over the face, and the other over the vertex, for this reason : it generally happens when the head is thus locked, it is in its transverse, or bi-parietal diameter, THE VECTIS, OR LEVER. 97 one parietal protuberance being held at the pubis, and the other at the projection of the sacrum; there is not space enough, therefore, at these points to admit the blades, and if they are to be applied to the head, it can only be on those parts that are free from great pressure, as the face on one side, and the occiput on the other. After applying the,forceps in these cases, they should be well pressed together, to prevent their slipping when the traction effort is made. The motion from handle to handle, assisted by the traction, will generally be sufficient to disengage the head, after which the forceps should be removed. Lastly, in pelvic presentations, when the trunk is delivered, and the head detained, the method of proceeding is as follows: if the face is in the hollow of the sacrum, the body, wrapped in a napkin, should be raised upwards, and held in a position nearly perpen- dicular; then the left branch is introduced and applied to the head, from the chin to the vertex, afterwards the right is adjusted, follow- ing the same rules as when the head descends first. If, however, the occiput is in the hollow of the sacrum, and it can- not be turned to the front of the pelvis by manual assistance, the child should be carried back over the perineum as far as can be done with safety to its neck, and the forceps introduced in front of its body, as before. In extracting the head, we should endeavour to act with such force as to cause the chin and forehead to emerge under the arch of the pubis. In all cases the trunk is to be turned towards the direction in which the occiput looks, and the forceps introduced along the sides of the head, in such a way that the concavity of its edges may be towards the front, or brought there in the progress of the operation. Under whatever circumstances the forceps are applied, the extrac- tion should always be performed in the line of the axes, and always with gentleness. THE VECTIS, OR LEVER. A just idea of this instrument will be had, by considering it as. one blade of the forceps, a little lengthened and enlarged, with the handle placed in a direct line with the blade, that is, without any lateral curvature. The general conditions and circumstances of labour before stated as requiring and allowing the use of the forceps, will hold equally good when the vectis is intended to be used. Three modes of using this instrument have been suggested ; either as a lever of the first order, or as an antagonist to the left hand introduced into the pelvis, or as a simple tractor; the last is considered the only safe method. If used as a lever of the first kind at all, the fulcrum should be made by the hand of the accoucheur, and not by the soft parts of the mother. 9 98 OBSTETRICS. In the second method it is evident that if there be sufficient room in the pelvis for the introduction of the fingers of the left hand, there can be but little necessity for instrumental assistance. Fig. 33. In the third method, that proposed by Dease, of Dublin, the in- strument is introduced as a single blade of the forceps would be, the point is carried fully over the child's head, and the handle grasped tightly, and held firmly by one hand, while the shank of the instru- ment is embraced by the other, and a movement, that of steady traction downwards, should be given by that hand which embraces the shank, thus converting the instrument into a lever of the third order. (Fig. 33.) The same posture and preparatory arrangement of the patient should be made, as in forceps cases; and in the same manner, the traction is to be made during a pain. This instrument may be used to correct malpositions, and to assist rotation and flexion. THE FILLET OR NOOSE, AND BLUNT HOOK. The first consists of a strip of strong cloth, silk, or leather, formed into a running noose, and intended to be introduced over the head in whatever way can be most easily accomplished; and this done, the loop is tightened, and extraction effected by main force. Its use is now discarded in head presentations. Some persons, however, still make CRANIOTOMY. 99 use of it to effect extractive force upon the ham, groin, or axilla ; but, as the blunt hook answers a better purpose, and is more easily applied, it is now rarely used, except to confine the hand in shoulder presentations, where turning is necessary. The blunt hook is applied to the groin in breech cases, or to the axilla where the shoulders are delayed ; it is also sometimes used to produce flexion in breech cases, when the body is born and the head detained. In these cases it may be tried first in the mouth, if that fail, it may be fixed upon the lower edge of the orbit. CRANIOTOMY. This operation is demanded at times on account of either mother or child; on account of the mother, in consequence of deformed pelvis; on account of the child, in consequence of the dispropor- tionate size of the head, tumours of the chest or abdomen ; or both these conditions may occur at the same time. Uniform smallness of the pelvis, or contraction of its brim, or of any part of its cavity or outlet, are, of course, most serious obstacles to labour. Unless timely aid be given, not only may the child be destroyed, but the mother's vital powers may be exhausted, in inef- fectual parturient efforts, and the most serious consequences result to the soft parts, from the long-continued pressure upon them, such as sloughing, apertures from the vagina into the bladder or rectum, and other accidents, rendering her miserable for life. Care should be taken, therefore, never to delay assistance until the woman has become exhausted. Shivering, or vomiting, dry brown tongue, and a pulse above 100, show a necessity for active interference. The object of the operation of craniotomy is to terminate the labour with safety to the mother in cases where, from the dispro- portion between the size of the foetal head and the pelvis,' a living child can neither be expelled by the natural powers, nor extracted by the forceps ; it being always understood that the distortion is not so great as to prevent the extraction of the child when mutilated. According to most authorities, whenever the bones of the pelvis approach much nearer to each other than three inches in the antero- posterior diameter, it is unequal to the transmission of the skull entire; and unless there be at the superior strait an antero-posterior diameter of an inch and a half with a transverse of three, it would be useless to attempt to deliver per vias naturales, even after the head has been reduced in size. In some cases, where the sutures are very loose, the evacuation of the brain is often sufficient, as the bones of the cranium collapse so much by the pressure of the womb, that the child may be expelled by the natural powers. But it is presumed in this case, that the pains are 100 OBSTETRICS. Fig. 34. strong and frequent. Should this not be the case, the brain must be evacuated and ex- tracting force applied, The instruments re- quired are of two kinds, — the one to perforate the skull, and the other to ex- tract, after the neces- sary diminution is ef- fected. The first are called perforators; the second,crotchets,blunt hooks, craniotomy for- ceps, &c. Mode of operating. —It is not absolutely necessary for the suc- cess of this operation, that the os uteri should be entirely dilated, al- though the wider the orifice is, the less dan- ger will there be of injuring that organ. The rectum and blad- der having been pre- viously emptied, the woman is to be placed in the same position as in forceps operations. The perforator should then be carefully applied upon the groove between two fingers of the left hand, previously introduced and placed upon the part of the head which it is proposed to open. It must now be passed forwards with a semi-rotatory motion until it penetrates the bone; if the scissors are used, the handles should be separated as widely as possible. The cutting edges are then to be placed at right angles to the first incision, and again separated so as to make a crucial opening. The instrument should now be passed into the skull, and the brain broken up, after which it (the instrument) should be withdrawn. (Fig. 34.) Then the crotchet should be introduced in the same manner, and fixed upon the inside or outside of the head, and extraction practised, being very careful to guard the soft parts of the mother. If the head cannot be delivered in this manner, recourse must be had to the craniotomy forceps, and the bones broken up and ex- tracted in pieces. Sometimes the forceps may be used advanta- CRANIOTOMY. 101 geously, where the crotchet cannot. There are a variety of in- struments recommended in the performance of this operation: in Fig. 35. the first stage, Smellie's scissors, and their modification by Holmes; an ordinary bistoury wrapped near to the point; the ordinary trocar; &c. In the second, the sharp crotchet; the blunt hook; the bone forceps of Dr. Davis; the cephalotribe of Baudelocque, jr.; the straight and curved forceps of Dr. Meigs, &c. (Fig. 35.) After treatment.—The nervous shock will be best treated by quiet, small doses of opium, and moderate stimulation. The condition of the vagina and uterus should be carefully watched and occasionally injected with warm water. If symptoms of inflammation arise, they should be met promptly by venesection, leeching, calomel and opium. In other respects, the patient should be treated as after a natural labour. 9* 102* OBSTETRICS. CESAREAN OPERATION. When from any cause the antero-posterior diameter of the superior strait, or the transverse diameter of the lower, is not more than 1J inches, there is no possibility of delivery " per vias naturales," and it becomes necessary to resort to the Csesarean operation. The conclusions that have been derived by Dr. Churchill from a careful examination of statistics are, " that in cases where we cannot deliver the patient by any other means, and when, consequently, both mother and child would inevitably die, we may afford each a chance by performing the Casarean section?' The best period for operating is at the commencement of the labour, provided there be no doubt as to the necessity. The strength of the woman is then unimpaired, she can bear the operation better, and runs less risk of inflammation. For the method of performing this operation, see text books. PROLAPSUS OF THE CORD, Whenever it occurs, may become a cause of preternatural labour. It may be produced in various ways, as for instance, by transverse presentation ; by over-distention of the uterus by a large quantity of liquor amnii; by sudden rupture of the membranes and a gush of the contained fluid; by presentations of the feet or knees, the lower portions of the uterus not contracting sufficiently around the child; and by excessive length of the cord. (Fig. 36.) The prognosis is, of Fig. 36. course, unfavourable, the child being very liable to perish from asphyxia produced by pressure upon the cord. Treatment.—Various expedients have been re- sorted to, in order to re- place the cord, none of which have been entirely successful. It has been proposed to push it up beyond the brim and hold it there till the head has engaged ; or to hook it over the limbs of the child; or to enclose it in a little bag attached to a catheter or slender rod, then return it, withdraw the rod, and leave the bag and cord in the uterus. If, however, the UTERINE HEMORRHAGE. 103 head has descended, and the parts are in a favourable condition, it is better to use the forceps. If the woman has had children, the pelvis is roomy and the soft parts dilated, and the presenting part not descended too low, the child may be turned. Should the cord have ceased to pulsate, we need not interfere. UTERINE HEMORRHAGE. There are three varieties of hemorrhage treated of by obstetrical writers, viz.: accidental; unavoidable; and hemorrhage after delivery. The first generally occurs before or during labour, and arises from a partial and accidental separation of the placenta, which is gene- rally in its usual position. The immediate cause of the flooding is the separation of some portion of the placenta from the womb, and laceration of its vessels ; the remote cause may be undue muscular exertion; blows; falls ; mental excitement; straining at stool; general plethora, &c. Diagnosis.—This variety of hemorrhage is distinguished from that which depends on implantation of the placenta over the cervix uteri by these circumstances : the os uteri may be felt on examination to contain nothing but the bag of waters ; that the hemorrhage occurs during the interval of the pains, and is arrested by the uterine contractions; and that we can generally make out some definite cause for accidental hemorrhage, and its occurrence is irregular. When the blood which is poured forth from the uterine vessels on the separation of the placenta, is at once discharged externally, the nature of the case is clear. But it may happen that the blood may be poured into the bag of membranes, or between the mem- branes and the womb, without appearing externally, and may thus prove fatal, without the practitioner being aware of the danger. This condition of things may be suspected, if, towards the end of pregnancy, the patient is subjected to any of the above causes that may produce hemorrhage, and if she complain of dull aching pains in the back, tenderness of the womb, with, perhaps, obvious swelling at some part of it, together with faintness, and the constitutional signs of loss of blood. Treatment.—If the patient has not arrived at her full time, the hemorrhage is not profuse, and the os uteri undilated, there is no immediate danger. She should be placed in a horizontal position on a hard mattress, and lightly covered ; cold applications to the pubes, or cold enemata, should be used. Internally, the infusion of rose leaves and aromatic sulphuric acid, or acetate of lead and opium, should be administered. Should these measures not succeed, recourse may be had to the tampon. It should be remembered, however, that this instrument should never be employed when the uterus is empty, as the blood might collect within the cavity till the woman perished from the loss. Should these means fail, there still exists another, viz.: rupturing 104 OBSTETRICS. the membranes and allowing the liquor amnii to escape. As soon as this is done, the uterus contracts, compresses the orifices of the bleeding vessels, and thus arrests the hemorrhage. Should the contractions not come on, the organ may be stimulated by the administration of ergot, and friction over the abdomen. The os uteri is generally so relaxed by the hemorrhage as to be very dilatable. It has also been proposed, if all these fail, to introduce the hand, turn the child, and thus terminate the labour. The placenta is usually expelled immediately after the child; if it be not, it is much better to extract it, and secure a firm contraction of the uterus, than to allow the hemorrhage to continue. If the patient's strength is much exhausted, stimulants should be used, and nutritious articles of diet exhibited. It is generally con- sidered advisable to keep down the reaction that succeeds excessive hemorrhages, by the administration of opium, combined, if necessary, with some stimulants. The patient should be kept in a strictly hori- zontal position till all danger of a recurrence is past. UNAVOIDABLE HEMORRHAGE. Placenta pravia ; placental presentation. — The hemorrhage which results in this case is the necessary and unavoidable conse- quence of the dilatation of the os uteri, by which the connexion between the placenta Fig. 37. and uterus is separated; the greater the separa- tion, the greater the hemorrhage, as the la- bour advances. The placenta may be situa- ted partially, or entirely over the os uteri. (Fig. 37.) The cause of the hemorrhage is the sepa- ration of the placenta from the cervix uteri, and the consequent ex- posure of the mouths of the bleeding vessels. Symptoms. — The first discharge generally occurs from about three to five weeks before la- bour commences; the amount varies, but is generally slight at first and unaccompanied by pain. It returns again UNAVOIDABLE HEMORRHAGE. 105 after a week or so, and without any apparent cause, and thus comes and goes till the end of gestation. With the first sensible contrac- tions, the flooding occurs more profusely, and is seen to increase during each pain. An internal examination is necessary to discover whether the implantation be complete or not. Diagnosis.—This variety of hemorrhage is distinguished by the fact, that it usually begins without evident cause, and that it is in- creased during a pain; a pervaginam examination also reveals the pre- sence of the placenta, which is distinguished from a clot of blood by its being firmer and not breaking down under the finger. If it only partially covers the os uteri, its edge will be felt continuous with the membranes, and through the latter the presentation may perhaps be felt. Treatment.—\f the hemorrhage is slight and the term of gestation not completed, palliative measures should be tried as before described. If so profuse as to demand interference, there is no hope of a natural termination, unless the pains be so violent as to force away the pla- centa before the child. This, however, is so rare as not to justify waiting. The only alternative is to turn and deliver as quickly as possible. It fortunately happens that the continued bleeding so softens the os uteri as to render it speedily dilatable. The hand is to be introduced in the usual manner, and insinuated between the os uteri and the placenta, on that side on which the pla- centa is believed to be thinnest; the membranes should then be rup- tured as high up as possible, and the feet seized and brought down. When the body of the child is in the pelvis it will act as a tourni- quet, and compress the bleeding vessels. Nevertheless, the labour should be terminated as early as possible. Some authors recommend that the hand should be pushed through the placenta—a thing much more difficult to effect. The placenta should always be delivered as quickly after the child as possible, and every care taken to prevent a recurrence of the hemorrhage. Some authors recommend that if the os uteri be undilated when the hemorrhage comes on, the tampon should be used till dilatation takes place. This has been objected to, on the ground, that it pre- vents the attendant from knowing when the os uteri is dilated or dilatable, and thus valuable time is lost. If the feet present, it is more favourable, as the operation of turn- ing is rendered easier. If the placenta is only attached to the edge of the os uteri, and the pains are active, it should be treated as°a case of accidental hemorrhage, by rupturing the membranes. The pressure of the head whilst dilating the os uteri will close the mouths of the bleeding vessels with the placenta, and so arrest the flooding till the child is expelled. Drs. Simpson of Edinburgh, and Radford, of Manchester, recom- 106 OBSTETRICS. mend that instead of turning in these cases, the whole placenta should be detached and extracted if possible, before the child. The following are Dr. Simpson's conclusions, based on the examination of a large number of cases. 1st. That the complete separation and removal of the placenta before the child, is very seldom followed by any great hemorrhage. 2d. That on the other hand, the previously existing hemorrhage almost always ceases from the moment the placenta is perfectly and completely detached from its connexions with the uterus. 3d. That the cessation of the hemorrhage is explicable, not on the idea that the descending head of the child acts as a plug or com- press upon the exposed orifices of the uterine sinuses, but on the mutual vascular economy of the" uterus and placenta, and the circum- stance that the hemorrhage principally comes from the partially de- tached surface of the latter. The practice has been condemned by other eminent authorities, and it is recommended, even if it be adopted, to seize and bring down a foot if it can be readily found; if it be determined not to turn, it is also recommended to give a scruple of ergot at the moment of separating the placenta, so as to bring on early uterine contractions. Hemorrhage after delivery.—The discharge in this case also pro- ceeds from the mouths of the vessels exposed by the separation (either partial or complete) of the placenta. A certain amount is lost after the birth of the child; it is only when it becomes so pro- fuse as to threaten serious consequences, that interference becomes necessary. It may occur after the escape of the head, while the body is retained; immediately after delivery; or at an interval of ten or twelve days after. The hemorrhage may arise from inaction of the womb; from an absence of that contraction which is the only safeguard. The uterus is felt large and flabby in the abdomen; the pulse becomes weak and tremulous; the patient restless; there are constant and deep sighings and groanings, and frequent syncope, dimness of sight, and ringing in the ears, and even convulsions. These symptoms, together with the escape of the blood, will be sufficient to establish the diagnosis. Treatment.—In every case, the indication is to make the womb contract. This may be done in various ways, viz., by friction to the abdomen ; by the application of cold to the genitals, or abdo- men ; by grasping the womb through the abdominal parietes; at the same time ergot should be administered to the same end. If these means fail, the hand should be introduced into the cavity of the organ, with the hope of exciting contraction. It has also been re- commended to introduce ice into the uterus; or a freshly cut lemon, and then to squeeze out the juice upon the internal surface. Among the internal remedies are, acetate of lead and opium ; PUERPERAL CONVULSIONS. 107 alum ; and monesia. Pressure upon the abdominal aorta, and liga- tures upon the limbs, are highly praised by some authors. Velpeau recommends the application of a sinapism between the shoulders as a revellent. Dr. Radford recommends galvanism as a powerful exci- tant of the uterine muscular fibres. The hemorrhage may, however, be attended with partial adhesion of the placenta to the uterus, with an irregular spasmodic or hour- glass contraction of the latter organ. In this case, having placed the left hand on the abdomen, so as to grasp and steady the womb, introduce the right hand, in a conical form, gently through the con- stricted portion of the womb ; separate the placenta, and then the contractions of the uterus will probably expel the hand and placenta together. The operation of transfusion has been recommended and practised by Dr. Blundell in cases of extreme danger from loss of blood, and has proved successful in fourteen cases, although it has failed in an equal number. The patient should be kept in a strictly horizontal position, and if syncope occurs, the head should be lowered and the feet elevated, so as to allow the blood to flow to the brain. Stimulants should also be administered, and the room kept cool and well ventilated. The after treatment is the same as in the cases already described. PUERPERAL CONVULSIONS. There are three varieties spoken of by obstetrical writers, viz., the hysterical, the epileptic, and the apoplectic. The first occurs generally during the early months of gestation, and in females of a nervous or hysterical constitution. It is distinguished by the ab- sence of insensibility, and frothing of the mouth, and the convulsive movements of the lower jaw. There is no stertorous breathing, and but slight contortion of the body; although in many cases, the muscles of the back are violently contracted, a symptom which is looked upon by Dr. Dewees, as pathognomonic of this form. The paroxysms often terminate in screams and tears, and the discharge of a large quantity of limpid urine. Treatment.—-If there be a quick, full pulse, or headache, vene- section may be practised, or a few leeches applied to the temple. In general, the attack is relieved by antispasmodics, such as musk, camphor, valerian, or assafoetida. Cold water poured from a height upon the head will often break up the paroxysm. When it has ceased, a small dose of opium should be administered. Epileptic convulsions.—The symptoms resemble those of an or- dinary epileptic attack, and the patient often has premonitions of what is coming, from the presence of pain in the head, ringing in the ears, obscure or partial vision, loss of sensation, rigors, nausea, &c. The aura epileptica is seldom felt. 108 OBSTETRICS. The attendant symptoms are, a turgid purple condition of the face; convulsive movements of the face and whole body ; foaming at the mouth; repeated and sudden closure of the under jaw, by which the tongue is often dreadfully bitten ; the respiration is at first irregular, and being forced through the closed teeth, and the foam at the mouth has a peculiar hissing sound which, once heard, can never be mistaken; the pulse is quick, full, and hard at the begin- ning, but afterwards becomes small and scarcely perceptible-; the urine and fseces are often discharged involuntarily. This fit lasts for a time varying from five minutes to half an hour, and then gradually subsides; the pulse often becoming calm, and the patient conscious; or she may remain in a state of complete coma with sibilant or stertorous breathing; the more profound the coma, the greater the danger. The calm is generally short in duration, being often followed by a recurrence of repeated paroxysms and intervals. Puerperal convulsions may come on either before, during, or after labour. When they occur before labour, uterine contraction is very apt to come on synchronously with the fit, and the child is born dead. When they occur during labour, the latter runs nearly its natural course, and the fits are synchronous with the pains though not re- curring with each. When they occur after labour, they generally take place from two to four hours after the child is born, and are attributable to some injury received by the brain and nervous sysem during the parturient effort. The causes are generally a loaded state of the stomach or bowel9| intemperance in eating or drinking ; fright; and in most cases, an accumulation of blood in the brain during the violent expulsive efforts. Primiparse are more frequently attacked than multipara?. Treatment.—The first indication is to protect the brain from the effects of an accumulation of blood. This should be done by taking away blood, in a full stream, from the arm, or temporal artery, and repeating it if the paroxysm continuue. This may be followed by cups or leeches to the temples and back of the neck; there is great tolerance of bloodletting in this disease. A strong purgative should next be given, (such as calomel and jalap,) and its operation assisted by stimulating enemata. It has also been recommended to combine tartar emetic with the purge, or to give it alone, in divided doses, after the bowels are moved. The head should be shaved, and cold applications made to it. In regard to the use of opium, most practitioners are in favour of it when judiciously used. If it. be given in the commencement of the attack, when the patient should be bled, it can only hasten the fatal result. But if the fits continue, especially after delivery, with signs of great irritation and exhaustion, it may be given with the hope of deriving benefit, remembering that depletion should always be premised. PUERPERAL FEVER. 109 Should the process of labour or parturition be interfered with 1 If the convulsions occur during gestation, the uterus should not be interfered with. Should they occur at the commencement of labour, the propriety of interference may be questioned; the safest plan is merely to rupture the membranes, (provided the os uteri is dilated or dilatable,) which sometimes hastens the progress of the labour. Version has been condemned. When the head has descended into the pelvis, and there is sufficient space, the forceps should be used. The attempt should be made during an interval of the paroxysm ; should the fit recur at this time, the blade should be withdrawn, for fear of injuring the mother. Should the head of the child be fixed in the pelvis, so as to be immovable with the forceps, it may be necessary to open the head. Before this is done, however, all the attendant circumstances should be carefully weighed; the child may be alive; the labour, if left to itself, may terminate naturally; and lastly, even if terminated by art, the fits may not necessarily cease. Apoplectic convulsions.—Generally speaking, in this form there is little or no convulsions, no distortion of the face, and no frothing at the mouth; the muscles are flaccid and powerless; the respiration is stertorous, the patient is insensible, and there is generally no repeti- tion of the paroxysm. The attack is generally preceded by headache, ringing in the ears, total or partial blindness, and flushing of the face. The pulse is full, slow, and laboured during the attack, and the pupils insensible to light. This form almost always occurs during labour, and is caused by the violent strain upon the cerebral vessels during the ex- pulsive efforts. Treatment.—Bloodletting in a full and copious stream, either from the arm, jugular vein, or temporal artery. This should be repeated, if needful, or followed by local depletion, in the form of cups or leeches. If the patient is benefited by it, the head should then be shaved and ice applied, and the bowels freely evacuated. If this variety occur during labour, and the uterine action be sus- pended, the patient should be delivered as speedily as possible, in order to save the child; for this purpose, if the head be within reach, the forceps should be applied. The after treatment of all these cases requires the greatest watchfulness and quiet. Should the patient be- come maniacal, all sources of irritation, within and without, should be removed, the patient kept quiet in a dark room, and under the in- fluence of tartar emetic. PUERPERAL FEVER. This malady has received various names, such as childbed fever, puerperal fever, peritoneal fever, puerperal peritonitis, low fever of childbed, &c.; by some it has been considered as a fever dependent on local inflammation, by others as a blood disease. Each author 10 110 OBSTETRICS. who has written upon the subject, has adopted a classification in ac- cordance with his own views and experience; it would be impossible, therefore, in a work of this kind, to give a synopsis of all. " The student is liable to be deceived, if he grounds his ideas of this ma- lady solely on the observations of one or two writers, especially those who have witnessed epidemics as they*have appeared in hos- pital practice, however graphic the representations may be; because scarcely any two have resembled each other; and because the symp. toms in all cases are much modified by the temperature and other qualities of the atmosphere, the season of the year, the localities in which the disease appears, and several external circumstances, inde- pendently of the constitution of the patient herself."* There may be said to be four principal varieties of this disease. The first and most common variety, is characterized by pain and tenderness in the abdomen, preceded by a chill, and accompanied by a hot skin, rapid pulse, and sometimes profuse perspiration. In this form the uterus and its appendages, or the peritoneum, receive the greatest force of the blow. The second form assumes the character of a mild typhus, accom- panied by intestinal irritation. It is ushered in by rigors, followed by a hot fit; and succeeded by nausea and vomiting, or diarrhoea, with most offensive evacuations. The tongue, at first loaded and white, soon becomes preternaturally red, as in those affected by chronic dysentery. The skin is dry and hot, and of a dusky yellow hue; the mind is unsettled, without being absolutely delirious; the debility is extreme, and the limbs tremulous. In some cases these symptoms are followed by acute inflammation of some important organ, or of the joints, softening of the womb, suppuration of its lymphatics, or veins. There is usually suppression of the milk, and sometimes of the lochia. In the third variety the main mischief seems to be expended on the nervous system; there is great delirium, agitation, and sense of impending death. This form is liable to be followed by fatal syncope and coma, and may supervene on either of the others. The fourth and worst form of puerperal fever affords the most extensive evidence of the diffusion of a poison over the system through the blood, and presents the most perfect analogy with scar- latina maligna. Shivering, and abdominal pain, are followed by rapid exhaustion, quick pulse, glassy eye, and dusky skin. There are often pain in the chest, husky cough, laborious breathing, and other evidence of inflammation of the lungs, which after death may be found gangrenous. Abscesses of the joints, and cellular tissue; phlebitis, and gangrene of the intestines, are among the ravages of this most fatal malady. * Ramsbotham, p. 415. MILK FEVER. Ill There are a few general symptoms which may be added to those mentioned above as characterizing the different forms. The pulse is always accelerated, ranging from 110 to 140, or 160; in the in- flammatory form it is full and hard; in the adynamic, weak and small; pain is not uniformly present, though most generally; there is great tympanitis, and generally constipation. The lochia and milk are usually suspended; the urine is suppressed, or voided with great pain; tormina and tenesmus are present; and there is often a vomiting of yellow or green bitter matter, and in the last stage, a discharge resembling black vomit. The intellect is often undis- turbed to the last, though the patient often takes a great aversion to her infant. Numerous causes have been laid down as productive of this dis- ease: among the predisposing, are atmospheric vicissitudes, de- pressing passions, unhealthy residences, dissipation, bad diet, &c. Among the exciting are, epidemic influences, intestinal irritation, retained placenta, difficult labour, suppression of lochia? and lacteal secretion, and contagion. There are many who look upon this as a blood disease, who believe that puerperal fever originates in a vitiation of the fluids ; and that the causes which are capable of vitiating the fluids are par- ticularly rife after childbirth; and that the various forms of puer- peral fever depend on this one cause, and are deducible from it. Others, on the contrary, believe that the primary impression is made upon the nervous system. The treatment must vary according to the form of disease we have to contend with. In the first, or inflammatory form, instant recourse must be had to bloodletting, which must be pushed to the extent of syncope if necessary. The abdomen should then be covered with leeches, which are to be followed by hot fomentations. The bowels should also be freely opened with a purgative, after which calomel and opium should be administered, with the view of producing its constitutional effects. In the second form, bleeding, except in the early stage, will be generally improper, and even then should be restricted to plethoric patients. The principal reliance must be placed on purgative medi- cines, as salines and mercurials. A full dose of calomel should be exhibited, and followed by a purgative; after free evacuation, calomel and opium should be administered. After the bowels are unloaded, purgation should cease, as it rather causes depression ; mercurials and salines, or tonic stimulants and carminatives, should oe used, according as the disease shows marks of excitement or depression. In the low form, bark, camphor, or ammonia appear to be particularly indicated. In the third or nervous form, warm purgatives should be ad- ministered, or laxative enemata, after which a few doses of opium should be exhibited. Bloodletting is generally uncalled for. 112 OBSTETRICS. In the fourth variety, the two indications are : First. To attend to the local lesions. Second. Never to forget that these are not the disease, but merely the effect of a more diffusive, though concealed cause, to act on which our remedies should be directed. The rationale of the treatment, therefore, consists in the exhibition of such remedies as will act on the cause, and such as will alleviate or remove the local affections ; taking care that in our attempt to effect the latter end, we do not so act on the constitution as to give addi- tional energy to the more deadly power of the concealed cause. (Ferguson.) In the early stage, leeches, blisters, calomel and opium, &c, should be used as required: and in the latter stage, stimulants and tonics. MILK FEVER. The milk fever generally begins on the third day after delivery, sometimes on the first or second, or not until the fourth, fifth, or sixth. It is ushered in with chills, headache, pains in the back and limbs; the pulse, at first small and hard, soon becomes developed, and the skin hot; the breasts grow hard, swelled, and painful in a few hours, so as to prevent the motion of the arms. This condition of things is followed by a sweat, and the fever abates in the course of twelve or twenty-four hours, and the secretion of milk is established; the breasts, however, remain tumid and painful much beyond this period, especially in women who do not give suck. The lochia, too, are often suspended or diminished during this time. Treatment.—The bowels should be freely moved by the adminis- tration of a saline cathartic, or oil. If the fever runs high, a small bleeding should be practised. If the breasts are painful to the touch, they should be covered with warm emollient poultices, and if not relieved by this, a few leeches should be applied to them. These means are important to prevent the formation of a mam- mary abscess. The breast should not be allowed to fill with milk, but should be drawn either by the child, or artificially, as often as it becomes distended. Should suppuration unfortunately take place, the pus should be evacuated as soon as possible, and a warm poultice applied. If sinuses remain from the burrowing of pus, compression should be made upon the gland by means of adhesive straps. If a milk fistula should be the result, the orifice should be filled with a tent, and the wound allowed to granulate from the bottom. INVERSION OF THE WOMB. The inversion may be either partial or complete. Partial inver- sion may be known by the absence of the fundus behind the pubes, and the presence of a large solid tumour in the vagina, accompanied by profuse hemorrhage, intense pain in the pelvis, violent tenesmus, INVERSION OF THE WOMB. 113 vomiting, fainting, cold, clammy sweat, and feeble or imperceptible pulse. Complete inversion is recognised by the presence of a reddish, livid tumour, filling the vagina, and protruding beyond it, resembling in shape the uterus after delivery. The os uteri may be felt at the superior extremity of the tumour, forming a kind of circular thicken- ing at its apex, and the uterus is wholly wanting in the hypogastric region. Causes.*—It may occur spontaneously in atony of the uterus, or from irregular contractions. Violence in extracting the placenta, shortness of the cord, delivery in the upright position, tumours of the uterus unconnected with parturition, have all been mentioned as causes of this accident. Treatment.—By some it is recommended to compress the tumour and pass it in through the vaginal orifice, followed by the hand, which, when in the vagina, should be formed into a cone, and made to press mainly upon the fundus uteri; after a while it will be found to recede, and on being farther pressed, it suddenly starts from the hand, and the organ is returned to its natural condition. Others advise that no compression be made; the womb should not be handled, but watching it carefully, at the moment when free from contraction, the fundus should be pressed with one finger and in- dented like the bottom of a bottle; when that much is effected, the reposition is sure, provided continual pressure be made: the fundus will be pushed up again through the os uteri and vagina, until the hand is found high up in the cavity of the uterus. If the placenta be adherent, some recommend that it be reduced with the fundus ; others, and the majority, that it be first removed, and then that reduction take place, as this procedure will facilitate the operation. THE END. HANDBOOK OF MATERIA MEDICA AND THERAPEUTICS. THE OTHER PORTIONS OF THIS SERIES ARE ANATOMY, WITH ONE HUNDRED AND FIFTY-SEVEN ILLUSTRATIONS. SURGERY, WITH FIFTY ILLUSTRATIONS. OBSTETRICS, WITH THIRTY-SEVEN ILLUSTRATIONS. PHYSIOLOGY, WITH FORTY ILLUSTRATIONS. CHEMISTRY, WITH NINETEEN ILLUSTRATIONS, AND PRACTICE OF MEDICINE. ANY ONE OF WHICH MAY BE HAD SEPARATELY DONE UP IN A WRAPPER FOR MAILING. A HANDBOOK OF MATERIA MEDICA AND THERAPEUTICS. WITH TWENTY-NINE ILLUSTRATIONS. BEING A PORTION OF AN ANALYTICAL COMPEND OF THE VARIOUS BRANCHES OE MEDICINE. BY JOHN NEILL, M.D., DEMONSTRATOR OF ANATOMY IN THE UNIVERSITY OF PENNSYLVANIA, LECTURER ON ANATOMY IN THE PHILADELPHIA MEDICAL INSTITUTE, ETC., AND FRANCIS GURNEY SMITH, M.D., LECTURER ON PHYSIOLOGY IN THE PHILADELPBWASSOCIATION FOR MEDICAL INSTRUCTION, ETC. PHILADELPHIA: LEA AND BLANCHARD. 1848. Entered, according to Act of Congress, in the year 1848, By Lea &. Blanchard, In the Clerk's Office of the District Court for the Eastern District of Pennsylvania. C. SHERMAN, PRINTER, 19 St. James Street. CONTENTS. Medicines—Definition, Modes of Action . Absorption of Medicines - - - Circumstance Modifying the Action of Medicines Administration of Medicines Forms of Medicines - Weights and Measures Classification of Medicines Class I.—Cerebro-Spinants Order 1. Paralysers Aconite.—(Aconitum, U. S.) Hemlock.—(Conium, U. S.) Order 2. Convulsives - Nux Vomica, U. S. Hydrocyanic Acid.—(Acidum Hydrocyanicum, U. Order 3. Stupefacients or Intoxicants Alcohol ------ Sulphuric Ether.—(iEther Sulphuricus, U. S.) - Opium ...... Lactucarium - Camphor.—(Camphora, U. S.) Hops.—(Humulus, U. S.) Bittersweet.—(Dulcamara, TJ. S.) - Order 4. Sedative Stupefacients - Foxglove.—(Digitalis, U. S.) Tobacco.—(Tabacum, U. S.) - Indian Tobacco.—(Lobelia, U. S.) - Order 5. Delirifacients - Henbane.—(Hyoscyamus, U. S.) - Thornapple.—(Stramonium, U. S.) Deadly Nightshade.—(Belladonna, U. S.) - Class II.—Stimulants - Order 1. Arterial Stimulants Carbonate of Ammonia.—(Ammonise Carbonas, U Oil of Turpentine.—(Oleum Terebinthinse, U. S.) Aromatics - Cayenne Pepper.—(Capsicum, U. S.) Ginger.—(Zingiber, U. S.) - Sweet Flag.—(Calamus, U. S.) Order 2. Nervous Stimulants or Antispasmodics - Castor.—(Castoreum, U. S.) Assafoetida, U. S. • Valerian.—(Valeriana, U. S.) S.) S.) VI CONTENTS. Class III.—Tonics ..... Vegetable Tonics ...... , Quassia, TJ. S. - Columbo.—(Colomba, U. S.) Gentian.—(Gentiana, TJ. S.) - Gold Thread.—(Coptis, U. S.) Peruvian Bark.—(Cinchona, U. S.) - Wild Cherry Bark.—(Prunus Virginiana, TJ. S.) - Virginia Snake Root.—(Serpentaria, U. S.) Chamomile.—(Anthemis, U. S.) - Thorough wort.—(Eupatorium, U. S.) - Cascarilla Bark.—(Cascarilla, TJ. S.) Canella, U. S..... Angustura, TJ. S. - Myrrh.—(Myrrha, TJ. S.) - Mineral Tonics ..... Iron.—(Ferrum, TJ. S.) - .... Copper.—(Cuprum, TJ. S.) - Zinc.—(Zincum, U. S.) - Silver.—(Argentum, TJ. S.) Bismuth.—(Bismnthum, TJ. S.) ... Mineral Acids—(Sulphuric, Nitric, Muriatic, Nitro-Muriatic) Class IV.—Astringents - Vegetable Astringents ..... Oak Bark.—(Quercus, TJ. S.) - Galls.—(Galla, U. S.) - Kino, U. S. ..... Catechu, TJ. S. Rhatany—(Krameria, TJ. S.) .... Logwood.—(Haematoxylon, TJ. S.) - Cranesbill.—(Geranium, TJ. S.) ... Blackberry and Dewberry Roots.—(Rubus villosus and Rubus alis, U. S.) - Pipsissewa.—(ChimapLila, TJ. S.) - TJva Ursi, U. S. - ...... Mineral Astringents ..... Lead.—(Plumbum, TJ. S.) - Alum.—(Alumen, TJ. S.) Class V.—Refrigerants .... Vegetable Acids . . - - - Saline Substances.—Nitrate of Potassa Antimony ....-- Class VI.—Diaphoretics .... Citrate of Potassa.—(Potnssae Citras, TJ. S.) Spirit of Mindereius.—(Spiritus Mindereri, U. S.)- Sweet Spirits of Nitre.—(Spiritus iEtheris Nitrici, U. S.) Dover's Powder—(Pulvis Ipecac, et Opii, TJ. S.) - Sassafras, TJ. S. Mezereon.—(Mezereum, U. S.) - Guaiacum, TJ. S. Sarsaparilla, TJ. S. - Class VII.—Diuretics ..... Cream of Tartar.—(Potassee Bitartras, TJ. S.) Acetate of Potassa —(Potasses Acetas, U. S.) - Carbonate of Potassa.—(Potassae Carbonas, U. S.) - Bicarbonate of Potassa.—(Potasses Bicarbonas, U. S.) - Squill —(Scilla, U. S.) ..... trivi- CONTENTS. Vll Meadow Saffron.—(Colchicum, U. S.) Turpentine.—(Terebinthina, TJ. S.) Tar.— (Pix Liquida, TJ. S.) - Creasote.—(Creasotum, U. S.) - Copaiva.—(Copaiba, TJ. S.) - Cantharides.—(Cantharis, U. S.) Juniper Berries.—(Juniperus, TJ. S.) Indian Hemp.—(Apocynum Cannabinum, TJ. S.) Dandelion.—(Taraxacum, TJ. S.) - Fleabane.—(Erigeron, TJ. S.) - Wild Carrot.—(Carota, TJ. S.) Parsley Root.—(Petroselinum, TJ. S.) - Class VIII.—Emetics ... Ipecacuanha, U. S. - Gillenia, TJ. S. Lobelia, U.S. .... Sanguinaria, TJ. S. - Tartar Emetic .... Sulphate of Zinc - Sulphate of Copper ... Class IX.—Cathartics Purging Cassia.—(Cassia Fistula, TJ. S.) Manna, U. S. Castor Oil.—(Oleum Ricini, TJ. S.) Rhubarb.—(Rheum, U. S.) - Aloes.—(Aloe, TJ. S.) - Senna, TJ. S. Scammony.—(Scammonium, TJ. S.) Jalap.—(Jalapa, TJ. S.) May Apple.—(Podophyllum peltatum, U. S.) Colocynth.—(Colocynthis, TJ. S.) - Black Hellebore.—(Helleborus, U. S.) . Gamboge.—(Gambogia, TJ. S.) Croton Oil.—(Oleum Tiglii, U. S.) Elaterium, TJ. S. - Saline Cathartics Epsom Salts.—(Magnesia Sulphas, TJ. S.) Glauber's Salts.—(Soda? Sulphas, TJ. S.) Sulphate of Potassa.—(Potassa? Sulphas, U. S.) Tartrate of Potassa.—(Potassa? Tartras, U. S.) - Cream of Tartar.—(Potassa? Bitartras, TJ. S.) Rochelle Salts.—(Soda? et Potassa? Tartras, TJ. S.) Phosphate of Soda.—(Sodae Phosphas, TJ. S.) Magnesia, TJ. S. Carbonate of Magnesia.—(Magnesia Carbonas, U Sulphur, U. S. . Calomel .... Enemata .... Class X.—Expectorants Nauseating Expectorants Stimulant Expectorants Seneka.—(Senega, TJ. S.) Squill .... Black Snake Root___(Cimicifuga, TJ. S.) Garlic—(Allium, TJ. S.) - Assafretida .... Ammoniac.—(Ammoniacum, TJ. S) S.) Vlll CONTENTS. Balsam of Tolu.—(Tolutanum, TJ. S.) - Balsam of Peru.—(Myroxylon, TJ. S.) Class XI.—Emmenagogues Savine.— (Sabina, TJ. S.) - Class XII.—Sialagogues ... Class XIII.—Errhines .... Class XIV.—Ecbolics Ergot.—(Ergota, TJ. S.) Class XV.—Epispastics Spanish Flies.—(Cantharis, TJ. S.) Class XVI.—Rubefacients Burgundy Pitch.—(Pix Abietis, TJ. S.) - Canada Pitch.—(Pix Canadensis, TJ. S.) - Solution of Ammonia.—(Aqua Ammonia?, U. S.) Mustard.—(Sinapis, TJ. S.) Class XVII.—Escharotics or Caustics - Lunar Caustic.—(Argenti Nitras, TJ. S.) . Potassa, TJ. S. Dried Alum.—(Alumen Exsiccatum, U. S.) Sulphate of Copper .... Arsenic.—(Acidum Arseniosum, U. S.) - Corrosive Sublimate .... Class XVIII.—Emollients - Class XIX.—Demulcents .... Gum Arabic.—(Acacia, TJ. S.) Tragacanth.—(Tragacantha, TJ. S.) - Slippery Elm Bark.—(Ulmus, TJ. S.) P'laxseed.—(Linum, TJ. S.) - Irish Moss.—(Chondrus, TJ. S.) - Iceland Moss.—(Cetraria, TJ. S.) Liquorice Root.—(Glycyrrhiza, TJ. S.) Barley.—(Hordeum, TJ. S.) . Arrow Root.—(Maranta, TJ. S.) - Tapioca, U. S. Sago, U. S..... Class XX.—Diluents .... Class XXI.—Antacids Magnesia ..... Carbonate of Soda.—(Sodae Carbonas, TJ. S.) Bicarbonate of Soda.—(Sodae Bicarbonas, TJ. S.) Carbonate of Potassa ... Lime.—(Calx, TJ. S.) ..... Ammonia .... Class XXII.—Anthelmintics Pink Root.—(Spigelia, TJ. S.) Wormseed.—(Chenopodium, TJ. S.) - Pomegranate Bark.'—(Granati Radicis Cortex, U Pride of China.—(Azederach, TJ. S.) - Male Fern.—(Filix Mas, U. S.) - Cowhage.—(Mucuna, TJ. S.) - Oil of Turpentine Tin.—(Stannum, U. S.) . . . Calomel ..... Class XXIII.—Medicines not Classified Mercury.— (Hydrargyrum, U. S.) Preparations of Mercury Iodine.—(Iodinum, TJ. S.) - Arsenic.—(Arsenicum, TJ. S.) - MATERIA MEDICA. Medicines are substances which have the power of so modifying the actual state of the organs, as to render them applicable to the cure of disease. They differ from remedies, which are of a more generic nature; and include all the various means employed to alle- viate or cure disease: thus heat, cold, electricity, a surgical opera- tion, &c, are all remedies, but cannot be called medicines. Materia Medica is the science which treats of medicinal sub- stances; Therapeutics—the application of remedies to the treat- ment of disease. Pharmacy is the art of compounding or preparing medicines for use. A complete knowledge of medicines includes an acquaintance with their physical characters, such as of colour, taste, odour, general appearance; their chemical properties ; their natural and botanical history; their modes of growth, collection, preservation, &c; their therapeutical applications; their physiological properties, or their method of affecting the healthy system ; and their toxicologicalpro- perties, or their poisonous effects. It is hence obvious that a correct knowledge of Materia Medica presupposes some acquaintance with Natural History, Botany, and Chemistry; and that of Therapeutics requires some familiarity with Anatomy and Physiology, and also with the principles of Mental and Moral Philosophy, as well as of the general powers or forces of nature, such as light, heat, electri- city, and magnetism. Along with medicines proper, it is usual to consider a set of sub- stances called aliments, which are often very useful as therapeutic agents, though they cannot be considered as medicinal in their action. They possess nutritive qualities, and when swallowed, they are digested and converted into chyle. Medicines, on the contrary, produce their effects upon the system, not by undergoing change through the digestive process, but either by being absorbed into the circulation, and thus influencing the blood and the various secretions by virtue of some chemical influence, or by means of nervous com- munication between distant parts and the part to which the remedy is immediately applied. Some few medicines appear to act upon the system mechanically, as some of the anthelmintics which expel worms from the bowels, simply by the mechanical irritation they produce; bran is thought 2 14 MATERIA MEDICA. to act as a laxative in the same manner; and metallic mercury has been employed to overcome introsusception of the bowels, by virtue of its gravity. As regards the absorption of medicines into the blood, there is abundant proof of the fact, since they have been detected, after beina swallowed, in the different secretions, in the solid tissues of the body, and in the blood itself. Thus rhubarb and turpentine have been found in the urine; garlic in the exhalation from the lungs; sulphur and mercury in the perspiration; garlic, various purgatives, narcotics, and other remedies in the milk; and so on. As regards the method by which medicines gain admission into the blood, there can be but two avenues—the lacteals or absorbents, and the veins. From various experiments made upon the lacteals, it is highly probable that their chief, if not exclusive function, is to take up alimentary substances—such as can be converted into chyle: medicinal substances were very seldom found in them. On the other hand, experiments are equally strong in proving, that the veins are chiefly concerned in the absorption of medicinal substances; thus Magendie found that if the lacteals be tied, nux vomica will affect an animal in six minutes, while, if the veins be tied, no effect is pro- duced. The mode by which absorption is effected is probably, to a great extent, physical, or by endosmose. The rapidity of absorp- tion is influenced by a variety of circumstances, as the part or tissue to which the medicine is applied, the nature of the medicine itself, the condition of the system, &c. It is said to be the greatest from the bronchial mucous membrane. There are various circumstances which modify the action of me- dicines upon the system; these may depend upon the medicine itself, as respects its dose, mode of combination, &c; or upon the condi- tion of the organism at the time of its administration. Under the latter head, the most important circumstances are:— 1. Age.—The young are much more susceptible to the action of medicines than the middle aged. Old persons are less able to bear an overdose than middle-aged. It is difficult to lay down any precise rule upon the subject: that of Dr. Young is often adopted ; it is "to diminish the dose of most medicines, for children under 12 years, in the proportion of the age to the age increased by 12;" thus at 2 years it would be ~2=h &c At 21, the full dose may be given. There are certain medicines, however, which cannot be given to young children according to the above rule; thus calomel and castor oil require to be given in larger proportionate doses; whilst the nar- cotics, and some of the metallic preparations, must be administered in much smaller proportionate quantities. 2. Sex.—Females, as a general rule, require smaller doses than males. The peculiarities of their system, at the different periods of menstruation, pregnane^ and lactation, must also be borne in mind. ADMINISTRATION OF MEDICINES. 15 3. Habit.—The effect of habit, in accustoming to the action of a medicine, is well known. The influence of acrid or irritating sub- stances is but little diminished by repetition. 4. Diseased condition of the body.—This is well seen in the power of the system to bear very large doses of opium in tetanus and mania-a-potu, and of the different effects of calomel in different con- ditions of the system. 5. Temperament and Idiosyncrasy will also modify the action of medicines. These should always be ascertained in the adminis- tration of our remedies. 6. Tissue, or organ. — The stomach is much more susceptible than the skin : carbonic acid, when inhaled into the lungs, acts as a poison; when swallowed into the stomach, it merely proves a grateful stimulant. ADMINISTRATION OF MEDICINES. Under this head may be included the parts to which medicines are applied, with the mode of their application,—and the forms in which they are employed. The parts of the body to which medicines are most usually ap- plied, are the stomach, rectum, skin, mucous membrane of the lungs, and nostrils. The stomach is most frequently resorted to, both on account of the facility of administration through it, its great susceptibility, and its intimate relation with other parts. The rectum is employed, where the patient cannot swallow the medicine, or where there is some objection for giving it by the mouth, or when a local impression is desirable. Medicines thus employed are called enemata, or clysters, or injections. If intro- duced in the solid state, they are named suppositories. The quan- tity of the medicine, as a general rule, is three times that given by the stomach. The skin is frequently made use of as a means of affecting the system by remedies. These may be applied either epidermically, or endermicaUy,—that is, to the sound skin, or to the skin deprived of its cuticle. The endermic method is by far the most prompt and powerful. The cuticle is best removed by means of a small blister: and the proper parts for the application are the epigastrium, and the insides of the limbs. The usual dose is three times the quantity given by the mouth ; and the powdered substance should be properly diluted, before being sprinkled upon the denuded surface. The cir- cumstances which may demand the endermic method of administra- tion are inability, or indisposition of the patient to swallow, or of the stomach to retain the medicine; inflammation of the gastric mucous membrane, or a want of susceptibility of this part to the action of the medicine, from frequent repetition ; the necessity, in urgent cases, 16 MATERIA MEDICA. of introducing medicines in all possible modes ; the indication that may exist to produce revulsion from internal parts; and the neces- sity for procuring the local effects of the remedy. When the cuticle is not removed, the medicines may be applied in various manners : thus, where their local effects alone are wanted — by lotions, fomentations, cataplasms, &c.; where their general impression is desired—by inunction, baths, and vapour. The most simple form of administering a vapour bath, is to elevate the pa- tient's knees under the bedclothes, and to place at his feet hot bricks enveloped in wet flannels; the vapour which is given off, has thus free access to the body. Another method is to place the patient in a tub of warm water, enveloping him in a blanket, after which a number of hot bricks are to be placed in the tub, until the requisite amount of steam is generated. If the vapour of a solid substance, as sul- phur, is required, the patient is to be placed in a properly contrived apparatus, and the solid body sprinkled in powder on a hot iron at his feet. The mucous membrane of the bronchi may also be employed for the introduction of medicines. They are applied here usually in the form of vapour* by means of an inhaler; or, when this cannot be had, by means of a teapot or basin, with an inverted funnel. It is not recommended to blow fine powders into the lungs. Occasionally, medicines are introduced through the nasal or pitui- tary membrane; they are however employed, in this manner, gene- rally with a view to their local impression. When they produce a discharge', they are called errhines; when sneezing, sternutatories. The practice of introducing medicinal substances through the veins has been occasionally resorted to; but it is not recommended, in consequence of the danger of the introduction of air, which is attended with fatal consequences. FORMS OF MEDICINES. Medicines are used in the solid or fluid state, each of which com- prises several forms. 1. Solid forms. These include pills, powders, confections, troches, iW.—Small globular masses, intended to be swallowed without chewing; they should not consist of substances requiring to be given in laro-e doses, nor of salts which are deliquescent or efflorescent, although the latter may be rendered fit, by first driving off the water of crystallization by heat. Some substances require only the addi- tion of water; others, the intervention of some viscid body, as gum or sucrar. The heavy metallic powders may be mixed with soft ex- tracts°or confections ; the light vegetable powders, with syrup, honey, or mucilao-e. When the requisite consistence has been given to the mass, it is°to be properly rolled out by means of a spatula, and then FORMS OF MEDICINES. 17 divided into the requisite number of pills. Sometimes they are co- vered with gelatine, to conceal their disagreeable taste. Powders.—Such medicines are given in the form of powder as are not very bulky, nor of very disagreeable taste, and have no cor- rosive property. Deliquescent substances, and those containing much fixed oil, are unfit to be used in powder; as also such crystal- line salts as contain water of crystallization, unless this be pre- viously expelled by heat. The substance may be reduced to the state of powder by means of a mortar and pestle, made either of metal, glass, or wedgewood. The coarser particles are separated by sieves made of various materials. Some require to be submitted to the processes of levigation and elutriation. By the former of these terms is meant the rubbing of the substance, previously moistened, between two smooth pieces of hard flat stone; the latter term signi- fies the agitation of the matter in water, allowing the coarser parti- cles to settle, pouring off the liquor far the finer ones to subside, and lastly, decanting and drying the powder. The lighter powders may be administered suspended in water, or any other convenient vehicle: the heavy insoluble ones, in syrup, molasses, or honey. Troches.—Small solid masses, in which the medicinal substance is incorporated with the sugar and gum,—intended to be held in the mouth and allowed slowly to dissolve. They are used chiefly in affections of the throat. Confections.—Soft solids, made by incorporating medical sub- stances with sugar: they comprise also conserves. Electuaries.—Usually extemporaneous prescriptions, made by mixing medicines (generally powders) with honey or molasses. 2. Liquid forms.—These include decoctions, infusions, mixtures, tinctures, wines, syrups, vinegars, oxymels, and honeys. Decoctions.—Preparations in which the active properties of ve- getables are extracted by boiling. The boiling should take place in a covered vessel. Certain vegetables are unfit for decoction, as those which possess a volatile oil, or such as contain much inert, starchy, or mucilaginous matter. Infusions.—These differ from decoctions in not being boiled. They may be made either with cold or boiling water. Cold water is preferred where the active principle is volatile, or easily injured by heat, or where it is desirable to avoid the solution of some prin- ciple which is insoluble at a low temperature. Both infusions and decoctions usually require to be filtered; this process may be per- formed either by using unsized paper in a common funnel, or by percolation or displacement. Mixtures.—These consist generally of one or more insoluble substances, suspended in water by means of gum, sugar, or yelk of egg. When an oil is suspended in this way, the mixture is called 2* 18 MATERIA MEDICA. an emulsion. A good deal of care and dexterity are requisite in making a uniform mixture. Tinctures.—Solutions of medicated substances in alcohol, or di. luted alcohol. They are usually macerated, at ordinary tempera- tures, in well-stopped bottles, frequently agitating. Undiluted (offi- cinal) alcohol is employed where the substance to be dissolved is insoluble in water,—as resins, essential oils, &c; but diluted alcohol is preferred when the substance is soluble both in alcohol and water. Syrups.—Preparations in which the medical substance is pre- served in a concentrated solution of sugar. Simple syrup consists of two and a-half pounds of white sugar dissolved in a pint of water, Medicated syrups are made either by adding the proper amount of sugar to vegetable infusions, decoctions, juices, &c, or by adding the tincture of the substance to simple syrup, and afterwards driving off the alcohol by the heat of a sand bath. Honeys.—These are analogous to syrups, the difference being that honey is employed to preserve the medical substance, instead of a solution of sugar. They are said to be less apt to become candied. Oxymels are preparations in which honey and vinegar are com- bined. Vinegars.—Liquids in which distilled vinegar is employed as the solvent. Besides the above forms of medicines, which are employed for internal administration, there are several others which are used ex- clusively as external applications; these are liniments, ointments, cerates, plasters, and cataplasms. Liniments.—Oily compounds intended to be applied to the sur- face by bathing, or by saturating cloths with them. Ointments.—Soft solids which melt at the temperature of the body. Cerates are rather harder than ointments: they do not melt at the temperature of the body. Simple cerate consists of fresh lard and white wax. Plasters.—These are solid at ordinary temperatures, and require to be heated before they can be spread. They are usually kept in rolls, and when wanted for use are spread upon sheepskin, linen, muslin, or even paper; a small margin being left at the edges un- covered. Cataplasms or poultices.—These are soft moist preparations, in- tended to relax and soften the parts to which they are applied, They are usually made from bread and milk, flaxseed meal, Hydrogen ,-- ( Oxygen------------------_Zr=E^a»^ Sulphate of Soda. Prop.—A colourless gas; gives off dense fumes on exposure to the air; has a very powerful affinity for water, and hence must be collected over mercury; condensed into a liquid by a pressure of 40 atmospheres; sp. gr. 1-269; water absorbs 418 times its bulk. The solution of this gas in water constitutes the muriatic acid of commerce. This, when pure, is colourless; but usually has a light straw colour—due to impurities. When mixed with nitric acid it forms aqua regia, which has the property of dissolving gold, in conse- quence of the chlorine evolved; water and nitrous acid are also formed at the same time. Hydrogen and Iodine.—Hydriodic acid, HI.—A gas much resem- bling hydrochloric acid;—prepared by heating water in union with iodide of phosphorus; the hydrogen combines with the iodine to form hydriodic acid, and the oxygen with the phosphorus to form phos- phoric acid. Prop.—Colourless, acid; has a strong affinity for moisture, and gives out white fumes in the air. It is decomposed by chlorine, with the formation of hydrochloric acid and evolution of iodine; sulphuric and nitric acid also decompose it by imparting oxygen, likewise evolving iodine. Hydrogen and Bromine.—Hydrobromic acid, HBr;—prepared like hydriodic acid, from a bromide of phosphorus. Prop.—A colourless gas, irrespirable, and acid; is decomposed by chlorine, but not by iodine. Hydrogen and Fluorine.—Hydrofluoric acid, HF;—prepared by the action of dilute sulphuric acid on fluoride of calcium (fluorspar); the chemical changes are analogous to those occurring in the pre- paration of hydrochloric acid. Prop.—At 32° it is a colourless liquid, but when exposed to the air, it flies off in dense white fumes; sp. gr. 1*0609;—its affinity for water surpasses even that of sulphuric acid, the combination being accompanied with a hissing noise; its vapour is extremely pungent; it is very destructive to organized bodies, as the skin, upon which it produces a deep and painful ulcer. It acts powerfully on glass, forming with it fluosilicic acid; on this account it must be prepared in metallic vessels. From its affinity for glass, it may be used for etching on that substance; the glass being coated with a thin film of wax and the figures traced with a pointed instrument; it is then submitted to the action of the gas which, acting only on the exposed portions of the glass, leaves an indelible mark upon them. COMPOUNDS OF HYDROGEN. 49 Under this head it will be convenient to allude to some other com- pounds of fluorine. Fluosilicic acid, SiF3,—is formed whenever hydrofluoric acid comes in contact with glass; it is best made by heating a mixture of powdered fluor spar and glass with strong sulphuric acid; the changes are as follows:—the hydrofluoric acid (generated by the action of the sulphuric acid on fluoride of calcium) reacts with the silicic acid of the glass so as to form water and fluosilicic acid, thus: tt j a -j S Fluorine ___________ Fluosilicic acid. Hydrofluoric acid J Hydrogen_ Chloride of Calcium. acid \ Hydrogen- T. S Calcium Lime ' ' ) Oxygen---------------------^Water. Prop.—A colourless gas, of a strong and pungent odour; very rapidly absorbed by water, (more than 700 times its own volume;) sp. gr. -589; has a powerful alkaline reaction; is condensed into a liquid under a pressure of 6-5 atmospheres at 60° ; cannot be formed artificially by a direct union of its elements, but is an abundant product of the putrefaction of animal substances; it may be decom- posed by the electric spark, by chlorine, and by being passed through a red-hot porcelain tube. The solution of ammonia (aqua ammonia) may be prepared by simply saturating water with gaseous ammonia; it is colourless,and possesses the pungent odour and alkaline reaction of the gas. Ammonia form! salts with the different acids, which are all de- composed by a red heat, and by a less powerful heat "ey ai« mixed with an alkali or alkaline earth. The ammoniacal salts were 5 50 CHEMISTRY. formerly considered to be formed by a direct union of the alkali and the acid; but, at present, the acid is believed to unite with the oxide of a hypothetical metal termed ammonium. This supposed metal has never been isolated,, but is inferred to exist from the fact that when ammonia is decomposed by a galvanic current, and the nega- tive wire terminates in some mercury, an amalgam is formed, having all the characters of an ordinary metallic amalgam : but when left to itself, this amalgam rapidly decomposes into mercury, hydrogen, and nitrogen. Ammonium is believed to be composed of ammonia and one eq. of hydrogen; it is represented by NH4, and the base of the ammoniacal salts would consequently be represented by NH40. The most important of these salts are the chloride of ammonium, (sal ammoniac,) the carbonates, the nitrate, and the sulphate. There is believed to be yet another compound of hydrogen and nitrogen, to which the name of amide, or amidogen, is given. Like ammonium, it has never been isolated: it is represented by NHa. Hydrogen and sulphur.— Sulphuretted hydrogen, hydrosulphuric acid, HS.—Conveniently prepared by the action of dilute sulphuric acid on sulphuret of iron; or by chlorohydric acid on sulphate of antimony, as follows :— Sulphuret of iron j f£Phur ------^__^ Hydrosulphuric acid. Water j Hydrogen Water . . . ^ Oxygen _ Sulphuric acid--------—------- ' Sulphate of iron or „ , , c S Sulphur —-----------—^ Hydrosulphuric acid. Sulphuret of antimony j An(lmony~~~^=^ * Hydrochloric acid . j ChlS" "^^^^ Chloride of antimony. Prop.—A colourless gas, having the odour of rotten eggs; irre- spirable, acting as a narcotic ; combustible, burning with a blue flame, producing water and sulphurous acid; a non-supporter of combus- tion ; becomes a liquid under a pressure of 17 atmospheres; is de- composed by chlorine, with a deposition of sulphur; sp. gr. 1*171; it has the properties of a weak acid, reddening litmus paper, and forming salts. The best test is acetate of lead, with which it forms the black sulphuret of lead. Hydrosulphuric acid is valuable to the chemist as a test for me- tallic solutions, causing with them an insoluble precipitate of the sulphuret of the metal. There is another compound of sulphur and hydrogen, called per- sulphuret of hydrogen. Hydrogen and Selenium.—Hydroselenic acid, HSe; — in its general properties, resembles hydrosulphuric acid. Hydrogen and Phosphorus.—Phosphuretted hydrogen, PaH8, pre- COMPOUNDS OF HYDROGEN. 51 pared by boiling together hydrate of lime, water, and phosphorus; the water is decomposed, and hypophosphite of lime and phosphu- retted hydrogen are formed, thus :— wHSCr 2 Phosphorus S Phosphuretted \ Hydrogen \ Hypopliospho- i ) rous acid. < Lime- \ Hypophosphite f of lime. The most remarkable feature of this gas is its spontaneous inflam- mability ; so that if the beak of the retort in which it is evolved be placed under water, as each bubble of gas rises through the liquid it takes fire, and forms a beautiful ring of a dense white smoke, which enlarges as it ascends. Compounds of Carbon and Hydrogen.—The number of these compounds has now become very great; but most of them belong properly to the domain of organic chemistry; two of them, how- ever, are generally considered under the head of inorganic che- mistry : these are Light carburetted hydrogen and Oleflant gas. Light carburetted hydrogen, marsh gas, fire-damp, dicarburet of hydrogen, CH3;—is formed in stagnant pools by the decomposition of vegetable matters ; and may be procured by stirring up the mud at the bottom of the pool, and collecting the gas. It may be pre- pared by strongly heating a mixture of acetate of soda, hydrate of potash and quicklime: the gas is derived from the de- composition of the acetic acid of water. Prop.—Colourless, tasteless, nearly inodorous; a non-supporter of combustion or respiration, but very combustible, burning with a bright yellow flame;—mixed with oxygen in due proportions, it forms an explosive mixture; products of its explosion or combustion, water and carbonic acid; sp. gr. -559. This gas is fre- quently evolved in large quantities from coal mines, and explodes on contact with the flame of the miner's lamp, causing the most disastrous consequences. Sir H. Davy's safety-lamp was invented to obviate these fatal results. It consists of a common oil-lamp, enclosed in a cage of wire-gauze, made double at the upper part, containing about 400 apertures to the square inch. When this lamp is taken into an ex- plosive mixture, although the fire-damp, passing inside the gauze, may burn within the cage with such energy as to heat the metallic tissue to redness, the flame is not communicated to the mixture on the outside, in consequence of the cooling effect produced upon the heated gas by the wire-gauze; most fortunately, the 49�75347 52 CHEMISTRY. fire-damp has a very high kindling point; it will not inflame at the red heat of wire-gauze. Chlorine does not act on light carburetted hydrogen, if kept in the dark; but if the light be admitted, a combination ensues, attended with the formation of hydrochloric and carbonic acids. . - Oleflant gas, C2H3;—so called, from its property of forming an oil-like liquid with chlorine. Prepared by heating a mixture of strong sulphuric acid and alcohol; at first ether is formed, and comes over along with vapour of alcohol; afterwards the oleflant gas comes over along with sulphurous and carbonic acid; the two latter are to be absorbed by potassa. Prop.—Colourless, tasteless, and inodorous ; water absorbs about $-th of its volume; a non-supporter of combustion and respiration; but burns with a dense bright light, producing carbonic acid and water ; mixed with a due proportion of oxygen, it explodes by means of the electric spark ; sp. gr. *981 ; mixed with chlorine, it combines with it in equal measures, forming a heavy, oily liquid, of sweetish taste and ethereal odour. The gas employed for illuminating purposes is usually made from coal, oil, resin, and other organic substances containing a large quantity of carbon and hydrogen. The coal is distilled in cast iron retorts, maintained at a bright red heat; and the volatilized products conducted through long pipes into receptacles where it is purified by means of hydrate of lime. Coal gas contains a number of different principles, as light carburetted hydrogen, oleflant gas, hydrogen, carbonic oxide, nitrogen, and some other volatile substances. Be- sides these, a number of other matters are separated in the processes of condensation and purification, as tar, sulphuretted hydrogen, sul- phate of ammonia, &c. The relative illuminating power of different varieties of coal and oil gas depends upon the relative amount of carbon and hydrogen contained ; the light being greatest when these are in excess, provided always, there be enough oxygen to burn them completely. COMPOUNDS OF NITROGEN AND CARBON. Cyanogen, Bicarburet of nitrogen, NC2 or Cy. Prepared by heating in a retort the bicyanide of mercury; the cyanogen passes off in the form of a gas, and the mercury sublimes. Prop.—Colourless, of a strong and peculiar odour; condenses into a liquid at 45° under a pressure of 3-6 atmospheres; a non- supporter of combustion, but inflammable, burning with a charac- teristic purple flame, producing water and carbonic acid. Water absorbs 4 or 5 times its volume, and alcohol much more; sp. gr. 1-806. Paracyanogen is the name given to the black matter left in the retort after the preparation of cyanogen. GENERAL PROPERTIES OF METALS. 53 Cyanogen and Hydrogen.—Hydrocyanic acid, Cyanhydric acid, Prussic acid, CyH. Prepared in the anhydrous form, by passing sulphuretted hydrogen over fragments of bicyanide of mercury, con- tained in a horizontal glass tube, and receiving the product in a vessel surrounded with a freezing mixture. Gentle heat is applied to the tube, and the cyanogen reacting with the sulphuretted hydro- gen, produces hydrocyanic acid and the sulphuret of mercury. Prop.—A thin, colourless liquid, exceedingly volatile; sp. gr. •7058 ; boils at 79° and freezes at 0° ; has a powerful characteristic odour of peach blossoms or oil of bitter almonds; has a very feeble acid reaction; unites with water and alcohol in all proportions. In its anhydrous state it is one of the must poisonous substances known. The best, antidotes are chlorine and ammonia. It is very liable to decomposition, especially if exposed to the light. The solution of hydrocyanic acid is best prepared by the action of dilute sulphuric acid on the ferrocyanide of potassium. Hydrocyanic acid is an organic product, being frequently met with in the vegetable kingdom. It is believed, however, not to pre- exist in vegetables, but to be due to the mutual reaction of two or- ganic principles, named amygdaline and emulsine, or synaptase, with water. CHAPTER II. METALS. GENERAL PROPERTIES. They are all conductors of heat and electricity; they are positive electrics ; they are opaque ; possess generally a well-marked lustre, termed metallic; are generally good reflectors of light. The num- ber generally admitted by chemists is forty-two. They vary greatly in specific gravity,—between potassium, which is lighter than water, and platinum which is twenty-one times as heavy.* Properties which are peculiar to certain metals.—Malleability, ductility, tenacity, the welding process, hardness, and the crystal- line structure. . All are solid at common temperatures, except mercury. Iheir fusing point varies very much—ranging between mercury, which is —39°, and platinum, which is infusible at the heat of a smith s forge. Metals often unite together to form alloys. When mercury unites with another metal, the compound is named an amalgam. Ex- amples of alloys : brass, from copper and zinc; bronze, from copper and tin; beU-metal, from copper and tin; type-metal, from antimony 54 CHEMISTRY. and lead; solder, from tin and lead; gold and silver coins are also alloys. Many of the alloys occur native. But few of the metals are found native, that is, in their uncom- bined form. They usually are united with either oxygen or sulphur, or else they occur as salts. Metals differ greatly in their attraction for oxygen; some have such a powerful affinity for this agent, that they decompose water, in order to unite with it. On the other hand, gold, silver, and pla- tinum are very difficult to oxidize. The term noble has been given to such metals as are not liable to tarnish on exposure to the air. Most metals may be oxidized by exposure to heat in the open air. This process was formerly termed calcination; and the product formed, a calx. Another mode of oxidizing is by deflagration, or by heating with nitrate of potassa, or chlorate of potassa. Nitric and nitro-hydrochloric acids are also powerful oxidizing agents. Metallic oxides may be reduced either by heat alone, as in the case of the oxides of the noble metals, or by the united agency of heat and combustible matter, as hydrogen, charcoal, and the black flux; or by galvanism, which is still more powerful; or by the agency of deoxidizing agents, as phosphorous acid, protochloride of tin, &c.; or by precipitation from their solutions by means of other metals; thus silver is thrown down from a solution of its nitrate by means of mercury; copper, by means of iron, and so on. The compounds of metals with oxygen, are for the most part oxides; occasionally, they are acids. Arsenic is the only one which forms an acid, without, at the same time, forming an oxide. Most of the metallic oxides act as salifiable bases—that is, form salts with acids. Generally, but not always, this property is confined to the protoxides. Chlorine, bromine, iodine, and fluorine have also a strong affinity for metals,—particularly the two former. Sulphur has a strong tendency to unite with metals : the combi- nation may be effected either by heating the powdered metal and sulphur together; by igniting together a metallic oxide and sulphur; by heating a sulphate, along with combustible matter, by means of which the oxygen is removed in the form of carbonic acid, or by the action of hydrosulphuric acid. Several of the metallic sulphurets (sulphides) occur native, as of lead, antimony, iron, zinc, &c. The compounds of selenium and the metals closely resemble the sulphurets. Phosphorus and hydrogen occasionally unite with the metals. CLASSIFICATION OF THE METALS. Class I. Metals of the Alkalies. " II. Metals of the Alkaline Earths. " III. Metals of the Earths. " IV. Metals proper. POTASSIUM. 55 SECTION I. CLASS I. METALS OF THE ALKALIES. The metals of the alkalies are Potassium, Sodium, and Lithium. POTASSIUM. Discovered in 1807 by Davy, by the agency of galvanism.— Prepared by exposing a mixture of carbonate of potash and char- coal to a high heat, in a gun-barrel; the potassium distils over, leaving carbonic oxide, thus : 1 eq. Carbonate of potassa 2 eq. Carbon, 2 C ~----z:::=^ 3 CO. Prop.—Solid at ordinary temperatures—soft and malleable be- tween the fingers—of a white colour and metallic lustre—brittle at 32°—melts at 150°; sp. gr. -865,—has a powerful affinity for oxygen; —cannot be kept in the air or water;—preserved under naphtha. It takes fire when thrown on water, with the disengagement of hydro- gen, which combines with a portion of the potassium, forming potas- siuretted hydrogen, which also takes fire, increasing the brilliancy of the flame ;—potash is formed as the result. The equivalent of potassium (kalium) is 39 15; its Symbol, K. It forms two compounds with oxygen, potash, KO, and the peroxide, K03. Protoxide of potassium or potash, is found whenever potassium is exposed to air or water. In the anhydrous form, it is a white solid, very caustic; has a strong affinity for water, with which it forms a hydrate. The hydrate of potassa, KO-f HO, also named common caustic and potassa fusa, is prepared by decomposing carbonate of potash, by lime; the carbonate of lime is thrown down, and the potassa remains in solution; this is concentrated by heat, and then poured out into moulds. Pure hydrate of potassa is a white solid, very deliquescent, soluble in water and alcohol. The common caustic potash may be purified by dissolving in alcohol. The solution, like lime-water, rapidly absorbs carbonic acid from the air. The solid hydrate, from its affinity for water, is used to free gases from hygrometnc mois- ture. . , i Peroxide of potassium, K03, is formed when potassium is burned in dry oxygen, or in the open air; it is of an orange colour. The most important salts of potassa are the nitrates, the carbo- nates, the sulphates, and the chlorate. The impure carbonate (pot 56 CHEMISTRY. and pearl ashes,) is procured by lixiviating the ashes of inland plants, and evaporating to dryness; purified by redissolving in water, and boiling. The pure carbonate (salt of tartar,) is made by decompo- sing cream of tartar by a high heat. Composition, KO + COa. The bicarbonate, KO+2COa, is formed by passing a stream of carbonic acid through a solution of the carbonate. It is not so solu- ble as the carbonate. A sesquicarbonate is said to exist. The sulphate, KO-f S03, is the residue left in the retort in the preparation of nitric acid. The bisulphate, KO + 2S03, is more soluble, and has an acid taste and reaction. There is also a sesqui- sulphate. The nitrate, KO+N05, named also nitre and saltpetre, occurs native, as an efflorescence on certain soils ;—is manufactured also from artificial nitre-beds. Shape of crystals, six-sided prisms ; very soluble; contains water mechanically confined, which causes the crystals to decrepitate when thrown upon hot coals. When heated, it gives off oxygen, and is converted into a nitrite ; a high heat entirely decomposes it. From its power of imparting oxygen, it is the active ingredient in gunpowder, which is a mixture of nitre, char- coal, and sulphur. When gunpowder is fired, the oxygen of the nitre combines with the carbon to form carbonic oxide; the sulphur with the potassium; and the nitrogen is set free. The chlorate, KO+C105, is remarkable for its deflagrating pro- perties ; it yields a large quantity of oxygen gas, on being heated. Sulphur, chlorine, iodine, and bromine, also form compounds with potassium. Tests for the salts of potassa.—1. Tartaric acid in excess gives the sparingly soluble bitartrate, (cream of tartar.) 2. A solution of chloride of platinum causes a yellow precipitate. 3. The alcoholic solution of carbazotic acid precipitates the yellow carbazotate of potassa. 4. The salts of potash usually colour the flame of the blowpipe purple or violet. SODIUM. History and mode of preparation the same as those of potassium. Prop.—A white metal; resembles potassium in most respects; sp. gr. *972; decomposes water with great violence, but does not in- flame on account of its rapid motion; if this be restrained by means of gum or sugar, it takes fire and is converted into soda. Eq. = 23*3 ; Symb. (Natrium,) Na. It forms two compounds with oxygen, the protoxide (soda,) Na O, and the peroxide, Na 03; these are formed like, and correspond with, the analogous compounds of potassium. Hydrate of'soda, NaO+HO,—prepared from the carbonate by the action of quicklime. Very similar in its properties to the hydrate of potassa. BARIUM. 57 Carbonate of soda, NaO+CO3-f-10HO. Prepared by lixiviating the ashes of marine plants, and evaporating;—this is known under the commercial names of barilla, and kelp, which contain many im- purities. A purer variety is made by heating together sulphate of soda, lime, and sawdust in a reverberatory furnace. Sulphuret of calcium, sulphurous acid, and carbonate of soda are formed. This salt is in large rhombic crystals, very soluble in water, of a caustic alkaline taste, and alkaline reaction. Bicarbonate, NaO+2C03+HO,—formed as the bicarbonate of potassa. Less soluble than the carbonate. Sesquicarbonate, 2NaO-f-3C03+4HO.—Occurs native. Sulphate of soda— Glauber's salt, NaO-f S03-f 10HO ; the residue left in the process for making hydrochloric acid. A very soluble salt; more so at 90° than at 212°. There is also a bisulphate. The nitrate of soda is very similar in properties to the nitrate of potash. The three phosphates are spoken of under the head of P IchloTide of Sodium,—Common Salt,—is found in sea-water and saline springs; it occurs also as a mineral, under the name of rock salt -—procured by evaporation from its solution. The crystals decrepitate when thrown on hot coals; are very soluble in water, and are slightly deliquescent. Iodine, bromine, sulphur, and fluorine, also combine with sodium. Tests for soda and its salts.—All the soda salts are soluble ; they communicate a yellow colour to the blowpipe flame. Soda forms with sulphuric acid, the well known Glauber's salt. Soda is less soluble than potassa. LITHIUM. Prop —A white metal resembling sodium, procured by electrical action from lithia, its protoxide, which is found in petalite and some few other rare minerals. The hydrate of lithia generally re- sembles the hydrates of soda and potassa but is less soluble- Test.-\t communicates a carmine-red colour to outer flame ot blowpipe. SECTION II. CLASS II. METALS OF THE ALKALINE EARTHS. This class includes Barium, Strontium, Calcium, and Magnesium. BARICM. Procured by means of mercury from baryta or its carbonate, through the agency of galvanism or heat. 58 CHEMISTRY. Prop.—A grayish-white metal, heavier than water; has a strong affinity for oxygen ; malleable.—Symb. Ba.; it forms two oxides. Protoxide or Baryta, BaO.—Occurs in nature as a carbonate and sulphate; may be obtained by decomposing the nitrate by heat. It has a strong affinity for water, forming with it a hydrate, with the evolution of heat. The hydrate is a white powder, resembling slacked lime; its solution, like lime-water, attracts carbonic acid from the air. Peroxide of barium, BaOa, is used in making the peroxide of hydrogen. The salts of baryta are chiefly remarkable for their high specific gravity ; the most important are the carbonate, sulphate, and nitrate. The sulphate is very insoluble. The soluble salts are poisonous. Chlorine, iodine, bromine, and sulphur, form compounds with barium. Test for baryta.—It forms a very insoluble sulphate. STRONTIUM. Procured as barium.—Symb. Sr. Forms two oxides. Protoxide,—Strontia, SrO,—prepared like baryta, which it much resembles. Its other compounds are similar to those of baryta. Test.—It communicates a blood-red colour to the flame of the blowpipe. CALCIUM. A silver-white metal, procured like barium ;—forms with oxygen two compounds. Symb. Ca. Protoxide, Lime, CaO,—obtained by heating the native car- bonates. Prop.—Lime is white,—infusible,—has a strong affinity for water, forming with it a solid hydrate, with the evolution of much heat; this is seen in the common process of slaking. The hydrate is far less soluble in water than those of baryta and strontia ; it is more soluble in cold than in hot water; lime-water is thus made. Ex- posed to the air, it attracts carbonic acid, forming a pellicle; hence it is a good test for carbonic acid; it has an alkaline reaction. The hardening of mortar is probably due to the gradual absorption of carbonic acid, or to the combination of the sand and lime, forming a silicate. The most important salts of lime are the sulphate, carbonate, phosphate, and hypochlorite. Sulphate of lime or Gypsum, CaO+S03, is found native; the native crystals are called selenite. Prop.—A sparingly soluble salt; forms with water a hydrate; it is found in most spring water. ALUMINIUM. 59 Carbonate of lime, Limestone, or Chalk, CaO+C03, Is also found native.—The purest varieties constitute marble. Prop.—Insoluble in water, but soluble if carbonic acid be present; exists in many natural waters, as a supercarbonate, and is deposited from them as stalactites. The phosphate of lime exists in bones. Chlorine, iodine, bromine, fluorine, and sulphur form compounds with calcium. Chloride of calcium is prepared by the action of hydrochloric acid on carbonate of lime. It is distinguished for its great affinity for moisture, and hence is of great use to the chemist in removing water from substances; also for forming frigorific mixtures. The fluoride is found native as fluor spar. Hypochlorite of lime, commonly called chloride of lime, is the well-known bleaching powder;—prepared by the action of chlorine on thin strata of hydrate of lime. Test for lime.—Oxalic acid forms an insoluble oxalate. MAGNESIUM. Obtained by heating the chloride with potassium. It is a white, malleable metal; heated in the air, is converted into magnesia. Magnesia is the only oxide, MgO.—Prepared by driving off the carbonic acid from the carbonate by heat. It is a soft, white, in- soluble powder. Carbonate of magnesia occurs native ; may be easily prepared by double decomposition;—is very nearly insoluble. Sulphate of magnesia, Epsom salts, MgO + S03+7HO, exists in sea-water, and certain mineral springs; it is very soluble; forms crystals of a right rhombic prism. Test for magnesia.—Forms the well-known Epsom salt with sulphuric acid. SECTION III. CLASS III. METALS OF THE EARTHS. This class includes Aluminium, Yttrium, Glucinium, Zirconium, and Thorium. ALUMINIUM. Prepared in the same manner as magnesium; has a gray colour; of difficult fusibility ; forms alumina when burnt in the air. Alumina is a sesquioxide, A1303; exists abundantly throughout nature, constituting the different sorts of clay; prepared by adding 60 CHEMISTRY. carbonate of potassa to a solution of alum ; the hydrate of alumina is precipitated. Properties.—Has no taste or smell; feels pasty to the tongue ; is very insoluble and infusible; has a strong affinity for water; acts but feebly as a base. The most important salt of alumina is alum—a double sulphate of alumina and potassa : either soda or ammonia may be substituted for the potassa in alum. The salts of alumina are useful as mor- dants in dyeing. Alumina forms the basis of porcelain and earthen- ware. Tests for alumina.—Caustic potash and soda give with it white gelatinous precipitates;—the well-known characteristics of alum ;—and the blue colour given by nitrate of cobalt by heat. The remaining metals of the earths are of no particular im- portance. SECTION IV. CLASS IV. METALS PROPER. This class may conveniently be subdivided into three orders, viz. 1. Metals whose oxides are reduced by heat alone,—noble metals; 2. Metals whose oxides form powerful bases; 3. Metals whose oxides form weak bases or acids. ORDER I.--METALS WHOSE OXIDES ARE REDUCED BY HEAT. GOLD. Occurs either pure, or combined with silver or copper; is usually separated from impurities by amalgamation with mercury, which is afterwards driven off by heat. May be obtained pure by dissolving in nitro-muriatic acid, and then precipitating by a protosalt of iron. Prop.—It has a well-known yellow colour ; is the most malleable, and one of the most ductile of all metals; is not tarnished by either air or moisture; sp. gr. 19*3. Symb. (Aurum,) Au. The only solvent for gold is a mixture of nitric and hydrochloric acids, or rather, the solution of chlorine which thence results. An etherial solution of gold is made by agitating ether with the strong aqueous solution; this may be used for gilding. If protochloride of tin be added to the solution of gold, the purple powder of Cassius is thrown down. Gold forms compounds with oxygen, chlorine, iodine, and * sulphur. Gold coins are always alloyed with copper or silver, which increase its hardness. The best test for gold is the protochloride of tin. PLATINUM. 61 SILVER. Occurs native, and in combination with gold and other metals ; also with chlorine and sulphur. One of the most abundant silver ores is the argentiferous galena. It is extracted either by amalga- mation, or by cupellation,—the latter process being only applicable to the combinations with lead. Pure silver may be procured by preci- pitation from a solution in nitric acid, by means of chloride of sodium ; and heating the resulting chloride with carbonate of soda. Prop.—The whitest of all metals ; has a brilliant lustre ; is very malleable and ductile; the best conductor of heat and electricity; sp. gr. 10*5; is not acted upon by moisture or air, unless sulphur be present; its proper solvent is nitric acid; Symb. Ag.; forms two or three oxides, of which the protoxide acts as a base. The most important salt is the nitrate, or lunar caustic,—made by dissolving silver in nitric acid, and evaporating. The crystals are colourless ; very soluble in water ; the solution becomes dark coloured when exposed to light, probably from the formation of an oxide. The arbor Diana is made by suspending mercury in a solution of the nitrate : the silver is precipitated in the form of crystals. It is also precipitated by the chlorides, phosphates, chromates, arseniates, arsenites, and several of the metals. The best test is chlorine, or a soluble chloride. Silver forms compounds with chlorine, iodine, and sulphur. PLATINUM, Occurs only in the metallic state, generally combined with other metals, particularly palladium, osmium, rhodium, and iridium. It is found in grains, which are converted into masses by intense heat and pressure. Prop.—It has a whitish colour; very malleable; the most ductile of metals; the heaviest body in nature ; sp. gr. 21-5 ; is soft; can be welded, like iron ; undergoes no change by exposure to air, mois- ture, or the highest heat of a smith's forge; can only be fused by galvanism or the oxy-hydrogen blowpipe * it is dissolved by nitro- muriatic acid. In its habitudes with oxygen, chlorine, and sulphur, it resembles gold. Spongy platinum has the singular property of causing the union of oxygen and hydrogen gases, producing combustion. Tests.—A solution of chloride of potassium produces with chlo- ride of platinum a double chloride, of a pale yellow colour; sal ammoniac gives with it a yellow precipitate, which, by heat, yields spongy platinum. The metal iridium is said to be a little heavier than even platinum; its sp. gr. being 21-8. The other metals associated with platinum. (palladium, osmium, and rhodium), need no particular description. 6 62 CHEMISTRY. MERCURY OR QUICKSILVER. Occurs in the metallic state; but more frequently as a sulphide or chloride;—extracted by heat, which sublimes the mercury. Prop.—The only metal fluid at ordinary temperatures;—has a silver-white colour, and brilliant lustre; becomes solid at —39°, when it is malleable ; boils at 662°;—sp. gr. 13-6 ; that of frozen mercury, about 14. Pure mercury is not altered by the air at common tern- peratures, but absorbs oxygen when heated. Hydrochloric acid has no action, nor sulphuric acid, unless concentrated and boiling; nitric acid, even when cold and dilute, acts upon it, forming a nitrate. Mercury forms two oxides, the black and the red. The eq. is 202, (Turner, Hare,) or 101, (Graham, Kane, &c.) The nomenclature of the different compounds will, of course, depend upon the adop- tion of either one of these. Protoxide, HgO, (suboxide, HgaO.)—Prepared by action of caustic potash on a solution of the nitrate, or on calomel; it is a dull gray powder, insoluble in water ;—decomposed, by the action of light, into the red oxide and metallic mercury. Peroxide, HgOa, (protoxide, HgO,) red oxide.—Prepared by the combined agency of heat and air ; by heating the nitrate ; or by pre- cipitation from a solution of corrosive sublimate, by means of potassa. It is often called red precipitate. It is in the form of fine red shining scales, very slightly soluble in water; converted by heat into me- tallic mercury and oxygen. Chlorine forms two compounds, calomel and corrosive sublimate. Protochloride, or calomel, HgCl, (subchloride, Hg3Cl.) Prepared either by precipitation, by means of chloride of sodium in a solution of the nitrate; or by subliming together the protosulphate of mer- cury and chloride of sodium. The rationale is as follows:— Protosulphate of \ MewTj- ^Calomel, HgCl. , Oxygen mercury j Sul'c acid Chloride of so- 5 Chlorine, dium ( Sodium __________^^-J3ulphate of soda. As prepared by ordinary sublimation, calomel occurs in yellowish white masses; but \f the vapour be conducted into a recipient con- taining watery vapour, it is condensed in a very fine white powder. It is insoluble, tasteless; sp. gr. 7-2; is apt to contain a little corro- sive sublimate, which can be removed by washing, or throwing down by ammonia. Potassa or lime decompose it, throwing down the black oxide. Bichloride, or corrosive sublimate, HgCla, (called chloride, HgCl.) —Prepared by burning mercury in chlorine gas ; by action of hy- drochloric acid on the red oxide; or preferably, by subliming to- gether tfie bisulphate with common salts, thus:—- IRON. 63 1 eq. bipersulphate of$ Mercury ----------- Bichloride of mer- mercury \\ Ogjea^ ^ cury, HgCla. ' 2 eq. chloride of so- \ 2 Chlorine dium 1 9 Sodium _ ^ 2 eq. sulphate of soda. Prop-—Crystalline; soluble in water, alcohol, and ether. The alkalies and their carbonates throw down from it the red oxide; am- monia in excess throws down from its solution the white precipitate, which is considered to be an amo-chloride of mercury (Kane) Albumen is the best antidote for it. There are two iodides, two bromides, and two sulphides of mer- cury. The bisulphide occurs native, under the name of cinnabar; its powder is called vermilion. Ethiop's mineral is made by tritu- rating mercury and sulphur together, until the globules disappear; it is considered to be a mixture of sulphur and the bisulphide. The most important salts are formed with nitric and sulphuric acids, each of which unites with the protoxide and the peroxide. The turpeth mineral is the subsulphate, formed by throwing the sulphate into water. SECTION V. ORDER II.--METALS WHOSE OXIDES FORM POWERFUL BASES. This order includes Iron, Copper, Zinc, Lead, Bismuth, Manga- nese, Cobalt, Nickel, Cadmium, Uranium, Cerium, and Lantanum. IRON. Very rarely occurs native;—exists in meteorites, combined with nickel and cobalt. As an oxide, it is widely diffused throughout nature. The most abundant ores of iron, are the oxides and sul- phurets, or pyrites. Some of the ores are magnetic, and some are not. Iron is extracted from its ores by roasting and then exposing to a high heat, along with charcoal; by this means the common cast iron is procured; this is converted into soft or malleable iron by exposure to a strong heat, while a current of air plays upon its sur- face ; by this means the carbonaceous matter is burnt off, and the fusibility of the metal is diminished. Steel is a carburet of iron, found by exposing alternate strata of soft iron and charcoal to an intense heat; a direct union ensues, by which the iron acquires greater hardness. Prop.—Iron has a peculiar gray colour—metallic lustre;—not very malleable—quite ductile—the most tenacious of all metals—is a hard 64 CHEMISTRY. metal—of a fibrous texture—sp. gr. 9*7—is very infusible—suscep- tible of the welding process—is attracted by the magnet—may itself be rendered magnetic by heating—does not oxidize in dry air at com- mon temperatures;—heated to redness, it becomes covered with a scaly coating of the black oxide—burns vividly in oxygen—rusts when exposed to air and moisture—decomposes water at a red heat, evolving pure hydrogen, and giving rise to the black oxide. Symb. (Ferrum,) Fe.-~Eq. 28.—It forms four compounds with oxygen. Protoxide, FeO,—the base of the native carbonate and of green vitriol. It can hardly be isolated, from its great proneness to absorb oxygen, and to pass into the state of sesquioxide; the hydrate of the protoxide is formed when an alkali is added to a solution of the pro- tosulphate; it is of a dirty green colour, and speedily becomes red by the absorption of oxygen. Peroxide, (Sesquioxide) Fea03,—occurs in nature under the name of red hematite;—made by dissolving iron in nitro-hydrochloric acid, and adding an alkali. Prop.—It is not attracted by the magnet;— forms reddish salts with most of the acids. It can easily be detected by the infusion of galls, which gives with it a bluish-black precipi- tate, the basis of ink,—by ferrocyanide of potassium, which throws down Prussian blue,—by sulphocyanide of potassium, which causes a blood-red colour. Black, or Magnetic Oxide, FeO+Fea03,—a mixture of the two former oxides ;—occurs native—is one of the most valuable of the ores; it is the product of exposing iron to high heat. It does not form salts. Ferric Acid, Fe03,—only recently discovered—obtained by heat- ing together one part of peroxide of iron with four parts of dry nitre, by which the ferrate of potash is found ; it is very difficult to isolate, on account of its extreme susceptibility to decomposition. Iron forms two compounds with chlorine. Protochloride FeCl,—formed by dissolving iron in chlorohydric acid and drying. Sesquichloride, Fe3Cl3, formed by the combustion of iron wire in chlorine gas. There are also two iodides ; the protiodide is used in medicine, made by digesting iodine in water with pure iron wire. Sulphur unites with iron in several proportions. Protosulphuret, FeS,—formed by heating iron and sulphur together; it has a blackish colour,—is attracted by the magnet. There is also a Sesquisulphuret, Fe3S3. Bisulphuret, FeS3, iron pyrites, exists native, has a yellow colour and a metallic lustre; is not magnetic. Magnetic iron pyrites, is a native ore, consisting of a compound of the protosulphide and bisulphide (Stromeyer). The most important salts of iron are the sulphates, the carbonate, and the nitrate. LEAD. 65 Protosulphate of iron, green vitriol, prepared by dissolving iron in sulphuric acid. It is crystalline—of a beautiful green colour—very soluble—efflorescent. Sesquisulphate of iron^—made by action of nitric acid on a solution of the protosulphate; it has a buff" colour, and is sparingly soluble. There is only one carbonate—the proto- carbonate; this is sometimes found native, and exists in chalybeate springs. There are two nitrates. The best tests for iron, are those mentioned under the head of the sesquioxide. COPPER. Occurs sometimes in native crystals; but, most commonly, as a sulphuret, from which the metal is extracted by roasting with charcoal. , prop.__The only red metal except titanium; has considerable lustre; sp. gr. 8-6 ; is very ductile, malleable, and tenacious; under- goes but little change in dry air; but, when moist, it is converted into a subcarbonate. Symb. (Cuprum,) Cu.—Eq. 31-6. Copper forms two or three oxides. Dioxide or red oxide, Cu30, occurs native, in octohedral crystals; may be formed by heating together the protoxide and copper filings. It forms colourless salts with bases, which, however, are very un- stable, from their tendency to absorb oxygen. Protoxide or black oxide, CuO, the basis of most of the salts of copper ;_prepared by calcining metallic copper, by precipitating from any salt by an alkali, and by heating the nitrate. Colour varies from a dark brown to a black. There is also a binoxide. There are two chlorides, iodides, and sulphides of copper, similar in com- position to the first two oxides. The most important salts of copper are the sulphate, nitrate, car- bonates, and acetates. The sulphate—well known in commerce, as blue vitriol—-is formed by the action of sulphuric acid on copper. The carbonate occurs native, in the mineral malectite. Verdigris is composed of one or more of the acetates of copper. The proper solvent of copper is nitric acid. Tests.—Ammonia, in small quantities, throws down from a solu- tion of the sulphate, the bluish-white hydrated protoxide ; but when added in excess, it redissolves the precipitate, forming a deep blue colour. Ferrocyanide of potassium gives a fine reddish-brown fer- rocyanide of copper. It is also precipitated upon iron or steel. Copper forms several important alloys, such as brass, with zinc; beU metal, with tin ; bronze, with zinc and lead. LEAD. Procured chiefly from the native sulphuret or galena,by roasting which converts most of it into a sulphate; the sulphate and sul- 6* 66 CHEMISTRY. phuret reacting upon one another, produce sulphurous acid, and free lead. Prop.—A soft, bluish metal; has a metallic lustre when freshly cut; somewhat malleable and ductile, particularly in the form of pipes ; not very tenacious ; sp. gr. 11-45 ; melts at 600° F. Exposed to moist air, it becomes coated with a film of the dioxide; also ab- sorbs oxygen when heated in the open air. Symb. (Plumbum) Pb. Eq. 103-6. It forms four oxides. Dioxide, Pb30, formed by heating dry oxalate of lead in a retort; it absorbs oxygen very rapidly. Protoxide, PbO, the basis of the salts of lead, is prepared by ex- posing the gray film which collects on the surface of melted lead, and which consists of the protoxide and metallic lead, to a high heat, with the access of air; this constitutes the massicot of commerce; when partially fused by heat, it becomes litharge; in this state it contains some peroxide. It has a yellow colour, is insoluble in water, unites with acids, forming salts, from which it is precipitated by alkalies as a hydrate, and as white lead by alkaline carbonates. Peroxide, puce, or brown oxide, Pb02, prepared by the action of nitric acid or red lead, which converts it into the protoxide and per- oxide. It has a flea-colour; is insoluble; by heat, it is converted into protoxide and oxygen. Red lead, minium, or red lead, Pb304, or 2PbO + Pb03, con- sidered to be a compound of the protoxide and peroxide ; is formed by exposing lead to heat in the air, without allowing it to fuse. It is a heavy, brilliant red powder ; decomposed, with the evolution of oxygen, by a strong heat; and converted into a mixture of prot- oxide and peroxide by acids. It is used as a pigment, and in the manufacture of flint-glass. Chlorine forms with lead a compound known as plumbum cor- neum, or horn lead. Sulphur forms with lead the well-known galena, which occurs in cubical crystals. Iodine, bromine, fluorine, and phosphorus also form compounds with lead. The most im- portant salts of lead are the carbonate and acetate ; also the nitrate and sulphate. Carbonate of lead, White lead,—is sometimes found in a native crystalline state ; may be prepared by precipitating from any soluble salt of lead by means of an alkaline carbonate ;—is manufactured by exposing sheet-lead in coils to the action of the vapour of vinegar, at the temperature of decomposing manure: the lead is oxidized, and then converted into a carbonate by the carbonic acid, which is de- rived from the decomposition of the acetic acid. It is a soft, white, very heavy powder, insoluble in water; much used as a pigment. Acetate of lead, Sugar of lead,—made by dissolving litharge in acetic acid; occurs in colourless, transparent crystals; has a sweet taste; is very soluble in water, also in alcohol. There are several CADMIUM. 67 subacetates of lead, made by boiling a solution of the acetate in litharge. Nitrate of lead, prepared by the action of nitric acid on lead. Nitric acid is the proper solvent of lead ;—it is soluble. Sulphate of lead, prepared by the action of a soluble sulphate, on a solution of the acetate of lead ; it is a very insoluble salt. Cold sulphuric acid has no action on lead ; but when boiling, the lead is slowly oxidized at the expense of the acid. Hydrochloric acid has no action on lead. Tests.—The alkaline carbonates throw down the insoluble carbo- nate ; the soluble sulphates throw down the insoluble sulphate; and sulphuretted hydrogen or a soluble hydrosulphate, throws down the black sulphuret. ZINC. Occurs in nature as a carbonate, (calamine), or as a sulphuret, (zinc blende.) It is procured from the former by heat and charcoal; and from the latter by a similar process, after roasting the ore; at a high temperature, the metal, being volatile, comes over by dis- til la tion. pr0p.—A bluish-white metal; has a crystalline texture; sp. gr. 7; brittle at common temperatures ; malleable between 250° and 300° ; very brittle at 400°; melts at 773°, and at a bright red heat it boils and burns with a brilliant green light, generating the oxide. It is called spelter in commerce, and is never quite pure; is slightly tar- nished by exposure to the air. Symb. (Zincum) Zn.—Eq. 33. Oxide of Zinc, ZnO ;—prepared by burning zinc in the air, or by heating the carbonate. It is a white, insoluble powder, the basis of the salts of zinc. Chloride of Zinc, ZnCl.;—prepared by heating metallic zinc in chlorine, or by dissolving zinc in hydrochloric acid, and drying. It is a white substance, has the consistence of butter, and hence called butter of zinc; very deliquescent, and soluble in water and alcohol. The important salts of zinc, are the sulphate and the carbonate. Sulphate of Zinc, while vitriol;—made by acting on zinc with dilute sulphuric acid; the water is decomposed, its oxygen going to the zinc, and the hydrogen escaping. It is a white, crystalline, soluble salt. , ,, Carbonate of Zinc,—occurs native, and may be formed by double decomposition between any soluble carbonate and the sulphate ot zinc. CADMIUM. This metal is usually found associated with zinc, in the reduction of which from its ores, the cadmium, being more volatile fl.es ofl Prop—It resembles tin in colour; very malleable; very volatile, 68 CHEMISTRY. sp. gr. 8*7 ; melts below 500° ; when strongly heated, it burns, form- ing the oxide. BISMUTH. Occurs both native, and in combination; may be procured pure by heating the subnitrate with charcoal. Prop.—A crystalline metal, of a reddish-white colour and me- tallic lustre ; when slowly cooled, it yields cubical crystals ; fuses at 476°, and in close vessels sublimes unchanged; in the open air burns with a bluish flame, and is converted into the oxide; its pro- per solvent is nitric aid. It forms two oxides. Sp. gr. 10.—Eq. 71. Protoxide, BiO;—the basis of all the salts, has a yellow colour; obtained by heating the subnitrate. Peroxide Bi303.—Bismuth unites also with chlorine and sulphur. Nitrate of Bismuth;—made by dissolving the metal in nitric acid, and evaporating. This, when thrown into water, is decomposed into the soluble supernitrate, and the insoluble subnitrate, which subsides as a white powder. The best test is the formation of the subnitrate. MANGANESE. Is found in nature as an oxide; procured from this by intensely heating with charcoal. Prop.—A hard, brittle metal, of a grayish-white colour, very in- fusible, sp. gr.; about 8; forms seven compounds with oxygen, viz.: Protoxide, MnO, Sesquioxide, Mn303, Peroxide, Mn03, Red oxide, Mn304, Varvicite, Mn407, Manganic acid, Mn03, Permanganic acid, Mn307. The most important of these, to the chemist, is the peroxide, or black oxide, which occurs abundantly in nature. It is used in the arts, in the manufacture of glass; and by the chemist for pro- curing chlorine, bromine, and oxygen. NICKEL AND COBALT. These two metals strongly resemble each other: both occur in combination with arsenic. Nickel is found associated with meteoric iron, and is strongly magnetic. Cobalt is not so. Both have a white colour. Nickel is malleable ; Cobalt is brittle. Nickel is em- ployed in the arts, in the preparation of German silver—an alloy of copper, zinc, and nickel. The best test to distinguish cobalt from nickel, is the fine blue colour communicated by the former to the flame of the blowpipe, when fused with borax. URANIUM, CERIUM, AND LANTANUM. These are very rare metals, and of no practical use. The latter, Lantanum, was very recently discovered by Mosander. ANTIMONY. 69 SECTION VI. OBDER III.--METALS WHOSE OXIDES FORM WEAK BASES, OR ACIDS. This order includes Tin, Antimony, Arsenic, Chromium, Vana- dium, Tungsten, Molybdenum, Columbium, Titanium, Tellurium, and Osmium. TIN. Is found in nature as an oxide, from which it may be procured by heating with charcoal. The varieties known in commerce are block and grain tin. Prop. — Has a white colour, silvery lustre, is very slowly tar- nished by exposure to the air; very malleable, quite ductile, soft, and inelastic, and produces a crackling noise, when bent backwards and forwards ;'sp. gr. about 7 ; fuses at 442°; heated to whiteness, it burns, and is converted into the peroxide. Symb. (Stanum) Sn.—Eq. 58. It forms three oxides. Protoxide, SnO;—formed by adding an alkaline carbonate to a solution of the protochloride; a white hydrated protoxide falls. Sesquioxide, Sna03,'—has a grayish colour. Peroxide, SnOa;—prepared either by precipitating by an alkali from a solution of the perchlqride, or by the action of nitric acid on metallic tin. Very strong nitric acid has no effect on tin; but, if diluted, violent effervescence ensues from the escape of nitrous acid and binoxide of nitrogen, and the hydrated peroxide is produced; ammonia is also generated at the same time, the hydrogen being furnished by the water. Protochloride, SnCl,—made by dissolving tin in hot hydrochloric acid; occurs in crystals. It is much used as a deoxidizing agent. Perchloride, SnCl3, called the fuming liquor of Libavius ;—made by heating the protochloride, or metallic tin, in chlorine; it is a very volatile, colourless liquid, emitting dense white fumes on being exposed to the air; it is used as a mordant in dyeing. There are three sulphurets of tin—the protosulphuret, sesquisul- phuret, and bi-sulphur et; the latter is sometimes termed mosaic gold. Test.—Solution of chloride of gold throws down, with the proto- chloride of tin, the purple of Cassius. ANTIMONY. Occurs in nature generally as a sulphuret, which, in commerce, is called crude antimony, while the pure metal is named regulus of antimony. It may be obtained from the sulphuret by heating it with iron filings. Prop.—A bluish-white colour—crystalline structure—brittle—sp. 70 CHEMISTRY. gr. 6-8;—at a high temperature it burns in the open air, the vapour condensing in white crystals of the sesquioxide, (argentine flowers of antimony;) it is acted upon by both nitric and hydrochloric acids. Symb. (Stibium) Sb.—Eq. 129. It forms three compounds with oxygen. Sesquioxide, Sb303,—prepared by burning antimony in the open air,—by precipitation from a solution of tartar emetic by means of an alkaline carbonate, or by the action of carbonate of potassa or soda on the sesquichloride, when put into water. It is a pale yel- low powder—volatile—liable to absorb oxygen;—the basis of all the antimonial salts. Antimonious acid, Sb304,—made by heating the oxide in open vessels;—a grayish-white powder—insoluble—combines with al kalies. Antimonic acid, Sb305,—made by action of strong nitric acid in antimony ; an insoluble straw-coloured powder; unites with alkalies, to form antimoniates. Sesquichloride, Sb3Cl3, (butter of antimony,)—made by burning antimony in chlorine gas; a soft solid at common temperatures; when put into water, hydrochloric acid and the sesquioxide are generated, and the latter combined with some undecomposed chloride, subsides as the powder of Algaroth. There are one or two other chlorides.—There are several sulphurets, of which the most impor- tant is the native sesquisulphuret; it is a lead-gray substance, brittle and fusible. It may be made by melting sulphur and antimony together. Kermes mineral.—Prepared by boiling sesquisulphuret of anti- mony in a solution of caustic potassa ; a partial double decomposi- tion ensues, by which an oxide of antimony, and a sulphuret of potassium are formed; the latter unites with undecomposed sulphuret of antimony to form a sulphur-salt, in which the sulphuret of anti- mony is the acid, and sulphuret of potassium the base. As the solution cools this double salt becomes decomposed, the sesquisul- phuret of antimony subsiding along with a variable portion of potassa and oxide of antimony. This is the kermes, which may hence be considered as an oxysulphuret. The mother waters still contain some of the above sulphur-salt, together with potassa and oxide of antimony; and, on the addition of sulphuric acid, the sesquioxide and sesquisulphide are precipitated together, but without the potassa; this is the golden sulphuret. The most important salt of antimony is tartar emetic;—made by boiling cream of tartar with the sesquioxide of antimony. It is a white, crystalline, soluble salt, which gives a brick-red precipitate (the sesquisulphuret) with sulphuretted hydrogen; it also yields precipi- tates with the alkalies, earths, tannic acid, &c. ARSENIC. 71 ARSENIC. Is sometimes found native, but is generally procured from the native arsienuret of cobalt and nickel, by means of heat. . Prop.—A steel-gray colour; metallic lustre; very brittle; tar- nishes in the air; sp. gr. 5*9; volatilizes by heat, and, if air be present, is converted into arsenious acid ; its vapour has the odour of garlic. Symb. As.—Eq. 76*4. It forms two well known compounds with oxygen, arsenious and arsenic acids;—no basic compound. Arsenious acid, white oxide of arsenic, fly- powder, As3Oa,—is always generated when arsenic is heated in the_ open air; that of com- merce is derived by roasting the native ores of cobalt. It is quite trans- parent and glassy when first prepared, but becomes opaque by exposure; volatile at 380°; vapour is inodorous, and condenses on cool surfaces; not very soluble in water ; reddens vegetable blues feebly; combines with bases, formingarsenites; it has an acid taste and is very poisonous. Arsenic acid, As305,—made by dissolving arsenious acid in strong nitric acid, mixed with a little hydrochloric acid, and evaporating to dryness. It is sour to the taste; much more soluble in water than arsenious acid; forms arseniates; is isomorphous with phosphoric acid; when strongly heated, is converted into arsenious acid and oxygen. There are three well known sulphurets of arsenic. Protosulphuret or Realgar, AsS, occurs native;—may be made by heating together sulphur and arsenious acid ; colour, ruby red. Sesquisulphuret or Orpiment, As3S3, is also found native;—made by transmitting sulphuretted hydrogen through a solution of ar- senious acid ; colour, yellow,—called king's yellow. Persulphuret, As3S3, made by action of sulphuretted hydrogen on a solution of arsenic acid ; it resembles orpiment in colour. The sulphurets are poisonous. Arsenic also unites with chlorine, iodine, &c. Arsienuretted hydrogen, As3H3, prepared by adding arsenious acid to the materials for generating hydrogen; colourless ; odour of garlic; sp. gr. 2-6 ; burns with a blue flame, generating arsenious acid ; a, non-supporter of combusion; very poisonous when breathed ; slightly soluble in water. Tests for arsenic.—1. Ammoniacal nitrate of silver (made by adding ammonia to a solution of nitrate of silver, until the oxide of silver which is thrown down is nearly all dissolved); arsenious acid added to this, throws down the insoluble arsenite of silver of a yellow colour. 2. Ammoniacal sulphate of copper, (made by adding ammonia to a solution of sulphate of copper,) throws down with arsenious acid, the insoluble arsenite of copper (Scheele's green). 72 CHEMISTRY. 3. Hydrosulphuric acid, when transmitted through a solution of arsenious acid, precipitates the sesquisulphuret, (orpiment.) 4. The production of arsienuretted hydrogen.—By adding the matter containing arsenic to the materials for generating hydrogen, on burning a jet of this gas, and holding over it a piece of glass or porcelain, an arsenical ring is formed. None of the above tests can be relied on singly. The best method is to reduce the arsenic by means of heat and charcoal, (or black flux,) in a glass tube; by which means the arsenical ring may always be produced, and the peculiar odour of burning arsenic be detected. The proper antidote for arsenic is the hydrated peroxide of iron, in a moist state. The remaining metals of this order are Chromium, Vanadium, Tungsten, Molybdenum, Columbium, Titanium, Tellurium, and Osmium. None of them are of practical importance except chro- mium, two salts of which are much used in the arts, viz.: chromate of lead, (chrome yellow,) and the bichromate of potash. CHAPTER III. SALTS. The term salt was formerly restricted to a compound of an acid and a salifiable base; but this definition was necessarily vague, on account of the difficulty of always accurately defining what was an acid and what was a base. Formerly an acid was considered to be an oxidized body which has a sour taste, reddens litmus, and neutralizes alkalies. Subsequent discovery showed the propriety of extending this definition ; for, first, the discovery of the hydracids proved that oxygen is not essential to acidity; and secondly, some compounds, owing to their insolubility, have neither a sour taste, nor do they redden litmus; yet they neutralize bases; thirdly, there are some acknowledged acids, as carbonic, hydrocyanic, &c, which are unable fully to destroy the alkalinity of potassa. Chemists of the present day agree to call all such bodies acid which unite with potassa or ammonia, and give rise to bodies similar in constitution and general character, to the salts which sulphuric or some other admitted acid forms. For similar reasons, the present notion of what constitutes an alkaline or salifiable base, is that of a body which unites definitely with admitted acids, to form with them compounds resembling recognised salts. There is a very important class of compounds, which, however, would not fall within the range of the above definition of a salt; and which yet have undoubted claims to be considered as such; they SALTS. 73 comprise the chlorides, iodides, bromides, &c, and are named haloid salts, from a Greek word signifying sea salt. The notion of a salt has been still farther extended. It is known that two metallic sulphurets occasionally unite together to form a compound called a double sulphuret. To such compounds Berzelius gave the name of sulphur-salts. They are precisely analogous in their composition to a common oxy-salt, as may be seen by simply substituting for the sulphur an equivalent quantity of oxygen. In these salts, the sulphur-acid is a sulphuret of some one of the electro-negative metals, as arsenic, antimony, tungsten, &c.; the sulphur-base is a sulphuret of an electro-positive metal, as potassium, sodium, mercury, &c. It has also been found that the haloid salts will unite together, to form what is termed a double haloid salt; which also may be con- sidered precisely analogous to an oxy-salt, the halogen element (chlorine, iodine, &c), simply taking the place of oxygen. By a double salt is meant one in which the same acid is united with two separate bases, as tartar emetic, (tartrate of oxide of anti- mony and potassa.) Nearly all salts are solid at common temperatures; most are capable of crystallizing ; their colour is variable; the soluble ones are more or less sapid ; very few are odorous ; they differ much in their affinity for water: some attract moisture from the air and be- come liquid ; such salts are called deliquescent; they differ very much in their solubility in water, which is in the direct ratio of their affinity for water, and in the inverse ratio of their cohesion. In many salts water acts as a base, and is hence termed basic water. As a general rule, every salt has its own distinct crystalline form, by which it may be recognised. Crystallization may be effected in various ways, as by solution and evaporation : the slower the evapo- ration, the larger and more regular the crystals ; if the evaporation be made very rapid by heat, a confused crystalline mass is obtained. Fusion and slow cooling may sometimes be employed; thus crystals of sulphur and bismuth may be procured. A third condition under which crystals form, is in passing from the gaseous to the solid state, as in the case of iodine. Many salts, in crystallizing, unite chemically with a definite por- tion of water, which belongs to the crystal, but not to the salt; this is termed water of crystallization. By a strong heat, all this water is expelled, and the salt is said to undergo the watery fusion. Such salts, when exposed to the air, are liable to part with a portion of this water, and crumble down into a powder ; they are said then to be efflorescent. Some salts, again, in crystallizing, enclose a portion of water mechanically within their texture; which, by its expansion, when 74 CHEMISTRY. the salt is heated, causes it to burst with a crackling noise; this is termed decrepitation. Atmospheric pressure exerts an influence on the crystallization of salts ; if, for instance, a hot saturated solution of sulphate of soda be corked up in a bottle while the latter is full of vapour, the solution will cool down to the temperature of the air without crystallizing; but on admitting the air, crystallization commonly commences, and the whole becomes solid in a few seconds. Crystals are of various forms: they are divided by crystallographers into simple and compound. By cleavage is meant that property of a crystal by which it admits of being split in certain directions. Bodies are said to be isomorphous when they have the same crys. talline structure, but a different chemical composition : thus arseniate of soda is isomorphous with phosphate of soda. On the other hand, the same substance may have, under different circumstances, two crystalline forms; in which case it is said to be dimorphous: sul- phur and carbon are examples. The instrument employed to ascer- tain the angles of crystals is termed a goniometer. SECTION I. OXYSALTS. This class of salts includes those, of which both the acid and base are oxides. It will be convenient to classify them according to their different acids. SULPHATES. Their solutions may always be recognised by yielding a white precipitate, (sulphate of baryta) with a solution of a salt of baryta. Heated in contact with charcoal or hydrogen they are converted into sulphurets, which, if moistened, yield the peculiar odour of sulphu- retted hydrogen. They are almost all insoluble in alcohol. The sulphates of baryta, tin, antimony, lead and bismuth, are quite inso- luble in water. Those of lime, strontia, mercury, silver, and a few others, are nearly insoluble; while all the other sulphates are so- luble. The most important sulphates are those of potassa, soda, magne- sia, lime, baryta, iron, copper, zinc, and mercury. The most important double sulphates are the different alums. Common alum is a double sulphate of alumina and potassa. It may be prepared from native alum stone, in which the materials exist ready formed, or from a direct union of its constituents. There are other varieties of alum, in which the sulphate of potassa is replaced by sulphate of soda, or sulphate of ammonia;—also iron PHOSPHATES. 75 and manganese alums, in which the sulphate of alumina is replaced respectively by the sulphate of iron, and the sulphate of manganese. The Sulphites, Hyposulphites, and Hyposulphates are of very little practical importance. NITRATES. These may be prepared by the action of nitric acid on metals,—on the salifiable bases,—or on the carbonates. As they are soluble salts, their acid cannot be precipitated by any reagent. They are distin- guished by deflagrating with charcoal and other combustibles. When exposed to a high temperature, they are decomposed with the evolu- tion of oxygen gas. If subjected to the action of sulphuric acid, they give off nitric acid fumes. When added to hydrochloric acid they form a solvent for gold leaf, by liberating the chlorine. The most important nitrates are those of potassa, soda, ammonia, copper, mercury, and silver. The Nitrites are comparatively unimportant. CHLORATES. These are very analogous to the nitrates. They are all decom- posed by a red heat into metallic chlorides and oxygen gas. They deflagrate with combustibles even more violently than the nitrates. They are nearly all soluble in water. The most important salt of this class is the chlorate of potassa, which is useful to the chemist in the preparation of oxygen. The Chlorites are chiefly remarkable for their bleaching and oxidizing properties. The Hypochlorites may be produced by the action of chlorine gas upon salifiable bases. The most important of them is the hypochlo- rite of lime, the well-known bleaching powder, commonly called chloride of lime. It is prepared by exposing thin strata of recently slaked lime to an atmosphere of chlorine: the chloride of calcium and hypochlorite of lime are formed. IODATES. These are compounds of iodic acid and a base. They bear a general resemblance to the chlorates, and may be recognised by the facility with which they are decomposed by deoxidizing agents, as hydrochloric, sulphurous, and phosphorous acids, which unite with the oxygen, setting iodine free. The Bromates generally resemble the iodates. PHOSPHATES. As regards this class of salts, it is to be remembered that there are three isomeric phosphoric acids, termed tribasic, bibasic, and monobasic, or phosphoric, pyrophosphoric, and metaphosplioric acids. 76 CHEMISTRY. Each one of these modifications forms its own peculiar salts, the tests for which were spoken of under the head of Phosphorus. The most important phosphates are those of soda, lime, ammonia, lead, and silver. CARBONATES. These are distinguished by their facility of decomposition by any of the acids, with effervescence. All the alkaline carbonates are de- composable by heat, except those of potassa, soda, baryta, strontia, and probably lithia. All, except those of potassa, soda, and ammo- nia, are sparingly soluble in water; but are more or less soluble in an excess of carbonic acid. Several of the carbonates occur native, as those of lime, magnesia, soda, baryta, iron, copper, and lead. The most important carbonates are those of potassa, soda, lime, ammonia, magnesia, baryta, iron, copper, and lead. ARSENITES AND ARSENIATES. These are salts of arsenious and arsenic acids respectively. The arsenites are all decomposed by a red heat; the arsenious acid being either dissipated in the form of vapour, or converted into arsenic acid. The arseniates are not so easily decomposed, requiring usually along with heat the aid of charcoal or black flux. CHROMATES. The salts of chromic acid are mostly of a yellow or red colour, the latter tint predominating whenever the acid is in excess; they are valuable as pigments. The most important of the chrornates are those of potassa and lead. BORATES. The salts of boracic acid are very easily decomposed. The most important one is the biborate of soda, or common borax. They may all be recognised by their solutions in strong alcohol, burning with a greenish flame. SECTION II. HYDROSALTS. By this term is understood such salts, of which either the acid or base contains hydrogen. Formerly, this class of salts was much - more extensive than it is at present, in consequence of the different views taken of the composition of the so called muriates, or hydrochlo- rates ; but which are now generally spoken of as chlorides. Indeed, all the haloid salts are now considered as compounds of the halogen element (chlorine, iodine, bromine, &c.) with a metal, rather than as compounds of a hydracid with the oxide of the metal, which was the DOUBLE HALOID SALTS. 77 former view. According to the present doctrine, when a hydracid is presented to any salifiable base, both are decomposed, water and a haloid salt of the metal being formed. Take hydrochloric acid and potash by way of example : Hydrochloric acid \ ™°rine ----------^Chloride of potassium. J ( Hydrogen ^— Potash . . . \ Potassium- ( Oxygen _____ ■---Wnter. The only hydro-salts which are now at all recognised are the compounds of ammonia with a hydracid ; though even these might be considered as haloid salts of the hypothetical metal ammonium. This will be evident by the following diagram :— Hydrochloric acid j ghIJrine-------------ChloT'me ) J o «°^en ^^^ \ Sal ammoniac. ( Nitrogen "^^sa^. Ammonium / The most important of the ammoniacal salts are the hydrochlorate, commonly called sal ammoniac, and the hydrosulpkate, formerly termed the fuming liquor of Boyle. SECTION III. SULPHUR SALTS. The sulphur salts are double sulphurets, just as the oxy-salts are double oxides ; the sulphuret of one metal acting as an acid, while the sulphuret of another metal acts as a base. The sulphur salts are so constituted, that if the sulphur in both the acid and base was replaced by oxygen, an oxy-salt would result. The principal sulphur-bases are, the protosulphurets of potassium, sodium, lithium, varium, strontium, calcium, and magnesium; and the principal sulphur-acids are the sulphurets of arsenic, tin, anti- timony, tungsten, molybdenum, tellurium, and gold, together with hydrosulphuric acid and bisulphuret of carbon. Kermes' mineral, an important antimonial medicine, is an example of a sulphur salt, being composed chiefly of sulphuret of antimony, united with sul- phuret of potassium. SECTION IV. DOUBLE HALOID SALTS. These salts are composed of two simple haloid salts, one of which acts as an acid, and the other as a base, in a manner analogous to the double sulphurets. The principal groups consist of double chlorides, double iodides, and double fluorides. When an oxide and chloride unite, they constitute a compound known by the name of oxy-chloride. PART III. ORGANIC CHEMISTRY. GENERAL OBSERVATIONS. Organic substances, whether derived from the vegetable or animal kingdom, are chiefly remarkable for the complexity of their composition, and for the limited number of their elements. Only four elements are considered essential to the composition of organic matter, viz. carbon, oxygen, hydrogen, and nitrogen,—though others are occasionally met with, as sulphur, phosphorus, chlorine, sodium, &c.; altogether they do not amount to more than fifteen. There appears, however, to be no limit to the number of definite compounds which may be produced out of merely the four above-named essen- tial elements, simply by a difference in their proportions and mode of arrangement. In consequence of the complexity of organic bodies, they are generally very instable, being prone to decomposition whenever the restraining force is removed. The products of such decomposition are water, carbonic acid and ammonia; and if sulphur be present, sul- phuretted hydrogen. As a general rule, the more complex is the constitution of an organic body, the more liable is it to decomposition; but this ten- dency is much lessened if the elements are in such proportions as completely to saturate each other; thus in sugar, starch, and Iignin, the proportions of oxygen and hydrogen are exactly sufficient to saturate each other, and to form water. Vegetable organic matter is usually ternary in its composition, and is not so prone to decomposition as animal organic matter, which is generally quarternary. Both are invariably decomposed by heat. Isomeric bodies are frequently met with among organic substances. By this term is meant bodies having the same chemical composition, but possessing very different properties; starch, sugar and gum are examples. Isomerism is believed to depend upon a different arrange- ment in the constituent atoms of a body,—their number remaining the same. COMPOUND RADICALS. 79 SECTION I. OF COMPOUND RADICALS. By the term compound radical, is meant a substance which, although containing two or more elements, acts precisely as a simple elementary body. The following are the most important of the admitted compound organic radicals, together with their chemical composition expressed in symbols. Carbonic oxide, or protoxide of carbon, Cyanogen, or bicarburet of nitrogen, Mellon, or sesquicarburet of nit Benzoile, benzule, or benzyle, Cinnamyl, or cinnamule, Salycyle, or salicule, Acetyl, or acetule, Formyl, or formule, Amide, - Ethyl, or ethule, Methyl, or methule, Cetyl, or cetule, Glyceryl, or glycerule, Amyl, or amule, Mesetyl, or mesetule, Kacodyl, or kacodule, •ogen, Formula. ■ CO. - CaN. - CBN*. C**H50*. C18H8Oa. C"H5CH. - C4H3. - C3H. . NH3. - C*H5. - CaH3. - C3aH33. - C6H7. - C^H". - C«H*. - C*H6. Besides these, there are some subordinate compound radicals. A few of the above radicals will be noticed now; the others will be spoken of when their compounds come under consideration. Amide NHa, or amidogen. This compound radical is believed to bv -enerated when ammonia is heated in contact with potassium or sodium; hydrogen is liberated, and a compound formed of amyde and the metal. When the amyde of potassium or sodium thus generated is put into water, this liquid forms ammonia by yielding up hydrogen to the amyde; and at the same time it converts the potassium into potash by giving up its oxygen. According to this view, ammonia is an amyde of hydrogen. Ammoniated mercury (white precipitate) is a compound of amyde and the bichloride of ^Carbonic oxide, CO, has already been spoken of as a compound of carbon. By combining with carbonic acid, CO3, it constates oxalic acid, CO3. The most important compounds of this' ^ical are carbamide, oxamide, and chloroxycarbomc acid, a compound ot carbonic oxide and chlorine. , - , j- i ~r \,an Benzule or Benzyle, C"H'03,-the hypothetical radical of ben- 80 CHEMISTRY. zoic acid, and of the oil of bitter almonds. By the addition of an atom of oxygen and an atom of water, it forms benzoic acid. By substituting an atom of hydrogen for an atom of oxygen, benzoic acid is converted into the oil of bitter almonds, or the the hydruret of benzule. This hydruret does not pre-exist in the bitter almonds, but is the result of the reaction of two organic principles contained therein, denominated amygdalin and emulsin, or synaptase, with water. Benzule forms a compound with amide called benzamide. Cinnamyl, C18H8Oa, has much analogy with benzule. It is the radical of the oil of cinnamon, and of a few other compounds. Glyceryl, C6H7, the compound radical of glycerine, the hydrated oxide of glyceryl, which is the base common to many oils and fats. Glycerine will be more fully spoken of under the head of Oils. Cetyl, CgJ-I.,;,, an organic radical, which performs precisely the same part in spermaceti that glyceryl does in ordinary fats. SECTION II. VEGETABLE NON-AZOTIZED SUBSTANCES. These embrace Gum, Sugar, Fecula, or Starch, and Lignin; and, according to Prout, they may be considered as hydrates of carbon. GUM. This is a proximate principle, which spontaneously exudes from various trees. It is distinguished from resin by being soluble in water and being insoluble in alcohol. Guerin divides the gums into three classes :—1. Arabin, of which gum arabic is the type, soluble in cold water. 2. Bassorin, of which tragacanth is the type, which swells into a jelly, but does not dissolve in water. 3. Cerasin, from the gum of the cherry-tree; insoluble in cold, but soluble in hot water. The mucilage of gum arabic differs somewhat from the mucilage of flaxseed : the former is precipitated by the subacetate of lead; the latter by the neutral acetate. Pecline, or the jelly of fruits, seems closely allied to the gums. It forms pectic acid. SUGAR. This is found in various saccharine natural juices, as of the Sugar Cane, the Maple, the Beet, &c. There are several varieties of sugar. Cane sugar, C^H^O^; prepared from the juice of the sugar-cane by boiling and evaporating; this constitutes common brown sugar; it is refined by dissolving in water, and removing the impurities by LIGNIN, OR CELLULOSE. 81 means of coagulating albumen. The uncrystallizable portion ia named molasses. Grape sugar, C^H^O^, exists in many vegetable juices, especially in grapes. Examples of it are seen in candied sweetmeats, and in raisins ; it also occurs in the urine in diabetes. Grape sugar differs from cane sugar in several particulars : it is less sweet, less soluble, and does not form such regular crystals. Strong mineral acids have but little effect on grape sugar; the alkalies, on the contrary, produce a decided effect. Sugar of milk, lactine, C^OJH^;—this is the sweet principle of milk: it is procured by evaporating whey. It undergoes fermenta- tion, like other sugars, but is believed to be converted into grape sugar in the process. Mannite or Manna sugar C6H706;—this differs from other sugars in not undergoing the vinous fermentation. There is also a sugar from mushrooms and liquorice. FECULA, OR STARCH. A very abundant proximate vegetable principle, abounding in roots, stems, and seeds. It is procured from flour or potatoes by the action of a stream of water upon them so as to wash of the insoluble par- ticles of fecula. , prop —Insoluble in cold water, alcohol, or ether; appears to be a homogeneous substance, but if examined by the microscope, it is found to consist of granules, having a thin insoluble envelope; when starch is put into hot water, the envelope bursts, liberating the con- tents, which form with the water a gelatinous mass ihe most delicate test for starch is iodine, which forms with it a blue colour. The size of the granules of fecula varies very much, according to the source from which it is derived. Arrow-root, sago, and tapioca, are examples of pure fecula. ,,..,/. *„♦•„„ In the process of the germination of seeds, and of the fermentation of malt, the starchy matter of the grain is converted into a sweetish gummy matter, called dextrine, and ultimately into grape sugar The cause of this remarkable change is due to a peculiar principle found resident in the grain at that period, named diastase, which acts by catalysis,—itself undergoing no change. Dextrine has the same composition as starch It is used mthe arts as a substitute for gum. Sulphuric acid also has ^ pow«nrf converting starch into sugar. Nitric acid converts it into oxalic acid. LIGNIN, OR CELLULOSE. This constitutes the basis of vegetables andI ofwood. It^pro- cured from sawdust by dissolving it successively »n ^'^ ' ether, dilute acid, and an alkaline solution. It has no taste, may 82 CHEMISTRY. be converted Into dextrine and grape sugar by the action of strong sulphuric acid. In its composition it is isomeric with starch. SECTION III. AZOTIZED VEGETABLE SUBSTANCES. These include Gluten, Vegetable albumen, Vegetable fibrin, and Vegetable casein, or Legumen. They are sometimes called vegeto- animal principles, from their strong analogy with similar principles found in animals. Gluten.—It owes its name to its adhesive property: to it is due the adhesiveness of wheat-dough. It exists chiefly in the seeds of plants, in combination with starch ;—may be separated by washing away the starch from wheat flour. It is almost insoluble in water, but soluble in alcohol; gluey when moist, but yellow and translucent when dry. It is a highly nutritious substance. It is owing to it that the rising of wheaten bread is due; the carbonic acid which is formed by the fermentation of the yeast being entangled in the meshes of the gluten, and thereby imparting the cellular structure to the loaf. Vegetable albumen, Vegetable fibrin, and Vegetable casein also exist in vegetables in combination with gluten. Vegetable albumen is coagulated by heat; vegetable casein is coagulated by acetic acid. The chemical composition of all these principles is nearly, if not quite identical, being C^HyN^O^, with some sulphur. SECTION IV. OILS AND FATS. Oils are divided into two classes, fixed and volatile; the former produce a greasy stain upon paper, which is permanent under the action of heat; the stain produced by the latter is removed by heat. There is no essential difference between oils and fats; the chief distinction is in their different degrees of consistency. All of them have more or less attraction for oxygen; some of them to such an extent as to produce spontaneous combustion of light substances moistened with them. This is very apt to be the case with linseed oil; from this results the division of fixed oils into drying and non- drying : the oils used in painting belong to the first class. The parts of vegetables which contain most oils are the seeds; olive oil is obtained from the fruit itself. The fixed oils have but slight odour or taste ; whenever these qua- lities are found in a fixed oil, they are due to a volatile principle associated with it, as in the case of butter. They are all insoluble OILS AND FATS. 83 m water, but slightly soluble in alcohol, with the exception of castor oil, but soluble in ether and in volatile oils. Although oils -ippear to be homogeneous, they in reality consist of several proximate principles. Of these, the most solid one in animal oils is called stearin; in vegetable oils, margarin; the most liquid in both is named olein, or elain. These principles may easily be isolated by submitting the whole to boiling alcohol, which, on cooling, deposites the margarine and stearine, but retains the olein. The margarine may be then separated from the stearine by ether, and the olein from the alcohol by distillation. These three principles consist respectively of an acid, united with a base. The acid is named oleic, stearic, and margaric; the base is the same for each; it is called glycerine. When any of the fixed oils or fats are mixed with an alkali, a change takes place denominated saponification, resulting in the for- mation of a soap; the several acids just mentioned quit the gly- cerine with which they were united, and combine with the alkali. Thus common soap, made by the action of potassa on fat, consists chiefly of a stearate of potassa. If a soap be decomposed by an acid, the particular fat acid of which the soap may have been con- stituted will be precipitated. The formation of the lead plaster is a true instance of saponification, the oleo-margarate of lead being formed, and the glycerine remaining in solution. Spermaceti.—This substance is found in the cranium of a certain species of whale, in union with an oil. It has a crystalline struc- ture, melts at 120°, is soluble to some extent in boiling alcohol, also in ether. It is saponified with difficulty, two substances resulting, called ethal and ethalic acid. Wax.—This substance, whether procured from the bee, or from the pollen and leaves of flowers, is found to consist of two distinct principles termed cerine and myricine; these principles may be separated by boiling alcohol. All the fixed oils are compounds of carbon, oxygen, and hydrogen. Volatile Oils.—These are very numerous, and impart the peculiar odours to plants. They are procured from the various parts of plants by distillation with water, common salt being sometimes added to elevate the boiling point. When pure, they are colourless, but they generally have a slight tinge; they have a powerful odour and strong taste; do not sapo- nify; absorb oxygen when exposed to the air; are freely miscible with the fixed oils ; are very slightly soluble in water; freely so in alcohol and ether. They consist of two proximate principles, ana- logous to those of the fixed oils, and named stearoptm and eleaopttn. Some of the volatile oils consist solely of carbon and hydrogen, as the oil of turpentine; others, of carbon, hydrogen, and oxygen ; and a few contain sulphur, as the oils of mustard, horseradish, &c. 84 CHEMISTRY. Camphor is a solid volatile oil, having all the characters of the essential oils. Resins.—These are generally found in vegetates associated with some volatile oil. Common rosin affords a good example; it is pro- cured from turpentine, which is a compound of rosin and the volatile oil of turpentine When turpentine is distilled, the oil passes off, leaving the rosin behind. Resins are insoluble in water, but soluble in alcohol, and in vola- tile and fixed oils; they are inflammable, and yield on distillation car- buretted hydrogen, and several other products; a moderate degree of heat imparts an adhesive quality to them. Some resins resemble fixed oils, in containing two principles, one being more soluble in alcohol than the other. Resins are also susceptible of saponification. Concentrated nitric acid acts upon resins with an explosive violence. The most important resins, beside rosin, are lac, copal, mastic, and dragon,s blood. Amber is a fossil resin. Caoutchouc, or India rubber, is an exudation from a tree, resem- bling both the volatile oils and the resins. It is peculiar in being elastic. Balsams. — This term is properly used to express a native compound of resin, volatile oil, and benzoic acid, as in the balsams of Tolu and Peru. The name is also given to compounds of resins and volatile oils, as copaiva. The term Gum-resins is applied to a class of vegetable sub- stances, consisting of a mixture of gum and resin, with some other principles : they comprise some of the most valuable medicines, as opium, gamboge, ammoniac, assafixtida, myrrh, scammony, &c. SECTION V. OF ETHER, ALCOHOL, AND SOME OTHER COMPOUNDS OF THE RADICAL ETHYL. The radical ethyl has not been isolated ; its composition is ex- pressed by 0*H*. Common ether is an oxide of ethyl, C4H*0 ; and alcohol is a hydrated oxide of ethyl, C4Hs0-f-H0. Consequently, the conversion of alcohol into ether only requires the removal of an atom of water. The rationale then of the action of sulphuric acid on alcohol, is merely to remove the water upon which the alcohol depended for its existence. There is hardly any acid with which a peculiar ether bearing its name has not been formed, such as nitric ether, acetic ether, tartaric ether, &c. The oxide of ethyl, in consequence of being procured by the action of sulphuric acid on alcohol, was formerly called sulphuric COMPOUNDS OF ETHYL. 85 ether, the name which it continues to bear in commerce; it is also frequently known by the simple name ether. Prepared by boiling together equal weights of alcohol and sulphuric acid, and receiving the products in a vessel surrounded by ice. Various other substances are generated at the same time, such as sulphovinic acid, oil of wine, sulphurous acid, and others. The ether obtained may be mixed with a little caustic potash, and redistilled by a gentle heat. Prop.—Pure ether is a colourless, transparent, fragrant liquid; sp. gr. about *720; boils at 96°; very volatile and inflammable; burns with a white flame, generating water and carbonic acid. Its vapour has a sp. gr. of 2-586. When mixed with oxygen, it ex- plodes with violence by means of an electric spark. When ether is transmitted through a red-hot tube, it is decomposed into oleflant gas, light carburetted hydrogen and aldehyde. It is very soluble in alcohol; but only one part is dissolved in ten of water. It may be separated from alcohol by the addition of water, which unites with the alcohol. It is a solvent for oils and fats generally ; but its solvent powers are inferior to those of either alcohol or water. Regarding ether to be a compound of ethyl with oxygen, or an oxide of ethyl, it is found that this oxide is capable of uniting with the ox- acids, and forming with them compounds analogous to salts. All the halogen bodies, as chlorine, iodine, bromine, &c, unite directly with the radical of ether, just as they do with metallic radicals. The following are some of the ether compounds: Ethyl, - - - - C'H* Oxide of ethyl, ether, - - C4H50 Hydrate of the oxide, alcohol, - C4HsO + HO Chloride of ethyl, - - - C4H5+C1 Iodide of ethyl, - - ■ C4H5+I Bromide of ethyl, - - - C*H5 + BL^ Nitrate of oxide of ethyl, - C4H*0+ NOs Hyponitrite of oxide of ethyl, - C4H*0+ N03 Oxalate of oxide of ethyl, - OH*0 + C203, &c. These compounds of ethyl and its oxide are obtained from alcohol— the hydrated oxide—by the action of the corresponding acids, as on an ordinary metallic oxide. Hydrate of oxide of ethyl, Alcohol.-This.compound can only be obtained through the medium of the vinous fermentation When a solution of sugar, in connexion with some ferment, as yeaT" s subbed to a temperature of 70* to 80°, an intestin., move ment commences, denominated fermentation ; bubbles of g£ «^M»; the liquor becomes turbid; but after a white £**«»»? 0tcupied b^ the suoar is found to have disappeared, and its place soCC^aby alcohol. Such a liquid will yield alcohol by distillation. The gas 8 86 CHEMISTRY. which is generated and escapes is carbonic acid. The chemical change which is produced is the conversion of one atom of anhy- drous grape sugar into two atoms of alcohol, and four atoms of car- bonic acid. Two atoms of alcohol - - - C8HttO« With four atoms of carbonic acid, - - C4 O8 Form one atom of sugar, - - - C^H^O" In the process of fermentation, the yeast, or ferment, itself under- goes no change whatever; its action being merely that of catalysis. The various kinds of fermented liquors, such as wine, cider, beer, &c, are made from the juices of different fruits, or from infusions of grain. These all contain sugar, and a fermenting principle, and hence will undergo the vinous fermentation, provided they be exposed to a proper temperature. The amount of alcohol contained in the fermented liquors varies from 3 to 20 per cent. By distilling any of the fermented liquors, the different spirituous liquors, or ardent spirits, are procured; these contain about 50 per cent, of alcohol; and by a second distillation, they yield the commercial alcohol, or rectified spirit, which has a density of -835, and which yet contains about 14 per cent, of water. Pure or absolute alcohol cannot be obtained by any number of distillations, unless quicklime, chloride of calcium, or sulphuric acid be employed at the same time, to combine with the water. Pure alcohol is colourless and limpid; has a sp. gr. of*793; is inflammable, burning with a pale bluish flame, and yielding water and carbonic acid; boiling point, 173°; unites with water in all pro- portions ; also with ether; has powerful solvent powers; it has never been frozen by the most intense cold. The process of making bread is an instance of the vinous fermen- tation : the yeast added to the dough, converting a small portion of its sugar into carbonic acid and alcohol. The gas thus liberated, forces the tough and adhesive mass into bubbles; these still further expand by the heat of the oven, which at the same time dissipates the alcohol. Chloride of Ethyl—Hydrochloric Ether.—This is prepared by the action of hydrochloric acid on alcohol, the products being collected in a cold receiver; or else alcohol may be added to the materials for generating hydrochloric acid, viz., common salt and sulphuric acid. The rationale is precisely similar to that of hydrochloric acid on a metallic oxide. Prop.—A colourless limpid liquid, very volatile, of a penetrating aromatic odour; sp. gr. *874; boils at 52°; soluble in 10 parts of water. ORGANIC ACIDS. 87 Bromide of ethyl—Hydrobromic ether;—a very volatile liquid, heavier than water,—of a penetrating odour and taste. Iodide of ethyl, Hydriodic ether;—very closely resembles the last. Sulphuret ofethyl;—a colourless liquid, of a disagreeable alliacious odour ; boils at 163°. Cyanide of ethyl—resembles the last. Sulphate of oxide of ethyl—Sulphovinic acid, C4H50, 2S03-f-HO. —Sulphuric acid forms no neutral compound with the oxide of ethyl. Sulphovinic acid is the acid sulphate of ethyl. It is formed by the action of strong sulphuric acid in alcohol, as in the preparation of ether; on cooling, it is diluted with water, and neutralized with chalk, which throws down sulphate of lime ; the sulphovinate of lime is afterwards deposited in crystals: from this, sulphovinic acid may be obtained by the aetion of dilute sulphuric acid. It is a sour liquid, very apt to be decomposed into alcohol and sulphuric acid; forms sulphovinates with bases, which are soluble. Phosphate of oxide of ethyl, or Phosphovinic acid, is a compound very analogous to the foregoing. Nitrate of oxide of ethyl, Nitric ether.—This compound has only lately been prepared. It is formed by the action of nitric acid on alcohol, with the addition of urea; the latter substance being requi- site, to prevent the formation of hyponitrous ether. It has a density of 1*112 ;—is insoluble in water;—has an agreeable sweet taste. Hyponitrite of the oxide of ethyl, Hyponitrous ether, Nitrous ether.—This is best prepared, according to Liebig, by the action of hyponitrous acid, derived from nitric acid on starch, on alcohol, and condensing the product. A better method—that of Dr. Hare—is to act upon hyponitrite of soda by sulphuric acid and alcohol; the pro- cess being conducted in a refrigerated receiver. It is a pale, yellow liquid, very volatile, possessing an exceedingly agreeable odour and taste; boils at 62°; sp. gr. -947. It is the active principle of sweet spirits of nitre, which consist of hyponitrous ether dissolved in alcohol. In the same way we have Carbonic Ether, Oxalic Ether, Acetic EiJier, Formic Ether, Spc. fyc. SECTION VI. ORGANIC ACIDS. Acetic acid, C*H303+H0.—The hypothetical organic radical °f this acid is Acetyl, C*H3 ; its hydrated protoxide is named Aldehyde, C*H30+HO ; and its hydrated peroxide, Acetic acid. Aldehyde is a clear, colourless liquid, of an etherial odour; has a density of *790, and boils at 72°. Acetic acid is formed in two ways: by the oxidation of alcohol, 88 CHEMISTRY. and by the destructive distillation of wood. Various fermented liquids when exposed to the air become sour, that is, their alcohol unites with the oxygen of the air, giving rise to vinegar. The formula for alcohol is C4H50-f HO. If to this we add four atoms of oxygen, we have C4H6OH-40, which gives the formula of hydrated acetic acid, = C*H303, HO+2HO. The vinegar of commerce is chiefly made from wine or cider. The acid from wood is procured by distilling hard wood in close ves- sels : acetic acid is found among the products which come over; this requires redistillation and some subsequent treatment. This variety is termed pyroligneous acid. The strongest acetic acid is prepared by distilling anhydrous ace- tate of soda with concentrated oil of vitriol. Crystals of hydrate of acetic acid are formed, which may be drained from the more fluid portion. At the temperature of 63° these crystals fuse into a limpid liquid, of a density of 1-063, possessing the pungent smell and taste of vinegar, and capable of blistering the skin. It is soluble to any extent in water and alcohol. Its vapour is inflammable. The water, which is essential to the constitution of acetic acid, is basic, and can only be replaced by some metallic oxide; anhydrous acetic acid, in a separate state, is unknown. The acetates are all soluble salts ; those of silver and mercury are least so. The most important acetates are the acetate and sub- acetate of lead, acetate of ammonia, (spirit of Mindererus,) and acetate of copper (verdegris). Acetone, orpyroacetic spirit, is a volatile, colourless liquid, which is produced when any of the metallic acetates are subjected to a de- structive distillation. It has a density of 792°, and boils at 132°; it is very inflammable, burning with a bright flame. Citric acid, C^ Hs Ou-f 3HO.—This acid is found in the fruits of the genus citrus, including the lemon, sour orange, citron, and lime; also in several others, in combination with malic acid. It may be procured by saturating lemon juice with chalk, and then de- composing the citrate of lime by means of sulphuric acid. The citric acid crystallizes on evaporation. It forms colourless prismatic crys- tals, very soluble in water, of a very sour taste. The three atoms of water which it contains are essential to its constitution. Malic acid, C5H408-f 2HO, derives its name from the apple, in which fruit it largely exists. It may be procured by saturating apple juice with lime, and decomposing the malate of lime by sulphuric acid. It is a deliquescent acid, without colour, and an acid taste. It is bibasic. Lactic acid, C6H505-f-HO, derives its name from the word lac, the Latin for milk. It is the acid which exists in sour milk. It has lately been shown to be the product of a peculiar fermentation called viscous, by which the sugar of milk is converted into lactic acid. It ORGANIC ACIDS. 89 is owing to the generation of this acid, that milk, when kept, becomes ^ curdled,—the acid which is formed coagulating the casein. It is mo- nobasic. Tartaric acid, C8H4O10+2HO.—This is the acid of grapes, tama- rinds, and several other fruits, in which it exists combined with potassa. The tartaric acid of commerce is prepared from the tartar or argol, an impure acid tartrate of potash, which is deposited from the grape-juice during the process of fermentation. The argol, when purified and deprived of its colour, constitutes cream of tartar. The acid is obtained from this salt by saturating it with carbonate of lime, by which it is converted into a tartrate of lime, and a tartrate of potassa; the latter is separated from the former, which is insoluble, by filtration ; the tartrate of lime is then decomposed by sulphuric acid. It forms colourless, transparent crystals, freely soluble in water, of a sour taste. As it is bibasic, it requires two equivalents of a base to form with it a neutral salt; hence, the salts which it forms with a single atom of a fixed base, have an acid reaction, and require the presence of an atom of basic water. Thus, the salt heretofore known as bitartrate of potash (cream of tartar) must now be considered as an acid tartrate of potash and water. This salt forms small transparent crystals ; it is tolerably soluble in boiling water, sparingly so in cold water; has an acid reaction and sour taste. There is also a neutral tartrate of potash, called soluble tartar, which contains two equivalents of the base united to one of acid. Tartrate of potash and soda,—Rochelle salts ;—made by neutra- lizing a solution of cream of tartar with carbonate of soda. It forms large prismatic, transparent crystals, freely soluble in water. Acids precipitate cream of tartar from its solution. Tartrate of antimony and potassa,— Tartar emetic ;—made by boiling sesquioxide of antimony in a solution of cream of tartar ; the excess of acid unites with the base. Tartar emetic crystallizes in octohedrons with a rhombic base; very soluble in boiling water ; has an austere metallic taste. Its solution is decomposed by both acids and alkalies ; the former throws down a mixture of cream of tartar and oxide of antimony ; the latter, the oxide. Sulphuretted hydrogen precipitates the sulphuret of antimony. Tartaric acid is distinguished by forming with any salt of potash the well-known cream of tartar. Heat converts tartaric acid into pyrolartaric acid. Tannic acid, C18H5Ob+3HO. This is the astringent principle found in many vegetables, as the oak, gall-nut, &c.; it is generally associated with gallic acid. It is best procured by pouring commer- cial sulphuric ether on coarsely powdered galls, and allowing it to percolate slowly. The water, which always exists in combination with common ether, dissolves out the tannic acid, while the ether 8* 90 CHEMISTRY. takes up the gallic acid and other matters ; hence the liquid which has passed through will consist of two distinct strata, the lower one, which is a concentrated aqueous solution of tannic acid, and the upper etherial solution. The latter having been carefully removed, the tannic acid may be obtained by evaporation. It has a light yel- lowish colour, of a porous, feathery texture; has a very astringent but not bitter taste; very soluble in water, less so in alcohol; insolu- ble in pure ether ; has an acid reaction. Tannic acid yields with the sesqui-salts of iron a deep bluish-black precipitate; it also precipitates the solution of tartar emetic, nitrate of silver, sulphate of copper, and acetate of lead; with gelatin it forms a dense whitish compound—tannate of gelatin, the basis of leather. The variety of tannin yielded by kino, catechu, and krameria, gives a greenish-black precipitate with the salts of iron. Leather is made by soaking hides, which have been deprived of their hair, for a considerable time in an infusion of oak-bark: the tannin which it contains combines with the gelatin of the skins. Gallic acid, C7H03 + 2H0, is usually found combined with tannic acid. It is believed to result from the action of the oxygen of the air upon tannic acid. It is not so soluble in water as tannic acid, nor does it precipitate gelatin, but it yields with sesqui-salts of iron a bluish-black compound.— Writing ink is a tanno-gallate of iron. The remaining vegetable acids are of less importance; the most interesting of them are : Formic acid—the acid of ants;—prepared from sugar or starch by the action of sulphuric acid and peroxide of manganese. It some- what resembles acetic acid. Benzoic acid,—oxide of benzule,—exists in the various balsams. It is best procured from gum benzoin by sublimation. It is in the form of white crystals, very light and feathery ; exhales a fragrant odour, not due to the acid itself, but to some of the volatile oil; it forms benzoalcs. Meconic acid,—exists in opium combined with morphia and codeia. It is characterized by forming a blood-red coloured compound with a sesqui-salt of iron. SECTION VII. THE VEGETABLE ALKALIES--VEGETO-ALKALIES. The vegeto-alkalies, or alkaloids, constitute a peculiar group of compounds. They are met with in various plants, always in combi- nation with an acid, which, in many cases, is itself peculiar in its nature, not occurring elsewhere in the vegetable kingdom. They VEGETABLE ALKALIES. 91 are generally insoluble in water, but dissolve in hot alcohol. Their taste in solution is usually intensely bitter, and their action on the animal economy very powerful, in consequence of which they are of the greatest value as medicines, containing, as they do, the most active properties of the plants in which they are respectively found. They all contain nitrogen, and are complicated in their constitution, having high combining numbers. The number of these bodies is very large; only the most impor- tant will be here noticed. Morphia,—the active principle of opium;—exists in it as a meconate; procured from an infusion of opium by means of ammo- nia which throws down the morphia, leaving the meconate of ammo- nia in solution. It forms small shining crystals, which are colourless; nearly insoluble in water; soluble in hot alcohol; forms soluble salts with the acids, the most important of which are the sulphate, muriate, and acetate. Narcotina,—exists also in opium ; it is separated from the other principles by boiling ether, which yields it on evaporation. Codeia,—exists in opium as a meconate; forms colourless crystals, rather more soluble in water than morphia. Codeia forms salts with the acids. Other principles found in opium are Paramorphia or Thebavny Pseudomorphia, and Narceia, besides Meconic acid, which has already been alluded to. Quinia and Cinchona,—the active principles of Peruvian bark;— exist in it in combination with kinic aeid; procured from an in- fusion of bark by the action of quicklime, which combines with the kinic acid, liberating the alkalies; these are then to be taken up by boiling alcohol, and decolorized by animal charcoal. Quinia occurs as a whitish powder; it does not crystallize. Cin- chona is in the form of minute crystals. Both are very insoluble in water, but dissolve in boiling alcohol. Their most important salts are the sulphates, which are soluble in water. Strychnia and Brucia, alkalies existing in the Strychnos nux vomica, St. Ignatius' bean, and false Angustura bark: they are associated with igasuric aeid. Veratria,—the alkaline active principle of the Veratrum sabadiUa, and of the Veratrum album, or white hellebore. Emetia is the alkaline principle of ipecacuanha. Colchicina,— the active principle of the Colchicum autumnale. Solania,—the alkali of the Solanum dulcamara. Caffeia, or Theine,—the active alkaline principle found both in coffee and tea. We have also Atropia, from belladonna ; Aconitia, or Aconitiney from aconite; Daturia, from stramonium; Coneia, from hemlock; Nicotina, from tobacco, &c, &c. 92 CHEMISTRY. Besides the foregoing vegetable alkaline principles, there exist a number of neutral principles in plants, possessed of very active properties. Some contain nitrogen, and some do not. The most important of them are Phloridzin, Salicin, Asparagin, Gentianin, Elaterin, Cathartin, Quassin, Lupulin, Ergotin, &c, &c. SECTION VIU. ANIMAL COMPOUNDS. Protein and its compounds.—The most important protein com- pounds are Albumen, Fibrin, and Casein. Albumen exists in eggs and the serum of the blood,—being com- bined in the latter with soda: the white of an egg affords a good example of it. It is not soluble in water, unless a little alkali be present; coagulates by heat, acids, creasote, alcohol, and electricity ; it gives precipitates with most of the metallic salts, particularly cor- rosive sublimate, for which it is the best antidote. It is composed of carbon, oxygen, hydrogen, nitrogen, sulphur, and phosphorus;—or supposing protein to be represented by Pr., the formula for albumen would be, Pr + P + Sa. Fibrin constitutes the chief portion of muscular flesh; it is also an important constituent of the blood, in which it exists in the soluble state. It may be procured either from muscle, or preferably, by whipping freshly drawn blood with a twig; the fibrin adheres to it in long white filaments. Its characteristic is its spontaneous coagulation ; it is in consequence of this tendency that blood coagu- lates when drawn from the body. Its composition is very nearly identical with that of albumen,—containing one equivalent less of sulphur. Albumen is converted into fibrin, in the living body, in the process of organization. Its proportion in the blood is liable to variation by disease. Casein is found in milk, and is the basis of cheese. It closely re- sembles albumen, but differs from it in not being coagulable by heat. In composition it is nearly identical with the two foregoing sub- stances, but it contains no phosphorus. From either of the above three compounds, protein may be pro- cured, by dissolving them in an alkaline solution, and then precipi- tating by an acid. Gelatin and Chondrin.—These principles constitute the bases of skins, tendons, cartilage, and fibro-cartilage, &c. Any of these, when boiled for a long time in water, yield a jelly, which, on cooling, solidifies into gelatin or glue. Isinglass is the dried swimming- bladder of the sturgeon. Chondrin is very analogous to gelatin : PROTEIN AND ITS COMPOUNDS. 93 it is procured in the same manner, from cartilage. Both are soluble in hot water. Gelatin is characterized by giving a precipitate with tannic acid,—tannate of gelatin. The different solids and fluids of the body all contain various in- teresting principles, as for example, blood, urine, chyle, bile, bonesy nerve-substance, &c.; but the space here allowed will not permit an examination of them. In fact, they more properly come under the division of Physiology, to which the student is referred for an ac- count of them. THE END. HANDBOOK OF THE PRACTICE OF MEDICINE. THE OTHER PORTIONS OF THIS SERIES ARE ANATOMY, WITH ONE HUNDRED AND FIFTT-SEVEN ILLUSTRATIONS. PHYSIOLOGY, WITH FORTY ILLUSTRATIONS. SURGERY, WITH FIFTY ILLUSTRATIONS. MIDWIFERY, WITH THIRTY-SEVEN ILLUSTRATIONS. MATERIA MEDICA AND THERAPEUTICS, WITH TWENTY-NINE ILLUSTRATIONS. CHEMISTRY, WITH NINETEEN ILLUSTRATIONS. ANY ONE OF WHICH MAY BE HAD SEPARATELY, SEWED IN A WRAPPER FOR MAILING. HANDBOOK PRACTICE OF MEDICINE: BEING A PORTION OF AN ANALYTICAL COMPEND VARIOUS BRANCHES OF MEDICINE. JOHN NEILL, M.D., DEMONSTRATOR OF ANATOMY IN THE UNIVERSITY OF PENNSYLVANIA, LECTURER ON ANATOMY IN THE PHILADELPHIA MEDICAL INSTITUTE, ETC. FRANCIS GURNEY SMITH, M.D., LECTURER ON PHYSIOLOGY IN THE PHILADELPHIA ASSOCIATION FOR MEDICAL INSTRUCTION, ETC. PHILADELPHIA: LEA & BLANCHARD. 1848. Entered, according to Act of Congress, in the year 1848, By Lea & Blanchard, In the Clerk's Office of the District Court for the Eastern District of Pennsylvania. C. SHERMAN, PRINTER, 19 St. James St. CONTENTS/ Fever, definition of .... Idiopathic and symptomatic fevers defined Classification of fevers .... Intermittent Fever . Causes, Varieties Seasons of occurrence . . . . Symptoms, stages .... Treatment during the paroxysm - " " the intermission Remittent Fever, definition, varieties of Symptoms ..... Congestive, or malignant remittent Anatomical characters, complications - Treatment -.-... Infantile Remittent Fever, varieties Symptoms - Diagnosis ..... Treatment...... Hectic Fever ..... Symptoms, Treatment .... Pernicious Fever, definition, varieties Symptoms, course, &c. - Cause, prognosis * Treatment - Yellow Fever, definition .... Symptoms, stages - Anatomical characters, cause, diagnosis, prognosis Treatment ------ Typhoid Fever, synonymes, symptoms, course Anatomical characters, cause, diagnosis - Prognosis - Treatment - * In the preparation of this part, the authors have had in view VI CONTENTS. Typhus Fever, synonymes, symptoms, course, &.c. Duration, anatomical characters .... Causes and nature of the disease .... Diagnosis, tabular view , - Treatment ....... Rubeola (measles), symptoms ..... Prognosis, sequela? - k - Treatment - Scarlatina, varieties of—Simplex, Anginosa Maligna Treatment ------- Erysipelas, varieties of - Treatment ------- Varicella, symptoms ...... Diagnosis, treatment ..... Variola, varieties ....... Stages ....... Treatment ....... Vaccination, ....... Rheumatism, parts attacked, forms- - - - - Treatment ------- Gout ..-..--. Symptoms, treatment during an attack Treatment during the interval, and in retrocedent gout Diseases of the Thoracic Viscera—Acute Laryngitis, symptoms Morbid appearances, treatment - Chronic Laryngitis—Croup, stages of- Physical signs, morbid appearances, treatment Spasm of the Glottis ------ Regions of the Chest. Table of physical signs - Bronchitis, varieties and symptoms of ... Sthenic and asthenic bronchitis, symptoms Of the sputum in bronchitis .... Physical signs of bronchitis - Morbid appearances - Treatment ------- Pertussis (hooping-cough), symptoms Physical signs, morbid appearances, treatment Chronic Bronchitis, causes, morbid appearances Treatment - - - - - - .. Spasmodic Asthma, exciting causes, symptoms - Physical signs, morbid appearances - Treatment ------. Diseases affecting the Tissue of the Lungs—Pneumonia Symptoms ....... Physical signs ....... CONTENTS. vii Morbid appearances, treatment ..... 71 Emphysema of the Lungs, Causes . . . . .73 Symptoms, physical signs, morbid appearances - - - 74 Treatment ---..„.. 75 Phthisis Pulmonalis. Tubercle, seat of - . - ib. Morbid appearances, pathology, stages of - - - - 76 Physical signs --...-.78 Of the sputum - - - - - - -80 Treatment .-...-.81 Diseases of the Pleura. Pleuritis. Symptoms - - - 84 Physical signs .......85 Complications, morbid appearances - - - - - 87 Treatment ------- 89 Diseases of the Heart and its Membranes. Auscultation of the heart in health........90 Morbid sounds of the heart ----- 92 Endocarditis and Pericarditis. Symptoms, physical signs - - 94 Frequency of the disease, morbid appearances, treatment - 95 Hypertrophy, Dilatation, and Atrophy of the Heart, Angina Pectoris ib. Consequences of diseased heart - - - - - 97 Angina Pectoris ....... ib. Symptoms, treatment - - - - - - -98 Of particular Hemorrhages. Epistaxis. Causes, symptoms, treatment ib. Hemoptysis and Pulmonary Apoplexy .... 99 Pathology, symptoms, treatment .... 100,101 Hjematemesis. Causes, symptoms Physical characters of the hemorrhage Treatment ... Hematuria. Symptoms ... Treatment Of Dropsies and their Causes Nephritic Dropsy Pathology, symptoms Causes, treatment - Hydrothorax - Symptoms, physical signs, treatment Ascites. Causes, symptoms Diagnosis, treatment Diseases of the Digestive Organs and their Appendages - 111 Cynanche Tonsillaris. Causes, symptoms, treatment - - - ib. Inflammation of the Pharynx. Treatment - - - - 112 Gastritis. Causes, symptoms, treatment - - - 1 • Chronic Gastritis. Symptoms, treatment - - - -113 Dyspepsia. Causes, symptoms, treatment - Dysentery. Causes, symptoms, morbid appearances - - - 115 Treatment 102 103 ib. 104 105 ib. 106 107 ib. 108 109 110 Vlll CONTENTS. Chronic Dysentery. Treatment .... Diarrhoea—Cholera Morbus. Symptoms, causes Treatment ...... Cholera Infantum. Symptoms - Treatment ...... Asiatic Cholera. Symptoms .... Morbid appearances, treatment .... Colic. Symptoms, treatment .... Colica Pictonum. Causes, symptoms, treatment Ileus. Symptoms, morbid appearances, treatment Peritonitis. Causes, symptoms, morbid appearances, treatment Enteritis ...... Chronic Peritonitis. Tabes Mesenterica . - - Worms. Varieties, treatment .... Hepatitis—Acute and Chronic .... Jaundice. Causes, symptoms, treatment ... Gall-stones. Symptoms, treatment Diseases of the Nervous System and its Appendages - Hydrocephalus. Causes ..... Symptoms, morbid appearances ... Treatment ...... Chronic Hydrocephalus ..... Encephalitis. Causes, symptoms, morbid appearances Treatment ------ Delirium Tremens. Symptoms .... Morbid appearances, treatment Apoplexy. Characteristics ..... Causes, symptoms ..... Serous Apoplexy. Diagnosis, morbid appearances Treatment ...... Paralysis. Paralysis from Cerebral Hemorrhage - Treatment ...... Epilepsy. Causes, symptoms..... Morbid appearances, treatment Chorea. Causes, symptoms ..... Treatment ...... Hysteria. Symptoms, treatment .... Appendix. Treatment of Typhoid Fever PRACTICE OF MEDICINE. FEVERS. Fever signifies an acute affection of the system, in which all the functions are more or less deranged; the most striking phenomena being sensorial or nervous irregularity, increased frequency of pulse, increased heat, and disinclination for food. The most common signs of fever, are shivering, followed by heat of skin, restlessness, and thirst; headache, flushed face, and quick pulse; general aching, and debility of the body. There are very many varieties of fevers; the first grand distinc- tion is into the idiopathic or essential, and the symptomatic. By an idiopathic fever is meant one which arises without any ob- vious local cause ; not being produced by or dependent upon disease of any particular organ of the body. By a symptomatic fever is meant one which depends upon or is caused by inflammation, or other local disease. Idiopathic fevers are often accompanied by inflammation;—thus inflammation of the mucous membrane of the throat accompanies scarlatina; inflammation of the cerebral membranes, or lungs, or intestinal mucous membrane, may go together with typhoid; hence some eminent physicians have persuaded themselves, that typhoid is not an idiopathic fever, but that it is symptomatic of a local inflam- mation. But, in a symptomatic fever, the local inflammation begins first— in an idiopathic fever, on the contrary, the feverish symptoms begin first, and may continue some time before any local disease appears, even if it appear at all. Idiopathic fevers are most commonly caused by some poison which gets into the blood. Their chief kinds are, the intermittent, remittent, continued, and exanthematous; each of which kinds has many varieties. Symptomatic fevers may be of an acute inflammatory type, or hectic, or typhoid. We may observe here, that ap intermittent fever 14 PRACTICE OF MEDICINE. is sometimes symptomatic of disease in the urethra, and remittent fever of worms and accumulations of sordes in the alimentary canal. classification of fevers. 1. Intermittent. 7. Vaccine disease. 2. Remittent. 8. Chicken pox. 3. Yellow fever. 9. Measles or rubeola. 4. Typhoid or enteric fever. 10. Scarlatina. 5. Typhus. II. Erysipelas. 6. Small pox or variola. 12. Plague. Of several of these there are varieties, as, for instance, we may have inflammatory, or congestive intermittents or remittents. Some are propagated by contagion, and are hence called contagious ; some have the property in common that they are attended with an erup- tive affection, and are denominated eruptive, or exanthematous fevers. These are, in many instances, interchangeable terms; most con- tagious fevers being exanthematous, and most of the exanthemata contagious. Each, however, is distinct individually. INTERMITTENT FEVERS, OR AGUES. These are characterized by febrile paroxysms, recurring at stated times, and by the absence of fever between the paroxysms. Causes.—They are commonly produced by a subtle atmospheric poison, which has received the name of malaria, or marsh miasma. It has been said that this poison is produced by the putrefaction of vegetable substances ; but it seems that a certain amount of heat and moisture are sufficient, without any vegetable matter. Thus it is very abundant on many sandy soils, where there is no vegetation at all; and—it must be noticed, that it does not proceed from lands which are inundated, so much as from those which have been flooded and are drying. It is more virulent in hot climates than in tempe- rate—in low situations than in high; the upper stories of a house being much more healthy in aguish districts than the lower. It is carried about by winds, but interrupted by trees; and is always more dangerous by night than by day. It is far more likely to at- tack persons exhausted by fatigue, intemperance, or illness, than the healthy : these, therefore, are predisposing causes. Cases sometimes occur, which proceed obviously from some temporary irritation, such as the introduption of instruments into the urethra, indigestible food in the stomach, worms in the intestinal canal, &c. Varieties.—The three most common varieties are— 1. The quotidian, in which the fit comes on every day, generally in the morning, and lasts about ten or twelve hours. 2. The tertian, which comes on alternate days, generally about noon, and lasts till evening. 3. The quartan, which comes on once in three days, usually ip INTERMITTENT FEVERS, OR AGUE. 15 the afternoon. It has the longest cold fit, but the shortest paroxysm altogether. There are also double quotidians, having two paroxysms every day. Double tertians, having a paroxysm every day, but at different hours. Sometimes there are two paroxysms on one day, and none the next; this is called a duplicated, or doubled tertian. The triple tertian has two paroxysms on one day, and one on the intervening. In double quartans, out of three days, two have each one paroxysm, and the other none. Of all these varieties, the double tertian is the only one which often occurs. A distinction is made between the interval, and the intermission of an ague. The interval, is the space between the beginning of one paroxysm, and the beginning of the next; which in the tertian is forty-eight hours; the intermission, is the space from the end of one paroxysm, till the beginning of the next: in other words, the time when the patient is free from the disease; which in the tertian is about forty-two hours. This is also called apyrexia. The type of the fever has a reference to the length of the interval. Besides the varieties mentioned above, there are quintans, sextans, octans, &c, but they are very rare. Seasons of occurrence. — The quotidian commonly occurs in spring; the tertian at the end of summer, and beginning of fall; the quartan later in the fall. Symptoms.—An ague fit consists of three stages : 1. The cold stage.—This begins with chilliness and constriction of the whole body; the nails are blue; the rings drop off the fingers; the skin is rough (cutis anserina), and there are violent shiverings, and chattering of the teeth; head-ache and back-ache, quick, small pulse, oppression at the precordia, and sometimes vomiting. After these have lasted some time, there comes the 2d, or hot stage, beginning with flushes of heat, which gradually increase, till the skin becomes very hot and dry, the face flushed, the temples throbbing, and the pulse full and hard. After a dura- tion of from three to eight hours, comes the 3d, or sweating stage.—Perspiration begins on the head and face, and becomes profuse all over the body; and the urine deposits a copious lateritious sediment. Now, in uncomplicated cases, the pa- tient feels well, but weak, till the next recurrence of the fit. Some- times one of the stages is wanting, as for instance the cold stage. This form is called a dumb ague. Sometimes the fever is wanting, or has neuralgic pains substituted for it. The sweating stage is also sometimes absent, or is supplied by copious urination, or diarrhoea. Treatment in ordinary cases.—First of all, give a grain or two of calomel with an aperient, so as to clear the bowels. If the sto- mach is very foul, an emetic may be used, though it is not essential. Then, during the paroxysm. During the cold stage, warm drinks of tea, or wine-and-water, if the patient be feeble, or addicted to its 16 PRACTICE OF MEDICINE. use ; hot foot-baths ; warm bed ; frictions of the spine. During the hot stage, cool drinks; and after the sweating, let the skin be rubbed dry with warm towels. When the fit is over, begin with some antiperiodic remedy, to prevent its recurrence. The best is quinine, of which from two to four grains should be given every four hours, in solution with a few drops of dilute sulphuric acid, tincture of orange-peel, and water. Under some circumstances, it may be necessary to administer the whole dose, either immediately before or after the paroxysm ; as, for instance, when the apyrexia is exceedingly short, as in the quo- tidian. Upon the whole, however, it is best, if possible, to introduce it into the system gradually. The remedy should be continued in gradually decreasing doses, for ten days or a fortnight after the last fit, as the complaint is very apt to return. If the quinine is rejected by an irritable stomach, it may be in- jected into the rectum in solution in distilled water, with a drop or two of laudanum; or a blister be applied to the epigastrium, and the surface be dressed with a strong solution. If the quinia cannot be procured, or if it does not produce good effects, the next best remedy is liquor arsenicalis, in doses of rr? v.— • x. ter die. Other remedies are, willow bark, piperine, sulphate of zinc, ammonia, sulphate of copper, and all the vegetable bitters and astringents; but they are much inferior in virtue to the quinine. Opium given in a full dose sometimes puts off the fit, if given just before it is expected; and it is also of great use to shorten the hot stage; but not of much service in the cold. Bloodletting, in the cold stage, was recommended by Dr. Macin- tosh, but in ordinary cases is now repudiated by most physicians. It may, however, be necessary in the violent agues of hot climates, when there is great internal congestion, or delirium and cerebral excitement. The great congestion in the abdominal veins which occurs during the cold stage, is very apt to produce enlargements and induration of the liver, and especially of the spleen, the tumour formed by which is commonly called ague cake; and the obstruction to the venous circulation caused by these is liable to induce dropsy. REMITTENT FEVERS. Syn.—Bilious fever:—Bilious remittent fever. In this form of fever, the febrile phenomena evince striking ex- acerbations and remissions, one paroxysm occurring in the twenty- four hours. It is caused by some atmospheric poison. It is most common in the middle and southern sections of the United States, although it occurs in all parts lying between the northern lakes and REMITTENT FEVER. 17 the Gulf of Mexico. The localities that it most frequents are the valleys of streams, the borders of lakes and ponds, the neighbour- hoods of marshes, and the western prairies. The seasons in which it occurs are the summer and autumnal months. Symptoms. — For several days previous to the invasion, the patient complains of uneasiness at the epigastrium, lassitude, pains in the back, limbs, and head, and restlessness at night. The inva- sion is attended by coldness of the surface, and frequently by shiver- ing ; this coldness is soon superseded by heat, by febrile flushes, or by alternations of heat and cold, by nausea, and occasionally by vomiting. The pains in the head, back, and limbs, now become aggravated; the mouth is clammy and dry; the tongue white or loaded; the surface very hot and parched; the face flushed; and the pain of the head attended by a feeling of distention and throbbing, often passing into delirium. The pulse is full, hard, and frequent; thirst is urgent; the bowels constipated; and the urine scanty and high-coloured. There is usually more or less epigastric tenderness, with nausea, and often with vomiting. These symptoms generally continue from about ten or twelve to eighteen hours, when perspira- tion breaks out; the pulse falls in frequency and strength ; delirium disappears, and the irritability of the stomach subsides: there is merely a remission or abatement, but no intermission of the febrile symptoms. The remission is exceedingly variable in duration, in some cases not lasting more than two or three hours, in others a whole day; being shorter or longer, according as the type of the fever may be quotidian or tertian. Another paroxysm then occurs, running the same course and ending in like manner, each successive exacerbation becoming, generally, more severe and protracted, and each remission less decided. The symptoms become now more violent. The remissions dis- appear; the skin becomes dry and harsh, or moist and clammy; the pulse small and irregular; the tongue black and crusted ; and the vomiting, and pain at the epigastrium, more constant. In the most unfavourable cases, yellowishness of the skin occasionally supervenes. The bowels become irritable, the evacuations being watery, greenish, and, at last, almost black. The urine is scanty and high-coloured, or sometimes of a yellowish-brown colour. The headache is intense, accompanied often by vertigo, tinnitus aurium, and delirium. The disease may run on thus for a time varying from the seventh to the fifteenth day, when it either declines with a profuse perspira- tion, a diarrhoea, or a general subsidence of all the symptoms, or else it runs on to a fatal termination. Sometimes it terminates in an intermittent; at others in a continued fever. Bilio-inflammatory remittent fever.—This form differs but slightly from the foregoing in its symptoms and course. Violent 18 PRACTICE OF MEDICINE. determination to the brain characterizes the commencement of reac- tion in this variety; and inordinate affection of the liver and mucous surface, the more advanced stages. Congestive, or Malignant remittent.—This is one of the severest and most fatal of endemic fevers. As its name implies, the disease is of a malignant type from the commencement. The great danger here is, that when the patient is raised, perhaps with great effort, out of the paroxysm, the practitioner may regard it as incipient con- valescence, and neglect the precautions necessary to ward off the next, which may prove fatal. Anatomical characters.—Inflammation of the stomach and bowels is perhaps the most frequent lesion. The glands of Brunner are often much developed, but Peyer's glands are unchanged. The membranes of the brain are sometimes inflamed, and sometimes there is congestion. The liver is often enlarged, more or less sof- tened, and, according to Dr. Stewardson, of a bronze or slate colour. The spleen is also enlarged and softened. Complications.—Gastro-duodenitis is among the earliest compli- cations of remittents ; in the more advanced stages, dysentery occa- sionally comes on. Diseases of the liver and spleen are common attendants on remittents. Determination of blood to ihe brain often occurs early in the more severe forms. In temperate climates, remittents are frequently associated with bronchial or pulmonary affections. Treatment.—In the mild form, before reaction comes on, and when there are no indications to forbid its administration, an emetic is generally very useful. After its full operation, a large dose of calomel, or calomel and opium, may be given, and an action be pro- duced on the bowels by purgatives and cathartic enemata. These means being repeated until morbid secretions and fsecal accumula- tions are removed, bark or quinine may be prescribed, if the re- missions are distinct, and there be no signs of cerebral or gastric inflammation. When a paroxysm of great violence has been sub- dued, and there is danger that the next may prove fatal, recourse should be had to the sulphate of quinia, no matter how short or im- perfect the remission may be. The quantity must be sufficient to bring the system under its influence before the next paroxysm. The remedy should be continued until two daily paroxysms have been prevented; after which the patient may be considered safe. In some cases, where the patient's strength will admit of it, moderate bleeding, in the stage of excitement, will shorten the disease, and render the remissions more perfect. During reaction, in the early exacerba- tions, frequent doses of James' powder with calomel, or tartarized antimony, given in repeated doses, will oftentimes promote a favour- able termination. The effervescing draught is considered by some authors as particularly applicable to bilious remittent fever. When INFANTILE REMITTENT FEVER. 19 given cold, it corrects the nausea and vomiting better than any thing else. If it gripes, a little laudanum may be added to it. The neutral mixture, and the spirit of Mindererus are also highly recommended. Cold sponging is often very refreshing to the patient, but should be discontinued if he complain of chilliness. Any complications that may be present will require distinct treatment, according to the organs that are affected. INFANTILE REMITTENT FEVER. This disease usually attacks children from nine or ten months to twelve or thirteen years old. It generally arises from errors in diet, and accumulation of morbid matter in the prima? vice. It may also arise from obscure miasmata. Writers in the three last cen- turies imputed this fever to worms, hence the term " worm fever /" but the presence of worms is rather a complication than a cause of the affection. Symptoms.—This affection commences gradually ; the bowels being irregular, generally costive, but occasionally relaxed and irritated. The child remains feverish and drowsy towards evening, but generally seems pretty well in the morning. The appetite is variable; the pulse ranges from 100 to 140; and the tongue is loaded. After these symptoms have lasted for several days, a dis- tinct chill or rigor is sometimes observed ; vomiting ensues ; and a more violent paroxysm of fever, drowsiness, flushed cheeks, and shooting pains through the abdomen and head, follow. The child constantly picks its lips and nose; and occasionally stiffness of the neck, great sensibility of the general surface, and tenderness in the course of the spine, are observed. In the more advanced stages, the ingesta are either thrown off unchanged, or passed undigested from the bowels. In very young children, convulsions come on ; in those of more advanced age, delirium often attends the night exacerbations. This is the most common form of the disease. Acute variety.—This form may occur rather suddenly. The bowels are irregular, commonly costive; the evacuations are morbid and offensive ; tbe urine turbid, pale, or milky ; and the tongue is loaded, especially at the base. Fever supervenes, and is ushered in by rigors or chills, the child being hot and restless at night. During the exacerbations, the child is drowsy ; and if it sleeps, moaning, starting, and even screaming, or incoherence, are observed; some- times with vomiting, there is flatulent distension of the abdomen, accelerated breathing and cough. The face is usually flushed; the abdomen and palms of the hands hotter than other parts of the body ; and the pulse varies from 120 to 160, according to the age. Occasionally the paroxysm terminates in a slight perspiration, which is often partial; the child falls into a quiet sleep, and the pulse sinks in frequency. 20 PRACTICE OF MEDICINE. Diagnosis.—In infantile remittent fever, the cerebral symptoms do not appear until near the close of the disease; in hydrocephalus, they invariably occur before the end of the first week, and often- times sooner. The acceleration of the pulse, the remissions and the diarrhoea, which are always constant symptoms of infantile remittent fever, will serve to distinguish it from acute hydrocephalus, in which the bowels are always constipated from the commencement of the disease, and the pulse occasionally slow. Chronic form of remittent.—This form either makes its approach insidiously or follows the acute. The child wastes, the abdomen enlarges, the breath is offensive, and the strength fails. The tongue is white or loaded, but moist, and has often a strawberry-like appear- ance; the bowels are generally costive, and the evacuations are always unhealthy. The pulse is usually about 100 in the day, but rises to 140 in the evening. There is generally one exacerbation in the twenty-four hours, and it seldom appears before evening, lasting until morning, and terminating in sweats. If the disease be not removed, tympanitic distention of the abdomen, emaciation, harsh discoloration of the skin, enlarged mesenteric glands, chronic diarrhoea, and lientery, supervene. This affection is liable to be mistaken for chronic inflammation of the pia mater in children. Treatment.—If the affection be acute, and the child strong, leeches should be applied to the epigastrium, calomel and James' powder ought to be given at night, and a mild aperient draught in the morning. If the bowels are not evacuated by these means, an enema should be given; equal parts of castor oil and oil of turpentine in water-gruel form the best enema in these cases. The calomel and James' powder should be repeated every night, or on alternate nights; and a purgative mixture be given in the morning. When the evacuations have been improved by these means, mild tonics may be employed ; of these, the infusions of cinchona, cascarilla, and of valerian, form the best; stimulating liniments, and other counter-irritants, should be applied to the abdomen. The foot-bath, some mustard flour being added to the water, will be found useful at bed-time. Small doses of sulphate of quinine may be exhibited; and if the disease assume the adynamic form, small doses of chlorate of potass, in an infusion of valerian or of cinchona may be given with advantage. Change of air, especially to a dry and elevated situation, should be recommended. Warm clothing, frictions of the surface, and light, but nourishing diet, are also very beneficial. During the complaint, farinacea, and weak broth, are the most suitable food. Where the disease has produced mesenteric obstruc- tion, small doses of iodide of potassium may be exhibited. When convalescence is established, the iodid. ferri will be found a useful tonic. PERNICIOUS FEVER. 21 HECTIC FEVER. Hectic fever is a remittent fever, rarely, if ever, idiopathic, but depending upon some local source of irritation, especially if attended with an exhausting discharge ; perhaps arising from the absorption of diseased secretions. Symptoms.—Hectic fever is attended with great and increasing debility, a weak, quick, and rather hard pulse, hurried respiration on any exertion, and increased heat of the skin. The exacerbations, which are at first slight, soon become more evident, particularly in the evening; are preceded by a slight or marked chill; are attended by increased heat, which is most evident in the hands and face, the skin being at first dry; and terminate in a free, profuse perspiration, especially the evening paroxysm, which subsides in this manner early in the morning. The bowels are at first costive, but soon become relaxed, and colliquative diarrhoea comes on: the urine is various; generally it is pale, and does not deposit; more rarely, it is high-coloured, and yields a lateritious sediment. While there is general pallor of the surface, the cheeks present what is very aptly styled the " hectic blush." As the disease advances, the whole frame becomes emaciated; the eyes are sunk in their orbits, but are brilliant and expressive; the ankles and sometimes the legs are oedematous, and the sleep is feverish and disturbed. At last, the diarrhoea and colliquative sweats become more abundant, the respi- ration more hurried, and the debility so great that the patient expires while making some slight exertion. Treatment.—This must essentially depend on the cause or patho- logical state which occasions the hectic fever. Where there is dis- ease of the digestive mucous membrane, the treatment consists in strict attention to the diet, in improving the condition of the secretions, in the administration of mild tonics, and the occasional exhibition of saline refrigerant diuretics, and diaphoretics. Gentle astringents, mineral acids, &c, are useful. Of the acids, sulphuric given in infusion of roses is to be preferred. Anodynes in the form of conium, hyosciamus, and humulus or opium are occasionally given. PERNICIOUS FEVER. Syn.—Congestive fever.—Pernicious intermittent.—Pernicious remittent.—This term should be restricted to an affection, in which there is great and sudden prostration or depravation of the nervous power, or, to use a customary phrase, in which the innervation is extremely and most dangerously defective or deranged. (Wood.) This modification of miasmatic fever may be intermittent, remit- tent, or continued. It is only, however, when of two or three days duration, that it can be called continued, for if the disease persist, it will almost certainly become paroxysmal. Most frequently it is inter- 22 PRACTICE OF MEDICINE. miltent; and although often a quotidian, is more frequently tertian in its type. Symptoms.—-In some cases the organic functions are most affected; then the evidences of disease are presented chiefly in the organs of digestion, respiration, circulation, calorification, and secretion. In other cases the blow falls upon the animal functions, then the brain is the organ most affected. Of the organic functions, sometimes one is selected in preference to the rest. Thus the force of the morbific cause appears to fall, in some instances upon the heart, in others, upon the alimentary canal, in others again, upon the surface of the body, either in its function of secretion or calorification. Sometimes it approaches like an ordinary intermittent, at others, with its own peculiar features. It may occur at any hour of the day or night. When the disease is fully formed and exists primarily in the organic functions, the face and hands are of a livid paleness, the features shrunk and expressive of alarm, the skin contracted and shrivelled like a washerwoman's, the extremities, the trunk, and sometimes even the breath are cold. The surface is, at times, moistened with a clammy perspiration, or bathed in a profuse sweat. The tongue is pale and cold, sometimes dry, sometimes unaltered; there is epigastric tenderness, with great internal heat and intense thirst. Nausea and incessant vomiting are present, with constipation, or the reverse. In the latter case the discharges consist of bloody serum, sometimes of blood, either coagulated or not. The respiration is characteristic, the breathing consists of deep sighs, and with two inspiratory efforts to one expiration. Sometimes it is hurried, irregular, and panting. The pulse is small, irregular, sometimes corded, but oftener feeble, fluttering, and sometimes intermittent. It is almost always frequent, amounting to as much as 120 or even 160 in the minute. With all these symptoms there is great restless- ness, the patient attempting to rise from his bed to reach the door or window. The duration of the paroxysm varies ; sometimes it will extend over two or three days, mingled with attempts at reaction, sometimes it will last but a few hours, and then reaction comes on, though in no degree equal to the preceding depression, and the patient seems as if about to be restored to health. At other times a slight degree of fever remains; it is only a remission that has taken place. If not arrested, the same train of symptoms recurs the next day or the day after with increased violence, the second paroxysm often proving fatal, though sometimes a third occurs, before death takes place. Sometimes the whole force is spent upon the heart, then the promi- nent phenomena are those of excessive prostration of the circulation. In some cases coldness is the prominent symptoms; in others an PERNICIOUS FEVER. 23 ordinary intermittent paroxysm runs its course and ends in profuse and exhausting perspiration, during which the pernicious symptoms appear. When the animal functions are affected the paroxysm usually begins with drowsiness, loss of memory, confusion, gradually passing into deep coma, or an apoplectic state with stertorous respi- ration. Pulse full, and either faster or slower than in health. Some- times convulsions are present. In some cases coma is preceded by delirium. Cause.—The cause is undoubtedly the same as that of ordinary intermittents and remittents. What it is that gives rise to its pecu- liar character is unknown; probably a more intense action of the poison, or a greater susceptibility to its influence. Its localities differ from those of ordinary bilious fever; while the latter occupy the table lands, the pernicious fevers prevail especially in the low lands skirting the rivers. Prognosis.—Exceedingly unfavourable; three-fourths of the cases, when not properly treated, die. Sometimes whole settlements are swept off by the disease. If seen during the first or second paroxysm the danger may be averted. Treatment.—The first indication is to bring about a reaction as speedily as possible. One of the most obvious remedies is artificial heat; sinapisms to the extremities and abdomen, or along the spine, and frictions with turpentine or cayenne pepper should be used. Opium is useful for its stimulating and anti-emetic properties, and for its influence in arresting alvine discharges ; it is best adminis- tered in substance, but should not be used when there is any affec- tion of the brain, as shown by active delirium or stupor. Internal stimuli should also be administered ; of these the sulphate of quinia is the best, and may be given even in the paroxysm before reaction. It should be used, however, in decided doses, and may be employed in any prostrate case, in which it can be borne by the stomach. Another remedy decidedly called for is calomel, and it may be ad- vantageously joined with both quinia and opium. The internal administration of cayenne pepper is also of great benefit; it may be taken in five grain doses. The proportions of these remedies must vary to suit the circumstances; so also must the articles employed. If these means fail to bring about reaction, wine or brandy may be given: cold affusion is also recommended, but it should not be car- ried too far. When coma is present, blood should be taken by cups, or from the arm, if admissible. The treatment in the intermission or remission should be the same as in ordinary intermittent, except- ing that the sulphate of quinia should be given in much larger doses. From 30 to 60 grains should be taken from the beginning of one paroxysm to that of the next. 24 PRACTICE OF MEDICINE. YELLOW FEVER. Synonymes.— Typhus Icterodes.—Bulam Fever.—Vomito negro. — Vomito prieto. This is a disease of warm climates, occurring mostly during the summer months, and ceasing on the appearance of frost. It is met with chiefly in towns upon the seaboard, or upon streams emptying into the ocean. Symptoms.—The attack may or may not be preceded by pro- dromic symptoms, very often coming on without any warning, and occurring in the midst of ordinary health. It is generally ushered in with a chill, and severe pains in the back and limbs. After febrile reaction has been established, the skin is hot and dry, the respiration hurried, the face flushed, the eyes red and watery, and the con- junctiva much injected. There is a sense of uneasiness, sometimes tenderness at the epigastrium, accompanied by nausea and vomiting. The tongue is at first moist and covered with a yellowish-white fur; there is also extreme thirst. The pulse ranges from the natural standard to 120 or even 140. Sometimes it is unnaturally slow; either extreme is significant of great danger. Sometimes there is delirium and prostration; at others, the mind is clear, and the mus- cular strength unimpaired. The bowels are ordinarily costive, and when discharges are obtained, they are commonly unhealthy in character. As the disease advances the pain in the limbs becomes more intense, especially in the lower extremities, the calves and front of the legs. This stage is called by some authors the stage of invasion, and lasts from a few hours to three days; the shorter the duration, the more violent, generally, is the disease. After this comes the stage of remission, or, as it is sometimes called, the stage without fever. All the symptoms abate, and the patient seems to be convalescent; there are symptoms present, how- ever, by which the experienced are warned of the continuance of the disease. The epigastrium is even more tender upon pressure, the skin becomes yellow or orange colour, the urine assumes a yellow tinge, and the pulse sometimes sinks as low as 40 in the minute. After a short calm the stomach assumes its former irritability, and the peculiar substance called black vomit is ejected. The tongue is dry, brown, and chapped. The patient becomes more and more prostrated; there are, at times, passive hemorrhages, at others, sup- pression of urine, or retention. The pulse becomes more and more feeble, the respiration sighing, the matter ejected from the stomach is brought up without effort, and discharges of the same matter take place from the bowels. This stage is sometimes called the stage of collapse. Sometimes, instead of collapse, symptoms of reaction set in, which are always to be regarded as a salutary effort of nature, YELLOW FEVER. 25 sometimes terminating in health, sometimes, however, running on to extreme exhaustion, or assuming a typhoid form. Anatomical characters.—The membranes of the brain are often found injected, and serum effused into the ventricles. The stomach usually presents traces of inflammation, having its mucous coat either reddened, thickened, softened, or eroded. The peculiar mat- ter called black vomit, is now generally believed to be blood altered by admixture with the acid secretion of the stomach. The liver is altered in colour and consistence. According to Dr. J. Hastings, U. S. N., it resembles old boxwood in colour, and is much harder than natural. Sometimes it is dry and anaemic, though rarely in- flamed. It varies in colour from a lemon yellow to a straw colour, and in consistence, from being soft and friable to positive induration. Cause.—Speculation is rife as to the cause of this disease. There is no doubt that it is as specific as that of small pox, though of its precise nature nothing definite is known. Heat and filth, alone, are not able to produce it; neither are marsh miasmata, independently of other causes. Strangers are more liable to it than long residents, and whites more than negroes. Among the predisposing causes are exposure, intemperance, fear, and sudden changes of weather. Diagnosis.—At first it is not easy. As the disease advances, how- ever, the severe pains in the back and lower extremities, the peculiar injection of the conjunctiva, the excessive irritability of stomach, the yellowness of the skin, and finally the black vomit, are enough to diagnosticate the disease. Prognosis.—Generally regarded as unfavourable, though much depends upon the person attacked, the character of the epidemic, and the severity of the symptoms. Symptoms of great prostration are very unfavourable, and a total suppression of urine is a certainly fatal sign. Strangury, however, is regarded as a favourable sign. Treatment.—Early in the disease, before there is much irritability of stomach, an emetic is of great service, particularly if the stomach be loaded ; it should only be used, however, under these circum- stances. Bloodletting, to be of service, should be employed early, and even then, not unless called for by the violence of the symp- toms and the state of the pulse. Mercurials are, on all sides, de- clared to be of great service in this disease. They should be admi- nistered first with a view to their cathartic action, and then to their specific influence, as rapidly as possible. Febrifuge medicines are also called for; of these perhaps none is so good as ice given inter- nally, together with cool sponging externally; the latter with caution. Ice also often allays the excessive irritability of the stomach, lo the same end the effervescing draught may be employed, and sina- pisms or leeches externally. If the pain in the head is very great, cups or leeches may be employed, together with cold applications to the part In the second stage, the febrifuge and depleting remedies 26 PRACTICE OF MEDICINE. should be suspended, except the mercurials, to which may be added the acetate of lead, with a view of diminishing the inflammation of the stomach, and also lor its astringent properties. Blisters may also be applied to the epigastrium, and the raw surface sprinkled with acetate of morphia. In the third stage cordials and stimulants are demanded. Sulphate of quinia, infusions of bark, or serpentaria, carb. of ammonia, cap- sicum, turpentine, wine whey, or brandy and water, may be admi- nistered. External stimulants, as frictions, sinapisms, hot baths, &c, may also be found beneficial. The apartment should be kept well ventilated, and all excrementitious matters removed. TYPHOID FEVER. Syn.—Common continued fever.—Enteric fever.— Typhusmitior. —Nervous fever.—Abdominal typhus.—Mucous fever.—Entero- mesenteric fever.—Follicular enteritis.—Dothinenteritis. Symptoms, course, fyc.—The disease is sometimes preceded by prodromic symptoms. There is a sense of weariness, languor, and general uneasiness, slight headache on rising in the morning, dull- ness of intellect, irregular flushes of heat, or chilliness, slight accele- ration of pulse, furred tongue, and a disposition to diarrhoea. These symptoms may last from several days to a week or more, after which the disease is established by the occurrence of a chill followed by the ordinary phenomena of fever. The disease being fairly established, there is increased frequency of pulse, ranging from 90 to 110 or 120; the latter usually in females ; as a general rule the pulse is under a hundred. There is headache, with a dull, heavy expression ; pain in the back and limbs ; restlesness and insomnia; epistaxis, and yellow watery diarrhoea. As the disease advances these symptoms become aggravated, the pulse is more frequent and strong ; the skin hot and dry; the tongue dries, and becomes red at the tip and edges: there is pain in the right iliac region, with a gurgling sound upon pressure ; tympanitis is also present, and there also appears about this time, symptoms either of bronchitis or pneumonia. About the seventh or ninth day, if the surface of the abdomen be examined carefully, there will be discovered upon it a number of small, round, red spots, disappearing upon pressure, these are called the rose-coloured spots, or taches rouges, and constitute a characteristic eruption. At the same time a crop of vesicles will also be detected upon the neck and thorax, called sudamina. All the symptoms at this period are aggravated, delirium supervenes, with ringing or buzzing sounds in the ears, followed by dullness of hearing or deafness. The eyes are injected, the tongue becomes incrusted with a black coating, which often cracks and peels off, TYPHOID FEVER. 27 nrZg Th i8"^ eXp°Sed' and the teeth are ^vered with sordes. Ihe pulse becomes more feeble and frequent, there is a low muttering delirium, and sometimes twitching or spasm of the muscles. As the patient becomes more feeble he slips down to the foot of the bed ; there are involuntary evacuations, hemorrhage fern the bowels or other mucous surfaces, with petechia and vibices upon the skin. 1 his is the usual course of the disease when it terminates unfavour- ably. If the disease is to terminate favourably, the symptoms abate, the countenance brightens, the tongue cleans, the pulse lessens in frequency, and the evacuations become more healthy. It often happens that at this time the emaciation becomes more evident than it was before. Sometimes in the course of the second week, the patient is seized with intense pains in the abdomen, vomiting of green, bilious matters, a small fluttering pulse, syncope, constipation, and coldness of the extremities. The cause of these symptoms is perforation of the in- testine, and escape of its contents into the cavity of the peritoneum, producing inflammation. It occurs most frequently in the mild forms of the disease, and is almost uniformly fatal. Anatomical characters.—There is scarcely an organ of the body that may not be the seat of some anatomical lesion. Those which are considered characteristic of this fever, however, are thickening, hardening, softening, and ulceration of the glands of Peyer ; the condition varying with the stage of the disease. Enlargement, soft- ening, and ulceration of the mesenteric ganglia, more especially those corresponding with the morbid patches in the intestine, and, according to some writers, ulceration of the solitary mucous follicles of the ileum. Other lesions met with are, ulceration of the pharynx and epiglottic cartilage; softening of the spleen, sometimes of the liver and kidneys; hepatisation of the lungs; softening of the heart; and sometimes in- flammation of the meninges of the brain with effusion. The blood drawn in this disease is generally deficient in fibrine, and is said by some authors to contain an excess of blood-corpuscles; this is doubtful. Cause.—On this point little is definitely known. It attacks all classes, rich and poor, though it is often generated where a number of persons are crowded together, with unwholesome, or insufficient food, and confined and vitiated air. It cannot be said either to be contagious, since it is very seldom if ever communicated in isolated cases. Age is a predisposing cause. It rarely attacks those beyond thirty. Strangers are more liable than long residents, and males than females. It may occur at any season, but most commonly in the autumn and winter. It rarely occurs more than once, hence, perhaps, its comparative infrequency in the aged. Diagnosis.—By the slowness and insidiousness of the attack ; by 28 PRACTICE OF MEDICINE. the diarrhoea; the dusky hue of the countenance; the epistaxis; the gurgling in the right iliac fossa; the tympanitis ; the rose- coloured eruption ; the stupor or delirium ; the appearance of the tongue; and lastly, by the duration of the disease, and the peculiar musty smell lAen the skin is dry, and acid smell when it is moist. Prognosis.—Not even the mildest cases can be looked upon as free from danger, and on the other hand there is no condition so low, no symptom so fatal, that death should be considered inevitable. Among the unfavourable symptoms, are constant delirium, a belief on the part of the patient that nothing ails him, a sudden shifting of position on the elbows, deep coma, stertorous respiration, great sub- sultus, rigidity of the limbs, profuse diarrhoea, or hemorrhage from the bowels, great prostration and frequency of the pulse, and exces- sive tympanitis. The favourable symptoms have been already mentioned. Treatment.—This should usually be commenced by some mild laxative, such as a small dose of sulphate of magnesia, castor oil, rhubarb and magnesia, or a seidlitz powder, according to the nature of the case. The practitioner should always bear in mind the diar- rhoea, or the tendency to it, and avoid all irritating and drastic cathartics. The next thing is to obviate febrile symptoms. This may be done by venesection, when the pulse is full and strong, and there is sanguineous determination to the brain. The protracted duration of the disease, must also here be borne in mind, and no blood drawn unless imperatively demanded. Leeches, or cups to the head, and to the right iliac fossa, may be advantageously em- ployed, where there are evidences of congestion in the first, or of in- flammation, as evinced by pain and tenderness, in the second locality. Diaphoretics are useful throughout the whole course of the disease. TYPHUS FEVER. Syn.— Typhus gravior.—Spotted fever.—Jail, camp, and ship fever.—Petechial fever.-—Putrid fever. Symptoms.—Before the attack the patient often exhibits certain premonitory symptoms. He is low-spirited and languid ; loses his appetite, and he feels ill without knowing why. There are usually at the same time sharp pains in the head, back, loins, and lower extremities. Violent shivering is often the immediate precursor of the disease; sometimes, however, the cold stage is so slight as scarcely to be noticed. The febrile condition, when fairly established, is generally well marked. The skin is hot and dry, and of the heat of that pungent, biting character called calor mordax. The pulse is full, frequent, and possessed of some degree of strength, but is easily compressed. The tongue is moist, and covered with a yellowish-white fur. Some- TYPHUS FEVER. 29 times there is nausea and vomiting. The bowels are costive, and no stools are procured without medicine. The aspect of the patient is peculiar; the countenance is of a dusky hue, with injection of the eyes ; the features are fixed and inexpressive, or expressive only of apathy and indifference. As the disease advances the symptoms augment in violence ; the heat of skin increases, the pulse rises in frequency, and diminishes in force, ranging generally from 120 to 150, or 160. The respira- tion is frequent, and, according to Gerhard, feeble and imperfect at the back and lower part of the chest, which is also dull on percus- sion. At a period ranging from the fourth to the eighth day, a peculiar eruption appears upon the surface, not confined, however, to any particular locality. It varies in colour from a dusky reddish- brown to purple or black. It is not elevated above the surface, neither does it disappear upon pressure. It is petechial in character. Sudamina are rare in this disease. The tongue becomes dry, brown and cracked ; the urine scanty and highly coloured ; the dejections, when procured, black and offensive ; a peculiar ammoniacal odour is exhaled from the body; the nervous symptoms become more prominent, there is dizziness, confused vision, tinnitus aurium, and sometimes deep stupor, which becomes characteristically more profound as the disease advances. Sometimes violent delirium (typhomania) takes the place of stupor; the patient is sleepless or restless, with the sen- sation of utter prostration and helplessness. Should no improvement take place the disease passes on to the last stage, that of prostration. The patient lies insensible, or in a muttering delirium, with subsultus tendinum, floccitation, hiccough, involuntary evacuations, and extreme insensibility of the surface, till at length death approaches silently and without violence. Sometimes a critical discharge takes place from some organ and the patient begins to convalesce, which is generally, however, by slow degrees, and under the influence of supporting remedies. The duration of the disease varies, sometimes, in mild cases, ter- minating on the seventh day, sometimes running out to three weeks or more. Death rarely occurs before the second week. Anatomical characters.—There is only one constant lesion, (and it is questionable whether it can be considered entirely characteristic,) that is, the want of coagulability in the blood, and the petechial erup- tion ; all the other lesions may be considered incidental. No disease is discovered in the glands of Peyer, unless in some few cases, in which there is a complication with typhoid fever. A very fatal form of typhus fever prevailed among the black population of Philadelphia, in the fall of 1847. Many died at the onset of the disease. A num. ber of post-mortem examinations were made but the results were uniform in but few particulars. The blood was fluid and uncoagu- lated, resembling the settlings from claret wine. Petechias were not 30 PRACTICE OF MEDICINE. confined to the skin, but were numerous in the muscles and deep seated cellular tissue. The skin, fasciae, muscles, and cartilages were often turgid with bile. There was great congestion of the liver, lungs, and brain. Thickening of the arachnoid, and effusion beneath it, were common appearances. Another common lesion was an effu- sion of blood in spots of variable size between the under surface of the dura mater and the outer lamina, or parietal layer of the arach- noid. Andral mentions two cases of this kind, and considers them rare. In one it was the result of an injury, and in the other the result of chronic inflammation of the membranes of the brain. Causes.—Crowding together a number of persons in badly venti- lated and filthy apartments; the persons so situated are capable of communicating the disease to others, although they may not have it themselves. Contagion is also a cause of this disease, though not a very powerful one where cleanliness and ventilation are duly attended to. Depressing influences of any kind are also capable of producing it: sex has little influence upon it; it is more common after 35 than before this age, and it is rare in infancy. It prevails at all seasons, and in all climates, though perhaps more in the winter, and in the temperate and cold climate. Of the nature of the disease little is known. The probability is, that a poison is absorbed which at once depresses the powers of the nervous system, and vitiates the blood. Diagnosis.—The peculiar hue of the countenance, with suffusion of the eyes ; the dark tongue, the sordes upon the teeth, the peculiar eruption, the constipation, the characteristic odour, and the collapse of the last stage, mark the disease. The differential diagnosis be- tween it and typhoid fever, with which it is often confounded, is pre- sented in a tabular form. TYPHOID FEVER. TYPHUS FEVER. Usually endemic; rarely epidemic. Epidemic usually. Not contagious. Certainly contagious; may be commu- nicated by those unaffected. Young adults and children most liable. Spares no age but infants. Age of greatest liability under 25. Age of greatest liability over 25. Best age for recovery from 15 to 25. Less fatal in early than in advanced life. Attacks strangers chiefly. Attacks all residents. Seldom ends before the 21st day. Ends sometimes by critical discharges from the 7th to the 14th day. Has no well-marked remissions. Remission after the 3d, 7ih and 14th day generally, and after marked ex- acerbations. Epistaxis common. Epistaxis very rare. Diarrhoea a frequent accompaniment; Costive usually until the 2d or 3d week; tympanitis. abdomen flat. Pulse usually under 100. Pulse usually over 100. TYPHUS FEVER. 31 Has a musty smell when the skin is dry; Ammoniacal odour, whether the skin is acid, when moist. drv or no^ Characteristic eruption appears about Eruption characteristic, appears earlier, the 7th or 8th day. and is more abundant. Sudamina from the 10th to the 15th day. Sudamina are rare in this disease. Petechia? are rare in this disease. Petechias and vibices are common. Has a constant anatomical lesion. Has no constant lesion. Has bronchitis commonly in the second Pneumonia of posterior part of lungs week. more common. No crisis by sweat, but a gradual re- Crisis by sweating in nearly every re- covery, covery. Occurs mostly in the fall and winter. Occurs mostly in winter and spring. Second attacks are rare. Second attacks do occur. Treatment.—A large well-aired room; frequent changes of linen; ablution of the patient's body ; removal of all unnecessary carpets and curtains; and the instant removal of all evacuations, are mea- sures desirable both to mitigate the patient's disease, and to prevent it from infecting his attendants. The chloride of lime may be scat- tered about the floor. The treatment of fever, according to the best modern physicians, should be expectant; that is, the symptoms should be watched and relieved as they arise, but no violent efforts should be made to cut the disease short. In the first stage, if there is much nausea and gastric disturbance, a mild emetic of ipecacuanha may procure relief. The bowels should be cleared out by an active aperient at the outset; say three grains of calomel, with rhubarb, and be kept open by milder doses; viz. hyd. c. cret., followed by castor oil, or an in- jection. Mercury, gently given, so as to touch the gums, has seemed of service in some epidemics, but not in others. The hair should be removed; and the head be bathed with cold lotion as long as there is much headache, and as long as it is agree- able to the patient. If there is great general heat of skin, the whole body may be sponged with tepid water. Bloodletting should never be practised from mere routine, but be reserved to combat any local inflammation that may arise. If the headache is very intense, with great heat, flushed face, and wild delirium, a small bleeding in the erect posture ; or rather a few leeches, or the loss of a little blood by cupping from the neck, will be advisable. Profound coma should be treated by a large blister to the shaven scalp. Great dyspnoea, with other signs of inflammation in the chest, must be combatted by a cautious cupping, followed by a blister, or mustard poultice; and small doses of senega. If the type of the fever is very low, and there is great feebleness, it will be necessary to give good beef tea, and small quantities of wine 32 PRACTICE OF MEDICINE. from an early period; and this need not hinder leeches from being applied to combat any local congestion. The use of opium in fever is nearly the same as that of wine. The general rule is to give opium, when nervous excitement exceeds vascular action, where there is much delirium, and sleeplessness, with a feeble pulse. In some cases it is right to give a good dose at once; in others, to feel the way cautiously with small doses. In some cases of excitement, in young subjects, opium may be given in small doses, gr. |, with tartar emetic, gr. £, (Vide Graves' Clinical Medicine.) Opium and wine may be known to do good in fever, if they make the skin and tongue moist, the pulse fuller and slower, and if they allay nervous excitement, and produce sleep. The state of the bladder should be inquired into every day ; and the bed be kept dry and clean. Any spots that seem likely to ulcerate, should be washed with brandy, and protected with soap. plaster. To conclude: the chief indications in the treatment of typhus and typhoid fever are, to nurse the patient carefully through it; to allay excitement; to prevent local inflammation; and to support the strength. rubeola (Measles). This is a contagious fever, with eruptions and catarrh. Symptoms.—1st day. Alternate shivering and heat, anxiety, las- situde, sense of pain and weight across the forehead and eyes, and dullness, with a disposition to sleep. The pulse becomes accelerated, the skin hot, the surface of the tongue white, and its points and edges of a bright red. Epigastric tenderness, with nausea, is frequently present, and sometimes there is vomiting. tid day. All the symptoms are aggravated ; the eyes become red and watery ; there is coryza, with frequent sneezing ; the throat is a little painful; and in very young children there is stupor, and sometimes convulsions. 3d day. A still further aggravation of all the symptoms is evi- dent ; the eyes become more inflamed ; the eyelids appear tumid ; a dry and frequent cough; dyspncea; a feeling of tightness across the chest, and pain in the head, precede the appearance of the erup- tion. Mh day. Appearance of the eruption.—The eruption first begins to appear in the form of small circular spots, on the forehead, chin, nose, cheeks, and around the mouth, and extends itself successively, within a day or two, to the neck, chest, and limbs. In general, the small spots are succeeded by larger ones, and the final arrangement of the patches is usually in a semicircular or a crescentic form. The red tint of the eruption assumes its greatest intensity on the face on the fifth day. MEASLES. 33 When the eruption is fully developed, the frequency of the pulse, heat, thirst, redness of the eyes, and coryza disappear, or are much alleviated ; the nausea and vomiting also subside. About the sixth day, the watchfulness disappears, the cough and dyspnoea being the only symptoms that remain. On the third or fourth day of the erup- tion, the spots become pale, and gradually assume a yellow tint; and when the redness has disappeared, the epidermis becomes detached in small furfuraceous scales. In children with a delicate skin, the eruption sometimes appears on the third day; but in those with a thick, brown skin, it may not be developed before the fifth day. In measles, the mucous membranes are very apt to be affected; generally, the membrane of the trachea, bronchi, fauces, nostrils, and eyelids, is principally affected, but sometimes that of the stomach or bowels principally suffers, producing nausea, vomiting, or purging. At other times, the membranes of the brain are implicated, inducing convulsions, stupor, or coma. The prognosis is unfavourable when the child is very young, when the eruption appears before the third day, or when it suddenly disappears. A leaden hue of the spots, petechia?, or excessive dyspnoea are also unfavourable signs. The prognosis is favour- able when the gastro-pulmonary symptoms are slight, the progress of the disease is regular, and when the skin is moist after the ap- pearance of the exanthema. The sequela of rubeola are, bronchitis, pneumonia, pleuritis, cseco- colitis, diarrhoea, or ophthalmia. Treatment.—When the gastro-pulmonary symptoms are slight, the treatment merely consists in keeping the patient in a mild tempera- ture, on spare diet, and giving mild laxative and diaphoretic medi- cines. If the soreness of the throat be very troublesome, the inha- lation of the vapour of warm water is useful. As a general rule, all inflammations that precede, accompany, or follow rubeola, when severe, should be treated as though that exan- thema was not present. Should pneumonia, or laryngitis, set in, the treatment according to the above rule should be on the general principles laid down for the removal or alleviation of these affections. If the eruption disappears suddenly, the treatment must depend upon the cause producing this effect. If it is induced by the sudden deve- lopment or increase of an internal inflammation, the attention must necessarily be directed to the immediate subduing of the inflamma- tory action. Secondly, if the recession depends on cold, the warm or vapour bath should be had recourse to. Diarrhoea frequently comes on during the convalescence, and, if not too severe, is useful in checkino- a tendency to thoracic disease; should it, however, pro- ceed too fa°r, small doses of Dover's powder, and the occasional use of the warm bath, will be found useful. A common sequela of 34 PRACTICE OF MEDICINE. measles is, a short hoarse and barking cough, which has a great deal of the croupy sound, but is not attended with dyspnoea. It readily yields to counter-irritants. SCARLATINA. This is a contagious fever, particularly affecting the skin and mu- cous membrane of the throat. About the second day of the affec- tion, the whole surface of the body presents little red points, which are soon followed by patches of a deep scarlet colour, serrated at their edges, which become confluent, and terminate by desquamation on the fifth or sixth day. Scarlatina occurs under three forms—Scarlatina simplex, S. an- ginosa, and S. maligna. SCARLATINA SIMPLEX. The precursory symptoms of this form are, general debility, nausea, shiverings, followed by flushes of heat and thirst. On the second day of the febrile symptoms, little points, at first of a light red, then becoming deeper, appear in great numbers on the face, neck, and chest. In the course of twenty-four hours, similar spots appear on the body, lips, tongue, palk^,J and pharynx. On the third day, most of the interstices which^ had been left are covered with large dotted patches, having serrated'edges. < In this stage, the pulse is full and frequent, the tongue is -covered with a creamy coat, through which the red and elevated papillse appear. This produces the peculiar appearance of the organ to which the term strawberry- like tongue is applied. The skin is much hotter in this form of ex- anthema than in any other. The scarlet colour is of a deeper tint on the groins, buttocks, and folds of the joints, than in other situations. About the fifth day the interstices between the patches become larger, the scarlet colour less vivid, and slight desquamation takes place on the neck, temples, and chest. On the sixth day, the cha- racter of the disease becomes less distinct; and on the eighth and ninth days, desquamation from the surface of the hands, feet, and the different regions of the body, takes place. SCARLATINA ANGINOSA. Symptoms.—This form commences with more intense fever, and a sense of stiffness of the neck and inferior maxilla. On the second day, the pharynx is inflamed, deglutition is difficult, the amygdala? become swollen, and the mucous membrane presents a vivid red appearance. In the S. simplex, the pharynx presents an exanthe- matous blush, but there is no effusion ; in this form, however, a quantity of thick, viscid fluid, sometimes of a whitish-yellow colour, but more generally, caseous-like matter, is thrown out on the amyg- dalae, pharynx, and anterior pillars of velum. During the second, SCARLATINA MALIGNA. 35 third, and fourth days, symptoms of gastro-enteritis are present; the tongue is of a bright red colour ; there is nausea, vomiting, diarrhrea, or constipation, dry cough, quick and vibrating pulse, and occasionally epistaxis. The eruption, which appears on the third day, is not so generally or equally distributed as in the former affection. It also sometimes disappears suddenly, frequently on the day after its appearance, and returns again after an uncertain period of time. The entire duration of this form is longer than in simple scarlet fever, and its order of appearance, and that of its desquama- tion, are not so regular. SCARLATINA MALIGNA. Symptoms.—This form comes on like the scarlatina anginosa, except that the symptoms are of a graver type even on the first accession. Sometimes, in fact, the patient is stricken dead by the poison in a very few hours before any eruption or local symptoms come on. The eruption does not present a scarlet appearance, but is more of a livid hue, and frequently interspersed with petechia?. It is irregular in its first appearance, and it may disappear and reappear several times. In this form of scarlatina, the pulse is small and irregular, the teeth and tongue are covered with brown or black incrustations, the eyes are much injected, and the vision is confused; the respiration is laborious, and the breath is foetid; the pharynx is covered with thick, viscid mucosity, and there is often sloughing of the surface of the amygdala?. Convulsions and coma are frequent concomitants of this affection in children, while delirium and deafness attend this form in the adult. The appearance of numerous petechia?, of abundant diarrhoea, of difficult respiration, or of persistent coma, announce the approach of death. The sequela of scarlatina are, anasarca, ophthalmia, otitis, bron- chitis, enteritis, orchitis, and cynanche parotidea, in adults; affec- tions of the sub-maxillary and inguinal glands, &c, in children. Treatment.—In scarlatina simplex, when the bowels are con- stipated, mild purges may be employed. Rest in bed, spare diet, cooling acidulous drinks, and, where the surface of the body is ex- tremely hot and burning, cold sponging, are the means principally to be relied on. In scarlatina anginosa, and maligna, the treatment must be the same in its nature as that of continued fever, but be varied to meet the symptoms. If there is violent cerebral excitement, or inflamma- tion of the throat, a few leeches may be applied; but if the powers of life are low, it may be necessary to give wine, beef-tea, &c, from the very commencement. The throat always requires great attention. Therefore the patient, if able, should assiduously use a gargle containing muriatic acid, or chloride of soda, and should 36 PRACTICE OF MEDICINE. inhale the steam of vinegar and water; and if not able to do it him- self, the same liquid should be copiously injected through the nose and mouth from an elastic bottle. The bowels should be regularly cleared by mild aperients and enemata. The citrate of ammonia, given in a state of effervescence, is an excellent medicine in most cases. Cool sponging is of service when the heat of the surface is steadily high; but in malignant cases it is to wine that the practi- tioner has chiefly to look for the safety of his patient. The internal and external use of chlorine throughout this disease is highly recommended by some authors. It may be used either in the form of the aq. chlorinii fjss, aqua? font, f §viij, and syrup, f 3j; a tablespoonful of the mixture being given every hour or two. Or it may be given in the form of a solution of chlorate of potassa, in the proportion of a drachm to a pint of water, and used ad libitum. It may also be used as a gargle to the throat. When pseudo-mem- branous or gangrenous patches are observed in the fauces, and the colour of the membrane is dark-red, an infusion of capsicum is an excellent application. The sulphate of zinc, or nitrate of silver, is also useful under similar circumstances. When the sloughs are offensive, the foetor may be often corrected by a creasote gargle, or a gargle of pyroligneous acid in solution. Belladonna is sometimes used as a preventive. It may be given in a solution made by dissolving three grains of the extract in a fluidounce of distilled water, of which three drops is the dose for a child under one year, increasing it one drop for every year. During convalescence, the patient should be protected from cold, and ought occasionally to employ tepid baths, and frictions to the surface. ERYSIPELAS. This is an exanthematous fever affecting the skin or the sub- cutaneous cellular tissue, or both. It arises from an animal poison, and is not contagious; but there are some minor varieties that ought rather to be called erythema, that are caused by disorder of the digestive organs or of the general health. There are two chief varieties of it:—the simple, which affects the skin, and ends in vesication and oedema; the phlegmonous, which affects the subcutaneous cellular tissue likewise, and causes unhealthy suppuration and sloughing. SIMPLE ERYSIPELAS. Erysipelas always begins with shivering, nausea, and other signs of fever, and derangement of the stomach. The skin of the part affected becomes slightly swollen, and of a red colour; there is acute pain, with a sensation of burning heat, but no throbbing, as in phlegmon. The redness disappears on the slightest pressure, ffiDEMATOUS ERYSIPELAS. 37 and reappears immediately on its removal. In some instances, small miliary vesicles appear, in others bulla? or phlyctena? are ob- served. The most favourable termination is in resolution, in which case the epidermis is thrown off in small scales. It occasionally assumes an erratic form, and sometimes it terminates by metastasis to some of the internal organs. PHLEGMONOUS ERYSIPELAS. In this form the redness is very vivid, and diminishes in intensity from the centre to the circumference. The cellular tissue being im- plicated in this affection, produces swelling, hardness, and a burning pain. This affection may terminate in resolution; but should it pro- ceed to suppuration, and measures are not employed to allow of the exit of the pus, abscesses will form, and the cellular tissue between the muscles will become implicated. The abscesses and sinuses thus formed, will gradually burst externally, when a quantity of gangrenous masses, mixed with foetid pus, will be discharged. The constitutional symptoms in this case indicate that much mischief is going on. The pulse becomes quick and hard, and the tongue brown; encephalitis, meningitis, or gastro-enteritis, may come on, and the patient sinks under diarrhoea, with low muttering delirium and coma. CEDEMATOUS ERYSIPELAS. This is the name given to simple erysipelas affecting loose cel- lular parts. The skin is smooth and shining; and pits on pressure. This affection often induces gangrene, the skin being deprived of its supply of blood through the distension of the cellular tissue; the accession of this is announced by acute pain, a red and shining skin, with sometimes a livid or leaden hue. The genitals in women, the scrotum in men, and the infiltrated limbs of hydropic patients, are the most usual seats of the oedematous erysipelas. Erysipelas of the head and face is generally of the simple or oedematous variety; and is the form which the disease assumes, when there is no wounded part for it to fix upon. It is very dangerous, as the contiguous irritation is liable to cause inflammatory excitement, or effusion within the cranium. Treatment.—When the surface of the inflamed part is of a deep or florid red, tense, and very hot; the pulse hard, full, or strong; the head much affected, and the papilla? of the tongue erect and excited, both general and local bloodlettings are requisite, especially in unbroken constitutions, in persons not addicted to drinking to excess, and very early in the disease. Local depletion by leeches or incisions, will often be sufficient, except the patient be of a phlogistic "At'the outset, m emetic may often be administered with advantage; 4 38 PRACTICE OF MEDICINE. at all events a dose of calomel and James' powder at night, fol- lowed by a cathartic draught in the morning. When the functions of the different secerning and excerning glands have been properly restored, tonics and alteratives should be employed ; of the former class, the preparations of cinchona are those most recommended. Cold applications have been recom- mended by several writers; this practice, however, is not always safe, and should not be adopted when the persons are of broken- down constitutions, or advanced in life, or in erysipelas of the head. Warm poppy fomentations are much safer. Mr. Higginbottom has recommended the application of nitrate of silver, in substance, or in strong solution; it should be applied either to the inflamed surface and the adjoining integuments, or only to the healthy skin surround- ing the affected part; it should raise the cuticle, or it will fail in isolating the disease. In the phlegmonous form, free incisions should be employed early, before the matter burrows deep, and causes much constitutional irri- tation. Permanent and diffusible stimuli should be used, and if there is much restlessness, opium should be exhibited, unless there is a tendency to coma. Free incisions, followed by poultices, are the most efficient means in this case, as they tend not only to allow of the escape of matter which acts as a foreign body in the system, but also to relieve the tension of the parts, and to destroy the inflam- matory orgasm in them. Bleeding from the incisions should be carefully watched, as it is sometimes profuse; and it may, if uncon- trolled, or unaccompanied by a sufficiently restorative treatment, especially in drunkards and those of broken-down constitutions, be attended by dangerous consequences. If the affection has been neglected until sloughing has occurred, before incisions have been made, lint dipped in oil of turpentine, or in equal parts of it and Peruvian balsam, should be applied, and covered by warm poultices. varicella (Chicken Pox). Symptoms.—Varicella is a contagious fever, attended by vesicles or pustules, which dry up from the fourth to the seventh day of their formation, generally leaving small red spots, but rarely cicatrices on the skin. In general, the invasion of varicella is preceded by slight fever, which lasts from twelve to forty-eight hours. In some cases, however, all the symptoms of violent gastro-intestinal irritation are present—acute pain in the epigastrium, nausea, vomiting, &c.; this state will continue for three or four days. On the first day of the eruption, small, red, oblong, flat spots ap- pear ; and on the second day, a prominent vesicle is observed at the centre of them, containing a fluid of citron hue. The third day, the colour of the fluid is yellowish. On the fourth day the vesicles VARIOLA. 39 diminish in size, and shrivel at their circumference ; and on the fifth, a small crust, adherent to the skin, is formed at their centre. On the sixth day, small yellowish and brownish crusts occupy the place of the vesicles; on the seventh, or eighth, the crusts fall off, leaving on the skin red spots, without depression, which remain for some days. This is the usual type of this disease ; but sometimes it assumes a pustulous form, in which case the accompanying symptoms are more severe, and the disease assumes, to some extent, the charac- ters of small-pox. This form has been divided into three kinds, which, differing in the external characters of the pustules, and in the progress of the eruption, have received the names of conoid, globu- lous, and umbilicated pustulous varicella. Pustulous varicella has been, and may readily be, confounded with variola, some believing that it is an imperfect form of that disease. The external characters which distinguish varicella from variola are— 1. The shorter duration of the vesicles, or pustules in varicella. 2. The small red spots of varicella, on the first day of their ap- pearance, feel to the finger like a flat seed ; on the contrary, in the same stage, the elevations of small-pox give the sensation of touching a round seed, and the sanguineous injection is much greater. 3. In varicella, the serosity, or pus, fills the vesicles, or pustules, on the first or second day of the eruption; in variola, the formation of the serosity is slower, and only takes place at the summit of the pustules. 4. Lastly, in varicella, the eruption is not so simultaneous as in small-pox; some vesicles and pustules appearing in the former, at the same time that the desiccation of others has commenced. Treatment.—When varicella is distinct and apyretic, the treat- ment is very simple; the patient should remain in bed in a tempe- rate atmosphere, have a mild purge, ought to be placed on low diet, and abstain from animal food for a few days, and should partake freely of diluent drinks. Tepid baths may be employed during convalescence. VARIOLA. This is a contagious eruptive fever, affecting at the same time the gastro-pulmonarv mucous membrane and the skin. It shows itself externally from the third to the fourth day of the febrile invasion. At first it is papular, it then becomes vesicular, and next pustules are formed, which at first are pointed, and then become umbilicated. This affection terminates, after from twelve to fifteen days' duration, in desiccation and scabbing, small irregular cicatrices remaining. Variola is commonly divided into the distinct and confluent forms. In the distinct, the pustules are few and thinly scattered over the 40 PRACTICE OF MEDICINE. whole surface of the body. In the confluent, the pustules are numo- rous, and are more or less united by the close approximation of their edges. Variola presents four stages—1st, that of incubation, or the latent period; being that which intervenes between the inception of the poison and the first appearance of symptoms; 2d, ofinvasion ; 3d, of eruption ; 4th, of desiccation. The latent period varies from six to twenty days. On the first day of the invasion there are more or less prolonged shiverings, alternating with flushes of heat, and loss of appetite. On the second day, there is nausea, epigastric tenderness, thirst for cold acidulous drinks, a quick pulse, and hurried respiration. Children are frequently seized with convulsions in this stage. The tongue is loaded with a whitish or a yellowish fur, and its point is red. There are pains in the head, back, loins, and limbs. These symptoms continue for three or four days. On the fourth day of ihe invasion, the eruption appears in small isolated spots on the lips, face, neck, chest, abdomen, and limbs. On the fifth day, the spots become more numerous, and their sum- mits become vesiculous. On the sixth and seventh days, vesico-pus- tular spots are observable on the skin, and sometimes on the mucous membrane of the mouth, pharynx, and eyelids. In the intervals between the pustules, the skin becomes red, and the subjacent parts swollen. On the eighth day, the eruption is perfectly pustular, having central indentations. The pustules being more numerous on the face than on other parts, it becomes hot, painful, and tense. Secondary fever now comes on, and on the ninth and tenth days the central indentation disappears, and the pustules become orbicular in form. On the eleventh and twelfth days, the pustules burst, and desiccation commences. The crusts or scabs, now fall off, those on the hands being detached a day or two later than those on other situations. A thick ropy salivation is established during the more advanced stages of this eruption. After the scabs have fallen off, circular spots of a red-brown colour are seen on the skin, and there are always small irregular cicatrices, which sometimes become the seat of furfuraceous desquamation. In confluent variola, all the symptoms are of a more grave type. The cerebral and gastric complications are more intense, there being persistent vomiting, and either delirium or convulsions. These affections may cause the death of the patient before the appearance of the eruption. The eruption, which is commonly simultaneous, and seldom successive, occurs about the second or third day, rarely on the fourth, and still more rarely on the fifth. The pustules are less prominent, and more aggregated, than in simple variola, and their edges run into one another. They are more numerous on the face than other parts; and in fact, when VARIOLA. 41 crusts begin to form, the whole face is covered, as it were, with a mask. This incrustation falls off from about the fifteenth to the twentieth day. Towards the termination of the suppuration, and the commencement of desiccation, some patients fall into a state of coma, and die within twenty-four or thirty-six hours. When the incrusta- tion first falls off, no cicatrices are remarked on the skin; furfura- ceous scales are, however, soon thrown off, which leave such cica- trices and ulcerations as completely disfigure and alter the expres- sion of the countenance. During the progress of the disease, pustules are seen in the mouth and pharynx, on the edges of the eyelids, and on the transparent cornea. This structure ulcerates, but is rarely perforated. The cornea frequently remains opaque in its whole extent after this disease. It is during the secondary fever, which is very violent in the con- fluent small-pox, that, most danger is to be apprehended. Out of 168 deaths, recorded by Dr. Gregory, 27 occurred on the eighth day of the eruption (eleventh day of the disease). Thirty-two died in the first week, 97 in the second, and 21 in the third. In the first week death seems to be caused by an overwhelming malignancy of the poison, oppressing the brain, and causing coma ; in the second week, from affections of the respiratory passages; and in the third from debility. Treatment.—When the disease is distinct and slight, it will be sufficient to keep the patient in pure air, in a large room, and at a mild temperature, and to open the bowels. The skin may be sponged with tepid water, if its temperature is very high. In the confluent small-pox, the treatment is often not so simple ; but requires to be varied to meet the symptoms that arise, just as in fever. Great restlessness, wakefulness, and delirium about the eighth or ninth day are generally benefited by opiates. If the pulse is feeble, broths and wine are required; especially if the pustules do not fill out. During the secondary fever, which generally sets in about the eleventh day of the disease, aperients, opiates, and nourishing diet should be given. Great dyspnoea requires a blister to the chest. The intolerable itching is best allayed by smearing the eruption with cold cream. Various measures have been proposed, in order to prevent the pitting and disfigurement occasioned by this horrid disease. Pen- cilling the pustules with lunar caustic; opening each of them; co- vering the face and hands with an ointment composed of litharge and mercurial ointment; keeping the patient in perfect darkness, have each been recommended; but with very doubtful success. Thev should all be tried before the eruption becomes vesicular. J 4# 42 PRACTICE OF MEDICINE. VACCINATION. The real nature of this excellent means of preventing the small- pox seems to be, that it is a kind of small-pox, modified and ren- dered milder by passing through the constitution of some of the domestic animals. It appears that if the cow be inoculated with small-pox matter, the disease, which the animal exhibits in conse- quence, is the same which is familiarly known as the cow-pox, and which, if communicated to the human subject, gives the same amount of protection, against a subsequent attack of small-pox, as an attack of that disease would. As a general rule, the exanthemata occur only once during life. But late experience shows that this rule is liable to many exceptions, since there is no kind of exanthema, which has not been known to occur twice in the same subject, and this is especially the case with small-pox. The protecting influence, therefore, of vaccination (if it can wear out, as is asserted by some authorities), should be renewed at intervals, at and after puberty. RHEUMATISM. Rheumatism is an inflammation of a peculiar character, affecting the fibrous structures primarily, but liable to implicate also the serous or synovial membranes in their vicinity. It causes intense pain, and effusion of serum or lymph, but very seldom, if ever, causes suppu- ration or gangrene. Its proximate cause or real nature seems to be an accumulation in the blood of certain acid and other excrementitious matters, that ought to be eliminated by the skin and kidneys. It generally attacks the fibrous tissue around the large joints; and a distinction is to.be made between fibrous and synovial rheumatism. The former attacks the fibrous, ligamentous, and muscular structures in the neighbourhood of the joints, without affecting the synovial membranes much; the latter (or rheumatic gout, as it is sometimes called) implicates the synovial membrane, causing effusion and con- siderable swelling of the joints. Rheumatism may be acute or chronic. Acute rheumatism is a disease of early life, often affecting children. Its usual exciting cause is exposure to wet and cold, combined with muscular fatigue. The most severe form of acute rheumatism is called rheumatic fever. There is a very high degree of fever; full jerking pulse; thickly furred tongue ; profuse sour perspiration ; scanty and high- coloured urine, depositing a copious lateritious sediment. Together with these constitutional symptoms, there is great pain in several of the larger joints, increased excruciatingly by pressure or motion; and slight redness and swelling. This inflammation is very apt to shift GOUT. 43 from joint to joint, (by metastasis, as it is technically called,) and most especially is it liable to affect the pericardium, and the lining membrane of the heart. Treatment.—If the patient is young and robust, and the fever very violent, venesection may be employed;—if employed it should be done early and decidedly, for a repetition of bleeding is not well borne, although the blood is buffed to the last; and too much bleed- ing is apt to induce metastasis to the heart. The next remedy deserving of notice, is that which is commonly known as Dr. Chambers' plan of treatment, and which consists in producing a large flow of secretions from the liver and intestines. Five or ten grains of calomel are given at bedtime every other night, and followed in the morning with a black draught; and this is repeated twice or thrice till a copious secretion has been produced from the liver and bowels. After this, diuretics and colchicum, alkalies, diaphoretics, and calo- mel and opium may be administered in conjunction, with almost equal claims on our confidence. The grand secret seems to be, to ensure a free discharge of all the secretions, from skin, bowels, and kidneys. The general plan is, to give a dose of calomel and opium at bedtime, and a saline draught of liq. am. acet. with vin. colchici twice or thrice during the day. When the acuteness of the fever has abated, and the urine is clearing, great benefit may be derived from bark combined with ammonia. Pain at night may be allayed by opium. Prof. J. K. Mitchell, who regards this as a disease of spinal origin, has had much success in the acute form by the appli- cation of cups to the spine, in the neighbourhood of the affected part. Chronic Rheumatism is of two kinds. One has a nearer affinity to the acute; it is aggravated by heat and stimulants, and is best treated by clearing out the liver, and securing a free action of the kidneys and skin; and at the same time taking care that the diet consists of nutritious and digestible substances, not disposed to acidity. The iodide of potassium is also extremely serviceable in these cases of subacute rheumatism, in doses of three grains ter die, with an alkali, and a bitter. It causes a great flow of urine, in which it may be detected by the proper tests. The other variety, which is very common in elderly people, is benefited by stimulants, especially by warmth, friction, ammoniated tincture of guaiacum, &c. GOUT. Gout is a constitutional disease, characterized by a superabundance of lithic acid in the system, which is deposited from the urine, and concretes around the joints in the form of what are called chalk-stones; which really consist of lithate of soda. 44 PRACTICE OF MEDICINE. Gout is generally a disease of advanced life, and seldom occurs till after puberty. It is liable to be brought on by sedentary habits, and indulgence in animal food and wine or malt liquors. It presents many resemblances to rheumatism, but differs in the following points:—1. Rheumatism affects chiefly the young or middle aged ; gout, the elderly. 2. Rheumatism prefers the larger joints; gout, the smaller, and especially the feet and hands. 3. Gout is attended with more obvious disorder of the digestive organs; the pain is of a more burning character, and the swelling greater and more vividly red. Symptoms.—-After suffering some time from premonitory symp- toms, such as irritability of temper, loss of appetite, and various anomalous aches and pains, there comes on (often suddenly in the night) a very severe burning, aching, wrenching pain in the ball of the great toe, or some other joint of the hand or foot; at the same time there is shivering, followed by feverish heat, thirst, foul tongue, scanty urine depositing lithic acid, and confined bowels. The pain usually remits towards morning, but occurs again for several days, till the fit is over, and then the cuticle of the inflamed part desquamates, with violent itching. After the fit is over, the patient feels better in his health than he had done for some time before. But without great care, another fit comes after some months; and the disease becomes established in paroxysms, which almost every time recur at a less interval and more severely; till at last in some cases the disorder becomes chronic and habitual. The joints affected, return to their usual plia- bility after the first few attacks, but gradually become stiff and crippled, and deposits of lithate of soda are formed in the cellular tissue. Besides these evils, gouty persons are liable to various anomalous and dangerous affections of internal organs. Sometimes they are seized with pain of a cramp-like character in the stomach, with cold- ness and deadly sickness;—sometimes with extreme pain of the heart, palpitation and dyspnoea;—sometimes with furious delirium and headache, or coma; and as these symptoms are relieved by the appearance of gout in the foot, it is evident that they arise from the gouty poison ; and such attacks are often called misplaced gout. If such symptoms come, upon the gout leaving the extremities, the case is said to be one of retrocedent gout. Gouty people are also liable to inflammations of the eye, lungs, and other parts, which are very stubborn when treated with common remedies, but yield generally to colchicum. Treatment during an acute attack.—The indications are to free the system from superabundance of lithic acid, by low diet and in- creasing the secretions ; and to allay pain. The first point is to act well on the bowels by calomel, followed by senna draught, and any other warm purgative. The diet should GOUT. 45 be merely tea and toast, water gruel, &c. The affected part should be bathed frequently in tepid water. Then colchicum may be given combined with alkaline diuretics or diaphoretics. Ten grains of bicarbonate of potass, three drachms of liq. am. acet. and n\,xv—xx. vini seminum colchici in a draught every six hours ; or a fluid drachm of acetum colchici, with twenty grains of carbonate and a drachm of sulphate of magnesia, in a draught thrice a day are favourite forms. But the great object should be, at the same time, or before giving the colchicum, to unload the liver and kidneys, and to avoid causing the nausea and faintness which are the poisonous effects of the drug, and which are by no means accessory to its curative effects. The patient should not be weakened by too much purging. During the interval, the patient should observe such a course ot life as would prevent the formation of much lithic acid, and cause it when formed, to be oxydized, and so converted into urea, which is much more soluble and easily eliminated from the system. The diet should therefore be abstinent, to the exclusion of too much animal food and wine. Animal food in excess at once supplies the pabulum for lithic acid; whilst alcoholic liquors, and other arti- cles of diet in excess abstract the oxygen which ought to convert it into urea. Plentiful exercise in the open air is good, as the most ready means of burning up effete and excrementitious matters; but great fatigue is always liable to bring on the gout. Plenty of liquid may be taken, to hold the lithic acid well in solution; and vegetables and most fruits (if they agree with the stomach) are wholesome from their containing an alkali. The bowels should be regularly kept open ; and a pill containing one grain of blue pill, one of acetous ex- tract of colchicum, and three of colocynth, is often prescnbed and of great use. Acidity in the stomach, moreover, should be combated by alkalies and magnesia; and if the urine becomes loaded, small doses of vin. colchici, with tartarized soda (soda potassio-tartras) should be administered; for the acid of the salt is digested, and the alkali passes off with the urine. For the chronic gout, the great points are to ™P«*e th > tone of the digestive organs, open the bowels, and keep up the strength with- out heating the system. The iodide of potassium in doses of gr. ij. ter die wfl a light bitter infusion; the dec Aloes c. with sod. cab. For sudden attacks of gout in the stomach, heart &c , thenndu*. tions are to put the feet in hot mustard and water, to JP^^r poultices to the epigastrium, and to give some warm stimulant inter nallv These may be followed, as soon as the symptoms permit by a do'se oS and opium, succeeded by a laxative to remove the offending matter from the stomach and bowels. 46 DISEASES OF THE THORACIC VISCERA. angina laryngea (Laryngitis). (Inflammation of the lining membrane of the larynx.) Symptoms.—Acute laryngitis may vary from the production of but a slight hoarseness, without stridulous breathing, and with little or no fever, to a violent irritation of the mucous membrane and sub- jacent cellular tissue of the glottis, epiglottis, and upper portion of the larynx, which, by inducing oedema, may cause death by suffo- cation. The developed stage of this disease is generally preceded by a sensation of irritation, heat, and tickling in the throat, pain in the region of the larynx, increased by pressure, and cough. General febrile excitement comes on, the respiration is stridulous, the voice becomes hoarse, sometimes descends into a whisper, and in extreme cases there is complete aphonia. Violent coughing comes on in paroxysms, during which the face becomes swollen and livid, the eyes turgid and prominent, and there is more or less cerebral dis- turbance. There is often dysphagia, and the drinks are returned through the nose; in some cases, the epiglottis may be felt swollen, turgid, erect, and on inspection is seen red and shining. The cough, which is at first dry, is afterwards attended with the expectoration of a thin and acrid secretion, which, should the case proceed favour- ably, becomes bland, viscous, and transparent, and gradually changes to a yellow. Should the disease progress to a fatal termination, all the symp- toms become aggravated; the mucous membrane of the larynx be- comes swollen, and the rima glottidis is so contracted as not to allow sufficient atmospheric air to pass to the lungs; hence, there is great dyspnoea, with violent action of the respiratory muscles. As the rima becomes more contracted, the difficulty of breathing increases, the patient sits up in bed, tosses about his limbs, his eyes are promi- nent and tearful; and he dies apparently exhausted by his efforts; or, if a strong person, in a convulsive struggle. When the disease terminates more slowly, it is supposed that death is produced by blood which is not duly aerated circulating in the brain. This disease may be mistaken for foreign bodies in the larynx, acute pneumonia, pleuritis, acute pericarditis, tumours pressing on the larynx, hysteric spasm, &c. CROUP. 47 Morbid appearances.—The mucous membrane lining the larynx, and particularly the glottis and epiglottis, is red and injected; this appearance is either in spots, or diffused to a greater or less extent. It is also somewhat tumefied, and presents a viscid or puriform fluid on its surface. When the disease has been protracted, the redness disappears, and the membrane becomes thickened; small ulcerations are occasionally observable in these cases, particularly at the sides of the glottis. Treatment.—In the earliest stage of this disease bleeding should be employed, and repeated, if it be requisite. Where bleeding is performed, it should not be carried to syncope. Leeches may be applied to the sides of the throat, or cups to the nucha. Warm fomentations are also of great service. Calomel, opium, and tartar emetic may also be given, but if the disease does not yield, trache- otomy is the only resource. Blisters to the throat are inadmissible in the early stages. Before giving a prognosis, and performing the operation, it is re- quisite to ascertain what is the state of the lungs; for the chance of success from opening the trachea will be much less, if the lungs are diseased. Sometimes the disease affecting the glottis is not so much acute inflammation, as oedema, the result of a low degree of vascularity. Tracheotomy and purgatives are the chief resource. CHRONIC DISEASE OF THE LARYNX May consist of chronic inflammation and thickening: of ulcera- tion, common, and syphilitic, disease of the cartilages, and morbid growths. Ulceration is very common in consumptive patients. In cases of chronic inflammation or ulceration, attended with husky voice, and irritating cough, and tenderness, the regular appli- cation of a few leeches, the very gentle administration of mercury ; or sometimes swabbing the upper orifice of the larynx with solution of lunar caustic, may be of use. But if dyspnoea and choking cough increase, the safest plan is to open the larynx, whereby spasm of the glottis is prevented, and the part being at rest is more likely to get well. CROUP. Symptoms. — Three stages of this affection have been noticed by the best authors — 1st, the invading, or catarrhal; 2d, the de- veloped, or inflammatory; 3d, the stage of albuminous exudation, with threatening suffocation. First stage.—In the catarrhal stage there are slight febrile symp- toms, consisting chiefly of alternating chilliness and heat, and in more acute cases the skin becomes hot, the pulse accelerated and 48 PRACTICE OF MEDICINE. hard, and the countenance flushed; the child is either dull or in ex- cited spirits; there is generally more or less pain in the head. In other cases, in addition to these symptoms, those of common catarrh are present; in some instances, the cough may be slightly resonant, but the respiration is not stridulous. Second stage.—The duration of the catarrhal stage is very va- riable ; it may continue but for two or three hours, or may last as many days, when the inflammatory stage sets in. The fever now increases rapidly; the respiration becomes difficult and sonorous; the cough may be either loud, dry, and clangous, as if passing through a brass tube; or it may resemble the barking of a young puppy. The inspiration is dry, hissing, and slow, and produces a sound similar to that which would be caused by forcing a piston down a dry pump. In most cases, the sympathetic fever runs very high; the skin is hot and burning; the pulse is frequent and hard; the face flushed, sometimes covered with perspiration; the bowels are constipated; and the urine is scanty, highly coloured, and gene- rally albuminous. The head is now commonly thrown backwards; and the child, either by its speech or attitudes, expresses a feeling of anxiety, with pain and constriction about the trachea and larynx, which are often tumefied externally. These symptoms, with the exception of the hoarseness of the voice, quickness of the pulse, peculiar cough, and sibilous inspiration, evince distinct remissions during the day. Third stage.—The cough, which was at first dry, or attended with a scanty muco-sanguineous expectoration, now becomes husky and suffocative, and is frequently attended with abortive efforts to excrete what is felt in the trachea; the sense of suffocation is in- creased, and the fits of coughing are accompanied by the expectora- tion of a glairy mucus, containing shreds of the adventitious mem- brane. As the disease advances, there is total absence of any dis- tinct remissions; the pulse becomes accelerated, small, weak, and irregular; and the cough is less frequent, less audible, but suffo- cative. If a fatal termination is approaching, the patient tosses about in great distress; seizes on objects around him, and grasps them convulsively for a moment; throws his head back; seizes his throat, as if to remove some obstacle to respiration; makes forcible efforts to expand the lungs; and, after a variable duration of such sufferings, seldom above twenty hours, dies, either with signs of con- vulsive suffocation, or those of complete exhaustion of vital energy. Such is the course of the severe form of croup, when left to nature, or when unchecked by treatment. In some slight forms, hoarseness, with a hard, ringing cough, succeeded by a crowing or stridulous inspiration, present chiefly in the night, and remitting during the day, are the only symptoms; the CROUP. 49 respiration and pulse being but little disordered in the intervals, and the febrile symptoms not very acute. Physical signs of croup.—Croup is to be recognised by the sud- den hoarseness, with fever, followed by the characteristic croupy cough, dependent on albuminous exudation from the mucous mem- brane of the trachea and bronchi. When the disease extends to the bronchi, the respiration about the sternum, which is naturally bronchial, becomes sibilant and whiffling; but it is sometimes diffi- cult to distinguish from a similar rhonchus which generally, also, has its seat in the trachea. The clearest physical sign of inflammatory tracheal croup is, the detachment and expectoration of the albuminous concretions formed in the air-tubes. Morbid appearances.—The mucous membrane lining the larynx, upper part of the trachea, and sometimes even the larger divisions of the bronchi, exhibits a greater or less degree of swelling and red- ness; it is sometimes covered by a false membrane, of a pale yellow or grayish colour, the thickness of which is greater in the larynx and trachea than in the bronchi. The false membrane of croup cor- responds exactly with the form of the canal which it covers; its consistence is about that of boiled white of egg, but this usually diminishes towards its extremities, so that it becomes sometimes, in these situations, scarcely more solid than the thick phlegm of catarrh. The false membrane is sometimes separated from the mucous mem- brane by a viscid or puriform fluid; at others, it adheres more or less intimately, according to the degree of inflammation, and also its proximity to the glottis. Those who die of croup generally ex- hibit a high degree of congestion of the lungs, and also of the cere- bral vessels. Treatment.—The medical man is seldom called in during the first stage of this disease, as the symptoms are often so slight as not to attract much attention. When, however, the child is seen in this stage, by judicious interference, the attack may be either cut short, or very much modified in its subsequent severity. The patient should be confined to his room, all stimulating diet forbidden, and an antimonial emetic immediately prescribed. After the vomiting, the child should be kept in bed, the bowels ought to be freely acted upon, tepid diluents should be given, and small doses of ipecacuanha be persisted in. A hot poultice may also be applied to the throat. But when the inflammatory stage has become developed, the treat- ment must be bold and decisive, for the life of the patient depends on what is done within the first six or eight hours of this disease. If croup be not accompanied by a strongly-marked asthenic diathesis, or does not occur in very young infants, the treatment of this stage ought to commence with one or two bleedings from the arm. Some authorities in this country recommend the abstraction of blood, from the jugular vein. In very doubtful cases, and where the disease has 50 PRACTICE OF MEDICINE. made much progress, it would seem preferable rather to omit bleed- ing than to destroy, by injudicious depletion, the powers requisite for the separation and excretion of the false membrane. In weak children, leeches to the throat may supersede the necessity for vene- section. Although this is the general practice, it would be advisable to adopt the suggestion of Dr. Farre, which is, not to apply leeches over the larynx, but rather along the line of the clavicles, as they often induce an oedematous state of the skin or ecchymoses, which occasion a stiffness of the parts, and add to the suffocating feeling of the patient. Two methods of treatment are strongly advocated in this disease, the one being the mercurial, the other the antimonial; some emi- nent practitioners recommend the former, others, and, those who have paid most attention to this disease, the latter. Dr. Copland recommends, immediately after depletion, calomel and James' pow- der ; from three to five grains of the former, and two to three of the latter. This powder may be repeated every second, third, or fourth hour, until two or three doses have been taken. After the first dose, the child should be put into a tepid bath, and be allowed as much tepid diluents as the stomach will bear, in which carbonate of soda may be dissolved, and which may be rendered agreeable with syrup. If the powders, given to the extent now mentioned, have not acted upon the bowels, castor oil, or some other purgative, should be administered. The treatment of croup by means of tartarized antimony is as follows : The exhibition of this medicine should commence from the very first period of the treatment: and Dr. Stokes advises, "that the medicine should be so exhibited as to produce free vomiting at least once in every three quarters of an hour." This treatment should be persisted in for several hours, when, according to circum- stances, the quantity of the antimony may be diminished. The solution employed by Dr. Stokes contains one grain of the salt to the ounce of distilled water, and of this a dessert-spoonful is given every quarter or half an hour, according to its action. Dr. Cheyne, who first introduced this powerful remedy in croup, observes—" In very few cases have I known the child survive the second stage of croup; and in all these the children recovered while using a solution of tar- tarized antimony. Emetics I had repeatedly given in the second stage of croup, but in these cases the patients were kept sick for two or three days, with scarce any interval." In the advanced stage, where there is feeble respiration, a weak and sinking pulse, pallor of the countenance, &c., stimulants and derivatives must be employed. It has also been recommended to give such medicines as will act on the mucous follicles of the affected part, causing them to throw out a fluid between the mucous and adventitious membrane, and thus promote the separation of the latter. REGIONS OF THE CHEST. 51 The preparations of squill, ammoniacum, and senega are amongst those commended. Coxe's hive syrup is one of the best remedies in this disease. Blisters may be applied between the shoulders, or on the sternum, but never on the neck, for the reasons stated when alluding to the application of leeches; and, further, because it may be necessary to open the air-tube, in which case we should have to cut through the inflamed skin. The operations of laryngotomy and tracheotomy have been per- formed in croup, where no other chance is left; the latter is the operation which has been attended with most success. SPASM OF THE GLOTTIS, Or spasmodic croup, as it is sometimes very improperly called, is very different from the preceding disease. It consists in a sudden choking fit, caused by a spasm of the muscles that close the glottis. There is no fever, nor any morbid appearances about the throat; the disorder is purely functional. It occurs to children, especially durino- the irritation of teething or weaning. The child suddenly loses Its breath, tosses up its arms, turns bluish about the mouth, and when it recovers its breath makes a long crowing inspiration. This complaint is often fatal. During the fit, the best remedy is to sprinkle a little cold water on the child's face; in the intervals the bowels must be opened, the diet rendered light and digestible, and the child put into the best possible state of general health. Very small doses of prussic acid with an alkali are sometimes of service. Before entering further into a description of the diseases of the respiratory apparatus, a tabular view of the thoracic regions, in rela- tion to the signs of auscultation, &c, is presented to the reader. (It is desired that full credit should be given to Meade's Manual, from which the appended table, somewhat modified to suit the American text-books, was drawn.) REGIONS OF THE CHEST.--(FigS. 1, 2, 3.) / 1. Supra-clavicular, L 2. Clavicular, } 3. Infra-clavicular, a. Anterior. J 4. Mammary, J 5. Infra-mammary, / 6. Upper sternal, \^ 7. Lower sternal. ( 8. Upper scapular, \ 9. Lower scapular, 6. Posterior. < 10 infra.scapular, ' 11. Inter-scapular. 5 12. Axillary, c. Lateral. ^ 13 Infra-axillary. Tabular View of the Thoracic Regions, in relation to the Signs of Auscultation, $-c. Modifledfrom Meade's Manual, g (See Figs. 1, 2, 3.) Regions. 1. Supra-clavicular. 2. Clavicular. 3. Infra-clavicular. 4. Mammary. 5. Infra-mammary Situation. Clavicles. From clavicle to the fourth rib. Between the fourth and eighth ribs. Between the eighth ribs and the mar- gin of tire carti- lages of the false ribs. Natural Sound on Percussion. Clear. Very clear to wards the st er- num ; clear in the middle; dull close to the humerus. Very clear. Very clear; particularly by mediate percussion. In women, a clear sound can be obtained through the mammae only by mediate percussion. Dull on the right side ; on the left irregularly dull, or unnaturally resonant. Interior Corresponding Parts. J Apices of the lungs. Superior lobes of the lungs. Middle lobes of the lungs; large bronchi in the upper part, near the sternum; the heart, generally covered by the lungs, in the lower part of the left region. The liver on the right, and the stomach on the left side, covered only on the upper part by the thin margin of the anterior inferior lobes of the lungs. Signs most commonly produced there by Disease. {Dulness on percussion in phthi- ( sis; generally most on one side. Irregular dulness on percussion, diffuse bronchophony, impaired respiration, and afterwards, ca- vernous rhonchus and pectorilo- quy, in phthisis. Rhonchi in catarrh; more rarely phthisical symptoms. On the left side, dulness on percussion in hydropericardium and enlarge- ment of the heart; increased impulse in hypertrophy, and in- creased sound of pulsation in di- latation of the heart; constant bellows or rasp sound in valvular disease. Crepitant rhonchus in incipient pneumonia. Extinction of respi- ration in advancing pleurisy.— Dry crepitation in interlobular emphysema. 6. Superior sternal. 7. Inferior sternal. 8. 9. Scapular. 10. Infra-scapular. Ci * 11. Inter-scapular. 12. Axillary. 13. Infra-axillary. Upper two thirds of the sternum. Lower part of the sternum and en- siform cartilage. The scapula? and the muscular ridge below them. Below the inferior angles of the sca- pula? and border of the serrati, to the level of the 12th vertebra. Between the inner margin of the sca- pula?. In the axilla? above the fourth ribs Between the fourth and eighth ribs at the sides. Very clear. In the upper part clear; rather less so in fat per- sons. Below, sometimes more dull; sometimes tympanitic. The pectoral resonance can be elicited from this re- gion only by mediate per- cussion. Clear on the upper portion, by striking on the angles of the ribs, or by mediate percussion. Below, dull on the right, and tympa- nitic on the left side. Pretty clear by mediate percussion, or when the arms are crossed, and the head bowed forwards. The spinous processes of the vertebra? sound well. Very clear. Very clear; unnaturally so, in emphysema of the lung. Large bronchi ri Margins of the middle lobes of the lungs Above, margins of the lungs; below, the heart,liver, and some- times the stomach. Middle posterior lobes of the lungs. Base of the lungs. The liver encroaches on the right, and the stomach on the left side. The roots, and inner parts of the posterior lobes of the lungs. Upper part of the late- ral lobes of the lungs. Large bronchi. Middle of the lateral lobes of the lungs. Bronchial rhonchi in catarrh. Only half the sternum dull on percus- sion in hepatization, the whole dull in extensive liquid effusion, of one side. Signs of diseases of the right side of the heart; dulness on per- cussion in effusion, or fat, in the pericardium, enlarged heart, &c. Catarrhal signs. iEgophony in pleurisy. Bronchophony in pneu- monia. Crepitant rhonchus and broncho- phony in incipient pneumonia and oedema; a?gophony in pleu- risy ; and dulness on percussion in both. Catarrhal signs. In the upper part, sound of respiration never de- stroyed in effusions into the pleura. In the lower portion, sometimes a?gophony in pleurisy, crepitation and bronchophony in advancing pneumonia. Signs of diseased bronchial glands. Dulness on percussion, cavernous rhonchus, pectoriloquy, &c, in phthisis. Catarrhal rhonchi. Dulness on percussion in advanced pleurisy; and on the right side, from enlarged liver. iEgophony in advancing pleurisy ; crepitant rhonchus, and bronchophony in advancing pneumonia. CO 54 PRACTICE OF MEDICINE. bo COMMON CATARRHAL BRONCHITIS. 55 BRONCHITIS. Bronchitis is an inflammation with altered secretion of the mu- cous membrane of the bronchi. There are several varieties of this disease, arising from its extent, or from the state of the constitution, or complications with which it is associated. It may present itself under three forms—viz., the primary, secondary, and complicated. The primary form is that in which the first morbid influence seems to be exerted on the respiratory mucous membrane, and in which any fever present must be regarded as symptomatic. In the secon- dary variety, on the other hand, the disease depends on the pre-ex- istence of some other malady ; especially disease of the heart, fever, and the exanthemata. The complicated form accompanies other diseases of the lung,—such as pneumonia, pleuritis, pulmonary hemorrhage, tubercle, &c. According to the habit of body and vital energy of the patient, and the extent to which the inflammatory action advances along the bronchial tubes, acute primary bronchitis may be subdivided into three forms :—1st, common catarrhal bronchitis, in which the larger bronchi and trachea are affected, constituting catarrh ; 2d, sthenic, or true bronchitis, which is of a highly inflammatory character, and in which the mucous and sub-mucous tissues of the smaller bronchi are also affected ; and, 3d, asthenic bronchitis, where, owing to de- pressed vital energy, the inflammation assumes a low type, and is attended with excessive secretion. COMMON CATARRHAL BRONCHITIS. Symptoms.—This is the most common form of the disease, and is commonly known as severe cold. It seems to affect the whole sur- face of the respiratory mucous membrane; from the nose, and frontal sinuses, downwards. It is evidently a constitutional disorder; and begins with shivering, headache, and feverishness, with pain and weight in the frontal sinuses (gravedo), and dryness, irritation of the Schneiderian membrane, sneezing, and snuffling, (coryza.) Then follow slight sore throat and hoarseness, and the irritation extends down into the chest. But in some instances the irritation commences primarily in the trachea and large bronchi, and is attended at first with a sense of roughness, and a constant desire to clear the throat. This is accompanied, or succeeded by titillation of the larynx, exciting a dry, hard cough ; hoarseness, with a sense of tightness across the chest ,* and sometimes pain on coughing or on making a deep inspiration, and soreness and heat behind the sternum, and between the shoulders, which are the great signs of bronchial irritation. The constitutional symptoms are, great lassitude, pains in the back and limbs, cold chills, quick pulse, dry skin, and high-coloured urine The cough, which was at first dry, is soon attended with the 56 PRACTICE OF MEDICINE. expectoration of a somewhat saline, glairy, thin fluid. If the disease be of a mild type, the expectoration, in two or three days, becomes thicker, more abundant, tenacious, and less irritating; and as amend- ment advances, the sputum increases in quantity, but is more opaque, tenacious, and deeper coloured, being frequently greenish-white. With these changes, the constriction, pain, and soreness, are miti- gated : the pulse becomes less frequent; the skin cooler and moist; and the urine less scanty, paler, and deposits a sediment. STHENIC, OR TRUE BRONCHITIS. Symptoms.—This form of bronchitis may succeed the catarrhal, if neglected. It is ushered in by chills, or sometimes complete rigors; which are soon followed by quickened and laborious respi- ration; oppression of the chest; sometimes a dull pain on coughing; quick, full, and often strong pulse ; pain in the forehead, back, and limbs; foul, loaded tongue ; constipated bowels, and high-coloured urine. As the diseases progresses, the frequency of the pulse, the cough, expectoration, and general febrile symptoms increase, as well as the tightness and soreness of the chest. Sometimes there is a very sharp, though transient, pain extending over the whole chest, particularly after fits of coughing. When the cough is violent, the patient feels also pain and weakness about the attachments of the diaphragm, along the borders of the false ribs, and in the back. The febrile and other symptoms are aggravated towards night, which is generally sleepless and disturbed. In extreme cases of this affection, collapse, with diminished expectoration, purple lips, orthopnoea, quick, depressed pulse, cold perspirations and extremities, with threatening suffocation, occur early. ASTHENIC BRONCHITIS. (Peripneumonia notha, or Suffocative Catarrh.—Bronchorrhea.) The disease which has received these names is an extensive in- flammation of the bronchial mucous membrane, in a weak constitu- tion with very great secretion of mucus. This copious secretion is the great source of danger. " There are four cases," says M. Laennec, " in which catarrh may become suffocative—1, in old persons; 2, in persons affected with oedema of the lungs; 3, in the dying ; 4, the acute catarrh may sometimes assume this character even in adults and children. "1. In old persons.—This affection, which is almost always mortal, occurs principally in winter, and in consequence of the super- vention of an acute catarrh on a chronic mucous catarrh, or phleg- morrhagy. It is liable to occur to old people with diseased heart, and with chronic catarrh, if they catch cold. If of any continuance, oedema of the lungs supervenes and hastens the fatal termination. SPUTUM IN BRONCHITIS. 57 2. With oedema of the lungs.—(Edema of the lungs is almost always accompanied by phlegmorrhagy, which may readily become suffocative, from the accumulation of fluid in the bronchi, especially in weak and old subjects. " 3. In dying persons.—The last agony, in almost all diseases, is accompanied by a copious tracheal rattle, and consequently by a real suffocative catarrh, except in those cases wherein the rattle is owing to the presence of blood in the bronchi. CEdema, or yet more commonly a sero-sanguineous congestion of the pulmonary texture, accompanies the flow of fluid into the bronchi; and it is to this cir- cumstance that the infiltration of the posterior parts of the lungs, observable in almost all dead bodies, is to be attributed. " 4. Acute suffocative catarrh of adults and children.—This is very rare in adults; in young children it is more common, and is often in them confounded with croup. It is recognised by the tracheal rattle perceptible by the naked ear, and by the imminent suffocation, and frequent lividity of the face. The stethoscope detects, over the whole chest, a loud mucous (and very liquid) rattle, and a very fre- quent and usually irregular action of the heart. This disease is acute catarrh, affecting the whole, or a very large portion of the mu- cous membrane of the lung; its duration is from twenty-four to forty-eight hours, or at most, some days ; at the end of which time the patient either dies, or expectoration commences, and puts an end to the suffocation, and the disorder then follows the progress of a simple catarrh." OF THE SPUTUM IN BRONCHITIS. In the first stage of bronchitis, the cough is dry, and as long as the cough continues so, the bronchitis must be considered as still at its commencement. At the end of a time, the length of which varies according to individual peculiarities, and according, as the patients are or are not subjected to proper treatment, each fit of coughing is followed by the excretion of a clear, transparent, serous or watery mucosity, which is at first slightly saline, but afterwards becomes tasteless. As the disease advances, the matter expectorated is a glairy mucus, like white of egg; when it is poured from one vessel into another, it is observed to flow in one mass of extreme tenacity. When the patient is attacked with violent fits of coughing, accom- panied by considerable heat within the chest, as also by marked distress and general anxiety, the expectorated matter acquires re- markable viscidity, and resembles a little the jelly-like sputa of acute pneumonia. When the bronchial inflammation is accompanied by much fever, the viscidity of the sputa becomes also greater during the febrile paroxysm, so much so, that an inexperienced practitioner may mistake it for that of pneumonia; on the cessation of the paroxysm, however, the sputa will be found to have lost their visci- 58 PRACTICE OF MEDICINE. dity. At other times, every species of expectoration is suppressed during the paroxysm ; which indicates an increase of irritation of the mucous membrane. Some patients present, towards the end of the perspiration which terminates the paroxysm, a copious expecto- ration of thick, opaque sputa, such as is observed in the last stage of bronchitis; but this is only a temporary state, and the patient soon expectorates anew a clear limpid mucus, as before the febrile exacer- bation. The sputa, in this stage, are frequently marked with some streaks of blood, arising from small vessels which are ruptured in the midst of an effort to cough. The blood is then mixed with mucus, but it is not combined with it, as happens in the reddened sputa of pneumonia. It often happens that in the midst of the trans- parent mucus, there are found, in greater or less numbers, small clots of a dull white; they do not come from the lung, but appear secreted in the pharynx and posterior part of the mouth, by the numerous cryptse with which the mucous membrane of these parts is supplied. These clots have been erroneously considered as portions of pulmo" nary tubercles, and consequently as one of the pathognomonic signs of phthisis. As long as the sputa present the appearance above described, the symptoms of bronchial irritation do not improve; but according as the inflammation proceeds towards resolution, the sputa change their character. The mucus which forms them gradually loses its trans- parence ; it is mixed with opaque, yellow, white, or greenish masses, which, scanty at first, continually increase, and ultimately constitute the entire sputa. Such an expectoration is ordinarily accompanied by marked remission in the different symptoms of bronchial inflam- mation. PHYSICAL SIGNS OF BRONCHITIS. Dr. Latham and Dr. Watson, have, with characteristic good sense, cleared away the phraseology and minute subdivision, which have overloaded the phenomena of auscultation. They now recognise two great divisions of morbid respiratory sounds; the dry and the moist. The dry are caused by the obstruction of the bronchial tubes by a swelling of their lining membrane, or by plugs of tough mucus. The moist are caused by the presence of liquid—whether mucus or blood, through which the air passes in bubbles in its entrance into and exit from the lung. The dry sounds are called rhonchus, when grave or deep because situated in the larger tubes; and sibilus, when of an acute whistling character because situated in the smaller tubes. The moist sounds are called crepitus; which may be large or small, according to the size of the tube in which it occurs. The first physical signs of bronchitis (and these sometimes are present before the cough comes on, and while the local feelings only PHYSICAL SIGNS OF BRONCHITIS. 59 indicate a coryza, or a raucity and dryness in the throat) are of the dry kind; sometimes a small whistling or hissing: sometimes like the prolonged note of a violoncello, and sometimes the cooing of a dove. When the membrane begins to secrete, the sounds above mentioned gradually disappear, and are replaced by moist or crack- ling ones produced by the successive formation and rupture of bub- bles in the air tubes. It sometimes happens that, during the course of a bronchitis, we suddenly cease to hear, in a certain extent of the lung, either the natural sound of the pulmonary expansion, or the crepitation. In this same part where the ear no longer hears any murmur, the chest when percussed retains its usual sonorousness. The explanation is, that the tube leading to a considerable portion of lung has been temporarily blocked up by mucus ; but it may often be cleared by a vigorous cough. This at once distinguishes bron- chitis from almost all other affections of the lungs. Thus, though percussion gives no direct result in this disease, its employment is of importance in the particular diagnosis. For example, if a person has had a severe cough, fever, hurried and difficult breathing for some days, and the chest still sounds well, the great probability is, that the disease is bronchitis. Morbid appearances.—After a mild and recent bronchitis, there is found some redness in a circumscribed portion of the mucous membrane ; particularly towards the termination of the trachea and commencement of the bronchi. If the inflammation has been more intense, the redness extends to a greater number of tubes; and to some of the smaller ramifications. It frequently occurs that this redness is exactly limited to the bronchi of only one lobe; it is the bronchi of the upper lobe which appear more particularly disposed to become inflamed. The red colouring of the bronchi sometimes presents itself in the form of a fine injection, which seems to exist simultaneously both in the sub-mucous cellular tissue and in the mucous membrane itself; sometimes vessels are no longer distin- guished, but only a number of small red points, crowded together, and collected round each other; sometimes there is observed a uni- form red colour. Frequently the redness exists only at intervals, in the form of bands or separate patches, which constitute, as it were, so many circumscribed inflammations, between which the mucous membrane is white and healthy—a form of inflammation similar to that so frequently observed in the intestines. When the inflamma- tion is chronic, the mucous membrane generally loses its bright red- ness ; it presents a livid, purple, brownish tint. It is very remark- able, that in persons presenting all the symptoms of an inveterate chronic bronchitis, with puriform expectoration, the mucous mem- brane of the air tubes is scarcely of a rose colour, or is sometimes even perfectly white through its whole extent. According to Bayle, this white state of the mucous membrane is not ran in pulmonary 60 PRACTICE OF MEDICINE. catarrh. The other changes remarked in chronic bronchitis are, thickening, softening, but rarely ulceration, of the mucous membrane; in chronic cases, dilatation of the bronchi. In only two instances has M. Andral detected ulcerations in the bronchi. Dry catarrh.—This name" is given by the French to a not uncom- mon variety of bronchitis; in which there is great dyspnoea, and intense congestion of the membrane, with sibilus or dry sounds; but the ordinary secretive stage is very slow to come on. It is also known by the name of bronchial congestion, and often follows the inhalation of acrid vapours. Treatment.—In simple catarrhal bronchitis, confinement to bed; inhalation of steam; an aperient; a warm bath; a few grains of Dover's powder with a little antimony at bed time; some demulcent for the cough; and low diet, are usually sufficient. When acute bronchitis occurs in a robust habit, a moderate bleed- ing is decidedly indicated; but, as in other mucous inflammations, we must regard general depletion more as a means for reducing the febrile excitement, and preparing the patient for local treatment, than for cutting short the disease. The bowels should next be attended to, and freely acted upon by mild aperients. After general bleeding and purgatives, local depletion will be found extremely beneficial; and Dr. Stokes recommends " that in severe cases the patient should be cupped under the clavicles, or between the scapulae, or a number of leeches be applied under the clavicles, or into the axilkc." After moderate depletion, it will be right to use some antiphlogistic reme- dy ;—and as mercury is not so beneficial in inflammations of mucous as of serous membranes, tartar emetic is to be preferred. It should be given in small doses at regular intervals—say gr. * 4tis horis in solution with a drachm of syr. papaveris and some distilled water, and be continued until it causes nausea, and lowers the heart's action. In some cases, after the system is brought under its influence, the disease yields suddenly; the oppression and wheezing cease, the cough becomes trifling, the lividity disappears, the pulse falls, and the respiration, with the exception of a slight crepitation, which is occasionally heard, is healthy, pure, and equal. In others, a copious secretion is produced, with great relief. Some practitioners prefer ipecacuanha as less likely to purge and weaken. Emetics are extremely useful in bronchitis, particularly in the asthenic form, and in the sthenic variety after bleeding; in children, their exhibition is attended with the best results. For children, ipecacuanha should be preferred; for aged persons, the sulphate of zinc; and, for the robust adult, tartarized antimony. When the inflammatory action and febrile heat have been subdued, blisters are of much service, and may be applied either between the shoulders or on the breast. A large warm poultice to the chest is also useful, especially for children. WHOOPING-COUGH. 61 Stimulating expectorants and tonics are now given with decided benefit. Amongst the first class, are included senega, the balsams, ammoniacum, squill, and myrrh; and in the second, improved regi- men, wine, bark, serpentaria, the preparations of iron, &c. In bad cases of bronchitis, in addition to the internal treatment, counter- irritants should be persisted in for some time. The counter-irritants most employed are, blisters, tartarized antimony ointment, croton oil, the acetum cantharidis, and pitch plasters containing either can- tharides or tartarized antimony. Dr. Stokes recommends a stimu- lating liniment, which, when applied to the chest daily, keeps up an erythematous state of the skin.* He considers that this liniment not only acts beneficially by its counter-irritating properties, but that the ingredients are absorbed by the surface, so as to act on the mucous membrane as direct stimulants. In asthenic bronchitis, with copious suffocative secretion, our greatest dependence is to be placed on emetics for children ; and for old people, on warm purgatives, blisters, and stimulating expecto- rants, especially senega and ammonia. Diuretics and astringents are afterwards of service. Opiates always require caution in bronchitis which is attended with profuse secretion. It is true, they ease the cough; but then it must be recollected that the cough is the only means of getting rid of that superabundant mucus which is choking the patient, and that if the cough stops, the patient will perish ; drowned, to all intents and purposes. Particular caution must be used if there is any ap- pearance of venous blcod circulating—livid lips, or coma. Yet, as it is right to allay inordinate irritation, small doses of paregoric may be combined with the stimulant expectorants, to moderate the violence of the cough; and a larger dose may be given at bed time, if the patient is worn out for want of sleep, and can expecto- rate freely. pertussis (Whooping-Covgh). This affection is contagious; it seldom occurs twice in the same individual, and particularly attacks children; but adults are liable to it, if they have escaped it in their childhood. Symptoms.—It commences with symptoms of common cold, or catarrh, which may last for some days; the cough then becomes convulsive, and recurs in fits at various intervals. The fits may last a quarter of an hour or more. Each fit is composed of a quick suc- cession of sonorous coughs, with scarcely any perceptible inspiration between ; but at intervals the expirations of coughing are suddenly interrupted by a very deep, sonorous inspiration, or whoop, which constitutes the pathognomonic sign of this disease. The peculiar * The following is his formula:—R. Sp. terebinth. 3iij.; Acid acet. gss.; Vitejl. ovi, j,; Aq. rosar. Siiss.; Ol. limon. 3j. M. 62 PRACTICE OF MEDICINE. whooping inspiration depends on spasm of the glottis. The face be- comes swollen and livid in the paroxysm, and particularly during the whooping. The fit terminates by the expectoration of a colour- less and scarcely frothy phlegm, and in many cases by vomiting also. The paroxysms at first recur several times every day, being always more severe towards evening, but less so during the night. After a certain time, they only return in the morning and evening; and towards the end of the disease, in the evening only. The dura- tion of whooping-cough varies from a few weeks to several months. Before it terminates, the paroxysms become shorter, lose their pecu- liar characters, and are attended by an expectoration more decidedly mucous. This disorder may be complicated with bronchitis, or pneumonia; which are the chief sources of danger:—or it may cause cerebral symptoms, or sometimes a real apoplexy. The younger the child, the greater the danger. In some cases, the disease degenerates into a chronic mucous catarrh, with emaciation, and other symptoms resembling phthisis. In the intervals of the paroxysms, the patient coughs but little, preserves his appetite and strength, and has rarely any fever, except in the case above men- tioned, or in the onset of a very severe attack. Physical signs.—In the intervals of cough, the respiratory mur- mur varies on different points of the chest; at one part it is lost; at another it is slight; at a third it is puerile ; there is some degree of sibilus and crepitus. The sound of the chest, on percussion, is good and unimpaired. The lungs do not become inflated during the strong inspiratory effort producing the whoop; for not only is the rima glottidis spasmodically affected, but in all probability the whole of the ramifications of the respiratory tree participate in this morbid action; for, during that period, if the ear is applied to the chest, no rhonchus or respiratory murmur is heard, except for a moment be- tween each cough. The great tendency of pertussis, in young children, to pass into pneumonia, oedema pulmonum, or intense bronchitis, makes frequent auscultation of the chest very necessary. At the first invasion, this disease may be mistaken for croup, or suffocative catarrh. Morbid appearances.—The most probable theory of the nature of whooping-cough is, that it is a peculiar irritation of the laryngeal branches of the par vagum. When it terminates fatally, it is usually upon the supervention of peripneumonia or oedema pul- monum ; in the first case, the lung will be found to contain san- guinolent serum, and here and there a lobule hepatized; in the second, a large quantity of highly spumous and colourless serum follows the scalpel on section of the pulmonary tissue. In some cases, the meninges of the brain are much injected; in rare in- stances there is also some effusion. Treatment.—In the early stages, the indications are, to avert in- CHRONIC BRONCHITIS. 63 flammation to promote expectoration, and to soothe irritation. The child should be confined to the house if the weather is inclement; it should have no meat; the bowels should be kept open; an emetic of vin ipecac, should be given about every other night, or whenever the chest appears much loaded with phlegm; a grain of calomel and a warm bath at bed time may be given if there is much fever- lshness: and if any inflammatory symptoms arise they must be combated by leeches. Frictions to the spine are beneficial throughout; olive oil, and oil. of amber; soap liniment and laudanum are useful materials. When the acuteness of the complaint is over, tonics, especially quinia and sulphate of zinc, and change of air, are the best means of getting rid of the dregs of the disorder. Various other remedies have been recommended in this disease, such as opium, hyoscyamus, belladonna, hydrocyanic acid, acetate of lead, sulphate of zinc, arsenic, nitrate of silver, ammonia, ether, musk, camphor, can- tharides, &c. Many of these have enjoyed considerable reputation, but are too dangerous for nursery use. Tartar emetic ointment has been rubbed into the back ; but it is too severe for children. CHRONIC BRONCHITIS. The chief symptoms of chronic bronchitis are, cough, shortness of breath, and expectoration of various kinds of mucus. Causes.—This complaint is very common, especially in old people. It may, like other chronic inflammations, be a consequence of one or more acute attacks; or it may, especially in old people, depend on that congestion which is infallibly produced in the lungs by disease of the heart. When habitual, and attended with much expectora- tion, it is called humoral asthma. The sounds heard by auscultation in simple cases, consist of the crepitation and bubbling of mucus in the air-tubes of various sizes. Sometimes this malady presents all the outward marks of phthisis ; wearing cough ; profuse purulent expectoration; wasting, night sweats, &c. But yet so long as no important organic change has occurred, it is quite curable. The diagnosis must be guided by the circumstance, that in chronic bronchitis there is no solidification of the upper lobes of either lung; no pectoriloquy, or signs indicating a cavity or vomica. Morbid appearances.—The mucous membrane after death may be of various shades of redness ; often deep purple ; but this is not constant. It may be ulcerated ; but this is extremely rare. It may also be thickened. But the most curious effect of long-continued cough, and difficulty of breathing, is dilatation of the bronchi; which is caused apparently by the accumulation of mucus, impelled by the 64 PRACTICE OF MEDICINE. efforts of coughing, and unable to escape. These bronchial dilata- tions, it is to be noticed, may present the auscultatory signs of tuber- cular cavities. Sometimes the expectoration is excessively profuse, but clear; coming up once or twice in the day to the extent of many ounces. Such cases are called pituitous catarrh by the French. Treatment.—Occasional leechings or cuppings to obviate conges- tion : blisters and other counter-irritants; mild, nutritious, unstimu- lating diet; change of air; tonics, such as sulphate of zinc, with small doses of pill scillae comp. and opiates, to allay the cough, are amongst the chief remedies for younger patients. For older habitual cases, and especially if the expectoration is profuse, the stimulating expectorants, especially tinct. benzoes c, bals. copaibse, senega, &c. are indicated; inhalation of tar vapour also is useful. SPASMODIC ASTHMA. Asthma is caused by a spasm of the muscular fibres encircling the bronchial tubes, and especially the smaller ones. The existence of these muscular fibres was proved by Reisseissen, and has been confirmed by Dr. Williams and others, who have pro- duced contraction of them by galvanism. The exciting causes of the purely spasmodic variety of asthma are those which impress the nervous system, as strong or peculiar odours, mental emotions, and particular states of the atmosphere, and especially, irritation of the stomach and bowels. The precursory symptoms of asthma are, languor, sickness, flatulency, and other dyspeptic symptoms ; heaviness over the eyes, and headache ; uneasiness and anxiety about the prsecordia, with a sense of fulness and straitness in this region and in the epigastrium. In some cases, pain is complained of in the neck, with unusual drow- siness and stupor. Symptoms.—The attack of spasmodic asthma takes place gene- rally about one or two in the morning, and during the first sleep. The patient suddenly awakes with a sense of suffocation, great tightness at his chest, difficulty of breathing, and excessive anxiety; he assumes with great eagerness the erect posture, and cannot bear the least incumbrance about the chest. The respiration is wheezing, interrupted, and laborious; the shoulders are raised, the elbows directed backwards, and every effort made to enlarge the thorax. The countenance, which was at first pale and anxious, becomes, especially in plethoric habits, suffused or bloated, and covered with perspiration. A considerable quantity of pale urine is voided at the commencement, or previous to the accession, of the paroxysm; and the lower extremities are usually cold. The pulse is generally SPASMODIC ASTHMA. 65 quick, weak, and somewhat irregular. During the fit, the patient has commonly an instinctive desire for cool air. When the fit has con- tinued from half an hour to one, two, three, or even four hours, some degree of cough and expectoration comes on, which relieve the patient; and after a brief period, his respiration, pulse, and feel- ings assume their natural state. Such is the common course of a first and moderate attack of this disease. Occasionally the patient has but one such fit, but more generally a slight constriction of the chest is felt through all the succeeding day, and the paroxysms return at the usual period of the night; this may occur for several nights, and at last the patient is altogether released from the attack. The disease may be suspended for several months, but it is liable to recur from changes of air, errors of diet, and the operation of other causes. Physical signs.—In spasmodic asthma, during the fit, the chest does not sound well on percussion, and the respiratory murmur is indistinct, even on the most forcible inspiration. But if the patient, after holding his breath a short time, be desired to breathe again quietly, the spasm will be for a moment overcome, and the entry of air into the cells will be heard in a clear and sometimes puerile sound ; after one or two inspirations, the spasm again comes on, and the respiration becomes as dull as before. In treating of the pathology of this disease, it was stated that the muscular fibres were in a state of spasm during the paroxysm ; the obstruction to the entrance of the air into the small bronchi and vesicles thus produced is obviously the cause of the diminution of the respiratory murmur. By this contraction also the lungs are in a manner collapsed within the chest, and the parietes of the thoracic cavity, pressed by the atmospheric weight on them, lose that sonorous elasticity produced by a fulness of their aerial contents. Complicated asthma.—A pure spasmodic asthma, affecting lungs otherwise healthy, is by no means common. In general there is some disease of the heart, or some chronic bronchitis acting as a source of permanent congestion, which both adds to the difficulty of breathing, and predisposes the parts to be more easily affected with fits of spasm. Sometimes a severe attack of dry catarrh is aggravated by spasm. This constitutes the bronchial asthma of Andral. Morbid appearances.—The changes which have been noticed in those who have died of asthma are to be regarded chiefly as acci- dental occurrences, or associated maladies, and, perhaps, more fre- quently as the remote results of repeated or protracted attacks No lesions, sufficient to account for the phenomena of uncomplicated asthma, could be detected by Laennec, Andral, Cruveilhier, Bouil- laud, and many other investigators. The most common cease- quences of the disease are, chronic inflammation and dilatation of 66 PRACTICE OF MEDICINE. the bronchi; the different varieties of emphysema and oedema of the lungs; hcemoptysis; tubercular deposits, with which asthma may be associated from its commencement; hypertrophy and dilata- tion of the cavities of the heart; atrophy of the heart; effusions into the pericardium ; effusions into the pleura; and, in some severe cases, congestions or effusions within the head, giving rise to coma, or apoplexy. Treatment.—The indications during the interval are, to strengthen the general health, and avoid all derangement of the stomach by im- proper diet, and irritation of the lungs by unwholesome air. The treatment of the fit consists in administering narcotics and antispasmodics. These should be given, if possible, as soon as the first sensations are felt, and then they may avert the attack ; and it is noticed, that those do most good which produce expectoration. Strong coffee; laudanum and ether; and stramonium smoked as tobacco, are the most trustworthy. Ipecacuanha first given in an emetic dose, and afterwards in small quantities, so as to keep up a constant nausea, sometimes has a powerful effect on spasmodic asth- ma. The tincture of lobelia inflata (Indian tobacco) is much used in asthmatic cases; it is nearly allied in its operation to stramonium and tobacco, and often succeeds in checking the paroxysm when given shortly before its invasion. Bloodletting is only required if there is inflammatory complication. DISEASES AFFECTING THE TISSUE OF THE LUNGS. PNEUMONIA. Pneumonia consists in an inflammation of the parenchyma of the lungs, and, according to the changes produced in the tissue, is most commonly divided into three stages. Three stages.—The first stage of pneumonia is the stage of en- gorgement, in which the organ is found intensely loaded with blood; the second, is the stage of hepatization ; in which it is solidified by an effusion of lymph: the third, is the stage of purulent softening, or suppuration. Pneumonia may be single or double ; in other words, it may attack but one lung or both at the same time. In one and the same lung it may be general or partial, attack the upper or lower lobe, be con- fined to the base, the root, or the centre (lobular pneumonia). It has been said, that all these different seats of pneumonia have been equally frequent. Some numerical results will settle the question. Out of two hundred and ten pneumonias, there were— On the right side.............121 " left side........•.....58 Both sides {double).............25 Cases where the seat could not be detected..... 6 PNEUMONIA. 67 It has been asserted that the upper pulmonary lobes are scarcely ever attacked with inflammation. This statement is not correct; those lobes are often affected, but not so frequently as the lower lobes. Morgagni, Frank, and Broussais, who draw their conclusions from dissections, state that the upper lobes are most frequently the seat of inflammation ; Laennec and Andral, on the other hand, who included cases of recovery in their calculation, found the lower lobes to be most commonly inflamed. This discrepancy may be reconciled, as Dr. Williams observes, by assigning as the cause of it the fact, that inflammation of the upper lobes is the most frequently fatal. The disease, as it generally occurs, presents the following cha- racteristic symptoms:—pain, more or less marked, in one of the sides of the chest; dyspnoea, viscid and bloody sputa, dull sound, and modification of the respiratory murmur. The patient lies on the back; the pulse accelerated, but variable in its character; the fever is generally of the inflammatory kind, but is occasionally typhoid. Of the pain.—The pain is generally on the level of, or a little below, either breast; more rarely it is seated either below the cla- vicles or entirely at the lower part of the ribs, and even in the hypo- chondria, or, in fine, over all the extent of the thoracic parietes of one side. In some cases it precedes, by several days, the appearance of the other symptoms; being then neither accompanied by fever, cough, nor dyspnoea, it simulates a pleurodynia, or simple rheumatic pain. The pain is increased by coughing, by the movements of in- spiration, sudden changes of position, and intercostal pressure and percussion; it is principally exasperated by lying on the side on which it exists. M. Andral says, " In all patients who presented this pain to us, we found the pleura inflamed, and covered with membra- niform albuminous exudations." Of the dyspnoea.—The dyspnoea, in pneumonia, is generally in the direct ratio of the extent of the inflammation, of its seat, and of its intensity in each of the points which it occupies. To this rule, however, many exceptions occur; for, owing to some peculiar idio- syncrasy, there are some individuals a very small portion of whose lung is in the first stage of inflammation, and whose respiration is nevertheless much embarrassed ; there are others, on the contrary, in whom a much more extensive inflammation of the lung in the second or third stage exists, and yet the dyspnoea is compara- tively slight. It appears, cseteris paribus, that inflammation of the upper lobe gives rise to greater dyspnoea than an equally extensive and equally advanced inflammation of the lower lobes. The dyspnoea in pneumonia presents various grades or degrees. In the mildest form, the patients are not aware of its existence; in a greater degree still, the patient may not feel any oppression, but the inspiratory movements are short and frequent; in a still higher 68 PRACTICE OF MEDICINE. degree, the patients complain of having on their chest, as it were, a weight which smothers them; when observed, they seem to be ab- stracted from all that is passing around them, and are entirely occupied with respiring; the face, of a violet red, or livid pale colour, expresses intense anxiety; the nostrils are dilated in a marked degree ; the respiratory movements are very frequent and short, as if the air could not penetrate beyond the first divisions of the bronchi. When the difficulty of breathing amounts to this last degree, the termination is seldom favourable. After most of the symptoms of inflammation of the lung have ceased, the breathing still remains embarrassed, and this is particularly observable on the slightest effort. As long as this residue of dyspnoea exists, the resolution of the inflammation is not complete. Of the sputum.—At the commencement of pneumonia there is frequently no expectoration, or it is simply catarrhal, being com- posed of mucus of moderate tenacity; but as the small crepitation becomes marked, the sputa assume their characteristic form. When the small crepitation becomes evident, which occurs about the second or third day, the sputa become bloody, that is, they consist of a tenacious matter intimately united with blood; not merely simple striae of blood, as in bronchitis; neither is it pure blood, as in hae- moptysis. According to the quantity of blood which they contain, the sputa are either yellow, of an iron-red colour, or of a marked red. They are at the same time tenacious and viscid; they adhere together so as to form a homogeneous whole; at this period of the disease, the sputa adhere firmly to each other, but they are not yet sufficiently viscid to adhere to the sides of the vessel. Frequently the sputa retain the above characters all through the disease; in this case, the inflammation of the lung does not ordinarily pass the first stage, but oftentimes the sputa acquire still greater viscidity, they are no longer detached from the vessel when it is turned upside down. We should, under these circumstances, have cause to apprehend that the second stage is advancing ; in fact, as the viscidity of the sputa increases, the chest, when percussed, yields a duller sound, and the murmur of pulmonary expansion is either gone altogether, or is changed into bronchial respiration. In fine, the degree of vis- cidity announces with tolerable precision the intensity of the inflam- mation ; and whenever, after having become thinner in the course of cure, the sputa regain their former viscidity, a relapse is indicated. In the suppurative stage of pneumonia the sputum is generally characteristic. It then occurs under two forms; in the one, we observe a purplish-red muco-puriform fluid; while in the other, the matter expectorated has all the characters of true pus. In some cases, pneumonia runs through its different stages without its exist- PNEUMONIA. 69 ence being announced in any way by the expectoration, which has been all through either absent or devoid of character. When pneumonia terminates in gangrene, it is announced by the expectoration of a liquid at first greenish, then of a dirty gray colour, reddish at intervals, and exhaling a foetid odour, like that of the gan- grene of external parts. At the commencement of this disease, the face is usually red; sometimes more so on the affected side than on the other. If the dyspnoea be considerable, the face presents a livid tint; and, when the lung is infiltrated with pus, a characteristic paleness is usually diffused over the entire face. Delirium is frequently present during pneumonia, and generally manifests itself during the night; in most cases where it appears only at intervals, it is an unimportant symptom. But when con- stant it is serious, as it shows there is a circulation of unoxidized blood. The character of the pulse is very variable in this affection; it is most frequently quick and full; but when the inflammation is very in- tense, it is sometimes remarkably small, and this smallness disappears after a copious bleeding. In some cases, particularly those occurring in old persons, the pulse retains its hardness and strength ; in such cases we may suspect that a hypertrophy of the left ventricle of the heart exists. M. Andral observes, " Great frequency of the pulse announces danger in this disease. It seldom happens that recovery takes place when the pulse exceeds one hundred and thirty. The frequency of the arterial pulsations is always in the direct ratio with the respiratory movements ; however, in the last periods, it is often observed that the pulse loses its frequency, and seems to have returned to its natural state, though the respiration becomes more and more accele- rated. This is invariably a fatal sign." Physical signs: First stage.—According to Dr. Stokes, an in- tense puerility of respiration in the affected part will be found to exist for some hours before the characteristic crepitus is heard. But as soon as the first stage is fully developed, we know that where the pain is manifested, the natural respiratory murmur has lost its clear- ness ; it is mixed to a greater or less extent with the small crepita- tion ; a sound caused by the breaking of minute bubbles in the air- cells, or by the separation of the adherent walls of the vesicles in inspiration, and resembling that caused by rubbing a lock of hair between the finger and thumb close to the ear. This sound indicates engorgement of the lung ; whilst it exists, it is a proof that in several points at least, the inflammation has not passed the first stage. As long as the natural respiratory murmur predominates over the cre- pitation, we should infer that the inflammation is slight; on the other hand when the crepitation prevails so as altogether to mask the re- 70 PRACTICE OF MEDICINE. spiratory murmur, it is a certain indication that the pneumonia has made progress, and that it has a tendency to pass to the second stage. These phenomena soon change, either by the resolution of the disease, or by its making further progress. In the former case, the crepitation diminishes in extent and intensity ; the murmur of respiration approaches its natural state ; the sound of the chest be- comes less dull, and its movements more regular ; and, finally, a large crepitation is evident, which indicates an approach to conva- lescence. In the first part of this stage the sound on percussion is only slightly impaired; but as the engorgement advances, and the pro- portion of air in the inflamed spot of lung is diminished, it becomes more dull over the corresponding part of the chest. Second stage.—The second stage of pneumonia is that in which the lung presents that change which is called by Laennec red hepa- tization. In this condition, the cells being obliterated, while the large tubes remain pervious, dulness on percussion, bronchial respi- ration, and a loud resonance of the voice (bronchophony), are pro- duced ; the extension or intensity of these signs furnishes, within certain limits, an accurate measure of the extent or intensity of the disease. The bronchial respiration specifically marks the second stage of pneumonic inflammation. It resembles the sound produced by blowing through a crow's quill, and is frequently so loud as to amount to a whistle. If the inflammation is extensive, the respira- tion is puerile in other parts of the lung. In order that this bronchial respiration should be produced, not only must there be solidity of the lung, but a certain expansion of the side must also take place; for, if the whole lung becomes solidified, the bronchial respiration ceases, and the signs then are, universal dulness, absence of the respiratory murmur, and resonance of the voice. The voice is much modified in its resonance, and this modification is not properly that of aegophony, nor pectoriloquy; it approaches more to broncho- phony. If the patient recovers from the second stage, and the infiltration diminishes, so that the air is again admitted to the minute tubes and vesicles, this is announced by a return of the small crepitation, which is of course favourable. (Crepitus redux.) Third stage.—In the third stage, the diseased lung becomes infil- trated with a purulent matter, which is generally consistent at first, but soon acquires the liquidity of common pus. In this stage, a peculiar muco-crepitating rhonchus is heard, at first in some points, then in the whole of the affected part. Of abscess.—In the infancy of pathological anatomy, the forma- tion of an abscess in the lung, as the result of acute or chronic in- flammation, was considered a very common thing. The common PNEUMONIA. 71 error has been to mistake tubercular vomicse, or interlobular pleuritic effusions, for abscess of the lung. When abscess, however, does form in an hepatized lung, the passage of air through the liquid will be indicated by the gurgling or cavernous rhonchus; and when the cavity has been emptied of the pus by expectoration, pectoriloquy and the cavernous respiration will be added to this sign. Pneumonia may also terminate in gangrene ; but this is nearly as rare a termination as abscess. The distinctive physical sign of gangrene is the foetid odour emitted from the diseased part in respi- ration and cough; and the expectorated matter is also extremely foetid. This change is usually attended by a collapse of the features, and great prostration of the vital powers. Morbid appearances.—In the first stage of pneumonia, the sub- stance of the lung presents an increase of weight and density; it is infiltrated with a frothy, sanguineous serosity, in considerable quan- tity ; it pits on pressure, but yet is still somewhat crepitant ; its integral cohesion is diminished, for it can be easily broken down between the fingers; the mucous membrane of the small bronchi is of a deep red colour. In the second stage, or that of hepatization, the lung no longer crepitates ; it now sinks in water; and, when cut into, a red liquid, not frothy, nor so abundant as in the preceding stage, flows from it. Externally, the lung is of a deep red colour, and internally it is studded with a number of red granulations, with patches of a white colour, marking the vessels, interlobular septa, &c, less affected with the inflammation. Its friability is very great; in many cases, it is sufficient to press it between the fingers to crumble and reduce it to a reddish pulp. The term " hepatization" is not strictly appli- cable to this condition of the lung; that of red softening gives a much more accurate idea of the real condition of the inflamed organ. In the third stage, the pulmonary tissue, dense, compact, and im- pervious to the air, as in the preceding stages, presents a charac- teristic grayish colour. When examined with a lens, it presents granulations of a white or gray colour; these can also be seen by the naked eye in many instances. In a more advanced degree, the colour is of a straw, or sulphur yellow, owing to the greater quantity of liquid pus ; the texture is considerably destroyed ; and if the lung be cut, and the tissue slightly compressed, without crumbling it, small drops of pus appear on the surface; these seem to issue either from the orifice of the capillary bronchi, or from the granulations themselves. This condition of the lung may be defined as " gray softening." Treatment.—Pneumonia is one of those diseases whose treatment is at once simple and efficacious, provided it be adopted at an early 72 PRACTICE OF MEDICINE. period; but not if the disease be allowed to run into the second and third stages. When the practitioner is called in early in this disease, he should have recourse to copious bleedings, holding in mind that they not only act as in all other inflammations, but that they have also the effect of directly diminishing the quantity of blood which, in a given time, must traverse the lung in order to be subjected to the action of the air. But bleeding, although to be performed with determination, must yet not be done indiscriminately, so as to empty the patient's veins, and take away the strength necessary for the laborious work of respiration and expectoration. " We want some remedy," says Dr. Watson, " to assist the lancet, or to employ alone when the lancet can do no more ; and we have two such in tartarized antimony and in mercury. The tartarized antimony I believe to be best adapted to the first degree of the in- flammation, that of engorgement; and the mercurial plan to the second—that of hepatization." The tartar emetic may be given in doses of gr. \ dissolved in water, with a few drops of syrup of poppies or laudanum, every hour :—after two or three doses the quantity may be doubled ;—and after two or three more it may be increased again, to a grain every hour. If the medicine acts favourably, it will relieve the dyspnoea, without causing more than very slight vomiting or purging. In those cases where tartarized antimony is inadmissible, or in- efficient, the mercurial treatment must be had recourse to; calomel and opium ought to be given internally, and mercurial inunction be employed. Aperients should be occasionally given in this disease, so as to keep the bowels open ; but too much purging is always injurious. When the patient is under the influence of antimony, enemata should be employed. Local depletion is also highly important in this disease. When the acute stage has passed, blisters may be applied to the chest. " After the inflamed lung has become solid and impermeable," says Dr. Watson, " the treatment must be regulated rather by the state of the system at large, than by the actual or present condition of the lung: we must look more for guidance to the general symp- toms than to the physical signs. If the pulse continues firm and steady, wait patiently the effect of the mercury. But when sunken features, a pallid face, coldness of the surface or extremities, a ten- dency to delirium, and above all, a feeble and irregular pulse, pro- claim that the vital powers are giving way, it will be requisite, as in other cases where death is threatened by asthenia, to administer cordial and stimulant medicines ; the carbonate of ammonia in a de- EMPHYSEMA OF THE LUNGS. 73 coction of senega; wine ; and to feed the patient well on milk or beef tea."* The regimen should be strictly antiphlogistic; and with a view to prevent vomiting, very little liquid should be allowed during the an- timonial treatment. During convalescence from this and all other acute diseases of the chest, visiters should be excluded, as talking, even in an under tone, is injurious to the patient. EMPHYSEMA OF THE LUNGS. The term emphysema of the lung, given to this disease by Laennec, is not strictly applicable, inasmuch as that term signifies an escape of air into the cellular tissue. This disease, more correctly speaking, consists in a dilatation of the air cells ; the parieties of which may also be ruptured, in which case several may coalesce, and form a cavity of some extent. Causes. — It has been staged that long-continued and violent coughing acts in distending the air-cells beyond their ordinary dimensions, and from this repeated dilatation they finally become permanently enlarged. Again, in cases of chronic catarrh, particu- larly of the dry kind, the small bronchial ramifications become so obstructed by the swelling of their membrane, or by the secretion of a viscid mucus, that the air can only be forced through them into the vesicles by a considerable effort. Now, an inspiration is more forcible than expiration ; the former may be sufficient to overcome the obstacle to the admission of air into the vesicles, while the latter is not adequate to its expulsion: thus the vesicles would be kept in a permanently distended state. Further, an additional cause has been suggested by Laennec, namely, the expansion of the air in consequence of the temperature of the body. Successive portions of air expanding by the increased temperature, are thus introduced and incarcerated in the cells, which are thereby kept in a continual state of dilatation. Dr. Williams observes—" In dry chronic catarrh the general starting point of emphysema, small particles of viscid mucus form a kind of movable obstruction, which, falling into a bronchial ramification, instantaneously and effectually plug up the tube. Now, suppose this to happen in a tube at the termination of an expiration ; inspiration takes place, but this pellet of mucus acts as a valve, preventing the entry of air into the cells, supplied by this tube; the consequence is, that the. air in the surrounding;cdls presses in to fill the vacuum, by dilating or rupturing their mem- branous tunics." Miliary tubercles, and other causes, pioducing^par- tial pressure and obstruction among the air-cells™^ * *e develooment of this disease. To the practical physician, however tJ greTpoint of consideration is, that this affection is the result of * Dr. Watson's Lectures, vol. ii., P- 93. 7 74 PRACTICE OF MEDICINE. bronchitis; and that, for its prevention and alleviation, the treatment must be conducted on this principle. Symptoms.—Habitual dyspnoea, which, during the earlier periods of the disease, is mitigated in summer, but returns in the winter with increased violence: the complexion is of a dusky hue; the countenance has an anxious and melancholy expression ; the nostrils are dilated and thickened; the lower lip is enlarged, and its mucous membrane everted and livid. The movements of the thorax are irregular and habitually unequal; inspiration is short, high, and rapid ; but expiration is slow, incomplete, and, as it were, graduated; there is thus a manifest difference in the duration of the two move- ments. The shoulders are elevated and brought forward, and the patient stoops habitually, a habit contracted in his various fits of orthopncea and cough; thus, even in bed, we find these patients sitting up, with their arms folded and resting on their knees, and the head bent forwards, the object of which seems to be to relax the ab- dominal muscles, and to substitute the mechanical support of the arms for that of muscles which would interfere with inspiration. During the fits, the respiration becomes convulsive. There is a constant cough, returning in fits, usually dry, but often attended with the expectoration of a viscid liquid, of a dirty gray colour. This is one of the diseases long confounded under the name of " asthma." Physical signs.—The chest yields a morbidly clear sound on percussion; it is not, however, tympanitic, as in pneumo-thorax, but may be described as the maximum of true pulmonary sound. This excessive resonance is not given equally at all points, as the disease seldom extends to the whole lung. But although percussion indi- cates the presence of air, the ear applied to the chest detects that the air is not in motion, for there is very little or no vesicular breathing. There is heard occasionally some large crepitation; this was called by Laennec dry crepitation, and he supposed it to be produced, like the crackling of a dry bladder, from the entrance of air into the dilated vesicles. Dr. Watson, however, believes it to be nothing more than the crepitation of large bubbles of mucus, arising from the catarrh, which is almost always present. Where this dis- ease is extensive, we generally find, owing to long-continued pul- monary obstruction, that the right cavities of the heart are hyper- trophied; this latter fact will obviously account for the congested and enlarged state of the liver which also occurs. Morbid appearances.—The ordinary appearance of an emphy- sematous lung is a remarkable coarseness of the vesicular texture, as seen through the pleura; it is also elastic, lighter, and less cre- pitant than usual, and does not collapse. In a greater degree, the enlarged cells look like the vesicular lungs of cold-blooded animals, and occasionally raise the surface of the lung into rounded inequali- PHTHISIS PULMONALIS. 75 ties. Single vesicles, like fish bladders, of various sizes, sometimes project from the surface or margins of the lung, in some instances attaining an extraordinary bulk.* Treatment.—This disease may exhibit itself under two circum- stances: first, it may have existed from infancy, or the causes which produce it may have been present from the earliest period of life; second, it may result, as before stated, from obstructions de- pendent on bronchitis and the other causes enumerated. Now, in the first case, our treatment avails but little ; all we can do is to pal- liate the symptoms: the mode of treatment in the second case is evident enough. In this disease we must, as in all others, direct our attention to the cause ; in fact, we should as soon as possible remove the obstruction of the tubes, and then endeavour to restore the lung to its original condition. The patient should clothe warmly, particularly about the feet, and should live in a sheltered genial situation. He should also take care to avoid all causes of indigestion and flatulency, because, if the ac- tion of the diaphragm is impeded, an attack of dyspnoea may be brought on directly. The fits of dyspnoea may often be relieved by opium and ether. PHTHISIS PULMONALIS. Phthisis pulmonalis is owing to the development in the lungs of a peculiar substance, called tubercle. Of tubercle.—Andral describes tubercle, at its origin, as a pale yellow, opaque, round body, of various degrees of consistence, in which no trace of organization or texture can be detected by the naked eye, although the microscope shows various forms of cells, imperfectly developed; so that tubercle evidently consists of un- healthy lymph, whose powers of organization are imperfect. Seat of tuberculous matter.—The prevailing opinion among pa- thologists is, that the seat of tuberculous matter is the cellular tissue of organs. It may, however, be formed on secreting surfaces ; as, in the mucous follicles of the intestines, on the surface of the pleura and peritoneum, and likewise in false membranes, or other morbid products, and in the blood itself. Dr. Carswell regards the mucous surfaces as the principal seat of tuberculous matter; and asserts, " that, in whatever organ the for- mation of tuberculous matter takes place, the mucous system, if con- stituting a part of that organ, is in general either the exclusive seat "" of this morbid product, or is far more extensively affected with it than any of the other systems or tissues of the same organ." Andral considers the cellular tissue its chief seat, but that it may occasion- * Dr. Hope's Morbid Anatomy, Part 2. 76 PRACTICE OF MEDICINE. ally occur on mucous and serous surfaces. Lombard supposes it to be restricted to the cellular tissue. In confirmation of Dr. Carswell's statement, he has shown it in the lungs formed on the secreting surface, and collected within the air-cells and bronchi; in the intestines, in the isolated and aggre- gated follicles; in the liver, in the biliary ducts and their extremi- ties ; in the kidneys, in the infundibula, pelvis, and ureters; in the uterus, in the cavity of that organ and Fallopian tubes; and in the testicle, in the tubuli seminiferi, epididymis, and vas deferens. The formation and subsequent diffusion of tuberculous matter is also ob- 'served on the secreting surface of serous membranes, particularly the pleura and peritoneum; and in the numerous minute cavities of the cellular tissue. The accumulation in the lacteals and lymphatics, both before and after they unite to form their respective glands, is frequently very considerable. Morbid appearances and Pathology.—Tubercles in the lungs, in their earliest stage, may present themselves in three forms: 1st. The common cheesy tubercle, in yellowish friable masses, in more or less rounded masses, or sometimes filling one or more of the bronchial tubes. 2d. Miliary tubercles; small granules, like millet seed, bluish white and semi-transparent, often found in great quantities. Some pathologists consider these as the earliest stage of the yellow cheesy tubercle; others, on the contrary, believe them to be merely some of the air-vesicles solidified by chronic inflammation. But certain it is that they have some relation to the regular tubercle, as they are found in the same person and in the same parts of the lung. 3d. Tubercular infiltration ; the morbid matter being diffused uniformly through a tissue, and not agglomerated in masses. Tubercle when deposited may lie dormant for a long time, with- out exciting any particular symptoms. In very rare and favourable cases, their softer particles may be absorbed; and nothing be left but the phosphate and carbonate of lime they contained, which may lie quietly in the lung for a whole life. But, in general, tubercle, after a time, acts as a foreign body, ex- cites inflammation and suppuration in the neighbouring sound parts, and is expelled. The first visible step is a softening, which depends most likely on the exudation of serum or pus by the surrounding lung, or by the cellular tissue, that may be entangled in the tubercle. This increases, till an abscess forms, called a vomica. The vomica enlarges till it bursts into a neighbouring bronchial tube; and then, in favourable cases, after the expulsion of the tuber- cular matter and pus by expectoration, the cavity may contract, become smooth and cartilaginous on its inner surface, and at last be obliterated, and the phthisis be cured. More generally, however, fresh tubercle is deposited, fresh vomicae PHTHISIS. 77 form, and unite, till the patient's lung is riddled with cavities, and he dies exhausted. One or more bronchial tubes are found opening into each vomica. Tubercle generally occasions some degree of pleurisy and conse- quent adhesion ; this diminishes the frequency of what, nevertheless, happens sometimes, viz., ulceration of the pleura, and escape of the matter from a vomica, and, of course, of air into the pleural cavity; constituting a kind of pneumothorax, sometimes met with in the last stages of phthisis. Ulceration of the larynx, tubercular deposits in, and ulceration of the intestinal glands, and a peculiar fatty condition of the liver, are morbid appearances often met with in the phthisical. Tubercles most frequently are found in the upper lobes, and gene- rally at first in the left lung; pneumonia in the lower lobes of the right lung. Symptoms which mark the onset of pulmonary phthisis.—Before the signs of pulmonary tubercles are observed, we may often remark first, a tendency to simple inflammation of the mucous membrane of the air-passages; secondly, one or more attacks of hsemoptysis; third^, an inflammation of the pulmonary parenchyma, or of the pleura. Among the acute exanthemata, there is one in particular after which we frequently see pulmonary phthisis makes its appearance —that is, measles. The reason of this will be readily understood if we reflect that in measles, much more than in small pox or scarla- tina, the bronchi are the seat of either an active congestion or an acute inflammation. Symptoms which appear during the progress of pulmonary phthisis.—Three stages of the affection are described by Dr. Stokes. In the first stage, the tubercle is developed, but not yet suppurated ; in the second, small ulcerations are formed; and in the third, we have vast caverns excavating great portions of the lung. " First stage.—The more prominent symptoms are those of irri- tation, cough, pain, and quickness of pulse, which in certain cases are preceded, but in the greater majority followed, by an unac- countable emaciation; the cough is almost always dry during the first few weeks, unless where the tubercle has succeeded to catarrh ; it may occur in every variety, but it is most commonly a slight, frequent, and irritating cough, referred by the patient to a tickling sensation in the trachea. The expectoration, when occurring, is scanty, and consisting of a thready, grayish, and nearly transparent mucus, occasionally dotted with blood ; a slight wheezing sometimes accompanies the cough. . " With these symptoms the patient frequently complains ot pain, which may be situated in any part of the side. In some instances, it is only felt in the lower, while in others it occupies the upper part 78 PRACTICE OF MEDICINE. of the chest, shooting from the clavicle to the subscapular regions, and often occupying the articulations of the shoulder, when it is often mistaken for rheumatism, or pain of hepatic disease; it occurs with various intensities, is generally remittent, and often relieved by anodyne, or slightly stimulating applications. This pain is com- monly accompanied by tenderness of the subclavicular region, and often with that irritation of the muscular fibres which causes their contraction on percussion ; the respiration is slightly hurried, and the first approaches of hectic can be perceived. " Second stage.—This is characterized by the establishment of decided symptoms ; the emaciation increases ; the pulse continues quick; the countenance becomes characteristic; the sweatings are more profuse ; the cough looser, the expectoration becoming puriform, tubercular, and often bloody. The digestive system now begins to suffer ; thirst, loss of appetite, and abdominal pains, torment the patient, and the first indications of the wasting and persistent diar- rhoea appear ; the patient feels he can lie better on one side than the other, and begins to feel pain in the opposite side of the chest, —a sure sign that his terrible disease has invaded the remaining lun2* " Third stage.—In this condition, the patient is often apyrexial, and the perspirations cease, particularly if the digestive system re- mains healthy ,* the pulse may be slow, though generally becoming accelerated before death; emaciation proceeds to the last extremity. The voice is sometimes lost, at others hollow and melancholy ; the cough is loose, the respiration tranquil, and expectoration easy; aphthae appear on the tongue, and spread over the cavity of the mouth; the limbs become cold; the breath gets a heavy odour, and the appetite in general fails." Life may, however, even under these circumstances, be protracted for a considerable time. Physical signs.—These may be divided into two classes ; first, those of the earlier stages, which betoken the presence of tubercles ; secondly, those of the later stages which show the existence of vomica, besides which, there are in the last stage of certain cases the signs of pneumo-thorax. Of tubercle.—When a portion of lung is solidified by the deposit of tubercle; the corresponding part of the chest will be dull on per- cussion. Vesicular breathing will be inaudible ; and instead of it the whiffling sound (called bronchial respiration, and arising from the passage of air through the bronchial tubes), will be heard if any such tube is enclosed in the solidified portion of the lung. Before the portion of lung is so filled with tubercle as to render its vesicles quite impervious, there are heard a feebleness and roughness in the respiratory murmur ; and the sound of expiration is prolonged. PHYSICAL SIGNS OF PHTHISIS. 79 Sf f?ce wlU be conveyed with unusual loudness through the solidified lung, so as to give the sensation called bronchophony. But yet auscultation is far from an infallible means of judging of the existence of tubercles in their earliest stage, and moreover, numerous tubercles, either still in a state of crudity, or already softened, may exist in the lungs ; these tubercles may give rise to all the symptoms of phthisis in the second and even in the third stage, and yet the sound yielded on percussing the parietes of the thorax may not have undergone any alteration. This perfect sono- rousness of the chest in phthisical patients is always observed, when the pulmonary parenchyma has retained its healthy state around the tubercles. Increased sonorousness may exist under three circum- stances—1st. When there exists a large tuberculous cavity, into which the air enters by one or two bronchi which open into it, and the parietes of which secrete but a little liquid, so that the cavity contains more air than pus. 2dly. Where a partial emphysema has been produced. 3dly. When a pneumo-thorax occurs as the result of the opening of a tubercular cavity into the pleura ; this occur- rence is generally manifested by the sudden accession of an acute pleurisy. When tubercular induration in the upper parts of the lung is con- siderable, it has the effect of conducting the sounds of the heart with great distinctness to the upper regions of the chest. This fact was first noticed by Dr. Townsend. Indications of vomica.—-First, supposing the vomica to be half filled with liquid, and to communicate freely with the air-tubes, there will naturally be heard on every entrance and exit of%.ir, a gurgling sound like the bursting of very large bubbles. The same may also arise from dilatation of the bronchi, or from abscess of the lung; but these conditions, and especially the last, are rare. If the vomica is empty of liquid, there will be heard a class of sounds called cavernous respirations ; consisting of certain variable sounds indicating the passing of air into and out of a cavity. If the vomica be partially full of liquid, the latter may perhaps be heard to splash, when the patient coughs. The particular resonance of the voice which constitutes pecto- riloquy, is another sign of a vomica. When a cavity of moderate size and regular form, empty, or nearly so, is in free communication with a large bronchial tube, and is very near the surface of the lung in contact with the thoracic parietes, or when the intervening struc- ture is rendered a good conductor by condensation, the voice is transmitted in the most perfect and unmodified manner, and seems to be produced in that spot of the chest, seemingly distinct from the oral voice. This is perfect pectoriloquy. If heard with the stetho- scope the sound of the voice seems to come through the tube, and enters the observer's ear louder than that which, coming from the 80 ' PRACTICE OF MEDICINE. patient's mouth, strikes the other ear ; but the utterance is never so distinct. When heard to this degree in parts where there is naturally little or no resonance of the voice, it proves beyond doubt the exist- ence of a cavity communicating with the bronchi. By imperfect pectoriloquy is meant that form in which the voice does not seem to enter the stethoscope, but only to resound at the end. This sign cannot be relied upon when heard in the sternal half of the infraclavian and mammary regions, the axillae, and in- terscapular spaces. There is yet another class of sounds to be spoken of. It was said before, that the pleura sometimes ulcerates, so that a communication is formed between a vomica and the pleural cavity. In consequence of this aperture, air passes at each inspiration into the pleural cavity, whilst the lung collapses ; and more or less liquid will also escape from the vomicae. The spot where this perforation occurs, is gene- rally, says Dr. Watson, opposite to the angle of the third or fourth rib. The indications of this state of things will be, 1st, great clear- ness on percussion; 2d, complete absence of respiratory murmur; 3d, a peculiar resonance of the voice, breathing, and cough, called by the French amphoric resonance. This is a sound of metallic character, and greatly resembles that produced by speaking or coughing over an empty barrel or copper boiler, or by blowing into an empty bottle ; 4thly, there is occasionally a tinkling sound of a metallic character, produced by the fall of a drop of liquid from the upper to the lower part of the cavity. Now, these four sounds, all indicating, as they do, the existence of a large cavity containing air and liquid, and communicating with the trachea, are generally caused by pneumo-thorax, as before said. But they may also, though very rarely, be caused by the presence of a very large vomica. In this case they will only be heard in the upper part of the chest, and instead of great clearness, there will be extreme dulness on percussion. Of the sputum,—In pulmonary consumption, there is no constant relation between the appearances of the expectorated matter and the state of the lung. In many cases, it is not at all characteristic; indeed, it may be mucous while large cavities exist in the lung, or purulent from bronchial irritation. Dr. Forbes observes—" In the earliest stage of the disease, the cough is either quite dry, or attended by a mere watery or slightly viscid, frothy, and colourless fluid: this, on the approach of the second stage, gradually changes into an opaque, greenish, thicker fluid, intermixed with small lines or fine streaks, of a yellow colour. At this period, also, the sputa are in- termixed with small specks of a dead white or slightly yellow colour, varying from the size of a pin's head to that of a grain of rice, and which have been compared by Bayle to this grain when boiled. These have been noticed by many writers, from Hippocrates down- PHTHISIS. 81 wards. After the complete evacuation of the tubercles, the expecto- ration puts on various forms of purulency, but frequently assumes one particular character, which has always appeared pathognomonic of phthisis, although the more accurate and extensive observation of modern pathologists has proved the same to exist occasionally in simple catarrh. The expectoration alluded to, consists of a series of globular masses, of a whitish-yellow colour, with a rugged woolly surface, and somewhat like little rolled balls of cotton or wool. These commonly, but not always, sink in water. This kind of ex- pectoration has appeared most common in young subjects, of a strongly-marked strumous habit, and in whom the disease was hereditary. At other times, in the cases in which these globular masses are observed, and also in those in which they have not appeared, the expectoration puts on the common characters of the pus of an abscess, constituting an uniform, smooth, coherent, or diffluent mass, of a greenish, or rather grayish hue, with an occa- sional tinge of red, (from intermixed blood,) and sometimes more or less foetid." Dr. Stokes considers the expectoration, in which the globular ragged masses here described are expelled, more pecu- liarly allied to phthisis than any other. He also adds, " I do not recollect a single case in which I observed this character, that did not turn out to be phthisis." Treatment.—In the treatment of consumption there are two grand rules—to diminish irritation or inflammation in the chest; and to support the general health and strength. Preventive treatment.—When persons are known to be disposed to phthisis, they should most carefully avoid every imaginable source of irritation in the chest; for a bad catarrh or pleurisy is exceed- ingly apt to bring consumption after it. A warm sheltered residence ; exercise in the open air, especially on horseback; and a diet calcu- lated to keep up the strength without producing feverishness, are very important. A prolonged course of iron is often of service. If the complaint has actually appeared, and is complicated with bronchitis, the patient must be confined to his room, and all exertion of the lung be prohibited. If he be of a robust habit, and has a full pulse, a single abstraction of blood from the arm is indicated; the bowels must be kept gently open, and the diet consist of milk, fari- naceous substances, and light vegetables. But it is on local deple- tion and counter-irritation we must chiefly rely. Leeches should be frequently applied to the sub-clavicular and axillary regions of the affected side ; the number used on each occasion should be small, and they ought to be applied alternately in each region. After this treatment has been persisted in for a short time, blisters and other derivatives are to be frequently applied under the clavicles and over the scapular ridge. Issues may also be established. During this treatment the cough is to be allayed by mild sedatives. In fine 82 PRACTICE OF MEDICINE. weather, horse exercise should be taken, and the Invalid, to promote his recovery, should remove to a milder climate. In cases where there is laryngeal or tracheal irritation, leeches should be applied over the part most affected, and a mild mercurial treatment had recourse to. Calomel and opium, or blue pill with opium, should be given so as to slightly affect the mouth. Blisters may be then applied to the nape of the neck and to the sternum. An individual in perfect health, or labouring perhaps under a slight cold, is attacked with copious haemoptysis, accompanied with considerable excitement of the heart. The hemorrhage having sub- sided, we find the respiration hurried and the pulse quick ; the cough % continues, and there may be local pain. The upper portion of one side sounds dull, and here the respiration is decidedly feeble, although generally with little crepitus. In these cases, the tubercular deve- lopment is very rapid, no interval occurring from the first invasion. In a considerable number of patients, it is in this way phthisis makes its outbreak. It is not uncommon, however, to see persons whose health is perfectly re-established after a first haemoptysis, so that it does not appear to be connected with anything serious. At the end of a longer or shorter time, a second haemoptysis supervenes, then a third, and again they are restored to health; finally, they have a new attack of spitting of blood, and this time their health does not return; they cough, and have oppressed breathing; and ail the symptoms of pulmonary consumption develope themselves. The treatment of this form consists in subduing the haemoptysis by proper means, and then paying assiduous attention to the condi- tion of the respiratory apparatus, especially the upper lobes of the lungs. Dr. Cheyne strongly recommends bleeding in the haemoptysical variety of consumption; and in bronchial hemorrhage, threatening consumption, he advises small bleedings at intervals of a week. He considers bleeding to be justified during haemoptysis, or any symp- tom or sign of inflammation. Laennec observes,—" I shall content myself with asserting briefly, in this place, that bleeding can neither prevent the formation of tubercles nor cure them when formed. It ought never to be employed in the treatment of consumption, except to remove inflammation or active determination of blood, with which the djsease may be complicated; beyond this, its operation can only tend to an useless loss of strength." Tartarized antimony, in nau- seating doses, is a useful remedy. Dr. Cheyne combines a quarter of a grain of the antimony with fifteen grains of nitre, and places much confidence in the combination. When phthisis is complicated with pneumonia, we must have re- course to frequent local depletions by leeches, continued counter-irri- tation, the use of setons, and a mild course of mercury. The idea of arresting the progress of scrofulous ulceration of the lung by PHTHISIS. 83 mercury occurred about the same time, and without any mutual communication, to Drs. Stokes, Graves, and Marsh. Dr. Stokes observes—"For the last few years, these gentlemen and I have treated with mercury several cases of incipient pulmonary disease, which in all probability would have ended in phthisis. But a great number of observations must still be made in order to establish the actual value of this practice, and it must be recollected that, in the cases thus treated, other and active means were employed to remove the local disease." When a tubercular excavation is formed, our art avails us but little indeed; in fact, all we can do is to palliate the concomitant symptoms. True it is, that in many cases of this kind, judicious treatment may prolong life for many years; in the great majority of cases, however, after a large cavity is formed, a fatal issue soon succeeds. In some cases, a healthy action is set up in the cavern, and the patient is saved, but, unfortunately, such an occurrence is exceedingly rare. The patient's best chance, under such circum- stances, is afforded by the use of setons, and travelling. The paUiative treatment must be directed to the more distressing symptoms, such as the hectic fever, cough, pain, diarrhoea, die. Hectic fever in this disease must be regarded more as a measure of the irritation than of the suppuration of the lung; it is often alle- viated by local depletions, by the occurrence of an haemoptysis, or by regulating the diet. The patient should stay as little as possible in bed, and should sit during the day in a large airy apartment; his chest should be sponged with tepid vinegar and water; frequent changes of linen are to be provided; and the state of the digestive system should demand our attention. Sulphate of quinine has been recommended, especially when the fever assumes an intermittent character. The pains are best relieved by leeches, blisters, and anodyne lini- ments. For quieting the cough, all the different forms of demulcents and narcotics have been employed; of the latter, the best are, the different preparations of opium, henbane, conium, and belladonna, and especially the old paregoric. When the cough resists these means, a few leeches may be applied to the trachea; in some chronic cases, where even these means fail, inhalations of the vapour of water, containing a narcotic extract, are frequently useful." The diarrhoea must be looked upon as proceeding from an enteritis, and it is best treated by attending carefully to the regimen; in the early stages, it can generally be controlled by the ordinary cretaceous and opiate medicines, but these soon lose their effect. In the more advanced stages, the metallic astringents, with opium, and anodyne enemata, are employed; in cases where even these fail, decided benefit is produced by the application of a blister to the abdomen. 81 PRACTICE OF MEDICINE. DISEASES OF THE PLEURA. pleuritis (Inflammation of the Pleura). It is more usual to meet pleuritis alone, without being complicated with pneumonia, than to meet pneumonia without pleuritis. The most striking difference existing between cases of pleuritis consists in the presence or absence of effusion. The form occurring without liquid effusion is rarely severe, unless it is very extensive; it is the dry pleuritis of authors. Symptoms.—Fever, acute pain in the side, hurried and interrupted respiration, dry cough, and a hard resisting pulse, are the marked symptoms of this disease in its early stages. The pain is often in- tense, all motions of the thorax increase it, and the affected side is fixed and motionless. The patient complains of intense heat within the chest, and there is occasionally an extreme tenderness of the in- teguments. The pain is usually felt below the breast; but it may be felt in the shoulder, the axilla, the lumbar region, or lower portion of the right hypochondrium. Sometimes the pain is wandering and fugitive, and it is not till the lapse of some days that it becomes fixed and continued. In this case it is often taken for a mere rheumatic pain. The pain, after continuing for forty-eight or sixty hours, in general diminishes or ceases altogether; and this coincides with an effusion. But in some severe cases the pain continues, with slight remissions, long after copious effusion has occurred, or even remains unabated up to the period of death. Sometimes, after having disap- peared, it shows itself anew with great violence; this is a sure sign of the return of the inflammation. During the first stage, the patient seldom lies on the affected side, in consequence of the position causing increase of pain. The rule generally is, that in the first stage he lies on the healthy, in the second, on the diseased side. When the diaphragmatic pleura is affected, there is generally orthop- noea; as might be expected, the respiration is more hurried and dif- ficult during the persistence of the pain. This disease, when established, runs one of two courses. The effusion may increase rapidly, and between the first attack and fatal termination no interval of ease is afforded the patient; or more fre- quently, as in other visceral irritations, a change of symptoms occurs, characterized by diminished suffering, and a transition from the in- flammatory to a hectic, or nearly apyrexial, condition. The symp- toms vary, according as the effusion is on the increase or stationary. In the first case, we observe the cough continuing, with increase of dyspnoea on motion; the patient emaciates; the countenance becomes pale, or sallow, and contracted; palpitations are often complained of; and the feet or ankles become slightly swollen. In this condition, the side will be found extensively dull ,* the mediastinum displaced; PLEURISY. 85 and in all probability, protrusion of the intercostal spaces will be found to exist. But when the effusion is not very extensive, nor on the increase, it may coincide with a constitutional state but little re- moved from health. The cough never occurs in fits; it is small, as if cut short, and frequent. It may be even entirely wanting, though the inflammation is intense and a considerable effusion exists in the pleura. In pure pleurisy there is little or no expectoration; but if it be complicated with pneumonia, there will be the characteristic sputa of that affec- tion. When the pleura covering the diaphragm.is inflamed, the distinc- tive symptoms are said to be,—1st, a more or less acute pain along the cartilaginous edge of the false ribs, generally extending into the hypochondria, and sometimes even to the flank ; 2dly, complete im- mobility of the diaphragm in inspiration; 3dly, a very remarkable anxiety, expressed particularly by the sudden alteration of the fea- tures; 4thly, an almost constant orthopnoea, with inclination of the trunk forwards. Patients in this situation dread the slightest motion, as being calculated to awaken the most violent pain; this symptom, which is sometimes absent, is considered by M. Andral to be one of the most characteristic. The less constant symptoms are,—hiccup, nausea, and vomiting; convulsive movements of the muscles of the face, and particularly of those of the lips; delirium, which supervenes either in a continued or intermittent form. Finally, when the dia- phragmatic pleura of the right side is the seat of inflammation, the liver may be sympathetically irritated, and jaundice develope itself. The coexistence of this jaundice with a more or less acute pain in the right hypochondrium may induce one to believe in the presence of hepatitis. Physical signs.—The earliest sign of pleurisy, occurring during the first stage, when the membrane is slightly roughened by lymph, is a rubbing sound heard during the movements of inspiration, and arising naturally from the friction of the roughened surfaces against each other. This sound is often perceptible to the patient himself. But it ceases as soon as the opposing costal and pulmonary mem- branes are separated by liquid effusion. When effusion has occurred, it is denoted by dulness on percus- sion of the portion of the chest corresponding to the effusion. This dulness, supervening much more rapidly than in ordinary pneumonia, and unaccompanied or preceded by crepitation, generally points out pleuritic effusion. The resonance of the chest is commonly dimi- nished first in the inferior dorsal and lateral regions, corresponding to the base of the lung. As the effusion increases, the dulness of sound gradually extends upwards, and becomes more pronounced. Sometimes the transition from the dull to the healthy sounding parts is so ahrupt that a horizontal line will exactly divide theni, and this, 8 86 PRACTICE OF MEDICINE. when well marked, is a very characteristic sign. A change of posi- tion will also alter this line in a manner quite distinctive, and, what can happen only in liquid effusion,—the dull sound always accom- panies the liquid as it gravitates to the lowest parts. When the effusion is copious, the entire side, from the clavicle down, may be dull. M. Reynaud has pointed out another effect of effusion, which may furnish a diagnostic sign, in its intercepting the slight fremitus or vibration which accompanies the voice in all parts of the chest. The hand applied to a healthy chest readily feels this general vibration; but a layer of liquid, interposed between the lung and the chest, acts as a damper, and prevents the transmission of the vibration. The respiration is usually heard becoming bronchial, as the effu- sion increases up to a certain point; but then, as the bronchi them- selves become pressed by further increase, it becomes faint, and at last ceases. The voice furnishes a valuable sign. If it traverses a thin layer of liquid interposed between the lung and the ribs, it throws it into vibrations, and is itself modified, and rendered sharp and tremulous, resembling the bleating of a goat or lamb. This modification of the voice M. Laennec therefore called agophony. Its most dis- tinctive mark is its tremulous or subsultory character. This is re- garded as a pathognomonic sign of effusion into the pleura, as it can only be produced by this cause. When the effusion is very considerable from the commencement, or becomes so during the progress of the disease, the aegophony dis- appears, and the respiration is no longer heard, unless where old adhesions retain some part of the lung near the ribs, and prevent it from being forced back by the effusion. The intercostal spaces be- come enlarged and elevated ; the affected side is more expanded than the sound one, but is no longer influenced by respiration, its immo- bility forming a striking contrast with the great mobility of the other, in which the respiratory murmur is increased in intensity, so much so as to assume the " puerile" character. Now, as the sound of this respiration is sometimes heard on the diseased side, through the liquid, it will be necessary to guard against the error of mistaking it for a faint respiration on that side. Another effect of a large collection of liquid in the chest is to dis- place the viscera in a remarkable manner. Thus an effusion on the left side will often displace the heart, and make it pulsate under, or even on the right of, the sternum. The liver will be pushed down- wards by a large collection of fluid on the right side. These signs are important, because they distinguish this disease from hepatiza- tion of the lung, which is liable to be mistaken for pleuritic effusion, but which produces no such displacements. A useful criterion of this kind, drawn from percussion on the sternum, has been pointed PLEURISY. 87 out by Dr. Stokes; a copious effusion on one side will displace the sternal mediastinum, and render the whole sternum dull on percus- sion. A hepatized lung, on the other hand, will not encroach on the mediastinum, but, lying under one half of the sternum, will render that half dull, whilst the other half will remain resonant as usual. The absorption of the fluid is indicated by the gradual return of the respiratory murmur : first, in those points where it had persisted latest; afterwards in others; and last of all in the parts where the accumulation had begun. It is very faint at first, and becomes stronger in time; but, generally, a very long period is required to bring it on a par with that of the healthy side. In other instances, however, the absorption is nearly as rapid as the effusion, and in these cases a returning aegophony (agophonia redux) also announces the diminution. As the absorption proceeds, there is sometimes heard a sound of friction, like that which accompanies the dry stage of pleurisy. This is produced by the approximation and habitual friction of the pleurae, the surfaces of which are covered with false membranes. In double pleuritis, where both sides are simultaneously affected, the indications given by percussion are less certain; for both sides sounding equally bad, the standard of comparison is lost. The upper parts of the chest, however, remaining sonorous, with the exact de- marcation between these and the line of effusion, will still charac- terize the disease. Complications.—Acute pleurisy may be complicated with pneu- monia, bronchitis, pericarditis, pneumo-thorax, or peritonitis. When pleuritis is not very acute, and the effusion is not extensive, it may be mistaken for phthisis, debility, remittent fever, liver disease, &c. Morbid appearances.—The pleura, when attacked, presents—1st, alterations of tissue ; 2d, alterations of secretion. 1st. Alterations of tissue.—When a person labouring under a slight pleuritis, dies of another disease, the pleura will be found to be red to a greater or less extent; but a careful examination soon shows that this redness is solely owing to the greater or less injec- tion of the vessels which pass through the sub-serous cellular tissue ; the membrane itself has retained its transparence, and no red vessel ramifies through it. Should the inflammation be more intense, the serous membrane itself then presents vessels, in greater or less number, filled with blood ; sometimes these vessels, not being very numerous, leave large intervals between them, and they scarcely disturb the transparency of the membrane ; sometimes their number is greater, they become agglomerated, and anastomose in various ways, so as to produce mere points, long streaks, large patches, and finally, a uniform red tint, to a greater or lesser extent; this last 88 PRACTICE OF MEDICINE. case is very rare. These different shades of inflammatory redness must not be confounded with the product of simple ecchymosis; sometimes after chronic diseases, or certain severe fevers, effusions of blood, merely passive, take place on the external surface of the pleura and peritoneum, in the same manner as they are formed under the mucous membranes and under the skin. In the majority of cases, the pleura, red or white, opaque or transparent, is not increased in thickness ; we very rarely find it really thickened. 2d. Alterations of secretion.—The alterations of secretion pre- sented by the inflamed pleura are more numerous and more varied than its alterations of tissue. The liquid exhaled by the inflamed pleura presents a multitude of varieties ; in some cases, it consists of colourless or lemon-coloured serum, perfectly limpid and trans- parent ; in more common instances, however, albuminous flocculi are observed to float in the limpid fluid. In other persons, there is found a liquid decidedly turbid, of a yellow, green, brown, or gray- ish colour, which is sometimes very thick, and as it were muddy. Finally, after several immediate states, this liquid presents itself under the form of real pus, such as it exists in an abscess. In some rare cases, the pleura is filled with a peculiar liquid, which is neither serum nor pus ; this liquid, usually deposited in compartments formed by false membranes, resembles either animal jelly half liquefied, or honey. Blood may also be effused into the inflamed pleura ; but sometimes the red tinge is so slight that it is evidently merely serum, mixed with colouring matter, which constitutes the effusion. In other cases, on the contrary, the pleura is found filled with a liquid altogether resembling the blood which comes from a vein. It cannot be doubted in this case but that natural blood was really exhaled by this membrane.* The different liquids effused into the pleura are always inodorous, unless a solution of continuity of the thoracic parietes, or a pulmonary fistula, establishes a communication between the cavity of the pleura and the exterior. Aeriform fluids sometimes exist in the pleural cavity, either alone, or, more frequently, mixed with a liquid. Their presence is principally ascertained—1st, by the hissing noise produced at the moment an incision is made into the chest ; 2dly, by the frothy state of the liquid ; 3dly, by opening the thorax in water. In some cir- cumstances, these gases are evidently the product of an exhalation from the membrane ; but most usually they are found in the pleura only when the latter communicates more or less immediately with the bronchi. A portion of the liquid exhaled by the pleura naturally tends to concrete and pass into a solid state. Hence the false membranes, * Besides, in the case of hemorrhagic pleurisy (hfemothorax), blood may be effused into the sac of the pleura from a wound, by the rupture of an aneurism, by pulmonary apoplexy, or by a passive transudation. PLEURISY. 89 which present so many varieties with respect to their organization, form, colour, extent, consistence, and thickness. Gangrene sometimes takes place in the pleura, presenting itself in the form of circumscribed spots of a dark-brown or greenish colour, penetrating the substance of the membrane, and extending in some cases to the sub-pieural cellular tissue, or to the surface of the adja- cent parts, which become infiltrated with a serous fluid. Treatment.—The treatment of pleuritis rests on the same basis as that of peripneumonia. When the patient is of a robust habit, and the inflammation runs high, free bloodletting must be employed. As soon as the pain appears, and there is as yet no effusion, leeches or cups applied over the painful side often remove the disease. This effect is obtained with more certainty if general bloodletting be premised. The combination of both is extremely useful. Large emollient cataplasms should be applied to the affected side. After a full bloodletting, a brisk cathartic may be given, so as to act freely on the bowels, and also produce derivative effects. In most cases, it will now be advisable to bring the system under the influence of mercury; and this may be effected in various ways. Some prac- titioners give blue pill and opium, others prefer calomel and opium: and again, some rely on mercurial inunction. Three grains of calomel, half a grain of opium, and a quarter of a grain of tartar emetic, made into a pill, to be taken every third or fourth hour; or the same proportions of calomel and opium, and one grain of digi- talis, instead of the tartar emetic; the pill to be taken in the same way. As long as the fever is high, we should not have recourse to revulsives ; but when it is lowered, and no signs of violent reaction are observed, a large blister should be applied to the affected side. The violent symptoms having been subdued, the effusion may be rapidly absorbed, and the sonoriety of the chest be restored. But in most cases the constitutional symptoms and local sufferings only are removed, while the effusion continues stationary, or perhaps even on the increase. It is at this period that, by small local bleedings, repeated counter-irritation, diuretics, and diaphoretics, we can gene- rally succeed in effecting a cure. In chronic pleurisy there is but little constitutional distress : yet the patient emaciates rapidly, the pulse is quick, and the breathing hurried. On examining the chest, one side is found dull and en- larged, the heart is displaced, and the respiration is puerile in the opposite lung. In such cases, the patient must be confined to bed, his bowels be freely acted upon, and his diet consist of farinaceous substances. A few leeches are to be occasionally applied to the affected side, and mild mercurials are to be exhibited, so as to induce slight ptyalism. Counter-irritants are now to be employed. M. Andral recommends, " that the blister to the chest should be replaced either by a seton, 8* 90 PRACTICE OF MEDICINE. the suppuration of which should be kept up for a long time, or by a moxa. As all febrile symptoms subside, we may improve the patient's diet by allowing light broths, fresh eggs, &c. ; diuretics should also be now had recourse to. In this stage, Dr. Stokes places great reliance on the internal and external use of iodine. When the absorption of the effused fluid has been effected, change of air should be recommended. Paracentesis.—If effusion into the pleura is so extensive as to en- danger the patient's life from the difficulty of breathing it occasions; or if his health and strength are giving way, it will be proper to make an aperture for the escape of the liquid by paracentesis. DISEASES OF THE HEART AND ITS MEMBRANES. Auscultation of the heart in health.—On applying the ear to the region of the heart in a healthy person, a sound is heard at each pulsation, followed by an interval of silence. This sound is double, consisting of a dull slow sound, immediately followed by a short quick one. The first sound is produced by the contraction (systole) of the ventricles, and is synchronous with the pulse of arteries near the heart. The second, or short one, accompanies the dilatation (diastole) of the ventricles. This second sound is said to be pro- duced by the shock caused by the tightening of the semilunar valves at the ventricular diastole. Laennec rates the relative, duration of these sounds to be as follows—The first sound, two-fourths ; the second sound, one-fourth, or a little more; the interval of silence, one-fourth, or a little less. These sounds are naturally most dis- tinct in the space between the cartilages of the fourth and seventh ribs of the left side, and on the lower part of the sternum; the for- mer part corresponding with the left, and the latter with the right side of the heart. Simultaneously with the first, or systolic sound, an impulse or shock is communicated to the stethoscope. It is most perceptible at and between the cartilages of the fifth and sixth ribs, where it may be felt by the hand; but the stethoscope commonly renders it sensible in lean persons over the whole praecordia. Con- siderable variety in the force of the impulse may occur from various extraneous causes acting on a healthy heart. Thus, the pressure of tumours behind it, flatulent distension of the stomach, great enlarge- ment of the liver and spleen, contraction of the chest from pleurisy, deformity of the spine, and similar causes, which have the effect of pushing the heart into closer contact with the anterior walls of the chest, will make its impulse against them stronger. Again, exten- sive effusions of air or liquid in the left pleura may displace the heart, so that its impulse can only be felt under or even to the right of the sternum. The action of the heart is naturally accelerated by exercise, stimulating drinks, heat, &c.; and this excited action is attended with an increased impulse and with louder sounds. DISEASES OF THE HEART. 91 Exact position of the heart.—" A line," says Dr. Hope, " drawn from the inferior margins of the third ribs, across the sternum, passes over the pulmonic valves a little to the left of the mesial line, and those of the aorta are behind them, but almost half an inch lower down. A vertical line coinciding with the left margin of the ster- num has about one-third of the heart, consisting of the upper portion of the right ventricle on the right, and two-thirds, composed of the lower portion of the right ventricle, and the whole of the left, on the left. The apex beats between the cartilages of the fifth and sixth left ribs, at a point about two inches below the nipple, and an inch on its sternal side." " Take the fifth costal cartilage on the leftside," says Dr. Latham, " and let a point midway between its junction with the sternum and its junction with the rib be the centre of a circle, two inches in diameter. This circle will, as nearly as possible, define the space of the praecordial region, which is naturally less resonant than the rest." Relation of the sounds to the state of the heart.—" A clearer sound," says Dr. Latham, " proceeds from a thin heart; and a duller sound from a thick heart; a sound of greater extent from a large heart, and a sound of less extent from a small heart. A more forcible impulse is given by a thick heart, and a feeble impulse by a thin one; the impulse is conveyed to a longer distance from a large heart, and to a shorter distance from a small heart."* " Sounds and impulses," continues Dr. Latham, "are the inter- preters of each other. The true meaning of the sound is tested by the impulse, and the true meaning of the impulse is tested by the sound. Thus, from a clearer sound, we argue only the probability of an attenuated heart, but we argue its certainty from a clearer sound, joined with a weaker impulse. From a stronger impulse we argue only the probability of an hypertrophied heart; but we argue its certainty from a stronger impulse joined with a diminished sound. When impulse and sound increase together, there is probably no hypertrophy, but the heart is only acting more forcibly from pure excess of nervous energy. When impulse and sound decrease together, there is probabfy no atrophy, but the heart is only acting more feebly from pure defect of nervous energy. When the sounds and impulse of the heart are both perceived beyond the praecordial region, they give notice (generally speaking) of dilatation of one or other of the ventricles. If, under these circumstances, sound pre- dominates over impulse, then with dilatation there is either attenua- tion, or somewhat less than a proportionate increase of its muscular substance. If impulse predominate over sound, with dilatation, there is either hypertrophy, or somewhat more than a proportionate increase of its muscular substance." * Lectures on Diseases of the Heart, vol. i. p. 18. 92 PRACTICE OF MEDICINE. Morbid sounds of the heart.—Unnatural sounds may be called murmurs; and they are of two kinds; the exocardial, produced external to the heart, that is to say, in the pericardium ; and the endocardial, produced in the heart itself. The endocardial murmurs have a blowing character, the exocar- dial give the idea of friction. " The endocardial murmur," says Dr. Latham, " is not only dif- ferent in kind from the natural sounds of the heart, but it takes their place, and is heard in their stead. It comes exactly where the first sound, or where the second, or where both sounds should be. It keeps strict time with the systole or with the diastole of the heart, or with both. " The exocardial murmur, too, is different in kind from the natural sounds of the heart. But it does not take the place of them; it is not heard in their stead. In proportion as it is louder, it obscures or overpowers the natural sounds. But the natural sounds are still apt to reach the ear through the exocardial murmur ; and when they do not reach the ear, it is because they are imperceptible under the circumstances, not because they cease to exist." Endocardial murmurs (i. e., murmurs within the heart) are caused by peculiar vibrations of the columns of blood which pass through the heart; and these vibrations may depend,—1st, upon an unnatu- rally thin quality, and deficient quantity of the blood, as in the mur- murs heard after hemorrhage; 2ndly, on disease of the valvular orifices of the heart, offering obstacles to the passage of the blood. A murmur caused by the passage of the blood through a diseased valvular orifice may be direct or regurgitant; that is, may be pro- duced during the flow of the blood along its natural channel, if con- tracted ; or during its regurgitation, which will happen if the diseased valve is unable to shut properly. In order to ascertain which valve is diseased, notice must be taken of the time at which the murmur is heard;—of the part of the praecordial space where it is heard most loudly ; and of the direction in which it is conveyed the farthest. Valvular disease of the right side of the heart is very rare indeed; and the diagnosis of it from disease on the left side is a matter of some uncertainty. The following observations, therefore, chiefly apply to the aortic and mitral valves. When a single endocardial murmur is heard during the systole of the heart, its seat is most probably the aortic valve, which is thick- ened, so as to impede the blood in its exit from the heart and to throw it into vibration. When a single murmur is heard, coincident with the heart's diastole, this also may be produced by a diseased aortic valve, if so diseased as to be incapable of closing, and permit the blood to regur- gitate into the ventricle. DISEASES OF THE HEART. 93 When there is a double murmur, both systolic and diastolic; these also may arise from disease of the aortic orifice alone; the former being a murmur caused by the flow of blood from the heart; the latter by its regurgitation. Again, when there is a single systolic murmur, it may be caused by disease of the mitral valve, permitting the blood to regurgitate into the left auricle from the ventricle, when the latter contracts. The spot where all endocardial murmurs are heard most distinctly, is immediately over the valve which originates them. And the space under which the cardiac valves lie, may be said to be comprised between the lower margin of the '3rd left costal cartilage, and the lower margin of the \th; extending inwards to the middle of the sternum. Here it is that almost all murmurs are heard most clearly. The method of distinguishing them from each other is based on the fact that the murmur will be conveyed along the direction of the column of fluid whose vibration causes it. Thus if a murmur be seated at the aortic valve, it will be heard most clearly over the left half of the sternum, between the 3rd and 4th costal cartilages. But the sound will also be conveyed with tolerable clearness in the course of the aorta and its branches ; that is to say, upwards and between the second and third ribs of the right side—perhaps it will also be heard in the carotids. If the disease (which is very rare) were seated in the pulmonic valves, the murmur would follow the course of the pulmonary artery, upwards between the 2nd and 3rd ribs of the left side. If it were seated in the mitral valve, the murmur would be lost if the stethoscope were moved upwards; but would still be heard dis- tinctly if it were moved downwards towards the apex of the heart. If the murmur is heard plainly in both directions, then both aortic and mitral valves are probably diseased. There are some few circumstances which must be taken into account in estimating the value of endocardial murmurs as signs of valvular disease. For first, they are sometimes absent altogether when the patient is in repose ; although they may be excited by causing the patient to move about, so that the heart may beat more forcibly. Secondly, the loudness of the sound is by no means a measure of the extent of the disease ; for in long standing cases, where a diseased orifice has become very contracted, the sound often becomes very feeble indeed. Thirdly, very violent action of the heart alone, without valvular disease, may occasion a murmur; this often happens to children ; seldom to adults. Fourthly, if the heart is embarrassed by deformity of the chest, or if it is too much pressed upon by the stethoscope, murmurs may be created. 94 PRACTICE OF MEDICINE. Fifthly, in cases of anaemia, after hemorrhages, or when the blood has become pale and watery through ill health, there will be a loud systolic murmur, conveyed along all the arteries; and also often accompanied by a continuous humming noise heard in the veins, especially the internal jugular. This state is to be remedied by nourishing food and tonics. Lastly, the sounds of respiration may imitate cardiac murnnurs so closely, that it may be necessary to make the patient hold his breath, to distinguish their real source. INFLAMMATION OF THE HEART; ENDOCARDITIS, AND PERICARDITIS. These maladies are generally found to be concomitants of rheu- matism. No doubt they do often occur from other causes; and they often occur, too in slight degrees without being complained of or suspected. Symptoms.—The symptoms of endocarditis are, 1st, pain in the heart; 2nd, disordered action of the heart which may be violent, or else feeble, irregular, and intermitting; 3rdly, some dyspnoea ; and, lastly, abnormal sounds; beginning with a roughness and after- wards, a murmur, arising from thickening of, or deposit on some of the valves. One or more of these symptoms, occurring in the course of acute rheumatism, may be considered a sign of endocarditis. The pain is sometimes so slight that the patient scarcely notices it, if at all; but in dangerous cases is an extreme anguish, liable to be followed by orthopnoea, restlessness, delirium and death. The murmur sometimes is heard at the very beginning, whilst there is no other symptom or complaint about the heart; sometimes it does not come on till the middle or end of the disease. The symptoms of pericarditis are, 1st, pain in the region of the heart, augmented by pressure and by a deep inspiration; 2ndly, irregular or violent action of the heart; 3rdly, difficulty of breathing; and, lastly, the physical signs—an exocardial murmur, caused by the rubbing of the roughened and inflamed serous surfaces of the heart and pericardium against each other; dulness of percussion over an unusually large space of the praecordial region; and some- times a distinct undulation visible between the cartilages of the 2nd, 3rd, and 4th left ribs. The exocardial murmur resembles the rub- bing of two rough surfaces against each other—it is called by Dr. Watson the to and fro sound; which name well expresses its charac- ter. The dulness on percussion, and the undulation, arise from the presence of fluid effusion in the pericardium. The friction sound ceases of course if the heart and pericardium become adherent together. Inflammation of the heart is sometimes attended with so much nervous and cerebral irritation, as to mislead the practitioner, unless ATROPHY OF THE HEART. 95 very cautious, and induce him to look to the head instead of the praecordia. Pericarditis, like endocarditis, may come on in the course of acute rheumatism, without being denoted by pain, or any symptom sensi- ble to the patient. The region of the heart should therefore be fre- quently scrutinized by the stethoscope in rheumatism, and proper measures be adopted as soon as there is the first indication of murmur. Frequency of the disease.—Dr. Latham shows that the heart is much more frequently inflamed in acute rheumatism than is often imagined. Out of 136 cases of that disease, the heart was inflamed in 90, about two-thirds; of these 90 cases there were 63 of endo- carditis ; 7 of pericarditis; 11 of endocarditis and pericarditis com- bined, and 9 in which the seat was doubtful. Out of this number there were but three deaths; but yet in the great majority of those who recovered, there was some deviation from the healthy state remaining, which, no doubt, laid the founda- tion of subsequent chronic disease of the valves. Morbid appearances in acute pericarditis.—The membrane in- tensely red ; perhaps ecchymosed, its cavity containing serum with flakes of lymph; and both the inside of the pericardium and the outside of the heart covered with a layer of lymph of variable thick- ness ; sometimes the opposing surfaces adhere; sometimes they are free, and the lymph is flocculent, or corrugated, making the heart's surface look like tripe. Of endocarditis.—The affected portion of the valves is generally found thickened, pink, and fringed with deposits of lymph. Treatment.—The treatment of inflammation of the heart is the same as that of acute rheumatism, only modified to meet the emer- gency. Bleeding must be employed, if the general state of strength and excitement show it to be demanded, and that it can be borne; cupping between the shoulders, or leeches to the pracordia, are in- dispensable. Full doses of opium, at bedtime, to ensure sleep; and calomel, with smaller doses of opium, in such quantities as the seve- rity of the disease may demand during the day; purgatives, so as to clear out the abdominal viscera, and colchicum are the main remedies. And it should be observed that it will be right to leech or cup the instant any abnormal sound is heard in the region of the heart, although no symptom of uneasiness there may be complained of by the patient. When the acute state has subsided, blisters will hasten the absorption of effusion or deposit of lymph. HYPERTROPHY, DILATATION, AND ATROPHY OF THE HEART, AND ANGINA PECTORIS. Hypertrophy signifies a preternatural increase of the muscular substance of the heart; and there are generally said to be three 96 PRACTICE OF MEDICINE. varieties of it, viz.,—Simple hypertrophy, in which the muscular parietes are thickened, but the cavities unaltered in size; hypertrophy, with dilatation, or eccentric hypertrophy, in which there is also an increase of the capacity of the cavities ; and concentric hypertrophy, in which the substance of the heart is thickened, and its cavities diminished. Modern pathologists have decided that the concentric hypertrophy is a pathological mistake; that, in fact, it depends on the state of contraction in which the heart happens to be left at the moment of death; and that the so-called concentric hypertrophy often vanishes as the rigor mortis goes off, and the heart dilates and becomes flabby. Hypertrophy of the left ventricle may be caused first, by circum- stances that excite the action of the organ to a great degree; such as high living, violent exercise, and mental excitement; and, secondly, by obstructions of the mouth of the aorta. These, of course, require greater muscular force to be exerted in order that the blood may be propelled in the same time through a small aperture as through one of the natural size. Hypertrophy with dilatation is much more common under the last mentioned circumstances, than simple hypertrophy; for the same cause that obstructs the current of blood, will also give the cavity a tendency to dilate, especially if the patient has but little tone and vigour in the muscular system. Dilatation without hypertrophy.—This is a kind of muscular atrophy, and happens to flabby cachectic patients, in whom the heart gives way and stretches in its efforts to carry on the circulation. Hypertrophy of the left ventricle, without valvular disease, causes the patient to feel an unnatural beating; the pulse is full and strong, the face florid, and there is a disposition to hemorrhage and inflam- mation. On auscultation, the impulse is felt to be strong and widely diffused; the systolic sound less loud and clear than natural. Treatment.—Spare, unstimulating diet, repose of body and mind, small bleedings and purgatives. Hypertrophy of the left ventricle, with valvular disease.—This is much more common than the last variety ; its symptoms are much the same, except that if there is much obstruction of the aortic valves, the pulse cannot be strong or full: if the obstruction is very great, the pulse will be feeble or intermitting. The valvular obstruction will cause a blowing murmur. Hypertrophy with dilatation of the left ventricle from valvular disease, is, as was before said, much more common than simple hypertrophy; and the greater the dilatation, the feebler will be the impulse and clearer the sound. A great amount of dilatation, like great obstruction of the aortic valves, causes the pulse to be feeble and intermittent; the extremities cold, and a tendency to faintness. Hypertrophy of the right ventricle with dilatation is often a con- ANGINA PECTORIS. 97 sequence of the obstruction the blood meets with from pulmonary disease. Consequences of diseased heart.—From the obstruction the circu- lation meets with, various organs become congested, and ultimately diseased, whilst the serum is apt to be effused, constituting various forms of dropsy. Great dyspnoea, with more or less bronchitis, and finally hydrothorax; congestion of the liver, and abdominal viscera, or of the kidneys ; blueness of the lips, and ascites and anasarca are the general precursors of death. Sometimes the heart becomes so thin and soft that it bursts or ulcerates at one point, causing sudden death from hemorrhage into the pericardium. Treatment.—The treatment of permanently diseased heart, must be palliative; whatever symptoms happen to be urgent must be relieved. The general rule is, that all violent exertion and mental anxiety, especially running up stairs, and fits of anger; all intempe- rance and unwholesome food must be shunned. Unwholesome food is very liable to cause distress, by distending the greater end of the stomach, and pressing it up against the heart. If there is much palpitation, pain, and dyspnoea, with blood to spare, leeches or a small cupping will relieve; a belladonna or opiate plaster over the heart, and small doses of hydrocyanic acid, if the stomach is irritable, are the remedies. But it must be borne in mind, that if the aortic orifice is contracted, increased action of the ventricle is beneficial, and must only be kept within reasonable limits. If the patient's condition is feeble and bloodless, and there seems evidence of dilatation, tonics, especially iron, given in very small doses for a long time, and a nutritious diet, are of service. The ferrum tartarizatum is a good form from its diuretic qualities. Diuretics are always of immense service in heart disease, by relieving vessels loaded with the blood which cannot pass rapidly enough through the heart. Digitalis in small doses, with squill and mercury, may be tried, especially if there is any dropsical ten- dency. Purgatives and mercurials for relieving abdominal and hematic congestion are often also necessary. Blisters and setons to the chest may be used if there is a suspi- cion of any inflammatory process about the heart, or pericard urn. Stimulants and antispasmodics, such as ammonia, aether, hen- bane, &c, in small doses, often give great relief where there is palpitation, combined with nervous debility and a languid circulation. ANGINA PECTORIS. This dreadful complaint attacks persons who have some organic alteration of the heart, and generally of an atrophic chara3ter. In some cases the heart has been found excessively loaded with fat; in 9 98 PRACTICE OF MEDICINE. others there has been a softness of the heart; in others disease of the valves or of the aorta ; and in several ossification of the coronary artery, a change which would, of course, greatly interfere with the proper nourishment of the heart. Symptoms.—These seem to be of the nature of a cramp, or spasm of the heart, combined with inability to propel its contents properly. The patient, in walking briskly, especially if he does so after a meal, is seized with a peculiar pain in the region of the heart. It is a pain of an alarming nature to the patient, who often feels that he must stop and support himself, and as if another step would be fatal. The pain goes through to the back, and often shoots down to the elbow of the left arm. The pulse sometimes stops during the paroxysm. When it has lasted some seconds, it goes off. » The attacks, generally, as the disease advances, become more and more frequent and violent, and more easily induced. Treatment.—This may be comprised in the word quiet. The patient should be warned of his danger; and the means which have been before spoken of should be employed to allay irritation of the diseased organ, taking care neither to weaken the patient too much on the one hand, nor on the other to let his veins become too full, or the liver and kidneys inactive. OF PARTICULAR HEMORRHAGES. epistaxis (Bleeding from the Nose). There is no part of the body more disposed to hemorrhage than the pituitary membrane, and none in which the recurrence of the discharge is productive of so little injury, as respects either the structure or the constitution. The blood effused from this membrane may be discharged either by the nostrils or by the mouth, after having passed into the posterior fauces. Causes.—In its idiopathic states, epistaxis occurs most frequently in children and young persons. In the more mature periods of life, it is most frequently symptomatic, or dependent upon disease of the heart, of the liver, spleen, or of some other viscus, or consequent upon the disappearance of some sanguineous or other evacuation. The external causes are, injuries, irritants, exposure of the face to fires or to the sun's rays. The internal causes are, whatever in- creases the flow of blood to the head, as mental excitement; sneez- ing ; catarrh, &c, &c. Symptoms.—The sthenic form is ushered in by pain of the head, vertigo, or somnolency; with increased pulsation in the temporal arteries. The sthenic epistaxis is often symptomatic or critical of several acute diseases ; especially the more inflammatory kinds of fever, and inflammations of the brain, or of the lungs, &c. The passive forms are frequently symptomatic of several cachectic HAEMOPTYSIS. 99 maladies, and of the last stages of malignant or low fevers. The quantity of blood discharged may vary from a few drops to many pounds,; and in the more obstinate passive states the patient may be reduced to the utmost danger, or may be carried off in a few hours or days, according to the continuance or violence of the dis- charge. Treatment.—If the patient be robust or plethoric; if he have ex- perienced attacks of determination of blood to the head ; the dis- charge should not be arrested until the vascular system is relieved, and when this is accomplished the epistaxis will cease of itself. If it should seem to cease prematurely, and particularly if the above symptoms still continue, depletions, purgatives, and an antiphlogistic regimen ought to be prescribed. When it is requisite to check the hemorrhage, the patient ought to be placed in a cool, airy apartment, with the head elevated, or held upright, and the feet plunged in warm water containing mus- tard. The neck should be bared, and cold fluids aspersed over it and the face, or ice applied upon the nape of the neck or upon the forehead ; and an active cathartic exhibited; the sulphate of mag- nesia with sulphuric acid is the best. Lemonade and cooling drinks may also be given. When the epistaxis has become habitual, or periodic, and especially if it be vicarious of menstruation, it may be anticipated by cupping on the nape of the neck. In the passive or atonic states of the disease, astringents should be injected into the nostrils, and astringents and tonics given inter- nally. A solution of acetate of lead, or of sulphate of zinc, or of sulphate of iron or copper, or of the sulphate of alumina, may be injected into the nostrils; or lint, moist with either of these solutions, introduced. The superacetate of lead, with acetic acid, and small doses of opium, may be exhibited with advantage. If the bleeding will not stop, the anterior and posterior apertures of the nostrils should be plugged. HAEMOPTYSIS AND PULMONARY APOPLEXY. (Hemorrhage from the Respiratory Organs.) Haemoptysis is one of the most frequent varieties of hemorrhage, owing to—1st, the very extensive bronchial and vesicular surface to which the blood is circulated for the purpose of undergoing the requisite changes during respiration ; 2d, to the delicate conforma- tion of the capillaries of the mucous membrane of this part; 3d, to the liability of the lungs to congestions, from impaired nervous power, from obstructions of the pulmonary veins and of the circu- lation through the left side of the heart, and from tubercular or other lesions of the substance of the lungs. We may admit three principal sources for the blood which is ex- 100 PRACTICE OF MEDICINE. pectorated in haemoptysis. It may come, first, from the mucous membrane of the bronchi ; secondly, from a vessel ulcerated in a tuberculous excavation ; thirdly, from an aneurism of the aorta, or of the large trunks arising from its transverse arch, in which case it will be soon fatal. Pathology.—Some few cases of haemoptysis depend on suppres- sion of the menses, and are habitual and not dangerous ; but in by far the majority of cases it depends on disease of the heart, or on the irritation of tubercle. Hypertrophy of the right ventricle is generally supposed to be a frequent cause of pulmonary hemor- rhage ; but the momentum caused by hypertrophy of the right ven- tricle is rarely sufficient to rupture any branch of the pulmonary artery. Dr. Watson states, " that every instance of pulmonary hemorrhage dependent upon organic disease of the heart, which he had observed, coincided with disease on the left side of that organ, mechanically obstructing the return of blood from the lungs. The obstacle has sometimes been placed at the entrance of the aorta; but it has most commonly consisted of narrowing of the left auriculo- ventricular orifice, and a rigid condition of the mitral valve." When these morbid states exist, it is easily brought on by violent exercise, or anything that irritates the lungs. Pulmonary hemorrhage may be simple, the blood being all spit up; or it may be attended with what is most improperly called pul- monary apoplexy; that is to say an infiltration of blood into the minute tubes and air cells, rendering a portion of lung solid. This, as Dr. Watson has shown, is an accident of pulmonary hemorrhage, and occurs in this way. A portion of the blood instead of being coughed out is drawn back by the patient's inspiratory efforts into one or more small tubes, and fills and blocks up one or more lobules ; giving rise to one or more knobs or masses, composed of blood that has coagulated in the air vesicles. Sometimes, though not often, the latter are broken down and ruptured by it. In other cases, hemorrhage occurs in the minuter tubes and vesicles, and goes on clogging up a large portion of lung progressively; there being not the circumscribed lumps just described, but a large irregular diffused solidification. Symptoms.—Some degree of pain or oppression at the chest, with cough, which brings up mouthfuls of blood, fluid or clotted. The quantity may vary from a teaspoonful to several pints; so that the patient may be suffocated by the abundance of the hemorrhage. The stethoscope is useful as indicating the extent and place of the hemorrhage, for wherever there is blood in the air-tubes or vesicles there will be a corresponding crepitation, or if the lung is solidified there will be absence of respiration. After pulmonary apoplexy, the blood is expectorated in dark red sputa, mixed with mucus. H/EMATEMESIS. 101 Treatment.—When the pulse is full, strong, and vibratory, bleed- ing is required, and the quantity of blood abstracted will necessarily depend on the strength of the patient. One bloodletting of twenty or twenty-four ounces on the first or second day, will have more effect in checking the hemorrhage than several pounds taken away in the course of a fortnight. When the patient's powers will not admit of general depletion, cupping or leeches should be resorted to. A free current of cold air should be allowed to pass over the patient, who should be lightly covered ; the bowels should be opened with Epsom salts and sulphuric acid ; and the best remedy is the acetate of lead with opium. Perfect silence should be enjoined; the diet be very meagre, and comprise lemonade or other acid drinks. If the hemorrhage assumes a passive character, alum, with dilute sul- phuric acid may be administered. In slighter cases, saline draughts, with small doses of digitalis, may suffice. Any inflammatory or irritative symptoms must be treated by blisters and other remedies that have been adverted to when speaking of phthisis. H-ematemesis (Hemorrhage from the Stomach). Causes.—Whatever irritates the mucous surface of the stomach, or interrupts the return of blood from that organ, will occasionally produce this disease. Blows and injuries on the abdomen, particu- larly on the hypochondria and epigastrium; violent concussions of the trunk ; external or internal pressure on the stomach; the inges- tion of irritating or hurtful matters into this viscus; intemperate in- dulgence in food or stimulating liquors; the presence of worms in the stomach or upper part of the small intestines; powerful or irri- tating emetics, especially when given in the advanced stages of fevers, or in cachectic or visceral diseases ; the suppression of accustomed discharges, particularly the menstrual or haemorrhoidal; the appli- cation of cold, or of cold and moisture, to the lower extremities or surface of the body during perspiration or the catamenial period; neglect of the bowels, and consequent accumulation of faecal matters ; diseases of the vessels of the stomach and neighbouring viscera ; the gravid uterus, and large tumours developed in any part of the abdomen. Symptoms.—-In most cases, there are premonitory symptoms, such as tension or pain about the epigastrium, with faintness, or a sense of sinking, or of anxiety, at this region; flatulent or acrid eructations ; lassitude with irregular chills and flushes of heat. The pathognomonic phenomena of the disease are, nausea, followed by vomiting of blood, either fluid or coagulated, pure, or mixed with the contents of the stomach. The blood and other matters thrown up come away with more or less effort, frequently with comparative ease, even when the hemorrhage is greatest, and seldom with much previous retching; it is sometimes gulped or eructated upwards. 102 PRACTICE OF MEDICINE. When the quantity of blood thrown up is great, the effort at ejecting it may sometimes occasion irritation in the pharynx, and excite coughing, and, from this circumstance, cause some doubt as to the seat of the effusion; but the history of the case will easily show the nature of the disease. After an attack of haematemesis, the bowels are generally relaxed, and the dejections dark coloured, from the presence of blood in them, and extremely foetid. Sometimes the evacuations are quite black, and of the consistence and appearance of tar. This state of the evacuations (the melana of old authors) often continues for some time after the vomiting has ceased; and they are often preceded by colicky pains through the abdomen, dis- tention, flatulence, tormina, and even slight meteorismus. The physical characters of this hemorrhage which require notice are merely those which are referable to the colour, consistence, and quantity of the effused blood. The blood effused into the stomach and intestines is seldom found to present its natural red colour, either when thrown out from these organs or when contained in them after death. It has often acquired a dark purple, and still more frequently a deep brown tint, or even the blackness of soot. The dark brown and sooty discolorations of the blood may always be regarded as the result of the action of an acid chemical agent, formed in the diges- tive organs, on the effused blood, except in those cases in which they are produced by the action of an acid poison. Hence we may con- clude, that the diseases called black vomit and melana are mere modifications of gastric and intestinal hemorrhage, the black colour being an accidental circumstance of no importance, and derived from the chemical action of the acid product on the blood, previous to its evacuation. The consistence of the effused blood is very generally increased with the darkness of colour which it has acquired. It is sometimes coagulated into large masses, or into a multitude of smaller portions, resembling a mixture of water, blood, and soot. This ap- pearance is peculiarly characteristic of the action of an .acid on the blood. The quantity of blood effused may vary from a few ounces to several pints; and although it is generally greatest in cases of perforation of an artery of the stomach, it is sometimes no less abundant when it has its source in exhalation from the mucous membrane. Of the different local lesions which are found to accompany gas- tric and intestinal hemorrhage, follicular ulceration is, perhaps, the most common. The mucous membrane may be perfectly pale when the hemorrhage has proceeded from perforation of an artery; red and vascular when preceded by congestion; or it may be of a deep red colour throughout a great extent, whatever be the source of the effusion, from imbibition alone. It almost always presents this deep red colour when the haemorrhage arises from a mechanical obstacle to the return of the venous blood, the submucous tissue HEMATURIA. 103 being at the same time in a state of great congestion, and infiltrated with blood. Treatment.—In plethoric and robust persons, in cases depending on congestion of the liver or spleen, or upon suppressed discharges, and where there are indications of increased or sthenic action, we should have recourse to copious or repeated bloodlettings, according to circumstances. Cupping over the hypochondria, purgatives, cathartic enemata, and external derivatives, should be resorted to. In the more active forms, a full dose of calomel, followed in a few hours by a purgative draught, and this by a cathartic enema, so as to procure copious alvine evacuations, should precede the use of astringents. When the hemorrhagic discharge is so copious as to forbid the delay which this practice would occasion, the calomel should be followed in a short time by a full dose of oil of turpentine, given on the surface of milk or of some aromatic water, or of this medicine conjoined with castor oil. If this draught be thrown off the stomach, it should be repeated; and it may be even again pre- ceded by the calomel. Notwithstanding its usual nauseating effect, turpentine is generally retained in haematemesis, and it allays the vomiting by arresting the hemorrhage. Of the astringents, the acetate of lead, in large doses, with opium, or with pyroligneous acid, acetate of morphia, and creasote, is the most efficacious. In the more passive states of the disease, the tonic astringents, as the tincture of the sesquichloride of iron, the oil of turpentine with aromatics, the sulphates and sulphuric acid with opium and infusion of roses, alum in milk-whey, are generally useful. During the continuance of the discharge, total abstinence should be enjoined ; but afterwards, mild mucilaginous drinks, and farina- ceous food in small quantity, may be allowed, and the transition to solid and more nutritious diet carefully and gradually conducted. The drink should be cooling and astringent, and appropriate to the state of the digestive organs, especially the liver and spleen. Sub- sequently, change of air, regular exercise on horseback, and the use of deobstruent mineral waters, ought to be recommended. H/Ematuria (Hemorrhage from the Urinary Organs). Symptoms.—The source of blood voided through the urethra may be either the kidney, ureters, bladder, or urethra. When it proceeds from an affection of the kidneys, it is attended with a sense of heat and pain in the loins, and sometimes with coldness of the extremi- ties, and the blood is intimately mixed with the urine. When the disease is in the ureters, there is a sense of pain and tension in their course; and coagulated shreds of fibrine, having the shape of the ureters are frequuetly voided. When the hemorrhage is from the bladder, it is usually preceded by heaviness and tension above the 104 PRACTICE OF MEDICINE. pubes, extending to the perinaeum, groins, and lumbar regions; the passing of the urine is attended with pain and difficulty; the blood is little, if at. all, combined with the urine. When the hemorrhage is from the urethra, pain is felt in a particular part of the canal, and the blood is red, liquid, and pure, and generally is voided guttatim. When the blood, however, flows back into the bladder, some uncer- tainty as to its origin is produced. Hemorrhage of the urinary organs presents little worthy of notice, as regards its physical characters, except when it occurs in the bladder. In this organ, it takes place from isolated points of the mucous membrane, which, as well as its sub-cellular tissue, presents a number of deep red patches, varying from a line to half an inch in diameter, the larger ones having often a small ash-coloured slough in their centre. These patches consist of blood effused into the mucous and sub-mucous tissues, and are accompanied by venous congestion of those tissues where the effusion has not taken place. This form of hemorrhage is chiefly observed in injuries of the spine; and appearances perfectly similar sometimes follow the ap- plication of blisters to the chest, abdomen, and other parts of the body. The most frequent cause of hemorrhage from the urinary organs is the presence of the fungoid disease in the prostate, and hence its much greater frequency in the male than in the female. Treatment.—The treatment of this affection will, of course, depend on its seat and cause. When the hemorrhage is from the kidney, if the patient be strong, and the pulse full, either general or local de- pletion, with the usual antiphlogistic treatment, is requisite. On the contrary, when the patient is debilitated, as in typhus or scurvy, the urine being generally alkaline, the mineral acids should be given. In ordinary cases, when neither excitement nor depression is present in a marked degree, small doses of copaiba, turpentine, or of the tinct. ferri sesquichlorid., the latter of which is the best, are to be administered. The avoiding of all stimulants, and absolute rest, should be insisted on. OF DROPSIES. If, in man, a large venous trunk be compressed or obliterated, so that the blood no longer circulates through it, whilst at the same time the collateral vessels can relieve but imperfectly the principal vein thus obstructed, an effusion of serum is sure to take place. But if the obstruction exists not merely in the veins of a limb, if it occur in a vessel into which the blood of a much greater number of parts empties itself, then the dropsy will necessarily become more con- siderable. If, for instance, the obstacle to the return of the blood should exist in the abdominal vena cava, the two lower extremities, as also the scrotum, will become filled with serum. If it be the trunk of the vena portae, which is more or less completely oblite- NEPHRITIC DROPSY. 105 rated, it is in the peritonaeum that the serous collection will first take place; it is in this way we may suppose that certain diseases of the liver become causes of ascites. If, in fine, the obstacle to the free return of venous blood exists at the very centre of the circulation, namely, at the heart, we must then draw the theoretical conclusion, that'in this case, the circulation of the venous blood being every- where embarrassed, serous collections must form in all directions, and the dropsy become general. This case, anticipated by theory, is actually established by experience; all practitioners know that dropsy is one of the most common symptoms of the different organic affections of the heart. The next cause of dropsy is cold, applied in such a manner as to check the secretion of the skin. From this cause we have frequently general anasarca, and effusions into the pleurae, the pericardium, the peritonaeum, &c. These cases are, from the attendant constitutional symptoms, called inflammatory dropsy. A third cause of dropsy is some exanthematous disease, and especially scarlatina. A fourth cause of dropsy is the granular degeneration of the kidney, first pointed out by Dr. Bright, and lately elucidated by the admirable researches of Dr. G. Johnson, of King's College.* A fifth source of dropsy is debility, exhaustion from loss of blood, &c. A sixth and frequent cause of dropsy is obstruction to the flow of the venous blood, owing to tumours pressing on the large venous trunks, and glandular enlargements, as hypertrophy of the liver, &c. The presence of albumen in the urine depends on the presence of blood, or else of the serum of blood. If serum only be present, the albumen may be detected by boiling a portion of urine, and add- ing nitric acid; if the entire blood be present, the red particles may be detected by the microscope, and will render the urine smoky or dusky in colour. These conditions of the urine in dropsy depend on a congested, or irritated, or diseased state of the kidney, so that the capillaries of the Malpighian bodies either exude serum, or else are ruptured and pour out blood. nephritic dropsy (Dropsy from Bright's kidney). Dr. Bright first pointed out, in 1827, the frequent connexion which exists between dropsy and what has since been called granu- lar degeneration of the kidney, and the presence of albumen in the urine, as an indication of the latter lesion; but it has been reserved for Dr. G. Johnson, of King's College, to detect the real nature of this most prevalent and fatal disease. » See two excellent lectures, by Dr. Todd, of King's College, in the London Med. Gaz. Dec. 19th and 26th, 1845. 106 practice of medicine. Pathology.—This state of the kidney is not an inflammation, but a slow degeneration of structure, commencing by an abnormal de- posit of fat in the epithelium cells lining the uriniferous tubes. It is a degeneration, therefore, much allied to the tubercular deposit, or to the fatty liver, common in phthisis, and may properly receive the name of the fatty kidney. It is a slow insidious disease, beginning generally much further back than the patient is aware of. The uriniferous tubes become by degrees blocked up with an ex- cessive accumulation of fatty epithelium; the result of this is, that the tubes become dilated, so as to press on the portal plexus of veins which surround them. The veins being thus compressed, the Mal- pighian capillaries, which open into them, are unable to discharge their contents, and so become distended with blood; and either allow serum to exude from their walls, or else burst and admit the escape of red particles and fibrine. As the accumulation goes on, portal plexuses and uriniferous tubes become atrophied, and hence, shrink- ing of the kidney and deficiency of secretion ensue. As, however, some Malpighian tufts remain healthy, the secretion from these is sometimes abundant, or even excessive. The morbid anatomy is thus described and explained by Dr. Todd :— 1. "Both kidneys are found in a diseased state. It seldom or never happens that the disease is limited to one kidney. 2. " We meet with irregular vascular congestion, the vessels are full at some parts of the organ, and empty at others, and this gives rise to a mottled appearance on the surface of the kidney. 3. " A deposit of a new matter is found either in or between the tubes of the kidney; this deposit has hitherto been called granular. 4. "As the disease advances, the kidneys, which at first.were enlarged, shrink, their cortical or external portion becoming wasted, here and there leaving depressions on the surface of the organ, cor- responding to the wasted portions; and thus a tuberculated aspect is given to the kidney. The blood-vessels are obliterated in many situa- tions, and it is impossible to inject such kidneys." Constitutional Symptoms. — These may be divided into three stages. In the first, the patient is weak and dyspeptic; and his blood loses its red particles in an extraordinary degree; but there is very little to call attention to the kidney. In the second stage, the symptoms are, a pallid pasty complexion ; dry hard skin ; drowsiness ; weakness; indigestion ; and frequent nausea; often retching the first thing in the morning; and palpita- tion of the heart. A most characteristic symptom is, that the patient is awakened once or twice in the night, with desire to make water. In the third stage, if the patient is exposed to cold, the kidney becomes congested; anasarca, with, perhaps, ascites, makes its ap- HYDR0TH0RAX. 107 pearance ; debility increases; the secretion of urine becomes more inefficient, urea, and other excrementitious matters accumulate in the blood; and drowsiness and coma, signs of effusion into the head, are sure precursors of death. Of the state of the urine.—In the first stage, if examined, it will often be found to contain particles of epithelium, loaded with fat. In the second stage, the urine is albuminous, and not only so, but contains sometimes red particles of blood, and little fibrinous shreds, moulds of the tubuli uriniferi, in which they have coagulated. Its specific gravity is generally very low; instead of 1025, the healthy average, it sinks to 1016, and gradually gets lower; down, per- haps, to 1004. It will often be found under the microscope to con- tain a large amount of fatty epithelium scales. In the last stage, the quantity of urine is very variable; some- times very scanty, or even suppressed, so that the patient dies comatose, from the urine retained in the blood; sometimes ex- tremely abundant; and sometimes before death the albumen entirely vanishes. Consequences.—This fatty disease of the kidney, besides dropsy, and fatal coma, is apt to induce acute inflammation of the serous membranes, disease of the heart, and obstinate indigestion. Causes.—It may be caused by intemperance, privation of air and light, and neglect of proper exercise ; frequent exposure to cold, and the other causes of scrofula and phthisis. Treatment.—If the disease assumes an acute character, with pain in the loins, fever, and evidence of renal congestion, cupping should be performed on the loins. But in most cases the treatment should be so conducted as to keep the emunctories open, and reduce the strength as little as possible. The skin should be kept open by baths; the bowels by saline purgatives ; and in the intervals of pur- gation, the kidneys should be solicited by the milder kinds of saline diuretics, such as tartarized soda. When there is an absence of fever the tartarized iron can sometimes be borne. Lastly, the diet should be plain and as nourishing as the stomach will digest, and fatty matters should be excluded from it as much as possible. hydrothorax (Dropsy of the Pleural Cavities). It was formerly the common opinion, and is even now believed by many, that idiopathic hydrothorax is a very common disease, producing a formidable array of symptoms, and often causing death by suffocation. In these late years, the erroneousness of this opinion has been shown, on the one hand, by the study of pathological anatomy, which has discovered, in the supposed cases of simple hydrothorax, extensive organic disease, without any effusion; and, on the other hand, by auscultation and percussion, which have not only proved the same during life, but have likewise taught us that 108 PRACTICE OF MEDICINE. hydrothorax, when it does exist, can have but a very small share in producing the symptoms that have hitherto been ascribed to it. Symptoms.—The patient feels an oppression and difficulty of breathing, and generally lies on the affected side, leaving the healthy one unencumbered in its functions. When the fluid is in both cavities, the respiration is still more difficult and short; the patient sits up in bed, and calls in the aid of all the muscles of inspiration; and his countenance assumes a cast of anxiety. Corvisart describes the chest as being more distended and rounded on the side which contains the fluid; and as the collection increases, the intercostal spaces are widened, the integuments of this side becoming oedema- tous, and, in a few instances, the arm on the same side. In the acute states of this disease, a feeling of soreness, tenderness, or pain, is often complained of in or over the seat of effusion. Symptomatic hydrothorax will combine with the common signs of pleuritic effusion those of whatever organic disease it is the consequence; and this will generally be found to be some lesion of the circulatory appa- ratus, by which its function is extensively impeded. Laennec states that it scarcely ever supervenes earlier than a few days before the fatal termination of such diseases, and may therefore be considered the immediate harbinger of death, the agony of which it increases by dyspnoea. Physical signs.—On percussion, a dull sound is emitted, resem- bling that produced by striking the thigh, on the side containing the fluid, or on both sides when the effusion has taken place into both. When the patient sits, or stands up, and the fluid only partially fills the cavities, the lower part of the thorax only will give out a dead sound. This sound generally changes its place with the change of position, owing to the gravitation of the fluid to the depending part. This, as M. Piorry contends, is an important diagnostic between the dead sound of effusion and that produced by hepatization of the sub- stance of the lung, which always retains the same situation. Upon auscultation, the respiratory murmur is found to have ceased in the region corresponding to the fluid collection ; and in its place is heard the bronchial respiration, When the effusion is not very great, agophony is occasionally heard. If the fluid be accumulated only in one cavity, mensuration of the thorax then becomes a useful mode of diagnosis; but the increased fulness of one side, and widening of the intercostal spaces, may be recognised at sight. Treatment.—The plan of treatment must depend upon the cause of the effusion, which may be, an organic lesion of the heart or lungs, or inflammation of the pleura; and these are to be managed on the general principles laid down when treating of those affections. Cathartics and purgatives, especially the hydragogues, often afford speedy relief; but they are admissible only when the powers of life are not greatly reduced, and in the more acute cases, not caused by ASCITES. 109 inflammation of the pleura. Diuretics are more certainly beneficial in this dropsy than in any other; and of this class digitalis is the most efficacious, particularly in the form of infusion. All authors agree in admitting the power of digitalis in this affection. Where there is much prostration of vital energy, we should combine tonics, and antispasmodics, with the diuretic medicines. Paracentesis thoracis, once so strenuously advised, is seldom or never resorted to, excepting in empyema. The chief danger in this operation proceeds from the introduction and action of the air; but not so much from its preventing dilatation of the lungs as from its action on the diseased pleura and °the fluid effused from it, which becomes putrid and poisonous. ascites (Dropsy of the Abdomen). Ascites, or dropsical effusion within the abdomen, may exist either alone or complicated with hydrothorax and general anasarca. Causes.—The great extent of the peritoneum, the number and importance of the viscera with which it is connected, and of the ab- sorbent glands it encloses, the numerous sources of disorder to which these organs are exposed, the great number and weakness of the veins which transmit their blood to the portal vessels, and the ab- sence of valves from them, in some measure account for the frequent accumulation of fluid in this cavity. Ascites may arise at any age. Camper, Lee, and others, have observed it in new-born infants; but it is most common in women and aged persons. It occurs more frequently in married than in unmarried females; and is often the consequence of the distention and pressure attending pregnancy, of difficult or instrumental labours, and of suppression of the puerperal secretions, or of the perspiration, of catamenia, or of the disappearance of this last evacuation. Pre-existent disease, particularly diarrhoea or dysentery, and sudden interruptions of these discharges; intestinal worms ; organic lesions of the liver and spleen, especially obstructions of their venous circulation; inflammation of the vena portae, and obliteration of one or more of its principal -branches ; the suppression of chronic erup- tions, or of the exanthemata,-as scarlet fever erysipelas, &c ; acute or sub-acute peritonitis ; organic change of the structure of the kidneys ; the rupture of cysts into the abdomen; uterine or ovarian disease ; intermittent or remittent fevers ; excessive evacuations and hemorrhages; are all occasionally productive of ascites. Sympto/ws.—Idiopathic ascites generally assumes ani acute, or even> inflammatory form. It usually occurs either in the_ young, the robust, or well fed, and presents all the symptoms of the phlogistic diathesis; the pulse is hard, thirst increased, the urine scanty; the £ is warm, hot, or coloured, and resists more or less the pressure of the finger There are evidences of inflammatory or excited action 110 PRACTICE OF MEDICINE. of the peritoneum, with pain, tenderness, and sometimes tension of the abdomen ; a quick, small, hard or wiry pulse, and suppression or diminution of all the secretions or excretions. Either consecu- tively on, or concomitantly with, these symptoms, fulness of the ab- domen is observed, which usually augments rapidly. At first, the increase is most remarkable in the lower part of the abdomen and iliac regions when the patient is sitting up, and the liver is not enlarged; but it is always diffused when the patient is in the supine posture, and without any limitation or tumour. Upon examining the abdomen, a dull sound is emitted by percussion, and fluctuation is easily perceived. As the effusion augments, all the abdominal func- tions are more and more disturbed, and at last respiration becomes difficult from the pressure of the fluid impeding the descent of the diaphragm, and the patient is unable to lie down. The abdomen is now large and prominent in its upper regions, and pushes, particu- larly in young subjects, the ribs and cartilages upwards. Irrita- bility of the stomach, anxiety, restlessness, want of sleep, great quickness of pulse, sometimes delirium, and ultimately coma and death, supervene, if temporary or more prolonged relief be not obtained from treatment. Ascites may be mistaken for tympanitis, ovarian dropsy, and for pregnancy. Tympanitis is readily recognised by the clear reso- nance furnished on percussion, by the absence of fluctuation, and of the oedema of the lower extremities, and by the history of the case. Ovarian dropsy is never general or uniform in its earlier stages, like ascites ; and fluctuation is usually very obscure, and to be de- tected only in the situation of the tumours, the circumscribed form of which may be determined until a very advanced period of the dis- ease. Pregnancy is distinguished from ascites by the state of the os uteri upon examination, by the progress of the enlargement, and the defined form of the uterus when the patient is supine, and the abdominal muscles relaxed ; by her unbroken health and clear com- plexion,—the countenance of dropsical persons being pale, sickly, and cachectic ; by the enlargement and firmness of the breasts, and the deep colour of the areolae,—these organs being soft and flabby in ascites. Let the patient lie on his or her back, and percuss the abdominal parietes. In ascites, they generally yield a dull sound towards the back, where the fluid settles, and clear in front, because the bowels float upwards through the serum. It is the reverse in pregnancy and ovarian dropsy. Treatment.—This must depend, as in other dropsies, upon the organ affected, and upon the extent and nature of the disease. The acute forms require vascular depletions, general or local, or both, tp an extent which the pulse and symptoms indicate. Mercurials and antimonials, at first so as to act on the bowels, and subsequently as CYNANCHE tonsillaris. 111 alteratives, or with opium, and pushed so far as to affect the mouth ; external irritants and derivatives ; deobstruent diuretics ; diaphoretics, and warm or vapour baths, followed by oleaginous frictions of the skin, in order to restore its perspiratory functions ; and lastly, gentle tomes conjoined with purgatives, or with diuretics, and assisted by warm iodine or medicated baths, will frequently succeed in removing disorder, if early employed, and if a vital or-mn have not experienced serious structural change. The symptomatic orms of ascites must be treated with strict reference to the original lesion or malady, as far as that can be ascertained. Graduated compression of the abdomen, by means of the belt recommended for ascites by the first Munro, has been employed successfully by Pro- fessor Speranza and M. Godelle, and, when it can be borne, may prove serviceable in some asthenic and chronic states of the disease. With respect to paracentesis abdominis, it should be avoided as long as possible, and, although it should not be proscribed from practice, the cases are few that will be benefited, and still fewer that will be cured by it. DISEASES OF THE DIGESTIVE ORGANS AND THEIR APPENDAGES. CYNANCHE TONSILLARIS. Causes.—The most frequent cause of common inflammation of the tonsils is, exposure to cold damp air,—hence it prevails with inflammation of the pharynx, at certain seasons of the year. Symptoms.—This disease is easily detected by the tumefaction, pain, and redness of one or both tonsils, which are covered with white spots, or an inflammatory crust. There are, moreover, pain on deglutition, dryness and heat in the fauces, frequent desire to swallow the saliva, and, when the inflammation is general and severe, the respiration becomes extremely impeded by the mecha- nical obstacle, and the symptomatic fever runs high. Treatment.—This is simple, but should be actively employed in severe cases. Bleeding or leeches, purgatives, calomel, cooling gargles of nitre, muriatic acid, &c, poultices to the throat, followed by stimulating liniments or blisters, and the inhalation of steam, will soon reduce the inflammatory tumefaction and give relief. The nitrate of silver, or sulphate of copper, is also often of great use. If, however, symptoms of suffocation be imminent, from considerable swellino- of both tonsils, the surgeon must immediately scarify the glands. After the disease has been subdued, it sometimes happens that the 112 PRACTICE OF MEDICINE. tonsil remains indurated, and very susceptible of becoming inflamed on exposure to cold, &c. In such cases, extirpation of the gland may become necessary, and has been practised with success. INFLAMMATION OF THE PHARYNX. This affection, which constitutes what is commonly called sore throat, may be easily detected by an inspection of the pharynx, which presents an uniform dark red colour, and is frequently spot- ted with whitish patches. The general symptoms resemble much those of tonsilitis, but there is seldom any marked degree of fever, and no difficulty of respiration. The leading signs are, redness at the back of the fauces, pain, and difficult deglutition, and a copious secretion of mucus from the part. Treatment.—General bloodletting will seldom be required. If the pain be very severe, leeches may be applied externally to the neck, and the bowels should be freely opened by active purgatives. At the commencement, the inhalation of steam affords most relief; and as the inflammation subsides, recourse may be had to astringent or stimulating gargles, nitrate of silver, and the internal use of ice. gastritis (Inflammation of the Stomach). Inflammation of the mucous membrane of the stomach may be either chronic or acute. The latter, however, is very rare. Causes.—The chief causes of acute gastritis are, external violence; acrid poisons; (the most frequent cause;) and cold drinks taken whilst the body is heated. Symptoms.—Heat, and acute pain, increased on pressure over the stomach, or by coughing, or deep inspiration; instant vomiting of the matters ingested; constipation and prostration of strength. The pulse is usually quick, small, and irregular; the tongue clean, and red at the point or edges. The skin is hot and dry ; there is thirst, and a desire for cold drinks. This disease is attended with great depression of the heart's action through the influence of the solar plexus of the great sympathetic. As it advances, the face becomes collapsed, the extremities cold, and the patient lies in a state of com- plete prostration; cerebral symptoms now supervene, the abdomen becomes tympanitic, and death soon closes the scene. The anatomical characters of acute gastritis are those of inflamma- tion in general, but they may vary according to the exciting cause. Thus certain mineral poisons may give rise to peculiar states of the mucous membrane. In some cases, the inflammatory injection and thickening are confined to particular spots ; sometimes they fol- low the course of the principal blood-vessels, and on other occasions the whole mucous membrane presents a uniform vivid or dark red colour. Treatment.—The first indication of treatment in this, as in all other affections, is the removal of the exciting cause. Should the presence of any poison be suspected, the proper antidotes are to be CHRONIC GASTRITIS. 113 at once administered, or vomiting excited ; circumstances alone can determine an election. Blood must be freely drawn from the arm in severe cases, and the venesection repeated according to circum- stances ; leeches, also, may be applied over the epigastric region. The pulse will often be found t© rise in force and fulness after bleed- ing. Warm fomentations, containing an anodyne, will be found useful in allaying the pain, but some prefer the immediate application of a large blister over the region of the stomach, and of sinapisms to the feet. The thirst may be allayed by the frequent administra- tion of cold water in small quantities, but it will be advisable to abstain from giving medicines by the mouth as long as acute inflammation exists. If any be given they should be of the least irritating nature. It is more prudent to administer laxatives by the rectum, to trust to general bleeding and strict regimen, with revul- sives orcounter-irritants; small doses of calomel and opium might in some instances be advisable. CHRONIC GASTRITIS. This is an occasional cause of the severer forms of dyspepsia, and is often attended with one or more ulcers in the stomach. The symptoms of chronic gastritis are extremely various, both in number and intensity. The following, however, are usually present in well-marked cases :—Pain and uneasiness about the region of the stomach, particularly increased after meals ; sense of constriction in the oesophagus, near the lower part of the neck ; imperfect digestion, accompanied by eructation, nausea, and occasional vomiting of food, or of mucus streaked with blood ; skin dry, but not warm ; pulse nearly natural, but sometimes accelerated; tongue covered with a whitish fur, or red at the tip and edges, or dotted with red spots from development and injection of the papillae. The patient often exhibits symptoms of hypochondriasis, and the spirits become low as the disease advances. Treatment.—The principal indications are fulfilled by the appli- cation of leeches to the region of the stomach, followed up by exter- nal irritation and a careful regulation of the bowels. Strict attention should also be paid to the diet. The patient should eat nothing but very light food, at regular intervals, and the general health should be improved by gentle exercise in the open air. In some cases, the stomach is so irritable that no food of any kind can be borne. Asses' milk, given by spoonfuls at a time, may be tried, and very small doses of prussic acid; but if all these measures fail, it will be advisable to abstain from administering food by the mouth, and to support the patient by nutritious enemata. After the subsi- dence of all symptoms, the tone of the digestive organs may be improved by mild tonics, but the best strengtheners will be found to consist in moderate exercise and a strict attention to diet. 10* 114 PRACTICE OF MEDICINE. DYSPEPSIA. Dyspepsia signifies any derangement of the functions of the sto- mach. It may be temporary and depend on mere functional derangement, or may be a consequence of the most serious organic disease. Causes.—The causes of dyspepsia are extremely various, as the function of digestion may be disturbed under a great number of dif- ferent circumstances; those which are now enumerated chiefly refer to simple indigestion. They are, irregularities of diet, the use of debilitating substances, indulgence in spirituous liquors, mental emo- tions, suppression of accustomed discharges, &c. The symptoms of dyspepsia are also extremely various, for the process of digestion is a complicated one, and its derangement acts differently on different individuals. The following are the most pro- minent characteristics of the disease, which differ according as the attack is acute or chronic. Acute dyspepsia generally arises from the ingestion of irritating food, or indeed of any alimentary substances in too great quantity. Errors of diet thus committed are sometimes followed by a sense of distention and uneasiness at the pit of the stomach, which is very sensitive to pressure; foetid eructations, nausea, and occasional vomiting; colicky pain of the abdomen; diarrhoea. The tongue is foul and loaded, the patient suffers from a " sick headache," and a variety of secondary symptoms present themselves. The treatment of this form, which often occurs in healthy individuals, is extremely simple. If we have reason to believe that the offending matters have passed into the intestinal canal, the administration of one or two drops of croton oil will effect their ejection in the most speedy and efficacious manner. Any other brisk purgative, will, however, act equally well, though more slowly. A purgative enema may also be given with good effects. Where the stomach is evidently the seat of disorder, an emetic should precede the use of purgatives. The following are the more common symptoms of chronic dys- pepsia and the most appropriate remedies for them :— Simple want of appetite ; often relieved by acids and bitters. Voracious or unnatural appetite.—Rhubarb and magnesia, bis- muth, and chalk mixture. Acidity, and eructations of acrid matter, causing heartburn.— Small doses of soda and ammonia, after meals, in aromatic water. Flatulence before meals, with loss of appetite.—Small doses of ferri sulph., with pil. rhei c, before meals. Flatulence after eating.—Sal volatile. Pain when stomach is empty.—Magnesia and bismuth, with a biscuit or crust of bread. Pain after eating.—Soda and ammonia; or bismuth and opium taken a little before eating. DYSENTERY. 115 Vomiting—vide chronic gastritis. Waterbrash, or pyrosis ; eructation of clear liquid.—Good plain meat diet, bismuth, kino, oil of amber, and tonics. Gastrodynia, severe spasmodic pain.—Bismuth, and magnesia, or nitrate of silver, or hydrocyanic acid. Constipation.—-A compound rhubarb pill before dinner, or dec. al. c. in the morning, or any other mild aperient taken habitually. The greatest attention should be paid to the diet and regimen; the patient should take gentle exercise, and the mind should be diverted by such occupations as combine amusement with moderate muscular exertion. Palpitation of the heart in dyspeptic patients is often a troublesome symptom. It may be palliated by the combination of sedatives with tonics, as the sulphate of iron with extract of hop, the nitrate of silver with henbane, or prussic acid. Dr. Johnson speaks highly of the nitrate of silver in cases of dyspeptic palpitation. A disordered state of the liver also frequently accompanies dyspepsia. Should this organ appear to be congested, some blood may be drawn by cupping glasses over the right hypochondrium, and small doses of blue pill, with saline aperients, administered three times a week. Finally, as auxiliaries, the change of air and scene, and the use of mineral waters, should not be neglected in protracted cases of dyspepsia. DYSENTERY. Dysentery is an inflammation of the colon, with much pain and spasm. It most commonly prevails in warm climates, when men are collected together in large numbers. It may, however, occur sporadically in the acute or chronic form. Causes.—The chief causes of acute dysentery are, exposure to cold damp air, acrid indigestible food, spirituous liquors, and expo- sure to unwholesome exhalations. It prevails most in autumn, and is held by some writers to be contagious. Symptoms.—General febrile excitement, nausea, vomiting, griping pains about the umbilical region, frequent, painful, straining, ineffec- tual efforts to pass stools ; heat of skin, frequent pulse, thirst, heat and pain about the anus, anxiety, and prostration of strength. The dejected matters are various: in the commencement the stools are often bilious ; but the evacuation of faeces soon ceases, and nothing is passed but small quantities of bloody mucus, intermingled with pus or shreds of albuminous matter. If the disease be not checked, the abdominal pain becomes more fixed, the pulse is feeble and extremely quick, the strength fails, the dejections assume a very foetid character, delirium supervenes; and the patient sinks at a period varying from fifteen to thirty days. The disease may terminate unfavourably by ulceration, gangrene, or the extension of the inflammatory action to the peritoneum. Morbid appearances.—Dysentery consists essentially in an in- 116 PRACTICE OF MEDICINE. flammation of the mucous and sub-mucous coats of the large intes- tine. Hence traces and effects of inflammatory action in various degrees are found in the rectum and colon. The mucous coat is more or less injected in several points, and certain portions of the caecum and colon are either ulcerated or entirely disorganized, the membranes hanging by shreds into the interior of the bowel. The ulcers are sometimes small and numerous; at other times they are elevated, hardened, and covered with sloughy or fungous granula- tions. Some parts of the great intestine may be in a state of sphacelus; and more or less coagulable lymph, mixed with shreds of disor- ganized cellular tissue, adheres to different points of its surface. Treatment.—The treatment of acute dysentery must be regulated by the form in which the disease presents itself; but as in this country the sthenic form usually prevails, the following remarks are applicable to it only. The chief remedial means then, in the begin- ning of the disease, are, local or general bleeding, with fomentations to the hypogastrium;—calomel and Dover's powder at night, and castor oil with laudanum in the morning; and starch enemata, so as to clear out all irritating faecal matters, and soothe the bowels. Some physicians, however, place more reliance on calomel and opium, and very extraordinary doses of the former medicine have been administered with the best effects, especially in warm climates. When the inflammatory symptoms have been completely subdued, and there are no longer any tenesmus and tormina, if the patient remain feeble, gentle tonics, such as infusions of cinchona or columba, with rhubarb, may be administered. The state of the bowels should be carefully regulated during convalescence. CHRONIC DYSENTERY. Chronic dysentery may either succeed the acute form or it may commence with diarrhoea, and gradually assume the character of dysentery. The symptoms are the same as those of the acute form, merely differing in intensity. The alvine discharges are more co- pious, but less frequent; they contain less blood, and less fibrinous matter. There is not much abdominal pain ; the pulse is commonly natural during the day, and symptoms of general excitement only occur on aggravation of the local disease. Treatment.—As long as there is any reason to believe that sub- acute inflammation exists in the intestinal canal, local depletion, aided by counter-irritants and diaphoretics, must be cautiously em- ployed ; but the disease often persists after the subsidence of all inflammatory symptoms. In such cases, a great variety of remedies has been recommended. Some place their chief reliance on small and frequently repeated doses of ipecacuanha; others advise the ad- ministration of astringents, such as the infusion of catechu, the sul- phates of zinc or copper, and the superacetate of lead. The last is frequently employed in combination with opium and ipecacuanha. CHOLERA MORBUS. 117 Tonics may also be given with advantage in the chronic stage, par- ticularly when the disease assumes an asthenic form. Those gene- rally administered are, cinchona and the infusion of serpentaria, colomba, or simaruba barks. Great attention should at the same time be paid to the condition of the liver; the bowels must be kept regular, and all errors of diet or exposure to damp, cold, &c, care- fully avoided. DIARRHffiA. Diarrhoea consists in the copious and frequent discharge of alvine evacuations, which are generally fluid, without tenesmus or fever. The symptoms are, frequent discharge of mucus or slimy stools, containing feculent or ill-digested matters, with griping pains, nausea, and foul tongue. The state of the skin is generally natural. Causes and Treatment.—The causes of diarrhoea are very various, and so must be the treatment adapted for various cases. 1st. Inflammatory diarrhoea. This arises from irritation, inflam- mation, or ulceration of the intestines, and is a frequent attendant of fever, phthisis, &c. It is characterized by pain, tenderness, thirst, and slimy evacuations; and is to be relieved by small doses of hyd. c. creta, and pulv. ipec. c.; injections of starch and laudanum ; rube- facients or fomentations to the abdomen; chalk mixture, &c. 2d. Diarrhoea from unwholesome food, or irritating substances, or foul accumulations in the intestines. This is a very common form, being often produced by unripe fruit, and it is in fact what is caused by a common dose of physic. This form of diarrhoea tends to work its own cure, which is best accelerated by a dose of rhubarb and magnesia or castor oil, followed by chalk mixture. 3d. Diarrhoea from debility and relaxation.—This form is apt to follow any of the others, and is to be recognised by the kind of con- stitution to which it happens, and by the freedom from active symp- toms. The various vegetable and mineral astringents with opium are the remedies. 4th. Diarrhoea in young children often arises from the irritation of weaning, or from an unnatural quality of the milk, or from attempts to bring up children by hand. A very small dose of hydr. c. creta with rhubarb, followed by chalk mixture with five or ten minims of paregoric, are the remedies. Baked flour or biscuit powder may be tried as food. In all cases of diarrhoea it is important to attend to the skin, and to keep it warm. CHOLERA MORBUS. Causes.—Costiveness ; exposure to change of temperature ; indi- gestible food ; putrid miasmata ; certain seasons. Symptoms.—Violent griping pain, followed by frequent vomiting, and purging of greenish bilious matter; spasms of the abdominal 118 PRACTICE OF MEDICINE. muscles, sometimes extending to the legs and arms; tongue dry; urine high coloured, scanty, or suppressed ,* thirst urgent; pulse frequent, but soon becomes small and weak. As the disease con- tinues, the spasms become more severe, the countenance anxious and collapsed; the strength is much reduced, and fainting occurs. As cholera morbus depends on simple irritation of the mucous lining of the alimentary canal, the morbid appearances after death are not very remarkable, consisting in some injection or congestion of the vessels. Treatment.—To allay the spasm and irritable state of the diges- tive canal, calomel and opium should be administered in a full dose, and then repeated injections of gruel or starch in large quantities, to bring away the irritating matters;—and opiates. Warm fomenta- tions may be applied over the abdomen, or the turpentine or ammo- niated liniments. When the surface of the body becomes extensively cold, and symptoms of exhaustion appear, it will be necessary to administer stimulants, as camphor, ammonia, small quantities of brandy, &c, combined with aromatics. When the more urgent symptoms have been relieved, the discharge of the different abdomi- nal secretions should be promoted by gentle laxatives, by enemata, &c.; and light nourishment may be permitted during the conva- lescence. CHOLERA INFANTUM. (Summer Complaint of Infants.) This disease seems to be peculiar to the United States. It pre- vails most extensively in large cities, during the hot months; and is one of the most fatal affections to which childhood is subject. It occurs in children from four to twenty months of age, or during the period of dentition; the second summer of children is con- sidered the period at which they are most liable to the disease. It commences with a profuse diarrhoea, the stools being light- coloured and thin ; this is succeeded by great irritability of the stomach, so that by constant vomiting and purging the child becomes languid and prostrate, often in a few hours. The pulse is quick, small, and often tense ; the tongue is white and slimy; the skin is dry and harsh ; the head and abdomen are hot, whilst the extremities are natural in temperature, or even cold. Towards evening there is fever, restlessness, and pain. Occasion- ally delirium occurs, manifested by violent tossing of the head, attempts to bite, the eyes becoming wild and injected. Death may result in six hours ; but generally the case is more protracted. The emaciation becomes extreme, the eyes languid and hollow, the coun- tenance pale and shrunken, the nose sharp and pointed, the lips thin, dry, and shrivelled ; • the skin upon the forehead tight and ASIATIC CHOLERA. 119 shining. The child lies in an imperfect doze, with half closed eye- lids, insensible to external impressions. The surface of the body is now cool and clammy, of a dingy hue, and often covered with petechiae ; the tongue is dark, and the fauces dry. The abdomen becomes tympanitic ; the discharges from the bowels are dark coloured, profuse, and offensive, resem- bling the washings of stale meat; in other instances they may be small, and consist of mucus, and undigested food. According to Dr. Condie, " the disease is evidently dependent for its production upon the action of a heated, confined, and impure atmosphere, directly upon the skin, and indirectly upon the digestive mucous surface, at an age, when the latter is already strongly pre- disposed to disease, from the effects of dentition, and from the in- creased development and activity of the muciparous follicles, which takes place at that period. Treatment.—The most important point in the treatment is to re- move the child from a heated and impure atmosphere. A nursing child should be confined exclusively to the breast; if weaned, to tapioca, arrow-root, or ground rice, and cool mucilaginous drinks. A tepid bath should be employed night and morning; the clothing should be light and dry, and the chamber well ventilated. The gums should be examined, and if swollen and hot, they should be freely lanced. Small doses of calomel, acetate of lead, and prepared chalk, will be found most serviceable in arresting the diarrhoea. The irrita- bility of the stomach may be overcome by small doses of calomel, or a few drops of spirits of turpentine; a blister applied over the stomach will also be decidedly advantageous. When there is much heat about the head, with injected conjunc- tiva and delirium, leeches should be applied to the temples, and cold lotions to the scalp. Stimulating pediluvia, and blisters placed be- hind the ears, will also be found extremely beneficial. After the irritability of the stomach is sufficiently quieted, the addition of a small quantity of ipecacuanha to the calomel, chalk, and acetate of lead, will most certainly, according to Dr. Condie, promptly restrain the disordered action of the bowels, and complete the cure. ASIATIC CHOLERA. This disease is endemic in India, but sometimes extends to other parts of the globe. It is, no doubt, propagated by atmospheric in- fluence. Symptoms.—There is generally a premonitory diarrhoea, with occasional nausea, slight cramps, and heaviness about the head. In other cases, it commences suddenly with violent vomiting and purging (not of bile as in common cholera) but of a rice-coloured 120 PRACTICE OF MEDICINE. fluid, with excessive and painful spasms of the abdominal and other muscles ; the pulse is quick, small, and soon disappears altogether; the skin is cold; the features collapsed; the urine altogether sup- pressed. As the vomiting and purging continue, the powers of life quickly fail; the extremities become deadly cold, and of a bluish colour ; the pulse ceases to be felt at the wrist; the breathing is laborious ; and the patient, who gets very restless, is generally car- ried off within ten or twelve hours. Morbid appearances.—The blue colour of the extremities, which are rigid, remains after death. The fingers are flexed and shrunk, and the nails blue. The arterial system is empty ; the venous, and particularly the right side of the heart, contains a quantity of dark, grumous, and uncoagulable blood ; the latter fluid is deficient in salts and serum. When death has taken place rapidly, the intestinal canal is often pale throughout; most frequently it presents an in- jected appearance, either in spots or along continuous surfaces, from congestion of the veins, or effusion of bloody serum underneath the mucous coat; there are no ulcerations or other signs of inflamma- tion. The abdominal viscera are gorged with dark venous blood, and the urinary bladder is empty, and contracted into a hard ball. Treatment.—A successful mode of treating Asiatic cholera still remains to be discovered. Many of the Eastern physicians strongly recommend bloodletting in the commencement of the disease, to be followed up by calomel and opium. Others reject venesection, and endeavour to allay the the most prominent symptoms—viz., the irri- tability of the alimentary canal and the spasms, at the same time such means as are best calculated to restore the circulation to the surfaces of the body. This, perhaps, is the most rational mode of treatment that can be adopted; but, unfortunately, medical men are not agreed upon the means. Some prescribe nothing but ice-cold water, as long as the vomiting continues; others vaunt small and frequent doses of calomel, or calomel and opium; others advise the administration of emetics ; and others again prefer stimulants, as cajeput oil, brandy, &c. In order to determine the blood to the sur- face, and allay spasm, the extremities should be assiduously rubbed with warm anodyne embrocations; or when the vapour or hot air bath can be obtained, these may be employed with advantage. Dr. Stevens speaks highly of the saline treatment, which consists in the administration of the salts of soda and potash in any appropriate vehicle. In extreme cases, these salts have been injected into the veins with apparent advantage in a few instances. When the symptoms have subsided, and the patient survives, a stage of reac- tion often succeeds, and is attended with symptoms of a typhoid character. The treatment should then be directed by the principles which have been laid down under the head of typhus fever. COLICA PICTONUM. 121 COLIC This disease is characterized by severe griping pains in the bowels, with costiveness, (sometimes with diarrhoea,) and frequently with vomiting. Colic may be produced by a variety of causes, the most common amongst which are, irritating ingesta, flatulency, or a morbid sensibility of the mucous membrane. Symptoms.—Severe twisting or griping pain in the abdomen, particularly in the umbilical region or along the course of the colon ; the pain is not increased by pressure, nor is there any fever,—cir- cumstances which distinguish the disease from peritonitis and ente- ritis ; it comes on in fits, and in the intervals there is perfect ease ; it usually comes on quite suddenly ; the muscles of the abdomen are often retracted; the patient also complains of borborygmi, or rum- bling noises from flatus in the canal. Treatment.—The first care of the practitioner should be to deter- mine, if possible, the exciting cause of the colic, and whether it be occasioned by an organic disease, such us hernia, intus-susceptio, tumours, &c. This done, and the complaint having been ascertained to be simple colic, he may at once administer anodynes combined with cordials, and proceed to evacuate the intestinal secretions by the use of enemata and mild purgatives. For this latter purpose, the blue-pill will be sufficient, or castor oil with laudanum, or the tincture of hyoscyamus may be given, either by the mouth or in enema. The abdomen should also be fomented with the decoction of poppy-heads. COLICA PICTONUM. (Painter's Colic.) Cause.—Exposure to the poison of lead. M. Andral considers lead colic as a neurosis, in which the spinal marrow and abdominal plexuses of the great sympathetic appear to be the peculiar seat of lesion. The constipation seems to depend either on the abolition of the contractile motion of the intestines, or on the suspension of the secretion of the intestinal mucus. Symptoms.—Violent pain at the umbilical region; sickness and obstinate constipation ; pains in the wrists, ancles, and neck; head- ache ; bitter eructations ; and occasionally paralysis of some of the voluntary muscles. Treatment.—The best mode of treatment consists in the free ad- ministration of purgatives with opiates, such as calomel and opium, followed by castor oil and laudanum; croton oil will sometimes be required to overcome the constipation. A warm bath should be given, with injections of a large quantity of warm water into the bowels while the patient is in the bath. 11 122 PRACTICE OF MEDICINE. Dilute sulphuric acid, which may be mixed with beer or made into a kind of lemonade, and extreme cleanliness, are the best pre- servatives from the poison of lead. Paralysis of the limbs sometimes accompanies lead colic, and re- mains after the removal of that disease. Here great attention must be paid to the bowels, and on the least indication of costiveness the purgative salts should be administered. The diet should be gene- rous; friction along the limbs with stimulating liniments should be practised, and the extract of nux vomica or strychnine administered internally. Great good is produced by supporting the paralytic limb in splints. ILEUS. This complaint consists of very severe colic with obstruction of the bowels, and generally ends in inflammation. Symptoms.—Violent griping and twisting pains about the umbi- licus, which is retracted j obstinate constipation; nausea, and vomiting of stercoraceous matter; tension and tenderness of the abdomen. The pulse is at first natural and the skin cool, but febrile symptoms soon set in, and are followed by hiccup, prostration, cold sweats, sinking, and death. Morbid appearances.—Mechanical obstruction in some part of the intestinal canal produced by knots of the bowels ; intussusception ;' adhesions; bonds of false membrane; strangulation of the gut; organic constriction of its calibre; foreign bodies, such as fruit stones, &c. The parts of the intestine above the obstructed point are generally dilated and inflamed, and in many cases the inflamma- tion has extended to the peritoneum, producing its usual results. Invagination of the intestine most frequently occurs in children, and, in addition to the symptoms already enumerated, may some- times be recognised by the presence of a painful tumour over the invaginated portion of gut. Treatment.—The medical treatment of ileus will seldom be of any avail, as may be readily inferred from a consideration of the pathological conditions with which it is connected. The forcible in- flation of air per anum has been recommended. Copious enemata frequently repeated, and mild purgatives given in moderate doses, regularly repeated, may be tried first. If they do not succeed, stronger purgatives may be tried, such as croton oil, or a combina- tion of aloes with sulphuric acid. But if the purgatives add to the sickness and pain, they should be suspended. Crude mercury in large quantities has been given by the mouth, and in some instances with relief. If inflammatory symptoms arise, they should be com- bated by bleeding or leeches, and the warm bath. The operation of gastrotomy has been frequently performed for the cure of ileus, and there are two or three cases of success on record. The great ENTERITIS. 123 objection, however, to its performance is, the obscurity and uncer- tainty of the symptoms. When the case seems hopeless, the patient's sufferings should be soothed with opiates, and his strength kept up by nourishing enemata. PERITONITIS. Causes.—Inflammation may exist at any point of the peritoneal sac, but the term peritonitis more properly belongs to inflammation of that portion which does not invest any of the viscera. The causes of peritonitis are the same as those of inflammation in gene- ral ; besides which are, external violence, metastasis, disease of the mesenteric glands, obstruction of the bowels, the irritation produced by disease of neighbouring viscera, and the effusion either of the contents of the alimentary canal or of the urinary bladder, &c. Symptoms.—Acute pain, commencing at a particular part of the abdomen, and gradually extending over the rest of the surface ; heat of skin; frequency and smallness of the pulse; in many cases, nausea and vomiting; constipation; anxious countenance; tongue dry, but not foul; respiration accelerated and costal; urine scanty. The patient lies on his back, with the thighs flexed, and cannot bear the slightest pressure on the abdomen, which becomes tumid or tym- panitic. In addition to these general symptoms, others will present themselves, according to the vicinity of the part inflamed to any of the principal abdominal viscera. Peritonitis from intestinal perfora- tion is characterized by the suddenness and the rapid progress of the symptoms, and the great accompanying prostration. Morbid appearances.—Injection, by patches, of the sub-serous tunic; effusion of lymph, or a sero-purulent fluid, into the cavity of the abdomen; adhesions, by means of soft, whitish false membranes, between the folds of the intestines. Treatment.—Bloodletting, to be repeated according to the patient's strength, &c.; leeches over the painful parts, and warm fomenta- tions, are the chief means on which reliance is to be placed at the onset of the disease; small doses of calomel may also be given, until the mouth becomes sore; and the bowels must be kept open with gentle laxatives or enemata. If the tympanitis be troublesome, enemata containing turpentine or assafoetida may be administered for the sake of obtaining temporary relief. In peritonitis from perfora- tion of the intestinal canal, the only hope of saving the patient lies in the instant administration of opium in doses sufficient to arrest the peristaltic motion of the bowels. This gives us some time for the employment of other means, with a faint chance of success. ENTERITIS. This term signifies inflammation of the serous and muscular tunics of some portion of the intestines; the point most frequently attacked being the termination of the ileum. 124 PRACTICE OF MEDICINE. Symptoms.—Pain in the abdomen, generally worst at some par- ticular spot, whence it radiates. It is of a severe burning character, unlike colic. It is aggravated by pressure. The patient lies on his back, with the knees drawn up, so as to relax the abdominal parietes, and breathes with the thorax. Coughing and deep breathing are painful. The pulse is small and wiry, there is often vomiting, ob- stinate constipation, and much distress of countenance. If the case assumes an unfavourable character, death ensues from failure of the heart's action. The pulse becomes very rapid and feeble; the features sunk; and there is great restlessness or hiccup. But perhaps the patient loses all pain, so that he and his friends flatter themselves with hopes of amendment, when death is at the very threshold. Causes.—Wounds or other injuries; hernia and ileus; or cold and wet, when the bowels are loaded or in an otherwise unhealthy state. Treatment nearly the same as of peritonitis. Bleeding according to the state of strength (and the pulse often rises under it); leeches to the abdomen ; opium after bleeding; and regular doses of calomel and opium to affect the mouth; warm fomentations and poultices to the abdomen, are the chief measures. But the bowels are obstinately costive, and what is to be done for that? Why, " the costiveness arises from their being inflamed and unable to propel their contents; and the proper remedies for it are such as will relieve the inflammation."—(Druitt's Surgery, p. 417.) Purgatives given during the acute stage only add to the sickness. But when the pain and tenderness are relieved, castor oil, or small doses of colocynth and henbane may be tried ; and throughout the disease, the bowels may be solicited by enemata. Blisters will be of service in the later stages. If there is any great tendency to faintness or collapse after bleed- ing, wine must be administered. CHRONIC PERITONITIS, AND TABES MESENTERICA. Chronic peritonitis is sometimes a sequel of the acute disease, sometimes, on the contrary, it begins in a very obscure and insidious manner, and is attended in scrofulous subjects by a deposit of gra- nules or tubercles external to the membrane. Symptoms.—Slight occasional abdominal pains, often scarcely noticeable, increased by pressure; fulness and tension of the belly, particularly a deep-seated tightness, as if the integument and muscles glided over the tight and thickened peritoneum; feverishness and emaciation. This disease is often attended by enlargement of the mesenteric glands, with which it is usually identical in symptoms. Morbid appearances.—The peritoneum thickened; the bowels WORMS. 125 glued together; the abdomen containing more or less turbid serum; perhaps ulceration of some part of the bowels; the omentum thick, red, and fleshy. Treatment.—Occasional leechings, blisterings, frictions, and flan- nel bandages to the abdomen ; or warm fomentations and poultices, if the pain is very severe; nourishing diet; small doses of mercu- rials, and mild laxatives and antacids. WORMS. There are three species of worms which most commonly in- habit the intestinal canal—viz., the ascaris lumbricoides, ascaris vermicularis, and tcenia. The lumbricus is a round worm, varying in length from four to ten inches ; the tail ends in a blunt point; the head is sharp, and set between three oblong tubercles. The ascaris vermicularis is very thin, and does not exceed an inch in length, but it is usually shorter; the tail terminates in a fine point. It inhabits the rectum. The tania is a very long, flat worm, articulated, and furnished with four suckers at the head. Two species of tania are met with in man. Worms very frequently exist in the intestinal canal without pro- ducing any irritation or inconvenience whatever ; on other occasions, however, they are attended with the following symptoms:—disgust of food, or irregular appetite; nausea, vomiting, griping pains in the abdomen ; tenesmus ; disturbed sleep, irregular accessions of fever; diarrhoea, with slimy stools; foul breath; headache; dilatation of the pupils; strabismus; and,in young children,cerebral disturbance, or convulsions. Ascarides often produce a sensation of itching about the anus, while the lumbricus occasions pain of a gnawing character in the umbilical regions. The stools should be constantly inspected, for the presence of the worm in them alone can render us certain of the correctness of the diagnosis. Treatment.—The objects of treatment are, to destroy and expel the parasitical animal. For this purpose various remedies, called anthelmintics, are administered. Common purgatives will sometimes suffice to expel the worms. Should these fail, we may employ the dolichos pruriens, or turpentine. M. Raspail regards camphor as a specific against ascarides ; and in France and Italy the root of the pomegranate is employed with success in cases of taenia. The con- dition of the bowels should be carefully regulated, and all errors of diet avoided, for worms are most frequently found in children who are ill fed upon unwholesome and indigestible vegetable food. After the complete evacuation of the parasitical animals, a course of vegetable or mineral tonics has been recommended; but wholesome food, exercise, and a proper regimen, will be found the best means 11* 126 PRACTICE OF MEDICINE. of preventing their recurrence. Small doses of ferri sulph. with pil. rhei. c, may be useful, if taken regularly. ACUTE HEPATITIS. Causes.—External violence; hepatic calculi; suppressed secre- tions ; influences of climate; duodenitis, &c. Symptoms.—General febrile excitement; lancinating or dull pain of the right side, increased on full inspiration; a sympathetic pain is also sometimes felt in the right (very rarely in the left) shoulder, and along the neck. Sense of uneasiness at the stomach, and nausea or vomiting ; short, dry cough ; hiccup ; bowels constipated; pulse frequent and hard; and the urine high coloured. The patient commonly lies on the right side, and the skin is often tinged with the yellow colour of jaundice. Rigors indicate suppuration. Morbid appearances.—In this climate, it is rather the peritoneal covering than the liver itself which is the seat of the disease. When the substance of the liver is inflamed, it becomes brittle and friable; the granulations are larger and more red than natural, and the lining membrane of the biliary ducts is injected and of a reddish brown colour. In most cases, abscesses are found in different parts of the liver, or the greater part of the organ may be converted into one large cyst containing pus. In other cases, the purulent matter is in- filtrated into the substance of the gland. Dr. Budd has called atten- tion to the fact, that the abscesses in the liver, following dysentery, are often owing to an inflammation of the hepatic veins. Treatment.—General bloodletting; leeches, or cupping over the region of the liver, followed by a large blister. The bowels must be kept constantly free by saline cathartics. The Indian practition- ers are very partial to mercury, which they administer in large doses to produce salivation as quickly as possible ; but in this country, when mercury is given, it should be exhibited more with a view of restoring the biliary secretion than of exciting salivation. CHRONIC DISEASE OF THE LIVER. This is denoted by more or less pain and tenderness, or weight and fullness in the right hypochondrium, with sallowness of the skin, emaciation, and depression of the spirits. It may be a consequence of acute inflammation, or of long resi- dence in unhealthy climates, or of diseases of the heart; one very frequent cause is intemperance. Sometimes the liver increases greatly in bulk, and may be felt low in the abdomen, or its limits be ascertained by percussion. Some- times, on the contrary, it is shrunken and atrophied. One common form of disease, which is often a precursor of ascites, is what is called the hob-nailed liver. This disease originally con- sists in an inflammatory thickening of Glisson's capsule, which JAUNDICE. 127 forms a sheath for the portal vessels, the hepatic artery, and biliary ducts. The thickening of this cellular sheath may compress the biliary ducts, and so cause jaundice, or the portal veins, and so cause ascites. Finally, the thickened cellular sheath shrinks and becomes atrophied, and by its shrinking compresses the hepatic artery, and so causes general atrophy of the organ; whilst by its shrinking it leaves the lobules projecting as little rounded eminences like the heads of nails. * The appearance called nutmeg liver, is a mere consequence of congestion. If after death the hepatic vessels, which run in the centre of each lobule, are injected, the liver presents on its surface numerous red spots, with pale interstices. If, on the contrary, the portal system only is injected, it will display pale spots correspond- ing to the lobules, with red interstices. Abscess in the liver may burst either externally, in which case the liver first adheres to the parietes of the abdomen, so as to pre- vent the escape of the pus into the peritoneal cavity; or in less for- tunate cases, it may burst into the pleura, or peritoneum, or lung, or intestines, generally with a fatal result. Treatment.—The general rules in treating chronic hepatic disease are, to diminish congestion of the portal vessels; to keep up the secretion of the urine, to allay irritation, and support the strength. Small doses of mercury with squill; saline aperients, and diuretics; taraxacum; sulphate of manganese; muriate of ammonia; iodine; colomba, and other light tonics; nitro-muri- atic acid, given internally, and used as a bath for the legs; occa- sional leeching, blistering, or frictions with mercurial ointment, or with iodine; Cheltenham waters; and a light nourishing diet, are the main remedies. JAUNDICE. The term jaundice is applied to a yellowish tinge of the skin and eyes, depending on the presence of bile in the circulating fluids. Causes.—These are, diseases of the liver; obstruction to the free passage of bile into the duodenum; congestion of the portal system, or excessive secretion of bile; gastro-duodenitis, &c. Symptoms.—The symptoms of jaundice will evidently depend on the nature of the cause which has given rise to the unnatural colour of the skin. The yellow tinge is the most prominent sign; it usually commences in the face, and thence may extend over the whole body, being most clearly distinguished underneath the conjunctivae. The digestive functions are deranged; the bowels usually costive, and the faeces untinged by bile; the urine is high coloured, and more or less of a saffron tint; the tongue is foul and covered with a yellow fur; the patient complains of headache, and very often of pain in the region of the liver. The 128 PRACTICE OF MEDICINE. condition of the pulse is extremely variable, and the skin is usually dry, with a sense of itching or stinging. The morbid appearances found in persons who have died with jaundice depend on the causes which have produced the disease; and they may be deduced from the enumeration of those already given. Treatment.—The treatment of jaundice requires much discri- mination on the part of the medical attendant. As it almost always depends on some affection of the liver or neighbouring organs, the chief attention should be directed to the cause of the malady. When the jaundice depends on excessive secretion of bile, local depletion over the region of the liver, with diaphoretic medicines, and demulcents, will be found useful. If the liver itself be inflamed, the treatment must be the same as that indicated under the head of " hepatitis." Jaundice from congestion of the vena portae should also be com- bated on the same principles. Finally, when the disease depends on some chronic affection of the liver, it is a symptom of compa- ratively little importance, as our whole care should be directed towards the organic lesion whence it originates. For jaundice depending on spasm of the biliary ducts, full doses of opium, aided by warm bath, and hot fomentations to the abdomen, will be found advantageous. GALL-STONES. Gall-stones may exist in any part of the biliary passages; they are also extremely various both in size, number, and shape. The causes of gall-stones are obscure, but their formation is frequently connected with imperfect assimilation of the nutriment. They are composed of the colouring matter of the bile, and of cholesterine. Symptoms.—Biliary concretions often pass into the duodenum without causing any disturbance; on other occasions, the patient is suddenly seized with acute pain in the right hypochondrium, increased on the slightest motion, and shooting backwards under the scapula; the pain is increased after meals. There are also nausea, vomiting, distention of the abdomen, and alternations of diarrhoea and constipation. The paroxysms occur at irregular intervals; the pulse is commonly natural, and the skin cool. Treatment.—The treatment of biliary calculi, or rather of the irritation produced by their passage into the duodenum, is merely palliative. Opium, or its salts, should be freely admi- nistered, to relieve the agonizing pain which is frequently the most prominent symptom, and warm anodyne fomentations should be applied to the abdomen. Dr. Prout recommends large draughts of warm water containing carbonate of soda in solution. The ACUTE HYDROCEPHALUS. 129 warm bath will also be useful in allaying spasm. When we have reason to think that the gall-stones have been evacuated, the patient should be ordered to take a course of vegetable bitters, and occasionally alkalies; the diet should be light, and a sojourn at some of the watering places should be recommended, when circumstances will permit. DISEASES OF THE NERVOUS SYSTEM AND ITS APPENDAGES. HYDROCEPHALUS (acute). Hydrocephalus is a name likely to mislead the student, as it signifies merely dropsy of tlie brain ; whereas, the disease which it is used to designate, is an acute inflammation of the brain and its membranes, often, but not invariably, ending in serous effusion. Predisposing causes.—The epochs of infancy and childhood may be called predisposing causes, because, at these periods, the great irritability of the nervous system disposes the cerebral cir- culation to frequent excitement. A scrofulous diathesis is also a powerful predisposing cause; and Dr. Cheyne attributes the hereditary disposition to this cause; it, however, occurs as a hereditary disease without a scrofulous taint existing. Fright and anxiety in the mother, during the last months of utero-gestation, predispose to it, the disease often appearing soon after birth. Amongst the other causes enumerated are, premature application to study; remittent and exanthematous fevers; syphilitic taint of the parents; application of cold to the head; torpor of the secretory system, &c. The exciting causes are, external injuries from blows, falls, &c, concussions of the brain, from whirling or tossing the child; the suppression of eruptions on the scalp, and behind the ears; the extension of inflammation from the ear; the retrocession of acute eruptions, and suppression of chronic discharges; the extension of irritation to the membranes of the brain, from inflammation of the pharynx, scalp, face, &c.; too copious depletion in exanthe- matous or other diseases; metastasis of various affections; the too free use of narcotics in young children, &c. This disease has usually been divided into periods, or stages; 130 PRACTICE OF MEDICINE. and the division employed by Dr. Cheyne, is, 1st, the stage of increased sensibility; 2d, that of diminished sensibility; and, 3d, that with palsy or convulsions. Symptoms: First stage.—After the existence of precursory signs, for a variable period, the child is attacked with head-ache, confined to the forehead or temples; the pulse becomes quick and hard; the skin hot and dry; and the bowels obstinately constipated. The tongue is loaded or furred; the stomach is exceedingly irritable, vomiting being frequently produced on the child changing its position; and the urine is scanty and thick. The temperature of the head is much increased; the pupils are contracted ; the brows are knit; there is an inability to sit up, and a whining or moaning noise when the child is lying down. The sleep is short and disturbed; the patient rolls its head on the pillow, or often wakens with a scream, or crying, and raises its hands to its head. Sometimes the attack begins by convulsions. Second stage.—The sensibility is now remarkably impaired; the drowsiness increases in degree; the pupils are dilated, and there is strabismus, and imperfect or double vision ; the eyes are dull, heavy, vacant, or staring; the eyelids drooping or half closed. The pulse, from being frequent, now becomes slow, and sometimes even more so than natural, when the patient is in the horizontal position; but if he attempts to sit up, it immediately acquires its former rapidity. Slight convulsions show themselves in momentary attacks in the eyes, mouth, or upper extremities, which are tremulous. The hands either are raised to the head, or the child picks its nose or mouth. The stupor is occasionally interrupted by loud and shrill screams from the child; and partial contractions of some of the limbs begin to manifest themselves. Third stage.—The last stage now comes on; the pulse is quick, thready, and weak; there are partial or general convulsions; and paralysis of one side or limb occurs. The pupils become more and more dilated, the eyes suffused, and the cornea dull and filmy. The patient is either comatose or delirious, rolls its head about on the pillow, grinds his teeth, and moans or breathes heavily and quickly. The skin becomes cold and covered with perspiration, or the sweat- ing may be partial; the respiration is irregular, or stertorous. The excretions are passed involuntarily, and the patient generally dies in a brief convulsive fit. Morbid appearances.—Inflammation of the pia matter, most commonly observable at the base of the brain, around and in the fissures of Sylvius. The cerebral substance is generally eno-orged, and the central white parts of the brain are more or less softened. The lateral ventricles frequently contain from four to six ounces of fluid. The most common complication of hydrocephalus is, tubercle of the nervous substance, which, amongst the poorer classes, occurs ACUTE HYDROCEPHALUS. 131 in nearly one-third of the cases. Tubercular deposits are also found in various other parts of the body, in a vast majority of cases. Treatment.—This should be strictly antiphlogistic, and should be resolutely employed at once. The patient should be placed in the erect posture, and blood should be drawn from the arm till the approach of syncope ; below the age of five, it will be more prudent to apply leeches to the temples or behind the ears; but some physicians deem it right to abstract blood from the arm, even in children of three or four years of age. The abstraction of blood must be followed up by free purging; and as the bowels are always constipated, recourse must be had to the most active purgatives, especially calomel and scammony; in many cases, the administration of croton oil will be found necessary to obtain evacuation of the bowels. During the employment of these means, the head should be shaved, and kept cool by the constant application of cold lotions. Calomel may be administered in small regular doses, till it causes green stools like chopped spinach. Great excitement or delirium may be mitigated by giving very small doses of tartar emetic in solution. When the force of the circulation and the acuteness of the disease have diminished, blisters may be applied to the nape of the neck. In the latter stages, digitalis, colchicum, and a variety of remedies have been recommended, but the case is almost beyond relief. There is, however, a combination of equal parts of crude mercury and fresh squills, rolled into a mass, which may be given in doses of five grains ter die, and it causes a great secretion of urine. Whatever mode of treatment be adopted, it should be had recourse to at the very onset of the disease, for experience unfortu- nately shows that little hope of recovery remains when the affection has arrived even at the second stage. Cerebral exhaustion in children produces many symptoms like hydrocephalus, for which it would be most dangerous to mistake it, as the causes, nature, and treatment are quite opposite. It occurs to children ill fed, or exhausted by depletion: the face is cool; the child very drowsy, and unable to hold its head up; the breathing irregular and sighing. One grand distinctive mark is, that the fipntanelle is sunken, showing that there is no vascular turgescence in the brain. Beef-tea, small doses of ammonia, good nursing, and warmth, are the remedies. Chronic Hydrocephalus.—This disease seems to depend, not on inflammation of the cerebral membranes, but on increased secretion of the cerebro-spinal fluid, which is commonly connected with some congenital lesion of the brain. Chronic hydrocephalus generally exists at the period of the infant's birth, but it sometimes appears during the first few years of infantile existence. It manifests itself by a gradual enlargement of the cranium, which occasionally attains 132 PRACTICE OF MEDICINE. an enormous size. The accumulation of fluid within the skull not only distends the bony cavity and impedes its ossification, but sepa- rates the bones from each other, leaving spaces at the fontanelles, and in divers other places, which are now merely protected by mem- branous expansions. The cerebral substance is also more or less injured. In some cases, a great portion of the nervous matter seems to have disappeared; while in others it is spread out in thin layers, which embrace the fluid, as it were, in a sac. The gradual aug- mentation of the head is the chief sign of chronic hydrocephalus; in addition to this symptom, we find that the infant gradually loses flesh, and becomes dull; manifests signs of suffering in the head; sympathetic vomiting is also frequently observed ; and the intellec- tual faculties and senses gradually become more obtuse. The child is unable to carry the head erect, and the muscles of the face be- come the seat of convulsive movements. As the disease progresses, the well-known symptoms of compression manifest themselves more and more, and the patient dies either in a state of idiotcy or in con- vulsions. Treatment.—There are only two modes of treatment worth men- tioning, viz., gradual compression of the head, and puncture. The former method, which was well known to the physicians of the seventeenth and eighteenth centuries, has been recently revived by Sir Gilbert Blane; while the happy results of puncture, through the anterior fontanelle, in the hands of Dr. Conquest, sufficiently justify us in having recourse to this operation as a probable means of cure. Compression should be well kept up after the operations. ENCEPHALITIS. (Inflammation of the Brain.) Causes.—Long exposure to a vertical sun, anxiety of mind, the inordinate use of ardent spirits, cold, fright, external injury, the sudden disappearance of an old discharge, &c, may produce this disease; it sometimes occurs as consequent on small-pox, or erysi- pelas of the face and scalp, and fevers, especially those of typhoid character, &c. Symptoms.—Violent inflammatory fever, hot and dry skin, flushed countenance, suffused eyes, quick and hard pulse, throbbing of the carotids, and delirium. The senses are morbidly acute, there being intolerance of light and sound. The person is extremely rest- less ; there is jactitation of the limbs, and rigidity of the muscles; the head is remarkably hot, the pupils contracted, and the excretions and secretions are suppressed. Occasionally, the muscles of the face are spasmodically affected, the upper eyelid hangs down, and the commissures of the lips seem to be drawn to one side. The tongue is white, loaded, red at its edges, and the papillae elevated; ENCEPHALITIS. 133 there is nausea and vomiting, and obstinate constipation of the bowels. This last symptom is common in congestion, or inflamma- tory affections of the brain. As the disease advances, all these symptoms are reversed; the morbid acuteness of the sensations changes into blindness and deaf- ness; the delirium passes into stupor, and gradually into coma. Convulsions and different forms of paralysis ensue ; the countenance is vacant or idiotic; the eye loses its lustre; the pupils become dilated; and occasionally there is strabismus. The respiration is now irregular, occasionally stertorous, the articulation imperfect, the pulse frequent and small, the limbs spasmodically convulsed or paralytic; there is retention of urine, and involuntary discharge of the faeces. In the still more advanced stage the countenance be- comes pale and sunken, the pulse weak and irregular, the urine passes off involuntarily, the skin becomes cold and clammy, the coma more profound, and death soon closes the scene. Morbid appearances.—The inflamed part of the brain presents different appearances, according to the time the disease has lasted. When it is only of some days' duration, the white substance, and still more perceptibly, the gray, exhibits a rosy, or slight red colour; and in it we perceive several vascular filaments. The firm- ness of the affected part is considerably diminished, and when cut into, the surface of the incision presents a number of small red points, which cannot be removed by ablution.* In a more advanced stage of encephalitis, the brain is red, the vascular injection more strongly marked, and the softening very considerable. Finally, in some cases, the blood becomes so intimately mixed with the cerebral substance, that its colour approaches that of the lees of wine, being of a deep dusky red ; there is no actual effusion of blood, except we consider as such some small dots, about the size of a pin's head, which we occasionally find in some particular points; in such cases, the brain is in a state of extreme ramollissement. Should it happen that the inflammation passes into these stages without causing death, then the part affected begins gradually to lose its softness, and ultimately becomes more dense than in the natural state; it retains for some time its red colour, but finally changes to a dusky yellow. The third stage of encephalitis is that of suppuration ; the red colour gradually disappears, and the blood is replaced by a sero- purulent fluid, which is infiltrated into the substance of the brain, combines with it, and gives to it, according to the extent of the admixture, a grayish, dull white, or yellowish-green colour. Some- times the pus is found in small isolated spots; at other times small * These small red spots differ from those of congestion, in which small drop« of blood reappear, as soon as the first are wiped away. 134 PRACTICE OF MEDICINE. distinct cavities form, and occasionally we find several small cavi- ties uniting to form a large one. In some instances, the pus is found enclosed in cysts, in which case the purulent matter assumes ihe same characters as that found in the cellular membrane of the body. The gray substance is the most usual seat of encephalitis ; and the parts most commonly affected are, the corpora striata, optic tha- lami, the convolutions, pons Varolii, and cerebellum. Treatment.—In this case, the most active treatment must be had recourse to. The patient should be bled to the approach of syn- cope ; the head should be shaved, and leeches applied to the scalp, or cupping to the nape of the neck. There is great tolerance of the loss of blood in this case, and it is extremely difficult to produce syncope, owing to the excited condition of the brain producing a continued determination of blood to that organ. Cold should be applied to the head, and this treatment is indicated in all cases of meningitis, and meningo-encephalitis, except in the rheumatic or erysipelatous forms. The bowels should be well emptied in the first instance by a large dose of calomel, and compound extract of colo- cynth, followed in about two hours by a brisk cathartic draught, aided in some instances by a purgative enema. Having procured a proper action on the bowels, repeated doses of calomel should be exhibited, either in combination with digitalis, colchicum, or James' powder ; and its action should be established in the system as quickly as possible. During the progress of the disease, enemata and brisk cathartics should occasionally be administered. In the advanced form, should there be deep coma, blisters to the scalp have been recommended. Blisters, however, should never be applied in this situation, unless there is profound sopor, weak action of the carotids, and no remark- able increase of temperature of the head. If applied in the earlier stages they seem to add to the excitement. Sinapisms may be applied to the feet, or inner sides of the legs or thighs; blisters are generally applied to the nape of the neck, or between the scapulae. DELIRIUM TREMENS. (Delirium c. tremore.) The brain fever of drunkards (Armstrong) is variously modified, according to the causes in which it originates, and the habits and constitution of the patient. It may, however, be divided into two species—the one being evidently connected with inflammatory irri- tation, or with excited vascular action in the meninges of the brain, and associated with great irritability; the other consisting chiefly of this last state, attended by exhausted nervous energy. Symptoms.—The phenomena of this disease vary remarkably, from the slightest forms of nervous tremor, with spectral illusions DELIRIUM TREMENS. 135 and accelerated pulse, to the most alarming state of vital depression, muscular agitation, and mental alienation. In ordinary cases, it is characterized by constant watchfulness, and tremulous quivering motion in the lips, hands, and muscles, generally, on making any effort. The pulse, which is at first slow, becomes quick ; there is a constant disposition to talk, now on one subject, and now on ano- ther. In the first variety mentioned, the pulse is full and hard, the skin dry, the delirium furious, the eyes injected, the temperature of the head increased, and the tongue is often dry, and red at its edges. In the second form, which is the most common, the pulse is small, or soft, and ranges between 100 and 120 ; the face is not flushed, nor the skin hot, but is covered with a clammy perspira- tion. As the disease advances, the mental delusion becomes con- stant, and is generally of a low or melancholic kind, with continued reference to the patient's ruling passions and occupations, and anxiety respecting them. He is perpetually haunted by frightful creatures, or occupied with the most extravagant ideas, and is con- tinually endeavouring to avoid them. If a favourable change do not now take place, the skin becomes more cold and clammy, and ex- hales a peculiar smell, which is, as Dr. Hodgkin has remarked, between a vinous and alliaceous odour; the pulse becomes still more frequent, small, weak, and thready, so that it cannot, in some cases, be counted ; the general tremor increases ; the patient talks inces- santly, and with great rapidity; the delirium increases, and the patient either sinks into the calm which sometimes precedes death, or is carried off in a convulsive effort. Morbid appearances.—The appearances on dissection give no direct information on the nature of this disease. In the true delirium tremens, the membranes of the brain evince but little change, the chief lesion consisting of slight opacity of the arachnoid, especially at the base of the brain. The pia mater is more or less injected, and an effusion of serum is occasionally observed in the ventricles. In those cases which have accompanied or directly followed intoxi- cation, the vessels are often much congested, particularly those of the velum interpositum ; the arachnoid is thickened, and the serum is more abundant, and occasionally is even sanguineous. The ap- pearances of the stomach and liver are not necessarily connected with the pathology of this disease. TrecUment.—In the form of this disease which is attended with increased vascular action, cupping below the occiput, or leeches behind the ears, will be required; cold lotions, or cold affusion to the head, when its temperature is increased ; sponging the body with tepid water ; purgatives, judiciously combined with stimulants ; and aperient and antispasmodic enemata. When the affection has been caused by spirituous liquors, we should assiduously watch the sub- sidence of the inflammatory symptoms, and anticipate the depression 136 PRACTICE OF MEDICINE. which ensues; with this intention, liquor ammoniae acetatis, with excess of ammonia, and camphor mixture, may be given. Moderate doses of opium, or of laudanum, with the view of lessening nervous irritability and inducing sleep, should also be exhibited. Or tartar emetic may be given in combination with opium, with the view of quieting both nervous and vascular action. In the treatment of the second variety, or the true delirium tre- mens, we should endeavour to cut short the disease by giving opium, with full doses of camphor and ammonia, and administering ene- mata, containing laudanum and assafoetida. Dr. Blake recommends the accustomed stimulus in moderate quantity and at short intervals ; it may, however, cause too violent reaction, unless the head be guarded by having frequent recourse to cold affusion. In some cases, warm spiced negus, or punch, may be allowed. Stimulating liniments applied over the epigastrium are occasionally very effica- cious. When the symptoms of nervous irritation have been allayed, we should direct our attention to the condition of the gastro-hepatic system ; in which, frequently, there is derangement of function. By the judicious combination of stimulants and medicines which will act on the liver, such as calomel or camphor, and stimulating purgative draughts, we again restore the proper secerning action of this gland, and dissipate any sanguineous injection or infarction of its structure. Having produced a proper action on the alimentary canal, we may again have recourse to opium if any signs of irritation remain. The use of opium is much abused in this disease, and in many cases it is pushed to a most unjustifiable extent. It is an important question, In how many cases of delirium tremens does the patient die in a state of narcotism ? It is certain that the use of large and repeated doses of opium promotes the supervention of coma, effusion, and paralysis; and that its effects nearly resemble the phenomena of the last stage of delirium tremens. During the convalescence, mild tonics should be given, the diet should be light and nutritious, and a suitable beverage, in moderate quantities, allowed. APOPLEXY. This affection is characterized by loss of consciousness, feeling, and voluntary motion ; or, in other words, by a suspension of the functions of the brain, respiration and circulation being also more or less disturbed.* The suspension of the cerebral functions may be connected with any of the following pathological conditions:—1. Great congestion of the brain, in which the vessels of that organ are gorged, but with- out extravasation of blood or serum ; this is termed, " congestive apoplexy." 2. Congestion of the vessels of the brain, with extra- Dr. Copland's Dictionary. APOPLEXY. 137 vasation on its surface, forming the " meningeal apoplexy" of Serres. 3. Hemorrhage into the substance of the brain, with lesion of its structure. 4. A serous effusion on the external surface, and into the ventricles of the brain, constituting what is defined, " serous apoplexy ;" but this is more frequently the termination of an inflam- matory or congestive disorder of the brain, than of that deranged state which constitutes the apoplectic attack. 5. Apoplexy may occasion death without leaving any sign at all in the dead body. To this variety, to which the older writers gave the names nervous, convulsive, and hysteric, Dr. Abercrombie has applied the term simple apoplexy. Causes.—Apoplexy is said to be hereditary. It may occur at an early period of life, but in the majority of cases the age is above fifty. Among the causes of apoplexy are—ossification, or aneurism of the arteries of the brain ; obstruction, thickening, induration, or obliteration of the canals of the sinuses; diseases of the heart, espe- cially hypertrophy of its left ventricle ; diseases of the kidney, par- ticularly the granular degeneration described by Dr. Bright; torpor of the liver, or other excreting glands; diseases of the air-tubes and lungs, especially those attended with violent fits of coughing; the coup de soleil; suppressed hemorrhages, particularly epistaxis and haemorrhoids; suppression of the menstrual discharge ; metastatic gout and rheumatism ; suppression of any vicarious discharge; de- pressed and anxious states of the mind; excessive use of wine or malt liquors; too great sexual indulgence; frequent indulgence in sleep after a full meal; the use of neckcloths worn too tightly round the neck, &c, are among the predisposing causes to apoplexy. Gastric disease, narcotics, and mephitic gases may also be enume- rated. Overloading the stomach and neglecting the bowels are often enough to cause an attack in the predisposed. Apoplexy is said to occur chiefly in persons of a full habit of body. Upon this point, M. Rochoux's cases afford important data Of his sixty-three patients, thirty were of an ordinary habit of body twenty-three were of a thin, meagre habit, and ten only were large plethoric, and fat.* Symptoms, (premonitory.)—Apoplexy is sometimes preceded at considerable intervals by precursory or warning symptoms, such as vertigo, headache, ringing in the ears, loss of memory, a feeling of drowsiness and lethargy, depraved vision, or partial palsy. In some cases, there is a sense of great fulness in the head, the veins of the head and forehead become turgid, the countenance is suffused and occasionally livid, and there are slight attacks of epistaxis. If any individual were to complain of several of these symptoms at any period of life, he might be regarded as on the very brink of some * Recherches sur l'Apoplexie, p. 214. 12* 138 PRACTICE OF MEDICINE. serious affection of the brain; and if the person be in the decline of life, it may safely be said he is in immediate danger of an attack of apoplexy. But it is a serious error to suppose that premonitory symptoms always occur; indeed, if we may trust the experience of M. Rochoux, one of the best authorities on apoplexy, they are by no means common. Of sixty-three cases which came under his notice, nine only had distinct precursory symptoms.* Symptoms of the attack.—In the mild form of apoplexy (the atonic apoplexy of Dr. Good), the patient, after experiencing some of the premonitory symptoms, is seized with alarming vertigo, lei- pothymia, or feeling of faintness ; nausea and vomiting; disturbance of the senses, particularly of the sense of sight; loss of memory; partial loss of sense, consciousness, speech, and voluntary motion ; weak, irregular, and sometimes quick pulse, and more or less of sopor. In the more active form (the entonic apoplexy of Dr. Good), the patient is more or less suddenly seized with profound sopor, the eyes being either open or closed ; the breathing deep, slow, sonorous, or stertorous ; and the pulse slow, full, hard, or strong, sometimes irregular. In this form of the disease, the above are often the chief symptoms, there being no paralysis ; but frequently the mouth is drawn to one side, the eyes are distorted, and one eyelid immovable, with relaxation, loss of sensation and of motion of a limb, or of one side of the body; the arm of the non-paralysed side being often closely applied to the chest or to the genital organs. The patient generally lies on the paralysed side, which is relaxed, incapable of motion, and insensible to the application of irritants. In the most severe and sudden forms of attack, the patient is struck down instantly, sometimes froths at the mouth, has a livid countenance, dilated pupil, complete relaxation and immobility of the voluntary muscles and limbs, and unconscious evacuation of the urine and faeces, and dies very shortly afterwards either with or without stertor, with cold, livid extremities, cold perspiration, and sometimes a cadaverous cast of countenance. This form constitutes the apoplexie foudroyante of the French, in which there is generally an immense extravasation of blood. Duration of the symptoms in fatal cases of apoplexy.—According to the common opinion, apoplexy may prove fatal instantly or in a few minutes. The best modern pathologists deny this, and assert that when death is so sudden the cause is commonly disease of the heart, and never apoplexy. Although, however, it seldom proves instantaneously fatal, it may undoubtedly cause death in much less than an hour. In some cases, on the other hand, patients remain even for months in a comatose, paralytic state. Loco citato, p. 70. APOPLEXY. 139 Of ser9us apoplexy.—It was once supposed in certain cases not attended with evidence of vascular excitement, that the symptoms were owing to an effusion of serum ; hence they were called serous apoplexies; but this distinction is now abandoned. Diagnosis between serous and sanguineous apoplexy. — The sanguineous was said to be distinguished by flushing of the counte- nance, and strong pulse, and by occurring in persons in the vigour of life ; the serous, on the other hand, was said to attack the aged and infirm, the countenance being pale, and the pulse weak, in such cases. But there are many cases whose symptoms and circum- stances come exactly within the description of the serous apoplexy, but still after death present the vascular engorgement, &c., of the sanguineous, whilst no serous fluid is effused. Speaking of these distinctions, Dr. Abercrombie observes, " it will be found that many of the cases which terminate by serous effusion, exhibit in the early stages all the symptoms which have been assigned to the sangui- neous apoplexy ; while many of the cases which are accompanied by paleness of the countenance and feebleness of the pulse will be found to be purely sanguineous." Morbid appearances.—Effusion of blood within the cranium may take place in the brain or cerebellum; in their crura; in the pons Varolii, and in the medulla oblongata; in the corpus callosum; in the ventricles ; on the surface of the brain beneath the pia mater; in the cavity of the arachnoid; between this membrane and the dura mater, which it lines; and between the dura mater and cranium. It has been found that certain parts of the brain are much more liable to sanguineous effusions than others. M. Rochoux's Dissections.—Forty-one cases. Extravasation of blood on the left side . . . . . 18 Do. do. right side.....17 Do. do. both sides.....6 41 Of the Situations of the Effusions. In the corpora striata........24 — optic thalami........2 In both these situations........1 Under the corpus striatum.......1 In the middle of the hemispheres......5 — posterior part of the ventricles ..... 2 — anterior and interior part of the hemisphere ... 2 — posterior and interior part......3 — middle lobe.........1 41 By this table it is shown that out of forty-one cases of effusion, twenty-eight were in the corpora striata and their vicinity. 140 PRACTICE OF MEDICINE. A summary of the resuU of 386 cases of apoplexy, from the Precis d'Anatomie Pathologique of Andral. Seats of the Effusion. In the substance of the hemispheres, on a level with the corpora striata and optic thalami.......202 In the corpora striata........61 — optic thalami ......... 35 — hemispheres above the centrum ovale .... 27 — lateral lobes of the cerebellum . . . . .16 — brain, anterior to the corpus striatum . . . .10 — meso-cephalon . . . . . . . . 9 — spinal cord . . . , . . . . 8 — posterior lobes of the brain......7 — middle lobe of the cerebellum......5 — peduncles of the brain.......3 — olivary bodies.........1 — peduncles of the cerebellum ...... 1 — pituitary gland....... 1 386 On reference to this table, it will at once be observed the vast preponderance of cases in which effusion has occurred into the hemi- spheres of the brain, the corpora striata, and the optic thalami. Treatment.—In the treatment of apoplexy, with active determi- nation to the head, full labouring pulse, carotids beating strongly, &c, the first indications are to relieve the head from the accumula- tion of blood, to prevent further congestion, and to obviate inflam- matory action: and for these purposes the only efficient means is bleeding. A full bleeding, then, must be immediately employed; the head should be shaved and freely leeched, and the patient may be cupped on the temples or the back of the neck. The adminis- tration of brisk drastic cathartics is attended with the best results, their derivative action being a powerful means of relieving the coma. Croton oil is the purgative generally used in these cases; but where the patient can swallow, other drastic cathartics may be given. Where the patient has completely lost the power of deglutition, the croton oil should be mixed with a little castor oil or mucilage, and passed into the oesophagus by means of an elastic tube. Drastic enemata will also be found beneficial. The head must be kept cool by means of cold lotions, iced waters, or by pouring a small stream of cold water on the scalp occasionally. When the coma is persistent, blisters should be applied to the nape of the neck, or to the head; sinapisms to the feet are also indicated. But it must yet be remem- bered that there is a certain injury done to the brain; that a portion of its substance has been torn up, and compressed by a clot of blood; and that a certain amount of injury has to be repaired. Hence a butcherly, indiscriminate use of the lancet, draining the patient's veins after all active congestion has ceased, is much to be repro- PARALYSIS. 141 bated. Something must be allowed to time, and the powers of nature. If the patient's face is cold, the carotids beating feebly, and the patient approaching a state of syncope, considerable caution must be used in abstracting blood. Purgatives should first be given, with small doses of ammonia, and sinapisms be applied to the feet—when the circulation has recovered its force, blood may be taken by cup- ping from the nape of the neck, and blisters be applied behind the ears, or to the nape of the neck. When an attack of apoplexy is known to follow habitually if the stomach is loaded with indigestible food, an emetic of sulphate of zinc may be given, as it evacuates the stomach with the least pos- sible straining. PARALYSIS. The most characteristic symptom of cerebral hemorrhage is para- lysis. Very slight effusion produces this effect, and in general its intensity is in the direct ratio of the extent of the effusion. Para- lysis may also arise from diseases of the brain, or its membranes, injuries of the brain or the spinal cord, diseases of the spinal cord or its membranes, pressure on, or injury of, the large nervous plexuses, the action of lead, &c. Paralysis has been divided into several varieties:—1st, paralysis of the nerves of motion ; 2d, paralysis of the nerves of sensation ; 3d, hemiplegia, which implies the existence of paralysis on one side of the body; 4th, paraplegia, which signifies that the lower extre- mities are paralysed ; and 5th, partial paralysis, as of the muscles of the mouth, or of an extremity; 6th, general paralysis, when the two sides of the body, whether in their entire extent or in some of their parts, are at once deprived of motion. PARALYSIS FROM CEREBRAL HEMORRHAGE. This form of paralysis developes itself at the very moment the effusion of blood takes place in ordinary apoplexy; acquires all at once its highest degree of intensity; then remains stationary, or be- gins to diminish. Sometimes the paralysed part has not previously experienced any disturbance with respect to either sensation or motion; sometimes, on the contrary, the patient has experienced in these parts pricking sensations, numbness, permanent or transient, an unusual feeling of cold, a sense of weight, and a certain degree of debility. These different phenomena may announce two things —either the existence of constant lesion in the same point of the brain where, at a later period, the hemorrhage shall take place,—as simple habitual sanguineous congestion; a softening which is still inconsiderable ; or a tumour; or else the more or less frequent re- turn of a more serious congestion in the part of the brain where the blood is to be effused. 142 PRACTICE OF MEDICINE. The paralysis following cerebral hemorrhage presents great varie- ties with respect to its seat, and pathological anatomy is far indeed from being always able to assign the cause of such numerous varieties. There has not as yet been established any special relation be- tween the seat of the effused blood and the paralysis of par- ticular organs. It has been asserted that paralysis of the superior extremities depends on the effusion taking place in the thalami, or in the cerebral substance situated on a level with, and posterior to them; and that paralysis of the inferior extremities depends on the effusion taking place in the corpora striata, or in the cerebral sub- stance situated on a level with, or anterior to them. It is certainly true that cases occur in which the relation of the effusion and the paralysis as above stated holds good ; but again, there are numerous cases which fully demonstrate, that paralysis of the extremities has no necessary connexion with effusion into these portions of the brain. It has also been asserted that loss of speech depends on the effusion occupying the anterior lobes of the brain ; but this observation derives still less support from actual experience than the former, for blood may be effused in the anterior lobes of the brain without giving rise to any modification of speech. The best established facts regarding the seat of cerebral hemor- rhage, and the relation which exists between it and paralysis, are the following:— 1. That the paralysis almost always occupies the side of the body opposite to that of the brain or cerebellum in which the effused blood is situated. 2. That the paralysis affects only one side of the body when the effused blood is confined to one hemisphere of the brain, or one of the lateral lobes of the cerebellum. 3. That the paralysis exists on both sides of the body when the hemorrhage has taken place in both hemispheres of the brain, or both lateral lobes of the cerebellum, into the ventricles, the pons Varolii, the medulla oblongata, and on the surface of the brain. 4. That paralysis of both sides of the body may also take place when the hemorrhage is confined to one hemisphere of the brain or lateral lobe of the cerebellum, but is so extensive as to produce com- pression of the opposite hemisphere or lobe. A most remarkable circumstance, connected with cerebral hemor- rhage, has been observed by Andral—viz., hemorrhage of one of the lobes of the cerebellum, like that of one of the hemispheres of the brain, gives rise to paralysis of the opposite side of the body; but if hemorrhage takes place into the left lobe of the cerebellum, and right hemisphere of the cerebrum, the paralysis is found to exist on that side opposite to the hemisphere of the cerebrum, which is the seat of the effusion, the other side remaining unaffected by the effusion in the cerebellum. PARALYSIS. 143 When blood is effused into the substance of the brain, its colour gradually changes from red to black, and in successive transitions to brown, dull green, orange, pale yellow, or yellowish white. When the clot has undergone the latter changes of colour, and the fibrine, separated from the other constituents of the blood has as- sumed a fibrous or laminated appearance, the blood-vessels are ob- served to form it. The fibrine may retain its distinctive characters for some time, and then become converted into firm fibrous tissue, which, gradually diminishing in bulk, forms eventually a small cicatrix; or, the organized fibrinous substance may be converted into a loose cellular tissue, filled with a serous fluid, (the apoplectic serous cyst,) and traversed by a considerable number of blood-vessels. Should the case, under these circumstances, proceed favourably, the serum of the cyst becomes absorbed, the walls approximate, and a cicatrix is formed. Finally, if a complete cure of the paralysis is effected, the cicatrix, whether formed by the first or last process de- scribed, disappears. Treatment.—The treatment of paralysis dependent on cerebral hemorrhage consists at first in the treatment proper for the different varieties of apoplexy ; and afterwards in the use of derivatives, and finally, general and local stimulants. The patient should be restricted in his diet, and all causes of cerebral excitement, whether physical or moral, should be avoided; the chief object in the first part of the treatment being to promote the absorption of the clot, which is best effected by moderately lowering the cerebral circulation. Much ad- vantage is derived from the insertion of a seton, or an issue, in the neck, which establishes a kind of drain in the vicinity of the disease. The bowels should be well acted upon, and the condition of the bladder attended to. When the organic disease of the brain is re- moved, and all symptoms of vascular excitement or congestion have disappeared, we may have recourse to strychnia. This substance, being a powerful medicine, should be given in doses of one-sixteenth of a grain at first; however, it may be gradually increased to half a grain, or even a grain in a day. Whenever it produces headache, vertigo, sickness of the stomach, and violent spasmodic twitchings, it must be discontinued. The local treatment consists in rubbing the parts with stimulating liniments, applying blisters to the spine, or along the course of the nerves, sprinkling the abraded surface with strychnia, and, finally, in using electricity. The use of the moxa has been strongly recom- mended ; if the paralysis exists in the lower extremity, it may be applied in the course of the great sciatic nerve; if in the upper ex- tremity it may be applied to the back of the neck, corresponding to the junction of the brachial nerves with the spinal cord. 144 "PRACTICE OF MEDICINE. EPILEPSY. Causes.—Epilepsy appears to be occasionally hereditary, but it is f more frequently an acquired disease. It generally arises from ex- cessive nervous irritation, either induced by sympathetic influences, or by direct causes. As examples of the former, may be enumerated, gastro-intestinal disturbance from indigestible food, worms, &c.; difficult dentition; uterine irritation; excessive sexual intercourse and masturbation; the abuse of spirituous and fermented liquors; the presence of calculi in the kidney, ureter, or bladder, or of gall stones in the excretory duct of the liver. The direct causes are— injuries of the head or spine; diseases of the cranial bones or of the vertebrae; tumours growing on the bones, or spiculae of bone pro- truding into the brain; ossific deposition in the dura mater or its processes; ossification of the arteries of the brain; concussions of the brain or spinal cord; and metastasis of gout or rheumatism to the encephalon. Dr. Meade is convinced that the relative frequency of disease of the spinal cord and its membranes in this affection is underrated; and that much may be done for the patient in many instances by attending to the state of this part of the nervous system. The other causes which have been enumerated are—fright, fits of passion, distress of mind, appalling sights, seeing others in the pa- roxysm, excessive hemorrhage, immoderate depletion, hypercathar- sis, the suppression of eruptions, irritation of remote nerves, and the syphilitic and mercurial poisons. Its causes may be divided into, 1st, the centric, consisting of disease, or causes of irritation in the nervous centres ; 2d, the eccentric or peripheral, consisting in causes of irritation in the viscera or external parts. Symptoms.—Epilepsy is generally a chronic disease, and fre- quently ends in insanity ; it sometimes, however, proves fatal during a paroxysm. It consists in fits of unconsciousness and convulsions. The epileptic fit is occasionally preceded by certain warnings, such as stupor, a sense of coldness, or creeping, or of a gentle breeze (aura epileptica) proceeding from a particular part of the body towards the head. M. Georget states, " that warnings do not occur in more than five cases in a hundred;" this is, however, underrating their frequency. In most cases, the patient utters a cry and suddenly falls sense- less ; the eyes are opened widely, the pupils are fixed, the face is drawn to one side, and the jaws are firmly closed; after some minutes, the muscles of the neck become rigid, the jugular veins distended, and the face is in a state of livid turgescence; the muscles of the face are now seized with frequent spasmodic contractions; there are convulsive movements of the extremities, particularly the superior; the thorax is fixed, and the respiration is exceedingly difficult. The EPILEPSY. 145 tongue is sometimes thrust with juolence out of the mouth, and is occasionally caught between the teeth, and severely bitten; in this case the frothy matter expelled from the mouth is tinged with blood. To this state, which may last from a few minutes to a quarter, or even half an hour, succeeds a deep sleep, general relaxation of the muscular system, paleness of the countenance, and a gradual return of free respiration; the countenance for some time retains an ex- pression of stupidity; the intellectual and sensorial faculties, how- ever, gradually resume their activity, the patient at the same time experiencing a creeping sensation all over his body. Occasionally it happens that one fit succeeds another, till the patient becomes comatose, and dies ; but, comparatively few die during a fit, unless the disease has existed for a considerable time. In some cases, the attack is much less violent, and consists merely of a momentary loss of sense, with slight and partial convulsions of the eyes, mouth, upper extremities, or fingers, and may or may not be accompanied by a fall. The most frequent complications of epilepsy are, apoplexy, mania, paralysis, chorea, hysteria, and catalepsy; hence the morbid ap- pearances are infinitely various. Morbid appearances.—Epilepsy may be connected with any of the organic lesions which occur in the brain and cranium. When a patient dies in a fit of simple epilepsy, the substance and the mem- branes of the cerebrum and cerebellum are found gorged with black blood. In complicated cases of epilepsy, especially with mania, the medullary substance of the brain is found indurated, and its vessels enlarged; occasionally, however, with dilatation of its vessels, it is softened and flabby. These structural changes are generally limited in extent. The cortical structure also occasionally presents evidence of chronic inflammation, and is, in some instances, adherent to the membranes. The medulla oblongata and spinal cord present, in many cases, alterations similar to those found in the encephalon. The Wenzels found the pituitary gland and infundibulum variously altered in colour, size, and consistence, in nearly all the cases of epilepsy which they examined ; and the crista galli of the ethmoid, and the clinoid processes of the sphenoid bone, more or less promi- nent, or otherwise changed in position and shape, in most of them. In the larger proportion of cases, the pineal gland was also changed in colour, and softened. Caries, thickening,internal exostoses, spiculae, malformations, and malpositions of the bones at the base of the skull, with various changes of the membranes, were met with in the larger proportion of cases. The heart, pericardium, lungs, liver, and kid- neys, have been found diseased in rare instances. Treatment.—But little can be done for the patient during the pa- roxysm, except placing him in the horizontal position, and preventing 146 PRACTICE OF MEDICINE. his being injured by the violence of his muscular exertions. One of the first things to be done is to put something between the teeth, to prevent injury to the tongue, and the dress must be loosened, parti- cularly stays and neckcloths. Bloodletting has been recommended in the paroxysm ; but unless the fits are attended by marked plethora or cerebral congestion, or in the first attack, especially when pro- duced by the suppression of some sanguineous evacuation, it should be deferred. It is in the convulsive stage of the paroxysm that bleeding is particularly indicated : it cannot, however, be easily per- formed in this stage. Cold affusion to the head has been recom- mended by Brera; it is not very efficacious, except in those cases complicated either with hysteria or uterine disease. Antispasmodic and purgative enemata are perhaps the most efficacious means during the fit; if there be not much determination to the head, assafcetida injections and castor oil may be employed; but when this symptom is present, turpentine should be preferred. After the paroxysm is over, the patient should be kept quiet, the bowels opened as quickly as possible, and light nourishing diet in moderate quantity is to be used ; the abuse of stimulants is to be ab- stained from; and every cause, corporeal as well as mental, which can possibly have the effect of disturbing the balance of the circula- tion, or exciting the nervous system, is to be avoided. If there be evidence of much disturbance in the cerebral circulation, the treat- ment must be more active; if the patient's strength will admit of it, general bleeding from the arm may be useful, or occasional cupping may be had recourse to, together with keeping the head shaved, ap- plying cold lotions, acting briskly on the bowels, and placing moxas or blisters behind the ears, or setons in the neck. In this form of the affection, Dr. Cheyne recommends James' powder to be taken at bedtime, beginning with two or three grains, and increasing the dose every night, until a sensible effect is produced on the skin, stomach, or bowels. When chronic inflammatory action is sus- pected, the potassio-tartr ate of antimony ointment should be applied along the spine, or over the nape of the neck, until it produces a copious eruption of pustules. Where this disease arises from an affection of the spinal cord or its membranes, it will necessarily re- quire either vascular depletions or tonics, or both, according to the degree in which plethora, increased action, or deficient power, is in- ferred to be present. Where incited action exists, cupping, the ap- plication of leeches, and dry cupping in the course of the spine, the insertion of setons or issues a little below the seat of the pain, or application of moxas, are the most efficient means. The effects of these means are increased by absolute rest, the antiphlogistic regi- men, and active purges. In some cases, associated with deficient power, whilst moderate local depletion, dry cupping, external deriva- CHOREA. 147 tion, &c, are resorted to, tonics and antispasmodics, such as vale- rian, castor, myrrh, cinchona, camphor, and the preparations of iron, should be prescribed. This state of disease is often induced by mas- turbation ; in which case cold aspersion of the genitals night and morning, sponging the spine with cold salt water or vinegar and water, and the internal use of the preparations of iron, will prove beneficial. Where epilepsy occurs in a scrofulous habit, the iodide of iron, or the iodide of potassium, may be given. If worms be suspected, turpentine and other anthelmintics must be exhibited. The diseases of the digestive organs, and the other complications of epi- lepsy, should be treated on general principles. Some medicines have been much lauded in the treatment of epi- lepsy ; the principal of these are—the nitrate or oxide of silver, the ammonio-sulphate of copper, arsenite of potash, sulphates of iron, zinc, or copper, quinine, extract of nux vomica, and strychnia. Among the antispasmodics employed are, ether, ammonia, camphor, musk, castor, assafoetida, galbanum, valerian, and serpentaria. CHOREA. This disease is popularly named St. Vitus's dance, Chorea Sancti Viti; the French call it the dance of St. Guy ; and the Germans, the dance of St. Weit. Causes.—The most common are, intestinal irritation from worms or morbid accumulations, and fright. It may also be caused by in- juries to the nervous system from blows or falls; by suppression of eruptions, or vicarious discharges ; by rheumatic metastasis to the membranes of the spinal cord ; by violent mental emotions; by ex- cessive venery ; by masturbation, &c. Symptoms.—Generally speaking, convulsive movements, or rather twitches, of the fingers and muscles of the face are first observed ; after a short time, the convulsive movements become more marked; strange contortions of the features take place ; the disease extends to the voluntary muscles of all parts of the body, and frequently those of the lower extremities are so continually excited that the patient appears to be dancing, which makes his gait very unsteady; he is chiefly affected when he is most desirous to control his actions. The disease is sometimes confined to one side of the body, or it is more perceptible on one side than the other; the muscles are also affected with a sensation of pricking, creeping, or of numbness. At first there is no constitutional derangement, there being no fever, and all the functions being properly performed, with the exception of the bowels being torpid; but after the disease has continued some time, the general health becomes impaired, and occasionally the mental faculties suffer. This affection is much more common in the 148 PRACTICE OF MEDICINE. female than the male, the proportion being, according to the best authorities, three of the former to one of the latter. It most fre- quently appears between the age of seven and fifteen. The nature of the disease is but very little understood; by several writers it is attributed to inflammatory action of some part of the cerebro-spinal axis; and Dr. Hamilton ascribed it to the disordered functions of the bowels affecting the muscular actions sympa- thetically. The seat of this disease is quite as obscure as its nature. M. Serres considers the corpora quadrigemina to be the seat of chorea, while MM. Bouillaud and Magendie conceive that it is seated in the cerebellum, the functions which they ascribe to this organ being those chiefly affected in this disease; it is, however, much more probable that the affection depends on disturbed function of the nerves arising from the spinal marrow. Treatment. — This consists in removing morbid secretions and faecal accumulations; in subduing, when evidently present, excited action of the vessels of the spinal cord or brain; and, finally, in rousing the energy of the organic nervous system. Purgative me- dicines have been prescribed with the best effects in this disease; a full dose of calomel should be given at first, and in a few hours after a brisk cathartic ought to be exhibited. Calomel and jalap are a common combination in this disease; and Dr. Hamilton recom- mends aloetic pills on the days when these are not employed. The compound infusions of gentian and senna, with a little sulphate of magnesia, may be given in the morning occasionally. The oil of turpentine also forms an excellent medicine in chorea, and is parti- cularly indicated where the presence of worms is suspected. The diet should be light and nourishing; every indigestible substance should be carefully avoided. Dr. Wood recommends the use of black-snakeroot, having frequently found it of itself adequate to the cure of the disease. If there be evidence of cerebro-spinal irritation, our attention must necessarily be directed to its removal; this is best effected by cupping, leeches, and powerful counter-irritation, over the parts par- ticularly implicated. Attention to the mental emotions, warm woollen clothing on the lower extremities, cold affusion on the head or on the spine, or the shower-bath, constitute important parts of the treatment. Boys are said to be more easily cured than girls. In obstinate cases, tonics must be employed, and those generally used in this disease are, bark, disulphate of quinine, arsenical solution, nitrate of silver, sulphate of zinc, the preparations of iron, and the ammo- nio-sulphate of copper; of the efficacy of the last substance, Dr. Burns speaks highly. The experiments of M. Baudelocque, at the HYSTERIA. 149 Children's Hospital, Paris, demonstrate that the disease may gene- rally be cured by a persevering use of sulphur-baths. Baron Dupuy- tren employed cold affusion with much success. The same mode of treatment has been found very efficacious at the Hopital des Enfans Malades. HYSTERIA. This is an apyrexial convulsive disorder, affecting females almost exclusively. The seat of this disease is altogether unknown. Symptoms.—Hysteria is an intermittent, irregular, chronic dis- ease, which comes on by fits, and usually attacks females from the age of puberty to the critical period; it very commonly occurs on the suppression or diminution of the menses, particularly in persons of a nervous or irritable temperament. In the slighter forms, the patient, without any assignable cause, bursts into a fit of weeping, which perhaps-is soon followed by convulsive laughter, which may last for a few minutes; and before composure takes place, the pa- tient gives several loud sobs; one of these fits may succeed the other, till the patient falls asleep. The fit sometimes begins with a yawning, numbness of the extremities, involuntary laughing and crying, alternations of pallor and redness of the face, and a sensa- tion as if a ball (globus hystericus) commencing at the hypogas- trium, ascended through the abdomen and thorax to settle at the throat, where it produces a violent sense of constriction, and of im- pending suffocation. In more severe instances of hysteria, there are convulsive movements, particularly of the hands, face, jaws, and muscles of respiration; they are of a clonic character. The pupils are dilated; and occasionally the paroxysm has a close resemblance to epilepsy, only that the insensibility is rarely complete. In this dis- ease there is a remarkable deficiency of the organic matters in the urine, and this fluid is very watery. Hysteria does not tend essen- tially to increase, nor does it determine as a consequence, mania or idiotcy. Treatment.—In those cases where there is reason to suspect any congestion or inflammation of the uterus, or of any portion of the brain, then blood should be drawn by cupping from the back of the head or loins. During a paroxysm, the stays and all tight strings should be loosened, and the free admission of air procured; the face is to be sprinkled with cold water, volatile salts are to be held to the nostrils, and, if the patient can swallow, a drachm of the aromatic spirit of ammonia, or the same quantity of ammoniated tincture of valerian, may be given in a wineglass-full of water. In the severer forms of the disease, the application of cold to the body is often a most effectual means of putting a stop to the paroxysm. The bowels should be kept regularly open, and the best purge in these cases is 150 PRACTICE OF MEDICINE. castor oil with oil of turpentine, given every, or every second morn- ing, according to circumstances; enemata containing assafoetida are also useful. The prevention of the recurrence of the symptoms is to be attempted by keeping up an action on the bowels, and adminis- tering tonics, such as the disulphate of quinine, the preparations of iron, &c. Foetids, such as assafoetida, castor, valerian, &c, are sometimes, but not invariably, useful. The menstrual action, if irregular, must, if possible, be rectified by appropriate means. The diet should be light, and every attention paid to the improvement of the general health. APPENDIX. We append the following on the treatment of Typhoid Fever; though out of place, its importance, we think, will warrant our placing it here. TREATMENT OF TYPHOID FEVER. Of the diaphoretics, the neutral mixture, with tartarized antimony, or sweet spirits of nitre, may be given in the early stages of the disease, and the spiritus mindereri with nitre, in the latter stages. Cold sponging, if it do not chill the patient, is an important remedy, and the internal use of ice is often very grateful. If the patient be very feeble, spirits and water may be substituted for pure water. Cold applications to the head, by means of ice in a bladder, are very serviceable in relieving the pain and delirium. The hair should also be taken off; and if the head be cold, while delirium is present, Chomel recommends the application of warm poultices. Should there be much abdominal tenderness, a few ounces of blood should be taken by leeches, followed by the application of warm fomentations. If the diarrhoea should be profuse, it should be checked by opium, either alone or in combination with ipecac, or some astringent. Nervous symptoms may be combated by the use of Hoffman's anodyne, camphor water, or opium, if not contra- indicated. In the advanced stage of the disease, when the tongue is dry, the urine scanty, and the skin parched, and there is delirium, or in- creased stupor, with an abatement of the vital actions, no remedy is so effectual as mercury, given so as slightly to affect the gums. Either blue mass or calomel may be used. Should the disease not yield, especially if the tongue remain dry, and the abdominal distension undiminished, Dr. Wood strongly re- commends the oil of turpentine, particularly in that stage of the disease when the tongue, instead of cleaning gradually from the edges and tip, parts rapidly with its fur, first from the middle or back part of its surface, which is left smooth and glossy, as if de- prived of its papillae. It should be given in doses of from five to twenty drops every hour or two. 152 APPENDIX. If the debility increase, the patient's strength should be supported by cordials and stimulants. Beef tea, or beef essence, wine whey, milk punch, together with the use of quinine, opium, serpentaria, &c, as the exigencies of the case may demand. Sloughing must be prevented by obviating pressure. Profuse epistaxis by plugging the nostrils. And in case of perforation of the intestine recourse must be had to large doses of opium. Some practitioners use quinine throughout the disease. Others rely upon bleeding, "coup sur coup" (Bouillaud). Others upon purging throughout (Delarocque). Professor Mitchell has great con- fidence in the internal use of nitrate of silver, beginning in doses from J to | of a grain, and increasing it till a metallic film appears upon the faecal evacuations. He speaks confidently of its controlling influence upon the diarrhoea and the nervous symptoms. By some it is supposed to act by coming in contact with the ulcerated plates of Peyer, upon which it exercises its specific astringent and sedative influence. Alum has been recommended for the same purpose. The diet should be mild and unirritating in the early periods of the disease, gradually becoming more nutritious as the disease ad- vances, and the debility increases. LEA AND BLANCHARD'S PUBLICATIONS. MEDICAL BOOKS. TO THE MEDICAL PROFESSION. The following list embraces works on Medical and other Sciences issued by the subscribers. 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