A 
TREATISE 
ON THE 
PRACTICE OF MEDICINE, 
BY 
GEORGE B. WOOD, M.D., 
PROFESSOR OF THE THEORY AND PRACTICE OF MEDICINE IN THE UNIVERSITY OF 
PENNSYLVANIA; 
PRESIDENT OF THE COLLEGE OF PHYSICIANS OF PHILADELPHIA; 
ONE OF THE PHYSICIANS OF THE PENNSYLVANIA HOSPITAL; 
ONE OF THE AUTHORS OF THE DISPENSATORY OF THE UNITED STATES OF AMERICA; 
ETC. ETC. 
FOURTH EDITION. 
IN TWO VOLUMES. 
VOL. II. 
PHILADELPHIA: 
LIPPINCOTT, GRAMBO, AND CO. 
No. 20 NORTH FOURTH STREET. 
1855. Entered, according to the Act of Congress, in the year 1854, 
By George B. Wood, M. D., 
in the Clerk's Office of the District Court of the United States in and for the Eastern 
District of Pennsylvania. PRACTICE OF MEDICINE. 
PART II., or SPECIAL PATHOLOGY, 
CONTINUED. 
CLASS III., or LOCAL DISEASES, 
CONTINUED. 
SECTION HI., or DISEASES OF THE RESPIRATORY ORGANS, 
CONTINUED. 
SUBSECTION III. 
ORGANIC DISEASES OF THE PULMONARY TISSUE AND PLEURA. 
Article L 
INFLAMMATION OF THE LUNGS, or PNEUMONIA. 
Syn.-Peripneumonia.-Pneumonitis.-Pulmonitis. 
The name of pneumonia is now universally applied to inflammation of the 
spongy tissue or parenchyma of the lungs. There are numerous varieties of 
this disease, which it will be most convenient to notice in the present place, 
because reference will be frequently made to them throughout the subsequent 
remarks. These varieties are founded upon the different portions of the 
lungs, or the different constituents of any one portion, which may be in- 
flamed, upon the relation of the disease to other diseases with which it may 
be associated, and upon the character of the accompanying fever or general 
state of system. The inflammation may occupy a considerable extent of the 
lungs continuously, embracing a whole lobe more or less, or even one whole 
lung. This is the common form of the disease, and the one usually meant, 
when the simple term pneumonia is employed. For the sake of distinction it 
is sometimes called lobar pneumonia. Sometimes small isolated portions of 
the lungs are inflamed, as, for example, distinct lobules or parts of lobules, 
with sound lung intervening. In this case, the complaint is denominated 
lobular pneumonia. Though the inflammation is usually confined to one 
lung, it occasionally involves both, and, in the latter case, is distinguished by 
the name of double pneumonia. In some rare instances, it appears to affect 
chiefly or exclusively the air-cells, and may then be called vesicular pneu- 
monia, though Rilliet and Barthez name it vesicular bronchitis. Again, the 
inflammation is sometimes seated more especially in the cellular tissue inter- 
vening between the different air-vesicles, or between the lobules, in which 
case it has been proposed to name it intervesicular, or interlobular pneumonia. 
Most generally, however, it occupies the whole of the constituents which form 
the pulmonary parenchyma, including the air-cells, the smaller bronchial 
tubes, the intervening cellular tissue, and the vascular ramifications. The 4 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[part II. 
pleura is very frequently involved with the substance of the lungs; but, 
when the inflammation is confined to that portion of the investing membrane 
which is in contact with the diseased pulmonary tissue, it is not generally 
deemed worth while to give the affection a distinct title. When large por- 
tions of the pleura are affected, the disease receives the name of pleuropneu- 
monia. The complaint is frequently primary; but it is also frequently a 
mere accompaniment of other diseases, in which case it is called secondary. 
When associated with a low or typhous condition of the system, it is named 
typhoid, pneumonia; and when with bilious disorder, whether dependent on 
simple derangement of the liver, or upon a concurrent bilious fever, bilious 
pneumonia. Finally, the disease may be of short, or of protracted duration, 
or in other words may be acute or chronic. In the following remarks, the 
ordinary arrangement pursued in this work will be deviated from by treating 
first of the anatomical characters of the complaint; because, without a know- 
ledge of these, we can have no just idea of the value of many of the symptoms. 
1. Common, or Lobar Pneumonia.-There are three well-marked stages 
in acute pneumonia; viz., 1. that of congestion, 2. that of fully-developed 
inflammation, and, 3. that of suppuration. 
In the first stage, or that of congestion, the affected portion of the lung is 
of a deep-red colour, crepitates under pressure, though less than in health, 
retains the impression of the finger, and, when cut, exudes copiously a bloody, 
turbid, and somewhat frothy serum. It is more compact and heavy, but less 
tenacious than in health, and, notwithstanding its increased density, still floats 
in water. The cells are not yet obliterated, and, though somewhat obstructed 
by extravasation, still contain air. The condition altogether very much re- 
sembles the mechanical congestion occasioned by the gravitation of the blood 
after death, or at the very close of life; but the colour is usually of a brighter 
red, and the softening greater. The position of the congestion may also 
sometimes aid in the formation of a correct judgment; as, if mechanical, it 
must occupy the most dependent part of the lung, which is not necessarily 
the case when it is vital. If the disease be arrested in this stage, the lung 
reassumes the healthy appearance; if not, it passes into the condition de- 
scribed in the following paragraph. Dr. Stokes maintains that the conges- 
tive stage,. with the characters above mentioned, is preceded by another, 
marked by intense arterial injection with dryness; in other words, a condition 
of irritation, which, as taught in this work, always precedes inflammation. 
The second stage, named by Laennec that of red hepatization, by Andral 
that of red softening, is characterized by a deep-red, reddish-brown, or gray- 
ish-red colour, the absence of crepitation under pressure, a density so much 
increased that the diseased lung will sink in water, and a diminution of cohe- 
sion still greater than in the first stage. The grayish colour sometimes ob- 
served is owing to an intermixture of particles of the black pulmonary mat- 
ter, and to the lighter hue of the interlobular tissue, which is occasionally 
less congested than the other parts. The softening is so great that the lung 
may be readily torn, and the finger may be passed through the parenchyma 
with little resistance. It is greater in proportion as the inflammation has 
been more acute and recent. When cut into, the lung bears a striking re- 
semblance to liver; and on this account is said to be hepatized. When pressed 
between the fingers, it exudes a reddish fluid, which is thicker, less frothy, 
and in less amount, than that observed under similar circumstances in the 
congestive stage. Ihe cut or torn surface of the lung generally exhibits 
numberless minute granules, which are probably the air-cells filled and dis- 
Anatomical Characters. CLASS III.] 
5 
PNEUMONIA. 
tended with concrete fibrinous exudation, though Dr. Williams ascribes them 
to interstitial deposit of lymph in the parietes of portions of the bronchial 
tubes and vesicles. The granular appearance, however, is not always ob- 
served. The surface is sometimes quite smooth and uniform, especially in the 
pneumonia of advanced life and that of infancy, probably in consequence of 
the obliteration of the cells by the pressure of effused matter without them. 
The same appearance is presented, when a portion of lung compressed by 
pleuritic effusion has become inflamed. Dr. Williams supposes the absence 
of the granular character to occur in those cases in which the inflammation 
is situated without the air-vesicles, in the cellular tissue between them, and 
which he distinguishes by the name of intervesicular pneumonia. This affec- 
tion has also been called interlobular pneumonia, though with less propriety. 
In the red hepatization, the bronchial tubes, the blood-vessels, and the inter- 
lobular cellular tissue are still obvious to examination. The lung does not 
collapse upon exposure to the atmosphere, as in a healthy state. 
In the third or suppurative stage, there are two conditions, one pf which, 
and infinitely the most common, is that denominated by Laennec gray hepa- 
tization, and by Andral gray softening, and the other is abscess. In the 
former, the lung is compact and dense as in the red hepatization, but, instead 
of.the dark-red colour, presents externally and within a yellowish or grayish 
appearance, and, when cut, exudes a yellowish, opaque, purulent fluid some- 
times tinged with blood. It is much softer too than in the second stage, so 
much so, that, if pressed between the fingers, it is almost wholly resolved 
into a purulent fluid, with only shreds of the solid tissue remaining. A very 
moderate degree of force, even a slight violence in handling, or otherwise ex- 
amining it, occasionally produces a cavity in its substance, which gradually 
fills with pus, and may easily be mistaken for an abscess. It generally still 
preserves, when cut or torn, the granular aspect, but sometimes exhibits a 
uniform surface, as in the red hepatization. The second condition above 
alluded to, or that of abscess, is exceedingly rare in adults. Not unfrequently 
the pathological anatomist meets with collections of pus in the lungs. Some- 
times metastatic abscesses are found after death from violent injuries, or severe 
surgical operations. Abscesses of the neighbouring parts, as in the pleural 
cavity, between the adhering lobes of the lung, in the mediastinum, liver, &c., 
occasionally open into the lungs, and form cavities in its substance. Tuber- 
culous vomicae, and enlarged bronchial tubes filled with pus, seem to have 
sometimes been mistaken for abscesses. But it is very uncommon to meet 
with collections of pus, as the result of the variety of pneumonia at present 
under consideration. Chomel states that, during an experience of twenty-five 
years, he had seen only three; -and of several hundred cases examined by 
Laennec, only five were of this kind. (Diet, de Med., xxx. 151.) These ab- 
scesses sometimes appear to be mere excavations in the hepatized mass, being 
everywhere surrounded by the diseased parenchyma of the lungs, which is in 
some instances gangrenous. In other cases, the walls of the cavity are lined 
by a smooth, grayish false membrane. Sometimes there is only one cavity, 
sometimes several, which may remain separate, or run together. The abscess 
may either be closed, or may communicate with the bronchia, pleura, pericar- 
dium, mediastinum, or even the peritoneum, or may open externally between 
the ribs. Such purulent collections are occasionally observed around tuber- 
culous deposits, or foreign bodies in the lungs. But, though true pneumonic 
abscess is rarely observed after death, there is reason to believe that it is more 
common in cases which recover. When large portions of the lungs are hepa- 
tized, the patient dies before the tissue so far breaks down as to form an ab- 
scess; but when a small portion only is affected, insufficient to destroy life, 6 
[part II. 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
there is time for this result. Hence abscesses are more apt to occur when the 
hepatization is moderate than when it is extensive; and hence too recoveries 
not unfrequently take place. 
Gangrene is a very rare result of ordinary pneumonia, though it does occa- 
sionally occur. (See Gangrene of the Lungs.') 
The three different conditions above described are sometimes, but not 
always, distinct. They are in fact often more or less intermingled. Thus, 
in the midst of a congested portion of the lungs, some spots of red hepatiza- 
tion may appear, and, in the midst of the latter, some spots of gray hepatiza- 
tion, which give a mottled appearance to a section of the diseased lung. 
Sometimes the three conditions exist at the same time, the gray hepatization 
being in the centre, the red around it, and the congestion on the borders of 
the latter, though the boundary between them is not accurately defined. In 
relation to the pathology of these different conditions, it may be sufficient to 
state that, in the first, the vessels are merely engorged with blood, and the 
air-cells partly filled with a sero-muqous, somewhat bloody effusion; in the 
second, a plastic extravasation has taken place, and the cells, as well as the 
intercellular tissue, are filled with a more or less concrete and bloody lymph • 
in the third, the place of the plastic secretion has been supplied by a purulent 
fluid. The pleura is very frequently, but not always, inflamed over the he- 
patized portion of the lung. Coagulable lymph is often thrown out, forming 
a false membrane upon its surface; and sometimes the two opposite surfaces 
adhere; while a little turbid serum is found in the pleural cavity. In some 
instances, the inflammation of the pleura is much more extensive; and then 
the disease comes under the designation of pleuro-pneumonia. (See Pleuro- 
pneumonia.) The bronchia, both large and small, are almost always inflamed, 
containing mucus, and exhibiting a reddened surface; and, if one lobe is in- 
flamed, the bronchial tubes going to that lobe are also affected. The bronchial 
glands are often enlarged, reddened, and softened. The right cavity of the 
heart frequently contains red and soft, or yellowish and firm coagula. 
In a great majority of cases, the morbid phenomena are confined to one lung; 
and the right lung is much more frequently affected than the left. From a 
comparison of 1430 cases, collected by M. Grisolle from various authors, it 
appears that the cases of double pneumonia were about 18 per cent, of the 
whole number, those of the left side about 30 per cent., and those of the right 
side about 52 per cent. In secondary pneumonia, the opposite sides appear 
to be about equally affected. In relation to the part of each lung attacked, 
Laennec stated that the lower portion was most frequently the seat of the in- 
flammation, and that when this occupied the whole lung, it almost always 
began in that portion. Some have considered the lower and middle parts as 
almost the exclusive seats of the incipient inflammation. It is probably true 
that these are most frequently affected; but observation has shown that tho 
disease not unfrequently also begins in the upper lobe; and in certain seasons 
this appears to be more frequently the case than in others, without any known 
cause for the difference. Of 264 cases investigated by M. Grisolle, the in- 
flammation began in the lower lobes in 133, at the summit in 101, and at 
the middle in 30. 
2. Lobular Pneumonia.-In this variety, which is most common in chil- 
dren below six years of age, and is comparatively rare in adults, the inflam- 
mation occupies distinct spots, surrounded by healthy tissue. These little 
islands of inflammation may be distinctly defined, occupying one or several 
lobules, and abruptly bounded by the interlobular areolar tissue; or they may 
gradually run into the surrounding parenchyma, so that their limits cannot 
be precisely fixed; or, finally, they may run together, and thus form one con- CLASS III.] 
PNEUMONIA. 
7 
tinuous mass of inflammation, as in the common form of the disease. Of 
these three forms, the first is less frequent than the other two; and sometimes 
all are found in the same patient. (Rilliet and Barthez;} The patches of 
inflammation are exceedingly diversified in size, form, number, and position. 
Those with definite boundary may vary in magnitude from the size of a millet- 
seed to that of an egg; may be spherical, elongated, or quite irregular; may 
number from one to thirty or more in the same lung; and may occupy both 
lungs, or, what is comparatively rare, may be confined to one, and, in either 
case, are most frequently met with in the posterior part of the lung. In con- 
sequence of the red coloui' of the inflamed spots, they often contrast strikingly 
with the healthy structure, and give the lung, both on its external and cut 
surface, a marbled appearance. They are also more prominent than the neigh- 
bouring tissue, from not collapsing when exposed to atmospheric pressure, and 
have a firmer feel under the finger. In fatal cases, they are sometimes found 
almost filling up both lungs, and leaving but a small portion permeable by the 
air. ( Gerhard.} They present the same stages of congestion, red hepatization, 
and suppuration, as occur in ordinary lobar pneumonia. In the third or sup- 
purative stage, when the pus is disseminated equably through the diseased 
structure, they do not differ materially in colour from the healthy parenchyma; 
but may be distinguished by their greater prominence and density, and by 
exuding a purulent liquid when pressed. Abscesses are not unfrequent in this 
variety of pneumonia, probably in consequence of the small extent of the in- 
flamed patches. These are sometimes single and isolated, sometimes run 
together, and generally have a tendency to approach the surface. They may 
communicate with the bronchia, or one of the neighbouring cavities, or may 
have no outlet. In the latter case, there is reason to believe that the pus is 
sometimes absorbed. They may occupy both lungs, but are more frequently 
found in one only. (Rilliet and Barthez.} 
It has been demonstrated by MM. Bailly and Legendre that, in many in- 
stances, what has been taken for lobular pneumonia in infants is not true 
hepatization, but a consolidation of the lobule such as exists in the fetal state. 
This consolidation they believe may be wholly independent of inflammation, 
and the consequence merely of the contractility of the pulmonary tissue, or 
may be the result of compression of the vesicles by vascular congestion exte- 
rior to them. Dr. Gairdner has rendered it probable that the condition is 
generally, if not always, the result of bronchitis, in which the viscid mucus so 
clogs certain bronchial tubes as to allow the exit, but to prevent the access of 
air, in consequence of which the air-cells, supplied by the tubes thus closed, 
collapse; and he has shown that the same result not unfrequently takes place, 
from the same cause, in adults. That the consolidation is produced by col- 
lapse, and not by inflammation of the pulmonary tissue, is proved by the 
fact that the solidified parts, unlike hepatized lung, may often be expanded 
by insufflation. As the affection, however, is connected with an inflammatory 
condition of the tubes, it is easily conceivable that this may have extended 
into the solidified portion before collapse, which may thus sometimes put on 
the appearance of parenchymatous inflammation. (See Vol. i. page 796.) 
But we may attach full credence to the observations of MM. Bailly and 
Legendre, and of Dr. Gairdner, without surrendering our previous convictions 
in relation to the existence of the lobular pneumonia of children. It is suffi- 
cient to admit that many cases have been mistaken for that affection, which 
were of a different nature. It is scarcely possible that the most accurate 
observers, who have investigated what they deemed lobular pneumonia, could 
have been altogether mistaken; and the progress of the isolated and defined 
patches of inflammation has been too often traced through its different stages, 
to admit of a denial of their occasional and even frequent existence. The 8 
[part II. 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
pneumonia of children, however, is much more apt than that of adults to 
result from a propagation of inflammation from the bronchial tubes to the 
vesicular structure; and it is probable that the lobular pneumonia generally 
originates in this way. 
3. Vesicular Pneumonia.-Under the name of vesicular bronchitis, Rilliet 
and Barthez describe a variety of pneumonia in which the inflammation ap- 
pears to be confined to the air-cells, and perhaps small portions of the com- 
municating bronchial tubes, without extending to the intervening cellular 
tissue. When the lung is cut, it exhibits a vast number of gray or yellowish 
granules, of the size of millet-seed, and bearing no inconsiderable resemblance 
to miliary tubercles, being about equal in size, and like them disseminated ; but 
distinguishable by their want of hardness, and by exuding a drop of pus and 
collapsing when cut. (^Maladies des Enfants, i. 21.) 
4. Typhoid Pneumonia.-When pneumonia is associated with a low or 
asthenic state of system, the disease appears sometimes scarcely to pass the 
stage of congestion; Or, if it does so, the blood remains liquid, and yields 
none of the plastic secretion which gives solidity to ordinary hepatization ; and 
the inflammation, if it continue, is apt to run into gangrene or imperfect sup- 
puration. Of this nature appears to be the condition of the lung called sple- 
nization, in which the diseased portion, though gorged with blood, and so 
dense as to sink in water, is quite soft like the spleen. The pneumonia in 
such cases is usually secondary, or associated with other diseases of a low and 
feeble character. Under this head may also be arranged the hypostatic pneu- 
monia of some writers, which results from the pulmonic congestion produced 
by lying long and constantly on the back, in debilitated states of the system. 
5. Chronic Pneumonia.-Under this head might be placed the abscesses 
which occasionally follow acute pneumonia, and continue sometimes for many 
months before coming to their termination in health or death. But there is 
another form of chronic pneumonia, in which the hepatization consequent 
upon acute inflammation, instead of undergoing resolution or passing into the 
suppurative stage, assumes a permanent character. In such cases, the lung 
is found compact and heavy, pitting little or none upon pressure, not crepi- 
tant, tearing with difficulty, sometimes almost cartilaginous, and, when cut, 
exuding only a little serous fluid. The cut surface is sometimes smooth and 
uniform, sometimes finely granular, and occasionally striated or veined. The 
colour is dull red, reddish or yellowish-brown, or grayish. When distinct 
lobules are affected, the lung has an irregular surface, and a knotty feel. 
The volume of the lung is somewhat diminished, and the chest consequently 
contracted. The pleura is often adherent. Sometimes abscesses exist within 
the hardened structure, and in one instance gangrene was observed by Andral. 
Rilliet and Barthez describe a condition of the lungs in the pneumonia of 
infants, which they call carnification, and consider as the result of chronic 
inflammation. The diseased portion of the lung is depressed on the surface, 
soft, and flaccid, not crepitant, and of a violaceous or pale-red colour, marbled 
with white lines which define the lobules. Its cut surface is red, glossy, and 
penetrable with difficulty, and when pressed exudes a bloody serum. Its ap- 
pearance is like that of a muscle with close and indistinct fibres. (^Maladies des 
Enfants, i. 73.) This, however, is undoubtedly the state of collapse described 
by MM. Bailly and Legendre, and which Dr. G-airdner has shown to exist 
occasionally in adults as a consequence of bronchitis. 
Symptoms, Course, Termination, &c. 
1. Common or Lobar Pneumonia.-This is usually ushered in with a chill, 
often very decided, followed by febrile reaction, difficult breathing, cough, CLASS III.] 
9 
PNEUMONIA. 
and severe pain in the side or back part of the chest. Sometimes the fever and 
local symptoms occur without an antecedent chill, especially in infants; and 
sometimes the local symptoms precede for a short time the general. Occa- 
sionally the characteristic symptoms of the disease are preceded for some 
days by general uneasiness, lassitude, loss of appetite, and more or less fever. 
Not unfrequently the disease commences with catarrhal symptoms, which 
continue for several days before signs of pneumonia become manifest. In 
secondary pneumonia, the disease often begins obscurely without pain, cough, 
or fever, unless this has previously existed, and is distinguishable only by the 
hurried respiration, depression of strength, and the physical signs. Pneumonia 
is apt to assume this obscure form, when complicated with cerebral disease. 
When fully developed, the complaint is characterized, in most cases, by 
fever more or less severe, quickened breathing, pain in some portion of the 
chest, cough, and a scanty viscid expectoration often intimately mixed with 
blood. On each of these symptoms it is necessary to dilate; as they are liable 
to great diversity. 
The pain may either precede, accompany, or follow the commencement of 
the fever. It is often in the beginning very acute and severe, is much in- 
creased by a full breath, coughing, or pressure between the ribs, and is situ- 
ated either in the side or back part of the chest, or in the mammary region. 
When both lungs are inflamed, it is sometimes felt on both sides, and some- 
times referred to the vicinity of the sternum. The sharp pain is probably 
owing to the participation of the pleura, covering the affected portion of the 
lung, in the inflammation. It is in general quickly subdued by depletion, 
or by the other remedies employed, and only an obtuse pain remains. But, 
in many instances, there is no acute pain either in the beginning, or in the 
course of the disease. Instead of it, the patient complains of a dull, aching 
sensation, or a feeling of soreness, oppression, stricture, weight, or heat, 
sometimes referred to the side, sometimes to the anterior part of the chest, 
and often to the epigastrium. Occasionally, the pain is rendered sensible 
only by a deep inspiration, or is evolved by percussion when otherwise latent. 
It sometimes happens that no uneasiness whatever is felt, calculated to excite 
suspicion. 
The breathing is always quickened. The number of respirations may be 
increased from between sixteen and twenty in a minute, the average standard 
of health, to thirty, forty, fifty, or even sixty. At the same time there is 
almost always a feeling of oppression which is increased by speaking, or other 
vocal effort. The dyspnoea is sometimes very urgent, necessitating an erect 
position, and rendering it difficult for the patient to speak. It is increased 
usually with the extent of inflammation, and of the consequent consolidation 
of the lung. But it differs very much in different individuals, even with the 
same amount of local disease. Inflammation in the upper lobe is said to be 
attended with more of it than in the lower. ( Watson.) Violent dyspnoea, 
with short and quick respiration, and a purple or livid colour of the face, is 
indicative of very great danger. 
Cough, in a greater or less degree, is almost always present in the course 
of the disease. I have known it, however, entirely wanting for several days 
after the commencement of a very severe attack, involving the greater part 
of the left lung. It is in some instances violent and painful, in others mode- 
rate and with little or no pain. At first it is usually dry, or attended with 
only a little mucous expectoration, if the disease is uncomplicated. But very 
soon, often in a day or two, a viscid semi-transparent matter is thrown up, 
which either is in the beginning or very soon becomes stained more or less 
with blood, so as to have a reddish or rusty colour, sometimes inclining to 
yellow or green, according to the quantity of blood present. As the disease 
NLM 10 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[PART II. 
advances, these properties of the sputa become more striking. The tenacity 
is so great that the matter adheres to the vessel containing it, when this is 
turned bottom upward. Sometimes, when more copious, it runs together, so 
as to form a kind of tremulous jelly. This viscid and rusty-coloured expecto- 
ration is probably the most characteristic general sign of pneumonia, and 
sometimes indicates its existence even when the physical signs fail. In some 
instances, nearly pure blood is expectorated; but this is comparatively rare, 
and very generally the blood is intimately incorporated with the viscid semi- 
transparent matter. The sputum is thus distinguished from that of bron- 
chitis, which is often streaked with blood. The expectorated matter comes 
from the minute tubes, and is the result of a slow exudation from the in- 
flamed vessels, during which the intimate admixture of its constituents takes 
place. It contains a large proportion of coagulated fibrin. Dr. R. Remak 
has observed that the expectoration of pneumonia, if carefully examined in a 
dark-coloured flat vessel filled with water, or upon a dark glass plate, will 
always be found to contain ramifying tubular coagula, corresponding with 
the minute bronchia in which they have been formed. (Brit. and For. Med. 
Rev., April, 1847, p. 505.) When catarrhal symptoms are mingled with 
those of pneumonia, there is often a more copious expectoration of transparent 
and sometimes frothy mucus; and, in such cases, portions of the true pneu- 
monic expectoration may be seen mixed with the catarrhal in the cup, one 
being thrown up at one time and the other at another. As the complaint 
advances, the secretion increases, but seldom becomes very copious in pure 
pneumonia. In the latter stages, the expectoration sometimes again becomes 
more scanty. Occasionally it is purulent, either in consequence of a changed 
secretion of the bronchial tubes, or, as I am disposed to think, of a discharge 
of the pus of the vesicles. In some rare cases, it becomes all at once puru- 
lent and copious, from having been previously scanty and albuminous. The 
quantity of matter is sometimes so large as to overwhelm the debilitated 
lungs, and thus to prove suddenly fatal. This result occurs more especially 
in very young children. It indicates the opening of an abscess into the 
bronchial tubes. This was formerly thought to be common; but has been 
proved by dissection to be a rare event in pneumonia. Sometimes, instead 
of the characteristic viscid sputa, we see a copious expectoration of a uniform 
liquid, like mucilage, which is more or less tinged with blood. Towards the 
close of bad cases, this assumes occasionally a dark appearance, like that of 
liquorice dissolved in water, to which it is compared by Andral. This is 
usually a fatal symptom. A fetid odour of the expectoration indicates gan- 
grene, but is very rare.* 
In relation to the decubitus, the patient most frequently lies on the back, 
with his head and shoulders somewhat raised. Sometimes, however, he pre- 
* Dr. Boling, of Montgomery, Alabama, has noticed in many cases of pneumonia, an 
appearance in the mouth, which he considers characteristic. " It consists of a deposi- 
tion on the teeth, just along the margin of the gums, of a matter of diiferent shades of 
colour, from a light orange to a dull vermilion, forming a line about the sixteenth of 
an inch wide, of a deeper tint at the gums, and paler as it recedes." He suggests that 
the miasmatic poisoning of the system in the pneumonia of the south, may lead to its 
production. (Am. Journ. of Med. Sci., N. S., xxiv. p. 278.) 
An observation originally made by Dr. Redtenbacher, in relation to the absence of 
chloride of sodium from the urine in pneumonia, has recently been confirmed by Mr. 
L. S. Beale, of London. The salt disappears from the urine when hepatization begins. 
Mr. Beale ascertained, as the result of numerous trials, that the chloride returns soon 
after resolution has taken place, that at the period of its absence there is more of 
the salt in the serum of the blood, and that the sputa contain a larger proportion than 
healthy mucus; and infers that the absence of the salt from the urine depends on its 
determination to the inflamed portion of the lung. (Land. Medico-Chirurg. Trans., xxxv. 
374.)-Note to the fourth edition. CLASS III.] 
PNEUMONIA. 
11 
fers lying on the side, and, in the case of inflamed pleura, on the one opposite 
to that affected. 
Fever is an almost uniform accompaniment of severe cases; and, in some 
instances, constitutes, with increased frequency of respiration, the only obvi- 
ous affection. It varies extremely in degree, being sometimes so mild as 
almost to escape notice, and sometimes in the highest degree intense. It is 
very often attended with flushed cheeks and pain in the head, especially 
about the brows or forehead, from which the patient may even suffer more 
than from the pain in the chest. Occasionally, the headache is the only 
symptom of which the patient complains for the first few days. Delirium 
now and then occurs, and is usually an unfavourable sign. The fever often 
has a remittent character; the exacerbations occurring daily, for the most 
part towards evening, and accompanied with increase of pain, cough, dyspnoea, 
and bloody expectoration. The pulse is usually full, strong, and only moder- 
ately accelerated; but it is sometimes very frequent even from the commence- 
ment, and in the latter case is apt to be smaller and less vigorous. It 
sometimes reaches one hundred and forty in the adult. Blood drawn from 
the arm is almost always buffed, and not unfrequently strongly cupped ; or, 
if it has not this character at the commencement, very soon acquires it. The 
skin is usually hot and dry, though occasionally moist. The urine is generally 
scanty and high-coloured. Thirst and loss of appetite are almost universal. 
The tongue is generally moist and coated with a white or yellowish-white fur; 
but is sometimes clammy, or dry and red. Vomiting and diarrhoea are occa- 
sional symptoms, the latter more especially in the advanced stage; but both 
are accidental. Frequently the patient is prostrated from the commencement 
of the attack; but, in mild cases, he sometimes keeps upon his feet for several 
days before taking to his bed. 
The physical signs are of the highest importance in the diagnosis of pneu- 
monia. The disease is often very obscure; and, before the discovery of the 
processes of percussion and auscultation, many cases ran their whole course 
quite unsuspected. Cough and pain in the chest are sometimes wanting; and 
fever with headache and hurried respiration, which are common to this with 
numerous other diseases, are the only observable phenomena.. Even the 
symptom of viscid and rusty sputa often fails us. Either the patient swal- 
lows the expectorated matter, as generally happens in infants; or no expecto- 
ration whatever may take place; or the discharge, from a predominance of 
catarrhal or hemorrhagic affection, may want the characteristic properties. In 
many of these cases, percussion and auscultation combined afford sure evidence 
of the nature of the disease. Yet even these do not always succeed; as, for 
example, when the inflammation occupies an interior portion of the lung, and 
is everywhere surrounded by healthy structure. For an explanation of the 
terms employed in the following remarks, the reader is referred to the obser- 
vations preliminary to the pectoral diseases. (See Vol. i. page 753.) 
In the first stage, or that of congestion, percussion affords little evidence 
of the condition of the lung. There is usually a slight diminution of the 
healthy resonance, but not so decided as to serve for a ground of diagnosis. 
A sense of diminished elasticity is imparted to the finger, when this is used 
as the pleximeter.* But auscultation is much more decisive. By this it may 
* According to Skoda, alteration of the sound does not take place from mere conges- 
tion, but is first perceived when exudation has begun, and is then somewhat tympanitic, 
so long as the portion of lung affected still contains air; and this tympanitic character 
of the percussion sound sometimes continues, even after it has become quite dull. No 
change will be perceived in the percussion sound, or in the sense of resistance, unless 
the infiltrated tissue is in contact with the thoracic wall, and at least an inch thick.- 
{Note to the fourth edition.) 12 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[part II. 
be discovered that the healthy vesicular murmur has given place to the cre- 
pitant rale, though the former may be sometimes heard mingling feebly with 
the latter, before it is quite lost. The crepitation is more distinctly audible 
the nearer the disease happens to be to the surface of the lung. It is gene- 
rally stated to be heard only during inspiration. Though it may at first be 
confined to the beginning of the inspiration, it soon extends throughout that 
movement. It is certainly extremely rare in expiration, and the analogous 
sound of capillary bronchitis and resolving hepatization, which belongs to the 
subcrepitant rale, has probably been mistaken for the true primary crepitant 
rale by those who suppose they have observed it in expiration. It should be 
recollected, as mentioned in the preliminary observations, that a full inspira- 
tion will often develope the crepitus, when not perceptible in ordinary breath- 
ing. This is the characteristic sound of pneumonia. Whenever it is heard, 
the existence of pulmonary inflammation is indicated; and the progress of this 
affection can be traced, with considerable accuracy, by marking the progress 
of its attendant sound. In some cases, however, of ordinary genuine pneu- 
monia, it cannot be discovered, even though the disease may be observed from 
the commencement; probably, as suggested by Dr. Walshe, in consecjuence 
of the rapidity with which the vesicles are filled with the exudation. About 
the inflamed part, when crepitation has not yet become manifest, a weakness 
of the respiratory murmur sometimes indicates the commencement of conges- 
tion. In other parts of the chest, the respiration is often puerile; and Dr. 
Stokes observed that this greater loudness of the natural murmur precedes 
the occurrence of the crepitant rale, an effect probably ascribable to the nar- 
rowing of the minute tubes, while the vesicles yet remain empty, so that the 
air has a more than usually rapid movement. According to Dr. Boling, of 
Montgomery, Alabama, a fine mucous or crepitant rale, heard in the larynx, 
even at some distance from the patient, persisting notwithstanding efforts at 
expectoration, and without evidence of disease or of the presence of mucus 
itself in the larynx, is a sign of pneumonia affecting the apex of the lung. 
One of the characters by which this sound may be distinguished from that 
produced by the presence of mucus in the larynx, is the perfect indifference 
of the patient, who makes no effort to clear his throat, unless prompted to do 
so. (dm. Journ. of Med. Sci., N. S., xiv. 125.) 
As the disease advances into the second stage, the crepitation ceases; and, 
the respiratory murmur having been previously abolished, either no sound is 
heard or only that of bronchial respiration, which is one of the cbaracteristie 
signs of hepatization. Dr. James Jackson, of Boston, observed that the expi- 
ratory murmur became prolonged and somewhat blowing, before the true 
bronchial respiration was established; and Grisolle states that, of twenty-four 
cases which he carefully examined, twenty-one presented the expiratory sound 
exclusively, before the respiratory murmur became in any degree bronchial. 
It is only in a comparatively few instances, that the ear is sensible of no other 
impression than the one produced by the rise and fall of the walls of the chest. 
This happens sometimes when the inflammation occupies the lowest portion 
of the lung where there are no large tubes, or the whole lung, so that respi- 
ration ceases on the side affected. Usually the bronchial respiration is heard 
distinctly. It is loudest when the parts surrounding the larger tubes are in- 
flamed, as near the root of the lung. The sound is owing to the consolidation 
of the inflamed structure, enabling it to convey to the ear the tubal vibrations, 
which, in the ordinary condition of the parenchyma, are arrested in its spongy 
texture. In some instances, during the passage of the congestion into hepati- 
zation, before the latter condition is fully established, the crepitant rale and 
bronchial respiration are mingled together, and give rise to a sound which has CLASS III.] 
PNEUMONIA. 
13 
been compared to that produced by the tearing of taffeta. Not uncommonly, 
while the bronchial sound is heard in one part, generally near the centre of 
inflammation, crepitation is audible in another, which is usually on the boun- 
daries. 
Besides the bronchial respiration, there is also a stronger vocal resonance in 
the stage of hepatization; the vibration produced in speaking being conveyed 
more readily through the condensed structure. Bronchophony is therefore 
another characteristic of the second stage. Should the patient be unable to 
speak, it is asserted that the resonance occasioned by the operator's own voice 
is conveyed more distinctly to the ear applied to the chest, than in a healthy 
state of the lungs. Still another important character of this stage is the 
greater vibration of the walls of the chest when the patient speaks or coughs, 
rendered sensible by placing the hand upon the chest over the part affected. 
Should the hepatization, however, be very extensive, I have noticed that this 
impression is scarcely felt in the more distant parts. But quite as important 
as either of the above signs is that yielded by percussion in this stage. In- 
stead of the slight diminution of clearness observed in the state of congestion, 
we have now decided dulness, and sometimes even perfect flatness in the parts 
most consolidated. 
In some instances, the bronchial respiration and bronchophony are wanting, 
perhaps in consequence of a filling up or obstruction, at some particular point, 
of the bronchial tubes entering the hepatized portion of the lung, so that the 
condition on which those sounds depend does not exist. Occasionally the sounds 
referred to may be heard at one time and not at another, in the same condi- 
tion of the hepatization. This may be owing to an alternate obstruction and 
opening of the tube, through the alternate presence and removal of concrete 
mucus, or from other cause. Dr. Walshe states that he has traced it, in one 
case, to a pressure on the main tube, acting at different times with different 
degrees of force. 
Should the disease be arrested in the stage of congestion, the crepitant rale 
gradually ceases, and the respiratory murmur of health is restored. After the 
establishment of hepatization, should resolution of the disease take place, the 
bronchial respiration and bronchophony vanish by degrees, and the crepita- 
tion returns, in general, however, somewhat modified, and assuming the cha- 
racter of the subcrepitant rale, in consequence of the more fluid nature of the 
secretion. This sound in its turn gives way to the respiratory murmur, the 
return of which, together with the healthy resonance upon percussion, is evi- 
dence of a restoration of the lung to its. healthy state. In some instances, 
there is a direct passage from the bronchial respiration to the healthy murmur, 
without the intervention of crepitation. 
The third stage cannot be distinguished by the physical signs, so long as 
the pus remains diffused in the parenchyma, constituting the gray hepatiza- 
tion of Laennec. It presents the same flatness on percussion, and the same 
respiratory sounds. The supervention, however, of a mucous rale upon the 
bronchial respiration, might sometimes lead to the suspicion that the concrete 
exudation with which the cells are filled in the second stage, has been replaced 
by the pus of the third stage. Should an abscess have formed, and opened 
into the bronchia, a gurgling rale, if the cavity contain a liquid, and pecto- 
riloquy with cavernous respiration, if it be empty, will be the diagnostic 
signs. 
To revert to the ordinary symptoms, should the disease yield to treatment 
in the congestive stage, as it sometimes begins to do on the second, third, or 
fourth day, the pain disappears, the expectoration becomes more copious, and 
more of the character of ordinary mucus, the frequency of the pulse and other [PART II. 
14 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
febrile symptoms diminish, the tongue begins to clean, and convalescence may 
be established in less than a week; though the disease may run on for two or 
three weeks, before all the symptoms disappear. A fatal result very'seldom 
happens in this stage, and only when a large portion of the lungs is involved 
at once. In the great majority of cases, the first stage advances to that of 
consolidation. This comes on at various periods from the commencement of 
the attack, but generally in from one to three days, and seldom so late as a 
week. The change is not marked by any very obvious general symptoms. 
There may be some increase of dyspnoea, frequency of respiration, fever, and 
debility, and the countenance may assume a duller expression, and a darker- 
red or more dusky hue. The pain, instead of increasing, is not unfrequently 
diminished. If the disease now advances, it passes into the stage of suppu- 
ration. This happens at a variable period, usually some time in the course 
of the second week, though occasionally in old persons so early as on the fourth 
or fifth day, and in other cases not before the end of the third week. There 
is no certain sign by which the accession of the third stage can be distinctly 
marked. But, generally speaking, the difficulty and frequency of respiration 
increase, so that the patient is compelled to lie with his shoulders elevated, or 
to maintain a half sitting position; the pain often quite vanishes; the expectora- 
tion diminishes in quantity, or becomes purulent, or assumes the appearance 
of a dark turbid liquid, or ceases altogether in consequence of the debility of 
the patient, which disables him from coughing up the secreted matter; the 
countenance becomes pale and haggard, and the pulse extremely feeble and 
rapid; the skin is bathed with a cold sweat; and death occurs, preceded by 
the rattling of accumulated mucus in the chest, while the mind usually re- 
mains clear to the last. Such is often the course of fatal cases; but much 
more frequently the disease takes a favourable turn in the second stage, per- 
haps at the end of a week from the commencement; and in four or five days 
more, convalescence is established, though not unfrequently the case is pro- 
tracted to two or three weeks, and occasionally the patient retains one or more 
of the symptoms for a considerable time, such as cough, dyspnoea, pain upon 
full inspiration, or a frequent pulse. It has been doubted whether recovery 
ever takes place from the state of diffused suppuration, usually constituting 
the third stage: but, when not yet advanced to complete disintegration of the 
tissue, I can see no impossibility in this result; and the course of the symp- 
toms, such as we occasionally observe them, including night sweats and puru- 
lent expectoration, in severe and protracted cases which nevertheless recover, 
has convinced me of the fact. That when the inflammation terminates in 
abscess, recovery frequently takes place, cannot be doubted; and the reason 
obviously is, that abscess is only apt to occur when the extent of inflamma- 
tion is moderate. Such instances are more frequent than the rarity of ab- 
scesses in post-mortem examination might lead us to imagine. Laennec states 
that he met with more than twenty cases of abscess in one year, all of which 
recovered except two. 
The return to health in pneumonia is frequently marked by the occurrence 
of certain discharges, or of other phenomena considered critical. Among these 
is a disposition in the urine to let fall a deposit upon cooling, and, as has been 
asserted, to coagulate with heat and nitric acid, showing the presence of albu- 
men, which is sometimes very abundant. But Dr. Walshe states that, though 
albumen may exist in the urine in small quantities at different periods of the 
disease, his own observations prove that there is no connexion between its ap- 
pearance and the occurrence of convalescence. A return of chloride of sodium 
to the urine, after an absence during the progress of the inflammation, may be 
considered a favourable sign. Copious perspiration, diarrhoea, epistaxis and CLASS III.] 
15 
PNEUMONIA. 
other hemorrhages, cutaneous eruptions, especially herpes about the lips, 
boils, and large abscesses, are also mentioned among the critical symptoms. 
Relapses are not uncommon in this disease. 
Various modifications of the symptoms above enumerated occur, some of 
which will be noticed under the heads which immediately follow, but others 
may be more conveniently considered here. In double pneumonia, the dys- 
pnoea is usually much greater than when only one lung is affected, the general 
strength is more depressed, and the countenance more expressive of anxiety. 
As the pain is often felt only upon one side, the case is liable to be mistaken 
for single pneumonia; but the physical signs will always enable the practi- 
tioner to come to a just conclusion. It should be recollected that, as the dul- 
ness may be about equal over both lungs, we are deprived of the advantage 
ordinarily derived from a comparison of the two sides. 
In some cases, the inflammation is situated in the centre of the lung, or at 
the mediastinum, so that it comes into contact at no point with the exterior 
surface. The symptoms are, in these cases, the same as in the ordinary form 
of the complaint, except that the acute pleuritic pain is wanting. The phy- 
sical signs here sometimes fail, in consequence of the intervention of the 
healthy tissue of the lung between the diseased portion and the ear. Perhaps 
a very expert hand may elicit by percussion the flat sound from its depths; 
perhaps a very acute and exercised ear may distinguish the far off crepitant 
rale through the superficial vesicular murmur; but most operators will be 
unable to detect the hidden disease by these means. When, therefore, all 
the ordinary symptoms of pneumonia, including the viscid and rusty sputa, 
and excepting only the acute pain, are observed in any case in which percus- 
sion and auscultation fail to yield any signs, we may conclude that the dis- 
ease occupies the interior of the lung. Such instances are rarely observed 
in dissection; for, when the inflammation is sufficiently extensive to prove 
fatal, it almost always reaches the surface before death. Walshe considers 
exaggerated normal respiration, in these cases, proceeding from the interven- 
ing healthy lung, as a sign of some value. 
Pneumonia is somewhat modified in its symptoms when it occurs in per- 
sons greatly debilitated by old age or other cause. It often happens, under 
these circumstances, that there is no acute pain, and little or no expectora- 
tion, and that any matter that may be coughed up wants the appearance 
which characterizes that of ordinary pneumonia. The only local symptoms 
are a little cough, dyspnoea, and hurried breathing, with some fever; and 
even these are sometimes wanting. Great prostration, a small and irregular 
pulse, sunken features, a pale or livid complexion, and a certain degree of 
mental aberration, may generally be observed, but afford an insufficient basis 
for a certain diagnosis. The crepitant rale, moreover, is apt to be obscured 
by mucous sounds, and bronchial respiration is from the same cause less 
observable; but the dulness on percussion, taken in connexion with the other 
phenomena, will be sufficiently distinctive. This form of the disease is very 
fatal. The patient sometimes sinks with great rapidity; and cases now and 
then occur in which the system never efficiently reacts after the depression 
of the chill. The cases denominated hypostatic have something of the same 
character. They arise from a mechanical congestion, consequent upon a long- 
continued position upon the back, in states of great debility. A low inflam- 
mation is produced, with few of the general signs; and the physician has to 
rely chiefly on the absence of the respiratory murmur, the occasional presence 
of bronchophony, and the flatness on percussion. The same remarks are ap- 
plicable to the pneumonia which sometimes comes on near the termination of 
other diseases, and sometimes at the very close of life. Inflammation of the 16 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[part II. 
lungs is very often complicated with other pectoral diseases, and especially 
with bronchitis, pleurisy, and pericarditis. 
2. Lobular Pneumonia.-Infantile Pneumonia.-The diagnosis of this 
variety of pneumonia is much more obscure than that of the preceding. It 
occurs, as shown conclusively by Dr. Gerhard, most commonly in children 
under the age of six; and, though it may in some rare instances be observed 
in adults, it may be emphatically entitled the pneumonia of infancy. After 
the age mentioned, the disease almost always assumes the common or lobar 
form. (Am. Journ. of Med. Sci., xiv. 330.) The age of the subjects has a 
great effect in embarrassing the diagnosis in lobular pneumonia. Children 
seldom expectorate, or at least they are apt to swallow what they raise from 
the lungs, so that the pulmonary secretions are not brought to light. It is 
difficult to ascertain whether they have pain, and what is the seat of it; and 
their constant movements and frequent cries often render the results of per- 
cussion and auscultation uncertain. Besides, the symptoms of the disease 
itself are often obscure. The matter of expectoration, when visible, instead 
of having the peculiar properties of that of ordinary pneumonia, rather resem- 
bles the mucus of catarrh. Pain is often wanting. The disease too is very 
often a mere consequence of other diseases, and is apt to escape especial 
notice, because the attention of the physician has received another direction. 
It has not unfrequently been unknown and even unsuspected, until revealed 
by dissection after death. It is probable, however, that many of those cases 
which have been considered as pneumonia only upon post-mortem examination, 
were, in fact, merely instances of that fetal consolidation of the pulmonary 
tissue, described by Bailly and Legendre, and referred to under the head of 
the anatomical characters of the disease. (Seepage 7.) 
Sometimes the disease begins frankly with fever, hard cough, hurried breath- 
ing, and pain indicated by the crying of the child when he coughs. But 
much more frequently the disseminated points of inflammation are insufficient 
to bring the constitution into decided sympathy, or the slight symptoms pro- 
duced are confounded with those of some previously existing disease, such as 
catarrh, measles, hooping-cough, &c. But, when the complaint is somewhat 
advanced, fever sets in, with a very rapid pulse, very frequent respiration, 
flushed face, contraction and expansion of the alee nasi, often great restless- 
ness, a frequent and sometimes painful cough, in some instances hard and dry, 
in others loose, but generally without expectoration. The pulse is scarcely 
ever under 120, sometimes as high as 140, 160, or even 180 in the minute, 
but usually regular. The number of respirations varies usually from 40 to 60, 
or 70, but is sometimes considerably greater, and has been known to exceed 
100. If the complaint now advances, the powers of the system begin to fail, 
the cough becomes feeble or quite suppressed, the voice can scarcely be heard, 
the cries grow faint or cease altogether, the pulse becomes exceedingly small 
and weak, the respiration irregular and sometimes interrupted with deep sigh- 
ing, the extremities cold, the face pale or livid, and death soon takes place, 
usually preceded by a period of drowsiness or stupor. Should the disease, on 
the contrary, take a favourable turn, all the symptoms begin to improve in 
about a week, more or less, and the child gradually returns to health. The 
duration of the disease is almost always longer than that of the ordinary form of 
pneumonia, often extending to two or three weeks before death or recovery. 
Sometimes it is much more protracted. Occasionally abscesses are formed, 
and, discharging suddenly, either overwhelm the lungs and produce sudden 
death, or are followed by purulent expectoration, severe cough, night sweats, 
hectic fever, and emaciation, until at length the child sinks exhausted, or, as 
sometimes happens under judicious treatment, returns gradually to health, after 
a struggle of several months' duration. CLASS III.] 
17 
PNEUMONIA. 
In the earliest stage of the disease, the physical signs often fail entirely to 
detect it; but, at a more advanced period, they become important and even 
indispensable aids to a just diagnosis. The crepitant rale is rarely heard, being 
covered by the mucous sounds, which are always audible in a greater or less 
degree. The most characteristic auscultatory sign is the subcrepitant rale, 
which is usually heard throughout the complaint, here and there all over the 
lungs, and is sometimes so fine as to approach closely to the crepitant. Should 
the proper crepitation of pneumonia be detected in distinct spots of the chest, 
with healthy respiration around them, it would be a clear indication of the 
nature of the complaint. In the advanced stages, bronchial respiration may be 
heard in the upper part of the lung, and there is an unhealthy resonance of the 
cry over the chest, which is one of the characteristic phenomena. Dr. G-erhard 
describes, as a peculiarity of this form of pneumonia, a modification of the res- 
piration, consisting in "a short, obscure blowing" inspiration, " almost without 
the vesicular murmur," with an indistinct expiration. (Am. Journ. of Med. 
Sci., xv. 100.) Percussion, which is wholly useless in the early stage, now 
becomes a valuable sign. There is dulness, and often perfect flatness, on the 
posterior part of the chest, usually equal on both sides. Should the operator 
be doubtful, in consequence of the equality of the sound on the two sides, and 
the want of a point of comparison, he may compare the sounds elicited with those 
of a healthy chest. Both in auscultation and percussion, he should direct his 
examination especially to the posterior part of the chest. In some cases of 
the disease, especially those occurring in the course of chronic complaints of 
debility, the general symptoms are so very slight and uncertain, that the phy- 
sical signs afford the only positive evidence of the existence of the affection. 
3. Bilious Pneumonia.-Bilious Pleurisy.-Pneumonia is not unfrequently 
associated with symptoms of bilious derangement. These may arise from 
different causes. When the inflammation occupies the lower portion of the 
right lung, an irritant if not inflammatory action is sometimes extended to the 
upper portion of the liver, and the symptoms of pneumonia become compli- 
cated with those of hepatitis, or at least of deranged hepatic function, such as 
pain and tenderness upon pressure in the right hypochondrium, pain in the 
right shoulder, nausea and vomiting, yellowness of the eyes and skin some- 
times amounting to jaundice, and deep-coloured, yellowish-brown urine. In 
other instances, a similar complication occurs in consequence of pneumonia 
supervening upon hepatic disease, as not unfrequently happens during the 
colder seasons in malarious countries. 
But by far the most frequent form of bilious pneumonia is that which 
occurs as an associate of remittent or intermittent miasmatic fevers. This is 
a very common disease in the miasmatic regions of the United States; and is 
especially prevalent in the cold seasons, in the low-lying parts of the western 
and southern sections of our country. The pneumonia may either be second- 
ary, making its appearance after the fever has set in, or it may be primary, 
and, by the disturbance which it excites in the system, call the pre-existing 
tendencies to the miasmatic fever into action. It occurs usually in the latter 
part of the autumn, in the winter, or in the early spring months, and appears 
to be caused by vicissitudes of the weather, acting on a predisposition acquired 
by exposure to malarious influences during the summer and early fall. It 
is most frequent and fatal in seasons which follow an unusual prevalence of 
bilious fever. It is very common among the black and coloured population 
of the South. The name by which this complicated disease is perhaps most 
generally known in our country is bilious pleurisy. From the frequency of 
acute pain at the commencement, there can be no doubt that, as in ordinary 
pneumonia, the disease of the lune is often attended with inflammation of the 18 
[PART II. 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
pleura; and it is possible that, in some instances, the inflammation may be 
confined chiefly to that membrane; but generally the lungs are most deeply 
involved, as shown by the bloody expectoration, the physical signs during 
life, and the results of post-mortem examination. 
The pectoral symptoms and physical signs do not materially differ, in this 
form of pneumonia, from those already described as characteristic of the un- 
complicated disease. It is not necessary, therefore, to repeat them. The 
peculiarities are those derived from the miasmatic complication. In those 
cases in which the fever is the primary affection, the chill and febrile symp- 
toms generally precede those proper to the pneumonia for one, two, or three 
days, and sometimes a longer period. In other instances, the pneumonia and 
bilious symptoms pursue an even march. When the complicated disease is 
established, we have usually, besides the signs of pulmonary inflammation, 
more or less of the following symptoms: viz., headache, a yellowish, or yel- 
lowish-white fur on the tongue, nausea and vomiting sometimes of bile and 
sometimes of the ordinary gastric fluids, a more or less yellowish tinge of the 
skin and conjunctiva, often a brownish colour of the face arising from the 
mixture of the pneumonic redness with the icterode hue, and a deep-coloured, 
yellowish-brown urine. The fever is always remittent, generally with daily 
paroxysms, which, howTever, are often more severe on the alternate days ; and 
occasionally the remission is so considerable, that the disease appears almost 
in the form of a quotidian or tertian intermittent. In the latter cases, we 
may consider any existing fever in the intervals as sustained by the pulmo- 
nary inflammation. The grade of inflammatory action is in general less ele- 
vated than in ordinary pneumonia, and sometimes the fever assumes a typhoid 
character; the pulse becoming feeble, the tongue brown and dry, and the 
mind often somewhat wandering. The Cases of intermittent pneumonia, 
spoken of by writers, probably belonged to this variety of the disease. Under 
proper treatment, bilious pneumonia generally terminates favourably; though 
it may prove exceedingly fatal, when associated, as it sometimes is, with the 
more malignant forms of miasmatic fever. 
5. Typhoid Pneumonia.-Occasionally pneumonia, occurring in persons 
with enfeebled constitutions, or who have been exposed to certain depressing 
influences calculated to impair the condition of the blood, puts on that cha- 
racter of feebleness and depravity, which, for want of a better term, is usually 
denominated typhoid. More frequently, perhaps, it is developed in the course 
of an attack of typhus fever, or other malignant disease, which necessarily 
influences the nature of the local affection. In either of these cases, the 
pulmonary inflammation is distinguished by the name of typhoid pneumonia. 
It was a mistake to attach the title of pneumonia typhoides, as was done by 
some of our medical writers, to the malignant epidemic which prevailed in 
many parts of the United States, between the years 1807 and 1820. It is 
true that the disease was in many instances attended with pneumonia; but 
so also was it attended with other inflammations, and very frequently ran its 
whole course without any inflammation whatever. It was properly typhus 
fever, and the pulmonary affection was merely an incidental accompaniment. 
In all such cases, we may speak of the pneumonia as typhoid, but wre must 
guard ourselves against considering it as the main disease, and especially 
against the practical error of treating it as such. 
In typhoid pneumonia, most of the local symptoms do not materially differ 
from those of the disease in its ordinary form. There are pain, dyspnoea, 
and cough; and the pain may be either acute or obtuse; but there is occa- 
sionally this peculiarity, that severe neuralgic pains are superadded, which 
are not necessarily confined to the exact seat of inflammation, but may be CLASS III.] 
19 
PNEUMONIA. 
felt even on the opposite side, and sometimes extend beyond the chest, down 
the back or sides, and even to the extremities. In many instances, however, 
painful sensations are quite wanting; and the local symptoms are in general 
masked, to a considerable degree, by the obtuseness of sensibility consequent 
upon the state of the brain. Another very striking peculiarity is the charac- 
ter of the matter expectorated. Even in the early stage, it is generally 
bloody, and sometimes almost pure blood. In all stages, it is less viscid, and 
usually more copious than in ordinary pneumonia. Not unfrequently it is 
brown or even blackish, and sometimes fetid. Either from want of energy 
in the vessels, or from the character of the circulating blood, there appears to 
be an oozing of this fluid, little changed, through the capillaries, instead of 
the somewhat plastic lymph that is exuded in vigorous inflammation. The 
general symptoms are those of depression. The pulse, though sometimes 
sufficiently full in the beginning, is weak and readily compressible, and sinks 
rapidly under the loss of blood. Further on in the disease, it is frequent, 
small, and very feeble. The skin is hot and dry, or cold and clammy, and 
not unfrequently covered with petechias. The pneumonic flush of the face, 
if it exist, is dark and dusky. The tongue is covered with a brownish fur, 
and in the advanced stages is dry; while the teeth, gums, and even lips are 
often incrusted with a dark sordes. The evacuations are generally dark and 
offensive. There is throughout an obtuse condition of intellect, often ex- 
pressed in the countenance, and degenerating towards the close into stupor or 
low delirium. The physical signs are dulness on percussion, and the loss of 
the respiratory murmur, with little or none of the crepitant rale, the place of 
which is supplied by the mucous sounds, or those arising from diminished 
caliber of the tubes. The consolidation of the lung is most commonly found 
in the posterior portion of the chest. Drs. Graves and Stokes have observed, 
in certain cases of pneumonia, especially of the typhoid form, a tympanitic 
sound of the chest succeeding dulness, and accompanied with an absence of 
respiratory murmur, showing the existence of air in the cavity of the pleura 
(Stokes, Diseases of the Chest, p. 333); and a similar case occurred to myself 
in the Pennsylvania Hospital, not precisely typhoid, though with a feeble 
state of system, in which the tympanitic sound extended above the nipple. 
This patient recovered. Recovery, though not unfrequent, is generally slower 
than in the sthenic forms of the disease; and the solidified portion of the 
lung is longer in undergoing resolution. 
This affection occurs most frequently in the course of malignant epidemics; 
but sporadic cases of it are now and then observed, as, for example, under 
those influences which produce a scorbutic state of system, or from the action 
of the sedative and poisonous gases, among which sulphuretted hydrogen is 
perhaps the most deleterious. 
6. Chronic Pneumonia.-1This is comparatively rare, and some doubts 
even of its existence have been expressed. But cases of protracted disease 
of the lungs following acute pneumonia, and running on for months or even 
years, do occasionally occur; and physical exploration shows that, in these 
cases, the lung still remains consolidated in the situation of the original 
hepatization. In a case of this kind occurring in a young woman under my 
care, the disease was confined exclusively to the upper lobe of the right lung, 
which was in no degree tuberculated. There is occasional pain in the part 
affected; but it is seldom steady, and is sometimes quite wanting. There 
is always, however, when the disease is at all extensive, more or less dys- 
pnoea, which is occasionally considerable, and is greatly increased by exer- 
tion. In the case of a female which occurred to me in the Pennsylvania 
Hospital, in whom the whole of one lung appeared to be consolidated, it was 20 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[part II. 
the only prominent symptom. The cough is usually moderate, either with 
or without expectoration, and the matter thrown up is mucus or pus, but not 
viscid or rusty. There is generally some frequency of pulse, with a little 
febrile heat towards evening. The appetite is impaired but not lost. The 
patient has usually sufficient strength to enable him to walk in the apart- 
ment, and sometimes to keep about. Occasionally hectic symptoms set in, 
and pus is expectorated in considerable quantities. When tubercles are not 
generated, there may always be hope for the patient. The physical signs 
are dulness or entire flatness on percussion, the absence of the respiratory 
murmur, and, when the consolidation is extensive, the want of all respiratory 
sounds, and even of vocal resonance in the distant parts of the lung. But, 
near the borders, bronchial respiration and bronchophony may be heard, and 
the hand upon the chest perceives a decidedly stronger vibration from the 
voice than upon the healthy side. In favourable cases, the return of respi- 
ration is generally first perceived in the upper portion of the chest, and gra- 
dually extends downward with the resolution of the solidified lung. 
A variety of chronic pneumonia has been described, which is characterized 
by an infiltration of the interlobular cellular tissue with fibrinous matter, 
which becomes indurated, causing contraction of the lung, obliteration of the 
air-vesicles, and sinking in of the side. It is the "cirrhosis" of Dr. Corri- 
gan. The characters by which this may be distinguished from chronic pneu- 
monia of the more common kind are mainly the retraction of the side, and 
the physical signs connected with dilated bronchia which usually attend it. 
( Walshe on Diseases of the Lungs and Heart, p. 337.) In a case described 
by Dr. Gairdner, the dilated portions of the bronchia had undergone a disor- 
ganizing process, their mucous membrane having been destroyed, and the 
muscular fibre split and separated so as to form a lining for the cavity. (Ed. 
Month. Journ. of Med. Sei., March, 1853, p. 267.) 
The diseases with which pneumonia is most liable to be confounded are 
bronchitis, pulmonary oedema, pleurisy, and certain states of phthisis. It 
will be sufficient here to mention the characters by which the disease may 
be distinguished from bronchitis. In reference to the other affections, the 
reader is referred to the articles respectively in which they are treated of. 
It is in cases of bronchitis extending to the minute ramifications of the 
bronchia, that the greatest resemblance is presented to pneumonia. But, in 
the former affection, the sensations are more those of soreness than acute 
pain, and are usually seated in the anterior and upper part of the chest, be- 
hind and in the vicinity of the sternum; the expectoration, though some- 
times streaked with blood, never has the extremely viscid and rusty character 
of the sputa of pneumonia, and when it once begins is much more copious; 
no true crepitant rale is heard, but instead of this the dry and mucous rales; 
there is no bronchial respiration or resonance, and very seldom a permanent 
want of the respiratory murmur in any part of the chest; and finally there 
is no considerable dulness on percussion. But not unfrequently the two 
diseases are combined; and, when the pneumonia is in the centre of the 
lung, or disseminated, it is sometimes difficult if not impossible to distinguish 
between them. 
Diagnosis. 
In cases of primary pneumonia, of the common or lobar kind, occupying 
only a portion of a single lung, occurring in persons of a good constitution, 
and without complication of any kind, there is every reason to hope for a 
Prognosis. CLASS III.] 
21 
PNEUMONIA. 
favourable issue. Cases of this kind almost always end in recovery under 
proper treatment, and not unfrequently even without remedies, or with such 
as are improper. The disease appears to be remarkably mild between the 
ages of six and twenty-one. Of forty cases observed by Dr. Gerhard and M. 
Bufz, in the Children's Hospital at Paris, occurring in children from six years 
old to the age of puberty, only one terminated in death. (J.771. Joum. of Med. 
Sci., xiv. 330.) In debilitated persons, and in those above fifty years, the 
disease is much more fatal. In very advanced age, it is extremely dangerous. 
It is said to be more unfavourable in its termination in the upper than in the 
lower lobes. The danger is much increased when the whole of one lung is 
affected; and in double pneumonia it is always very great. It is more apt 
to terminate fatally in hospitals than in private practice, chiefly, in all pro- 
bability, in consequence of the previously shattered constitutions of the pa- 
tients, and of the advanced stage at which it is brought into the wards, after 
previous neglect or ill treatment. In tuberculous subjects, or those having 
the scrofulous diathesis, pneumonia is sometimes attended with copious tuber- 
culous deposition, which, under these circumstances, may be considered as 
inevitably fatal, and often runs a very rapid course. Secondary pneumonia 
is much more fatal than the primary, and the lobular than the lobar variety; 
but the greater danger of the lobular, independently of the fact that it is 
more liable to escape notice, and therefore not to be treated properly, is owing 
to the fact, that it is generally secondary, and is apt to occur in debilitated 
constitutions. In bilious pneumonia, the fatality probably depends more 
upon the febrile disease, of which it is a mere accompaniment, than upon the 
pulmonary inflammation. Though it generally yields very happily to reme- 
dies, yet, if improperly treated, it is sometimes extremely dangerous, espe- 
cially in cases in which a typhoid or malignant tendency complicates the 
disease. The same remark may be made of typhoid pneumonia. When 
associated with a malignant epidemic it is often very fatal. But, when ori- 
ginating in local or accidental causes, it may be comparatively mild. It has 
occurred to me to attend between twenty and thirty persons of various ages, 
from childhood to middle life, in an institution in Philadelphia, all affected 
in one season with typhoid pneumonia of various grades, and all of whom re- 
covered. The cause of the disease, so far as could be ascertained, was an 
excessively offensive exhalation which filled the whole house, and proceeded 
from a cellar into which the contents of a privy had been discharged by the 
giving way of a separating wall. But the mortality of typhoid pneumonia 
depends much on its management. If treated with the same energetic de- 
pletion which is adapted to the ordinary form of pneumonia, it may be enor- 
mously fatal. 
In any case of pneumonia, an exceedingly hurried respiration, inability to 
lie down, very dark and consistent or thin brownish or blackish or fetid expec- 
toration, copious diarrhoea or colliquative sweats, and an extremely frequent, 
feeble, or irregular pulse, amounting in the adult to 140 in the minute, are 
all very dangerous symptoms. 
Vicissitudes of the weather are among the most frequent causes of pneu- 
monia. Sudden exposure to cold, when the body is warm and perspiring, is 
very apt to induce it. This is especially the case, when the individual ex- 
posed is at the time labouring under a catarrhal attack. Direct violence, 
acrid or poisonous inhalations, the excessive use of the voice, violent exertion 
of any kind which accumulates the blood in the lungs, powerful emotions, ex- 
cesses in drinking, the suppression of habitual discharges, the retrocession of 
Causes. 22 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[part II. 
gout or rheumatism, and the sudden disappearance of cutaneous eruptions, are 
ranked among the occasional causes. A long continued position upon the 
back is said to give rise to the disease in debilitated persons. It sometimes 
follows accidental injuries, or surgical operations of a severe character; at 
least, abscesses in the lungs have been observed under these circumstances, 
though it may be doubted whether they are not rather the result of the depo- 
sition of pus produced elsewhere, than of original pulmonary inflammation. 
Various diseases are apt to be accompanied with pneumonia, and are thought 
to favour its production. The one in which it most frequently occurs is pro- 
bably bronchitis; but it is also frequent in measles and hooping-cough. It is 
an occasional attendant upon smallpox, scarlatina, and erysipelas. Phthisis 
can scarcely run its course without more or less of it. Affections of the heart 
not unfrequently occasion it, by the pulmonary congestion to which they so 
often give rise. It is not unfrequent in enteric or typhoid fever, and is occa- 
sionally associated also with the miasmatic and typhus fevers.* Chronic diar- 
rhoea appears to predispose to it in young children. {Gerhard.') It is one 
of the most common inflammations which attend reaction after the collapse 
of malignant cholera. It is occasionally epidemic, but probably only as an 
associate of other diseases. 
Of the predisposing causes, cold may be ranked among the most efficient. 
Hence, the disease prevails most in cold countries, and in the colder seasons. 
It is probably as common in cold and dry as in moist climates. It is not un- 
common in the mountainous regions of this country. It is especially apt to 
occur towards the end of winder, and in spring. Those occupations are be- 
lieved to predispose to it which expose the lungs to injury from over-exertion, 
or the inhalation of irritant substances, and which render necessary an ex- 
posure to the vicissitudes of the weather, without due protection. Some per- 
sons have a peculiar tendency to the disease, without any known cause, and 
suffer from repeated attacks. Age and sex do not appear to have any very 
considerable influence over the frequency of its occurrence. In the first five 
or six years of life, it is not uncommon; but is then apt to be connected with 
other diseases, which are probably its real causes. It is most commonly the 
lobular variety which occurs at this age. Perhaps the period of life at which 
it is most frequent is from 20 to 30 or 35, when the body has attained its full 
height, but is still spreading laterally. The disease is more frequent in men 
than women; but the reason of this probably is, that the former are more ex- 
posed to the vicissitudes of the weather and to other exciting causes. 
Treatment. 
In no disease is it more important to make a proper discrimination in the 
treatment. The measures which are salutary and even essential under cer- 
tain circumstances, are injurious and may be fatal under others. In order to 
make the importance of this distinction in the mode of practice more obvious, 
it will be best to treat, under distinct heads, of the varieties of the disease 
which most differ in the measures they require. 
1. Common Pneumonia.-In persons with vigorous constitutions, bleed- 
* From the observations of Dr. Woillez, it appears that in most acute febrile dis- 
eases there is an attendant pulmonary congestion, evinced by expansion of the chest 
with diminished elasticity, feebleness of the respiratory murmur with or without sono- 
rous rales, and some degree of dulness on percussion, especially behind. The sonorous 
rales he conceives to be much more frequently a sign of congestion than of bronchitis. 
This condition of the lungs may readily pass into inflammation, and hence the not un- 
frequent occurrence of this affection in acute febrile diseases. (Archives Gen., Mai, 
1854, p. 578.) Note to the fourth edition. CLASS III.] 
PNEUMONIA. 
23 
ing is the most efficient remedy. No disease bears the loss of blood better 
than open, well-developed pneumonia. This evacuation is called for, not only 
in reference to its direct effect in relieving inflammation, but also with the 
view of diminishing the labour of the lungs, and thus procuring rest for the 
diseased organ, so far as this is possible. As all the blood in the body must 
pass through the lungs after reaching the heart, before it can be again dis- 
tributed, and as in pneumonia a considerable portion of the lungs performs 
the duty but imperfectly, a greater burden necessarily falls upon the remain- 
der ; and thus, not only is the sound part of the lung unduly loaded with 
blood, but the movements of respiration must be accelerated in proportion. 
By diminishing the amount of blood, we relieve the lung of a portion of this 
duty. In deciding upon the quantity to be taken, we must be guided by 
the stage of the disease, the state of the pulse, and the constitution of the 
patient. In a vigorous patient, in the earlier stage of the disease, with a 
strong pulse, and before hepatization has been fully established, from sixteen 
to thirty ounces may be taken at the first operation. There is some reason 
to hope, in this stage, that we may arrest the progress of the disease by de- 
cided measures. Should the symptoms have in no degree abated, we may 
bleed again at an interval of from twelve to twenty-four hours, and the opera- 
tion may be repeated again and again, should the pulse not have been reduced, 
nor the inflammatory symptoms decidedly checked. In the subsequent bleed- 
ings, it will seldom be proper to take as much as at the first; but the pulse 
and general condition of the patient must be the guides. The occurrence of 
nausea or faintness, while the patient is bled in the sitting posture, should be 
a signal to stop the discharge. Cases sometimes occur, in which the loss of 
blood is necessary, though the pulse may not seem to indicate it. The lungs 
are overwhelmed with the sudden and extensive congestion, and the function 
of respiration consequently so much impeded as to occasion a partial asphyxia, 
in which the surface becomes pallid or purplish, and the pulse very small, 
frequent, and feeble, suggesting the idea of great prostration of the vital forces. 
In these cases, however, the fault is not in debility, but in excessive action in 
a vital organ; and the remedy is not stimulation, but abstraction of blood. 
It is proper to excite the surface by irritants; but the important object is to 
unload the lungs. It generally happens that the pulse rises under the lancet, 
and this affords an indication that the remedy has been rightly employed. 
There may be some difficulty in discriminating between such cases and those 
of true debility. Should the apparent prostration come on suddenly, in per- 
sons previously in tolerable health, and the respiratory movements exhibit 
evidences of great oppression of the lungs, it is much the safer plan to treat 
the case as one of active pulmonary congestion, and to try the lancet. 
Should the pulse become still weaker, the bleeding must be stopped; but 
should it rise, the operation ought to be continued until the symptoms are 
relieved, or the patient can bear no further loss. Laennec proposes, as a test 
of the propriety of bleeding under such circumstances, the application of the 
stethoscope to the heart. Should the pulsation of the heart be found propor- 
tionably much stronger than that of the arteries, he considers it an indication 
that bleeding is proper. 
After the first bleeding, the bowels should be thoroughly evacuated by an 
active cathartic, as calomel and jalap, the compound cathartic pill, infusion 
of senna with Epsom salt, &c.; but subsequently, throughout the case, it will 
be sufficient merely to keep them open once or twice a day, which may be 
effected, if necessary, by small doSes of a saline cathartic, castor oil, or mag- 
nesia, or, what may sometimes be preferable, by enemata. But it very often 
happens that the remedies employed to meet other indications have the effect 24 
[part II. 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
of sufficiently loosening the bowels, so that measures are not required for that 
purpose especially. 
The bowels having been evacuated, recourse should be had to small doses 
of tartar emetic, repeated at short intervals; from the twelfth to the quarter 
of a grain, for example, every hour or two hours, during the day. When the 
skin is hot and dry, this may be accompanied with the neutral mixture or 
nitre, if borne well by the stomach. In cases attended with vomiting, the 
effervescing draught should be substituted for the antimonial. 
After two or three days, when the force of the circulation has been suffi- 
ciently subdued by the lancet, a mixture consisting of a grain of opium, a 
grain of ipecacuanha, and two or three grains of calomel, may be given at 
night, in the form of pill; the treatment above pointed out being continued 
through the day. Sometimes it may be deemed proper to increase the dose 
of the anodyne, when the system is not very susceptible to its influence. In 
such cases, twice the quantity of materials just mentioned may be made into 
four pills, two to be taken at bedtime, and one at intervals of an hour or two 
afterwards, until the soporific effect is produced. The advantages of this 
combination are, that it procures rest for the patient, obviates the injurious 
effects of the cough, directs action to the skin, and lays the foundation for a 
mercurial impression, if this should subsequently be deemed advisable. 
If the pain should continue after general bleeding has been carried as far 
as may appear admissible, and especially if the physical signs indicate the 
unchecked progress of inflammation, blood should be taken by cups or leeches 
from the chest to an extent corresponding with the strength of the patient. 
From four to ten ounces may be abstracted in this way, and sometimes with 
great advantage. Large emollient cataplasms are also sometimes useful; but 
their use requires great caution, lest they may render the patient liable to 
cold by improper exposure of the wet surface. 
Very frequently, under this treatment, the symptoms of inflammation will 
gradually subside, and the patient recover without further remedies. But, 
should the disease prove obstinate, it will be proper to resort to the mercurial 
impression. The combination of calomel, opium, and ipecacuanha, before 
given only at night, may now be continued through the day, in smaller doses, 
repeated at short intervals. The relative quantity of the ingredients must 
vary according to circumstances; the ipecacuanha being increased or dimi- 
nished according as it is well borne by the stomach or nauseates it, and the 
opium and calomel proportioned to the susceptibility of the patient. Gene- 
rally speaking, half a grain or a grain of calomel, one quarter of a grain of 
ipecacuanha, and the same quantity of opium, may be given at intervals of 
one, two, three, or four hours, so that not more than from two to four grains 
of opium shall be administered in twenty-four hours. When the symptoms 
are threatening, and a speedy mercurial impression is requisite, three or four 
grains of calomel with half a grain or a grain of opium may be given every 
four hours. Sometimes, even thus combined, calomel produces purging, and 
worries the bowels. In such cases, the mercurial pill should be substituted, 
in proportional doses, with the same additions. It is important to push the mer- 
curial plan until the gums become somewhat affected, when the symptoms 
will generally begin to improve. A profuse ptyalism is never requisite; and, 
as soon as evidence is given, by the state of the gums, that the system is 
affected with mercury, it should be suspended for a time, or continued in 
diminished quantities, so as merely to sustain the effect produced, until all 
symptoms of pectoral inflammation shall cease. It will often be proper to 
commence the mercurial plan upon the fifth day, if the symptoms have not 
begun to decline before that period; but the precise time may be earlier* or CLASS III.] 
25 
PNEUMONIA. 
later in any particular case, and must be left to the judgment of the practi- 
tioner. 
At the same time that this plan is in operation, a blister may with great 
propriety be applied to the chest. It should be large, not less, as a general 
rule, than six inches by eight, and often as much as eight by ten. Before 
this period it would be improper; as, without unseating the inflammation, it 
might injuriously aggravate the fever. Should the case linger, the blister 
may sometimes be repeated with advantage. 
In the declining stages of the disease, expectorant medicines are often 
useful. The syrups of squill and seneka may be combined with a little tartar 
emetic and one of the salts of morphia, and given in such doses as the stomach 
will bear without being nauseated. If the pulse, as sometimes happens, remain 
frequent, the tincture of digitalis may be added to the other ingredients. 
Not unfrequently it will be found best to omit the antimonial, in consequence 
of its depressing properties. 
Should the strength fail in the advanced stages, it will often be found very 
useful to employ carbonate of ammonia, in two and a half, five, or ten-grain 
doses, at intervals of two hours. Wine-whey may also be added, and, if 
hectic fever should set in, recourse should be had to sulphate of quinia. Oil 
of turpentine has also sometimes proved highly useful, given in pretty large 
doses. The timely employment of moderate stimulants, with a nutritious 
diet, under such circumstances, has, I believe, often saved life. Gangrenous 
symptoms may be met with chloride of lime and opium, quinia, and the 
mineral acids, especially the nitro-muriatic. 
It is highly important, in the cases of intemperate individuals, not entirely 
and at once to abstract their accustomed stimulus. It should be diminished, 
but not quite cut off. Otherwise, delirium tremens would be likely to set in, 
and the patient would sink under the requisite depletion. In such persons, 
the alcoholic liquor in moderated amount ceases to be a stimulant. It is only 
one of the agents requisite to the support of their nervous system at the 
requisite point of elevation. The right plan is to allow the stimulus, and at 
the same time to bleed. The nervous system is thus supported, while the 
inflammation is combated. 
If pneumonia is not seen until it has reached an advanced stage, bleeding 
must be employed with more caution. Still, moderate quantities of blood 
may often be taken with advantage both generally and locally; and, if there 
be any doubt about the propriety of the lancet, cups or leeches will at least 
generally be proper. After four or five days, there is little hope of cutting 
short the disease by direct depletion. It will run its course, and the strength 
must be husbanded for the future struggle. Fatal consequences have, I am 
convinced, often resulted from profuse bleeding under these circumstances. 
Still, as stated, it should be employed in moderation, if called for by the state 
of the pulse, and of the local symptoms. Nor can copious bleeding always 
be employed with propriety, even at the commencement. When the disease 
occurs in persons enfeebled by previous ill-health, or by extreme old age, or 
when it is associated with diseases of a low grade of vital force, as scarlet 
fever, malignant erysipelas, &c., the loss of blood is badly borne, and one 
moderate bleeding is generally all that is admissible. Sometimes it may be 
more prudent to omit this, and employ leeching or cupping in the place of it. 
In very young children, too, local bleeding is often preferable to general. In 
these patients, it should be effected by leeches. 
Such as above described is the course of treatment which I have generally 
employed in pneumonia. But other means have been highly recommended, 
which it would be improper to pass over without notice. Among these is the 26 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[PART II. 
use of tartar emetic in large doses. This plan was in modern times introduced 
by Rasori, of Italy, was subsequently employed and highly recommended by 
Laennec, and has been much in vogue both in America and Europe. It un- 
doubtedly has much influence over the disease, and, even unaided by the 
lancet, has probably often effected cures. Some indeed have relied upon it 
to the exclusion of' blood-letting. More generally, however, its advocates 
bleed moderately once or even oftener in the early stage, and then give the 
antimonial. Others treat ordinary cases with blood-letting, and have recourse 
to the antimonial in cases deemed unsuitable for the lancet, and yet demand- 
ing a sedative treatment. The antimonial does good probably in various ways. 
It depletes by its frequent emetic and cathartic effect, acts as a derivative to 
the alimentary canal from the lungs, and immediately reduces arterial excite- 
ment by its powerful sedative agency. Though it generally vomits at first, 
and often purges, the stomach and bowels not unfrequently become subse- 
quently reconciled to it, so that in some instances it scarcely produces nausea, 
in doses in which it originally vomited. Rasori gave it in enormous quanti- 
ties; for example, from one to three drachms in twenty-four hours, in divided 
doses. Laennec gave a grain of tartar emetic in three ounces of liquid vehicle 
every two hours, suspending it in mild cases, after the sixth dose, for seven 
or eight hours; but, in those of a threatening character, continuing steadily 
on until amendment was evident; and, in the worst cases, increasing the dose 
to a grain and a half, two grains, or even two grains and a half. Other prac- 
titioners use the medicine in smaller quantities. The safest plan is probably 
to begin with small doses, and gradually increase to the larger if necessary. 
From one quarter of a grain to two grains may be given every two, three, or 
four hours, in from half a fluidounce to two fluidounces of water. The vehicle 
may be pure water, or water rendered demulcent by gum arabic and loaf 
sugar, or some mild aromatic infusion. A little laudanum should be added, 
if the antimonial shows a disposition to produce exhausting purgation. Dr. 
Williams recommends the addition of a few drops of hydrocyanic acid, if it 
continue to vomit. Its effect, even when it does not vomit, which occasionally 
happens even from the beginning, and frequently after the administration of 
two or three doses, is to produce great depression of the pulse and coolness of 
the skin, which are often attended with a striking amelioration of the disease. 
As, if the remedy is now omitted, the inflammation is apt to increase; it is 
necessary to continue it, though in somewhat moderate quantities, for some 
days after the beginning of amendment. The antimonial plan, however, is 
not without its dangers. The depression may be too great, or gastro-intesti- 
nal inflammation may be induced, or the patient may be exhausted by the 
excessive vomiting and purgation. A patient who is put upon its use should 
seldom be long from under the oversight of the practitioner, as serious evils 
may happen in the intervals of his visits, if long protracted. The plan is 
altogether unsuited to cases in which there is already gastro-intestinal irrita- 
tion. It is, I believe, upon the whole, less manageable than the lancet, and 
less safe than the mercurial plan, when the lancet is not admissible. Having 
witnessed fatal effects from the abuse of tartar emetic, I have been from the 
first averse to the plan; and the result of the few cases in which I have seen 
it employed has not tended to reconcile me to it. In one instance, it appeared 
to me to have hastened, if not occasioned the fatal issue. Since the publica- 
tion of the first edition of this work, Dr. J. F. Peebles, of Petersburg, Virgi- 
nia, has recorded several interesting cases, in which a hemorrhagic tendency 
seemed to have been generated by the antimonial plan of treatment, which re- 
sulted fatally after all signs of the pulmonary inflammation had disappeared. 
(Am. Jodrn. of Med. Sei., N. S., xv. 338.) Dr. Boling, of Montgomery, CLASS III.] 
PNEUMONIA. 
27 
Alabama, has repeatedly witnessed death occurring rather suddenly in pneu- 
monia, after a rapid subsidence of the pectoral symptoms, which he ascribes 
to a translation of the inflammation from the lungs to the alimentary mucous 
membrane, consequent on the irritant revulsive influence of tartar emetic. 
(Ibid. xxii. 331.) In small doses, it is a safe and useful adjuvant to the 
lancet; and I habitually use it in the early stages, when not contra-indicated 
by the existence of nausea or vomiting. 
Other remedies, which have been used with asserted benefit in pneumonia, 
are acetate, of lead, hydrocyanic acid, digitalis, muriate of ammonia, the 
alkalies and their carbonates in the earlier stages, and iodide of potassium in 
the advanced stages, when the lung remains consolidated, and fever has dis- 
appeared. When opium disagrees with the patient, hyoscyamus or conium 
may be substituted; and small doses of camphor in addition to opium and 
ipecacuanha, after due depletion, have been highly recommended. Dr. Madi- 
son, of Petersburg, Va., has found pneumonia to be cut short by the exhibition 
of emetics at the commencement. (Stethoscope, iv. 63.) 
Varentrapp, of Frankfort, Germany, has employed chloroform by inhala- 
tion as the main or exclusive remedy, with remarkable success, having lost 
only four and one-third per cent., while of cases previously treated by him in 
the ordinary mode he had lost fifteen per cent. About sixty drops were placed 
on compressed cotton, and the vapour allowed to enter the lungs, for ten or 
fifteen minutes; and the dose was repeated every two, three, or four hours. 
It was not permitted to produce unconsciousness. There was a gradual 
amendment of the symptoms, which ended in recovery on the twelfth or 
thirteenth day of the disease. (See Am. Journ. of Med. Sci., N. S.,xxiii. 517.) 
But the course of treatment would be very imperfect, without attention to 
various points of management not yet particularized. It is important not to 
disturb any of those actions which may be considered as critical, but, as a 
general rule, rather to follow the lead of nature, and encourage them. Should 
the disease have arisen from repelled eruptions, or translated irritations of 
any kind, efforts should be made to restore them to the surface, or exterior 
parts, by the warm bath, hot pediluvia, and blisters or rubefacients. The pa- 
tient should lie with his shoulders somewhat elevated, and, in protracted or 
debilitated cases especially, should have his position changed occasionally, in 
order to prevent the settling of blood into any one portion of the lungs, under 
the influence of gravitation. This remark is peculiarly applicable to infants. 
In the physical examination of the chest, care should be taken to expose the 
surface as little as possible. Percussion should not be made so strongly as 
to occasion pain. The air of the apartment should be of a uniform tempera- 
ture and warm, but purified by sufficient ventilation. In the early stage, the 
diet should be of mucilaginous or farinaceous drinks, such as gum-water, 
barley-water, thin gruel, &c., to which may be added the decoction or infu- 
sion of the dried fruits, and the juice of oranges or fresh grapes, the indigesti- 
ble portions of these fruits being rejected. At a more advanced period, when 
the fever has been somewhat subdued, tea and toasted bread or crackers, with 
a little rice or Indian mush may be allowed; after these, milk; and finally, 
in convalescence, broths, and the lighter meats, eggs, oysters, &c. In cases 
of debility, it is highly important to resort to these nutritious substances be- 
fore convalescence. There is reason to believe that patients in pneumonia 
have sometimes been starved to death. 
Lobular or Infantile Pneumonia.-There is nothing so peculiar in this 
form of pneumonia as to call for a different set of remedies. The treatment 
is to be conducted upon the same general plan as in the ordinary variety. 
But reference must be had especially to the origin of the disease, and the 28 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[part II. 
strength of the patient. Arising frequently in debilitated subjects, and in 
the course of other diseases, it will not, in many instances, bear the depletory 
measures so strongly called for in the more frank and uncomplicated cases. 
The age of the subject also requires attention. In very young infants, 
leeches may be advantageously substituted for the lancet. Emesis is often 
beneficial; and tartar emetic maybe employed for this purpose. It may 
also be continued afterwards in small doses; but the gigantic plan of admin- 
istering this remedy, recommended in cases of adults, is too hazardous in 
children. Calomel is a most invaluable remedy, and may be given in the 
same combinations as already mentioned. But there is, perhaps, no point in 
the pneumonia of children, to which it is more important to direct attention, 
than to the treatment of the advanced stages. Debility is here a prominent 
character, and often demands the use of stimulants. Carbonate of ammonia, 
wine-whey, and assafetida, with a nutritious diet, and the addition of sulphate 
of quinia when hectic symptoms appear, are the chief remedies. A mistake 
at this stage of the disease, and the substitution of depletory for supporting 
measures, would prove almost certainly fatal. In cases of the fetal state of 
lung, simulating pneumonia, depletory treatment is inadmissible, and stimu- 
lating and supporting measures are often required. 
Bilious Pneumonia.-If this owe its peculiarities merely to an association 
of hepatic with pulmonary inflammation, no modification of the treatment 
before recommended will be necessary, except that the mercurials should be 
employed at the beginning, and continued until they affect the mouth. But 
if the disease be associated, as it generally is in this country, with miasmatic 
fever, or a miasmatic state of system, it will require other measures. Bilious 
pneumonia does not bear bleeding so well as the uncomplicated disease ; but, 
in general, the loss of twelve or fifteen ounces at the commencement is advan- 
tageous, and sometimes the operation may be repeated. Much depends upon 
the grade of constitutional force in the febrile affection. A good plan is to 
place the patient erect in bed during the operation, and, with the finger on 
the pulse, to stop the discharge when this begins to falter. When bleeding 
can no longer be supported, and in cases which do not admit of it, cups or 
leeches are generally safe and useful. It is best, in cases in which the pro- 
priety of the lancet is doubtful, to commence with an emetic, or an emeto- 
cathartic. For this purpose, a dose of tartar emetic may be prescribed, 
followed by a purgative dose of calomel; or a mixture of ipecacuanha or 
precipitated sulphuret of antimony with calomel may be given at first, and 
the mercurial afterwards carried off by sulphate of magnesia, or a combina- 
tion of this with infusion of senna. After the thorough evacuation of the 
alimentary canal, the loss of blood may be still resorted to, if called for by 
the symptoms. In this affection, when the bowels are not irritable, purga- 
tives into which calomel enters may in general be occasionally employed 
throughout the complaint, or at least until evidences of debility are pre- 
sented. In other respects, with a single exception, the treatment may be 
conducted as in ordinary pneumonia. That exception consists in the early 
use of sulphate of quinia. Whenever the remission is decided, after the 
thorough evacuation of the bowels, and the abstraction of whatever amount 
of blood may be deemed advisable, recourse should be had to this medicine, 
as in remittents without the same complication. By arresting the paroxysm 
we do infinitely more good, in relation to the inflammation, than the stimu- 
lant action of the quinia can do harm. There is no stimulant so powerful as 
the paroxysm itself, and each recurring one has a strong tendency to sustain 
the inflammation. Indeed, the pneumonic symptoms are almost always 
worse in the exacerbation of the fever, and decline as that remits. From CLASS III.] 
PNEUMONIA. 
29 
twelve to eighteen grains of the sulphate of quinia should be given between 
the paroxysms, usually in divided doses of one, two, or three grains, accord- 
ing to the length of the interval. Should the disease put on, as it not unfre- 
quently does, a typhoid character, this medicine becomes still more proper, 
and in malignant cases it is absolutely indispensable. In these latter cases, 
it must be administered unsparingly; for it is of the utmost importance to 
prevent the recurrence of the paroxysm. The quinia may often be advan- 
tageously combined with calomel, opium, and ipecacuanha. Very commonly, 
the pneumonia subsides along with the fever, and requires little further treat- 
ment when the paroxysms have been superseded. Should it remain, how- 
ever. it may then be managed as if an original affection. Should the disease 
be intermittent, the propriety of employing this remedy is still more obvious. 
In low cases of bilious pneumonia, it sometimes becomes necessary to stimu- 
late, as in the following variety. 
Typhoid Pneumonia.-Bleeding is not usually well borne in this variety 
of the disease, and, if pushed far, is not unfrequently fatal. Occurring gene- 
rally as an attendant upon malignant epidemics, and assuming in its onset 
features which to the inexperienced eye are not strikingly different from 
those of ordinary pneumonia, it is apt to be treated at first, in a similar man- 
ner, by blood-letting and other evacuants, until the practitioner becomes 
alarmed by its terrible fatality, and finds it necessary to change his measures. 
An early insight into the nature of the disease, or a fortunate warning from 
sources where it has before prevailed, has been the basis of great professional 
reputation and success to many a young physician. When there is doubt as 
to the nature of the disease in any particular case, much stress should be laid 
upon the character of any epidemic that may be prevalent in the same or 
some neighbouring region, and, if this be typhous, great caution should be 
exercised in the use of the lancet. In some cases, a moderate loss of blood 
may not be unsafe, and may even be advantageous; but these are to be con- 
sidered as rather the exceptions than the rule; and, in general, leeching or 
cupping is the most that should be done in the way of direct depletion. The 
best plan is usually, if the disease is seen in its earliest stages, to commence 
the treatment with an emetic of ipecacuanha or sanguinaria, and to follow 
this with a purgative dose of calomel, or of calomel and rhubarb conjointly. 
Afterwards, the patient should be put immediately upon the use of opium 
and ipecacuanha with calomel, a dose of which, containing half a grain of 
each of the first two ingredients and one or two grains of the third, should be 
given every three or four hours; and persevered in until the gums become 
affected; the mercurial pill being substituted for the calomel, should the 
latter purge. So soon as decided signs of debility or prostration appear, 
stimulants should be resorted to, the milder being first employed, and the 
more energetic afterwards, if these should not answer the purpose. Infusion 
of serpentaria, small doses of carbonate of ammonia, and wine-whey may be 
first used; then, if necessary, compound infusion of Peruvian bark or quinia 
with wine; and, lastly, brandy in the form of milk-punch, or beat up with 
the yolk of eggs and sugar. When the debility is considerable, wine and 
sulphate of quinia are the standard remedies, and should be- used freely, 
without intermission, until the danger is passed. Ardent spirit must be re- 
sorted to in the cases of those in any degree accustomed to it. Oil of turpen- 
tine very freely given is also serviceable, and may be considered as especially 
applicable when there is considerable bloody discharge from the lungs. Musk 
has been highly recommended in the dose of twenty or thirty grains. Dry 
cupping and blistering are important adjuvants. If the bowels are confined, 
they should be kept daily open by means of rhubarb, in the form of aromatic 30 
[part it. 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
infusion or tincture. The diet should be nutritious, and sometimes even 
stimulating. In the earlier stages, tapioca, sago, arrow-root, &c., prepared 
with nutmeg, sugar, and a little wine; in the advanced stages, milk, egg and 
wine, rich broths and jellies, and even essence of beef, should be employed. 
Chronic Pneumonia.-In this affection, the treatment must be directed 
by circumstances. If the consolidation of the lung continue, without evidence 
of suppuration or abscess, it may sometimes be proper to take a little blood 
from the arm or chest, especially when there is pain or exacerbation of fever. 
But the remedy should be used with caution. The most efficacious measure 
is probably a steady course of the mercurial pill, in small doses, so repeated 
and continued as to produce and sustain the slightest visible impression on 
the gums for a considerable time. Should mercury fail, iodide of potassium 
may be tried. Squill and seneka, with or without ipecacuanha, tartar emetic, 
or sanguinaria, will be found valuable adjuvants. These medicines may in 
general be most conveniently combined together, in the form of their officinal 
liquid preparations; and advantage will accrue from adding to them some 
preparation of opium, especially one of the salts of morphia, or, as a substi- 
tute for this, hyoscyamus, lactucarium, or conium. Blisters should be applied 
in rapid succession to the chest; or a steady external irritation should be 
kept up by means of tartar emetic, croton oil, an issue, or a seton. When 
suppuration has taken place, and hectic symptoms appear, infusion of wild 
cherry bark with one of the mineral acids, morphia or one of the other nar- 
cotics with expectorants to allay cough, and the inhalation of tar vapour, are 
the chief remedies. In this case no mercurial should be given. In infantile 
cases especially, I have apparently found the greatest advantage from causing 
the child to inhale constantly, for weeks or months together, the air of an 
apartment more or less impregnated with the vapours of tar. This may be 
effected by exposing tar in a water-bath to a moderate heat by means of a 
nurse-lamp. The diet must be regulated by circumstances, being exclusively 
of vegetable aliment, when there is increase of inflammatory symptoms, of 
this with milk in moderate cases, and, when there is debility, of the more 
nutritious and digestible forms of animal food. 
Article IL 
GANGRENE OF THE LUNGS. 
This occurs sometimes, though rarely, as a consequence of ordinary pneu- 
monia. When this disease is sufficiently extensive and violent to prove 
fatal, death results before the parenchyma, even if it has lost vitality, has 
had time to undergo that putrefactive decomposition which characterizes 
gangrene. Hence, this affection is most frequently connected with cases of 
circumscribed pneumonia, which sometimes ends in abscesses, and in which, 
on account of the smaller extent of the disease, life is in less immediate 
danger than when the inflammation is more extensive. It is probable, too, 
that gangrene is less frequently dependent on the mere violence of the in- 
flammation, than on a peculiar predisposition, derived from a vitiated state 
of the blood, or a depraved and debilitated condition of the system. 
But, in most cases of gangrene of the lungs, the antecedent or attendant 
inflammation is so slight as to have led to the suspicion, that it is not the 
cause, nay, that it is sometimes even the effect of the mortification, and quite 
analogous in its origin to that which surrounds an eschar resulting from the 
external use of caustic. This may be true in some cases in which the gan- CLASS III.] 
GANGRENE OF THE LUNGS. 
31 
grene results from mechanical causes interfering with the circulation in por- 
tions of the lung. But the probabilities are, that, as some degree of inflam- 
mation is always present, and, where examinations have been made, has 
usually been found to precede the evidences of gangrene, it is in fact generally 
the cause of this state. The inflammation, however, is so modified by its 
cause, or by the condition of system, as to be peculiarly disposed to run into 
gangrene; and thus modified it deserves to be considered as a distinct va- 
riety, which might very properly be designated as gangrenous inflammation 
of the lungs, as we speak of gangrenous erysipelas, sore-mouth, &c. 
Two varieties of gangrene of the lungs are admitted by Laennec and most 
subsequent writers, in one of which the disease occupies a large portion of 
the lung, and is without definite boundary, in the other is of comparatively 
small extent, and has a precise outline. The former may be called diffused, 
and the latter circumscribed gangrene. The diffused is comparatively rare; 
only six out of sixty-eight cases, collected from various sources by M. Lau- 
rence, belonging to that variety. {Diet. de Med., xxvi. 48.) 
Anatomical Characters.-In the diffused gangrene, the greater portion of 
one lobe or of a whole lung is usually involved; the mortified and healthy 
portions being insensibly blended, or separated by inflamed parenchyma in the 
stage of congestion, or more rarely of hepatization. The lung is more moist 
and less cohesive than in health, has the density of the congestive stage of 
pneumonia, and presents dirty whitish, greenish, brownish, and blackish hues, 
variously intermixed, and sometimes still further diversified by portions of a 
livid redness. Here and there parts of the lung are softened and completely 
disorganized, and exude when cut a greenish-gray and excessively putrid 
sanies. Among the lesions present are sometimes also diffused infiltration 
of blood, and small spots of sanguineous extravasation. 
The circumscribed, gangrene generally occupies only a small portion of the 
lung, but is sometimes very extensive. In either case, it is characterized by 
having a definite boundary. Three stages are distinguished by Laennec; the 
first, that of recent mortification, the second, that of deliquescence or break- 
ing down of the tissue, the third, that of a cavity or abscess. These stages 
present the following characters. In the first, the mortified portion is of a 
black or greenish-black colour, of a firmer and denser consistence but moister 
than in health, and of an offensive odour. In the second, the slough has either 
been softened, and converted into a greenish-gray, sometimes bloody, and ex- 
cessively fetid pasty matter, or much more rarely has been separated from 
the pulmonary tissue, and lies unconnected. In the third, the putrid col- 
luvies has been discharged through the bronchial tubes, and a cavity exists, 
sometimes traversed by blood-vessels which have escaped destruction, and 
generally containing a purulent, or blackish, sanious, and extremely offensive 
matter, secreted by the walls of the cavity, and sometimes blood proceeding 
from the open mouths of divided vessels. Around the cavity is a portion of 
inflamed lung, seldom more than an inch in thickness, and in a stage usually 
of hepatization. A newly organized secreting membrane generally lines the 
cavity, but sometimes no such membrane exists, and the walls consist of the 
inflamed pulmonary tissue. They are in some instances firm, dense, and dry, 
in others soft and fungous. 
Instead of opening into the bronchia, the cavity sometimes forms a com- 
munication with the pleura, into which its contents are discharged. In other 
instances, it communicates with the bronchia and pleura at the same time. 
In both cases, pleurisy and pneumothorax are produced; the air in the 
former being derived from the decomposition of the disorganized tissue of 
the lung. Occasionally the layers of the pleura are consolidated by adhe- 32 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[PART II. 
sion, and the matter makes its way into the cellular structure beneath the 
skin. A case is recorded in which a large portion of mortified lung escaped 
through an abscess formed in the walls of the chest beneath the mamma, and 
the patient ultimately recovered. (Lond. Med. Times and Gaz., iv. 578.) 
Besides the form of gangrene above described, this condition is sometimes 
found in the walls of abscesses, or of tuberculous cavities. 
Symptoms.-In the diffused gangrene, great prostration takes place at the 
commencement, with much oppression, a small, frequent, and feeble pulse, 
and a copious fetid greenish or dark bloody expectoration. But the patient 
soon loses the power of throwing off the matter, which accumulates in the 
lungs, and produces suffocation. In the circumscribed variety, a great diver- 
sity of symptoms precedes those which indicate the existence of gangrene. 
Usually there are some signs of inflammation; but a degree of prostration and 
anxiety is exhibited, altogether disproportionate to the extent of local disease, 
as indicated by the symptoms, or by physical exploration. The patient ex- 
pectorates a rather opaque mucus, and sometimes blood. But nothing cha- 
racteristic of the affection is perceived, until the matter coughed up begins to 
have a putrid smell. The cavity has now opened into the bronchia; and, if 
the ear be applied, a gurgling sound, or cavernous respiration and pectoriloquy 
will be heard, according as the cavity contains liquid matter or is empty. 
These physical signs, connected with the excessive fetor of the breath, and 
the character of the expectoration which now takes place, are sufficiently dis- 
tinctive of the affection. The matter discharged is purulent or sanious, of a 
greenish, yellowish-brown, or ash-gray colour, and intolerably fetid. Accord- 
ing to Dr. Stokes, the breath may not be offensive, while the sputa are very 
much so; and Rilliet and Barthez state that, out of sixteen cases in children, 
five only were accompanied with a gangrenous odour of the breath, and three 
others with a simply fetid odour. Blood is frequently expectorated, and 
sometimes disorganized portions of the pulmonary tissue. Pain of the most 
violent character occasionally attends the progress of the complaint. The 
patient often sinks rapidly, and dies in the second or beginning of the third 
stage. Sometimes he is cut off suddenly, by an attack of haemoptysis. But 
occasionally the first shock is survived, and the disease runs on for weeks or 
months. In this case, the expectoration becomes quite purulent, though still 
extremely offensive, and hectic fever sets in, with night-sweats, great debility 
and emaciation, and all the obvious symptoms of pulmonary consumption, 
under which the patient at lengths sinks exhausted. The termination, how- 
ever, is not always unfavourable. After a severe struggle, the system some- 
times rallies, the matter discharged gradually diminishes in quantity, becomes 
mucous instead of purulent, and ceases to be offensive; the hectic symptoms 
disappear, and the patient is restored to perfect health. From the researches 
of Laurence, it appears that, out of sixty-eight cases recorded by various 
authors, eight terminated favourably. Valleix, however, upon analyzing the 
reported cases of cure, finds that they are very defective in precise details. 
The offensive odour and purulent expectoration are not alone sufficient evi- 
dences of gangrene, without the signs of a cavity. Cases have occurred pre- 
senting the two former symptoms, which, after death, have exhibited no ap- 
pearance of mortification; though Laennec observes that, in two instances of 
the kind which he had seen, there was an unusually strong tendency to putre- 
faction in the body generally. It is very possible also, as already stated, that 
gangrene in the lungs may exist without evincing itself by fetor of the breath. 
An example of this we have in cases which terminate in death, before the 
gangrenous cavity has communicated with the bronchia. But we have no 
means of certainly ascertaining the existence of this state of things during life. CLASS III.] 
GANGRENE OF THE LUNGS. 
33 
It may be suspected when great prostration comes on, along with evidences 
of a moderate extent of pulmonary inflammation, and without any general 
typhoid tendency. Gangrene, supervening upon tuberculous vomicae, may be 
known by the antecedent symptoms. Should the signs of a cavity have been 
presented before the gangrenous odour of the breath, and without the marks 
of pneumothorax, it may be taken for granted that either an inflammatory or 
tuberculous abscess preceded the occurrence of gangrene. Rilliet and Barthez 
consider expectoration of blood as one of the most conclusive signs of gangrene 
in children, having observed this phenomenon in six out of sixteen cases; a 
very large proportion, when the rarity of pulmonary hemorrhage in children 
is considered. 
Causes.-These have not been well ascertained. The diffused variety is 
said sometimes to be produced by exposure to deleterious vapours, as when 
persons die from descending into old privies. Whatever greatly debilitates 
the system, and depraves the blood, may act as a predisposing cause. Hence, 
the affection is apt to occur in the intemperate, and those exhausted by de- 
pressing diseases. Dr. Fischel, of Prague, found it peculiarly prevalent 
among the insane, having noticed it in more than seven per cent, of his 
autopsies among that class of patients. (See Med. Exam., N. S., vi. 334.) 
It is said sometimes to have followed pulmonary apoplexy. According to Dr. 
Stokes it may be induced by tumours pressing on the nutrient vessels and 
nerves of the lungs. (Dub. Quart. Journ. of Med. Sci., ix. 1.) It attacks 
preferably persons in middle life. The very young and very old are rarely 
affected. 
Treatment.-This must be directed chiefly to the support of the general 
strength, until the diseased lung shall have gone through the 'requisite pro- 
cess for throwing off the slough, and repairing the consequent loss of sub- 
stance. At the same time, it is important to counteract the morbid tendency 
of system by improving the quality of the blood. Both of these indications 
are met by the use of tonics and stimulants, and a generous diet. It is ob- 
vious that the degree of stimulation must be proportioned to the apparent 
exigencies of the case. It is not altogether incompatible with this plan, that 
a little blood should be taken by cups from the neighbourhood of the affected 
part,'when the pain and other evidences of inflammation are considerable. 
A depraved blood may be quite capable of supporting the inflammatory pro- 
cess, even more so than the same fluid properly constituted. We may, there- 
fore, very properly attempt to produce good blood by nutritious food, and a 
degree of stimulus necessary at once to a proper assimilation of that food, 
and the support of the nervous power, while we abstract a certain quantity 
of the diseased fluid. But experience has shown that depletion must be used 
very cautiously in such cases. Carbonate of ammonia, wine, and even ardent 
spirit may be necessary when the debility is great; and these should be con- 
joined with opium or camphor, or both. Bark or quinia is also an excellent 
adjuvant, in order to give a more permanent support. When the case runs 
on into suppuration and hectic, the mineral acids, and especially the nitro- 
muriatic, are appropriate remedies. In this stage, sulphate of quinia or in- 
fusion of wild cherry bark should also be given freely; and malt liquors are 
perhaps preferable to the more concentrated forms of alcohol. Chloride of 
soda, or creasote may be used internally, and chlorine gas, as it issues from 
moistened chloride of lime, may be inhaled with the air of the apartment. 
The gas is useful also by sweetening the air. Dr. Probart, of England, has 
met with great success from the use of chlorate of soda and common salt, 
which he was induced to give originally from discovering that a patient af- 
fected with the disease had abstained from the use of salt for five years. 34 
[part II. 
(Trans, of the Prov. Med. and Surg. Assoc., xvii. 351.) Professor Skoda 
has found inhalation of the vapour of oil of turpentine successful. He pours 
the oil on boiling water, and causes the patient to inhale the vapour for fifteen 
minutes, every two hours, using sulphate of quinia at the same time. (See 
Lond. Med. Times, and Gaz., April, 1854, p. 382.) The cough and nervous 
irritation should, throughout the disease, be allayed by opium, hyoscyamus, 
lactucarium, or one of the other narcotics. The diet should be at once easy of 
digestion and highly nutritious. The farinaceous substances, fresh fruits, milk, 
oysters, soft boiled eggs, soup, and the lighter meats, should be employed. 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
Article III. 
INFLAMMATION OF THE PLEURA, or PLEURISY. 
Syn. -Pleuritis. 
This is one of the most frequent of the inflammatory diseases. There is 
reason to believe that it often occurs without being recognized, or perhaps 
even attracting serious attention; as, in most cases of post-mortem examina- 
tion, no matter what may have been the cause of death, adhesions of the 
pleura are found, which must have resulted from inflammation of that mem- 
brane at some period more or less remote. In treating of this disease, as in 
the case of pneumonia, it will be most convenient to notice first its anatomi- 
cal characters; because a knowledge of these is necessary to a proper appre- 
ciation of its signs. The pleura, being less complex in structure than the 
pulmonary parenchyma, offers less diversity in its inflammatory affections. 
It will be sufficient, for practical purposes, to treat of these under the two 
varieties of acute and chronic pleurisy. The disease may be associated with 
bilious fever or other form of bilious disorder, or with a typhoid state of sys- 
tem, and, in such cases, may be denominated bilious and typhoid pleurisy ; 
but these are very frequently complicated with pneumonia, and all that is 
peculiar in them, as regards either character or treatment, may be sufficiently 
learned by referring to the account of the latter disease similarly modified. 
(See Vol. ii., pages 18 and 29.) The inflammation may occupy both pliurse, 
or may be confined to one; but the former event is comparatively very rare, 
unless where the disease is associated wTith phthisis. The right side is more 
frequently affected than the left. Sometimes the whole membrane, and 
sometimes only a part of it is involved. 
Anatomical Characters. 
Acute Pleurisy.-The first observable deviation from the healthy state is 
redness of the membrane, which, however, is dependent on the injection of 
the subserous blood-vessels rather than inherent in the proper serous tissue. 
This is in most cases speedily followed by increased secretion. The product 
is either concrete, or liquid, or both. Sometimes a serous fluid is poured out 
by the inflamed vessels, which are relieved by this depletion, and the surface 
of the membrane remains smooth. On the other hand, an exudation occa- 
sionally takes place, which, becoming concrete immediately after elimination, 
adheres in the form of false membrane to the surface of the pleura, and is 
attended with no liquid, or with a quantity too small to be appreciated. But 
more frequently the two forms of extravasation are associated, if not at the 
beginning of the disease, yet very soon afterwards. 
At first the coating of concrete matter is very thin and soft, and over a 
great portion of the lung is scarcely visible, being rendered sensible only by CLASS III.] 
PLEURISY. 
35 
scraping it from the surface. It afterwards becomes thicker, and has a gray- 
ish, grayish-white, or slightly reddish hue; but is still soft, paste-like, and 
easily detached. I have, however, seen it almost black, probably in conse- 
quence of the simultaneous deposition of melanotic matter. Somewhat later, 
it has acquired a firmer consistence, and become more adherent. Its surface 
is usually somewhat rough, from the inequality of its deposition, as well as 
from the friction of the opposite portions of membrane, though in some in- 
stances it is nearly smooth. Its extent corresponds with that of the inflam- 
mation, and it sometimes covers the whole of one pleura, though not always 
equably. It is of a fibrinous nature, and is susceptible of organization, ex- 
hibiting first red points, then red lines ramifying here and there, and at 
length forming a close vascular connexion with the pleura. At first there is 
little liquid along with this concrete substance; but the quantity gradually 
increases, and sometimes becomes very great, varying from a few ounces to 
several pints. Occasionally it is traversed by filaments or bands of the plas- 
tic matter, running between the costal pleura and that of the lung. When 
copious, it fills up the cavity of the pleura, and, in some rare cases, has been 
known, in the course of a few days, largely to distend the chest, and by its 
pressure to displace very considerably the neighbouring viscera, whether of the 
thorax or abdomen. But it is more frequently in the protracted cases, or 
chronic form of the disease, that these results take place; and they will be 
more particularly noticed hereafter. In acute pleurisy, the distension is not 
often very striking. In relation to the character of the liquid, it is usually 
a yellowish, limpid, or slightly clouded serum, with flocculi of concrete mat- 
ter floating in it. Often, however, it is more turbid, like whey; sometimes 
is sero-purulent, sometimes purely pus, and occasionally bloody, with or with- 
out coagula. In ordinary cases it has little or no odour. It is usually free 
in the pleural cavity, changing its position with the movements of the pa- 
tient; but it is sometimes limited or confined by old or recent adhesions of 
the pleura. 
The lung is compressed by the fluid, and forced from its ordinary position, 
generally towards the mediastinum or spinal fossa. The degree to which it 
is compressed and displaced depends upon the quantity of the liquid; and, 
when this is very great, it is sometimes reduced to a sort of flattened cake, 
scarcely larger than the hand, which is confined to the upper and back part 
of the chest. This, however, is more common in chronic than acute pleurisy. 
The air-cells, though compressed, do not in recent cases contract adhesions, 
and may be readily expanded by the insufflation of the lungs. 
During these changes, the proper serous membrane is not thickened or 
materially softened; and, if it sometimes appears swollen, this is owing to the 
injection or infiltration of the cellular tissue beneath it, or to the superposi- 
tion of false membrane. It may sometimes be peeled off from the lung or 
chest more easily than in health. It almost always happens that, when a 
portion of the pleura is coated with concrete exudation, that opposite to and in 
contact with it is similarly affected. Sometimes a small portion of the surface 
of the lung is gangrenous, in which case, the fluid in the cavity, as well as 
the false membrane, has an extremely offensive odour. Occasionally the 
pleurisy has been caused by the opening of a tuberculous or gangrenous cavity 
of the lung, communicating with the bronchia, into the pleural cavity, which 
thus contains air along with purulent fluid. (See Pneumothorax.} 
In cases which terminate favourably, the effused liquid is gradually ab- 
sorbed, and, if no false membrane has been formed, the parts are restored 
without change to their original condition. But this is probably a compara- 
tively rare result. More commonly the opposite surfaces unite, in conse- 36 
[part II. 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
quence of the adhesion and organization of the coagulable lymph with which 
they were coated. When no liquid exists in the cavity to prevent the con- 
tact of these surfaces, the union often takes place in a very short time. But 
when liquid is present, it must be removed by absorption before such a union 
can be effected, and more time is of course necessary for the cure. The whole 
of the inflamed surfaces do not unite at the same time; but those parts first 
which first come in contact, and afterwards other |>arts successively, as the 
fluid undergoes absorption. Occasionally, portions of the fluid are retained 
here and there in the meshes of the false membrane. The changes do not 
end with the mere junction of the pleural surfaces. The organized lymph 
undergoes a vital process by which its superfluous parts are removed, and at 
length the connecting medium is reduced to a delicate tissue of cellular mem- 
brane. Sometimes the whole cavity of the pleura is thus abolished; in which 
case, the patient cannot be again attacked with pleurisy of the same side. In 
other instances, the adhesion is only partial; and sometimes filaments of cellu- 
lar membrane run from the pleura of the ribs to that of the lungs, having 
been formed, probably, during the plastic state of the exuded lymph, by the 
movement of the lung upon the wall of the chest during respiration, drawing 
it out into slender connecting bands. With the absorption of the liquid, the 
lung again expands; but, if the compression has continued long, the air-cells 
do not at first yield completely to the expanding force, and the lung conse- 
quently does not immediately recover its original dimensions. The walls of 
the chest are, under these circumstances, forced inward, and the contents of 
the abdomen upward, to supply the deficiency. But this rarely happens to 
any considerable extent in acute pleurisy; and, even when the chest is at 
first somewhat contracted, it in time usually resumes its former shape, in con- 
sequence of the recovered expansibility of the lung. In chronic pleurisy, the 
case is sometimes much otherwise. Occasionally, the lesions resulting from 
inflammation are confined to the interlobar, and diaphragmatic pleura. 
Chronic Pleurisy.-As this form of pleurisy is in general nothing more 
than a continuation of the acute, the same anatomical appearances are pre- 
sented, though somewhat modified by the influence of time. The false mem- 
branes are usually thicker, and often exhibit several layers of different con- 
sistence, those first deposited being firmest and adherent to the pleura, and 
the recent, softer and nearer the surface. The liquid, though sometimes 
limpid, is less frequently so than in the acute disease. It is generally turbid 
with abundance of fibrinous flocculi, or is quite purulent, and not unfre- 
quently has a disagreeable odour. Sometimes it is of a consistence like that 
of thin jelly. The quantity of the fluid is usually much greater than in the 
acute form. It is sometimes enormous, producing great dilatation of the 
thorax, and compressing the lung into a very small space along the spine 
and mediastinum, in the upper portion of the chest. In consequence of the 
length of time during which it is thus compressed, the lung changes its tex- 
ture, ceases to be crepitant, and assumes an appearance somewhat similar to 
that of the same organ in the foetus. It is scarcely penetrated by air or 
blood; and is sometimes bound down in its confined position by organized 
false membrane, so that it could not expand, even were its cells not oblite- 
rated. The mediastinum, heart, and upper abdominal viscera are displaced 
much more than in acute pleurisy. In some instances, instead of this great 
distension, the lung is here and there adherent to the wall of the chest, 
forming one or more sacs in which fluid is contained; and bands of false 
membrane are frequently observed passing from one part of the pleura to 
another. 
When the effusion is not purulent, and the disease is not complicated, CLASS III.] 
37 
PLEURISY. 
absorption of the liquid, under proper treatment, generally takes place in the 
end, and the case advances towards a cure. But, as the lung cannot now 
readily expand by the admission of air, the walls of the chest, the mediasti- 
num, and the diaphragm are forced by the atmospheric pressure into the space 
before occupied by the liquid. A portion of the space is also filled up with 
false membrane, which is sometimes very thick, so much so that it cannot be 
converted wholly into cellular tissue, as in acute pleurisy, and therefore 
assumes a fibrous consistence, and occasionally becomes the seat of various 
morbid processes, resulting in the production of cartilaginous or bony plates, 
tubercles, abscesses, hemorrhagic effusions, and even gangrene. In certain 
rare cases, the ribs themselves undergo a peculiar change, their internal sur- 
face being replaced by a new bony formation, which gives them a prismatic or 
triangular form. (Parise, Arch. Gen., 4e ser., xxi. 320 and 478.) Sometimes 
the walls of the chest are forced inward contrary to their elasticity, so that, 
when a puncture is made from without, the air rushes in to supply the va- 
cuity produced by their resilience. 
In some instances secretion goes on as rapidly as absorption, and the liquid 
accumulation remains for a great length of time. This is especially the case 
in empyema, or collections of pus in the cavity of the pleura. Sometimes the 
pus makes its way into the substance of the lung, and a fistulous communi- 
cation is formed between the bronchia and the pleural cavity, through which 
pus is discharged and air admitted. In other instances the liquid takes an 
external direction, and by means of ulceration escapes into the cellular tissue 
without the chest, and, travelling occasionally for considerable distances, pro- 
duces subcutaneous abscesses in various parts of the chest, which ultimately 
open, unless life is previously worn out. In thus travelling, the pus has 
been known to occasion caries of the ribs and vertebrae. Sometimes the 
purulent collection is found to be connected with a tuberculous vomica. 
Pleuro-pneumonia.-It has been stated,-under pneumonia, that this disease 
is very frequently attended with inflammation of that portion of the pleura 
which immediately covers the inflamed part of the lung. Strictly speaking, 
the name of pleuro-pneumonia might be conferred upon it under such circum- 
stances ; but, as it is seldom attended with liquid effusion, and the pleurisy 
does not extend beyond the hepatized tissue, the cases are not usually con- 
sidered otherwise than as simple pneumonia. To constitute a case of pleuro- 
pneumonia, in the sense in which it is here considered, there must be an ex- 
tension of the pleuritic inflammation beyond the hepatized structure; or at 
least such an amount of it as to produce observable effusion. Such cases are 
not very uncommon. Out of 247 patients with pneumonia who came under 
the notice of M. Grisolle, 31 exhibited signs during life of more or less pleu- 
ritic effusion, or about one in eight. The liquid, unless confined by old ad- 
hesions, is found in the most dependent part of the cavity, no matter what 
part of the lung may be inflamed. The appearances are those already de- 
scribed as characterizing the two diseases, with this difference, that, in con- 
sequence of the consolidation of the lung by inflammation, it is less com- 
pressed, and for the same reason the quantity of effusion is less than in 
simple pleurisy. A peculiar condition of the lung was observed by Laennec 
in cases in which pneumonia had supervened upon copious pleuritic effusion, 
and was named by him carnification, from its close resemblance in appear- 
ance to muscle that has been beaten to render it tender. The affected por- 
tion of the lung is more compressed than in ordinary pneumonia; the air- 
cells are obliterated; the granular appearance is wholly wanting ; the colour 
is redder; and the texture is more flabby and less solid. Resolution is 
effected more slowly than in hepatization, but the part seldom advances to 38 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[part II. 
suppuration, probably because the inflammation is moderated by the pres- 
sure. Dr. Williams says that this form of pneumonia sometimes proves a 
cause of dilatation of the bronchia, at the period of convalescence. The 
compressed air-cells do not yield readily to the expanding force of the air, 
when the liquid effusion has been absorbed, and the bronchia are dilated to 
supply the deficiency. 
Symptoms, Course, &c. 
Acute Pleurisy.-This disease commences usually with a febrile chill, and 
sharp pain in the side; and the characteristic symptoms subsequently are pain 
in the side, cough, short and quick breathing, and fever. Each of these re- 
quires a more particular notice. 
The pain may come on before the chill, or along with it, or a short time 
after it. In character, it is severe and sharp, as if from the thrust of a sharp 
instrument, and hence it is frequently designated by the term stitch in the 
side. It is usually confined to one spot, most commonly somewhere in the 
mammary region; though it is occasionally felt elsewhere, as, for example, 
near the lower margin of the chest, when the pleura of the diaphragm is 
inflamed. The reason of this concentration of the pain is probably that, 
when nervous trunks are inflamed, the suffering is referred to the part in which 
the nerves are distributed rather than to the real seat of disease; and, as the 
nerves coming off from the spinal marrow, are distributed over the anterior 
part of the chest, the inflammation affecting them in their course makes itself 
felt in the latter position. Sometimes, however, it is diffused over the side, 
and is then less severe. It is increased by inspiration, cough, pressure 
in the intercostal spaces, and generally by lying upon the affected side, 
probably in consequence of the weight of the lung bearing upon the inflamed 
membrane. It may often be suspended by holding the breath. Sometimes 
it is observed to increase and diminish along with the exacerbations and re- 
missions of the fever. Occasionally it is attended with a burning sensation. 
It generally moderates considerably in the course of one, two, or three days, 
as the effusion increases; and the difficulty of lying on the affected side is now 
greatly diminished or ceases. In some cases, it is scarcely felt from the begin- 
ning, unless in consequence of full inspiration or coughing, and, in others, is 
quite wanting, or felt only as soreness when pressure is made between the ribs. 
The cough is at first short and dry, or attended with a slight mucous or' 
frothy expectoration, and may remain so throughout the complaint. Fre- 
quently, however, in consequence of the existence of some bronchial inflam- 
mation, the discharge is more copious; and occasionally it is streaked with 
blood. In some cases, it is exceedingly painful; and the patient often en- 
deavours to restrain it, though not always successfully. It is, however, much 
influenced by these efforts, sounding as if interrupted and unfinished, in con- 
sequence of the partial contraction of the muscles concerned in it. Cases now 
and then occur in which it is wholly wanting; and, as pain is also sometimes 
wanting at the same time, the disease has, under these circumstances, been 
designated by some writers as latent pleurisy. 
The breathing is almost always more or less difficult or embarrassed. In 
consequence of the pain produced by a full expansion of the lungs, the inspi- 
ration stops short before it is completed. The patient is said to have a catch 
in his breath. As less air is thus taken in at one inspiration, the deficiency 
must be supplied by a more frequent repetition; and hence the breathing is 
not only short but rapid, though the patient is often scarcely aware of the 
change. The dyspnoea, instead of diminishing with the pain, often increases 
as the disease advances; but it now arises from the compression of the lung 
by the effused fluid. The function of one lung is always cramped, sometimes CLASS III.] 
PLEURISY. 
39 
entirely suspended; and the other lung is scarcely adequate to the increased 
duty. The patient, therefore, feels a want of breath, which is sometimes dis- 
tressing. This is especially the case when the effusion is at once sudden and 
copious. When it is gradual, the system accustoms itself to the new condi- 
tion of the respiratory organs, and the want is less felt. The dyspnoea also 
differs greatly in different individuals, according to their constitutional pecu- 
liarities. It is often the most prominent symptom in the latter stages. 
The decubitus is generally at first on the sound side; but, when the acute 
pain has subsided, and considerable effusion has taken place, this becomes 
difficult in consequence of the dyspnoea excited, partly by the interference of 
the weight of the body with the movements of the ribs, but chiefly by the 
pressure of the contents of the chest upon the sound lung, the only one now 
capable of performing the office of respiration. Hence, the patient, in this 
stage, generally lies on the back, or in a position intermediate between that 
upon the back and that on the diseased side. 
The fever is usually considerable, and attended with all the characteristic 
phenomena of this form of disease, such as a chill, followed by heat of skin, 
frequent pulse, loss of appetite, furred tongue, scanty urine, &c. The pulse 
is generally frequent, full, and tense ; but sometimes, when the pain is exceed- 
ingly violent, it is contracted. Occasionally, though very rarely, there is de- 
lirium. The fever often undergoes a daily remission and exacerbation, the 
former occurring in the morning, the latter towards evening. It usually 
moderates considerably in four or five days. 
The physical signs are often of the highest importance in forming a correct 
diagnosis. The motion of the affected side is observably less than that of the 
sound side. At the commencement of the attack, before effusion has taken 
place, percussion is quite clear, and no other auscultatory sign is given than 
some diminution of the respiratory murmur, consequent upon the deficient 
expansion of the lung, which is rendered more evident by a comparison of the 
two sides. But, as this depends merely upon the pain of inspiration, it is 
obvious that the same result must take place in all other cases in which the 
pain is equally acute, and especially in pleurodynia, so that the sign is of no 
great value. But, very soon after the onset of the disease, when the concrete 
exudation has had time to cover in some degree the surface of the membrane, 
a peculiar and characteristic sound may generally be heard, especially in the 
middle portions of the chest. This is the friction sound, produced by the rub- 
bing of the opposite roughened surfaces against each other. It is thought 
that the sound may be developed even before the commencement of exuda- 
tion, by the rubbing together of the pleuritic surfaces, rendered dry by the 
commencing inflammation, or unequal by the enlarged vessels. The grating 
movement which gives rise to the sound, may be felt by the hand applied 
flatly to the side. But, as the conditions upon which the sound depends are 
of short continuance, the sign must also be evanescent. It must vanish 
whenever union of the opposite surfaces takes place, or as soon as they are 
separated by the liquid effusion. Though, from its uncertain occurrence and 
fugitive character, it cannot be always depended on, yet, when perceived, it is 
a valuable sign, especially in cases unattended with liquid effusion, such as 
have sometimes been called dry pleurisy, 
But the most decisive signs are those afforded after liquid effusion has com- 
menced. A diminution of the healthy resonance upon percussion may very 
soon be perceived by a comparison of the opposite sides; and the dulness 
goes on increasing with the increase of the effusion, until at length it often 
amounts to perfect flatness. At first, it is observed in the most dependent 
parts of the chest, and rises higher and higher with the advance of the 40 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[PART II. 
disease. It usually varies with the position of the patient, following, of 
course, the position of the liquid, which necessarily gravitates to the most 
dependent part, while the lung, which is lighter, has a tendency to float above 
it. The only exceptions to this rule are the cases in which the lung, and 
consequently the liquid, are confined by adhesions, and those in which the 
whole cavity is filled. In the latter, flatness is universal over the affected 
side of the chest. The last part to lose its resonance is generally the sub- 
clavicular region. In percussing the left side in pleuritic effusion, allowance 
must be made for the resonance of the stomach, which, when that organ is 
full of air, often modifies the sound for a considerable distance up the chest. 
Sometimes, when a small portion pf the lung is in contact with the walls of 
the chest, while all the rest is separated from them by the effusion, a tympa- 
nitic sound is yielded on percussion, which might be mistaken as the sign of 
pneumothorax or a pulmonary cavity. (Notta, Arch. Gen. 4e s6r., xxii. 437.) 
Skoda states that, " when the lower portion of the lung is entirely compressed 
by pleuritic effusion, and the upper portion reduced in volume, the percussion- 
sound at the upper part of the thorax is distinctly tympanitic. This pheno- 
menon, which has long been noticed as an occasional event, is ascribed by Dr. 
Williams to the increased conducting power of the lung, which causes the 
vibratory movements excited in the trachea and bronchial tubes to reach the 
ear; and, under similar circumstances, cavernous or even amphoric respiration 
and amphoric resonance of the voice have sometimes been noticed, ascribable 
probably to the same cause. (Behier, Archives Gen., Aug. 1854, p. 129.) 
The respiratory murmur, somewhat enfeebled by the defective movement 
of the lung from pain, is still more so when liquid effusion takes place, and 
goes on diminishing with the increase of effusion, and of the consequent com- 
pression of the lung, until it entirely ceases in those cases in which the liquid 
is abundant. In parts in which the lung is still in contact with the chest, the 
healthy murmur is often superseded by bronchial respiration, dependent upon 
the compression of the air-cells, which thus more readily convey the vibra- 
tions of the bronchia to the surface. This sound is usually greatest near the 
root of the lung, and diminishes as we recede from that part, though it often 
extends more or less over the whole side of the chest. But, when the effusion 
is very abundant, this sound also is quite lost, except in the region between 
the scapulae, and sometimes even there. On the opposite side of the chest, 
the respiration is louder than is usual in health, and often becomes puerile. 
The vocal resonance, increased at first while the exudation is plastic, be- 
comes at a somewhat more advanced stage of the disease quite peculiar. When 
a moderate effusion has taken place, and a thin stratum of liquid intervenes 
between the lung and side of the chest, the tremulous, quivering, or bleating 
sound of the voice denominated aegophony is heard. The bronchial sound, 
conveyed outward by the compressed parenchyma, is modified as it passes 
through the trembling liquid, and acquires the striking character alluded to 
before it reaches the ear. This modified sound is heard especially between 
the third and sixth ribs, in the interscapular regions, and between the scapula 
and the mamma. It is most obvious in women and children, in consequence 
of the higher tone of their voice. Over the larger bronchia, near the spine, 
for example, it is often mingled with the bronchial resonance, and the sound 
acquires a peculiar complex character. As the effusion increases, aegophony 
diminishes, and at length ceases altogether. Dr. Williams is of opinion that 
little sound of the voice is transmitted, when the stratum of intervening 
liquid exceeds an inch in thickness, except over the larger tubes. When the 
quantity of liquid is very great, no vocal resonance is heard, unless in a nar- 
row space upon the side of the spine. These results are of course modified, CLASS III.] 
PLEURISY. 
41 
when the lung adheres more or less extensively to the sides of the chest. In 
such cases, the bronchial resonance is usually loud and distinct at the adhering 
parts, in consequence of the compression of the air-cells. When the extent 
of adhesion is small, the compressed lung forms a column, or kind of internal 
stethoscope, for conveying the sound to the ear. The vibration of the walls 
of the chest is affected similarly with the sound of the voice, being somewhat 
increased while the effusion is plastic, gradually diminished with the increase 
of liquid, and suppressed where the intervening effusion is copious, but still 
distinctly observable where the lung adheres. Hence, when one hand is placed 
upon the sound side, and the other upon the diseased one, and the patient is 
told to speak, little or no movement is felt in the latter, with the exception 
just mentioned; while in the former the thrill is distinct. 
Besides the above signs, there are others derived from the movements and 
shape of the chest; and the relative position of neighbouring organs. Thus, 
the affected side may sometimes be observed to be quiescent, while the other 
moves in respiration. When the effusion is great, the chest may be visibly 
distended, and, if measured by a tape, in the direction of a line around the 
body at the scrobiculus cordis, will be found to be larger on the diseased than 
the sound side. This, however, is not common, to any great extent, in acute 
pleurisy. Any difference that may exist will be most readily detected by 
making the measurement at the moment of full expiration, as it is then 
greatest, in consequence of the non-contraction of the distended side. But 
the fact must always be taken into account, that the right side in health 
ordinarily measures from a quarter to half an inch more than the left. The 
displacement of the heart, liver, &c., is much more frequently to be observed 
in the chronic than the acute form of the disease. 
The course of acute pleurisy is very variably and uncertain. There is reason 
to believe that, if the disease is vigorously treated by depletion at the begin- 
ning, it may often be arrested almost at the threshold, before it has exhibited 
any other signs of its existence than pain, decubitus on the sound side, a little 
cough, and a chill followed by fever. Exudation not having yet taken place, 
the physical signs are wanting. Should a catarrhal cough have preceded the 
attack, or should no cough exist, as sometimes happens, there are no means 
by which the disease could be certainly distinguished from febrile pleurodynia, 
which has the general symptoms above mentioned, and the same diminution 
of the respiratory murmur, arising from the restrained movements of the 
chest. Hence the doubt, in these cases, whether it was pleurisy or rheumatism 
of the intercostals that was cured. 
In other cases, along with the general symptoms mentioned, there is the 
friction sound upon auscultation, which is sufficiently decisive as to the nature 
of the complaint. The effusion of coagulable lymph has probably taken place, 
and a longer period is necessary for the cure. Sometimes, however, the 
morbid phenomena wholly disappear in from three to five days, leaving no 
unhealthy sound in the chest. In such cases, the opposite surfaces of the 
pleura have united, and the friction sound ceases because the surfaces do not 
move on each other. 
In a third set of cases, the signs of liquid effusion are perceived sometimes 
on the first day, sometimes not until the second, third, or even fourth day, 
when the severe pain abates. In these cases, the friction sound, if observed 
at all, is soon followed by feebleness and gradual cessation of the respiratory 
murmur, by bronchial respiration, aegophony, and dulness on percussion. 
Should the progress of the disease be now arrested, the general symptoms 
abate, and the morbid sounds gradually give way to the healthy, as th'e fluid 
is absorbed. The friction sound is sometimes heard for a brief period after 42 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[part II. 
absorption has taken place, and before union between the opposite surfaces 
has been effected. The disease is usually cured in five or seven days. 
But, instead of the favourable turn at the period above alluded to, there is 
often a continued advance of the disease; the effusion goes on increasing; 
Eegophony ceases; the bronchial respiration becomes more and more distant, 
until this also ceases; or is but faintly heard; flatness upon percussion prevails 
to a. greater or less extent over the chest, generally varying with the position 
of the patient; the dimensions of the affected side of the chest are sometimes 
even visibly enlarged; and the healthy vibratory movement of its walls in 
speaking is much lessened or quite wanting, as may be ascertained by apply- 
ing the hand to the surface. The pain has nearly ceased, and the fever 
moderated; but the dyspnoea is often great, and the patient is unable to lie 
upon the sound side. The disease, in this form, continues for a very variable 
period. Sometimes recovery takes place in two or three weeks, sometimes 
not for months; and the complaint not unfrequently assumes the chronic 
form. Should it terminate favourably, the fever, cough, and dyspnoea gra- 
dually disappear, the dulness on percussion diminishes, Eegophony occasionally 
returns in the progress of the absorption, the respiratory murmur is again 
heard, the friction sound may be noticed for two or three days or more, and 
health is at length re-established. The clearness on percussion, and the 
healthy respiratory sound, return usually first in the upper part of the chest, 
and afterwards in the lower. As the lung has not been sufficiently long com- 
pressed to have lost its expansibility, it is generally dilated as the fluid is 
absorbed; but sometimes, either from its own altered state, or because bound 
down by false membrane, it does not completely resume its original dimen- 
sions, and a degree of contraction in the diseased side of the chest ensues, 
which, however, generally diminishes, or disappears with time. The favour- 
able termination is often attended or preceded by certain critical affections, 
as urinary sediment, copious perspiration, diarrhoea, eruptive affections of the 
lips and skin, phlegmonous tumours, and rheumatic pains. After convales- 
cence, the patient not unfrequently complains of a stitch in the side upon 
taking a long breath; and sometimes a degree of cough, dyspnoea, and fre- 
quency of pulse remains for a considerable time. 
I have known the friction sound, after being first noticed at the commence- 
ment of the disease, to continue uninterruptedly for a long time, gradually 
becoming coarser with the continuance of the disease. This may be ascribed 
to the exudation of a fibrinous matter imperfectly coagulable, with too little 
adhesiveness to serve as a bond of union between the opposite pleural sur- 
faces, and insufficient vital force to undergo organization. 
Other diversities in the disease require notice. When the inflammation 
occupies both pleurae, the pain may be felt in both sides, or one only, or 
may be absent; the dyspnoea is much greater than in the ordinary variety; 
and the fever and other attendant symptoms are more severe. There is no 
longer the advantage of a comparison of the two sides in auscultation or per- 
cussion. Nevertheless, the signs are generally sufficiently evident. Double 
pleurisy is much more dangerous than that which is confined to one pleura. 
The inflammation in pleurisy is often partial; being limited by previous 
adhesions, or prevented from spreading over the whole membrane by some 
unknown cause. Thus, it may occupy only the costal and the opposite pul- 
monary pleura, in which case the symptoms are all those above enumerated. 
It seldom if ever happens that one of these surfaces is inflamed, for any 
length of time, without involving the opposite surface, when in contact with 
it. The pleura of the diaphragm is sometimes the exclusive seat of the dis- 
ease. In such cases, the pain is usually along the lower border of the chest, CLASS III.] 
43 
PLEURISY. 
or in the hypochondriac region, and is much increased by vomiting, eructa- 
tion, inspiration, and sometimes by pressure on the abdomen. M. Gueneau 
de Mussy has pointed out, as extremely sensitive to pressure, a spot situated, 
one or two fingers' breadth from the linea alba, on the level of the bony part 
of the tenth rib. Not only is extreme pain felt when this point is slightly 
pressed, but there is at the same time experienced a sudden increase of the 
dyspnoea, so great as apparently to threaten suffocation. (Arch. Gen., Sept. 
1853, p. 274.) The patient breathes with the ribs rather than the diaphragm. 
The difficulty of respiration is sometimes so great as to render the erect pos- 
ture necessary. Occasionally the pleurisy is associated, in these cases, with 
nausea and vomiting, and symptoms of jaundice, probably in consequence of 
the extension of irritation from the pleura to the subjacent organs. In fatal 
cases, delirium often precedes death for some days. Again, the inflammation 
may be seated in the mediastinum, or in the fissures between the lobes of the 
lungs; but there is scarcely a sign by which it could be certainly distin- 
guished in these situations. The position of the pain, and the absence of the 
peculiar signs of other diseases, might lead to probable inferences. Occa- 
sionally, abscesses have been found in these situations after death; and sudden 
discharges of pus by expectoration sometimes occur, which may be conjec- 
turally ascribed to the opening of such abscesses into the bronchia. 
Pleurisy sometimes occurs, and runs its whole course, without pain, cough, 
or observable dyspnoea, and without having attracted attention during life. 
These latent attacks usually take place in the progress, or at the close of 
other diseases, or in individuals previously much weakened, or cachectic. 
When acute pleurisy is about to terminate fatally, which very seldom hap- 
pens in the uncomplicated disease if well treated, the effusion increases, the 
breathing becomes very greatly oppressed, the countenance assumes a pale 
hue and anxious expression, the pulse increases in frequency and at length 
becomes small and feeble, and the heart ceases to beat, in consequence of the 
imperfect performance of the respiratory function. In the advanced stages, 
death sometimes results from a gradual failure of the powers of the system, 
under the combined exhaustion from the discharge, and irritation from the 
diseased structure. In double pleurisy, according to Andral, a fatal issue 
may take place from the mere influence of the inflamed membrane, without 
any discoverable amount of fluid effusion. (Clinique Med., iv. 513.) 
Chronic Pleurisy.-This is, in most instances, a mere continuation of the 
acute, though sometimes apparently of the same lower grade of action from 
the beginning. When pleurisy is connected with other complaints of a 
chronic character, such, for example, as phthisis, it is apt to assume itself 
the chronic form; and, in very obstinate cases of the disease, which long 
resist the plans of treatment ordinarily most effective, there is ground for 
suspicion, that the obstinacy may be owing to some other existing though 
possibly concealed organic affection. 
In this form of pleurisy, there are occasionally sensations of acute pain, 
but more frequently of mere soreness, oppression, weight, or vague uneasi- 
ness. There is also in general more or less cough, which is sometimes short 
and dry, but sometimes also attended with even copious expectoration, which 
may be either mucous or purulent. In the latter case, the disease is usually 
complicated with chronic bronchitis. In some instances cough is wanting. 
The most prominent general symptom is dyspnoea, which is in some cases 
very distressing, in others scarcely observable unless in consequence of bodily 
exertion. It is usually less troublesome in chronic than in acute pleurisy 
from an equal amount of effusion, because in the former the accumulation is 
more gradual, and the respiratory organs adapt themselves in some measure 44 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[PART II. 
to the new circumstances. The patient is often able to walk about, though 
in general pale, feeble, and more or less emaciated. Sometimes the face ap- 
pears slightly bloated, and the extremities somewhat edematous; and the 
oedema is said to be apt to appear on the chest and arm of the side affected. 
The circulation is in some instances little disturbed; but generally there is 
frequency of pulse, sometimes great frequency, with paroxysms of hectic fever, 
night-sweats, and great emaciation. In such cases, there is reason to suspect 
the existence of pus in the pleural cavity, constituting empyema. 
The physical signs are usually conspicuous. The chest is considerably and 
sometimes enormously distended, bulging outwards usually in the lower por- 
tion upon the side affected, which measures more than the other side. The 
intercostal spaces are widened, and, instead of being somewhat concave, as in 
the healthy state, are either flat or convex. Sometimes fluctuation can be 
felt between the ribs, by placing the flat of the hand upon the side, and 
striking quickly but gently with the finger one of the intercostal spaces. The 
ribs do not move in respiration. The heart is sometimes displaced by the 
pressure. If the effusion is on the' right side, it may be found to pulsate on 
the left of the left nipple, or even in the axilla; if on the left, it may beat 
under or beyond the right side of the sternum, or in the epigastrium. The 
mediastinum is also displaced, and affords a dull, instead of the clear healthy 
sound, to percussion upon the sternum. The liver is sometimes depressed 
several inches below the margin of the false ribs, and the affection has in 
consequence been mistaken for chronic hepatitis. The spleen and neigh- 
bouring colon are also below their ordinary level in the abdomen. 
Percussion yields a perfectly flat sound over the distended part of the chest, 
and sometimes over the whole side affected, though this is comparatively rare. 
Very frequently the limits of the flatness vary with the position of the pa- 
tient, always, indeed, if liquid is present in any considerable quantity, and 
not confined by adhesions, or by fulness and distension of the whole pleural 
cavity. The respiratory murmur is wanting, there is no vocal resonance, 
and even bronchial respiration is but faintly if at all heard, in the distended 
portion of the chest. 
But the above signs are sometimes modified by adhesions. In some places, 
the lung may adhere to the costal surface, in others, may be separated from 
it by effused liquid. In such cases, bronchial respiration and bronchophony 
may be heard distinctly in certain parts, and not in others. Sometimes the 
adhesions are in the lower portion of the chest, which may yield a clear sound 
on percussion, with the sounds also of respiration and the voice, while the 
upper parts present the ordinary signs of effusion. Again, the relative posi- 
tions of the adhesion and the effusion, and consequently of their characteristic 
signs, may be reversed. Occasionally the diaphragm or mediastinum may 
adhere to the lung, so that displacement of these parts may not be produced, 
or at least to the same extent as when no such adhesions exist. 
In the progress of chronic pleurisy, either absorption after a time predom- 
inates over effusion, and the liquid is partially or wholly removed; or the 
pleural cavity remains distended until the patient is worn out, or until the 
fluid is discharged by a natural or artificial outlet, independently of absorption. 
In the former case, as the liquid is removed, and the sides of the chest and 
the lung are brought together, adhesion takes place, accompanied with con- 
traction of the chest, resulting from the want of expansibility in the long com- 
pressed lung, or its restraint by false membrane, and its consequent inability 
to fill up the vacuity. The shrinking of the chest is not at first general. 
The upper part of the pleural cavity, being for the most part first freed from 
the liquid, the contraction will be first observed in the corresponding part of CLASS III.] 
PLEURISY. 
45 
the chest, and it will gradually extend downward with the progress of ab- 
sorption. The contraction may be slight, so as to occasion no obvious de- 
formity, and not materially to interfere with the restored health. Sometimes, 
however, it is very great; so that the chest, after the completion of the pro- 
cess, scarcely exceeds one half its former capacity. The contraction of the 
false membranes, in the progress of their organization, may contribute to 
increase the effect, after all the liquid has been removed. The deformity in 
these cases is considerable. The shoulder is drawn down, the scapula is rela- 
tively more prominent and nearer the spine, the ribs are lower and lie more 
closely together, the liver encroaches upon the chest, and the heart may some- 
times be heard on the right side of the sternum; reversing exactly the de- 
rangement previously occasioned by the effusion. More or less disorder of 
the general health attends this condition of the chest. The patient is affected 
with shortness of breath and palpitations, especially upon exertion, and con- 
tinues liable to them for a long time, if not during life. But, if young, he 
may in a considerable degree surmount these disadvantages, in consequence 
of the gradual expansion of the lung, and the conversion of the pseudo-mem- 
branous products into distensible cellular tissue. During the continuance of 
the contraction, the sounds of respiration and of percussion are usually some- 
what imperfect, even though the liquid may have been wholly removed. 
When the effusion has been partial, and limited by firm adhesions, the chest 
cannot contract sufficiently to fill the emptied space, which is therefore occu- 
pied by air, by the neighbouring viscera thrust into it, or by the semi-solid 
residue of the absorbed fluid. ( Williams.'') 
In the instances in which absorption is not effected, the fluid may be of a 
serous character, or may be pus. In the latter case, the danger of a fatal 
result is the greatest. Large collections of pus in the pleural cavity are sel- 
dom if ever absorbed. The symptoms do not always enable us to discrimi- 
nate between these two conditions. When, however, the affection is very 
obstinate, and attended with hectic symptoms, the existence of proper empy- 
ema may be suspected. Nature occasionally attempts, and even accomplishes 
a cure of this affection. A communication is formed between the pleural 
cavity and the bronchia, and the pus escapes by expectoration. If not so 
abundant as to overwhelm the lungs, and produce suffocation, it may thus be 
discharged, and the patient may possibly reach health through a long and 
doubtful struggle. Sometimes, moreover, the pus makes its way externally, 
forming a soft, rounded, subcutaneous abscess upon the chest, which may 
ultimately open, and thus form a direct communication between the cavity of 
the pleura and the external air. Such an abscess may be recognized by the 
changes it undergoes in the act of breathing, being firm during expiration 
and soft during inspiration. In some instances, the tumour disappears under 
pressure, and by change of position; and reappears when these causes cease 
to act. By whichever outlet the pus escapes, air is apt to enter the cavity, 
and, by exciting putrefaction in the purulent matter, to occasion fresh inflam- 
mation, and thus increase the immediate danger. In all these cases, the 
result is very doubtful, and the patient not unfrequently perishes in the end. 
Sometimes death comes suddenly and unexpectedly; sometimes the patient is 
worn out by hectic, with diarrhoea, dropsical effusion, &c. Chronic pleurisy 
may terminate in a few months, or may run on for years. Its danger is much 
increased by complication with tuberculous, or other organic disease. 
Pleuro-pneumonia.-In this there is a combination of the peculiar general 
symptoms of pneumonia and pleurisy, of which the viscid and rusty expec- 
toration is most characteristic of the former, and the sharp stitch in the side 
of the latter. The physical signs of the two affections are also to a greater 46 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
PART II. 
or less degree combined in the case. The crepitation of pneumonia is gene- 
rally heard early in the disease, and, after being quite lost in consequence of 
the accumulation of liquid, sometimes returns when this is absorbed. The 
friction sound, aegophony, and flatness on percussion indicate the existence of 
pleurisy. Sometimes the two inflammations occupy different portions of the 
lungs, the pleurisy for example the lower, and the pneumonia the upper. In 
such cases, the peculiar signs of each affection are perceived in the part which 
it occupies. But more frequently both affections exist at the same time in 
the lower portion of the lung. Here we have a mixture of the peculiar 
signs of both. The crepitant rale may be heard at an early period, but is 
gradually lost as the liquid in the pleura accumulates, when flatness on per- 
cussion supervenes, with bronchial respiration, and, instead of pure mgophony, 
a mixture of this with bronchophony, constituting a sort of double voice, 
which has been compared to that heard in the performance of Punch. Chomel 
states that this complication was first noticed by himself. Sometimes no re- 
spiratory sound can be heard unless the patient draw a quick and full breath, 
as after coughing; and then the peculiar signs of pneumonia may be per- 
ceived. Occasionally, by changing the position of the patient, pneumonic 
sounds become evident, which were before covered by the liquid. Vocal re- 
sonance is said by Williams to be greater in pleuro-pneumonia than in either of 
its component affections separately; and, indeed, all the auscultatory sounds 
of pneumonia may be increased by pleuritic effusion, when not too copious. 
According to Laennec, pleuro pneumonia is less dangerous, caeteris paribus, 
than either pleurisy or pneumonia. The compression of the lung by the 
pleuritic effusion he supposed to diminish the intensity of inflammation in its 
parenchyma; while, in consequence of the less yielding nature of the inflamed 
lung, it diminishes the space for effusion, and renders it more easy of absorp- 
tion by limiting its quantity. 
The most frequent cause of pleurisy, as of so many other inflammations, is 
exposure of the body to cold, especially when previously heated or perspiring. 
It is said that cold drinks, under similar circumstances, sometimes produce 
the disease. Other causes are mechanical injuries, the transfer of irritations 
from without, the sudden checking of habitual discharges, and the influence 
of various diseases. Among the most frequent of these are tubercles. They 
may occasion pleurisy either by a direct irritation from their contiguity to the 
membrane, or by the discharge of the matter of a vomica, through an ulcer- 
ated passage, into the pleural cavity. The latter result is not unfrequently 
prevented by the adhesions, consequent upon the former. Tubercles in the 
membrane itself may also be the cause of the disease. Inflammation of the 
lungs is not unfrequently propagated to the pleura; and gangrenous abscesses 
in the parenchyma, or mortification upon the. surface of the lung, sometimes 
give rise to pleurisy, the former by opening into its cavity, the latter by the 
contact of its putrescent products. Apoplexy of the lungs is said occasionally 
to produce it. Inflammation, ulceration, and abscesses of the walls of the 
chest, as well as cancerous or other malignant disease of the same parts, or of 
the lung itself, are not unfrequent causes of pleurisy. This affection has re- 
peatedly been observed to follow operations for the removal of tumours from 
the breast and axilla. (Broca, Arch. G^n.. 4e ser., xxii. 395.) 
The disease is more frequent in men than in women, chiefly, in all proba- 
bility, because they are more exposed to the ordinary causes of it, and partly, 
perhaps, on account of their stronger general inflammatory diathesis. It is 
common to all ages. The robust and vigorous, and persons of sanguine tem- 
Causes. CLASS III.] 
47 
PLEURISY. 
perament, are said to be most liable to it. The disease is most frequent in 
winter and spring. 
Diagnosis. 
The only diseases with which pleurisy is peculiarly liable to be confounded 
are rheumatism of the intercostal muscles or pleurodynia, pericarditis, and 
pneumonia. In pleurodynia, the physical signs which have been mentioned 
as characteristic of pleurisy are wantfhg, with the exception of the dimin- 
ished respiratory murmur, and other results of the want of free expansion of 
the chest in breathing. There is usually also an absence of fever and cough. 
Besides, in pleurodynia, the pain is often more shifting than in pleurisy, is 
frequently felt in neighbouring parts, and is more apt to be increased by a 
twisting motion of the chest. For the means of distinguishing pericarditis, 
the reader is referred to that disease. 
It will be proper to give in this place the diagnosis between pleurisy and 
pneumonia. In the former, the pain is sharp and severe, and usually concen- 
trated in one spot; in the latter, it is moderate and dull when the pneumonia 
is wholly uncomplicated; but, as this is generally associated with inflammation 
of the pleura which invests the inflamed portion of the lung, the symptom is 
little to be relied on. The character of the expectoration is more important, 
being viscid and rusty in pneumonia; mucous and transparent, or whitish, or 
simply streaked with blood, in pleurisy. In the latter, the crepitant rale of 
pulmonary inflammation is wanting; in the former, the friction sound and 
asgophony of pleurisy. In both, bronchial respiration may exist; but it is 
more extensive, and heard over remoter parts of the chest, in pneumonia, 
than in pleurisy with much effusion. In the latter affection, over the part 
where compression is greatest, respiration is often scarcely if at all heard, and 
vocal resonance is wanting; while in pneumonia, with the highest degree of 
dulness on percussion, bronchial respiration is usually distinct, and the vocal 
resonance much greater than in health, amounting often to bronchophony. 
Percussion yields no distinctive sound in the earliest stage; but the dulness 
is perceived earlier in pleurisy, and the flatness of the advanced stage is more 
complete. In pleurisy, the flatness often changes with the position of the 
patient, which is not the case in pneumonia. The whole sternum may be flat 
in pleuritic effusion, only one half of it in hepatization. The hand placed 
over the seat of copious pleuritic effusion feels no vocal vibration, while in 
pneumonia it is more striking than in health. In pneumonia, the distension 
of the chest, flatness or bulging of the intercostal spaces, and the displacement 
of the heart, liver, stomach, &c., which occur in pleurisy with large effusion, 
are wholly wanting. 
In some cases of partial pleurisy, especially the interlobar and mediastinal, 
the diagnosis is very uncertain, and at best but conjectural. When, more- 
over, the disease is unattended with pain and cough, it is very apt to be over- 
looked. This happens most frequently when the pleurisy comes on in the 
course, or towards the termination of other diseases. It is, therefore, a good 
rule, whenever in any complaint a sudden increase of fever, or othei- material 
change for the worse occurs, not readily traceable to its cause, to examine the 
chest minutely, and ascertain whether pleurisy may not exist. 
In chronic pleurisy, when the effusion is not confined by adhesions, there 
can generally be little difficulty in making a correct diagnosis. But, when 
partial and limited by old adhesions, it is not always so easily distinguished. 
Not to speak of the interlobar and mediastinal forms, which are generally first 
recognized after death, unless in certain rare cases in which the pus escapes 
through the lungs, and thus leads to plausible conjecture as to the scat of dis- 48 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[PART II. 
ease, even the costal cases are occasionally somewhat embarrassing. The flat- 
ness on percussion, and the shortness of breath, cough, and other general 
symptoms, are not always sufficient proofs of pleurisy; for they are met with 
also in pneumonia and phthisis, and may result from tumours within the chest, 
and even from the enlarged liver pushing up the diaphragm considerably above 
the ordinary level. Chronic pneumonia, however, is rare; and, besides, some 
bronchophony and bronchial respiration may be heard, which is not usually 
the case in pleurisy, unless in those points at which the lung adheres to the 
chest, and which may be distinguished by their strong contrast with the part 
in which the flatness is perceived. In phthisis the dulness is usually con- 
fined to the upper part of the chest, and various sounds are perceived by aus- 
cultation, which are wholly wanting in pleurisy. (See Phthisis.') Neither in 
pneumonia, nor in tuberculous cases, does the dulness on percussion equal 
that produced by liquid effusion. In relation to tumours, in which there is 
the same flatness, and the same absence of auscultatory sounds as in pleurisy, 
the discrimination must be founded on a survey of the origin and course of the 
complaint, and its general symptoms, and on the fixed character of the physi- 
cal signs. The same is the case with enlarged liver, in which the symptoms 
of chronic hepatitis, or the existence of some cause in the abdomen calculated 
to push that viscus upward, would be apt to lead to a correct conclusion. 
Prognosis. 
Simple pleurisy of one lung almost always terminates favourably, if treated 
properly in the earlier stages. When copious effusion has taken place, the 
cure is more uncertain, but may generally be effected in uncomplicated cases. 
It is usually by association with other diseases that pleurisy acquires great 
obstinacy, and becomes very dangerous. Thus, when it occurs in the course 
of febrile affections, or in persons debilitated by some wearing complaint, it 
increases the danger, and not unfrequently hastens the fatal issue. Perhaps 
the most frequent cause of its obstinacy is the existence of tubercles in the 
lungs. Hence, an intractable character, or disposition to very frequent recur- 
rence in pleurisy, is a reasonable ground for apprehending the existence of 
latent phthisis. Coexisting organic disease of the heart, liver, or kidneys, 
adds to the danger of the complaint. It is more serious in the old than in 
the young and vigorous; because in the latter, independently of their greater 
ability to withstand disease in general, there is a tendency to the effusion of 
coagulable lymph, and to consequent adhesion of the pleura, while in the 
former the disposition is to the secretion of serum or pus, both of which inter- 
fere with the curative process. Indeed, pus in the pleural cavity is always 
very hazardous. Purulent expectoration, hectic fever, and emaciation are 
very unfavourable signs in this complaint; as is also the escape of pus through 
the walls of the chest; though in both cases recovery sometimes takes place. 
Double pleurisy may always be regarded as a very serious affection. 
Treatment. 
Acute Pleurisy.-At an early period of the disease, the lancet should be 
freely employed. Few diseases bear bleeding better, or call for it more strongly 
than acute pleurisy. The patient should be placed in a sitting posture in bed, 
and the blood allowed to flow until a decided impression is made upon the 
pulse, or some degree of sickness of the stomach or faintness is produced. 
From twelve to twenty-four ounces may usually be taken at the first opera- 
tion. The disease is thus not unfrequently arrested at the outset, or rendered 
so mild as no longer to be an occasion of solicitude. Should the sharp pain 
not have ceased, or should it return, after having been mitigated, the bleed- CLASS III.] 
49 
PLEURISY. 
ing may be repeated in the same or the subsequent period of twenty-four 
hours; and, indeed, once or twice again, if the pain call for it, and the pulse 
permit. Even after the pain has ceased, should the pulse remain strong, and 
the physical signs afford evidence of a progress of the inflammation, the lan- 
cet may still be resorted to. Nor is this remedy to be limited by time. No 
matter what may be the period of the complaint, the coexistence of pain and 
a strong pulse indicates the propriety of the remedy; T>ut less blood must be 
taken at once in the advanced than in the early stages. 
After the first bleeding, the bowels should be thoroughly evacuated by 
sulphate of magnesia, the infusion of senna with salts, or calomel combined 
with or followed by an active cathartic. Subsequently, throughout the 
complaint, it will generally be sufficient to keep them opened once daily; 
for which purpose the saline laxatives, castor oil, or enemata may be used if 
necessary. 
The bowels having been unloaded, and the febrile symptoms reduced by 
the lancet, opium and ipecacuanha in the dose of a grain each, combined with 
two or three grains of calomel, may be given at bedtime, if the pain should 
be sufficient to prevent sleep. During the day, small doses of tartar emetic 
may be given every two or three hours, with the effervescing draught or 
neutral mixture, when the skin is hot and dry. 
Should the inflammation continue after the pulse has been subdued by 
general bleeding, leeches or cups may be freely applied to the chest, and 
followed by an emollient poultice; great care being taken not to allow the 
moistened skin to be exposed to the cool air. At the end of the third, fourth, 
or fifth day, after depletion has been sufficiently employed, great advantage 
will often accrue from a blister over the affected part. This should be large, 
eight by ten inches for example, and kept on in the adult ten or twelve hours, 
or even longer, should it not have drawn previously. 
At the same period, if the effusion be considerable, and the general symp- 
toms do not indicate a speedy and favourable issue, it will be proper to 
employ mercury, which should be given in moderate doses, and at short inter- 
vals, until the gums are touched, when it should be suspended. Calomel is 
in general preferable to any other preparation, though the blue mass may be 
substituted, if the former prove too irritating to the stomach or bowels. 
Sometimes it may be advisable to associate the mercurial with opium; but it 
will generally be sufficient to give this narcotic at night, as before recom- 
mended. 
After the decline of the fever, should effusion remain, attempts may be 
made to promote the absorption of the liquid by squill in connexion with 
calomel, if this be still administered, and with digitalis if there should be a 
frequent pulse, and no great debility. Seneka is also useful, when catarrhal 
symptoms coexist with those of pleurisy. If these measures fail in producing 
absorption of the liquid, nitre freely given in a large proportion of water, or 
cream of tartar may be substituted, and colchicum, muriate of ammonia, and 
iodide of potassium are recommended by some writers. Nitre is peculiarly 
appropriate when some febrile action continues, and may, under these circum- 
stances, be given in conjunction with the mercurial and digitalis, instead of 
squill. Repeated blistering is also here a most valuable remedy. 
In the treatment of pleurisy, reference must always be had to the state of 
the system; and, when this is asthenic, depletion must be employed with 
caution, and the mercurial practice commenced earlier. In such cases, it will 
often be sufficient to leech or cup instead of bleeding. Blisters may often 
also be very promptly applied. In bilious pleurisy, purging with calomel, 
and an early recourse to the mercurial impression are usually indicated; and, 50 
[PART II. 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
as in the case of the same variety of pneumonia, quinia should be used freely 
when the disease assumes an intermittent form, or even when it is very dis- 
tinctly remittent, provided there be at the same time a typhoid tendency. 
The observations made under typhoid pneumonia are applicable to pleurisy 
when similarly complicated. When pleurisy is associated with tubercles, 
care should be taken, if mercury be employed, that it be not allowed to pro- 
duce a deep effect, or to act long upon the system, lest it might favour their 
further deposition. 
The diet in acute pleurisy should be very low, consisting, in the early 
stages, chiefly of the mucilaginous or farinaceous liquids, and, at a somewhat 
more advanced period, of toasted bread and tea, fresh fruits, as oranges or 
grapes, and stewed dried fruits or preserves. Refreshing acidulated drinks 
may be allowed freely. The patient should be kept at rest, and should avoid 
speaking or coughing as much as he conveniently can. He should lie with 
his shoulders and chest somewhat elevated with pillows. It is important that 
the temperature of the chamber should be uniform, and comfortably warm, 
day and night. Caution must also be employed not to expose the naked chest 
unnecessarily, in any physical exploration which may be deemed requisite. 
Chronic Pleurisy.-Occasionally, in this form of pleurisy, moderate bleed- 
ing is admissible; but in general, when the loss of blood is indicated, local 
measures are preferable. The existence of pain with sufficient strength of 
pulse offers the requisite indication. Blisters are here invaluable. They 
should follow each other rapidly, or be kept constantly open by stimulating 
dressings. I prefer the former plan, as a more copious discharge may thus 
be obtained. Free pustulation with tartar emetic, and, in very chronic cases, 
issues or setons, may be substituted for blistering. Of internal remedies the 
most effective are probably combinations of calomel, squill, and digitalis. 
Seneka may sometimes be advantageously added, or substituted for one of the 
two latter ingredients. With the view of promoting absorption, iodide of 
potassium, or of mercury, or the compound solution of iodine, may be used 
internally, and the ointment of iodine applied to the surface by means of 
friction. Mercurial frictions will sometimes also be found useful. Opium, 
hyoscyamus, or some other narcotic should be employed th allay cough. 
When hectic symptoms appear, they must be combated by mild tonics, such 
as infusion of wild-cherry bark, the mineral acids, and the chalybeates, in- 
cluding iodide of iron, and by sulphate of quinia, if the debility is consider- 
able. Opium should also be given, and the diet should be nutritious without 
being stimulant. In doubtful cases, milk with the farinaceous substances, 
fresh vegetables, and fruits should be used; and, in greater debility, the 
lighter kinds of animal food, as eggs, oysters, broths, and boiled meats. 
Empyema.--Whether in the acute or chronic form of pleurisy, when the 
liquid in the chest is so copious as to threaten suffocation, recourse should be 
had to the operation of paracentesis. This operation is also called for in 
chronic cases, when all other measures have failed to remove the fluid, and 
life is threatened by its continuance in the chest. Though it often fails to 
effect cures, and though it sometimes aggravates the inflammation of the 
pleura, probably by the admission of air into the cavity, and the consequent 
chemical changes produced in the contained liquids, yet it generally affords 
temporary relief, often protracts life, and sometimes saves it. Out of sixteen 
cases recorded by Dr. Davies, in which the operation was performed, twelve 
recovered; but this is an unusually large proportion; and it is highly probable 
that many of them might have been relieved without it. The operation is 
more successful in serous than purulent accumulation, but the necessity for it 
is much greater in the latter. The nature of the liquid may be ascertained CLASS III.] 
PLEURISY. 
51 
by introducing a grooved needle, which may be done with little pain, and 
almost no risk. The quantity of fluid which has sometimes been discharged 
is enormous. A case is mentioned by Dr. Townsend, in which fourteen im- 
perial pints were drawn off by Mr. Crampton, of Dublin. ( Watson's Lectures.') 
Writers differ upon the questions, whether the liquid should be drawn off 
wholly at once, or by successive operations, and whether the orifice should 
be closed or left open. When the quantity of the liquid is large, and the 
whole is taken away at once, it is thought that the consequent entrance of 
air into the cavity must prove injurious by giving rise to inflammation of its 
walls; and the fact is, that, after the operation, the fluid if before serous is 
apt to become purulent, and if purulent, to undergo putrefaction; and the 
danger of the case may thus be aggravated. When the liquid is serous, and 
not in itself irritant, and when there is reason to think, from the period of 
the disease at which the operation is performed, that the lung may retain a 
considerable degree of expansibility, it appears to me best that such a por- 
tion only should be drawn off at once as will flow out readily, under the 
force of the contracting chest and the dilating lung. The plenum is thus 
preserved, and no air admitted; and, before a second operation is performed, 
the lung will probably acquire a still greater expansibility, and the chest a 
still greater contractile power, so that more may flow out without solicitation. 
In this way, it is possible that an equilibrium may be preserved between the 
diminution of the fluid, on the one hand, and the supplying expansion of the 
lung and contraction of the thorax on the other, until the parts are restored 
to their healthy state. Sometimes only one operation is necessary; as nature, 
assisted by remedies, is competent to the removal of the remaining liquid. 
But, if the liquid be pus, as much should be withdrawn as possible; and it is 
even recommended by some to withdraw it by means of a syphon or suction 
instrument. It is also recommended to wash out the pus by the injection of 
warm water. 
In relation to the question whether the wound should be closed or left open, 
the answer must depend upon the nature of the fluid. Should it be serum, 
it will be obviously proper to close the wound, so as to obviate the danger of 
inflammation from the admission of air, or the imperfection of the cavity. 
If it be pus, and this have a tendency to accumulate rapidly, the wound 
should be allowed to remain open, so that the liquid may escape as rapidly as 
it forms. If, therefore, the wound be closed after the first operation, and 
the cavity become again speedily distended, there can be little doubt that 
subsequently the external communication should be kept free, and nature 
imitated in the process, by which she sometimes effects a spontaneous cure 
through an external opening. It may, however, possibly happen that the cause 
producing the pus may have ceased in great measure to operate, and that the 
quantity drawn off may be replaced slowly if at all. In such a case, it would 
be fortunate that the danger of inflammation from a permanent imperfection 
of the cavity should have been avoided by a closure of the orifice. 
When the pus discharged is offensive, and the parts exhibit no tendency to 
a recovery of their healthy state, it has been recommended to inject antiseptic 
and moderately stimulant liquids, such as a weak solution of creasote, or of one 
of the chlorinated compounds. Several successful cases have been recorded 
from the use of iodine injections. The pus having been washed out by a 
mucilaginous injection, as of decoction of marshmallow, a solution composed of 
one part of iodide of potassium, ten parts of tincture of iodine, and a hundred 
parts of water, making altogether about four fluidounces, may be thrown into 
the cavity every two or three days; and the strength of the injection may be 
increased as the parts become accustomed to the impression. (Bojnet, Archives 
Gin&rales, 5e ser., i. 523.) 52 
[part II. 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
The method of performing the operation of paracentesis belongs to the 
subject of surgery. It will be sufficient here to state, that the operator should 
be perfectly satisfied of the existence of liquid at the spot where he makes 
the opening, lest he should wound the lung, or the liver, if this should hap- 
pen to have encroached upon the thorax. As a general rule, the space be- 
tween the fifth and sixth ribs should be preferred. In the upper part of the 
chest, adhesion is apt to exist; in the lower, the liver might be in the way. 
In relation to the treatment of pleuro-pmmmonia, no special instructions 
are necessary. The practitioner who understands how to treat each disease 
separately, will have no difficulty in deciding upon his measures when the 
two are conjoined. 
Article IV. 
PNEUMOTHORAX. 
This name, first applied by M. Itard to the affection in which air is con-, 
tained in the cavity of the pleura, has been generally adopted. To Laennec 
belongs the merit of having first fully investigated the subject; and little has 
been added to what was taught by him. The affection scarcely deserves to 
rank as a disease; being a mere incident in the course of several very different 
complaints and injuries of the respiratory organs. 
Pneumothorax may exist in three distinct forms; 1. that in which the cavity 
of the pleura has no communication with the external air, 2. that in which it 
communicates with the air through the bronchial tubes, and 3. that in which 
the communication is directly through the walls of the chest. The second is 
by far the most common, and sometimes coexists with the third. Another dis- 
tinction might be founded on the presence or absence of organic lesion; but the 
latter condition is comparatively so rare, that it might almost be considered 
as an anomaly scarcely worthy of notice. Still another distinction has been 
made, dependent on the presence or absence of liquid in the cavity; and the 
name of hydro-pneumothorax has been proposed for the variety which is cha- 
racterized by the former condition, while pneumothorax simply is retained for 
that in which there is only air. This nomenclature, however, has not been 
generally adopted, and the simpler title is usually employed to express the 
two varieties indiscriminately. It is a rare event, however, to find air quite 
alone in the pleural cavity. 
Symptoms.-The general symptoms are very equivocal, and altogether in- 
sufficient to serve as the basis of a confident diagnosis. Dyspnoea, dependent 
upon the compression of the lung, is an almost constant symptom. It varies 
greatly in degree, according to the amount of air and liquid within the cavity 
of the pleura, to the rapidity and permanence of the accumulation, and to the 
state of the opposite lung. Sometimes the quantity of air and liquid com- 
bined is so small as to occasion but slight compression of the lung, in which 
case there may be little inconvenience of breathing from this cause. When 
the accumulation is gradual, the organs of respiration and circulation accom- 
modate themselves, in some measure, to the new condition of things, and the 
suffering is less than under opposite circumstances. It happens, however, 
most frequently, that the entrance of air into the cavity is sudden. In that 
case, severe dyspncea usually comes on immediately, attended frequently with 
sharp pain in the side, and sometimes with a sensation as if something had 
given way in the chest. Occasionally these sudden attacks are marked by 
the occurrence of a copious expectoration of pus, consequent upon the opening CLASS III.] 
PNEUMOTHORAX. 
53 
of the pleural cavity, in a state of empyema, into the bronchia. It may hap- 
pen that the opening which admits air into the cavity during inspiration, shall 
be large or free enough to admit its ready expulsion during expiration. In 
such a case, excessive pressure upon the lung may not occur, and the dyspnoea 
may not be exceedingly violent. In other instances, on account of the orifice 
being under the surface of the liquid in the cavity, or of its having a kind of 
valvular arrangement, the air admitted during inspiration is either not ex- 
pelled at all, or only partially so during expiration, and consequently goes on 
accumulating, and thus compressing the lung, until suffocation ensues, unless 
through change of position, violent effort, or other cause, the air can find an 
exit. The fatal issue, under such circumstances, may take place very speedily, 
and is preceded by the most painful and laboured breathing, intense anxiety, 
and universal prostration. When one lung is from previous disease unfit for 
duty, and pneumothorax occurs upoii the opposite side, speedy death is almost 
inevitable. 
When the communication first takes place between the lung and the pleural 
cavity, there is not only dyspnoea, but often also a sharp pain in the side, and 
severe cough, in consequence of irritation of the membrane. The irritation is 
sometimes so intense as to be attended with a temporary depression of the vital 
functions; but inflammation and febrile reaction soon follow. These effects 
are usually ascribed to the direct influence of the air upon the pleura; but, 
when it is considered how innoxious is air in the cellular tissue, as in emphy- 
sema, this explanation must be received with hesitation; and the probability 
appears much greater, that the real source of irritation is the liquid, often 
highly acrid, which is at the same time admitted into the cavity from tuber- 
culous vomicae, gangrenous abscesses, &c. Should liquid have pre-existed in 
the cavity; then the admission of air may prove the source of irritation indi- 
rectly, by causing putrefaction in the liquid. The patient generally prefers 
the sitting posture, or, if he lie down, does so of choice upon the side affected, 
at least after the first violence of the pleuritic pain has subsided. 
The physical signs afford the only certain evidence of this affection; and 
these are quite distinctive. Sometimes there is distension of the chest, with 
enlargement and bulging of the intercostal spaces, and displacement of the 
neighbouring viscera, as in copious liquid effusion; but these effects are not 
constant. When the air is between the ribs and lung, percussion yields a clear, 
drum-like sound, much clearer than upon the corresponding part of the healthy 
side, and of a different character, being analogous to that produced by percussion 
over the stomach. If liquid exist in the cavity at the same time, percussion 
produces over it a flat sound, strongly contrasting with the tympanitic sound 
occasioned by the air; and the limits of the resonance and dulness are often 
well defined, and vary with the position of the patient, the former occupying a 
place in the chest above that of the latter. Thus, if the patient sit, the clear- 
ness will be in the upper and the flatness in the lower portion; if he lie upon 
his back, the former will be anterior and the latter posterior and vice versa. 
But this sign is of itself not sufficient; for the difference between the sound 
of the lung in health, and the sonorousness of pneumothorax is not always to be 
depended upon. Auscultation here lends its aid and supplies the deficiency. 
The ear, applied to the chest, perceives no respiratory murmur in the part 
where the sound upon percussion is clearest; while, at the corresponding spot 
on the opposite side, the percussion is less clear, and the respiration heard 
distinctly. The vocal resonance, and vibratory thrill of the walls of the chest, 
are also less over the tympanitic than over the healthy part. These signs 
taken in connexion with the movable limits of the dulness and sonorousness, 
are peculiar and distinctive. Sometimes, owing to adhesions of the lung to 54 
[part II. 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
the side, the respiration is heard; but other sonorous parts exist where the 
sound is wanting. If the quantity of air is very great, and no adhesions 
exist, the respiratory murmur is nowhere audible, except near the root of 
the lung. Besides this sign, there are others which belong equally to this 
affection, and to large cavities in the lung. Such are the amphoric respira- 
tion, amphoric resonance of the voice and cough, and metallic tinkling. For 
the value of these signs, the reader is referred to the remarks preliminary to 
the subject of diseases of the respiratory organs. (See vol. i., pages 757, 760, 
and 763.) Of course, the first two are heard only when the cavity commu- 
nicates with the bronchia, and the last most frequently under the same cir- 
cumstances, though the metallic tinkling may be occasionally produced in the 
closed cavity, as for example by change of position, when drops of the liquid 
which has adhered to the surface now uncovered fall into the mass of liquid 
beneath, and by rales in the bronchial tubes, &c. Still another sign is the 
sound of fluctuation or splashing, which is sometimes heard, especially if the 
ear be applied to the chest during succussion, that is, a quick and sudden 
movement of the body, as when shaken by a person having hold of the shoulders. 
This sound is produced only when there is a considerable quantity of liquid 
along with the air. It is often audible to the patient in moving. 
The course of this affection is various, being dependent on the nature of the 
disease of which it is an attendant. Sometimes it is very speedily fatal, with- 
in an hour, or a few hours, or a few days, and, when produced by the rupture 
of the pleura in tuberculous and gangrenous affections of the lungs, generally 
in the course of a week or two. Sometimes, however, it runs on for months 
and years, and cases are on record in which it continued for three and even 
six years. The termination is usually sooner or later in death, though reco- 
veries do occasionally take place, especially when the affection has originated 
in pleuritic effusion. Sometimes the symptoms of phthisis are ameliorated 
after perforation of the pleura. 
Causes.-By far the most frequent cause of pneumothorax is the opening 
of a tuberculous vomica, already communicating with the bronchia, into the 
cavity of the pleura. Hence, the affection is not a very uncommon accom- 
paniment of phthisis. The opening is made either by ulceration, or by the 
rupture of the membrane over a superficial vomica, in consequence of some 
violent action of the chest, as in a paroxysm of coughing. As a communica- 
tion is thus established between the cavity and the external air, this of course 
enters the pleura at every expansion of the chest, and, if the communication 
be perfectly free, passes out again in great measure during expiration, only 
so much remaining as may be necessary to occupy the space left by the elastic 
contraction of the lung. Should the exit, however, be less free than the 
entrance, the air goes on accumulating in the cavity, and the lung becomes 
very much compressed. In general there is only one opening, but sometimes 
there are several. As the tubercles producing them are seated usually in the 
upper part of the chest, the opening is most commonly found in the same 
part. In this variety of pneumothorax, the attack is often very sudden; for, 
though the ulceration may make its way gradually to the surface of the lung, 
yet, when the pleura only remains, this is apt to give way under some more 
than usual violence, and the phenomena at once occur. 
Upon the same principles, pneumothorax occasionally arises from gan- 
grenous or phlegmonous abscesses of the lungs, and hemorrhagic effusions in 
their tissue, making a passage into the pleural cavity; and the progress of 
cancerous ulceration, and the rupture of a hydatid, have led to the same result. 
But all these cases are very rare. 
In some instances, the opening is made from the pleura into the lungs. CLASS III.] 
PNEUMOTHORAX. 
55 
This happens in cases of empyema, in which the pus excites inflammation and 
ulceration in the pleura, and by the same processes opens a passage through 
the pulmonary parenchyma into the bronchial tubes, and is discharged. 
Sometimes it makes its way externally through the walls of the chest, instead 
of into the lungs, and thus establishes a direct communication between the 
cavity and the outer air. In either of these modes, pleurisy may be the cause 
of pneumothorax. 
The operation for empyema, and other penetrating wounds of the chest, 
occasionally give admission to the air through its walls; and, when the lung 
is penetrated at the same time, from the bronchial tubes also. A fractured 
rib sometimes causes pneumothorax by wounding the lung; and the same 
result is said to have been produced by violent compression from without, 
rupturing the pulmonary air-cells and pleura. In an emphysematous state of 
the air-cells, it sometimes happens that the superficial cells are ruptured in 
violent paroxysms of dyspnoea, and the air, escaping beneath the pleura, 
ruptures that also, and enters the cavity. 
In all the cases hitherto alluded to, there is an external communication. 
But the affection sometimes occurs without such communication. Occasion- 
ally a portion of the surface of the lung becomes gangrenous, and the gases 
arising from its decomposition are confined in the pleural cavity. Ulcerous 
communications have also been formed between the hollow abdominal viscera 
and this cavity, which has thus been filled with air. In some rare cases of 
partial pleurisy, in which the liquid effusion is limited by adhesions, it is said 
that the place of the liquid absorbed is sometimes supplied by air, the lungs 
not being sufficiently expansible, nor the ribs sufficiently flexible, to fill up 
the vacuity. It is probable that the air, in such cases, proceeds from the 
liquid, which always contains more or less of it under the ordinary atmospheric 
pressure, and yields it when that pressure is removed. Sometimes the liquids 
contained in the cavity of the pleura, especially when mixed with blood, un- 
dergo decomposition, and give out gaseous matter. Again, it is thought that, 
in some rare instances, air is secreted by the pleura, without any observable 
organic lesion. Such an event may happen in certain low states of the sys- 
tem, analogous to those in which a similar secretion of air takes place into 
the cells of the exterior cellular tissue. It is possible that the air occasionally 
found in the pleural cavity after death, without any discoverable organic 
affection, may be the result of the debility immediately preceding death, or 
even a pure cadaveric phenomenon. 
In relation to the comparative frequency of the foregoing causes of pneu- 
mothorax, it is stated by M. Saussier that, out of 147 cases of the affection, 
it was in 81 the result of phthisis, in 29 of pleurisy, in 8 of gangrene of the 
lungs, in 5 of emphysema, in 3 of hydatids, in 3 of wounds; while none of 
the other causes enumerated had produced more than a single case. (Diet, de 
Mid., xxv. 236.) 
The nature of the gas in pneumothorax depends on the cause of the affec- 
tion. Sometimes it is inodorous, as when derived immediately from the 
atmosphere; sometimes highly offensive, as when the product of gangrene, or 
of putrefactive decomposition of the pleural liquid. 
The lung is sometimes pressed against the spine, sometimes into the upper 
part of the chest, and very rarely into the anterior part. The degree of com- 
pression varies greatly. In some instances, it is so slight as scarcely to be 
sensible; in others, the lung is reduced to the size of the fist or even less. 
Sometimes it is much limited by the adhesion of the lungs to the parietes of 
the chest. There is occasionally much difficulty in finding the fistulous 
opening after death. 56 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[part II. 
Though generally fatal, pneumothorax is not necessarily so, even when 
dependent on phthisis. Dr. Woillez has shown that perforations of the lungs 
by tubercles are sometimes closed spontaneously by false membrane, connect- 
ing the parts around the orifice with the opposite costal pleura; and that, 
after this has taken place, the signs of pneumothorax may gradually disap- 
pear. (Archives Gen., Dec. 1853, p. 695.) 
Treatment.-This is usually directed less to the removal of the air con- 
tained in the pleura, than to the relief of the attendant symptoms. Imme- 
diately upon the occurrence of a sudden attack, it is often proper to allay 
irritation and obviate depression by opiates and sinapisms. The subsequent 
pleuritic inflammation must be combated by such an amount of depletion, 
either by the lancet or preferably by leeches, as the patient can bear, by 
emollient poultices, and blisters or antimonial postulation, by refrigerant 
laxatives and diaphoretics, and, if the case be not tuberculous, by a moderate 
mercurial impression. At the same time, the various remedies mentioned 
under pleurisy, as fitted to produce absorption of the effused fluid, should be 
employed. Opiates or other narcotics should be given to allay cough ; and, 
when symptoms of hectic appear, with night-sweats and emaciation, the 
strength of the patient must be supported by tonics and nutritious food. 
The only measure directed especially to the air in the pleura, is the making 
of an opening through the walls of the chest in order to let it out. This is 
warrantable only where the accumulation is so great as to threaten speedy 
suffocation. The operation should be performed as in empyema. Sometimes 
it affords instantaneous relief; and, if the pneumothorax depend upon reme- 
diable causes, may be the means of saving the life of the patient. But gene- 
rally it is only palliative ; and, in the advanced period of phthisis, when death 
must ensue ere long in the ordinary progress of the disease, the performance 
of the operation, for the sake of a few days' respite, is, to say the best of it, of 
equivocal propriety. 
Article V. 
EMPHYSEMA OF THE LUNGS. 
This name has been applied to that affection of the lungs in which their 
tissue is morbidly distended with air. There are two varieties of the affection; 
one in which the dilatation is confined to the air-cells, the other in which the 
air has escaped from the vesicles into the extravesicular or interlobular cellu- 
lar tissue, or upon the surfac.e of the lung beneath the pleura. The former 
was called by Laennec vesicular emphysema, the latter may very properly be 
designated as extravesicular. The complaint is not uncommon, but has not 
been well understood until recently. Laennec gave the first satisfactory and 
consistent account of it, though many isolated facts had been recorded by 
previous pathological anatomists. 
Anatomical Characters.-In vesicular emphysema, the lung does not col- 
lapse on the opening of the chest, but sometimes on the contrary expands, as 
if previously compressed by the ribs and diaphragm. This is ascribed to an 
inelastic or rigid condition of the membrane which forms the cells, consequent 
probably upon a sort of hypertrophy which not unfrequently thickens the 
walls of distended cavities. In consequence of this rigidity, they do not con- 
tract upon the air which they contain, and therefore remain distended. The 
lung is very light, and does not sink so much in water as in the sound state. 
It crepitates less upon pressure, has a firmer feel, and pits under the finger. CLASS III.] 
EMPHYSEMA OF THE LUNGS. 
57 
The surface is sometimes irregular in consequence of unequal projecting 
vesicles, and occasionally single vesicles are observed, sometimes as large as 
a pea or larger, of a globular form, and apparently attached by a pedicle. 
This, however, is only a contracted portion of the vesicle, which continues 
beneath into the substance of the lung. That these are distended air-cells 
and not extravasated air, is proved by the circumstance, that they cannot be 
moved from place to place under the pleura by pressure. If the lung is dis- 
tended by blowing into it, these vesicles appear to flatten and sink away ; but 
the fact is, that they remain unaltered, while the sound structure around them 
swells to their level. 
When the diseased lung is cut into, the air-cells are found to be in various 
degrees enlarged, generally to about the size of a millet-seed, sometimes to 
that of a hazel-nut; and occasionally one is observed of much greater magni- 
tude. The smaller cavities are probably mere dilated vesicles, the larger are 
sometimes produced by the rupture of the intervening coats, and the gradual 
absorption of the torn membrane. In order that the structure may be well 
exhibited, the lung should be fully inflated and dried before being sliced, 
and, in order to compensate for any air that may escape through the mem- 
brane, the inflation should be repeated now and then during the drying process. 
In consequence of the distension of the cells, the whole amount of surface 
over which the blood-vessels can ramify is diminished, and these, therefore, 
undergo absorption. There is consequently a diminished supply of blood, 
and the portions of lung affected have a whitish appearance, which sometimes 
contrasts, in a marked degree, with the colour of the healthy parts. The lung 
is also less moist than in health. 
The dilatation may affect only one or a few cells, or may occupy isolated 
spots, as single lobules, for example, while others remain unchanged, or may 
extend to large and continuous portions of the parenchyma. It may be con- 
fined to one lung, or may affect both. The latter is most frequently the case. 
When one lung only is the seat of the complaint, it is much larger than the 
other, so as sometimes observably to displace the mediastinum and heart. The 
dilatation is more frequent in the upper portion of the lung, and at its borders, 
than elsewhere. The edge of the lobes is sometimes irregularly fringed with 
the projecting dilated vesicles, of different sizes. The small bronchial tubes 
are usually also dilated in the emphysematous part. 
Extravehicular Emphysema.-In this variety, the air is sometimes effused 
upon the surface of the lung, underneath the pleura, producing little bladders 
of various size and form, in some instances not larger than a shot, in others 
as large as an egg, and even larger. An instance is mentioned by Bouillaud, 
in which the bag of air was equal to a common stomach in size. The affec- 
tion differs from that in which the vesicles are dilated in the circumstance, 
that, in the former, the air can be pressed from point to point beneath the 
pleura, while in the latter the vesicles are not movable. The effusion results 
from rupture of one or more air-cells. Sometimes the pleura gives way, and 
the air escapes into its cavity, constituting pneumothorax. (See Pneumotho- 
rax, vol. ii. page 55.) 
In some cases, the air is effused into the interlobular cellular tissue; and the 
affection, under these circumstances, is named by Laennec, interlobular em- 
physema. The partitions of cellular matter between the lobules, which in 
health can but just be distinguished by the eye, are now much expanded, 
being from a line to half an inch, and sometimes nearly an inch in thickness. 
On the surface of the lung they appear as translucent bands, sometimes run- 
ning in parallel directions, but frequently intersecting each other, so as to 
form lozenge-shaped spaces of sound lung. If the effusion of air take place 58 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[part II. 
near the root of the lung, it escapes into the mediastinum, and thence into 
the cellular tissue of the neighbouring parts of the neck, which thus becomes 
emphysematous; and the affection may extend to the cellular tissue under- 
neath the skin, and among the muscles, over the whole body. Though the 
emphysema in this case, is no doubt dependent on some solution of contin- 
uity in the air-cells or bronchial tubes, this cannot be detected. The proper 
cells of the lungs are generally not themselves dilated; though sometimes 
this kind of emphysema is associated with and dependent upon the vesicular 
variety. 
Ivilliet and Barthez state that, in children, they have almost always found 
inflammation of the bronchial tubes, or of the parenchyma; though these 
lesions have not generally occupied the same portion of the lung as the em- 
physema. (^Maladies des Enfants, i. 137.) 
Symptoms.-Very slight emphysema cannot be certainly detected either 
by the general symptoms or physical signs, and is first known to have ex- 
isted after death. When so considerable as to produce observable effects, it 
is always attended with dyspnoea, which, in very mild cases, may be occa- 
sional, appearing only under the influence of exciting causes, but, in those of 
a higher grade, is in a greater or less degree continuous and unceasing. In 
the latter cases, however, it varies exceedingly, being sometimes quite toler- 
able, at others exacerbated into the most distressing paroxysms, similar to 
those of spasmodic asthma, with which this affection was formerly confound- 
ed. These paroxysms occur quite irregularly, whenever, indeed, the patient 
may happen to be exposed to causes which call for' more than ordinary ex- 
ertion of the lungs, or in any degree tend to cramp their action, such as 
violent muscular effort, elevated situations where the atmosphere is rarefied, 
the horizontal position which throws the weight of the bowels partly upon 
the diaphragm, flatulence and overloading of the stomach, which act in the 
same manner by confining the lungs, and, above all, acute catarrhal attacks. 
As one of the consequences of the dyspnoea, the patient usually prefers the 
erect position, and in some instances finds it difficult to Ije with his head low. 
Cough is a very frequent attendant; but is rather a result of some concomi- 
tant disease than of the emphysema itself. It is not, as Laennec appears to 
have believed, invariably present in the complaint. Sometimes there is either 
no expectoration, or only of a small quantity of clear and viscid or frothy 
mucus; but, in other cases, and especially when the patient labours under a 
catarrhal attack, there is a copious discharge from the bronchia, which affords 
considerable relief to the dyspnoea. When not complicated with acute in- 
flammatory affections, the complaint is entirely free from fever, and the pulse 
is usually slow and regular. During the paroxysms, the face often exhibits 
the usual marks of imperfect aeration of the blood, being pale or livid with 
purple lips; and in bad cases there is sometimes an habitual dusky hue of the 
countenance. According to Stokes, these phenomena are most common when 
the lower lobes are chiefly affected. 
The physical signs, however, are much more accurately diagnostic than 
the general symptoms. When the affection is severe, there is usually some 
dilatation of the chest, which is general or partial according to the extent 
of the emphysema. The thorax is more cylindrical than in health, being 
rounded somewhat both before and behind. The intercostal spaces are 
widened, though not bulging, the ribs have a more horizontal direction, and 
the hollow above and below the clavicle is apt to be filled up. Sometimes 
only one side is enlarged, and sometimes the bulging is quite partial. The 
heart, spleen, and liver are occasionally displaced as in empyema. If the 
movements of respiration are closely watched, it will be found that the chest CLASS III.] 
59 
EMPHYSEMA OF THE LUNGS. 
falls little if any during expiration. Mr. Corfe gives as a diagnostic sign 
of emphysema of the upper lobes, the appearance of a tumour in the tri- 
angular space between the clavicle, sterno-cleido-mastoid, and omohyoid 
muscles at each spell of hard coughing; a phenomenon resulting from a sort 
of "hernia of the lung" in consequence of a want of support to the pleura 
at this place. (Med. Times, March 18, 1848.) 
But these deviations from the normal shape of the chest are not always 
present. The most sure signs are those afforded by percussion and ausculta- 
tion combined. Under the former, the chest over the affected portion of lung 
emits an unusually clear and hollow sound, which is not, as in health, in- 
creased by a full inspiration; while by the latter the respiratory murmur can 
be heard but very feebly if at all. The expiratory sound is often much pro- 
longed, probably owing to narrowing of the bronchia. The vocal parietal 
vibrations of the chest are generally diminished in emphysema; though the 
resonance is said to be sometimes natural, and sometimes augmented, even to 
bronchophony. Pneumothorax is the only affection which yields the same 
combination of signs; and as this is generally attended with liquid effusion, 
the marks of the existence of such effusion are sufficiently diagnostic, espe- 
cially when taken in connexion with the very different origin of the two affec- 
tions, and their very different course. In pneumothorax, moreover, there is 
a total want of the respiratory murmur, which can usually be heard, though 
feebly, in emphysema; while in the latter the metallic sounds are quite 
wanting. 
The dry and moist rales of catarrh are often heard, and occasionally, accord- 
ing to Laennec, a dry subcrepitant rale, which, Dr. Gerhard says, is " nothing 
but the slight rustling sound produced by the bubbles of air, either forcing 
themselves into the cellular tissue and forming little bags which rub against 
the pleura, or the dilated vesicles themselves, which are occasionally suffi- 
ciently rigid to give rise to some friction." (Med. Examiner, iii. 583.) Of 
course, in the purely vesicular emphysema, the sound can proceed only from 
the latter of these two causes. 
Vesicular emphysema is almost always a chronic and very protracted affec- 
tion. Beginning not unfrequently in childhood, it may run on to an advanced 
old age, and seldom proves fatal, unless through some concomitant affection. 
At first, the dyspnoea is usually slight, and the paroxysms at distant inter- 
vals. But, as life advances, the general difficulty of breathing increases, and 
the paroxysms become more frequent or distressing. In consequence of the 
interruption afforded to the passage of blood through the lungs by the great 
diminution of the circulating vesicular surface, the right side of the heart is 
apt to be affected with hypertrophy and dilatation, and hence a cachectic state 
of system, and dropsical effusion. When certain parts of the lungs are 
affected and others sound, it is evident that a greater than the due portion of 
the circulating office must fall upon the latter, so that they become especially 
liable to congestion and consequent pneumonia. It is probably by this affec- 
tion that life most frequently terminates, in pulmonary emphysema. 
According to Rilliet and Barthez, the physical signs of emphysema in 
children are different from -those above given. The respiratory murmur, 
instead of being diminished, is remarkably exaggerated, the sound upon per- 
cussion remains about as in health, and the walls of the chest are not changed 
in form; so that it is not always easy to recognize the disease. They ascribe 
the louder murmur to the great efforts made by infants in breathing, the state 
of percussion to the naturally resonant character of the chest, and the want 
of alteration in the walls of the chest, to the rapid march of the affection. 
But emphysema may always be suspected, in children affected with rachitis, 60 
[part II. 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
or with an acute disease of the chest, which has continued for some days, and 
occasioned violent respiratory efforts. (Maladies des Enfants, i. 138.) 
The extravesicular variety differs somewhat in its course from the vesicular. 
Instead of being very chronic, it is generally induced suddenly by causes cal- 
culated to rupture the air-cells. When dyspnoea comes on all at once, after 
violent efforts at inspiration, it may be inferred to belong to this affection. 
The patient is sometimes sensible, under these circumstances, of a feeling of 
crackling. Laennec says that a characteristic sign always present is a dry 
subcrepitant rale, or, as he expresses it, a dry crepitant rale with large hub- 
bies. It is much more constant and more marked in this than in the vesicular 
variety. lie distinguishes this from the friction sound, which is also heard, 
and which is produced by the irregular surface of the lungs rubbing against 
the ribs, diaphragm, or mediastinum. It appears to me that Dr. Gerhard 
has given the true explanation of this phenomenon in the sentence already 
quoted. The vibration which produces the sound may sometimes be felt by 
the hand upon the chest. If, along with the above signs, there is an appear- 
ance of emphysema about the anterior parts of the neck, there can be no 
doubt of the nature of the case. 
This form of pulmonary emphysema is in general a comparatively trifling 
affection. It may, in some very rare instances, be so extensive as to occasion 
suffocation; but usually absorption of the effused air takes place, the rup- 
tured orifices heal, and the patient recovers in a short time. 
Causes.-Whatever produces and sustains severe dyspnoea, while from any 
cause portions of the tissue of the lungs have been rendered incapable of ordi- 
nary expansion, may prove the cause of pulmonary emphysema. The expand- 
ing power of the muscles of inspiration, thus abnormally and excessively 
exerted, is brought to bear not on the whole of the pulmonary tissue, as in 
health, but on the portion remaining expansible, which is, therefore, forcibly 
dilated beyond the normal extent, and, by a continued application of the cause, 
becomes permanently dilated, the vesicles being not unfrequently ruptured at 
the same time. In asthma, the deficiency to be supplied by the expansion 
of the air-vesicles results from the spasmodic contraction of all the bronchial 
tubes. Hence, the emphysema is apt to be general in that affection. So 
constant an attendant, indeed, is it upon spasmodic asthma, when of consider- 
able duration, that some pathologists have been induced to consider the latter 
complaint as nothing more than emphysema. But the mere mechanical dila- 
tation of the air-cells is wholly insufficient to account for the nervous pheno- 
mena of asthma, which is undoubtedly the original affection. Besides the 
disease just mentioned, bronchitis is a frequent cause of emphysema, partic- 
ularly when it affects the smaller tubes, and is attended with a very viscid 
obstructive secretion. It then affords the two conditions mentioned, in a high 
degree, causing much dyspnoea, while, by obstructing the tubes in certain 
parts of the lungs, and thereby disabling the tissue supplied by them from 
expanding duly, or, as shown by Dr. Gairdner, even producing collapse, it 
throws the whole office of expansion upon the remainder. Dr. Williams has 
ingeniously suggested, as an immediate cause, a want of longitudinal exten- 
sibility in the bronchia, consequent upon chronic bronchitis, the result of which 
is, that the vesicles necessarily dilate towards the surface of the lung, so that 
this may remain in contact with the expanding walls of the chest. 
Cardiac affections, pulmonary abscesses, partial induration, atrophy, con- 
cretions, and tumours of all kinds pressing upon the bronchia, and partially 
filling the cavity of the chest, may be ranked among the causes of the com- 
plaint. In a slight degree, therefore, it should attend tubercles in the lungs; 
and though, according to Louis, the disease is seldom complicated with phthisis, CLASS III.] 
61 
EMPHYSEMA OF THE LUNGS. 
yet, from the more recent observations of M. Gallard, it would appear that 
more or less of an emphysematous condition of the pulmonary tissue is a 
constant and almost necessary result of tuberculous deposition. (Archives 
G^n., Aug. 1854, p. 200.) It follows, from what has been said, that pulmo- 
nary emphysema is usually a secondary affection, originating in dyspnoea, and 
aggravating the cause which produced it. 
Violent efforts at expanding the chest, or which require that the chest 
should be kept long in the expanded state, are also capable, unaided, of pro- 
ducing emphysema, though it is more frequently the extravesicular than the 
vesicular variety which results. Playing upon wind instruments, lifting very 
heavy burthens or other violent straining, and the practice of diving and remain- 
ing long under water, may be mentioned as examples of this kind of cause. The 
extravesicular emphysema is very apt to occur in the course of the other 
variety, upon the superadded operation of such causes; and the two forms, 
therefore, not unfrequently coexist. 
Treatment.-During the exacerbations of dyspnoea, the patient must be 
kept at rest, and all existing occasional causes of the dyspnoea removed as 
far as possible. Should evidence be presented of the existence of acute bron- 
chial inflammation, or active pulmonary congestion, blood should be taken 
by the lancet, or from between the shoulders by cups, or both generally and 
locally, according to the state of the circulation, and the urgency of the 
symptoms; and small doses of tartar-emetic may be given, at short intervals, 
during the continuance of the acute inflammatory symptoms. After these, 
if existing, have been reduced, and originally in cases in which they do not 
exist, narcotics, antispasmodics, and local irritants are highly useful. Such 
are laudanum and Hoffmann's anodyne, with sinapisms to the breast or back. 
The smoke of stramonium may also be tried, if not contraindicated by cere- 
bral symptoms; and the various remedies enumerated under spasmodic asthma 
may be resorted to if necessary. To promote expectoration, and relieve the 
bronchial spasm, few remedies will probably be found more efficacious than 
mixtures of equal parts of syrup of squill and seneka, with twice the quantity 
of tincture of lobelia. One or two teaspoonfuls of such a mixture may be 
given every hour or two, or even more frequently unless it nauseate, until 
the symptoms are relieved. For a more permanent effect than can be ob- 
tained from sinapisms, blisters or pustulation by tartar-emetic may be had 
recourse to, when the dyspnoea is protracted. 
But the most important part of the treatment is that which is directed to 
the prevention of the paroxysms of dyspnoea. Towards directly relieving the 
habitual amount of it, little can be done; but there is reasonable ground to 
hope that, if the exacerbations can be prevented, the progress of the disease 
may be delayed or arrested, and that, especially in the young subject, the 
air-cells may in the end gradually contract, and a positive amelioration of the 
disease take place. The patient, therefore, should carefully avoid all the 
causes calculated to bring on dyspnoea. He should never use any great mus- 
cular exertion likely to put him out of breath; should never, for example, 
attempt to run, or rapidly to ascend heights, or to lift heavy burthens. lie 
should guard with peculiar caution against taking cold; and should therefore 
clothe himself warmly with flannel next the skin, always keep bis feet dry, 
and take care not to expose himself, when heated, to currents of cold air. 
Laennec recommends frictions with oil as a preventive of catarrh. Measures 
should be promptly taken to relieve attacks of inflammation in any part of 
the air-passages. Residence in a warm and equable climate is highly desira- 
ble; and sea voyages in the warmer latitudes may prove beneficial. When 
the original cause of the dyspnoea continues to exist, and can be reached, the 62 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[PART II. 
efforts of the physician should be especially directed towards it. Thus, in 
anemic cases, the chalybeates and other means calculated to restore the pro- 
per condition of the blood, should be used. 
In the extravesicular form, little treatment is requisite. In cases of ex- 
treme and threatening dyspnoea, bleeding should be resorted to in order to 
lessen the duty of the lungs; and, if emphysema should appear about the 
neck, the air may be let out by punctures. . • 
Article VL 
BRONCHIAL DILATATION. 
This is not so much a disease in itself as an effect of disease. It is worthy 
of notice chiefly from the close resemblance of its signs, in some instances, to 
those of phthisis, and the consequent occasional difficulty of diagnosis. 
The smaller tubes are more commonly affected than the larger, probably 
because they have less of the cartilaginous structure. The dilatation is in 
different forms. Sometimes the tube is equably enlarged, and of a nearly 
cylindrical form for a considerable distance; sometimes the dilatation is 
confined to one spot, and is somewhat spherical in shape; and again, there is 
a succession of dilatations and contractions in the same tube. In the first 
case, the bronchial passage maybe dilated from the size of a fine straw to that 
of a crowquill, or the finger of a glove. A number of the branches of one 
of the large bronchia are often affected, and sometimes the whole of those 
going to a particular part of the lung. The globular dilatations vary, to use 
the language of Laennec, from the size of a hempseed to that of a cherry-stone, 
almond, or even walnut. 
These cavities often contain pus. Their coats are sometimes much and 
irregularly thickened, and exhibit little or nothing of the healthy structure. 
In other instances, they are so thinned by distension as to have the appear- 
ance of fine membrane. Frequently the pulmonary tissue without them is 
considerably compressed by their dilatation; and a compact layer of this com- 
pressed tissue forms a sort of exterior coating to the tube. 
Symptoms.-There are no general symptoms by which this affection can be 
recognized with tolerable certainty. It is almost always accompanied with 
cough and expectoration, which, however, are the signs of an attendant chronic 
bronchitis, and not of the dilatation. The expectoration is often purulent, 
and sometimes fetid, possibly in consequence of being detained in the enlarged 
tubes, and undergoing decomposition there. When the dilatation is considera- 
ble, it produces more or less dyspnoea, consequent upon the compression of 
the lungs, and is sometimes attended by a pale or livid complexion, a gene- 
ral cachectic appearance, and dropsical effusion, arising from deficient aeration 
of the blood. 
The physical signs are much more decisive. The hand applied to the chest 
is sensible of a more than healthy vibration from the voice and cough. Dul- 
ness on percussion often results in some degree from the compression of the 
tissue of the lungs. Sometimes percussion elicits a tubular sound, such as is 
produced by the same means over the trachea. The mucous and subcrepitant 
rales of bronchitis may usually be heard by auscultation. When the affection 
consists in a general enlargement of the tubes of a particular part of the lung, 
a diffused sound of bronchial respiration, and a bronchial resonance of the 
voice, are audible. When the dilatation is a rounded cavity, the respiration 
is cavernous; and, if liquid is present, there is a cavernous gurgling, and the CLASS III.] 
PHTHISIS. 
63 
voice issues from the wall of the chest in the form of bronchophony or pecto- 
riloquy. These are the signs also of a tuberculous cavity; and there are no 
certain means of distinguishing the two affections, except by their general 
symptoms and course. (See Phthisis.) Some aid may be derived from the 
situation of the physical signs. Tuberculous vomicae generally exist near the 
apex of the lungs; while dilatation is certainly not less frequent in the middle 
and lower than in the upper lobe. According to Skoda, the bronchial walls 
must be thickened, or surrounded by consolidated lung tissue, to yield the 
sounds above referred to. 
Causes.-Two causes may produce bronchial dilatation. One of these is 
the loss of the equable distribution of atmospheric pressure, and its concen- 
tration in an especial manner upon some one portion of the bronchial surface; 
the other is a morbid alteration in the coats of the tubes, which, by impair- 
ing their elasticity and muscular contractility, disposes them to dilate under 
any pressure that might be applied to them. Both of these causes operate in 
chronic bronchitis. By the abundant mucus secreted, or by the thickening 
of the tubes, the access of air to some part of the lungs is diminished or pre- 
vented, and, as this part cannot expand fully with the dilatation of the chest, 
the deficiency must be supplied by the more than ordinary expansion of the 
neighbouring structure. Bronchitis too, produces the altered state of the 
tubes themselves, which has been alluded to as favouring their dilatation. 
The violent cough which often attends the complaint increases the result, by 
augmenting the force of the expanding agency. Hence, chronic bronchitis 
and hooping-cough are the complaints in which bronchial dilatation is most 
frequent. Whatever is capable of producing similar obstruction may occa- 
sion the same result. Hence, pulmonary tumours pressing upon the bronchia, 
such as aneurisms, scirrhus, or enlarged bronchial glands, are among the 
causes of dilatation. Dr. Williams has noticed another condition in which 
the affection is sometimes produced. In pleuro-pneumonia, the air-cells of 
the lung, compressed by the pleural liquid, are sometimes unable to expand 
sufficiently to fill the vacuity caused by the absorption of the liquid, and the 
deficiency is supplied by the dilatation of the bronchia. Those of the middle 
size are usually most affected. 
Treatment.-The mere dilatation of the bronchia requires no treatment. It 
cannot be relieved by medicines. Attention must be directed to the diseases 
in which the dilatation originated, and by which it continues to be accom- 
panied. Of these the most frequent is chronic catarrh or bronchitis, to the 
remarks upon which the reader is referred for an account of the proper treat- 
ment. The chief practical point of interest, in connexion with this subject, 
is the importance of not abandoning, as incurable, cases of pectoral disease 
presenting most of the general characters, as well as physical signs of phthisis, 
unless it should have been well ascertained that they are not chronic bronchitis, 
with dilated tubes. 
Article VIL 
PHTHISIS. 
Syn.-Pulmonary Consumption.-*-Tuberculous Consumption.-Phthisis Pulmonalis. 
As employed in this work, the term phthisis is restricted to that form of 
tuberculous disease, in which the lungs are the part prominently affected. 
Formerly, various other pulmonary diseases, bearing a close resemblance to 
that under consideration, were confounded with it under the same general 64 
[part II. 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
name; but, anatomical investigations having shown an essential difference 
between them, and the comparatively recent improvements in the means of 
diagnosis, by the discovery of percussion and auscultation, having offered the 
means of detecting this difference during life, there is an obvious propriety in 
distinguishing them also by name; and most writers now recognize phthisis 
as the distinctive title of the tuberculous complaint. This disease is probably 
the greatest existing scourge of the human race, at least in the northern and 
middle latitudes. It will not be deviating far from the truth to state, that it 
causes about one-sixth or oncTseventh of all the deaths north of the tropics.* 
In treating of phthisis, it will be proper to give first its anatomical characters; 
as a knowledge of these is requisite to a thorough understanding of all other 
parts of its history. In detailing these characters, I shall not confine myself 
to the appearances usually presented after death, but shall endeavour to trace 
the progress of organic change from the commencement to the close, as ascer- 
tained by the minute and indefatigable researches of pathological anatomists, 
in every stage and variety of the disease. 
Anatomical Characters. 
Though there is reason to believe that the pulmonary affection is a conse- 
quence of a previously existing vice of the system, yet the first discoverable 
process, the first overt act of the disease, is the deposition of tuberculous mat- 
ter in the lungs. This appears in different forms, and with different charac- 
ters^ being sometimes deposited in small roundish well-defined bodies denomi- 
nated tubercles, sometimes irregularly infiltrated into the pulmonary tissue, 
and, in relation to its sensible properties, varying from a firm consistence, 
and grayish translucent appearance, to a yellowish opacity with or without 
hardness. Each of these modifications requires a more particular notice. 
1. Pulmonary Granulations.-Gray Granulations.-Miliary Tubercles.- 
Under these various names have been described by different authors, minute, 
roundish, shining, translucent, hard, homogeneous bodies, often not larger 
than a millet-seed, but varying from this size to that of a pea, which appear 
often in great numbers as the first step of phthisis. They are usually grayish, 
but sometimes have a light-reddish, and sometimes a dull dark-red or brown- 
ish colour; and occasionally are nearly colourless. They are either isolated, 
or clustered in small bunches, or in aggregate masses in which portions of the 
pulmonary tissue are inclosed and consolidated. In the latter state, they are 
almost always confined to the upper portion of the lungs; but, in the distinct 
or isolated condition, they are occasionally dispersed thickly throughout the 
whole or a greater portion of these organs, giving rise to great pulmonary irri- 
* From a table contained in the report of Dr. J. Curtis, published in the Transactions 
of the American Medical Association (ii. 540), it appears that the deaths from phthisis in 
Boston, during the twenty-eight years from 1821 to 1848 inclusive, were one in 5.76, or 
17.36 per cent. Dr. Hayward, from an examination of the statistics of New York for 
thirty years, gives the proportion in that city at 1 in 5.547, or about 18.02 per cent. (Am. 
Journ. of Med. Sci., N. S., xx. 312.) In Philadelphia, in the ten years from 1831 to 1840 
inclusive, according to the tables of Dr. Emerson, the deaths were 1 in 7.03, or 14.16 
per cent. (Ibid. xvi. 28.) In the ten years preceding 1820, on the same authority, the 
proportion in Philadelphia was 1 in 6.38, or 15.67 per cent. (Morton's Illustrations, p. 
167.) The mean of these will give for Philadelphia, during a period of twenty years, 
1 in 6.705, or 14.91 per cent. To give the results in one view, the average mortality 
by consumption in Boston has been 1 in 5.76 of the whole number of deaths, or 17.36 
per cent,, in New York 1 in5.547 or 18.02 per cent., in Philadelphia 1 in6.705, or 14.91 
per cent. From a subsequent statement, it will appear that the mortality from this 
cause has greatly diminished in Philadelphia since the year 1840, which is the latest 
date to which the above estimate extends. (Note to the third edition.) CLASS III.] 
PHTHISIS. 
65 
tation. In children they are often situated immediately beneath the pleura, 
producing an irregularity perceptible to the fingers; and the same is not 
unfrequently the case in adults. 
2. Gray Tuberculous Infiltration.-The same kind of matter which forms 
the granules above described, is often also deposited in the cellular tissue of 
the lungs, in irregular masses, sometimes one, two, or even three inches in 
cubic dimensions, without definite boundaries, or limited only by the extent 
of the lobules. This is the gray tuberculous infiltration of Laennec. It is 
homogeneous, hard, translucent, and of a grayish colour, sometimes darkened 
by the black matter of the lungs, portions of which become enveloped in the 
masses as they are formed. In some instances, no traces of pulmonary tissue 
can be detected in the masses; in others, they present remains of blood-ves- 
sels, bronchial tubes, and cellular membrane; and occasionally they are par- 
tially penetrated by the air in respiration. 
3. Gelatinous Infiltration.-Under this name, Laennec described a colour- 
less or rose-coloured substance, more transparent than the gray matter noticed 
in the last paragraph, and of a jelly-like consistence, which he had observed 
to be deposited in small quantities in the tissue of the lungs, in the intervals 
of the tuberculous granules, and which he believed to be gradually converted 
into proper tuberculous matter. Louis states that he has met with this spe- 
cies of infiltration, but has not noticed in it the yellow tuberculous points 
spoken of as not uncommon by Laennec. Dr. Morton, in his Illustrations of 
Pulmonary Consumption, gives two cases in which the tuberculous trans- 
formation appeared to have commenced in this gelatinous matter. 
4. Crude Tubercle, and Yellow Tuberculous Infiltration.-The gray trans- 
lucent matter constituting the first two deposits above noticed, appears to 
undergo a gradual conversion into what has usually been considered the pro- 
per tuberculous substance. In the miliary granulations, the transformation 
commences by a small yellowish-white spot, which most commonly appears 
at or near the centre, and gradually enlarges until the whole granule assumes 
that character. In this altered state, the little bodies are denominated crude 
tubercles. In the aggregated granules, the change commences at several points, 
each probably answering to a distinct granule; and considerable masses of 
yellow opaque matter result from the extension and ultimate coalescence of 
these central spots. The same transformation takes place in the infiltrated 
translucent matter, beginning in like manner with isolated opaque spots, and 
spreading until it involves the whole deposit, which, when thus altered, re- 
ceives the name appropriated to it by Laennec of yellow tuberculous infiltration. 
This may be distinguished from the crude tubercle by an irregular and angu- 
lar, instead of roundish form, and by a less definite line of division between 
it and the pulmonary tissue. There is no doubt that both the crude tubercle 
and yellow infiltration are often originally deposited, without the preliminary 
formation of the translucent matter. 
The minute bodies originally deposited in the state of crude tubercle, that 
is, yellow and opaque, are also frequently called miliary tubercles, especially 
when found in other tissues than the lungs; and, in the general observations 
on tuberculosis in the first volume of this work, the name of miliary tubercle is 
applied as well to the opaque as to the translucent granules. (See Vol. i. p. 112.) 
Progress of Tubercles.-The yellow tubercle, whether original, or the re- 
sult of a transformation of the gray, gradually increases by new accretions. 
As observed upon dissection, it is frequently found when quite mature, about 
as large as a pea; but it varies from the size of a large pin's head to that of 
a hen's egg, is irregularly roundish, and consists of a yellowish-white, opaque, 
friable substance, which easily breaks up between the fingers. In relation to 66 
[PART II. 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
its chemical composition, microscopic characters, and peculiar constitution, 
the reader is referred to the general remarks on tuberculosis, in the first part 
of this work. 
The next change in the tubercle is that of softening. This usually begins 
in or near the centre, and gradually advances towards the circumference, 
until the whole tubercle is converted into a soft, pultaceous, yellowish mass, 
not unlike pus in appearance. The same alteration takes place in the infil- 
trated masses. In some instances, instead of this gradual change, the whole 
tuberculous deposit, whether circumscribed or not, appears to be simultane- 
ously softened; and large portions of the lungs may be thus rapidly converted 
into pultaceous matter. According to Rilliet and Barthez, the softening of 
tubercles is comparatively rare in infants; and gradually becomes more fre- 
quent, as the child becomes older. ^Maladies des Enfants, iii. 231.) 
At this stage, the irritating properties of the confined matter produce in- 
flammation of the adjacent parts, which at length ends in ulceration, and thus 
opens a communication between the tubercle and the bronchial tubes. The 
matter now escapes, and is expectorated, leaving a cavity which is technically 
called a vomica. The cavities thus formed are sometimes lined by a secret- 
ing membrane formed out of fibrinous exudation, and are sometimes as it were 
hollowed out of the substance of the lung itself, without any intervening 
tissue. When recent, the lining membrane is delicate and easily separable; when 
old, it is firm, translucent, grayish, and sometimes of an almost cartilaginous 
consistence. The surrounding pulmonary parenchyma is sometimes healthy; 
but much more frequently it is altered, and often greatly so, being crowded 
with tubercles, or with tuberculous infiltration, or both, in various stages of 
advancement. The cavities are sometimes isolated and remain so; but not 
unfrequently they gradually spread by the breaking down of the surrounding 
tissue, and thus run together, forming caverns of various dimensions, and of 
very irregular shape, occasionally winding, and now and then crossed by bands 
of solid tissue, composed generally of the tuberculated substance of the lungs, 
but sometimes of altered blood-vessels which remain in a certain degree per- 
vious. Dr. Morton has in some instances traced, by means of a delicate probe, 
a communication between these vessels, and branches of the pulmonary artery 
or veins. (lUust., p. 30.) The tuberculous cavity may not be larger than a 
pea, or it may occupy a whole lobe of the lungs; and there is every grade 
between these extremes. The bronchial tubes, ulcerated in the progress of 
the tuberculous deposit, open directly into the cavities, with the lining of 
which their own mucous membrane is often continuous. The tubes show signs 
of inflammation in their increased thickness, and the redness and occasional 
ulceration of the mucous coat. 
The contents of the cavities, after the evacuation of the altered tuberculous 
matter, consist of pus secreted by the lining membrane or the surrounding 
tissue, with which are occasionally mixed small quantities of blood, tubercu- 
lous matter from the falling in of the walls, and even portions of disorganized 
pulmonary tissue. They ?re usually inodorous, but sometimes fetid. The 
proper blood-vessels of the lungs are generally obliterated in the immediate 
vicinity qf the cavity ; and the new tissue formed around it is nourished by 
new vessels, derived either from the bronchial arteries, or, when the lung ad- 
heres to the side of the chest, from the intercostals. Cavities are much less 
commonly produced in children than in adults. 
By the progress of the changes above described, the lung is at length so 
far destroyed as to be no longer adequate to the performance of its office, and 
the patient perishes. But the march towards this result is by no means steady 
or constant. In many instances, clear evidence is afforded by dissection of CLASS III.] 
PHTHISIS. 
67 
attempts, not always fruitless, to repair the mischief which has been done. 
When the tissue around the cavity is healthy, its lining membrane sometimes 
eeases to secrete; the walls contract, and the opposite surfaces, coming in con- 
tact, unite together, and are consolidated into a fibro-cartilaginous body, which 
is quite harmless in the lungs. Such cicatrices have been repeatedly observed 
in parts of the lungs where tuberculous vomicae are most apt to form. They 
are rare, it is true, but there can be no doubt of their occasional existence, 
and little of their tuberculous origin. In such cases, a cure must result, if 
the morbid deposition has been confined to this one spot. Another mode in 
which the tubercle may terminate favourably is by its conversion into a cal- 
careous concretion. This may happen by the absorption of the albuminous 
portion of the tuberculous matter, the earthy or saline constituents being left; 
and repeated depositions, followed by similar absorption, may finally result in 
the filling of the cavity with the earthy matters. Now such concretions, of 
size varying from that of a hemp-seed to that of a chestnut, are not unfre- 
quently found in the lungs, especially of old persons, though not of these ex- 
clusively. They are sometimes soft like chalk, sometimes much harder; but 
in both cases consist of the same ingredients, which are chiefly carbonate and 
phosphate of lime; the same essentially as the inorganic constituents of tu- 
berculous matter. The difference in consistence appears to be owing to the 
effect of age, in producing a firmer aggregation. The inference from these 
facts is fair, that the calcareous concretions are altered tubercles; and that 
some of them are so, can scarcely be doubted; for tubercles have been found 
with portions of calcareous matter in the midst of their ordinary contents, 
showing a commencement of the process. According to M. Valleix, tubercles 
are sometimes seen consisting of hard calcareous matter in the centre, next of 
a softer layer of the same substance, and lastly of unchanged yellow matter 
at the circumference. {Diet, de Med-, xxiv. 327.) This would seem to show 
that a change had begun in the centre, and was gradually proceeding outward. 
Nevertheless, it is possible to commit an error in referring these concretions 
always to a change of tubercles; for they may sometimes be nothing more than 
calcareous deposits in cavities resulting from distension of bronchial tubes. 
The views here given of the origin and progress of tubercles are not uni- 
versally admitted. They are, however, such as, upon a careful examination 
of the subject, have appeared to the author to approach nearest the truth. 
They correspond essentially with the opinions of Laennec and Louis, and with 
those of M. Valleix, as contained in an excellent essay upon the anatomical 
lesions of phthisis, in the Archives Generates (3e ser., x. 133 et 279). 
There are yet several interesting questions in relation to the anatomical 
history of tubercles. In the first place, in what precise portion of the pulmo- 
nary tissue are they deposited? Various opinions have been put forth upon 
this point. Thus, they have been supposed to be enlarged absorbent glands; 
but this opinion is supported by no fact, while it is contradicted by the absence 
of all signs of organization, and by the utter want of any proof of the exist- 
ence of such glands in many situations where the tubercles are found. Another 
opinion considers them as the result of exudation into the air-cells, to which 
they are thought to owe their shape. But they are found of the same shape 
in other organs, where no such cells exist. Finally, they have been placed in 
the radicles of the veins, in the mucous membrane or cavity of the bronchial 
tubes, and in the intervesicular tissue. The fact, however, appears to be, that 
they are confined to no particular position; but are found wherever there are 
blood-vessels to throw out the materials of which they are composed, whether 
in the vesicles, the minute bronchia, the cellular tissue between the air cells, 
or that between the lobules. 68 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[part ii. 
A second point of inquiry is in relation to their origin. Many persons, and 
of these some whose names stand among the highest in pathology, have main- 
tained that they are the result of an inflammatory process. But, though it is 
readily admitted that inflammation sometimes precedes the tuberculous depo- 
sition, and may even favour or give rise to it when a predisposition exists, yet 
there are many other cases in which not a trace of it can be detected, either 
at the origin or in the early stage of the tubercle; and, when it afterwards 
occurs, there is good reason to consider it as the consequence, and not the 
cause of that morbid product. A strong argument against the inflammatory 
origin of tubercle is deduced from the fact, that it is least frequently found 
in those parts of the lungs where inflammation is most frequent; the former 
almost always preferably occupying the upper, while the latter is most common 
in the lower portion. Laennec and Louis have been among the most strenu- 
ous opponents of the inflammatory hypothesis; and the general opinion of 
the profession is at present against it. 
The mode of softening in tubercles has been another subject of controversy. 
Many have maintained that this is effected by the infiltration of purulent or 
serous fluid secreted by the tissue which invests the tubercle, and which is 
stimulated by its presence into an inflammatory condition. Broussais, An- 
dral, and Carswell have been, among others, the supporters of this hypothesis. 
But there is one difficulty in the way of its reception, which cannot well be 
surmounted. The softening commences at or near the centre of the tubercle, 
or at least at some point within its substance. Though there may be some 
exceptions, the fact is, beyond all reasonable doubt, generally as stated. To 
this effect we have the concurrent testimony of the closest observers, among 
whom may be cited Starck, Baillie, Laennec, and Louis. The last-mentioned 
writer, who is perhaps the highest authority upon the subject, speaks unequivo- 
cally upon this point. Now, as the tubercle ha^ no blood-vessels penetrating 
through its substance to the point of softening, it appears impossible that this 
should result from the influence of any secrete'd liquid. The change is pro- 
bably altogether spontaneous. The tuberculous matter appears to be secreted 
with the character of change impressed upon it. When thrown out originally 
in the form of gray translucent granules or masses, it first becomes yellow 
and opaque, and then softens into a pus-like substance. Each alteration com- 
mences in the centre, because that was the seat of the first deposition, and the 
time of change for any portion of the matter must obviously be in the order 
of its production. We may go even beyond the softening, and suppose that, 
in relation to each tubercle, when the softened matter fails to make its way 
out of the cavity containing it, nature may have provided another remedy, by 
rendering it liable to a last change, which may end in the separation of its 
earthy and saline ingredients, and such a modification of the animal matter 
as to enable it to be absorbed. Thus the chalky concretions may be accounted 
for. From the latest researches into the nature of tubercle, it is most proba- 
ble that, as thrown out from the blood-vessels, it possesses a feeble vitality, 
which enables it to take on a partial organization, characterized by peculiar 
cells, and ending, after various changes, in complete disintegration. (See 
Tuberculosis, vol. i., page 117.) 
The first seat of the tuberculous deposition is, in the great majority of 
cases, in the upper part or near the summit of the lung; and when, as not 
unfrequently happens, it occurs in other parts, the tubercles are almost always 
more abundant, larger, and more advanced, in the situation alluded to than 
elsewhere; and it is here also that vomicae form. Large cavities are generally 
nearer the posterior than the anterior surface. The tubercles seem to evince 
a preference of the upper over the lower lobe, even at the same level. Thus, CLASS III.] 
PHTHISIS. 
69 
the former may be completely occupied with the morbid deposit, while the 
latter is nearly or quite free from it. When the tubercles are widely diffused, 
they usually begin to appear above, and extend gradually downward; and of 
course the upper are more advanced than the lower. Gray miliary tubercles 
are sometimes scattered through the whole of the lungs; but, in such cases, 
the patient is apt to perish before they have advanced to the crude state. In 
those rare instances in which the middle and lower portions of the lung are 
first affected, the deposition is apt to be in the form of yellow and opaque 
tubercle at the commencement. 
In almost all cases, there is more or less of the tuberculous deposition in 
both lungs, sometimes in about an equal degree, but much more frequently 
in one to a greater extent than in the other. Sometimes the tubercles are 
confined exclusively to one lung. According to the observations of Louis, the 
left lung is more frequently affected than the right; and this appears to be the 
general experience, though Laennec has made a contrary statement. 
Sometimes the tubercles are few and isolated; and the surrounding pul- 
monary structure may be quite healthy. But much more frequently they are 
numerous; and, if the disease is of long standing, they are found in different 
stages, showing a deposition at successive periods; those in the upper portion 
of the lung being most advanced, and the others appearing less and less so as 
they descend. Occasionally something like a boundary line, though never 
quite precise, may be observed between the successive crops. Thus, in the 
same lung, tubercles may often be found in all their different stages. It not 
unfrequently happens that large portions of the lungs are consolidated by a 
mixture of tubercles and tuberculous infiltration, and, when cut into, present 
a mottled appearance, arising from the different colours of the deposit in its 
different stages, and of the portions of pulmonary tissue which remain. In 
the midst of this consolidation are frequently isolated or communicating cavi- 
ties, which gradually increase by the falling in of the disorganized structure, 
until at length vast caverns are sometimes formed ; and almost the whole lung 
may thus become excavated, or otherwise rendered unfit for duty. 
Very often, and, when the disease is extensive, almost always, the pleura 
of the lung is found adhering to that of the side. Of 112 cases examined by 
Louis, there was only one in which no adhesion could be found in either lung. 
Generally it is limited to that portion of the surface which corresponds with 
the tuberculous affection; but in some instances it is very extensive, and may 
be even universal. The adhesion is the result of inflammation of the pleura, 
and the consequent effusion of organizable lymph, and is found in different 
stages, from the mere cohesion of the recently deposited fibrin, to the perfect 
union by intervening cellular tissue. It often answers an admirable purpose, 
by preventing the effusion of the contents of the tuberculous cavities into the 
pleural cavity. Sometimes, however, such effusion does take place, and gene- 
ral inflammation of the pleura results, which adds greatly to the danger. 
Should a communication, in such cases, exist also between the vomicae and 
the bronchia, air enters the pleural cavity, and the affection denominated 
pneumothorax results. (See Pneumothorax.) 
The bronchia are always more or less inflamed in the advanced stages of 
phthisis, especially those which communicate with the tuberculous cavities. 
Occasionally, numerous minute ulcers may be seen in their mucous surface. 
These, however, are more frequent in the trachea, especially in its posterior 
part. They are found also not unfrequently in the larynx, and upon the 
posterior surface of the epiglottis. Occasionally the bronchial tubes are 
dilated, and partial emphysema of the lungs is very common. The bronchial 
glands are frequently enlarged, indurated, and loaded with yellow tuberculous 70 
[part II. 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
deposition. In very many cases, the pulmonary tissue is more or less in- 
flamed, but generally in isolated patches. Hepatization of large and continu- 
ous portions of the lungs is not common, and when it occurs, arises generally 
from incidental causes, unconnected with the tubercles. 
Appearances in other parts of the body.-As tubercles in the lungs are the 
result of a general predisposition, it might be expected that they would be 
found in other organs; and this is very frequently the case. It is a singular 
fact, that, without the lungs, the deposition seldom takes place in the form 
of translucent granules, but almost always in that of the yellow and opaque 
tubercle. Nevertheless, the translucent granulations, the opinion of Andral 
to the contrary notwithstanding, have been seen by many observers in differ- 
ent parts of the body. (Archives Gen., 3e s^r., x. 136.) I have myself 
seen them in countless multitudes in the liver of a patient who died 
of phthisis. The extra-pulmonary tubercles are generally consecutive to 
those in the lungs, but by no means universally so; and the exceptions are 
not unfrequent in children. They have been observed in the pleura and its 
false membranes, the pericardium, the peritoneum, the stomach and intestines, 
the mesenteric glands, the liver, spleen, and kidneys, the prostate gland and 
testicles, the membranes and substance of the brain, the external lymphatic 
glands, and even in the bones. Indeed, there seems to be scarcely a living 
part of the body which is not liable, in a greater or less degree, to this depo- 
sition. In relation to their relative frequency in different organs, Louis found 
that, of all the cases of pulmonary tubercles occurring in persons over the 
age of fifteen, one-third presented tubercles in the small intestines, one-fourth 
in the mesenteric glands, one-ninth in the large intestines, one-tenth in the 
cervical glands, one-twelfth in the lumbar glands, one-fourteenth in the spleen, 
and a smaller proportion in other organs. 
In the great majority of cases, the stomach exhibits after death signs of 
organic disease. It is usually larger and thinner than in health, and the 
mucous membrane has all the marks of chronic inflammation, including 
sometimes ulceration. Similar marks of inflammation also exist in the small 
intestines ; but the lesions here are more frequently of a peculiar character. 
Small tuberculous granules are developed in the substance of the intestinal 
coats, in the glands of Peyer as well as elsewhere, which undergo the regular 
process of softening and discharge, and terminate in ulcers. These are small 
when isolated, but, by running together, frequently acquire considerable di- 
mensions, sometimes occupying the whole inner circumference of the intestine. 
They are most numerous in the vicinity of the.caecum. Other little tumours, 
not of the tuberculous character, are also often visible in the mucous mem- 
brane of the small intestines. They are of a semi-cartilaginous consistence, 
and are thought by Louis to be inflamed mucous glands. Like the tubercles 
they end in ulceration. Occasionally, the tuberculous ulcers penetrate the 
coats of the intestines, and allow their contents to escape into the peritoneal 
cavity. Ulcers are also not unfrequently found in the large intestines, and 
sometimes of enormous extent. The mesenteric glands are often enlarged 
and inflamed, in consequence of the deposition of tuberculous matter within 
them. The liver is subject to a singular fatty degeneration, with great en- 
largement. In children, the membranes of the brain are frequently tuber- 
culated, with all the phenomena of hydrocephalus. (See Tuberculous Menin- 
gitis.) From observations made by Dr. Theophilus Thomson, it appears that 
the average weight of the heart is above that of health, a result which might 
have been anticipated from the excessive action of this organ. (Clin. Leet, on 
Pul. Consump., Am. ed., p. 89.) Various other lesions are frequently ob- 
served in the dissection of consumptive cases; but they are generally such as CLASS III.] 
PHTHISIS. 
71 
equally attend other affections, and have no peculiar dependence either on the 
tubercles or the tuberculous diathesis. 
Symptoms, Course, &c. 
Two stages may be observed in the course of phthisis, corresponding with 
the two stages in the progress of the tubercles, one preceding and the other 
following the period of their maturation and discharge. These are not always 
separated by a precise line of division ; and it is often difficult to decide, in 
particular cases, where exactly the first ends and the second begins. But 
each stage is sufficiently characterized in its prominent symptoms, at periods 
when the pathological condition peculiar to it is quite unmixed. 
First Stage.-Phthisis begins in different modes. Most frequently, per- 
haps, the first symptom is a short, dry, hacking cough, very slight at the 
commencement, so as often scarcely to attract any notice, but gradually in- 
creasing, and, after a longer or shorter time, attended with expectoration first 
of transparent mucus, and afterwards of a white or yellowish opaque matter, 
as in common catarrh. For some time there is little other observable de- 
rangement of system. The appetite is good, most of the functions are regu- 
larly performed, and the patient is scarcely sensible of any diminution of 
strength. Perhaps, upon the occasion of any unusual exertion, there may be 
some shortness of breath, and a more than ordinary feeling of fatigue. The 
pulse, too, is often accelerated, especially during exercise; and, as the com- 
plaint advances, the patient begins to experience febrile sensations towards 
evening, with some flushing of the cheeks, and heat in the palms of the hands 
and soles of the feet. Occasionally fugitive pains are felt between the shoul- 
ders, in the sides, or about the sternum. But probably the most characteris- 
tic symptom is a slight but progressive emaciation, which cannot be ascribed 
to any discoverable failure of the appetite or digestive powers, and seems out 
of proportion to any existing evidences of disease. This, however, is not a 
uniform attendant upon the incubative stage. Indeed, the symptoms alto- 
gether are frequently such as occur in other complaints, especially dyspepsia; 
and it is not uncommon for patients with the latter affection to entertain 
serious apprehensions of phthisis, while those really consumptive have no such 
fears. In the condition above described, the patient may continue for weeks, 
or months, and sometimes even for years. Ilis cough he ascribes to an ob- 
stinate cold, or to frequently taking cold; his pains, if he have any, to rheu- 
matism; and he either shuts his eyes against the other symptoms, or explains 
them in some satisfactory manner. At length, however, the increase of cough 
and fever, the occurrence of severe pain, or, perhaps, still more frequently, 
an attack of hemorrhage from the lungs, excites alarm. Sometimes the he- 
morrhage, which usually subsides spontaneously, or readily yields to remedies, 
is followed by an amelioration of the cough, fever, and pains, and the patient 
feels himself much better, and even believes himself recovering. In other 
instances, it appears to mark an aggravation of the disease, the progress of 
which is afterwards much more rapid. Not unfrequently the haemoptysis 
returns again and again; and, in some cases, the patient is seldom long with- 
out the discharge of blood from the lungs. But, whether hemorrhage occurs 
or not, the symptoms continue to advance, sometimes regularly, but more 
frequently with remissions, which are occasionally of considerable duration, 
and always a source of hope and comfort to the patient. The cough at length 
becomes very troublesome, often disturbing sleep, and sometimes occurring in 
violent paroxysms. The expectoration takes on a more decidedly purulent 
character. The dyspnoea and thoracic pains often increase, and the febrile 
symptoms are more decided, the pulse being almost always frequent, the face 72 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[PART II. 
often flushed, the tongue somewhat furred, and the appetite impaired. In 
some instances, the fever exhibits a tendency to the paroxysmal form, and the 
patient not unfrequently perspires during sleep. The first stage is now at 
its height, and, having continued in this state a variable length of time, passes 
sometimes abruptly, sometimes by imperceptible degrees into the second. 
Occasionally, instead of beginning and gradually increasing as above de- 
scribed, the disease, with no observable premonitory symptoms, or at least 
with none that attract notice, comes on suddenly with an attack of haemop- 
tysis, after the subsidence of which the characteristic phenomena are devel- 
oped, slowly or rapidly, according to the susceptibilities of the patient. 
Again, the disease has its origin apparently in some inflammatory affection 
of the respiratory organs, as bronchitis, pneumonia, or pleurisy, or follows 
closely in the footsteps of some febrile disease, such as smallpox, scarlatina, 
typhoid fever, or bilious fever. In these cases, after the subsidence of the 
peculiar symptoms of the disease, the pulse remains obstinately frequent; 
cough, if previously wanting, sets in, or, if already existing, perseveres beyond 
the usual period; and the other characteristic phenomena of early phthisis 
show themselves, for the most part, with unwonted severity. Sometimes a 
catarrhal affection glides so imperceptibly into phthisis, that it is impossible 
to decide which was the original disease, unless the catarrh may have com- 
menced suddenly in sound health, and with unequivocal symptoms, as in 
influenza and measles. 
Another mode in which phthisis occasionally commences is with the symp- 
toms of chronic laryngitis, which prevail for some time before those of the 
pectoral affection are developed, and often serve to mask the latter until the 
complaint is far advanced. 
Lastly, cases occasionally though rarely occur, in which the disease comes 
on so insidiously as altogether to escape notice, until it breaks forth fully 
formed, and with the most fatal symptoms. In such cases, there is little or 
no cough, no pain, and no observable febrile excitement. Perhaps the patient 
may experience some dyspnoea upon any unusual exertion, may feel rather 
weaker than in his ordinary health, and may gradually become thinner; but 
these effects, if they happen at all, are so slight as scarcely to attract notice, 
and, if perceived, are referred to some other cause. At length, some symp- 
tom calculated to excite suspicion occurs, which leads to a physical explora- 
tion, and unequivocal signs of extensive disease are found in the upper part of 
the chest; or the vomica which has been imperceptibly forming, opens into 
the bronchia, and the symptoms of the second stage are at once developed. 
Second Stage.-1This often comes on so gradually that the precise time of 
its commencement cannot be fixed. There is not unfrequently an increase of 
fever preceding the opening of the vomica, consequent probably upon the in- 
flammation excited by the matter of the tubercle, seeking an outlet through 
this means. The patient, previously walking about, now takes to his bed, 
and suffers with pains in the chest, heat, thirst, loss of appetite, furred tongue, 
&c.; till at length the character of the expectoration proves that an outlet has 
been made; after which there may for a time be a subsidence of the febrile 
symptoms. But, in many instances, the second stage sets in gradually with- 
out any such premonition; and occasionally, as already stated, bursts at once 
upon the patient almost without previous warning of any kind. The most 
characteristic symptom of this stage is the peculiar appearance of the expec- 
toration, which is now decidedly purulent, and generally in distinct well de- 
fined masses, with an occasional accompaniment of softened tubercle, in the 
shape of small lumps of yellowish cheesy or curdy matter. These, however, 
often escape notice. The cough is now generally increased, and is especially CLASS III.] 
PHTHISIS. 
73 
troublesome in the morning, when the accumulations of the night are to be 
discharged from the lungs. The fever assumes a decidedly hectic character. 
The pulse, almost always frequent, becomes considerably more so at some 
period of the twenty-four hours, generally towards evening; and this exacer- 
bation is accompanied with increased heat of skin, flush of the face often 
circumscribed upon the cheek, and a remarkable clearness of the conjunctiva 
and general brilliancy of the eye. The febrile paroxysm often subsides with 
a gentle perspiration. Not unfrequently, chills occur at somewhat regular 
periods every day, followed by fever and perspiration, like the paroxysms of 
intermittent, but less regular, usually less violent, and with much less pain 
in the head. These chills do not occur in all cases, and are frequently inter- 
rupted, to return again, often without any appreciable cause for either change. 
The patient very frequently perspires during sleep, and, in the progress of 
the complaint, the night-sweats become profuse and exhausting. They are 
not necessarily connected with the febrile paroxysms; but continue when these 
are suspended, and are sometimes very abundant, even in those rare cases in 
which the pulse is little excited. Sharp pains in the sides and posterior parts 
of the chest are frequently experienced, which are sometimes neuralgic, but 
oftener probably the result of pleurisy, which is a very common accompani- 
ment of phthisis. In the latter case, the pains are generally attended with 
some increase of fever, which subsides again upon their removal. Hemor- 
rhage from the lungs now and then takes place, but not in all cases, and less 
frequently and copiously than in the first stage. The purulent expectoration 
is generally very copious; and this, together with the exhausting night-sweats, 
and the constant irritation of system, hastens the progress of debility and 
emaciation. The ends of the finger nails often curve forward, giving a pecu- 
liar appearance to the fingers which has been thought to be characteristic of 
phthisis, but is found, though less frequently, in other chronic and exhausting 
diseases. The menses are almost always suppressed in the course of the com- 
plaint, though at uncertain periods. The appetite is often greatly impaired, 
if not lost. All these symptoms, however, are occasionally relieved, or quite 
disappear for a time. The discharge of pus diminishes and at length ceases; 
the cough and fever subside; the appetite returns; and the patient even begins 
to recover flesh. The vomica has been emptied, and has probably begun to 
take on the healing process; but a new crop of tubercles is deposited, and the 
delusive calm is generally succeeded by a return of the original symptoms, 
often more violent than at first. At an advanced period of this stage, the 
stomach and bowels often become involved in the disease. The patient suf- 
fers from frequent attacks of diarrhoea, which are sometimes very exhausting. 
They occasionally alternate with the night-sw'eats; but not unfrequently the 
two discharges are simultaneous. Nausea and vomiting are occasionally added 
to the other sufferings of the patient; and, in some instances, food of all kind 
is rejected by the stomach. Hoarseness and total loss of voice are not un- 
common, and the dyspnoea sometimes becomes very distressing. 
In some instances, the patient is suddenly carried off by the supervention 
of some secondary affection, such as pneumothorax, profuse hemorrhage from 
the lungs, severe peritoneal inflammation consequent upon perforation of the 
bowels, the bursting of a large vomica overwhelming the lungs, and disease 
of the brain produced by tuberculous deposition in that organ or its mem- 
branes. This last cause of death, however, is almost peculiar to children. 
Generally, the fatal termination approaches more gradually. Among the 
symptoms now presented, in one or another case, are oedema of the extremi- 
ties, especially of the feet and legs; redness of the tongue, with the loss of its 
papillary appearance, and an aphthous exudation upon its surface; a total loss 74 
[PART II. 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
of appetite, with vomiting and diarrhoea, the latter sometimes approaching to 
dysentery; severe dyspnoea; extreme emaciation; and complete prostration of 
strength. The adipose matter is almost wholly absorbed, the muscles are 
wasted, the cheeks are hollow, the eyes sunken, and the bones everywhere 
prominent, unless concealed by oedema. Not unfrequently the back sloughs, 
in consequence of pressure upon the bony prominences. Until near the close, 
the debility is sometimes less than might be anticipated; the patient being 
frequently able to sit up much of the time until a few days before death. 
But at last the weakness becomes so great that expectoration is no longer 
possible; the cough ceases; the pus accumulates in the lungs, and life ends, 
because respiration cannot be carried on. The intellect generally remains 
clear to the last. 
Dr. Theophilus Thompson has called attention to the frequent existence, 
in consumptive patients, of a reddish streak or margin at the reflected edge 
of the gums, having in decided cases a vermilion tint, inclining to lake, and 
sometimes more than a line in breadth. It is present in the earliest as well 
as in the advanced stages, and when seen in women, may, according to Dr. 
Thompson, be considered as almost conclusive evidence of the existence of a 
tuberculous state of system. Its absence is a favourable sign. {Clin. Leet, 
on Pul. Consumpt.^ Am. ed., pp. 171 and 184.) 
But the disease is liable to great diversities, and there is scarcely a symp- 
tom which does not vary in different cases. Complications also exist which 
require notice. It is, therefore, necessary to add to the above general picture 
some account of individual symptoms, and of different attendant or intercur- 
rent diseases. I shall endeavour to avoid the repetition of facts already stated, 
so far as may be consistent with clearness. 
1. Cough and Expectoration.-Cough is generally the most prominent and 
distressing symptom, though sometimes wanting until near the close. In the 
early stage, it is probably the result of bronchial irritation, produced by the 
increasing tubercles, which act like so many foreign bodies in the lungs. It 
has been described as generally trifling at the commencement; but, in some 
instances, it is from the first severe, occurring in irregular and distressing 
paroxysms, owing probably to some ill defined nervous irritation. It gene- 
rally increases with the advance of the disease, and in the second stage be- 
comes very harassing, so as sometimes almost to prevent sleep, and thus 
greatly to aggravate the complaint. The cause of this increase is partly the 
necessity for discharging the contents of the vomiem, but probably still more 
the bronchial inflammation, induced by the contact of the irritating tuber- 
culous matter with the mucous membrane in its passage. The expectoration, 
which, until this time, had been purely bronchial, now assumes a peculiar 
character. It is in distinct, somewhat globular sputa, of a thick semifluid 
consistence, homogeneous, destitute of air, of a yellowish or greenish-yellow 
colour, often streaked with deeper yellow lines, and generally somewhat ragged 
or flocculent at the borders. When discharged into water, they flatten out 
without quickly losing theii' distinct character, and either sink or float as they 
happen to be more or less connected with mucus. Along with these sputa 
are occasionally minute portions of curdy matter.* Besides this kind of ex- 
* According to Schroeder Van der Kolk, of Utrecht, the existence of a cavity in the 
lungs may be infallibly detected by the aid of the microscope, which reveals in the ex- 
pectorated matter the presence of the elastic fibres which surround the air-vesicles. 
These fibres are curved, very thin, sharp at the borders, and sometimes surrounded with 
fatty matter, which is dissolved by ether. They are distinguishable from a species of 
conferva which soon appears in the sputa, by the ramifications of the latter, terminating 
in cells. {Rev. Med. Chirurg., viiL 222.)-Note to the third edition. CLASS III.] 
75 
PHTHISIS. 
pectoration, the patient often also discharges a large quantity of more liquid, 
purulent or muco-purulent matter, which no doubt proceeds chiefly from the 
inflamed bronchia. The peculiar distinct sputa come from the cavities, and 
are among the most certain general symptoms of phthisis. Sometimes, though 
very rarely, they are met with in other complaints of the chest. They consist 
of pus, and the liquefied tuberculous matter, which, according to Louis, is in- 
dicated by the yellow streaks. The quantity of matter expectorated varies 
exceedingly in different cases. In some, very copious and even exhausting, 
in others it is scanty, and in others again scarcely observable. In the last- 
mentioned cases, there is reason to suppose that the bronchia are little involved. 
I have known a case, in which the whole amount during the progress of the 
disease, so far as could be ascertained, scarcely exceeded the dimensions of the 
vast cavity which was found in the lungs after death. Sometimes the distinct 
sputa are quite wanting; the expectoration being exactly like that of chronic 
bronchitis in the purulent stage. This is apt to happen when there are large 
caverns in the lungs. Occasionally the pus in this stage of phthisis is streaked 
with blood. In some instances, after having been copiously discharged, it 
gradually diminishes, and at length ceases, at least for a time. There is then 
reason to suppose that the cavity has taken on a healthy action, and to hope 
that it may in time become obliterated. Very commonly, however, other 
tubercles maturate, and the discharge is renewed. In the last period of the 
disease, the pus is sometimes of a reddish or brownish appearance; and por- 
tions of the pulmonary structure and of unchanged tubercle have been ob- 
served in it, derived from the falling in of the walls of the caverns during 
their enlargement. The cough in advanced phthisis often has a deep hollow 
sound, which has long attracted notice as one of the fatal signs of the disease. 
Both the expectoration and cough are apt to cease a few days before death, in 
consequence partly of the muscular debility of the patient, which renders him 
unable to use the necessary efforts, partly, in all probability, to that insensi- 
bility which creeps over the system, and prevents any impression upon the 
sensorium by the matter which may exist, or be accumulating in the lungs. 
Dyspnoea.-This is a much less prominent symptom in phthisis than might 
be supposed. Very often in the early stage, and not unfrequently in the 
second, till within a short period before death, the patient is scarcely sensible 
of any difficulty of breathing; and it is not uncommon for persons in this 
complaint to expand their chest to its full limits, in order to show how free 
they are from disease of the lungs. This frequent exemption from dyspnoea 
is probably owing, in the first stage, to the very gradual progress of the tuber- 
culous encroachment, whidh enables the system to accommodate the quantity 
of blood produced to the capacity of the lungs; and, in the second, when the 
encroachment is more rapid, to the colliquative sweats and diarrhoea, which, 
while they exhaust the strength, have the compensatory effect of duly propor- 
tioning the circulating fluid to the diminished extent of the respiratory func- 
tion. The feeling of dyspnoea, being generally owing to an insufficient change 
of the blood in the lungs from venous to arterial, is not experienced when all 
the blood which the system requires passes through these organs, and under- 
goes the requisite alteration in its passage. But when the patient uses un- 
wonted exertion, he becomes more or less short of breath, because the lungs 
are inadequate to the due aeration and transmission of the increased quantity 
of blood sent to them in a given time, in consequence of the heart's increased 
action. Sometimes, however, severe dyspnoea is experienced in phthisis, es- 
pecially towards the close. This is peculiarly liable to happen when the dis- 
ease is complicated with pleuritic effusion, or pneumothorax. I have known 
a patient to maintain steadily, for one week before death, a sitting posture. 76 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[part II. 
leaning forward with his head resting upon the hands of his nurses, because 
extreme dyspnoea rendered any other position insupportable. In the cases of 
diffused miliary tubercles, which sometimes rapidly deteriorate the powers of 
respiration, and produce speedy death, dyspnoea may be throughout the dis- 
ease a somewhat prominent symptom. 
Pains.-Pains in the chest are not usually among the most striking phe- 
nomena in consumption. In many cases they are slight, and in some are 
almost wholly wanting throughout the complaint. There are, however, in- 
stances in which they are frequent and severe; and, in the majority of cases, 
the patient is subject to sharp fugitive pains, attacking various parts of his 
chest, sometimes ascribable to inflammation of the pleura, sometimes merely 
neuralgic. Occasionally, neuralgic pains are felt also in other parts of the body. 
Hemorrhage.-This is one of the most prominent features of phthisis. Oc- 
casionally, as before stated, it appears to usher in the disease; but more fre- 
quently occurs in the course of it. Even in the latter case, however, it is apt 
to be regarded by the patient as the initial symptom, because the cough which 
may have preceded it has scarcely been noticed. Sometimes the hemorrhage 
is copious; but more frequently it is slight, and in itself insignificant. It 
almost always yields speedily to remedies, or subsides spontaneously. In 
some cases there is only one attack, in others the attacks are frequent; and 
they are more apt to occur in the first than in the second stage of the disease. 
The obstruction of a portion of the lungs necessarily produces congestion in 
other parts of the organ, which is probably the immediate cause of the hemor- 
rhage in most instances. In the latter period of the disease, this congestion 
is relieved by the copious purulent secretion, not to mention the night-sweats 
and diarrhoea; and the hemorrhagic predisposition is thus diminished. Those 
rare instances in which a sudden and copious hemorrhage overwhelms the 
lungs, in advanced phthisis, are usually ascribed, and probably with justice, to 
the opening of a large vessel in the course of the pulmonary disorganization. 
Though a frequent symptom, there are many cases in which haemoptysis 
does not occur from the commencement to the end, unless so far as merely to 
stain the sputa. Out of 87 cases noticed by Louis, it was observed in 57. It 
is among the most certain diagnostic symptoms of phthisis. When a patient 
with a chronic cough and emaciation, spits blood copiously, he may be regarded 
as almost certainly tuberculous. Louis goes much further than this, and states 
that since his attention had been directed to the subject, he had seen haemop- 
tysis in no other affection than phthisis, except in females attacked suddenly 
with amenorrhoea, and in cases of external violence. (JDict. de Med., xxiv., 
344.) The same author, in his great work on phthisis, expresses the opinion, 
that, with the exception just named, haemoptysis indicates, " in a manner infi- 
nitely probable, whatever may be the period of its appearance, the presence of 
tubercles in the lungs." (Recherches, p. 194.) But I am convinced that this 
most accurate observer has, in this instance, permitted himself to draw an 
incorrect general inference from his personal observations. I presume that 
every practitioner of large experience, in this country, has known many in- 
stances of spontaneous hemorrhage from the lungs, in male subjects, from 
which the patients have perfectly recovered, without, through the subsequent 
course of their lives, evincing any signs of phthisis. Such cases have re- 
peatedly fallen under my own observation ; and there are men to be seen 
daily in our streets, in good apparent health, whom I know to have suffered 
with haemoptysis at various periods from ten to thirty years since. It is 
hardly probable that all these cases are examples of the cure of phthisis. 
Besides, what is there in the structure or position of the bronchial mucous 
membrane, which should exempt it from an affection so common in other CLASS III.] 
PHTHISIS. 
77 
mucous membranes? I have insisted more than I otherwise should have done 
on this point, because I believe that the impression of the almost certainly 
fatal significancy of hemorrhage from the lung, is calculated to do much, 
harm, by alarming patients, and discouraging their medical advisers. The 
affection is more frequent in women than in men, and is very rare in children. 
Frequent Pulse.-Fever.-Night-sweats.-Next to the cough, there is pro- 
bably no symptom more constant than a frequent pulse. An obstinate con- 
tinuance of these two symptoms alone should always be regarded with great 
solicitude, unless they have some other obvious cause than tubercles. The 
frequency of pulse often begins early, and continues steadily until the close 
of the disease. It is usually increased in the second stage, when it not un- 
commonly amounts to 120, and sometimes to 130, or even more, in a minute. 
In some cases, however, the pulse is unaffected as to its frequency through 
the whole course of the disease. It is in general very much accelerated by 
exertion. In the early stage, there is often, as before stated, a slight irrita- 
tive fever, with flushed face and heat of hands and feet, coming on especially 
towards evening. The source of this affection is not by any means always 
obvious. It occurs sometimes when no inflammatory action can be shown 
to exist in the lungs, and cannot, therefore, be certainly ascribed to the direct 
irritation of the tubercles upon the neighbouring pulmonary tissue. It is not 
improbable that a strong tuberculous diathesis may be capable of generating 
a moderate febrile movement, in which case, this affection may be a mere ac- 
companiment, and not a result of the tubercles. Nevertheless, whatever may 
be its origin, it is certainly often much aggravated by the inflammation pro- 
duced by the tuberculous deposit, acting as foreign matter in the lungs. As 
the disease advances, the fever gradually assumes a hectic character, with a 
tendency to the paroxysmal form, and to perspiration at night. This often 
occurs before the commencement of the second stage, perhaps under the in- 
fluence of the pus secreted by the bronchia, or that which may be contained 
in the tuberculous cavities yet unopened. But it is not until the cavities 
communicate externally, that the hectic fever, as a general rule, becomes de- 
cided. The night-sweats are often extremely distressing, giving rise to so 
much discomfort and exhaustion upon the awakening of the patient, that he 
often dreads going to sleep. They appear- to depend on a debility of the 
capillaries, which allows the watery portions of the blood to pass without 
resistance; and they occur during sleep, because then the vital forces, and 
among them contractility, are at their lowest ebb. 
Emaciation.-Debility.-Emaciation without apparent cause, in a patient 
having any other evidences of consumption, is an alarming symptom. Should 
the appetite fail, or any obvious disorder of digestion or source of exhaustion 
exist, sufficient to account for the loss of flesh, this in itself need occasion little 
solicitude. It is when apparently independent, that it becomes important as 
a sign. We know that some vice of system must be sapping its foundation ; 
and experience has taught us that the existence of tubercles, or perhaps even 
a strong tuberculous diathesis, is one of the most common of these depravities. 
Occasionally, in the course of phthisis, the patient gains flesh during the re- 
missions of the disease. This is a most favourable sign; and, if it persevere, 
even under other circumstances much less favourable, we have good grounds 
for the cheering impression, either that the disease is not really tuberculous, 
or that it is undergoing a process of amelioration. The debility is in general 
scarcely proportionate to the loss of flesh. It not unfrequently happens that 
the patient is not confined to his bed one day, until very near the close of 
the disease; and he is often able to walk out almost to the last. It is gene- 
rally when associated with disease of the stomach and bowels, that the debility 
is greatest. 78 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[PART II. 
Laryngeal Symptoms.-These may precede the signs of tubercles in the 
lungs, but much more frequently they come on in the course of the disease, 
and often not till it has advanced considerably into the second stage. At first, 
there is some hoarseness, with perhaps a feeling of dryness or huskiness of 
throat, or some pain in the larynx; and the affection may stop at this point. 
But not unfrequently, what was at first only inflammation becomes at length 
ulceration of the larynx, and this in its progress gives rise to loss of voice, 
difficulty of deglutition, the return of drinks by the nostrils upon attempts to 
swallow, and a most harassing and sometimes convulsive cough. The affec- 
tion hastens the fatal issue, and sometimes proves an immediate cause of 
death through suffocation. (See Chronic Laryngitis.} 
Stomachic and Intestinal Symptoms.-Little upon this point is required 
in addition to what has been already stated. In the first stage, the appetite 
is generally little impaired, though cases now and then occur in which the 
symptoms of dyspepsia or chronic gastritis appear to precede those of the 
tuberculous affection, and have given origin to the name of dyspeptic consump- 
tion, which has sometimes been applied to the disease in this form. The com- 
plication is probably merely accidental, at least in most instances. It is not, 
however, impossible, that the debility arising from deranged digestion may 
aggravate a previously existing tuberculous diathesis into a more speedy ex- 
plosion in the lungs. It has been observed that, when chronic gastritis with 
occasional diarrhoea attends the early progress of phthisis, its march is more 
rapid than under ordinary circumstances. Except as attendants upon the 
symptomatic fevers that occasionally occur in the course of phthisis, it is not 
usually until the second stage, and even a somewhat advanced period of that 
stage, that severe gastric symptoms appear. Loss of appetite, heat, pain, or 
oppression at the epigastrium, with nausea and vomiting, are now experienced. 
The vomiting is occasionally very obstinate, so that every article of food or 
medicine is rejected. These symptoms are usually the result of chronic gas- 
tritis, the signs of which are very often found after death. The gastritis ap- 
pears to be a consequence of the unceasing fever, rather than the direct result 
of a deposition of tubercles in the mucous membrane. Sometimes obstinate 
vomiting occurs, without leaving behind it in the dead subject any marks of 
inflammation whatever. Diarrhoea also is in general a symptom of the ad- 
vanced stages. It shows itself in every form, mild and severe, scanty and 
copious, with and without abdominal pains, sometimes approaching to dysen- 
tery, sometimes accompanied with hemorrhage from the bowels, and not un- 
frequently indicating, by the character of the stools, a perverted or deficient 
action of the liver. Unlike the stomachic symptoms, it seems to be most 
commonly dependent upon tubercles in the bowels, which, by their softening 
and discharge, give rise to ulcers and inflammation. That the inflammation 
is the result, and not the cause of the tubercles, is proved by the fact, that 
the latter are frequently found unattended with the former, in their early 
stage. The diarrhoea, after having been fully established, is, for an obvious 
reason, seldom permanently cured. It may often be arrested by medicines 
for a time, but generally returns, and often hastens the fatal result. 
Nervous Symptoms.-There is generally a remarkable exemption from 
nervous disorder, when the duration and severity of the disease are consid- 
ered. The cerebral functions are very little disturbed, and the intellect 
usually remains unclouded until the close, or near it, unless the membranes 
of the brain become involved in the tuberculous disease. When there is no 
disease of the stomach or liver, the patient almost always evinces a cheerful 
and hopeful frame of mind. He either believes that he will recover, or is 
calmly resigned to the fatal issue. The powers of self-deception, in this com- CLASS III.] 
79 
PHTHISIS. 
plaint, when the patient is unwilling to admit the idea of death, are truly 
wonderful. In the last stage of the disease, lying upon his bed, exhausted, 
breathless, and scarcely able to speal^ he assures his medical attendant that 
he is better, and will soon be about again. Even physicians, perfectly ac- 
quainted as they are with the nature of the disease, and the value of the 
symptoms, are scarcely less apt than others to deceive themselves as to the 
probable issue. 
Sexual Symptoms.-In male patients, nothing remarkable occurs in con- 
nexion with the sexual functions. It is otherwise with women. Suppression 
of the menses is very common, and may generally be considered as increasing 
the danger. The occurrence of pregnancy undoubtedly, in many instances, ar- 
rests for a time, the progress of the disease; and lactation appears to exercise 
a favourable influence over it. Alarming symptoms often disappear during 
gestation; and it sometimes happens, in young married women, that the 
disease is kept at bay many years by child-bearing and nursing; occasionally, 
indeed, so long, that the predisposition appears to be overcome. In most 
instances, however, it returns after delivery, and sometimes appears to com- 
pensate for the lost time by a more rapid march.* 
Complications.-The laryngeal and. gastro-entcric affections already de- 
scribed, being either the direct result of the same diathesis which produces 
the pulmonary tubercles, or a secondary effect arising from the tubercles 
themselves, must be considered rather as parts of the disease than as compli- 
cations. The same may be said of the bronchial inflammation, which flows 
from the irritation of the tubercles, or that of the tuberculous matter in its 
passage, which is the source of most of the matter expectorated in phthisis, 
and which is scarcely ever quite wanting in the course of the disease. The 
partial inflammation of the pulmonary tissue, in the vicinity of the tubercu- 
lous deposit, may be placed in the same category; as may also the pleurisy 
which results directly from the irritation of the tubercles near the surface of 
the lungs, or from the escape of the contents of a tuberculous vomica into 
the pleural cavity. (See Pneumothorax.} Tuberculous meningitis, which 
occasionally complicates phthisis, though very rarely in adults, belongs to 
the same category. For the symptoms of this affection the reader is referred 
to the article specially devoted to it. There is always reason to suspect it, 
when vomiting, headache, and a quiet delirium occur. 
But accidental attacks of all these affections now and then supervene upon 
phthisis, arising from cold, epidemic influence, or other ordinary cause. Tn 
such cases, they are properly complications, and often add greatly to the im- 
mediate danger, and hasten the fatal result. They differ in various respects 
from the analogous inflammations constituting a part of phthisis. Thus, they 
may occur at any period of the complaint; and, if they do not prove fatal, 
very generally disappear spontaneously, or yield to remedies, though fre- 
quently more obstinate than the same diseases under other circumstances. 
* Some observations have been made which tend to throw doubt over this long ad- 
mitted fact of the influence of gestation in retarding phthisis. But, independently of 
the general belief, my own personal observation has been such as to render it impos- 
sible for me to have any doubt upon the subject. I have repeatedly seen the disease, 
even in its somewhat advanced stages, apparently quite arrested on the occurrence of 
pregnancy. Two cases are prominent in my recollection. The patients were admitted 
into the Pennsylvania Hospital, with cavities in their lungs, and all the symptoms of 
decided phthisis. After a time, they began to improve wonderfully and unaccountably. 
The general symptoms vanished almost entirely, and they became fat and quite healthy 
in appearance. This change was found to be coincident with the occurrence of preg- 
nancy. They left the institution before delivery, and I have not learned what became 
of them afterwards. (Note to the third edition.) 80 
[part II. 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
Their precise seat, also, is not always exactly the same. Thus, accidental 
bronchitis may attack any portion of the lungs, while that essentially belong- 
ing to phthisis is confined to the bronchia connected with the tuberculated 
structure. Accidental pneumonia occupies usually the lower lobes, instead 
of being limited to the neighbourhood of the morbid deposit. Accidental 
pleurisy may affect any portion, or the whole of either membrane, even that 
of the healthy side, and is much more apt to be attended with liquid extrava- 
sation than the proper phthisical affection. An increase of fever generally 
attends these phlegmasim, and the existence of some one of them may be 
suspected, when a consumptive patient is suddenly seized with chill, followed 
by fever, under circumstances which render the occurrence of hectic fever 
improbable. 
There are diseases between which and phthisis a certain degree of incompati- 
bility is thought to exist. Thus, consumptive patients are little disposed to 
attacks of acute rheumatism; and to this circumstance it is ascribed by Dr. 
T. K. Chambers that, of a large number of cases of pericarditis examined in 
St. George's Hospital, London, a very small portion relatively was associated 
with tubercles of the lungs. {Med. Times and Gaz., v. 455.) Rokitansky 
teaches that cyanosis affords a complete protection against tuberculosis, and 
that whatever produces a similar venous condition of the blood, has more or 
less of the same protective effect. Though this is, perhaps, generally true, it 
is not so universally; for a case is on record in which the two affections.ex- 
isted conjointly. (Assoc. Med. Journ., March 10,1854, p. 222.) Few habit- 
ual drunkards are attacked with phthisis; and the exemption may possibly be 
owing to a somewhat similar carbonaceous condition of the blood. It has 
been supposed that miasmatic fevers afforded some protection against tubercu- 
lous disease; but proof is yet wanted of the truth of this conjecture. There 
can be little doubt, however, that, as a certain condition of the blood favours 
the developement of tubercles, so there may be diseases which may have a 
contrary effect, by their influence upon that fluid. 
Physical Signs.-In the earliest stages these are very equivocal. When 
the deposition is considerable, some dulness may be perceived in percussion 
under the clavicle, and upon that bone. This sign is more significant, if the 
dulness upon one side is decidedly greater than on the other, and especially 
if greatest upon the left side. A similar inequality of sound upon the two 
sides exists in emphysema and pneumothorax, the diseased side being, in 
these cases, more sonorous than the other; and there may be some danger 
that the diseased side may be considered healthy, and the sound side tubercu- 
lous. But the mistake may be avoided by recollecting that, in both of these 
affections, the respiration is feebler where percussion is most sonorous, than 
where it is least so. If the dulness be very slight, some advantage may be 
derived from the fact, that the increase of clearness on percussion, during a 
full inspiration, is greater on the sound than on the affected side. An em- 
physematous condition of the lung, in the vicinity of the tubercles, may render 
this sign nugatory by compensating for the partial solidification, so that the 
percussion may not materially vary from that of health. 
Among the first deviations from health discovered by auscultation, is feeble- 
ness of the respiratory murmur below the clavicle. While this is observed 
in one part, another may yield a more than usually loud sound, in consequence 
of being compelled to perform a greater amount of duty. As the consolida- 
tion advances, the respiration becomes somewhat rough, or even bronchial, 
with a considerable prolongation of the expiratory sound, which is one of the 
most striking characteristics of this stage of tuberculous deposition. At the 
same time, the inspiration is sometimes interrupted, wavy, or jerking. The CLASS III.] 
81 
PHTHISIS. 
sounds of the heart are more distinctly audible in the part. The vocal reso- 
nance, and that of the cough, are also increased; but it must be remembered 
that, near the sternum, both bronchophony and bronchial respiration are heard 
in health; so that, in order to be of any weight as signs of tubercles, they must 
be found towards the humeral extremity of the clavicle. Allowance must also 
be made for the natural difference of the two sides, in respect to these sounds. 
(See vol. i., p. 755.) It is said that the greater extension of healthy bron- 
chial respiration, more or less pure, on the right side than the left, is most 
observable in females. Hence, in relation to these, special care must be ob- 
served not to mistake the normal for an abnormal state. Another physical 
sign is the increased vibratory motion from the voice, felt by the hand applied 
to the sub-clavicular space. All these signs may also, in general, be per- 
ceived, though in a less degree, over the upper portion of the scapula, behiud. 
They indicate solidification, more or less complete, of the pulmonary tissue; 
and, when this takes place under the clavicle without the ordinary evidences 
of acute pneumonia, the probability is very strong that it is owing to tubercles. 
In a more advanced state of the deposition, the mucous and subcrepitant 
rales, and occasionally also the sonorous and sibilant rales, make themselves 
heard in the same position. These are the sounds of catarrh; but this, occurring 
as an original disease, commonly affects other regions of the lungs. Percussion 
is still more dull than before, and the vibrations produced by the cough and 
voice still more perceptible by the hand. Very frequently too the upper part 
of the chest is obviously contracted or sunken, and there is less movement of 
the ribs in respiration. This sinking is probably owing in part to atrophy 
and shrinking of the pulmonary tissue, partly to the formation of false mem- 
brane between the pleural surfaces, and the contraction which it undergoes in 
the process of organization. Another sign consequent upon the formation of 
false membrane is the friction sound, which may sometimes be heard for a 
short time; but it is so fugitive as usually to escape notice. In general, the 
progress of the formation of a cavity can be followed with considerable ac- 
curacy. At first, a loose crackling sound will be heard, during inspiration, 
at a point where induration exists; the bubbles become more numerous, 
larger, and somewhat more diffused, and are audible both in inspiration and 
expiration; and finally all the signs of a cavity are perceptible. 
After the vomicae have opened, a new set of signs are presented. Percus- 
sion usually remains dull, the increased vibratory movement of the wall of 
the chest with speaking and coughing continues, and the contraction of the 
sub-clavicular space and its comparative want of motion, are still observable. 
But the characteristic sounds of cavities are now perceived; as the cavernous 
rale or gurgling when the cavity is partly filled with liquid, cavernous respi- 
ration and resonance of the voice and cough, and at length pectoriloquy. 
Skoda denies that these signs can be certainly relied on, as all of them, even 
pectoriloquy, may arise from a condensed lung without a cavity. Yet, when 
they are all perceived, there can be little doubt upon the point, especially 
when their indications are in accordance with those of the general symptoms. 
When the cavity is very large, the vibrations produced by the voice imme- 
diately over it, are diminished, but they are increased at the margin, where 
the lung is solidified. Frequently, in large cavities, the respiration becomes 
amphoric, the voice acquires an amphoric resonance, and the sound denominated 
metallic tinkling may be heard. This is particularly the case when the walls 
of the cavity are very firm, approaching the consistence of cartilage. These 
are unfailing signs. When other means fail, the existence of a cavity may 
sometimes be detected by a sound of fluctuation produced by coughing, or a 
slighter sound of the same nature occasioned by the impulse of the heart on 82 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[PART II. 
the contained liquid. It has been stated that percussion usually continues 
dull in this stage. It is so occasionally for a very considerable extent. But, 
in some cases where the cavity is very large, and near the surface, it yields 
a hollow tubular or somewhat tympanitic sound, such as is produced by per- 
forming percussion over the trachea, or an amphoric sound like that which 
results from striking the distended cheek, or, finally, the bruit de pot fete of 
Laennec, or cracked-metal sound, which is compared by Dr. Walshe to that 
occasioned when the hands, loosely folded, are struck against the knee so as 
to allow air to be forced out from between them.* 
Hutchinson's spirometer may sometimes be advantageously resorted to, in 
order to ascertain the rate of progress of the disease. (See vol. i , page 770.) 
Course, Duration, &c.-Upon these points it is necessary to add something 
to the general description already given, in order to present a complete view 
of the disease. 
The duration of phthisis is exceedingly variable. While some cases run 
their course to a fatal termination in less than a month, others have been 
known to continue thirty or forty years. The greater number of cases pro- 
bably terminate in from one to two years. When the disease is very rapid 
in its course, it is sometimes denominated acute phthisis, or vulgarly gallop- 
ing consumption. Its whole duration is only one, two, or three months; and 
sometimes death occurs in the third week. It is associated with different 
pathological conditions of the lungs. In one variety, there is a diffusion of 
miliary tubercles, in countless numbers, through the pulmonary tissue; and 
the diffusion is pretty uniform, except that there may be a somewhat greater 
accumulation towards the summit of the lung. These tubercles in general 
do not advance even to the yellow or crude state before death. Sometimes 
they may be attended with infiltration of gray matter, which also remains, 
throughout, in its first stage. There may occasionally be some softening of 
the tubercles in the upper part of the chest, and possibly a few small cavities 
in the more protracted cases. The attack in these cases is usually sudden, 
and the disease quickly acquires great violence. The symptoms, almost from 
the outset, are dyspnoea, severe cough, occasional pains in the chest, great 
frequency of pulse and respiration, a hot skin, headache, loss of appetite, and 
other marks of considerable fever. The expectoration is not generally co- 
pious, and is exclusively bronchial; never exhibiting the peculiar purulent 
sputa of ordinary phthisis in its second stage. Occasionally there is hemor- 
rhage. As the disease advances, the symptoms acquire greater intensity, 
though sometimes a remission is observable, even in their short course. 
Towards the last, the pulse and respiration become exceedingly frequent, 
night-sweats occur, and the patient rapidly emaciates, though not to the same 
degree as in the more chronic forms. The ordinary physical signs of phthisis 
are often wanting. There may be no peculiar dulness under the clavicle, no 
signs of extensive consolidation anywhere, and none of the marks of a cavity. 
* This sound, which was supposed by Laennec to indicate the presence of air and 
fluid in a pulmonary excavation, may, according to Walshe, be produced without the 
presence of fluid, all that is necessary being a large anfractuous cavity, communicating 
freely by several openings with the bronchia. The cause of the sound is probably the 
vibrations produced in the sides of the bronchia, as the air is driven into them from the 
cavity by percussion over it. A proof of this, stated by Walshe, is that if, during per- 
cussion, the mouth and nostrils be firmly closed, the sound is not emitted, because re- 
sistance is afforded to the entrance of air into the passages. Dr. R. C. Golding observed 
this peculiar sound to be produced by percussion over a circumscribed sub pleural em- 
physema, in the upper part of the lung, the air from which was driven by the blow into 
the surrounding cellular tissue, and returned on the cessation of the impulse.-[Land. 
Med. Gaz., July 1848, p. 83.) Note to the second edition. CLASS III.] 
83 
PHTHISIS. 
The clearness upon percussion may be somewhat diminished here and there; 
and the respiration may be feeble in some points, and puerile, rude, or 
somewhat bronchial in others. The sibilant, sonorous, mucous, and subcre- 
pitant rales of bronchial inflammation are beard in various parts of the chest. 
That the disease is not pleurisy or pneumonia will be inferred from the want 
of the characteristic signs of these affections. Bronchitis exists, but the on- 
ward course of the disease, the greater frequency of pulse and respiration, 
the occasional presence of haemoptysis, and the occurrence of night-sweats 
without purulent expectoration, evince that there is something more, and this 
can be phthisis only. Death, in these cases, appears to arise from the inter- 
ference of the tubercles with the functions of the lung, and the exhaustion of 
system from the wearing effect of the local irritation. 
Another variety of acute phthisis, presenting almost the same symptoms, 
and equally wanting the peculiar purulent expectoration of the ordinary dis- 
ease, is connected with a rapid and copious deposition of tuberculous matter, 
so as to produce almost complete consolidation of a large portion of the lungs, 
or perhaps of one whole lung, and thus destroy life before the tubercles 
have had time to reach the second stage. Portions of the tuberculous depo- 
sition may in these cases be yellow and opaque, and even softened; but they 
have formed little communication with the bronchia. In such cases, the 
peculiar physical signs of the first stage of phthisis are observable in a marked 
degree. 
A third variety of the acute disease is that which runs through all the 
stages with great rapidity. In these, the whole train of symptoms character- 
izing the last stage of ordinary phthisis, including the peculiar sputa, comes 
on in the course of a few weeks; and physical examination evinces beyond 
doubt the existence of vomicae, sometimes of considerable size. Such cases 
sometimes follow an attack of copious haemoptysis, or supervene upon inflam- 
matory affections of the lungs, and febrile diseases of various kinds. 
Ordinary phthisis, even when of considerable duration, is sometimes regu- 
lar in its march, beginning in the usual insidious manner, and steadily ad- 
vancing, with little or no remission, to its fatal close. But much more 
frequently it undergoes temporary interruptions; and, in many instances, the 
occasional signs of amendment are so considerable that both the patient and 
his friends indulge strong hopes of a favourable issue. The general and local 
symptoms abate, the appetite and digestion improve, and the patient gains 
strength and flesh. These changes occur both in the first and second stages, 
and, in some cases, several times in the course of the disease. Occasionally 
they may be traced to some known cause. Thus, the occurrence of preg- 
nancy, as before stated, may partially or entirely supersede the symptoms of 
phthisis, even though advanced into the second stage; and the same favour- 
able influence is in some degree exerted by lactation. An external direction, 
also, of the scrofulous disease appears to divert the tendency to tuberculous 
deposition from the lungs. This was strongly insisted on by the late Dr. 
Parrish, of Philadelphia, as one of the results of his extensive observation. 
I recollect well two instances of the disease in women of middle age, in which 
the symptoms of phthisis rapidly followed the disappearance of a long con- 
tinued scrofulous swelling of the neck, and appeared to have been kept back 
by the external affection. The influence of fistula in ano, and of old ulcers 
in the leg, in restraining the progress of phthisis, must be familiar to the ex- 
perience of most practitioners who have seen much of the disease. Not un- 
frequently, also, the amendment occurs simultaneously with the return of 
mild weather, which not only appears to exercise a directly favourable influ- 
ence over the tuberculous diathesis, but is indirectly useful by favouring 84 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[part II. 
exercise in the open air. Some consumptive patients appear to regain in the 
summer what they lose in winter, and run on for many years, sometimes 
even to the end of a long life, never entirely free from tuberculous disease 
in the lungs, and yet enjoying much comfort in existence. I was for many 
years in the habit of attending a gentleman with this disease, who died at 
the age of seventy, and had suffered with cough, some dyspnoea, and occa- 
sional attacks of hemorrhage from the lungs, from an early period of life. 
These alternations in the symptoms of phthisis are explained by the fact, 
that the tubercles are often deposited, not continuously, but in successive 
crops. Those first deposited advance to maturity, are discharged through 
the bronchia, and leave cavities which have a tendency towards health. 
Should the predisposition not be strong, and nothing occur to call it speedily 
into action, no new deposition may take place until the first crop has ceased 
to exert any unfavourable influence on the system, and the patient apparently 
recovers his health. Indeed, there is every reason to believe that permanent 
recoveries occasionally take place in this way. But much more frequently 
a fresh deposition occurs before the disappearance of the symptoms, or soon 
afterwards; and thus the disease only remits, or returns after having seemed 
to cease. Still more frequently, the process of amendment has had time to 
make but little headway, before the new crop is sown, and then the remission 
is but slight. In other cases, again, either the original deposit is sufficient 
to destroy life in its course towards maturation, or the progress of deposition 
is so constant as to sustain a nearly regular advance in the symptoms, until 
the lung becomes unfit for duty. Cases sometimes occur, in which the most 
cheering signs of amendment appear, so far as regards the general symptoms; 
while to physical exploration the lungs yield evidence, not only of undimin- 
ished disease, but of a continual progress of disorganization. In these cases, 
of course, the favourable symptoms are altogether deceptive. No case can 
be considered as having undergone a real amendment or cure, unless the 
physical signs coincide with the general symptoms. 
Sometimes phthisis is latent so far as regards the ordinary signs of its ex- 
istence, and continues so until a short period before the end. The tuberculous 
deposition takes place slowly, so as not to excite sensible irritation in the sur- 
rounding tissue, which, therefore, undergoes the necessary absorption or con- 
densation, without any of those external expressions which constitute the early 
symptoms of the disease. Accumulation may thus gradually go on, and the 
tuberculous matter pass through all the regular changes, until one or more 
large collections are formed. These now make themselves felt by the inflam- 
mation necessary to effect their discharge; and, when the communication with 
the bronchia is opened, the irritating influence of the pus superadds bronchitis; 
and all the symptoms of the last stage are speedily developed. But another 
cause of the occasional latency of phthisis is, that tubercles after deposition, 
and a certain degree of advance, cease to make further progress, becoming, as 
it were, indolent, and sometimes remaining so for years. There is, indeed, 
reason to believe that in such cases they sometimes undergo absorption, and 
leave only calcareous matter in the place of the tuberculous. 
Nature and Causes. 
Phthisis does not consist merely in the deposition of tubercles in the lungs, 
and its consequences. There is, besides, a morbid state of system which pre- 
cedes and attends the deposition, and upon which it probably depends. This 
state of system is commonly denominated the tuberculous diathesis or predis- 
position. It is either identical with the scrofulous diathesis, or closely analo- 
gous to it, and has been sufficiently treated of, in a general way, in the section CLASS III.] 
PHTHISIS. 
85 
upon general pathology. In the present place, it is considered only in its 
relation to pulmonary tubercles. What is the exact nature of this diathesis 
is unknown. It may consist essentially in a certain laxity of the tissues, 
which leads to weakness or perversion of function, so that, instead of well 
elaborated material for the purposes of nutrition, there is separated from the 
blood a peculiar product, of the lowest grade of vital force, with the tend- 
ency to degeneration fixed upon it, which exists as foreign matter in the midst 
of the living structure. It is possible that the blood also may be in fault. 
The only defect, however, which has been shown to exist in it, is a want of 
the due proportion of red corpuscles, and this defect has not been proved to 
be essential. It goes on increasing with the advance of the disease (Andral 
and Gavarret}, and may, in this state of things, be as much the result as the 
cause of tubercles in the lungs. The fibrin of the blood is sometimes redun- 
dant in the course of the complaint; but this appears to be owing to some 
one of the inflammatory affections which so often attend it. But, whether the 
blood is in any degree essentially perverted or not, this much may be considered 
as certain, in relation to the tuberculous diathesis, that it is accompanied with 
a reduction of the vital forces below the healthy standard, or, in other words, 
is a condition of debility. What else there may be cannot be told in the 
present state of our knowledge ; though, that there is something besides mere 
debility, is sufficiently obvious from the consideration, that an equal degree 
of this condition often exists without any production of tubercle, or any ap- 
parent tendency towards it. 
The causes of phthisis are either those which create this morbid state of 
system, or those which call it into action, when it might otherwise remain qui- 
escent. These will be separately considered under the heads of predisposing 
and exciting causes. 
1. Predisposing Causes.-Decidedly the most influential of these, so far as 
known, is inheritance. Phthisis is pre-eminently a hereditary disease. One 
parent very often entails it upon the offspring, but both almost with certainty. 
Whole families thus descended are not unfrequently swept away by this fear- 
ful malady. Even where the immediate descendants of consumptive parents 
escape its developed form, they nevertheless often retain the predisposition, 
and hand it down to their children. So strong is the influence of this cause, 
that a mere suspicion of the existence of pulmonary consumption, arising from 
an observation of the symptoms, is strengthened into conviction by the known 
possibility of an inherited taint. 
Next, perhaps, in the degree of influence, is cold. Allusion is not here 
made to the vicissitudes of weather, which so frequently occasion attacks of 
inflammation. Cold may act in this way as an exciting cause; but its most 
pernicious agency is probably connected with its long continued and steady 
application. Moderate and temporary reductions of temperature are often 
indirectly tonic, by the reaction they occasion. But, under a steady continu- 
ance of cold, the power of reaction at length becomes exhausted, so that a 
condition of debility ensues; and experience has shown that the debility thus 
induced often assumes the character of the tuberculous diathesis. Hence, 
chiefly, the greater prevalence of the disease in cold than in warm climates. 
It is true that phthisis is said to be less prevalent in the coldest regions of 
the north, as, for example, in Russia, than it is in the more temperate lati- 
tudes. .But this apparent anomaly is easily explained. The inhabitants of 
the north suffer in fact less from cold than those further south. The inten- 
sity and steadiness of the cold in the former regions lead to precautions, both 
as to dress and dwellings, which effectually guard the inhabitants agaiust its 
injurious influence; while the variable temperature of the latter, causing the 86 
[part II. 
LOCAL DISEASES.--RESPIRATORY SYSTEM. 
clothing which may be no more than comfortable one day, to be oppressively 
hot the next, induces a disposition to submit to some inconvenience from the 
cold rather than to have the trouble of constant changes.* It is a great mis- 
take to attempt to harden the body against the inclemencies of the weathei' in 
winter by light clothing in the day, and insufficient covering at night. Many 
may succeed, but many also will perish in the process. This fact has been 
strongly exemplified within my own observation. Negroes, from their greater 
susceptibility to cold than the whites, are much more subject to phthisis in 
cold or temperate climates. 
Whatever has a tendency to produce permanent or long-continued debility 
will generate, in some individuals, the consumptive diathesis. Hence, we may 
enumerate among the predisposing causes, besides that just mentioned, an in- 
sufficient diet whether as to quantity or nutritive properties, living in an 
unwholesome air, sedentary habits, exhausting indulgences, grief, anxiety, dis- 
appointment whether of the affections or in business and all other depressing 
emotions, long watchings, copious evacuations both spontaneous and artificial, 
the abuse of mercury, and the influence of various debilitating diseases. The 
history of phthisis affords numerous instances in which the above causes, 
singly or combined, have induced the disease; for, when the diathesis is suffi- 
ciently strong, no exciting cause is required to aid those which are here, not 
perhaps with strict propriety, denominated predisposing. 
2. Exciting Causes.-Anything which is capable of irritating or inflaming 
the lungs, of producing in them an unusual influx of blood, or an unusual 
secretory effort, may act as an exciting cause of the deposition of tubercles, 
in persons predisposed to them. What would, in other persons under such 
circumstances, be organizable fibrin, or a product amenable to the vital pro- 
cess of absorption, becomes in these, in part at least, the matter of tubercles. 
Thus cold, as by its continued action it is a powerful cause of the diathesis, 
so also by its intermittent action, is a no less powerful exciting cause of the 
local affection. It operates chiefly by producing catarrh, though pneumonia 
and pleurisy, which are equally the result of it, appear sometimes to be the 
immediate predecessors of the tuberculous deposition. Other causes, capable 
of producing bronchitis or pneumonia, may through these give rise to the 
developement of phthisis. Such are the inhalation of acrid gases or vapours, 
or irritating powders, any habitual and excessive exertion of the lungs, and 
external violence. The febrile movement appears to be an efficient exciting 
cause; as are also the suppression of long-continued morbid evacuations, the 
too hasty resolution of external scrofulous tumours, the healing of cld ulcers, 
especially fistula in ano, and the cessation of the menses and of child-bearing. 
Tight lacing has been accused of frequently inducing consumption; and it is 
highly probably that, by interfering with the functions of the lungs, it may 
favour the formation of tubercles in those predisposed to them. 
There are certain influences, which, though referrible to one or both of the 
above heads, require a separate notice. 
Age is not without influence in the production of phthisis. The time of life 
at which there is the greatest proneness to the disease appears to be for some 
* From observations made during a visit, in the summer season, to England, I was 
strongly impressed with the conviction, that the great prevalence of phthisis in that 
country is owing, in part at least, to the coolness of the summer, which is often so great 
as to be uncomfortable, but is not sufficiently guarded against, from the inconvenience 
of frequently making fires, and changing clothing. The robust resist the sedative influ- 
ence, and from the reaction of their systems are apparently invigorated; but the feeble, 
and those predisposed to phthisis, sink into that state of general depression which is 
most favourable to the deposition of tubercle. (Note to second edition.) 87 
CLASS III.] 
PHTHISIS. 
years after the cessation of growth. The force of nutrition, or that by which 
the aliment prepared by the processes of digestion and sanguification is ap- 
propriated to the growth or repaii- of the organs, is now much diminished, and 
probably in a greater degree than that of the two functions intended to sup- 
ply it with material. This material, therefore, being in excess, is thrown 
out in a less elaborate condition, and, in those of a consumptive constitution, 
takes the form of tubercle. In this view of it, age may be considered as an 
exciting cause of the disease. Perhaps the ten years in which the greatest 
number of cases of phthisis originate are from seventeen to twenty-seven. It 
will be observed that this is somewhat different from the age at which the 
greatest number of deaths occur. This, according to Sir James Clarke, is 
from twenty to thirty. Louis places it between twenty and forty. The pe- 
riod of life in the next degree prolific in phthisis is infancy. 
Sex.-The disease is much more common in women than in men, occurs 
in them at an earlier age, and is generally more rapid in its progress. There 
are various causes for this difference. In the first place, the original organ- 
ization of the female is more delicate, and exposes her consequently more to 
diseases of relaxation and debility. In the next place, the sedentary habits 
of women, as well as their greater sensibility and probably greater exposure 
to the various depressing emotions, and their frequent and anxious watchings 
in the confined and impure air of the sick chamber, have no little influence 
in producing the consumptive diathesis. Though less frequently exposed 
than men to the exciting causes, they are, from their previous habits of life 
and modes of dress, much more readily affected by them. Of 123 hospital 
cases noticed by Louis, 70 were in women. It is probable that the propor- 
tion of females is even larger than this in the higher walks of life. The 
earlier age at which woman attains her full growth, accounts for the earlier 
occurrence of the disease, as a general rule, in her case. 
Occupations.-The sedentary occupations are much more favourable to the 
occurrence of consumption than those which require vigorous exercise, espe- 
cially in the open air. Hence weavers, tailors, milliners, sempstresses, 
teachers, students, and the inmates of convents and penitentiaries, are 
thought to be peculiarly liable to it. Occupations which expose the indivi- 
dual to the inhalation of acrid or irritating particles of matter, such as stone- 
cutting, dry-grinding, feather-dressing, and brush-making, are accused of a 
tendency to develope the disease. 
Residence.-The influence of a cold climate has been already noticed. It 
is thought that a damp and variable climate is more injurious than one which 
is steadily cold and dry. Even within the same country, consumption is 
found to prevail more in low and damp situations, than in those which are 
elevated and dry. The seacoast is peculiarly liable to it, partly, in conse- 
quence of its exposure to the dampness of. the ocean, but probably still more 
from the saline particles which are driven up into the air during storms and 
by the breakers, and serve to irritate the lungs when inhaled. On this account 
it is, probably, more than from difference of latitude, that Philadelphia is 
less exposed to phthisis than New York or Boston; for there is little differ- 
ence between these two latter cities. I have been informed by persons who 
have passed considerable time in the north-western portions of our country, 
in the vicinity, for example, of Lake Superior, that the climate is highly 
favourable to consumptive patients, probably in consequence of its uniformity 
and dryness in winter. 
Other Diseases.-These act in producing phthisis, partly by the relaxed 
and debilitated state in which they are apt to leave the system, and partly by 
a direct irritant influence upon the lungs, favouring the developemcnt of 88 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[part II. 
tubercles. It is, however, denied by some, and by Louis among the number, 
that the inflammatory pulmonary affections have been proved to exercise more 
influence in inducing phthisis than other diseases of a febrile character. But 
the general experience and opinion of the profession are in opposition to this 
view. Some go so far as to maintain that tubercles always originate from 
inflammation, acting on a peculiar diathesis. But this dogma has certainly 
never been proved. Tubercles have frequently been observed, without the 
least evidence of inflammation, other than that which is afforded by their 
own existence; and to assert this as a proof is to beg the question. The 
truth probably lies between these extreme opinions. There can be little 
doubt that tubercles are often deposited from the mere intensity of the dia- 
thesis, without the slightest inflammatory excitement of the part; and this I 
am disposed to think is most frequently the case; but there is, I think, as 
little doubt, that inflammation often causes an earlier developement than 
would otherwise take place, and sometimes perhaps gives rise to them, when, 
without its occurrence, the patient might have escaped them altogether. 
The diseases which are peculiarly prone to be followed by phthisis are measles, 
smallpox, scarlatina, hooping-cough, typhoid fever, and the pulmonary in- 
flammations, bronchitis, pleurisy, and pneumonia. 
Diagnosis. 
It is in general only in the first stage that there is much difficulty in re- 
cognizing phthisis. When a short cough, either quite dry or attended only 
with a slight mucous expectoration, continues for weeks or months, with more 
or less general emaciation, which cannot be explained by a loss of appetite or 
any apparent failure of digestion, there is reason to suspect the existence of 
tubercles. If to these symptoms are superadded irregular pains between the 
shoulders or about the breast, frequency of pulse, and shortness of breath 
upon exertion, the suspicion becomes very strong. An attack of haemoptysis 
would now complete the proof. In the absence of this, or in connexion with 
it, the occurrence of dulness upon percussion in the subclavicular region, and 
any considerable deviation from their healthy character in the respiratory 
sounds, or vocal resonance, in the same part, would, in addition to the symp- 
toms above mentioned, render the existence of phthisis quite certain. But, 
in numerous instances, the characteristic symptoms and physical signs are 
much less distinct; and in all doubtful cases it is best, before giving a decided 
opinion, to wait for the developement of further evidence. This is afforded 
by the appearance of the peculiar expectoration already described, the occur- 
rence of hectic fever, and the physical signs indicating a cavity near the sum- 
mit of the lungs. There is, however, one condition of the disease in which 
the physical signs often quite fail in establishing the diagnosis, and it is 
necessary to depend upon the somewhat equivocal evidence of the general 
symptoms. Allusion is here had to the form of acute phthisis characterized 
by the diffusion of miliary tubercles through the lungs. A pretty good 
guess may be made, in such instances, as to the nature of the affection, from 
the character and course of the symptoms; but the only positive proof is that 
afforded by dissection.* 
Bronchitis is the complaint to which phthisis bears the closest resemblance 
in its general symptoms, and with which it is most liable to be confounded. 
* M. Beau believes that he has discovered an almost invariable symptom in phthisis, 
which may be useful in the diagnosis of doubtful cases. This is tenderness on pressure 
with the finger in the anterior intercostal spaces, near their sternal extremity. In the 
early stages, this is confined to the upper spaces, being greatest in the first. (See Ed. 
Month. Retrosp. of Med. Sei., A. D. 1849, p. 200.) CLASS III.] 
PHTHISIS. 
89 
But in the early stage, this affection, if sufficiently severe to impair the 
general health, is accompanied with more fever than phthisis, and, if mild, 
does not then present the emaciation, nor, in general, the frequent pulse of 
the latter affection. It is, moreover, unattended with haemoptysis; the ex- 
pectoration is usually much more copious than in the tuberculous affection; 
and the disease, instead of remaining long stationary or advancing slowly, is 
marked by successive and comparatively rapid stages of progress and decline. 
Those auscultatory signs which are common to the two affections are in bron- 
chitis spread more or less over the lungs, while, in phthisis, they are confined 
to the upper portion; and the dulness on percussion beneath the clavicle, as 
well as the sinking of the chest at the same spot, so characteristic of the 
latter, are wanting in the former. The greatest difficulty is in discriminating 
between bronchitis, and those cases of acute phthisis in which miliary tuber- 
cles are disseminated equably through the lungs. As before stated, the phy- 
sical signs may here fail entirely; but there is a difference in the physiognomy 
of the two diseases by which they can be distinguished with much probability, 
if not an approach to certainty. The points of this difference have been 
already referred to. (See page 83.) The persistence for a long time of a 
mucous or submucous rale throughout one or both lungs, unchanged by all 
the treatment which usually proves effectual in chronic bronchitis, and attended 
with emaciation, frequent pulse, night-sweats, and other general symptoms of 
phthisis, would indicate with some degree of certainty the existence of the 
miliary form of that complaint. In the advanced stages of the two diseases, 
there is in general little difficulty in the diagnosis. The absence of the pecu- 
liar sputa of phthisis (see page 74), the inferior degree of emaciation, the total 
want of dulness on percussion and of the ordinary signs of a cavity, together 
with the previous course of the complaint, and its exemption from attacks of 
haemoptysis, are sufficient to distinguish the bronchial from the tuberculous 
disease. It is only when dilatation of the tubes coincides with bronchitis, 
that material embarrassment occurs. In such cases, signs of a cavity exist; 
but this cavity is not often at the summit of the lungs, the resonance on per- 
cussion is not so much diminished as in phthisis, and the character of the 
signs is more unchangeable; and these circumstances, taken in connexion with 
the absence, or much less degree, of some of the characteristic general symp- 
toms of tubercles, such as pains in the chest, emaciation, tuberculous expecto- 
ration, and occasional haemoptysis, enable the practitioner, for the most part, 
to arrive at a just conclusion. 
Pneumonia in its chronic form, which might present some analogy with 
phthisis, is a very rare disease, and still more rarely occupies the upper part 
of the lung. The previous course of the symptoms would also serve to dis- 
tinguish the affection. If attended with an abscess, it might be discriminated 
with greater difficulty; but the situation of the abscess in the lower lobe, and 
the previous signs of pneumonia, such as the crepitant rale followed by bron- 
chial respiration, and the rusty and viscid sputa, would be sufficiently diag- 
nostic. Gangrenous abscess may likewise be distinguished by its lower position, 
as well as by the intense fetor of the expectoration, and the want of the 
characteristic tuberculous sputa. 
Pulmonary emphysema occurring near the summit of one lung only, and 
attended with catarrh, might lead to the suspicion, in consequence of the 
greater sonorousness on percussion of the side affected, that the sound side 
might be the seat of tubercles; but the affection may be distinguished by the 
greater feebleness of respiration on the more sonorous side, and by the swell- 
ing or bulging of the chest often attendant on emphysema. 90 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[PART II. 
Pneumothorax, which might possibly be mistaken for a large tuberculous 
cavity, is distinguishable by its loud tympanitic resonance on percussion, by 
the want of any depression of the chest in the part, by the frequently movable 
character of the sounds, and by the coexistence of liquid effusion. 
Not unfrequently the diseases above mentioned are mingled with phthisis, 
and serve to mask it, so that it may not for some time even be suspected; but 
a careful examination will generally enable the physician to detect its peculiar 
signs, and the more readily, as these are almost always to be found in the 
upper part of the chest, while those which characterize the other affections 
are generally connected with the lower part. 
Prognosis. 
In the very great majority of cases, this is certainly unfavourable; but I 
am not one of those who believe that phthisis is in all cases necessarily fatal. 
On the contrary, I believe that, in one stage or another, it is occasionally 
cured, or at least ends in perfect recovery. It is no very unfrequent event 
to see threatening symptoms of phthisis give way under suitable treatment. 
It cannot be proved, with absolute certainty, that these symptoms were tuber- 
culous; because the evidence of dissection is wanting, and the physical signs 
are not sufficiently positive, in mild cases of early phthisis, to authorize a 
certain conclusion. But they are undistinguishable from symptoms, which, 
in other cases, are the forerunners of confirmed phthisis; and we have abundant 
evidence from dissection, that tubercles are capable of undergoing favourable 
modifications. The probability is, that the tuberculous matter is absorbed, 
and sometimes, as shown by dissection, replaced by calcareous matter; and, if 
the diathesis be so far subdued as to prevent the deposition of other tubercles, 
before these have completely run their course, the disease may be said to be 
cured. The circumstance that such remains of tubercles are not unfrequently 
found in the lungs of old persons, who have died of other diseases, would 
seem to show that these cures are sometimes permanent. 
But this is not all. It occasionally happens that consumptive symptoms 
disappear entirely, even in the second stage of the disease, after the formation 
of a cavity. This event, it is true, is comparatively rare; but some such 
cases have probably fallen within the notice of almost every practitioner of 
extensive experience. Even should the disease ultimately return, still, the 
case may be said to have been cured; as the occurrence of a second attack of 
pneumonia is certainly no proof that the first was not cured. But there have 
been cases in which no return of the symptoms has taken place during the 
residue of life, even though considerably protracted. Two instances of this 
kind have occurred in medical men of this city. One of the patients was 
affected, when a young man, with all the symptoms of phthisis, including fre- 
quent attacks of haemoptysis, severe cough, hectic fever, &c., from which he 
completely recovered, and continued exempt up to the time of his death, 
which occurred many years afterwards of typhoid fever. (See W. Am. Med. 
and Surg. Journ., viii. 277.) The other was my preceptor and friend, the 
late Dr. Joseph Parrish, who in early life laboured for a time under the symp- 
toms of phthisis, and, after his death, at an advanced age, was found to have 
several cicatrices in the upper part of one lung, which were obviously the 
remains of tuberculous cavities. (See Am. Journ. of Med. Sei., xxvi. 256. J 
The probabilities upon the whole are, that each tubercle has a tendency 
towards health, and, if alone, would in time end in perfect recovery; so that 
the great fatality in phthisis consists in the continued predisposition which 
causes the constant or frequently repeated deposition of other tubercles, be- 
fore those first deposited have had time to run a favourable course. We may, CLASS III.] 
PHTHISIS. 
91 
therefore, always entertain some hope, if applied to in the early stage, in cases 
of no great severity, of seeing a cure effected; and, even in the second stage, 
when the diathesis is not very strong, or the local disease extensive, there is 
no reason for absolute despair. Since the introduction of cod-liver oil into 
use, I have seen several cases of apparent phthisis in the early stage arrested, 
at least one case in the advanced stage, with a cavity, and general symptoms 
of the most threatening character, quite cured, and many cases in various 
degrees amended, of which I have been unable to trace the ultimate result. 
The post-mortem observations of Professor Bennett of Edinburgh, made in 
vast numbers in the Hospital of that city, have shown that from one-third to 
one-fourth of all who die after the age of forty, exhibit cretaceous masses, 
puckerings, or other evidences of previous tubercles in the lungs, which have 
undergone spontaneous cure; and similar examinations made by MM. Rogee 
and Boudet, in the Hospitals of Paris, give analogous results. In his work 
on Pulmonary Tuberculosis, Professor Bennett gives in detail several consump- 
tive cases, seen by him during life, which upon death subsequently from other 
diseases, have shown undoubted evidence in the lungs of pre-existing tuber- 
culous deposit. There can, therefore, scarcely be a doubt of the occasional 
cure of phthisis. Even in cases which appear to offer no chance of ultimate 
recovery, we may hope to be able very much to prolong the duration of the 
complaint, and sometimes even to add years to a valuable life. When the 
second stage is clearly established, with severe constitutional symptoms, and 
the physical signs of extensive disease in the lungs, there is little ground for 
hope. If to the ordinary symptoms, in such instances, are superadded con- 
tinued vomiting and diarrhoea, the case may be considered as quite desperate; 
and speedy death may be expected. 
As tubercles, when once formed, almost always run their course, notwith- 
standing all the remedies that can be employed, the prominent indications in 
the treatment of phthisis appear to be, first, to prevent their further deposi- 
tion, and secondly, to guard the lungs and the system at large against their 
injurious influence during their progress. The first of these indications is 
all-important, and should claim the especial attention of the practitioner. 
1. To prevent the further Deposition of Tubercles or Tuberculous Matter.- 
In fulfilling this indication, there are two objects to be aimed at; first, to cor- 
rect the predisposition, and, secondly, to obviate the influence of the causes 
which excite the predisposition into action. 
So far as we understand the tuberculous diathesis, it consists in' a depre- 
ciation of the general tone and vigour of the system, and of the character of 
the blood. Our object must, therefore, be to restore due vigour to the solids, 
and a healthy state to the circulating fluid. The remedy best adapted to 
these ends is exercise in the open air. To be effective, this must be vigorous 
and long continued. It is not sufficient to take a short walk now and then 
when the weather is pleasant. Such exercise is altogether inadequate to the 
end in view, of changing the constitution of the patient. It must be sus- 
tained daily, and as far as possible unremittingly, for months and even for 
years. There is no necessity for carrying it to the point of great fatigue. It 
should at first be moderate, not longer continued nor severer than the patient 
can well bear, and gradually and perseveringly increased, as the increasing 
strength may permit. Cold weather should not be considered as any obstacle. 
By clothing himself warmly, and carefully protecting himself from the wet, 
the patient may, in the early stages of the disease, and frequently also in its 
second stage, venture out at all seasons and in almost any weather. Certainly 
Treatment. 92 
[PART II. 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
it is better to encounter freely all the rigors of winter weather, properly 
guarded, than to shut one's self up for a whole season in a warm room of regu- 
lated temperature, as recommended by some. Nevertheless, the patient may 
be influenced, in this respect, in some degree by his own experience. If he 
find that exposure in bad weather occasions frequent attacks of catarrh, it 
may be best to avoid it. The contrary, however, will generally be found to 
be the case, with the precautions before mentioned; and the liability to ca- 
tarrh will be found to diminish with the amount of exposure. Cold dry wea- 
ther may almost always be encountered with impunity. Of course, during 
the existence of any considerable hemorrhage from the lungs, or of intercur- 
rent attacks of pleurisy, pneumonia, or bronchitis, especially when attended 
with fever, it will be proper to intermit the exercise until they shall have been 
removed; after which it should be resumed as before. The remarks of the 
late Dr. Joseph Parrish upon this subject are highly valuable. That excellent 
physician, having early in his practice observed the futility of the modes of 
treating phthisis then in vogue, and indeed their frequently marked effect in 
hastening the march of the disease, was induced to throw them all aside, and 
return to the practice recommended by Sydenham. The following remarks 
are extracted from a paper of his, published in the North American Medical 
and Surgical Journal (viii. 279). "Vigorous exercise, and free exposure 
to the air, are by far the most efficient remedies in pulmonary consumption. 
It is not, however, that kind of exercise usually prescribed for invalids-an 
occasional walk or ride in pleasant weather, and strict confinement in the 
intervals-from which much good is to be expected. Daily and long-con- 
tinued riding on horseback, or in carriages over rough roads, is, perhaps, the 
best mode of exercise; but, where this cannot be commanded, unremitting 
exertion of almost any kind in the open air, amounting even to labour, will 
be found highly beneficial. Nor should the weather be scrupulously studied. 
Though I would not advise a consumptive patient to expose himself reck- 
lessly to the severest inclemencies of the weather, I would nevertheless warn 
him against allowing the dread of taking cold to confine him on every oc- 
casion when the temperature may be low or the skies overcast. I may be 
told that the patient is often too feeble to bear the exertion; but, except in 
the last stage, when every remedy must prove unavailing, I believe there are 
few who cannot use exercise without doors; and it sometimes happens that 
they who are exceedingly debilitated find, upon making the trial, that their 
strength is increased by the effort, and that the more they exert themselves, 
the better able they are to support the exertion." 
Experience, from the time of Sydenham, has shown that the best mode of 
taking exercise, upon the whole, for consumptive patients, is on horseback. 
In his own case, Dr. Parrish resorted to the plan of driving over the rough 
pavements of the city, in a vehicle without springs, in his ordinary professional 
rounds; and to this cause, probably, as much as to any other, owed the for- 
tunate result. The great difficulty, in relation to exercise, is in inducing the 
patient to submit perseveringly to the necessary hardships. Hence, they are 
most fortunate who are so situated as to be compelled to exert themselves. It 
has often been observed that consumptive patients entering into military ser- 
vice have entirely surmounted the disease; and it will be found, in civil life, 
that they who are under the necessity of exerting themselves to the utmost to 
gain bread are apt in the end to fare the best. The life of a country physi- 
cian who visits his patients on horseback is, probably, independently of its 
anxieties, as conducive as any other to a favourable result in phthisis. The 
best substitute for this compulsory exercise is a long journey on horseback, or 
in a somewhat rough vehicle; and, if some object of business or pleasure with- CLASS III.] 
PHTHISIS. 
93 
out reference to health, can be connected with the journey, it will be so much 
the better. 
Perhaps next in importance to exercise is a proper regulation of the tem- 
perature of the body. The patient should sedulously guard against the general 
depressing influence of cold. This he is not to do by shutting himself up 
in a heated apartment during winter. He would thus lose the advantages 
of exercise and pure air, which are of greater importance than the uniformity 
of temperature. The best plan is to guard himself against the cold by flan- 
nel next the skin, and sufficient exterior covering to render him perfectly com- 
fortable; care being taken, at the same time, to protect the lungs, if the 
temperature be very low, or the bronchia peculiarly sensitive, by means of 
two or three thicknesses of gauze worn over the face as a veil. Advantage 
will often accrue, with the present style of dress, from covering the breast by 
a dressed rabbit skin, or by cotton wadding quilted between pieces of silk, 
worn under the shirt. While in the house, the patient should take care never to 
allow himself to feel cold, and especially should cover himself warmly in bed. 
While thus avoiding the general sedative influence of cold, he should equally 
avoid that partial application of it, and that sudden alternation with warmth, 
which are so apt to occasion bronchial or other inflammation. He should, 
therefore, keep his feet and his hands dry and warm, should take care never 
to expose himself to cold when perspiring, and should avoid partial currents 
of air as much as possible, consistently with the more important object 
already mentioned. To insure the advantages of warmth, it may be advisa- 
ble that, if residing in cold regions, be should remove during winter to those 
which are warmer. Another benefit resulting from such a removal is the op- 
portunity which it affords for constant exercise out of doors, without the 
danger of taking cold. In choosing a place of residence, preference should 
be given to those situations which are at the same time dry and of a uniform 
temperature. For Americans, there is probably no better residence than the 
interior of Georgia, Alabama, and Florida. The immense pine forests of 
these regions may add the advantages of their exhalations to those afforded 
by the comparative dryness and warmth of the climate. Some of the West 
India Islands may also be selected; and preference is generally given to Santa 
Cruz or Cuba. In Europe, no situation is probably liable to so little objec- 
tion as the South Eastern parts of Spain. Almost always, however, a situa- 
tion should be selected at some distance from the sea shore. Independently 
of the dampness of the air, there is another great disadvantage, resulting 
from the salt driven up into the atmosphere with the spray, and carried for 
some distance inland. Experience has shown that this is often very irritating 
to delicate lungs. When it is impossible for the patient to remove to a distant 
region, .he should endeavour to select the driest spot within his reach near 
home. 
But, while thus careful to guard against cold, the patient should exercise 
some caution also in relation to excessive heat. The warmest portions of our 
summers are almost as injurious to consumptive patients, especially in the ad- 
vanced stages, as the cold of winter. " From my own observations," says Dr. 
Chapman, "I am pretty well persuaded that, in this city (Philadelphia), the 
greatest degree of mortality is in the early part of the spring, and the close 
of summer; the effects of intense heat being more baneful than those of se- 
vere cold, and quite equal to the influence of the fluctuations in our vernal 
weather." (^Lect. on Thoracic and Abdom. Dis., p. 45.) If, therefore, the 
patient is .to seek a warm climate in winter, he will find advantage, during 
the heats of summer, in a resort to some elevated mountainous district, not 
so high as to be involved in frequent fogs, and affording good opportunities 94 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[PART II. 
for horseback exercise. The author has found no situation superior, in these 
respects, to Schooley's Mountain in New Jersey. 
Some consideration is always necessary in sending a patient abroad in this 
disease. In severe cases, in the advanced stage, when there can be no hope 
of ultimate good, it would be cruel to separate him from the comforts and 
consolations of his own home, to suffer, and perhaps die, among strangers. 
Nor should he, as a general rule, be sent away while labouring under any 
active inflammation, which might be aggravated by the necessary exposures 
and disturbances of the removal. 
The regulation of the diet constitutes also an important part in the treat- 
ment of phthisis, under the first indication. As the objects are to sustain a 
vigorous tone of system, and at the same time to avoid the exciting influence 
of pulmonary inflammation and fever, the general rule is to recommend a ge- 
nerous diet, but with such restrictions as shall guard against the produc- 
tion of an inflammatory or febrile condition. While the most nutritious 
articles of food may be allowed, those should be preferred which are least 
stimulating. Thus, farinaceous substances, milk, fish, oysters, eggs, and the 
lighter meats, are preferable to the stronger meats which contain some stimu- 
lant principle independently of their mere nutriment; and, when the* latter 
are employed, they should in general be boiled. Fruits and the digestible 
vegetables are very suitable. But, when there is fever, local inflammation, or 
hemorrhage, in the early stages, animal food should be suspended, and the 
patient confined exclusively to fruits, vegetables, and farinaceous substances. 
In doubtful cases, milk and the farinacea are excellent intermediate articles 
of diet. Stimulant drinks should not be allowed to persons previously unac- 
customed to them, in the first stage, unless indicated by obvious debility. It 
is proper, also, to proportion the diet in some degree to the amount of exer- 
cise, more nutritious substances being allowed, and in greater quantity when 
the patient undergoes continued bodily fatigue, than under other circum- 
stances. In the second stage, after suppuration has fairly set in, moderately 
stimulant drinks, such as porter and ale, are often useful. 
Mental influences are frequently important therapeutical agents in this dis- 
ease. When there is reason to believe that the patient is sinking under some 
disappointment of the affections, or other grief or anxiety, concealed or open, 
every effort should be made to discover and remove the source of mischief. 
Intense application to study, or any sedentary business must be avoided. The 
hopes of the patient should be encouraged, and his tendency to cheerfulness 
cherished, so far as may be deemed compatible with higher interests. It is 
probably in part by the agreeable distraction of the mind, and the stimulating 
influence of a succession of pleasing or interesting novelties, that travelling 
owes a portion of its success as a remedial measure. Short sea voyages, in 
interesting regions, may be useful in the same way. 
Medicines are generally of less avail in this disease than the hygienic mea- 
sures already recommended. Nevertheless they are sometimes highly useful. 
When the system readily responds to exercise, and the other means enume- 
rated, when the appetite and digestion remain unimpaired, and the nutrition 
improves, and when there is no derangement of function requiring interfer- 
ence, it will be best, upon the whole, to avoid energetic medicines altogether, 
with a single exception to be adverted to directly. But should the case be 
otherwise; should the patient remain feeble and anemic, and the vital pro- 
cesses alluded to be inadequately performed, benefit will often accrue from the 
use of mild tonics. Of these, the one most applicable to the circumstances 
of phthisis is perhaps wild-cherry bark, the primus virginiana. of the U. S. 
Pharmacopoeia. This has the great advantage of uniting a tonic influence CLASS III.] 
95 
PHTHISIS. 
over the digestive and nutritive functions, with a sedative action upon the 
nervous system and the general circulation. The latter effect is strongly 
indicated by the great irritation of pulse, and general excitability of system, 
which attend and characterize this disease, often even in its earliest stage. 
The best plan of administering the remedy is in the form of the officinal in- 
fusion, which may be given in the dose of a large wineglassful two, three, or 
four times a day, and continued for months or even years, with occasional 
intermissions. With the exception before referred to, there is no other medi- 
cine which has seemed to me so efficacious. It was a favourite remedy with 
the late Dr. Parrish, and has come into extensive use. Should this become 
offensive to the patient, recourse may be had to pipsissewa, or one of the sim- 
ple bitters, as columbo, gentian, quassia, or American centaury, to which 
either hydrocyanic acid or tincture of digitalis may be added, when the pulse 
is very frequent, and the system irritable. Occasionally, much good may be 
done by the use of the chalybeates, which are especially indicated in anemic 
cases, and in females with amenorrhoea. The preferable preparations of iron 
we. pill of carbonate of iron (Ui S. Phi), tartrate of iron and potassa, tinc- 
ture of chloride of iron, and solution of iodide of iron; but any other of the 
preparations of the metal may be selected, which may happen to agree better 
with the stomach, taste, or prejudices of the patient. It is probably chiefly 
as a tonic, that iodine sometimes proves serviceable in the first stage of 
phthisis. When chalybeates are indicated, this may perhaps be given best in 
the form of iodide of iron ; otherwise the compound solution of iodine ( U. S. 
Phi), or iodide of potassium, should be preferred. I have little faith in the 
supposed influence of this medicine in promoting the absorption of the tuber- 
culous matter. The preparations of iodine should be immediately abandoned, 
if found to interfere injuriously with the digestive process, to excite bronchial 
irritation; or in any other way to disturb the functions. A general corrobo- 
rant impression may be made on the system by frictions, applied to the whole 
surface of the body. 
But of the medicines used in phthisis no one, nor any combination of them, 
has hitherto proved so efficient as coddiver oil. When the second edition of 
this work was published, the experience of the author had not been favoura- 
ble to that remedy; but this was simply because he had not persevered with 
it a sufficient length of time, in the several cases in which it was employed. 
The oil seldom produces any very observable effect under a period of from 
three to six weeks; and, despairing of any good result, he had in every in- 
stance omitted it too soon. Subsequent experience has convinced him of its 
inestimable value. For the last five years, he has used it in nearly every 
case of phthisis which has come under his notice either in private or hospital 
practice, and almost always, when it could be retained on the stomach, with 
either temporary or lasting benefit. His experience coincides generally with 
that of the writers who have testified favourably of its effects. In the worst 
cases, and most advanced stages, it usually improves the condition of the 
patient, renders him more comfortable, and postpones the fatal issue. Under 
less desperate circumstances, it often arrests for a time the march of the dis- 
ease, giving hopes even of ultimate recovery; and, in some few instances, these 
hopes are justified by the result, so far as time has hitherto enabled us to 
judge. Given at the first appearance of the symptoms, I have frequently 
found it to set them aside altogether, and believe that, with the aid of other 
suitable remedies, it is capable of effecting permanent cures in many in- 
stances. Its observable effects are usually to improve the digestion, to ren- 
der the patient fatter and stronger, to diminish the frequency of the pulse 
and check the sweats at night, to relieve the cough, and, in fine, greatly to 96 
[PART II. 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
ameliorate all the general symptoms. The patient often becomes fleshy, ex- 
changes his paleness for a ruddy or healthy colour, and feels himself nearly if 
not quite well. Unhappily, the physical signs do not generally undergo the 
same rapid improvement. If there was evidence of considerable solid deposi- 
tion, this goes on to softening and the formation of a cavity; if there was a 
cavity at the commencement of the treatment, this not unfrequently enlarges, 
while others form; and, after a period of very flattering amendment, perhaps 
for months, perhaps for a year or more, the symptoms return, and the patient 
too often sinks at last. Yet it is not always so. Sometimes suspicious phy- 
sical signs in the early stage entirely disappear, and cavities either remain 
stationary or heal. The following, so far as I am capable of judging from 
my own observation, and the recorded experience of others, appears to be 
the real value of the remedy. It does not act as a specific, and is wholly 
incapable of producing, by any direct influence of its own, the removal of the 
deposited tuberculous matter. But it invigorates digestion, improves the 
character of the blood, and by a peculiar power modifies the nutritive process, 
so as to obviate, in a greater or less degree, the tendency to the deposition of 
tuberculous matter. When this tendency is not very strong, and other suita- 
ble measures are made to co-operate with the oil, it appears capable of arrest- 
ing the further formation of tubercles altogether. But the matter deposited 
must pass through its own destined changes. If small in quantity, as in the 
earliest stage of the disease, it may undergo the calcareous metamorphosis, 
and thus cease to do harm. If larger, it must soften, and be discharged, 
leaving a cavity, which may ultimately heal if not increased by further ac- 
cessions of tubercle. If abundant, it must undergo the same change, and 
then must necessarily prove fatal, should so much of the lung be destroyed 
in the process as to render the remainder insufficient to fulfil the purposes of 
respiration, or should the strength be inadequate to support the exhausting 
effects of the necessary irritation and suppuration. It is seen, therefore, that 
cod-liver oil though a very valuable agent, perhaps the most valuable, should 
be looked on only as one of the means of confirming the general health, and 
thus affording the best possible protection against the further progress of the 
malady, and enabling the system to withstand the depressing and exhausting 
influences necessarily exerted upon it in the elimination of the tuberculous 
matter. These views are certainly encouraging ; and they would seem to be 
supported by the fact of the recent diminution of the general mortality from 
phthisis, as evinced by the statistical reports, in the city of Philadelphia, 
which can be ascribed to no other known cause than the general use of cod- 
liver oil.* But great care must be taken to guard against the error of rely- 
* From a statistical table, prepared by Dr. Condie, of the relative number of deaths 
from phthisis in Philadelphia, from the year 1826 to 1851, inclusive, published in the 
Quarterly Summary of the Transactions of the College of Physicians of Philadelphia (N. S. 
i., 261), it appears that, during the ten years from 1840 to 1849, inclusive, the average 
proportion of mortality from phthisis was 1 in about 6.76 from all causes, or 14.8 per 
cent., not very different from the average of the twenty preceding years (see page 64); 
while in the years 1850 and 1851, during which cod-liver oil has been in extensive use, 
the proportion has fallen to 1 in 8.33, or about 12 per cent. In the latter of these two 
years, viz., 1851, the mortality has been smaller than in the preceding, being 1 in 8.43 
or 11.86 per cent. As observed in the text, there has been nothing to which this result 
can be ascribed, unless to the very general employment of the oil. This is certainly 
very encouraging. It must be recollected, however, that the acknowledged effect of 
the oil is to postpone the fatal result, and it may be that the present gain may be com- 
pensated by future loss. During the years in which cholera prevailed in Philadelphia, 
viz., 1832 and 1849, the deaths by phthisis were somewhat short of 11 per cent. But 
in the year following 1832, they rose to upwards of 19 per cent., while in that following CLASS III.] 
PHTHISIS. 
97 
ing on this alone, to the neglect of exercise, exposure to pure air, and the 
various other methods of invigorating the system, already referred to. A 
tablespoonful of the oil should be given three times a day, and the remedy 
persevered in for many months, nay, interruptedly, even for years, should it 
continue to agree with the patient, and the disease not appear to be sooner 
eradicated. As the diathesis is often constitutional and inherited, it will be 
necessary to be always on the watch, even after the disappearance of the 
symptoms, in order to meet them promptly should they return. As the oil 
favours the production of a rich blood, it is obvious that, upon the occurrence 
of haemoptysis or acute inflammation, it should be suspended until these have 
been subdued, and then resumed. For the best modes of administering it, 
and various other points in relation to it, of interest to the physician, the 
reader is referred to the last edition of the U. S. Dispensatory.* 
Among the measures requisite for the fulfilment of the first indication is 
attention to the various functions, which must be maintained in as healthy a 
condition as possible. It would be altogether superfluous to point out here 
the means that may become necessary for this purpose. They are mentioned 
elsewhere under the beads of the several diseases consisting in derangement 
of these functions. It will be sufficient to call attention to such of the func- 
tions as most frequently require medical interference. The digestive organs 
should be especially attended to; dyspepsia, constipation, and diarrhoea should 
be corrected by means the least calculated to diminish the strength of the 
patient; the hepatic function should be sedulously guarded against derange- 
ment; and the menses, if suppressed, should be restored as speedily as possible. 
The measures above recommended are calculated to correct the tuberculous 
diathesis. It comes next in order to notice those by which the influence of 
the exciting causes may be obviated. As the chief exciting causes are such 
as occasion irritation or inflammation of some portion of the lungs or their 
investment, attention should be directed to prevent these effects, and to cor- 
rect them when they take place. For this purpose, the patient should clothe 
himself warmly, should avoid unnecessary exposure to vicissitudes of tempera- 
ture, and especially to cold when perspiring with heat, should guard himself 
1849, they were only 12.15 per cent., which is another strong fact in favour of the effi- 
cacy of the cod-liver oil treatment. {Note to the third edition.'} 
The above note was prepared for the last edition of this work, and brought our expe- 
rience in regard to the mortality down to the end of the year 1851. It will have been 
noticed that the mortality for the years 1850 and 1851, had diminished from 1 in 6.7, 
which had been the average of the preceding ten years, to 1 in 8.33. It was stated 
that, as the effect of the oil, when it did not cure, was to postpone the fatal result, we 
might expect an increase of deaths subsequent to the last mentioned years. From an 
examination of the bills of mortality for 1852 and 1853, 1 find that the deaths from 
phthisis were in the former of these years, 1 in 8.50 (Jewell, Phil. Med. Exam., N. S., ix. 
95), and in the latter 1 in 7.82. This slight falling off in the last year is not more than 
was anticipated from the effect of postponement. The average mortality for the four 
past years has been 1 in 8.22, which, compared with the 1 in 6.7 of the preceding ten 
years, is certainly a very encouraging gain, and, so far as I am capable of judging, to 
be ascribed mainly, if not exclusively, to the cod-liver oil. {Note to the fourth edition.') 
* Other fixed oils, both animal and vegetable, have been employed as substitutes for 
the cod-liver oil, but none, so far as I can gather from a general comparison of sentiment, 
are altogether equal in their effects. Dr. Th. Thompson has found good effects from 
sperm oil, neat's-foot oil, and cocoa-nut oil, the last of which he thinks possesses 
similar properties to those of cod-liver oil. {Clin. Leet, on Pul. Consump., Am. ed., pp. 
120, 122, and 128.) Under the impression that the oil owed its virtues to iodine, an 
attempt has been made to substitute for it other fixed oils impregnated with that medi- 
cine ; but experience has determined unfavourably as to the efficacy of the substitute. 
{Arch. Gen. 4e ser., xxvii. 354.) Note to the fourth edition. 98 
PART II. 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
against the inhalation of noxious vapours or irritating powders, and, in pursu- 
ing the various measures recommended for the general health, should always 
endeavour to restrain them within the point of producing inflammatory or fe- 
brile action. Should inflammation occur, it ought to be treated by measures 
least calculated to exhaust still further the failing powers of the system. Blood 
should be taken less freely than in the same affection under other circumstances; 
and local bleeding and blistering should be preferred to venesection, where 
there is a good probability that they will answer the purpose. As the arrest- 
ing of habitual discharges, and the removal of long established external dis- 
eases, sometimes prove exciting causes of phthisis, it is proper, in this place, 
to put the practitioner upon his guard against a too hasty attempt to cure such 
affections. Thus, it is better, as a general rule, that old ulcers on the legs, 
fistula in ano, hemorrhoids, and external scrofulous tumours, should be en- 
couraged as safe outlets of the morbid tendencies, than that any effort should 
be made to get rid of them. In arranging his remedial plans, the physician 
should bear in mind the effects of pregnancy and lactation in checking the 
progress of phthisis, if not sometimes in arresting it altogether. 
The foregoing remarks are applicable to all stages of phthisis; for in all 
stages the only hope of cure is to prevent the further deposition of tubercles. 
Yet, when the amount of pectoral disease, as ascertained by the physical signs, 
is,so great, and the strength of the patient, as evinced by the general symp- 
toms, so much exhausted, that the disease must necessarily prove fatal in a 
short time, it would be proper to urge the remedial measures suggested only 
so far as may be quite compatible with the comfort of the patient, which, under 
such circumstances, becomes the chief object of attention. 
2. To obviate the Effects of Tubercles.-As it is through these effects that 
all the sufferings of the patient arise, and that death comes at last, it is highly 
important to correct them as far as possible; and, though our powers in this 
respect are limited, we yet are able to do much towards promoting comfort, 
prolonging life, and sometimes towards effecting a cure. 
Cough.-This, when troublesome or violent, must be alleviated, as, by agitat- 
ing the lungs and disturbing sleep, it proves positively injurious. Demul- 
cents may be first tried, either in the form of lozenges, to be held in the mouth 
and allowed slowly to dissolve, or in the liquid form, to be occasionally sip- 
ped. Should these fail, it will be necessary to conjoin narcotic remedies with 
them. When the cough is one of mere irritation, or when it is attended with 
pretty free expectoration, no remedy is so efficient as opium, in some one of 
its various forms of preparation. Of these, the one should be preferred, in 
favour of which experience may pronounce in each particular case. Upon 
the whole, I prefer one of the salts of morphia, as they have appeared to me 
less disposed than opium, or most of its other preparations, to produce con- 
stipation, or restrain the bronchial secretion. Small doses, not exceeding the 
fifth or sixth of a grain of opium, or its equivalent, repeated two, three, or 
four times a day, should be given at first; and the inevitable tendency to in- 
crease the dose should be restrained, as far as may be at all compatible with 
the comfort of the patient. This remark is applicable to the other narcotics 
also. When the cough depends upon bronchitis; and the indication to pro- 
mote expectoration is prominent, or when opium disagrees with the patient, 
as occasionally happens, hyoscyamus, lactucarium, conium, stramonium, bella- 
donna, or hydrocyanic acid, may be substituted. Aconite and chloroform, 
internally administered, may also be tried. The narcotic employed should be 
given with mucilage or syrup, or combined with other ingredients in expec- 
torant mixtures; and it may be associated with almost any of the medicines 
which may be used to meet the indications of the disease. Sometimes the CLASS III.] 
99 
cough is very much aggravated by the irritation of an elongated uvula, which, 
in such a case, if not sufficiently contracted by astringents, should be amputated. 
Dyspnoea.-So far as this is dependent solely upon organic disease of the 
lungs, whether tuberculous or inflammatory, it will yield only to measures 
addressed to that condition; but there is occasionally much dyspnoea, arising 
from nervous derangement, which may be advantageously treated by the 
nervous stimulants and narcotics, such as assafetida, compound spirit of sul- 
phuric ether, aromatic spirit of ammonia, tincture of lobelia, extract of stra- 
monium, &c., separately, or variously combined, to suit the individual case. 
Occasionally, too, relief may be obtained from the inhalation of the vapours 
of ether, camphor, or tincture of conium, or of the smoke of stramonium or 
tobacco ; though these means should be employed with caution. 
Haemoptysis.-The hemorrhage from the lungs frequently requires atten- 
tion. Sometimes it affords relief to the pulmonary symptoms, and, in this 
case,*if moderate, may be allowed to continue until it shall subside sponta- 
neously, as will generally happen in the course of a few days. But, if con- 
siderable, or not disposed to cease, it becomes an object of treatment. The 
same measures are to be employed as recommended under haemoptysis; but 
it should always be borne in mind, that, in phthisis, the great object is to 
husband the strength of the system; and blood-letting, therefore, though it 
may be necessary if there is much general excitement with a strong full 
pulse, should be more moderate than might be deemed proper in cases un- 
connected with tubercles. As a general rule, it will be better to lessen the 
pulmonary congestion by cups or leeches to the chest, and the subsequent 
application of a blister, if necessary; while the patient is kept at rest, upon a 
low diet, and under the use of refrigerating or sedative medicines, such as 
the antimonials, citrate of potassa, nitre, or ipecacuanha, with cool drinks. 
A little common salt taken undissolved into the mouth, and swallowed in that 
state, will often at once check the hemorrhage. If unattended with much 
fever, or symptoms of local congestion, it may be treated with astringents, 
as acetate of lead, kino, rhatany, or tannic acid, which may often be usefully 
combined with opium and ipecacuanha in minute doses. I have repeatedly 
found the hemorrhage to yield very happily to oil of turpentine, or to ergot, 
when the astringents have failed. 
Pectoral Pains.-In the early stages of the disease, as the pains are pro- 
bably connected frequently with inflammation of the pulmonary tissue or 
pleura, excited by the neighbourhood of the tubercles, it may be proper to 
treat them by the occasional application of a few cups or leeches, which may 
be followed or alternated with small blisters, allowed to heal and then reap- 
plied. When the pains are moderate, it will often be sufficient to employ 
friction, dry cups, or some rubefacient liniment, such as liniment of ammo- 
nia, oil of turpentine diluted or not with olive oil according to the suscepti- 
bility of the skin, tincture of capsicum, &c.; and a plaster of Burgundy pitch, 
or a warming plaster, will occasionally afford much relief, if worn steadily 
for a considerable time. Issues, setons, and pustulation with tartar emetic, 
though sometimes useful, produce, I think, as a general result, less good by 
revulsion than harm by irritation. 
Bronchial Inflammation.-This almost constant accompaniment of phthisis 
requires particular attention, in conducting the treatment of the disease. Al- 
lusion is here had not to the attacks of bronchitis which occur incidentally in 
the progress of the complaint, and may be seated in any portion of the lungs, 
but to the affection as it takes place in those bronchia only, which are in direct 
connexion with the tuberculated structure, and is produced by the irritation 
of the tubercles, or by the matter discharged from them. This is a cause of 
PHTHISIS. 100 
[part II. 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
much of the severe cough of consumption, and of much of that copious ex- 
pectoration which is apt to attend the latter stages. It often no doubt tends 
to aggravate the febrile symptoms, and contributes materially towards ex- 
hausting the strength of the patient. In the early stages, it may be advan- 
tageously combated by small doses of tartar emetic, ipecacuanha, sanguina- 
ria, or lobelia. It is probable that the alleviation which sometimes accrues, 
in the early period of phthisis, from the long-continued use of a very weak 
solution of tartar emetic in cold water as a common drink, depends chiefly 
upon its influence over the bronchial affection. For this purpose, it has been 
proposed to dissolve about one-sixth or one-eighth of a grain of the antimo- 
nial in at least a pint of water, which may be used at meals, or whenever the 
patient is thirsty. In a somewhat more advanced stage, when the expecto- 
ration begins to be opaque or purulent, squill or seneka, or both, may be added 
to the medicines above mentioned, or substituted for them. A very good 
mixture consists of equal measures of syrup of squill and syrup of s^heka, 
and half the quantity of antimonial or ipecacuanha wine, and of the solution 
of sulphate of morphia ; of which one or two fluidrachms may be given two, 
three, or four times in twenty-four hours. In the last stage of the disease, 
when suppuration is fully established, there may be advantage sometimes in 
resorting to the still more stimulating expectorants, as the balsams, turpen- 
tines, copaiba, ammoniac, assafetida, and even carbonate of ammonia. In 
the selection, reference must be had to other existing indications, such as 
that of nervous disorder calling for assafetida, and that of great general de- 
bility calling for the ammoniacal remedies. The expectorants may often also, 
with great propriety, be combined with any tonic which may be employed. 
Thus, the compound mixture of iron of the Pharmacopoeia, in which myrrh 
acts the part of the expectorant, is an excellent remedy in certain anemic 
cases with amenorrhoea, and without gastric inflammation. The narcotics 
which may be deemed advisable to counteract the cough, or allay nervous 
disorder, may also be given in connexion with the expectorants. 
Much benefit may be obtained, in reference to the bronchial inflammation, 
from certain inhalations; and it is probable that the greatly vaunted results 
of these remedies, in certain cases of phthisis, have been owing more to 
their influence on the diseased mucous membrane than on the tubercles them- 
selves, or their cavities. It is not impossible, however, that in cavities quite 
emptied of tuberculous matter, and not surrounded by tuberculous deposit, 
they may favour the healing process by a gently stimulant impression. They 
should be employed only in the second stage of the disease. As a general 
rule, the best mode of effecting inhalation is to impregnate with the volatile 
matter the air ordinarily breathed by the patient. When circumstances con- 
fine him to his chamber, he may thus be kept constantly under the remedial 
influence; and, at any rate, it may be made to act upon him through the 
night. This steady impression is much more effectual than a more powerful 
one made at certain intervals, while it will be less apt to irritate the lungs. 
When this mode of inhalation is impossible or inexpedient, some one of the 
instruments denominated inhalers may be resorted to. The particular sub- 
stance which, within my observation, has appeared most effectual, applied in 
this way, is tar vapour. The air of a chamber may be conveniently impreg- 
nated with it by placing a little tar in a cup, which is to be immersed in water 
contained in another vessel, and heated by a spirit-lamp. The common nurse- 
lamp answers the purpose admirably well. The effects of a water-bath are 
thus obtained, and the igneous decomposition of the tar prevented. Neither 
with this, nor with any other vapour, should the air be so far loaded as to be- 
come at all oppressive when breathed. Other terebinthinate and balsamic CLASS III.] 
101 
PHTHISIS. 
vapours may be applied in the same way. Their use, to be effectual, must be 
persevered in for months, sometimes for years. It is probable that the advan- 
tage, which experience has shown to be occasionally derived from a residence 
in the midst of pine forests, is owing chiefly to the terebinthinate exhalation 
from the trees. The inhalation of chlorine, and of the vapour of iodine, has 
of late years been much praised. I have occasionally tried them both, but 
with little observable advantage. Nevertheless, others have found them useful, 
and I do not wish to discourage their employment. Great care is requisite 
to prevent them from irritating the lungs; and a mistake in this respect may 
lead to serious disadvantage. As respects chlorine, the best mode is to cause 
it to be gradually extricated into the atmosphere of the chamber from a 
vessel containing some chloride of lime, or one of the alkaline chlorides, into 
which some dilute acid may be made to fall drop by drop. Iodine should be 
applied by means of an inhaler. (See U S. Dispensatory.) 
For the treatment of the laryngeal, affection, which so frequently attends 
phthisis, the reader is referred to Chronic Laryngitis. 
Frequent Pulse.-The excessive frequency of pulse which constitutes so 
marked a feature of the disease, cannot but react injuriously on the system, 
and even on the lungs themselves, and should, therefore, be controlled if 
possible. Wild-cherry bark, already recommended for another purpose, often 
serves in some degree to fulfil this indication. In the absence of this medi- 
cine, hydrocyanic acid may be tried alone. But the most effectual remedy 
for restraining the frequency of the pulse, when not dependent on inflamma- 
tion, is probably digitalis; and this is the chief advantage to be expected 
from that once highly praised narcotic. Sometimes it acts most happily and 
speedily; but not unfrequently it either fails, or, while it depresses the pulse, 
depresses also injuriously the general strength. Dr. Chapman makes the 
following statement in relation to this remedy. " As the result of no slender 
experience with digitalis, I am prepared to state, that the only case of phthisis 
in which it can be much relied on, is the incipient stage, usually attended 
with a slight hmmoptoe, small, quick, irritated pulse, extreme mobility of 
system, short impeded respiration, and hard, dry, diminutive cough, where 
venesection and other evacuant means are precluded. {Leet, on Dis. of Thorac. 
and Abdom. Viscera, p. 60.) It is probable that black snakeroot or cimici- 
fuga, which has been long popularly employed in consumption in this country, 
and has been highly recommended by Dr. F. J. Garden, of Virginia (Am. 
Med. Record, Oct. 1823), and Dr. C. C. Hildreth, of Ohio (Am. Journ. of 
Med. Rd., N. S., iv. 281), owes its beneficial effects, in part at least, to its 
sedative influence over the circulation. Dr. Hildreth found it peculiarly 
advantageous in the early stages, in combination with iodine. 
Night-sweats and Hectic Fever.-A vast variety of means have been recom- 
mended for the relief of these affections, and all of them too frequently without 
any permanent advantage. For the colliquative sweats, which, in consequence 
of their exhausting as well as very disagreeable effects, it is highly desirable 
to be able to control, nothing is probably, on the whole, more useful than the 
mineral acids, and especially the sulphuric, which is usually employed in the 
form of elixir of vitriol, or the aromatic sulphuric acid of the Pharmacopoeia. 
From five to fifteen drops of this preparation may be administered, in a wine- 
glassful or more of cold water, or some bitter infusion, three or four times 
a day, or more frequently. Nitric or nitro-muriatic acid may be substituted, 
if more acceptable to the palate or stomach. Various other internal remedies 
have been recommended. Among them are acetate of lead, alum, tincture of 
chloride of iron, prepared chalk or lime-water, and the vegetable astringents, 
of which pure tannic acid is probably the most efficient. Gallic acid, how- 102 
[part II. 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
ever, has been very highly commended. Dover's powder may sometimes 
prove useful, by substituting its own active, but less copious diaphoresis, for 
the passive one of the disease. The prominent indication would seem to be 
to stimulate the skin moderately but universally; and this indication is met 
by a /ic^-bath, rendered more excitant by the addition of common salt, or a 
little mustard or Cayenne pepper. Friction to the surface with a solution of 
alum in hot brandy, in the proportion of two drachms to a pint, is highly 
recommended; but the fact is that the spirit is the chief agent, as little if any 
of the alum is dissolved. The flesh-brush, or friction with coarse flannel, is 
also sometimes useful. The patient should always sleep in flannel, which should, 
however, be very light in summer. It is said that sponging the body, at bed- 
time, with warm water, or warm vinegar, sometimes proves serviceable. 
For the hectic paroxysms, no remedy is so effectual as sulphate of quinia, 
which, given to the extent of ten or twelve grains in the intervals, will often 
set aside the chills, though they are very apt to return. It is obvious that 
nothing can permanently arrest them while the cause remains; and it is not 
only futile, but injurious, by endangering the healthy state of the stomach, to 
load this viscus with that great variety of drugs which have been recommended 
for this affection. One of the least injurious is vinegar, of which one or two 
teaspoonfuls may be given every hour or two, sufficiently diluted with water, 
and sweetened. Griffith's antihectic myrrh mixture {Mist. Ferri Comp., 
U. S. Ph.) may be tried, when the stomach is not irritated or inflamed. 
When the chills occur regularly, and are very distressing, they may fre- 
quently be prevented by anticipating them with a full dose of opium. During 
the fever, the patient may often be much relieved by small doses of the neu- 
tral mixture, or effervescing draught, or citrate of ammonia, with or without 
a little spirit of nitric ether, and solution of sulphate of morphia. Sponging 
the surface with warm vinegar or spirit sometimes has a soothing effect. 
Vomiting and Diarrhoea.-When the nausea or vomiting is attended with 
tenderness at the pit of the stomach, indicating gastritis, a few leeches may 
be applied, followed by emollients and blisters. If there is considerable fever, 
the patient should be confined for a time to demulcent or farinaceous drinks. 
When the general and local excitement is less, advantage will sometimes 
accrue from an exclusive diet of lime-water and milk, with stale bread or 
crackers; but it often happens that the debility is too great to admit of this 
exclusiveness, and it is necessary to allow something more nutritious. The 
ordinary remedies for vomiting may be tried, such as the effervescing draught, 
when there is fever, and carbonic acid water, creasote, &c., under other cir- 
cumstances. (See Vomiting, vol. i. page 564.) Nitrate of silver, with a little 
opium, is likely to prove the most efficacious remedy, when there is reason to 
believe that the mucous membrane is ulcerated. For the diarrhoea, opiates, 
chalk, the various astringents, and a milk diet, may be used as palliatives; 
but, when it is considered that the affection generally depends upon tubercles 
in the bowels, little permanent good will be expected from any remedy that 
can be employed. Dr. Theophilus Thompson, of London, recommends strongly 
subnitrate of bismuth, in the dose of five grains, three times a day. (Lond. 
Med. Gaz., July 14, 1848.) M. Monneret employs the same remedy, in a 
quantity varying from two to twenty drachms in the course of a day, and de- 
clares that he has never observed the slightest inconvenience from these large 
doses, even in children. (Am. Journ. of Med. Sei., N. S., xviii. 463.) Char- 
coal is said to be sometimes useful, its operation being ascribed to the absorp- 
tion of acrid matters in the bowels. Dr. Physick once told the author, that 
be had found nothing so efficacious in the diarrhoea of phthisis as a diet 
exclusively of milk. CLASS III.] 
PHTHISIS. 
103 
The great debility of the last stage requires attention. One of the main 
objects in the treatment of this condition, is to impart sufficient muscular 
power to the patient to enable him to expectorate the secretions, which often 
accumulate in the bronchia, and, if not discharged, must produce suffocation. 
Carbonate of ammonia, wine-whey, milk-punch, and egg with wine, may be 
used.' Life may sometimes be considerably protracted by these means. 
Lastly, it is often necessary, in the final stage, to protect the prominent 
points of the body, especially the hips, sacrum, and shoulders, by means of 
spirituous lotions, the lead plaster, down pillows, and circular pillows with an 
opening in the centre, from the inflammation, sloughing, and ulceration, which 
are so apt to ensue from friction and pressure, in cases of great emaciation, 
and long confinement to bed. Dr. Purefoy states, in the Dublin Med. Press, 
that he has effectually prevented these unpleasant results, by placing under- 
neath the parts liable to injury a beef's bladder, oiled and partially filled 
with air. (Journ. de Pharm. et de Chim., xiii. 121.) 
The plan of treatment, above detailed, is that which the author believes 
best adapted to the alleviation, and, when this is possible, to the cure of the 
disease. But numerous plans and remedies, not here mentioned, have been 
proposed at different times, many of them with the claims of a specific, and 
all with the support of asserted cures. Each, when announced, has been re- 
ceived with more or less confidence by an eager public, to be in its turn aban- 
doned after a trial of longer or shorter duration; and every now and then one 
of them is revived to run again a brief career of experiment, failure, and ne- 
glect. To enumerate and discuss all these plans and remedies in this place, 
would be incompatible with the purposes of the work. It will be sufficient to 
notice some of the more prominent or more recent among them. The frequent 
use of emetics, in the early stages, has been very strongly recommended. They 
have been given daily, or every other day, and continued for months. Dif- 
ferent articles of the class have been employed by different practitioners, some 
preferring tartar emetic, others ipecacuanha, sulphate of zinc, or sulphate of 
copper. Residence in a miasmatic district has been proposed, upon the ground 
that the disease is much less frequent in such districts than in others of the 
same temperature, and that the occurrence of miasmatic fever sometimes su- 
persedes phthisis. But these are yet very doubtful points, and the remedy 
is too hazardous for trial without more certain proof of its efficiency. Tanners 
are said to be remarkably exempt from the disease; and, this exemption 
having been ascribed to the exhalations f rom the oak bark employed in their 
business, attempts have been made to derive therapeutical effects from simi- 
lar exhalations, by placing the material affording them in the sleeping apart- 
ment of the patient. The extravagant practice has even had its advocates, 
of causing patients to breathe habitually the air of stables, in which cows are 
kept, because the breath of these animals has been supposed to exercise a favour- 
able influence over the disease. Among the inhalations which have been em- 
ployed, at various times, besides those already mentioned, are oxygen gas, 
carburetted hydrogen, carbonic acid from burning charcoal, the vapours from 
copaiba and storax, and air loaded with certain powders, such as myrrh, for 
example. Digitalis and hydrocyanic acid have fallen from the rank of spe- 
cifics, which many were at first disposed to give them, into that of mere pal- 
liatives of some of the symptoms. Naphtha and common salt have been more 
recently recommended, but with even less success. Sulphurous baths, and the 
use of sulphurous waters internally, have been supposed to have a specific 
curative influence. Alcoholic lotions to the chest are said by Dr. Marshall 
Hall to be among the most efficacious means of checking the deposition and 
softening of tubercles. (See Am. Journ. of Med. Sei., N. S., viii. 218.) Phos- 104 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[part II. 
phate of lime alone, or in combination with other phosphates, as those of soda, 
iron, &c., has been of late considerably used; but experience has not decided 
in its favour. Dr. Simpson, of Edinburgh, has suggested the external use 
of oil, on the ground that persons engaged in wool factories, whose skins are 
always greasy with the oil employed, are remarkably exempt from the disease. 
Compression of the chest, and even the operation of paracentesis, in order to 
induce collapse of the diseased lung, have been proposed, but are not likely 
to be adopted. 
3. Prophylactic Treatment.-It is of the utmost importance, in cases of a sup- 
posed tendency to consumption, to prevent the establishment of the diathesis. 
For this purpose, all those measures, already treated of as applicable to the 
prevention of tuberculous deposition, should be brought to bear upon the 
case. The great object should be to impart vigour of constitution. There 
is no greater mistake, though it is one often made by anxious parents, than 
to bring up a child with a consumptive tendency, in a peculiarly delicate 
manner, and to give him a trade or occupation which requires little exposure 
or bodily exertion. Exactly the opposite course should be pursued. The 
business of a farmer, carpenter, seaman, engineer, &c., is greatly preferable, 
for such a person, to one of the sedentary trades or professions. An infant 
should never be allowed to derive its nourishment from the breast of a con- 
sumptive or scrofulous nurse. The frequent use of the cold bath, and fric- 
tions to the surface, will often serve a useful purpose in giving strength; and 
are more applicable as prophylactics than remedies, because the system is 
more likely to react efficiently before than after the developement of the 
consumptive diathesis. But it should be remembered, in the use of the cold 
bath, that, unless followed by prompt reaction, it will be likely to do more 
harm than good. Above all things, in guarding against consumption, we 
should insist on the necessity of vigorous exercise in the open air. 
Miele VIII. 
VARIOUS ORGANIC AFFECTIONS OF THE LUNGS. 
The lungs are liable to various organic affections besides those already de- 
scribed. Their rarity, however, the obscurity of their diagnosis, and the total 
inefficacy of treatment, render any minute account of them unnecessary, in a 
treatise like the present. It is scarcely necessary to call attention to the oc- 
casional existence of tumours in the air-passages, which, if they ever occur in 
the interior of the lungs, can seldom be recognized with an approach to cer- 
tainty during life. Aneurisms of the great vessels within the chest, though 
they often very much interfere with the function of respiration, belong pro- 
perly to diseases of the circulatory apparatus. (See Aneurisms.) Foreign 
bodies, accidentally introduced through the larynx, sometimes lodge in the 
bronchia, and give rise to very serious symptoms, which, however, may all be 
referred to obstruction more or less complete of the air-passages, and to in- 
flammation of these passages, or of the substance of the lungs. Death may 
result very speedily from obstruction, in the course of a few days from in- 
flammation, or after months or years of suffering from cough, dyspnoea, pains 
in the chest, purulent expectoration, and hectic fever. Cases have occurred 
in which, after many years, the patient has coughed up the offending matter, 
and been restored to health. In some instances, the body is movable, and 
rises occasionally into the trachea or larynx, producing violent paroxysms of 
cough and dyspnoea. In such cases, there may be good hope of affording 
relief by the operation of tracheotomy. CLASS III.] 
105 
VARIOUS ORGANIC AFFECTIONS OF THE LUNGS. 
Calcareous, cartilaginous, and bony tumours are sometimes found in the 
lungs after death, chiefly in old persons, and most frequently in the upper 
portion of the organ. They are usually small, and during life seldom occasion 
symptoms which give rise to the suspicion of their existence. Occasionally, 
they may excite a little inflammation of the neighbouring pulmonary tissue, 
and they have been known to cause a slight dyspnoea by pressure on the 
bronchia. There is reason to suppose that, in some instances at least, they 
are the remains of tubercles which have undergone absorption. 
Serous cysts and hydatids have been observed in some very rare instances. 
The latter have been known to attain great magnitude, and to interfere much 
with the functions of the lungs. I have in my possession an hydatid cyst of 
enormous size, which projected from the upper surface of the liver high into 
the lungs, and was mistaken during life for pleuritic effusion. 
Malignant tumours occur in the lungs as elsewhere. Genuine schirrus is 
exceedingly rare; but the medullary or encephaloid disease is not very un- 
common, and melanosis is now and then observed. These affections exist 
either in the form of encysted or non-encysted tumours, or of infiltration into 
the pulmonary tissue. They appear sometimes to undergo the process of 
softening and partial discharge, thus giving rise to cavities of greater or less 
magnitude. But they are much less apt to run this particular course than 
tubercles. Being usually slow in their progress, they give rise at first to few 
prominent symptoms. A little cough and oppression in breathing are per- 
haps all that attract attention. These increase, and are after a time attended 
with pains more or less severe, and at length with constitutional symptoms, 
such as a frequent pulse, emaciation, the sallow complexion of cancerous dis- 
ease, and dropsical effusion. There is, however, usually, less fever than in 
phthisis. Haemoptysis is not unfrequent. The breath in the advanced stage 
is often fetid; and, in the cases in which softening occurs, the morbid mat- 
ter is sometimes visible in the puruloid expectoration, which, in the medul- 
lary cancer, may be streaked with red and white, and in melanosis may be 
occasionally black. The signs afforded by percussion and auscultation are 
such as indicate consolidation of the lungs, and sometimes those of a cavity. 
The diagnosis between these affections and phthisis is often only probable. 
The constant flatness on percussion over the affected part, the total absence 
of the healthy respiratory murmur, and the tubal or tracheal respiration, with- 
out rales, are mentioned by Valleix among the diagnostic characters. The 
occurrence of external tumefaction and hardness of the areolar tissue on the 
chest, neck, or arm, connected with the above signs, would tend to confirm 
the diagnosis. It would indicate the probable coagulation of the blood in one 
or more of the great venous trunks, consequent upon the cancerous disease. 
A case of this kind occurred to me, in which the whole upper portion of the 
chest and the right arm were enormously swollen and hardened, presenting 
characters not unlike those of phlegmasia dolens. Sometimes the tumour 
presses on the blood-vessels, respiratory passages, or oesophagus, producing 
various derangements such as are not occasioned by pulmonary tubercle. In 
cases of cancerous infiltration of the lung, this organ is usually contracted, 
and the side of the chest is flattened, with slight depression of the intercostal 
spaces. But the most certain evidence of the disease is afforded by the ex- 
istence of a corresponding affection in other parts of the body. When pec- 
toral symptoms of a consumptive character supervene upon external cancer 
or melanosis, there is reason to suspect that the same disease exists in the 
lungs; and the suspicion would be strengthened, should the breath be fetid, 
and the patient wear away with comparatively little fever. The treatment is 
purely palliative, and confined chiefly to the use of narcotics. 106 
LOCAL DISEASES..-RESPIRATORY SYSTEM. 
[PART II. 
An affection denominated spurious melanosis has been described by recent 
English writers, as occurring in persons long confined to a smoky atmosphere, 
or to one loaded with coal dust. A black carbonaceous matter, wholly dis- 
tinct in nature from the black matter of true melanosis, is found dispersed 
through the substance of the lungs. The patients exhibit during life the 
ordinary symptoms of pulmonary disease, with the expectoration of a black 
matter, by which the affection is characterized. After death, the lungs are 
found to be variously disorganized, exhibiting in some parts black hepatiza- 
tion, in others cavities containing an inky black fluid, and in others again an 
edematous condition with a serous fluid, which is also black. Even the 
sound parts of the lungs may present the same black colour. There seems 
to be no doubt that this is owing to carbonaceous matter derived from without, 
which, finding an entrance into the substance of the lungs, resists absorption 
on account of its insolubility, and remains unless discharged by the disor- 
ganization of the pulmonary tissue. The question is, how the black matter 
makes its way into this tissue. The most probable explanation is, that it 
enters through lesions already existing, and that the disorganization is less 
the effect of the carbonaceous matter than of previous organic disease. It is 
possible that, once admitted, it may act as an irritant, and extend the inflam- 
matory and ulcerative processes. The matter is capable of penetrating the 
epithelial cells, for it has been observed between their walls and the con- 
tained nuclei, by examination under the microscope. (Ed. Month. Journ. of 
Med. Sei., Sept. 1851, p. 265.) The most important point in the treatment 
is to remove the patient into a better atmosphere. In a pure air, the symp- 
toms are ameliorated; and, if not affected with an incurable organic lesion, 
independently of the foreign matter, the patient may possibly recover. 
The bronchial glands not unfrequently become diseased, being sometimes 
merely enlarged by chronic inflammation, sometimes loaded with tubercu- 
lous deposit, and sometimes again affected with medullary, melanotic, or 
other malignant degeneration. Of these conditions, the tuberculous, which 
is the most common, is elsewhere specially treated of. The symptoms pro- 
duced by the enlargement of these glands, are chiefly such as result from 
pressure on the bronchial tubes and great blood-vessels. Its existence may 
be suspected when, in connexion with such symptoms, there is dulness on 
percussion at the top of the sternum, without the characteristic signs of aneu- 
Yismal tumours, and especially when the cervical or axillary glands are swol- 
len. The nature of the affection must be inferred from the character of dis- 
ease existing elsewhere, and the state of the constitution. When the com- 
plaint is not tuberculous or malignant, good effects may be expected from 
local depletion, revulsion by blisters, &c., and the general and local use of 
iodine or mercury. 
SUBSECTION IV. 
FUNCTIONAL DISEASE OF THE PULMONARY TISSUE. 
Article L 
LOSS OF BREATH, APNGEA, or ASPHYXIA, 
A suspension of the respiratory process is usually designated by the very 
inappropriate name of asphyxia, which literally signifies want of pulse. I CLASS III.] 
APNCEA, OR ASPHYXIA. 
107 
prefer the term apnoea, employed by Dr. Watson, as at least equally eupho- 
nious, and of an origin corresponding with its application. 
The real pathological condition, in this affection, is a retardation or stop- 
page of the circulation through the pulmonary capillaries. The blood, arrested 
in the lungs, ceases to reach the heart in quantities sufficient to support the 
actions of that organ, and the phenomena of life are suspended. In order that 
the blood may pass from the pulmonary arteries into the pulmonary veins, it 
must change from venous to arterial. The capillaries will not convey black 
or unarterialized blood in quantities sufficient to maintain the contractions of 
the heart. Why this is so must be left to the physiologist to determine. The 
fact has been sufficiently established by the experiments of Drs. Williams 
and Ray. Any cause, therefore, which prevents the arterialization of the 
blood, will arrest the pulmonary circulation, and give rise to the phenomena 
of apnoea or asphyxia. It is not at all impossible, that there may also be a 
condition of the pulmonary capillaries themselves, altogether independent of 
this change of the blood, which may disable them from performing their func- 
tions duly. Such a condition is often observed in the external capillaries. 
When these approach to a loss of their vitality, or quite lose it, the blood 
flows through them more slowly, or ceases to flow altogether. The pulmo- 
nary capillaries may in like manner become as it were palsied, and no longer 
contribute their share towards the conveyance of the blood. But we are too 
little acquainted with the nature or causes of this possible disease of the pul- 
monary capillaries to make it a subject of discussion. So far as the actions 
of these vessels can be positively traced, they cease to convey the blood be- 
cause this is not duly changed. 
The consequences of this diminution or cessation of the circulation in the 
pulmonary capillaries are of two kinds. In the first place, the blood reaches 
the left cavities of the heart in gradually decreasing quantities, until it be- 
comes insufficient to stimulate them to contraction; and we have all the results 
of a failure of the general circulation. Secondly, as there is a necessary accu- 
mulation of blood behind the place of obstruction, congestion takes place in 
the pulmonary arteries, the right cavities of the heart, the great venous trunks, 
and the larger viscera, as the brain, liver, spleen, stomach, and intestines; 
and the phenomena of venous engorgement are everywhere exhibited. With 
these two sets of morbid effects, a third is often more or less mingled, arising 
not directly from the suspension of the pulmonary circulation, but from the 
unchanged or insufficiently changed venous blood, which finds its way, though 
in gradually diminishing quantities, into the heart, and thence into the arte- 
rial system generally. It is highly probable that the presence of this bad 
blood in the nutritive vessels of the heart itself may tend to impair its pow- 
ers; and some of the cerebral phenomena may depend upon the same injuri- 
ous influence in the vessels of the brain. 
In tracing the chain of morbid actions from the incipient link in the capil- 
lary vessels, we come next to the encephalon. The nervous centres suffer 
both from a deficient supply of arterial blood, consequent upon the dimin- 
ished action of the left ventricle, and from venous congestion. They become, 
therefore, incapable of performing their functions, whether in the reception of 
impressions, or the transmission of nervous influence. The sensation of 
breathlessness, at first painfully excited by the failure of the proper respira- 
tory function, ceases to be felt; and the muscles of respiration, at first often 
tumultuously agitated by the stimulus from the troubled brain, now become 
powerless from an utter want of that stimulus. The patient, therefore, ceases 
to make any respiratory effort; and the original failure in the capillary cir- 
culation of the lungs, if before only partial, now becomes complete. The 108 
[part II. 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
heart no longer receives the partial supply of blood, which, for a time, sus- 
tained its decreasing actions, and ceases to beat altogether. It is probable 
that this loss of motion in the heart depends upon the want of blood in its 
own peculiar arteries, quite as much as upon the same deficiency in its left 
cavities; for both sides of the heart cease to act simultaneously, though the 
right cavities are filled with blood. It has been supposed that the distension 
of the right cavities might be the cause of their suspended motion, by para- 
lyzing the muscular fibres; but if this were the sole cause, the opposite sides 
of the heart would scarcely stop at the same moment. The influence under 
which the whole organ becomes quiescent at once, must affect the whole of it 
equally; and such an influence can be exerted, so far as the supply of blood 
is concerned, only through the coronary arteries. It appears, then, that the 
heart is the last organ to die, in true and uncomplicated apnoea. Observation 
has proved that this organ even retains its contractility for a considerable time 
after its motions have ceased, and will resume its actions if the necessary 
stimulus be afforded. 
But there are many cases of apnoea in which the starting point of the dis- 
ease is in the nervous centre of respiration, or in the conductors by which that 
centre communicates with the organs which it controls. The affection, in such 
cases, is obviously complicated. The precise mode in which cerebral disease, 
involving the medulla oblongata, which is the centre of respiration, gives rise 
to the phenomena of asphyxia, has not been absolutely determined in all in- 
stances. There can be no doubt that it often acts by paralyzing the muscles 
of respiration, so as to render the expansion of the chest, and consequently 
the entrance of fresh air into the lungs impossible; and some maintain that 
this is the only mode in which it can act. But we occasionally meet with 
cases, in which, though the muscular movements of respiration are fully per- 
formed, and air is admitted freely into the lungs, symptoms closely analogous 
to those of apnoea are exhibited, apparently dependent on a want of nervous 
power. This condition of things is sometimes presented in pernicious fevers, 
and other diseases characterized by great nervous prostration. It is not at 
all improbable that, in such cases, the pulmonary capillaries cease to convey 
the blood in consequence of some modification of their nervous condition not 
well understood; and it is possible that a similar modification, with similar 
results, may sometimes arise from the causes which tend to weaken or paralyze 
the muscles; so that the two influences may be exerted conjointly, and with 
a greater effect than would flow from either alone. 
Symptoms.-These vary essentially according to the state of the nervous 
centre, or that of the nerves connecting it with the respiratory apparatus. 
When these are not primarily involved, the most prominent symptom is at 
first a distressing sense of the want of breath, consequent upon the presence 
of unchanged venous blood in the capillaries of the lungs, and probably also, 
in some degree, of an insufficient supply of blood to the capillaries of the 
system generally. This sensation, which is the provision of nature for calling 
from the nervous centres a supply of energy to the respiratory movements, 
adequate to the increased wants of the system, becomes in the present in- 
stance, the source of greatly increased efforts, both voluntary and involuntary, 
for the supply of air to the lungs. Along, therefore, with great anxiety of 
countenance, and an intense expression of distress, there is quick and violent 
movement of all the muscles of respiration capable of action. The chest 
heaves, the shoulders are elevated, the alse nasi are dilated, and the patient, 
panting or gasping for breath, throws himself about convulsively, or seizes 
with a spasmodic grasp upon objects in his neighbourhood. But, when the 
affection is severe and acute, these symptoms do not last long. The brain CLASS III.] 
APNOEA, OK ASPHYXIA. 
109 
soon becomes involved, and a feeling of vertigo is speedily followed by stupor 
and insensibility, not unfrequently attended with convulsions. Respiration 
now ceases to be in any degree under the influence of the will, and the move- 
ments which continue are involuntary and irregular. At the same time, signs 
of venous accumulation are presented in the livid hue of the face, the dark- 
purple colour of the lips, the distended veins, and the prominent eyes. In- 
voluntary discharges take place from relaxation of the sphincters. The pulse 
gradually becomes weaker, but is still distinct. The involuntary movements 
of respiration now cease, and the patient breathes no more. The whole sur- 
face of the body exhibits a somewhat livid paleness, the feet and hands are 
purple, and purple patches are often seen on various parts of the body. At 
last, the pulse ceases at the wrist, though the heart continues to beat feebly 
for a short time after all external signs of life have ceased. Nor, even when 
this ceases to pulsate, is death absolute. Vitality still lingers for an uncer- 
tain period, prepared to respond to efforts of resuscitation; and a restoration 
of the respiratory process by artificial means has often revived the patient, 
when not a vital movement in any portion of the body could be detected. 
The degree to which the pulmonary circulation is suspended has a great 
influence over the phenomena. If the suspension is complete, the struggle 
is very speedily over; and sometimes the impression upon the brain is so 
quickly produced, that the patient experiences scarcely any suffering. Respi- 
ration, under such circumstances, usually ceases in a period varying from 
somewhat less than two to five minutes, and the circulation in about ten 
minutes; but there is in this respect much difference in individuals, and 
habit has a great influence. Divers in the pearl fishery, for example, can do 
without air much longer than others not accustomed to remain under water. 
When the obstruction to the pulmonary circulation is only partial, the suffer- 
ing is more or less protracted; and the patient may be tortured with ex- 
cessive dyspnoea for days or weeks, nay even for months, before sinking into 
complete apnoea. This is, indeed, among the most painful symptoms of vari- 
ous diseases which impede the due aeration of the blood. The sensation of 
want of breath is, in such cases, not unfrequently referred to the praecordia, 
when the real cause exists at some very distant point. In these protracted 
cases, death often results as much from a gradual failure of all parts of the 
system, under a deficient supply of imperfectly arterialized blood, as from the 
direct influence of suspended respiration. 
When the cause of the pulmonary affection resides in the nervous centre, 
or in the nerves of respiration, the symptoms may be in some respects very 
different from those above enumerated. Insensibility of the medulla oblon- 
gata, or imperfection in the afferent nerves, prevents the perception of the 
want of respiration, which is the essential stimulus to this function; and the 
individual ceases to breathe, without previous suffering, and of course with- 
out those struggles for breath which usually precede death from apnoea. 
Should the imperfection exist only in the afferent nerves, the brain and effer- 
ent nerves remaining sound, respiration might be sup^prted for a time under 
the suggestion of the intellect, and by the effort of the will, but it would 
be immediately interrupted by sleep. Practically, however, we seldom or 
never meet with such a case. When the defect is in the efferent nerves, or 
in any portion of the conducting medium between the nervous centre and the 
organs of respiration, as in the spinal marrow above the origin of the phrenic 
nerve, the brain and medulla oblongata remaining sound, the patient will 
experience all the distress of a want of breath incident to ordinary apnoea, 
but will be unable to exhibit it in muscular efforts, because the muscles them- 
selves are paralyzed. 
After recovery from apnoea of any considerable duration, and in the pro- 110 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[part II. 
gress of partial apnoea, the patient is apt to suffer from inflammation of the 
lungs, resulting from the congestion of the pulmonary arteries and their 
ramifications. Similar affections may be experienced in the brain, liver, 
kidneys, and bowels, arising from the venous engorgement of these organs. 
The obstruction of the pulmonary circulation endangers also hypertrophy and 
dilatation of the right ventricle of the heart; and the same cause may give 
rise to dropsical effusion in all parts of the body. Apnoea, therefore, when 
incomplete and long continued, is anything but an uncomplicated disease. 
Appearances after Death.--The livid appearance of the skin, occurring be- 
fore the extinction of life, continues in the dead body; and the purple spots 
are found to depend upon vascular congestion, sometimes connected with 
extravasation of blood. The right cavities of the heart are distended with 
black blood, as are also the pulmonary arteries, the great venous trunks, and 
the vessels of the larger viscera, as the brain, liver, spleen, and intestines. 
Indeed, the whole venous system is more or less congested. At the same 
time, the left cavities of the heart, the pulmonary veins, and the arteries 
generally are nearly or quite empty. When death has been sudden, the blood 
is generally either quite fluid, or but imperfectly coagulated. This tendency 
of the blood to remain fluid, in suspended animation from apnoea, is highly 
important in a therapeutical point of view ; as coagulation of this fluid would 
render all attempts to restore the vital actions fruitless. 
Causes.-The causes of apnoea are very numerous. Independently of 
those which primarily operate upon the aeration and consequent movement 
of the blood, there is a great number of diseases, especially of the brain and 
respiratory organs, in which death is finally accomplished in the capillaries 
of the lungs, after a series of morbid actions elsewhere. All the well known 
causes may be ranked under the heads of 1. those which primarily operate 
by suspending the movements of respiration; 2. those which prevent the 
access of air to the vesicles of the lungs, without directly affecting the respi- 
ratory muscles; and 3. those, through the agency of which, though air may 
reach the ventricles, it is admitted in such a state as to be unfit for the arteri- 
alization of the blood. To these might be added a fourth set, those, namely, 
which render the capillaries incapable of performing their office in the trans- 
mission of blood, even though air of the proper kind may be freely admitted; 
but we know too little of these causes to render it worth while to discuss 
them. It will be perceived that, of the three sets above mentioned, all have 
the effect of preventing the requisite change in the blood. 
1. Of the causes which suspend the respiratory movements, the most fre- 
quent is a paralytic condition of the muscles concerned. This may arise 
from congestion, effusion, inflammation, or disorganization in the brain, in- 
volving the medulla oblongata primarily or secondarily; from similar disease, 
or from mechanical injury of the spinal marrow above the origin of the phre- 
nic nerve, as in dislocation of the neck, by hanging; from the same affections 
of the spine below the origin of the phrenic nerve, but above that of the 
intercostals, in which case, though respiration may continue for some time, 
it is effected imperfectly, and at length ceases; from division or disorganiza- 
tion, in various degrees, of the afferent nerves on both sides; and, finally, 
from the operation of extreme cold, and of numerous narcotic poisons, which 
render the nervous centres insensible to the impressions sent up to them 
from the lungs, and incapable of transmitting the necessary influence to the 
muscles, through the nerves of motion. 
Under this head must also be ranked a continued spasmodic constriction 
of the muscles of respiration, such as sometimes occurs in tetanus, and is 
said also to result from nux vpmica in poisonous doses. 
Mechanical compression may have the same effect, as when the body, with CLASS III.] 
APNCEA, OR ASPHYXIA. 
111 
the exception of the head, is buried by the falling of loose earth about it, or 
as in the case of the pugilist, recorded by Dr. Roget {Cyc. of Pract. Med., 
art. Asphyxia), whose chest, in consequence of an attempt to take a plaster- 
cast of his body in one piece, was so much compressed by the setting of the 
plaster as completely to prevent the action of the muscles of respiration, and 
to occasion imminent danger of death, which was the greater as he was pre- 
vented from speaking, and could not give warning to those about him. His 
situation, however, was fortunately perceived in time to save his life, by break- 
ing the case which was forming around him. 
2. The causes which act by directly preventing the access of air are very 
numerous. Under this head may be ranked smothering by the closure of 
the mouth and nostrils, as in the notorious process of burking, or in the acci- 
dent of being buried in falling earth; submersion either of the whole body, 
as in drowning, or of the face alone, as sometimes happens to the infant at 
birth in the maternal discharges, and to drunkards in a puddle; and strangu- 
lation, whether by means of a cord around the neck, as in hanging, the 
application of the bow-string, &c., or by solid bodies in the larynx, pharynx, 
or oesophagus, mechanically closing the air-passage, or producing the same 
effect by causing spasm of the glottis. 
Similar effects often result from disease. Thus, excrescences in the 
larynx, closure of the rima glottidis by inflammatory swelling or spasm, 
palsy of the dilating muscles of the glottis, and tumours pressing upon the 
air-passages from without, as bronchocele, aneurisms, &c., may all produce 
suffocation by excluding the air. Accumulations in the bronchial tubes, 
whether solid or liquid, such as the false membranes of inflammation, blood 
from haemoptysis or the bursting of aneurisms, and mucus or pus in chronic 
bronchitis, the last stages of phthisis, and other pectoral affections in which 
the secretion exceeds the ability to discharge it, all act in the same way. The 
obstruction may also exist in the air-cells or extravesicular tissue, as in ex- 
tensive inflammatory hepatization, tuberculous deposit, apoplectic congestion 
of the lungs, or pulmonary oedema. Finally, air is equally excluded from 
the lungs by pressure on their exterior surface, as by serous, purulent, or 
aeriform collections in the pleural cavities, by the ascent of the abdominal 
contents through a rupture in the diaphragm, by the free admission of air 
into the chest through large wounds in both sides, or even by enormous tym- 
panitic distension of the abdomen. 
3. The third set of causes are those which affect the air respired. As 
oxygen is the agent essential to the arterialization of the blood, and as the 
escape of carbonic acid from that fluid is equally essential to the same result, 
it follows that whatever excludes oxygen, or causes the retention of carbonic 
acid, must produce apnoea. The atmospheric air may be so much rarefied as 
to supply an insufficient quantity of oxygen; and it is possible that suffoca- 
tion in the vicinity of great fires may arise partly from this cause, in connex- 
ion with the inhalation of the results of combustion. At very great heights, 
the air is so rarefied as often very much to affect respiration; but no eleva- 
tion has yet been attained, at which fatal apnoea would result from this 
cause alone. Nitrogen and hydrogen gases appear to have no direct noxious 
properties, and may be inhaled for a short time with impunity. They allow 
of the escape of carbonic acid from the blood, but, not containing oxygen, 
they are insufficient to support life, and an animal soon dies of pure apnoea, 
which is confined in them. These gases are, however, almost never a real 
source of danger to life, because they are nowhere collected in large quanti- 
ties in nature, and, when artificially produced, are so confined as scarcely to 
admit of being breathed injuriously unless on purpose. The inhalation of 
carbonic acid is a frequent cause of death from apnoea. Difference of opinion 112 
[PART II. 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
has existed as to the action of this gas, some considering it as operating by 
the mere exclusion of atmospheric oxygen, others ascribing its results to a 
positively poisonous influence. That the former opinion is not correct is 
proved by the fact, that air containing the usual proportion of oxygen, but 
in which the place of the nitrogen has been supplied by carbonic acid, cannot 
be breathed with impunity. The latter opinion would seem scarcely more 
tenable, when we reflect that carbonic acid is constantly present as a natural 
result in the blood, and in the air of the lungs. The probability appears to 
be, that it acts by opposing an obstacle, according to a well known physical 
law, to the escape of carbonic acid from the blood of the pulmonary arteries, 
and consequently to the absorption of oxygen. Thus the blood not only re- 
ceives no oxygen, but retains its carbonaceous principles, and consequently 
either ceases to pass through the capillaries, or goes loaded with these prin- 
ciples to the heart and to the brain. Hence, the effects of the inhalation of 
carbonic acid are more rapid than those of hydrogen or nitrogen, which, 
though they furnish no oxygen, do not oppose a physical obstacle to the 
escape of the carbonic acid of the blood, and allow of the absorption of the 
little oxygen that may have previously existed in the bronchial tubes. It 
would appear, therefore, that carbonic acid is not itself positively poisonous, 
like certain other gases, but merely affords by its presence a physical impedi- 
ment to the changes necessary for the support of respiration. But even the 
poisonous gases, such as carburetted hydrogen, carbonic oxide, and hydrosul- 
phuric acid, act partly, and when breathed in a concentrated state, probably 
in chief, by producing apnoea. The inhalation of chloroform has of late been 
a frequent source of fatal apnoea. It probably acts, in general, by directly 
depressing the nervous centre of respiration, and thus suspending the func- 
tion ; but there is reason to believe that it has sometimes proved fatal by the 
mere exclusion of the atmospheric air, to the consequences of which the 
patient is rendered insensible by its ansesthetic operation. The highly irri- 
tant or corrosive gases, such as chlorine, muriatic acid gas, &c., scarcely ever 
enter the lungs sufficiently to occasion this affection directly. Their fatal 
effects are owing to inflammation of the respiratory passages. 
Of the above causes, many are themselves diseases, and as such are suffi- 
ciently treated of elsewhere in this work. But there are a few which merit 
particular notice here, as prominent agents in the production of apnoea, and 
interesting, in a medical point of view, chiefly on that account. Such are 
drowning, strangulation, and extreme cold. 
Drowning.-A person falling into the water usually sinks, chiefly in con- 
sequence of the impulse of the fall, but partly, also, perhaps, from a dimi- 
nished specific gravity, resulting from the collapse of fear, and the refrigerating 
effect of the new medium. In a short time, he generally rises again to the 
surface, aided by his partly voluntary and partly convulsive movements; but, 
unless able to swim, he speedily sinks again; and this alternation of sinking and 
rising is, in some instances, repeated several times before the last struggle is 
over. As the specific gravity of the body is, in general, slightly above that 
of water, it usually remains after death beneath the surface, until rendered 
lighter by the gases generated by decomposition. During the efforts at inspi- 
ration, water sometimes enters the bronchial tubes; but the probability is, 
that, while life continues, this cannot happen to any considerable extent, in 
consequence of the spasmodic closure of the rima glottidis upon the contact 
of the liquid. After death, it occasionally finds its way into the lungs in 
considerable quantities, so as to fill the bronchia to their ultimate ramifica- 
tions. Water is also sometimes swallowed largely, probably during the con- 
vulsive but vain respiratory efforts. 
Death from submersion has been referred to apoplexy; but it is surely un- CLASS III.] 
113 
APNOEA, OR ASPHYXIA. 
philosophical to ascribe a result, so easily accounted for upon other principles, 
to a cause, which, occurring under different circumstances, is seldom immedi- 
ately fatal. That cerebral congestion should be observed after death, is what 
might be expected from our knowledge of the pathology of apnoea; and, when 
hemorrhagic effusion has been discovered, it has probably been the result of 
previous apoplexy, which may have led to the accident, or of some violent 
injury of the head, antecedent to or consequent upon the fall. Another con- 
jecture has made death the result of water in the lungs; but experiment has 
abundantly shown, that the amount of water which usually enters the bron- 
chial tubes of drowning persons is altogether insufficient to destroy life. It 
is quite unnecessary to search for any other cause of death, in ordinary cases, 
than the mere exclusion of atmospheric air. It has been plausibly supposed 
that, in some instances, syncope or fainting may take place, either from alarm, 
or the physical shock of the accident upon the nervous system; and attempts 
have been made, upon this principle, to account for certain peculiarities in the 
appearances after death, and in the results of treatment. 
There is often about the mouth and nostrils of the drowned more or less 
frothy mucus, which is sometimes stained with blood. The same appearances are 
observed, upon dissection, on the surface of the air-passages; and some water 
in a frothy state is notunfrequently found in the bronchia. In most instances, 
the right cavities of the heart, the large veins, and the great viscera, including 
the brain, are gorged with venous blood; while the left ventricle contains 
comparatively little. Sometimes, however, the brain and all parts of the body 
are found in a normal state, without any marks of congestion; as if the cord 
of life had been suddenly snapped, before the healthy course of the blood had 
become perverted. These are the cases in which syncope is supposed to have 
occurred immediately before, or at the moment of submersion. 
It is an important question, how long the body may remain under water 
before life becomes wholly extinct, and resuscitation impossible. If recovered 
within five minutes, there is every reason to hope that, though external signs 
of life may have disappeared, the patient may be saved; and there is no 
reason to despair of a favourable issue, though ten, fifteen, or even twenty 
minutes may have elapsed from the time of submersion. Resuscitation very 
seldom takes place after half an hour. The longest period in the records of 
the Humane Society of London, is three quarters of an hour; and, out of 
twenty-three cases of recovery reported by the similar establishment at Paris, 
the patient had in one been under water three quarters of an hour, in four 
half an hour, and in three fifteen minutes. It is true that accounts are on 
record of recoveries after hours of submersion; but no one at present attaches 
any faith to them. In those well-authenticated cases of recovery in which 
the period of apparent death has been protracted much beyond the usual time, 
it has been supposed that the patient might have been affected with syncope 
at the moment of submersion; as, in this condition, the system does not re- 
quire the support of the respiratory process, and the vital susceptibilities may 
linger for a longer time than when impaired by the poisonous influence of the 
misplaced venous blood. 
Strangulation.-Allusion is here had to strangulation by means of a cord 
about the neck. This may be effected either without suspension or with it, 
and the results are somewhat modified accordingly. In both cases, death 
generally depends upon the exclusion of air, consequent upon a closure of 
the trachea. It has been ascribed to apoplexy, produced by pressure upon 
the jugular veins, and the prevention of a return of the blood from the head. 
There is, no doubt, great congestion of the cerebral veins and sinuses, and, in 
some instances, probably apoplectic effusion. But death from this cause is 114 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[PART II. 
much slower than is usually the case in strangulation; and, if it ever happen, 
it must be in cases in which the entrance into the lungs is not entirely closed. 
This occasionally occurs in consequence of ossification of the larynx, or an inac- 
curate adjustment of the cord, and the fatal event maybe in this way consider- 
ably protracted, if not averted altogether. An instance is on record in which 
a female, after hanging all night, was found still living in the morning, owing 
to the ossification of the larynx; and another, in which a man, in whom the 
trachea had been opened, and a tube inserted previously to hanging, though he 
became insensible, was restored to a brief animation, after having been taken 
down from the gallows. The inference is, that though, when the closure of 
the air passages is incomplete, death may result from apoplectic congestion or 
effusion; yet, in ordinary cases, it scarcely even contributes to the result. 
When strangulation is effected by hanging, in the ordinary mode in which 
criminals are executed, the weight of the body in falling sometimes occasions 
dislocation of the vertebrae, and death may then ensue immediately from in- 
jury of the spinal marrow, above the origins of the phrenic nerve. This also 
happens in other forms of strangulation adopted as a mode of execution, in 
which a sudden twisting of the neck is effected along with the closure of the 
trachea. 
The time, therefore, which elapses before death in hanging varies accord- 
ing to circumstances; and the phenomena of course also vary. When the 
neck is broken, death is almost immediate, and probably without the least 
suffering. When the closure of the trachea is complete, without dislocation 
of the cervical vertebrae, there is a brief feeling of suffocation, and a struggle 
for breath; but very soon the brain becomes insensible to pain, and the con- 
vulsive movements which take place are involuntary, and wholly without con- 
sciousness. When the closure is incomplete, as when the cord passes above 
the larynx, and over the angles of the jaw, consciousness and suffering con- 
tinue for a shorter or longer period; but, even in this case, insensibility and 
death ultimately ensue, either from pressure upon the brain, from the imper- 
fect admission of air, or from the two causes conjoined. It is a singular fact, 
that, in cases of strangulation by suspension, there is very often a turgescence 
of the genital organs, with erection of the penis, and even seminal discharge. 
This has been variously explained, but not quite satisfactorily. Perhaps it 
may be connected with disturbance of the spinal cord. The face is swollen 
and livid, the eyes open and prominent, the conjunctiva injected, and the 
tongue often projected from the mouth, from which also a bloody mucus occa- 
sionally issues. For the appearances after death, the reader is referred to 
works on medical jurisprudence. It may be mentioned here, that a mark pro- 
duced by the cord around the neck is always visible.* 
Extreme Cold.-The first effect of severe cold, applied generally to the 
body, is extremely painful, owing to the impression made upon the extremi- 
ties of the nerves. Should the cause, however, continue to operate after the 
tendency in the system to react has been overcome, the patient becomes sen- 
sible of a benumbing effect, and gradually evinces in his feelings and move- 
ments the signs of cerebral depression. If walking, his steps become uncer- 
tain and tottering, his utterance indistinct, and a drowsiness which he is 
unable to resist steals upon him, and gradually increases into deep sleep and 
entire insensibility, from which it is impossible to arouse him. Death now 
speedily follows. Different views have been taken of the pathology of the 
* A case is recorded in the Dublin Quarterly Journal of Medical Science (Aug. 1854, 
p. 86), in which this mark was so slight that, unless sought for, it might readily have 
escaped notice; and no disturbance of the subcutaneous tissue could be discovered upon 
dissection of the part. (Note to the fourth edition.] CLASS III.] 
115 
APNCEA, OR ASPHYXIA. 
case. The fatal result has been ascribed to paralysis of the respiratory 
muscles from the direct influence of cold; but this view does not account for 
the cerebral phenomena. Some have supposed that the heart first feels, the 
fatal influence, and that the patient dies of syncope. But this does not cor- 
respond with the appearances after death, which are those usually found in 
apnoea. The probability is, that the benumbing influence, which is first ex- 
perienced in the extreme nerves, gradually extends to the nervous centres, 
which are thus incapacitated for the performance of their functions, and respi- 
ration consequently ceases. After death the right cavities of the heart, the 
large venous trunks, and the great viscera, including the brain, are gorged 
with black blood; but no apoplectic effusion is observed. Resuscitation has 
been effected in these cases after all the phenomena of life had ceased. 
Treatment.-1The first object, in the treatment of apnoea, is to remove the 
cause, and, if this be obscure, the most careful examination should be directed 
to its discovery. This rule is equally applicable, whether the cause be ex- 
traneous to the system, or consist in some diseased state of the respiratory 
organs, or other part of the'body. Life not unfrequently depends upon prompt 
obedience to this precept; and hence the importance of studying carefully all 
the possible causes of the affection, so as to be prepared for any emergency. 
When the appearances of life have not ceased, the removal of the cause will 
often be the only remedial measure required. In suspended animation, the- 
following measures may be employed, as a general rule. 
The body should be stripped of clothing, wrapped in a warm blanket, and 
placed in bed in a well-aired apartment, with the head and shoulders some- 
what elevated. As the suspension of respiration is the important pathologi- 
cal condition, efforts should be immediately made to restore this function, and 
it is of the utmost consequence that no time should be lost. The object may 
sometimes be accomplished by throwing cold water upon the face, or dashing 
it upon the shoulders, in cases in which the temperature of the surface has 
not already been reduced by the cause of the apnoea, as in freezing or drown- 
ing. The sudden impression of cold upon the surface is a powerful stimulus 
to the respiratory process. Any one may become sensible of this, by observ- 
ing that the effect of cold water, sprinkled upon his own face, is to induce 
immediately an involuntary gasping inspiration. When the nervous centre 
yet retains susceptibility, this slight remedy is sometimes alone sufficient to 
rouse it into action, and to cause a transmission of the requisite motor influ- 
ence to the muscles of respiration. The remedy is especially applicable, 
when the insensibility has been produced by a sedative poison, such as hy- 
drocyanic acid, or one of the irrespirable gases, as carbonic acid gas, or the 
vapours of chloroform. For a similar purpose, powerful irritants may be ap- 
plied carefully to the nostrils. One of the most efficient of these is the solu- 
tion or spirit of ammonia, which may be held near the nostrils, or applied, 
properly diluted, by means of a feather or camel's-hair pencil, to the Schneide- 
rian membrane. Caution, however, is necessary to avoid such a use of it as 
to provoke inflammation of the nasal or respiratory passages, upon the occur- 
rence of reaction. Serious consequences may readily ensue from imprudence 
in this respect. Perhaps the burning of a match under the nostrils, which 
has also been recommended, may be somewhat preferable on this account; as 
sulphurous acid gas is less corrosive than ammonia. It has been proposed to 
rouse the respiratory organs into activity by operating on the sensibility of 
the glottis, and for this purpose to introduce one or more fingers deep into the 
throat, so as to come into contact with the top of the larynx. This was done 
with success by Dr. Escallier in two cases of apnoea from chloroform. (A' Union 
Mid., A. D. 1849, No. 143.) 116 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
[PART II. 
But the all-important measure is artificial respiration. This should be 
resorted to in all cases of complete apnoea, and should never be delayed longer 
than may be necessary for the requisite preparation. The measures above 
mentioned may be employed in the interval. The most convenient instru- 
ment for the purpose is a pair of bellows. The nozzle may be inserted either 
directly into one nostril, or into the larger end of a smooth tube, the smaller 
end of which has been introduced into the nasal passage. A pair of bellows, 
furnished, like those of the Humane Societies, with a flexible tube and a 
smooth nose-piece, should be preferred if at hand. The instrument being 
properly adjusted, an assistant should carefully close the unoccupied nostril 
and the mouth with one hand, while with the other he gently presses the 
pomum adami of the larynx backward and downward so as to close the 
oesophagus. The operator is then to blow into the lungs at intervals, allow- 
ing free exit to the air, after each inflation, by removing pressure from the 
nose and mouth, and aiding the elasticity of the walls of the chest by moder- 
ate pressure with his extended hand upon the epigastrium. Natural breath- 
ing should be imitated as nearly as possible, both in relation to the quantity 
of air injected, and the frequency of the operation. At one time, it was 
thought best to expand the chest to its utmost dimensions, so as to cause the 
air to penetrate fully into the air-cells, and to displace the useless or injurious 
gases that might be contained in the chest. But such a procedure is hazard- 
ous, by endangering the rupture of the air-cells, and thus irreparably injuring 
the delicate pulmonary texture. Only so much, therefore, should be intro- 
duced as may cause a degree of dilatation of the chest as nearly as possible 
equal to that of healthy respiration; and the operation should be repeated 
about fifteen times a minute. The force employed should be as slight as is 
compatible with the end in view. 
Should no proper instrument be at hand, the operator should use his own 
lungs, applying his mouth to that of the patient, or, what is better, to one of 
the nostrils by means of a suitable pipe, taking great care not to injure the 
delicate mucous membrane by the hardness or roughness of the tube employed. 
Whatever avenue for the admission of air may be selected, the others should 
be closed, and gentle pressure should be made on the larynx in the manner 
already described. An objection has been urged to this mode of artificial respi- 
ration, on the ground that the air proceeding from the lungs of a living 
person has become unfit for use; but experience has shown that it is still suffi- 
ciently oxygenized to reanimate suspended respiration; and, in fact, chemical 
analysis has proved that each portion of air expired has undergone but little 
change. To obviate the objection, however, as far as practicable, the operator 
may take a deep breath two or three times before commencing the process of 
inflation, so as to have the air in the purest possible state. Advantages of 
the method are that the air introduced is of the proper temperature, and that 
there is less danger of injury to the lungs of the patient, as the operator's 
own powers of insufflation will afford the best measure of the capacity of re- 
sistance in the organs acted on. Another advantage is, that it can be applied 
immediately, as soon as the body is placed in a proper position, and the air- 
passages, when requisite, properly cleansed. It is peculiarly adapted to cases 
of infants, and has been employed, within the knowledge of the author, with 
the effect of restoring suspended life in a child, apparently dead from the 
effects of laudanum. 
It has been recommended, when instruments suitable for inflating the 
lungs cannot be obtained, to imitate respiration by means of the elasticity of 
the chest, by first making pressure around the thorax and upon the abdomen, 
so as to lessen the dimensions of the thoracic cavity, and thus expel a portion CLASS III.] 
APNCEA, OR ASPHYXIA. 
117 
of the air, and afterwards allowing the parts to expand again to their natural 
dimensions, so as to cause the entrance of fresh air. But this is a very in- 
sufficient substitute for artificial respiration, and can never be necessary; for, 
when there are hands for its performance, there is also a mouth for the much 
more effectual process of insufflation. 
In order to obviate the difficulty which is sometimes experienced of forcing 
the air beyond the glottis, it may be advisable to attempt the introduction of 
a catheter or other tube into the larynx, and through it to force air into the 
lungs by a pair of bellows or the mouth. Orfila recommends a tube eight or 
nine inches long, larger anteriorly than posteriorly, somewhat flattened to- 
wards its smaller end, so as to adapt it to the shape of the larynx, properly 
curved, and surrounded near the flexure with a piece of soft leather which 
may serve to close the upper opening of the glottis. As a last resort, should 
other means fail of introducing air into the lungs, tracheotomy should be per- 
formed, and artificial respiration sustained through a tube introduced into the 
opening. This, however, can be very seldom necessary, unless in the case of 
some positive obstruction existing in the larynx. 
A plan of effecting artificial respiration by galvanism has been proposed by 
M. Leroy d'Etioles, which consists in introducing a fine needle into each side 
between the eighth and ninth rib, a few lines deep, so as to touch the attach- 
ments of the diaphragm, and then connecting the needles with the opposite 
poles of a small galvanic battery. As soon as the diaphragm feels the influ- 
ence of the passing current, it contracts. The galvanic circuit is now to be 
interrupted so as to allow of relaxation; and afterwards to be renewed and 
interrupted alternately, so as to keep up a succession of contractions and re- 
laxations as in healthy breathing. The author of this process found it suc- 
cessful in animals, apparently dead from submersion. 
By whatever plan artificial respiration is effected, it should not be hastily 
abandoned if unsuccessful, though a perseverance of six hours, as recom- 
mended by Dr. Curry, can scarcely ever be requisite. An important caution 
is not to leave the patient too soon after resuscitation has been effected. This 
is especially necessary when the cause still continues to operate, as in insensi- 
bility from narcotic poisons. An instance is on record, in which, after appa- 
rent death from opium, and complete resuscitation by artificial respiration, 
the patient was nearly lost in consequence of being prematurely left. A re- 
lapse took place, from which, however, a reapplication of the same measure, 
and a perseverance in its use, fortunately rescued the patient, (dm. Journ. 
of Med. Sci., xx. 450.) In relation to the efficacy of artificial respiration, 
success may be expected from it, if the heart continue to contract in the least 
degree, though respiration and arterial pulsation may have ceased; nor is 
there reason to despair even when the heart no longer moves; for, as before 
stated, this organ often retains its contractility for a short time afterwards, 
and may respond to the stimulus of arterialized blood. 
In apnoea from sedative poisons, as chloroform, for example, the introduc- 
tion of nitrous oxide or the exhilarating gas into the lungs, would probably 
prove useful; and I would suggest to the surgeon who may deem it advisable 
to have recourse to the anaesthetic properties of chloroform in his operations, 
the propriety of being provided with a bag full of this gas, which might be 
forced into the lung, should respiration cease. 
But, while attempts are thus made to restore the action of the lungs, the 
nervous centres should be stimulated by impressions made upon the skin and 
other accessible parts. It is important that the surface should be kept warm, 
and for this purpose bottles or other vessels filled with warm water, heated 
bricks wrapped in flannel, or woollen cloth sufficiently heated, should be applied 118 
[part II. 
LOCAL DISEASES.-RESPIRATORY SYSTEM. 
about the body; but caution must be observed, that the substances employed 
be not so hot as to burn the skin; and a good rule is not to permit the tempe- 
rature to exceed 100° F. Gentle friction over the whole surface may also 
be used, either with the hand, a piece of flannel, or a soft brush ; but here 
again care is requisite not to injure the skin. Should the least sign of sensi- 
bility be evinced, rubefacients may also be resorted to, such as oil of turpen- 
tine, Cayenne pepper heated with brandy, and liniment of ammonia, with 
the same regard to the present want of susceptibility, and to future possible 
reaction, as in the case of the other remedies. Though the skin may not ex- 
hibit, during the collapse, the least sign of the action of heat, friction, and 
rubefacients, yet an impression is made by them, which, when sensibility and 
vital action are restored, may evince itself, if due caution be not observed, in 
violent inflammation, ulceration, and even sloughing. 
As the lower bowels often retain a degree of impressibility until the very 
last, it will generally be advisable to employ stimulating encmata, among 
which oil of turpentine, carbonate of ammonia in solution, the ethereal pre- 
parations, and brandy, are perhaps the most suitable. They are especially 
indicated when the cause of the affection is of a directly depressing nature, 
as in the case of certain narcotic poisons. It has even been proposed to in- 
troduce these stimulants into the stomach by means of a tube and syringe; 
and cases no doubt occur in which the measure might prove salutary. 
The powerful agency of electro-magnetism may also be resorted to. A 
current made to pass from the pit of the stomach to the back part of the head 
will sometimes rouse sensation, when life is almost extinct. 
It has been a practice with some to detract blood in cases of apnoea. This 
measure can be proper only in those instances in which, from the peculiar 
nature of the cause, there is unusual congestion in the brain; and even in 
these should be employed with great caution. The blood should be taken 
preferably from the jugular vein; as both the brain and the right side of the 
heart, which is also usually overloaded, are thus directly relieved. 
The danger is by no means always passed, in apnoea, when the vital actions 
have been restored. The brain not unfrequently evinces signs of disorder, 
arising from the previous congestion; and imperfect inflammation, and various 
functional derangement in the thoracic and abdominal viscera, are not uncom- 
mon from the same cause. The errors too of an irregular general reaction, 
sometimes excessive, and sometimes deficient, require careful watching. But, 
in the treatment of these affections, the physician must be guided by his 
general knowledge of disease; as the effects are too diversified and uncertain 
to admit of special therapeutic rules. The original cause has much influence 
in the production or modification of these secondary symptoms, and not un- 
frequently it continues to operate, in a greater or less degree, after the patient 
has been rescued from its more violent effects. 
A few remarks in relation to special measures, required in apnoea from 
certain peculiar causes, will be necessary to complete a view of the treatment. 
Drowning.-It has been a popular practice to suspend the body by the feet, 
immediately after removal from the water, in order to allow the liquid which 
may have been swallowed to run out by the mouth. It is scarcely necessary 
to state that this is an irrational practice, and can be productive only of injury, 
as it adds the influence of gravitation to the causes which have already over- 
loaded the veins and sinuses of the brain. 
The body should be immediately stripped of the wet clothing, then wiped 
perfectly dry, and wrapped in a blanket as already recommended. It is espe- 
cially important, in cases of drowning, to keep the surface duly warm; as 
much of the vital heat has been withdrawn from the body by the conducting 
power of the medium by which it has been surrounded. The mouth should CLASS III.] 
DISEASES OF THE HEART. 
119 
be carefully cleansed of the frothy mucosities, by means of the finger or the 
feathered part of a quill. Recourse should then be had to artificial respira- 
tion, and the other measures above indicated; and the efforts at restoration 
should not be relaxed for several hours. A remedy formerly much relied on, 
in the treatment of the drowned, was the injection of tobacco smoke into the 
rectum. This would seem, with our present notions about the sedative action 
of tobacco, to be clearly contraindicated; and, accordingly, most recent authors 
discard it altogether. But it should be recollected that the empyreumatic 
products of tobacco do not operate precisely in the same manner as that nar- 
cotic itself; and it is affirmed by Foder6 (JDict. des Scienc. Med., Art. Noyas'), 
that the proportion of the drowned who have been rescued since the abandon- 
ment of this measure has been considerably less than while it was in use. 
It has been stated before that considerable quantities of water sometimes 
penetrate into the bronchial tubes even down to their remotest ramifications. 
Now it is obvious that, in such cases, the beneficial operation of artificial respi- 
ration must be much impeded, if not altogether prevented; and it is highly 
important to rid the lungs of their burden. This maybe done in some degree 
by suction. When, therefore, the chest yields a dull sound upon percussion, 
and respiration does not appear to be satisfactorily performed, attempts may 
be made, by means of a catheter introduced into the larynx, and an air-tight 
syringe or the mouth applied to its outer extremity, to withdraw the liquid 
from the air-passages. It has even been proposed to effect the same object, by 
the same instruments, through an artificial opening in the trachea; and this 
might be justifiable as a last resort. 
Strangulation.-The only special measure requiring attention in this case 
is the abstraction of. blood. In consequence of the severe cerebral congestion 
which results, in most instances, from the mode in which the cause acts, it is 
more necessary in these than in ordinary cases of apnoea to unload the veins 
of the brain; and a moderate bleeding from the jugular would therefore ap- 
pear to be called for. 
Freezing.-Here the first object is to restore warmth, but yet to restore it 
very gradually. It has been found that, in cases of insensibility from cold, 
the sudden exposure of the body to an elevated temperature is certainly fatal. 
If reaction takes place, it is short and violent, and the patient soon dies, not 
unfrequently with delirium. In order to avoid this danger, the surface should 
be first rubbed with snow if at hand, which, though cold, is when near the 
melting point warmer than the frozen body; or the patient should be im- 
mersed in a bath of very cold water; and afterwards the applications made 
should be gradually less and less cold, until the temperature is at length raised 
to the natural standard. As soon as the muscles and other soft parts are suf- 
ficiently relaxed to admit of easy motion, artificial respiration, and the other 
means already enumerated as appropriate to apnoea in general, should be tried. 
SECTI0N4V. 
DISEASES OF THE CIRCULATORY SYSTEM. 
SUBSECTION I. 
DISEASES OF THE HEART. 
Disease of the heart was imperfectly understood until within a comparatively 
recent period. In its organic forms, it was thought to be very rare, and almost 
uniformly fatal. It was not generally recognized until in its advanced stage, 120 
[PART II. 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
when beyond the reach of remedies; and often it escaped recognition alto- 
getfier, being concealed by certain prominent morbid affections of which it was 
the cause, such as pulmonary congestion and hemorrhage, apoplexy, and 
different forms of dropsy. Cases formerly considered and treated as simple 
hydrothorax were very generally diseases of the heart. 
These affections are now known to be very frequent. They are supposed, 
taken in the aggregate, to be inferior only to phthisis in fatality. Though 
confined to no age, they are much more frequent late than early in life. They 
have been said to be in the old what pulmonary consumption is in the young. 
Out of more than five hundred dissections witnessed by Dr. Glendinning, about 
one-third presented signs of diseased heart; and the proportion of males was 
twice that of females. 
Though very dangerous, they are not so uniformly fatal as was at one time 
supposed. Treated in their early and forming stages, they are often effectu- 
ally cured; and, what is no less important, they may, in numerous instances, 
be prevented by a judicious treatment of certain conditions of the system, 
which, if neglected, are very apt to induce them, but which are entirely under 
the control of remedies. 
For our improved knowledge of cardiac diseases, we are indebted mainly to 
Corvisart, Laennec, Louis, Collin, and Bouillaud in France; Hope, Williams, 
Latham, and Stokes in Great Britain; and Dr. Pennock in this country; 
though facts of importance have been contributed by many others. 
As preliminary to the consideration of the particular diseases, it will be of 
advantage to treat of the means of exploring them which modern investiga- 
tions have placed in our hands, and which render their diagnosis at present 
almost as easy, with proper study and practice, as it was formerly difficult 
and uncertain. I shall take it for granted that the reader has a general 
knowledge of the structure, position, and actions of the heart; but introduce 
a figure, with brief anatomical references, in order that the student, by con- 
sulting it in connexion with the remarks which follow, may be able more 
clearly to understand them.* The signs of the heart's action and condition 
* The figure here introduced, with the following references, has been copied, by per- 
mission of the author, with some slight changes, from a communication made by Dr. 
C. W. Pennock to the Pathological Society of Philadelphia, and published in the Medi- 
cal Examiner for April, 1840 (vol. iii. p. 213). 
" The heart is represented with the pericardium removed, the lungs drawn back- 
wards by hooks, leaving its entire anterior surface exposed-the cartilages and ribs in 
front of it, indicated by dotted lines. 
8, Outline of the sternum. 
C, Clavicle. 
1, 2, 3, 4, 5, 6, &c. The ribs. 
lz, 2Z, 3Z, 4Z, 5Z, 6Z, &c. The cartilages 
of the ribs. 
4ZZ, Right and left nipples. 
a, Right ventricle. 
b, Left ventricle. 
c, Septum between the ventricles. 
d, Right auricle. 
e, Left auricle. 
/, The aorta. 
f', Needle introduced through the mid- 
dle of the sternum, perpendicular to its 
plane, opposite the cartilages of the third 
rib, passing into the aortic valves. 
g, The pulmonary artery. 
g', Needle introduced between the se- 
cond and third cartilages, half an inch to 
the left of the sternum (perpendicular to 
the plane of the thorax), passing into the 
valves of the pulmonary artery. 
h, Vena cava deseendens. 
i, Line of direction of the mitral valve. 
The dotted portion is that part of it poste- 
rior to the right ventricle. 
i', Needle introduced perpendicular to 
the plane of the thorax, three inches from 
the left margin of the sternum, at the lower 
edge of the third rib, and passing into the 
mitral valve at its extreme left. 
k, Line of the tricuspid valve. 
m, n, Needles introduced perpendicmlar 
to the thorax, at points where the dulness 
of percussion of the heart ceases, and 
which, being projected, pass to the borders 
of that organ. 
o, Trachea. 
2>, Apex of the heart. CLASS III.] 
121 
DISEASES OF THE HEART. 
will be considered under the several heads of 1. those recognized by the touch, 
2. those obvious to vision, 3. those afforded by percussion, 4. those yielded by 
auscultation, and 5. general symptoms. It will be most convenient, under 
each of these heads, so far as appropriate, to treat first of the signs as they are 
presented in health, and afterwards of their modifications, and of the new signs 
exhibited in disease. 
1. Signs by Touch.-Pulsation or Impulse. 
The beating of the heart may almost always be felt in health, in one posi- 
tion or another of the body, by placing the hand upon the chest, as nearly as 
may be opposite to the apex of the organ. The pulsation is owing to the 
striking of the small extremity of the heart against the ribs. It has gene- 
rally been thought to be synchronous with the contraction of the ventricles, 
and to result from that contraction. According to Hope, during the systole 
of the ventricles, the apex is drawn somewhat towards the base of the heart, 
" Upon reference to the drawing, it will be seen that the valves of the aorta lie beneath 
the middle of the sternum, opposite the lower edge of the cartilages of the third ribs; 
that the valves of the pulmonary artery are more superficial, and are placed to the left, 
and about half an inch above. The aorta, from its origin, curves upwards towards the 
right, extending between the cartilages of the second and third ribs slightly beyond the 
right margin of the sternum ; at the lower margin of the second cartilage, the arch of 
the aorta commences and inclines to the left, crossing the pulmonary artery where it 
lies beneath the left second rib, and ascending as high as the first rib, turns downwards. 
The pulmonary artery, from its origin in contact with the sternum, commences at its left 
margin, where it is joined by the cartilage of the third rib, bulges at the interspace be- 
tween the second and third cartilages close to the sternum, and dips beneath the aorta 
opposite the junction of the second cartilage and sternum. 
" The right divisions of the heart, being most superficial, form the greater part of the 
anterior surface; the right auricle reaches from the cartilage of the third rib, to that of 
the sixth, and between the third and fourth, where its breadth is the greatest, it extends 
laterally near one inch and one third {when full of blood*) to the right of the sternum. 
About one-third of the right ventricle lies beneath the sternum, the remaining two-thirds 
being to the left of that bone ; the septum between the ventricles coincides with the 
osseous extremities of the third, fourth, and fifth ribs, and, on the fourth rib, is midway 
between the left margin of the sternum and nipple. A small part, say one-fourth of the 
left ventricle presents anteriorly; and, when the lungs are separated, a portion of the 
left auricle is visible between the second and third left ribs, two inches from the left 
margin of the sternum. With the exception of these portions, the whole of the left 
ventricle and auricle lie posteriorly to the right ventricle; and the entire left divisions, 
with the exception of a small portion of the base connected with the semi-lunar valves 
of the aorta, lie on the left of the sternum. 
" The heart being movable, the tricuspid and mitral valves necessarily change their 
relative position to the parietes of the thorax, with every change of posture of the body. 
When examined in the dead body, the normal situation of these valves is as follows: 
the tricuspid valve extends obliquely downwards from a point in the middle of the ster- 
num, immediately below the third rib, to the right edge of the sternum, at the lower 
margin of the cartilage of the fifth rib; the mitral valve commences beneath the lower 
margin of the left third rib, near the junction of its cartilage with its osseous extremity, 
(two and a half to three inches to the left of the sternum), and runs slightly downwards, 
terminating opposite the left margin of the sternum, where it is joined by the cartilage 
of the fourth rib. 
" The apex of the heart, when an individual is standing erect, beats between the fifth 
and sixth left ribs, about two inches below the nipple, and one inch on its sternal side. 
But as the heart is attached only at its base by the large blood-vessels, 'the body of 
that organ is not fixed in relation to the walls of the chest, but hangs in a certain degree 
loose,' and liable to displacement by change of posture, and by the motions of the chest. 
Hence, the pulsations of the apex are felt at diiferent points of the chest, and the im- 
pulse is affected by the stage of the respiratory act. During full inspiration, the impulse 
of a healthy heart is scarcely perceptible, but upon expiration, and especially if, at the 
same time, the body be bent forward, the cardiac pulsations become very forcible." 
* An alteration in the text suggested by Dr. Pennock. 122 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
[part II. 
and at the same time tilted upwards and forwards. Various explanations 
have been given of the mechanism of the movement, one of which refers it 
to the greater length of the anterior muscular fibres of the ventricles; another, 
to the contraction' of the spiral muscles, which, fixed as these muscles are in 
the tendinous rings about the base of the heart, must have the effect of rais- 
ing upwards the apex towards the walls of the chest. It has always seemed 
to me, admitting the impulse to be systolic, that it most probably arose from 
the reaction of the current of blood in the great vessels, as they proceed 
from the heart, which must have the effect of projecting that organ forward 
to a greater or less extent. Somewhat different is the explanation of Dr. Gut- 
brod, of Germany, previously put forth by Dr. Alderson, of England, that 
the forward movement is owing to the rebound of the heart, consequent upon 
the pressure of its own blood, when by the opening of the valves that pres- 
sure becomes unequal, exactly on the principle of the rebound of the gun, or 
the motion of Segner's wheel, which, as a jet of water proceeds in one direc- 
tion from its circumference, turns in the opposite direction. But the cases 
are not exactly analogous; for the opening of the heart is into another cavity, 
upon the walls of which the force is exerted so as still to maintain very 
nearly an equilibrium. According to cither of these latter views, the apex 
of the heart should be moved somewhat downward as well as forward, which 
is in fact what the phenomena of the impulse require. But no explanation 
hitherto given, is, I think, quite satisfactory; and, indeed, the question has 
not yet been definitively decided, whether the impulse really occurs during the 
systole, or is owing to the expansion of the heart which takes place during 
the diastole.* 
* In a recent work on General Pathology, Dr. Alfred Stills, of Philadelphia, defends 
the opinion that the impulse of the heart is synchronous with and produced by the 
diastole of the ventricle, and not, as generally supposed, the systole. The following is 
a summary of his arguments in support of that view. It is difficult to comprehend how 
a hollow muscle by contracting could give a blow to a body exterior to itself. When 
the heart of a frog, which is transparent, is examined, the projection of the apex is 
found to coincide with the diastole, and its retraction with the systole of the ventricle. 
In one or two cases in which the human heart has been distinctly seen in action, the 
ventricular systole was observed to be accompanied by a contraction of the heart in 
every diameter, and the diastole, which had the rapidity and energy of an active move- 
ment, to be attended with a decided projection of the heart downwards. From an an- 
alysis by Dr. Corrigan, of Dublin, of a number of cases of ventricular hypertrophy, it 
appears that in all of them the impulse of the heart was less than natural, and in some 
could not be felt, proving that the impulse must be owing to some other cause than the 
ventricular contraction. If cases of hypertrophy of the heart with increased impulse, 
are compared with others in which the impulse is diminished, it is found that in the 
former there is auricular hypertrophy, and in the latter either exclusive ventricular 
hypertrophy or thinning and dilatation of the auricle. The want of correspondence, in 
some instances, between the number of the heart's pulsations and those of the arteries, 
is best explained by the hypothesis of the diastolic origin of the impulse. This want 
of correspondence occurs chiefly when the heart is weak, or the mitral orifice contracted. 
It may be readily conceived, under these circumstances, that the auricle may throw a 
quantity of blood into the ventricle sufficient to produce the impulse, but insufficient to 
excite it to contraction, and that two or even three of these efforts may be made, before 
the systolic movement which produces the arterial pulsation is effected. (Elem. of Gen. 
Pathol., p. 319.)-Note to the second, edition. 
These arguments of Dr. Stillb are not without much force ; and are supported very 
strongly by the observations of Dr. Thos. Robinson, of Petersburg, Virginia, and of M. 
Beau, of France. These were made in the cases of new-born infants, in whom the 
breast-bone was wanting, and the heart was exposed to view uncovered by the peri- 
cardium. Dr. Robinson's case is recorded in the American Journal of Medical Sciences 
(vol. xi. p. 346, Feb. 1833); and a reference to two similar cases presented by M. Beau 
to the Academy of Medicine of Paris, will be found in the Archives Generates (April, 
1851, 4e ser., xxv. 460). In the case of Dr. Robinson, the following was the succession CLASS III.] 
123 
DISEASES OF THE HEART. 
The point at which the apex of the heart strikes, and where the impulse is 
most distinctly felt, in a state of medium expansion of the chest, and in the 
erect position, is between the fifth and sixth ribs, about an inch within and 
two inches below the nipple, and somewhat more than two inches to the left 
of the junction between the sternum and xiphoid cartilage, in an individual 
of ordinary size. But this point varies very considerably in health, according 
to the position of the body, and the stage of the respiratory act. The heart 
hangs to a certain extent loosely in the cavity of the chest, and therefore 
yields in some degree to the influence of gravitation. In the erect posture, 
the apex is about an inch lower than in the horizontal. When an individual 
lies upon the back, the heart recedes from the walls of the chest, so that the 
impulse often ceases to be perceptible; when upon the face, the organ falls 
upon the ribs and makes its pulsation very obvious. The same happens in 
the position upon the left side, in which the pulsation is often felt to the left 
of the nipple. During inspiration, the ribs move at the same time forwards 
of the heart's actions as obvious to the eye. Beginning from a state of rest, the 
heart suddenly and forcibly dilated in all directions, the dilatation commencing appa- 
rently with the auricles and proceeding with great rapidity to the ventricles. The 
apex thus elongated was projected forwards, and would of course, in the normal con- 
dition of the parts, have struck against the parietes of the chest and produced an im- 
pulse. Immediately after the completion of the diastole, and without the least observable 
interval, the heart contracted forcibly, and was now diminished in all its dimensions, 
with a receding of the apex. The systole began also in the auricles and proceeded to 
the ventricles with great velocity. The whole of this complicated movement was made 
with such rapidity that it almost seemed like one act of the heart, the systole beginning 
in the auricles at the instant of the completion of the diastole in the ventricles, and 
altogether occupying less than half a second. A period of rest followed, which con- 
siderably exceeded the time occupied by the diastolic and systolic motions combined. 
In the cases presented to the Academy, the heart, starting from a state of repose, 
appeared suddenly to dilate in all the dimensions of the ventricle, with projection of the 
apex, and then immediately to contract without observable interval, the apex retreating; 
after which came the period of rest. 
At a meeting of the Medical Society of the. Hospitals of Paris, M. Aran stated that he 
and M. Bernard had performed experiments upon frogs, and young animals at birth, 
which confirm M. Beau's opinions as to the successive actions of the heart; namely, 
that the auricle having been passively dilated during the repose, suddenly contracts, 
thus throwing the blood into the ventricle, which consequently suddenly dilates, and 
subsequently contracts without any observable interval. Hence, of the two periods of 
the heart's action, theirs? is occupied by the contraction of the auricle, and the dilata- 
tion and contraction of the ventricle, successively; the second by the dilatation of the 
auricle. (Archives Gen., Avril, 1854, p. 500.) 
If these facts in relation to the dilatation and contraction of the ventricles be 
admitted, and it seems impossible to deny them, the heart's impulse is easily ex- 
plained, and must be referred to the active diastolic movement. The observations of 
Drs. Pennock and Moore in relation to the elongation of the heart, when carefully 
considered, may perhaps be considered as confirmatory of this view. These experi- 
menters found the heart to be elongated from the base to the apex, during the ventricular 
contraction. This was noticed both in the sheep and the horse, the increase in the for- 
mer being about one-quarter of an inch. (Am. Journ. of Aled. Sci., xxv. 418.) Now, 
acjording to the above-mentioned observations, there is no interval whatever between 
the diastole and the systole, and without close attention the two movements might be 
considered' as one. May not, therefore, the elongation noticed by Drs. Pennock and 
Moore have been really diastolic, though so immediately followed by the systole as to 
have been confounded with it? It should be mentioned, however, that some experi- 
ments made in Edinburgh on dogs, as viewed by Drs. Bennet, Gairdner, and others, 
tended to confirm the generally received views on this subject, though Dr. Cartwright, 
who also witnessed them, and who maintains the diastolic theory, did not admit their 
conclusiveness. (Ed. Month. Journ. of Med. Sci., Feb. 1854, p. 189.) 
Though the views of the heart's actions here given are highly plausible, and probably 
in a considerable degree correct, they have not yet been generally adopted; and I have 
thought it best to retain in the text the commonly admitted explanations, until the question 
can be determined by accumulated observations. (Note to the third and fourth editions.') 124 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
PART IT. 
and upwards, so as to remove the walls of the chest from the heart, and to 
lower the position of that organ in relation to any particular rib; and the con- 
trary takes place during expiration. Hence, when the chest is fully expanded, 
the pulsation is lost or rendered less distinct, and the apex will strike, if at 
all in contact with the chest, below the sixth rib; while, in a forced expira- 
tion, the pulsation is strongest between the fourth and fifth ribs, and may 
be felt to a considerable extent over the chest, so high sometimes as the third 
rib. From all this it is obvious that, when the pulsation of the heart is very 
indistinct, the best means of rendering it perceptible is to cause the patient 
to lie upon his face or left side, or, if in the sitting posture, to bend forward 
and to the left, and to exhaust his lungs as far as possible of air. 
The force and extent of the impulse vary greatly, in health, with the vary- 
ing activity of the circulation, and the thickness of the walls of the chest. 
In some persons it can scarcely be felt, especially in very fat and phlegmatic 
individuals; in others again it is very powerful, and may be felt through a 
large space, as in those who are very thin and of a nervous temperament. 
In children it is usually more distinct than in adults. After great muscular 
exertion, it is sometimes violent, and perceptible almost throughout the chest. 
The frequency of the pulsations is also liable to great diversity within per- 
fectly normal limits. For the average number in a minute, the reader is 
referred to the article upon the pulse (see vol. i. p. 183) ; under which head 
are also detailed the causes that occasion diversities in the number without 
deviation from health, as sex, age, the sleeping and waking state, the time of 
day, posture, muscular exertion of all kinds, mental influences, and various 
accustomed stimuli. It is sufficient here to state that the cardiac pulsation, 
in perfect health, corresponds in frequency with the arterial, as both depend 
upon the same cause. In the larger arteries the pulse is synchronous with 
the beating of the heart, in that at the wrist, follows it at a very minute, 
though still appreciable interval, equal perhaps to one quarter of a second. 
There is also in health a fixed relation between the number of respirations and 
of pulsations, the latter being to the former very nearly as four and a half to 
one. {Hooker.} 
In perfect health, the pulsations occur usually at regular intervals, though 
not uniformly so. In old persons, it is not uncommon to meet with inter- 
missions in the heart's contractions, and some persons are subject to them 
from infancy, without, in either case, the suspicion of disease. It is a singu- 
lar fact, often noticed, that in such cases the irregularity is apt to disappear 
during attacks of fever or other severe illness, and to return with the return 
of health. Intermissions, however, in the pulse at the wrist are not always a 
sign of the same state in that of the heart; for it occasionally happens that 
the ventricular contraction, though sensible near the heart, is too weak to 
transmit an impulse to the extreme vessels; and the systole may even be so 
feeble as to occasion a seeming intermission in the beating at the chest. 
There are, however, frequently true intermissions in the ventricular con- 
tractions without amounting to disease. 
The impulse is much and variously.altered by disease. It may be mor- 
bidly increased or diminished in strength and extent; may be changed in its 
character; may become more or less frequent than in health; and may suffer 
irregularities of different kinds in the relation of the successive pulsations. 
Its strength has been generally thought to be augmented by hypertrophy or ex- 
cessive developement of the walls of the heart, and by whatever stimulates that 
organ to excessive action; and sometimes becomes so great as to give the im- 
pression almost of a hammer within the chest. It is diminished, on the contrary, 
by weakness of the heart, whether functional or from thinness or degeneration 
of its parietes, and by whatever tends to remove that organ from the ribs, as ad- CLASS III.] 
125 
DISEASES OF THE HEART. 
Lesions posteriorly, distension of the pericardium, or the formation of a pleural 
sac anteriorly. It not unfrequently, indeed, happens that the impulse is wholly 
lost in disease. The extent to which it may be felt is increased by excessive 
action, hypertrophy, or dilatation of the heart; and the increase may be con- 
fined to a few inches around the apex, or may embrace almost the whole chest. 
The heart may be so confined by adhesions, that the point of impulsion against 
the ribs shall vary less than it ought to do with the varying position of the 
patient; while, on the contrary, in a distended state of the pericardium, its 
beating, if felt at all, will be apt to change place more readily than in health, 
because the organ is no longer restrained in its movements by the investing 
membrane. The character of the impulse is often much altered. Perhaps 
to this category belongs the short, sharp, quick stroke of irritation, which is 
wholly different from mere frequency of beat, the former referring to the in- 
dividual pulsations, the latter to their succession. Instead of resulting from 
the striking of the apex of the heart against the ribs, the impulse is some- 
times produced by the whole organ rising up as it were under the hand, and 
giving rise to the sense of a slow heaving motion, rather than of a blow.* 
This happens in dilatation and hypertrophy. In relation to the repetition of 
the impulse, it may become so frequent that it cannot be counted, even ex- 
ceeding 200 strokes in a minute, or may be reduced even so low as 15 or 20 
in the same length of time. The relation of the successive impulses to each 
other is liable to excessive irregularities. Sometimes a stroke is now and then 
omitted, either at certain intervals or quite irregularly. In such cases the 
pulsation is said to be intermittent. Occasionally it is as it were remittent, 
one or several strokes being more feeble than those which precede and fol- 
low. Not unfrequently the rapidity of succession varies greatly; the pulsa- 
tions being now very short and rapid, almost running into one another, then 
again prolonged, slow, and distinct; and all these diversities may be com- 
bined in the same case. The double or triple impulse, which is sometimes 
felt in quick succession, may be owing to as many partial contractions of the 
ventricle, before the full systole is accomplished. Some have supposed that 
the diastole is concerned in these irregularities, as there is at that period a 
sudden and apparently active swelling out of the ventricle, which must make 
some impression upon the parietes of the chest. It has been maintained that 
there is normally a double impulse of the heart, scarcely sensible in its ordi- 
nary state, but becoming obvious in excitement, the first impulse being de- 
pendent upon the systole, the second, much feebler, upon the diastole, and 
felt between the second and third ribs. (Bellingham and Sibson, Land. 
Med. Gaz., March, 1850, p. 445.)f All these derangements of the heart's 
impulse may be purely functional; but, when they persist steadily for a long 
time, without any return to the regular condition, there is reason to suspect 
the existence of some organic disorder. It must always be remembered that 
certain modifications of disordered impulse may depend upon diseases of the 
lungs or other neighbouring parts, the heart being itself perfectly sound. 
Thus, extensive effusion in the pleura, tumours of different kinds, and even 
the upward pressure of the contents of the abdomen, may very much change 
the place in which the heart will be felt beating. 
* It appears to me that this fact is somewhat in favour of the opinion which ascribes 
the impulse of the heart to the diastole. 
I This may be readily understood, if the view of the heart's action be admitted 
which ascribes the main impulse to the active diastole. The systole immediately fol- 
lowing, by throwing the blood into the great vessels which are posterior to its own base, 
must have the effect of tilting the heart somewhat forward, and of course against the 
chest, so as probably to produce a sensible impulse when examined under favourable 
circumstances. (Note to the third edition.) 126 
[part II. 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
Purring Tremor.-Besides the stroke or pulsation above treated of, the 
hand placed over the heart becomes occasionally sensible of an entirely differ- 
ent impression; a sort of thrill or slight jarring movement, very similar to 
that produced by a purring cat, and hence called purring tremor, and by the 
French writers fr^missement cataire. This is the result of a quick vibratory 
movement of the walls of the chest, propagated from the interior of the heart or 
blood-vessels, and from the surface of the organ, and depends upon the same 
causes as the bellows murmur and the friction sounds hereafter to be noticed, 
with which it is often associated. A similar sensation is often imparted to 
the fingers by the pulse at the wrist, in diseases of the heart. 
2. Signs by Inspection. 
Mere inspection is of very little use in the diagnosis of diseases of the 
heart. In health, all that the eye can discover, having any direct relation to 
that organ, is occasionally a slight movement near the sixth rib. In certain 
morbid states, this becomes very manifest, so much so as to be visible through 
the clothing, and at a considerable distance. Occasionally, the action may be 
seen to extend to the carotids and even to the jugulars, and, in some instances 
of severe cardiac disease, the whole body seems to be jarred by the violence 
of the palpitation. But no inference can be drawn from this sign alone, except 
that the heart is acting inordinately. It may be of use in connexion with 
others of a more definite character. 
Sometimes the outline of the chest is visibly altered. A prominence over 
the cardiac region is a not unfrequent attendant upon copious pericardial effu- 
sion, and is of some value as a sign of that affection. The left nipple in such 
cases is observably more projecting than the right. It is said that a contrac- 
tion or sinking at the epigastrium is sometimes observed, during the contrac- 
tion of the ventricles. Such a depression may be supposed to result from firm 
adhesions of the pericardium to the heart, as well as to the parts around it, so 
that, when the ventricles contract, being fixed posteriorly, they must pull 
backward the movable anterior parts of the chest. 
3. Signs by Percussion. 
In the ordinary state of the heart and lungs, there is an irregular roundish 
space, an inch and a half or two inches across, extending from the sternum 
about the fourth intercostal space towards the left nipple, but without reach- 
ing it, in which a portion of the surface of the heart, including nearly the 
whole antero-superior surface of the right ventricle, a small part of the right 
auricular appendix, and the outer edge and apex of the left ventricle, lies in 
contact with the wall of the chest. In this space, percussion is decidedly dull. 
The dulness, however, is not marked by a precise boundary line, but is gra- 
dually shaded off into a clearer sound, as the overlapping portions of the lung 
become thicker, until at length the pure pulmonary resonance only is heard. 
Even when common percussion yields a clear sound, the dulness of the most 
deeply covered portions of the heart may in some degree be brought forth by 
a stronger blow; and, by a delicate ear and practised hand, the outline of the 
heart may thus be ascertained and chalked out with tolerable accuracy, extend- 
ing obliquely downward from the third left sterno-costal articulation to a part 
of the fifth intercostal space about two inches to the left of the sternum, 
and, in a horizontal line, from the vicinity of the nipple to a short distance 
beyond the sternum, and thus embracing almost all the lower half of this 
bone. The sound elicited varies according to the position of the body, and 
the degree of expansion of the chest in health, and is much affected by dif- 
ferent diseases of the lung, pleura, or neighbouring parts, wholly independ- CLASS III.] 
DISEASES OF THE HEART. 
127 
ent of the heart, all of which, therefore, must be taken into account before 
any practical inference is deduced from the results of percussion. The dul- 
ness is greater in the erect position than in supination, and still greater when 
the body bends forward, or lies upon the face. It inclines also to the side of 
the body which is lowermost. The affections which interfere with the indi- 
cations of percussion in complaints of the heart are, on the one hand, those 
which occasion dulness, such as pleuritic effusion, hepatization of the lung, 
tumours of various kinds, enlargement of the left lobe of the liver, an over- 
loaded stomach, &c., and, on the other, those which tend to counteract the dul- 
ness, as emphysema of the lungs, pneumothorax, and great gastric flatulence. 
With due allowances for all these circumstances, percussion may afford very 
useful indications in heart disease, by proving the existence of enlargement 
of the heart, or effusion into the pericardium. 
4. Signs hy Auscultation. 
The action of the heart is attended with sounds, which, though not audible 
under ordinary circumstances in health, become so by the mediate or imme- 
diate application of the ear to the chest, and sometimes may be distinctly 
heard at some distance from the body, not only in disease, but also in certain 
conditions of excitement, which can scarcely be regarded as morbid. Persons 
sometimes distinctly hear the sounds of their own heart, so much so, indeed, 
as to be greatly annoyed by them. In examining these sounds by ausculta- 
tion, it is best generally to employ the stethoscope, at least when any great 
nicety of discrimination is necessary; as they are often very limited in their 
origin, and can scarcely be referred accurately to their several sources, unless 
by the aid of an instrument by which small and isolated spots can be exam- 
ined. As slight morbid sounds may not be brought out unless with a more 
than ordinarily rapid movement of the blood, it may sometimes be desirable 
to increase this movement, and consequently to direct the patient to walk 
about, or otherwise exert himself, previous to the examination. 
There are two sounds with every pulsation of the heart, one immediately 
following the other, and afterwards a short interval of silence. The first 
sound is heard during the contraction or systole of the ventricles, and is syn- 
chronous with the beating of the heart, and with the pulsation in the large 
arteries, near the centre of circulation, but anticipates, by a very minute, but 
still appreciable interval, the pulse at the wrist. It is longer and duller than 
the second, and is heard most distinctly over that part of the chest which is 
in contact with the ventricles, and in which percussion is dull, a space, namely, 
of nearly two inches in diameter, on the left of the sternum, below the in- 
sertion of the fourth rib. 
The second sound occurs during the dilatation of the ventricles. It is 
quicker, shorter, and clearer than the first, and bears a close resemblance to 
that produced by lightly tapping with the soft extremity of the finger of one 
hand near the ear, the knuckle of a bent finger of the other hand. {HopeE) It 
is heard most distinctly over the semilunar valves; that is, "upon the ster- 
num, opposite to the inferior margin of the third rib, and thence for about 
two inches upwards, along the diverging courses of the aorta and pulmonary 
artery respectively, the sound high up the aorta proceeding mainly from 
the aortic valves, and that high up the pulmonary artery being mainly from 
the pulmonic."* 
* This explanation must be modified if we admit the im pulse to be diastolic. In that 
case, the first sound must occupy the whole period of active diastole and systole, and 
the second must occur immediately after the systole, when the heart returns to its state 
of rest, and the elastic force of the aorta and pulmonary Pirtery causes a quick closure 
of the semilunar valves. (Note to the third edition.) 128 
[part II. 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
The whole period which elapses from the commencement of the sounds in 
one pulsation to the same point in the next, is usually about a second, of 
which, according to Dr. Hope, one half is occupied by the first sound, one 
quarter by the second, and the remaining quarter by the interval of silence. 
At best, however, this division is only an approximation to the reality. 
Opinions have differed greatly as to the cause of the two sounds. Those 
at first entertained, being chiefly conjectural, have not stood the test of ex- 
amination. Those at present most prevalent have been deduced from nume- 
rous experiments, made with great care, and are probably in the main true. 
For an account of some of the most conclusive of these experiments, the 
reader is referred to Pennock's edition of Hope's Treatise on Diseases of the 
Heart. Our limits permit only a statement of the results. 
The first or systolic sound, is now generally admitted to be complex, and 
to proceed from different sources. One of these sources is undoubtedly the 
contraction of the ventricles. It has been proved that the contraction of 
muscles is attended with a sound audible by means of the stethoscope. Those 
of the heart, acting so energetically as they do, could scarcely fail to manifest 
this effect; and, accordingly, they have been found to emit a faint sound, 
even after separation from the body, and when the ventricles contained no 
blood. But with the muscular sound are combined others, proceeding from 
the auriculo-ventriculai' valves as they close and become tense, the rushing of 
the blood from the ventricles into the aorta and pulmonary artery, and proba- 
bly sometimes the impulse of the heart against the walls of the chest. At 
any rate, it is rational to suppose that the contact of the apex with the pa- 
rietes of the chest, may serve to convey the sounds produced in the interior of 
the organ more clearly to the ear. In addition to the above sources of the 
first sound, the contraction of the auricles must also be taken into account. 
The emission of sound by the contracting auricles was denied by Dr. Hope, 
but it has been satisfactorily proved by the experiments of Drs. Pennock and 
Moore, as well as others subsequently performed in England. The following 
has been considered as the succession of the heart's actions. First the auri- 
cles contract feebly, and throw into the ventricles, now perfectly quiescent 
and full, a little additional blood, by which they are distended, and thus 
stimulated to action; and the resulting ventricular systole immediately fol- 
lows the auricular, without the least appreciable interval, so that one seems to 
run into the other. After contraction, the ventricles suddenly and forcibly 
dilate, as if by an inherent active expansive power, and thus draw in blood 
from the auricles, now perfectly quiescent, causing them observably to shrink. 
Then follows a period of complete ventricular repose or passiveness, during 
which the auricles become distended by the influx of blood from the pulmo- 
nary veins, which again stimulates them to contraction; and thus the circle 
of actions begins again. Now, as no appreciable interval exists between the 
auricular and ventricular contractions, it follows that none can exist between the 
sounds; and, as these sounds are of the same nature, though the auricular 
is more feeble, they must strike the ear as continuous, and therefore not dis- 
tinguishable. It is true that observers have usually found the first sound to 
commence and end with the ventricular systole; but the comparatively very 
feeble auricular sound may have escaped attention, absorbed as it is in the 
much louder one of the ventricles. Dr. Williams, to whom much credit 
is due for the investigation of the muscular sound of the heart, and who 
considers the first sound to proceed directly from the contraction of the ven- 
tricles, asserts that a thin ventricle produces a louder and clearer sound than 
a thick one, because, in the latter, the fibres "muffle each other's vibrations." 
The fact is, that a dilated heart sounds more loudly than one affected with CLASS III.] 
DISEASES OF THE HEART. 
129 
hypertrophy; and they who regard the muscle as the chief or exclusive 
source of the sound, must admit the explanation, though not very satisfactory, 
in order to escape the inference, that the muscular walls of the heart convey 
the sound from within, and of course do so with more loudness and clearness 
when distended and thin than when thickened. Dr. Leared, of Wexford, 
Ireland, maintains the opinion that the first sound is ascribable mainly to the 
concussion of the columns of blood sent forth by the contracting ventricles 
with the quiescent columns of the aorta and pulmonary artery; and, in support 
of this opinion, adduces experiments which show that a similar sound is pro- 
duced by the shock of similarly meeting columns of liquid out of the body. 
(Dublin Quart. Journ. of Med. Sci., xiii. 354.) 
The second sound is now almost universally ascribed to the closing of the 
semilunar valves, by the elastic contraction of the aorta and pulmonary artery, 
during the diastole of the ventricles. Hence its short, quick, flapping cha- 
racter, and abrupt close. Some have conjectured that the active expansion 
of the ventricles in the diastole might produce sound; but this has not been 
proved.* 
As the two sides of the heart act precisely together, the sounds produced 
by them must be perfectly synchronous, and therefore constitute in fact one 
sound. It is probable, however, that the sounds produced by the two ventri- 
cles are somewhat different; as experiment has shown that, when the muscu- 
lar walls of the heart are thin, they produce a clearer and louder sound than 
when thick; and Dr. Pennock states, as the result of his observations, that 
the sound of the right ventricle is of a clearer and more flapping character 
than that of the left. 
The sounds of the heart undergo considerable diversity, in a state of per- 
fect health, in their loudness, duration, extent, and relation to each other. 
They are louder in proportion to the quickness and energy of the ventricular 
contraction; and are influenced also in this respect by the thickness of the 
walls of the chest. In very fat persons, they are comparatively feeble and 
of limited extent; in the very thin and narrow-chested, they are louder and 
more diffused. The interval of silence is sometimes almost annihilated, when 
the heart is acting rapidly, under the influence of mental emotion or great 
bodily exertion. The sounds may also be greatly modified by disease within 
the thorax, though the heart itself may be perfectly healthy. The extent 
over which they may be heard is much increased by any cause which substi- 
tutes a solid mass, or a collection of liquid, for the cellular tissue of the 
lungs. They may. thus be conveyed even to the most distant parts of the 
chest; and occasionally they are louder at a distance than near the heart, 
where a solid structure intervenes in one case, and the loose texture of the 
lung in the other. 
We now come to the consideration of the sounds as affected by disease of 
* The causes of the sounds, in accordance with the views given in previous notes, would 
not materially differ from those presented in the text, though the succession of the actions 
differs so much. Thus, the first sound might be considered as a combination of those 
produced 1. by the blood rushing into the ventricles through the auriculo-ventricular 
orifices during the active diastole, 2. by the impulse, 3. by the muscular contraction of 
the auricles and ventricles, 4. by the closure of the mitral and tricuspid valves, and 5. 
by the rushing of the blood through the orifices of the aorta and pulmonary artery; 
commencing with the first and ending with the last of these movements; and its com- 
parative duration may thus be explained, occupying the period of the diastole and 
systole, which, according to Dr. Robinson, is about one-third, or perhaps somewhat 
more, of the whole period from the beginning of one pulsation to that of another. The 
second sound, in either view, succeeds the systole, and is produced by the closure of the 
semilunar valves. (Note to the third edition.) 130 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
[PART II. 
the heart. The influence of disease may be shown either in the alteration of 
the healthy sounds, or in the production of new ones. The healthy sounds 
may suffer change in their intensity, duration, extent, relation to each other, 
and rhythm or regularity of succession. Sometimes one of the sounds is 
quite wanting, and this may happen in relation to either. Sometimes the 
first sound is greatly prolonged, or is doubled from a double contraction of 
the ventricle, in either case interfering with the second. It is asserted that 
the sounds are sometimes increased to three or four instead of two; and this 
may be readily conceived to be possible, if it be admitted, that the ventricles 
may not always act simultaneously. Of course, the regular recurrence of the 
double sound must be liable to all the interruptions which have before been 
noticed in relation to the pulsation. None of these deviations, however, from 
the healthy state necessarily imply organic disease of the heart; and, when 
considered alone, may be of no very great importance; but, in connexion 
with other morbid signs, they sometimes acquire great significance. 
New or abnormal sounds often occur, mingling with, following, or quite 
superseding the healthy. These are usually denominated murmurs, and, with 
one or two exceptions, may be considered as modifications of the bellows mur- 
mur, or bruit de soufflet of the French. This, in its purest form, is a smooth 
blowing sound, named from its resemblance to that made by a pair of bellows. 
It may be single or double, soft or loud, of a low or a high key, short so as 
merely a little to prolong one of the natural sounds, or continuous, so as to fill up 
more or less completely the space between the impulses. Sometimes it wholly 
supersedes the healthy sounds, and nothing is heard but one continuous bellows 
murmur; but such cases are rare. Not unfrequently it becomes in various 
degrees rough or broken; and attempts have been made to designate the modi- 
fications thus produced by the terms filing, rasping, sawing, &c. Dr. Pennock 
very properly suggests, that as sawing is a double motion, the name should be 
restricted to the double murmurs produced by the alternate motion of the 
heart. (Hope's Treatise, Am. ed., p. 110.) In some instances, the murmur 
is of a musical or whistling character, and has been compared to the chirping 
of young birds. 
In its pure form, the bellows murmur often exists without any organic 
disease of the heart, and may be produced artificially by alterations in the 
diameter of one of the larger arteries, even in health. The mere pressure of 
the stethoscope upon the artery will sometimes occasion it. The most frequent 
cause of the sound is probably an abrupt contraction at one of the orifices, or 
in one of the tubes through which the blood passes. It will be readily un- 
derstood that the fluid, as it emerges from the stricture, and spreads out to 
fill the larger space beyond it, breaks into currents, which set against the sides 
of the tube, and, being thence reflected, and perhaps again reflected, occasion 
vibrations which result in sound. They who have observed the appearance 
of the stream of urine, as it issues from a strictured urethra, can easily com- 
prehend this explanation. An abrupt expansion in the passage will have the 
same effect upon the currents of the blood, and consequently in the produc- 
tion of the murmur.- Thus the sound may result from contraction of any of 
the orifices of the heart, or the expansion of one of the great arteries imme- 
diately beyond them, and, in the former case, may be produced either by or- 
ganic, or by functional disease, as spasmodic constriction. Any pressure upon 
the heart or great vessels from without, so as to diminish the cavity, whether 
from tumours, deformity of the spine, or force applied to the chest, and any 
partial obstruction by concretions within, as by coagula of blood or fibrin, 
may give rise to the same effect. 
Another frequent cause of the bellows murmur is a watery state of the blood, CLASS III.] 
DISEASES OF THE HEART. 
131 
such as occurs in chlorosis or anaemia.. The liquid is in this state more mov- 
able, the particles more easily glide over each other; and hence currents are 
more easily formed by whatever affects the regular movement of the blood. It 
is in such cases that the bellows murmur is most easily produced by the pres- 
sure of the stethoscope upon the arteries; and there can be no doubt that the 
anemic state very much favours the action of other causes operating in the 
heart. Indeed, a very watery state of the blood is alone capable of producing 
the sound, without any change in the capacity of the orifices; the ordinary 
movements being sufficient, in such a case, to form the requisite currents. In 
anemic individuals, the slightest increase in the circulation is sufficient to ge- 
nerate the murmur; and, as the anemic state is very apt to be attended with 
excessive action of the heart, it seldom exists to any considerable extent with- 
out this accompaniment. The condition can at any time be induced by free 
and frequent bleeding. 
The roughness implied by the terms filing, rasping, and sawing, is ascrib- 
able to inequalities in the surface over which the blood flows, especially in the 
orifices of the great .vessels, produced by depositions of lymph, excrescences 
of various kinds, osseous or cartilaginous productions, &c. These modifica- 
tions of the bellows murmur are accordingly in general supposed to indicate 
organic disease in the valves, or the valvular openings. 
Another source of cardiac murmurs is frequently some defect of the valves, 
either loss of substance, irregular thickening, dilatation of the orifice, or some- 
thing else which prevents their accurate closure, and thus allows regurgita- 
tion of the blood. It may be supposed that, in these cases, the sound is ascri- 
bable not only to the irregularity given to its backward movement through 
the insufficient valve, but also in some measure to the conflict of the reverted 
with the regular current of blood; as, for example, when the blood of the con- 
tracting ventricle is sent through the insufficient auriculo-ventricular valve 
against the current entering the auricle. 
The degree of softness or loudness is influenced by the less or greater force 
of the moving cause; and hence the systolic ventricular murmurs are louder 
than the diastolic; the former depending on the powerful contraction of the 
ventricles, the latter on the much feebler elactic pressure of the great arteries. 
The key or tone of the murmur, according to Hope, is higher or lower, ac- 
cording as the sound is generated at a less or greater depth, by a less or 
greater force, or in a less contracted or more contracted passage. Roughness 
of sound is proportionate to irregularity in the surface producing it. The 
musical tone appears to afford no particular indication. Hope found it most 
frequently as an attendant upon regurgitation. Any of these sounds may be 
changed by altering the force of the heart's action. Thus, when the cardiac 
affection is insufficient to generate a murmur in the ordinary state of the cir- 
culation, the sound may sometimes be developed by exciting the heart; and a 
murmur which, under ordinary circumstances, is smooth, may be roughened 
by increasing the rapidity of the current. The quantity of blood, according 
to Dr. Williams, modifies the murmurs, increasing and prolonging them when 
excessive, and rendering them loud and short when defective, and attended 
■with excited action of the heart. 
By a close examination, it can often be ascertained in which of the valvular 
orifices the murmur originates, and whether it depends upon obstruction, or 
upon deficiency of the valves and consequent regurgitation. 
In the first place, the seat of the murmur, as perceived by the stethoscope, 
will tend to fix its origin. When the sound is loudest on the sternum, im- 
mediately below the insertion of the third rib, and thence extends upward for 
about two inches along the course of the great vessels, it may be considered as 132 
[PART II. 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
having its source in the semilunar valves. If the sound be perceived most 
distinctly along the course of the ascending aorta upon the right, it is pro- 
bably seated in the aortic valves; if along the pulmonary artery on the left, 
it is in the pulmonic valves. When the murmur is most distinct over that 
part of the chest on which percussion is dull, that is, where the ventricles are 
in contact with the walls, it may be inferred that it is generated either in the 
mitral or tricuspid valve; in the former, when the point of greatest loudness 
is a little to the right of the left nipple and an inch or so below it, in the latter, 
when the analogous point is on or near the sternum in the same horizontal line. 
In the second place, the solution of the question, whether the sound de- 
pends upon contraction or any other obstruction of the valvular opening, or 
upon deficiency or insufficiency of the valves themselves, in other words, 
whether it is generated in the regular onward course of the blood, or by re- 
gurgitation, is aided by observing the course of the sound, its relation as to 
the time of occurrence to the contraction or dilatation of the ventricles, and 
the character of the sound itself. The course of the sound will generally be 
in the direction of the current of blood from the originating point. In con- 
traction of the semilunar valves, and insufficiency of the auriculo-ventricular 
valves, the sound will be synchronous with the ventricular systole; in the 
opposite states of these valves respectively, with the diastole. The sounds 
produced during the systole of the ventricle are louder than those during the 
diastole. First, in relation to the aortic valve,, if it be obstructed, the mur- 
mur will be heard during the systole, will be rather loud, resembling, according 
to Dr. Hope, the whispered letter r, and will follow the course of the aorta, 
sometimes even as high as the carotid, without being perceived, or but faintly 
so, over the ventricle. If the valve be insufficient, so as to occasion regurgi- 
tation from the aorta, the murmur will be heard during the diastole, will be 
of a lower key than the preceding, resembling, according to Dr. Hope, the 
word awe whispered in inspiration, and will be most distinct over the ventricle 
into which the regurgitating current from the aorta is directed, though it may 
also be heard for some distance up the aorta. These two murmurs, succeeding 
each other, may be considered as a sure sign of conjoined contraction and in- 
sufficiency of the aortic orifice. Secondly, in relation to the mitral valve, 
obstruction is indicated by a diastolic murmur, heard over the left ventricle, 
very feeble and low-toned in consequence of the weakness of the auricular 
contraction and the depth of the valve, and compared by Hope to the word 
who, whispered feebly. Insufficiency, producing regurgitation, is attended with 
a louder sound of the same character, is systolic, and may be heard near the 
apex of the heart, but does not, like the semilunar murmur, extend far up the 
aorta. Thirdly, the same rules apply to the murmurs of the right side of the 
heart, those namely of the pulmonary semilunar valve, and the tricuspid. 
They are usually higher toned than those of the left side, because nearer the 
surface. They will be sought for of course along the direction of the pulmo- 
nary artery, or over the right ventricle. They are comparatively very rare. 
The auriculo-ventricular sounds are sometimes wanting, even when there is 
considerable constriction of the orifices, in consequence of the feebleness of 
the auricular contraction. They may occur either immediately after the sys- 
tole, along with the second sound, in which case they are produced probably, 
in chief, by the force given to the blood by the suction of the dilated ventricle, 
or immediately before the systole and after the period of repose, when the 
contraction of the auricle takes place.* 
* Some modification of these views as to the auriculo-ventricular murmurs becomes 
necessary, if we adopt the theory of the diastolic impulse. Thus, the murmur often 
heard near the apex of the heart, synchronous with the impulse, and occurring in the CLASS III.] 
DISEASES OF THE HEART. 
133 
It is often highly important to be able to decide whether a cardiac affec- 
tion is organic or merely functional. An accurate appreciation of these morbid 
sounds is valuable on this account. The pure bellows murmur is an attendant 
on both forms of disease; but when rough, of the rasping or grating character, 
it indicates usually some organic derangement of the valves. If the morbid 
sound be traced to some one of the valves, and be found constant there, it 
may be considered as an almost certain sign of structural change. The murmurs 
of regurgitation are probably in general of organic origin, though it is possi- 
ble, that regurgitation at the mitral valve may sometimes occur, from a slight 
irregularity in the contraction of the fleshy columns, consequent upon nervous 
disturbance; and the same result might readily flow from gouty or rheumatic 
irritation affecting these columns. The same may be true also of the aortic 
and pulmonary regurgitant murmurs, if, as maintained by some anatomists, 
there are muscular fibres in the semilunar valves, the irregular action of which 
may interfere with their accurate closure.* 
A sound similar to the bellows murmur is sometimes caused in the bron- 
chial tubes by the pressure of an enlarged heart. This is distinguishable 
from the proper cardiac murmur by the fact, that it may be suspended by 
holding the breath. It may serve sometimes as a sign of disease of the 
heart, but may proceed from so many other causes, that little reliance can 
be placed upon it. 
A friction or rubbing sound, analogous to that sometimes observed in pleu- 
risy, is frequently heard in disease of the pericardium, and results from the 
moving upon each other of the opposite surfaces of that membrane, rendered 
rough by the exudation of coagulable lymph. It may be distinguished from 
the similar sound of pleurisy by the circumstance, that it is not affected by a 
suspension of the respiration. When the membrane is at the same time very 
stiff and rough, it gives rise to a modification of the friction sound, which has 
been called creaking-leather sound, from its resemblance to the noise made 
by new leather. Both of these sounds have an alternating character, de- 
pendent on the double motion of the heart. They are said to be strongest 
in the systole, and after expiration. The friction sound often closely resem- 
bles the endocardial murmurs; and it is sometimes difficult to distinguish 
between them. 
A churning or washing sound occasionally results from the presence of a 
certain amount of liquid in the pericardium. All these pericardial sounds 
are more superficial than those proper to the heart itself. 
A strong pulsation of the heart- may develope the mucous and sibilant rales 
by a movement given to the air in inflamed bronchial tubes, and sometimes 
occasions the metallic tinkling in large tuberculous cavities. 
time of the first sound, instead of being regurgitant, and indicating mitral insufficiency, 
must, on the diastolic theory, be considered as a murmur of contraction, produced by 
the rush of blood through the narrowed auriculo-ventricular opening during the active 
diastole; and the remarks made in the text on the signs of constriction of the auriculo- 
ventricular openings must be looked on as inaccurate. More will be said on this point 
under the head of chronic disease of the valves. The author will at present merely 
observe that the views given in the*text are mainly those of Dr. Hope, and were proba- 
bly originally adopted by that writer as much from their conformity with his opinions 
in relation to the heart's actions, as in accordance with actual observation. They are, 
however, allowed to stand; because, though their entire accuracy is doubted by the 
author, they have high authority in their favour, and those of a different bearing still 
want the support of further investigation, and the sanction of general opinion. (Note 
to the fourth edition.) 
* See an abstract of a paper by Dr. Monneret, presented to the French Academy of 
Sciences, Oct. 16, 1849, hi the Lond. Med. Gaz., March, 1850, p. 408. 134 
[part it. 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
Sometimes along with the sounds of the heart, whether otherwise normal 
or abnormal, there is heard a peculiar musical or metallic tinkling, the origin 
of which is not well understood. A similar sound may be at any time produced 
by applying the palm of the hand to the ear, and gently striking the back 
of it with the finger. It is noticed under various circumstances, and differ- 
ent explanations have been given. (See Lond. Med. Gaz., March, 1851, p. 
536.) M. Barth has observed it in connexion with the existence of air in 
the cavity of the pleura, and the idea has been suggested that it might in 
some instances be connected with gaseous distension of the stomach. It is 
most probably produced by a quick impulse of the heart, producing vibration 
in a tense structure, as a similar sound is caused in large cavities with elastic 
walls containing air. It is of no great importance in diagnosis. 
Vascular Sounds.-A slight sound is sometimes occasioned by the motion 
of the blood in the arteries, which is very much increased by whatever 
roughens the internal surface, or produces any sudden change in the capacity 
of the vessels, whether aneurisms, or the pressure of a tumour from without. 
A watery condition of the blood very much promotes it, so much so that, in 
anemic individuals, it can be produced with great facility by merely press- 
ing the artery with the end of the finger, or the stethoscope. It is synchro- 
nous with the systole of the heart, and consequently takes place during the 
diastole of the arteries. Sometimes a double murmur is produced in the arch 
of the aorta, the first corresponding with the systole, the second with the dias- 
tole of the heart. The diastolic murmur is supposed to be produced by a 
regurgitant movement of the blood from the great arterial branches in conse- 
quence of want of due elasticity in the diseased and dilated aorta. (Belling- 
ham, Lond. Med. Gaz., Sept. 1850, p. 399.) 
M. Beau thinks he has proved that the arterial murmur, and especially 
that of the carotids, is produced whenever an increased wave of blood is 
thrown into the great vessels, in consequence of dilatation of the heart. 
(Archives Generates, 4e ser., xiv. 133.) 
In large veins, too, a peculiar murmur has been noticed, especially in ane- 
mic individuals, which received from M. Bouillaud the designation of bruit 
de diable, from the name of the humming top, the noise of which it was sup- 
posed to resemble. It may properly be called the humming sound. It is 
observed especially in the internal jugular vein; but occurs also in the ex- 
ternal jugular, in the vena innominata, and in the crural vein. (Arch. Gen., 
4e ser., xxiii. 326.) It differs from the arterial bellows murmur by being 
continuous, though it is by no means uniform, having characteristic swells 
and remissions, which correspond with the diastole and systole of the arteries. 
Occasionally it has quite a musical tone. It probably depends upon altered 
capacity of the vessel at the moment of examination, as by the tension caused 
by turning the bead on one side, and upon a deficient viscidity or abnormal 
mobility of the blood. Dr. Ogier Ward states that it may be heard in all 
children under the age of seven, and considers the watery condition of their 
blood a sufficient explanation. (Lond. Med. Gaz., May, 1851, p. 784.) 
These are either directly connected with the heart, or secondary. To the 
former section belongs the pulse, which, though dependent on the contraction 
of the left ventricle, is not, as felt at the wrist, exactly synchronous with the 
impulse of the heart, but follows it at a very slight interval. Being liable 
to all the irregularities of the cardiac pulsations, whether as to force, duration, 
or the relation to each other of the successive beats, it is highly important in 
diagnosis, and often enables us immediately to detect derangement in the 
5. General Symptoms. CLASS III.] 
DISEASES OF THE HEART. 
135 
central organ of the circulation. It is almost always more or less deranged 
in diseases of the heart. Its indications, however, must not be received 
without allowance. Intermission in the pulse is not always a sign of inter- 
mission in the contractions of the heart. It not unfrequently happens that 
an occasional ventricular contraction is too feeble to transmit an impulse to 
the arteries in the extremities. The pulse may be very weak when the heart 
appears to act tumultuously, because, though the extent of the motion is 
considerable, the force of the contraction is not great; or it may be, that the 
left ventricle may contract under certain circumstances less vigorously than 
the right; or, finally, there may be an insufficient quantity of blood in the 
left ventricle, consequent upon the retardation of the current in the pulmo- 
nary capillaries. Very frequently the heart continues to beat after all pul- 
sation at the wrist has ceased.* Other circumstances which influence the 
condition of the pulse, independently of the mere cardiac contractions, are 
the quantity of blood in the vessels, and the general tone of the system. 
These facts are sufficient to show that the pulse is not to be relied on im- 
plicitly, as an index of the state of the heart. Its relation to particular car- 
diac diseases will be treated of under those diseases respectively. 
Dyspnoea is among the most prominent and distressing symptoms of car- 
diac affection. It sometimes depends upon mere nervous disorder; but more 
frequently arises from direct interference with the functions of the lungs, 
either by pressure upon that organ, congestion, or effusion into the pulmo- 
nary tissue or the pleural cavities. 
Pain is little to be depended on as a sign, of disease of the heart. The 
most violent and fatal affections are often attended with little positive pain, 
even pericarditis and endocarditis sometimes running their course without it. 
In other cases it is very acute; and not unfrequently the patient experiences 
great distress about the praecordia, of a vague and indescribable character, 
altogether different from ordinary pain. Though thus uncertain, the exist- 
ence of pain in the region of the heart should be regarded with suspicion, 
and lead to an accurate investigation of its cause. 
Palpitations, by which are meant pulsations of the heart disagreeably sen- 
sible to the patient, are a very frequent symptom. It does not necessarily 
follow, that there should be an increase of the impulse of the heart against 
the chest. The symptom is often connected with very slight disease, and 
becomes alarming only when long continued, or associated with other signs 
of a serious import. Its existence, however, for any length of time, should 
always lead to inquiry. Palpitations will be more particularly treated of 
among the inorganic affections of the heart. 
The secondary symptoms are very numerous. They are chiefly such as in- 
dicate morbid effects of irregularities in the circulation. Either the blood is 
driven with too great a force into certain organs, as into the brain in hyper- 
trophy of the left ventricle, and into the lungs in the same condition of the 
right ventricle; or it becomes congested in various parts, from impediment to 
its passage through the heart, as in the general venous system of the body, 
including especially the viscera of the abdomen, when the impediment exists 
in the right side, or in the pulmonary vessels when in the left; or finally it is 
* These anomalies are perhaps more readily explained on the theory of diastolic 
impulse. A ventricular contraction strong enough to produce a perceptible impulse 
upon the walls of the chest, should cause a pulsation in the artery at the wrist; but 
we may easily conceive that there may be a diastolic impulse, while the systole is very 
feeble and insufficient to produce a pulse. Again, the seemingly tumultuous beating 
of the heart when the pulse is feeble may be diastolic, while the systole may correspond 
in feebleness with the movement of the artery at the wrist. [Note to the fourth edition.') 136 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
[part II. 
distributed with insufficient force, or in insufficient quantity, to the body at 
large, in consequence of debility or obstruction of the propelling organ. 
Hence the phenomena of active or passive congestion in the brain, the 
lungs, the liver, the kidneys, and the whole alimentary canal. Hence ver- 
tigo, tormenting headaches, irritable temper, epistaxis, apoplexy, pulmonary 
hemorrhage and inflammation, hepatic disease, hmmatemesis, various forms 
of disordered stomach and bowels, and an anemic state of the blood. Hence, 
too, dropsical effusion, sometimes general, sometimes in the form of anasarca 
or hydrothorax. It is not pretended that these phenomena occur in all 
cases of affection of the heart; but there is not one of them which does 
not occasionally present itself. These symptoms of course vary, according 
as the congestion is active or passive. Thus, in the former we have the 
flushed and swollen face, the prominent eye, and the general turgid state of 
system; in the latter, the pallid or livid complexion, the purple lips, the puffy 
eyelids, and the universal tendency to oedema. It has been observed, that 
the great viscera are apt to be hypertrophied in consequence of the congestion 
to which they are incident, and that this effect is produced whether the con- 
gestion is active or passive. Besides the sources of secondary disorder above 
mentioned, there is another, consisting in the pressure of the enlarged organ 
or distended pericardium upon the neighbouring lungs, and the disturbance 
of the pulmonary functions from the mere mechanical effect of the heart's 
frequently excessive action. 
It very seldom happens that the whole heart is diseased at once; and, when 
both sides are affected, one is so ordinarily in a greater degree than the other. 
In like manner, when the two cavities of the same side are diseased, they 
seldom suffer equally. Not unfrequently the disease is confined to a single 
valve, or a single cavity. 
Article I. 
INFLAMMATION OF THE PERICARDIUM, or PERICARDITIS. 
The heart includes three distinct tissues, which, though frequently inflamed 
conjointly, are nevertheless liable to be separately affected, and therefore 
require separate consideration. The tissues alluded to are the pericardium 
or investing membrane, the endocardium or lining membrane, and the inter- 
vening or muscular structure. Inflammation occurring in these several parts 
is denominated respectively pericarditis, endocarditis, and carditis. These 
affections were formerly confounded, as no means existed of discriminating 
accurately between them. Nay, the diagnostic symptoms of inflammation of 
either or all of these tissues were so uncertain, that the best informed physi- 
cians were often at a loss to determine, in particular cases, whether it existed 
or not. Even Laennec admitted the impossibility of forming a certain di- 
agnosis in pericarditis. To Louis belongs the credit of opening the way to 
a more accurate knowledge of this complaint, by the discovery of certain 
characteristic signs. Since his publication, a flood of light has been poured 
from various sources upon the subject; and we are now in possession of the 
means, not only of recognizing the existence of pericarditis, but of distin- 
guishing it with considerable certainty from endocarditis. The same, how- 
ever, cannot yet be said in relation to inflammation of the muscular tissue, 
or carditis, the symptomatology of which, as a distinct affection, is very ob- 
scure. The student, in perusing the following remarks, must not forget that, 
in many, perhaps in most cases of pericarditis, inflammation of the lining CLASS III.] 
137 
PERICARDITIS. 
membrane exists at the same time, and mingles its characteristic signs with 
those of the former complaint. 
Pericarditis is not unfrequent. It has been inferred from a vast number 
of post-mortem examinations, made in the hospitals of Paris and elsewhere, 
that about one in twenty-three of all who die at an adult age, exhibit marks 
of recent or former attacks of this disease. The proportion is probably 
greater of persons who are affected with it at some period of their lives; for 
there is reason to believe that it often occurs, in a moderate degree, without 
leaving any permanent vestiges behind it. 
Anatomical Characters.-The first effect of inflammation of the pericar- 
dium is probably to produce congestion, and consequent swelling of the sub- 
serous cellular tissue, with diminution of secretion, and dryness of the serous 
surface. But the first appearance, obvious to anatomical examination, is red- 
ness, which may be in points, or in patches or streaks of various shape and 
size, and, even in the latter case, has a somewhat punctuated or mottled cha- 
racter. Mere redness, however, unattended with effusion, cannot be consid- 
ered as certainly indicative of inflammation; for it may result from congestion 
alone, or may be cadaveric. Nor is it always observable iu cases of undoubted 
inflammation, disappearing sometimes in instances of very early death, as 
erysipelatous redness is known to do upon the skin. Very soon after the 
commencement of the attack, there is an increased secretion from the internal 
surface of the membrane. The matter secreted is sometimes almost exclu- 
sively coagulable lymph, which concretes as soon as it exudes, sometimes 
almost exclusively serum, which remains liquid; but, in the great majority of 
cases, is a mixture of the two; the coagulable lymph or fibrinous matter ad- 
hering to the surface, and the serum accumulating in the pericardial sac, with 
flocculi or shreds of the concrete matter often floating in it. 
The quantity of the liquid varies greatly, amounting, in some instances, 
to little more than three or four fluidounces, in others to as many pints. 
Generally it exceeds nine fluid,qunces. Frank mentions a case in which six 
pounds of liquid were found in the cavity. Occasionally it is limpid and 
nearly colourless; but more generally is yellowish or greenish-yellow, opa- 
lescent, of a whey-like appearance, or milky; and sometimes is of a red or 
sanguineous hue. In certain hemorrhagic states of the constitution, it is 
largely mixed with blood. In some cases, especially in the advanced stages 
or chronic form of the disease, it is sero-purulent; and rare instances occur, 
in which, from the peculiar condition of system, it is originally pus, either 
well formed and nearly pure, or in various degrees sanious and offensive. 
The fibrinous matter or lymph is at first generally in the form of a soft 
delicate film, spread over the surface of the membrane, from which it is easily 
separable; but occasionally it is deposited in distinct masses. With the pro- 
gress of the inflammation, it increases in quantity, and at the same time be- 
comes firmer and more adhesive. Its colour is usually yellowish-white, but 
sometimes pinkish or reddish-brown from the intermixture of blood. It is 
singularly arranged, not being uniformly spread over the surface, but very ir- 
regularly, presenting a reticulated or cellular appearance, which has been aptly 
compared to that produced by first bringing into contact and then separating 
two layers of soft butter, spread upon pieces of board or other solid body. 
The irregular surface of the pericardial exudation is owing to a similar cause. 
It is, no doubt, produced by the alternate meeting and separating of the cardiac 
and free surfaces of the membrane, with the alternate dilatation and contraction 
of the heart. The little prominences and depressions thus formed are alto- 
gether irregular in their shape, size, and arrangement. Thus, the surface has 
been variously compared, in different conditions of the exudation, to that of 138 
[PART II. 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
a piece of cut sponge, to honey-comb, to the interior of the stomach of a ru- 
minating animal, as seen in tripe, and to a congeries of earth-worms. Some- 
times the pericardium is studded over with soft roundish granulations, and 
sometimes exhibits innumerable slender papillary projections. 
The coating of coagulable lymph or false membrane is of various thick- 
ness, from less than a line to-nearly or quite an inch; but in general it is be- 
tween one and three lines. In some instances, it covers the whole serous 
surface of the sac, in others, is confined either to the cardiac or to the free 
surface exclusively, and in others again, is in separate patches very different 
in their extent. It is commonly thickest upon the heart. Beneath it, the 
serous membrane is usually reddened, but not always. Dr. Hope states that 
the pericardium is itself very rarely thickened, and that, when apparently so, it 
generally owes the effect to a layer of old adherent false membrane, opaque 
and of a bluish-white colour, the result of previous inflammation. Real thick- 
ening, when it occurs, is seated not in the proper serous tissue, but in the cel- 
lular or fibrous structure without it. In consequence of the softening of this 
sub-serous cellular structure, the true membrane may sometimes be peeled off 
from its natural attachment. 
The anatomical changes which take place in the course of the complaint 
are not always the same. There is reason to believe that the inflammation 
sometimes terminates before effusion has occurred, and that in other instances 
absorption of the effused matter, whether fibrinous or serous, ensues, and 
resolution is effected. But generally, when coagulable lymph has been exuded, 
at least in any considerable quantity, the course is different. When the exu- 
dation is chiefly concrete, the opposite surfaces, though they may at first separate 
to a certain extent with every contraction of the heart, gradually as the lymph 
hardens and becomes more adhesive, cohere more and more firmly, until they 
at length remain permanently united. Incipient blood-vessels, in the shape 
of red points and variously branching lines, soon show themselves in the new 
deposit, which thus by degrees becomes organized, at first imperfectly, but, 
through the agency of absorption and the consequent removal of superfluous 
matter, in the end completely, so as-to be converted into cellular tissue scarcely 
if at all distinguishable from original structure. The pericardial cavity is thus 
permanently obliterated, and the membrane sometimes appears as though it 
had never been double. 
In those cases, constituting much the greater number, in which the serous 
effusion is so copious early in the disease as to keep the opposite surfaces sepa- 
rate, adhesion is of course prevented so long as the liquid continues unabsorbed. 
But, as the inflammation abates, the process of absorption takes place, the 
amount of serum is gradually diminished, and successive portions of the 
surfaces, coming into contact, unite together, and gothrough the same changes 
precisely as those above described. Sometimes, though rarely, the coating 
of coagulable lymph becomes organized before the serum is absorbed; and 
then, after death from other causes, the surface of the heart is observed to be 
covered, in the whole or greater part of its extent, with false membrane, 
without any obliteration of the pericardial cavity. I have recently seen a 
case of this kind. 
It has been stated that the layers of coagulable lymph are sometimes partial. 
When two of these patches are opposite to each other, they coalesce, and some- 
times unite firmly, so that the sac, instead of being wholly obliterated, is di- 
vided into sections which mayor may not communicate. But, in other instances, 
the union is not firm enough to resist the separating action of the heart, and 
the plastic lymph is thus drawn out into bands or filaments, which, being con- 
verted by the organizing process into cellular tissue, continue permanent in CLASS III.] 
PERICARDITIS. 
139 
the sac. Often, however, the patches are not opposite. In such instances, 
they are equally converted into false membrane, but now form only whitish 
opaque spots, which have been frequently noticed, in post-mortem examina- 
tions, on the surface of the heart, and were at first mistaken for mere disco- 
lorations. Their nature, however, is rendered evident by dissection, by means 
of which a lamina of thin membrane may be separated, leaving the proper 
surface of the pericardium quite distinct. These white patches are of the size 
of the nail or larger, and, being the remains of former inflammation, are 
among the proofs of the frequently curable nature of pericarditis. 
Sometimes the effused liquid is only partially absorbed, and adhesion, from 
this cause, but partially effected. This is especially the case when the liquid 
is purulent, and hence pus is sometimes found, in such cases, filling the in- 
tervals of the adhesions. Again, the sac may continue long or permanently 
distended, either from defective absorption, or from the continuance of exces- 
sive secretion. In such instances, coagulable lymph continues to be deposited, 
so that the coating sometimes at length attains great thickness, exhibiting 
different layers, which have different degrees of consistence and firmness, the 
most superficial, as the most recent, being generally the softest. The first 
layer, becoming organized, serves as a secreting surface from which the next 
may proceed. Cases of this kind are apt to terminate fatally; but sometimes 
not until after a long time and various changes. The liquid is occasionally at 
length absorbed, and the opposite layers, thus brought together, form a thick 
mass, too unwieldy to admit of a perfect organization. Hence, it is converted 
into fibrous, or fibro-cartilaginous, and sometimes even into bony matter, 
which firmly embraces the heart, cramps its movements, and, by offering a 
constant stimulus to its actions, may end in hypertrophy, or, by restraining 
them, in atrophy of the organ. In tuberculous constitutions, the false mem- 
brane sometimes becomes the seat of tubercles. It appears also to be liable 
to inflammation, and has occasionally been found interspersed with purulent 
collections. 
The substance of the heart is often morbidly affected in fatal cases of peri- 
carditis, being, in relation to colour, redder, browner, or paler than in health; 
in relation to consistence, harder or softer; in relation to bulk, increased, as 
in hypertrophy with or without dilatation, or diminished, as in atrophy. 
When long surrounded by liquid, it experiences the sedative influence of 
such exposure, and becomes soft, flabby, and pale, with a great diminution of 
its energy. 
Symptoms.-1The general symptoms of pericarditis are exceedingly diversi- 
fied, being very different in different cases, and though, when occurring con- 
jointly in considerable numbers, they may serve to indicate the disease with 
an approach to certainty, yet they are very seldom conclusive, and often alto- 
gether insufficient to serve as the basis of a correct diagnosis. 
The attack is usually ushered in with a chill, which is sometimes repeated, 
and always followed by fever. It is said that occasionally the onset is marked 
by faintness or positive syncope rather than by chilliness. Among the symp- 
toms which attend the complaint, though by no means always in the same 
cases, and in some nearly or quite wanting, are pain, oppression, weight or 
other uneasiness in the region of the heart, palpitations, cough and hurried 
respiration, dyspnoea, a preference for certain positions, occasional vomiting 
and painful deglutition, headache and delirium, frequent and often irregular 
pulse, great debility, attacks of faintness approaching or amounting to syn- 
cope, restlessness, great anxiety of countenance, and oedema of the face and 
extremities. From this enumeration of symptoms no definite notion of the 140 
[part II. 
LOCAL DISEASES. -CIRCULATORY SYSTEM. 
complaint can be drawn ; and it is necessary to dwell more in detail upon 
each of them individually. 
Fever is always present, unless in very mild cases, and is attended by the 
usual signs of this affection in the phlegmasia; generally, such as frequent 
pulse, hot skin, sometimes dry and sometimes perspiring, furred tongue, loss 
of appetite, scanty urine, &c. 
The pulse is an important symptom. Dr. Todd states that an intermit- 
tent pulse, occurring when there is reason to apprehend the supervention of 
cardiac inflammation, is a very suspicious symptom, indicating the probable 
approach of either pericarditis or endocarditis. According to Dr. Williams, 
the pulse is sometimes slower than natural at the commencement; but, unless 
in the chill, such an event must be very rare. It is usually, after the fever 
has been fairly established, much increased in frequency, beating often from 
310 to 120 times in a minute, and regular. Early in the disease, it is gene- 
rally full and strong, with a sharp angry beat; but sometimes it is small and 
wiry. As the complaint advances, it very often becomes irregular, and occa- 
sionally very much so, beating rapidly for a few strokes and then slowly, with 
a sort of hobbling movement, and not unfrequently intermittent. The irregu- 
larity is sometimes temporarily developed by excitement of any kind, as by 
quick motions or mental disturbance. Towards the close, it is small and very 
feeble, sometimes scarcely to be felt; and this weakness of the pulse at the 
wrist may be observed occasionally when the heart is apparently tumultuous 
in its action. It is probable that the irregularity and intermission of the 
pulse are often owing rather to accompanying endocarditis or carditis, than 
to the proper inflammation of the pericardium. When it is exceedingly fre- 
quent and small, or peculiarly jerking, endocarditis may be strongly sus- 
pected. The different condition of the pulse at different stages of the disease 
may be considered as indicative of the condition of the cardiac muscles ; which 
are at first irritated into excessive action, as shown by the strong, full, sharp 
pulse; subsequently weakened but still irritated, causing the frequent and 
irregular pulse; and lastly, prostrated by their previous excitement, so that 
the pulse becomes more and more feeble till the close. This weakness of the 
pulse, towards the end, may also be referred in part to the cramping influence 
of the effusion, liquid or concrete, by which the heart is surrounded. Dr. 
Stokes has noticed in two cases increased action of the carotids. 
Pain is a very uncertain symptom. Sometimes it is exceedingly acute, 
shooting from the praecordia to the back between the shoulders, and extend- 
ing often to the left shoulder and down the left arm, sometimes as low as the 
elbow or even the wrist. It is often aggravated by a deep inspiration or 
coughing, by percussion, by pressure on the intercostal spaces and in the 
epigastrium, especially upwards beneath the ribs somewhat to the left of the 
middle line, by forcible stretching, and by lying on the left side. More fre- 
quently, however, sharp pain is wanting, and it has been supposed that it is 
never experienced, in its severest form, unless the pericarditis is accompanied 
with pleurisy. This, however, is a mistake; as uncomplicated inflammation 
of the pericardium has been known to occasion the most excruciating pain. 
Instead of this sharp pain, the patient very often complains only of a slight, 
dull, aching, or intermittent pain, or of indefinite uneasiness about the left 
portion of the chest, variously described as a feeling of tightness or constric- 
tion, weight, burning, or oppression, and occasionally involving, to a certain 
degree, the left shoulder or arm. In some instances, the uneasiness is refer- 
red to the epigastrium ; and cases occur in which no pain of any kind is 
experienced, nor any sensation calculated to direct attention to the heart as 
the seat of disease. The cardiac uneasiness is, moreover, sometimes masked CLASS III.] 
PERICARDITIS. 
141 
by severer pain in other parts of the body, or escapes notice in consequence 
of the delirium of the patient. When acute pain is felt, it is generally in the 
earlier stages, and is diminished upon the occurrence of effusion. 
Dyspnoea occurs in most, though not in all cases, and is sometimes very 
distressing. It is probably in part a nervous phenomenon, connected with 
derangement of the par vagum, partly the result of pressure made by the accu- 
mulated fluid of the pericardium upon the lungs. Occasionally, it is so severe, 
that the chest visibly heaves in respiration; speaking is difficult, and the 
patient is unable to rest in the horizontal position, preferring to sit, with his 
body leaning forward and towards the left side. The respiration is in general 
nearly thirty in a minute, and sometimes much more, especially in cases com- 
plicated with pleurisy or pneumonia. The irritation occasionally extends to 
the diaphragm, giving rise to hiccough, and, as it is said, to the sardonic 
laugh ; but these symptoms, as well as the vomiting, difficulty of deglutition, 
and derangement of voice which sometimes attend the disease, are with as 
much probability ascribable to the propagation of disordered impressions 
through nervous channels. 
Cough, though it may attend pure pericarditis, is not a prominent symptom 
unless in complicated cases. It is usually dry. The palpitations are often 
violent, occurring most commonly in paroxysms, which are apt to come on in 
the night, and often without apparent cause. Sometimes, however, they are 
induced by any muscular exertion, or strong mental emotion. Cerebral dis- 
order is not unfrequent, being exhibited in headache, disturbed sleep, fright- 
ful dreams, or delirium; and these symptoms are so severe, with so little 
obvious cardiac disease, that they have sometimes been referred to inflamma- 
tion of the brain, and the heart quite overlooked, though dissection has 
proved the former organ to be sound, and the latter only affected. 
A disposition to syncope has been supposed to be characteristic of pericar- 
ditis. It no doubt occasionally exists, and fainting is sometimes probably 
the immediate cause of death; but it is by no means a constant symptom. 
Great restlessness, jactitation, anxiety of countenance, and general prostration 
are phenomena of bad cases, and especially mark the close of the disease. 
The peculiar anxious expression is sometimes observed when there is no pain 
or other local uneasiness to account for it, and has been ascribed to a nervous 
influence, propagated through the pneumogastric nerve to the brain, and 
thence transmitted to the muscles of the face. 
(Edema, though more common in the chronic form of the disease, is some- 
times observed in the acute, affecting more especially the lower extremities, 
and owing, in all probability, to the ineffectual action of the heart in the ad- 
vanced stages, and the consequent venous congestion. 
The blood in pericarditis almost always presents, when drawn from the 
arm, the buffy coat and cupped surface of inflammation, in a high degree; 
and is not apt to lose this character even after copious depletion. 
Physical Signs.-These are such as depend either 1. on simple excitement 
of the heart, 2. on accumulation of liquid in the pericardium, or 3. on the 
friction of the roughened surfaces of the membrane upon each other. 
1. In consequence of irritation propagated to the muscular tissue from the 
inflamed membrane at the outset, the ventricles contract with increased 
energy; and, consequently, both the sounds of the heart are louder, and its 
impulse stronger than in health, and than they are subsequently in the dis- 
ease. The impulse, however, though regular in its recurrence at this period, 
is often unequal in the relative strength of the successive pulsations. 
2. When the effusion is considerable, dulness on percussion is always ob- 
servable to a greater extent than in health; and, as the cause is very com- 142 
[part II. 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
mon, the sign is highly characteristic. It is not usually perceived, at the 
commencement of the disease, nor until it has continued for two, three, or 
four days; though, in some instances, a copious effusion is one of the first 
effects, and dulness consequently one of the earliest signs. In extreme cases, 
it may extend from the edge of the false ribs to within two or three inches of 
the clavicle, and occupy a space seven and a half inches in height, and nine 
inches across at the base of the heart. (Louis.) Sometimes the diaphragm 
is depressed by the distended sac, and the stomach and liver displaced. But 
such instances are extremely rare. When the effusion is moderate, it is best 
discovered by placing the patient in a sitting posture; because, when upon bis 
back, the fluid is separated by gravitation from the anterior wall of the chest. 
The dulness is distinguished from that of pleurisy by its position, and its 
definite outline, and sometimes from that of hypertrophy with dilatation by 
extending more in the vertical direction. Allowance must be made for tur- 
gescence of the heart, which, in the early stage, may occasion some increase 
of dulness. 
Other signs dependent upon the same cause are the absence of the respi- 
ratory sounds over the region of the heart, where they are observed in health, 
and a diminution of the cardiac sounds, which are feeble and seemingly dis- 
tant, in consequence of the intervening liquid, and are sometimes scarcely 
perceptible. But the second sound may be heard with considerable distinct- 
ness over the upper part of the sternum, in the course of the pulmonary 
artery and aorta, because these parts are uncovered, and the sound is gene- 
rated at the valves of these arteries. The impulse of the heart is also much 
diminished, and sometimes its pulsations cannot be felt at all. When strong 
enough to be perceptible, they may often be observed to change their posi- 
tion in consequence of the free movement of the heart in the fluid of the 
pericardium, and impart an undulatory sensation to the hand, occasioned by 
the wave of the fluid as it is displaced with every systole. Dr. Latham says 
that this undulating motion is often visible to the eye between the cartilages 
of the second and third, or of the third and fourth ribs, or both at the same 
time; but he has never seen it in any other place. (Leet, on Clin. Med., &c., 
i. 133.) A common effect of copious effusion into the pericardium is, by 
pressing the heart backward and upward, to raise the point of impulse and 
move it somewhat to the left, so that the stroke is felt behind or even to the 
left of the nipple, when the patient is on his back. ( Walshe.) Still another 
sign dependent upon the effusion of liquid is a prominence of the chest at the 
praecordial region, observable by the eye. This occurs later than the dul- 
ness, as it requires a greater amount of fluid for its production. It is often 
absent; and is most apt to take place in the young, in consequence of the 
greater flexibility of their cartilages and ribs. Avenbrugger noticed a swelling 
at the epigastrium as one of the symptoms of the disease; but this is rare. 
Most of these signs were pointed out by Louis, who thus made a vast advance 
in the diagnosis of pericarditis. But they will not always answer; for the 
condition upon which they depend, that namely of a certain amount of effu- 
sion, does not always exist. 
Another sign dependent upon the effusion is a sort of churning sound, 
which is occasionally produced in the liquid by the movements of the heart. 
3. Happily, another set of signs is afforded by cases in which the preceding 
are not observable. They are the rubbing sounds, produced by the friction 
of the inflamed surfaces against each other. Attention was first called to the 
existence of these sounds by M. Collin, but they have since been much more 
accurately and thoroughly investigated by Dr. Stokes and other observers. 
They are supposed to depend upon the roughness of the opposed surfaces CLASS III.] 
PERICARDITIS. 
143 
produced by the coagulable lymph, sometimes possibly upon their dryness in 
the commencement of the disease. They are almost always double, from the 
double motion of the heart; and may be triple or even quadruple as the con- 
tractions of the auricles are capable also of producing them. (Pennock.') 
They are generally more distinct with the first cardiac sound.* They vary 
considerably in character, according to the roughness of the membrane, and 
probably also its stiffness or consistence, as well as to the energy of the 
heart's contraction. The ordinary form is that denominated simply friction 
sound, which is very similar to the friction sound of pleurisy, and is some- 
times so soft as to resemble the bellows murmur. The harsher forms are 
designated sometimes by the epithets grating, rasping, &c. Occasionally 
the sound imitates the rustling of crumpled parchment. As the varying 
circumstances which modify the sound may all exist in the same case, so may 
also the different varieties of the sound. As first observed by M. Collin, it 
had a creaking character like that made by new leather, and this form of it 
is hence called the creaking-leather sound. 
The friction sound is not heard at the very commencement of the inflam- 
mation, but usually becomes sensible early in the disease, when the pericar- 
dial surfaces are not yet separated by liquid effusion, nor contracted adhesion. 
It is then owing either to the dryness of the membrane, or the thin coating 
of coagulable lymph, and generally, in all probability to the latter. When 
the effusion is slight, the sound should be sought for about the base of the 
heart, near the centre of the sternum. Adhesion of the pericardium, or 
separation of its surfaces by the liquid effused, soon abolishes it more or less 
completely. Sometimes it may be made to return, after having ceased, by 
causing the patient to lean forward, and thus throw the fluid towards the 
apex. When lost in consequence of adhesion, Williams states that it is last 
heard below the left breast. The sound is occasionally audible only over par- 
ticular portions of the pericardium, independently of adhesions or the presence 
of fluid. Hence it has been inferred that the membrane is liable to partial 
inflammation; and the same inference has been drawn from the white patches 
now and then observed upon the heart; but, though the fact may be true, it 
requires other proofs than those mentioned; as the whole membrane may be 
inflamed, and yet concrete exudation take place only in parts of it. 
The friction sound, lost in consequence of copious effusion, is again heard 
after the liquid has been so far absorbed as to permit the surfaces to come 
once more into contact. But here again its duration is brief; for the sur- 
faces soon contract adhesions, and cease to move upon each other. It is, 
therefore, to be sought for in the earlier, and in the somewhat advanced 
stages of pericarditis, and answers an admirable purpose as a supplement to 
the signs derived from effusion, being present more especially under the cir- 
cumstances in which these are wanting. 
There is some risk, unless with due attention, of confounding the friction 
sounds with the valvular murmurs which indicate the existence of endocar- 
ditis. Skoda states that, according to his experience, there is no endocardial 
murmur, except the whistling, which may not be imitated by a friction sound; 
and he knows no distinctive sign except that the internal murmur corresponds 
with the rhythm and the natural sounds of the heart, while the external follow 
its movements. (Treat, on Auscult. and Percus., Bond, ed., p. 219.) But the 
friction sounds are more superficial than the endocardial, are rougher, espe- 
* If the diastolic impulse be admitted, the first friction sound would occur during 
the active dilatation and the immediately succeeding systole, while the second would 
be confined to the period of slow passive dilatation from the vis a tergo. In this view 
the greater distinctness of the former can be readily understood. 144 
[part II. 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
cially when coincident with the second sound of the heart, are more apt to 
change their position, and are inaudible at the distance of two or more inches 
up the pulmonary artery or aorta, where the murmurs of the sigmoid valves 
are heard distinctly, and are not, like the murmurs of the auriculo-ventricular 
valves, uniformly loudest near the apex of the heart. (Graves, Hope, Stokes.'') 
Besides, along with the friction sound, there is often a vibratory tremor dis- 
tinctly felt by the hand placed over the region of the heart; and this is said 
by Dr. Hope to be generally stronger than the analogous thrill, sometimes 
attendant, in a slight degree, upon the valvular murmurs. (Treat. on Dis. of 
the Heart, Am. ed., p. 182.) Dr. Stokes observed it in five out of six cases. 
He considers, as an important diagnostic character between the friction sound 
and the valvular, the fact that the former is very rapidly modified and often 
removed by local treatment, as by leeching or cupping, which has compara- 
tively little effect upon the latter. Another distinction is that the friction 
sound is increased by pressure, which has no effect on the endocardial 
murmurs. (Sibsoni) 
Dr. Latham declares that the friction sound is in general not altered nor 
abolished by the effusion of serum; and that it may often coexist with the 
dulness, and is sometimes even preceded by it. By change of the position of 
the patient, the cardiac surface may generally, however great the effusion, be 
brought at some point or another in contact with the free surface, and thus 
give rise to friction. He ascribes this remarkable difference of the relation of 
the friction sound to the dulness in pericarditis and pleurisy, to the firmness 
of the heart contrasted with the yieldingness of the lungs. (Lectures on Clin. 
Med., &c., i. 129.) 
There may be some danger of confounding the friction sound with the 
mucous rales of bronchitis in the parts of the lungs lying over the heart; but 
the latter cease when the breath is held, while the former continues unabated. 
When the friction is strong, it may absorb the natural sounds of the heart, 
and thus lead to the suspicion that these are wanting. But the latter may 
always be perceived, under such circumstances, by applying the instrument to 
the upper part of the sternum. 
The loudness and roughness of the friction sound must not be taken as a 
measure of the amount of plastic exudation; as with a weak action of the 
muscles, there may be little of the sound though the exudation is copious. 
Dependent on the same cause as the friction sound are the parietal vibra- 
tions, which communicate a thrilling sensation to the hand applied to the chest 
over the region of the heart. 
It has before been stated that, in a very large proportion of cases, endocarditis 
coexists with pericarditis. In these, of course, both the friction sounds and 
valvular murmurs will be produced, though the latter may often be masked by 
the former. In relation to the valvular murmurs as signs of inflammation of 
the endocardium, more will be said under that disease. One cause, probably, 
of the frequent coincidence of these two affections is the thinness of certain 
parts of the cardiac walls, as in portions of the right auricle, and around the 
orifices of the aortic and pulmonary valves, where the investing and lining 
membranes come very nearly in contact, so that inflammation may readily 
pass from one to the other. 
Air has, in some very rare instances, been found to exist in the pericardial 
cavity, being either secreted, or introduced from the stomach or lungs by a 
fistulous opening. It produces crackling, coughing, and metallic sounds very 
different from those ordinarily noticed, and sometimes so loud that they can 
be heard at a great distance. (Stokes, Dis. of Heart and Aorta, p. 37.) 
When adhesion of the pericardial surfaces has taken place, there are no CLASS III.] 
PERICARDITIS. 
145 
signs by which it can always be certainly recognized. Dr. Hope considers a 
peculiar jogging motion of the heart as characteristic of it; but his views upon 
this point are not generally admitted. When there is, at the same time, ad- 
hesion between the external surface of the pericardium and the pleura ante- 
riorly, the obscurity is not sO'great. The heart, as observed by Dr. Williams, 
is then tied to the chest, in contact with which it must remain, whatever may 
be the motions of the ribs. Its movements, therefore, may be seen, and its 
impulse felt more distinctly than under ordinary circumstances, the intercos- 
tal space being drawn in at each contraction; and the site and distinctness of 
the pulsation, and the dulness on percussion, do not vary with the position of 
the patient, nor with the respiratory movements. Dr. Sanders has observed, 
in cases of close adhesion, each contraction of the ventricle to be attended by 
a depression in the left portion of the epigastrium^ and such an event may be 
readily conceived to occur, if the pericardium shall have also contracted ad- 
hesions posteriorly. According to Skoda, this is not true of the epigastrium, 
at least he has not seen it; but, when the lower half of the sternum is retracted 
during the systole, it is a certain sign of adhesion of the pericardium to the 
heart, and to the vertebral column also. Skoda states, as the result of his 
observation, that the apex of the heart gives no systolic beat in pericardial 
adhesion, being prevented from moving downward and to the left, and drawn 
on the contrary to the right and upwards. (See Ed. Month. Journ. of Med. 
Sci., July, 1852, p. 82.)* 
Course and Termination.-In some violent cases, the disease has been 
known to run its course in a very short time, and to terminate fatally in less 
than forty-eight or even thirty hours. But such instances are'extremely rare. 
Sometimes it is of a moderate grade and protracted march, running on for 
several weeks, without, however, entirely losing its acute character. But, in 
ordinary cases which terminate favourably, the disease generally begins to 
yield in the course of a week or ten days, and sometimes much sooner under 
active treatment. The fluid now begins to be absorbed, as shown by the 
diminishing dulness, the increasing sounds of the heart and respiration, the 
returning friction sounds, &c.; adhesion soon follows; and the cure is com- 
pleted in less than three weeks. In slight cases, there is good reason to believe 
that the cure may take place still sooner, and without adhesions. If about 
to prove fatal, the complaint is marked with great general weakness, oppres- 
sion, and anxiety; the pulse is very frequent, small, feeble, irregular, and at 
length scarcely to be felt; the extremities are cold; the face is pale, wan, and 
haggard, with purple lips; delirium not unfrequently comes on; and life at 
last closes, sometimes in the midst of convulsions. Occasionally, death occurs 
suddenly, without any premonition, under circumstances in which there was 
no apparent danger of such an issue. It is probably always the result of a 
direct loss of power in the muscles of the heart. 
Symptoms of Chronic Pericarditis.-Under the name of chronic pericar- 
ditis are included long-protracted cases of the acute disease which have lost 
their original violence, and certain other cases of a slow progress, which have 
been of the same mild grade from the beginning. These are often attended 
with pain, either dull or sharp, in the vicinity of the heart, sometimes extend- 
ing to the left shoulder or arm; but the pain is in general only occasional, and 
seldom very severe. Not unfrequently, too, the patient is without pain, and 
complains only of oppression, stricture, or weight. There is usually more or 
less shortness and quickness of breath, and disturbance of pulse, the latter 
* This retraction of the apex of the heart during the systole seems confirmatory of 
the diastolic theory of the impulse. 146 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
[PART II. 
being somewhat more frequent than in health, and often irregular, but almost 
always feeble and irritated, rather than strong and active. It is occasionally 
hectic. The breathing is sometimes so much oppressed that the patient lies 
down with difficulty. Prominence over the region of the heart, dulness on 
percussion, absence of the respiratory sounds, distance and feebleness of those 
of the heart, and deficiency of impulse, are even more constant symptoms than 
in the acute form. The friction sound may also be occasionally heard. The 
face is usually pale and puffy, and the lips purplish; and I have seen the 
whole surface of the same dark hue. An anasarcous condition of the extremi- 
ties is very common. The patient is not usually confined to his bed; and 
often continues for months, sometimes better and sometimes worse, until at 
length the disease takes a favourable turn, or carries him off. Death, when 
it occurs, is often sudden. ^The disease may terminate in three or four months, 
or may run on much longer. 
The only affections with which this is likely to be confounded are dilata- 
tion of the heart, and dropsy of the pericardium. The former is usually 
attended with an extended and peculiar impulse, and even increased loudness 
of the cardiac sounds, and never with the noise of friction. When the car- 
diac muscles, however, are very feeble, the contractions may scarcely be 
sufficiently strong to produce sound. In such cases, the very gradual origin 
and very slow progress of the disease, will be sufficiently diagnostic. Dropsy 
of the pericardium is without local pain or febrile action, and may usually be 
distinguished by the coexistence of a universal dropsical tendency, of which 
this is only one of the results. 
The anatomical peculiarities of chronic pericarditis have already been de- 
tailed. Its causes, so far as they can be distinguished from those of the 
acute form, are an impoverished or depraved condition of the blood, feeble- 
ness of the general powers of the system, and a scrofulous or tuberculous 
diathesis. Tubercles are occasionally found in the pericardial tissue. 
Causes of Pericarditis.-The ordinary causes of inflammation are capable 
of producing it in the pericardium. One of the most frequent direct exciting 
causes is exposure to cold, when the body is warm and perspiring. Direct 
mechanical violence, fatiguing muscular effort, strong mental excitement, the 
abuse of stimulating drinks, suppression of hemorrhages or other morbid 
discharges, the retrocession of erysipelas or other eruptive affections, may 
also produce the disease. I have seen it result apparently from the cure of 
psoriasis by local applications. It is an occasional attendant on the exanthe- 
matous fevers. But pericarditis occurs more frequently, beyond all compari- 
son, as an attendant upon acute rheumatism, than from any other cause, or, 
perhaps, all others unjted. It is asserted by some of the highest authorities, 
that at least one-half of the cases of acute rheumatism are accompanied with 
pericarditis, endocarditis, or with the two conjointly. Of 136 cases of acute 
rheumatism observed by Dr. Latham, 18, or between a seventh and an eighth 
of the whole number, were affected with pericarditis, either alone or in con- 
nexion with endocarditis. (Leet, on Clin. Med., i. 144.) It has been dis- 
puted whether the cardiac affection in these cases is the result of metastasis, 
or is simply a part of the rheumatic disease. This appears to me to be very 
much a dispute about words. In rheumatism, it is well known that different 
parts, whether internal or external, are often affected successively, the inflam- 
mation leaving one seat as it fixes itself in another. It is also well known 
that many parts are often affected simultaneously. So it is in the case before 
us. Sometimes the rheumatic inflammation, when it seizes the membranes 
of the heart, is relieved in the limbs; and under these circumstances is said 
to be the result of metastasis. Sometimes it exists conjointly with the ex- CLASS III.] 
147 
PERICARDITIS. 
ternal affection, and occasionally may even precede it. Though the connexion 
between rheumatism and pericarditis has long been known in Great Britain 
and this country, yet the profession is undoubtedly indebted to Bouillaud, in 
a considerable degree, for our p»esent much more precise knowledge of the 
subject. Formerly the disease was supposed to be only an occasional inci- 
dent in the course of rheumatism; now it is known to be a very common 
accompaniment. Pleurisy and pneumonia probably often give rise to peri- 
carditis by the direct propagation of inflammation from tissue to tissue. It 
is not unfrequently associated with Bright's disease of the kidneys, and has 
been ascribed to the ureous impregnation of the blood attendant on that 
affection. The disease appears also to have sometimes occurred epidemically 
in confined localities. 
Among the predisposing causes, age must certainly be counted. The dis- 
ease is much more prevalent in early than in advanced life. Persons between 
eight and thirty-five are thought to be peculiarly predisposed to it. Sex also 
has some influence. Men are more frequently affected than women. The dis- 
ease is more apt to attack persons of vigorous constitution than the feeble and 
delicate. The rheumatic and gouty diathesis, convalescence from exanthe- 
matous diseases, especially scarlatina and erysipelas, and the existence of 
hypertrophy and dilatation of the heart, are undoubtedly predisposing causes; 
and the same is asserted of pregnancy and the puerperal state. 
Diagnosis.-The diseases with which pericarditis may be most readily con- 
founded are endocarditis, pleurisy, pneumonia, and pleurodynia. From the 
first it may be distinguished by the dulness on percussion, the prominence of 
the chest, the absence of the respiratory sounds, and the faintness or distance 
of those of the heart, or, in case of the want of these signs, by the existence 
of the friction sounds and the purring tremor, and the absence of the valvu- 
lar murmurs. From pleurisy it is distinguished by the more precise outline 
and peculiar position of the dulness, and its not changing with the posture of 
the patient, by the situation of the friction sounds, which accompany the 
heart's actions and not the movements of respiration, and by the absence of 
aegophony. Pneumonia may occasion dulness on percussion in the same re- 
gion, but it is without the projection of the chest, the friction sound, and the 
altered cardiac sounds; while it presents symptoms of its own not found in 
pure pericarditis, such as the rusty and viscid sputum, the crepitant rale, and 
the bronchial resonance and respiration. Pleurodynia is without any of the 
physical signs mentioned as characteristic of pericarditis, and is also usually 
unattended by some of the most prominent of its general symptoms, such as 
chill and fever, anxiety of countenance, oppression, irregular pulse, faintness, 
&c. The only coincident symptoms are acute pain, tenderness on pressure 
between the ribs, and difficulty of respiration. It must be great carelessness 
which would confound the two affections. 
But some embarrassment might be experienced in distinguishing pericardi- 
tis, when associated, as it often is, with the febrile phlegmasiae above men- 
tioned, especially with pleurisy and pneumonia of the left side. In the case 
of complication with pleurisy, the existence of the pericardial inflammation 
would be indicated by the friction sound over the heart existing independently 
of respiration. If this should be wanting, the general symptoms would aid 
much in deciding the point. Thus, should pain be felt over the heart, dul- 
ness and prominence exist in that region, and the cardiac sounds be feeble 
and distant, though these signs might arise from pleurisy, yet, if the pulse 
were very frequent and irregular, the countenance very anxious, and a tend- 
ency to syncope, with palpitations and distressing dyspnoea observable, there 
would be every reason to suspect the existence of pericardial inflammation. 148 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
[PART II. 
In pneumonia, a coexisting pericarditis would be indicated by the friction 
sounds, prominence of the praecordia, a greater degree of flatness on percus- 
sion here than elsewhere, and by faintness and remoteness of the cardiac sounds. 
The general symptoms would here also aid the diagnosis. Indeed, the super- 
vention of increased fever, with an irregular pulse, oppression, dyspnoea, palpi- 
tation, &c., in a case of pectoral inflammation, would afford strong ground for 
suspecting that pericarditis had set in, and should lead to a careful physical 
examination of the heart. In cases, too, of apparent cerebral affection, and 
of general inflammatory rheumatism, the practitioner should always be on 
his guard, and allow his attention to be directed to the praecordial region by 
the occurrence of the slightest symptom of a suspicious character.* 
Prognosis.-This is generally favourable., The disease was formerly con- 
sidered very dangerous, because recognized only in its worst forms. In the 
great majority of cases, it is a mild affection, and often wholly escapes notice 
in cases of inflammatory rheumatism, getting well under the treatment ad- 
dressed to the disease in general. Not unfrequently, in all probability, it 
would subside spontaneously, like so many other inflammations, under a pro- 
per regimen, as relates to diet, rest, &c. Simple cases of pericarditis rarely 
prove fatal. It is when complicated with pleurisy and pneumonia, that it 
becomes so dangerous as it has generally been supposed to be. There is no 
doubt, however, that, even in its simplest form, it is capable of destroying life, 
and, therefore, requires prompt and energetic treatment. It is most fatal 
when supervening upon organic affections of the heart, and occurring in per- 
sons worn out by previous disease. 
It may always be considered very dangerous when attended with a very 
frequent, irregular pulse, great dyspnoea, large effusion in the pericardium, 
and the general signs of imperfectly circulated, and badly aerated blood. 
There are two modes of favourable termination, one and the most favoura- 
ble in resolution, the other in adhesion. Some authors, however, have main- 
tained that adhesion is only a temporary cure; and that sooner or later it 
almost always, if not always, leads to dangerous and even fatal lesions of the 
heart. Dr. Hope strenuously advocated this view. He believed that, among 
other effects, in consequence of the constant struggle of the muscles of the 
heart under the constraint of the adhering membrane, hypertrophy and all 
its terrible results ensue. This may be true in relation to some of those cases 
in which the effusion of coagulable lymph has been very copious, and in 
which only an imperfect organization has been effected into a stiff, fibrous, or 
fibro-cartilaginous envelope. But I am quite convinced that it is not true as 
a general rule; and the opinion is combated by some of the best French au- 
thorities. Louis and others have observed in their dissections numerous in- 
stances of old pericardial adhesions, in persons who have died of other com- 
plaints, and in whom there was no suspicion whatever of cardiac disease 
during life; and at present the weight of authority, even in Great Britain, is 
in opposition to the views of Dr. Hope. Pericardial adhesion is probably 
scarcely less innocent in relation to the heart, than the pleuritic is in relation 
to the lungs. 
Treatment.-Bleeding is undoubtedly the most important remedy in the 
* A case is recorded in the Dublin Quarterly Journal of Medical Science (viii. 241), in 
which a rough crackling friction sound, heard over the region of the heart, and accom- 
panying the motions of that organ, was supposed, in connexion with other symptoms, 
to indicate the existence of pericarditis, but after death was found to depend on emphy- 
sema of the anterior mediastinum. The pericardium was perfectly free from inflam- 
mation. The sound was produced by the pressure of the dilating heart upon the 
emphysematous structure. (Note to the third edition.') CLASS III.] 
PERICARDITIS. 
149 
earlier stages of acute pericarditis. Yet it is not to be employed indiscrimi- 
nately and unsparingly in all cases. Great loss of blood indirectly stimulates 
the heart. The blood is rendered so thin and watery that it is incapable, as 
ordinarily distributed, of supplying the wants of the system; and such are 
the sympathies of the heart, that a sense of this deficiency, transmitted every- 
where from the periphery of the circulation to the nervous centre, excites, on 
every occasion calling for an increased expenditure of blood, excessive action 
in that organ, in order, by a more rapid current, to compensate for the defect- 
ive quality of the fluid. Hence, any existing tendency to hypertrophy or 
dilatation is greatly promoted; and one of the very objects aimed at, that, 
namely, of quieting the heart, defeated. It is certainly possible to push the 
depletion beyond the point of reaction; but this would scarcely be safe, in 
reference to immediate results. Besides, when the pericarditis depends on 
rheumatism, as it usually does, bleeding alone will not generally subdue the 
inflammation ; and the heart is thus left to struggle with the irritation of the 
disease, and the indirect irritation of the remedy. There is, under such cir- 
cumstances, should the patient survive, great danger of organic disease of the 
viscus. These are not arguments against blood-letting, but only against its 
abuse. The application of the remedy is to be guided exactly upon the same 
principles as in other cases of serous inflammation. The stimulating quality 
of the blood should be reduced by depletion, and the direct sedative effects of 
its loss upon the heart obtained, without pushing it to the point calculated to 
promote reaction. The theory which urges to any amount of risk, in order 
to avoid the terrors of adhesion, should not be allowed the least weight. 
From a robust individual of previously unimpaired health, and at or near 
the commencement of the attack, from twelve to twenty-four ounces of blood 
may be taken at first, and the operation repeated, one, twice, or oftener, during 
the three or four succeeding days, if justified by the strength of the pulse, 
and the unchecked progress of the disease. After the first bleeding, which 
ought to be carried so far as to produce a decided impression on the.pulse, but 
without inducing syncope, it is usually advisable, upon the recurrence of the 
excitement, to attempt its reduction by cups freely applied over the region of 
the heart, so as to abstract from eight to twelve ounces. The general bleed- 
ing can afterwards be repeated if this should not be found to answer. In 
persons debilitated by previous disease, or ordinarily of a delicate or anemic 
constitution, blood must be drawn more sparingly; and, in many cases of this 
kind, it is best to rely upon local depletion by means of cups or leeches. It 
is generally advisable, after cups, or leeches, to cover the praecordia with an, 
emollient poultice, care being taken to protect the moistened surface from ex- 
posure to cold air. 
At the commencement of the treatment, the bowels should be thoroughly 
evacuated by some active cathartic, as, for example, by three or four compound 
cathartic pills, or a dose of infusion of senna with sulphate of magnesia, or 
from ten to fifteen grains of calomel, followed in a few hours by castor oil or 
Epsom salt. Afterwards, throughout the complaint, it will be sufficient to 
keep them open once or twice daily by saline laxatives or enemata if necessary. 
After reducing sufficiently the excitement of the pulse by depletion, and 
thoroughly evacuating the bowels, we are next to have recourse to mercury 
with the view of affecting the system. This is inferior only to the lancet in 
importance, and, in certain cases in which the propriety of depletion may be 
doubtful, will bear off the palm even from that remedy. The union of opium 
with the mercurial is beneficial, not only by obviating any tendency which 
the remedy may have to run off by the bowels, but also by restraining the 
violence of the heart's action. In pericarditis, every contraction of the heart 150 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
[part II. 
tends to aggravate the disease, by keeping the inflamed part in motion. Opium 
renders it in some measure insensible to the irritation from the inflamed mem- 
brane, and consequently has a tendency to diminish the frequency of its con- 
tractions. During the existence, however, of the fever, it is best to qualify 
its stimulant action by combining it with a nauseating diaphoretic. These 
various indications will be met by giving from two to four grains of calomel, 
or from eight to sixteen grains of mercurial pill, with half a grain or a grain 
of opium, and double the quantity of ipecacuanha, every four hours. Or, the 
mercurial may be given with the opium alone, and, instead of the ipecacuanha, 
small doses of tartar emetic, as the eighth or sixth of a grain, may be given 
every hour or two. Should the skin be hot and dry, a tablespoonful of the 
neutral mixture, or a dose of the effervescing draught, or from five to ten 
grains of nitre, may be given with each dose of the antimonial, or without it 
if ipecacuanha should be preferred. In conjunction with these measures, 
hot pediluvia may be employed daily. So soon as the gums are affected, the 
quantity of the mercurial should be moderated; but the impression should 
be sustained for ten days or two weeks, or until convalescence is established. 
Should difficulty be experienced in affecting the gums, the external use of 
mercury maybe conjoined with the internal; and, for this purpose, a drachm 
of the mercurial ointment may be rubbed upon the insides of the extremities 
once or twice in the day, and any blistered surface that may exist may be 
dressed with it daily. The course here recommended is applicable to severe 
cases. Should the symptoms be mild, the mercurial should be employed more 
sparingly; and in very slight cases it may be omitted. 
After three or four days, should effusion have taken place, a large blister 
should be applied over the praecordia, and repeated, after the surface heals, 
if the symptoms continue. It is often proper in this stage, when there may 
be some uncertainty as to the sufficiency of the reduction, to apply cups or 
leeches again; and this may be conveniently done between the shoulders, in 
order to avoid interfering with the blistered surface. 
At this period of the disease, also, colchicum will sometimes be found use- 
ful, when the complaint is of rheumatic origin. Should the pulse be very 
frequent, it may be proper to control it by means of digitalis. To meet the 
two indications, when coexistent, twenty or thirty drops of the wine of colchi- 
cum root, and ten or fifteen of the tincture of digitalis, may be given every 
four hours; and, in cases of much nervous irritation, the addition of one of 
the narcotic tinctures, as that of hyoscyamus or conium, in pretty full doses, 
.may be beneficial. Aconite, camphor, and hydrocyanic acid have been re- 
commended, under similar circumstances. 
Perfect rest of body and composure of mind, throughout the complaint, are 
of the utmost importance. The patient should be sedulously guarded from the 
influence of causes calculated to excite him in any way; and all unnecessary 
persons, therefore, should be excluded from the apartment. The diet should 
in the early stage consist of mucilaginous or farinaceous liquids, and animal 
food should be avoided up to the period of convalescence. Cooling drinks 
should be given throughout the complaint. 
Should the disease assume a chronic form, it will be necessary to sustain a 
slight mercurial impression; to keep up a constant succession of blisters over 
the heart; to apply occasionally, in case of pain, a few cups or leeches between 
the shoulders; and, when the effusion is copious, to employ the diuretics, 
especially squill, digitalis, and bitartrate of potassa. Some have recommended, 
instead of blisters, pustulation by tartar emetic, or the employment of a seton 
or issue; but it is very doubtful whether these are in any respect preferable 
to the former remedy. Bouillaud applies ten grains of the powder of digitalis CLASS III.] 
ENDOCARDITIS. 
151 
daily to the blistered surface, when the heart continues to act excessively; 
but the remedy requires very cautious watching, lest it produce too great de- 
pression. Dr. Joy proposes turpentine in quantities sufficient to induce irri- 
tation of the urinary passages, in order to promote the absorption of the effused 
coagulable lymph; and states that iodide of potassium has been used advanta- 
geously with the same view. The alkaline carbonates and bicarbonates are 
also occasionally employed. Narcotics are often required, in connexion with 
the other remedies, to control nervous irritation, to relieve pain, and produce 
sleep. The diet must vary with the condition of the patient. When the 
system is debilitated and the blood impoverished, animal food should be per- 
mitted; and it may sometimes be advisable to allow a cautious use of the fer- 
mented liquors. 
In cases originally of a chronic character, the same general plan of treat- 
ment may be employed; but in these cases moderate venesection may be occa- 
sionally called for; care being always taken not to induce an anemic condition 
of the blood. The remedy, however, upon which our main reliance must be 
placed is mercury, judiciously but perseveringly employed. The mercurial 
pill is usually preferable to calomel under these circumstances, as less liable 
to disturb the stomach and bowels. 
Article IL 
INFLAMMATION OF THE ENDOCARDIUM, or ENDOCARDITIS. 
Endocarditis is inflammation of the interior or lining membrane of the heart. 
For much of what is known of the disease, we are indebted to M. Bouillaud. 
Others were aware of the fact, that the inner surface of the heart is sometimes 
the seat of inflammation; but the frequency of the affection, its rheumatic 
origin in most cases, and its fatal influence in the developement of organic 
changes in the heart, were first clearly ascertained by the author mentioned. 
Anatomical Characters.-Inflammation leaves behind it, in the internal 
membrane of the heart, much less prominent characters than in the external. 
The reason of this is obvious. Exuded fibrin, serum, and pus, the ordinary 
results and evidences of inflammation, are in this affection generally carried 
away from the diseased surface, as fast as thrown out or generated, by the 
incessant current of the blood. Hence, perhaps, it was, fhat endocarditis so 
frequently escaped the notice of pathological anatomists. Redness was visible; 
but this, being frequently the result of cadaveric imbibition, or of the same 
process in the last stages of life, has now long been considered as in itself but 
a very equivocal proof of the existence of inflammation, and certain only when 
accompanied with other evidences. These, however, though not very obvious, 
have revealed themselves to the more careful search of recent observers; and 
the frequent existence of endocarditis is now universally admitted. 
Redness in points, arborescent ramifications, or patches gradually fading 
into the general hue of the membrane, may be observed more especially about 
or upon the left valves, and not unfrequently extending into the aorta. The 
reddened membrane is often thickened, in consequence either of turgescence 
of the proper endocardial tissue, or by effusion beneath it; is sometimes also 
softened, and occasionally presents roughness, inequality, or a whitish opacity 
of the surface. Concrete fibrinous matter, notwithstanding the current of the 
blood, may generally be found in small quantities, either adhering to the 
valves and the membrane in their neighbourhood, or entangled in the meshes 
of the columnae carneae. [Bouillaud.') Sometimes it exists in the form of a 152 
[part II. 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
filmy layer, but more frequently in granulations, from the size of a small shot 
to that of a pea. These granulations are either of crude lymph, or in various 
stages of organization; and are supposed to be the origin of the fungous or 
warty excrescences, called vegetations, which have often been observed in the 
same position. Watson speaks of them as disposed generally upon the semi- 
lunar valves, in the shape of two crescentic rows, one on each side of the 
central corpus aurantii, and extending thence to the point of insertion of the 
valve. These curved lines correspond with the edge of the fibrous structure, 
which is inclosed within the fold of serous tissue'constituting the valves, but 
does not reach to the full extent of the duplicature, and leaves, consequently, 
a small portion of the membrane thinner and translucent, like the section of 
a plano-convex lens, the two points of which terminate respectively at the 
central corpuscle, and the place at which the valve is inserted. The rubbing 
of these thin portions of membrane against each other, at every closure of the 
valve, appears to displace the lymph that may be effused upon their surface, 
and to cause it to accumulate, in the lines alluded to, like a festoon of minute 
beads. In the auriculo-ventricular valves, upon the same authority, the ex- 
udation is arranged either in the shape of serrations upon the free edge of the 
laminae, or in a continuous line near it. In more advanced cases, the laminae 
of the valves are sometimes seen adhering to the surface of the heart, some- 
times to one another by their edges; causing in the former instance imperfect 
closure, and in the latter more or less obstruction. Besides being deranged 
in the modes above described, the valves are liable to be puckered up, and in 
various degrees distorted, and their tendons to be contracted, so as to interfere 
with the free movement of the blood through them, or, from imperfect closure, 
to admit of its regurgitation. 
Another source of embarrassment to the circulation in endocarditis is the 
formation of fibrinous coagula directly from the blood, which are supposed 
to contract adhesions to the lining membrane, at any accidentally rough or 
prominent point, and may be seen twisting about the fleshy columns, and 
valvular tendons. (Bouillaud.) These are of various magnitude, whitish, 
elastic, and adhesive, analogous to the buffy coat of inflammatory blood, and 
apparently capable of an imperfect organization. Indeed, Laennec ascribed 
the origin of the warty vegetations, before mentioned, to these coagula. 
They are stated sometimes to inclose a nucleus of exuded fibrin. Dr. Ger- 
hard considers them as more frequently the cause than the effect of endocar- 
ditis, and ascribes- their origin to that highly fibrinous condition of the 
blood which characterizes inflammatory diseases generally. (Tweedie's Syst. 
of Pract. Med., Am. ed.) Sometimes they are so attached as to be movable 
in the cavity, and may thus at one time interfere with the passage of the 
blood, and at another leave the valvular openings free. In this way we may 
account, in part, for the fact, that the sounds which indicate derangement of 
the valves are not always constant, even in cases of permanent organic dis- 
ease; and that the most alarming symptoms of cardiac obstruction, in cases 
of heart disease, sometimes suddenly come on, or as suddenly disappear, 
without any discoverable cause. 
It is said that ulceration, and even gangrene, have been observed as the 
result of acute endocarditis. But the former is exceedingly rare, and the 
existence of the latter in any case doubted. In chronic disease of the heart, 
ulcers are now and then seen upon the inner surface, which have been sup- 
posed to have their origin in some accidental rent or abrasion of the mem- 
brane, as from the separation of calcareous incrustations. 
It is believed that the fibrinous sub-serous exudation, which takes place in 
acute inflammation of the endocardium, is sometimes converted, in protracted CLASS III.] 
ENDOCARDITIS. 
153 
cases, into dense, fibrous, cartilaginous, or bony structure, and thus produces 
permanent disease of the valves. Sometimes patches of a similar exudation 
upon the surface of the membrane become organized, and occasion whitish- 
opaque spots similar to those before noticed as occurring upon the outer sur- 
face of the heart, and capable of being detached by dissection, without affect- 
ing the integrity of the membrane. 
General Symptoms.-These are very nearly the same as those enumerated 
under pericarditis, and, as in that affection, are insufficient for the positive 
diagnosis of the disease, though they may lead to the suspicion of its exist- 
ence, and thus induce an examination by the stethoscope. It will be neces- 
sary here to notice only those which are somewhat characteristic. At an 
early period, before the valves are much affected, there may be frank open 
fever, with a pulse strong, full, and excited, without being extraordinarily 
frequent. At no period is there severe pain, unless the affection is compli- 
cated with pericarditis or pleurisy; and, according to Bouillaud, pure endo- 
carditis is in no degree painful. There is, however, almost always more or 
less uneasiness about the region of the heart, and a feeling of anxiety which 
is often expressed upon the countenance of the patient. When the valves 
have become so much thickened, or in other modes deranged, or coagula have 
formed so largely as to interfere with the proper movement of the blood, a 
new and alarming train of symptoms sets in. Stimulated not only by the 
inflamed membrane, but also by the impediments offered to the circulation, 
the heart contracts with excessive rapidity, so that the pulse not unfrequently 
amounts to 140, and occasionally reaches 150, or even 160 in the minute. At 
the same time, though the heart appears to act quite'tumultuously, the pulse 
is extremely small and feeble. It is often also unequal and irregular, with 
occasional intermissions, which, however, are not always dependent upon a 
correspondent intermission in the cardiac pulsations, but upon a deficiency 
in the quantity of blood expelled from the ventricle. Another condition of 
the pulse is sometimes observed, which is connected with the existence o. 
regurgitation through the aortic valve. The impulse produced by the sys- 
tole of the ventricle is propagated to the artery at the wrist with unimpaired 
force; but this is not sustained as in health by the entire effect of the elas- 
tic contraction of the aorta, which is now partly expended in a backward di- 
rection. The blood, therefore, appears suddenly to glide away from beneath 
the fingers; and the pulse has a peculiar quick, jerking feel, somewhat cha- 
racteristic of this condition of the heart. When either the excessively fre- 
quent, or this peculiar jerking pulse, occurs in a case of pericarditis, it may 
be strongly suspected that the inner membrane is also inflamed. 
Various other symptoms result from the altered movement of the blood in 
the heart. They proceed from two distinct sources, namely, from a deficient 
supply of arterial blood to the system at large, and from a congestion of the 
venous blood. The contracted or otherwise obstructed orifices do not permit 
enough blood to pass them; or, if the defect be an insufficient closure of the 
valves and consequent regurgitation, that which has passed them returns in 
part upon its course, and consequently is not distributed in ordinary propor- 
tion through the body. The same causes which impede the onward move- 
ment of the arterial blood, occasion an accumulation of the venous blood 
behind; and hence congestion in the right cavities, in the lungs, in the great 
venous trunks, and in fact in all the great organs, and to a certain extent in 
the whole venous system. Hence, in the worst cases, great debility, faint- 
ness sometimes amounting to syncope, an almost cadaveric paleness or livid- 
ness of the surface, cold sweats, extreme anxiety, great restlessness and jac- 
titation, and a most distressing sense of impending suffocation. The venous 154 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
[PART II. 
blood in the brain sometimes occasions mental wandering, drowsiness or stu- 
por, and even convulsions; the same cause in the portal circle gives rise to 
various evidences of gastric and hepatic derangement; and the universal ve- 
nous congestion produces in the end a more or less general oedema. 
In some cases, however, it is asserted that most of these symptoms have 
occurred without any signs of mechanical impediment to the circulation, and 
merely in consequence of imperfect or deranged innervation. 
Physical Signs.-Early in the disease, the impulse of the heart is felt 
much more strongly, and to a greater extent over the chest, than in health; 
and this strong impulse often continues after the pulse has become small and 
weak. At length, however, the muscular power of the organ is exhausted, 
and the impulse becomes feeble. 
There is usually a greater extent of dulness on percussion than in health, 
sometimes, according to Bouillaud, over twice as great a space. This is pos- 
sibly owing in part to a turgescence of the walls of the heart, but probably 
much more to a distension of the cavities by the accumulated blood. The 
dulness in this case may be distinguished from that of pericardial effusion, by 
the sounds of the heart being louder and less distinct, and by the impulse 
being more superficial, as well to the sight as the touch, synchronous with 
the first sound instead of fluctuating, and confined to one spot, instead of 
moving from point to point of the chest. Nor is there, in this case, complete 
absence of respiration in the region of the heart. 
But incomparably the most valuable physical sign is the bellows murmur. 
This is usually perceived in a prolongation of the first sound, and, when com- 
bined with symptoms of an acute febrile disease, uneasiness in the prsecordia, 
palpitation, and a frequent small pulse, all occurring in a person previously 
in good health, may be considered as quite characteristic of endocarditis. If 
rheumatism exist at' the same time, there can scarcely be a doubt as to the 
nature of the complaint.* The murmur proceeds, in these cases, from partial 
obstruction or defective closure of the valvular orifices, or from both causes 
conjoined. There is reason to believe that a spasmodic contraction of the 
columnar carneae, attached to the auriculo ventricular valves, may sometimes 
contribute to the production of the sound, by preventing a closure of the 
orifices during the systole of the ventricles. But, with the symptoms above 
mentioned, such a contraction would itself be an evidence of inflammation of 
the lining membrane. The murmur is sometimes soft, sometimes in various 
degrees rough or harsh, and sometimes musical. It is occasionally so power- 
ful as entirely to mask the ordinary sounds. Both sounds of the heart may 
be attended with the murmur in the early stages; but, when the cavities have 
become greatly congested, the second sound may be nearly or quite lost, and 
regurgitation cannot take place in a sufficient degree to occasion a murmur. 
In the general remarks upon the morbid cardiac sounds, the reader will find 
* The reader, however, must bear in mind the fact, that the bellows murmur is an 
almost constant attendant on anaemia, and, when this condition of the blood exists, can- 
not be admitted as a sure sign of endocarditis, unless attended with other symptoms indi- 
cative of that affection, such as those mentioned in the text.-[Note to the second edition.) 
There is another possible source of endocardial murmur, which is worthy of consider- 
ation, though not sufficiently established by positive proof to justify' us in allowing it at 
present great practical weight. It is well known that the blood is very highly fibrinous 
in acute rheumatism, and is consequently disposed to deposit fibrin. Now it is not im- 
possible that, in many of the supposed cases of endocarditis, as indicated by the valvular 
murmurs, the phenomenon may be due simply to such a deposition of fibrin on the 
surface of the valves, without any inflammation whatever. See remarks on this subject 
by Mr. Simon, in the .American Journal of Medical Sciences, N. S., xx. 477, extracted 
from the London Lancet.-[Note to the third edition.) CLASS III.] 
155 
ENDOCARDITIS. 
some rules for ascertaining whether the murmur is from a contracted passage 
or from regurgitation, and in which of the valves it may be seated. But great 
dexterity in auscultation, and an acute ear, are necessary for a correct deci- 
sion ; and after all, the points to be decided are of no great practical import- 
ance; for they do not affect the treatment. In the great majority of cases, 
the murmurs have their origin in the left cavities of the heart, which may 
therefore be considered as the most frequent seat of endocarditis; and it has 
been observed that, in relation to the different valves, the aortic and mitral 
are simultaneously affected in by far the greater number of cases, and, when 
they are separately affected, that the mitral is much more apt to suffer than 
the aortic. (Barclay, Medico-Chirurg. Trans., xxxv. 10.) 
It has been before stated that this affection is very often associated with 
pericarditis. Their coexistence may generally be inferred, if the valvular mur- 
murs are heard in connexion with the signs peculiar to the latter disease. 
Causes.-These do not materially differ from the causes of pericarditis, to 
the account of which, therefore, the reader is referred. Occasionally endo- 
carditis occurs as an original affection; but it is much oftener an accompani- 
ment or the result of other diseases. The complaint with which it is most 
frequently associated is, beyond all comparison, acute rheumatism. It is 
more common in this affection even than pericarditis, though the two are fre- 
quently connected. The cause of this association is probably, in part, the 
intervention only of a little fibrous matter in certain parts of the heart, espe- 
cially in the vicinity of the valves, between the external and internal mem- 
branes, thus allowing a ready communication of disease from one to the other; 
but it is probable also that both are often simultaneously attacked, in conse- 
quence of their equal susceptibility to rheumatic inflammation, just as two 
joints suffer at the same time. Of one hundred and thirty-six cases of acute 
rheumatism observed by Dr. Latham, seventy-four were affected with endo- 
carditis (L'ect. on Clin. Med., i. 144); but, as that author considers the bel- 
lows murmur, occurring in acute rheumatism, a sure sign of inflammation of 
the endocardium, his evidence as to the frequency of the affection may not be 
implicitly received by all; for the bellows murmur is an ordinary accompani- 
ment of a certain condition of the blood, which may sometimes attend 
rheumatism; and there is reason to believe that fibrin may be deposited on 
the valves without inflammation in certain highly fibrinous states of the blood; 
so that the murmur alone, without other symptoms of endocardial affection, 
might be deemed an uncertain sign. Pleurisy and pneumonia are sometimes 
accompanied with endocarditis; and some of the very worst cases of the dis- 
ease occur as a consequence of phlebitis, the inflammation being propagated 
directly along the lining membrane of the veins to the heart. Mechanical 
violence is probably less apt to induce the interior than the exterior inflam- 
mation ; but cases of endocarditis are said to have arisen from paroxysms of 
excessive coughing, and from violent muscular efforts, producing a rupture of 
the valves. According to Dr. Copland, the disease is not rare in infancy, 
occurring either as a primary affection, or as a sequel to one of the exanthe- 
mata. Organic diseases of the heart predispose to it. The presence of urea 
in the blood is supposed to occasion the several cardiac inflammations, which 
are therefore not unfrequent attendants on disease of the kidneys interfering 
with the excretion of that principle from the circulation. 
Prognosis.-Endocarditis generally ends in recovery, if not complicated 
with pleurisy, pneumonia, &c. Under proper treatment in the early stages, 
it may usually be brought to a favourable issue in a week or less. The ces- 
sation of the valvular murmurs is important as an indication of perfect cure. 
Should these remain after the subsidence of the febrile symptoms, they must 156 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
[part II. 
be regarded with solicitude, as indicative of continued derangement of the 
valves; unless, indeed, they may be accounted for by the existence of anaemia. 
Violent cases, especially those of a complicated character, sometimes end in 
death in the course of a few days. It is supposed that coagula may in such 
instances form in the cavities of the heart, and thus arrest the circulation. 
Cases, however, with very threatening symptoms, occasionally run on for 
weeks before reaching a fatal termination. Extreme frequency, smallness, 
feebleness, and irregularity of pulse, violent palpitations, distressing dyspnoea, 
and syncope or a frequent tendency to it, are unfavourable symptoms. 
Upon the whole, the worst result of endocarditis is chronic alteration of the 
valves. It does not follow, however, that cases in which the bellows murmur 
remains, after the disappearance of the acute symptoms, will necessarily be 
attended with permanent valvular disease. On the contrary, the exuded 
lymph is often gradually absorbed, and the disease ends in perfect recovery. 
But sometimes it is otherwise ; and the permanent embarrassment of the cir- 
culation, consequent upon the valvular derangement, leads ultimately to the 
most fatal lesions, such as hypertrophy and dilatation, and all their terrible 
consequences. Neglected rheumatism is apt to have this termination. 
From the observations of Dr. Kirkes, of London, there is reason to believe 
that endocarditis occasionally acts in another and hitherto scarcely suspected 
mode in producing serious disease, especially of the brain. Portions of the 
fibrinous deposit or exudation, as the case may be, detaching themselves from 
the valves or surface of the heart, appear to be carried with the current of 
the blood, and are sometimes of sufficient size to block up arteries of con- 
siderable size, and thus give rise, in the parts supplied by the artery affected, 
to all the consequences of a defective supply of blood. Softening of the brain 
and hemiplegia have resulted from this cause. (Lond. Medico- Chirurg. Trans., 
xxxv. 281.) 
Treatment.-This is almost precisely the same as in pericarditis; though it 
is probably even more important than in that affection alone to have early re- 
course to the lancet and mercury. It is unnecessary to repeat the several 
remedies and their succession, which were recommended under the head of 
pericarditis, to which the reader is referred. 
An important point in the treatment of endocarditis is not to consider the 
patient safe, so long as the bellows murmur continues; and hence the pro- 
priety of continued watchfulness in such cases. To produce absorption of the 
effused lymph, and in the mean time to control the excessive action of the 
heart, are the prominent indications; and these are to be met by the per- 
severing, but at the same time very cautious use of mercury and digitalis. 
These may be continued for many months if requisite, with occasional inter- 
missions, care being taken never to push the mercurial influence beyond the 
slightest observable effect upon the gums. The preparations of iodine may 
also be employed to promote absorption. Rest, low diet, and mental quietude 
are important auxiliaries. But another caution, of very great moment, is that 
the practitioner should not mistake the bellows murmur of anaemia for that 
of organic valvular disease; for in the former affection mercury would be in- 
jurious, and an invigorating instead of reducing regimen is necessary. It is 
also important that, in the treatment of real chronic endocarditis, he should 
not carry depletion to a point calculated to produce anaemia. Much judgment 
and prudence are often necessary to enable the practitioner to steer a correct 
course between these difficulties. CLASS III.] 
157 
CARDITIS. 
Article III. 
INFLAMMATION OF THE HEART, or CARDITIS. 
By the term carditis is now generally understood inflammation of the mus- 
cular and intermingled cellular tissue of the heart. That this affection occa- 
sionally takes place, dissection has abundantly proved. It is evinced by the 
softening of the muscular fibre, with a dark-red and livid or a pale-grayish or 
yellowish discoloration, and the presence of pus. It is, however, an exceed- 
ingly rare event, to find the whole heart thus affected. One case is recorded 
in the Medico-Chirurgical Transactions for 1816 by Mr. Stanley, in which 
the whole muscular tissue was of an intensely dark red, or almost black colour, 
much softened and easily separable, and the ventricular walls infiltrated with 
a bloody pus. There was, at the same time, exuded coagulable lymph on the 
surface of the pericardium. But cases of partial inflammation are not very 
uncommon. Numerous instances are on record of small abscesses in the sub- 
stance of the heart, of the size of a bean, hazel-nut, &c. It has been supposed 
by some that these abscesses are metastatic. Occasionally they may be so; 
but generally they are attended with unequivocal marks of local origin. 
Ulcers of greater or less depth have also frequently been observed. These 
may sometimes result from the opening of abscesses, but they much more 
frequently commence upon the surface, and almost always upon the internal 
surface. Instances have occurred, in which they have completely perforated 
the walls of the heart, so as to allow of the escape of the blood into the peri- 
cardial cavity. They have also sometimes perforated the septum, and have 
been supposed, under these circumstances, to occasion cyanosis, in consequence 
of the mixture of the black and red blood. But this is not a necessary con- 
sequence ; for, as the two sides act simultaneously, unless the opening be very 
large, the pressure upon the two columns of blood will force each forward in 
the channel open to it, with little or no admixture. Should there be any 
difference in the force of the pressure, it must certainly be in favour of the 
left ventricle, so that any change of the current would probably be from the 
left to the right side. 
The evidences of inflammation above mentioned are unequivocal. But not 
unfrequently portions of the heart exhibit increased redness or other discolor- 
ation, with softening or induration of the muscular tissue, without purulent 
infiltration, abscess, or ulceration; and, as these characters have been observed 
as the result of inflammation in other muscles, they are probably so in this, 
though the conclusion has not been universally admitted. A fact, very strongly 
confirmatory of their inflammatory nature, is their occurrence in cases of peri- 
carditis and endocarditis, in the more superficial part of the muscle in contact 
with the inflamed membrane; while the interior of the muscular wall is sound. 
There are, however, instances of softening, which, as they exhibit no other 
sign of inflammation, and occur especially in feeble cachectic states of the 
system, are probably dependent upon diseased nutrition rather than upon in- 
flammatory action. Induration, supposed to be the consequence of chronic 
inflammation, has been repeatedly noticed; and sometimes the muscular tissue 
has degenerated, possibly under the influence of the same process, into some- 
thing like cartilage or even bony matter. 
Wherever inflammation of the substance of the heart has been observed, it 
has, thus far, been almost always associated with the same condition either of 
the investing or the lining membrane, or of both together. Such an affec- 158 
[part II. 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
tion as independent carditis, of any considerable extent, has not yet been 
proved to exist. 
The symptoms of carditis are, therefore, necessarily intermingled with those 
of pericarditis and endocarditis. Nor can they be discriminated. When 
signs of proper cardiac inflammation have been observed after death, there 
have generally been, during life, pain in the prsecordia or epigastrium, a fre- 
quent, irregular, fluttering pulse, much dyspnoea, anxiety, faintness, and great 
prostration, with cold sweats, &c. Sometimes death has been very speedy, 
sometimes protracted. It is highly probable that the peculiarly irregular and 
feeble pulse so often an attendant upon pericarditis and endocarditis, occasion- 
ally depends on inflammation of the substance of the heart, which is thus 
necessarily much disturbed in its actions. It is not impossible that the sud- 
den death which sometimes occurs in these affections may be the result of an 
acute carditis; the muscles of the heart losing their power of contraction, just 
as those of the intestines, which are equally involuntary muscles, are known 
to do under similar circumstances. 
The physical signs are equally fallible with the general symptoms, in the 
diagnosis of proper carditis. All pathologists agree as to the impossibility of 
distinguishing it from the membranous inflammations. It may, however, be 
suspected to exist, when, along with other symptoms of cardiac affection, the 
pulse becomes very frequent, irregular, intermittent, and fluttering, with faint- 
ness, dyspnoea, anxiety, and prostration, without any bellows murmur indica- 
tive of endocarditis and consequent obstructions in the heart, and without 
the signs of considerable pericardial effusion. 
The causes of carditis are the same as those of pericardial and endocardial 
inflammation. Persons in whom the evidences of the affection have been 
discovered upon dissection have usually been the subjects of rheumatism. 
In relation to the treatment, there is absolutely nothing in which it differs 
from that of the two affections mentioned. Indeed, it would not be amiss, 
in a practical point of view, to treat of pericarditis, endocarditis, and carditis 
as the same disease, under the name of inflammation of the heart; but the 
nicety of modern pathology requires that discrimination should be made; 
and, if we cannot better cure the disease, we are likely at any rate to have 
more precise ideas as to its nature and effects; and ultimately, perhaps, even 
therapeutics may be benefited. 
Article IV. 
CHRONIC VALVULAR DISEASE. 
Chronic disease of the valves of the heart is frequent, and of very serious 
import. Those of the left side are much oftener affected than the right. 
From an examination of four hundred cases of valvular disease, Dr. Hope 
inferred that the proportion of disease in the right valves was about one in 
twenty. Dr. Glendinning found it once in every sixteen cases, out of a hundred 
which came under his notice. The causes of this discrepancy are not very 
obscure. The greater power of the left ventricle must cause a greater strain 
upon the valves, and, in relation to the auriculo-ventricular valves, the mitral, 
being accurately closed, while the tricuspid is supposed to remain partially 
open during the systole, may feel the strain in a still greater degree.* It is 
* It is denied by Valentin that the tricuspid valve is thus imperfect in its action. He 
declares, as the result of careful experiment, that its several laminae are exactly 
adapted to each other in the systole of the ventricle, so that frequently not a drop of 
blood escapes into the auricle. (Lehrbuch des Physiol, des Menschen, Band. i. s. 425.) CLASS III.] 
159 
CHRONIC VALVULAR DISEASE. 
known, too, that the left side of the heart is much more liable to endocarditis 
than the right, and this affection is a copious source of valvular derangement. 
Possibly the greater predisposition to inflammation may be owing, in part, to 
the more stimulating character of the blood of the left cavities. The fibrous 
tissue in all parts of the body is peculiarly susceptible to the sort of degene- 
rations with which the valves of the heart are most commonly affected; and, 
as this tissue is more abundant about the left than the right valves, because 
required to support the greater muscular action, it follows that the former 
will be more subject to disease than the latter. Sometimes valvular derange- 
ment exists in both sides at the same time; in which case, it is almost always 
worst in the left. Of the several valves, the aortic have been said to be most 
frequently diseased, next the mitral, and after these the tricuspid; those of 
the pulmonary artery being very rarely affected. But from a table prepared 
by Dr. E. L. Ormerod, it appears that, in 132 cases, the mitral valves were 
diseased in 104, the aortic in 85, the tricuspid in 14, and the pulmonary in 
6. (Lond. Med. Gaz., March, 1851, p. 507.) 
Anatomical Characters.-1The morbid changes in the valves or their ori- 
fices are numerous. They may be merely thickened without any other alter- 
ation of structure, and retaining the natural consistence. This is the least 
serious of their diseases, and, unless followed by other changes, is usually of 
no great importance. Their edges may unite together by adhesive inflam- 
mation, so as very much to narrow the aperture through which the blood 
passes. Their laminae may, from the same cause, contract adhesions with 
the neighbouring surface, and thus prevent the possibility of closure. The 
tendinous cords and fleshy columns with which the valves are connected, 
sometimes become shortened and thickened, and sometimes elongated; in the 
former case injuriously restraining their motion, in the latter permitting them 
to move too freely. In either case, the orifice is not accurately closed. 
But a much more frequent affection is a degeneration of the fibrous tissue, 
which enters into the structure of the valves, and forms a sort of ring about 
their openings, thus giving them strength, and affording a tendinous attach- 
ment for the muscles. This undergoes the same changes as are often ob- 
served in the same tissue in other, parts of the body. It is first thickened 
and indurated, and afterwards converted successively into fibro-cartilage, 
proper cartilage, and something similar to bone. The orifices are thus dimi- 
nished in various degrees by proper cartilaginous or osseous rings, or by 
irregular masses projecting from their edges; and the laminae of the valves 
become stiffened, and not unfrequently very much distorted, so that they are 
no longer susceptible of accurate adaptation, and therefore cannot fully close. 
At first, the surface of the serous membrane external to these morbid struc- 
tures is quite smooth, and the membrane may even be separated from the 
cartilage unaltered. But the growth appears at length to become irregular, 
giving a rough, tuberculated, or variously corrugated outline to the new tis- 
sue, and causing prominences of a corresponding shape upon the serous 
surface. Instead of this conversion of tissue, there is not unfrequently a 
deposition underneath the serous membrane of new matter, generally of a 
calcareous character, either in the form of small plates, or of irregular gra- 
nules, which in some instances coalesce so as to form considerable masses. 
In consequence of the pressure of this foreign matter, the membrane occa- 
sionally inflames, and is ulcerated or absorbed, leaving the calcareous surface 
bare. Steatomatous matter is sometimes deposited instead of calcareous, 
producing ulceration, and sometimes considerable destruction of the valves. 
In some cases, these conversions of tissue and depositions are confined to the 
fibrous tissue about the orifice, in others to the valvular laminae; sometimes 160 
[PART II. 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
affecting exclusively the base of the valves or their free border, leaving the 
central portions sound, and sometimes the whole structure. The stiffness 
and brittleness of the altered tissues cause the valves occasionally to give 
way to the force of the blood, and thus fissures and ruptures are produced. 
Ulcers, too, arise from the inflammation excited by the prominent morbid 
masses, and cause openings through the valvular laminae, or even separate 
them partially from their connexions, so as to cause them to hang loosely in 
the heart's cavity. 
Excrescences, as remarked under endocarditis, frequently form upon the 
surface of the valves, or neighbouring parts, sometimes few and isolated, 
sometimes thickly studding the membrane, of all dimensions, from that of a 
minute granule to the size of a pea, or even a large bean, and occasionally 
clustering so as to form irregular cauliflower tumours. Some of these are 
soft and fleshy, others warty and almost cartilaginous. Their colour is 
whitish, or presents some tint of yellow, gray, or red. They are apt to 
arrange themselves preferably along the edges of the valves, or at their base. 
The surface of the membrane beneath them is often diseased; and their for- 
mation is probably owing either to exudation from this surface, or to the 
adhesion of fibrinous coagula formed directly from the blood. 
Another organic affection of the valves is atrophy or wasting of their tis- 
sue, which sometimes proceeds so far as to reduce them almost to a gauze- 
like texture, and occasions openings through them, by which the blood is 
permitted to pass, and regurgitation thus produced. 
When the heart is much dilated, the valvular openings are enlarged in the 
same proportion; but it sometimes happens, from their morbid state or other 
cause, that the valves themselves retain their original dimensions, and are 
thus insufficient to effect complete closure of the orifices. 
Causes.-The causes of these valvular affections are different. The most 
common is undoubtedly inflammation, either acute or chronic, and generally 
of rheumatic origin, or connected with granular disease of the kidneys. 
From this cause probably arise hypertrophy and adhesions of the valves, the 
various conversions of the fibrous tissue, and most of the excrescences upon 
the surface. Sometimes, however, the cartilaginous and bony degenerations 
appear to be independent of inflammation, occurring under the same influ- 
ences as those which produce ossification of the .arteries, especially in old 
people. Calcareous depositions have, no doubt, occasionally at least, the 
same origin as the chalk stones in the joints of persons long subject to 
gouty affections. Excessive and continued action of the heart, by straining 
the valves, has a tendency to produce hypertrophy and induration of their 
tissues, if not ultimately the cartilaginous and osseous conversions. Violent 
straining or other excessive muscular effort occasionally produces rupture of 
the valves or their tendons, and especially when the tissue has been pre- 
viously rendered brittle by disease. Finally, an impoverished condition of 
the blood, or other depravation of health, may give rise to atrophy of the 
valves; though it is not impossible that this condition may also sometimes 
proceed from inflammation. Dr. Williams states that he has observed this 
condition in the greatest degree upon the right side of the heart, in which 
inflammation is least common. 
Effects.-A moderate degree of disease of the valves may exist without 
materially impairing their efficiency, and consequently without giving rise 
to any serious results. This may continue indefinitely with little or no 
change, or may increase more or less rapidly, and occasion at last the most 
distressing and fatal consequences. 
The office of the valves is to open before the current of the blood passing CLASS III.] 
161 
CHRONIC VALVULAR DISEASE. 
in the legitimate direction, and to close against its return. If unable to per- 
form this duty, it is clear that they must occasion serious disturbances in the 
circulation. In the first place, contraction of the orifice, or any morbid de- 
rangement or change in the structure of the valves which impedes the passage 
of the blood, must produce accumulation in the cavities and vessels behind 
the point of impediment, while the supply is morbidly deficient to all the 
parts in front of it. Thus, constriction of the mitral valve must occasion 
congestion of the left auricle, of the pulmonary veins, and, if considerable, 
even of the pulmonary arteries, the right cavities, and the whole venous sys- 
tem; while the left ventricle, receiving less of the blood than is essential to 
the due performance of its office, is deficiently stimulated, and consequently 
falters in its actions, and the whole arterial system suffers. So also constric- 
tion of the aortic orifice, or any impediment there, causes congestion of the 
left ventricle, and may occasion, when considerable, a somewhat deficient 
supply to the arteries generally; but the ventricle is stimulated to increased 
contraction by the presence of the unusual quantity of blood, and is thus 
enabled, when the constriction is moderate, to obviate the latter consequence 
in a great degree. 
Secondly, an imperfect closure of the valves, when it is their duty to close, 
must allow regurgitation of the blood, and thus, in a different manner, pro- 
duce the same results as constriction, namely, accumulation behind and defi- 
ciency in front. Besides, it brings forces to bear upon parts which they were 
not intended by nature to act upon, and necessitates new modifications of 
these parts, either as the direct result of the pressure, or in order to enable 
them to sustain it. Thus, insufficiency of the mitral valve must permit the 
force of the left ventricle to bear in some measure upon the walls of the left 
auricle, where, as well as in the lungs, the right cardiac cavities, and the 
veins generally, there must be accumulation; and, just in proportion to the 
excess of blood in this direction, must be its deficiency in the arteries. A 
similar condition of the valves of the aorta occasions regurgitation from that 
artery into the left ventricle during its diastole, resulting both from the elas- 
tic contraction of the aortic coats, and the active expansion of the heart. The 
ventricle is thus congested, and peculiar effects are produced upon the arteries 
by the sudden collapse of the current after its first vigorous impulse. 
It is easy to conceive what must be the result of similar changes in the 
valves of the right side of the heart, and the complicated effects of coexisting 
derangements of the different valves, or dissimilar derangements of the same; 
for it is very possible, and, indeed, not unfrequently happens, that a con- 
tracted aperture and imperfect power of closure exist in the same structure. 
But the irregularities of the circulation thus prodpced are not the only, 
nor the worst effects of diseased valves. The increased stimulus applied to 
the muscles of the heart, and the increased pressure within its cavities, give 
rise to excessive growth of the one, and excessive distension of the other; in 
other words, to hypertrophy and dilatation. These are almost uniformly, 
sooner or later, the result of any considerable disease of the valves, and con- 
sequently very much complicate the morbid effects which flow directly from 
that cause. These affections and their modes of production will be considered 
in a subsequent article. 
General Symptoms.-The general symptoms of diseased valves are so inti- 
mately associated with those of hypertrophy and dilatation, that it is difficult 
if not impossible, accurately to discriminate between them, or to decide, in all 
cases, how much is to be attributed to the one, and how much to the other 
cause. I shall, therefore, postpone a full account of the symptoms until we 
reach these latter diseases. There is no doubt, however, that disease of the 162 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
[PART II. 
valves is capable, of itself, and before the production of hypertrophy or dila- 
tation, of giving rise to obvious morbid phenomena, among which are the 
results of sanguineous congestion on the one hand, and of a deficiency of blood 
on the other. Very often the patient complains of some pain or uneasiness 
about the region of the heart, extending, not unfrequently, to the left shoul- 
der and arm, and occasionally even to the fingers. In some cases, this pain 
is lancinating and severe, occurring in paroxysms, similar to the attacks of 
angina pectoris; but this is probably owing less to disease of the valves than 
to coexisting neuralgia of the heart. Perhaps, most frequently, it is only a 
vague sense of oppression, which is converted into positive pain, with a feeling 
of weight or tightness at the sternum, upon any considerable excitement of 
the heart from muscular exertion or other cause. There is usually also more 
or less dyspnoea, and occasional palpitation, which are rendered more obvious, 
and sometimes distressing, by any considerable exercise, such as running, or 
ascending heights. The pulse is often much deranged; and this is among 
the first symptoms by which attention is called to the state of the heart. The 
character of the pulse, however, varies much with the valves affected. Upon 
this point, the remarks of Dr. Hope are valuable. According to that author, 
in disease of the mitral valve, whether it impedes the flow of blood by con- 
traction, or allows of regurgitation from imperfection, the pulse is "in vari- 
ous degrees small, weak, irregular, intermittent, and unequal." This, indeed, 
might be inferred to be the case, from the diminished supply of blood to the 
left ventricle in the one case, and the retrogression of a portion of it in the 
other. In very great contraction of the aortic valves, the pulse is sometimes 
small, weak, and irregular; but in general it continues full, regular, and of 
due strength, in this affection. Regurgitation of the aortic valves is attended 
with a peculiar jerking pulse, the stroke being at first quick and strong, but 
rapidly receding as it were from the fingers, in consequence no doubt of the 
backward movement of the blood at the origin of the aorta. Sometimes the 
pulse not only has the jerking character just mentioned, but, as stated by Dr. 
Corrigan, may be seen beating in various parts of the body. Dr. Williams 
considers this phenomenon, in its highest degree, and especially when it is 
observable in all states of the circulation, as characteristic of aortic regurgi- 
tation. Disease of the right valves has no direct effect upon the pulse. 
Disease of the valves, when attended only with the symptoms above enu- 
merated, may be considered serious, chiefly from the probable indication which 
it affords of approaching disease of the proper structure of the heart.. In its 
advanced stages, if it advance at all, the symptoms become much more dis- 
tressing, and conditions of system are gradually developed which sooner or 
later terminate in death. But, before it assumes this alarming character, 
hypertrophy, or dilatation, or both, have supervened, and the affection now 
ceases to be exclusively valvular. Cough, distressing dyspnoea, orthopnoea, 
haemoptysis, apoplexy of the lungs, pneumonia, pulmonary oedema, dropsy of 
the pleura and pericardium, a pallid or livid complexion, purple lips, puffiness 
of the face, general anaemia, oedema of the extremities, passive hemorrhage 
from the alimentary mucous membrane, sickness and vomiting, bilious de- 
rangements, drowsiness or stupor, apoplexy, &c., are only a portion of the 
symptoms, which, in greater or less number and degree, attend this compli- 
cated disease of the heart. 
Physical Signs.-These consist in the bellows murmur and its modifications, 
and the purring tremor. For a particular account of these, the reader is re- 
ferred to the introductory remarks upon diseases of the heart. By means of 
the valvular murmurs, it is possible for an experienced ausculter to decide, 
with tolerable accuracy, in which of the valves the disease exists, and to a CLASS III.] 
163 
CHRONIC VALVULAR DISEASE. 
certain extent what is the nature of the disease, whether, for example, it con- 
sists in a constriction or insufficiency of the valves, whether it offers a direct 
impediment to the circulation, or permits regurgitation of the blood. The 
following are the rules, chiefly from Dr. Hope, by attention to which, accord- 
ing to that very high authority, an almost certain diagnosis may be made. It 
is proper, however, to observe that the want of murmurs is not a proof of 
the absence of all valvular disease, any more than their existence is a posi- 
tive proof of its presence. Sometimes, in the advance of destructive cardiac 
disease, murmurs previously existing may cease. This has been observed 
especially in connexion with contraction of the orifices. {Stokes.') It may 
depend on great muscular weakness of the heart. 
1. Aortic Valves.-1The murmur of contraction is heard during the ven- 
tricular systole, over the site of the valves, upon the sternum opposite the 
lower margin of the third rib, and thence two inches or more upwards towards 
the right of the sternum, along the course of the aorta, where it is louder than 
at any point below its place of origin. The sound strikes the ear as superficial, 
and resembles the whispered letter r. That it does not proceed from the pul- 
monary valves is proved by the fact, that it is not heard high up the pul- 
monary artery towards the left. It cannot be connected with the auriculo- 
ventricular valves, because the murmur of these, if heard at all in the situa- 
tion referred to, will be very faint and remote, and in a lower key, like the 
whispered word who. 
The aortic murmur of regurgitation accompanies the second sound, or the 
diastole of the heart, and is distinguished from the synchronous auriculo- 
ventricular murmurs by being louder over the aortic valves than near the apex 
of the heart, where the latter are heard most distinctly. It may be known 
not to be seated in the valves of the pulmonary artery by being heard more 
loudly up the course of the aorta, and down the left ventricle, than up the 
pulmonary artery and down the right ventricle. From the murmur of aortic 
contraction it is distinguished by occurring during the period of the second 
sound, by being more audible down the ventricle, by its occasional prolongation 
through the period of repose, and even through an intermission of the ven- 
tricular contractions, and by its inferior loudness, greater softness, and lower 
key, resembling as it does the word awe, whispered in inspiration. The 
jerking charactei' of the pulse of regurgitation must also be borne in mind; 
as well as, in some instances, the visible throbbing of the arteries over the 
body. Sometimes the reflux of the blood stimulates the ventricle to a second 
contraction. ( Williams.) 
Sometimes the aortic orifice is contracted, at the same time that the valves 
cannot accurately close; and the two sounds are both produced, the one being 
heard after the other, and giving rise to a proper sawing murmur. 
2. Pulmonary Valves.-The sounds of the pulmonary valves are the same 
as those of the aortic; but they are nearer the ear, and of a higher key, ap- 
proaching a whispered s. They are inaudible two inches up the aorta, but 
quite distinct the same distance up the pulmonary artery. The murmur of 
regurgitation is not attended with any peculiar jerking of the pulse, or 
visible throbbing of the arteries. The systolic murmur cannot be confounded 
with the synchronous auriculo-ventricular sound, because the latter is never 
heard up the pulmonary artery, or but very feebly. These murmurs of the 
pulmonary valves are very rare. 
3. Mitral Valves.-The murmur of regurgitation is supposed to be heard 
during the systole, is often rough, and of a low key, like the whispered word 
who, and is louder near the apex of the heart, somewhat to the right of the 
nipple, than over the cartilage of the fourth rib, near the sternum, beneath 164 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
[PART II. 
which it is seated, because, in the latter position, the intervening lung deadens 
the sound. Other reasons why this murmur is heard most distinctly near the 
apex of the heart, are, first, that the fleshy columns attached to the valves are 
inserted at this part, and thus serve as direct conductors of the sound, and, 
secondly, that the apex is in contact with the wall of the chest at the time 
that the murmur is formed. The regurgitant mitral murmur sometimes quite 
drowns the healthy first sound on the left side. Dr. Hope says that he has 
met with the purring tremor more frequently with this than with any other 
valvular lesion, especially when associated with a hypertrophied and dilated 
ventricle. According to the observations of Dr. Williams, a very large pro- 
portion of the cardiac murmurs, say five-sixths, in women and in the young 
below twenty, arise from mitral regurgitation; while in the older and in men, 
more depend upon disease of the aortic valves. 
The murmur from contraction of the mitral valves is heard in the same posi- 
tions as that of mitral regurgitation; but occurs during the diastole or second 
sound, and is comparatively very feeble and soft, in consequence of the slight 
force with which the blood enters the ventricle. The purring tremor never 
attends it.* 
A mitral murmur, heard with an increase of the second sound in the right 
ventricle, or along the pulmonary artery, may be considered a pretty certain 
sign of organic disease of the mitral valve; as the effect of this is to produce 
impediment to the progress of the blood from the right side of the heart, 
which stimulates the right ventricle to increased effort, and thus increases the 
pulmonary semilunar sound. Skoda thinks that, without this increased in- 
tensity in the sound of the pulmonary valves, the mitral murmur cannot be 
considered as indicating defect of the mitral valves, but only roughness of 
their surfaces. {Treat. on Auscult. and Percus., Lond. ed., 229 and 230.) 
The absence of the first sound, and of all murmurs in the place of it, may 
result from excess of the causes which tend to dull the sounds of the heart, 
and may not, therefore, indicate disease of the mitral valve; but, according 
to Skoda, if there be at the same time greater loudness of the sound of the 
pulmonary valves, or the second sound over the left ventricle be replaced by a 
murmur, there is reason to believe that the mitral valves are contracted, and 
probably also defective. {Ibid., p. 231.) 
4. Tricuspid Valves.-1The morbid sounds of these valves are heard, like 
those of the mitral, a little above the apex of the heart; but are loudest more 
to the right, near or over the sternum. The pulse is not irregular, or but 
slightly so; and Dr. Hope states that he has never known the purring tremor 
* An entirely different view of these mitral sounds must be taken in accordance with 
the theory of diastolic impulse, and one, as it seems to me, more compatible with acknow- 
ledged facts. Thus, the murmur considered as systolic and regurgitant is heard most 
distinctly at the apex of the heart, which is contrary, to the supposed direction of the 
blood ; a fact, I think, very unsatisfactorily explained in the text. According to the 
diastolic theory, it is heard in the active diastole along with the impulse, and so far 
from being a regurgitant murmur, is one of contraction. It ought to be, as it is, heard 
most distinctly near the apex, because this is the direction of the current of blood which 
produces it. Dr. H^rard, of Paris, in a recent dissertation on the signs of contraction 
of the mitral orifice, asserts, as the result of observation, that the murmurs heard 
with the impulse at the apex are owing to contraction of that orifice, and that insuffi- 
ciency of the mitral valves, generally supposed to give rise to this murmur, in the vast 
majority of cases is incapable of determining the production of any murmur whatever. 
[Archives Gen., Fev. 1854, p. 193.) If any regurgitant murmur is produced, it must, 
according to the diastolic theory, immediately follow the impulse, occur with the closing 
portion of the first normal sound, immediately precede the normal second sound, and 
accompany the semilunar murmur of contraction, if this murmur exist. [Note to the 
fourth edition.) CLASS III.] 
CHRONIC VALVULAR DISEASE. 
165 
attend them. Distension of the jugular veins, or a visible pulsation in these 
vessels, synchronous with a murmur replacing the first sound in the right 
ventricle, is pretty certain evidence of deficiency of the tricuspid valves. 
Without the murmur referred to, the venous pulsation might result from 
contraction of the right auricle alone. (Skoda.} 
Sometimes the auriculo-ventricular, and the semilunar valves produce mur- 
murs at the same time. In such instances, the characteristics of each are 
found in the same case, and the diagnosis may be made out with due atten- 
tion and patience. 
It is proper to state that very experienced ausculters consider the mere key 
of the murmur, to which Dr. Hope attached some importance, as not reliable 
in diagnosis, varying as it does with the varying force of the movement, and 
perhaps other not appreciable causes. 
Diagnosis.-The most important diagnostic question for solution, in cases 
attended with the general symptoms and physical signs of valvular disease, 
is, whether they may not be the result of mere functional derangement. Most 
of the general symptoms may undoubtedly accompany anepaic disease, without 
any lesion of the valves. We meet with them not unfrequently in dyspepsia. 
The bellows murmur is well known to be present in similar cases, and even 
the purring tremor is occasionally felt. It is important that, in such cases, 
the decision should be correct; as it must influence the treatment. It will 
probably be sufficient to attend carefully to the following considerations. 
When the murmurs depend on organic disease, they are more constant, being 
in many cases heard under all circumstances of the circulation, whether the 
patient has been at rest or under excitement; and when this is not the case, 
showing a certain degree of constancy under apparently similar circumstances, 
which is usually wanting in those of a merely nervous or functional character. 
The latter are often absent when the patient is at rest, and the heart calm, 
and, though they may be temporarily excited by the stimulus of muscular 
exertion, are in the end benefited by moderate exercise, and often yield entirely 
to a tonic course of treatment. In nervous and anemic affections, the bellows 
murmur is free from roughness or harshness; in the organic, it is often very 
rough, with various modifications, forming the grating, rasping, sawing mur- 
mur, &c. In the latter, the continuous venous murmur of the jugulars, so 
characteristic of anaemia, is wanting, unless this complaint be a complication 
of the valvular disease. 
Dyspepsia is often accompanied with deranged action of the heart; but it is 
also a frequent result of disease of that organ, as are also those hepatic and 
gastric derangements usually called bilious symptoms. The physician should, 
therefore, be on his guard against mistaking real cardiac disease for mere dys- 
pepsia, or disorder of the liver. Whenever, along with the latter affections, 
there is irregular action of the pulse, especially if the patient exhibit dyspnoea, 
or complain of pain or tightness in the praecordia, and of palpitation, though 
these are very frequently nothing but purely nervous symptoms, the heart 
should be carefully examined by the stethoscope, so that any organic disease, 
if existing, may be detected. 
Treatment.-It will be sufficient, in this place, to treat only of those thera- 
peutic measures which have an immediate reference to the valvular disease. 
The plans of treatment adapted to the complicated affections which have their 
origin in that disease, will be more conveniently considered under hypertrophy 
and dilatation, which are generally the immediate agents in their production. 
Valvular disease is not necessarily fatal. Patients affected with it, in a 
greater or less degree, often live for many years, sometimes to old age, even 
though it may have begun early in life. In some instances, it appears to have 166 
[PART II. 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
no decided tendency to produce other organic changes in the heart; and its 
ordinary proneness to end in hypertrophy and dilatation may often be con- 
siderably controlled by treatment. Dr. Williams thinks that, while the 
ordinary sounds and impulse of the heart remain unimpaired, whatever ab- 
normal sounds may be heard, and however loud, there is little ground for 
present alarm. It is when the healthy sounds are displaced by the abnormal, 
that most is to be apprehended, as the proper working of the heart is thus 
shown to be interfered with. A little excrescence, for example, may exist in 
a valvular opening, which may produce a murmur; but the regular action of 
the valve may not be impaired, the normal sound remains, though mixed with 
the abnormal, and no serious result ensues. 
The remedial measures are, first, such as are calculated to correct the dis- 
ease of the valves, and, secondly, such as may prevent its effects, so far as 
possible, by restraining the action of the heart. Unfortunately, our attempts 
to meet the first of these indications are often altogether vain. The disease 
has but too frequently advanced so far, before being recognized, as to be quite 
insusceptible even of amelioration by treatment; and it is sometimes, at the 
very commencement, of a nature which no remedies can control. Should it, 
however, have proceeded from inflammation, whether acute or chronic, there 
may be some hope of removing it, especially if attacked in its earlier stages. 
The means to be employed are such as will promote the absorption of the 
coagulable lymph already exuded, and prevent its further deposition. Of 
these, the moderate and long continued use of mercury is the most efficient. 
It should be pushed no further than to produce the slightest observable effect 
upon the gums, and may even stop short of this point; but should be perse- 
vered in for months, if necessary, with occasional intermissions. Indeed, it 
may be proper, in some cases, to give it at intervals for years, where physical 
examination shows that it operates favourably, while at the same time there 
is a great tendency to a return of the symptoms. The mildest preparations 
should be preferred; and, upon the whole, the blue pill is perhaps the best. 
The preparations of iodine may also be employed, with the hope of advantage. 
Either the compound solution, or iodide of potassium may be used internally, 
and the ointment may be applied over the region of the heart. This remedy, 
also, to be effectual, must be long employed ; and care must be taken that it 
do not disturb the stomach, or excite the circulation materially. As rheu- 
matic or gouty disease may favour the deposition, any signs of these affections 
in or about the heart should be met as they occur by appropriate remedies, 
especially the wine of colchicum, with magnesia and a saline cathartic when 
laxatives may seem to be called for. Occasional cupping or leeching in the 
praecordial region, or between the shoulders, and repeated blistering or pus- 
tulation by tartar-emetic over the heart, may prove useful under similar cir- 
cumstances, or whenever the disease is attended with pain or much uneasiness. 
In gouty cases, or whenever, from calculous depositions elsewhere, there may 
be any reason to apprehend similar deposition about the valves, the free use 
of bicarbonate of soda or bicarbonate of potassa is indicated. Half a drachm 
of it may be given with carbonic acid water twice or three times a day, and 
continued for a long time. 
As the greatest danger from diseased valves is the production of hypertro- 
phy or dilatation, attention should be especially directed to the prevention of 
these affections, or, if their prevention be impracticable, to the rendering of 
their progress as slow as possible. For this purpose, it is necessary to restrain 
the action of the heart, and, as far as possible, obviate congestion in its cavi- 
ties. The remedies to be used must vary with the state of the system. If the 
patient is plethoric, with a florid face and a full strong pulse, blood may be CLASS III.] 
CHRONIC VALVULAR DISEASE. 
167 
taken occasionally from the arm, in moderate quantities; but the practitioner 
must be on his guard not to push this remedy to the point of producing 
anaemia, which is even a more powerful stimulant to the heart than plethora. 
An occasional dose of sulphate of magnesia will be an excellent adjuvant to 
the lancet, or a substitute for it when the plethora may hardly be sufficient to 
justify its use. In cases already anemic, with paleness of face, lips, and 
tongue, even though the pulse may be frequent and voluminous, bleeding 
should be avoided; and it may even be advisable to employ chalybeates, and 
the milder vegetable bitters. In cases not of great debility, digitalis or hydro- 
cyanic acid may be used in order to lessen the frequency of the pulse when 
excited. Should the heart beat frequently in consequence of disorder of the 
nervous system, narcotics and nervous stimulants will sometimes be useful, 
reference being had, in the selection of the article, to the general strength. 
Thus, hyoscyamus and conium are preferable in sthenic cases; .opiates, with 
camphor-water, Hoffmann's anodyne, aromatic spirit of ammonia, valerian, or 
assafetida, in debility. Wild-cherry bark is admirably adapted to cases of 
this kind, in which tonics may be indicated. I am much in the habit of using 
it in connexion with the tincture of digitalis. The state of the stomach should 
be carefully attended to, as any disorder of this organ is very apt to excite 
the heart. Hence, antacids, laxatives, and all the remedies applicable to dys- 
pepsia, are sometimes called for. 
Attention to the diet is highly important. This must be regulated of 
course by the state of the system. As a general rule, it should be such as 
sufficiently to support nutrition, without stimulating. When there is decided 
plethora with vascular excitement, it should consist of vegetable food exclu- 
sively; in ordinary cases, with a tendency to plethora, milk may be added to 
the vegetables; and, when there is no such tendency, the more nutritious 
kinds of animal food may be allowed; but, unless in positive debility or 
anaemia, meats should be sparingly used, and should generally be preferred 
boiled, because in this state they are less stimulating. If the patient find by 
trial that milk and the farinaceous substances, with vegetables and fruits, are 
sufficient for the support of his strength, it would generally be best that he 
should restrict himself to them exclusively. 
Exercise is important, in order to sustain a due condition of the digestive 
and nutritive functions, and prevent an irritable state of the nervous system. 
Absolute rest, though well adapted to acute cardiac diseases, becomes highly 
injurious in chronic cases, by impairing the general health, and increasing 
the excitability of the heart. Yet active exercise is even more injurious, by 
directly stimulating the circulation. Hence, the patient should never run, 
nor walk very rapidly, nor ascend heights, nor use violent muscular exertion 
of any kind. It is necessary that he should keep a constant watchfulness 
over his movements in these respects. One hasty ascent of an abrupt or 
considerable elevation may undo the effects of months of caution. Passive 
exercise, on horseback or in a carriage, is usually preferable to walking; and, 
in selecting the horse, one of easy gait, and which requires little muscular 
effort to control him, should be preferred. 
Tranquillity of mind is essential in these cases; and the vigilance of the 
patient is more especially requisite in its preservation, as disease of the heart 
is very apt to be attended with an irritable or excitable temper. There is no 
lesson which it is more important to inculcate upon an individual affected 
with valvular disease of this organ, than to school himself early into a control 
over his emotions, and, when this is unattainable, to avoid with the greatest 
care every occasion of disturbance to his equanimity. 168 
[part II. 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
Article V. 
HYPERTROPHY and DILATATION. 
The dimensions of the heart may be increased either by augmentation of 
its muscular tissue, or enlargement of its cavities. To the former of these 
changes, when the result of an overgrowth of the organ, without appreciable 
degeneration of its substance, the name of hypertrophy has been given; to the 
latter, that of dilatation. As they are most frequently associated together, 
often dependent on the same cause, and in many respects productive of the 
same symptoms, they will be most conveniently treated of under one general 
head; all that is common to them in their several distinct relations being 
first considered, and afterwards what is peculiar to each. They were at one 
time confounded under the common name of aneurism of the heart, applied 
to them by Baillou and Lancisi. Corvisart made a great advance by distin- 
guishing two forms of cardiac expansion, one with increased thickness, the 
other with attenuation of the muscular parietes. The former he called active, 
the latter passive aneurism. But it was not till the publication of the 
memoirs of M. Bertin, in 1811, that the subject was fully understood. It 
was he who first clearly pointed out the occasional distinct existence of hy- 
pertrophy and dilatation, and gave that precision to the knowledge of their 
different forms and associations which is now possessed by the profession. 
The five following forms are at present recognized, viz. : 1. simple hypertro- 
phy, in which the walls of the heart are thickened, without any change in the 
size of its cavities; 2. hypertrophy with contraction, in which, along with the 
increased thickness of the walls, there is a diminution of one or more of the 
cavities; 3. hypertrophy with dilatation, in which both the walls are increased 
and the cavities enlarged; 4. simple dilatation, in which there is increase of 
the bulk of the heart, with attenuation of its parietes; and 5. partial dilata- 
tion, or proper aneurism of the heart, in which a portion only of the walls of 
one of the cavities is expanded, forming an aneurismal sac upon the surface. 
In order to decide, in all cases, upon the existence of either hypertrophy 
or dilatation, it is necessary that we should be acquainted with the dimen- 
sions of the heart in health. Unfortunately, these cannot be determined 
with accuracy. The heart varies in size with the period of life, not only 
growing with the growth of the body, but, according to the best authorities, 
continuing to enlarge after maturity, even to old age, at least so far as re- 
gards the left ventricle. It is considerably larger in males than females, 
and differs, in the same sex, according to the size of the body, especially the 
breadth of the chest or shoulders, to the relative proportion of the sangui- 
ferous system, and, in some degree, to the more or less vigorous habits of the 
individual; and all within the limits of perfect health. These circumstances, 
therefore, must be taken into consideration in determining how far any sup- 
posed enlargement of the heart is morbid; and, even in the case of a con- 
siderable deviation from the average standard of health, we should hesitate 
to pronounce it the result of disease, if no morbid phenomena had been pre- 
sented during life. 
Laennec roughly estimates the size of the healthy heart to be about that 
of the fist of the individual. Elaborate measurements have been made by 
M. Bouillaud, Dr. Glendinning, and M. Bizot, for an account of which the 
reader is referred to Dr. Pennock's edition of Hope's work upon Diseases of 
the Heart. According to Dr. Glendinning, the average weight of the adult CLASS III.] 
169 
HYPERTROPHY AND DILATATION. 
heart is in the male about 9 ounces, in the female 8 ounces, or somewhat 
more. M. Bouillaud makes the mean circumference at the base 8 or 9 
inches; the transverse and longitudinal diameters about 3.5 inches, the 
former being generally somewhat greater; the antero-posterior diameter about 
2 inches; the thickness of the left ventricle at the base from 6 to 7 lines; 
that of the right ventricle at the base 2.5 lines, of the left auricle 1.5 lines, 
and of the right auricle 1 line. The ventricular walls are thickest near the 
base, and gradually diminish towards the apex. The left is somewhat more 
than twice as thick in the adult as the right; but the disproportion is less in 
the foetus and young infant, and gradually increases during life. The left 
ventricle does not collapse when opened, the right collapses. The four cavi- 
ties are about equal, but, the walls of the auricles being much thinner, these 
seem to constitute together only about one-third of the heart. Bouillaud 
states that the ventricular cavities will, on an average, contain a hen's egg, 
though the right is somewhat larger. From the tables of M. Bizot, it may 
be inferred that the several measurements of the heart, as to length, breadth, 
and thickness of the walls, are in children from one to four years old, some- 
where about one-half, from 5 to 9 about two-thirds, and from 10 to 15 about 
three-quarters those of the adult above 50. 
Anatomical Characters. 
The enlargement, whether of hypertrophy, dilatation, or the two combined, 
may affect the whole heart, or only one or more of its cavities, leaving the 
others sound; and the latter event is much more common than the former. 
In some instances, one cavity is affected in one manner, and another in an- 
other ; and it not unfrequently happens that, when two or more are affected 
by the same disease, they are so in different degrees. 
Hypertrophy with or without Dilatation.-The ventricles are more fre- 
quently hypertrophied than the auricles, and the left ventricle and auricle 
more frequently than the right. The whole heart is rarely affected, but the 
two ventricles not unfrequently. The auricles are seldom thickened inde- 
pendently of the ventricles ; and, whenever they become so, it is the appendix 
that is chiefly affected. The fleshy columns, the partitions between the cavi- 
ties, and even the valves, may also be thickened, either independently, or in 
connexion with the walls. The right cavity has been known to be nearly filled 
with the overgrown columnae carneae. The hypertrophy may even be confined 
to a portion of one of the ventricular walls. 
According to Cruveilhier, hypertrophy cannot be said to exist unless the 
heart weigh 10 or 12 ounces, and, in relation to the ventricles, unless the left 
have a thickness of 7 or 8 lines, and the right of 4 or 5. Reference is had 
to the adult male. But, according to Bizot, a thickness of 3 lines would in- 
dicate hypertrophy of the right ventricle, which, upon the same authority, is 
in health only 2.1 lines thick in its thickest part, in men between the fiftieth 
and seventy-ninth year, and 1.25 lines at the same age in women. Though 
the thickness in the ventricles is usually greatest near the base, and gradually 
diminishes towards the apex, yet sometimes it is nearly equal throughout, 
sometimes greatest either in the middle or at the point. In the left ventricle, 
it is said to have reached 2 inches, though it does not often exceed 1.25 inches 
or 15 lines. The right ventricle is rarely more than 5 or 6 lines thick, but 
has been known to be as much as 15 lines or more. It does not collapse, 
when cut into, as in the healthy state. 
The substance of the muscle is often changed in consistence and colour, 
being usually firmer and redder than in health. It is not, however, always 
thus; but, in cases of a cachectic, anemic, or otherwise debilitated condition 170 
[part II. 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
of system, sometimes participates in the paleness and flabbiness that charac- 
terize the muscular tissue in general. In some instances, too, it is found, when 
examined by the microscope, to have undergone fatty degeneration. Compli- 
cations of pericardial adhesion, and of various alterations of the valves and 
lining membrane of the cavities, evincing previous inflammation, are not un- 
frequently found upon dissection. 
Simple Hypertrophy.-This is not frequent, as the capacity of the cavities 
is generally altered in one way or the other. The affection is confined to the 
ventricles; the auricles when hypertrophied, being almost invariably dilated 
also. The bulk of the heart is somewhat increased, but not very greatly so. 
Hypertrophy with Contraction. - Concentric Hypertrophy. (Bertin.)-In 
this variety, the heart is not necessarily augmented in bulk. The walls are 
sometimes very thick, and the cavity exceedingly contracted, occasionally to 
the size of a pigeon's egg, or even the shell of an almond. Doubts, however, 
have been entertained as to the morbid character of this diminution of ca- 
pacity. Cruveilhier has suggested that it might be owing to vigorous contrac- 
tion at the time of death, or immediately afterwards. In support of this 
opinion, the facts are adduced, that a similar diminution has been observed in 
criminals after execution, and that the contracted cavity has been dilated by 
the finger. But, though the explanation may apply to some cases, it cannot 
be considered as applicable to all; for the contraction has been often observed 
in cases of lingering death, and, even admitting that the cavity may be dilated 
by the finger in all instances, which has certainly not been proved, still this 
may be owing to a mechanical expansibility of the tissue, and not to the re- 
laxation of a muscular spasm. 
Hypertrophy with Dilatation.-Active Aneurism of the Heart. (Corvisart.) 
Eccentric Hypertrophy. (Bertin.)-This is by far the most frequent of the 
varieties of cardiac enlargement. It may exist in two forms, in one with, in 
the other without thickening of the walls. As the cavities are distended, it 
is obvious that, in the latter as well as in the former case, there must be in- 
crease of the muscular tissue, and consequently hypertrophy, unless the pa- 
rietes are absolutely attenuated. Indeed, some attenuation might exist, and 
the quantity of muscle still be greater than in health. 
The degree of enlargement varies from the slightest excess above the mea- 
sure of health, to twice, thrice, or even four times the ordinary volume. A 
case is on record, in which the weight of the organ was 5 pounds, and an- 
other in which the length was more than 9 inches, and the circumference at 
the base 15.5 inches. {Diet. de Med., viii. 287.) Dr. Glendinning found the 
average weight in eighty hypertrophied hearts which he examined, to bn 15 
ounces, not quite double that of the healthy heart. The cavity is sometimes 
expanded sufficiently to hold a large orange, or the fist. 
When the whole heart is affected, it usually assumes a somewhat globular 
shape, the apex being nearly or quite obliterated. It also takes a transverse 
position in the chest, when considerably dilated, as the diaphragm does not 
allow it to descend. When one side is greatly enlarged, and the other sound, 
the latter appears like a mere appendage to the former, sometimes not extend- 
ing more than half its length. The fleshy columns are sometimes thickened, 
sometimes stretched out and attenuated. The valvular orifices expand with 
the cavities; and the valves themselves usually increase in magnitude, so as 
to close the orifice, and support the increased pressure; but, in cases of great 
dilatation, this coaptation does not always take place, and the valves are some- 
times imperfect, so as to allow of regurgitation. 
Simple Dilatation.-Passive Aneurism. (Corvisart.)-In this affection, the 
walls of the heart are simply distended or stretched out, without any addition CLASS III.] 
171 
HYPERTROPHY AND DILATATION. 
of .substance. They are, therefore, thinner than in health; and the degree 
of attenuation is proportionate to that of dilatation. It is very rarely indeed 
that the whole heaft is thus affected. The right ventricle is said to be more 
frequently dilated than the left, but both together more frequently than either 
separately. The auricles, though they yield more easily to any distending 
force, are less subject to the disease than the ventricles, in consequence of 
being less exposed to the causes. The left auricle is more apt to be affected 
than the right, because the mitral valve is more frequently deranged than the 
tricuspid, and the distending force of the left is greater than that of the right 
ventricle. The fleshy columns appear as if stretched; the interventricular 
septum is less attenuated than the walls ; and the valvular orifices, even more 
frequently than in hypertrophy with dilatation, are enlarged in greater pro- 
portion than the valves themselves, so as to be imperfectly closed, and thus 
permit regurgitation of the blood. 
The degree of dilatation is sometimes very considerable, but not equal to 
that which may occur in connexion with hypertrophy. The heart has been 
known to attain three times its natural size. The walls are in some instances 
very thin. Those of the left ventricle have been reduced to a thickness of 
two lines; and in some places, especially at the.apex, the muscular fibre has 
been occasionally quite wanting; the external and internal membranes being 
in contact, or only separated by a deposit apparently intended to give them 
additional strength. As in hypertrophy with dilatation, the heart is apt to 
assume a roundish form, and a transverse position in the thorax. 
The heart is sometimes found greatly distended with blood after death,, 
without having suffered dilatation. The former condition may be distin- 
guished from the latter by the disposition evinced to return to the ordinary 
size when emptied, whereas the dilated walls do not contract under similar 
circumstances. 
Pure dilatation, unmixed with hypertrophy, is comparatively rare; but, 
for practical purposes, all those cases in which the peculiar phenomena of 
dilatation predominate may, with propriety, be ranked under this head. 
The muscular fibre in this affection is usually pale, softened, and flaccid, 
sometimes, however, purplish or violet, as if congested in common with most 
of the other great organs. The heart collapses when empty. In some in- 
stances tin? distension has been so great as to produce a rupture of the walls, 
and effusion of blood into the pericardium. 
Partial Dilatation.-Aneurism of the Heart.-The term aneurism applied 
to ordinary enlargement of the heart is not correct, as there is no analogy 
between that affection, and the disease of the arteries to which the name 
properly belongs. Such an analogy, however, is strikingly exhibited by the 
partial dilatation now under consideration, which has, therefore, very properly 
been named aneurism of the heart by recent writers. To Mr. Thurnham the 
profession is indebted for the precision which has been introduced into the 
pathology of this affection. It consists of a pouch, produced by the dilatation 
of a portion of the walls of one of the cavities, and usually forms a tumour on 
the surface of the heart, though sometimes scarcely projecting, being formed 
in the wall itself by the expansion of the inner membrane, and the absorption 
of the muscular tissue before it. Generally only one pouch exists, but in- 
stances have been recorded in which there were two or more. They vary 
greatly in size, from the smallest dimensions up to those of an orange, or of 
the heart itself. Sometimes all the constituents of the walls are distended, 
including the muscular tissue; sometimes this is wanting, and the sac con- 
sists of the outer and inner membranes; and again, the endocardium is rup- 
tured or ulcerated, and the parts exterior to it dilated. In some instances, 172 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
[part II. 
adhesions have been formed with the loose portion of the pericardium; in 
others, the tumour has opened into the cavity formed by that membrane. 
The sac often contains laminated coagula of blood, especially when its mouth 
is narrow. The tissues of the heart are found variously degenerated; either 
the endocardium, or muscular layer, or both, exhibiting organic changes. 
Symptoms. 
It will best conduce to an accurate understanding of the subject, to detail 
first the general symptoms common to the affections above mentioned, and 
afterwards, so far as they can be distinguished, those peculiar to each. 
The disease usually makes its advances very slowly. In the beginning, 
the patient complains only of occasional palpitations, dyspnoea, and perhaps 
slight prmcordial pain, stricture, or other uneasiness, induced by some un- 
wonted muscular exertion, mental excitement, or excess in eating or drinking, 
and sometimes without any obvious cause, especially at night. He finds 
himself unable to run, or mount hills, or ascend flights of stairs, with the 
same facility as before, and is more readily fatigued by ordinary exercise. 
These symptoms, however, are at first seldom sufficient to excite alarm. It 
is a fact noticed by Dr. Hope, that, though at the commencement of active 
movement the patient may experience some of the inconveniences alluded to, 
he often loses them by a continuance of the exertion, in consequence probably 
of the blood being more strongly diverted to the surface. The disease may 
remain long in this state, sometimes, indeed, to extreme old age, if great care 
is taken to regulate the habits of body and mind; but it often gradually in- 
creases; slighter causes induce the peculiar symptoms; and the palpitations 
and dyspnoea at length become habitual, being either induced by the least 
excitement, or never entirely absent, though still liable to remissions and 
exacerbations. The throbbing of the heart is almost always sensible to the 
hand applied to the praecordia, and often visible to the eye; and occasionally 
it is so violent as obviously to agitate not only the chest but the whole frame. 
Acute pains, similar to those of angina pectoris, shoot in some instances 
through the chest, and into the left arm; and, when these are wanting, the 
patient frequently complains of dull pain, oppression, tightness, weight, or 
other uneasiness about the praecordia or epigastrium. 
The pulse is very differently affected, being sometimes full and strong, 
sometimes soft, small, and feeble, generally regular and little increased in 
frequency in the early stages, except during paroxysms of palpitation, but at 
an advanced period often becoming intermittent and irregular, and always so 
in cases in which certain kinds of valvular disease are connected with that 
of the muscular tissue. 
Along with these symptoms, which proceed immediately from the heart, 
the patient experiences many others resulting from various secondary affec- 
tions. The head generally suffers more or less, either from excess or defi- 
ciency of arterial blood, or from venous congestion. Hence headache, vertigo, 
ringing in the ears, flushed or pallid face, swollen features, prominent and 
watery eyes, frequent attacks of epistaxis, and, in the advanced stages, not 
unfrequently faintness or partial syncope, mental hebetude, drowsiness, stu- 
por, coma, and finally apoplectic effusion. 
The lungs are almost always sooner or later involved. The blood is driven 
into them too forcibly, or, escaping with difficulty through the pulmonary 
veins, becomes congested in their vessels. The proper function of the lung 
is thus impeded; effusion of serum, or sero-mucous fluid, or of blood, takes 
place into the bronchia and air-cells; serous liquid is often poured out into 
the cellular tissue of the lungs or into the pleural cavities; and bronchitis, CLASS III.] 
HYPERTROPHY AND DILATATION. 
173 
pneumonia, or pulmonary apoplexy, may be added to the already formidable 
list. Dyspnoea, cough, expectoration more or less copious and difficult, 
haemoptysis active or passive, disturbed sleep, sudden startings at night, 
horrible dreams, great uneasiness in the horizontal position, and occasionally 
complete orthopnoea, are the consequent symptoms. Indeed, many cases, 
such as were formerly considered as asthma, are nothing more than chronic 
dyspnoea, dependent on disease of the heart. It is not difficult to understand 
the source of this disorder of respiration. The augmented size of the heart, 
the sanguineous congestion of the lungs, the collection of fluid in the air-cells, 
bronchial tubes, and intervesicular tissue, the consolidation from pneumonia, 
and the pressure from pleuritic effusion, all may contribute their part, some 
in one case and some in another, in preventing the proper access of air to the 
blood; while, from the mechanical obstacle opposed by the cardiac disease, 
the blood itself is detained in the lung, and often cannot pass on in due quan- 
tity to fulfil its office in all parts of the system. From the lungs, therefore, 
from the heart itself, and from all parts of the body, goes up by the afferent 
nerves an impression to the nervous centres, which excites in these the 
painful sense of want of breath, and leads to violent reflex actions in the 
respiratory organs, for the purpose of supplying the deficiency. These severe 
respiratory symptoms occur more or less paroxysmally, being brought on by 
accidental influences disturbing the cardiac functions, and not unfrequently 
without appreciable cause. 
But the organs mentioned are not the only ones affected. Congestion of 
the liver, stomach, bowels, and kidneys, either active or passive, but espe- 
cially the latter, gives rise to numerous symptoms indicative of derangement 
in these viscera. Hence dyspeptic sensations in the epigastrium, irregular 
appetite, nausea and vomiting, constipation or diarrhoea, obvious enlargement 
of the liver, jaundice, disordered alvine evacuations, melaena, albuminous 
urine, and hemorrhage, usually of the passive kind, from the stomach, bowels, 
and urinary passages. It is not pretended that all these phenomena are pre- 
sent in every case; but every one of them, and many others of a similar origin, 
make their appearance occasionally in one or another case of heart disease. 
It has, indeed, been ascertained by Dr. Glendinning, as the result of dis- 
section, that hypertrophy of the viscera mentioned is very apt to ensue, in 
consequence of the sanguineous congestion to which they are exposed. 
At length a universal disposition to dropsical effusion is developed. The 
venous system everywhere loaded, or the arterial capillaries everywhere dis- 
tended, relieve themselves by the extravasation of the serous portion of the 
blood. Edematous swelling, first showing itself as a general rule in the feet, 
gradually extends upwards, until it involves at length the whole body, in- 
cluding not only the cellular tissue, but often the serous cavities also. The 
urine becomes scanty and high coloured, and the skin dry, as in dropsy from 
other causes. The distress from shortness of breath now becomes extreme; 
the paroxysms of cough and dyspnoea increase in violence; the patient, unable 
to lie down in bed, often sits day and night, with his body bending forward, 
and his head supported, harassed by want of rest, and the dread of impending 
suffocation; the chest heaves with the forced inspirations, and the body shakes 
under the tremendous impulses of the heart. The appetite fails, the pulse 
sinks, the skin becomes cool, and the lips and extremities assume a purple or 
livid hue. Finally, one of the great vital organs, the brain, the lungs, or the 
heart, sinks under the overwhelming burden; and death, frequently preceded 
by stupor or delirium, closes the long series of suffering. 
Happily, it is not always that the patient is exposed to these protracted 
and most painful struggles. Death not unfrequently surprises him at a com- 174 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
[part II. 
paratively early period, and before be has yet suffered greatly. Sudden death 
is, indeed, one of the characteristics of heart affections. The patient, perhaps 
wholly unconscious of the nature of his complaint, supposing himself to be 
affected with asthma, or chronic catarrh, or dropsy in the chest, or possibly 
only with weakness, is suddenly seized, while walking in the street, or resting 
in his chair, or in his bed at night, with a sense of faintness, which soon be- 
comes perfect insensibility, and life is often extinct before relief can be obtained. 
Such a result sometimes proceeds from rupture of the heart; but more fre- 
quently it is only a prolonged intermission, if we may so express ourselves, 
of the heart's pulsation. It is a continued syncope. Apoplexy is another 
mode which nature has kindly provided for escape from protracted suffering. 
It frequently happens, moreover, that some intercurrent inflammatory disease, 
which might prove harmless if occurring in health, is rendered fatal by the 
cardiac complication. 
In the last stages of the dropsical affection, the distended skin of the lower 
extremities sometimes gives way, either by rupture, ulceration, or inflamma- 
tion followed by sloughing; and considerable relief is obtained from the more 
violent symptoms by the escape of serum through the openings. In such 
instances, however, death almost always follows in a short time, though in a 
mitigated form, from the exhaustion of the discharge, and of the irritative 
fever. Sometimes gangrene of the lower extremities takes place, independ- 
ently of the mere effusion, being the direct result of the impeded circulation. 
In the more complicated cases above described, the muscular affection of 
the heart is very often associated with disease of the valves, and it is by the 
united influence of the two forms of derangement that the symptoms are pro- 
duced. It is, in fact, in this way that organic valvular disease, when it is to 
end fatally, generally terminates. 
Special Symptoms of Hypertrophy.-So far as relates to treatment, it is 
sufficient to point out the symptoms, characteristic severally of hypertrophy 
and dilatation, without attempting a more minute diagnosis. But, as the two 
affections are often united in various degrees, it is not always possible to draw 
a precise line between them. We must, therefore, be content with referring 
to the head of hypertrophy those cases in which, though there may be great 
dilatation, the symptoms characteristic of an excess of the muscular tissue 
predominate; and to that of dilatation those in which the characteristic phe- 
nomena of the latter affection prevail, though there may actually be some 
degree of hypertrophy present. It is of no consequence to know that, in a 
case of enlarged heart, the absolute quantity of muscular fibre is greater than 
in health, provided all the indications of treatment, deduced from the symp- 
toms, are the same as in pure dilatation. 
The effects of hypertrophy, when not complicated with valvular disease, or 
fatty degeneration, are those of excessive action of the heart. The additional 
muscular fibre gives additional energy to the heart's contractions, and con- 
sequently increased force to the current of blood. In hypertrophy of the left 
ventricle or of both, the pulse is full, hard, strong, and prolonged, suggesting 
in its highest grades the comparison of the stroke of a sledge-hammer, and 
so characteristic of its cause, that its existence should always lead to the sus- 
picion of cardiac disease. It is said, moreover, to be less changed than the 
healthy pulse by difference of posture, and sometimes not to be changed at all. 
In the earlier stages, the general health does not appear to be materially im- 
paired. On the contrary, there is often a show of increased vigour in all the 
functions, consequent upon the more rapid supply of blood to all parts of the 
body. Yet, besides the pulse alluded to, the patient shows signs of the dis- 
ease in the occurrence, now. and then, of vertigo, headache, or other sensorial CLASS III.] 
175 
HYPERTROPHY AND DILATATION. 
disturbance, especially when stooping, and in occasional bleeding from the 
nostrils. When the complaint is in full force, the cephalic symptoms are 
highly characteristic. They are such as result from active determination of 
blood to the head, and not from venous congestion. The face is flushed, and 
of a bright-red or purplish hue, though sometimes, when naturally very pale, 
it is but little coloured; the features are swollen; the eyes projecting and bril- 
liant^ and occasionally inflamed ; the carotids beat with great force; and the 
fulness and tension of the cerebral arteries are said occasionally to result in 
attacks of apoplexy. The lungs suffer less than the brain in hypertrophy of 
the left ventricle, because their main supply of blood is from another source; 
and the same may be said of the liver; though both these organs suffer occa- 
sionally from venous congestion, consequent upon disease of the mitral valves, 
associated with hypertrophy. It may be stated, in general, that all the parts 
freely supplied with arterial blood are kept in a state of tension and excite- 
ment highly favourable to the occurrence of inflammation or hemorrhage. It 
is asserted that the kidneys are generally enlarged in hypertrophy of the heart, 
and often undergo the kind of degeneration designated as Bright's disease. 
Dropsical symptoms often also result from this affection, though at a more 
advanced period, and to a less extent than in dilatation. 
Various circumstances modify the above symptoms. When the hypertrophy 
is attended with contraction of the cavity of the ventricle, the pulse, though 
tense, is necessarily small from the diminished amount of blood sent forth at 
each ventricular systole. Dieease of the valves also has a powerfully modify- 
ing influence. In mitral regurgitation, the force of the ventricle is partly 
expended in a backward direction; and, while congestion of the lungs thus 
results through the left auricle and pulmonary veins, the symptoms indicative 
of powerful arterial action are less observable in the pulse, in the head, and 
indeed throughout the system. In stricture of the aortic orifice, the smallness 
of the opening counteracts, in some measure, the force of the ventricle, and 
the pulse, though firm, is not so full as in pure hypertrophy, and the brain 
suffers less. It is said that the hypertrophy of the ventricle may be so exactly 
balanced by the contraction of the orifice, as completely to neutralize its 
peculiar influence, and little deviation from health will be observed in the 
system at large, excepting merely a preternatural hardness of the pulse. When 
there is insufficiency of the aortic valve, and consequent regurgitation, a por- 
tion of the force of the ventricle is by reflexion expended on itself, and less 
blood passes onward. Hence, the pulse, though strong from the ventricular 
impulse, is less full and prolonged than in pure hypertrophy, and has a quick 
jerking character. The brain in this case also receives less blood, and con- 
sequently suffers less than when the valve of the aorta is unaffected. In these 
valvular affections, moreover, the pulse differs from the purely hypertrophic 
pulse in being frequently irregular and intermittent. 
Hypertrophy of the right ventricle exclusively has no direct effect upon the 
arterial circulation through the body, and consequently wants entirely the 
characteristic symptoms of the same disease in the left ventricle. It was 
inferred theoretically that it must occasion in the lungs effects similar to those 
produced in the brain by the latter affection, namely, active congestion, hemor- 
rhage, and a tendency to inflammation; but observation has not fully confirmed 
this opinion. The comparative absence of these results in the lungs has been 
ascribed to the incomplete closure of the tricuspid valve, admitting of regurgi- 
tation, and consequently of a division of the ventricular force. But by this 
reaction through the tricuspid valve, the impulse is directed towards the brain, 
which thus suffers from venous congestion, and pulsation is imparted to the 
jugular vein. Though the patient, therefore, may suffer with vertigo, head- 176 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
[part II. 
ache, &c., yet the face instead of being turgid with red blood, is pale or of a 
dusky hue, and the lips are purplish or livid. A double pulsation of the 
jugular vein, the first being weak and corresponding with the auricular sys- 
tole, the second stronger and synchronous with that of the ventricle, may be 
considered as one of the most characteristic signs of hypertrophy, or of this 
with dilatation, of the right side of the heart. 
The physical signs of hypertrophy differ with the degree in which the heart 
is enlarged. In simple hypertrophy, the impulse is usually much stronger 
than in health, and may be felt over a somewhat larger extent of the chest. 
In some cases, however, though strong under excitement, it may, under ordi- 
nary circumstances, be calm, or scarcely perceptible. There is little or no 
observable alteration of the healthy resonance under percussion. But the 
sounds are materially changed. In consequence of the thickness of the ven- 
tricular walls, the first sound is prolonged and very dull, occasionally indeed 
almost wanting. The second sound is also more feeble, and the interval of 
silence is shorter. In hypertrophy with dilatation, the field of impulse is 
extended in proportion to the expansion of the heart. There is a sensation 
of slow, heaving, and forcible movement imparted to the hand, and, when the 
ear is applied to the chest, the head of the observer may be seen distinctly to 
rise with every systole of the heart. The surface of the chest is often visibly 
elevated and depressed; and the whole chest and even the whole frame of the 
patient are sometimes observably shaken. According to Skoda, in order that 
the chest may be heaved with sufficient force to raise the head of the ausculter, 
there must be hypertrophy and dilatation of both ventricles. Dr. Hope noticed 
a sort of sudden shock following the recession of the impulse, which he ascribed 
to the quick refilling of the ventricle during the diastole.* The impulse is 
diminished, in the advanced stages, in consequence of the supervention of 
debility of the heart; and is occasionally masked by emphysema of the lung, 
though the latter is a very rare event. Percussion is dull to a greater extent 
than in health, sometimes over a space three or four inches in diameter, and, 
in extreme cases, from the third to the seventh or eighth rib. The sounds of 
the heart are heard over a wider space than in the normal state of the organ. 
They are loud in proportion to the thinness of the walls; and, when the dila- 
tation is considerable, with no great increase of thickness, a greater loudness 
of the first sound is produced than results from any other derangement of the 
heart. Auscultation should be resorted to, in these cases, when the heart is 
most tranquil. When the organ is excited, the sounds are sometimes heard 
by the patient, and by others at some distance from him. In very bad cases, 
a prominence may often be noticed in the prsecordial region. In such cases, 
according to Dr. Hope, there is often adhesion of the pericardium, which 
prevents the heart from falling, and thus causes its expansion to be directed 
against one point of the chest. A prominence from this cause may be dis- 
tinguished from that resulting from pericardial effusion, by the continuance 
of the respiratory murmur over the former, while it is wanting over the latter; 
the lung overlapping the heart in one case, and being wholly displaced in the 
other. When the valves are diseased, their peculiar murmurs mingle with 
the hypertrophic sounds. 
It is not always easy to distinguish hypertrophy of the right from that of 
the left ventricle by the physical signs. But, when the impulse and dulness 
on percussion are increased exclusively to the right of the prsecordial region, 
* According to the theory of diastolic impulse, this secondary shock may be readily 
explained by referring it to the systole, forcing the blood into the great vessels, which 
reacting on the base of the heart move the whole organ forward. {Note to the third edition.) CLASS III.] 
HYPERTROPHY AND DILATATION. 
177 
or behind the lower portion of the sternum, we may infer that it is the right 
ventricle that is principally affected; while a similar extension towards the 
left side will indicate the corresponding ventricle as the seat of the disease; 
and the diagnosis will be much aided by attention to the general symptoms 
already alluded to. It may sometimes be important to form a correct diag- 
nosis in relation to hypertrophy of the right ventricle when it exists alone; 
for, as the symptoms of excessive vascular action and arterial congestion of 
the brain and other organs, which guide to a proper practice in hypertrophy 
of the left cavities, are wanting in that of the right, and yet the real indica- 
tions of treatment may be the same, it is only by recognizing the existence of 
the latter condition of the heart, that we are likely to pursue the correct thera- 
peutical course. 
Special Symptoms of Dilatation.-1The peculiar characters of dilatation 
have their origin either in the feebleness of the heart's contractions, or in 
venous congestion. The attenuation of the muscular tissue, as well perhaps 
as the condition of the tissue which led to the attenuation, is calculated to 
diminish its power; and the accumulation of blood in the cavities of tbe heart, 
consequent upon this very debility, has a tendency to check the onward current 
in the rear. When the left side is dilated, the arterial blood is distributed 
with insufficient force, and in insufficient quantity through the branches of 
the aorta, whence arise symptoms of a want o'f aerated blood in the brain, and 
in fact in all parts of the system; while, at the same time, the pulmonary veins 
become loaded, and congestion extends backward successively to the capillaries 
of the lungs, to the pulmonary arteries, to the right cavities of the heart, and 
thence to the veins of the whole body. Dilatation of the right side throws 
back the venous blood upon the brain, liver, kidneys, stomach and bowels, and 
the venous system at large; while the pulmonary circulation, and consequently 
the arterial side of the heart, and the arteries generally are badly supplied. 
Hence arise the soft, weak, and not unfrequently, especially in the advanced 
stages, small and irregular pulse; the feeble prolonged palpitations; the general 
feeling of debility, and tendency to faintness or syncope; the paleness of sur- 
face and coolness of extremities; the pallid, dusky, or livid hue of the counte- 
nance; the purple lips; the dyspnoea and bronchorrhoea of pulmonary conges- 
tion; the mental hebetude, dejection, drowsiness, &c., of a feeble or congested 
brain; the nausea, vomiting, and other dyspeptic symptoms arising from an 
oppressed stomach; the general tendency to passive hemorrhage from the 
mucous membranes whether of the air-passages, the alimentary canal, or the 
urinary organs; and finally, the universal dropsical effusion, arising from the 
loaded veins, and forming so prominent a feature in cardiac affections. Dila- 
tation of the right ventricle is very apt to be attended, either as a cause or 
effect, with various disease of the lungs and liver; as chronic bronchitis, 
emphysema, dilated bronchia, congestion, inflammation, hemorrhage, &c., of 
the former, and great enlargement with disordered or defective secretion of 
the latter. , 
The general symptoms enumerated are insufficient to enable us to discrimi- 
nate between dilatation of the left and of the right ventricle; nor is such a 
discrimination a point of any great practical importance. Perhaps the most 
characteristic general sign of dilatation of the right ventricle is the constant 
tension of the external jugular, without pulsation, and not disappearing when 
pressure is made upon the vessel in its upper part. 
In moderate cases of dilatation, the patient often continues for a long time 
without other signs of disease than slight symptoms of asthma, occasional 
palpitations, a pale or sallow hue of the face, and a feeling of greater or less 
general debility. 178 
[part II. 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
The reader must guard himself against the impression, that the characters 
above given as those of hypertrophy and of dilatation respectively, are to be 
commonly met with unmixed in nature. Though sometimes found isolated, 
they are much more frequently mingled in the same case, because both 
elements usually exist more or less together, either in the same cavity, or in 
different cavities of the heart; and, in forming his therapeutical conclusions, 
the practitioner must endeavour to ascertain which element preponderates, 
and act accordingly. 
The physical signs of dilatation, compared with those presented in health, 
are an impulse usually felt over a larger space, but soft, neither forcible nor 
heaving, and sometimes, in very feeble cases, quite wanting; more extensive 
dulness on percussion; and a greater loudness and clearness of the sounds of 
the heart, which are also heard over a larger portion of the chest. In rela- 
tion to percussion, care is necessary to avoid fallacy from consolidated or com- 
pressed, and from emphysematous lung, the former of which occasions dul- 
ness, the latter sometimes masks it when existing. To obviate these sources 
of error, the patient should be told to lean forward, and to make a full expi- 
ration, so as to withdraw the lung from before the heart, and bring this into 
contact with the walls of the chest. In regard to the sounds, it is the first 
or systolic sound which is chiefly affected. It is quicker and shorter than 
in health, and bears a closer resemblance to the second sound, from which it 
is sometimes scarcely distinguishable except from its relation to the pulsation, 
or from its position; the first sound being most distinct a little above the 
apex of the heart, the second over the semilunar valves near the insertion 
of the third rib, and thence up the sternum. In judging of the loudness of 
the sound, it should also be remembered, that this quality is increased by the 
intervention of compressed or consolidated lung, which conveys sound better 
than the loose pulmonary tissue. In extreme thinness of the walls of the 
heart, the first sound, instead of being loud, is sometimes very feeble, in con- 
sequence of the very feeble contraction. The bellows murmur is often heard 
in dilatation, partly in consequence of valvular disease, partly from the anemic 
state of the blood, which is common in this affection. 
The different position of the dulness and sounds, may serve to distinguish 
dilatation of the right from that of the left ventricle, as well as the symptom 
already alluded to of turgescence of the external jugular. Dilatation of the 
auricles may be suspected, when there are signs of disease of the auriculo- 
ventricular valves, along with those of dilatation in general. Dr. Stokes 
relates a case in which dilatation of the right auricle was attended with a 
distinct diastolic impulse between the second and fifth ribs on the right side. 
It has been thought that the position of the impulse also indicated the side 
of the heart affected, when on the left side, proceeding from disease of the 
left ventricle, and when behind the sternum, from that of the right. But 
the fact appears to be that the point of impulse depends, not on the part of 
the heart dilated or hypertrophied, but on the general position of the whole 
organ* whether horizontal or vertical; being in the former case on the left 
side, and in the latter behind the sternum. Enlargement of the heart itself, 
when considerable, has a tendency to produce the horizontal position, and 
consequently an impulse on the left; but various other circumstances extra- 
neous to the organ control this tendency, such as pleuritic effusion, pneumo- 
thorax, and emphysema, which push it towards the side opposite to their own, 
and, when on the left side, render it vertical under the sternum, and abdomi- 
nal distension from any cause, which pushes it upward, and renders it conse- 
quently more horizontal. {Skoda.} 
Partial dilatation or aneurism of the heart cannot be distinguished, with 
an approach to certainty, by any signs during life. CLASS III.] 
HYPERTROPHY AND DILATATION. 
179 
It should be borne in mind, in forming a diagnosis in diseases of the heart, 
that the import of many of the signs is very much modified by various or- 
ganic affections exterior to the heart. Thus, tumours aneurismal or other- 
wise, and partial pleuritic effusions behind the heart, may push it forward, 
so that a larger portion shall be in contact with the chest, and thus occasion 
increased impulse, and dulness over a greater extent than in health. By simi- 
lar causes, the heart may be removed laterally in either direction from its 
normal position, or may be thrust upward or downward, so as to vary the 
point at which its impulse may be felt, and its sounds heard. The effects of 
pulmonary consolidation or compression, emphysema of the lungs, and effu- 
sion into the pericardium, in obscuring the diagnosis, have been already 
noticed. In relation to the last-mentioned affection, it may not be amiss to 
repeat that, along with the dulness on percussion which it has in common 
with enlargement of the heart, there are the distinguishing symptoms of the 
comparative feebleness and distance of the sounds of the heart, and the entire 
absence of those of respiration. Finally, it is often extremely difficult to 
decide between organic and functional derangement of this organ; as, in 
nervous and anemic cases, and under strong excitement, the heart not unfre- 
quently presents phenomena which closely correspond with those enumerated 
among the characters of its anatomical changes. This subject will be treated 
of more fully under functional diseases of the heart. 
Causes. 
The causes of hypertrophy and dilatation are often the same, though ope- 
rating upon different principles. Whatever stimulates the muscular action of 
the heart may produce the former affection, whatever has a tendency to dis- 
tend the walls may produce the latter. Now no stimulus, probably, is greater 
to the muscular fibres than the pressure of the blood within the cavity which 
they surround; and no cause tends more strongly than this to produce dis- 
tension. It is not surprising, therefore, that the two conditions of hypertro- 
phy and dilatation often coexist in the same portion of the heart's structure. 
Whether one or the other shall predominate, depends chiefly upon the degree 
of constitutional vigour, and of the consequent tonic cohesiveness of the car- 
diac tissue. When these are great, the tendency is to the increase of the 
muscle, when feeble, to its distension; and it may happen that the power of 
resistance on the part of the muscle shall be sufficient to prevent all dilata- 
tion, or so exceedingly feeble as to offer scarcely any impediment to the pro- 
cess ; so that we may have pure hypertrophy or pure dilatation. It is not 
unlikely that, in many cases of enlarged heart, where both the walls are 
thickened and the cavities increased, the result may be one of over-action 
alone; for the natural result of the growth of a circular fibre is to enlarge 
the circle within it, as its length is greater than its thickness, and the growth 
will probably be proportion ably greater in the former than in the latter di- 
rection. Besides, there may be many causes of stimulation to the muscular 
fibre which have little or no effect in distending the cavity; and it is there- 
fore easy to account for the fact, that pure hypertrophy is not very unfre- 
quent. Distension of one of the cavities must always be a stimulus to the 
muscular walls; therefore pure dilatation is comparatively rare. 
Special Causes of Hypertrophy.-Among the causes which immediately 
stimulate the heart, and may therefore operate in producing hypertrophy, are 
excessive and continued muscular exertion of any kind, exciting passions, 
sensual indulgences, excess in the use of stimulating food and drink, and 
nervous disorder giving rise to obstinate palpitation. Inflammatory irritation 
may have the same effect. Hypertrophy of structure is one of the natural 180 
[PART II. 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
results of a certain degree of irritation. Rheumatism and gout, but especially 
the former, undoubtedly affect occasionally the muscular tissue of the heart, 
and give rise immediately to this result. The affection may be original in 
this organ, or may be translated to it from some external part. An extension 
of irritation, whether rheumatic or not, from the inflamed pericardium or en- 
docardium to the muscle, may also develope hypertrophy in the latter. It is 
not impossible that repelled eruptions may sometimes operate in this way. 
There are some causes which are to a certain extent mechanical. Anything 
which impedes the current of blood, and causes it to accumulate in one of the 
cavities of the heart, may, for reasons already mentioned, produce hyper- 
trophy. Anything which diverts the current of blood from its due course 
may have the same effect, by bringing into play the sympathies that connect 
the heart with the rest of the body, and are intended to secure a due supply 
of blood to all its parts. It is on these principles that structural derange- 
ment of the valves, and of the great blood-vessels near the heart gives rise to 
the disease in question. The valves either impede the passage of the blood 
by their constriction, or admit of its regurgitation by their insufficiency. 
Stricture of the aortic valvular orifice, or of the aorta itself, by causing an 
accumulation of the blood in the left ventricle, is a fruitful source of hyper- 
trophy of that cavity. The effect is, in this particular instance, increased by 
the augmented quantity of blood that is driven into the substance of the heart 
through its coronary vessels, in consequence of the excitement of the ventricle. 
Imperfection of the aortic valves, so as to permit regurgitation, has the same 
result by throwing back upon the ventricle a portion of the blood, while the 
ventricle is stimulated to increased action by the wants of the system. Con- 
traction of the mitral valve causes accumulation in the left auricle, which thus 
becomes hypertrophied and dilated; and the congestion, extending backward 
through the lungs to the right side of the heart, occasions congestion and 
hypertrophy of the right ventricle. Sometimes it happens that, while the 
right ventricle is hypertrophied and dilated from this cause, the left becomes 
thickened and contracted. The cause of the contraction is obviously the de- 
ficient supply of blood in consequence of the narrowing of the mitral orifice; 
that of the hypertrophy is not so clear. Perhaps it is the sympathy which 
binds all parts of the heart in harmonious action, and causes the left ventricle 
to share in the same irritation which is stimulating the right; perhaps it is 
the wants of the system, insufficiently supplied with blood, stimulating the 
ventricle through the nervous centres. Deficiency of the mitral valves, with 
regurgitation, leads to increased efforts on the part of the left ventricle, con- 
sequent on the partial diversion of the current from its legitimate course, and 
to augmented pressure upon the corresponding auricle, which not only receives 
more than its due share of blood, but is subjected also in a degree to the 
ventricular force, to which it is altogether unaccustomed. Hence, both these 
cavities may become diseased, the ventricle being hypertrophied, and the 
auricle both hypertrophied and dilated. In the same manner precisely, dis- 
ease of the right valves may induce disease of the right cavities; but, as the 
former is much less common than upon the left side, so also is the latter. 
From the observations of Dr. Glendinning, however, it may be inferred that 
hypertrophy, though not unfrequently the result of valvular disease, proceeds 
in a much larger proportion of cases from other causes. Of about 140 cases 
of hypertrophy, only about 30 presented well marked disease of the valves. 
Obstruction of the lungs operates in producing hypertrophy on the same 
principles precisely as disease of the valves; namely, by impeding the onward 
course of the blood, and thus producing congestion in the right cavities of the 
heart. Hence, chronic bronchitis, pulmonary emphysema, asthma, artificial CLASS III.] 
181 
HYPERTROPHY AND DILATATION. 
pressure upon the chest, &c., rank among the causes of this disease. Dr. 
Gairdner has suggested, as another cause.for cardiac distension, the expanding 
force of inspiration, when the lung is diminished in capacity, as in the par- 
tial collapse often attendant on bronchitis. (Brit. & For. Medico- Chirurg. Rev., 
April, 1853, Am. ed., p. 371.) It may be considered singular that phthisis, 
by which so large a portion of the lungs is often destroyed, and so small a 
portion left capable of carrying on the circulation, does not tend to produce 
disease of the heart. The reason probably is, that the quantity of blood be- 
comes in this complaint gradually accommodated to the capacity of the lungs, 
and congestion of the heart is thus avoided. 
Permanent dilatation of the right side of the heart sometimes occasions 
distension of the left,- with its necessary results, by pressing on the aorta. 
A preternatural communication between the two sides of the heart is said 
to induce hypertrophy of the right ventricle. That it should do so may be 
readily understood; as the opening tends to equalize the duties of the two ven- 
tricles, and thus to equalize also their powers, and consequently their amount 
of muscular fibre. 
Anaemia is another cause of hypertrophy. It acts by the steady excess in 
the cardiac contractions which it induces. (See Aneemiaf The muscular 
structure, however, being badly nourished, is apt to be pale and flabby; and 
thus the heart becomes liable to dilatation also. 
Predisposing causes to hypertrophy are original predominance of the cir- 
culatory system, inherited tendencies, and advanced age. The disease occurs 
at all periods of life, but most frequently in the old. 
Special Causes of Dilatation.-All the causes just enumerated, which are 
capable of producing distension of the heart's cavities, may give rise to dila- 
tation of its walls, if these have been previously weakened, as happens in 
anaemia, scurvy, typhoid and typhus fevers, and other diseases of debility. It 
is probable that the softness sometimes induced by inflammation predisposes 
to the same result. This diminution of the tonic cohesion of the muscular 
fibre is often connected with fatty degeneration. It may be alone sufficient 
to give rise to dilatation, as it incapacitates the heart from resisting the ordi- 
nary pressure of the blood, and leads to an increase of this very pressure, by 
lessening the force with which the blood is carried forward, and thus causing 
its accumulation in the cavities of the heart; but the cases are very rare in 
which dilatation exists uncomplicated with obstruction, or impediment to the 
circulation from valvular disease or other cause. This predisposing flabbiness 
of the muscular tissue is sometimes original, sometimes the consequence of 
disease. It is more apt to occur in women than in men, and hence dilatation 
is most common in persons of the former sex. Contraction of the mitral 
opening, is very often the origin of dilatation of the right cavities. 
By proper treatment in their earlier stages, both hypertrophy and dilata- 
tion, if not complicated with incurable valvular disease of the heart, nor 
attended with organic derangement of the muscular tissue, may often be 
effectually cured, and, when not curable, may be much palliated, and greatly 
retarded in their progress. They yield much more readily in the young than 
in the old; and, in the cases of children, the hope mgy always be indulged 
that the enlargement of the heart, if it has not proceeded too far, will be 
overtaken by the general growth of the body, and that this organ will after- 
wards advance at even pace with the rest of the system. This is nothing 
more than we constantly see in other parts of the body. A muscle, hyper- 
trophied from excessive use, resumes its original dimensions when allowed to 
Prognosis. 182 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
"PART II. 
rest; and the urinary bladder, enormously as it is sometimes dilated, contracts 
again upon the removal of the distending caus^. The reason that diseases of 
the heart have been looked upon with so much dread is, that they h'kve usually 
not been detected until so far advanced as to be beyond the reach of remedies. 
Hence the importance of those means of diagnosis by which changes of 
structure can/be recognized while yet curable. The difficulty in diseases of 
the heart is, that the causes are often beyond oui' reach. Hence it is that 
they are so fatal when connected with chronic valvular disease. As a gene- 
ral rule, it may be stated that hypertrophy or dilatation, with considerable 
organic derangement of the valves, is incurable. The same is the case in 
their advanced stages, when the secondary symptoms are prominent; when, 
for example, dropsy has been developed, and the dyspnoea, which is at first 
occasional, has become constant. In old age, moreover, even moderate de- 
grees of the two complaints are generally incurable. But, in all these cases, 
much may be done to protract life, and to render it more comfortable. Hy- 
pertrophy and dilatation are generally very slow in their progress, running on 
usually for years, sometimes for.many years, before they reach their fatal 
termination; and individuals not unfrequently live to old age, with the heart 
more or less affected by one or the other or both of these diseases. In some 
instances, however, their advapfee is rapid and fatal. They are often greatly 
aggravated by the supervention'of febrile or acute inflammatory diseases, and, 
under such circumstances, not unfrequently.render fatal an attack w'hich 
might otherwise terminate favourably. 
Treatment. 
In both forms of enlargement of the heart, the first and most important 
indication is to remove the cause of the disease, and, when it is not remova- 
ble, to diminish its influence as much as possible. . If the business pursuits, 
pleasures, indulgences, or habits of life of the patient, tend in any respect to 
sustain the affection, it is imperiously necessary that they should be regulated 
so as to obviate their injurious effects, or altogether abandoned. Should the 
moral influences under which he may be placed be suspected of any causative 
agency, they should be watched with the greatest' solicitude, and modified as 
far as possible. Rheumatism or gout, if existing, should be treated by suita- 
ble remedies. If valvular disease be detected, measures should be adopted 
for its relief, when any chance of success may be presented; and beneficial 
effects may sometimes be hoped for from a moderate and long-continued course 
of mercury. (See Valvular Disease of the Heart.} Disease of the lungs must 
be corrected if possible. Attention should be paid to the state of the nervous 
system, and to the condition of the blood. These, when disordered, often act 
very injuriously by sustaining palpitation. The blood may over stimulate the 
heart either directly by its too great richness, or indirectly by its poverty. 
In the one case it must be reduced, in the other enriched, so as to keep it at 
the point at which the heart will be most tranquil under its influence. (See 
Plethora and Aneemia.^ Lastly, the stomach and bowels should be carefully 
regulated. It is especially important to obviate dyspepsia, constipation, &c.; 
as their constant tendency is to derange the nervous system, and through this 
to disturb the heart. 
In relation to the ^rect treatment of the cardiac affection, it may be divided 
into 1. that which is suitable in cases of hypertrophy, or in which the symp- 
toms of hypertrophy predominate, and 2. that adapted to simple dilatation, 
or to cases in which, though some hypertrophy may exist, the peculiar phe- 
nomena of dilatation are most prominent. It is very important that this 
distinction should be borne in mind. In the great majority of cases, there is CLASS III.] 
HYPERTROPHY AND DILATATION. 
183 
a mixture of the two affections; but the treatment must be directed especially 
towards that which exhibits itself most prominently in the symptoms. 
1. Hypertrophy.-Large bleedings, perfect rest, and the lowest diet have 
been recommended in this affection; in short, the treatment employed by 
Valsalva with so much asserted success in aneurism. But experience has not 
proved its efficacy; and it is opposed by sound pathological doctrine. Hyper- 
trophy of the heart is a chronic affection, and .cannot be cured in a short 
time. The enlargement is the result of excessive growth, and not of inflam- 
matory congestion. It must be removed therefore by a slow vital process- 
the reverse of that which called it into existence A long-continued excess 
of action in the heart produced it; a steady continuance of reduced action 
must be aimed at in the cure. Now copious and quickly repeated bleedings, 
without at once removing the disease, exhaust the strength, so that a perse- 
verance in the plan becomes almost impossible, and a failure in the treatment 
of course unavoidable. Besides, the blood is rendered watery, and, according 
to principles elsewhere fully developed, the heart is stimulated by slight causes 
into excessive action. It has already been stated, that the anemic condition 
favours the production of hypertrophy of the heart. 
But moderate bleeding is highly important. Six or eight ounces may be 
taken, according to the degree of plethora, once or twice a month, or less fre- 
quently. Should pain exist about the heart, it would be best to take this 
amount of blood by cups or leeches between the shoulders, or upon the breast; 
under other circumstances, it should be drawn from the arm. 
In the intervals between the bleedings, saline cathartics should be employed 
in moderate doses, once or twice a week, or oftener. They diminish the volume 
of the blood, without depriving it too much of its nutritive matter; and some- 
times afford great relief to the patient. Sulphate of magnesia or bitartrate of 
potassa may be used. The latter has the advantage of stimulating the kid- 
neys as well as of operating on the bowels, but is probably rather more dis- 
posed to derange digestion. 
A low diet is also highly important, indeed indispensable. It should, how- 
ever, be regulated according to the condition of the blood. When this is rich 
and in excess, it should consist exclusively of vegetable food; but, as one 
great object is to prevent the production of anaemia and nervous or dyspeptic 
disorder, which have a tendency to agitate the heart, it becomes important 
not to carry restriction too far; and, should the strength begin to fail, and 
the face to assume a pallid hue, milk should be allowed, with occasionally 
some fish, or perhaps a soft boiled egg. Small quantities of meats may be 
given in cases with more decided symptoms of depression; but in no case 
should the diet be stimulating. In all doubtful cases, the practitioner can- 
not go far astray by confining the patient to milk and the more digestible 
vegetable substances. All kinds of stimulating drinks, including tea and 
coffee, should be strictly forbidden; and spices should be very sparingly em- 
ployed, if at all. 
Absolute rest is not desirable; as it favours the generation of dyspeptic 
and nervous derangements; but it is highly important to abstain from all 
kinds of exertion which stimulate the heart. Running, ascending heights, 
the use of wind instruments, singing or loud speaking, and long-continued 
standing should be avoided. Moderate and slow walking may be permitted 
and even encouraged; but passive exercise is decidedly preferable to active; 
and the patient should ride frequently in a carriage, or upon a very easy and 
quiet horse. Should the latter mode of exercise, however, be found to excite 
the heart, it should be abandoned. 
Equanimity is highly necessary for the patient, who should, therefore, scru- 184 
[PART II. 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
pulously avoid every occasion of mental excitement, and should keep a careful 
watch and command over his feelings on all occasions. 
The plan of treatment above prescribed is adapted to the earlier stages, 
and to cases in which there are obvious hypertrophic symptoms, with some 
excitement. It is not absolutely necessary that the pulse should be very 
full and strong; for, when the right ventricle is hypertrophied, the pulse is 
not especially affected. But the impulse of the heart should always be strong 
before the plan is adopted. In weighing the symptoms, should the balance 
incline somewhat towards dilatation, or waver between the two forms of disease, 
depletion must be used with more caution, if not omitted altogether. On the 
contrary, should the action of the heart be very excessive, and symptoms threat- 
ening inflammation or hemorrhage in the brain or lungs appear, it may be 
proper to meet the indication by one or two copious bleedings, and when it 
has been fulfilled, to resort again to the original plan. 
As auxiliary to the above measures, recourse may be had to medicines cal- 
culated to diminish the action of the heart. The most efficient of these is 
digitalis, which may be given in the dose of a grain of the powder, or ten 
drops of the tincture, twice a day, and very cautiously increased until it is 
ascertained what quantity is sufficient to affect the system. It should never 
be carried so far as to sicken the stomach, or produce prostration. Hydrocy- 
anic acid has also been recommended; and may prove serviceable occasionally 
as a substitute for digitalis. I have employed acetate of lead with a view to 
its sedative as well as astringent action, and have seen the heart apparently 
diminished in size under its influence; but, in order to do good, it must be 
continued long, being suspended when it produces any symptoms of gastric 
or intestinal disorder, and resumed when these have ceased. I have not seen 
it do permanent injury; but have always made it a point to watch its action 
closely. Its careless employment might easily lead to the production of the 
lead disease. Dr. Silvester speaks highly of the Iberis amara, or candy tuft, 
in hypertrophy of the heart. He gives the seeds, rubbed to powder with cream 
of tartar, in the dose of from one to three grains. The remedy was first 
brought into notice by the late Dr. Williams of St. Thomas's Hospital, Lon- 
don. (Prov. Med. and Surg. Journ., Aug. 25, 1847.) 
Some good may be expected, when there is pain or much uneasiness about 
the heart, from permanent external irritation and discharge, maintained by 
frequently repeated or perpetual blisters, by pustulation with tartar emetic or 
croton oil, or by an issue or seton. I prefer repeated blistering. This counter- 
irritation is especially useful in cases of a rheumatic origin or character. 
Dilatation.-In this affection, the most prominent indication is to bring 
about and sustain a proper balance between the quantity of blood, and the 
power of the heart to circulate it. As the disease very generally depends, in 
part, at least, upon a want of tone in the muscular tissue of the heart, it is 
necessary to obviate this condition. The watery or anemic state of the blood, 
so common in the complaint, is frequently one of the causes of the want of 
tone alluded to. It also indirectly stimulates the heart to excessive effort, and 
thus still further tends to exhaust it. Moreover, by the bulk of watery liquid 
which it contains, it distends the cardiac cavities, and thus directly favours 
dilatation. Hence, it is of the greatest importance to correct this state of the 
blood. Our efforts should be directed towards rendering that liquid at once 
moderate in quantity, and of good quality as regards its nutritive ingredients. 
From what has been said, it is obvious that bleeding can very seldom be 
required. Generally, indeed, it would prove highly pernicious. It will not 
even diminish the bulk of the blood permanently; for, in the place of that 
taken, water will be absorbed, and the vessels will soon be filled again. Its CLASS III.] 
185 
HYPERTROPHY AND DILATATION. 
real effect upon the blood is still further to impoverish it, and thus secondarily 
to irritate, while it directly debilitates the heart. 
The mild tonics and a nutritious diet are the most efficient means of meet- 
ing the indications mentioned. Of the tonics, the chalybeates are the best. 
They at once strengthen the heart, and improve the blood. They should be 
continued until the anemic condition, if it exist, shall be corrected. The 
vegetable bitters may be given as auxiliaries, or as substitutes when the iron 
has answered the desired purpose. The mineral acids are often excellent ad- 
juvants to the bitters, especially when there is defect of appetite. Small doses 
of the saline catharticswill sometimes prove useful by diminishing the watery 
portion of the blood. Animal food should be employed, but with care to select 
the most digestible and least stimulating varieties. Little drink should be 
taken, as it tends to make the blood watery. Porter or ale, in moderate 
quantities, may be allowed when the patient is very feeble. 
Another important indication is to diminish the frequency of the heart's 
contractions when it is excited, and to obviate palpitation. This tends to ex- 
haust the heart by over-exertion. The object is in great degree effected by 
the means calculated to restore the blood to its normal state. But, in ad- 
dition, it may sometimes be proper to employ sedatives. Digitalis may be 
used, but with greater caution than in hypertrophy, as its depressing effects 
might readily be carried too far. Perhaps one of the best remedies to meet 
this indication is hydrocyanic acid, in the shape of wild cherry-bark tea. This 
may be given as freely as the stomach of the patient will conveniently bear. 
Nervous disorder, which is so apt to cause palpitations, should be corrected by 
the antispasmodics, as assafetida, valerian, camphor water, Hoffmann's ano- 
dyne, aromatic spirit or solution of carbonate of ammonia, &c. Narcotics 
are also useful for the same purpose. Opiates are the most effectual, and of 
these the salts of morphia are perhaps on the whole to be preferred. A little 
camphorated tincture of opium is often very useful. As substitutes or adju- 
vants of opium, conium, hyoscyamus, and lactucarium may be given inter- 
nally, and the extract of stramonium or belladonna applied externally in the 
form of plaster. Opium should not be used, at least in large doses, when the 
lungs are loaded, and the expectoration deficient. Dyspepsia should be guarded 
against, and corrected if present. Constipation should be obviated by rhu- 
barb and aloes, or other laxatives, when the saline cathartics may be no longer 
indicated. The stomach should never be overloaded. Moderate exercise of the 
passive kind is not less indicated in this complaint than in hypertrophy; but 
the patient should guard against all sorts of exertion calculated to bring on 
palpitations. He should not less carefully guard against mental excitement. 
Flannel next the skin is necessary to obviate the effects of cold; and frictions 
to the surface are useful by giving a centrifugal direction to the blood, and 
thus relieving the heart. 
Secondary Affections.-In relation to these, it is not necessary to go into 
detail. They are to be treated very much in the same manner as similar af- 
fections from other causes. When there is great determination of blood to the 
head, it may become necessary, in addition to general bleeding, to apply cups 
or leeches to the temples or back of the neck, cold water to the head, and hot 
stimulating pediluvia to the feet. Pulmonary apoplexy must be encountered 
with free depletion, when the patient will bear it; and in congestions, inflam- 
mations, and hemorrhage of the lungs, the usual remedies must be employed, 
qualified, however by the state of the system. In dilatation, the pulmonary 
affections must be treated much more cautiously by depletion than in hyper- 
trophy. The stimulant expectorants, as seneka, ammoniac, squill, assafetida, 
and the ethereal and ammoniacal preparations may be used when there is 186 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
[part II. 
great debility, with oppressive bronchial secretion. In the paroxysms of 
dyspnoea, the antispasmodics, narcotics, and stimulating expectorants may be 
conjoined; and the hot foot-bath, used for a long time, occasionally affords 
much relief. In vomiting, the aromatic spirit of ammonia is one of the best 
remedies; but other anti-emetics may be employed if necessary. (See Vomit- 
ing.') The state of the liver sometimes requires an alterative course of one 
of the mercurials, with purgatives to relieve congestion. Nitro-muriatic acid 
may sometimes be substituted both internally, and by pediluvium. The treat- 
ment of cardiac dropsy is elsewhere considered. It is to be encountered chiefly 
by diuretics and hydragogue cathartics, of which bitartrate of potassa is the 
best. When the limbs become enormously swollen, with great oppression in 
breathing, it is proper to make shallow punctures with a very sharp lancet in 
the legs. These often afford great relief by allowing the escape of serum; 
though they sometimes occasion inflammation, and give rise to a sort of 
gangrenous erysipelas, which hastens the fatal issue. 
In the latter stages of both hypertrophy and dilatation, the efforts of the 
practitioner should be directed to palliation exclusively. All very active 
measures should be abandoned, as there is no longer any hope of cure, and 
the-object is to render the patient as comfortable as possible. 
In the treatment for the cure, in the earlier stages, the means employed 
should be persevered in steadily for one, two, or three years. This length of 
time is usually required for a restoration of the heart to its normal dimensions. 
Dr. Hope states that the great majority of recoveries, within his experience, 
take place between one and two years from the beginning of treatment. Even 
should the symptoms disappear earlier, the remedies should nevertheless be 
persevered in ; nor, indeed, should the patient consider himself free from dan- 
ger of a return of the malady, nor from the necessity of great caution in the 
regulation of his habits in all respects, during the remainder of his life. 
Article VI. 
VARIOUS ORGANIC DISEASES OF THE HEART 
Atrophy. 
The heart is sometimes of much less than its average dimensions in health. 
Thus, it has been found in the adult scarcely larger than that of an infant at 
birth. The walls are usually quite sound. In some instances, their thick- 
ness is not diminished, and the only morbid condition is a reduction of size. 
Occasionally a wrinkled appearance is presented, as if the organ had shrunk 
more interiorly than upon the surface. In other instances, again, the walls 
are attenuated, and this condition is usually accompanied with dilatation. All 
cases of dilatation in which the mass of the heart is less than in health, may 
be considered also as cases of atrophy. 
There are no symptoms by which this affection can be certainly recognized 
during life. It may be suspected when the pulse is uniformly threadlike and 
weak, the impulse of the heart against the ribs scarcely discoverable or quite 
wanting, the usual dulness on percussion diminished, the sounds very feeble, 
and no sign observable of other organic affection. 
The relative smallness of the heart has been thought to be sometimes con- 
genital, sometimes the result of a sudden arrest of developement. It has also 
been ascribed to continued pressure upon the organ by morbid productions in 
its neighbourhood, or disease of its pericardial investment. It is said to have 
resulted from firm adhesion of the opposite surfaces of the pericardium, in CLASS III.] 
187 
SOFTENING OF THE HEART. 
the young. But the most common causes are probably those which interfere 
with the general function of nutrition, and produce emaciation throughout the 
body; such as severe and long-continued abstinence, and the wasting influence 
of various chronic complaints, among which may be mentioned phthisis, cancer, 
and mesenteric disease. Atrophy of the heart has also been traced to obstruc- 
tion or obliteration of the coronary arteries. 
No treatment addressed especially to the heart will be likely to do good. 
All that can be expected from remedial measures is the cure or alleviation of 
the condition of the system upon which the atrophy may depend. 
Softening of the heart is not uncommon. That form of it which depends 
on inflammation has already been treated of under carditis. At present our 
attention will be confined to the affection proceeding from other causes. It 
may be general or partial; that is, may occupy the whole organ, or may be 
limited to the walls of one of the cavities, or even to a small spot in the walls. 
When the heart generally is involved, it is flaccid or flabby, and, in extreme 
cases, collapses when emptied or cut into, like a wet bladder. In all cases, 
the cohesion is more or less diminished. The muscular tissue is easily torn, 
often admits the finger to be readily passed through it, and is sometimes re- 
ducible by pressure to the state of a pulp. Occasionally, as in old age, it is 
of an almost gelatinous consistence; the fibres being soft, tremulous, and of a 
translucent appearance. The colour is various; sometimes very pale, grayish, 
or whitish, in other instances yellowish and compared by Laennec to that of 
dead leaves, and in others again deep-red, livid, or violaceous. 
Softening is often associated with other morbid conditions of the heart, as 
with obesity, fatty degeneration, and dilatation. The last-mentioned affection 
is thought very often to result from it. 
Symptoms.-The pulse is usually small, feeble, and intermittent, or other- 
wise irregular. The impulse of the heart is feeble, as are also the sounds, 
especially the first, which is sometimes wanting. It is probably owing to the 
attendant softness, that, in great dilatation, the heart, instead of yielding the 
loud sound which ordinarily accompanies that affection, can in some instances 
scarcely be heard. A disposition to syncope, and all the other consequences 
of an insufficient supply of arterial blood, and of venous congestion in the 
lungs and elsewhere, which have been enumerated under the heading of hy- 
pertrophy and dilatation, are experienced in softness of the heart. They are 
owing to the feebleness of the cardiac contractions, which fail to send the 
blood forward sufficiently, and consequently permit its accumulation poste- 
riorly. When these symptoms are offered in any case, without valvular 
murmurs, or evidence of dilatation, and without any reason for ascribing 
them to nervous disorder, they may be considered as indicative of softening 
of the heart. 
Causes.-Whenever, along with the softening, there is pus in the muscular 
tissue, or ulceration, or inflammation of the investing or lining membrane, it 
may be considered as of an inflammatory character; and the same is probably 
the case with most of the partial softenings. In other instances, the affection 
depends either on defective nutrition from poverty of the blood or general 
debility, as in anaemia, wasting chronic complaints, old age, and the prostra- 
tion which follows acute diseases; upon a depraved condition of the blood, as 
in malignant fevers and scurvy; or, finally, upon continued venous congestion 
of the substance of the heart, as in certain valvular diseases of that organ, 
and in dilatation. It may also depend upon obstruction, or other morbid 
condition of the coronary vessels. When caused by anemic conditions of the 
Softening. 188 
[PART II. 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
system, or mere chronic debility, the softening is usually pale or yellowish. 
As attendant upon typhous or scorbutic disorder, it is often dark-red or livid, 
and is occasionally accompanied with extravasation of dark blood, either upon 
the surface of the heart, or in disseminated spots through its muscular sub- 
stance. It is frequently associated with fatty degeneration. Dr. Wm. 
Pepper, of Philadelphia, found softening of the heart to accompany that 
sudden prostration of system which follows excessive fatigue, with exposure 
to a hot sun, and which, under the name of sun-stroke, is sometimes con- 
founded with active congestion of the brain. (^Summary of the Trans, of 
Coll, of Phys, of Phila., iii. 100.) 
Effects.-Softening may prove fatal by rupture, dilatation, or syncope con- 
sequent upon the direct loss by the heart of its power of contracting. It is 
probably often remediable, though it adds greatly to the danger of the com- 
plaints with which it is associated, and is probably one of the direct causes 
of fatal prostration in malignant fevers. 
Treatment.-This must be addressed to the state of the system. In chronic 
and anemic affections, the chalybeates are most to be relied upon, aided occa- 
sionally by the simple bitters or quinia. The mineral acids are also useful, 
but must be employed cautiously with the preparations of iron, because some- 
times chemically incompatible with them. They may often be advan- 
tageously associated with tincture of chloride of iron. When the debility is 
very great, it may be necessary to resort to the more powerful stimulants, 
as carbonate of ammonia, oil of turpentine, wine, and even brandy. The 
diet should always be in the highest degree nutritious and digestible. 
The muscular tissue of the heart sometimes becomes simply hardened, 
without undergoing any other appreciable change. Corvisart describes a case 
in which the organ gave, when struck, a sound similar to that of a dice-box, 
and produced a crepitant sound when cut. Cases similar in relation to the 
sound were noticed by Laennec and Hope; and Broussais mentioned instances, 
within his own observation, in which the heart resembled a cocoa-nut in hard- 
ness. One would suppose that the power of contraction must be lost under 
such circumstances; but this does not appear to be the case. The affection 
is extremely rare. It is of unknown origin, though referred by some to 
inflammation. 
Induration. 
Degeneration, and Abnormal Products. 
Under this head are included all the affections in which the tissues of the 
heart undergo changes so as to lose entirely their original character, or in 
which morbid products, whether the result of growth or mere deposition, en- 
croach upon its substance. These are numerous, but all of them rare. 
1. Fibrous, cartilaginous, and osseous degeneration have before been 
treated of as occurring in the lining or investing membrane, or in the cellu- 
lar tissue intervening between these and the muscular structure, or in the 
valves. (See Pericarditis, Endocarditis, and Valvular Diseased) The same 
degeneration has been observed, in some rare instances, in the muscular 
tissue. It is probable, however, that, in these cases, the fibre has rather 
undergone absorption in consequence of the pressure of the newly deposited 
matter, than been the subject of transformation. Sometimes isolated calcu- 
lous masses have been found embedded in the thickness of the cardiac walls. 
Ossification of the coronary artery is not a very rare occurrence in persons 
advanced in life. It does not necessarily give rise to observable morbid 
effects; though angina pectoris has been ascribed to it. CLASS III.] 
189 
FATTY DEGENERATION OF THE HEART. 
2. Fatty degeneration has been noticed by various pathologists, and has 
been ascertained to be a more common affection than was at first supposed. 
The muscle undergoes a partial change into fatty matter; and oil globules 
may be seen, by the aid of the microscope, occupying the place of the proper 
muscular fibre, within its sarcolemma. The heart, or the portion of it 
affected, is pale, yellowish, or of a dirty pink colour; and this discoloration 
is often in patches, giving the organ a mottled appearance. Sometimes the 
altered colour is confined to one portion of the heart. Softening to a greater 
or less extent is always present, sometimes having the character of flabbiness, 
sometimes of friability. The natural fibrous appearance gives place to a uni- 
form or granular aspect of the cut surface. In advanced cases the fat is so 
copious as to be obvious to the eye, and to give a greasy feeling to the texture. 
The chief seats of the degeneration are said to be the inner portion of the 
walls of the heart, and the fleshy columns. 
This affection is dependent on diminished vital force in the heart, allowing 
chemical influences to supersede the proper nutritive function, and may be 
connected either with general debility, or with local impediment to the due 
nourishment of the organ, as from disease or obstruction of the coronary arte- 
ries. It is most apt to occur in old age, and is favoured by inaction and in- 
temperance. It is not unfrcquently observed in hypertrophied hearts. The 
affections with which it is most frequently associated are phthisis, chronic 
gout, chronic disease of the liver and kidney, atheromatous degeneration of 
the aorta, and a general tendency to fatty degeneration. It may or may not 
be attended with disease of the valves of the heart. The effects of this dis- 
ease are such as necessarily result from debility in the central organ of circu- 
lation. A feeble, slow, and irregular pulse, faintness, syncope, precordial 
uneasiness or oppression with a sense of sinking at the heart, neuralgic 
pains in the chest, dyspnoea, vertigo, dimness of vision, and coma, are among 
the symptoms, not all, however, appearing in the same case. Attacks re- 
sembling apoplexy, but not accompanied with palsy, are not uncommon. 
Rupture of the heart sometimes takes place. In the great majority of cases, 
the disease ends in sudden death. The arcus senilis, or white zone observed 
in the eyes of the old, and sometimes also of the young, and ascertained to 
be a fatty degeneration of the cornea, has been found by Mr. Canton to be 
generally attended with the same affection of the heart, and may therefore be 
looked on as a valuable diagnostic symptom. (Ranking's Abstract, Am. ed., 
xiii. 207.)* It is, however, stated by Dr. E. B. Haskins, of Clarksville, 
Tennessee, as the result of his observation of twelve cases of the arcus senilis, 
that only two offered any symptoms of organic alteration of the heart. (Am. 
Journ. of Med. Sci., N. 8., xxv. 107.) The characteristic physical signs are 
feeble impulse, and a feeble first sound, which is sometimes scarcely audible. 
There is not unfrequently a murmur with the first sound from disease of the 
aortic valves, while the second sound is healthful. 
The affection is incurable. Patients may live long with it, but are apt to 
die suddenly upon the occurrence of other diseases, of surgical operations, or 
of any accident that may interfere with the heart's action. It is in this affec- 
tion, too, that rupture of the heart is most apt to take place. Though it is 
impossible to restore the muscular fibre which has undergone the fatty de- 
generation to its normal state, yet it is probable that much may be done, by 
* I have recently had an opportunity of confirming this coincidence of the two affec- 
tions. An old seaman, entering the Pennsylvania Hospital, was observed to have the 
arcus senilis. The impulse and sounds of his heart were very feeble. Fatty degene- 
ration of the heart was diagnosticated. He died suddenly, and the diagnosis was fully 
confirmed on post-mortem examination. [Note to the fourth edition.') 190 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
[part II. 
correcting the state of system, to retard if not check its progress. This must 
be effected by the usual methods, care being taken to avoid everything calcu- 
lated to overtask the heart, lest it may suddenly fail to perform its duty. 
For a full account of the disease, the reader is referred to a paper by Dr. 
Richard Quain in the London Medico-Chirurgical Transactions (xxxiii. 121). 
3. Obesity of the heart is not very unfrequent. The fat is deposited 
between the pericardium and muscular substance, and sometimes penetrates 
between the fibres of the latter. Occasionally it accumulates in enormous 
quantities, so as completely to conceal the muscular structure, and materially 
to interfere with the heart's motion; and has been thought in some instances 
to have caused death. The muscular layers beneath it sometimes become 
softened and attenuated, probably from absorption produced by pressure. 
The affection is most frequent in very fat individuals, though it has some- 
times been noticed in connexion with great general emaciation. 
The symptoms are not usually striking. Sometimes no morbid pheno- 
mena are observed, and the existence of cardiac derangement is first disco- 
vered after death. In other cases, the patient suffers with dyspnoea, palpita- 
tion, and other ordinary signs of embajjrassed action of the heart. In the 
cases in which the fibres undergo atrophy, there are weakness and irregular- 
ity of pulse, with feeble impulse and diminished sound. When these symp- 
toms occur in very fat persons, with no other discoverable cardiac disease, 
they may be conjecturally referred to obesity. They have been observed to 
increase and diminish with an increase and diminution of the general fatness; 
and a case is mentioned by Chomel, in which violent symptoms of derange- 
ment of heart, occurring in an obese individual whose case presented the 
phenomena just alluded to, yielded to abstinence and depletion. 
The treatment in this affection must be directed to the fatness in general, 
and should consist chiefly of a spare diet without fats, such depletion as the 
system can well support, exercise of the passive character, and the use of the 
vegetable acids as freely as can be borne without impairing the digestion. 
4. Tubercles have been found in the heart, but are very rare. The same 
is the case with cancerous disease, whether in the form of scirrhus or medul- 
lary fungus. These affections scarcely ever seize upon the heart, unless 
previously existing in other parts of the system. It is said that scirrhus has 
sometimes occasioned acute lancinating pains; and the cachectic sallowness 
usually characteristic of cancer may be supposed to attend it. A certain 
diagnosis, however, in these cases, is quite impossible. Cysts and hydatids 
have been discovered in the heart upon dissection; but there are no signs by 
which they could be recognized during life. 
Rupture of the Heart. 
Rupture of the heart, in a healthy state of the organ, may happen from 
mechanical violence, as a heavy blow, a crushing fall, or the pressure of some 
great weight, as of a wagon-wheel, upon the chest. It may also happen from 
disease. Fatty degeneration of the heart is probably the most frequent cause 
of rupture. Extreme dilatation may have the result ; and this is one of the 
fatal terminations of partial dilatation, or proper aneurism of the heart. The 
accident is not relatively unfrequent in hypertrophy. In that affection, the 
parietes are very often unequally thickened; and, as the ventricle contracts 
with much more than the usual force, it might be expected that the thinnest 
portion would give way. Now, as the ventricle is thinnest at the apex, it 
would seem to be a fair inference, that the rupture must take place most 
frequently at or near that point than any other. The fact is, that it does 
occasionally take place there; but it is asserted that a more frequent seat of CLASS III.] 
191 
RUPTURE OF THE HEART. 
the accident is in the thickest part of the heart, towards the base of the ven- 
tricle. The only explanation of which this fact appears to be susceptible is, 
that, in hypertrophy of the muscular substance, the fibres lose their cohesive- 
ness in a greater degree than their force of contraction; and that a rupture 
takes place, as in the gastrocnemius, from a sudden and violent action of 
that muscle. Whether the heart has been hypertrophied or dilated, con- 
traction of some one of the orifices has been noticed in a large proportion of 
the cases of rupture. It is obvious that, in the different organic changes to 
which the walls of the heart are exposed, a degree of brittleness may some- 
times result, which may predispose to rupture under an excited action of the 
organ; and hypertrophy of the heart has been ascertained to be not unfre- 
quently associated with fatty degeneration. Ulceration and abscess of the 
heart have sometimes been the cause of the accident, by reducing the walls 
to a thinness, unequal to the necessary resistance against the pressure to 
which they are exposed. The effusion of blood into the substance of the 
heart is also ranked among the disposing causes. Whatever may be the 
morbid state of heart disposing to the rupture, it is apt to be caused immedi- 
ately by an unusual degree of action or distension in the organ, proceeding 
from unusual muscular exertion, paroxysms of anger, violent coughing or 
vomiting, or some other source of excitement. It is said to occur more fre- 
quently in men than in women, and in old persons than in the young. 
The rupture is sometimes large and completed at once, sometimes small at 
first, and gradually extended. Cases are on record in which two or more 
openings existed in the same heart. The rupture is occasionally partial, not 
entirely penetrating the walls. Sometimes only the fleshy columns or cordae 
tendinae are broken. The accident is much more frequent in the left than in 
the right ventricle, and more so in the right ventricle than in either of the 
auricles. In cases, however, of rupture from violence, the right cavities are 
most apt to be affected, because more exposed by situation, and less able to 
resist from their thinner walls. Some rare instances are on record in which 
the coronary artery has been ruptured, filling the pericardium with blood. 
{Archives G&nArales, 4e s£r., xiv. 195.) 
The antecedent symptoms vary, of course, according to the cardiac affec- 
tion which gives rise to the rupture. Sometimes none are observed, unless 
perhaps slight dyspnoea. Instances have occurred in which the rupture was 
preceded for a short time by excruciating pain, remittent or continuous, shoot- 
ing from the praecordia to the back, and into the left shoulder and arm. This 
pain has been ascribed to the gradual rending of the muscular fibres. 
In the great majority of cases, the consequence of rupture of the heart, 
and effusion of blood into the pericardium, is almost instant death. The 
patient suddenly becomes excessively pale, speedily loses consciousness, and 
dies of syncope. This, however, is not always the case. Instances occur in 
which life continues several hours, and even for a considerable period. When 
the opening is very small, death may be long protracted; and there is reason 
to suppose that a spontaneous cure is not impossible. A case is on record, in 
which, after death from rupture, the remains of a former rupture were ob- 
served, in which the vacuity was filled up with a fibrinous concretion adhering 
to the walls of the heart. 
There are no symptoms by which a partial rupture of the walls can be re- 
cognized. When the fleshy columns or tendinous cords are torn, the loose 
ends of the columns, or the liberated laminae of the valves, float into and out 
of the orifices with the current of blood, and occasion much embarrassment 
of the circulation, both from obstruction and insufficient closure of the valves. 
There is usually violent pain, with sudden and great oppression amounting 192 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
[part II. 
almost to suffocation, and much disturbance in the actions of the heart. The 
most confused sounds are heard in the chest, and among them not unfrequently 
the murmurs of constriction and regurgitation. A tremulous uncertain pulsa- 
tion of the heart may be felt by the hand in the cardiac region. Should the 
patient survive long, hypertrophy or dilatation is likely to ensue. 
Little need be said in relation to the treatment of rupture of the heart. 
Usually death has taken place before the physician arrives. Should the case 
be somewhat protracted, the indications are to keep the patient perfectly at 
rest, and to quiet any irritation of system by anodynes. The great point to 
be aimed at is, that the heart should act as little as possible compatible with 
the maintenance of life. 
Two kinds of fibrinous concretion 'are found in the cavities of the heart; 
one formed either after death or at the moment of dissolution, the other some 
time before death. 
The former are wholly unorganized, and consist of coagulated fibrin, which 
has separated from the mass of blood, as the buffy coat separates in inflamma- 
tory blood removed from the body. They are whitish or yellowish-white, 
translucent, sometimes of a tremulous jelly-like consistence, sometimes firmer, 
occasionally with a darker nucleus in the centre, and but slightly adhering to 
the surface of the cavity, from which they can be readily separated without 
altering the structure of the endocardium. They are usually found in the 
right cavities, and probably result from an excess of fibrin, or a high degree 
of coagulability of that principle, which is brought into action by the stasis 
of blood. 
The second variety of concretions, which better deserve the name of poly- 
pous that has been applied to both, are real morbid products, and give rise 
during life to very serious symptoms. These are firmer than the preceding, ■ 
more opaque, of a fibrous texture, and sometimes composed of successive layers. 
In size they are extremely diversified, in some instances being very minute, 
in others almost filling one or more of the cavities of the heart, and of all 
intervening dimensions. Their colour is usually white, but occasionally red- 
dish from the presence of blood, which has been thought to be contained in 
rudimentary vessels that ramify in the mass, and constitute the commence- 
ment of an imperfect organization. They adhere firmly to the surface of the 
endocardium, so that, when separated, they leave an appearance as if torn off; 
and sometimes a vascular communication seems to exist between them and 
the inner surface of the heart. Different opinions have been entertained as to 
their mode of formation, some ascribing them to the coagulation of a portion 
of the blood, which afterwards contracts adhesion with the heart, others con- 
sidering them as the product of fibrinous exudation from the inner cardiac 
surface in a state of inflammation. They are probably produced sometimes 
in the one way, and sometimes in the other. When the blood contains an 
excess of fibrin, and is from any cause delayed in the heart, it may readily 
be conceived capable of forming coagula, and especially when a small portion 
of concrete exuded fibrin is present to serve as a nucleus. In like manner, it 
is altogether probable that the inflamed endocardium, like other serous mem- 
branes, sometimes throws out coagulable lymph in sufficient quantity to form 
concrete masses of considerable magnitude. To the former origin may be re- 
ferred the globular vegetations of Laennec, which vary in size from the magni- 
tude of a pea to that of a pigeon's egg, sometimes adhere to the surface by a 
pedicle more recent than themselves, and contain within a central cavity a 
bloody or pus-like fluid. To the latter probably belong the warty vegetations, 
Polypous Concretions. CLASS III.] 
CYANOSIS, OR BLUE DISEASE. 
193 
which have been before mentioned as occasionally forming upon the valves 
and in their neighbourhood. These concretions may always be distinguished 
from the unorganized variety, according to the observations of M. Friedault, 
by containing proper pseudo-membranous matter, in which primarily cells are 
observable by aid of the microscope, and afterwards fibres formed from them. 
(Arch. Gen., 4e ser., xiv. 63.) 
But, however formed, these concretions prove sources of great inconvenience, 
and often of danger. They diminish the cavity in which they are placed, and, 
by narrowing the orifices through which the blood passes, or preventing a 
proper coaptation of the valves, may produce all the effects of the most serious 
valvular disease. Their symptoms are uncertain. They may be suspected, 
however, when the movements of the heart, previously regular, become sud- 
denly much embarrassed, with irregular and confused pulsations, great dys- 
pnoea, and the general signs of a diminished supply of arterial blood on the one 
hand, and of venous congestion on the other. Among the most frequent symp- 
toms are great prostration, a feeble irregular pulse, coldness of the surface, pale- 
ness of face, extreme anxiety, the utmost difficulty in respiration, with a sense 
of suffocation, and inability to lie down in bed. Nausea and vomiting have 
been noticed as attendants on the affection. (Basking, Am. Journ. of Med. 
Sci., N. S., xx. 404.) The symptoms, in some instances, cease for a time 
and again return, probably in consequence of the newly formed mass being at 
one time carried within reach of the valves so as to derange their functions, 
and then floating away for a time so as to leave them free. This may easily 
happen when they are attached by a pedicle which allows them free motion in 
the cavity. But the diagnosis is always uncertain. 
It has been recommended, in order to prevent the formation of these con- 
cretions, to bleed very freely in cases of endocardial inflammation, or others 
in which a tendency to their production may be supposed to exist. But to 
push depletion, from fear of cardiac concretions, beyond the point required 
upon other grounds, would be to run the hazard of very serious evils, to avoid 
one which may be altogether imaginary. They may, therefore, very properly 
be left out of view, unless as an additional inducement to the cure of all in- 
flammatory diseases by means adapted to the obvious circumstances of each 
case. When already formed, they are generally beyond the reach of remedies; 
though, in recent cases, it may not be amiss to employ alkaline medicines, in 
the hope that their solvent influence over fibrin may have some effect in pro- 
moting the solution of the exuded or concreted matter. 
Malformation of the Heart. 
A great variety of congenital malformations of the heart are recorded. 
Most of them, however, have little interest for the practitioner. I shall notice 
them here only in connexion with a certain state of the circulation, which, 
being marked to common observation chiefly by the discoloration of skin that 
attends it, has from this cause received the name of the blue disease. 
Cyanosis.-Morbus Ceeruleus.-Blue Disease.-The colour of the skin 
in this affection is bluish, purplish, or livid, but varies very much in degree 
in different cases, and even in the same case, being sometimes slightly livid, 
sometimes so dark as to approach to blackness. In very mild cases, it is 
perceived chiefly in the lips, mucous membrane of the mouth, ends of the 
fingers, &c., where the capillaries are most numerous, or nearest the surface. 
In some instances, it is almost or quite wanting at one time, and present in a 
high degree at another. The intensity of the colour is very generally increased 
by whatever increases the action of the heart. Along with the discoloration 
is usually an unnatural coolness of the surface; and the patient is either ha- 194 
[part II. 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
bitually subject to dyspnoea and palpitation, or is frequently attacked by them. 
Other attendant symptoms are an irregular and intermittent pulse, occasional 
fainting, in some cases convulsions, and, if the complaint continue long, more 
or less dropsical effusion. The patients are generally subject to violent suffo- 
cative paroxysms, in which the palpitations and dyspnoea are excessive, and 
the skin assumes its deepest hue. Such attacks are induced by unusual 
muscular effort, mental emotion, or whatevei' else unduly excites the heart. 
They are very apt to end in syncope; and it is generally in one of these 
paroxysms that the patient expires. 
Cyanosis is most frequently congenital. Of 71 cases collated by Dr. More- 
ton Stills, it existed at birth in 40. (Am. Journ. of Med. Sei., N. S., viii. 
42.) When not congenital, it usually makes its appearance first in early 
childhood, though sometimes in adult age. It is often quickly fatal, but may 
run on for many years, and sometimes from birth even to middle or advanced 
life. Of the 40 congenital cases above alluded to, 17 died within a year, 10 
between one and ten years, 10 between ten and twenty years, and three only 
survived the last-mentioned period, of whom one attained the age of 57. The 
disease is rather more frequent in males than in females. 
Bluish or purplish discoloration of skin may arise from different causes. 
Stagnation of the blood in the capillaries from debility of these vessels, gene- 
ral venous congestion from obstruction in the heart, lungs, or pulmonary ves- 
sels, and deficient aeration of the blood from any cause which permits a 
continuance of the circulation, may produce it. But, in that intense degree, 
and with those associated symptoms, which are necessary to constitute a case 
of cyanosis, as generally recognized, the affection depends exclusively upon 
organic disease of the heart or large vessels; and in that light only it is 
viewed here. There is not, however, even in regard to the disease thus re- 
stricted, a coincidence of opinion among pathologists as to the precise cause 
of the discoloration. 
Two different views are entertained, one ascribing the colour to an inter- 
mixture of the venous and arterial blood, and the other to general venous 
congestion consequent upon obstruction at the heart. But neither of these 
seems to be quite satisfactory. 
The opinion, which ascribes the result exclusively to an intermixture of 
the two kinds of blood, supposes that nothing more is necessary to its pro- 
duction than such a direct communication between the two sides of the heart, 
or between the cardiac receptacle of venous blood and the arteries which sup- 
ply the system, as to render some mixture necessary. Now cases have been 
adduced in which such a communication has beyond all doubt existed, and 
the arterial and venous blood have necessarily flowed together intimately 
united throughout the body, and yet no cyanosis has resulted. Nor does it 
seem that it ought to be an essential physiological consequence of such a 
mixture. The colour of the surface in health is not owing to arterial blood 
alone. The venous and arterial capillaries ramify everywhere together, and 
the colour no doubt depends upon both, and may be considered as intermediate 
between the two. The effect, therefore, is the same as though they were 
flowing together through the same vessels, mingled in the same proportion. 
It follows that the mere intermixture of the two kinds of blood, instead of 
producing cyanosis, may give rise to the ordinary healthy hue of the skin, 
provided the change in the capillaries be diminished in the proportion of the 
amount of venous blood added to the arterial; and this may be readily con- 
ceived to be possible. 
Against the second opinion also, though plausibly there seem to be strong 
objections. If a mere impediment to the circulation existing in the heart or CLASS III.] 
CYANOSIS, OR BLUE DISEASE. 
195 
its great vessels, even a very considerable impediment, were sufficient alone 
to produce cyanosis, we ought to have it as a very frequent disease; for such 
impediments in the heart are of constant occurrence, often in such a degree 
as to prove fatal. But cyanosis is very rare, and especially in old age, when 
such cardiac obstructions are most common. It is true that a certain amount 
of discoloration is produced by this cause, especially in the lips and extremi- 
ties ; but no one thinks of ranking the cases in which it occurs with cyanosis. 
Indeed, it is impossible that an amount of venous congestion throughout the 
system, capable of producing this change of colour, could remain long with- 
out calling into operation the obviating powers of the system. The excess is 
thrown off in the form of dropsical effusion, hemorrhages, &c., and the ine- 
quality is thus to a certain extent relieved. 
What then is the true explanation of the change of colour? To answer the 
question correctly, we must understand what is the character of the lesions 
with which the disease is connected. These may be included under two 
heads; first, those which establish a direct communication between the venous 
and arterial circulation; secondly, those which obstruct the access of blood to 
the lungs, or, by producing congestion in that organ, interfere with the due 
aeration of the blood. Under the first head may be ranked a want of closure 
in the foramen ovale, a preternatural opening between the two ventricles, 
perviousness of the ductus arteriosus, the existence of but one ventricle, and 
a false position of the great vessels, as, for example, of the aorta arising from 
both ventricles or from the right exclusively, or forming a common trunk 
with the pulmonary artery. Of these, the open or enlarged foramen ovale is, 
according to Gintrac, the most common, being found in 33 out of 53 cases. 
Sometimes it is so much enlarged as to admit the thumb. It is obvious that, 
in consequence of any one of these lesions, the venous blood may find entrance 
into the aorta and circulate along with the arterial blood. Of the second set 
of lesions alluded to, the most frequent and important is partial or complete 
obstruction, or obliteration of the pulmonary artery. Of the 53 cases col- 
lected by Gintrac, this artery was contracted or obliterated in 27; and it may 
have been so in others, in which its condition appears not to have been stated. 
According to Dr. Stille, in whose valuable paper, before referred to, much 
statistical information is collected and collated, of 62 cases in which the state 
of the pulmonary artery was observed, it was either u contracted, obliterated, 
or impervious" in 53. This, then, may be considered as one of the most 
common lesions in cyanosis. Others having precisely the same effect, namely, 
to impede the access of blood to the lungs, are a contracted state of the right 
ventricle, and diminution of the right auriculo-ventricular orifice. Others, 
again, which may act by producing congestion of the lungs, and diminishing 
the amount of aerated blood, are contraction of the left ventricle or of the 
aorta near its origin, and diminution of the left auriculo-ventricular opening. 
Itr appears, therefore, that in almost all cases of cyanosis there is a co-ex- 
istence of a preternatural communication between the arterial and venous 
circulation, with impediment to the access of blood to the lungs, or imperfect 
aeration of that which reaches them. Among all the'cases collated by Dr. 
Stille there are only 5 exceptions to the former branch of this statement, and 
in two of these the cyanosis was partial. To the latter branch of the statement 
there is scarcely a single well-authenticated exception. This may be considered 
as a virtual establishment of the rule; as the very small number of exceptions 
may be readily referred to imperfect or mistaken observation, or to a latitude 
in the application of the name of the disease; a certain amount of blueness 
of the skin being occasionally found wholly unconnected with organic lesions 
of the heart. 196 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
[PART II. 
These data being admitted, it is not difficult to explain the occurrence of 
cyanosis. A mere communication between the two cavities, even allowing 
that a considerable mixture of the venous and arterial blood may occur, which 
does not by any means necessarily follow, is insufficient to account for the 
phenomenon ; as such a mixture may not produce a different colour from the 
natural, unless the quantity of venous blood be very large. Hence, in cases 
in which such a communication exists, with a free access of blood to the lungs, 
and a free aeration of it there, cyanosis is not produced. But let the entrance 
of the blood into the lungs be impeded, as in obstruction of the pulmonary 
artery, or let aeration take place imperfectly, as in pulmonary congestion from 
various organic cardiac lesions, then, the proportion of arterialized or aerated 
blood being lessened, if the two kinds are mingled together, the venous must 
predominate; and everywhere in the capillaries of the body will circulate a 
blood darker than the mean of the two kinds, which exist in the interlacing 
venous and arterial capillaries in health, and upon which the natural colour 
of the surface depends. Hence, the skin must be darkened; and the degree 
to which it is so must be inversely proportionate to the amount of venous 
blood arterialized in the lungs, and directly to the perfection in which the 
blood of the two sides of the circulation are mingled together. 
Much importance has been attached to the patency of the foramen ovale, 
much more, indeed, than it deserves. While the actions of the heart are pro- 
perly balanced, this is of little consequence. The venous and arterial blood 
might mingle slightly; but not to any considerable extent. The two auricles 
being filled at the same moment, and contracting together, balance each other, 
and each sends the blood into its corresponding ventricle. Any inferiority 
of power on the part of one of the auricles would speedily be repaired by an 
increase of growth, resulting from the stimulus of the increased pressure. It 
is only when connected with other lesions that this becomes important. Con- 
traction of the pulmonary artery, by causing accumulation in the right ven- 
tricle and auricle, must send a current through the foramen into the left side 
of the heart. Thus, the same cause which prevents aeration of a portion of 
the blood by preventing its access to the lungs, occasions its mixture with the 
portion already aerated. The opening of the foramen is probably produced 
in general by the accumulation of blood, and consequent excess of pressure 
in the right auricle; and may be considered as a provision of nature for par- 
tially remedying a greater evil, and thus prolonging life. 
That discoloration of skin which occasionally takes place in new-born in- 
fants, and speedily yields to the ordinary influences, is probably owing in 
general to a yet imperfect permeability of the lungs, and the consequent cir- 
culation of a non-aerated blood. 
The treatment of cyanosis must be merely palliative. Life may be pro- 
longed, and the comfort of the patient promoted by a strict observance of those 
rules calculated to maintain the circulation in a moderate and equable condi- 
tion. Tranquillity of the body and mind are of the highest importance ; and 
scarcely less so, a proper regulation of the diet, which should be moderately 
nutritious, without being in the least stimulating. Animal food should be 
used sparingly. The digestion should be attended to, and nervous disorder 
quieted, if necessary, by the occasional use of narcotics and antispasmodics. 
Passive exercise is highly useful. 
It would be improper to omit here the notice of a remedial measure, in the 
blueness of new-born infants, which comes recommended by the great expe- 
rience of Dr. C. D. Meigs, Professor of Midwifery in the Jefferson College 
of Philadelphia. His plan is to lay the infant " on its right side, with its 
head and shoulders inclined upwards on pillows/' and to keep it " for several CLASS III.] 
197 
FUNCTIONAL DISEASES OF THE HEART. 
hours in that position." Dr. Meigs has succeeded by this treatment 11 in 
rescuing from impending death upwards of twenty persons." (^Proceedings of 
Amer. Phil. Soc., iii. 174-5.) Though we may not admit the theory, which 
attributes the success of this measure to the effect of gravitation in keeping 
the foramen ovale closed, we have no right on that account to reject it as a 
therapeutical measure, sanctioned by so high an authority. 
Article 
VIL 
FUNCTIONAL or NERVOUS DISEASES OF THE HEART. 
These are, on several accounts, highly deserving of the notice of the phy- 
sician. They are very frequent, are in themselves often the source of much 
inconvenience, distress, and even danger, and occasionally terminate, when of 
long duration, in fatal organic affections of the heart. Besides, imitating, as 
they often do very closely, these affections, they are apt to occasion much 
anxious apprehension on the part of the patient, lest he may be labouring under 
incurable disease. In order, therefore, to be able to give all proper consola- 
tory assurances, and with the view also of obtaining just indications of treat- 
ment, which often differs greatly in the two orders of diseases, it is of great 
importance to form a correct diagnosis. This is not difficult in decided cases; 
but there are some in which a sure decision is almost impossible, and the 
greatest skill must be satisfied with probable conjecture. When, for example, 
an organic affection is in that stage of advancement in which it exhibits signs 
only during an excited state of the heart, and when these signs coincide ex- 
actly with those which are sometimes offered by mere functional disorder, we 
must be content with a very doubtful appeal to the existing or preliminary 
state of system, the probable causes, and other circumstances of an equally 
uncertain character. In those eases, moreover, in which the functional is just 
passing into the organic, it is not possible always to determine the boundary 
between them; and when, as occasionally happens, the two are combined in 
the same case, without any necessary mutual dependence, as when rheumatic 
or gouty neuralgia supervenes upon a structural lesion, an accurate discrimi- 
nation is not always within our reach. The best plan of diagnosis is, proba- 
bly, first, to determine what circumstances are incompatible with the idea of 
mere functional disorder, and secondly, what are compatible only with that 
idea. We shall thus, at least, separate the certain from the doubtful; and it 
will be found, in practice, that only a comparatively small number of cases 
will be left undecided. 
1. In nervous or purely functional diseases, the characteristic symptoms 
are scarcely ever, perhaps never, constant during a great length of time. In 
the organic, though there are some cases in which the signs are not always 
obvious, and many in which they are much more obvious at one time than 
another, yet in the great majority, as the lesion is invariably present, so also, 
are its evidences, which may be discovered if carefully sought for. When, 
therefore, the signs of cardiac disorder are discoverable at all times, and under 
all circumstances, by night and by day, in sleeping and waking, during rest 
and exertion, not only for days, but for weeks, months, or years, the inference 
is unavoidable that they are something more than functional. 
In cases attended with continued or permanent secondary affections, result- 
ing from the strong sanguineous determination and venous congestion of car- 
diac disease, such as bloated features, purple lips, bleedings from the nose, 
apoplexy, pulmonary hemorrhage and oedema, general dropsy, &c., the pro- 198 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
[PART II. 
babilities are altogether in favour of the existence of organic derangement. 
Of course, this rule does not hold, when the affections alluded to are mere 
accompaniments of the cardiac disease and not effects of it. 
Again, the same conclusion is justifiable, when the existence of preterna- 
tural dulness on percussion in the precordial region, not traceable to disease 
of the neighbouring parts, indicates enlargement of the heart, or distension 
of the pericardium. So also, when a morbid state of the second sound of the 
heart exists, evincing regurgitation through the semilunar valves, which can 
scarcely happen from mere disordered action in the organ.* The case, how- 
ever, is different in regard to the auriculo-ventricular valves, regurgitation 
through which has been observed without organic lesion, probably dependent 
on spasm of one or more of the fleshy columns, connected with the' valves 
through the tendinous cords. A strong murmur, traceable far up the large 
vessels, may be considered as indicative of organic disease. 
2. When the symptoms of cardiac disease are ameliorated by vigorous ex- 
ercise, as not unfrequently happens, we may be very certain that the complaint 
is not organic. It does not follow that every case of functional derangement 
is directly relieved by this means. On the contrary, when such derangement 
accompanies anaemia, it is often greatly aggravated by bodily motion. We 
only infer that it must be functional, whenever it is susceptible of permanent 
alleviation in this way. 
Moreover, when the cardiac symptoms can be traced to some particular 
cause, appearing when that is in action, and disappearing when it ceases to 
act; as, for example, when they accompany the abuse of narcotic or stimulat- 
ing substances, and vanish when these are used no longer, they must be con- 
sidered as strictly functional. 
Cases which do not fall into one of the above categories, must be judged 
of according to the weight of probabilities. The conditions which should 
incline the scale towards organic disease have been mentioned under the in- 
dividual complaints belonging to that division. Those of a contrary tendency 
will be alluded to under the following heads. 
Functional disease of the heart may evince itself by alteration either in 
the movements or. the sensations of the organ, and in either case may have 
the character of irritation or of depression. Deranged movement may be 
included under the two divisions of palpitation in which the heart is under 
excitement or irritation, and syncope in which it acts feebly or ceases to act. 
Neuralgia of the heart, or angina pectoris, includes all the cases of mere 
functional affection of a painful character; and this may be associated with 
elevation or depression of the vital power of the organ. 
1. PALPITATION. 
This term is used to signify inordinate pulsations of the heart, sensible to 
the patient himself, or readily perceived by the observer. Such pulsations 
are often excited, in a perfectly healthy individual, by incidents and emotions 
which come within the limits of ordinary life. Under these circumstances, 
* If it be true, as maintained by some, that muscular fibres exist in the semilunar 
valves, controlling their movements, then regurgitant aortic and pulmonary murmurs 
may possibly be merely functional, and their presence less positively indicative than has 
been supposed of the existence of organic disease of the heart. (See Lond. Med. Gaz., 
March, 1850, p. 408.) Skoda states that he has occasionally heard a double second 
sound without any organic disease of the heart or its valves. This may be explained 
upon the supposition of a want of perfect synchronism in the action of the ventricles, 
which may depend on nervous disorder. CLASS III.] 
PALPITATION. 
199 
they can scarcely be considered as morbid. Palpitation is a disease only when 
so frequent, or so readily excited, as to become a source of inconvenience or 
apprehension. It must be recollected that, in this place, we are considering 
it only as a functional disorder, and not in its connexion with organic disease 
of the heart, of which it is one of the most common attendants. 
Symptoms.-Palpitation varies, in degree, from a scarcely perceptible move- 
ment to one so tumultuous and violent that it visibly agitates the whole chest, 
and occasions great distress. The pulsations may be increased in frequency, 
or in force, or both. They are sometimes regular, but more frequently irre- 
gular, intermittent, and fluttering; and the pulse partakes of the same quali- 
ties. The latter is in some instances small and feeble, in others fuller and 
stronger; but generally it is characterized rather by a quick, jerking, irritated 
motion than by strength. The impulse of the heart may be felt much more 
widely than in health, sometimes over a great portion of the left side of the 
chest, and even on the right side. The sounds too are much louder. Occa- 
sionally they are heard distinctly by the patient himself, especially when lying 
on his left side, and even by a bystander at the distance of some feet. The 
patient is sensible of a whizzing, rushing noise, which seems to ascend up 
the neck; and sometimes he hears both of the cardiac sounds. When the 
palpitations are violent, a metallic ringing sound is often heard in ausculta- 
tion, which has been ascribed to the impulse of the heart against the chest, 
but has seemed to me to proceed from a deeper source. Not unfrequently a 
bellows murmur attends the first sound; but is confined to this, and is said 
by Dr. Hope to be limited to the aortic valves; but it has been observed by 
others over the mitral valves. Often also the murmur characteristic of anaemia 
is heard in the jugular veins, and slight bellows murmurs are emitted by the 
large arteries when compressed. 
The attack often comes on under some mental or physical excitement; but 
often also when the patient is at rest, and not unfrequently in the night, 
awakening him perhaps from his first sleep. When violent, it may occasion 
much distress. The heart feels as if bounding upward into the throat; a 
sense of anxiety or oppression is experienced in the precordial region, with 
hurried respiration or dyspnoea, so that the patient is frequently unable to lie 
down; ringing in the ears, and vertiginous sensations often occur; and oc- 
casionally faintness and even syncope. The duration of a paroxysm is quite 
uncertain, sometimes not exceeding a few minutes, sometimes lasting for days 
without absolute intermission, though varying much in violence during that 
time. Most commonly it terminates within thirty minutes or an hour, recur- 
ring afterwards quite irregularly, sometimes daily or several times a day, and 
sometimes not until after a long interval. 
Causes.-Strictly speaking, palpitation is rather the result of disease than 
a disease itself; and the real morbid condition upon which it depends, leaving 
organic affections out of view, is either deranged innervation of the heart, or 
an unhealthy state of the blood, which may be too rich and abundant, con- 
stituting plethora, or too watery or otherwise depraved, as in anosmia, scurvy, 
&c. The true causes, therefore, are such as produce either of these conditions. 
1. The causes of deranged innervation are almost innumerable. Among 
the most prominent is the abuse of tea, coffee, alcoholic drinks, and tobacco. 
These induce an irritable state of the nervous system, in which it is liable 
to disturbance from causes that ordinarily only sustain its healthy action. It 
may be objected to this statement, that strong tea is sometimes very efficient 
in the relief of palpitation. This is exactly what might be expected. The 
morbid condition is not the direct result of the stimulant, but that which fol- 
lows its long-continued use. The resulting disorder is relieved for the time 200 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
[PART II. 
by a fresh dose ; as the horrors which succeed a debauch are relieved by an 
additional draught of the poison. Similar in their influence are various other 
causes which habitually and unduly excite the nervous system, such as severe 
study, diversified mental excitements, and all sorts of sensual excess. The 
depressing emotions, sedentary habits, and loss of rest, have a similar effect 
directly. It has often been remarked that students just entering into man- 
hood, and especially medical students, are peculiarly liable to palpitation. This 
may be readily accounted for by referring to the above list of causes. 
Numerous diseases have the occasional effect of inducing palpitation. It is 
frequently the result of a gouty or rheumatic irritation, affecting the heart 
through the nerves. Dyspepsia is a fruitful source of it, partly by a direct 
irritation imparted through the nervous centres, partly by that irritable state 
of the nervous system which it is so apt to induce. The same may be said of 
hepatic disease. Any irritation in the alimentary canal may be propagated to 
the heart, and occasion palpitation. Hence, it arises from flatulence, acid in 
the stomach and bowels, and intestinal worms, especially the tape-worm. It 
is a very frequent attendant upon hysteria, and many violent cases may be 
traced to tenderness in the spine. Pulmonary disease produces it either by a 
direct sympathy, or by modifying the influences which the heart receives from 
the blood. Everything that causes pressure upon the heart may also derange 
its actions. Tight lacing, ascites, tympanites, abdominal tumours, and the 
pregnant uterus may all have this effect. 
2. The causes which act through the blood are such as induce plethora on 
the one hand, or an impoverished or depraved state of that fluid on the other. 
These are sufficiently treated of elsewhere. (See Plethora, Anosmia, Scurvy.) 
An excess of nutritive or stimulant matter in the blood operates by directly 
exciting the heart into excessive action; and the affection, when unattended 
with fever, hemorrhage, &c., is considered simply as palpitation. In this 
case, the pulsations may be strong and regular; differing very strikingly from 
those which mark the affection as arising from other causes. Anmroia is one 
of the most frequent causes of obstinate and excessive palpitation. Its mode 
of operation is easily understood. The actions of the heart in health are ex- 
actly proportionate to the wants of the system in relation to the supply of 
blood. Let these wants be increased, as by vigorous muscular exertion or 
cerebral excitement, and the heart responds by an increase in the force or fre- 
quency of its contractions; let them be diminished, as by rest, and the actions 
of the heart are diminished. These wants are made sensible by the nerves 
proceeding from all parts of the body to the nervous centres; and thence is 
transmitted the influence which regulates the heart. Now, in anaemia, the 
blood being deficient in its healthy qualities, does not adequately meet the 
requisitions of the nutritive and other functions, and more of it is demanded 
to produce the necessary effect. The wants of the system are therefore greater; 
the sense of them is transmitted to the nervous centres more strongly; and a 
corresponding increase in the stimulant influence sent to the heart is the con- 
sequence. This organ is, therefore, stimulated, and often powerfully so, by 
this state of the blood. Of course, the stimulation is felt most strongly when 
there is any additional duty to be performed by the blood; and consequently 
the least exertion is sufficient to induce palpitation. In this form of the com- 
plaint, the pulsations, though frequent, are not usually strong, because the 
heart wants power. On the contrary, they are apt to be weak, intermittent, 
and irregular, with a pulse, which, though it may be voluminous, and some- 
times short or sharp, is always easily compressible. In this form also it is, 
that the cardiac murmurs are so much like those of valvular disease. Unlike 
mere nervous palpitation, this is aggravated by active exercise. The depraved CLASS III.] 
201 
PALPITATION. 
state of the blood, in scurvy and malignant diseases, may give rise to palpita- 
tion of the heart, upon the same principles as its diluted state in anaemia. 
The age at which palpitation is most frequent is that which intervenes 
between puberty and perfect maturity. Females are more apt to be affected 
with it than males. 
Paroxysms of palpitation, in one predisposed to it, may be induced by any- 
thing of an exciting nature, whether intellectual, emotional, or purely physical. 
Diagnosis.-The most important point, in the diagnosis of palpitation, is 
to decide whether, in any particular case, it is or is not connected with organic 
disease of the heart. Rules have already been given, under the general head 
of functional diseases of the heart, in relation to cases in which the signs may 
be considered as certain. In others, the decision must be made upon the 
ground of strong probability. When palpitation occurs paroxysmally, with 
perfect intermissions; when it is apparently traceable to some one of the 
causes of functional disturbance above enumerated; when it occurs in a young 
person, or in a nervous or hysterical subject, and increases and subsides with 
the rise and subsidence of other nervous symptoms; when it is relieved by 
exercise, or, if not so, shows an evident connexion with anaemia; when its 
paroxysms come on during perfect rest; when it is unattended with valvular 
murmurs, or these, if present, are perceptible equally on both sides, and only 
with the first sound, and little if at all in perfect calmness of the heart; and, 
finally, when venous and arterial murmurs coexist with the palpitation; when 
all or most of these circumstances exist, there can be little doubt that the 
affection is purely functional; and, in proportion to the number of them which 
are observable in any instance, and the degree to which they prevail, will be 
the probabilities in favour of this view of the subject. The pulse in palpita- 
tion, unattended with altered structure of the heart, however violent and tu- 
multuous the action may be, is destitute of the extraordinary hardness and 
strength which characterize the pulse of hypertrophy; nor is the sensation of 
heaving force so strongly felt, when the ear is applied to the chest. Another 
point of distinction, according to Dr. Joy, between the palpitation of func- 
tional and that of organic disorder, is the greater feeling of distress which 
usually attends the former. 
Effects.-It may be readily conceived that excessive palpitation, frequently 
repeated and long continued, may at length induce hypertrophy; and what 
is at first merely nervous, may thus end in organic disease. Injurious results 
may also happen to other organs from the irregular supply of blood consequent 
on this affection. Dr. Stokes describes a condition in which permanent exci- 
tation of the heart, without any necessary connexion with organic disease of 
the organ, is attended with turgescence of the thyroid gland, and enlarge- 
ment of the eyeballs. The double sound and impulse are often, in these 
cases, developed in the carotids, the throbbing of which is visible to the ob- 
server, and painful to the patient. The enlargement of the thyroid is attended 
with a diastolic pulsation and purring thrill. The vision is not necessarily 
impaired. The affection is most frequent in women, and is apt to be associated 
with hysteria, neuralgia, or uterine disorder. (Dis. of Heart and Aorta, p. 296.) 
Treatment.-In the treatment of functional palpitation, the most important 
point is to remove the cause. The use of all nervous stimulants and narcotics, 
including tea, coffee, and tobacco, should be suspended or abandoned; injurious 
habits of indulgence should be overcome; the most watchful guard should be 
kept by the patient over his emotions, and while the mind is moderately occu- 
pied, all over-exertion should be avoided; a due amount of sleep and of bodily 
exercise should be obtained; and, whenever there may be reason to suspect 
the agency of some other disease, our efforts should be especially directed to- 202 
[PART II. 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
wards its removal. As the anxieties and fears of the patient tend strongly to 
aggravate and perpetuate the complaint, we should endeavour to cheer him 
by every assurance of a favourable termination which the circumstances of 
the case may justify. 
It would be out of place to detail the various modes of cure adapted to the 
several diseases, of which the palpitation may be a result, or by which it may 
be sustained. It will be sufficient to say that, if the patient is clearly plethoric, 
with a full strong pulse, he should lose blood, take saline cathartics, and live 
upon vegetable food or milk until this condition has been subdued; if anemic, 
he should, on the contrary, use chalybeates and a generous diet; if gouty or 
rheumatic, he should be treated with colchicum, antacids, laxatives, and stimu- 
lating pediluvia; if dyspeptic, he should pay especial attention to his diet, ex- 
ercise freely in the open air, and employ mild tonics and laxatives; in fine, 
whatever source of irritation to the heart can be discovered, whether existing 
in the lungs, the liver, the intestines, the uterus, or the spine, should receive 
a careful attention, and be removed if possible. In the cases of spinal tender- 
ness, recourse should be had to cups or leeches over the tender spot, followed 
by blistering or pustulation. Tight lacing, and all other artificial modes of 
cramping the movements of the heart, should be avoided. 
In the paroxysms, relief will often be afforded by the nervous stimulants, 
as assafetida, musk, valerian, the ammoniacal and ethereal preparations, cam- 
phor, strong tea, &c. Among the best of these are Hoffmann's anodyne, and 
the aromatic spirit of ammonia, which may be given separately or mixed. 
The preparations of opium or hyoscyamus, or one of the other narcotics, may 
sometimes be usefully conjoined with the antispasmodics. A fluidrachm of 
the camphorated tincture of opium will often afford relief. Aromatics, com- 
bined with antacids, are sometimes useful by expelling flatus and correcting 
acid. One or two fluidrachms of the compound spirit of lavender may be 
given with this vie^r, in connexion with aromatic spirit of ammonia. When 
an overloaded stomach is suspected as the exciting cause, an emetic dose of 
ipecacuanha may not be amiss. Should a gouty or rheumatic diathesis exist, 
and stimulants be indicated, a good preparation is the ammoniated tincture of 
guaiac. None of these remedies, however, should be employed when the 
palpitation is dependent upon plethora. 
To control the tendency to excessive action in the heart, digitalis may be 
cautiously administered, in cases not attended with great debility, and should 
be continued for a considerable time. Hydrocyanic acid has also been recom- 
mended. These remedies should be seconded by measures calculated to in- 
vigorate the system, such as exercise in the open air, which should be of the 
passive kind in anemic cases, the occasional or daily use of the shower-bath, 
frictions to the surface, and a diet of nutritious and easily digested food. 
2. SYNCOPE. 
Syncope is a diminution or temporary cessation of the action of the heart, 
with loss of consciousness, and a suspension more or less complete of respira- 
tion. It sometimes comes on suddenly; but is much more frequently preceded 
by premonitory signs, such as a feeling of nausea or of sinking in the epigas- 
trium, clouded or otherwise disordered vision, mental confusion, pallid and 
shrinking features, and a rapidly failing pulse. In general, the prelimi- 
nary sensations are disagreeable, sometimes exceedingly so; but occasionally 
they are grateful to the patient. In complete syncope, the features are col- 
lapsed and of a ghastly paleness, the surface cool, the pulse quite absent at CLASS III.] 
203 
SYNCOPE. 
the wrist, respiration suspended, and consciousness entirely wanting. Some- 
times involuntary discharges take place from the bowels and bladder. The 
heart, however, seldom quite ceases to beat. The ear applied to the chest 
will generally detect the first sound, greatly weakened, but not the second. 
This is an important sign in diagnosis; as, when observed, it always gives 
hope of saving life. After a short time, the patient again draws his breath, 
colour gradually reappears in the lips and cheeks, the pulse may be felt at 
the wrist, consciousness returns, and very soon the recovery is complete. 
This is sometimes attended with feelings of much distress. 
It very frequently happens that the syncope is only partial; the prelimi- 
nary symptoms above mentioned being exhibited in a greater or less degree, 
but the patient never entirely losing bis consciousness, nor entirely ceasing to 
breathe; while the pulse, if not perceptible at the wrist, may be felt in the 
larger arteries. Such a state is frequently designated as faintness, especially 
in its lighter grades. 
The duration of syncope is variable, sometimes not more than an instant, 
usually some seconds or minutes, and, in certain rare instances, extending to 
hours or days. The cases of apparent death, in which it is believed that pre- 
mature interment sometimes takes place, are of this kind. Instances have 
occurred in which the pulse, respiration, and consciousness have been absent 
for several days, and yet the patient has ultimately recovered. The system 
is in a sort of hybernation, in which vitality remains, though the vital func- 
tions are suspended. It is probable that, in such cases, a very careful auscul- 
tation might detect a slight sound in the heart. 
Causes.-These are such as act either directly upon the heart, or indirectly 
through the nervous system. Of the first set of causes there are compara- 
tively few, if we except the organic diseases of the heart, which not unfre- 
quently produce syncope, and occasionally terminate in that way. Among 
the direct causes, however, may be ranked sudden attacks of neuralgia of the 
heart, translated rheumatism or gout, certain poisons which operate immedi- 
ately upon the circulation, especially the antimonials, and a state of depression 
following excessive excitement of the organ. To the same category may be 
referred the sedative influence of the warm bath, the presence of air in the 
circulation, and a stroke of lightning. Air, admitted into the large veins, in 
consequence of surgical operations, has, in numerous instances, produced fatal 
syncope. It probably acts by entering the cavities of the heart, and depriving 
the organ of the requisite stimulus. The idea has been suggested, that air is 
sometimes spontaneously developed within the blood-vessels during life; but 
no satisfactory proof of the occurrence has been advanced. 
The causes of syncope which act on the heart through the nervous system 
are very numerous. Whatever opinion we may entertain as to the inherent 
and independent irritability of the heart, this much is quite certain, that it is 
under the controlling influence of the nervous system, and often ceases to act 
when that influence is suspended or perverted. Violent shocks, which para- 
lyze the nervous centres for an instant, are frequent causes of syncope. 
Hence the effects of sudden intelligence, whether exciting or depressing; of 
certain offensive or fearful sights, as a public execution, or a painful surgical 
operation; of sudden and excruciating pain, as sometimes in spasm of the 
stomach or bowels; and of violent injuries, whether from accident, or the 
knife of the surgeon. Much milder impressions on the nervous system often 
have the same effect upon the heart; such, for example, as result from 
certain rich and oppressive odours, the feeling of nausea connected with gas- 
tric disorder, the sensations excited in pregnancy by the movements of the 
foetus, and excessive hunger, or rather want of food. The presence of indi- 204 
[part II. 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
gestible matters in the stomach sometimes has a powerful effect of this kind. 
A well-known case of protracted syncope, in which the subject, a gentleman 
of this city, narrowly escaped interment, but ultimately recovered, and lived 
many years, was believed to have resulted from the eating of fresh and badly 
baked bread. Cold water, drank when the body is very hot and perspiring, 
especially after exercise, is apt to induce syncope of an alarming and often 
fatal character. Under the head of causes acting through the nervous system, 
may also be placed certain powerful poisons, as digitalis, tobacco, and hydro- 
cyanic acid. 
Deficiency or loss of blood is well known to be a frequent cause of syncope. 
How far this acts directly on the heart is not certain. There can be no 
doubt that this organ must feel any deficiency in its wonted stimulus; but 
there is nevertheless reason to believe that the cause acts more powerfully 
through the brain than immediately upon the heart. When the former 
organ is defectively supplied with blood, the latter appears to feel the con- 
sequences almost instantaneously. Hence, the loss of much less blood is 
required to produce fainting in the erect than in the horizontal position. 
Hence, too, it not unfrequently happens that a person, already weak from 
deficiency of blood, faints suddenly upon attempting to sit up in bed, or to 
rise and walk. Sudden death is occasionally produced in this way in diseases 
of debility. Excessive loss of blood, with consequent syncope, may occur 
from the operation of bleeding, from accidental wounds, and from sponta- 
neous hemorrhage. The quantity requisite for the effect differs greatly in 
different individuals, and in different states of system. The robust and 
plethoric will bear a much greater loss, as a general rule, than the feeble and 
anemic and the very fat; and inflammatory diseases much more than the 
typhous or scorbutic. But individuals also have idiosyncrasies, in this re- 
spect, which cannot be explained by any general rule; one person, for in- 
stance, fainting from a small loss of blood, and another bearing an enormous 
loss without this result, though there may be in other respects no very ob- 
servable difference between the two. The rapidity with which the blood is 
withdrawn has much effect. Fainting is produced by a smaller loss when 
the bleeding orifice is large than when it is small. Profuse discharges from 
excessive secretion, as in cholera and diarrhoea, often produce syncope. The 
sudden removal of a long-continued pressure upon any portion of the body, 
has the same effect. Hence the fainting which sometimes follows delivery, 
and the operation of tapping, unless care is taken to supply the place of the 
lost pressure by that of a bandage. The effect, in these cases, may be 
ascribed in part to a loss of balance between the blood in the brain and in the 
newly liberated vessels, but much more to the effect upon the nervous centres 
of the feeling of vacuity, consequent on the removal of the pressure. 
Diagnosis.-The only conditions from which syncope may not be readily 
distinguished are apnoea and death. In the former, there is the same ab- 
sence of consciousness, respiration, and pulse at the wrist; but the aspect 
of the body is in general sufficiently diagnostic. In apnoea there are signs 
of general venous congestion, such as purple lips, swollen features, and a 
dingy or livid hue of the surface; while in syncope the countenance is pallid 
and collapsed, and the skin apparently bloodless. The cause, if known, will 
also frequently serve to aid in the diagnosis. If it be such as acts primarily 
on the lungs it produces apnoea, if upon the heart, syncope. 
There is a condition of insensibility of an hysterical character, in which 
the patient lies sometimes for days, without motion or consciousness, and in 
which the breathing is so gentle that, without close examination, it may be 
supposed to be suspended. I have been sent for, in such a case, to decide CLASS III.] 
SYNCOPE. 
205 
whether death had not taken place. The physician, however, has no diffi- 
culty in the diagnosis; for, upon placing the fingers upon the wrist, he finds 
the pulse beating as in health. An accidental deviation of the radial artery 
from its ordinary course, an event not at all uncommon, might in such a case 
lead to a very false conclusion, if the physician should not be upon his guard, 
and examine the pulse elsewhere. 
The most embarrassing problem, in relation to the diagnosis of syncope, is 
to decide between cases of apparent and positive death. In prolonged syn- 
cope, we might expect something in the general aspect of the case different 
from the exterior cadaveric characters, though it would be difficult to say 
what. There is occasionally something life-like in the countenance and sur- 
face, which has led on the part of observers to persevering convictions of 
continuing life, which the event has justified. In such cases, the interior 
temperature should be observed, and if higher in the fauces or rectum than 
upon the surface, it must be considered as a favourable indication. The 
probability is, that a careful auscultation of the heart might detect some faint 
remaining sound. There is an absence, moreover, of the cadaveric rigidity, 
which is probably the last vital act of the expiring tissues, occurring some 
time after the great functions of life have been suspended. In real death, 
there is a sinking of blood to the most dependent parts of the body, indi- 
cating a complete surrender of the vital powers to the ordinary physical laws. 
But, whenever there is any doubt, the body should not be buried until after 
the commencement of putrefaction, which is quite decisive. Happily, the 
warmth necessary to the restoration of the patient, if living, hastens the 
occurrence of this decisive test in death. 
Prognosis.-1This is generally favourable, when the syncope is unconnected 
with organic disease. Sometimes, however, the affection is fatal when it 
proceeds from the loss of blood, even though the hemorrhage may have 
ceased, from severe shocks upon the nervous system, and from slight exertion 
in cases of great debility. There is reason to believe that death takes place 
occasionally from syncope, consequent upon some sudden affection of the 
heart, paralyzing its power of contraction; as the closest post-mortem exami- 
nation, in instances supposed to be of this kind, has failed to detect any lesion 
to which the result could be ascribed. 
Treatment.-The first thing to be done in syncope, threatened or existing, 
is always to place the patient in a horizontal position, with the head at least 
as low, if not lower than the rest of the body. By this simple measure, em- 
ployed when the premonitory symptoms are first felt, an attack may very 
frequently be averted; and it is also one of the most effectual means of 
restoration after the attack; sometimes, indeed, absolutely essential to re- 
covery. Hence the importance of distinguishing such cases from those de- 
pendent upon congestion of the brain. An individual subject to syncope, 
should at once lie down when he feels an attack approaching. Sometimes, as 
in cases of excessive hemorrhage, it is necessary to maintain the horizontal 
position steadily for a considerable time; until, in fact, the blood-vessels are 
again supplied in the course of nutrition. At the same time that this mea- 
sure is employed, all pressure from tight dresses, corsets, cravats, &c., should 
be carefully removed from the chest, neck, and abdomen, and the patient 
should be surrounded with pure fresh air. 
Means should also be employed to rouse the nervous system. For this 
purpose spirit or solution of ammonia, strong acetic acid, or other very pun- 
gent volatile substance, may be so applied that the vapours may enter the 
nostrils; but care must be taken not to carry the remedy too far, lest it pro- 
duce severe inflammation of the part. The smoke of burnt feathers has been 206 
[PART II. 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
employed for the same purpose. Sprinkling cold water upon the face is also 
useful by the shock which it produces on the nerves. Slapping the palms of 
the hands, and making a shrill sound in the ears of the patient, are vulgar 
remedies not without effect. Any good result which may have followed the 
application of the tourniquet to a limb, is to be ascribed to the influence of the 
measure rather upon the nervous system than the circulation. If the patient 
can swallow, he may take a draught of cold water, which seems to act upon 
the mucous surface in the same manner as on the skin, by exciting a sensa- 
tion that leads to reaction. Diffusible stimulants should also be adminis- 
tered, especially the ethereal and ammoniacal preparations; and, as in palpi- 
tations, the most convenient forms are Hoffmann's anodyne, and aromatic 
spirit of ammonia. In cases of great debility, brandy may be used. Should 
the patient be unable to swallow, and the syncope not speedily yield to the 
measures above recommended, stimulants, such as oil of turpentine, brandy, 
and carbonate of ammonia, properly diluted, should be injected into the rectum. 
Remedies must also be applied to the surface. The body should be kept 
warm, but not overheated; friction should be made with a flesh-brush or 
coarse flannel; and rubefacients should be applied along the spine and to the 
extremities, care being taken not to permit them to remain so long, or to be 
used of such a strength, as to endanger much inflammation on the occurrence 
of reaction. A good mode of exciting the skin might be one suggested to 
the author by Dr. Cartwright, of Natchez, that, namely, of slapping the 
whole surface with a lady's slipper. It has been recommended to apply 
briefly to the epigastrium, or over the spine, a piece of heated metal, as the 
blade of a case knife, or the bowl of a spoon, in order to excite sensation; 
and a live coal from the fire has been efficiently employed for the same pur- 
pose. Electricity may also be cautiously used; and recourse should be had 
to artificial respiration in cases which resist other measures, though the same 
good is not to be expected from this remedy as in asphyxia. 
When the syncope has proceeded from large draughts of cold water taken 
into the stomach in hot weather, the patient, if able to swallow, should take 
full doses of laudanum, with ether, solution of ammonia, hot brandy-toddy, 
or even water alone made as hot as it can well be borne; and, in cases of com- 
plete unconsciousness, these or similar remedies should be administered by 
means of the stomach-tube. The other remedies above mentioned may be 
used at the same time, and especially a sinapism over the epigastrium. 
When an overloaded stomach, or some acrid or indigestible matter in the 
stomach, is the cause of the affection, it is proper to administer an emetic of 
powdered mustard with warm water or warm chamomile tea, which may be 
aided if necessary by a little ipecacuanha. 
3. NEURALGIA OF THE HEART, or ANGINA PECTORIS. 
Neuralgia of the heart and angina pectoris are considered by some as dif- 
ferent diseases; but it is impossible to point out any important distinction 
between them. Though angina has frequently been found in connexion with 
organic disease of the heart, yet frequently also no such affection has been 
detected upon examination after death; so that it must be considered as essen- 
tially nervous. Angina is, therefore, a painful nervous affection, and this is 
the very definition of neuralgia. If it be maintained that angina appears 
under a peculiar characteristic form, differing from other painful affections of 
the heart, it may be stated in reply that, though there may be striking dif- 
ferences between two extremes of any affection which admits of diversity, yet CLASS III.] 
ANGINA PECTORIS. 
207 
this is not a valid reason for constituting them into distinct diseases, espe- 
cially when, as is the case with the complaint in question, the extremes are 
connected by a chain of insensible gradations, so that they cannot be separated 
without doing violence to some link. The only admissible distinction be- 
tween the terms appears to be, that, while neuralgia shall be considered as 
embracing all the purely nervous cardiac pains, angina pectoris shall be 
limited to the more violent and dangerous. 
Symptoms.-The disease is characterized by severe pain in the precordial 
region, occurring paroxysmally, with freedom from pain in the intervals. In 
the paroxysm, the pain generally shoots through the chest towards the back, 
and into the left shoulder, and not unfrequently extends down the arm, where 
it is attended with a feeling of numbness. This combined sensation is some- 
times felt as far as the fingers, proceeding downward from the elbow along 
the course of the ulnar nerve. Sometimes also the pain spreads to the ante- 
rior part of the chest, ascends up the left side of the neck, or descends to the 
left leg; and cases are mentioned in which it has even extended to the right 
side of the body. There is occasionally exquisite tenderness of the left 
mamma in the female, and pain upon pressure in different parts of the chest, 
both anteriorly and posteriorly, in both sexes. There is every grade of vio- 
lence in the sensation, from a dull aching numbness, up to the most acute 
and excruciating pain, for which the imagination of the sufferer has laboured 
in vain to find terms of comparison sufficiently expressive. Along with the 
pain, in bad cases, there is often a sense of tightness or oppression in the 
chest, with dyspnoea, inability to lie down, and sometimes violent palpita- 
tions ; and the patient not unfrequently has the feeling that he cannot live 
unless speedily relieved. Though the breathing is apparently much oppressed 
and difficult, yet the lungs can generally be fully expanded by a voluntary 
effort. The pulse is usually small, irregular, and feeble, but sometimes 
strong and voluminous. Occasionally, the paroxysm ends in convulsions or 
syncope. There is often much flatulence of stomach, and the urine during 
the paroxysm is pale and limpid. 
The paroxysm varies in length from a few minutes to half an hour, or an 
hour, and sometimes, though rarely, exceeds the last-mentioned period. The 
patient is sometimes free from pain, and in apparent health, during the inter- 
vals; but more frequently he suffers with occasional uneasiness in the prae- 
cordia, and often exhibits signs of cardiac disease. 
The first attack, which is in most cases comparatively mild, is usually ex- 
perienced upon the occasion of some extraordinary exertion, such as ascending 
a height, especially in the face of a cold wind. The patient is suddenly seized 
with pain, and immediately stops, feeling that it is impossible for him to ad- 
vance, and as if he should die were he to make the effort. After a few minutes, 
however, the pain subsides, and he is enabled to proceed. The attack is 
afterwards repeated, but at a very uncertain interval, after one or more weeks, 
for example, or months, or a year; but the interval generally diminishes with 
the continuance of the complaint; so that at length the patient becomes liable 
to a paroxysm upon the slightest excitement, and even without any apparent 
exciting cause. In this condition, any movement of the body, or any mental 
emotion, however slight, may become the cause of pain; and the swallowing 
of food, the act of defecation, turning in bed, coughing, or other equally in- 
significant cause, is sufficient to induce a paroxysm. The patient is not un- 
frequently attacked at night, especially, as it is said, after the first sleep. 
He is now scarcely ever free from suffering or the apprehension of it, and life 
not unfrequently becomes a burthen, which he is glad to lay down. Cases 
which have advanced thus far sometimes terminate suddenly, in fatal syncope. 208 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
[part II. 
The patient is also frequently carried off by some of the secondary affections 
incident to organic disease of the heart, in which simple neuralgia, if severe 
and long continued, is apt to terminate. 
But there are many cases much less severe than those above described. The 
pain may not be less acute; but it is not so extensive, recurs quite irregularly 
both as to degree and time, and may disappear for a very long period, or never 
return. There are, indeed, fugitive pains in the heart as in other organs, de- 
pending on various causes of nervous derangement, and quite trivial in their 
nature, which it is necessary, if they are classified at all, to place along with 
neuralgia. The same may be said of that sort of uneasy feeling about the 
heart, extending often to the shoulder and arm, which consists in a sense 
rather of stricture, weight, or aching numbness, than of positive pain, and 
which is not uncommon in nervous and dyspeptic patients of a gouty or rheu- 
matic constitution. 
Instances of cardiac neuralgia have been observed, in which the paroxysms 
returned at certain fixed periods, with perfect freedom from pain in the inter- 
val. Such cases are strictly analogous to the intermittent or periodical neu- 
ralgia, which frequently occurs in other parts of the body. • 
It is asserted that angina pectoris has sometimes disappeared upon the 
breaking out of certain eruptions upon the skin. 
Dissection often reveals nothing to which the complaint could be ascribed; 
but often also organic disease has been observed, such as ossification of the 
coronary vessels, valves, or aorta; hypertrophy, dilatation, or softening of the 
heart; morbid obesity, and pericardial effusion. It is impossible to determine 
how far these diseases are mere accidental coincidences, and how far they 
stand towards the neuralgic affection in the relation of cause or effect. 
Causes.-These are often very obscure; and, as in other cases of obscurity, 
various opinions have been advanced by authors. Dr. Parry, whose attention 
was particularly called to ossification of the coronary arteries, ascribed the 
disease to that lesion. By others it has been referred to general plethora, to 
gout, to affections of the pericardium, to spasm of the diaphragm, and to 
organic disease of the liver or other abdominal viscera. Dr. Hope was inclined 
to the belief, that, in its worst forms, it was owing to structural disease of the 
heart or great vessels, in which some portion of them were deprived of their 
elasticity by osseous, cartilaginous, or steatomatous degeneration, and that 
the pain was owing to over-tension of the rigid portion. But these affections 
so often occur without any trace of angina, and angina has been so often ob- 
served without structural disease, that great doubt is necessarily thrown 
over the justness of this opinion. I am disposed to believe that, where the 
two affections coexist, they are both the result of the same morbid cause, or 
that the organic is the consequence, as so often happens elsewhere, of the 
continued functional derangement. The opinion of Dr. Chapman that angina 
is a gouty affection is probably true, in at least a large number of cases; and 
the tendency of gouty irritation to favour the deposit of calculous matter in 
the fibrous tissues is well known. Both the pain and the ossification may in 
such instances be nothing more than gouty phenomena. So far as my per- 
sonal observation has gone, neuralgic affections of the heart have generally 
occurred in persons who have inherited a gouty or rheumatic diathesis, but 
whose habits of life, more abstemious than those of their forefathers, have 
prevented the ordinary inflammatory developement of those diseases, and 
given them a disposition to assume a neuralgic form. 
Like neuralgia in other situations, that of the heart may be associated with 
and possibly in some measure dependent upon, general debility, nervous de- 
rungement of the system at large, and the chlorotic or anemic condition of CLASS III.] 
209 
ANGINA PECTORIS. 
the circulation. It is one of the forms in which hysteria shows itself, and is 
apparently, in some instances, connected with tenderness of the spine. It 
occasionally alternates with neuralgia elsewhere, especially in gouty or rheu- 
matic individuals. It has sometimes appeared to originate in continued and 
deep distress of mind. There is good reason to believe that it is sometimes 
a result of miasmatic influence. Occasionally it is associated with general 
plethora, which may possibly serve as the exciting cause. Dyspepsia and 
disease of the liver often occasion neuralgic sensations in the .heart, probably 
through the nervous centres which associate the seats of these affections. 
The complaint is apt to come on when the stomach is overloaded with food, 
distended with flatus, or irritated by acid or indigestible matters. The com- 
munication of the irritation is probably effected through the instrumentality 
of the pneumogastric nerve. It is not improbable that disease at the origin 
or in the course of this nerve may sometimes be the source of the affection. 
Males over fifty are most liable to the severest forms of this complaint; 
females less advanced in life to the milder. 
Prognosis.-When the disease is associated with structural alteration in 
the heart, the prognosis is very unfavourable, though the patient often lives 
long. Under other circumstances, the affection may very generally be alle- 
viated, and sometimes cured. When of a gouty character, though removed 
for a time, it is always liable to return, because the gouty diathesis can 
scarcely be eradicated. 
Treatment.-The remedial measures are first, those adapted to the parox- 
ysm, and secondly, those which are to be,used in the interval. 
1. During the paroxysm, the patient should be kept at rest. If the pulse 
should be strong, and the general habit plethoric, blood may be taken freely 
from the arm; but bleeding is not frequently required, and, when the dis- 
ease is associated with general debility, or the anemic condition, would be 
positively injurious. Whenever the patient is habitually pale, with a languid 
circulation, and in a generally feeble state of health, blood should be taken 
very cautiously, if at all, and by cups or leeches between the scapulae, rather 
than by the lancet. Local bleeding may also be used, as an adjuvant of vene- 
section, in cases to which that remedy is adapted. 
To relieve the pain, anodyne and antispasmodic medicines should be given 
freely; and none are so efficacious as the preparations of opium, such as lauda- 
num, the black drop, and the salts of morphia, of one of which a large dose 
should be given promptly, and repeated if the first should not prove successful. 
When there is a gouty or rheumatic tendency, the wine of colchicum root 
should be given pretty freely along with the anodyne. Should the pulse be 
feeble, the skin cool, and the action of the heart corresponding, the ammoniacal 
or ethereal preparations, musk, assafetida, or camphor, should be prescribed, 
separately or variously combined; and, in such cases, with a gouty or rheu- 
matic taint, ammoniated tincture of guaiac may be substituted'for the prepa- 
ration of colchicum. Should evidences of acid or flatus in the stomach exist, 
carbonate of ammonia, or aromatic spirit of ammonia, is well calculated to meet 
the indications; or various mixtures of aromatics and antacids may be admin- 
istered. When there is reason to suspect an overloaded stomach as the cause,* 
vomiting should be produced by ipecacuanha, aided by warm water or infusion 
of chamomile. Inhalation of chloroform has been recommended. 
Hot pediluvia, rendered more stimulating by mustard, or Cayenne pepper, 
should be employed simultaneously with the internal remedies, especially in 
gouty cases. Speedy rubefaction over the region of the heart, by means of 
strong solution of ammonia or sinapisms, is sometimes desirable; and similar 
applications to the spine may not be without advantage. Laennec recom- 210 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
[PART II. 
mends the application of two magnets on opposite portions of the chest; but 
all their effects are probably produced through the mind of the patient. 
Acupuncture is said to be sometimes useful. 
2. In the interval, the exciting causes should be carefully avoided, and the 
patient should, therefore, sedulously cultivate calmness of mind and perfect 
equanimity, while he avoids all vigorous muscular effort. At the same time, 
the general health should be carefully attended to as the best safeguard against 
the attacks of the disease. Dyspepsia should be corrected with especial care, 
along with its concomitants, acidity, flatulence, and constipation. (See Dys- 
pepsia.') In employing exercise in reference to the state of the general health, 
the passive kinds, as on horseback, or in a carriage, should be decidedly pre- 
ferred to the active. Any existing morbid tendency which may have predis- 
posed to the disease, or excited it, should receive due attention. Hence, gout, 
rheumatism, anaemia, or hysteria, if present should be treated with appropriate 
remedies; but when either of the first two of these affections is seated in a safe 
and convenient spot, caution should be observed not to remove it by repellent 
measures. 
Sometimes advantage will accrue from a strong impression upon the nervous 
system by means of the metallic tonics, associated with the narcotics. Nitrate 
of silver, sub-carbonate of iron in half drachm or drachm doses, subnitrate of 
bismuth, the salts of copper, or those of zinc, may be given in connexion with 
the extract of belladonna, of stramonium, or of hyoscyamus, or of the three 
combined. For the periodical cases, sulphate of quinia is the appropriate 
remedy. The paroxysms, when apt to occur at bedtime, may sometimes be 
effectively anticipated by a full dose of opium. 
Nor should local remedies be neglected in the intervals. Issues in the 
thighs have been highly recommended. Blistering, antimonial pustulation, 
setons, or issues may be employed on the back between the shoulders. Ad- 
vantage has also accrued from a belladonna plaster upon the breast, and from 
frictions with aconitia or veratria. 
Finally, in very obstinate cases, not attended with serious structural disease 
of the heart, much good may be expected from the mental distraction, various 
enjoyments, and exciting novelties of foreign travel, which places the nervous 
system under wholly new influences, and often subverts those tenacious morbid 
associations which sustain, if they do not originate neuralgia. 
SUBSECTION II. 
DISEASES OF THE ARTERIES. 
Article L 
INFLAMMATION OF THE ARTERIES, or ARTERITIS. 
The arteries are one of the components of our frame least liable to inflam- 
mation. It is not unusual to find arterial trunks wholly sound, though sur- 
rounded with inflamed and even suppurating structure. Hence it may be 
inferred that idiopathic arteritis is a rare disease. Some pathologists, how- 
ever, have adopted a contrary opinion, based upon the supposition that the 
redness, often observed after death upon the inner surface of the arteries, is 
of an inflammatory character. Among these was Dr. Frank, of Vienna, who 
regarded arteritis as the essential cause of a peculiar and very dangerous form CLASS III.] 
ARTERITIS. 
211 
of fever. But a closer scrutiny has determined that the redness is not a cer- 
tain evidence of inflammation, but is, on the contrary, in general, the result 
of imbibition of blood after death, or during the last agony. The observations 
of Chaussier, Laennec, Berard, Andral, MM. Trousseau and Rigot, and Dr. 
Hope, all concur to this end. The inference, therefore, as to the frequency 
of arteritis, drawn from the phenomenon alluded to, is not supported; and all 
other considerations lead to the conclusion that it is a rare disease. 
The want of vascularity in the interior membrane of the arteries would 
appear to be the chief cause of their resistance to ordinary causes of inflam- 
mation. Trousseau and Rigot found that neither alcohol of the sp. gr. 0.835, 
nor dilute nitrous acid, nor putrefying animal substances, occasioned inflam- 
matory action in the arterial lining membrane. (Hasse's Anat. Descrip, of Dis. 
of Circ. and Resp., Lond. ed., p. 59.) 
Symptoms.-The symptoms of arteritis are very uncertain. When mode- 
rate and of small extent, as it ordinarily occurs, for example, after the tying 
of an artery, it scarcely gives rise to any obvious disturbance. In a higher 
degree, it is said to occasion heat and pain along the course of the inflamed 
vessel, tenderness upon pressure, increased pulsation or throbbing, and a rust- 
ling sound upon auscultation, which has been ascribed to roughness of the 
internal surface. When seated in the larger vessels, it generally produces a 
sympathetic irritation of the heart, and other symptoms of fever, sometimes 
attended with restlessness, great anxiety, and a feeling of faintness. In the 
thoracic aorta, it may also give rise to oppressed breathing. The same symp- 
toms, however, may result from so many other morbid conditions, especially 
in the thoracic and abdominal cavities, that a certain diagnosis is almost im- 
possible; and the practitioner must be content, even in the best marked cases, 
with a high degree of probability. The absence of any other discoverable 
lesion or functional disorder, to which the symptoms can be ascribed, will 
afford good probable grounds for referring them to this cause. 
It very seldom happens that the aorta, or other large arteries of the trunk, 
are absolutely obstructed in consequence of inflammation; but this result is 
occasionally attendant upon the disease in the arteries of the extremities. In 
such cases, the vessel, though it may have at first pulsated with more than 
its usual force, either suddenly ceases to beat, or gradually beats more and 
more feebly, until pulsation can no longer be felt, either at the seat of the 
affection, or in the limb below it. The artery may now be felt like a tense 
cord running along the limb. The obstruction may be owing either to the 
effusion of fibrin into its cavity, or to the coagulation of the blood; and some- 
times to a mere thickening of the coats. The blood appears to have a strong 
tendency to coagulate upon the inflamed surface of the vessel, and the clot 
sometimes extends for a great distance along its course, blocking it up com- 
pletely. The limb sometimes becomes swollen and painful during the pro- 
gress of the disease; but, when the obstruction has occurred, the phenomena 
resulting from a deficient supply of blood are exhibited in a degree propor- 
tionate to that of the obstruction. A feeble or absent circulation, diminished 
temperature, a sensation of numbness or even paralysis, and lastly mortifica- 
tion, preceded by gangrenous phlyctsenaa, are among the results. It is highly 
probable that many of the cases of apparently spontaneous gangrene of the 
extremities have their origin in inflammation of the arteries. The blood in 
the vessels of a mortified part coagulates; but the coagulation does not neces- 
sarily extend far beyond the seat of the affection. In these cases of supposed 
spontaneous gangrene, the main artery has been observed to be filled, far 
above the utmost limit of the mortification, with coagulated blood adherent 
to its inner coat, or separated from it by a layer of pus; showing that the 212 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
[PART II. 
original disease was probably in the vessel itself, and the gangrene, therefore, 
a result and not a cause. It would, however, be going too far to assert that, 
in all instances, spontaneous gangrene arises from arteritis. It undoubtedly 
originates from various other causes. The loss of the limb is not a necessary 
consequence. Blood may be supplied to it through anastomosing vessels, or 
others generated on the occasion. Should this supply be furnished sufficiently 
before the occurrence of absolute mortification, the limb may be restored, 
and, even after mortification, only a portion may slough, and the remainder 
be preserved. But, in cases of extensive coagulation reaching far up the 
artery, death is the necessary result. When recovery takes place, the artery 
becomes obliterated by absorption. If not completely obstructed, however, 
it may remain pervious on the subsidence of the inflammation. 
. In the advanced stages of extensive arteritis, a new set of phenomena are 
sometimes presented, consequent upon the contamination of the blood with 
the pus, lymph, &c., which may be secreted by the inflamed interior mem- 
brane, and washed away by the current of the circulation. The fever now 
assumes a typhoid character, with a frequent, feeble, and irregular pulse, 
torpid capillary circulation, hurried breathing, subsultus tendinum, and low, 
muttering delirium. This condition of system attends, from the beginning, 
certain cases of arteritis, originating in local inflammations, abscesses, or 
unhealthy ulcers, which appear to impart their own depraved action to the 
inner coat of the arteries of the part affected, along which it is transmitted 
towards the heart. Guthrie, who has published an account of such cases, 
considers the inflammation as erysipelatous. The cases are rare; for the 
tendency in arteries, unlike that of the veins, is to propagate inflammation 
towards the circumference, instead of the centre of the circulation. 
From the evidence of dissection, it may be inferred that chronic inflamma- 
tion of the arteries is not unfrequent; if, indeed, it be admitted that the 
various organic changes which have been noted, such as alterations of texture 
and thickness, and different kinds of morbid deposition, are really the result of 
the inflammatory process. But there are seldom symptoms sufficiently marked 
to characterize the affection, before the organic change has taken place; and 
this then becomes the prominent object of attention. (See the next article,.') 
Anatomical Characters.-Redness of the internal coat has been before 
stated not to be admissible alone as an evidence of previous inflammation. 
Scarlet and brown or violet discolorations are frequently the result of mere 
imbibition of blood. Berard considers the proposition incontestable, that 
"the red bands and patches of the internal surface of the arteries, which are 
not attended with any other appreciable physical change in the coats of these 
vessels, are not of an inflammatory nature." {Diet, de Med., iv. 100.) But, 
when the redness is accompanied with a roughness or loss of polish upon the 
interior surface; injection of the vasa vasorum; softness, friability, loss of 
elasticity, or thickening of the parietes; a facility of separation between the 
several coats; and the existence of effused coagulable lymph or of pus, there 
can be no doubt of the previous existence of arteritis. The lymph has been 
observed variously in flocculi, patches adhering to the inner surface, and 
masses to a greater or less extent filling and obstructing the channel of the 
vessel. Pus is formed upon the inner surface, underneath layers of coagu- 
lated blood or false membrane, and sometimes between the coats. But it is 
not a frequent product of arteritis, which is much more disposed to plastic 
exudation than the generation of pus. Coagulated blood is frequently observed 
lining the vessels, or occupying their cavities, sometimes for a great distance. 
The presence, however, of pus or lymph is probably less frequent than it 
would be, were not these substances often washed along with the blood as fast CLASS III.] 
213 
ARTERITIS. 
as secreted. Ulceration is sometimes seen upon the inner surface of the vessel, 
though very rarely as the result of acute arteritis. All these signs of inflam- 
mation are seldom or never observed in one case; nor are they all of equal 
value. Laennec is disposed to believe that thickening of the coats, and un- 
usual apparent vascularity, may exist in connexion with redness, without 
necessarily implying inflammation, when the body is much infiltrated, and 
the tissues very moist; and Dr. Hope states that he met with a case present- 
ing these phenomena, which a brief examination proved not to be inflamma- 
tory. (Cyc. of Pract. Med., Art. Arteritis.) The most incontestable evidence 
of inflammation is that afforded by the existence of exuded fibrin or of pus. 
The marks left by chronic arteritis are a dirty redness, thickness, softness, 
or other organic alteration of the coats, ulceration, and various morbid depo- 
sits. In relation, however, to the organic changes of arteries, it is by no 
means certain that they are always the result of inflammation. Some of them, 
indeed, would appear, from a close scrutiny, to be wholly independent of that 
process in their origin. But, either as cause or effect, they usually have 
more or less connexion with it; and they may, therefore, be most conve- 
niently treated of here, so far as they require notice in an elementary trea- 
tise, at least with the exception of ossification and aneurism, which will be 
considered under distinct headings. 
Noninflammatory organic alterations. Arteries are sometimes found 
dilated, and sometimes contracted. Of their dilatation occasion will be taken 
to treat under aneurism. Their contraction is either mere stricture without 
alteration of their coats, or, as more frequently happens, it is the result of 
a thickening of one or more of the coats, or a deposition of foreign matters 
in their substance. In the former case, it is very limited; in the latter, it 
sometimes affects a considerable extent of the vessel. 
The coats of the arteries are variously changed. Occasionally they lose 
their elasticity, at the same time becoming white, more opaque, and denser 
than in health, without other appreciable alteration. This condition is said 
to predispose to dilatation. In other instances they are thickened, as well as 
inelastic and fragile, especially the inner coat; whence arises a diminution of 
their caliber, and sometimes even complete obstruction. Sometimes they are 
much softened; and this also is particularly true of the inner coat. In this 
condition, the vessel is liable to an accident to which attention was first 
called by Dr. Turner, in the Transactions of the Medico-Chirurgical Society 
of Edinburgh. In consequence of some movement in which the artery is 
elongated, the inner membrane is ruptured, and a portion of it, being rolled 
backward, impedes the current of the blood, and induces coagulation to such 
a degree as quite to obstruct the vessel. A sudden stoppage of circulation is 
experienced in the limb below, with all the necessary consequences of the want 
of blood. 
Of the morbid deposits, one of the most frequent consists of cartilage-Ulce 
patches on the inner surface of the artery. From the researches of Bizot, it 
would appear that these are the result of acute inflammation; having been 
traced from their incipient stage of a viscid gelatinous exudation, of a pale 
rosy colour, through gradual changes, to the state in which they are ultimately 
found, of firm, white patches, of almost cartilaginous hardness, supplanting 
the inner coat of the vessel, in the places where they are deposited. {System 
of Pract. Med., article Arteritis.) Hasse, however, regards them as deposits 
directly from the blood. {Hasse's Anat. Descriptions, &c., p. 75.) According 
to the same author, these patches never ossify, differing in that respect strik- 
ingly from the affection to be noticed in the following paragraph. 
Another kind of deposition is that which has been variously denominated 214 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
[part II. 
atheromatous (pulpy), melicerous (of the consistence of honey), and steatoma- 
tous (of the consistence of suet), according to its degree of cohesion. It is 
usually deposited in the form of a yellowish, soft, friable, cheesy substance, 
either in the cellular tissue between the inner and middle coats, or, accord- 
ing to Berard, in the substance of the lining membrane itself, between its two 
laminae. {Diet, de Med., iv. 132.) It first appears in numerous minute gran- 
ules, which coalesce and form masses, sometimes of considerable size. These 
masses either become the matrix of a calcareous deposition; or, being gradu- 
ally softened, and converted into a pus-like matter, by a process analogous to 
the softening of tubercles, produce ulceration or absorption of the middle and 
inner coat {Hasse, 78), and thus escape into the current of the blood, leav- 
ing small ulcers behind them. Sometimes the two changes go on simultane- 
ously in the same patch. This deposit is found most frequently in the aorta, 
especially near its arch, and in the great vessels which put out from that trunk, 
especially near their commencement. There seems to be no reason to suppose 
that it is the product of inflammation, as no marks of this condition necessarily 
attend its origin. By the aid of the microscope, it has been found to consist 
of oily or fatty matter, which is said to be deposited from the blood, and not 
to result from a change of the tissue itself, which, though broken up and disin- 
tegrated, has become so by the compression made upon it, and the interrup- 
tion of its nutrition. (Hanfield Jones, Brit. & For. Medico-Chirurg. Rev., 
April, 1853, p. 264.) Its effect, in the small arteries, is sometimes to produce 
obstruction; in the larger, to weaken their coats so that they yield to the 
force of the circulation, or to accidental violence, thus giving rise to aneurism, 
or to rupture and hemorrhage. 
Tubercles, and small abscesses from ordinary inflammation, are said to exist 
occasionally between the coats of arteries, and to produce ulcers by opening 
into the cavity of the vessels. They are, however, very rare, and it may even 
be doubted, whether, in the cases observed, they were not identical with the 
atheromatous deposition in some of its stages. 
Ulceration. This is frequently observed as a consequence of the above de- 
rangements. It is said to result most frequently from the detachment of the 
cartilaginous scales from the surface of the vessels, from openings made through 
the inner coat by the atheromatous matter, or from irritation and inflammation 
produced by the calcareous deposits. The ulcers vary in size from that of a 
mustard seed to that of a split pea, are sometimes superficial and sometimes 
deep, and occasionally perforate all the coats of the artery, giving rise to fatal 
hemorrhage. They are also occasionally the first stage in the formation of 
aneurisms. Hasse states {Descriptions, &c., p. 81) that the ulcers are con- 
fined almost exclusively to the abdominal aorta. Sometimes the ulcers pro- 
duced by the disappearance of the atheromatous matter heal, leaving scars. 
{Ibid., p. 79.) Ulceration is sometimes propagated to the arteries from dis- 
ease in neighbouring parts, such as abscesses, wounds, and ulcerous affections, 
whether simple or malignant. 
The morbid conditions above enumerated are seldom found separate. Often 
several of them are united in the same vessel; and thickness, fragility, and 
ulceration of the coats, may be found in association with the cartilaginous 
scales, the atheromatous deposit, and osseous degeneration. 
Causes.-1The causes are, in many instances, not less obscure than the symp- 
toms. It is known that various kinds of violence, as wounds either accidental 
or surgical, the tying of arteries, and sudden and great elongation of the ves- 
sels, sometimes produce arteritis. That it may originate in the vessels of parts 
inflamed or suppurating, and thence be carried towards the heart, has been 
already stated. Cold probably sometimes causes it, and it is highly probable CLASS III.] 
OSSIFICATION OF THE ARTERIES. 
215 
that it may result from acrid and poisonous substances, which have found an 
entrance into the blood-vessels by absorption or otherwise. Perhaps the abuse 
of alcoholic liquors may operate in this way, as well as by sustaining an ex- 
cessive action of the heart. The disease is thought also to have arisen from 
repelled eruptions, and the metastasis of gout and rheumatism. Anything 
which has a tendency to over-excite the circulation, and thus distend the 
blood-vessels, or subject them to an extraordinary impulse, may be looked 
upon as giving a predisposition to it. Hypertrophy of the heart may act 
in this way. Grouty and rheumatic subjects are thought to be peculiarly 
liable to the disease. It is probable that an inflammatory constitution of 
the blood would act as an especial predisposition. Adults are more apt to 
be affected than children. 
Of chronic arteritis one of the most frequent causes is probably the pre- 
sence of morbid deposits, as of tuberculous, steatomatous, and calcareous mat- 
ter, which act as irritants to the parts around them. This would be equally 
true, whether these deposits be considered as themselves originating from in- 
flammation, or as the result of some other morbid process. 
Treatment.-Whenever the existence of arteritis can be well made out, if 
attended with the ordinary symptoms of inflammatory excitement, it should 
be treated by general and local bleeding, carried as far as the strength will 
bear. Saline cathartics, with the antimonials and other refrigerants, may be 
given internally; the patient should be kept at perfect rest in the horizontal 
position; all compression of the limb or part affected should be carefully 
guarded against; and the whole antiphlogistic regimen should be adopted. 
Local bleeding is best effected by leeching along the course of the inflamed 
vessel. This may be followed by fomentations or cataplasms, and, ultimately, 
by blisters or pustulating applications. Should the disease not yield to deple- 
tion, recourse should be had to the mercurial impression. Calomel may be 
employed for this purpose, combined with opium, hyoscyamus, or other ano- 
dyne, to relieve the pain and restlessness. After gangrene has occurred, it 
will be necessary to support the system, until the processes requisite for the 
repair of the mischief shall have been completed. 
•Article II. 
OSSIFICATION OF THE ARTERIES. 
This term has been applied to that condition of the arteries, in which, in 
consequence of the presence of earthy or calcareous matter, they possess a 
firmness and hardness analogous to that of bones. It has been questioned 
whether the new structure is really an osseous growth, or merely the result of 
a deposition of earthy matter in the pre-existing tissues. In favour of the 
former opinion is the fact, that, when these concretions are macerated in dilute 
muriatic acid, a portion of animal matter is left, having the appearance of 
organized parenchyma. But this may be merely the tissue in which the 
earthy substance was deposited. Brande found the bony laminae to consist of 
65.5 per cent, of phosphate of lime, and 34.5 of animal matter; and, accord- 
ing to Dr. Hope, the proportion of the latter constituent is, in some instances, 
considerably less. This is not exactly the constitution of bone. Besides, in 
the atheromatous deposits spoken of in the last article (pays 214), it has 
been shown that calcareous particles exhibit themselves at first in small 
numbers, and gradually increase until they supplant the original pultaceous 
secretion. 216 
[part II. 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
The affection is readily recognized by the hardness and diminished com- 
pressibility of the vessel under the fingers. In the earliest stage, the de- 
parture from the healthy state is slight, and the sense imparted to the touch 
by the artery is rather that of cartilage than of bone. The firmness, however, 
gradually increases, until at length not unfrequently pulsation can be felt no 
longer, and a bony cord seems to have taken the place of the elastic tube. 
All parts of the arterial system, carrying red blood, are liable to this degene- 
ration. It is exceedingly rare in vessels which convey venous blood, though 
calcareous deposits have been in some instances noticed in the pulmonary 
artery. Dr. Hope, however, states that, of a thousand cases in which he had 
examined this vessel, he had never met with such a deposit in a single one. 
The affection is most frequent in the aorta, and, after this, in its larger divi- 
sions. It is stated to be more frequently met with in the ascending portion 
and arch of the aorta than in any other part of that vessel. It is more com- 
mon in the lower extremities than in the upper. The ossification is usually 
partial, occupying but a small proportion of the vessels of the body; but some- 
times it is almost universal. A case is recorded by Dr. Adams, in the Dublin 
Hospital Reports, in which no pulsation could be felt in any part of the body, 
and even the heart offered no other sign of action than a slight undulating 
sound. Upon dissection, in this case, even the coronary arteries were observed 
to be ossified, and their cavity quite obliterated for some distance near their 
origin. The old are much more liable to be affected than the young or mid- 
dle-aged, and men than women. No age, however, is quite exempt, and the 
affection has been observed even in infancy. 
The deposition generally takes place between the middle and inner coats, 
though the earthy phosphate is asserted to have been observed in the sub- 
stance of both of' these coats, especially of the former. At first, it occurs 
here and there, and often at distant points, in small plates or scales, which 
increase in number, and at length coalesce, forming patches of considerable 
extent, and sometimes complete bony tubes. The plates are sometimes 
marked by the annular fibres of the middle coat, with which they are in contact. 
Causes.-Ossification of the arteries has behn ascribed to chronic inflamma- 
tion, but altogether without proof. If marks of inflammation have sometimes 
been observed in the ossified vessel, they have more frequently been quite 
wanting, and, when present, have much more probably been the result than 
the cause of the change of structure. It is not impossib]^||that inflammation 
may sometimes determine a deposit of calcareous matter; but it is-not the 
ordinary or necessary cause. Dr. Hope thinks that over-distension of the 
arteries produces a condition favourable to this species of degeneration, and 
adduces the following among other reasons; that the affection is most common 
when the left ventricle of the heart is hypertrophied, that it is more frequent 
in men than in women, who are less exposed to severe muscular exertion, and 
that it is most apt to attack the vessels most liable to distension, as the arch 
of the aorta, and the arteries of the brain. (Cyc. of Pract. Med., Art. Arte- 
ritis.') It is probable that gout and rheumatism may favour calcareous depo- 
sitions in the arteries, as in other parts of the body. In this case, the result 
is to be ascribed rather to vitiation of the blood than to vascular irritation. 
Old age strongly predisposes to the affection. It is, indeed, so common in 
old persons, that total exemption is comparatively rare, and the inference 
might almost be drawn, that it is one of the normal results of advanced life. 
Mr. Crisp has seen elevated soft patches on the coats of the arteries, some of 
which were advancing to the cartilaginous state with a little ossific deposition, 
others were half ossified; and he believes that ossification is in general the 
mere termination of the atheromatous and cartilaginous lesions. (Treat, on CLASS III.] 
217 
ANEURISM. 
Struct., Dis., &c. of the Blood-vessels, p. 72.) Hasse, however, denies that 
the cartilaginous patches ossify. 
Effects.-Ossification produces inequalities in the inner surface of the artery, 
and thus exposes particular points to an increased impulse from the current 
of the blood. The lining membrane, previously weakened by inflammation, 
or thinned by absorption, is readily ruptured. The middle coat is at the same 
time attenuated and enfeebled, from the pressure of the increasing deposition, 
and in its turn also gives way. The foundation is thus laid for aneurism. 
Sometimes the whole of the coats are ruptured, and fatal hemorrhage ensues. 
This is especially apt to happen in the arteries of the brain, from their want 
of the cellular coat, and the yielding medium in which they are embedded. 
Inflammation and ulceration of the artery sometimes result from the presence 
of the foreign matter within its coats ; and the consequent exudation of fibrin, 
or coagulation of the blood, produces a complete obstruction of the vessel. 
Hence atrophy or mortification of the parts which depend on the vessel for 
their blood. Gangrene of the extremities in old people sometimes arises from 
this cause. The ossified arteries, moreover, can no longer perform their part in 
the circulation ; and may thus possibly contribute to the failing nutrition, and 
general decay of old age. Atrophy and consequent feebleness of the brain 
and of the heart have sometimes appeared to result from ossification of their 
vessels. Another injurious effect is an increased risk from surgical operations 
and accidental violence. 
There is no known remedy for ossification of the arteries; and our efforts 
must be confined to measures calculated to obviate its causes, and, as far as 
possible, its injurious effects. To prevent undue excitement of the heart, and 
unnecessary stress upon the vessels, are the chief indications; to answer 
which, mental equanimity, abstinence from stimulants, and the avoidance of 
strong muscular exertion, are the means most worthy of reliance. 
Article III. 
ANEURISM. 
By the term aneurism, as here employed, is meant a tumour containing 
blood, and formed "by the expansion of one or more of the coats of an artery. 
Scarpa made a distinction between dilatation and aneurism, applying the 
former name to an expansion of the whole of the arterial coats for a limited 
extent, the latter, to an expansion of the exterior coat, occurring in conse- 
quence of a solution of continuity in the inner and middle. In relation to 
cases in which the entire circumference of the vessel is dilated, there is some 
ground for this distinction; as certain phenomena characteristic of ordinary 
aneurismal tumours are wanting in these. But, when the dilatation affects 
only a portion of the circumference, tumours are formed in no respect distin- 
guishable, during life, from other aneurisms. Besides, in the progress of 
dilatation, the inner and middle coats not unfrequently undergo a solution of 
continuity, so that an identity of character is given to the two affections. 
So close a connexion, therefore, exists between dilatation and aneurism, that 
they may be properly considered under one head. The following remarks 
apply particularly to internal aneurisms, which, from their position, are be- 
yond the reach of surgical aid.* The varieties which have been recognized 
* The internal aneurisms bear a large proportion to the whole number. Of 551 
cases compared by Mr. Crisp, 288 were of that character, not including those of the 
carotids and external iliacs. {Treat. on Struct., Dis., ^c. of the Blood-vessels, p. 113.) 218 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
[PART II. 
are 1. complete dilatation ; 2. partial dilatation; 3. sacculated expansion of 
the oitter coat with solution of continuity in the two inner; 4. dissecting aneu- 
risms, in which the blood separates the coats; and 5. hernial aneurism, in 
which the interior coat protrudes through an opening in the middle. 
1. Complete Dilatation.-In this affection, the whole circumference of the 
artery is expanded equably, or nearly so, and sometimes for a considerable 
extent. Sometimes the expansion is greatest at a certain point of the vessel, 
and gradually diminishes in both directions, so as to form a spindle-shaped 
or ovoidal tumour; and a number of fresh tumours may occur successively 
along the same vessel. In other cases, the dilatation is equable in the longi- 
tudinal direction, and consequently has a cylindrical shape. Again, the 
artery may be lengthened, as well as expanded, thus becoming somewhat tor- 
tuous, like a varicose vein; and the term aneurismal varix has been applied 
to this affection. In dilatation of the artery, the coats sometimes become 
thinner than in health; but, in most cases, they either retain their original 
or acquire an increased thickness. They are almost always changed in struc- 
ture ; becoming denser, more opaque, and less elastic, or exhibiting some of 
those morbid depositions noticed under Arteritis and Ossification, with & 
rough, fragile, or softened state of the lining membrane. 
Hasse states that, in every instance which has come under his notice, in- 
cluding as well partial as complete dilatation, the inner, surface was covered 
with semi-cartilaginous patches and false membranes, rendered uneven, soft- 
ened, or partially exulcerated by atheromatous deposits, and extensively ossi- 
fied. {Anatom. Descrip., &c., p. 85.) The internal and middle coats are 
sometimes completely or almost completely destroyed, and their place sup- 
plied by these morbid deposits, which, however, may present the appearance 
of the natural coats, of which the middle is represented by the atheromatous 
matter, and the inner by the cartilaginous patches, and a delicate, smooth, 
semi-transparent, false membrane. {Ibid., p. 86.) 
The predisposing cause of dilatation is probably almost always this altered, 
inelastic condition of the coats, which disables them, when expanded under 
the heart's impulse, from returning to their former dimensions when the im- 
pulse ceases. Whatever tends to accelerate or give increased force to the 
movement of the blood may prove an exciting cause. Hypertrophy of the 
left ventricle favours the production of the disease. Vicinity to the heart 
must have the same effect, as >the greatest force is there applied to the blood- 
vessels. Hence, dilatation is most frequent in the ascending portion and 
arch of the aorta. It is sometimes, however, found in the larger branches of 
this trunk, especially those which go off at right angles, and even in the 
smaller and more distant vessels. It has been met with, though rarely, in 
the pulmonary artery. The aorta is often dilated to twice its ordinary cali- 
ber, and occasionally much more. Very large dilatations sometimes present 
lesser bulgings upon their surface. 
One of the points in which these dilatations most strikingly differ from 
the ordinary forms of aneurism, is the want of coagula. The surface is too 
uniform to impede the movement of the blood, and thus favour its concretion. 
In some instances, however, when the inner membrane happens to be ulcer- 
ated, rent, or otherwise irregular, the blood coagulates upon its surface, form- 
ing layers which more or less completely fill the cavity. 
While the dilatation is small, it produces no observable effect upon neigh- 
bouring organs; but, when much increased, it may give rise to phenomena 
of compression, such as result from other aneurismal tumours. Sometimes 
the two inner coats lose their continuity from fissure, ulceration, or other 
cause, and the dilatation is converted into a proper aneurism. When the CLASS III.] 
219 
ANEURISM. 
dilatation is considerable, it has been thought to occasion enlargement of the 
heart, which complicates the phenomena, and increases the danger. 
2. Partial Dilatation.-Sometimes that condition of the coats which causes 
an artery to yield to the force of the circulation-is confined to a portion of its 
circumference, which is consequently the only part dilated. A tumour is 
thus formed upon the side of the Vessel, with which it communicates by an 
abrupt orifice usually narrower than the body of the pouch. Such tumours 
have been repeatedly observed with all the coats of the artery apparently en- 
tire; but there is reason to believe that a smooth, false membrane, often 
found lining the aneurismal sac, has been mistaken, sometimes at least, for 
the proper inner tunic. They are sometimes denominated true aneurisms, to 
distinguish them from the following variety, to which, however, as by far the 
most frequent, the name would seem more appropriately to belong. The 
blood finds an easy entrance into and exit from these tumours, but, being 
somewhat impeded in its passage, is more apt to coagulate than in the pre- 
ceding form of dilatation. The coagula, however, do not generally adhere to 
the whole interior surface, forming concentric layers, as in the next variety; 
but appear to be attached by a kind of peduncle to certain portions of the 
surface, which, from being ulcerated, fissured, or otherwise roughened, en- 
tangle portions of the blood as it passes over them, and favour its coagulation. 
These partial dilatations are most frequent in the ascending portion and 
arch of the aorta, though found in other parts of this trunk, and occasionally 
also in its branches. They arise usually from the anterior or lateral portion 
of the aorta, where the vessel is least supported. They are much less fre- 
quent than dilatations affecting the whole circumference. They sometimes 
attain a great magnitude; but, in this case, the inner and middle coats are 
generally ruptured, the expansive force is directed against the outer or cellu- 
lar coat, and an aneurism of the following variety is engrafted upon the origi- 
nal dilatation. The affection thus complicated is called by some a mixed 
aneurism. In positions where the exterior coat is wanting, the artery bursts 
without previously forming this kind of tumour. Such is the case with dila- 
tation of the aorta occurring near its origin, where, instead of the usual ex- 
terior coat, the vessel is invested with the pericardium. This, being less 
extensible than the ordinary cellular coating, gives way before the expanding 
force, and the blood escapes into the pericardial cavity. 
3. Aneurism from Rupture of the Inner and Middle Coats.-This is by 
far the most frequent form of aneurism,gand the one considered by Scarpa as 
especially entitled to the name. By many writers it is called false aneurism, 
in contradistinction to tumours arising from partial dilatation, which have been 
called true aneurisms. In this variety, the interior and middle coats, either 
from absorption, ulceration, or rupture, give way at some point; and the 
blood, passing through the opening, presses directly upon the cellular or outer 
coat, which, being tougher and more expansible, yields to the pressure, and 
forms a pouch or sac on the side of the artery. The orifice is of various shape 
and dimensions, but its diameter is generally less than that of the sac. It is 
not always in the middle of the tumour. The caliber of the artery is almost 
always diminished below the orifice. The tumour gradually increases with 
the continuance of the distending force. Its walls, instead of being rendered 
thinner by the distension, take on increased nutritive activity, and become 
thicker, denser, and more resistant, so as sometimes to be fibrous or even 
fibro-cartilaginous. The tissues pressed upon by the tumour are either ab- 
sorbed, or stretched over its parietes, with which they are sometimes incorpo- 
rated, giving them increased thickness and strength. No structure has been 
found permanently to resist its progress. Even bone gradually yields, being 220 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
[part II. 
absorbed, or worn away by the attrition of the blood, which, in consequence 
of the absorption of the periosteum, and the adhesion of the sac to the cir- 
cumference of the denuded portion of the bone, sometimes plays directly 
upon its surface. The periosteum is sometimes absorbed, sometimes incor- 
porated with the walls of the sac. In the latter case, it is said to secrete 
earthy matter, which serves to increase the strength as well as the bulk of 
this morbid structure. The viscera of the chest and abdomen, as the heart, 
lungs, stomach, liver, &c., are frequently forced out of their place by the 
augmenting tumour, or undergo a partial absorption to make room for it. 
Cartilage opposes the greatest resistance, being little if at all affected; and 
portions of this tissue occasionally remain, after the bones to which they were 
attached have disappeared. The tumour at length frequently approaches the 
surface, and becomes obvious to inspection. In the mean time, changes have 
been going forward in the interior of the sac. Almost from its commence- 
ment, the blood -in contact with its rough internal surface coagulates, and 
successive fibrinous layers are formed, which are disposed concentrically, and 
often fill up a large portion of the cavity. It is probable that inflammation 
of the surface of the sac favours this tendency to fibrinous deposition. The 
layers have been found to be light-coloured, and dense in proportion to their 
vicinity to the wall of the tumour; those nearest it being whitish or yellow- 
ish and firm, while the coagula near the centre are soft and blackish-red. 
The thickness of these layers is commonly from half an inch to an inch and 
a half, but it has been known to be three and even five inches. Sometimes 
the coagula, instead of being firm, are remarkably soft and fragile, owing pro- 
bably to the peculiar state of the blood. In the progress of the aneurism, 
some portion of its covering, in consequence of a greater pressure from within 
or without, or from some peculiarity in its structure, is absorbed; and the 
tissue beyond it, previously condensed by adhesive inflammation, supplies its 
place for a time. This is in its turn absorbed, and thus the sac advances 
until it reaches the skin or the lining membrane of some cavity, when an 
opening is effected, and the blood escapes. This happens somewhat differently 
in the different tissues. When only the skin intervenes between the contents 
of the sac and the external air, the most prominent part assumes a bluish or 
purplish colour, and at length sloughs. As soon as the dead portion begins 
to separate, an oozing of blood takes place; and a more complete separation 
is often followed by a tremendous gush, which nothing can control, and which 
sometimes produces death almost'instantaneously. The first portions of blood 
discharged are accompanied with dark and broken up coagula from the sac. 
The opening of the aneurism into the mucous cavities is effected in the same 
manner. But when it approaches one of the serous membranes, this is thought 
to be mechanically ruptured by the distending force, without previous morti- 
fication. Hasse, however, believes that the opening is in this, as in the other 
cases, a vital process. Instead of pursuing the course mentioned, the blood 
is sometimes effused, through an opening in the sac, into the cellular tissue 
not previously consolidated by inflammation, and then spreads to a consider- 
able distance through this tissue, forming a diffused tumour. 
Aneurisms of the descending aorta, and of the smaller arteries, are gene- 
rally of the kind above described. They are said sometimes to originate in 
a different mode from the one pointed out. Corvisart met with encysted 
tumours beneath the outer coat of the artery, attended with a destruction of 
the two inner coats. These he supposed might be converted into aneurisms 
by the softening and discharge of their contents, and the entrance of the 
blood into the empty cysts; and such cysts have been subsequently seen 
already opened, and communicating with the aorta, by M. Berard. {Diet, de CLASS III.] 
221 
ANEURISM. 
Med., iii. 15.) Hodgson, however, maintains that these tumours were the 
remains of cured aneurisms, instead of the origin of new ones. 
4. Dissecting Aneurisms.-This name was given by Laennec to a form of 
aneurism, in which the blood, having passed through an opening in the inte- 
rior and middle coats, afterwards, instead of forming a prominent tumour by 
the distension of the outer coat, diffuses itself between this and the middle, 
along the course of the artery. Sometimes the blood re-enters the vessel by 
another opening; and the portion of artery, intervening between the points of 
exit and re-entrance, may become obliterated. Several cases of this kind of 
aneurism are recorded by Dr. Pennock, in his edition of Dr. Hope's Treatise 
on Diseases of the Heart (Am. ed., A.D. 1842, p. 402). In one of these, 
under the care of Drs. Pennock and Goddard, the dissection of the aorta by 
effused blood extended around nearly its whole circumference, and throughout 
its length, beginning near the semilunar valves, and terminating in a cul-de- 
sac at the bifurcation into the primitive iliacs; so that the aorta appeared 
like a double artery, one tube being inclosed within the other. From an ex- 
amination of this and other pathological specimens, and from the fact, ascer- 
tained by experiment, that the middle coat of the aorta consists of layers less 
firmly connected together than the outer coat is with the surface of the mid- 
dle, Dr. Pennock was led to the conclusion, that, in dissecting aneurisms of 
considerable extent, the blood will be found not between the middle and exte- 
rior coats, but between the laminae of the middle coat. This explains the 
otherwise not readily explicable phenomenon, that the outer coat, usually so 
readily extensible, resists in these cases the force of the circulation, and con- 
fines the blood to the course of the artery. It is aided by the greater firm- 
ness and elasticity of one of the laminae of the middle coat. 
5. Some cases are on record of another variety of aneurism, in which the 
middle or fibrous coat is ruptured, while the inner one remains entire. The 
latter is forced by the blood through the opening in the former, and thus 
produces a sort of aneurismal hernia. Such cases are very rare; nor can the 
tumour ever attain a great magnitude without rupturing the inner coat, and 
thus being converted into the common aneurism of the third variety. In- 
stances have occurred of another kind of aneurismal hernia, in which the 
cellular coat has given way, and the inner and middle coats project. 
Effects of Aneurisms.-From all the varieties of aneurismal tumours the 
most serious consequences usually result. By pressure on the neighbouring 
organs, they materially derange their functions, and not unfrequently occa- 
sion organic changes of a dangerous and often fatal character. Not only does 
the organ immediately compressed suffer, but also distant parts and functions, 
which depend for their due condition upon the healthy state of that organ. 
As examples of these effects may be adduced, pressure upon the air-passages, 
producing dyspnoea; upon the oesophagus, dysphagia; Upon the heart, dis- 
placement of that organ and great disorder in its actions; upon the lungs, 
congestion, inflammation, pulmonary hemorrhage, and oppressed breathing; 
upon the arteries, obliteration of their cavities and consequent atrophy or 
gangrene in the dependent parts; upon the great venous trunks, venous con- 
gestion, oedema of the face and limbs, and, when the descending cava is com- 
pressed, congestion of the brain, and even apoplexy; upon the thoracic duct, 
general atrophy and oedema; and upon the nervous centres or the nerves 
themselves, the most excruciating pains, innumerable disorders of sensation, 
motion, and other functions, and sometimes paralysis. In the abdomen, the 
functions of the stomach, bowels, liver, and urinary apparatus, are in different 
cases very seriously interfered with. The bones affected are chiefly the ster- 
num, ribs, clavicle, vertebrae, and scapula. By absorption of the bony case 222 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
[part II. 
of the spinal marrow, and consequent irritation of this nervous structure, the 
most intense disturbance has been created in various functions depending for 
their healthfulness upon its integrity. Patients are not unfrequently de- 
stroyed by complicated sutfering, and various functional and organic derange- 
ment from these causes, before the tumour has opened. 
Another effect, which aggravates the symptoms greatly, is a hypertrophied 
state of the left ventricle of the heart, which is a frequent attendant upon 
internal aneurisms, especially those of the ascending aorta and arch, being 
induced probably by the incessant stimulus extended to that organ by the 
embarrassed condition of the circulation. 
When the patient escapes these dangers, he is exposed to the utmost hazard 
from the rupture of the sac into one of the internal cavities. This sometimes 
takes place at a comparatively early stage, before the aneurism has become so 
far developed as to call attention to its existence. The first intimation of the 
disease is occasionally that afforded by dissection. The sac may open into 
the trachea or bronchia, producing copious haemoptysis, or overwhelming the 
lungs ; into the oesophagus, giving rise to haematemesis; into other arteries, 
the veins, or even one of the cavities of the heart, causing great derangement 
of the circulation;* into the posterior mediastinum, and the pleural or pericar- 
dial cavities, fatally oppressing respiration and the action of the heart. In the 
abdomen, it sometimes opens into the peritoneal cavity, the stomach, intes- 
tines, and bladder. In most of these cases there is a twofold danger, that of 
suspension of one of the vital functions from the pressure of the effused blood, 
and that of exhaustion from its loss. 
Finally, should death result in neither of these modes, the tumour ulti- 
mately reaches the surface, and terminates life by external hemorrhage. The 
bleeding, whether internal or external, after the opening of the sac, is not 
always so copious as might have been anticipated. Sometimes it is restrained 
by the smallness of the cavity into which the blood escapes, sometimes by 
the narrowness of the opening, and adhesions formed around it, and some- 
times by the fibrinous depositions and coagula contained in the sac itself. 
The duration of the disease is very various. It may last only a few weeks or 
months, or may continue many years; and not unfrequently patients die of 
other diseases during the progress of this. 
Notwithstanding these numerous dangers from internal aneurism, it is not 
necessarily fatal. Cases of cure have been recorded; and the affection some- 
times terminates favourably without aid. Spontaneous cures take place in 
various modes. Sometimes the sac is completely filled by the deposited fibrin 
and coagula, and, being no longer distended by the blood entering it, gradu- 
ally contracts, undergoes absorption, and terminates at length in a small fleshy 
tumour attached to the artery; the caliber of the vessel being usually oblite- 
rated if small, but remaining pervious if large, especially in the aorta. It is 
said that, even in dilatation, layers of coagulated blood, concentrically ar- 
ranged, sometimes fill up the expansion, leaving a smooth canal in the middle, 
of the size of the arterial caliber. Another possible mode of termination, 
though in relation to internal aneurism, it must be very rare, is the oblitera- 
tion of the artery above the orifice of the sac, by the pressure of the tumour 
upon it. Finally, inflammation or gangrene may come on in the sac, attended 
with effusion of fibrin and coagulation of blood so as to obliterate the artery; 
and the patient may ultimately recover, provided the parts below the tumour 
can be sufficiently supplied with blood by the anastomosing vessels, and pro- 
* Cases are on record in which aneurisms have opened into the right ventricle and 
right auricle, and into the pulmonary artery. CLASS III.] 
ANEURISM. 
223 
vided also there be sufficient vigour of constitution to sustain the long and 
exhausting processes of inflammation, sloughing, suppuration, granulation, &c., 
through which the diseased parts must pass in their return to health. 
Causes.-A diseased condition of the arteries is probably essential to the 
production of aneurism. It is doubtful whether any amount of force which 
the heart is capable of exerting, or any degree of mechanical injury, could 
directly induce aneurism such as we have described it, in an artery previously 
in perfect health. The inner or middle coat, or both coats, may be ruptured ; 
but, if the vessel is quite sound, there is reason to believe that coagulable 
lymph will be thrown out, and the injury repaired. The true causes of 
aneurism, therefore, are such as induce a morbid state of the arteries; whether 
this consist in an altered condition of their proper tissue, or the deposition of 
new substances upon or within theii' coats, such as atheromatous, cartilagin- 
ous, calcareous, or tuberculous matter. These causes and their results have 
been already sufficiently considered under arteritis, and ossification of the 
arteries. Syphilis has been supposed to occasion a softness of the arteries, 
and ulceration of their inner coat, favourable to the production of aneurism. 
The same may probably be said, with even more truth, of habitual intemper- 
ance, at least so far as concerns its effect upon the cohesion of the vascular 
tissue. There appears to be some affinity between aneurism and cancer. The 
aneurismal diathesis is seldom overcome. When one tumour disappears, an- 
other is apt to form in the same or a distant artery. The aspect of the patient, 
moreover, is frequently analogous to that so commonly observed in cancerous 
disease. (Rokitansky, quoted by Hasse, Anat. Descript., p. 95.) 
When the arteries are thus diseased, even the ordinary force of the circula- 
tion may bring on aneurism; but whatever increases this force, whether habit- 
ual or accidental, will hasten the occurrence of the affection, and render its 
progress more rapid. Hence, hypertrophy of the heart, the use of stimulants, 
and all excessive excitement, whether mental or bodily, may rank among the 
exciting causes. Tight lacing may have the same effect by producing irregu- 
larity in the caliber of the vessels, and exposing certain parts to greater dis- 
tension than others. External violence, and especially such as occasions a 
sudden elongation of the artery, would be apt to rupture the coats already 
diseased, and thus bring on an immediate attack. Some of these causes act 
doubly, both as predisposing and exciting. Thus, a constant over-distension 
of the vessels by excessive action of the heart may induce, in the end, either 
through an exhaustion of their excitability, or the production of chronic 
arteritis, a state of their coats favourable to aneurism, while it may directly 
bring on the complaint after the predisposition has been established. The 
position of the artery is not without influence in relation to its liability to 
aneurism. Vessels near the heart, or most exposed from their shape to the 
force of the current of blood, or from their position to external violence, are 
most apt to be affected. Men are much more liable than women, because 
more exposed to violence, over-exertion, intemperance, and other causes. Mr. 
Crisp states that, upon a comparison of upwards of 500 cases, he found the pro- 
portion of females rather less than one-eighth. The disease is very rare in 
infancy. 
General Diagnosis.-When the disease has made its way externally, and 
appears in the form of a tumour upon the surface, it may generally be distin- 
guished without difficulty. The tumour is usually roundish, with a greater 
prominence at one point; is soft and compressible, returning to its original 
shape upon the removal of the pressure; and pulsates under the finger, and 
sometimes visibly to the eye. Pulsation, synchronous with the action of the 
heart, is the most characteristic symptom of aneurismal tumours. It is of a 224 
[part II. 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
somewhat peculiar quality, slow, expansive, and heaving, as if the whole 
tumour was enlarging under the hand. It may, moreover, be felt in all parts 
of the swelling. If the artery be compressed above the tumour, its bulk 
diminishes and the pulsation ceases ; if below, the force of the pulsation is 
increased. Sometimes, however, from thickness of the walls of the sac, or 
the great quantity of coagulated blood contained in it, there is little or no 
pulsation, and the tumour scarcely yields to pressure. The same is to a cer- 
tain extent the case when the blood has been effused into the cellular tissue. 
But, even in these cases, a careful examination will almost always detect pul- 
sation in some part of the swelling, at one time if not at another; and, if the 
fingers fail, recourse may be had to the stethoscope, which will reveal the 
pulsation, and frequently also render sensible a rasping or bellows sound in 
the tumour. Swellings which are not aneurismal sometimes pulsate in con- 
sequence of being situated over an artery, or connected with it, so as to be 
influenced by its movements. But, if they are solid, there can be little diffi- 
culty in distinguishing them. The pulsation is elevating instead of being 
expansive, and ceases if the tumour be separated from the artery by raising 
it. Nor will the tumour undergo any change by pressure on the artery be- 
tween it and the heart. Collections of liquid diffused around an artery might 
occasion more difficulty in the discrimination. In such cases, a just inference 
may generally be drawn from the circumstances attending the origin and pro- 
gress of the tumour. In relation to the signs of aneurisms, while still con- 
fined within the great cavities, I shall treat under the head of aneurisms of 
these cavities respectively. It is sufficient here to say that none of the gene- 
ral symptoms are absolutely conclusive, unless the tumour can be felt; and 
certainty can be attained only through the medium of the physical signs 
afforded by auscultation and percussion. 
Internal aneurisms occupy either the cavity of the cranium, that of the 
thorax, or that of the abdomen.* In relation to the first, little can be known 
of them during life, except conjecturally; and even for conjecture there is 
scarcely any plausible ground ; for all the symptoms which they produce much 
more frequently arise from other causes. Dissection has occasionally revealed 
aneurismal enlargements, or more strictly dilatations of the carotid, vertebral, 
and basilary arteries; and death, with apoplectic symptoms, has resulted from 
their rupture. Indeed, from the deficiency of the cellular coat, they are 
peculiarly liable to rupture when dilated. Headache, vertigo, and tinnitus 
aurium, are among the symptoms which precede the attack of apoplexy in 
which they terminate. Possibly, auscultation may yet succeed in penetrating 
these mysteries, and surgical aid may be brought to the rescue of the patient. 
Indeed, a case has been recorded by Dr. Whitney, of Newton, Massachusetts, 
in which a harsh bellows murmur was perceived by applying the ear to the 
cranium, and an aneurism of the basilar artery was found upon dissection after 
death. {Am. Journ. of Med. Soi., N. S., vi. 314.) Our attention here will 
be confined to the two other cavities. 
Thoracic Aneurisms. 
All the considerable arteries of the chest are liable to aneurismal disease in 
some ope of its forms. So long as it is confined within the bony walls of the 
cavity, the diagnosis is often exceedingly obscure, and sometimes, with all 
the aid that modern skill can bring to the investigation, more or less uncer- 
* As to the relative frequency of these aneurisms, Mr. Crisp states that, of 288 cases, 
175 were of the thoracic aorta, 2 of the pulmonary artery, 20 of the innominata, 23 of 
the subclavian, 59 of the abdominal aorta and its branches, 2 of the common iliac, and 
7 of the cerebral arteries. {Treat. on Struct., Dis., ^c. of Blood-vessels, p. 113.) 225 
CLASS III.] 
ANEURISM. 
tain. The general signs can scarcely ever be confidently relied on. They, 
nevertheless, assist materially towards the forming of a correct judgment, in 
connexion with those afforded by physical exploration. 
When the aneurism is not so large as injuriously to compress the neigh- 
bouring organs, it often escapes notice entirely, and, as before stated, may go 
on to fatal rupture without being suspected. Occasional dyspnoea, and vague 
feelings of pulsation or other irregular action in the chest, are insufficient to 
excite alarm. As it increases, however, and even almost from the commence- 
ment, in certain cases, it gives rise to various disorders of function, which, 
though perhaps few and slight at first, augment in number and degree, till 
they sometimes acquire a fearful intensity. The symptoms about to be enu- 
merated never all occur together in the same case. Some cases are attended 
with one set of them, others by another, according to the situation and size of 
the tumour. Among the most common is a feeling of tightness, fulness, or 
oppression of chest, resulting from the presence of a new body within a space 
already filled. Respiration is sometimes attended with a harsh, wheezing, 
hissing, or stridulous sound proceeding from the chest, while the voice is 
hoarse, croaking, or whispering, owing to pressure upon one or more of the 
larger bronchial tubes or the trachea, or to irritation or injury of the recur- 
rent nerve. It is sometimes so striking, and the difficulty of respiration so 
great, that practitioners have supposed the larynx to be diseased, and have 
even performed tracheotomy. The absence, however, of tenderness upon pres- 
sure in the larynx, of swelling in the vicinity, and of redness of the fauces, 
taken in' connexion with the mode of attack, and the simultaneous and ante- 
cedent pectoral symptoms, will enable a just conclusion to be formed on this 
point. The breathing is often hurried and laborious, and sometimes attended 
with paroxysms of dyspnoea like those of spasmodic asthma. Cough in various 
degrees is very common, sometimes troublesome and even violent and convul- 
sive, with haemoptysis, or bloody expectoration. In consequence of pressure 
upon the bronchia, there is occasionally feebleness of respiration in one lung; 
and this is considered by Dr. Stokes, when not explicable by the presence of 
a foreign body in the air passages, or other discoverable pectoral disease, as a 
sign of great importance. It may result from a small tumour insufficient to 
cause pulsation, dulness, or stridor in breathing. The above symptoms, with 
various others, as palpitations, disposition to syncope, pallid, livid, or purplish 
complexion, oedema of the face and limbs, swelling at the lower part of the 
neck, dropsy of the serous cavities, oppression of the brain, a varicose or dis- 
tended state of the external veins of the chest, &c., arise partly from pulmo- 
nary congestion or inflammation excited by the tumour, partly from its pres- 
sure upon the venous or lymphatic trunks, but still more from disease of the 
heart, so frequent an attendant upon aneurism, and often one of its conse- 
quences. Congestion of the liver and whole portal circle, and of the brain 
amounting even to apoplexy, has resulted from compression of the ascending 
and descending vena cava. Another occasional symptom is greater or less 
difficulty in swallowing, and in the eructation of gases, resulting from com- 
pression of the oesophagus, which, without care, may lead to the notion of the 
existence of stricture in this tube, and the consequent use of the bougie or 
probang. 1 have had a case in which excessive dyspnoea was induced by every 
attempt to swallow food, owing, as was proved upon dissection, to an aneuris- 
mal tumour pressing immediately on the trachea in front of the oesophagus. 
Pains of various degrees and character are often felt in the chest, sometimes 
vague and dull, sometimes acute, lancinating, and exceedingly severe, shoot- 
ing, in different directions, from the middle of the cavity or from the back 
towards the diaphragm, neck, shoulder, and arms, especially the left arm, 226 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
[part II. 
which is not unfrequently affected with formication, and partial loss of sensa- 
tion and motion. The pressure of the tumour upon the spinal column, and 
the brachial plexus, is sufficient to account for these symptoms. Deep-seated 
and excruciating pains, of a boring character, are said to attend the wearing 
action of aneurisms upon the spine. 
The pulse is frequently much deranged. When the aneurism intervenes 
between the heart and the arteries of the arm, the vibratory motion received 
by the blood in its passage must be extended more or less to the artery at the 
wrist. Hence the thrill so often observable in the pulse in aneurisms of the 
chest. The pulse at the wrist is often different on the different sides, and is 
sometimes quite wanting in one arm, in consequence of compression or ob- 
struction of the innominata or left subclavian. From a degree of the same 
cause, the pulsation at one wrist has been observed, in some cases, to be con- 
siderably later than that of the heart. Dr. Billing has indicated a resilience 
of the pulse, depending on that of the aneurismal tumour, after each beat of 
the heart, as a means of detecting aneurism in its early stages; and Dr. Joy 
has suggested that the simultaneous presence of this character in the pulse of 
the upper and lower extremities, or its presence in the latter and absence in 
the former, might be an index of the position of the affection, in the one in- 
stance, near the origin or at the arch of the aorta, and in the other, at some 
point in the vessel below the origin of the left subclavian. (Tweedie's Syst. 
of Pract. Med.} Numerous other irregularities of the pulse frequently ac- 
company aneurisms, but they depend more commonly on the coexisting disease 
of the heart, than on the arterial affection. 
The attitude of the patient will assist in the diagnosis. In consequence of 
the necessity of alleviating by position, as much as possible, the pressure of 
the tumour upon the air-passages, he generally prefers some one posture, to 
which, though he may frequently change it from restlessness, he is always 
disposed to return. This is different in different cases. The most common 
attitude is that of sitting, with the head bent forward, or to one side. Some 
find greater ease on one side than the other, and some even incline the body 
backward. The necessity of giving free scope for expansion of the chest, in 
consequence of effusion or other source of embarrassment to the respiration, 
is probably even a more cogent reason for the erect position. 
Dulness on percussion over certain parts of the chest, especially the middle 
and upper, often exists in cases of thoracic aneurism, though, according to Dr. 
Hope, not unless the tumour is larger than an egg. Sometimes the outline of 
the tumour may be pretty accurately defined in this way. 
If the hand be applied over the middle or upper part of the sternum, a 
vibratory thrill may sometimes be felt, similar to the motion of a purring 
cat; and the same sensation is produced above the clavicles. This purring 
tremor, as it is called, sometimes results from mucus in the bronchia; but, 
in this case, may be readily distinguished by ceasing when the patient holds 
his breath. It is more observable, according to Dr. Hope, in simple dilatation 
than in sacculated aneurism; and is ascribed by him to the asperities of the 
inner surface so common in the former affection. 
But none of the foregoing phenomena is so characteristic as pulsation, dis- 
tinct from that of the heart, and felt beneath the ribs or sternum at the upper 
part of the chest, or above the sternum and clavicles. In order that it may 
be sensible in the latter position, it may be necessary to press the fingers down 
as deeply as possible, with the- head of the patient bent forward. By pressing 
with the palm of one hand anteriorly on the chest, and with that of the other 
posteriorly, and by making the examination at the end of a full expiration, the 
impulse may sometimes be felt, when it would otherwise escape notice. (Stokes.} CLASS III.] 
ANEURISM. 
227 
In thoracic aneurisms the impulse is usually double, a fact which is, I think, 
best explained by Dr. R. D. Lyons, of Meath. That this result should take 
place, it is necessary, according to Dr. Lyons, that the aneurism should be 
sacculated. The wave of blood sent forth by the systole of the heart pro- 
duces the first pulsation; the elastic contraction of the aorta which follows, and 
which is not participated in by the sac, produces the second. (Dublin Quar- 
terly Journ. of Med. Sci., ix. 344.) A throbbing of the aorta from mere 
functional disturbance, as from the irritation of gout, may be mistaken for a 
time for the aneurismal impulse; but its subsidence and ultimate disappear- 
ance under treatment would correct the error. 
Evidences of Auscultation.-The stethoscope renders the pulsation more 
sensible to the ear, and at the same time reveals a peculiar sound in the aneu- 
rismal tumour. This, as described by Dr. Hope, is a deep, hoarse, bellows 
murmur, more or less rasping or grating, of short duration, and tvith an abrupt 
commencement and termination; but the fact is, that it varies greatly in dif- 
ferent cases, being sometimes closely similar to the first sound of the heart, 
sometimes very feeble, and not unfrequently wanting. When this sound is per- 
ceived at a distance from the heart, it affords presumptive evidence of the exist- 
ence of an aneurism. But the diagnosis is still not without its difficulties. The 
sounds of a diseased heart, and, in some thoracic affections, those of the heart 
in a healthy state, are often to be heard over a considerable extent of the chest, 
and might be mistaken for the sounds of an aneurism. The difficulty is less 
when the aneurismal sound is single; but not unfrequently, these tumours, 
especially the thoracic, imitate the heart by offering a double sound, which 
tends to confuse the diagnosis. Dr. Hope, however, has suggested considera- 
tions which diminish, if they do not remove the difficulty. The aneurismal 
murmur is generally different from the first normal sound of the heart with 
which it is synchronous, and even from the murmurs produced by valvular 
disease of that organ. These are usually not so loud as the aneurismal sound, 
are less hollow and more prolonged, and have a gradual rise and fall, instead 
of the abruptness of the latter. The depth and hollowness of the aneurismal 
murmur are usually greater above the clavicles than below. If the sound be 
traced in a direction from its origin towards the apex of the heart, it is found 
gradually to diminish, and, at the distance of an inch from the apex, either to 
have ceased entirely, or to be feeble and remote; while the sound of the heart 
is loudest at that point, and diminishes as you recede from it. This remark 
is true both of the healthy sound of the heart, and of the morbid sound or 
murmur proceeding from regurgitation through the auricular valves. In 
relation to the murmur arising from obstruction at the semilunar valves, 
there is greater difficulty. This murmur is propagated two inches or more 
along the aorta or pulmonary artery, as the case may be; but it has been 
shown that, if louder and on a higher key, at this distance from the origin of 
the vessel, than opposite to the semilunar valves, the sound is owing to dila- 
tation, aneurism, or roughness in the inner surface of the vessel; and if, sup- 
posing a tumour to exist at the side of the sternum, the murmur should be 
loud and distinct on the outer or humeral side of the tumour, the inference 
is justifiable that it is aneurismal; for the semilunar murmur is very feeble 
or quite inaudible at so great a distance from the course of the artery. When 
the first sound of the aneurism can thus be distinguished from that of the 
heart, the absence or presence of the second is of little importance. 
The first aneurismal sound is ascribable to the friction of the blood, trans- 
mitted from the heart, against the orifice and sides of the sac. There has 
been considerable difference of opinion in relation to the cause of the second 
sound. Sometimes it has been thought to be a murmur from the semilunar 228 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
[part JI. 
valves propagated along the column of blood in the artery, in which case it 
could be traced back with a progressive increase of intensity to its origin. In 
other instances, it has been ascribed to a regurgitation of blood from the 
aneurismal tumour during the diastole of the ventricle. In this case, it would 
be distinguishable from the valvular murmur by its brevity, and by not being 
audible down the course of the ventricles; and would add to.the evidence of 
the existence of an aneurism. Dr. Bellingham ascribes it to the regurgita- 
tion into the aneurism of the blood from the aorta and great vessels putting 
off from it. There can be no doubt that it proceeds from the same movement 
which produces the second impulse; and, consequently, Dr. Lyons' explana- 
tion is that which seems to the author most satisfactory; namely, that the 
two sounds are owing, the first to the systole of the heart, the second to the 
contraction of the aorta following its expansion, each movement driving blood 
into the sac. • 
The aneurismal sound, though when distinct it has generally somewhat of 
the character above assigned it, is sometimes softer and sometimes harsher, and 
varies also in its pitch. In old aneurisms, with thick walls, and filled with 
fibrinous deposit, the sound is remote and dull.* 
Both the aneurismal murmur and the purring tremor are said to be 
stronger, when the blood-vessels are imperfectly filled, than when in their 
healthy state in this respect. Hence they should be more observable in 
anaemia, and aortic regurgitation. 
Aneurisms of the Aorta.-1The aorta is by far the most frequent seat of 
thoracic aneurism, and the part of this vessel oftenest affected is the arch, and 
the upper portion generally. Near the origin of the vessel, wThere it is covered 
with the pericardium, the disease is very rare. The investing membrane is 
too firm to be distended under the pressure of the blood, and, if the two inner 
membranes are ruptured, instead of dilating, it usually bursts, and the blood 
is poured into the cavity of the pericardium. A very few cases of sacculated 
aneurisms have been observed in this part of the artery. They are said to 
have a tendency to expand towards the heart, and the sac has been observed, 
in some instances, to be actually embedded in its parietes. 
When the disease occupies the ascending portion, or the arch, pulsation is 
felt above the sternal ends of the clavicle, on both sides simultaneously. If 
the ascending portion is affected, though felt on both sides, the pulsation is 
stronger on the right. If the disease be a simple dilatation, affecting the 
whole circumference, the pulsation is not felt upon the sternum or ribs, un- 
less the distension be very great. The purring tremor is sensible above the 
clavicles and not below. A hoarse aneurismal murmur synchronous with the 
pulse is also perceived above the clavicles. It is said to be louder than in 
sacculated aneurism. If the dilatation affects the ascending portion, the 
* Some interesting observations have been made by Dr. Bellingham in relation to the 
sounds of aneurism of the arch of the aorta, for an abstract of which the reader is re- 
ferred to the Am. Journ. of Med. Sei., N. S., xvi. 442. The more important inferences 
of Dr. Bellingham are, that aneurisms of the arch of the aorta are characterized by a 
double sound, which closely resembles the double sound of the heart; that either of 
these sounds or both may be replaced by a murmur, which may be either blowing, 
sawing, or filing in character, according to the condition of the surface in contact with 
which the blood flows ; and that the first sound is thus much more frequently super- 
seded than the second, because of the greater force with which the blood is transmitted. 
All the sounds arise from friction of the blood against the orifice or walls of the sac, 
and the murmurs differ from the proper aneurismal sounds only from the roughness of 
the surface increasing the friction. It certainly seems to have been shown that Dr. 
Hope attaches too much importance, so far as aneurisms of the arch of the aorta are 
concerned, to the peculiar character of the murmur. CLASS III.] 
229 
ANEURISM. 
sound is louder above the right than the left clavicle, is perceptible along the 
course of the vessel up the sternum, is of a superficial and hissing or whizzing 
character, and is usually distinctly audible in the back. Dr. Pennock says 
that percussion yields a dull sound to a greater extent than in health, along 
the margin and over the upper third of the sternum, provided emphysema of 
the lungs does not exist in the vicinity. (Am. ed. of Hope on Dis. of the 
Heart, p. 426.) General dilatation is usually distinguishable, according to 
Dr. Lyons, from the sacculated forms of aneurism by the absence of the 
double murmur. 
Anmmia is sometimes attended with pulsation and a bellows murmur 
above the clavicle; but the impulse is feebler, and the murmur much slighter 
than in dilatation, and the purring tremor is feeble or wanting. The absence 
of dulness on percussion in pure anaemia, and the existence of the venous 
musical murmur would be further diagnostic signs. Aortic regurgitation, 
according to Dr. Hope, is often also attended with similar phenomena above 
the clavicles; but the impulse is more jerking and the sound not so hoarse as 
in dilatation; and, besides, there are signs by which this derangement may 
be discovered if attention be directed to the heart. 
In sacculated aneurism of the upper portion of the aorta, pulsation is felt 
on both sides above the clavicle, and generally in a still greater degree below. 
If the disease is seated in the ascending portion, the pulsation is strongest on 
the right side; if in the beginning or middle of the arch, it is strongest above 
and below the right clavicle and about the top of the sternum, with some 
tumefaction in the same neighbourhood; if at the commencement of the 
descent, both the pulsation and tumefaction are most observable upon the 
left, and sometimes extend even to the shoulder. In every case, the pulsa- 
tion will be found to be stronger over the aneurismal tumour than at a point 
between it and the heart. Sometimes it is so strong as to produce a perceptible 
heaving of the walls of the chest. The sound upon auscultation is of the same 
general character as in dilatation, but usually weaker and less rasping. In 
old aneurisms filled with coagula, the sound is dull and remote, and some- 
times loudest on the side of the neck opposite to that on which the tumour 
is situated. The sound may also be heard in the back. The purring tremor 
above the clavicles is weaker than in dilatation, and in old aneurisms is often 
wanting. Deficiency in the respiratory murmur, and in resonance upon per- 
cussion, is present in proportion to the magnitude of the tumour. When the 
aneurism is seated in the descending portion of the aorta, the pulsation is not 
felt in front, but along the spine, especially on the left side, where the aneu- 
rismal murmur is also to be heard, and more loudly than upon the anterior 
part of the chest. If a sound can be detected along the spine, more abrupt 
and rasping than that of the heart in front, it is almost a certain proof of the 
existence of an aneurism. Occasionally, however, both the pulsation and 
sound in the back are wanting; and the diagnosis becomes very difficult. In 
this case, if the tumour be seated behind the heart, it is said by Dr. Hope to 
occasion in that organ a double impulse corresponding with the diastole and 
the systole, and described as of a jogging character, which results from two 
other causes only, adhesion of the pericardium, and displacement of the heart 
to the front of the spine. It is only, however, the existence of a tumour that 
is thus indicated, and upon other grounds must be based the decision as to its 
aneurismal character. In relation to sacculated aneurisms of the aorta, it 
must be borne in mind that various tumours occasionally exist in the chest, 
to which pulsation is imparted by the vicinity of the great vessels. But, in 
these cases, the aneurismal sound is not perceived, or only in a slight degree, 
and no pulsation or thrill is to be felt above the clavicle. When the heart 230 
[part II. 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
is pressed out of its proper position by collections of pus or serum in the 
pleural cavities, the existence of pulsation in an unusual spot may lead to the 
suspicion of aneurism. But if, under these circumstances, the pulsation of 
the heart should be found wanting in the normal position, the difficulty is at 
once solved. 
Aneurisms of the innominata, subclavian, and root of the carotid, when 
very large, are sometimes scarcely to be distinguished from those of the aorta. 
In relation, however, to the two latter arteries, there is a ground of diagnosis 
in the fact, that the pulsation, aneurismal murmur, and tremor above the 
clavicle, are usually confined to the affected side, and.are more superficial and 
distinct than in aneurisms of the arch of the aorta. Dr. Hope compares the 
murmur of a subclavian or carotid aneurism to the sound of a small hand- 
bellows, while that of an aneurism of the aorta bears a greater resemblance 
to the blast of a forge-bellows.* 
Dilatation of the pulmonary artery is characterized, according to Dr. Hope, 
by pulsation and tremor between the cartilages of the second and third ribs 
of the left side, perceptible in a decreasing degree downwards, but wholly 
wanting above the clavicle; by a slight prominence between these ribs; and 
by a very loud, superficial, harsh, sawing sound above the clavicles, and over 
the whole precordial region, but loudest upon the prominence between the 
two ribs mentioned. 
When aneurisms make their way out of the thoracic cavity so as to form 
tumours upon the surface of the body, they appear in positions correspond- 
ing in some measure with the portion of the artery from which they proceed. 
Those of the ascending portion and bend of the aorta, appear usually upon 
the right side of the chest and in front; those of the descending portion, upon 
the left side and behind. When the tumour appears on the right, at the 
level of the fifth and sixth ribs, it may be assumed to spring from near the 
origin of the aorta; when at the level of the third and fourth ribs, from the 
anterior part of the arch; when at the root of the neck behind the sternum, 
from the uppermost part of the arch. (Chomel et Dalmas, Diet, de Med.) 
Abdominal Aneurisms. 
Not only the aorta, but all the other considerable arteries of the abdomen 
are liable to aneurism. These tumours have been found, for example, in the 
coeliac, hepatic, splenic, superior mesenteric, spermatic, and iliac arteries. 
The general signs of abdominal aneurisms, like those of the chest, are such as 
arise from disturbance of function and organization in the parts pressed upon 
* Dr. T. S. Holland, of Cork, Ireland, gives the following as the diagnostic signs of 
aneurism of the innominata, compared with aneurism of the transverse part of the arch 
of the aorta, with which it may most easily be confounded. They were derived from 
an analysis of twenty-four cases of the former affection. In aneurism of the innomi- 
nata, external tumour is more frequent, earlier, and situated above the inner third of 
the right clavicle, while in that of the transverse arch it is to the left of the sternum or 
behind it. In the former, the arteries of the right arm and right side of the neck pul- 
sate more feebly than those of the left; in the latter, the case is reversed. The various 
affections of the voice, breathing, cough, and deglutition, so common in the aortic aneu- 
rism, are comparatively rare in that of the innominata. In the latter, pain, oedema, 
and venous enlargement begin on the right side of the arm and head ; in the former, 
on the left. Partial paralysis of the right arm, and dislocation of the clavicle, trachea 
or larynx, are frequent in the innominatal, and rare in the aortic affection. Alteration 
in the intensity of the respiratory murmur, so common in the latter, is rare in the 
former. Murmurs in the right carotid and subclavian attend on the aneurism of the 
innominata, the pulsations of which are checked by pressure on those arteries; neither 
of which facts is true of that of the transverse arch. (Dub. Quart. Journ. of Med. Sci., 
xiii. 296.) CLASS III.] 
ANEURISM. 
231 
by the tumour. But, as the parietes of the abdomen are more distensible 
than those of the thorax, the organs have a greater opportunity of retiring 
before the pressure, and therefore suffer less, or at least suffer longer without 
fatal results. Abdominal aneurisms produce disorder .of the stomach and 
bowels, in the form of dyspepsia, vomiting, colic, constipation, flatulence, &c.; 
of the liver, in that of jaundice, and hepatitis; of the kidneys and bladder, in 
that of nephritic irritation and inflammation. By pressure upon the nerves 
which so abundantly surround them, and on the spine in which they occasion 
caries or absorption, they sometimes give rise to a great diversity of deranged 
sensation and perverted function, and to the most acute abdominal and lum- 
bar pains, which occasionally .shoot downward into the testicle and lower ex- 
tremities. These also sometimes suffer from spasm, and, with the bladder, 
are in various degrees paralyzed, in consequence of injury to the spinal mar- 
row. The abdominal derangements from aneurisms are generally attended 
with less disturbance of circulation, less defect of appetite and nutrition, and 
less general loss of health, than would be expected from an equal amount of 
suffering and disordered function, proceeding from original disease of the vis- 
cera. But none of them can be considered as characteristic symptoms of 
aneurism. These must be looked for in the physical signs. 
Perhaps the most distinctive sign of abdominal aortic aneurism is a strong 
expansive pulsation, much stronger under the stethoscope than the hand, 
felt over the. surface of a fixed and compressible tumour, the outline of 
which may be traced, by means of the instrument pressed down upon it, ex- 
tending beyond the line of the aorta. The pulsation is almost always single, 
though instances have been observed in which it was double. It is constant, 
and is felt as strongly laterally, or nearly so, as in the forward direction. 
If the tumour is very large, dulness on percussion will be obvious; and 
a brief, abrupt bellows sound, less loud and hoarse than that of thoracic 
aneurism, may often be heard over the course of the artery, in the front of 
the abdomen, and sometimes in the back. It is more perceptible below than 
above the tumour, because propagated downward by the course of the blood. 
It is sometimes wanting. To render it perceptible, when not so under ordi- 
nary circumstances, it has been recommended to examine the patient in the 
recumbent posture, with the abdomen elevated above the chest, so as to 
diminish the pressure of the blood in the abdominal vessels, and thus favour 
its entrance into and exit from the sac. Sometimes a small artery runs over 
the sac, and, if pressed on by the stethoscope, yields a murmur which might 
be mistaken for the aneurismal. It may, however, be easily distinguished 
by being more superficial, more hissing, confined to one spot, and entirely 
removable by pressing with the instrument so as to close the artery. Besides 
the above signs, another is afforded in the vibratory thrill which may some- 
times be felt by pressing the hand firmly down over the surface of the 
tumour, and upon the vessel below. 
In some instances, the tumour is restrained by the crura of the diaphragm, 
or by viscera beneath which it may lie, and which may have contracted ad- 
hesions so as to render them immovable. In such cases, it cannot be felt by 
the hand, and might yield no impulse. But, should general signs lead to 
the suspicion of its existence, it is possible that this evidence might be con- 
firmed by the stethoscope applied along the spine. In cases of uncertainty 
in relation to the existence of a tumour, it has been suggested that, by 
placing one hand in front of the abdomen and the other on the back, and 
making pretty firm pressure, a tolerably correct inference might be drawn 
from the apparent thickness of the intervening space. 
Tumours of various kinds existing in the abdomen, and receiving an im- 232 
LOCAL DISEASES. -CIRCULATORY SYSTEM. 
[part II. 
pulse from some neighbouring artery, might sometimes without care be mis- 
taken for aneurism. But the impulse is more feeble and less expansive, and 
is sometimes scarcely perceptible when the stethoscope is applied laterally, as 
may be done most conveniently by placing the patient on his side. If the 
tumour is displaced either laterally or anteriorly, the impulse will cease. 
The anterior displacement may be aided by causing the patient to support 
himself on his knees and elbows. Should the tumour, when removed from 
its position, still pulsate, the inference would be that it was an aneurism of 
one of the smaller arteries. The absence of aneurismal character might be 
inferred, if it were hard and quite incompressible. Such tumours by pressure 
upon an artery may occasion a bellows murmur; but it is much less percepti- 
ble than in aneurisms, and, if the tumour is displaced, or if the stethoscope is 
applied laterally, ceases with the impulse. Anemic pulsations of the aorta, 
as they are attended with the murmur, and are frequently associated with 
compressible tumours arising from air confined in some portion of the bowels, 
may occasion embarrassment in the diagnosis; and, should solid tumours co- 
exist, they would receive a more than ordinary impulse from this cause. But 
attention to the condition of the system, and the existence of the anemic 
murmur elsewhere, would, independently of the different character of the 
sound, generally lead to a correct conclusion. The occasional removal and 
recurrence of the tumour if dependent on flatulence, would satisfactorily dis- 
prove its aneurismal character. If the stethoscope be pressed, along the course 
of the artery, firmly upon the vessel, it will indicate an equable diameter in 
different parts of it, showing that no part was expanded. The pulsation in- 
stead of being gradual, expansive, or heaving, as in aneurism, is quick and 
jerking though sufficiently vigorous. In cases of abdominal tumours gene- 
rally, the administration of brisk purgatives will sometimes settle the question 
by removing the source of difficulty, as in cases of impacted feces, concretions, 
flatulent collections, and masses of worms. 
Sometimes the aneurism opens into the cellular tissue without the perito- 
neum, and pulsating tumours form in various positions, which may continue 
for a considerable time before the fatal termination. Such tumours appear 
in the iliac, hypochondriac, and lumbar regions. In other instances, the 
aneurism gradually makes its way in the ordinary manner to the surface, re- 
moving everything that opposes it, and, when presenting posteriorly, causing 
a partial destruction of the ribs and vertebrae. It sometimes attains an 
enormous size before bursting. An aneurismal sac has been known to originate 
near the upper boundary of the abdomen, and, after filling almost the whole 
cavity, to show itself beneath Poupart's ligament in the groin. 
Aneurisms of the smallei' abdominal arteries cannot always be accurately 
distinguished from those of the aorta. Inferences must be drawn from their 
position. When the tumour is readily movable, it may without hesitation be 
referred to one of the smaller vessels. Aneurisms of the primitive iliacs, in 
their early progress, must be judged of by the same rules which guide the 
practitioner in forming his opinion of those of the great arterial trunk. They 
often in the end make their appearance externally in the iliac fossa or the 
groin, and it is not always easy to distinguish them from those of the exter- 
nal iliacs. This, however, is a problem for the surgeon. 
Treatment. 
Though internal aneurisms are in the end generally fatal, yet much may 
be done to palliate their harassing symptoms, and to prolong life; and, when 
the tumour is of that kind in which coagula form, hopes may even be in- 
dulged of effecting cures. It is very certain that spontaneous cures have CLASS III.] 
233 
ANEURISM. 
taken place; and there is reason to believe, from the reports of practitioners, 
that the efforts of nature have in some instances been materially aided by the 
resources of art. It must be always borne in mind by the practitioner, that 
the method of cure employed by nature is generally to fill the sac with fibrinous 
deposits or coagula of blood, and his efforts should be directed to assist in this 
process. 
Two indications are obvious-one to lessen the distending force, and the 
other to sustain or increase the coagulability of the blood. A third may be 
added; that, namely, of producing contraction in the parietes of the sac. 
These should be constantly borne in mind in the treatment. 
To meet the first indication, those measures at once suggest themselves 
which are calculated to reduce the heart's action, and lessen the volume of 
the blood ; and of these venesection would seem to be the most efficient. 
Hence, this remedy has long enjoyed great reputation in the treatment of 
aneurism, especially in connexion with a very low diet and perfect rest. This 
was the method of cure employed by Valsalva and Albertini, which has 
given celebrity to their names. By copious and repeated bleeding, and a 
rigid system of abstinence and of rest, these physicians and their followers 
kept their patients, for months, at the lowest point of reduction compatible 
with life; and are said to have had considerable success. But subsequent ex- 
perience has not confirmed the first favourable reports as to the efficacy of this 
plan; and the probability is, that, from the uncertain means of diagnosis at 
that time employed, cases were occasionally mistaken for aneurism which were 
of a different nature. Nor would the views at present prevalent, relative to 
the influence of venesection upon the blood, lead us to expect anything else 
than failure from a plan of reduction so excessive. In the first place, inordi- 
nate depletion does not always produce a reduction of the heart's action. On 
the contrary, by inducing a state of anaemia, it frequently occasions an irrita- 
ble condition of the circulation, in which the pulse becomes frequent and jerk- 
ing, and the heart beats tumultuously; a condition anything but favourable 
to the cure of aneurisms. (See Anaemia.') In the second place, it impairs 
the coagulability of the blood, and thus deprives nature of the very instru- 
ment upon which she relies for the repair of the injury. Thirdly, it tends to 
increase that depressed condition of the vital forces, upon which the organic 
disease of the vessels, so often the first step in the formation of aneurism, 
probably, at least in some measure, depends. Besides, in a feeble constitu- 
tion, especially when disease of the heart is associated with the aneurism, it 
would favour the tendency to dropsical effusion, and would greatly increase 
the danger, already considerable, of fatal syncope. Nor will patients gene- 
rally submit to SQi rigid a system of self-denial so long continued ; and, if 
attempted, it can seldom be carried thoroughly into effect. The blood may 
be taken, and the strength thus reduced to the lowest standard; but who is 
to prevent some unusual and forbidden movement of the patient, which, in his 
state of exhaustion, might prove of serious injury, if not fatal, by calling the 
heart into a degree of action beyond its power? But, notwithstanding these 
dangers of excessive depletion, the indication for a diminution of the quantity 
of the blood and the force of its motion still remains; and the question is how 
it may be best answered. The reply must depend on the condition of the 
system. If the patient is plethoric, with a strong, full pulse, and apparently 
rich blood, he should lose a sufficient quantity to reduce and keep down the 
excess. If the aneurism be complicated, as it not unfrequently is, with some 
thoracic or ventral inflammation, the indication for bleeding is strengthened. 
Perhaps it would be proper to keep the action of the heart a little below par. 
Prom twelve to twenty ounces may be taken at once, and afterwards a smaller 234 
[part II. 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
quantity, say from six to eight ounces, at intervals of some weeks, or when- 
ever the system may exhibit evidences of a return to the original excess. But 
if the paleness of lips, and irritable state of the circulation, characteristic of 
the anemic condition, should begin to make their appearance, the plan of de- 
pletion should be at once abandoned; and great caution should be exercised 
not to confound this condition with one of real vital exaltation. Individuals 
show a marked constitutional difference in this respect, some being disposed 
to plethora and others to anaemia. This difference should be attended to, and 
allowed to influence the course of treatment. 
The lancet may with great propriety be aided by the use of purgative 
medicines; and these may be resorted to in cases in which that remedy might 
be improper. The saline cathartics are generally to be preferred; and jalap 
and cream of tartar form an excellent combination. The saline cathartics 
are peculiarly useful by diminishing the bulk of the circulating fluid, with- 
out depriving it in an equal degree of its coagulability, and, at the same 
time, by their tendency directly to diminish the action of the heart. Another 
advantage is the removal of the serous effusion, so frequently attendant upon 
the disease, and which, if in the chest, very greatly increases the distress of 
the patient. The cathartic may be repeated twice or three times a week, 
and even more frequently in some cases. A very good plan, when there 
are dropsical symptoms, is to give from half an ounce to two ounces of 
bitartrate of potassa, in divided doses, diffused in water, every day, and con- 
tinue the medicine until it shall produce dyspeptic symptoms, when it may be 
omitted, to be resumed after their disappearance. The diuretic action of this 
salt is of great advantage. 
In decidedly anemic cases, a wholly different plan of treatment must be 
adopted. In these, the excessive action of the heart is sustained by the im- 
poverished condition of the blood. To quiet the circulation it is necessary 
to enrich that fluid, and in doing so we meet also the second indication above 
referred to, that, namely, of rendering the blood more coagulable. Instead 
of the lancet and active purgation, we must now resort to mild tonics; and 
of these the preparations of iron are beyond all others applicable to the case. 
The pill of carbonate of iron, combined with a little rhubarb or aloes, if a 
laxative effect is required, and continued for a considerable time, will be found 
perhaps the most efficient remedy. The infusion of wild-cherry bark is also 
admirably calculated to meet the indication, by its tonic influence over the 
digestive function, and its sedative action on the heart. 
In either of the above cases, digitalis may be employed as an adjuvant. It 
should be given in moderate quantities, long continued, with occasional inter- 
missions, however, to prevent the effects of accumulation. It proves useful 
by repressing the action of the heart, without impairing the coagulability of 
the blood; and, by its diuretic action, lessens the quantity of watery fluid in 
the circulation, and promotes the absorption of any that may have been effused. 
Hydrocyanic acid may also be used in reference to its sedative influence, but 
caution is required in its management. It is worthy of consideration whether 
ergot would not prove advantageous. Its application to this disease is sug- 
gested by its admitted power in restraining hemorrhage, and by its occasional 
extraordinarily sedative action upon the pulse. To do good it must be con- 
tinued long. Danger might be apprehended from its known tendency, in 
large quantities, to occasion mortification of the extremities. I have, however, 
never seen or heard of such a case, occurring in consequence of the employ- 
ment of ergot in medicinal doses; and cannot but think that, with moderate 
caution in watching its effects, any danger of the kind may be avoided. 
Acetate of lead has been considerably used as a remedy in aneurism, and CLASS III.] 
235 
ARTERIAL PALPITATION. 
very favourable accounts of its action have been published. I have employed 
it with apparent benefit; but have never seen a complete recovery under its 
use. To be effectual it must be given so as to affect the system, and after- 
wards persevered in for a long time. In this case it is apt to produce colic, 
with nausea or vomiting, which proves so disagreeable to the patient, that he 
is sometimes with difficulty induced to resume the remedy after the subsidence 
of the symptoms. A grain may be given three or four times a day, and con- 
tinued until it induces some disturbance of the primae viae, when it should be 
suspended for a time, and afterwards resumed. It is better calculated than 
any other internal remedy to meet the third indication in the treatment of 
aneurism, that of contracting the parietes of the sac. With the same view, 
alum has been employed in aortic aneurism. 
If thoracic or abdominal inflammation attend the aneurism, or if the sac 
itself is inflamed and painful, it may be proper to detract blood locally by 
cups or leeches, and afterwards to apply blisters or other revulsives. But if 
the tumour should be near the surface, these remedies should not be applied 
immediately over it, for fear of causing the skin to slough. Calomel and 
squill will sometimes prove useful, especially when there is effusion in the 
chest. 
It will often be necessary, in the course of the treatment, to employ nar- 
cotics or antispasmodics to relieve pain, and quiet nervous disturbance. Opium, 
hyoscyamus, camphor, assafetida, &c., may be resorted to. 
Local applications may be made over the tumour with the hope of aiding 
in its reduction. Cold water and ice have been recommended ; but they can- 
not be long steadily persevered in. Perhaps some good might result from 
cold astringent poultices, made, for example, with decoction of oak bark or 
infusion of galls. Dr. Hope recommends a belladonna plaster, when the 
tumour is painful or requires support. 
The diet should conform to the circumstances of the case. It should 
always contain materials capable of furnishing fibrin to the blood. Bread, 
fruits, and vegetables, with milk, and a small quantity of boiled meat, would 
be applicable to ordinary cases. In those of an anemic character, meat may 
be more freely employed. Boiled are preferable to roasted meats, as less 
stimulating, while they contain an equal amount of fibrin. Broths are ob- 
jectionable, as they contain the most stimulating and least nutritious portions 
of meat, while they tend to increase the bulk of the blood. As little drink 
should be allowed as is compatible with the comfort of the patient. 
In relation to exercise, the patient should be kept for the most part at rest, 
and should most cautiously avoid all hasty movements, and all kinds of ex- 
ertion. Passive exercise in an easy carriage may prove useful by sustaining 
the digestion, and the general processes of secretion and nutrition, in a health- 
ful state. The utmost care should be taken to preserve mental equanimity; 
as few things have a more powerful influence in calling the heart into undue 
and dangerous action than strong moral excitement. 
Article IV. 
ARTERIAL PALPITATION. 
This name is given to an increased pulsation or throbbing in the arteries, 
which can be felt by the individual affected. It bears the same relation to 
the ordinary state of these vessels that palpitation of the heart does to the 
healthy action of that organ. It may occur in any of the larger arteries, but 236 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
[part II. 
is most frequent in the aorta, especially in that portion of it which lies behind 
the epigastrium. It is only in the abdominal aorta that it has attracted par- 
ticular attention, or requires special notice here. From its frequent occur- 
rence at the pit of the stomach, it is sometimes designated by the name of 
epigastric pulsation. 
Symptoms.-Upon the application of the hand to the epigastrium, the 
throbbing is distinctly felt; and so violent is it occasionally, that it may even 
become sensible to the eye. Though not usually attended with pain, it is 
often very annoying to the patient, and sometimes occasions harassing fears of 
aneurism, or other serious organic disease. It is in general intermittent in its 
character, occurring in paroxysms, which, however, are altogether irregular, 
both in their degree, and recurrence. In some instances, it remains pretty 
constant for a considerable length of time. A feeble bellows murmur has 
been observed generally to attend it, audible especially when the patient is in 
a horizontal position. It is not necessarily connected with over-action of the 
heart, though the two affections are not unfrequently coincident. 
Causes.'-The causes are numerous. Whatever is capable of extending an 
irritation to the great sympathetic nerve, and especially to the solar plexus 
and its ganglia, seems to be capable of producing it. The persons in whom 
it is most apt to occur are those of a highly nervous temperament. Hypo- 
chondriacal, hysterical, and anemic individuals are peculiarly susceptible to it. 
Perhaps it is most frequent in anaemia, and especially in that form of it usually 
associated with uterine derangement, as in chlorotic and hysterical females. 
It has been observed to follow copious hemorrhage from the stomach, rectum, 
and uterus. Hepatic derangement, an irritated or dyspeptic state of stomach, 
disorder of the bowels, in short, congestion, irritation, or inflammation of the 
abdominal viscera generally, appear to be capable of exciting it. Tenderness 
in the epigastrium is a not unfrequent attendant. It has been observed in 
connexion with tenderness of the spine. It sometimes appears to be one of the 
forms of nervous gout and rheumatism; as it has been known to cease sud- 
denly upon the occurrence of gout in the extremities. There is reason to be- 
lieve that it sometimes results from the excessive use of tobacco, coffee, and 
tea. Simple flatulence of the bowels will sometimes bring on a paroxysm in 
those predisposed to it. Dr. Stokes has found it to attend intestinal and peri- 
toneal inflammation, as increased pulsation of the radial artery attends a 
whitlow. Indeed, he considers it a good sign of intestinal inflammation, when 
it exists along with fever, and the aortic pulsation is proportionably more active 
than that at the wrist. Notice has been especially attracted towards it as an 
accompaniment of pancreatitis, of which it has even been supposed to be a 
pathognomonic sign. It may arise from the pressure of tumours or enlarged 
viscera. It is not improbable that it sometimes results from an original irri- 
tation, active congestion, or inflammation of some portion of the solar plexus, 
which supplies nerves to the artery. 
Diagnosis.-The affections for which this pulsation is most apt to be mis- 
taken, are aneurism, and organic diseases of the heart. If no abdominal 
tumour exist, there can be little difficulty in distinguishing it from the former 
affection. Its irregular occurrence and frequent absence, its occasional 'disap- 
pearance upon the removal of some temporary cause, such as flatulence, the 
state of system with which it is frequently associated, and the character of 
the pulsation, which is quick and jerking, instead of being slow, expansive, 
and heaving, as in abdominal aneurisms, are generally sufficiently diagnostic. 
But positive certainty may be obtained with the stethoscope. By the aid of 
this instrument, the pulsation may be observed for a considerable distance 
along the aorta instead of being confined to one spot, and in no part of the CLASS in.] 
PHLEBITIS. 
237 
vessel extends laterally beyond its limits, as it does in aneurism. The mur- 
mur, too, is very different from the aneurismal; and is often associated with 
a similar murmur in the carotid and subclavian arteries, and a venous murmur 
in the jugulars. When tumours exist in the abdomen, and receive an impulse 
from the throbbing artery, the diagnosis is more difficult, but may still in 
general be made out with sufficient distinctness. (See Aneurism, p. 231.) 
The absence of organic disease of the heart will be best proved by the want 
of its characteristic physical signs. 
Treatment.-From what has been said above, it will be inferred that no 
single plan of treatment is adapted to all cases of aortic palpitation, depend- 
ing as it does upon causes so numerous and different. The primary object 
must be to search out the derangement, functional or organic, in which it may 
have originated, and to apply remedies to this derangement. The condition 
of the liver, of the stomach, of the bowels, and of the abdominal contents 
generally should be carefully examined, and corrected by appropriate means 
if found deranged. Should evidences of inflammatory congestion or irritation 
exist in the spine, or should there appear good reason for suspecting its exist- 
ence in the solar plexus, cups or leeches applied to the back, followed by 
blisters or other revulsives, would be the proper remedies. It might even be 
advisable to .take blood from the arm, should the pulse be strong and excited. 
Under the same circumstances, saline cathartics and a restricted diet will be 
useful. In anemic cases, an opposite plan must be adopted, consisting in the 
use of chalybeates and nutritious animal food. Care must be taken also to 
arrest all exhausting discharges. Sometimes narcotics and antispasmodics 
become necessary to allay nervous disorder. For this purpose, hyoscyamus, 
conium, lactucarium, camphor, valerian, assafetida, musk, compound spirit of 
sulphuric ether, or opium, may be resorted to. The cold shower-bath will 
occasionally prove useful. If the patient is much troubled with flatulence, a 
fluidrachm of one of the aromatic tinctures, as the compound spirit of laven- 
der, or the compound tincture of cardamom, or a draught of strong infusion 
of ginger, will often dissipate the symptoms. In very obstinate cases, it may 
be advisable to resort to a gentle mercurial course, with the object of remov- 
ing any latent inflammation, in which the pulsation may originate. The use 
of tobacco, coffee, and strong tea should be abandoned, or at least suspended 
for a time, till it is ascertained whether they might have been the cause. Ex- 
ercise, fresh air, agreeable mental occupation, cheerfulness of spirit, and, as 
the most effectual method of combining these requisites, a journey to some 
watering-place, especially to one of the chalybeate and saline springs, will be 
among the most effectual remedies. 
SUBSECTION III. 
DISEASES OF THE VEINS* 
Article I. 
INFLAMMATION OF THE VEINS, or PHLEBITIS. 
Inflammation of the veins, though not often an original disease, is a fre- 
quent consequence of other affections, especially of wounds or other injuries, 
whether accidental or the result of operations, and is one of-the greatest causes 
of solicitude to the surgeon and obstetrician. 238 
[part II. 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
Symptoms, Course, &c.-The complaint is characterized by pain and great 
tenderness along the course of the affected vessel, which often feels like a 
hard cord, knotted at intervals, and rolling under the fingers. It is usually 
attended with swelling of the parts adjacent, and of those through which the 
ramifications of the vessel are distributed. The limb below is often greatly 
distended, partly from the effusion of liquid consequent upon obstruction to 
the returning blood, and partly from the propagation of inflammation to the 
other tissues. This tumefaction sometimes obscures the hardness of the ves- 
sel itself, which therefore escapes notice unless upon careful examination. 
Fibrinous matter is thrown out by the coats of the inflamed vessel, and 
blood coagulates in layers upon its inner surface, so as at length completely 
to fill up its caliber, and thus to produce that obstruction to the circulation, 
and hardness of the vessels above alluded to. If the vessel affected is small, 
the consequences of the obstruction are not necessarily serious; but, if one of 
the larger trunks, especially those in the interior, is the seat of the inflamma- 
tion, they may be fatal, and are always dangerous. 
If the inflammation should now subside, it may happen, partly by the 
solution of the coagulum, and partly by the pressure from behind, that the 
blood may make its way again through the vessel, and the circulation be 
restored. But more frequently the obstruction continues, the blood finds a 
passage through other vessels which are enlarged for the purpose, and the 
inflamed vein, through a process of organization and absorption, is gradually 
reduced to the condition of a hard impervious cord, or ligamentous string. 
With the return of the circulation the swelling in the limb gradually subsides, 
and the patient ultimately recovers, though not always without some residuary 
hardness or tumefaction of the parts affected. 
But, if the disease advances, suppuration ensues; and the pus, which is 
sometimes largely produced, is either confined by the coagulated blood and 
effused lymph within certain portions of the vessel, thus constituting ab- 
scesses along the vein, or, if not thus restrained, is carried along with the 
current of blood, and contaminates the circulation. The former of these 
events is the more desirable; as the disease then remains local, and the 
question of recovery is resolved into the extent of the inflammation, and the 
patient's strength of constitution. If he have vigour enough to carry him 
through the processes requisite for the discharge of the pus, and the granu- 
lation of the abscesses formed, recovery will take place; and this may be 
confidently expected when only the smaller vessels are involved. But if the 
caliber of the vein remain pervious, and the pus mix with the mass of the 
blood, the consequences may be most serious. Even then, however, if the 
purulent admixture be very small, it is probable that no constitutional dis- 
turbance of any moment will ensue. If large, if often produces fatal disorder. 
In some cases, owing to peculiarity in the cause and. consequent nature of 
the inflammation, or in the previous health or constitution of the patient, the 
purulent secretion is not preceded or attended by adhesive inflammation and 
fibrinous exudation, and the blood in the vessel has no disposition to coagulate. 
Pus is thrown out by the inner surface of the vein, and is washed away by 
the current of the blood, which thus becomes contaminated. This condition 
of venous inflammation is by far the most dangerous, giving rise to the most 
violent constitutional disturbance, and, if life is not thus immediately de- 
stroyed, to the formation of abscesses or purulent depositions in various parts 
of the body, by which the system is at length exhausted.* 
* Mr. Henry Lee,'Surgeon of the Lock Hospital, London, infers from experiments 
performed by himself, that the coagulated fibrin, lining the inner surface of the veins, 
or more or less completely filling the cavity, in phlebitis, is not produced by exudation CLASS III.] 
PHLEBITIS. 
239 
The constitutional symptoms of phlebitis vary with the stage of the inflam- 
mation and its character. In the ordinary adhesive variety, in its earlier 
stages, they are those of common symptomatic fever, commencing usually 
with more or less rigor, and differing only by greater frequency and less 
strength of pulse. The occurrence of suppuration is usually marked by re- 
peated chills, and a general relaxation of surface, attended frequently with 
profuse sweats, especially during sleep. In those cases in which there is 
reason to believe that pus has somewhat largely entered the circulation, the 
fever is of a low and often typhoid character. The pulse is very frequent, 
small, and feeble; the respiration, hurried; the skin pale, and often sallow 
or dusky; the extremities, cold; the countenance, anxious, sunken, and hag- 
gard; the tongue, generally dry, and covered with sordes; the stomach, occa- 
sionally irritable; and the bowels, costive, or affected with diarrhoea. Extreme 
restlessness, muttering delirium, and other marks of nervous derangement 
are frequent attendants on the disease, which, under these circumstances, is 
generally fatal. It is not impossible that these symptoms may sometimes 
occur, independently of the generation of pus, from a propagation of inflam- 
mation extensively along the great venous trunks towards the heart, or from 
a general vitiation of the blood, and prostration of the nervous energy, in 
consequence of some other poisonous influence. 
When pus is produced, the larger the vein the greater is the danger, for 
the less is the chance that this liquid may be confined by the obstruction of 
the vessel. 
The diagnosis of phlebitis in the extremities is usually not difficult; but 
obscurity often attends it when seated in the internal veins of the abdomen 
or thorax. In such eases, the occurrence of a hard oedematous swelling, with 
more or less of a purplish aspect, in exterior parts, the veins of which carry 
blood into the interior trunk affected, may be regarded as a strong evidence 
of its existence. Thus, such a swelling in one of the lower extremities, 
occupying the whole limb, without any evidence of inflammation of the 
femoral vein, may be considered as diagnostic of phlebitis of the correspond- 
ing iliac vein, and, if in both limbs, of the same disease in the vena cava. 
I have had a case exactly of this kind, in which the diagnosis was confirmed 
by post-mortem examination. The original cause of the phlebitis, in such 
cases, is apt to be cancer of one or more of the viscera. 
Inflammation of the portal vein. Portal phlebitis.-Generally in relation 
to the external veins, and not unfrequently in relation to the interior venous 
trunks which convey the external blood to the heart, there are signs by which 
inflammation may be recognized with considerable certainty. But it is different 
with the portal vein, which both begins and terminates within the abdomen. 
It is highly probable that inflammation of this vein and its ramifications occa- 
sionally takes place, and, ending favourably, escapes notice from the obscurity 
of its symptoms. It is only in the fatal cases, the nature of which is revealed 
by dissection, that it has been recognized with an approach to certainty. A 
short account of the symptoms, in these cases, may prove useful by facilitating 
a diagnosis of the disease in its milder forms, or earlier stages, while yet 
amenable to remedies. The affection has been generally overlooked by sys- 
from the surface of the vein itself, but is deposited directly by the blood. In an expe- 
riment upon an ass, in -which measures were taken to produce inflammation of the 
jugular vein, the blood being entirely excluded, the lining membrane was found perfectly 
smooth and glossy, and there was no fibrinous exudation observable. But this experi- 
ment, unless confirmed by numerous others, performed under varying circumstances, 
cannot be admitted as conclusive, in opposition to what has hitherto been almost uni- 
versally admitted as established by observation and experiment. (Medico-Chirurg. 
Trans., xxxv. 191.) 240 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
[PART II. 
tematic writers. I am indebted for most of the following facts to a paper of 
Dr. E. Leudet, of Paris, published in the Archives Generates for February, 
1853 (^page 145), which contains a detailed account of a case observed by 
himself, and a summary of facts* deduced from an examination of the cases 
heretofore placed on record. The affection makes its attack in general some- 
what abruptly, but sometimes gradually. The first observable symptom is 
usually a dull pain in the epigastrium or hypogastrium, increased by pressure, 
and, as the case advances, extending more or less over the abdomen, which 
becomes in some degree tympanitic. Occasionally the superficial veins are 
distended. Febrile symptoms set in, attended with a remarkable tendency to 
chills, which are among the most striking features of the complaint. These 
chills occur quite irregularly, in some instances several times in the same day, 
and are not generally followed by sweats, though these do sometimes take 
place. The liver is often enlarged, and the patient is more or less jaundiced; 
but neither of these conditions is universal. The spleen is also sometimes en- 
larged. Not unfrequently there is more or less nausea, vomiting, and diarrhoea. 
Typhoid symptoms make their appearance before the close, with frequent pulse, 
delirium, coma, and great prostration. The duration of the complaint is from 
one to three weeks, or more. The cases have uniformly terminated fatally. 
The cause is for the most part unknown. In general the affection seems to 
have been idiopathic; but in a few instances it has originated in some focus 
of inflammation or local injury previously existing. In one case, the cause 
was a fish bone which had passed through the coats of the stomach, and per- 
forated the portal vein. In a case which had been observed by M. Leudet 
himself, the starting-point seemed to be an injury inflicted on the rectum by 
the point of a syringe. A case is recorded in the New York Medical Times 
(ii. 162), which probably originated in inflammation of the bowel, consequent 
on a partial strangulation of one of the folds of the intestine, passing through 
a rupture in the omentum. It is probable that some of the cases of multi- 
plied abscesses of the liver, accompanying tropical dysentery, are the result of 
portal phlebitis, having its origin in the ulcerative affection of the bowel. 
The anatomical characters of the affection will be given below. 
Anatomical Characters of Phlebitis.-The appearances after death, are red- 
ness of the inflamed vessel; a thickened, contracted, softened, or indurated 
condition of its coats; coagulable lymph adhering to its inner surface, or loose 
within its cavity; coagula of blood often completely plugging up the vessel 
for a considerable extent; and generally more or less pus, sometimes confined 
by adhesions within small portions of the tube, sometimes completely sur- 
rounded by coagulated blood, and again lying loosely in the vessel. Occa- 
sionally, too, portions of the vein are quite obliterated, and reduced by ab- 
sorption to the form of an impervious cord. The parts about the vessel also 
exhibit signs of inflammation, having contracted adhesions from fibrinous exu- 
dation, or being more or less infiltrated with pus. Redness alone, without 
thickening, softening, ulceration, or either fibrinous exudation or the presence 
of pus, is not considered a sure sign of inflammation. 
In portal phlebitis, the coats of the veins have been found of a grayish 
colour, and so much thickened that the vessels did not collapse. The inner 
coat was much thickened, coagulated fibrin adhered to the inner surface of the 
portal vein, and occasionally the clots were so large as nearly to fill the vessel. 
There was usually abundance of pus, more or less mingled with blood, both 
in the trunk, and in its intestinal and hepatic ramifications, and sometimes in 
the splenic vein. Numerous abscesses existed in the liver, and between the 
folds of the mesentery; and the veins in their course were sometimes bathed 
in pus. In some instances, the peritoneum exhibited signs of inflammation. CLASS III.] 
PHLEBITIS. 
241 
Causes.-Phlebitis almost always arises from local injury or inflammation, 
in which the veins of the part are involved, either directly, or by contiguous 
sympathy, or from the entrance of acrid or septic matters into their cavity. 
The inflammation once established, is readily propagated along their course; 
and the tendency of phlebitis appears to be, contrary to what has been ob- 
served of arteritis, to run from the smaller vessels to the larger with which 
they are continuous, thus following the course of the blood. Sometimes very 
slight injuries are sufficient to give rise to the disease, partly owing to the 
state of the patient's constitution at the time, and partly to the peculiar cir- 
cumstances attending the injury. Thus, it may arise from a slight focus of 
inflammation, whether ulcerative or not, in one of the toes, and may thence 
run up the leg and thigh, with serious consequences. Any wound of a vein, 
which, from its nature or inaccurate closure, does not unite by adhesive in- 
flammation, is apt to generate phlebitis. Hence its occasional occurrence 
after venesection, especially when a dull lancet has been employed, or one 
soiled by contact with diseased matter. Hence too the frequency of the dis- 
ease after division of the saphena, or other operation for varicose veins of the 
leg. Perhaps the great liability to phlebitis, and the consequent danger in 
these cases, depend partly upon the previously morbid condition of the ves- 
sel. Amputations and operations on parts largely supplied with veins not 
unfrequently prove fatal, in consequence of venous inflammation proceeding 
from the cut surface. Puerperal women are peculiarly liable to this disease; 
the veins of the womb taking on inflammation after delivery, and propagat- 
ing it to the larger venous trunks with which they communicate. The veins 
proceeding from the part of the uterus at which the placenta was attached 
are especially liable to be affected, and the spermatic vein upon one side is 
most frequently inflamed. The hypogastric veins are also apt to be attacked, 
and through them the inflammation sometimes reaches the iliac and femoral 
veins, and even extends into the vena cava. Some of the worst forms of 
puerperal fever probably owe their malignancy to phlebitis originating in the 
womb; and phlegmasia dolens may generally be traced to the same origin. 
Fractures of the skull are apt to occasion phlebitis. Contusions, abscesses, 
cancerous sores, caries, ulcerated surfaces, and any other form of suppurative 
inflammation, may become a focus whence the disease may spread, and carry 
the seeds of danger or death into the system. The veins running from such 
centres have often been observed to be filled with pus. It has been a ques- 
tion whether, in such cases, the pus is taken up by the veins, and merely 
conveyed by them into the circulation, or whether it is the result of an in- 
flammatory process in their own structure. Possibly both events may hap- 
pen; but, taking all the circumstances into consideration, it seems to me 
most probable that it is generated for the most part in the veins themselves; 
for, if it were taken up by them, why should we not find the vessels simi- 
larly loaded in all cases of large purulent collections of similar character ? 
Of one of the results of this morbid process there will be occasion to treat 
directly. ■ Phlebitis has sometimes, though very rarely, arisen from cold, 
like other inflammations; and it is said to have resulted from the translation 
of rheumatic or gouty irritation. From the circumstance that it originates 
generally in local injuries, it follows that the large interior venous trunks are 
seldom primarily affected. 
The existence of a predisposition seems to be, if not essential to the pro- 
duction of phlebitis, certainly very promotive of it; as precisely the same 
local condition, so far as can be discovered, which produces it in one case, 
will have no such consequence in many others. The character of the pre- 
disposition has great influence in determining whether the resulting inflam- 242 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
[part it. 
mation is to he adhesive or suppurative. A feeble and depraved state of 
health is most favourable to the latter, and therefore greatly aggravates the 
danger of the disease. It is probable that some unknown distemperature of 
the atmosphere favours the origin of phlebitis, which appears occasionally to 
prevail almost epidemically, especially among puerperal women. 
There are two affections, usually considered of obscure origin, one of which 
has been recently traced, if not with certainty, yet with a considerable degree 
of probability, to phlebitis as its source, and the other is considered by many 
as having the same origin. These are phlegmasia dolens, and metastatic 
abscess. They can be considered nowhere more appropriately than in the 
present place. 
1. Phlegmasia Dolens.-Phlegmasia Alba Dolens.-Crural 
Phlebitis.-Milk-leg.-This affection occurs generally in women after 
delivery, but sometimes also in the unmarried, and occasionally even in males. 
It usually commences about a week or two after delivery, though the interval 
may be much longer. In some instances, it is preceded by febrile symptoms, 
in others, is ushered in with a chill occurring simultaneously with the local 
affection, and in others again, and these are the most numerous, commences 
with pain. This is usually felt first in the loins or lower part of the abdo- 
men, whence it extends to the groin, and thence to the vulva, and down the 
thigh and leg. Sometimes, however, it shows itself first in the lower parts of 
the limb, as in the calf, travelling upwards, and in other cases in two distant 
points at the same time. At first it may be only an aching sensation with 
soreness, and a sense of weight or stiffness in the part; but it soon increases 
and becomes acute, severe, and sometimes even excruciating, being felt most 
along the course of the internal cutaneous and crural nerve in the thigh, and 
of the posterior tibial in the leg. The limb soon begins to swell, and in the 
course of forty-eight hours is sometimes of twice its usual dimensions. The 
labium pudendi is similarly affected. With the swelling, the acuteness of the 
pain generally abates in some measure, but the soreness continues, and is 
aggravated by every movement. The limb is in general slightly flexed, and 
quite motionless as if paralyzed. The swelling, when at its height, is uniform 
over almost the whole limb, which is unnaturally white, shining, hot, and 
firm and elastic to the touch. It does not pit upon pressure, except some- 
times at the commencement, and at the decline of the swelling. When cut, 
it exudes only a small quantity of fluid. Sometimes red lines are observed 
in the course of the crural veins, and red patches here and there upon the 
limb; but the colour, as just stated, is usually white. The tenderness is 
greatest along the femoral vein, which may almost always be felt like a hard 
cord. Sometimes this hardness is confined to the groin, sometimes may be 
felt all the way down the thigh and leg, and in other instances occurs in dis- 
tinct parts of the course of the vessel. The uniformity of the cord is inter- 
rupted by occasional nodules, arising either from inflamed cellular tissue, or 
coagula in the cavity of the vessel. The lymphatic glands of the groin are 
usually hard and swollen. Both limbs are seldom attacked at the same time; 
but it sometimes happens that one becomes affected after the recovery of the 
other. The left is more frequently attacked than the right. 
The disease is said sometimes to extend to the arm of the affected side. It 
is attended with a very frequent pulse and other febrile symptoms, often with 
nausea and vomiting, and sometimes with suppression of the lochia and the 
milk. 
Phlegmasia dolens generally terminates favourably, though constitutional 
symptoms occasionally make their appearance, such as have been ascribed 
above to the entrance of pus into the circulation, and the patient sinks. The CLASS III.] 
243 
PHLEGMASIA DOLENS. 
acute symptoms are in most cases over in two weeks; but the limb often con- 
tinues more or less swollen or hard, for a long period, sometimes even for life. 
In favourable cases, the symptoms gradually subside; the pain, hardness, and 
swelling abate; and the blood, which can find no passage through the large 
internal veins of the limb, is returned by the superficial vessels, greatly enlarged 
for the purpose. Sometimes erysipelatous inflammation occurs in the limb, 
and abscesses form in different parts of it, as well as in different parts about 
the pelvis, greatly increasing the danger of the patient, and, in some instances, 
proving fatal. 
In all the fatal cases examined within a few years, marks of inflammation 
have been found in the femoral vein, frequently extending into the veins of 
the leg, and sometimes occupying almost all the venous ramifications of the 
limb. The caliber of these vessels has been filled by coagulated blood, effused 
fibrin, and pus; and coagula have also been observed in the external, inter- 
nal, and primitive iliac veins. In the external iliac the signs of inflamma- 
tion have been strongly marked, and were traced by Dr. Lee from these to 
the veins of the uterus. The other tissues of the limb have also been found 
inflamed, but apparently in a secondary manner. 
Very different opinions have been held as to the nature of phlegmasia 
dolens. At first considered as the result of a metastatic secretion of milk in 
the limb, it was afterwards with more appearance of reason ascribed to inflam- 
mation of the absorbents, and still later to general inflammation of the cellu- 
lar tissue, muscles, and inner surface of the skin. Various observers had 
detected evidences of phlebitis in the great veins of the thigh, among whom 
Dr. Davis, of England, and M. Bouillaud, of France, were the most conspicu- 
ous ; and the opinion was advanced that the disease might consist essentially 
of this affection; but it was not until the inflammation was traced to the veins 
of the womb by Dr. Lee, and the point of origin thus clearly established, that 
this opinion acquired full confirmation. There scarcely appears room at pre- 
sent to doubt that, however other tissues may be subsequently involved in the 
disease, the structure primarily affected is the veins; and that, when the com- 
plaint is consequent upon delivery, inflammation of the uterine veins is its 
starting-point. But the comparative rarity of the disease, under circum- 
stances of delivery not essentially different, would seem to point to some other 
cause than injury of the uterine vessels; and we must seek for this in pecu- 
liarity of constitution, or the peculiar state of system at the time. 
Affections in most respects identical with phlegmasia dolens have been ob- 
served in women after abortion, and in others affected with malignant ulcera- 
tion or other organic diseases of the unimpregnated uterus, or in whom that 
organ has suffered violence, as from the application of a ligature for the re- 
moval of polypus. Men, too, have been similarly affected in consequence of 
organic disease in the pelvic viscera, or injury inflicted on these parts; and 
attention has been called by Drs. Tweedie, Graves, and Stokes, to the occa- 
sional occurrence of inflammation of the lower extremities, in all essential 
points identical with that under consideration, following fevers. A case of 
the kind occurred in a patient of my own after recovery from an attack of 
peritonitis, which came on during convalescence from typhoid fever. The 
same thing has also been observed in dysentery; and, in one fatal case, in-' 
flammation and consequent obstruction of the common and external iliac and 
femoral veins were discovered upon dissection.* 
* By experiments upon dogs, Dr. F. M. Mackenzie, of London, has proved, 1. that 
inflammation artificially excited in the veins of these animals in health is confined to 
the vicinity operated on, and does not spread to the veins below, so as to produce phe- 
nomena analogous to those of phlegmasia dolens ; 2. that irritation or inflammation of 244 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
[PART II. 
2. Metastatic Abscess.-Purulent Infection.-Pyogenic 
Fever.-Abscesses, or collections of pus, occasionally form in various parts 
of the body, with little or no observable preceding inflammation in the part 
affected. Sometimes one of these collections springs suddenly into existence, 
and as suddenly disappears, to show itself in another situation. They have been 
observed especially in the parenchyma of the lungs and liver, where they are 
of various sizes, from the magnitude of a pea to that of a walnut; but they form 
also in other parts, and not unfrequently in the cellular tissue beneath the skin 
and among the muscles. The eye has been known to be broken down and de- 
stroyed by such an abscess. These purulent collections are usually surrounded 
by a greater or less amount of inflammation. In many instances, their forma- 
tion has been found to be coincident with the existence of some focus of ulcera- 
tion or suppurative inflammation, as in the stump of an amputated limb, cancer- 
ous sores, caries of the bones, diseased uterus, ulcerated intestines, fractures of 
the skull, &c.; and the veins proceeding from such points have been observed 
loaded with pus. Different explanations have been given of these phenomena. 
One of the most obvious was that pus, absorbed from the focus of suppura- 
tion, and carried into the general circulation, is deposited at distant points, 
forming the abscesses in question. But to this view it was conclusively ob- 
jected, that, in many instances, more pus exists in these metastatic collections 
than can possibly have been taken up from the supposed source, which is 
sometimes altogether trivial. But the difficulty was evaded by the supposi- 
tion, that the corpuscles of pus, reaching capillaries too minute to admit of 
their entrance, are arrested in their progress, and excite inflammation in the 
surrounding tissue, which, from the nature of the cause, speedily advances to 
a copious suppuration; and this explanation was supported by the experiments 
of Cruveilhier, who found that metallic mercury, when introduced into the 
the internal surface of a vein causes the blood in contact with it to coagulate; and 3. 
that an irritant injected into the circulation, coming into contact with the internal sur- 
face of the veins generally, may produce extensive irritation and consequent coagulation 
of the blood. {Medico-Chirurg. Trans., xxxvi. 169.) Hence, it was concluded by Dr. 
Mackenzie that phlegmasia dolens does not depend on the propagation of inflammation 
from the veins of the uterus to those of the lower extremity; but upon a diseased state of 
the blood, which, acting as an irritant to the inner surface of the veins of the limb, causes 
the coagulation of the blood within them, and thus gives rise to the phenomena of the 
disease. But it is not shown why the general condition of the blood should affect simply 
the veins of one extremity, in preference to those of other parts which are equally ex- 
posed to its irritant influence. It appears to the author that Dr. Mackenzie's experiments 
simply prove that in health a local phlebitis is not extensively propagated, and that in 
order to this result there must be some vice of constitution peculiarly predisposing to 
it, which is exactly what has been stated in the text. Whether this vice exist in the 
solid tissues, or in the blood, has not been determined; but that it does not consist of 
an irritant in the circulating fluid, operating as the direct excitant agent, is, I think, 
shown by the almost uniform localization of the affection in a particular part. It may 
readily be conceived that the predisposition consists in a peculiar irritability of the 
veins, the result possibly of a depraved nutrition, which determines that, a point of 
inflammation being established, it shall rapidly spread through the tissue, just as, in 
the erysipelatous predisposition, inflainmation in a single point of the skin will be rapidly 
propagated over an extensive surface. It seems, therefore, most probable that, in this 
disease, the focus of inflammation exists in the uterus, whence, in consequence of the 
predisposition referred to, there is a propagation of the affection through the lining 
membrane of the veins, causing, wherever it attains a suificient degree of intensity, 
coagulation of the blood in contact with the membrane; and this disposition to coagu- 
lation of the blood, under the circumstances mentioned, is the most interesting result of 
Dr. Mackenzie's experiments. Why the irritation should extend towards the origin of 
the veins, contrary to the direction of the blood, and contrary to what ordinarily hap- 
pens in phlebitis, is not obvious. Perhaps it may be that coagulation at any one point, 
producing obstruction there, and causing the blood to be delayed in the veins below, 
may be the determining agency. {Note to the fourth edition.) CLASS III.] METASTATIC ABSCESS.-PURULENT INFECTION. 
245 
veins, was carried to the capillaries of the lungs, and there occasioned small 
abscesses, which being opened were found to contain a globule of the metal in 
their centre. But there was another difficulty in the way of this hypothesis. 
It often happens that large collections of pus disappear, probably by the pro- 
cess of absorption, without any of the evil consequences which are ascribed by 
the hypothesis to even small quantities entering the veins. In reply it may 
be said that, when pus really enters the vessels by absorption, it must have 
been previously disintegrated and rendered liquid; as microscopic observation 
has shown that no orifices exist in the walls of the vessels by which the pus 
corpuscles can possibly gain admission. When thus prepared for absorption, 
it may be thought to have undergone changes which divest it of noxious pro- 
perties. It may be only when admitted into the circulation in the form of pus, 
that it produces the ill effects ascribed to it; and this happens not by absorp- 
tion, but through openings in the veins, resulting either from ulceration or 
wounds. With the qualification here stated, it is certainly not impossible 
that the metastatic abscess should take place in the manner supposed; but 
the abnormal openings in the veins, which are necessary to the explanation, 
have not been proved to exist in such cases. ' 
It would, therefore, seem more probable that the pus, found in the veins 
proceeding from suppurating parts, is not taken up by the vessels, but actually 
formed in them, in consequence of inflammation of their tissue, propagated 
from the original point of disease, and disposed to take on the suppurative 
character by the previous condition of the system. Phlebitis, according to 
this view, is the true source of metastatic abscess. That inflammation of the 
veins has not always been detected, is no proof that it may not have existed; 
for, in a system of parts so extensive, an inflamed surface may easily have 
escaped observation, more especially as the indication afforded by the pre- 
sence of pus may be wanting, in consequence of this product being washed 
away by the blood as fast as formed. 
Another opinion, which on the whole appears to me to approach nearer the 
truth than either of the preceding, is that which looks upon the affection as 
the result of pvrulent infection of the blood. By this expression is not 
meant a mere contamination of the blood by an admixture of pus, but a 
change effected in its essential constitution through a poisonous action of the 
cause, analogous to that produced in smallpox and typhus fever, by the ab- 
sorbed matter of contagion. The results, therefore, are not produced directly 
by the pus, but by the morbid state of the blood which it may have induced 
by a sort of zymotic influence. Purulent deposits are not the only phenome- 
non to be noticed in these cases. There is a tendency also to a low erysipela- 
tous inflammation in various parts of the surface, not unfrequently ending in 
subcutaneous suppuration, and sometimes in gangrenous abscesses. There is 
also a train of general symptoms of the typhoid character, such as a frequent 
feeble pulse, hurried respiration, a somewhat leaden or jaundiced hue of the 
skin, and, in bad cases, a dry tongue, sordes on the gums and teeth, stupor 
or low delirium, subsultus tendinum, sometimes diarrhoea, and great general 
prostration. The same state of system precisely may take place, quite inde- 
pendently of any known local inflammation as its origin. I have had under 
my care, in the Pennsylvania Hospital, a patient with all the symptoms 
characteristic of purulent infection, including abscesses, erysipelatous inflam- 
mation here and there upon the surface, and general typhoid symptoms, who 
was attacked in consequence of exposure to severe cold, great privations, and 
fatigue, with habits of intemperate drinking, and without any discoverable 
original inflammation as the starting-point. Here, as well as in the cases of 
metastatic abscess, there is a diseased condition of the blood, and, so far as 246 
[part II. 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
symptoms and results can be admitted as proof, this condition is the same in 
the two cases. In the one case, it is produced apparently by altered pus, or 
other sanious product of inflammation, absorbed into the veins, and setting on 
foot a zymotic change in the blood, especially, it is probable, in the fibrin; in 
the other, by causes acting through the digestive organsand the nervous system. 
In both, the blood is degraded in character and at the same time irritant, 
so that it provokes a low inflammation, in which, instead of the plastic lymph, 
exuded in a vigorous state of that process, a matter is thrown out which is 
immediately converted into pus. It is not essential to the production of this 
affection, even when dependent on some focus of previous inflammation, that 
pus as such should have been absorbed. The probability is that it is rather 
a sanious product, resulting from a decomposition of the pus, or directly se- 
creted from the diseased vessels in the inflamed part, which acts as a poison 
when taken up and admitted into the circulation; for, as before stated, it can 
scarcely be allowed, in the present state of microscopic investigation, that un- 
altered pus can undergo absorption. In cases of true suppurative phlebitis, 
it is probable that the pus formed in the veins has the same effect on the blood. 
The name of pyogenic fever is given by Dr. Jenner, of London, to the 
affection here described. 
These cases of metastatic abscess or purulent infection are very apt to prove 
fatal; but they are by no means necessarily so; and in the milder forms often 
end in recovery. 
3. Chronic Phlebitis.-Various organic changes have been observed 
in the veins after death, which may have originated in chronic inflammation. 
Thus, they have been found thickened so as considerably to diminish their 
caliber, ulcerated, perforated, and softened; and rupture has sometimes oc- 
curred, in consequence of an unusual stress upon their coats in this fragile 
state. They are not unfrequently thinned and distended; their valves are 
sometimes partially or wholly destroyed; and calcareous deposits are found, 
though very rarely, between their coats. The small, loose concretions, of 
the size of a pea, or less, called phlebolites, which are occasionally met with 
in the veins, may, as suggested by Andral, sometimes originate in their coats, 
and, projecting into the cavity with a slender attachment, may be separated 
by a slight force; but they are thought generally to form in the blood itself, 
probably at first as a coagulum of blood or lymph, in which calcareous matter 
may be subsequently deposited. The veins are liable also to other organic 
affections, as steatomatous tumours and hydatids, and participate in the various 
ordinary or malignant diseases of neighbouring tissues. The derangements 
alluded to, however, are more objects of curiosity than of practical interest; 
for they generally offer during life no phenomena, which would lead either to 
an accurate diagnosis or a just treatment. 
Treatment.-The pulse in phlebitis is not usually strong enough to call 
for the lancet, though in some instances it may be resorted to with advan- 
tage, especially in the earlier stages. It should never be omitted when the 
symptoms are active, and the circulation tolerably vigorous. The very free 
use of leeches along the affected vein is of the greatest importance. They 
should not only be applied once, but should be repeated over and over again, 
if the symptoms of inflammation should persevere. In phlegmasia dolens, 
they are in general most effectively applied in the groin and upper part of 
the thigh, over the femoral vein ; but they should also follow the track of the 
tender and hardened vessel, wherever it can be traced. The leeches may be 
followed by cold saturnine lotions, or simply cold water, applied by means of 
linen cloths, or by warm fomentations and emollient cataplasms, according as 
one or the other of these measures is found most comfortable to the patient. CLASS III.] 
247 
PHLEBITIS.-VARICOSE VEINS. 
The local vapour bath has sometimes proved salutary. To relieve the very 
severe paiu, anodynes, such as the preparations of opium, hyoscyamus, bella- 
donna, conium, stramonium, or hops, may. be incorporated with the refrigerant 
or emollient applications. When the bowels are not already too much dis- 
turbed, as they are apt to be in bad cases of the disease, saline cathartics may 
be employed, alternated with diaphoretic doses of tartar emetic, the neutral 
mixture, and other internal refrigerant remedies. Should the disease not 
seem disposed to yield, mercury should be resorted' to, and pushed to a 
moderate salivation. Calomel or the blue pill may be given, in combination 
with opium or hyoscyamus; and mercurial frictions may be employed to 
hasten the impression upon the system. Throughout the complaint, it is 
often necessary, or at least advisable to control the severe pain and relieve 
restlessness by anodynes, and especially opium, which may be combined with 
ipecacuanha or tartar emetic in the earlier stages. After the subsidence of 
the violent symptoms, if the swelling should remain hard, and appear dis- 
posed to assume an indolent character, blisters should be employed; and, 
when leeches cannot be procured, they may be resorted to at an earlier period. 
A low diet, and perfect rest of the limb affected in the horizontal position, 
are also essential parts of the treatment. When great prostration comes on, 
whether from the absorption of pus, or the exhaustion of the suppurating 
process, it is necessary to support the system by stimulant remedies and a 
nutritious diet. Wine-whey, carbonate of ammonia, quinia or infusion of 
Peruvian bark, opiates, and animal broths and jellies are now appropriate; and 
these general measures may be employed, even though it may appear proper 
to make efforts for the relief of the inflammation by local depl^on. In cases 
of metastatic abscess or purulent infection, the indication is nllike manner 
to support the strength of the system. In addition to the meats necessary 
for' this purpose, I am in the habit of using nitro-muriatic acid, with a view 
to its alterative influence on the blood; and chlorate of potassa, chloride of 
lime or soda, or chlorine-water may be tried with the same object. 
During convalescence, care should be taken not to employ very energetic 
measures for hastening the reduction of the tumefaction. Time is required 
for the sufficient enlargement of the new veins, through which the blood md%t 
make its exit from the limbs. Premature irritation might endanger an in-^ 
creased inflammation. But, with this caution, ointments of iodine or mercury, 
or of both, may often be usefully applied with the view of promoting absorp- 
tion ; and blisters may be resorted to with the same object. Should consider- 
able oedema remain, it may generally be corrected by bandages, and the use 
of diuretics, such as squill and bitartrate of potassa. 
Article IL 
VARICOSE VEINS. 
This affection, which consists in a dilatation of the veins, belongs in gene- 
ral to the province of surgery, and a very few remarks will suffice in this 
place. The dilatation may be extensive and pretty uniform, or local, and as 
it were in pouches. The vein is also generally lengthened, causing that tor- 
tuous appearance so common in the affection. In most instances there are 
knots at intervals along its course. The coats of the vessels are sometimes 
thickened, sometimes attenuated. The affection may originate in relaxation 
of the veins, in consequence of which the ordinary pressure produces their 
expansion; or in a long-continued and unusual degree of pressure from posi- 248 
[part it. 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
tion, ligatures, &c., even though the vessel may have been previously healthy. 
Not unfrequently the two causes act conjointly. When the internal veins be- 
come obliterated or obstructed, thosemear the surface often enlarge very much, 
under the pressure of the increased amount of blood which seeks a passage 
through them. Varicose veins upon the surface of the chest and abdomen are 
among the signs of impediment to the passage of blood through the great 
trunks of the interior of these cavities. It is probable that they may also 
result from rapid growth, under the influence of the recuperative powers of 
the system. The affection has been ascribed to disease of the valves, which, 
ceasing to close the vessel, no longer support the column of blood, which 
therefore presses with undue force upon the coats below. This is probably 
true in some cases; but not to the extent at one time supposed. As the veins 
dilate, the valves become incapable of performing their duty, and the disease 
may advance more rapidly from this cause. In consequence of the pressure 
of the accumulated blood, its return from below is retarded, and hence arise 
tumefaction and occasional oedema of the limb, sometimes attended with much 
pain, inflammation, and obstinate ulceration. 
Spontaneous cures are sometimes effected by the occurrence of adhesive in- 
flammation, giving rise to the effusion of coagulable lymph, obstruction of 
the vessel, and its ultimate obliteration through the process of absorption. 
Various attempts have been made to effect cures by surgical operations; but 
these have often proved fatal by inducing phlebitis, and are much less fre- 
quently resorted to than formerly. The safer measure of equable and firm 
pressure is preferred when it is applicable. This may be assisted by the 
frequent application of cold water over the enlarged vessels; and some advan- 
tage may be Expected from astringent lotions and cataplasms, where circum- 
stances adnjift of their continued use. If inflammation should supervene, rest, 
a horizontal or elevated position, leeches, and lead-water, are the appropriate 
remedies. A stimulating diet and stimulating drinks should be avoided as 
conduce to plethora. The mechanical measures necessary to produce pres- 
* sure, and give due support to the vessels, belong to the surgeon. 
SUBSECTION IV. 
DISEASES OF THE BLOOD. 
Article I. 
PLETHORA. 
A morbid increase of the blood beyond the wants of the system is called 
plethora. It is not, however, a mere augmentation of volume in the circulat- 
ing fluid that is entitled to that name. This may result from an excess of 
the watery ingredient, and is not incompatible with the state of anaemia, which 
is the opposite of that of plethora. There must be a morbid increase of those 
constituents of the blood upon which its nutritive and stimulant properties 
depend, and to which it owes its peculiar character, such as the red corpuscles, 
fibrin, and albumen. There may or may not be an increase of bulk. 
There is no precise proportion of the active principles of the blood, which 
is alone compatible with health. Their quantity constantly varies with the 
varying sources of supply, and extent of consumption; and, within certain 
limits, no inconvenience is experienced from this irregularity. Even when CLASS III.] 
249 
PLETHORA. 
derangement of function results from an excess of blood, if it be moderate, 
and speedily relieved, as very often happens, by an increased activity of se- 
cretion, or a diminished vigour of the process of sanguification, the excess 
scarcely deserves to be considered morbid. It is only when the derangement 
is threatening or very inconvenient, or continues long without relief, that the 
affection would come under the designation of plethora. 
It is not necessary that there should be an absolute increase of the blood, 
in order to the existence of the disease. The quantity may remain precisely 
the same, and yet, if the wants of the system for the support of its various 
functions should diminish, the phenomen^bf plethora may result; for it is the 
loss of balance between the supply and consumption, the former being in ex- 
cess, that constitutes the affection. 
Symptoms.-Florid cheeks, and redness of the lips, tongue, conjunctiva, 
and mucous surfaces generally wherever visible, are usually considered as evi- 
dences of plethora; and they frequently are so; but they are also occasion- 
ally wanting, when the capillaries are from any cause inactive, or the excess 
is not so much in the red corpuscles as in the other active constituents of the 
blood. The pulse is ordinarily full, strong, and somewhat accelerated. When 
the affection is moderate, there is a slight feeling of heaviness, mental and 
bodily hebetude, and disposition to sleep, which increases in severe cases, and 
is attended with a sense of fulness or tension in the head, vertigo, tinnitus 
aurium, or headache; and sometimes palpitations of the heart and oppressed 
breathing are added to, or replace the cephalic symptoms. Bleeding from the 
nose or rectum is not uncommon. Blood drawn from the arm is often more 
highly coloured than in health, and affords a larger coagulum, with compara- 
tively little serum. It seldom exhibits the buffy coat, unless the affection is 
complicated with inflammation. Plethora is said by writers to be frequently 
attended with obesity. This may occasionally be the case; but, though the 
habit is often full, I have not usually found plethoric patients fat, and not un- 
frequently they are quite thin; the very deficiency in the nutritive function 
being probably one of the causes of the excess of blood. The copious se- 
cretion of adipose matter has a tendency to keep down any plethoric accumu- 
lation to which the individual may be predisposed. 
Causes.-A loss of equilibrium between the supplying and expending pro- 
cesses is the immediate cause of plethora. Digestion and absorption are rela- 
tively more vigorous than nutrition and secretion. The former processes may 
be healthy, while the latter are defective; or the former may be in excess 
while the latter are healthy; or both may be deranged in different directions, 
and thus co-operate to the same result. Whatever occasions this loss of equi- 
librium, is a remote cause of the disease. Excessive eating, especially of 
animal food; stimulating condiments or drinks, which excite digestion into 
preternatural activity; and indolent or sedentary habits, which occasion a 
deficient expenditure of blood in the various vital processes, are, singly or 
conjointly, the most efficient agents in the production of plethora. It is 
especially apt to result, when long-continued active exercise is suddenly fol- 
lowed by sedentary life. The invigorated appetite and digestion produced 
by the former, continue for a while after its cessation, and throw copious 
supplies into the circulation; while the previous expenditure is cut short or 
diminished, in consequence of the want of bodily activity. Continued mode- 
rate warmth, especially following cold weather, sometimes gives a morbid 
vigour to the process of sanguification. Hence, the system is apt to become 
plethoric in spring. Certain constitutional influences have the same effect; 
such, for example, as pregnancy, which is often attended with plethora. Some 
individuals have a peculiar tendency to the over-production of blood, and 
become plethoric without any assignable cause; and these are of course most 250 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
[part II. 
readily affected by ordinary causes. Whatever checks secretion may give rise 
to the complaint. Cold sometimes probably acts in this way. The sudden 
stoppage of an habitual discharge, to which the system has accommodated 
itself, is an occasional cause. Hence, in part, the accidents which follow the 
drying up of long-continued issues, the healing of old ulcers, the cessation of 
habitual hemorrhage from the nostrils, rectum, or uterus, and the omission of 
venesection after its frequent employment at certain intervals. From what 
has been said, it might be inferred that plethora is more common in'females 
than males; and such is asserted to be the fact. Children are thought to be 
less subject to it than adults, in consequence of the vigour of their nutritive 
process. Perhaps the period at which it is most apt to occur, is that of ap- 
proaching maturity, when the body ceases to expand, and the processes con- 
cerned in sanguification have not yet fully adapted themselves to the new 
condition of the system. 
Nature and Effects.-An excess of either of the active ingredients of the 
blood, without a diminution of the others, would strictly constitute plethora. 
The cases, however, which most frequently attract notice are those character- 
ized by a superabundance of the red corpuscles; because the affection is, in 
these, more obvious to a superficial examination, and the occurrence of hemor- 
rhages gives greater apparent occasion for solicitude. But there may be 
others not less important, in which the fibrin and albumen have become un- 
duly accumulated. The tendency, in the former cases, is to hemorrhages and 
febrile action, in the latter, probably, to inflammation. Both may give rise to 
congestions. Andral expresses the opinion, that plethoric patients are not 
more likely to contract inflammation than others; and the remark may be true 
if, with him, we restrict the application of the term plethora to cases of excess 
merely of the red corpuscles. My own observation would lead to a different 
conclusion in relation to the disease, as I understand and have defined it. 
Treatment.-In the treatment of plethora, reference must be had to its 
duration. If it be temporary, and not immoderate, it will be sufficient to 
restrict the diet to vegetable food exclusively, or to this along with milk, to 
administer refreshing and mucilaginous drinks, and to keep the bowels freely 
open by saline laxatives. Should the symptoms be in any degree alarming, 
threatening apoplexy, for example, or indicating dangerous pulmonary con- 
gestion, the lancet should be resorted to, and employed with a freedom cor- 
responding to the danger. There is some hazard, however, in a too frequent 
resort to venesection in this complaint. The system accommodates itself at 
length to the repeated losses by a proportionate increase in the activity of 
sanguification ; and if, under these circumstances, the abstraction should be 
inadvertently omitted, serious hemorrhages or other lesions might ensue. In 
cases of a protracted character, where the tendency to plethora is such that 
an excess is generated almost as fast as relieved by depletion, the lancet is 
admissible only, to obviate immediate danger. The cure is to be effected here 
by a careful removal of all the causes; by a regulation of the diet, the avoid- 
ance of stimulants and tonics, and by frequent bodily exercise, of a kind not 
calculated greatly to excite the heart. In relation to the food, the abstemi- 
ousness should be in proportion to the obstinacy of the case. The patient 
should not sleep too warmly, and mattresses are therefore preferable to feather 
beds. He should also avoid confinement in over-heated apartments. The 
secretions should be sustained. If the skin is dry and the capillaries inactive, 
advantage will accrue from the occasional use of the warm bath and moderate 
friction to the surface. Scanty urine may be relieved by cold drinks, with 
the aid of saline diuretics, especially bitartrate of potassa. Constipation must 
be obviated by the refrigerant laxatives. But the most important remedies 
by far will be found in diet and exercise properly regulated. CLASS III.] 
ANAEMIA. 
251 
Article II 
ANJEMIA. 
By anaemia (from a, privative, and aip.a, blood,) is understood a morbid 
deficiency or poverty of the blood. It is not necessary that there should be a 
deficiency in the volume of the circulating fluid. On the contrary, this is 
often quite as great in the disease as in health, and perhaps.sometimes even 
greater. But, in such cases, the nutritive constituents of the blood are in 
less than their regular proportion, while the watery part is in excess. Any 
condition of the blood would come under our notion of this disease, in which, 
either from deficiency in its general amount, or want of due proportion in its 
nutritive and stimulant ingredients, the functions of the body should be de- 
ranged in a considerable degree, or for a considerable length of time. 
There are two forms of this disease, one suddenly, and the other gradually 
induced. The former may be called acute, the latter chronic anaemia. 
Under these names they are here considered. A peculiar form of anaemia 
has recently been noticed, characterized by an excess of the white corpuscles 
of the blood, which will be considered at the end of this article under the 
name of leucocythemia, proposed for it by Dr. Bennett. 
1. Acute Anaemia. 
This consists in a sudden diminution of the mass of blood, produced by 
copious bleeding or profuse hemorrhage. The whole volume of the blood is 
lessened, while its ingredients bear to each other the ordinary relation. The 
morbid phenomena attending the affection depend on two causes, firsts the 
sudden abstraction of the stimulus of pressure exerted upon all parts of the 
system when the blood-vessels are full, and secondly, the diminution of the 
supporting and stimulant influence of the blood upon all the functions of life. 
It is marked by universal paleness and coolness of the surface, diminution in 
the force and volume of the pulse, giddiness, disordered or impaired vision, 
dilated pupil, nausea and vomiting, great muscular debility, faintness, cold 
sweats, and not unfrequently irregular muscular contraction, amounting even to 
convulsions. Sighing, gasping, restlessness, jactitation, and delirium, are also 
among the occasional symptoms. Not unfrequently complete syncope results. 
If, upon the occurrence of this phenomenon, the blood ceases to flow, recovery 
may generally be effected, though not always. If the loss continue unabated, 
it must terminate in death. It has its origin usually either in venesection, 
spontaneous hemorrhage, ruptured aneurisms, ulceration or sloughing of the 
larger vessels, bleeding from wounds, or flooding in childbirth. The treat- 
ment consists of means calculated to arouse the failing or suspended actions 
of life, and, when immediate danger is passed, of such as tend to supply the 
deficient blood. To answer the first purpose, the patient should be placed 
with his head low, cold water should be sprinkled on the face, and ammonia- 
cal liquids held near the nostrils. Should these fail, artificial respiration may 
be resorted to, or even the transfusion of blood from the veins of a healthy 
individual, in cases otherwise desperate. After animation has been restored, 
the patient should be kept at rest, in a recumbent position, for a time pro- 
portionate to the degree of debility; as injury might result from the over- 
action of the heart consequent on fatiguing exertion under such circumstances. 
This measure is highly important. A man was once brought almost blood- 
less into the Pennsylvania Hospital, in consequence of profuse hemorrhage 252 
[part it. 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
from the bowels. The hemorrhage had ceased, but he was in the last degree 
exhausted. Particular direction was given that he should on no account 
leave his bed; but in the night he arose to go to the water-closet, and fell dead 
on the floor. On examination no blood was found in the bowels, so that his 
death was not occasioned by a recurrence of the hemorrhage. It is scarcely 
necessary to state that the diet should consist of nutritious and easily digesti- 
ble articles of food. 
This is a frequent attendant upon other recognized diseases, which impair 
the processes of digestion and sanguification, or drain the system of its blood; 
but it also appears to have occasionally an independent existence, and often 
requires the chief attention of the practitioner. It, therefore, merits distinct 
consideration. One of its most ordinary forms is that usually designated by 
the name of chlorosis or green sickness. Some authors consider this as distinct 
from true anaemia; but even these place its characteristic feature in poverty 
of the blood; and it would be difficult to point out a single essential phenome- 
non in the complaint, which may not be traced to that source. The circum- 
stance that it generally occurs in girls or young unmarried women, would 
only prove that there are circumstances in their situation, peculiarly operative 
in the production of the disease, and not that there is anything peculiar in 
the disease itself. Nor is chlorosis confined to girls, or even to the female 
sex. The authors who treat of it as a distinct affection, acknowledge that it 
is sometimes met with in married women, and in males of delicate constitu- 
tion, especially about the age of puberty. In these latter cases, there is 
scarcely a shadow of distinction between it and anaemia proceeding from 
causes which leave no doubt as to its nature. I shall, therefore, consider it 
under the present head. 
Symptoms.-When the complaint is fully formed, there is commonly uni- 
versal paleness of the skin ; the lips, tongue, and mucous surfaces in general 
are also strikingly pale; there is extreme whiteness of the conjunctiva; and 
the whole surface of the body appears bloodless. Sometimes the face is yel- 
lowish or sallow, and has a waxen aspect. With this change of colour there 
is often a puffiness of the face, especially of the eyelids; the skin seems 
translucent; and, when the fingers are held up, the light shines through their 
edges. The lower extremities are apt to be edematous. The patient is feeble, 
and cannot bear much exertion, to which also he is usually indisposed. The 
circulation is irregular, but almost always weak. The pulse is often full, fre- 
quent, and thrilling or vibrating as in aneurisms; but it is soft, and easily 
compressed, showing a want of energy in the heart's impulse. It is almost 
always greatly quickened by bodily exercise or mental emotion. When the 
patient is entirely quiet and in a recumbent posture, it is often small, rather 
slow, and feeble. Palpitation of the heart is a very common symptom. It 
is sometimes continuous, sometimes irregularly intermittent, and may be in- 
duced by the slightest causes mental or physical. Violent exertion often 
throws the heart into the most tumultuous action. Pulsation in the carotids 
is often obvious, and the stethoscope applied over these arteries or the sub- 
clavians, discovers almost always morbid sounds, such as the bellows murmur; 
while the large veins, as the jugulars, yield a humming sound. The respira- 
tion, though quiet when the patient is at rest, becomes hurried and even pain- 
fully agitated under exertion, as in running, ascending heights, &c. The 
nervous system is often greatly disordered. Vertigo, dizziness, tinnitus aurium, 
and faintness are very common; and spasmodic movements of the muscles, 
sometimes amounting to convulsions, are not unfrequent, especially in females. 
2. Chronic Anaemia.-Chlorosis. CLASS III.] 
ANEMIA. 
253 
Violent and obstinate neuralgic pains in the head, side, breast, or other part 
of the body, are also frequent attendants upon the disease. Even delirium 
has been noticed. The secretions are sometimes diminished; and associated 
•with this condition are extraordinary dryness of the skin, brittleness of the 
nails, and harshness of the hair. In other cases, on the contrary, there are 
profuse and exhausting sweats. In females, the menses are almost always 
either altogether wanting or greatly deficient, being scanty, and light-coloured 
or even serous. The bile is also frequently scanty; and costiveness, with un- 
healthy alvine evacuations, and a dyspeptic state of stomach, are extremely 
common. Various organic affections are often associated with anaemia, some 
of which act as causes of the affection, and others probably are effects. Among 
the latter, there is good reason to believe that hypertrophy and dilatation of 
the heart may be included. The excessive action of the heart so common in 
anaemia may lead to the former of these affections, and the feebleness of the 
parietes from a defective nutrition, to the latter. Dr. James Bigbie has no- 
ticed goitre, and a dropsical enlargement of the eyeballs, as attendants on the 
disease, and is disposed to consider them among its effects. (Ed. Month. Journ. 
of Med. Sci., Feb. 1849, p. 495.) 
When blood is drawn, it is found to be much lighter coloured than in 
health; sometimes, in extreme cases, appearing like reddish dish-water. 
Upon coagulation, it exhibits a great excess of serum; the clot being very 
small, of a light-reddish or rosy tinge, instead of the deep redness of health, 
and floating in an abundance of nearly or quite colourless liquid. It is, how- 
ever, usually rather firm, and not unfrequently exhibits a buffy and even 
cupped surface. The proportion of red corpuscles is obviously much dimi- 
nished ; and the same is probably the case, to a certain extent, with the fibrin; 
for, though Andral states, as the result of his experiments, that the fibrin 
and albumen are in the normal proportion in spontaneous anaemia, this re- 
mark is not applicable to cases which result from repeated hemorrhage, and 
even in the former case, considering the occasional exceeding diminutiveness 
of the coagulum, can hardly be received as of universal application, unless 
after a much more extended series of observations. It must be admitted, 
however, that there is usually a great deficiency of red corpuscles, not only 
in relation to the watery portion of the blood, but also to its remaining solid 
constituents. Even in the anaemia from hemorrhage, this relative deficiency 
is observable; for, though all the constituents are lost in the same proportion, 
yet the organs concerned in the production of blood, find in the system much 
larger supplies of the albuminous and fibrinous principles, than of those which 
constitute the red corpuscles; and, besides, as these probably are a higher re- 
sult of vital organization, they must be the last to be generated. The cause 
of the buffy coat of the clot in anaemia is the relative excess of the fibrin over 
the red corpuscles. It is altogether independent of inflammation. 
It has been stated that a bellows murmur is heard when the stethoscope is 
applied over the large arteries of the neck. The same sound is in a less de- 
gree heard in the heart. Andral asserts that it is never absent in true anaemia, 
and that it is inseparably associated with a diminution in the due proportion 
of the red corpuscles. He never met with it in cases in which the proportion 
of fibrin or of albumen alone was lessened. The degree and continuance of 
the sound bear some relation, though not a constant one, to the diminution 
of the corpuscles. Supposing the mean proportion of the corpuscles to be 
125 in health, Andral found that the bellows sound exists constantly in the 
arteries when the proportion is reduced below 80, occasionally when it falls 
between this number and the physiological mean, and not at all when it ex- 
ceeds the latter point. Some inference may thus be drawn as to the degree 254 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
[part II. 
in which the Blood is impoverished in anaemia. The commencement of the 
affection may thus also be detected, before it has begun to exhibit itself by its 
characteristic feature of paleness. Occasionally persons with a rather florid 
complexion exhibit many symptoms of anaemia, such as general debility, 
feebleness and excitability of the pulse, palpitation and hurried respiration 
during exertion, &c. In these it would be difficult to verify the existence of 
the affection unless by means of auscultation. 
In that form of anaemia commonly called chlorosis, the subjects are usually 
girls between the periods of puberty and maturity. The complaint is in most 
cases very gradual in its advance, and is often from the beginning attended 
with deranged digestion and costiveness. The appetite is irregular, sometimes 
defective, sometimes excessive, and occasionally morbid in its preference for 
particular substances. The breath is often offensive. Listlessness, indisposi- 
tion to exertion, and an expression of sadness or dejection, are not unfrequent 
features of the disease in its earlier stage. The complexion gradually fades, 
until at length it becomes of a pale sickly hue, with a yellowish or greenish 
tinge, which has given rise to the name of the complaint. The other symp- 
toms already enumerated are slowly developed. The menses either do not 
make their appearance, or, if they have occurred, gradually undergo diminu- 
tion in colour and amount, until they entirely cease. The nervous symptoms 
are peculiarly prominent, and the patient is not unfrequently afflicted with all 
the harassing train of hysterical disorders. 
In its early stage, the disease is usually very manageable, and, when there 
are no organic complications, and the patient can be withdrawn from the in- 
fluence of the causes, may in general be cured, or at least placed in a fair way 
of recovery, in a period of time varying from two to four weeks. Under op- 
posite circumstances, and especially when improperly treated, it may termi- 
nate fatally. When long continued, it is apt to induce dropsy, and probably 
also organic disease of the heart. The excessive action into which this organ 
is thrown by the call from the capillaries for a more rapid current of blood, to 
supply the deficiency of nutritive material, leads to its enlargement; while 
defective nutrition renders it soft aud flabby. 
Upon dissection, the arteries and veins are found empty or scantily sup- 
plied with a serous fluid; the flesh is dry and does not bleed when cut; effu- 
sion of serum is observed in the pleura, pericardium, peritoneum, and cellular 
tissue; the heart is pale, soft, flabby, and often dilated; and various organic 
affections are not unfrequently discovered, such as tubercles, carcinomatous 
tumours, and enlargement or other disease of the liver, spleen, kidneys, or 
ovaries. When these latter affections are found, the probability is that they 
were the cause and not the effect of the morbid state of the blood. 
Causes.-The lymphatic temperament is believed to predispose to this com- 
plaint. The immediate causes are either such as directly detract from the 
amount of the blood, or such as diminish its production. Frequent bleedings 
repeated at short intervals, and spontaneous hemorrhages constantly recurring, 
such as epistaxis, the hemorrhoidal flux, haematemesis, and menorrhagia, are 
among the first set of causes. In the same category may be placed excessive 
secretory discharges, especially from the bowels and uterus. . To the second 
set of causes belong, in the first place, the want of due materials out of which 
the blood may be elaborated, and, secondly, derangement of the processes of 
digestion and sanguification by which it is produced. Food insufficiently 
nutritive, of difficult digestion, or otherwise unwholesome; the abuse of coffee 
and tobacco; excessive drinking, even of water; habitual exposure to cold and 
dampness; sedentary habits, or prolonged over-exertion; debilitating agencies 
in general; the depressing emotions, as grief, disappointment in love, ambi- CLASS III.] 
255 
ANEMIA. 
tion, or business, concealed and unanswered affections, and mental anxieties 
of all kinds, may be ranked among the causes of anaemia. The influence of 
the sexual apparatus may possibly in some unexplained mode interfere with 
sanguification, so far as to induce or favour the production of the disease. 
This is inferred merely from the circumstance, that it is most apt to attack 
young women about the age of puberty. Amenorrhoea, which has been some- 
times ranked among the causes of the disease, is more probably one of its 
effects, or at most a joint result of the same influence. Organic diseases of the 
stomach, bowels, liver, spleen, and heart, are frequent causes of anaemia, pro- 
bably by interfering with the processes by which the blood is produced. Chronic 
debilitating diseases have the same effect, partly through a similar influence, 
and partly by exhausting the blood. Bright's disease of the kidneys, in its 
chronic form, is very generally attended with anaemia, resulting in part at 
least from the loss of albumen, and probably, as shown by Dr. J. T. Plummer, 
of the extractives of the blood, with the urine. (See Am. J. of Med. Sci., 
N. S., xxvi. 389.) Among the most frequent causes of anaemia in this coun- 
try are the miasmatic fevers, and the visceral disorder, whether splenic or 
hepatic, which they so frequently leave behind. Chronic disease of the 
spleen is an extremely frequent associate of the affection, and probably very 
often in the relation of its cause. Cases have occurred in which the disease 
has attacked at the same time numbers of persons employed in coal mines, 
and the result has been ascribed to the dampness and want of light and pure 
air; but such cases are uncommon, while the causes to which they are 
ascribed are always in operation. In the particular cases recorded, the 
anaemia was preceded by severe disease of the bowels, to which, probably, as 
much as to the circumstances alluded to, the effect may be ascribed. (Diet, de 
Med., xii. 581.) Dr. Addison has called attention to a condition of anaemia 
in adult males, of which three cases proved fatal, and in all was found disease 
of the supra-renal capsules. (Ranking's Abstract, ix. 194.) The constitu- 
tional action of the preparations of lead has sometimes been evinced in the 
production of anaemia. 
Treatment.-In the treatment of this disease it is of the utmost importance 
to remove the causes. While these continue to act, the use of remedies will 
be of only temporary benefit. Should the digestive system be in disorder, it 
must be corrected; constipation must be obviated; any hemorrhage or other 
drain which may exist must be arrested; the menses, if retained, suppressed, 
scanty, excessive, or otherwise irregular, must be restored to the healthy 
state; and, in general, any other existing disease which may impair the di- 
gestive and assimilative processes, or debilitate the system at large, must, as 
far as possible, be removed. The modes of treatment which may be neces- 
sary for these purposes are given under the heads of the affections respect- 
ively to be corrected, and need not be repeated here. Close attention must 
be paid to the peculiar circumstances of the patient; and, whenever any moral 
cause is discovered to which the complaint may in part or wholly be ascribed, 
efforts should be made to obviate its influence. Moderate exercise in the open 
air, and especially on horseback, should be encouraged; the patient should 
sleep in well ventilated apartments; and the ill effects of unequal temperature 
should be prevented by flannel next the skin. All these measures, by invigo- 
rating the general health, will have a tendency to produce a more copious 
supply of well-conditioned blood. The same end will be promoted by a nutri- 
tious and digestible diet, as recommended in dyspepsia. 
The medicines best adapted to the disease are tonics, and especially the 
chalybeates, which, besides an invigorating influence over the process of 
digestion and the vital processes generally, have a peculiar power of increas- 256 
[PART II. 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
ing the richness and redness of the blood, by an operation not exactly under- 
stood. They produce, indeed, the very effect that is most wanted in this dis- 
ease, an augmentation, namely, of the proportion of red corpuscles.* Hence, 
the preparations of iron have been long considered almost as a sovereign re- 
medy in chlorosis. It matters little which of the preparations is employed, 
provided the iron finds access into the system. That one should be selected 
which irritates the stomach least, and is most rapidly absorbed. Perhaps the 
best is the pill of carbonate of iron of the U. S. Pharmacopoeia, which may be 
given in the dose of from 5 to 20 grains three or four times a day. The 
black impalpable powder of iron, the subcarbonate, black oxide, tincture of the 
chloride, solution of the iodide, potassio-tartrate, citrate, lactate, or sulphate, 
may also be used, at the discretion of the practitioner. Tannate of iron has 
been recommended as especially efficacious. When the case is one of pure 
anaemia, the chalybeates alone, united with a proper diet, will be sufficient 
for the cure. But, when the digestion is feeble, they may be advantageously 
combined with the simple bitters, such as the extract or infusion of gentian 
or quassia, and the powder or infusion of columbo; and the combination will 
be rendered more acceptable to the stomach, by the conjunction of some aro- 
matic, as ginger, or cinnamon. Mild laxatives may be added in cases of con- 
stipation, and of these, when uterine disorder is not involved, the best is 
rhubarb. But if amenorrhoea exist, aloes is the appropriate laxative, and 
should be given with each dose of the chalybeate in the quantity of one or 
two grains. The preparations of manganese have been recommended, and 
may be tried in cases which resist the chalybeates. The mineral acids are 
sometimes useful when the appetite is very languid, and, if the liver is func- 
tionally deranged, nitromuriatic acid should be preferred. But care should 
be taken that they do not prove injurious by a chemical incompatibility with 
the particular chalybeate employed. Nervous derangements may be com- 
bated by the occasional use of the antispasmodics, especially valerian and 
assafetida, and of the narcotic extracts, such as those of hyoscyamus and 
conium. The severe neuralgic pains which often attend the complaint may 
be relieved by blisters applied near the seat of the affection, and, if necessary, 
sprinkled with morphia after the removal of the cuticle. The daily use of the 
cold shower-bath, if followed duly by reaction, will often be found useful, and 
.may be resorted to in obstinate cases; and dry frictions over the surface have 
been recommended. 
It is often advantageous, in order to hasten or confirm convalescence, or 
evdn as a remedy in obstinate cases, to send the patient upon excursions to 
chalybeate springs at a distance from home, so as to combine with the medi- 
cinal effect of the iron the happy influences of exercise, pure air, novelty of 
* The effect of iron upon the constitution of the blood is astonishing. The proportion 
of the solid constituents, and especially of the red corpuscles, is rapidly increased. The 
fibrin, however, appears to be somewhat diminished. The following results were ob- 
tained by Herberger, and correspond essentially with those of Andral and Gavarret, and 
of Simon. (See Simon's Chemistry, Syd. ed., i. 313.) The blood examined was that of 
a chlorotic female of 20 years. The first column contains the results before she had taken 
iron, the second, after a course of chalybeates, which continued eight weeks. 
1 
2 
1 
2 
Water 
868.340 
807.080 
Albumen 
78.200 
81.509 
Solid constituents 
131.660 
192.290 
Globulin 
y Red corpuscles < 
36.470 
94.290 
Fibrin 
3.609 
1.950 
Hmmatin 
1.590 
4.029 
Fat 
2.310 
2.470 
Extractive matters and salts 
8.921 
8.236 
The diminution of fibrin is probably consequent upon its conversion into the substance 
of the red corpuscles. CLASS III.] 
LEUCOCYTHEMIA. 
257 
scene, and the enjoyments of society. Unless complicated with serious organic 
lesions, the disease may generally be cured, or materially relieved, by the 
means above detailed, in a period varying from two to six weeks. 
3. Leucocythemia. 
This name, signifying white-cell blood (zsvxo$ white, xvto$ cell, and ai^a 
blood), has been proposed by Professor Bennett, of Edinburgh, for a peculiar 
form of anaemia, characterized by the presence in the blood of a great excess 
of the white or colourless corpuscles, readily distinguishable from the blood- 
disks by their spherical shape, their greater size, their granular aspect, and 
the exhibition of nuclei when treated with acetic acid. A case of the disease 
had been examined after death by Virchow, of Berlin, who named it leukhemia, 
signifying white blood; but, as the blood has the ordinary colour, this name 
is inappropriate, and I prefer that of Dr. Bennett, who also deserves the credit 
of having first given a full account of the affection. (See Ed. Month. Journ. 
of Med. Sci., Jan., April, Aug., and Oct., 1851.). 
So far as the mere condition of the blood is concerned, there does not ap- 
pear to be any considerable difference between the symptoms of this disor- 
der and other forms of anaemia. The surface is usually strikingly pale, and a 
tendency to oedema is generally observable. But, in all cases hitherto noticed, 
the complaint has been associated with organic diseases, upon which it probably 
depended, and which gave rise to most of the attendant symptoms. Of these 
associated affections, enlargement of the spleen is the most common, having 
indeed been noticed in almost all the cases. In many the liver was enlarged, 
as were also the lymphatic glands. No case, I believe, has been observed, in 
which one of these structures was not affected. Abdominal dropsy, jaun- 
dice, diarrhoea, vomiting, hemorrhage especially from the nostrils, and occa- 
sional attacks of fever, which occurred in several of the cases, were obviously 
dependent less on the state of the blood, than on the accompanying organic 
complaints. There seems to be little doubt that the spleen is the real source 
of the blood affection in almost all the cases noticed. How it produces this 
effect may, in the present state of our knowledge, be conjectured, but remains 
yet to be proved. There is some reason to suppose that the white corpuscles 
of leucocythemia are in fact pus corpuscles, and not the genuine healthful 
white corpuscles of the blood. In the first place, the general symptoms of 
the disease are of a character to render this highly probable; and secondly, 
according to Mr. De Chaumont, they are affected in the same manner as pus 
corpuscles by chloroform, which clears them up and brings the nuclei into 
view, while it has no effect on the colourless corpuscles of the blood. (Ed. 
Month. Journ. of Med. Sci., May 1853, p. 470.) Most of the cases described 
terminated fatally, and in relation to the remainder the result does not seem 
to have been determined. No case of a positive cure is recorded by Dr. 
Bennett. It is highly probable that this condition of the blood is very com- 
mon in the miasmatic regions of the United States, in which disease of the 
spleen abounds. An interesting case of the kind came under my care in the 
Pennsylvania Hospital, which ended in apparent recovery, and of which some 
details are given in a note below.* Another case has since come under my 
notice, with enormous disease of the spleen, which ultimately proved fatal. 
* The patient was a lad about seventeen years of age, who came to the hospital from 
sea, having been in the West Indies, and on the coast of North Carolina. We could not 
learn from him that he had been aifected with intermittent or remittent fever. He was 
extremely anemic, with edematous limbs, and very feeble. The spleen was enormously 
enlarged, and the abdomen tumid. Dr. Addinell Hewson, one of the resident physicians 
of the hospital, examined the blood, and found it to abound in the white corpuscles. 258 
[part II. 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
Article III. 
SCURVY, or SCORBUTUS. 
Scurvy may be defined to be a disease in which the blood is depraved, and 
the system debilitated, with a tendency to hemorrhage and petechiae, and to 
local congestion or feeble and imperfect inflammation in various parts of the 
body, but especially in the gums, and without any necessary febrile compli- 
cation. There can scarcely be a doubt that its essential character is an 
altered state of the blood, and that all its phenomena flow directly or indi- 
rectly from that source. 
The complaint has probably existed from the earliest times; and obscure 
notices of it may be found in the writings of the ancients. The first distinct 
account of it is contained in the history of the Crusade of Louis IX., in the 
thirteenth century, against the Saracens of Egypt, during which the French 
army suffered greatly before Damietta, from this among other diseases. But 
it was little noticed by medical writers until the sixteenth century, when the 
revival of letters gave a new impulse to inquiry in every direction. At that 
time it prevailed endemically in various parts of Europe, especially in the 
north; and it continued to prevail, with little abatement, until towards the 
middle of the last century. Though found among the peaceable population 
of towns and villages, and especially among those engaged in other than 
agricultural pursuits, it was most destructive in armies and besieged cities, 
and in the seafaring classes; the hardships and privations incident to the life 
of the soldier and seaman being the most efficient causes of the disease. The 
accounts of its ravages given by historians and medical writers, during the 
period mentioned, are in the highest degree revolting. Many thousands were 
often cut off, within a few months, in single armies and garrisons; and it is 
probable that more seamen perished of scurvy alone than from all other 
causes combined, whether sickness, tempest, or battle. The narrative of 
almost every long voyage made in the sixteenth, seventeenth, and earlier part 
Not less than thirty were visible in a portion of diluted blood in the field of the micro- 
scope. The patient was put upon the use of sulphate of quinia, the pill of carbonate 
of iron, and rich animal food. His general health rapidly improved, the spleen grew 
less, the dropsical symptoms quite disappeared, and he became florid and full under 
the treatment. But the white corpuscles were little diminished; and it was soon noticed 
that, though the spleen had shrunk nearly to its normal size, the liver had become greatly 
enlarged, and was somewhat painful on pressure. Attributing the hepatic affection to 
excess of stimulation from the medicine and rich food, I directed the quinia and iron to 
be omitted, small doses of the blue mass to be administered, a blister to be applied over 
the liver, and the diet restricted to vegetable food. Under this plan the liver was soon 
much diminished, but the spleen again increased in size, and the anemic symptoms 
began to reappear with a somewhat mottled and purplish hue of the surface. As the 
gums were slightly affected by the blue pill, this was omitted, nitromuriatic acid was 
substituted, a blister applied over the spleen, and a milk diet directed. His health now 
rapidly improved, and the spleen and liver were both gradually reduced in size ; but as 
he continued anemic, the acid was omitted, and the pills of carbonate of iron, with a full 
diet ordered. Under this treatment he continued steadily to amend, and at length was 
restored to perfect health, with a good colour, strong, fleshy, and free, so far as could 
be ascertained, from splenic or hepatic disease. The proportion, moreover, of the white 
corpuscles gradually diminished, and, when the blood was last examined, it exhibited 
only two or three in the field of the microscope, where thirty or more had been pre- 
viously seen. He was dismissed from the hospital, after having been under treatment 
59 days. A particular account of the case has been published by Dr. Hewson, who 
made all the microscopic observations. (See Am. Journ. of Med. Sei., N. S., xxiv. 365.) CLASS III.] 
259 
SCURVY. 
of the eighteenth centuries, is a record of its terrible fatality. Whole crews 
were prostrated, fleets crippled, and great expeditions frustrated by this sin- 
gle scourge. The memorable voyage of Lord Anson, in which more than 
eighty out of each hundred of the original crews perished of scurvy, is fami- 
liar to every reader. The extension and improvements of agriculture, the 
ameliorated condition of the lower classes, the altered modes of warfare, and 
a more generally diffused knowledge of the causes of the disease and the 
modes of preventing it, have gradually diminished its prevalence in Europe, 
where it is now comparatively rare; and, since the time of Captain Cook, who 
led the way in the adoption of effectual means of prevention at sea, it has 
ceased to be the terror of seamen, and occurs only where the requisite pre- 
cautions have been carelessly neglected, or rendered nugatory by unavoida- 
ble accident. In this country it is very little known, and there are many 
practitioners, even in our cities, who have never seen a decided case of it. But, 
as its prevalence depends on causes which may be brought into operation at 
any time, and in any place, it becomes important that the profession should 
be thoroughly conversant with all that relates to it, so that it may be at once 
encountered when met with, and means of prevention suggested wherever 
they may seem to be required. This remark is especially applicable to the regu- 
lation of the diet in prisons, hospitals, asylums, garrisons, ships, &c., which fre- 
quently comes under the direction of the medical man, and should always 
have reference to the possible occurrence of the disease in such situations. 
Even the regimen of the sick, in ordinary private practice, should be regu- 
lated by the physician with some regard to scurvy, which, within the expe- 
rience of the author, has appeared to result, in one instance at least, from a 
restricted diet, too long continued, under medical direction. 
Symptoms, Course, &c.-Scurvy is generally very gradual in its approach, 
so that it is scarcely possible to say, in any particular case, what was its pre- 
cise time of attack. Attention is commonly first attracted by an unhealthy 
paleness of complexion; a feeling, on the part of the patient, of languor and 
despondency, with an indisposition to bodily action, and unusual fatigue after 
exercise; a sensation of weariness and aching in the limbs as from over- 
exertion, though the patient may have been at rest; and some swelling, red- 
ness, and tenderness of the gums, with a tendency to bleed from slight causes.* 
With the advance of the disease, the face becomes paler, and assumes a some- 
what sallow or dusky hue, and often a degree of puffiness; the lips and tongue 
become pallid, and contrast strikingly with the gums, which are purple or 
livid, especially at their edges, rise up between and around the teeth, are soft 
and spongy, and bleed from the slightest touch; the breath is offensive; pur- 
plish spots or blotches appear upon various parts of the surface, beginning 
usually upon the lower extremities, and afterwards extending to the trunk, 
arms, and neck, though seldom affecting the face; hemorrhage frequently 
occurs, most commonly from the nose, gums, and mouth, but sometimes also 
from the stomach, bowels, and urinary passages; the feet become edematous, 
and the legs swollen and painful; the general debility increases; and mus- 
cular exertion is apt to be attended with palpitation of the heart, panting, 
vertigo, dizziness, and a feeling of faintness. The petechial spots are obvi- 
* Dr. Foltz, of the U. S. Navy, in a report on the scur,vy which appeared in the squa- 
dron blockading the ports in the Gulf of Mexico, states that "lassitude and indisposition 
to muscular energy were not among the symptoms which ushered in the disease," and 
that "there were great activity and not unfrequently cheerfulness, good appetite, and 
sound sleep at night, after the teeth were loosened, the gums ulcerated, the limbs edema- 
tous and discoloured." When at last the patient gave way, "it was not an indisposition 
to corporeal exertion, but an actual disability." (Am. Journ. of Med. Sci., N. 8., xv. 47.) 260 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
[PART II. 
ously owing to the extravasation of blood within the cutaneous tissue. They 
are usually small and irregular, but sometimes as large as the palm of the 
hand, or even larger. Occasionally portions of surface look as if bruised, 
without having suffered any violence; and blows, which, under ordinary cir- 
cumstances, would produce no effect, now give rise to extensive ecchymoses. 
Should the disease still continue, all the symptoms become aggravated. The 
complexion assumes often, with its paleness, a livid or leaden hue; the gums 
swell greatly, and put forth a blackish fungous growth, so as sometimes to 
conceal the teeth; blood continually oozes from them; sloughing occasionally 
takes place, laying bare the neck of the teeth, and extending, in very bad 
cases, even to the cheek; the teeth become loose and sometimes fall out; the 
patient is unable to chew solid food in consequence of the state of his gums; 
the breath becomes intolerably offensive; hard and painful tumefactions occur 
in the calves of the legs, among the muscles of the thigh, upon the tibiae and 
lower jaw, and in the hand, with stiffness and contractions of the joints, espe- 
cially of the knees, and severe pain in the extremities upon every attempt at 
movement; and the debility, before so prominent a feature in the case, now 
becomes excessive, so that the least exertion is dangerous, and the patient 
sometimes dies suddenly upon rising from bed, or upon being conveyed, with- 
out great caution, from one situation to another. Various other unpleasant 
phenomena are often presented. Wounds, and even slight scratches, degene- 
rate into unhealthy ulcers, old cicatrices break out afresh, and existing ulcers 
assume a new and much worse aspect. A sanious liquid flows from their 
surface, or blood oozes out and coagulates, forming an adhering crust, or a 
soft, thick, gory mass, which sometimes increases rapidly and attains an in- 
credible size. The ulcerated surface itself is soft, with large flabby granu- 
lations about the edges. The bones are said to be softened, united fractures 
are again opened, and, in the young, the epiphyses sometimes separate from 
the bones. Eruptions upon the skin assume a purplish or livid colour; and 
the seats of existing or previous injury of almost every kind become points 
for new morbid action. Thus, when the gums are affected by mercury, they 
usually suffer more and in a greater degree than under ordinary circum- 
stances. Along with the prostration of the vital powers, there is often dis- 
played a strong tendency to local congestions of a low inflammatory character, 
attended with the effusion of blood or fibrin, which not unfrequently coagu- 
lates, and, when in vital organs, becomes a source of great danger. Hence 
the hard and painful tumours of the extremities already spoken of. These 
congestions and effusions may take place in the substance of the lungs, simu- 
lating pneumonia; in the cavities of the pleura and pericardium, giving rise 
to dyspnoea and fatal oppression; within the cranium, producing drowsiness, 
coma, and apoplexy. Similar extravasations happen in the synovial cavities. 
But in none of these cases, as a general rule, does genuine suppuration occur. 
Serous effusion also frequently takes place into the cellular tissue and closed 
cavities, and is sometimes so copious as to amount to general dropsy. When 
in the parenchyma of the lungs, it occasions great embarrassment of respira- 
tion. Death sometimes results from pure debility, sometimes from derange- 
ments of the vital organs, and is occasionally preceded by irritative fever, and 
wearing affections of the bowels. 
Throughout the complaint, the tongue is usually clean and moist, and the 
appetite and digestion remain unimpaired almost to the last, unless the dis- 
ease, as sometimes happens, should be complicated with fever. Indeed, there 
is often a craving for food, especially for fresh fruits and vegetables; and one 
of the most painful circumstances in the complaint is sometimes the inability 
to indulge this craving, either from the want of wholesome food, or from the CLASS HI.] 
261 
SCURVY. 
impossibility of chewing the hard materials supplied, in consequence of the 
state of the gums and teeth. Occasionally, however, there is vomiting, with 
epigastric distress, and other evidence of stomachic disorder. The bowels are, 
in most cases, costive, and in some obstinately so; but diarrhoea also not un- 
frequently intervenes, with black or bloody and offensive evacuations. The 
pulse is generally small, feeble, and slow; and the skin below the healthy 
temperature; but cases occur in which the pulse becomes very frequent, and 
the surface febrile, probably from the sympathy of the system with various 
local irritative congestions. The skin is usually dry, and is said not unfre- 
quently to assume the appearance of goose-flesh, though smooth and shining 
upon the extremities when swollen. The urine is scanty and high-coloured. 
Great emaciation usually attends the disease when severe or lasting, but not 
invariably. Little cerebral disturbance is ordinarily observable; and the 
patient often retains full possession of his senses and intellect to the close. He 
is even scarcely sensible of his weakness; feeling while at rest, as if compe- 
tent to exertion, and only learning his error upon trial. Sometimes, however, 
delirium occurs in the advanced stages. Nyctalopia has been occasionally ob- 
served as a commencing symptom.* The patient is often unable to sleep at 
night; and this is said to be among the most painful symptoms. 
Scurvy is very variable in its course. Generally, as already stated, it is 
gradual in its approaches. Sometimes, after remaining latent for a conside- 
rable time in the system, it breaks out fiercely, and runs a very rapid course 
to its termination. In other cases, it remains for a great length of time with- 
out aggravation, and ceases under a change of circumstances. Much depends 
upon the constitution and previous strength of the patient. Persons debili- 
tated by disease, age, or intemperance, yield most readily to its onset, and 
sink soonest under it. At sea, it is usually much more violent than upon 
land, in consequence of the greater intensity of its causes. Conversely, how- 
ever, land-scurvy is in general more obstinate under treatment, probably 
because the constitutional tendency must be stronger, to have led to the dis- 
ease under circumstances so much less unfavourable. Land-scurvy, as usually 
seen at present, is a comparatively mild affection; seldom exhibiting severer 
symptoms than an altered complexion, red, swollen, tender and bleeding 
gums, offensive breath, occasional epistaxis, petechias on the extremities, 
edematous feet, a weak pulse, and more or less muscular debility. There 
does not, however, appear to be any real ground for the distinction which has 
sometimes been made into sea and land scurvy. The affections are identical, 
and, when the causes upon land are as powerful as at sea, as sometimes hap- 
pens in besieged cities, the ravages of the complaint are not less fearful. 
Scurvy is occasionally complicated with other diseases, which greatly aggra- 
vate the danger. Of these, the most fatal are probably typhus fever and 
dysentery, which are the more common attendants, as they are produced by 
causes which, if not identical, are very frequently coincident with those of the 
complaint under examination. 
The disease generally occurs towards the close of winter or early in spring. 
It is more prevalent in cold than in warm countries, and among the poor than 
among those in comfortable circumstances. Officers frequently escape when 
the disease is rife among the common soldiers and seamen. It is more fre- 
quent and fatal in the old than in the young, though no age is exempt. 
Anatomical Characters.-1The most characteristic'phenomenon revealed by 
* See papers by Mr. George Bennett, in the London Med. Gaz. (vol. ix.); by Dr. 
Edward Coale, of the U. S. Navy, in the American Journ. of Med. Sci. (N. S. iii. 72); 
and by Dr. John Rees, of the British Navy, in the Lond. Med. Times and Gaz. for Sept. 
1854 (page 233). 262 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
[PART II. 
dissection is the presence of extravasated blood, in greater or less amount, in 
various parts of the body. The purple spots upon the skin are nothing more 
than so many ecchymoses in its substance, or in the subcutaneous cellular 
tissue. Similar purple or blackish stains are observed in the/mucous and 
peritoneal coats of the bowels, and the mucous coat is often stained with 
effused blood. Clots of extravasated blood or coloured fibrin are found in the 
cellular tissue, the substance of the muscles, between the periosteum and 
bones, and occasionally in the serous cavities. Dr. Budd states that, in the 
cases in which the bones were thus separated from the periosteum, he ob- 
served no signs of caries or exfoliation. Not uncommonly, dark liquid blood 
distends the cavities of the pleura, pericardium, and peritoneum, and those 
of the synovial membranes, but seldom the arachnoid. Dr. Karawagen, out 
of sixty patients who died of scurvy at Kronstadt, found bloody effusion in 
the pericardium in thirty cases, in the pleura in twenty-two, in the perito- 
neum in two, and within the cranium only in one. The liquid in the peri- 
cardium amounted to four or five pints, in the pleura to ten or twelve pints, 
and in the peritoneum to from thirty to thirty-five pints. (See Med. Ex- 
aminer, iv. 525.) These, however, were uncommon cases; and the disease, 
which occurred among the seamen of Kronstadt as a kind of epidemic in the 
spring and summer of 1839, was peculiarly characterized by this tendency to 
bloody effusion in the cavities. Serous effusion, transparent or coloured with 
blood, is also found in the cellular tissue, the serous cavities, and the paren- 
chyma of organs, especially of the lungs. Though generally free from bloody 
extravasation, the ventricles of the brain frequently contain considerable 
quantities of serum. Coagula of blood or of fibrin are found in the cavities 
of the heart, and thin, liquid blood in the great veins. Andral observed, in 
one case, the aorta filled with liquid black blood. (Clin. Med., i. 585.) The 
spleen is often enlarged, distended with blood, and very soft. When not 
coloured by effused blood, the muscles and mucous membranes are pale. The 
texture of the heart and muscles generally is often flabby. The bones have 
sometimes been found unusually fragile, infiltrated with blood, separated 
from their cartilages and epiphyses, and disjoined in the position of old and 
united fractures. Various results of recent or old inflammatory processes in 
different parts of the body have also been noticed; but these were probably, 
in most cases, mere complications, and not essential parts of the disease. 
Causes.-Different opinions have been held as to the causes of scurvy; and 
the medical world is not yet united. Some have thought that it arises from 
the use of salted provisions, and that an excess of salt is the source of the 
mischief. This opinion was advocated by Cullen, and seemed to be in some 
measure justified by the fact, that the disease had been most severe among the 
crews of ships, who were confined for a long time exclusively to salt meat and 
bread or biscuit. But subsequent experience has proved that it may occur 
among persons plentifully supplied with fresh meat, and with that exclusively; 
while patients will recover from the disease though using salt meat freely, if 
also furnished with fresh vegetables. 
Some writers have ascribed the disease to the use of spoiled meat, worm- 
eaten bread, and putrid water, which, as they supposed, could not but supply 
a putrid blood. Crews furnished exclusively with this kind of aliment have 
undoubtedly suffered terribly with scurvy; but in all such cases there was a 
want of vegetables; and 'the use of putrid meats, under other circumstances, 
does not necessarily induce the disease. 
Others have found a solution of the problem in the influence of impure air, 
especially when aided by cold and dampness. In explaining the prevalence 
of the disease at sea, they look less to the provisions than to the confinement CLASS III.] 
263 
SCURVY. 
of the seamen in close, crowded, and filthy holds. Hence, too, the frequency 
of the disease in prisons, camps, and besieged towns, where great numbers 
are crowded together. But they do not appear to have adverted to the fact 
that, notwithstanding the utmost care in ventilating ships, and preserving 
cleanliness and purity of air, the disease has arisen and raged unchecked, so 
long as the proper food was wanting. Besides, these causes are at present 
constantly operating in various over-crowded cities; and we are as constantly 
witnessing their influence in the production of typhoid diseases; but we 
scarcely ever see scurvy result from them. The greater prevalence of the 
disease in cold countries has been ascribed to the influence of temperature; 
but even in the coldest regions there is an entire exemption from it, when 
fresh vegetables are sufficiently supplied; and the fair inference is, that 
climate acts chiefly as it favours, or otherwise, an access to this kind of food. 
Meat, whether fresh or salt, cannot be the cause of the disease; for it is 
sometimes produced when little or no meat is furnished, as among the people 
of India, when confined in hospitals or prisons, and fed upon rice and other 
farinaceous products. The author has witnessed a case of the disease in a 
young lady, who was confined for a long time, for the cure of an obstinate 
diarrhoea, to a diet exclusively of barley. 
Dr. Budd, the author of an elaborate treatise on scurvy, contained in 
Tweedie's System of Practical Medicine, has diligently compared a great 
number of accounts of the disease drawn from various sources, and appears 
to have pretty nearly established the conclusion, that the one essential cause 
is the want of fresh succulent fruits and vegetables, or their juices, which he 
supposes to furnish some principle necessary to the due constitution of the 
blood, and not to be found elsewhere, or, at least, nowhere in the same per- 
fection. In all the instances adduced of the prevalence of scurvy, there was 
a deficiency of this kind of food, and in none did the disease occur when it 
was sufficiently supplied. No matter what the diet, so that this was wanting, 
scurvy would make its appearance; while with it, neither salted nor spoiled 
provisions, nor confined and impure air, nor cold, moisture, and fatigue, nor 
all these agents together, were competent to produce it. Hence the preva- 
lence of the disease in the latter part of winter and the beginning of spring, 
when fresh vegetable food has been exhausted, and the new growth has not 
yet sprung up; and its sudden cessation with the return of vegetation. 
Hence its comparative frequency in voyages commenced in early spring, 
when the blood has been depraved by a long confinement to a winter diet, 
and the ship has sailed either scantily supplied with fresh vegetables, or en- 
tirely without them. Hence, too, the general subsidence of the disease with 
the advance of agriculture, its comparative absence among an agricultural 
population, and the exemption now enjoyed by the poor, who have, in gene- 
ral, easy access to fresh vegetables, and live largely upon potatoes, considered 
among the very best antiscorbutics. The almost total expulsion of scurvy 
from public ships of war, since care has been taken to furnish them with the 
proper sort of food, is another proof of the same kind. The recent prevalence 
of scurvy in some parts of Great Britain and Ireland, where it had been pre- 
viously unknown, is very probably owing to the omission of potatoes as an 
article of diet, consequent upon the blight which has so extensively affected 
that important crop; and, indeed, the malady has, in many instances, been 
traced directly to this origin. But there is still some difficulty in admitting, 
without reservation, the opinion of the necessity of fresh vegetables, and their 
exclusive possession of the antiscorbutic power. How, upon this ground, can 
we explain the exemption of the Esquimaux, who, during their long winters, 
live on the food they draw from the ocean; and of our western hunters, who 264 
[part II. 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
feed almost exclusively upon game during the same season ? In the report 
of Dr. Gale, of the U. S. Army, dated Council Bluffs, October, 1820, it is 
stated that scurvy broke out in the regiment stationed at that point, near the 
close of January, and raged with great severity until the 7th of April, when 
wild vegetables appeared, and an immediate check was put to it. The soldiers 
were confined to a diet of 11 salted or smoke-dried meats, without vegetables 
or groceries," in an extremely inclement season, and when their strength had 
been exhausted by unusual exertion. It is not surprising that the disease 
was fatal among them; but the point of particular interest at present is, that 
the hunters who resided in the woods, and subsisted on game, and a detach- 
ment of troops who were sustained in the same way, were entirely exempt. 
(Am. Journ. of Med. Sei., N. S., iii. 79.) It appears, from this statement, 
that fresh wild meat is a preservative against scurvy; unless, indeed, the 
hunters and soldiers who escaped may have employed some antiscorbutic de- 
rived from the forest-trees. 
Though it appears to be pretty well proved that the want of fresh vegetable 
food is the most frequent cause of scurvy, it must be admitted that other 
causes often co-operate with this, and produce a predisposition which favours 
the attack of the disease. Whatever debilitates the system, or tends to de- 
prave the blood, will probably have this effect. Among these accessory or 
predisposing causes may be enumerated, previous disease, famine, unwhole- 
some diet, as of putrid meat and worm-eaten, musty, or otherwise injured bis- 
cuit and bread, bad water, foul air, sedentary and indolent habits and want of 
personal cleanliness, the depressing passions, exhaustion from fatigue, exposure 
to cold, intemperance, and the debility of old age. It has often been observed, 
on octasions when scurvy raged among multitudes of people, that persons in 
sound health, with a cheerful and confident spirit,,and active habits of mind 
and body, escaped entirely, or were but slightly affected, though partaking of 
the same fare with those who were dying around them. 
Nature.-All the phenomena of scurvy, as well as the character of its 
cause, point to the blood as the original seat of the disorder. Some have 
supposed that the first link of the chain of diseased action is in the func- 
tion of digestion, which fails to effect a due elaboration of chyle out of the 
materials presented, and thus produces a vitiated blood. But the fact is, 
that the organs of digestion are remarkably exempt from derangement, 
throughout almost the whole course of the complaint. The appetite is unim- 
paired, and the food readily digested; and as soon as suitable materials out of 
which good blood can be prepared are offered, there is no deficiency in the 
powers of assimilation. It is, indeed, wonderful how rapidly the system re- 
covers from the lowest depths of prostration, when the opportunity is presented, 
proving that the fault is not in its actions but in its supplies. But, though it 
is easy to decide that the blood is disordered, it is not so easy to say in what 
manner. Writers on scurvy have generally stated that the blood is dissolved; 
that when taken from the body it refuses to coagulate, or coagulates partially, 
forming a black, semi-fluid, jelly-like mass, from which the serum separates 
but imperfectly, if at all. When the serum does separate, it has been de- 
scribed as reddish from the corpuscles held in solution, and has even been said 
to have an acrid taste. (Roupe, De Morb. Navig., p. 147.) After death, 
too, the blood is asserted to be found as a dark fluid in the larger vessels. 
There is, no doubt, some truth in these statements. But it is certain that 
this is not always the condition of the blood. It has been noticed, for exam- 
ple, that, where scurvy is complicated with inflammation, not only does the 
blood coagulate, but the clot exhibits the buffy and cupped surface. In the 
blood of three patients affected with well-marked scurvy, Dr. Budd states CLASS III.] 
SCURVY. 
265 
that the separation into serum and clot was as perfect and as rapid as in that 
of healthy persons. In two of these, the coagulum was small, firm, huffy, 
and cupped. Though liquid blood exists in the large vessels after death, coagula 
of blood or fibrin are often found in the heart. Dr. Budd considers the blood 
as resembling that of chlorosis in the diminution of red corpuscles; and that 
there is a deficiency of this constituent is evinced by the paleness of the 
surface during life, and of the mucous membranes, when not stained by 
extravasated blood, after death. Andral found in the blood of a scorbutic 
patient whom he examined a great deficiency of fibrin, and is disposed to 
consider this as characteristic of the disease. (Patholog. Haematol., Am. ed., 
p. 96.) He is thus enabled to account for the frequent hemorrhages that 
attend it. Mr. Busk, however, found a great excess of fibrin in the blood of 
three scorbutic patients, with as marked a diminution of the colouring mat- 
ter. ( Tweedie's Sy st. of Pract. Med., Article Scurvy.) It is obvious, there- 
fore, that neither an excess nor a deficiency of fibrin characterizes the blood 
of scurvy. A deficiency of the red corpuscles, though it probably in general 
attends the complaint, is not its distinguishing character; for the same de- 
ficiency exists in chlorosis, which is an essentially different disease. From 
the observations of the same experimenters, it may be inferred that the pro- 
portion of albumen is not materially different from that of health. The 
distinguishing peculiarity of scurvy, therefore, does not consist in the want 
of a due proportion of either of the three prominent constituents of the blood. 
This proportion may be deranged, but there is something else; there is some- 
thing wanting which is afforded by a diet of fresh, and especially of succulent 
fruits and vegetables. What this is has not been determined, and it is use- 
less to conjecture. The question must be left for solution to the skill of the 
analytic chemist.* 
* Since the first publication of this work, numerous experiments have been made 
with a view of determining the condition of the blood in scurvy. It has frequently 
been found to coagulate, and even to present the cupped surface. In relation to its 
organic constituents, the results have been confirmatory of the statements made in the 
text. From a comparison of those most to be relied on, it appears that, upon an average, 
the proportion of albumen is about as in health, that of fibrin slightly increased, and 
that of the red corpuscles greatly diminished. The saline constituents are in about 
the normal quantity. The microscopic characters of the red corpuscles, and their 
chemical constitution so far as discovered, do not appear to be altered. MM. Chatin and 
Bouvier noticed that the albumen, in a case which they examined, required a tempera- 
ture for coagulation of 165° F., at least 5° higher than is requisite in health, and that the 
plasticity or cohesion of the fibrin was greatly diminished. For a particular account of 
the results of the several analyses, the reader is referred to the British and Foreign 
Medico- Chirurgical Review for October, 1848. 
Some interesting experiments have been made by Dr. Garrod, of London, which direct 
attention to potassa as the ingredient of the blood, a deficiency of which may be the 
characteristic pathological condition of scurvy. Dr. Garrod found 1. that articles of food, 
the exclusive use of which were known to produce scurvy, contained less of the salts of 
potassa than those which are capable of supporting the system in the healthy state; 2. 
that those substances which act as antiscorbutics, such as fresh fruits and vegetables, and 
especially potatoes, contain a large proportion of these salts; 8. that the blood of a scor- 
butic patient examined by himself contained a much smaller proportion of potassa than 
healthy blood, and that less was excreted with the urine; and 4. that the disease may 
be cured by the addition of small quantities of some one of the salts of potassa to the 
food. Dr. Garrod also makes the suggestion, that the muscular debility of scurvy may be 
explained upon the supposition, that the muscles are deficient in potassa, which is con- 
tained in them largely in health, and, according to Liebig, is essential to their action. 
But it appears to me that much further investigation will be necessary before the truth 
of this hypothesis can be considered as established. Opposed to it at present are the 
facts, that nitre, which is a salt of potassa, though said to be occasionally useful in scurvy, 
has often failed to cure it; that, on the contrary, the disease has been cured simply by 266 
[PART II. 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
Diagnosis.-The only disease with which scurvy is liable to be confounded 
is purpura, which resembles it in various points. The diagnostic characters 
of the two affections will be pointed out under the head of purpura. 
Treatment.-No disease of equal severity yields more rapidly to proper 
treatment than scurvy, and in none is the treatment more simple. Remove 
the patient from the influence of the causes which produced the complaint, 
and give him suitable food, and it is wonderful how quickly recovery begins, 
and bow rapidly it proceeds. A ship's crew affected with scurvy, daily losing 
one or more of their number, with scarcely enough upon their feet to navi- 
gate the vessel, and no other prospect before them than a miserable death, 
unexpectedly come across a green island, and cast their anchor in one of its 
quiet bays. The deepest despondency gives way to cheering anticipations, 
and exertions are made which would before have seemed beyond their power. 
The helpless are landed, shelter is obtained, and all are plentifully supplied 
with fruits and vegetables. An almost instantaneous improvement takes place. 
The complexion begins to assume the hue of health, the gums become firm, 
hemorrhage ceases, the petechias fade away, muscular strength returns, ulcers, 
if existing, take on a healthy aspect, and, in the course of a few days, the 
patient, whom the next day or even the next hour might have'seen perish 
without relief, is so far recovered as to be able again to assume the discharge 
of his active duties. 
The important point in the treatment of scurvy is, therefore, the supply of 
suitable food; and it is highly desirable to understand what substances have 
the antiscorbutic virtue, and the relative degree in which they possess it. It 
has already been stated that fresh fruits and vegetables are highly antiscor- 
butic. Probably the most effectual among these are lemons, limes, oranges, 
and other fruits belonging to the family of Aurantiaceae, most if not all of 
which contain citric acid. Lemon-juice is in itself an excellent remedy for 
scurvy, and if to be obtained should be freely administered to the patient in 
the form of lemonade. Most acidulous fruits have similar virtues, and it has 
been observed that they are usually most effectual when eaten before they 
have become perfectly ripe. Fresh succulent vegetables perhaps come next 
in order, and they are generally better raw, as in the form of salad, than 
cooked. Those belonging to the natural order of Cruciferae have long had an 
antiscorbutic reputation. Such are cabbage, turnips, radishes, horseradish, 
scurvy-grass, mustard, water-cresses, capers, &c. Cabbage, in the form of 
sour-krout, in which it has undergone a slight fermentation and become sour, 
is highly esteemed, and considered as among the best remedies in scurvy. 
The different sorrels, lettuce, spinage, celery, parsley, endive, garlic, onions, 
carrots, and potatoes, are all classed among the antiscorbutic vegetables. Raw 
potatoes have long enjoyed some credit; and, from the statements of Dr. Bally, 
of England, it appears that they are highly antiscorbutic when boiled. From 
an examination of the dietaries of different prisons and pauper asylums, he 
found that, when potatoes were excluded, or allowed only in small quantities, 
scurvy was apt to occur, while in those well supplied with them it was want- 
ing; and he succeeded in banishing the disease from the Milbank Peniten- 
tiary by their use. From three to six pounds, he thinks, should be allowed 
weekly to each inmate of similar institutions. (Braithwaite's Retrospect, Am. 
the addition of pure citric.acid, which contains no potassa, to the diet of the patient; and 
that nitre is frequently used in the preparation of salted beef, which is one of the promi- 
nent substances used as food by scorbutic crews. When in London, in the summer of 
1848, I was informed of a case of scurvy, which, after failure under a course of treat- 
ment with the salts of potassa, immediately began to recover when the patient was 
allowed to eat fresh vegetables. (Note to the second edition.') CLASS III.] 
SCURVY. 
267 
ed., No. 7, p. 197.) Perhaps one of the reasons why scurvy is less preva- 
lent among the poor than formerly is the general use of the potato; and it 
has been already stated, that the recent prevalence of the disease in some 
parts of the British Islands has been ascribed to the want of it. Milk is 
thought to be antiscorbutic. Perhaps, to a certain extent, it is so; but cases 
of the disease have occurred among persons plentifully supplied with milk, 
but destitute of fresh vegetables. The pines, spruces, and firs, probably have 
antiscorbutic properties. Their tops, in the form of decoction, have often 
been used as a remedy or preventive with asserted advantage. This know- 
ledge may be of use to hunters, and others who spend long winters in the 
pursuit of furs, and subsist chiefly on game. Various fermented liquors have 
enjoyed some reputation. Among them may be mentioned, spruce beer, cider, 
malt liquors, and wines, particularly the lighter and acidulous kinds. Infu- 
sion of malt was highly esteemed by Captain Cook. Pure farinaceous sub- 
stances have little antiscorbutic virtue; the disease often breaking out among 
persons plentifully supplied with this kind of food. But the sowens of the 
Scotch, a mixture of oatmeal and water, which has undergone a slight acetous 
fermentation, is said to be of great efficacy. It was a natural inference from 
the general usefulness of sour vegetables, that vinegar might be found anti- 
scorbutic ; but it has repeatedly failed on trial, and the same may be said of 
the mineral acids. Nevertheless, pickled fruits and vegetables are not with- 
out virtue. Dr. G-. Perin, of the U. S. Army, found the juice of Agave 
Americana, the maguey of the Mexicans, in the dose of two or three fluid- 
ounces three times a day, an excellent remedy in scurvy, more efficacious even 
than lime-juice. (W K Journ. of Med., N.'S., vii. 182.) 
From what has been said, it may be inferred that a patient with scurvy 
should drink freely of lemonade, and, along with a due proportion of easily 
digested fresh animal food, and farinaceous substances, should also partake of 
potatoes, raw cabbage or sour-krout, or such other vegetables included in the 
above list as he may prefer, or as may be attainable. In the absence of fresh 
lemon or lime-juice, citric acid may be employed, though probably less effica- 
cious. While the gums are sore and the teeth loose, milk, and soups con- 
taining vegetables, may be substituted for harder food. If there is consider- 
able debility, cider, the malt liquors, or wine should be allowed. In cases of 
very great debility, the patient should not be incautiously removed from his 
bed or hammock; and, when removal is necessary, he should, as recommended 
by Dr. Lind, take previously a drink of wine with lemon-juice. It scarcely 
need be stated that the influence of all the accessory causes of the disease 
should be obviated as far as possible. 
Little is required in the way of medicinal treatment. Constipation may 
be corrected by mild laxatives, such as rhubarb and castor oil. If the appetite 
is feeble, it may be stimulated in some instances by the bitters and mineral 
acids. The astringents may sometimes be found useful in checking hemor- 
rhage. Opium should be given to procure sleep in obstinate wakefulness. 
Nitre, or a solution of this salt in vinegar, has been recommended as having 
strong antiscorbutic virtues. Dr. Garrod recommends the salts of potassa, 
on the ground that these are deficient in the blood of the scorbutic; and the 
carbonate and bitartrate of that base were employed with success, in several 
cases, in New Mexico, by Dr. W. A. Hammond, assistant surgeon of the 
U. S. Army; no fresh vegetables being given, because none could be ob- 
tained. (Am. Journ. of Med. Sci., N. S., xxv. 103.) Tincture of cantharides, 
which has also been recommended, needs further trial before it can be ad- 
mitted into the list of remedies. All writers admit that the use of mercury 
is very pernicious. Bleeding and blisters are also generally condemned, the 268 
[part II. 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
former from the fear of debility, the latter from the danger of gangrene. It 
is possible that, in some cases complicated with inflammation, blood might be 
advantageously abstracted either generally or locally; but it must be done, if 
at all, with the greatest caution. In cases of abundant effusion of blood into 
the pericardial and pleural cavities, paracentesis was resorted to in several 
cases by Dr. Karawagen, in all with relief, and in one case of pericardial effu- 
sion, in which three pints and a half of fluid were withdrawn, with the effect 
of saving the life of the patient. 
As local remedies, solution of chloride of lime, very dilute muriatic acid, 
or metallic astringent solutions, as those of sulphate of zinc, sulphate of copper, 
nitrate of silver, or acetate of lead, may be applied to the gums; and a mouth- 
wash of solution of creasote may be used to correct the fetor of the gangren- 
ous ulcers. For ulcers upon the surface, the best application is said to be 
dressings of lint, soaked in a mixture of one part of lemon juice and two or 
three parts of water, with a covering of oiled silk to prevent evaporation. 
When the limbs are swollen and painful, some relief may be obtained from 
anodyne and emollient cataplasms or fomentations. 
Prevention.-Prophylactic measures in relation to scurvy are of the utmost 
importance in sea-voyages. It is owing to the general employment of these, 
that this scourge of seamen has within the last half century been deprived of 
almost all its terrors. Nor are these measures difficult of execution. It is 
only requisite to attend to the cleanliness and ventilation of the ship, the 
general comfort of the crew, and the supply of suitable provision. The last 
is by far the most important, so far as scurvy merely is concerned. It is 
obvious that whatever provision is employed should be entirely sound; and 
care should also be taken to keep the water sweet. But something more 
is necessary. The ship should be supplied with a sufficiency of those sub- 
stances which have been shown to possess antiscorbutic virtues. Lemon or 
lime-juice is perhaps the most efficient of these. In the British navy, a 
fluidounce of lemon-juice, with a sufficient quantity of sugar, is furnished 
daily to each one of the crew, after the ship has beeen two weeks at sea. The 
difficulty is in the preservation of the juice. For this purpose, it has been 
recommended to boil it down to the consistence of syrup. But in this state 
it is said to have lost some of its antiscorbutic power. The same remark 
would apply to the solid citric acid. The juice will keep well if made into 
a syrup with two pounds of sugar to the pint. The addition of spirit will 
answer- the same purpose. Dr. Budd states that the juice used in the British 
navy is preserved unimpaired by the addition of one-tenth of strong brandy. 
But it appears, from published statements, that lemon-juice has not always 
afforded protection; whether from the bad quality of the juice employed, or 
from some other cause, it might be difficult to decide. Other antiscorbutic 
substances, therefore, should not be neglected. Of the vegetables the po- 
tato and cabbage, in the form of sour-krout, unite, perhaps, more than any 
others, efficiency with capability of preservation. A supply of these, or of 
some equivalent substances, should always be added to the salt meat and 
biscuit, or bread, or other farinaceous product, which constitute the main diet 
of the seamen. Pickles, though probably possessed of some virtues, cannot 
be relied on. In long voyages, the ship may generally avoid danger by tak- 
ing, at the start, as many fresh vegetables as can be kept, and using the same 
precaution at each stopping-place. The appearance of scurvy in the crew 
ought to induce the search of fresh vegetable provision at the nearest port, 
should higher duties permit this deviation from the plan of the voyage. Fresh 
meat, when attainable, should be added to the ship's provision, not so much 
for the sake of any antiscorbutic property, as from the circumstance that the CLASS III.] 
PURPURA. 
269 
occasional use of it will tend to sustain a healthy digestion, and thus obviate 
one of the predisposing causes. For this purpose, in very long voyages, some 
of the various forms of preserved animal food may be resorted to, which modern 
art has learned to prepare in such perfection. It may not be amiss, also, espe- 
cially in extreme northern or southern latitudes, to be well supplied with the 
seeds of mustard and garden cresses, which may be made to germinate in pots, 
and thus afford an antiscorbutic salad. The remarks made in relation to ships 
are not less applicable to the provisioning of cities or garrisons against long 
sieges. An equal attention should be paid, in regulating the dietaries of 
prisons, asylums, hospitals, and other institutions in which numbers are crowded 
together under some general oversight, to furnish the inmates plentifully with 
fresh succulent vegetables, and, among others, with potatoes, a neglect of 
which precaution is inexcusable, when the requisite supply is in general so 
readily obtained. 
Article IV. 
PURPURA. 
Syn.-Hemorrhoea petechialis. 
This disease is characterized by dark-red or purplish spots, called petechia, 
caused by the extravasation of blood beneath the cuticle, with a frequent tend- 
ency to hemorrhage, and without any other essential obvious derangement of 
the system. Petechias frequently appear as -one of the symptoms of various 
diseases, as scurvy, typhus fever, malignant exanthemata, and other adynamic 
aifections, in which the blood has more or less of that condition, in which it 
is said to be dissolved. The particular state of the blood, or of the capillaries, 
which induces this appearance, is probably analogous, in some measure, to 
that which occurs in purpura; but the affection does not receive this name, 
unless original, and without complication with other well-marked and recog- 
nized diseases. 
Purpura is usually ranked among the cutaneous eruptions, but, as seems to 
me, upon insufficient grounds. The appearance upon the skin has nothing 
in common with a proper eruption. In the latter, there is always some de- 
ranged sensation, or some evidence of vascular irritation, or of inflammation. 
But nothing of this kind is observable in true purpura. The petechiae are 
the result merely of effused blood; and are not, in fact, confined to the sur- 
face, but exist often in other parts of the body. The disease is much more 
closely allied to the hemorrhages; but as there is good reason for considering 
it as essentially connected with a disordered state of the blood, it is here 
ranked among the diseases of that fluid. 
The disease has been divided, by the writers who follow Willan and Bateman, 
into several varieties, which, however, appear to differ rather in degree than 
in essential character. The Purpura simplex and Purpura haemorrhagica, of 
these authors, are mere grades of the same affection. The occurrence of he- 
morrhage is an incident to which simple purpura is always liable; and no 
case, therefore, can be certainly said to belong to this variety until its close. 
Symptoms.-The appearance of the petechiae is sometimes preceded by 
various symptoms indicative of deranged health; such as languor, general 
uneasiness, indisposition to active exercise, muscular weakness, paleness or 
sallowness of the complexion, irregular pains in the back, limbs, and abdo- 
men, slight headache, diminished appetite, and, sometimes, great general de- 
bility and faintness. They are also said to be occasionally ushered in by a 270 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
[part II. 
dry and frequent cough. Some cases are attended with some of these symp- 
toms, others with others; and, as a general rule, their grade of severity, espe- 
cially as regards the debility and pains in the back and limbs, may be looked 
upon as a measure of the violence of the subsequent affection. In many 
instances, the preliminary symptoms are wholly wanting; and the appearance 
of the petechiae marks the commencement of the disease. 
The spots generally appear first upon the lower extremities, especially be- 
low the knee, and afterwards extend to the arms and trunk, and occasionally, 
though comparatively seldom, to the hands and face. Sometimes, in mild 
cases, they are confined almost exclusively to the legs. It is said that they 
occur usually at night, and are first observed in the morning. The latter 
statement is undoubtedly correct; as it is in the morning generally that the 
legs are seen bare, and an opportunity for discovering the affection is afforded. 
The former is probably an inference, and by no means a necessary one. The 
size of the petechiae varies exceedingly, from the minutest speck to several 
inches in diameter; but they are mostly about the size of a flea-bite, to which 
they bear some resemblance, though without the darker central spot, that marks 
the point at which the beak of the insect was inserted. They are generally 
somewhat circular; but, in severe cases, are often mingled with long streaks 
and irregular patches of the same colour, as if produced by the stroke of a 
whip or by a bruise. Their colour is at first bright-red in vigorous subjects, 
but purplish-red in the feeble and old. It afterwards assumes successively a 
purple, violaceous, and brownish or yellowish-brown hue, and at last gradually 
fades away, disappearing entirely in the course of six or seven days. In the 
mean time, however, fresh crops have successively appeared, and spots of dif- 
ferent colours are thus intermingled, giving the skin a mottled aspect. In 
some instances, the succeeding crop does not make its appearance until the 
first has quite faded. The author has had under his care a case in which 
this recurrence was at regular weekly intervals. No sensation whatever 
attends the occurrence of the petechiae, and, in ordinary cases, there is no 
elevation of the cuticle. The patient first becomes aware of their existence by 
seeing them. In hemorrhagic purpura, small bloody blisters occasionally 
mingle with the stains of the skin. No degree of pressure alters the colour 
of the spots, proving that they are produced by extravasated blood, and are 
not true eruptions. 
Some cases are wholly without exterior hemorrhage; in others, this is the 
most prominent symptom. The former are usually mild, the latter often very 
severe. In the hemorrhagic variety, there may frequently be seen upon the 
tongue and other parts of the mucous membrane of the mouth, small bloody 
blisters, which, from the delicacy of the epithelium, easily break, and occasion 
an oozing of blood from this surface. Hemorrhage of various degrees of vio- 
lence takes place from different mucous membranes, and sometimes from all. 
Blood escapes from the nostrils, gums and other parts of the mouth, conjunc- 
tiva, external auditory meatus, stomach, bowels, kidneys and urinary passages, 
rectum, and vagina; sometimes largely, so as to occasion immediate alarm, 
but generally in small quantities. It usually ceases spontaneously, to return 
at irregular intervals; but it is sometimes continuous, and sustained by a con- 
stant leakage, as it were, from the membranes. Occasionally the hemorrhage 
takes place into one of the vital organs, as within the cranium or into the 
parenchyma of the lungs, producing cerebral and pulmonary apoplexy, and 
very greatly endangering life. The blood is said to coagulate imperfectly, 
forming a soft semi-fluid or jelly-like mass. Sometimes, however, it is as- 
serted to have coagulated firmly, and the clot to have presented the buffy and 
cupped surface. In the latter cases, the complaint was probably complicated 
with inflammation. CLASS III.] 
PURPURA. 
271 
The pulse, in mild cases, is rarely much affected; being, perhaps, in general, 
somewhat weaker than iri health, and occasionally a little accelerated. In 
severe cases, attended with bleeding, it is usually feeble and yielding; but 
sometimes strong, and sometimes decidedly febrile. In debilitated cases, it 
may be very frequent as well as weak. Paroxysms of fever, not unlike those 
of hectic, occasionally attend the complaint. 
The digestive system is variously affected, being in one set of cases quite 
healthy, in another more or less disordered, with tenderness and tension in 
the epigastrium, nausea, constipation or diarrhoea, and sometimes deep seated 
pains in the abdomen; symptoms which indicate congestion, if not sub-inflam- 
mation of the alimentary mucous membrane, or of the whole portal circulation. 
Deep seated pains in the chest and back, which sometimes occur, may indi- 
cate a similar condition of one of the thoracic viscera or the kidneys, though 
they may also be of a merely neuralgic character. 
Much debility often attends the complaint throughout, and some patients 
are liable fib frequent spells of faintness, or to positive syncope. In long- 
continued cases, the face becomes sallow or of a dingy paleness, great emacia- 
tion often occurs, and some oedema is observable of the face, in the horizontal, 
and of the feet, in the erect position. 
The duration of the disease varies from a few days to two years or more. 
Slight cases of simple purpura are without danger; and even the hemorrhagic 
cases usually recover, though this form of the disease sometimes proves fatal, 
either directly by the hemorrhage, or indirectly by the suspension of the func- 
tions of a vital organ, in consequence of the extravasation of blood within it. 
Old persons, especially females, are sometimes affected with ecchymosis 
upon the outside of the forearm, occurring in dark purplish patches of irregular 
shape and extent, which fade away in eight or ten days, leaving a brownish 
hue behind them. These recur at irregular intervals, sometimes for years, 
without any obvious cause, and with little or no observable ill effects upon the 
health. This affection is described by Bateman under the name of Purpura 
senilis. Such a case, in an elderly female, came under the notice of the 
author. Nothing was done for it, and the patient did not appear to suffer. 
The colour of the patches was sometimes very dark; and the slightest bruise 
produced an ecchymosis. 
The Purpura urticans of Willan and Bateman is scarcely, I think, a pure 
example of this disease. It is characterized by roundish elevations of the 
cuticle, of a reddish colour, somewhat like those of urticaria, but without the 
itching and tingling which attend that affection. It is sometimes preceded 
by a feeling of stiffness or weight in the limbs affected, which are most com- 
monly the legs, though the eruption sometimes appears also in the thighs, 
arms, and trunk. The small tumours gradually subside, assuming a darker 
tint, and disappearing in the course of a week, while fresh ones exhibit them- 
selves before the others have quite faded. The usual duration is stated to be 
from three to five weeks. I have had under care a case which ran on for 
several months before recovering. The affection appears to me to be a true 
eruption, perhaps a variety of erythema, occurring in persons having purpura 
at the same time, and receiving its peculiar character from that disorder. 
The elevated spots, as I observed them, seemed to be owing to a distension 
of the bloodvessels, and not to extravasation. Proper petechias are frequently 
interspersed among them, showing the coexistence of purpura, and at the 
same time its partial independence of the eruption. There is nothing pecu- 
liar, so far as is known, in the cause or treatment of this variety. 
Anatomical Characters.-The spots upon the skin are found to be owing to 
blood extravasated immediately beneath the cuticle, or in the texture of the 272 
[part ii. 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
cutis itself. Blood is also occasionally observed in the subcutaneous cellular 
tissue, forming extensive ecchymoses. This may be washed away, leaving 
the vessels without any marks of injection, or other evidence of inflammation. 
Similar petechias to those upon the skin are found in the mucous membrane 
of the alimentary canal, and sometimes, though more rarely, and less numer- 
ously, upon the serous membranes, as the pleura, pericardium, and peritoneum. 
Extravasated blood sometimes exists also in the lungs, in the parenchyma of 
the viscera, and in the substance of the muscles. Cazenave states that, in 
several instances of post-mortem examination in the Hospital Saint Louis, the 
blood was found to be remarkably fluid, even in the tissues into which it was 
effused in considerable quantity. 
Causes.-These are somewhat obscure. In some instances, the disease ap- 
pears to arise from causes of a debilitating nature, calculated to impair the 
efficiency of the processes of sanguification, while, at the same time, there is a 
want of due material out of which the blood is to be made. Hence, unwhole- 
some, indigestible, and scanty food, confined and impure air, indolent or seden- 
tary habits, depressing emotions, continued fatigue, and the debility induced 
by various diseases, as smallpox, measles, and scarlatina, have been ranked 
among the causes of purpura. But the disease occurs also in individuals of 
good constitution, exempt from all these evils and privations, and apparently 
in robust and vigorous health. Suppression and retention of the menses ap- 
pear to predispose to it; or, possibly, the two affections may be merely coin- 
cident, and dependent upon the same cause. Purpura has been known to dis- 
appear immediately after a profuse hemorrhage from the uterus. 
The disease occurs at all ages, but more frequently among the old and the 
young than those in middle life. The hemorrhagic variety is most common 
in females, and in boys before puberty. It is said to occur more frequently 
in the warm than in the cold seasons. Certain individuals have a strong con- 
stitutional predisposition towards it. 
Nature.-Purpura is probably a disease of the blood. The extravasation 
of blood, which characterizes it, has, indeed, been ascribed to a morbid state 
of the capillaries. It is probable that debility of these vessels sometimes 
favours the effusion; but, in many instances, it is impossible to ascribe the 
result in any degree to this cause; for, as before stated, the complaint occurs 
in the robust, as well as in the feeble. Nor can irritation of the extreme 
vessels be accused of the result ; for all evidence of irritation is wanting, both 
during life and after death. Congestion of the venous system has also been 
considered as the immediate cause of the extravasation ; and, if existing, must 
undoubtedly aid in its production ; but that-this cannot be the essential cause 
is proved by the fact, that such congestion is not a uniform antecedent or 
attendant upon purpura. If it be true that an excess of red corpuscles re- 
latively to the fibrin of the blood favours hemorrhage, we have a plausible 
explanation of the phenomena of the disease. In the cases attended with 
vigorous health and a full strong pulse, there may be an excess of the red 
corpuscles, and the normal quantity of fibrin, as in plethora (see Plethora); 
in those of debility, the fibrin may be deficient, with tbe red corpuscles in their 
normal amount, as in the blood of malignant fevers. In the former case, the 
disease would rank with the active, and in the latter, with the passive hemor- 
rhages. In an examination of the blood in two cases of purpura, by Dr. 
Parkes, of London, the only striking result was, along with a somewhat dimi- 
nished proportion of the solid constituents in general, a remarkable increase in 
that of iron. (See -Am. Journ. of Med. Sei., N. S., xix. 191.) 
Diagnosis.-Scurvy is the only disease with which purpura is liable to be 
confounded. The two are, indeed, by some authors considered identical. But CLASS III.] 
PURPURA. 
273 
the differences between them are too numerous and striking to admit of this 
view of their mutual relation. The following maybe particularly noted. 1. 
In purpura there is not the same tendency to soreness, softness, and swelling 
of the gums as in scurvy, nor to the production of those painful tumours in 
the extremities, with stiffness and contraction of the joints, which so frequently 
attend the latter complaint. 2. The colour of the eruption is usually, on its 
first appearance, brighter red in purpura, and that of the lips and tongue less 
pale. Indeed, the lips have sometimes in this affection a deep-purple colour. 
3. The causes of the two complaints are different. The want of fresh vegeta- 
bles is a prominent, if not the essential cause of scurvy. Purpura often occurs 
when there is no deficiency in this kind of food. The latter affection some- 
times arises under circumstances, in all appearance, favourable to health; the 
former, seldom or never. Scurvy usually shows itself late iu the winter or 
early in the spring, when fruits and vegetables are deficient; purpura, in sum- 
mer and early autumn, when these products abound. 4. The two complaints 
differ also in the treatment. Lemon-juice and fresh vegetableswill generally 
cure scurvy, which is injured by bleeding and mercury; while purpura, which 
will not yield to the former remedies, is often benefited by the latter. 
From all eruptive diseases, purpura is distinguished by the circumstance 
that the colour of the spots is not diminished by pressure. Occasionally, 
however, these affections are complicated with a state of system such as exists 
in scurvy or purpura, and then put on the livery of these latter diseases. It 
is sufficient to be aware of this fact, in order to make the requisite discrimina- 
tion. The ecchymosis from external injuries is distinguished from purpura 
by its fixed local character, and the circumstances of its origin. 
Treatment.-There is no specific or peculiar treatment adapted to this com- 
plaint. The most opposite measures are occasionally found necessary in dif- 
ferent cases. In all, however, one clear indication is presented; that, namely, 
of correcting the condition of the blood. For this purpose, the diet, which 
furnishes the materials of the blood, must be properly regulated, and derange- 
ments of the digestive and other functions concerned in sanguification must 
be removed. 
In cases attended with debility, and originating apparently in causes calcu- 
lated to impoverish the blood, and impair generally the vital functions, such 
as bad or insufficient food, impure air, fatigue, anxiety, previous ill health, &c., 
care must be taken to supply a nutritious and digestible diet, to obviate as far as 
possible all other debilitating influences, and to support the system by tonics, 
and, if necessary, by mild stimulants, such as wine and the malt liquors. The 
simple bitters, the preparations of Peruvian bark, the mineral acids, and the 
chalybeates may be employed. Especial attention should be directed to the 
digestive organs. Constipation, if it exist, should be corrected by mild laxa- 
tives, as rhubarb, sulphur, castor oil, &c.; depraved or deficient hepatic se- 
cretion, by alterative doses of mercury, taraxacum, or nitro-muriatic acid; 
and debility of stomach, by the measures particularly directed under dyspep- 
sia. If, at the same time, the menses are retained or suppressed, aloes may 
be employed in connexion with chalybeates, and other means resorted to as- 
recommended for amenorrhoea. With all these, exercise in the open air should 
be insisted on as of great importance. 
On the contrary, should the pulse be full and strong, the previous health 
of the patient vigorous, and the disease in no respect traceable to debilitating 
influences; and, especially, if, along with this general condition, local inflam- 
matory congestions should exist in the viscera of the chest or abdomen, there- 
should be no hesitation in resorting to the lancet, an antiphlogistic diet, and 
active purgation; the last-mentioned remedy being peculiarly indicated;when. 274 
[PART II. 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
the case is complicated with constipation, or portal congestion, or both. Calo- 
mel combined with other cathartics may be employed under such circumstances 
with advantage. The compound cathartic pill will be a suitable combination. 
When the evidences of active congestion are very decided, cups or leeches 
might possibly be resorted to with advantage after general depletion; but they 
should always be used with caution, in consequence of the great liability to 
hemorrhage from even slight wounds. The loss of blood in cases of active 
purpura, if we may be allowed the term, is advantageous not only by dimin- 
ishing the impulse of the heart, but also by correcting the hemorrhagic cha- 
racter of the circulating fluid; the effect of bleeding being, as elsewhere 
explained, to lessen the proportion of red corpuscles, without equally dimin- 
ishing that of the fibrin. 
Cases of a mixed nature may occur, in which it may be difficult to determine 
which of the above courses is to be preferred. A small tentative bleeding 
may be employed in such instances, to the extent of two or three fluidounces. 
If the pulse flag under the operation, and the blood, upon inspection, appear 
dark-coloured and indisposed to coagulate perfectly, the inference will be 
drawn, that depletion is not advisable. Should the contrary be the case, the 
remedy may be carried further. It will frequently happen in these cases, that 
purgatives will act favourably even when the lancet is inadmissible. They 
unload the congested portal circle, and restore the digestive organs to a con- 
dition favourable to the production of a better blood. In some cases, it has 
been found advantageous to combine oil of turpentine with the cathartic, in 
pretty large doses, as a drachm or more. A mixture of oil of turpentine and 
castor oil has been highly praised. For the relief of congestion of the ali- 
mentary mucous membrane, refrigerant measures are often found useful, even 
where there may be considerable debility. Iced drinks may be employed; and 
the patient will frequently derive great comfort, especially when the lining 
membrane of the mouth and throat is hot, dry, and red, from small pieces of ice 
held in the mouth and allowed slowly to dissolve. Even stimulating and tonic 
beverages may often be usefully refrigerated in this way; the general support- 
ing influence being thus obtained, without injury and sometimes even with 
benefit to the local congestion. The alterative effect of nitre on the blood is 
said to have proved useful in purpura. 
When the hemorrhage is the prominent symptom, remedies should be em- 
ployed calculated to restrain it for a time, while other plans are in operation 
for its ultimate cure by a correction of the blood. For this purpose, several 
of the vegetable and mineral astringents may be resorted to. Kino, rhatany, 
alum, and acetate of lead are among those best adapted to the case. Acetate 
of lead with a little opium will often be found useful, care being taken to ob- 
viate its tendency to produce constipation. Gallic acid has been advantageously 
employed. Oil of turpentine, in moderate doses frequently repeated, creasote 
given in like manner, and ergot, may be used to meet the same indication. 
Dr. Eberle speaks of having successfully treated a case with nitrate of silver 
and oil of turpentine. Dr. Neligan has found very large doses of oil of tur- 
pentine, connected with castor oil to insure its purgative effect, promptly suc- 
cessful. He gave from an ounce to an ounce and a half to adults, and from two 
to four drachms to children. When the pulse is very frequent, with insuffi- 
cient strength to justify the use of the lancet, digitalis may be combined with 
the other remedies. When the hemorrhage proceeds from accessible parts, 
local measures should also be used. Ice or iced water, solutions of alum and 
acetate of lead, and infusion of galls, kino, or catechu may be thus employed, 
being applied by means of cloths saturated with them, or, in case of hemor- 
rhage from the rectum or vagina, by injection. When other means fail, me- CLASS III.] 
HEMORRHAGE. 
275 
chanical measures afford a last resort. Thus, uterine hemorrhage and epistaxis 
may be arrested by plugging the vagina and the nostrils. 
Pains and restlessness should be obviated by opiates or the narcotic substi- 
tutes for opium; and emollient fomentations or cataplasms will be found highly 
beneficial in painful local congestions, even of the internal organs. The cold 
bath has been recommended, and may prove serviceable in cases having suffi- 
cient vital energy to insure reaction. 
SUBSECTION V. 
DISEASES OF THE BLOOD AND BLOOD-VESSELS CONJOINTLY. 
Article I. 
HEMORRHAGE. 
I shall first treat of hemorrhage generally, and then of its particular forms, 
in relation to the part from which it proceeds. 
By the term hemorrhage is meant the escape of blood from the vessels, in 
which it is contained in health. This is one of those instances in which, for 
the sake of convenience, a mere symptom of various pathological conditions 
has been elevated to the rank of a disease. 
- Numerous attempts have been made to classify hemorrhage; but all 
arrangements are more or less defective; because the different morbid states 
of the system upon which the affection is dependent frequently coexist, and 
any category which can be formed must contain varieties belonging also to 
another; and, besides, during life, it is often impossible to decide as to the 
real existing pathological condition. The following are divisions which have 
been recognized by different authors. 
Hemorrhage has been divided into traumatic and spontaneous ; the former, 
including those instances in which a vessel has been directly divided, or rup- 
tured by a wounding body, the latter, those in which the flow of blood pro- 
ceeds from some cause acting through the organization. But it is often 
impossible to decide whether the hemorrhage is, or is not traumatic; for the 
violence, instead of directly dividing the vessel, may have operated through 
the medium of a sudden congestion, or an increased force imparted to the 
heart's action; and the term spontaneous implies the obvious fallacy, that a 
flow of blood may take place of its own accord, without any other cause than 
that which is inherent in itself. Besides, the hemorrhage which proceeds 
from a wound inflicted by a calculus in the pelvis of the kidney, or by hard- 
ened feces upon the hemorrhoidal vessels, though strictly traumatic, often 
cannot be distinguished from a so-called spontaneous hemorrhage. 
Another division is into the symptomatic and idiopathic or essential; both 
of which are embraced in the spontaneous. Symptomatic hemorrhage is that 
which results from some other recognized morbid state, as malignant fever, 
tuberculous or cancerous disease, inflammation, ulceration, aneurism, &c.; 
idiopathic or essential, that which itself constitutes the disease, without 
the necessary existence of any other derangement. But, strictly speaking, 
hemorrhage is always and necessarily symptomatic. It is impossible to con- 
ceive of a discharge of blood, without a morbid state of the vessel from which 
it proceeds, of some other part of the structure, or of the blood itself. The 
disease may be latent; but it must nevertheless exist. There is, therefore, 276 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
[part ii. 
no ground for such a division; and, even admitting into the rank of idio- 
pathic hemorrhages all those which have their origin in some deviation, not 
hitherto recognized, from the normal state, still, it is frequently altogether 
impossible to decide, during life, whether any particular case ought to take 
this position; for it cannot be told whether there may not be irritation, in- 
flammation, or some peculiar degeneration of the part affected, or some other 
part, which may be the real cause of the discharge. 
Again, hemorrhages have been divided into active and passive, according 
as the vital forces or vital actions are above or below the standard of health. 
But this division, though to a certain extent founded in truth, fails, if in- 
tended to be of universal or even of general application. There are, un- 
doubtedly, many cases of hemorrhage, in which the discharge appears to be 
essentially associated with a state of local or general excitement, and a display 
of increased vital force, and others which have their origin in a quite opposite 
condition; but there are also many in which neither of these states can be 
said to exist, and we not unfrequently meet with cases in which general de- 
bility is connected with irritation or excitement in the part affected. 
Other denominations of hemorrhages are constitutional, in which the dis- 
charge was originally connected with the ordinary health of the individual, or 
has by habit become essential to that state; vicarious, in which a hemorrhage 
from one part has been superseded by another, from an unconnected and 
perhaps distant part; critical, in which the hemorrhage occurs in the pro- 
gress, or at the close of any disease, marking, and perhaps producing, either 
a decided amelioration, or a sudden aggravation of the symptoms; periodical, 
in which it occurs at definite intervals; arterial, in which the blood proceeds 
from arteries; and venous, in which it proceeds from veins. How far there 
are grounds for these distinctive designations will appear in the course of the 
following remarks. 
Without insisting on any general classification of hemorrhages, I shall en- 
deavour to attain the more important end of ascertaining, as far as practicable, 
the different pathological conditions in which this morbid phenomenon is ex- 
hibited, as one of the characteristic symptoms or results. 
1. Rupture or other division of the blood-vessels, in a previously healthy 
condition.-This may be the result either of direct violence from causes pro- 
perly extraneous to the system, as wounds, blows, &c., or of distension of 
the vessels, produced by causes essentially connected with the economy itself. 
As a general rule, it is only hemorrhage proceeding from the latter source, 
that falls within the domain of medical pathology. Cases do, indeed, occa- 
sionally come under the care of the physician, in which a vessel is divided 
by an internal wounding body, as those before alluded to of hmmaturia from 
calculus in the kidney, and hemorrhoidal flux from hardened feces; but these 
are exceptions; and, generally speaking, the surgeon has the charge of all 
hemorrhages resulting from direct extraneous violence. Our attention, there- 
fore, will be confined to those in which the rupture occurs from some vital 
agency, exerted through the functions of the system. That this occasionally 
happens in perfectly healthy vessels can scarcely admit of a doubt. Of 
course, congestion arising from an irritation seated in the vessels themselves is 
here excluded from the list of causes, because the vessels are in this condition 
not in a perfectly healthy state. There are two modes in which the disten- 
sion producing rupture may arise; first, from the excessive force with which 
blood may be thrown into a particular part of the body, and secondly, from 
its great accumulation in the part, in consequence of some impediment to its 
return. As examples of the first, may be adduced distension of the pulmo- 
nary vessels, arising from hypertrophy and consequently increased power of CLASS III.] 
277 
HEMORRHAGE. 
the right ventricle of the heart, and of a similar state of the cerebral vessels 
from a similar condition of the left ventricle. It is true that, in hypertrophy 
of the left ventricle, the increased force is felt more or less throughout the 
frame. But the head, from its position, as well as from the great propor- 
tional quantity of blood thrown into it, is more peculiarly exposed to the 
morbid impulse, and, therefore, is most apt to feel its effects. Any exces- 
sive action of the heart, proceeding either from physical or moral causes, 
may produce the same effect. Still it may be doubted whether, in these 
cases, a rupture of the vessels would take place if perfectly sound; and it is 
impossible to prove the fact, because it is impossible to show that the vessels, 
in case of rupture, may not have been more or less diseased. Certainly, the 
impulse must be unusually violent, which is necessary to produce this effect; 
otherwise, the cases of hemorrhage from this cause would be much more 
numerous than they are. That they do, however, sometimes occur, I am dis- 
posed to believe, partly from the occasional suddenness of the hemorrhagic 
attack in apparent health, and partly by the consideration that, the coats of 
the vessels having been made capable of rupture, they must give way before 
a sufficient force; and there is no reason to suppose that this may not be 
supplied by the heart, when acting with its utmost power, especially when 
this power has been greatly augmented by a morbid developement of the 
muscular structure of the organ. Morbid accumulation of blood from impe- 
diment to its return, mentioned above as one of the probable causes of rup- 
ture of the healthy vessels, may proceed from certain organic diseases of the 
frame itself, or from temporary influences interfering with the due course of 
the circulation*. Great inequality in the size of the cavities of the heart, en- 
largement of the liver interrupting the return of the blood through the vena 
portarum and the vena cava, and scirrhous tumours diminishing the cavity of 
veins in their neighbourhood, are examples of the first; external compression 
by ligature or otherwise, certain postures which oppose the agency of gravita- 
tion to the natural course of the blood, and diminished atmospheric pressure 
acting especially on the Schneiderian and bronchial mucous membrane, are 
examples of the second. But the more frequent cause of the vascular disten- 
sion which leads to rupture is, probably, a combination of the two conditions 
of increased force of the blood and impediment to its return. Such a com- 
bination is produced by excessive muscular efforts, as the lifting of heavy 
weights and other violent straining, which at the same time stimulate the 
heart to greatly increased action, and compress the abdominal and external 
veins, thus causing accumulation of blood in the more protected cavities of 
the head and the chest. When these causes act conjointly with hypertrophy 
of the heart, or other favouring organic affection, we have the condition of 
things most conducive to vascular rupture. 
2. Rupture or other division of the blood-vessels, in a previously morbid 
state.-The diseased condition of the vessel may be merely functional. Upon 
principles already explained (see vol. i. p. 52 and 53), irritation invites a flow 
of blood to the part affected, and thus occasions congestion. This may possibly 
exist to such a degree as to rupture the coats of vessels otherwise healthy, 
especially when aided by an increase of the vis cl tergo. Violent passion, pro- 
ducing irritation and congestion of the brain, may occasion rupture of the 
cerebral vessels, and excessive exertion of the voice may produce a similar 
effect in those of the air-passages. But the morbid state of the vessel lead- 
ing to rupture or other solution of continuity, is probably much more fre- 
quently organic. The coats of the vessels may be softened by previous in- 
flammation ; or thinned by absorption, in consequence of pressure from scir- 
rhous tumours or tuberculous deposit; or weakened by fatty degeneration; or 278 
[PART II. 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
otherwise diseased, so as to render them more brittle and less capable of re- 
sistance than in health, as in cases of aneurism. In, all these instances, they 
may yield to the ordinary force of the circulation ; though, much more fre- 
quently, the rupture will be likely to take place under circumstances calcu- 
lated to produce an unusual distension of the vessels, as explained in the 
preceding paragraph. Another condition leading to solution of continuity in 
the blood-vessels is ulceration, whether of the ordinary character, or such as 
attends the progress of tuberculous and cancerous disease. Hence, in part, 
the frequency of hemorrhage from the bowels in typhoid fever, from the lungs 
in phthisis, and from the stomach in cancer of that organ. Still another 
source of hemorrhage belonging to this category, though it comes more 
frequently under the notice of the surgeon than the physician, is the slough- 
ing which follows mortification of the vessels. 
3. Active elimination from, the vessels, without rupture.-Opinion formerly 
referred almost all hemorrhages to rupture or division of the vascular parietes. 
The observations of Morgagni long since threw some doubt upon the correct- 
ness of this hypothesis as one of universal application; but it was reserved for 
Bichat completely to change the current of medical sentiment upon this sub- 
ject. The surfaces from which fatal hemorrhage had proceeded were carefully 
examined after death by this accurate observer, without exhibiting any marks 
of a ruptured vessel even under the microscope; and his observations were 
confirmed by subsequent pathologists. The cases were comparatively rare in 
which any laceration, or other solution of continuity, could be discovered. 
The inference was obvious, that the hemorrhage probably occurred by transu- 
dation through natural pores; though it must be confessed that the evidence 
was not conclusive; for the rupture may possibly have existed, and yet 
escaped attention. The aid of other considerations, therefore, was necessary 
to establish the fact of transudation. One of these was the condition of things 
in menstruation. The internal surface of the uterus has been examined 
during this process, in a case of complete prolapsus, and the menstrual dis- 
charge observed oozing by drops, in the manner of any other secretion. ( Cyc. 
of Pract. Med., Art. Hemorrhage.') It is true that, in this case, the blood 
may be somewhat altered, constituting a kind of secretion rather than a 
hemorrhage; but the fluid bears so close a resemblance to unaltered blood, 
that, so far as concerns their mode of escape from the vessels, what is admit- 
ted of one, may, without any great violence to probability, be admitted of the 
other. In the progress of inflammation, there is very frequently an extrava- 
sation of blood, along with coagulable lymph, in the tissue or on the surface 
of organs; and there could be little doubt, it was thought, that the fluid is 
eliminated here by a simple transudation. What happens in inflammation 
may readily be supposed also to happen in mere irritation. But still more 
strongly confirmatory of the idea that hemorrhage might be simply transuda- 
tion, was the well-established fact, that blood had, in several instances, been 
seen issuing from the surface of the skin, without any rupture of vessels, 
oozing through the pores in fine drops like dew, and, when wiped away, reap- 
pearing in the same manner several times successively. (Sir Henry Marsh, 
Dub. Quart. Journ. of Med. Sci., xii. 260.) As the possibility of the escape 
of blood through the natural pores of the vessels seemed thus to be proved, 
and as the most minute post-mortem examination had generally failed to dis- 
cover any rupture of the vascular coats in cases of hemorrhage, there seemed 
to be good grounds for the prevalent opinion in relation to the character of 
this affection. But this opinion has again begun to yield to the old notion of 
rupture of the vessels; for microscopic investigation has never detected pores 
in the capillaries sufficiently large to admit the passage of the blood cor- CLASS III.] 
279 
HEMORRHAGE. 
puscles, or in fact any pores whatever; and it would seem, therefore, that 
blood, unless with a previous destruction of the corpuscles, could not transude 
through the coats of the vessels. Nevertheless, it is scarcely probable that 
rupture can take place in so many countless contiguous points, as must happen 
in cases of oozing of blood if the theory of rupture is true; and it would seem 
also a very clumsy provision of nature, in the case of menstruation, to effect a 
normal function through a mechanical bursting of the vessels. The probability 
appears to me to be, that pathological solutions of continuity take place in the 
capillaries, in a state of congestion, by which openings are effected sufficient 
for the escape of the corpuscles, and closed when the immediate occasion of 
their formation is passed. That such openings, under vital laws, may take 
place in the delicate walls of the capillaries, and afterwards close, is easily 
conceivable, when it is considered with what rapidity a number of the ulti- 
mate cells, placed in a line, are formed into a tube by the disappearance of 
their walls at the points of junction, and how rapidly capillary vessels are 
formed in new structure. Therefore, though the blood cannot be said to pass 
unchanged through the unchanged walls of the vessels, yet its escape may 
not be altogether mechanical, but may be caused and regulated by certain 
physiological laws, which place the resulting hemorrhage rather in the posi- 
tion of transudation from the vessels than in that of the mere result of rup- 
ture. What circumstance it is that, in certain cases of irritation, disposes to 
the elimination of blood, rather than of those fluids which are observed in 
other cases, it is impossible, in the present state of knowledge, to do more 
than conjecture. It may possibly be owing to the state of the blood itself, 
which, as will hereafter be more particularly explained, is often peculiarly 
affected in hemorrhagic cases. That the hemorrhage, whatever may be the 
mode of escape from the vessels, is often the result of local irritation, is 
proved by the fact, that its appearance is preceded and attended by a feeling 
of weight, fulness, warmth, oppression, &c., in the part from which it pro- 
ceeds. It may or may not be associated with a state of general vascular ex- 
citement; and it is by no means incompatible with general debility. 
4. Passive elimination, without rupture.-It is easy to conceive that the 
coats of the capillary vessels possess a degree of tonicity or vital organic con- 
tractility, which, in full health, prevents the escape of the blood; and that 
a diminution or loss of this power may result in such a relaxation as to permit 
that fluid to pass. We see this event of very frequent occurrence, after death, 
from the mere influence of gravitation. In a state of debility approaching 
death the same result might be expected, especially as there is now a certain 
degree of the vis a tergo to act as the extravasating force. But the tone or 
contractility of capillaries is not necessarily lost in the same degree as the 
energy of those organs immediately necessary to life. Death may, therefore, 
and frequently does take place without hemorrhage. It is only in cases in 
which the capillaries themselves are greatly relaxed that this phenomenon 
would be likely to occur. When this happens in connexion with considerable 
remaining activity of the circulation, we may look for hemorrhage. Hence, 
perhaps, in part, the frequency of this affection in low and malignant diseases. 
In such cases, if the explanation given be true, the hemorrhage should be 
more or less general; and, accordingly, in these diseases, there appears to be 
a tendency of the blood to escape by various avenues, especially from the 
mucous membranes, in which the least degree of mechanical resistance is op- 
posed. It is possible, however, that the debility or loss of tone may be con- 
fined to the vessels of a particular part or organ; and we may thus have pas- 
sive hemorrhage as a purely local affection. The same difficulty in admitting 
the escape of the unbroken blood-corpuscles through the unruptured walls of 280 
[PART II. 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
the vessels exists in this case as in that of active hemorrhage, and may be 
explained in the same way. But, in this variety of hemorrhage, it often 
happens that the blood is in some degree dissolved while in the vessels, the 
corpuscles being ruptured, and their red contents diffused through the general 
mass of the fluid. In such a case, even the microscopist sees no impossibility 
in the escape of the blood, or at least the fluid part of it, through the capilla- 
ries by mere transudation. 
Hitherto our attention has been directed to the condition of the vessels 
from which the hemorrhage proceeds. There are, besides, morbid states of 
the system, which are essential in some forms of hemorrhage, and, therefore, 
require notice in this place. They may be divided into those affecting the 
circulation, and those which have their seat in the blood. In considering 
them, some repetition of what has .been already said will be necessary to a 
full and consistent view of the subject. 
5. Morbid states of the circulation in hemorrhage.-In many instances, 
there is a morbid activity of the circulation, which precedes and accompanies 
the hemorrhage, and probably essentially contributes to its occurrence. This 
is especially associated with that form of the disease which depends upon irri- 
tation of the bleeding vessels. Sometimes it is so considerable as to constitute 
a genuine febrile attack, being attended with rigors at the commencement, 
with loss of appetite, and even with disordered nervous phenomena. It does 
not bear any fixed relation to the degree of local vascular irritation, and is 
probably, therefore, in many instances, at least, wholly independent of it. 
Its origin, like that of many other forms of fever, is obscure, but is, not im- 
probably, connected with the condition of the blood. 
Another frequent derangement of the circulation is that of increased vigour 
arising from hypertrophy of the heart. This has been already alluded to, in 
the paragraph which treats of a solution of continuity in the coats of healthy 
vessels. Its force is directed to different parts, according as. one or the other 
cavity of the heart is affected; to the lungs, for example, when the disease is 
seated in the right ventricle, to the brain, when it is seated in the left. It is 
highly probable that, when aided by accidental causes, which may concentrate 
its force upon a particular organ, it is capable of effecting the rupture even of 
a healthy vessel. That it often produces this effect in vessels organically dis- 
eased, or even greatly debilitated, there can be no doubt. But it probably 
operates, in the greater number of cases, by producing an irritation or excite- 
ment of the vessels, in consequence of the superabundance of blood furnished 
to them, and thereby inducing an elimination of this fluid through their 
coats in the manner already explained. 
A third deranged condition of the circulation, attending and producing 
hemorrhage, is that dependent on some impediment offered to the return of 
blood through the venous trunks. One example of this condition is presented 
by inequality in the cavities of the heart, and by constriction or imperfection 
of the cardiac valves. The modes in which these organic affections produce 
inequalities in the circulation have been already fully explained, in the 
articles on hypertrophy and dilatation of the heart, and on chronic valvu- 
lar disease of that organ, to which the reader is referred. Another example 
of congestion from impediment to the return of blood is* afforded in those 
organic derangements which have the effect of narrowing the capacity of 
the great veins. Thus, enlargement of the liver, diminishing the caliber of 
the vena cava ascendens, and of the vena portarum, produces congestion of 
the whole portal circulation, and predisposes, if it do not actually give rise 
to hemorrhages from the stomach and bowels. This sort of passive conges- 
tion may act, in producing hemorrhage, conjointly with any of the patholo- 281 
CLASS III. 
HEMORRHAGE. 
gical conditions of the vessels above described, proceeding from other causes; 
or it may be itself the primary agent, by inducing a hemorrhagic irritation 
in the vessels of the congested organ. It may possibly even occasion a rup- 
ture in healthy vessels, when aided by some accidental cause, giving a direc- 
tion of the blood strongly to the affected part. 
6. Morbid states of the blood.-These may have relation either to quantity 
or to composition. The blood may be in excess, constituting plethora, which 
is one of the most fruitful sources of hemorrhage. The mode in which this 
may operate is too obvious to require explanation. Its influence has been 
long and universally recognized. But the influence of an altered condition or 
composition of the blood has but recently begun to be understood; at least it 
is only of late that any precise knowledge upon the subject has been obtained. 
From the experiments and observations of Magendie and Andral, it appears 
that a deficiency of fibrin in the blood, relatively to the proportion of red cor- 
puscles, strongly predisposes to hemorrhage. It may, indeed, produce the 
effect without the co-operation of any discoverable lesion or other morbid state, 
and very much favours the action of hemorrhagic causes in general. Accord- 
ing to Andral, there are two conditions of the blood, in relation to the propor- 
tion of its fibrin and red corpuscles, both of which are favourable to hemor- 
rhage, but which differ greatly in their attendant phenomena. In one, the 
proportion of fibrin to the general mass of blood is the same as in health, but 
there is an excess of red corpuscles, and the fibrin, therefore, does not bear its 
usual proportion to the latter constituent. This condition is observed in ple- 
thora and disposes to the production of the hemorrhages usually denominated 
active. In the other, there is a positive deficiency of fibrin, while the propor- 
tion of red corpuscles is undiminished. This condition is much more favour- 
able to profuse hemorrhage than the preceding. It is supposed to occur in 
purpura, malignant fevers, &c.; and constitutes one of the characteristic fea- 
tures of passive hemorrhages. The ordinary phenomena which mark these two 
forms of hemorrhage, and consequently indicate the character of the blood in 
each, will be detailed among the symptoms. Andral believes that the blood, 
in either case, never presents the buffy coat, unless the disease be complicated 
with inflammation. The clot is usually large in consequence of the abundance 
of red corpuscles, and soft from the deficiency of fibrin. By the loss of blood 
in hemorrhages the quantity of red corpuscles is diminished more rapidly than 
the fibrin; the two are at length brought into their normal proportion; and 
the hemorrhagic tendency ceases. What it is that produces originally the 
deficiency of fibrin in the blood has not been satisfactorily ascertained. It 
has been ascribed to an excess of alkali altering the character of this principle, 
and rendering it uncoagulable. But no such excess has been proved to exist 
generally; and any attempt to investigate the question further would throw 
us into the unprofitable field of mere conjecture. Nor is it much better under- 
stood, in what manner the deficiency of fibrin occasions the result ascribed to 
it. We may suppose that the stimulus of a certain proportion of this princi- 
ple is necessary to preserve the capillary pores in their due state of vital con- 
traction, that relaxation consequently results from the want of it, and the 
blood passes through from the force with which it moves. This may happen 
in the passive hemorrhages. We may suppose, moreover, that, in local irri- 
tations, a strong disposition of the blood to coagulate may cause the first ex- 
travasated portion to become concrete, and thus close the orifices, before it 
has penetrated the tissue which intervenes between the vessel and the air. 
We know that this happens in inflammation, in which there is an excess of 
fibrin. Whether, therefore, any existing irritation is to end in inflammation 
or hemorrhage may, according to this view, depend upon the excess or defi- 282 
[PART II. 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
ciency of fibrin. In the former case, the extravasated blood coagulates before 
it escapes externally, closes the orifices, and gives rise to the phenomena of 
inflammation. In the latter case, the blood, remaining fluid, penetrates the 
basement membrane and cuticle or epithelium, or whatever separates the 
capillary from the air or the adjacent cavity, and, being thus removed, is 
followed by another portion from the irritated vessel; so that a hemorrhage 
is established, which tends to relieve the irritation by unloading the vessels, 
and thus leads to its own cure. The last remarks are of course applicable to 
the active hemorrhages. It must be confessed, however, that this explana- 
tion, both as relates to the passive and the active hemorrhages, is, in great 
measure, hypothetical. 
The above, so far as occurs to me, are all the morbid conditions which 
essentially attend hemorrhages in one or another form, and which strictly con- 
stitute the disease of which the hemorrhage is a symptom. Two or more of 
them often coexist; and the hemorrhagic tendency must bear some proportion 
to the degree of this complication. Thus, organic disease or high irritation 
of certain blood-vessels may be joined with febrile excitement, plethora, defi- 
ciency of fibrin in the blood, and finally hypertrophy or dilatation of the heart. 
An escape from hemorrhage, under these circumstances, would be improbable. 
There is no portion of the body from which hemorrhage may not occur, 
whether the free surfaces of the mucous membranes and the skin, the serous 
and synovial membranes, the cellular tissue, the parenchyma of glands, and 
other organs, as the lungs, spleen, &c., the substance of the brain and spinal 
marrow, or even the bony structure. So far, however, as the affection is 
peculiar in each situation, it will be treated of under the head of particular 
hemorrhages. 
Symptoms, Course, &c.-When the hemorrhage takes place from a part 
communicating externally, the discharge is generally sufficiently obvious to 
the senses; but the same is not the case when the blood is effused into a close 
cavity, or into the substance of an organ. Under these circumstances, the 
diagnosis is often difficult. The distension, the sense of fulness and oppres- 
sion, the greater or less disturbance of the functions of the organ or organs 
exposed to pressure and irritation from the effused blood, the existence of 
fluctuation in those cases which admit the application of this test, the signs 
of extravasated liquid afforded by percussion and auscultation, the suddenness 
of the attack, and the absence of phenomena which would indicate another 
origin for the symptoms, are the evidences of internal hemorrhage chiefly to 
be relied on. When the blood escapes externally, it is not always easy to 
decide upon the exact source of the hemorrhage, as, in more than one instance, 
several organs, from any one of which it may proceed, have the same outlet. 
The judgment will be influenced, upon this point, by the mode in which the 
blood is discharged, by the evidences which it presents, in its greater or less 
freshness, of the length of its detention after extravasation, by the substances 
with which it is mixed, by the alteration which it has undergone under the 
influence of certain known chemical or vital agents, and by the phenomena 
which would call attention to one or another organ as the seat of disease. 
There are no certain limits to the amount of blood discharged. It may be 
only sufficient to stain the secretions with which it may be mixed, or may be 
so great as to be incompatible with life. 
The character of the blood is exceedingly diversified. It is sometimes pure, 
fresh, and quite liquid, as if immediately from the blood-vessels; sometimes 
partially, or quite coagulated; sometimes mixed with air, or with various 
secretions, or with the accidental contents of the cavity in which it may have 
been for a time retained. In some instances, it is much altered by the influ- CLASS III.] 
HEMORRHAGE. 
283 
ences to ■which it may have been exposed before reaching the surface, as by 
that of the gastric juice in the stomach. It may be coagulable, as in the 
active hemorrhages; or but partially coagulable, or altogether incoagulable, 
as in those which attend malignant fevers. In colour it is sometimes red, 
and sometimes more or less approaching to black. It has been conjectured 
that, when bright red, it proceeds from arteries, and, when dark, from veins; 
but colour affords no evidence of this kind. The blood is, in many instances 
of disease, dark coloured in the arteries; and it often becomes so when re- 
tained for a short time after extravasation. It proceeds in general from the 
capillaries. The only certain cases, of venous hemorrhage are those proceed- 
ing from the rupture of a vein, as sometimes happens in hemorrhoids. 
The hemorrhage may or may not be preceded or attended by symptoms 
indicating irritation or congestion of the part affected; it may or may not be 
accompanied with excitement of the circulation and other symptoms of febrile 
action. There is generally some derangement of the bleeding organ, in con- 
sequence of the interference of the effused blood with its functions. Thus, in 
hemorrhage of the lungs there is more or less oppression and cough; in that 
of the stomach, nausea and vomiting; in that of the bowels, griping and diar- 
rhoea. Sometimes this interference is so great as to endanger or destroy life; 
as in the case of haemoptysis, which is occasionally, though very rarely, so 
abundant as to produce suffocation. The danger is much greater when the 
hemorrhage takes place in close cavities, or the substance of organs, than in 
those cases in which the blood has the opportunity of escaping. Thus, effusion 
of blood within the cranium often produces fatal apoplexy; within the peri- 
cardium, syncope; within the pleura and peritoneum, inflammation of these 
membranes respectively. 
It has been already stated that the system is in a very different condition, 
in different forms of hemorrhage; sometimes exhibiting evidences of excite- 
ment, sometimes of depression both general and local. Hence has arisen the 
division of hemorrhages into active and passive. It must not, however, be 
understood that all hemorrhages are included in these two classes. Many 
cases exist, in which there are no signs either of increase or diminution of the 
vital powers or actions. It not unfrequently happens, moreover, that general 
depression or debility is associated with local irritation. Again, a state of 
great prostration is frequently induced by the hemorrhage itself, which must 
not be confounded with the debility that sometimes occasions, or at least 
favours the origin of hemorrhage in other cases. Nevertheless, the distinc- 
tion is sufficiently obvious, and general in its application, to be of practical 
importance. It will be proper, therefore, to detail the symptoms by which 
the two conditions may be recognized respectively. 
In the active hemorrhages, signs of irritation or active congestion, in the 
part affected, often precede the eruption of the blood. These are somewhat 
different in different organs. Among them, are a sense of oppression, fulness, 
weight, warmth, titillation, and even pain ; and, when the part is visible, an 
obvious redness, vascular distension, and increased force of pulsation in the 
neighbouring arterial trunks. Simultaneously with these symptoms, coolness 
of the extremities and rigors sometimes occur, followed by febrile reaction; 
and both the local and general disturbance continues usually, to a greater or 
less extent, for some time after the first appearance of the hemorrhage, though 
the discharge has a tendency to relieve it. The blood is usually bright-red 
and coagulable; but the clot is in most cases large and soft, and, according 
to Andral, there is no buffy coat, unless the affection be complicated with 
inflammation. It contains, according to the same authority, an excess of red 
corpuscles, without a corresponding increase of fibrin. The hemorrhage pro- 284 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
[PART II. 
ceeds only from one organ, and not from various parts of the body at the same 
time, as often happens in the passive hemorrhages. The affection is said to 
occur most frequently in young, robust, and florid individuals, accustomed to 
full living without sufficient exercise; circumstances which strongly favour 
the production of a plethoric state. But it is not unfrequent also in a very 
different habit of body, in meagre and delicate persons, in whom there is a 
rapid production of blood, in consequence of a vigorous digestion, without a 
corresponding tendency to its expenditure in the process of nutrition. When 
not associated with organic disease, active hemorrhage in general readily yields 
to treatment. 
Passive, hemorrhages are neither preceded nor attended by local or general 
excitement, unless some other disease exists at the time, such as a malignant 
fever, of which the hemorrhagic affection is a mere accompaniment; and, even 
in such cases, the excitement is of a feeble character, such as is produced by 
some irritant or stimulant influence operating upon real debility. On the con- 
trary, the symptoms are those of a depressed condition alike of the vital forces, 
and vital actions. There is a feeling of languor, a deficiency of muscular 
strength, and weakness of the circulation, though the pulse is sometimes more 
frequent than in health, especially during exertion. The capillaries are indo- 
lent; the blood circulating very slowly through them, and imparting, in con- 
sequence of its stagnation, a somewhat dark hue to the surface, which is 
otherwise pale. Pressure often occasions the marks of a bruise, and slight 
contusions give rise to ecchymosis. The blood which escapes is dark-coloured, 
sometimes almost black, and little disposed to coagulate, or altogether unco- 
agulable. The serum and clot separate but imperfectly, and the latter is sel- 
dom or never cupped. The fibrin is deficient, while the red corpuscles are 
undiminished. Sometimes the blood is like reddish serum. The hemorrhage 
is not usually confined to one organ; but blood escapes at the same time from 
different points of the mucous surfaces, and is not unfrequently extravasated 
into or beneath the skin, forming petechiae and ecchymoses. The affection is 
much less frequently original than attendant on other recognized diseases, as 
malignant smallpox and scarlatina, typhus fever, scurvy, and hemorrhagic 
purpura. 
When hemorrhage is considerable, it usually produces signs of depression, 
such as weakness of pulse, paleness of face, coolness of the extremities, nausea, 
faintness, vertigo, and cold sweats; when sudden and very copious, it may even 
induce syncope, preceded in some instances by convulsions. But the depres- 
sion of the circulation usually causes a suspension of the hemorrhage, before 
it reaches the point of absolute fainting. The fears of the patient not unfre- 
quently co-operate with the loss of blood in producing signs of depression; 
and sometimes, when the hemorrhage is too slight to be capable of producing 
directly any constitutional effect, great paleness and apparent prostration re- 
sult from the former cause alone. The ultimate, effects of profuse, or often 
repeated hemorrhage, are those described under the head of Anaemia. (See 
page 251.) An important fact, ascertained by Andral, is that it produces a 
diminution of the red corpuscles, without lessening in any considerable degree 
the healthy proportion of fibrin, unless very copious or prolonged. Hence, 
one of the effects of hemorrhage is to remedy that, condition of the blood 
which favours its production, and thus to cure itself. 
Hemorrhage is very apt to return after being arrested, in consequence of the 
persistence of the causes in which it originated. Generally the periods of its 
return are altogether irregular, depending on the casual influence of exciting 
causes, during the continuance of the predisposition. Sometimes it assumes 
a periodical form, returning at certain stated intervals. When it occurs once CLASS III.] 
HEMORRHAGE. 
285 
a year, as occasionally happens, the result may be reasonably ascribed to the 
influence of the season; when daily, or every other day, it is probably under 
the operation of those causes which lead generally to periodicity in disease. 
(See vol. i. page 195.) The most common interval is that of a month; and 
this is most frequent in females with suppression of the menses, in whom the 
hemorrhage may be considered as vicarious to that discharge. Even in men 
there is sometimes a monthly recurring hemorrhage, especially from the he- 
morrhoidal vessels, which seems designed to relieve a periodical plethora, and 
may be considered, therefore, as entering into the health of the individual. 
Some believe that, in the male as well as the female system, there is a monthly 
flux and reflux of vital action, which sometimes becomes excessive at the full, 
and relieves itself by some discharge, especially by hemorrhage. Without 
admitting the generality of this fact, we may allow that such an analogy of 
the male with the female system does occasionally exist, and may thus account 
for some of the periodical hemorrhages to which certain individuals of the 
stronger sex are subject. In such cases, the same premonitory symptoms are 
exhibited as by women before menstruation; and the same dangers are in- 
curred by the suppression of the discharge. Another analogy between this 
form of hemorrhage and menstruation is, that it is apt to cease spontaneously 
at a certain period of life. 
By the frequent repetition of hemorrhagic discharges, even when of acci- 
dental origin, the system sometimes becomes, at length, habituated to them. 
The processes of digestion and sanguification acquire an activity, which 
serves to secure the health against material injury, by supplying an additional 
quantity of blood equal to that lost. The hemorrhage then almost ceases to 
be morbid; and its hasty suppression would endanger plethora, and consequent 
hemorrhage in other, and, perhaps, more hazardous situations. Thus, the 
suppression of an habitual discharge of blood from the rectum may cause 
haemoptysis, or a fatal apoplexy. 
Constitutional Hemorrhage.-In some persons, a strong constitutional tend- 
ency to hemorrhage exists, so much so that the slightest causes will often 
bring on an attack, and, when the blood begins to flow, it is exceedingly 
difficult to arrest it. A slight wound, even the scratch of a pin, will some- 
times occasion a serious and even alarming hemorrhage. ' Contusions, which 
would not be noticed in ordinary persons, induce extensive ecchymoses; and 
blistered surfaces occasionally bleed profusely. The hemorrhage often also 
comes on spontaneously, or from the least unusual effort, as from coughing, 
sneezing, or straining at stool; and, when the predisposition is very strong, 
blood sometimes issues simultaneously from all the mucous surfaces; while 
extravasation takes place also beneath the cuticle, and in various internal parts 
of the body. The individuals thus affected do not appear to have the same 
liability at all times; for causes which are sufficient to produce copious hemor- 
rhage on one occasion, appear to be inoperative on another. The attack is 
often attended with a quick, irritated pulse; and not unfrequently with febrile 
action, which appears to increase the hemorrhagic tendency. 
This constitutional predisposition is sometimes a family peculiarity, being 
found in several children of the same parents, even when the father and 
mother have exhibited no such tendency. It is also not unfrequently here- 
ditary, passing even through several generations, and occasionally, like other 
hereditary affections, omitting one generation to exhibit itself in that imme- 
diately succeeding. The attention of the profession in this country appears to 
have been first specially called to it by communications of the late Dr. Otto, of 
Philadelphia, in the New York Medical Repository (vol. vi., A. D. 1803), and in 
Coxe's Medical Museum (vol. i., A. D. 1805); and numerous very interesting 286 
[PART II. 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
instances of this family peculiarity have been since recorded in the Journals.* 
Among the most striking are those given by Dr. Riecken, in the Medizinisch- 
Chirurgische Zeitung, Nov. 15, 1830.f Out of a family of twelve children 
four died of hemorrhage; and a sister, who escaped and became the mother 
of six children, lost three of them by the same disease. Of those who died, 
only one was a female, though the whole family, including both generations, 
was equally divided between the two sexes. The almost exclusive direction 
of this family predisposition to the males has existed in nearly all the cases 
published. Nothing has been noticed in the habits or previous health sufficient 
to account for the peculiarity. It seems, in some instances, to have been asso- 
ciated with a rheumatic or gouty diathesis; and has displayed itself chiefly in 
the young. In the cases referred to by Dr. Hughes (Transylv. Journ., Ap. 
1832), the tendency to hemorrhage diminished as the patient advanced in life, 
and in old age was replaced by rheumatism. 
The state of system, attending this constitutional disposition to hemorrhage, 
is probably very nearly the same as that which exists in hemorrhagic pur- 
pura. The blood has been observed, in some cases, not to be coagulable; 
and there is reason to believe that the whole difficulty may have its origin in 
a deficiency of fibrin, either positive, or relatively to the red corpuscles, in 
the circulating fluid. 
Critical Hemorrhage.-Near the termination of certain diseases, or at cer- 
tain periods in their course, hemorrhage sometimes occurs, with the apparent 
effect of relieving the morbid action, and even of putting an end to the com- 
plaint. The discharge, however, may prove too copious, and, instead of re- 
lieving, may aggravate the danger, and even lead to a fatal result. Such 
hemorrhages have been called critical. They differ, however, in nothing from 
ordinary hemorrhages, which are almost always the result of a morbid state 
of system preceding the attack, and not unfrequently serve to remove that 
state. The only apparent difference is, that, in the one case, the antecedent 
disease is obvious and well known, in the other, is perhaps concealed. 
Hemorrhage is seldom fatal by its immediate effects, unless in cases of 
organic disease of the vessels, as in aneurism; or where the escape of the ex- 
travasated blood is prevented, and the functions of vital organs are interfered 
with by its accumulation, as in apoplexy. 
Causes.-Many of the remarks which might have been made here, have 
been necessarily anticipated in the preceding sections. The immediate cause 
of hemorrhage is often nothing else than the pathological condition of which 
it is a symptom, and This has been already considered in all its obvious diver- 
sities. Our attention, in this place, will be confined to the agencies through 
which the pathological condition is produced. Considered in this light, we 
must rank, among the causes of hemorrhage, 1. whatever produces a direct 
division of the coats of a blood-vessel, whether operating from without, as 
wounds, bruises, and other kinds of violence, or internally, as calculous con- 
cretions in the urinary organs; 2. all those influences which induce over- 
excitement of a part liable to hemorrhage, including excessive exercise of the 
organ, as of the lungs in speaking, or of the brain in thought or passion; the 
local application of stimulants or irritants, as of alcohol to the stomach, or of 
acrid vapours to the lungs; partial exposure of the body to heat, as in the 
case of cooks who are in the habit of stooping over the fire; and the direct or 
* See an interesting paper by Dr. Reynell Coates in the N. Am. Med. and Surg. Journ., 
vi. 37 ; a communication by Dr. J. N. Hughes in the Transylvania Journ., for April, 1832 ; 
and various notices in the Am. Journ. of Med. Sciences, ix. 199, and N. S., v. 202; and in 
the Med. Examiner, n. 344 and 475. 
f See Am. Journ. of Med. Sci., ix. 201. CLASS III.] 
HEMORRHAGE. 
287 
indirect action of cold; 3. whatever contributes to give the blood an unusual 
impulse towards any organ, or to impede its exit from the organ; as lifting 
weights, wrestling, straining violently at stool, or any other excessive muscu- 
lar exertion; diminished atmospheric pressure; the unequal action of the dif- 
ferent cavities of the heart; certain postures; and everything that diminishes 
the caliber of the venous trunks, whether from without or within the body; 
and 4. whatever increases the fulness of the blood-vessels, or the force of the 
heart's impulse, as animal food in excess, especially conjoined with sedentary 
habits, stimulating drinks and condiments; violent exercise, exposure to heat, 
excitant emotions, the amputation of a limb, and the suppression or diminu- 
tion of habitual discharges. The period of life has also considerable influence 
as a cause of hemorrhage, probably by giving rise to plethora. The age at 
which the affection is most common, is that at which the body has nearly or 
quite attained its full height. There is apt, at this period, to be a loss of 
balance between the processes of sanguification and nutrition. As the blood 
is no longer wanted to supply the growth of the body, it is not expended so 
rapidly as before; while the functions by which it is elaborated do not always 
abate in their activity proportionably to the diminished demand. It, there- 
fore, accumulates in the blood-vessels, and may thus readily become a source 
of hemorrhage. Among the remote causes, we must also rank those which 
occasion a deficiency of fibrin in the blood. Of these, however, we know too 
little to admit of a positive enumeration of them; but there is reason to believe 
that unwholesome diet has much influence. Certain noxious effluvia, such as 
those which generate typhus fever; and certain nervous influences, not well 
understood, but especially those of a depressing character, probably have a 
similar tendency. It is probable that the excessive and long continued use 
of alkaline substances may produce the same effect; as the presence of an 
excess of free alkali in the blood is said to impair its coagulability. 
Treatment.-The first consideration, in the treatment of hemorrhage, is 
how far its diminution or suppression is desirable. When it is situated in a 
safe place, and at the same time appears to have the effect of relieving some 
pre-existing morbid affection, more serious than the hemorrhage itself, great 
caution should be used in employing measures for arresting it. Under such 
circumstances, it should, in general, be allowed to run its course without in- 
terruption. It would be hazardous, for example, to arrest a bleeding from 
the nose which might appear to be rescuing a patient from apoplexy. Indeed, 
if the hemorrhage be deficient, it may be desirable somewhat to promote it, 
and, if prematurely arrested, to favour its return by the application of hot 
water or hot vapour to the part. Should the bleeding, on the contrary, be 
in excess, it would be proper to moderate it; and, should it continue after 
having accomplished the object desired, efforts should be made to arrest it. 
In all cases, when the hemorrhage is in itself dangerous from its situation, we 
should endeavour to check it; at the same time employing other measures 
for obviating any evil which it may have been calculated to remedy. Thus, 
bleeding from the nose or the rectum may often be left to its course with im- 
punity and even advantage; but from the stomach or lungs, and especially in 
the closed cavities, should in general be subjected to treatment. But, on the 
various points above alluded to, much must be left to the judgment and dis- 
cretion of the practitioner. 
Another important consideration is the state both of the part affected, and 
of the system at large, in relation to their vital force and activity. Remedies 
to a certain degree opposite are required in the two opposite conditions of 
exaltation and depression; and the intermediate state, in which neither of 
these irregularities exist, demands also its own appropriate treatment. The 288 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
PART II. 
measures to be employed, in any case, divide themselves into such as are 
appropriate during the continuance of the hemorrhage, and such as are ap- 
plicable to the interval. I shall treat of these successively. 
If the bleeding is moderate, and unconnected with any obvious excitement, 
either general or local, or with debility, it will usually subside in a short time 
if the patient and the part affected be kept as much at rest-as possible; the 
body placed in such a position as that gravitation may counteract the flow of 
blood; the apartment freely supplied with fresh and cool air; cool drinks 
allowed; everything stimulant, whether in the form of drink or food forbid- 
den ; and the dress or covering so arranged that the patient may be com- 
fortably waim without being heated, and no pressure made upon the veins 
returning from the vicinity of the hemorrhage. 
Should the hemorrhage be attended with moderate arterial excitement, in 
addition to the measures above enumerated, saline cathartics and refrigerant 
diaphoretics may be employed with advantage, such as sulphate of magnesia, 
bitartrate of potassa, the neutral mixture, nitre, and the antimonials. 
If evidences exist of CQnsiderable plethora or febrile action, with a full, 
strong pulse, bleeding should be resorted to, and the remedy may be repeated 
once or more, should the same symptoms continue. It is best that the blood 
should be drawn by a large orifice, so as to make a prompt impression on 
the system; and the quantity taken should be regulated by the state of the 
pulse. Where it is of great importance that the hemorrhage should be arrested 
very promptly, it is generally admissible to push the bleeding until symp- 
toms of faintness appear; as the occurrence of syncope is almost always at- 
tended with a cessation of the discharge which, in many instances, does not 
return with the returning circulation. In order to obtain this effect without 
an unnecessary loss of blood, it is sometimes desirable to bleed the patient 
standing, or, if this be not admissible, in a sitting posture. The effect of the 
lancet may be materially aided by nauseating doses of tartar emetic or ipe- 
cacuanha. Should the pulse remain very frequent after bleeding, with too 
little force to allow of further depletion, digitalis will sometimes be found 
useful in addition to the other remedies. 
When the hemorrhage, either from the amount of effusion, as in some cases 
of haemoptysis, or from the peculiarity of its position, as within the cranium, 
puts life into great and immediate danger, the lancet should be promptly re- 
sorted to, even though not apparently called for by the state of the pulse, and 
should be urged until a decided impression is produced. The danger, in these 
cases, is not from the loss of blood, but from its effects upon the organs in 
which it is effused. Thus, in the instance of pulmonary hemorrhage, death 
may result from suffocation, and in that of cerebral hemorrhage, a fatal apo- 
plexy may occur, unless there be a timely interposition of measures calculated 
to check the discharge; and nothing is so effectual for this purpose as the 
faintness produced by bleeding. 
While the general measures above mentioned are employed, cold water or 
ice may be applied as near to the seat of hemorrhage as possible. A powerful 
hemostatic effect is sometimes produced by the same application made to the 
arm-pits, between the shoulders, or to the external genitals. The liability, 
however, of cold, partially applied to the surface, to produce internal inflam- 
mation, should be borne in mind; and, in cases of hemorrhage from either of 
the great cavities, it would perhaps be best to avoid cold water to the exterior 
of the cavity, unless the loss of blood should be alarming. The local abstrac- 
tion of blood by leeches or cups is often highly useful, w'hen the hemorrhage 
is accompanied with symptoms of local irritation or active congestion. Ad- 
vantage may also be derived from warm pediluvia; and sometimes, when arte- CLASS III.] 
289 
HEMORRHAGE. 
rial excitement either has not existed or has been subdued, revulsion by 
means of rubefacients or blisters to the extremities may be resorted to. 
Sinapisms and blisters in the neighbourhood of the affected part are also some- 
times beneficial by removing the remains of irritation, after a sufficient use of 
general and local bleeding. The tourniquet has been recommended as a 
derivative measure, and may sometimes prove advantageous as a substitute 
for depletion, when the propriety of the latter remedy is doubtful. 
When hemorrhage is at the beginning without excitement, or when this 
has been subdued and the hemorrhage continues, recourse may be had to as- 
tringent or other hemostatic remedies, which operate upon the capillaries, and 
either close their bleeding orifices, or in some measure paralyze their circula- 
tory power. If the hemorrhage is very profuse, even though accompanied 
with general excitement, it may be necessary to resort to some of these reme- 
dies immediately; and, under such circumstances, those should be preferred 
which unite a sedative with their astringent property, as the acetate of lead, 
or which diminish action in the capillaries without materially affecting the 
heart, as appears to be the case with ergot. These may be combined, in 
cases of excitement, with small quantities of ipecacuanha. The particular 
astringents, which are applicable to particular cases, will be mentioned under 
the head of the several hemorrhages. It is here sufficient to say that almost 
all the individuals belonging to the class, whether vegetable or mineral, have 
been used with more or less advantage. The only hemostatic remedies not 
belonging to this class, which I deem worthy of notice, are the oil of turpen- 
tine and ergot, both of which exert an extraordinary influence, under certain 
circumstances, in arresting hemorrhage. It is obvious that the oil of turpen- 
tine should not be resorted to in cases of excessive action.* 
In connexion with the remedies just mentioned, great benefit will often 
accrue from the use of opiates, or other narcotic medicines, such as hyoscy- 
amus or conium. As a general rule, these should not be given during the 
existence of high local vascular irritation, or febrile excitement. They are 
useful by quieting nervous commotion, and thereby equalizing the circulation, 
and frequently also by relieving those slight irritations of a nervous charac- 
ter, which tend to sustain the hemorrhage, such as cough in haemoptysis, and 
excessive retching in haematemesis. Opium is useful also by directing to the 
surface, and this tendency should be favoured by combining it with ipecacu- 
anha or tartar emetic. Another advantage of this narcotic is that it tends to 
prevent fatal syncope in cases of exhausting hemorrhage, probably by stimu- 
lating the brain. Opium and ipecacuanha may often be very happily con- 
joined with one or more of the astringents, in the same formula. 
Dr. N. Chapman speaks very highly of the use of emetics in hemorrhage, 
unattended with high vascular excitement, or considerable local inflammatory 
or congestive disorder. (Am. Journ. of Aled. Sei., ii. 129.) 
In cases to which the internal use of astringents is applicable, the same 
remedies may often be advantageously applied locally, when the seat of he- 
morrhage can be reached in this way, as in bleeding from the nose and rec- 
* Dr. James Warren has employed for thirty years, with uniform success, a styptic 
prepared in the following manner. Take of sulphuric acid (by weight) gv; oil of tur- 
pentine, alcohol, each, fgij. Add the oil slowly to the acid, stirring constantly ; then 
add the alcohol in the same manner, stirring till fumes no longer arise; then put the 
liquid in a bottle with a ground glass stopper. It should be of a dark red colour, but 
transparent. The dose is 40 drops, repeated every hour till three or four doses are 
taken if necessary. Each dose should be mixed with sugar, and taken in a tea-cup 
full of water. (W. K Journ. of Med., N. S., xii. 299, from N. Y. Med. Times.) 290 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
[part II. 
turn. Recourse may be had, in some instances, to mechanical compression, 
with very decisive results, when other measures have failed. 
In the strictly passive hemorrhages, depletory remedies are inadmissible. 
The astringents and other hemostatics may here be brought into immediate 
use; while, at the same time, efforts are made to give due tone to the capil- 
laries, to support the actions of the system in general, and to ameliorate the 
character of the blood, by the use of tonics and stimulants, with a generous 
diet. The preparations of Peruvian bark, wine, the malt liquors, and animal 
and farinaceous food of easy digestion, may be employed, with greater or less 
freedom, according to the circumstances of the case. Oil of turpentine is 
here often a very valuable remedy. When the fault lies exclusively in the 
blood, as happens in scorbutic cases, attention to the diet is all-important. 
(See Scurvy.) When the hemorrhage is dependent upon relaxation of the 
vessels, connected with an anemic condition of the blood, as appears not un- 
frequently to happen in bleeding from the uterus, the chalybeates are the 
proper remedies. Cases, in which local irritation is associated with general 
debility, may often be advantageously treated by tonic and otherwise support- 
ing measures addressed to the system, while the local excitement is counter- 
acted by leeches or cups, cold, and blisters. 
In vicarious hemorrhages, as the substitute is often more hazardous than 
that which it has superseded, it is often advisable to endeavour to restore the 
original discharge by inviting a flow of blood to the part. This may be 
done by the use of hot vapour, local warm or hot baths, and various stimulat- 
ing applications, as alcohol, ammonia, &c. The same rule applies when the 
hemorrhage has resulted from the suppression of some healthy secretion, as 
the menses, or the drying up of some habitual discharge, as that from old 
ulcers, &c. In the latter case, perpetual blisters or issues should be estab- 
lished as near as possible to the original seat of disorder. When it is thought 
advisable to restrain or altogether arrest an habitual hemorrhage, which has 
become constitutional, measures should be simultaneously taken to supply 
the place of the suppressed evacuation by means of purgatives, blisters, 
issues, setons, &c., or by an occasional bleeding from the arm; care being 
observed to diminish the artificial discharge gradually, so that the vital pro- 
cesses may accommodate themselves to the new condition of things. 
The treatment of those hemorrhages which proceed from a strong consti- 
tutional, family or hereditary predisposition, must be conducted upon general 
principles. Much will depend upon the condition of the blood. If it be 
rich in red corpuscles, and offer a large and consistent coagulum, and if there 
be at the same time febrile action and considerable strength of pulse, it may 
be proper to have recourse to direct depletion, a restricted diet, and the anti- 
phlogistic regimen generally. If, on the contrary, as probably happens in 
the greater number of instances, the blood be deficient in coagulability, and 
of the character observed in passive hemorrhage, a diet of animal food, aided 
by tonics and moderately stimulating drinks, as malt liquor or wine, may be- 
come necessary. In the case recorded by Dr. Coates, the hemorrhage, after 
having resisted a great variety of measures, yielded at last to generous food, 
stimulants, and laudanum. In the cases of Dr. Otto, sulphate 'of soda ap- 
peared to be the only efficient remedy; and Dr. Hay states that, in a similar 
family affection under his notice, an ounce of this salt, given daily for several 
days, generally effected a cure. (Wew England Journ., ii. 221.) As might 
have been anticipated, this remedy has not been found to answer equally well 
in all subsequent cases. It may have acted merely as a purgative; but more 
probably, there was some deficiency in the blood which this salt served to CLASS III.] 
HEMORRHAGE. 
291 
supply; and, as the condition of that fluid is not alike in all cases, the same 
remedy cannot be expected to succeed in all. 
The treatment adapted to the interval of the attacks of hemorrhage re- 
mains to be considered. Here also it is necessary to refer to the state of tife 
system. In active hemorrhage, it is important to regulate the diet so as to 
obviate plethora and vascular excitement. But it is also important not to carry 
a system of reduction so far as to produce debility; for this rather favours 
than prevents those irregularities in the circulation which lead to congestion 
and consequent hemorrhage. The quantity of food, and its quality in relation 
to nutrition and stimulating power, should be somewhat under the standard 
adapted to a state of health. If the tendency to the accumulation of blood, 
and to an excess of the red corpuscles, be strong, the patient should be con- 
fined to vegetable food and milk, until that tendency has been corrected. In 
cases of a less decided character, a small proportion of the lighter meats may be 
allowed; and, where there is any doubt upon the subject, the trial should be 
made first with boiled meats, as less stimulating than those prepared in other 
modes. Exercise is also important, in order to maintain an equable vigour 
in the various functions, and thus obviate local determinations. Passive 
exercise, as in riding, driving, and sailing, is preferable to active, because less 
calculated to call particular organs into excessive action. All excitements, 
physical or mental, should be scrupulously avoided. .■ Great bodily exertion 
of any kind, as running, leaping, wrestling, lifting weights, straining, ascend- 
ing heights, &c., may provoke a return of the hemorrhage; and fits of anger, 
or any other strong emotion, are scarcely less injurious. To maintain a gen- 
tle exercise of all the bodily functions, and an equable temper of mind, 
should be the constant aim of the patient. All artificial causes of an unequal 
distribution of the blood should be avoided. Hence, care should be taken 
that no part of the clothing should be so tight as to interfere with the circu- 
lation, and that the body should not be kept long in a position which might 
cause the blood to gravitate towards the organ affected. The excitant effect 
of excessive heat, and particularly its partial application, should be guarded 
against; and not less so, any exposure to cold which might tend to produce 
congestion or inflammation. For the same reason, constipation of the bowels 
should be carefully obviated. Indeed, when the plethora and tendency to local 
congestion are strong, a dose of one of the saline purgatives, once or twice a 
week, will not be found amiss. Steady revulsion towards some portion of the 
body distant from the part affected is one of the most efficient prophylactics. 
Hence the utility of a perpetual blister, a seton, or an issue upon the arm or 
thigh. If at any time there should be threatening symptoms of an attack, they 
should be met by saline cathartics, a very low diet, rest, and even the ab- 
straction of blood. It has been recommended to apply cold water occasionally 
to the former seat of hemorrhage ; but this practice is somewhat hazardous ; 
as, unless the cold be perseveringly maintained, there might be risk of reac- 
tion upon its removal; and, if continually applied, it would endanger internal 
irritation or inflammation. 
In the passive form of hemorrhage, the great object of the practitioner, in 
the intervals, should be to restore vigour to the functions without over-exciting 
them, and a healthy constitution to the blood. This is to be effected by a 
nutritious diet, fresh air, passive exercise, and agreeable mental occupation, 
assisted occasionally by tonic medicines, especially the simple bitters, quinia, 
and the preparations of iron. 
In either form, should the hemorrhage return periodically, at short inter- 
vals, much might be expected from the use of sulphate of quinia, and, if this 
should be inapplicable, from the arsenical medicines. 292 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
[PART II. 
In all cases, the practitioner should thoroughly investigate the condition of 
the system, to ascertain whether there may not be some concealed source of 
the hemorrhage in organic derangements, and, if successful in his search, 
should direct his remedies towards the removal of these causes. 
In treating of individual hemorrhages, our attention will be directed first to 
those of the mucous membranes, which are infinitely the most frequent and 
important; including indeed all which are generally treated of in nosological 
arrangements. Those which occur in the other tissues will afterwards be 
briefly noticed. 
•Article II. 
HEMORRHAGE FROM THE NOSTRILS, or EPISTAXIS. 
The mucous membrane of the nostrils is probably the most frequent seat 
of hemorrhage. The affection in this situation is liable to all the diversities 
which have been enumerated in our general remarks upon the subject. To 
treat of them here would be mere repetition. 
Symptoms, Course, &c.-When the hemorrhage is of the active kind, it is 
often preceded by signs of local disorder; as a feeling of fulness, heat, itch- 
ing, &c., in the nostrils, weight, tension, and pain in the forehead, giddiness, 
general headache, buzzing in the ears, dizziness, disordered vision, redness of 
the eyes and nostrils, flushing of the face, and coldness of the hands and feet. 
All these symptoms are not usually present in the same case, nor in equal 
degree in different cases. Sometimes nothing more is felt than a fulness or 
sense of weight about the head or nostrils; and frequently the eruption of 
blood is preceded by no observable disorder. The blood is usually of a florid 
colour and coagulable, forming a large clot, which is little disposed to part 
with its serum. It issues, in most cases, from one nostril only, but some- 
times from both. It may fall drop by drop, or in a continuous stream, and 
varies from a few drops to a quantity sufficient to endanger life. Occasion- 
ally it flows posteriorly as well as anteriorly, and then escapes by the mouth. 
It may even take this direction exclusively. When the hemorrhage is con- 
siderable, portions of the blood are often swallowed, so as even to occasion 
nausea and vomiting. Small portions, too, sometimes pass into the glottis, 
and produce coughing. Fears of the existence of hmmatemesis or haemopty- 
sis may thus arise; but, when the blood flows also from the anterior nostrils, 
there can be little difficulty in forming a correct diagnosis. There may be 
some obscurity when the hemorrhage occurs during sleep, and takes a direc- 
tion exclusively backwards. The patient, awaking, vomits or coughs up 
blood, and becomes much alarmed. A close examination, however, will gene- 
rally detect traces of epistaxis. Blood, for example, will be brought away 
by blowing the nose, or clearing out the posterior nares; and its fresh charac- 
ter will show that it had not been lodged there from the stomach, in vomiting. 
Should there, then, be no return of the discharge from the stomach or lungs, 
the fears of the patient may be confidently quieted. f. 
Epistaxis is very irregular in its occurrence, duration, and progress. It 
comes on at uncertain times, lasts from a few minutes to many hours, some- 
times even a day or more, and is very frequently suspended,Ao recur again at 
short intervals, occasionally from some slight cause, occasionally without any 
observable cause whatever. It is very seldom dangerous, and often, indeed, 
proves salutary by relieving pre-existing disorders, especially those attended 
with a strong determination of blood to the brain. It is sometimes, however, CLASS III.] 
293 
EPISTAXIS. 
in such excess as to justify alarm, and has been known to prove fatal, though 
no instance of this kind has fallen under the notice of the author. The most 
profuse, and most dangerous form of epistaxis, is that in which the hemorrhage 
is of a strictly passive character. Great quantities of blood are sometimes 
lost in such cases, and the suppression of the hemorrhage is often difficult. 
This form of the affection is the more dangerous, as it generally attends dis- 
eases of a prostrate character, which can ill bear the loss of blood. It is pro- 
bable that most of the fatal cases have been thus complicated, and that death 
has resulted much more from the pre-existing disease than from the hemor- 
rhage, though perhaps hastened by this cause. 
Causes.-Where no predisposition to epistaxis exists, it is seldom produced 
except by direct violence; but, with such a predisposition, very slight causes 
are sufficient to induce an attack. A moderate blow upon the nose, picking 
the nostrils, sneezing, a violent paroxysm of coughing, a sudden jar of the 
body, strong muscular efforts of any kind, stooping, tight cravats, exposing 
the head to the fire or the sun, sudden changes in the temperature of the body, 
the introduction of irritating powders or vapours into the nostrils, stimulating 
food or drink, paroxysms of anger or other strong emotion, and, in general, 
any other agency capable of producing a rush of blood to the head, or of im- 
peding its return through the veins, may serve as causes of this hemorrhage. 
The predisposition consists either in the state of the mucous membrane, in 
that of the system, or in the two combined. In those subject to the affection, 
a swollen and peculiarly tender state of the Schneiderian membrane has 
sometimes been observed. The hemorrhage is an occasional attendant upon 
common colds or coryza, and is a not unfrequent result of the apoplectic ten- 
dency. It often accompanies polypus and other organic diseases of the nostrils. 
A plethoric state of system, an excited state of the circulation, and a hemor- 
rhagic constitution of the blood, predispose to it. The predisposition is occa- 
sionally so strong as to lead to the result without any exciting cause. It exists 
to this degree in various febrile and inflammatory complaints, in which bleed- 
ing of the nose is a common occurrence, especially in typhoid fever. Phthisis 
in its advanced stages, congestion and organic disease of the liver, malignant 
exanthemata, typhus fever, scurvy, and purpura are also among the complaints 
often attended with epistaxis, which in these affections is usually passive. 
The scrofulous or tuberculous state of system constitutes a predisposition to 
it. The affection occasionally follows suppression of the menses, of the he- 
morrhoidal flux, and of other natural or habitual discharges. I have known 
it apparently the result of pregnancy. The time of life appears to have some 
influence in forming the predisposition; for the complaint is very common 
about the age of puberty, though it may occur at any period from childhood 
to old age. Very often, however, a strong predisposition exists which can be 
traced to no known cause. The general hemorrhagic tendency is apt to show 
itself in the form of epistaxis. 
Treatment.-In relation to the propriety of attempting to suppress this 
hemorrhage, in any particular case, the remarks already made upon hemor- 
rhage in general are applicable. When no constitutional symptoms exist 
which it may be calculated to relieve; when there is no increased energy of 
the circulation, plethora, or uneasiness about the head; and when the hemor- 
rhage is not vicarious to some more hazardous discharge; endeavours should 
be used to check it, if it do not soon cease spontaneously; and, even in cases 
which offer the objections above alluded to, if it continue after the relief of 
the symptoms, or be so copious as to endanger life, it should be arrested. 
In the passive form it should be suppressed as soon as possible; as, in this 
state, instead of relieving the disease, it tends to aggravate the debility in 
which it originated. 294 
[part II. 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
The patient should be placed in a sitting posture, in a chair or in bed, with 
his head erect, or slightly inclined backward. The air of the chamber should 
be cool and fresh. The cravat, or anything acting in the form of a ligature 
about the neck, should be removed. Cold water, ice, or snow should be ap- 
plied to the outside of the nose, the head, or the back of the neck. Dipping 
the head in cold water, or holding it under a pump, sometimes causes an im- 
mediate cessation of the hemorrhage. Immersion of the arms in cold water, 
and the application of cold to the arm-pits, groins, or other very sensitive 
part, have also been recommended. Should these measures fail, recourse 
should be had to astringent injections. The author usually employs a strong 
solution of alum, in the proportion of fifteen or twenty grains, or even more, 
to the fluidounce, with almost uniform success. Kino, catechu, or extract of 
rhatany, may be added to this solution, or used separately in the form of very 
strong infusion. Acetate of lead may also be used in the same way ; but care 
must be taken that too large a quantity of this salt be not swallowed during 
the operation. The liquid should be thrown up by means of a syringe, and 
should be directed to different parts of the nostrils. Some recommend various 
powders, astringent and otherwise, to be blown up the nostrils by means of a 
quill. Finely levigated charcoal, galls, kino, alum, &c., are among the sub- 
stances thus employed, and great advantage is asserted to have accrued from 
powdered gum arabic, used in the same way. Dr. Ruschenberger has found 
pulverized matico very efficient. {Am. Journ.of Aled. Sei., N. S., xiii. 78.) 
During the employment of these local measures, hot and stimulating pedilu- 
via, and mustard cataplasms to the feet or inside of the legs, may be resorted 
to, especially when the extremities are cold, and the difficulty of arresting the 
hemorrhage or its disposition to return, immediately after having been checked, 
is very considerable. Should the pulse be strong, full, and excited, it may 
be proper to abstract blood from the arm; and this remedy should always 
be employed, when, along with the condition of the pulse alluded to, are symp- 
toms of sanguineous determination to the brain. Saline cathartics, cold beve- 
rages, and the antiphlogistic regimen generally, should be conjoined with the 
bleeding; and, where the latter remedy is not considered necessary, should be 
employed whenever the hemorrhage is active and persistent. Advantage will 
sometimes accrue from brisk purgation by senna, jalap, or calomel combined 
with one of the drastic cathartics. 
Dr. Negrier, of Angers, in France, has called the attention of the profession 
to a remedy, which he has employed frequently, and with uniform success, in 
the treatment of epistaxis. It consists simply in causing the patient, in a 
standing posture, suddenly to raise one or both arms perpendicularly upward, 
and to retain them for a short time in this position. If one only is raised, it 
should be that of the side from which the hemorrhage proceeds; and then 
the patient may compress the bleeding nostril with the other hand. In young 
children, the physician may perform both offices for the patient. The remedy 
has always succeeded, even in very bad cases, when all other means had failed. 
The effect is almost instantaneous, and usually continues permanent, if the 
patient has lost a certain quantity of blood, say from six to nine troy ounces. 
The elevated position of the arm should be sustained a few minutes, in order 
to give the blood in the bleeding orifices time to coagulate. Dr. Negrier ex- 
plains the result by the consideration that, as the blood, in the erect position 
of the arm, requires a much greater force to sustain it than when the arm is 
pendent, the energy of the heart's contraction must be in the same proportion 
diverted from the carotid to the subclavian. {Archives Generales, 3e ser., 
xiv. 168.) 
If the measures above enumerated should prove insufficient, direct com- CLASS III.] 
STOMATORRHAGIA. 
295 
pression, if properly applied, can scarcely fail to arrest the hemorrhage. For 
this purpose a piece of soft sponge or patent lint, of a cylindrical shape, and 
saturated with some astringent solution, should be carefully introduced into 
the nostril, so as if possible to come in contact' with the bleeding surface. 
Perhaps small pledgets of raw cotton, successively and carefully introduced 
by a probe, would be still more effectual. Abernethy never failed of success, 
by winding a piece of moistened lint around a probe, so as to form a cylin- 
drical plug, passing this along the floor of the nose for its whole length, then 
carefully withdrawing the probe, and allowing the lint to remain for three or 
four days. {Tweedie's Syst. of Pract. Med., Article Epistaxis f Another 
plan is to introduce a portion of hog's intestine, properly prepared and closed 
at one end, deeply into the nostril, then to inject some cold, water forcibly, 
and tie the other extremity of the tube. But should the blood, notwithstand- 
ing these measures, continue to flow through the posterior nares into the 
throat, efforts must be made to close both extremities of the nasal cavity. 
This is to be done by passing through the nostril, in a canula, a doubled piece 
of cat-gut, thin wire, or other stiff ligature, somewhat bent at its looped ex- 
tremity, so that the end, when advanced beyond the canula, may have a ten- 
dency downward; pushing the ligature till, having passed beyond the velum 
pendulum, it may be seized by the finger or a suitable instrument in the 
throat; then drawing it forward through the mouth, attaching to it firmly a 
suitable piece of sponge or lint, and, by means of the string in the nose, 
drawing the plug somewhat firmly into the posterior nostril. Another string 
should be attached to the plug and left hanging out of the mouth, so as to 
enable the practitioner to remove the foreign body when desirable. The an- 
terior nostril should, at the same time, be closed by a piece of sponge or lint 
introduced by a probe. This operation, however, is of difficult performance; 
always produces a great deal of irritation in the throat, with irresistible con- 
vulsive movements, as in vomiting; and is very seldom necessary. Abernethy 
never had occasion to resort to it. 
Sometimes epistaxis may be arrested by pressure upon the upper lip, near 
the nostrils, so as to close the small artery which proceeds in this direction to 
the septum. (S. R. Smith, Bost. Med. and Surg. Journ., xli. 243.) 
For the constitutional measures requisite to prevent a return of epistaxis 
when arrested, the reader is referred to the general remarks on hemorrhage. 
Should the predisposition to the affection consist in an irritable state of the 
nasal membrane, it is recommended to protect it by the daily application of 
some simple ointment; and, when the membrane is chronically inflamed, 
leeches externally, and injections calculated to correct this morbid condition, 
as solutions of acetate of lead and sulphate of zinc, may be found useful as 
prophylactics. 
Article III. 
HEMORRHAGE FROM THE MOUTH, or STOMATORRHAGIA. 
The mucous membrane of the mouth is much less liable to hemorrhage 
than that of the nostrils; but cases of stomatorrhagia now and then occur; 
and the affection requires a brief notice. In the mouth may be here in- 
cluded, for convenience sake, all the parts visible from without; the gums, 
tongue, cheeks, fauces, and even the posterior and upper portion of the pha- 
rynx. Hemorrhage may occur from any portion of this surface, but is most 
frequent from the gums. 296 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
[part II. 
The symptoms are too obvious to require enumeration.' When moderate 
in quantity, the blood is discharged by spitting; when very profuse, it runs 
in a stream from the mouth. In general, there is very little difficulty in the 
diagnosis. Not unfrequently, if the mouth is gashed out with water, the 
point or surface from which the blood proceeds may be seen. It may hap- 
pen, in some instances of very copious hemorrhage, particularly in the fauces, 
that the effused fluid may be swallowed, or fall down upon the glottis, thus 
provoking vomiting or coughing of blood, resembling hsematemesis or haemo- 
ptysis. But the practitioner can have little difficulty in detecting the nature 
of the case, if his attention is directed to the mouth. The absence of the 
peculiar signs of gastric and pectoral disease, other than mere vomiting or 
coughing; the difference in the appearance of the blood; and the fact that it 
will run out of the mouth if the patient hold his face downward, will be 
sufficient to point out the true seat of the hemorrhage. It may not be so 
easy to decide, when blood has passed into the throat during sleep, or in cases 
of infants who swallow all the blood effused in the mouth, especially if the 
hemorrhage has ceased before the visit of the practitioner. In such instances, 
the judgment must be formed upon the .appearance of the blood, and the 
presence or absence of symptoms pointing to the chest or stomach. The 
blood in epistaxis is sometimes discharged from the mouth; but there is at 
the same time bleeding from the anterior nostrils, or if not, the blood will 
appear there upon holding the face downward. A complete stoppage of the 
nostrils by tumours or other cause, so as to prevent the escape of blood 
anteriorly, would render the diagnosis more difficult. The peculiar motion 
made in clearing the upper surface of the soft palate, and the absence of any 
visible hemorrhagic point in the mouth or fauces, would, in that case, lead to 
the supposition that the blood might come from the posterior nares. 
Stomatorrhagia is the result of the same general and local causes which 
produce hemorrhage elsewhere. Most commonly it proceeds from wounds of 
the mouth, either by the teeth, by blows or other external violence, or by 
surgical operations, as in the extraction of a tooth, the division of the fraenum 
linguae, or the lancing of tumours. One of the most profuse cases of hemor- 
rhage from the mouth, that ever came under the notice of the author, pro- 
ceeded from a soft tumour upon the palate, which was opened under the 
impression that it was an abscess, but proved to consist of a mere congeries 
of blood-vessels. This hemorrhage is also frequently produced by inflam- 
mation and ulceration, as in the mercurial sore-mouth, of which one of the 
greatest dangers is the profuse bleeding that sometimes attends it. In some 
rare cases, it appears to be the result of a mere hemorrhagic irritation of the 
membrane, and is then preceded by redness and tumefaction, and sometimes 
by the usual evidences of determination of blood to the head, such as precede 
epistaxis. In these cases, it is said to be occasionally periodical, especially 
when vicarious to the menses or to other periodical discharge, as it is thought 
sometimes to be. The constitutional or family predisposition to hemorrhage 
not unfrequently shows itself in the mouth, especially in the gums, which 
bleed profusely from the slightest wound, and sometimes even without any 
wound at all. In a case, which occurred to Dr. Condie, of Philadelphia, the 
blood flowed from the mouth in a stream, and, when the gums were wiped 
with a sponge, " it was seen to start up at every pore from the whole sur- 
face." (Ai Am. Med. and Surg. Journ., vi. 51.) Large quantities of blood 
are often lost from the gums and other parts of the mouth in scurvy, purpura, 
and malignant fevers, sometimes escaping from ulcers, but more frequently 
from the surface of the membrane. 
This hemorrhage is not often of itself dangerous, though it sometimes in- CLASS III.] 
HEMOPTYSIS. 
297 
dicates a dangerous state of disease. Fatal cases are recorded of bleeding 
following the extraction of a tooth, and the division of the fraenum of the 
tongue. The obstinacy of the hemorrhage in such cases proceeds generally 
from the constitutional tendency of the patient. 
Treatment.-Ordinarily, little is required besides ice-water in the mouth, 
and astringent washes, such as strong solutions of acetate of lead and alum, 
and infusions of kino and catechu. When the hemorrhage proceeds from 
wounds, the same applications may be employed; or, what is often more 
effectual, the powder of alum, kino, catechu, galls, or tannic acid, may be 
brought in contact with the bleeding surface. In the case of hemorrhage from 
the roof of the mouth above alluded to, kino applied thickly upon a piece of 
patent lint, and pressed upwards by the tongue, arrested the discharge. When 
the blood issues from the socket of an extracted tooth, the same remedies 
will often answer. If not, the cavity may be filled with wax, or with lint, or 
a piece of sponge saturated with the astringent; and pressure may be made 
by means of a cork fitted to the cavity, and held in its place by confining the 
jaws with a bandage. Dr. Physick used to recommend, in hemorrhage of the 
mouth from wounds, that the mouth should be kept open by means of a piece 
of wood or other firm substance between the teeth, having often found this 
remedy to answer in hemorrhage after operations. (R. Coates, N. Am. Med. 
and Surg. Journ., vi. 43.) In bleeding from the divided fraenum, if other 
means fail, it may be necessary to employ the actual cautery. When bleed- 
ing from the mouth is vicarious to the menses, efforts should be made to re- 
store the function to its healthy state; when dependent upon morbid states 
of the blood, these must be corrected. 
Article IV. 
HEMORRHAGE FROM THE LUNGS, or HAEMOPTYSIS. 
Syn.-Spitting of Blood. 
The term haemoptysis, though, from its origin (ai^a, blood, and rttva, I 
spit), applicable to any case in which blood escapes through the mouth, is 
now universally restricted to hemorrhage .from the lungs, and their append- 
ages, the trachea and larynx. The blood may proceed either from the mu- 
cous membrane of the air-passages, including the larynx, trachea, and bron- 
chial tubes, or from the air-cells of the lungs. Another form of hemorrhage 
wdiich may come under this head, though not always attended with discharge 
of blood from the mouth, consists of bleeding into the pulmonary parenchyma 
or interlobular tissue, and is named apoplexy of the lungs. 
Symptoms, Course, &c.-The first feeling of the patient is, not unfre- 
quently, a tickling or other unusual sensation in the trachea or larynx, which 
induces a slight cough, followed by the expectoration of blood. A return of 
the sensation leads to a more or less frequent repetition of the same effort, 
producing a greater or less discharge, until the hemorrhage ceases. More 
frequently, however, there are various preliminary symptoms, such as sensa- 
tions of fulness, weight, tightness, heat, soreness, and oppression, over the 
whole chest or in some particular region of it, often attended with an excited 
pulse, flushed cheeks, and headache, and occasionally with cool extremities, 
general rigors, and decided febrile symptoms. In many instances, moreover, 
a dry cough precedes for some time the expectoration of blood. These symp- 
toms of local and general excitement mostly continue, for a longer or shorter 298 
[PART II. 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
time, after the commencement of the hemorrhage, by which, however, they 
are usually at length relieved. 
The appearance of the blood discharged differs according to its precise ori- 
gin, quantity, length of detention, &c. It is usually liquid, florid, and more 
or less frothy, owing to the admixture of air in the respiratory passages. 
When the quantity is very great, it is less frothy, though a portion will still 
generally be observed in this state, upon the surface of the expectorated blood 
in the vessel which receives it. Occasionally it is partially coagulated, espe- 
cially when small in quantity, and detained for some time in the bronchia. 
In such instances, it is little if at all mixed with bubbles of air. When it 
has been long detained in the air-passages, it is of a dark colour; and this 
appearance, following the arterial redness which generally characterizes the 
freshly discharged blood, indicates a moderation or cessation of the hemor- 
rhage. The blood is also frequently mixed with mucus. It may have this 
character throughout the attack, when the hemorrhage is slight, but, in the 
much greater number of cases, the phenomenon is confined to the latter stages, 
when the bloody transudation has begun to give way to mucous secretion; 
and the proportion of blood gradually diminishes until the expectorated mat- 
ter is entirely free from it. There is a difference in the mode of admixture. 
Sometimes the blood appears in the form of distinct streaks in the mucus, 
indicating an origin of the two liquids from different, and possibly distant 
points. In other cases, the blood and mucus are intimately blended, giving 
a rusty hue to the expectoration, which gradually becomes lighter as the 
quantity of the former fluid diminishes, until an opaque whitish or yellowish 
puruloid matter is left. In such cases, the two fluids have probably issued 
from the same portion of membrane, and that, in a condition of very high 
irritation, or positive inflammation. Occasionally the blood is mixed with a 
very tenacious mucus, as in pneumonia. This would appear to indicate an 
origin in the air-cells, or minute bronchial ramifications. Important infer- 
ences may thus be drawn from the appearance of the discharged-blood. 
The quantity of blood varies from enough merely to tinge the expectora- 
tion, up to several pints. In the great majority of cases, the loss is moderate, 
and of itself wholly insufficient to produce any serious impression on the sys- 
tem. In some instances it is directly fatal, though very rarely so. 
The presence of the effused blood in the lungs, when considerable in quan- 
tity, produces more or less difficulty of respiration, with wheezing, and some- 
time a gurgling or rattling sound, from the passage of the air through it, 
both during inspiration and expiration. The dyspnoea is occasionally very 
great, being attended with heaving of the chest, a sense of fulness and great 
oppression, and marks in the countenance of imperfect respiration. The cough 
which attends the hemorrhage varies according to circumstances. Sometimes 
it depends wholly upon the presence of the effused blood; but more frequently 
it originates also in a tuberculous or inflammatory state of the lungs, and then 
tends to sustain and aggravate the hemorrhage. The cough which is pro- 
voked by the effused blood varies with the quantity and seat of the effusion. 
When the blood is pure and in the larger bronchia, it is usually evacuated 
without much effort; but, when in the air-cells or minute bronchial ramifica- 
tions, or mingled with tenacious secretions, or allowed to remain until it has 
coagulated, it provokes full, deep, and frequeptly hard and painful coughing. 
In some few instances, the gush of blood into the air-passages is so sudden 
and copious as to produce a feeling of impending suffocation, and to give rise 
to convulsive efforts of all the muscles of expiration for its discharge. It is 
thus thrown forcibly into the fauces, and escapes not unfrequently both by 
the mouth and nostrils, occasioning, at the same time, probably by its pre- CLASS III.] 
HEMOPTYSIS. 
299 
sence in the throat, spasmodic contractions of the muscles concerned in vomit- 
ing. The contents of the stomach are thus mingled with the blood from the 
lungs; and, at first sight, the case may bear a close resemblance to haemate- 
mesis. But the symptoms of disturbed respiration, and the evidences pre- 
sented by auscultation, will be sufficient to indicate its true nature. 
Along with the phenomena already mentioned, there are often present, 
especially upon the first attack of haemoptysis, various symptoms ascribable 
to the very natural alarm of the patient; as great paleness, anxiety of coun- 
tenance, a quickened and agitated but feeble pulse, tremblings, faintness, and 
even nausea. These have fortunately, in many instances, a tendency to 
diminish the hemorrhage. In the subsequent attacks, the patient in gene- 
ral feels less apprehension; but the idea of great danger, connected with 
spitting of blood, is so firmly fixed in the public mind that few are found 
capable of resisting the impression entirely. When the loss of blood is great, 
the effects of this are added to those of alarm, and symptoms of great pros- 
tration are occasionally presented. It is usually, however, more from the 
long continuance than from the great copiousness of the hemorrhage, that 
the debilitating consequences of loss of blood are experienced in any great 
degree. Like any other hemorrhage, that from the lungs may be of a purely 
passive character, though this form of the disease is comparatively rare. 
The course of haemoptysis varies as much as the symptoms already enu- 
merated. Sometimes the whole attack is limited to a few acts of expectora- 
tion, slight or copious as the case may be, and no return is experienced on 
the particular occasion. Sometimes the discharge is suspended during a 
longer or shorter interval, for example, a few hours, a day, or more than a 
day, and then recurs, to cease again, and again recur; and the affection may 
thus continue irregularly, sometimes better and sometimes worse, for weeks 
and even months. In other cases, again, it is continuous for many days, with 
little or no interruption, except that occasioned by the slow accumulation of 
the extravasated blood. It rarely happens that an individual, if he live many 
years after the first attack, escapes a return; and, in very many cases, the re- 
turns are frequent. In these cases, the patient, in general, dies ultimately of 
pulmonary consumption. In some instances the attacks are periodical, occur- 
ring especially once a month. This is apt to be the case in women with 
amenorrhoea; and the same monthly returns are said occasionally to have been 
observed in men, as vicarious to a suppressed hemorrhage from the rectum. 
Such cases are not usually attended with much danger. 
Haemoptysis is very seldom directly fatal. The instances of death from 
this cause, without organic disease of the lungs or great blood-vessels, are 
exceedingly rare. One is recorded by Andral, in which the patient died from 
the mere transudation of blood from the bronchial vessels, without ulceration, 
rupture, or any other discoverable cause of hemorrhage. Death may result 
in two different modes. The quantity of blood may be so great, and its effu- 
sion so sudden, that it cannot be discharged from the lungs, and the patient 
must, therefore, die of suffocation; or the loss of blood from the circulation may 
occasion a fatal syncope. It is probable that sudden death results usually 
from the former cause. In some instances, the patient is exhausted by a long- 
continued discharge. Generally speaking, however, when a patient dies with 
pulmonary hemorrhage, it is through some coexisting disease, especially of 
the lungs or the heart. 
It is often desirable to know from what part the blood proceeds. It may 
be suspected to come directly from the mucous membrane of the larynx^ espe- 
cially from the neighbourhood of the glottis, when the preliminary symptoms 
of irritation exist in this part, and are wanting in the lungs; when the excit- 300 
[PART II. 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
ing cause was one peculiarly calculated to act upon the glottis, as loud speak- 
ing, or singing; when no proofs are afforded by auscultation of effusion in the 
bronchial tubes; in fine, when the blood is in small quantity) little mixed with 
air, and discharged by that peculiar cough by which irritating substances are 
removed from the glottis, and which may very properly be called laryngeal. 
Hemorrhage from this vicinity may result from simple irritation of the organ, 
aided by a hemorrhagic diathesis; but it is probably, in the greater number 
of cases, dependent upon ulceration of a scrofulous character, and associated 
with tubercles in the lungs. 
The same absence of pulmonary symptoms, the same character of the cause, 
and similar appearance of the blood discharged, with a cough neither laryn- 
geal, nor apparently connected with the lungs, and the localization of the 
preliminary sensations of uneasiness in the trachea, would fix attention upon 
this portion of the air-passages as the seat of the disorder. But hemorrhage 
seldom takes place from the trachea. 
The symptoms which point to the bronchial tubes, as the source of the 
hemorrhage, have been already sufficiently described. All cases in which 
there is no particular reason for referring it to some other seat, may be con- 
sidered as bronchial. They are beyond all comparison the most numerous. 
In addition to what has been stated, it is only necessary to mention that, in 
these cases, the sounds produced by liquid in the bronchia will be discovered 
in the chest by auscultation. 
It has been mentioned that blood is sometimes effused in the air-cells, and 
the interlobular cellular tissue, constituting what Laennec has called apoplexy 
of the lungs. This is not always attended with the escape of blood from the 
mouth; and, in such cases, an accurate diagnosis is very difficult, and perhaps 
impossible. When there is a considerable reddish and very frothy expecto- 
ration, with great oppression of breathing, and a sense of impending suffocation, 
and when, at the same time, an absence of respiration in a certain portion of 
the lung is indicated by auscultation and percussion, with a sub-crepitant or 
sub-mucous rale in the vicinity of the dulness, and a coarse mucous rale in 
the large tubes, there is reason to suppose that the hemorrhage may be of 
the kind alluded to; though it must be confessed, that the inference is not 
necessarily correct. These cases are always alarming and dangerous, but 
by no means inevitably fatal. The effused blood, when not of great extent, 
is surrounded in time, after the cessation of the hemorrhage, by a sort of cyst 
similar to that formed in cerebral apoplexy, which probably serves not only 
to isolate the matter thus become foreign to the system, and consequently irri- 
tant, but to effect its ultimate absorption. 
Diagnosis.-Hemorrhage from the mouth, fauces, and posterior nares, is 
sometimes mistaken for haemoptysis, to the great alarm of the patient. In 
ordinary cases, there can be no difficulty in the diagnosis. In some instances, 
however, the nature of the case is not so clear. Thus, in epistaxis, when the 
blood escapes exclusively by the posterior opening of the nostrils, and through 
the mouth, if the quantity is considerable, portions are apt to fall upon the 
glottis, excite coughing, and thus seem as if they came from the air-passages. 
Even when the hemorrhage is slight, if it occurs during sleep, the same result 
often happens, and the patient, on awaking, supposes that he is coughing up 
blood. The physician may also be deceived, unless he carefully examine into 
the case. It generally happens that, upon close inspection, blood may be 
observed at the anterior opening of the nostrils, or, at least, may be made to 
appear there, if the patient be directed to blow the nose smartly. The blood 
discharged is not mixed with air, and is without that semi-coagulated con- 
sistence, and somewhat regular form, that often belong to the sputa in hmmo- CLASS III.] 
HEMOPTYSIS. 
301 
ptysis, when not frothy. When the hemorrhage is slight, coagulated blood 
may often be seen in the fauces, hanging over the velum, upon which it 
rests. After the suspension of the bleeding, coughing brings up no more 
blood, while, if the patient clear out the nostrils posteriorly by drawing air 
suddenly through the nose, either blood, or mucus mixed with blood, is dis- 
charged through the mouth. When the hemorrhage is from the mouth or 
fauces, a close inspection will often discover the precise source. The diag- 
nosis is here also aided by the appearance of the blood, which resembles that 
from the nostrils. In both cases, the symptoms of effusion into the bronchial 
tubes, whether of a general nature, or those revealed by auscultation, are 
wanting; though there might be some difficulty in this respect, if the hemorrhage 
should be complicated with catarrh. In some rare instances of haemoptysis, 
the blood escapes by the nostrils as well as the mouth, and there might be risk 
of mistaking the case for one of epistaxis. But here the pectoral signs would 
probably be abundant; as the quantity of blood effused must be considerable, to 
be attended with such a phenomenon. The diagnostic signs between haemo- 
ptysis and haematemesis will be given in the account of the latter hemorrhage. 
Anatomical Characters.-In most cases, no other phenomenon is presented 
by the mucous membrane from which the hemorrhage proceeded than a cer- 
tain degree of redness, and occasionally of inflammation; and sometimes even 
these are wanting. The most careful search generally fails to detect any 
rupture, ulceration, or other solution of continuity. The inference is, that 
the blood has escaped by transudation from the vessels. But it is possible 
that morbid openings may exist, large enough to admit the issue of blood, yet 
so minute as to escape the strictest scrutiny; and I am disposed to think that 
an absolute rupture may take place more frequently than some pathologists 
have been willing to allow. When the discharge comes on very suddenly and 
in considerable quantities, there is reason to believe that it takes place through 
a solution of continuity in a vessel; for transudation, whether as a healthy or 
morbid process, is almost always somewhat gradual at the commencement. 
When the effusion of blood has taken place into the pulmonary parenchyma, 
constituting apoplexy of the lungs, a circumscribed solid portion is observed, 
of greater or less extent, from one to many cubic inches, which, upon being 
cut, exhibits a deep reddish-black colour, and a somewhat granular structure. 
There appear to be two pathological conditions which have been confounded 
under this name. In one, the effused blood is contained in the air-cells, and 
smaller bronchial tubes, completely blocking them up; but without any rup- 
ture of the cellular tissue, or vascular coats. In this case, when the cut surface 
of the solidified mass is scraped by the scalpel, small isolated portions of 
coagulated blood are removed, and the tissue of the cells is exposed. In the 
second of the conditions alluded to, the tissue is ruptured to a greater or less 
extent, blood has escaped into the interlobular structure, and sometimes clots 
are found, as in cerebral apoplexy, contained in cavities hollowed out in the 
substance of the lungs. Andral considers these to be cases of true pulmonary 
apoplexy. The extent of the effusion is in some instances very great, involving 
even one or more lobes; and the blood sometimes lacerates the pleura also, 
and escapes into the cavity of that membrane. A third condition, which 
might be confounded with effusion into the air-cells, is that in which the blood 
has issued from the bronchial mucous membrane, and gravitated, or been 
forced by inspiration, into the cells of a certain portion of the lungs, so as to 
fill them up completely, as well as the minute ramifications of the bronchia. 
That such an event occasionally happens, may be inferred from the observa- 
tions of Andral (Anat. Pathol., iii. 488), and those of Dr. Watson (Med. Gaz., 
ix. 656). But Dr. Burrows states that, though his field of observation in 302 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
[PART II. 
relation to the pathology of the lungs has been very extensive, he has never 
met with an instance in which the blood has not appeared to be coagulated in 
the position in which it had been extravasated. {Tweedie's Syst. of Pract. 
Med., Article Hemorrhage from the Lungs.') 
Causes, &c.-The causes of pulmonary hemorrhage are blows or other form 
of external violence; severe exertion of the lungs in speaking, hallooing, 
singing, coughing, sneezing, laughing, or playing on wind instruments; strain- 
ing at stool or urine, or in the lifting of weights, wrestling, &c.; other forms 
of violent muscular exertion, as running, leaping, ascending heights, &c.; a 
sudden diminution of the atmospheric pressure, whether upon the surface of 
the earth, or at great elevations; the inhalation of irritating gases or powders, 
or of hot or very cold air; tight lacing, and other artificial methods of com- 
pressing the chest or abdomen; whatever conditions of health or disease have 
a tendency to diminish the capacity of the lungs, and thereby expose the pul- 
monary vessels to distension, and whatever block up the abdomen so as to 
throw the blood especially upon the chest, as pregnancy, ascites, and large 
abdominal tumours; the transfer of gouty or rheumatic irritation to the lungs; 
the suppression of habitual discharges, whether healthy or morbid; vicissitudes 
of temperature; organic diseases of the lungs and heart, producing either 
irritation, inflammation, ulceration, or mechanical congestion of the bronchial 
membrane; a relaxation of the pulmonary tissue consequent upon great de- 
bility ; and, finally, a morbid state of the circulation either in relation to the 
force of movement, or the quantity or quality of the blood. Some of these 
causes are only exciting or occasional, others are both exciting and predis- 
posing, according to the circumstances of their action. Whatever is common 
to them, as causes of hemorrhage in general, has already been sufficiently dis- 
cussed. Age has great influence as a predisposing cause. By far the larger 
proportion of cases of haemoptysis occur between puberty and full maturity, 
or from fifteen to thirty-five. The disease, however, is not uncommon in 
middle and old age. It is rare in infancy. 
Haemoptysis may be associated with all the different pathological states 
which have been enumerated under the head of hemorrhage in general, and 
which it is unnecessary to repeat in this place. But there are certain morbid 
affections which are especially productive of this hemorrhage, and therefore 
require a particular notice. Those which merit attention may be included 
under the heads of 1. bronchial or pulmonary inflammation; 2. phthisis; 3. 
organic diseases of the heart; 4. aneurism, and 5. suppression of habitual dis- 
charges whether healthy or morbid. 
With Inflammation.-Whether irritation is to end in hemorrhage, or to 
advance to inflammation, depends frequently upon an unappreciable condi- 
tion of the part affected, or of the system. It is highly probable that the 
hemorrhagic constitution of the blood sometimes leads to the former instead 
of the latter result. Now it may readily happen that the scale may be very 
nicely balanced between these two affections; that the tendency to neither 
exclusively may be very decided; and that consequently an irritation may first 
exhibit itself in the extravasation of blood, and, if not relieved in this way, 
may end in inflammation. Hence bronchitis and pneumonia may be ushered 
in by an attack of haemoptysis. The case appears at first to be only an 
ordinary one of active hemorrhage; the symptoms of decided inflammation 
being subsequently developed. But, even after inflammation has been es- 
tablished, more or less blood is often extravasated, and escapes by expectora- 
tion. The quantity, however, is now usually small, and generally mixed with 
mucus. In pneumonia, bloody expectoration is so frequent, as to be looked 
upon almost in the light of a characteristic symptom. Though, in most CLASS III.] 
HEMOPTYSIS. 
303 
cases, the sputa are merely tinged so as to give them a rusty hue, yet it 
sometimes happens that pure blood is discharged. This occurs especially in 
pneumonia with a typhoid tendency; and, in bad cases of this kind, con- 
siderable quantities of dark blood are occasionally coughed up. A hemor- 
rhagic character of the mass of the blood is here probably associated with the 
causes of inflammation. One of the effects of inflammation is to soften the tissue, 
which it affects. There is reason to believe that blood-vessels, whose power 
of resistance has been thus diminished, sometimes yield to the vis a tergo, 
and that hemorrhage ensues from their rupture. Another mode by which 
inflammation occasionally gives rise to hemorrhage is through ulceration. 
Haemoptysis, however, from this cause is rare. A case is recorded by Dr. 
Carswell, in which ulceration had penetrated through one of the bronchial 
tubes, and opened a branch of the pulmonary artery, with a speedily fatal 
effect. 
With Phthisis.-This is by far the most frequent complication of haemo- 
ptysis. Bleeding from the lungs has been so frequently followed by pulmo- 
nary consumption, that the two are usually associated in the common mind; 
and hence the dread with which this hemorrhage is almost universally re- 
garded. The notion was formerly very prevalent, even among medical men, 
that the hemorrhage was the incipient step in the disease, the efficient 
cause in fact of the fatal symptoms which followed. Pathologists now gene- 
rally, and, as I believe, more justly, regard it as a mere symptom of a pre- 
vious pathological condition, and alarming only from the fatal character of 
the affection, the existence of which it intimates. Haemoptysis is associated 
with tuberculous disease in three different modes. 
1. It is probable that the scrofulous or tuberculous predisposition consti- 
tutes also a predisposition to hemorrhage. We see this often in epistaxis. 
The morbid tendency may, in either case, depend upon the state of the blood, 
upon that of the capillary vessels, or upon both conjoined. In persons of the 
age at which tubercles are most apt to be deposited in the lungs, the circum- 
stances which give this direction to the deposition of tuberculous matter would 
probably dispose to the extravasation of blood in the same locality. The pri- 
ority of one or the other of these affections would depend upon accidental causes. 
Hence it happens that haemoptysis occasionally precedes the deposition of 
pulmonary tubercles, which afterwards make their appearance with fatal re- 
sults. It is not that the hemorrhage induces the subsequent disease. Both 
are the mere consequences of a previous morbid state of system. There may 
be cases, in which the first appearance of the hemorrhage, and the commence- 
ment of the formation of tubercles coincide. In these the result may be 
ascribed to some local irritation, which calls the tendency simultaneously into 
action in both directions. It does not, however, follow that hmmoptysis, even 
in persons of a tuberculous predisposition, must always be succeeded by con- 
sumption. The fact is often otherwise. If the hemorrhage has of itself any 
positive tendency to favour the developement of tubercles, it is probably only 
through the depression of system, occasioned by the loss of blood, and by the 
very natural anxiety and alarm of the patient. 
2. Though haemoptysis occasionally precedes the evidences of tuberculous 
deposition in the lungs, yet it much more frequently does not take place until 
after that event. It is not necessary to the occurrence of the hemorrhage, 
that the tubercles should have advanced to the ulcerative stage. Much more 
frequently the first attack of spitting of blood is experienced while the tuber- 
cles are yet solid. It may, in these cases, be partly dependent upon the 
general diathesis, as in those alluded to in the last section; but its great com- 
parative frequency leads necessarily to the inference, that the tubercles them- 304 
[PART II. 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
selves have some agency in its production. They probably act both by irri- 
tating, as foreign bodies, the mucous membrane of the neighbouring bronchial 
tubes, and by diminishing the capacity of the lungs, thereby rendering a dis- 
tension of the permeable vessels necessary for the accommodation of the blood 
sent to these organs. 
3. After the tubercles have advanced to maturation and ulceration, hemor- 
rhage is, in many cases, very frequent, occurring sometimes without premoni- 
tion, but often with the usual preliminary symptoms of irritation or congestion. 
In this stage of the disease, the bleeding may be owing to the opening of a 
vessel by ulceration, and, when sudden and profuse, is perhaps justjy ascriba- 
ble to that cause. Generally, as the work of ulceration advances, it is pre- 
ceded by the inflammatory process of adhesion, which obliterates the caliber 
of the vessels; but this does not always take place, and is especially liable 
to be wanting in those bands which are occasionally observed running across 
tuberculous cavities, with a considerable blood-vessel contained in them. M. 
Renaud observed, in one case, a small tubercle in contact with the surface of 
a blood-vessel, the coats of which, except the inner one, had been absorbed, 
without the obliteration of the cavity. The softening and evacuation of a 
tubercle thus situated might readily form a communication between the vessel 
and one of the bronchia, so as to occasion a copious hemorrhage. (Diet, de 
Med., xv. 138.) The cases, however, are very few, in which an ulceration 
or other opening in a blood-vessel has been positively observed; and it may 
well happen that, even in the advanced stages of phthisis, the hemorrhage 
may, in many if not in most instances, be a simple extravasation resulting 
from the conjoint irritation produced by the tubercles, and congestion arising 
from the mechanical impediment offered to the free circulation of the blood. 
Notwithstanding the frequency of the connexion between haemoptysis and 
pulmonary consumption, some recent pathologists have, I think, erred in the 
extremes to which they have carried their opinions upon this point. Thus, 
Louis seems to believe that, in almost all cases, any considerable hemorrhage 
from the lungs, not dependent on mechanical violence, or connected with 
amenorrhoea, is associated with tubercles, and may reasonably be supposed to 
indicate their existence, even in the absence of other positive signs; and 
Andral has advanced the opinion, that not more than one-fifth of those who 
have been affected with haemoptysis ultimately escape consumption. This is, 
no doubt, true of the cases which occur in the hospitals of Paris. The patients 
in these institutions are from the lowest classes, have been exposed to frequent 
hardships, and are consequently the subjects among whom phthisis might be 
expected. Besides, cases of hemorrhage from the lungs not unfrequently 
occur, which never receive the notice of the. physician. The bleeding ceases 
soon, and, leaving no unpleasant effect behind it, is forgotten by the patient. 
It is, probably, as a general rule, only the more obstinate attacks which seek 
a refuge in the hospitals. So at least it is in this country. The opinions of 
the pathologists, above mentioned, may be true in relation to the sphere of 
their own extensive observation. I am, however, quite sure that it is not 
true in relation to this country, or at least so much of it as I am familiar 
with. I have known many instances of men once or oftener attacked with 
haemoptysis, who have either died in advanced life of other complaints, or are 
still living, long after the period of their attack, in good health and free from 
tuberculous symptoms. Though unable to adduce accurate statistics upon 
this point, I am disposed to believe, as the result of observation, that, inde- 
pendently of menstrual derangement, more cases of hemorrhage from the 
lungs occur without tubercles than with. 
Hemorrhage in consumption is not generally in itself a very serious symp- CLASS III.] 
HAEMOPTYSIS. 
305 
tom. It is, in most instances, moderate or readily under control. When not 
so profuse as to occasion exhaustion, and thus favour the tuberculous dia- 
thesis, it is probably useful by relieving those occasional accessions of irrita- 
tion or sub-inflammation, which are so frequent in phthisis, and which, if 
they do not provoke an original deposition of tubercles, probably hasten the 
developement of those already commenced. It not unfrequently happens 
that consumptive patients, especially females, live many years, and even 
through a long life, with occasional attacks, of haemoptysis. It is not impos- 
sible that these attacks, while they control any excess of local excitement, 
may serve, to a certain extent, when not so profuse as to produce debility, 
as outlets for the tuberculous diathesis itself. 
With Organic Disease of the Heart.-Persons affected with organic diseases 
of the heart are very liable to haemoptysis. It results, probably, from con- 
gestion of the pulmonary vessels, proceeding either from the increased force 
with which the blood is transmitted to the lungs, or from some impediment 
offered to its return. This congestion may be such as to rupture the vessels, 
especially if previously weakened, or it may induce a hemorrhagic irritation, 
or, finally, in persons disposed to the passive form of hemorrhage, may simply 
cause transudation through the relaxed vascular walls. The particular conditions 
of the heart which give rise to this result are various. It has been ascribed to 
hypertrophy of the right ventricle, especially when connected with dilatation. 
It may also result from disease of the left side of the heart, especially of the 
auriculo-ventricular orifice, which, when contracted, opposes the return of the 
blood through the pulmonary veins, and, when enlarged or imperfectly closed 
by the valve, allows the blood to regurgitate under the contraction of the 
hypertrophied left ventricle, and thus not only passively impedes its return 
from the lungs, but causes a direct and powerful pressure upon the vessels 
which convey it. The symptoms of haemoptysis, in these cases, are mingled 
with those of diseased heart, so that it is not always possible to determine 
how much belongs to one, and how much to the other cause. The oppression 
and dyspnoea are often exceedingly distressing. The hemorrhage itself is 
seldom very copious, and is often not greater than is sufficient to tinge the 
mucous expectoration. It not unfrequently assumes the form of pulmonary 
apoplexy. 
With Aneurism.-Aneurisms of the large vessels sometimes burst into one 
of the bronchial tubes, or into the trachea, producing a gush of blood which 
is usually almost immediately fatal. The hemorrhage sometimes affords the 
first positive intimation of the existence of the aneurism, which is revealed 
upon examination after death. The physician has, in general, no opportu- 
nity of examining such cases until after the fatal issue. Sometimes, however, 
the opening into the air-passage is very small, and coagula existing in the 
tumour afford some impediment to the escape of blood. In these instances, 
the bleeding may be moderate for a time, and undistinguishable from ordinary 
haemoptysis, unless evident signs of aneurism exist; and even then the diag- 
nosis is by no means certain. 
Vicarious Haemoptysis.-Bleeding from the lungs may be vicarious to the 
menses, to hemorrhage from the rectum, to epistaxis, or to other habitual 
discharges. But it is only its association with the menstrual function that 
requires particular notice. This association is often accidental, the same dis- 
ease producing both the hemorrhage and the suppression of the menses, as in 
the case of phthisis. Frequent haemoptysis may possibly even induce ame- 
norrhoea. But, in both these instances, the hemorrhage has nothing in it 
peculiar. It is only when the spitting of blood comes on in consequence of 
retention, suppression, or deficiency of the menses, that it assumes the proper 306 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
[PART II. 
vicarious character. In such cases, it is apt to recur monthly, at the usual 
menstrual period, and is, on each occasion, frequently preceded by those 
symptoms of constitutional disturbance which so generally precede the ap- 
pearance of the menses. It is not essentially associated with any form of 
organic disease, and is generally an innocent variety of hemorrhage. Its 
suppression might, indeed, without a restoration of the discharge for which it 
is substituted, be attended with some danger. A monthly haemoptysis is 
said sometimes to have occurred in men, as a substitute for a suppressed 
hemorrhoidal flux which had appeared with the same interval. I have, in 
some instances, noticed that the discharge, when vicarious to the menses, 
consisted of a rather thin, bloody, uncoagulable liquid, instead of ordinary 
coagulable blood; and also that sometimes, instead of being as usual periodi- 
cal, it is continuous during long periods of time. 
Treatment.-It may be considered as always proper to attempt to arrest 
haemoptysis. There is no doubt that, in many cases, the affection is rather 
salutary than otherwise, by relieving irritation and congestion in the lungs, 
or by serving as an outlet for blood that might otherwise possibly be effused, 
even in a more dangerous situation. But we have no means of accurately 
discriminating such cases; and, as the hemorrhage is sometimes dangerous, 
we cannot be certain that it may not become so in any case. Besides, when 
there are evidences of serious irritation, congestion, plethora, &c., we have 
the power of relieving them by safer methods, such as general and local de- 
pletion, measures of revulsion, and regulation of the diet. 
The patient should be placed on his back in bed, with his head and shoul- 
ders considerably elevated, and thus supported by pillows or a bed-chair. All 
the clothing which has any effect in restraining the freedom of respiration, 
such for example as may compress in the least degree the chest or abdomen, 
should be loosened or removed. The body should be kept comfortably warm 
by bedclothes, while the air of the apartment is fresh and cool, and for this 
purpose the room should be well ventilated. The patient should be enjoined 
to keep perfectly at rest, moving his body or limbs as little as possible, never 
speaking except when necessary, and restraining the disposition to cough as 
much as he conveniently can. All sources of agitation or excitement of any 
kind, should be avoided. On this account, as well as to keep the air pure, 
no persons besides the necessary attendants should remain in the apartment. 
The physician should endeavour to allay the agitation of the patient, by the 
calmness of his own deportment, and all proper assurances of safety. These 
measures are not all essential in slight cases. Persons attacked with haemop- 
tysis, occasionally continue to pursue their usual avocations, as if nothing 
were the matter with them, yet recover perfectly, without serious inconve- 
nience. But this course is hazardous; fatal results might follow neglect; 
and it is the duty of the physician to act, in every case, as if danger were to 
be apprehended. 
As soon as the patient is properly disposed in bed, he should take into his 
mouth a heaped teaspoonful or more of common salt, undissolved, and swal- 
low it as he best can; and the dose may be repeated if necessary. This 
remedy seldom fails to check the hemorrhage for a time. Its method of ope- 
rating is probably by a rapid revulsion from the lungs to the irritated mucous 
membrane of the mouth, fauces, pharynx, and oesophagus. The same method 
of arresting a sudden return of the bleeding may be resorted to in the course 
of the complaint. 
It has generally been considered proper to take blood from the arm in 
haemoptysis. Indeed, this affection is almost inseparably associated, in the 
minds of many practitioners, with the necessity for venesection. But discrimi- CLASS III.] 
HAEMOPTYSIS. 
307 
nation is, I believe, as important here as in other diseases, and much injury 
has resulted from the improper use of the lancet. From robust individuals, 
with a full, strong pulse, and other signs of plethora or morbid excitement, 
and, especially, when local irritation or active congestion in the lungs is ob- 
vious, blood should be taken promptly and freely, no matter what may be the 
precise origin of the hemorrhage; and, if the symptoms are not relieved by 
one operation, it should be repeated again and again, at intervals varying 
with the circumstances of the case. The objects of bleeding are twofold; 
first, to diminish the distension of the vessels by lessening the quantity of 
the circulating fluid and the force of the heart's action, and, secondly, to alter 
the character of the blood. The indication for the first of these effects is ob- 
vious. To accomplish the object as effectually as possible the blood should 
be withdrawn suddenly, by a large orifice, so as to bring on, if possible, a 
slight tendency to faintness, and thus give the bleeding orifices the opportunity 
to close under the greatly diminished impulse of the blood. The second 
effect, that, namely, of altering the character of the blood, is important 
towards a permanent cure. So long as the red corpuscles are in excess, in 
relation to the fibrin, there will be danger of a continuance or renewal of the 
hemorrhage; and experiment has shown that the corpuscles diminish, under 
the lancet, much more rapidly in proportion than the fibrin; the latter being 
apparently more easily supplied by the processes concerned in sanguification. 
Hence the propriety of a repetition of the bleeding, so long as the fulness and 
strength of pulse, and the existence of plethora, appear to require it. Should 
symptoms of apoplexy of the lungs exist, the necessity for prompt and ample 
depletion is even more urgent than in ordinary cases. 
In many cases, when the symptoms above mentioned are not so prominent, 
blood may still be taken, but more moderately, and more in reference to the 
ultimate condition of the system. But, when the patient is rather delicate, 
and the pulse, though frequent, is feeble, general bleeding should not be re- 
sorted to, unless the hemorrhage is alarming from its quantity, or obstinately 
resists other measures. In such cases, any irritation or active congestion of 
lungs that may exist, should be relieved by local depletion and revulsion. In 
passive haemoptysis, bleeding is seldom necessary or proper. 
The existence of tubercles in the lungs, or a strong tendency to them, should 
be allowed to weigh against bleeding, when the balance between the two op- 
posite courses is, in other respects, doubtful. Even in this case, if the co-ex- 
istence of plethora and excitement appears to call for the remedy, it should 
be employed, though with more caution than under other circumstances. Blood 
should be withdrawn in small quantities, and less frequently. If the patient 
is feeble, and the indications for blood-letting not very decided, it should be 
omitted altogether. In consumption, it is of great importance to husband the 
resources of the system. Debility strongly favours the deposition of tuber- 
culous matter. Our only hope from therapeutical measures is in the counter- 
action of this predisposition. Whatever, therefore, exhausts the patient, and 
consequently an improper use of the lancet, contributes to the progress and 
danger of the disease. There can be little doubt that the old methods of 
treating haemoptysis frequently hastened the fatal result of consumption; and 
it is highly probable that the disease was developed or rendered incurable, 
when, under a different course, it might either have been averted, or conducted 
to a favourable issue. The patient, bled largely and repeatedly, though, per- 
haps with little blood to spare, fell into a state of prostration, with a pale 
and almost bloodless surface, a feeble and frequent pulse, and altogether with- 
out energy to resist the disease which was lying in wait to seize him, or had 
already fixed itself upon his system. I have often known consumptive patients 308 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
[part II. 
with occasional attacks of haemoptysis, which they have disregarded, pursuing 
their usual avocations as if nothing had happened, and using no means what- 
ever to suppress the hemorrhage, or only such as did not interfere with their 
engagements. I have known such patients to recover, without difficulty, from 
their temporary attacks, and to live for a long time, sometimes for many years, 
when, probably, if strictly confined and copiously depleted, they would have 
sunk in the course of a few months. I do not advocate this plan; for there 
are cases in which a judicious treatment, including even moderate depletion, 
maybe very useful; but it would, in my judgment, be much better, upon 
the whole, to leave the hemorrhage of consumptive individuals altogether to 
nature, than to treat it with the free and indiscriminate use of the lancet. 
In cases attended with febrile excitement, refrigerant cathartics and dia- 
phoretics may be employed as auxiliary to the lancet, or as substitutes, where 
it maybe contraindicated. Sulphate of magnesia, Seidlitz powders, bitartrate 
of potassa, the neutral mixture or effervescing draught, nitre, and tartar emetic 
in small doses, are, upon the whole, the most suitable medicines. Should the 
pulse be very frequent, and rather feeble than strong, digitalis may be some- 
times added with advantage to the other remedies. When purged, the patient 
should not be allowed to rise from his bed, but should make use of the bed- 
pan. At the same time, he may take cold and refreshing drinks, as ice-water, 
solution of gum Arabic, lemonade, &c. Whatever he employs, either as drink 
or food, should be cold. 
During the employment of the above measures, should symptoms of inflam- 
matory or irritative action in the chest be obvious, cups or leeches should be 
applied to the breast or sides, or between the shoulders, according to the seat 
of the affection; and these should be followed in due time by blisters, if the 
symptoms should not yield. When the debility is too great to admit even of 
local bleeding, dry cups applied freely over the chest will sometimes do good. 
Hot and stimulating pediluvia, the introduction of the hands and arms into 
similar liquids, the tourniquet to the arms or legs, and sinapisms or blisters to 
the extremities, are other remedies which co-operate to the same end. When 
the hemorrhage is so copious as to be alarming, cold water may be applied to 
the breast, back, and axilla; but this measure should be resorted to with 
caution, in consequence of the danger of giving rise to internal inflammation. 
While on the subject of local remedies, it may be proper to mention that, in 
long-continued and obstinate cases, in which the hemorrhage ceases and re- 
turns irregularly, a constant revulsion towards the extremities should be es- 
tablished by means of issues, setons, or perpetual blisters. 
After general excitement has been sufficiently subdued, and at the com- 
mencement of the case when the degree of excitement is moderate, acetate of 
lead should be employed internally. This is one of the most efficient reme- 
dies in haemoptysis, and is peculiarly adapted to the early stages, by its union 
of sedative with astringent properties. From half a grain to two grains may 
be given every hour or two hours, according to the urgency of the symptoms, 
and the condition of the stomach. It will often be found useful to combine 
it with a little opium, which quiets cough, and renders the salt more acceptable 
to the stomach, and with ipecacuanha, when this is not forbidden by its nau- 
seating effects. During the use of the acetate, the bowels should be kept 
open by injections. Should febrile action return, the remedy may be sus- 
pended, and recourse again had to refrigerant medicines. The acetate should 
not, as a general rule, be pushed beyond the quantity of twenty-four or thirty- 
six grains, without intermission; as it might endanger an attack of colica 
pictonum. In ordinary active hemorrhage from the lungs, little can be ex- 
pected from astringents, should the preparation of lead fail. CLASS III.] 
HAEMOPTYSIS. 
309 
The happiest effects sometimes result from ergot in this complaint. I have 
seen it promptly successful, under circumstances which appeared to me not to 
admit a doubt of its efficacy. It may be employed in cases to which the ace- 
tate of lead is adapted, and as a substitute for that salt when it fails to pro- 
duce the desired result. Ten grains may be given every two hours, and con- 
tinued for a day or two, or until the hemorrhage ceases, when the intervals 
between the doses should be gradually prolonged. I have seen no other 
unpleasant effect from its use in this way than occasional nausea. Should 
this be considerable, the ergot should be omitted, or diminished. It should 
not be employed in cases of haemoptysis occurring during pregnancy. 
Another hemostatic medicine which sometimes acts very promptly and effi- 
ciently in haemoptysis is the oil of turpentine. How it operates is not well 
understood, though probably by some influence upon the capillaries. It is 
applicable to cases without inflammatory action or febrile excitement; and, if 
plethora has existed, it should have been subdued, before recourse is bad to 
the oil. Mere frequency of pulse does not contra-indicate it. I have found 
no remedy more efficacious than this under circumstances favourable to its 
use. In one apparently desperate case, it succeeded after failure with all 
other means. Ten drops of it may be given every hour or two. If the 
hemorrhage is very copious, the dose may be much larger.* 
When no decided local irritation, general fever, or plethora exists, and 
especially when the surface is pale and the pulse feeble, alum and the vege- 
table astringents, as tannic and gallic acids, kino, catechu, rhatany, geranium, 
galls, &c., may be used in the form of solution or infusion. The compound 
infusion of roses of the Pharmacopoeias is an agreeable and useful drink in 
some of these cases, especially when attended with night-sweats. The infu- 
sion of wild-cherry bark, with or without small doses of aromatic sulphuric 
acid, may be used advantageously under similar circumstances. 
Sometimes an emetic of ipecacuanha proves highly efficacious in cases of 
the kind last mentioned. It should not be employed during the existence of 
plethora, and febrile or great vascular excitement. 
Passive hemorrhage from the lungs requires the same treatment as hemor- 
rhage of the same character from other parts. The astringents, oil of turpen- 
tine, the mineral acids, the preparations of Peruvian bark and of iron, and a 
nutritious diet are the chief remedies. Wine or malt liquors may sometimes 
also be usefully employed. 
In all cases, after the reduction of undue vascular action, general and local, 
opiates are useful by allaying cough, and thus preventing one of the strongest 
and most frequent provocatives of haemoptysis. Their stimulating properties 
may often be usefully modified by combination with ipecacuanha. When 
from any cause opium is contraindicated, hyoscyamus may be substituted for 
it in reference to the same indication. 
When haemoptysis depends upon disease of the heart, bleeding, general 
and local, rest, and digitalis, are the chief remedies; though any of those 
above mentioned may be employed, under favouring circumstances. 
Vicarious hemorrhage from the lungs requires to be treated with some cau- 
tion. If very moderate, the attack may often be allowed to run its course 
without disadvantage; but, when considerable, it should always be met by 
remedial measures; care being taken to prevent injurious consequences by 
* I first employed this remedy in haemoptysis about twenty years since, having de- 
rived my impressions in its favour from Dr. James L. Pierce, then a student of medicine, 
who was much afflicted with this disease, and had found the oil of turpentine a most 
effectual remedy in his own case. {Note to the fourth edition.) 310 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
[part II. 
inviting the current of blood towards the seat of the suspended discharge, by 
means of leeches to the part, warm fomentations, and stimulant applications. 
When the hemorrhage has resulted from a retrocession of gout or rheumatism, 
this should be recalled to its original position by the application of hot water 
or stimulating infusions, followed by sinapisms or blisters. 
The diet must be varied according to the character and stage of the hemor- 
rhage. When it is active, and in the early stages, the food should consist 
chiefly of cold farinaceous or mucilaginous drinks. When there is no excite- 
ment, and yet no marked debility, solid vegetable food is admissible, and 
sometimes rennet-whey, or milk may be added to the other articles. In de- 
cided convalescence, especially when the system is enfeebled, and consumption 
exists or is threatened, light and easily digested animal food may be allowed, 
such as soft-boiled eggs, oysters, boiled meats, weak broths, jellies, and the 
white flesh of poultry. In strictly passive haemoptysis, the most nutritious 
food may in general be used. 
To prevent the return of the bleeding, recourse must be had to the mea- 
sures already detailed under the head of hemorrhage in general. The most 
important are moderate exercise on horseback and on foot, free exposure to 
the open air in suitable weather, a proper attention to the clothing, which 
should be such as to protect the body against atmospheric vicissitudes, a 
moderate diet, the avoidance of stimulating drinks and all other causes of 
direct excitement, and the preservation of all the functions in the healthiest 
possible condition. A long sea voyage, and a residence during winter in a 
warm and equable climate, are also highly useful. These precautions are 
recommended chiefly as protective against the developement or advance of 
phthisis. When there is no reason to suspect the existence of that disease, or a 
predisposition to it, and when the hemorrhage appears to depend upon a ple- 
thoric state of the circulation, the diet should be for some time exclusively 
vegetable; an occasional dose of sulphate of magnesia or other saline cathartic 
should be employed; and, wdien the symptoms are threatening, recourse may 
be had to the lancet. But, as the evidences of plethora disappear, these mea- 
sures should be gradually moderated, and at length abandoned, when the 
health seems to have been perfectly re-established. 
Article V. 
HEMORRHAGE OF THE STOMACH, or H^EMATEMESIS. 
Syn.-Vomiting of Blood.-Gastrorrhagia. 
The term haematemesis (derived from ai^a, blood, and euw, I vomit) sig- 
nifies literally vomiting of blood, but is employed, in its technical sense, to 
signify hemorrhage of the stomach, which though usually attended with 
vomiting of blood, is not always so, and does not necessarily exist even when 
blood is vomited; as this fluid may be swallowed and afterwards ejected, with- 
out any gastric hemorrhage. The complaint is not uncommon in this country, 
though much less frequent than epistaxis or haemoptysis. 
Symptoms, Course, &c.-An attack of haematemesis is sometimes preceded 
by loss of appetite, and a feeling of oppression, weight, fulness, heat, &c., in 
the epigastrium, with pain or tenderness on pressure; symptoms which indi- 
cate the existence of irritation or inflammation of the gastric mucous mem- 
brane. Occasionally, also, general uneasiness, chilliness or rigors, and sub- 
sequent febrile reaction are experienced. These phenomena yield, after a 
time, to nausea, dizziness, faintness, paleness of surface, and depression of CLASS III.] 
311 
HJEMATEMESIS. 
pulse; in the midst of which vomiting of blood takes place, with the frequent 
effect of partially relieving the antecedent symptoms. In many instances, 
however, the vomiting is preceded only by sickness of stomach, and its usual 
attendant phenomena, without any signs of local or general excitement. In 
some cases, especially those in which malignant diseases are accompanied with 
hsematemesis, the patient does not even experience nausea, but discharges the 
blood in mouthfuls, by a sort of regurgitation rather than by vomiting. Ten- 
derness in the epigastrium is apt to continue after the stomach has been 
evacuated, and pressure in this region sometimes occasions emesis. Pain and 
tenderness in one or both hypochondriac regions, costiveness, and sallowness 
of skin, mark a complication of the complaint with disease of the liver or 
spleen. From the combined effects of nausea and loss of blood, the system is 
sometimes very much depressed; the surface being cold and bloodless, the 
pulse absent or scarcely perceptible, and the patient in a state of partial or 
complete unconsciousness. In this condition he occasionally is when first 
seen by the physician;- the hemorrhage having ceased in consequence of the 
depressed state of the circulation. The system, however, generally reacts, 
with or without a return of the hemorrhage. In some cases, febrile symptoms, 
with a furred tongue, attend the complaint throughout its course. 
The quantity of blood thrown up varies greatly, being in some cases trifling, 
in others amounting to several pints or even quarts. It is generally con- 
siderable. The blood differs in appearance according to its quantity, its length 
of detention in the stomach, and the character of the disease in which the 
hemorrhage may have originated. When very copious, it may be bright-red 
and liquid, because not detained so long in the stomach as to have undergone 
there any material change. Commonly, however, it is dark and more or less 
coagulated; the coagula being sometimes shaped as if moulded in the stomach; 
but more commonly in irregular lumps, much broken up, and mixed with 
liquid, and sometimes with the remains of the food. They occasionally appear 
as if partially digested, and not unfrequently are more or less deprived of the 
red corpuscles, in consequence of which they have a light brownish-red or 
dirty whitish colour. Sometimes the blood is almost black, or of a brownish- 
purple or sooty colour, especially when the hemorrhage occurs towards the 
close of malignant diseases. Dr. Carswell ascribes this appearance to the 
action of an acid upon the blood in the stomach. The dark mattei* like coffee- 
grounds, consisting of blackish flocculi floating in a colourless liquid, and 
known commonly by the name of black vomit, which is discharged so fre- 
quently in the last stage of yellow fever, and occasionally in other affections 
attended with gastric inflammation, is considered by the same writer as blood 
altered by acid in the stomach. This cannot, however, be the case in all in- 
stances; for the vomited matter would, in this case, exhibit very frequently an 
imperfect change, from the variable proportion of acid present; while, in fact, 
it generally remains uniform, though sometimes thrown up in great quantities 
and by rapidly succeeding efforts. There can, I think, scarcely be a doubt 
that it issues from the blood-vessels in the condition in which it is vomited, 
or acquires that condition in its passage through the epithelium. But that 
actual effused blood may undergo a change analogous to this, in the cavity of 
the stomach and bowels, by the reaction of acids, has been sufficiently proved 
by experiment. The stools in hmmatemesis often present a black appearance, 
resulting from the passage of blood through the pylorus, and the reaction of 
the intestinal liquids upon it before its discharge. 
It has been before stated that hemorrhage into the stomach sometimes 
takes place without vomiting. This may happen when the quantity of effused 
blood is too small to provoke vomiting, or when it is so great, and the dis- 312 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
[part II. 
charge.so sudden, as to take the stomach by surprise, and distend it beyond 
the power of contraction. In the former case, it is impossible to form a cer- 
tain diagnosis, although, if the usual premonitory symptoms of gastric hemor- 
rhage be followed by the appearance of black stools, there may be reason for 
suspecting that this affection has actually existed. In the latter case, also, 
the diagnosis is uncertain. Generally the hemorrhage proves speedily fatal, 
and the nature of the affection is revealed by dissection. Should the patient 
come under the notice of the physician, he would infer the very probable ex- 
istence of gastric hemorrhage, if he should find the epigastrium prominent and 
dull under percussion, and should learn that the symptoms of prostration, 
which are always present, had occurred rather suddenly, after a previous 
longer or shorter duration of gastric disorder. Death is not a necessary re- 
sult. Should the hemorrhage cease upon the occurrence of partial or complete 
syncope, the system may react, and the blood may gradually pass into the 
duodenum, until the stomach is wholly rid of it, or is enabled, by the reduc- 
tion of the quantity, to discharge the remainder by vomiting. 
The symptoms of gastric hemorrhage are very commonly mixed with those 
of other affections in which it originated; and it is sometimes difficult to say 
how much is ascribable to the one and how much to the other cause. 
Sometimes the hemorrhage ceases after the first full evacuation of the sto- 
mach, and does not return. More commonly, however, it continues for a 
longer or shorter period, with frequent repetitions of vomiting; and may thus 
run on for many days or weeks. The stomach is often, in such cases, very 
irritable, and substances swallowed are rejected even when there is no blood. 
The patient at length, in consequence of the loss of blood, falls into a com- 
pletely anemic state. Even when the hemorrhage has been suspended for a 
considerable time, he is liable to relapses from slight causes, or without any 
apparent exciting cause, in consequence of the persistence of the affection 
which originated the bleeding. Instances are not uncommon of a periodical 
return of the hemorrhage. This happens especially in females with amenor- 
rhoea, in whom haematemesis occurs monthly, as a substitute for the menses. 
It is said also sometimes to assume a similar periodicity, with the same in- 
terval, in men, when vicarious to a suppressed hemorrhoidal flux. 
Haematemesis occasionally produces death immediately, and more frequently 
causes or hastens a fatal issue by the exhaustion resulting from its long con- 
tinuance, or frequent repetition. But it is not usually very dangerous in itself. 
Cases not connected with organic or malignant diseases end favourably in the 
great majority of instances; and, when death occurs during the continuance of 
the affection, it is in general merely hastened, and would sooner or later occur 
from some coexisting complaint, of which the hemorrhage is merely a symptom. 
Diagnosis.-The hemorrhages with which haematemesis may sometimes be 
confounded are those which take place from the nostrils, fauces, and air-pas- 
sages. From all these sources blood is occasionally swallowed, and subse- 
quently vomited. For the modes in which the two former hemorrhages may 
be distinguished, the reader is referred to the article on epistaxis. It is suf- 
ficient here to say that a close examination will almost always discover the 
seat of the hemorrhage, when from the nostrils or throat; and the absence of 
preliminary gastric symptoms other than the mere nausea and oppression, 
which may be occasioned by the presence of the blood in the stomach, and 
the cessation of all signs of haematemesis after the stomach has been once 
thoroughly evacuated, will render the probability very great, that the blood 
which may have been vomited had been swallowed. In some instances of 
young children, where no external evidences could be discovered of the origin 
of the hemorrhage, it might be very difficult to form a correct judgment; but, CLASS III.] 
313 
HAEMATEMESIS. 
as infants often swallow the blood which comes into their fauces, from-what- 
ever source, and as proper gastric hemorrhage is an exceedingly rare affection 
at that age, it may be inferred that any blood which they may vomit, has 
probably proceeded from some other source than the stomach. 
In ordinary cases, there can be no difficulty in discriminating between 
haematemesis and haemoptysis. In the former, the blood is usually dark, 
coagulated, often much altered, and mixed with the contents of the stomach, 
and is discharged by vomiting; in the latter, it is bright-red, often frothy, 
never in large coagula, frequently mixed with mucus, and is thrown up by 
coughing. Besides, the preceding and attendant phenomena are, in the one 
case, referrible to the stomach, and, in the other, to the lungs. But in those 
instances of haemoptysis before alluded to (see page 298), in which the blood 
is thrown up suddenly in large quantities, by a sort of convulsive movement 
of the muscles of expiration, while vomiting is at the same time produced, 
probably by the irritation of the blood in the pharynx, the diagnosis is not so 
easy. Such cases, however, are very rare, and, when they do occur, may 
generally be distinguished by a careful investigation of the circumstances. 
The seat of the preliminary symptoms must be examined, as well as the 
existing state of the stomach and the lungs. If, on the one hand, there has 
been no preceding uneasiness of stomach, if pressure upon the epigastrium 
occasions little or no pain, if the stools are free from blackness, and none of 
those diseases are known to exist which predispose to haematemesis; if, on 
the other hand, there has been pre-existing cough, pectoral oppression, or 
other symptoms of disease in the chest, if evidence is presented by ausculta- 
tion, or otherwise, of abundant liquid in the bronchial tubes, if the sudden 
eruption of blood has been preceded, and should be followed, after subsidence, 
by bloody expectoration; there would be abundant reason for the conclusion, 
that the hemorrhage was exclusively from the lungs. In more doubtful cases, 
the judgment of the practitioner must be influenced by the preponderance of 
one or the other set of phenomena above alluded to. It is not at all impossible 
that blood may issue at the same time from the bronchial and gastric mucous 
membrane, thus constituting a mixed case of haemoptysis and haematemesis. 
Cases have been recorded in which individuals have purposely swallowed 
blood, so as to induce vomiting, with the view of producing the false impres- 
sion that they were labouring under this disease. Such instances, however, 
are very rare, and must be judged of by a comparison of the symptoms they 
present, with those characteristic of proper haematemesis. 
Causes.-The following may be enumerated as causes of haematemesis; 
blows on the epigastrium, wounding bodies that may have been swallowed, 
acrid or caustic substances introduced into the stomach, violent straining in 
the act of vomiting, the drinking of very cold water, the abuse of alcoholic 
liquors and stimulating condiments, excesses in eating, the translation of gout 
or rheumatism, the suppression of habitual discharges, fits of anger or other 
strong emotion, whatever, in fine, is capable of inducing irritation, inflam- 
mation, ulceration, or simple congestion of the gastric mucous membrane. 
Plethora, a relative excess of the red corpuscles over the fibrin of the blood, 
and general excitement of the circulation from any source, are causes common 
to this with all other hemorrhages. Agencies which debilitate the vessels of 
the stomach, or deprave the blood, may, under certain circumstances, lead to 
passive haematemesis. In relation to many of these causes, the same one may 
be remote or predisposing in one case, and immediate or exciting in another; 
and it not unfrequently happens that a cause, ordinarily predisposing, is 
capable, when it acts long and powerfully, of inducing the complaint without 
other influence. Sex and time of life may be considered among the predis- 314 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
[PART II. 
posing causes. Women are more liable to the disease than men; and persons 
of middle age, from thirty-five to fifty-five, much more so than the young and 
the old. Infants are very rarely attacked with it. 
As all other hemorrhages, this may depend immediately upon functional 
derangement of the vessels from which it proceeds, without organic disease 
in the stomach, or disease of any kind elsewhere. But such exemption is 
comparatively rare. The following are the particular affections with which 
haematemesis is most frequently associated as one of their effects. 
1. Inflammation and ulceration of the stomach.-In the early stages of 
gastritis, the vessels occasionally throw out blood in greater or less amount; 
though the hemorrhage from this cause is generally trifling, and not the chief 
object of attention to the practitioner. It is perhaps most common, and most 
abundant, in the inflammation which results from irritant poisons acting directly 
on the stomach. In the ulcerative stage of the affection, copious hemorrhage 
sometimes occurs. The blood may proceed from the ulcerated surface gene- 
rally, or from one or more vessels which have been divided in its progress. 
Sometimes the ulceration destroys the whole thickness of the affected portion 
of the mucous membrane, and penetrates a considerable artery of the stomach, 
as, for example, the coronary artery. The hemorrhage is occasionally the 
first decided intimation of the existence of disease; the progress of the ulcer- 
ation having been so slight, or the sensibility of the ulcerated surface so feeble, 
as scarcely to have excited the serious attention of the patient. Another 
condition of inflammation which may be attended with haematemesis, is the 
advanced stage of the acute form of the disease, when the vessels have become 
much enfeebled, and their coats offer little resistance to the force which pro- 
pels the blood. This occurs sometimes in the last stages of yellow fever, and 
other malignant affections attended with gastritis. It is obvious that the 
hemorrhage is in this case passive. 
2. Cancer.-Cancer in the stomach is not unfrequently attended with 
hmmatemesis. The hemorrhage may take place either before or after ulcera- 
tion of the tumour. In the former case, it may proceed from mechanical ob- 
struction to the circulation, or from irritation and congestion of the vessels 
excited by the contiguous disease. In the ulcerative stage, in which it is most 
frequent and copious, it may result from the oozing of blood from numerous 
points of the ulcerated surface, or from some considerable vessel which has 
been divided in the progress of the affection. The vessel thus divided may 
belong either to the stomach, or to some one of the neighbouring structures, 
as the spleen, liver, mesentery, or omentum, which have formed adhesions 
with the stomach, and communicate with it by ulceration. In these cases, the 
hemorrhage often, happily for the patient, hastens the fatal issue by its ex- 
hausting effects. The blood thrown up is often brownish, or chocolate- 
coloured and quite broken down, in consequence probably of changes under- 
gone after effusion; but it is possible that, as in the black vomit of yellow 
fever, it may sometimes be altered in the process of extravasation. 
3. Disease of the liver and spleen.-Hsematemesis, connected with disease 
of the liver and spleen, is probably more frequent in this country, and in 
tropical climates, than the same disease from any other, or all other causes. 
When the hepatic circulation is languid from debility, or obstructed by con- 
gestion, inflammation, or other organic disease, there are necessarily produced 
delay and congestion of blood in the portal veins, and consequently through- 
out the whole of the alimentary canal and its appendages. This congestion 
is felt most in the stomach, and there its results are apt to be displayed in 
various modes of derangement, among which is hemorrhage. Another mode 
in which ha?matemesis may have an hepatic origin, is by impediment to the CLASS III.] 
H2EMATEMESIS. 
315 
return of the blood to the right side of the heart, in consequence of stricture 
of the ascending vena cava, produced by enlargement of the liver. Disease 
of the spleen probably acts as a cause of stomachic hemorrhage in a somewhat 
different manner. There is reason to believe that one at least of the offices 
of this viscus is to serve as a diverticulum, or reservoir for the superfluous 
blood of the portal circulation, so as to prevent the injurious consequences 
which might otherwise much more frequently result from congestion in this 
system of veins. Now, when the spleen has become already congested, it is 
of course, in the same degree, less capable of serving as a diverticulum, and 
the consequences of the portal congestion, should it still continue, are more 
likely to be experienced in the stomach. Great enlargement of the spleen 
may also act mechanically by impeding the circulation through the aorta, or 
through venous trunks which return the blood from the viscera to the vena 
cava. In the former case, the stomach may suffer along with the other organs 
to which the excess of blood is sent that cannot find its way through the 
aorta; in the latter, by the direct interruption of its own returning blood. It 
has also been supposed that hemorrhage in the stomach may take place from 
ramifications of vessels communicating directly with the splenic vein, and 
thus be an immediate result of congestion of the spleen. In many cases of 
haematemesis, of hepatic or splenic origin, the hemorrhage is probably useful, 
partly by directly relieving congestion of the stomach, and thus preventing 
more injurious results in that organ, partly by exhausting the sources of the 
disease in one or both of the viscera referred to. It is a recorded fact, that 
very large swellings of the spleen have been suddenly reduced by the occur- 
rence of hemorrhage from the stomach. 
4. Other organic affections.-Solid tumours within the abdomen, whether 
scirrhous or not, large aneurisms, and even the pregnant uterus, may act as 
causes of haematemesis by pressure upon the veins which return the blood of 
the portal circle, or upon the great descending trunk of the aorta or the 
primitive iliacs. Organic diseases of the heart may have the same effect by 
impeding the return of the blood through the vena cava, and thus producing 
general venous congestion. Another origin of gastric hemorrhage may be 
the bursting of an aneurism into the stomach. 
Hmmatemesis is not a very uncommon affection in females, as the result 
of suppression of the menses; and is then, as before stated, apt to assume 
a periodical form. It is liable especially to occur in nervous females; but 
perhaps this association is merely accidental; the nervous symptoms being a 
mere dependence of the uterine affection, without any direct relation to the 
hemorrhage from the stomach. It is, however, peculiarly apt to be excited 
in such patients by causes calculated to disturb their equanimity. 
This hemorrhage is also an occasional attendant upon malignant fevers, 
scurvy, purpura haemorrhagica, and other affections in which the blood has 
assumed the hemorrhagic character. In these cases, it is generally associated 
with hemorrhage from other sources, and is passive in its nature. 
As in all the other hemorrhages, the blood in haematemesis may escape 
through a wound or rupture of the vessel, through an opening produced by 
ulceration or sphacelus, or through the coats without any discoverable solution 
of continuity; and, in the last-mentioned case, it may be active or passive, 
the result, namely, either of increased vascular action, or of a mere relaxa- 
tion of the walls allowing the blood to pass without the usual resistance. 
The hemorrhage is believed to occur much more frequently by transudation 
than through an abnormal opening in the vessel. 
Anatomical Characters.-If the hemorrhage has proceeded from a wound 
or rupture of a vessel, the orifice may generally be found upon close inspee- 316 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
[part II. 
tion. A case is recorded in which it resulted from the bite of a leech swal- 
lowed with the water of a rivulet. (Diet. de Med,., xii. 330.) In many cases, 
the most careful examination of the surface of the stomach reveals no vascular 
solution of continuity; and the inference is almost irresistible that the hemor- 
rhage was a mere transudation. In these cases, the gastric mucous mem- 
brane is sometimes quite healthy both in consistence and colour; but, more 
frequently, it exhibits evidence of congestion or inflammation, in a greater or 
less degree of vascular redness, sanguineous effusion into the mucous or sub- 
mucous tissue, or of softening. In some instances, dark points appear thickly 
strewed over the mucous surface. These have been considered as small co- 
agula of blood arrested in the follicular orifices, and blackened by the action 
of thq gastric liquors. Sometimes ulcers are discovered, with their surfaces 
covered over with thin coagula, or exhibiting specks here and there, at points 
from which the hemorrhage probably proceeded. Sometimes large vessels 
are found open by ulceration. 
Treatment.-The patient should be placed in bed, and kept perfectly quiet 
both in body and mind. He should take a little ice-water now and then, 
and may even swallow small pieces of ice if agreeable to him. At the same 
time, excitement should be directed towards the extremities by immersing 
the hands and feet in hot water. When the hemorrhage is very copious, it 
has been recommended to apply ice or cold water to the epigastrium. 
If there should be much nausea, retching, and ineffectual effort to vomit, 
with the discharge of a little coagulated blood, giving rise to the suspicion 
that much more blood might be remaining in the stomach, and serving as a 
source of irritation, it might be proper to effect its complete evacuation by a 
moderate dose of ipecacuanha. The action of the medicine would be less likely 
to provoke hemorrhage than the spontaneous movements alluded to, and after 
its operation the stomach would probably be left comparatively quiet. But, 
under ordinary circumstances, emetics are of doubtful propriety. 
Should the pulse be excited and of sufficient strength, and especially if, 
at the same time, there should be symptoms of gastric inflammation or vas- 
cular irritation, blood should be taken from the arm, in quantities propor- 
tioned to the effects of the operation upon the pulse; and a continuance of 
the same circumstances would justify a repetition of the measure. Some- 
times, when the patient is too feeble to admit of bleeding, and the local 
symptoms alluded to exist, leeches to the epigastrium may be substituted; 
and these will often be found useful auxiliaries to the lancet. The system, 
however, is often too much exhausted to admit of depletion in any shape. 
Sinapisms and blisters to the epigastrium may then be used. 
When the patient is very prostrate, with a pale and cold skin, and a feeble 
or absent pulse, much advantage may sometimes accrue from the hot bath, of 
the temperature of about 105°, by which the blood is drawn to the surface, 
and a safe stimulus applied to the system. The same remedy may also be 
used in less prostrate conditions, in the more advanced stages of the disease, 
when it is deemed highly advisable to give a centrifugal direction to the blood. 
Acetate of lead, in small and frequently repeated doses, combined with a 
little opium, is one of the most efficient internal remedies. If this should be 
rejected, or should fail from other causes, recourse may be had to other 
astringents, such as alum, kino, catechu, krameria, aromatic sulphuric acid, 
and some of the liquid preparations of iron. But these are incompatible with 
much irritation, and with acute inflammation of the stomach. In the ad- 
vanced stages, and in cases of little or no local excitement at the commence- 
ment, oil of turpentine, or creasote, with, or without laudanum, may be given 
in small doses. The former is peculiarly adapted to the hemorrhage which CLASS III.] 
317 
INTESTINAL HEMORRHAGE.-MELINA. 
sometimes occurs in the last stage of gastric inflammation. Ergot might be 
tried with some hope of advantage; but it occasionally nauseates, and the 
author has not employed it in this hemorrhage. 
Excessive irritability of the stomach should be allayed by lime-water and 
milk, if not incompatible with the case, by injections of laudanum, and by a 
sinapism or blister over the stomach. The bowels should be kept open, when 
the stomach is irritable, by enemata; when it is retentive, by mild cathartics, 
as the Seidlitz powders, magnesia, sulphate of magnesia, castor oil, &c. Some- 
times active purgation is indicated, especially in congestion of the portal circle, 
and then infusion of senna with epsom salts may be used. 
When the liver or spleen is in fault, the hepatic secretion should be pro- 
moted by minute and frequently repeated doses of calomel or mercurial pill, 
alternated with mild cathartics; and this plan should be pursued until the 
stools exhibit yellow bile, or the gums of the patient are touched. In some 
cases, it is possible that a purgative dose of calomel would act more efficiently; 
but in general the alterative plan is preferable as the safer. Other remedies 
may also be employed calculated to relieve disease of the viscera affected. 
When there is reason to suspect erosion of a blood-vessel, the general plan 
above indicated may be pursued; care, however, being taken to avoid all sub- 
stances that might irritate the stomach. Perfect rest is the most important 
measure in these cases. Bleeding is seldom, if ever, admissible. 
In vicarious haematemesis, besides employing the means already mentioned, 
the practitioner should endeavour to produce a derivative effect towards the 
seat of the suppressed discharge by leeches, warm fomentations, and stimu- 
lating applications to the part. In cases of amenorrhoea, constitutional means 
should be employed for the restoration of the menses. In these cases, pur- 
gatives have been found highly beneficial. 
In passive haematemesis, the plan must be pursued which has already been 
pointed out, as applicable to the passive hemorrhages generally. (See page 
290.) The chief remedies are the astringents, mineral acids, sulphate of 
quinia, the chalybeates, and oil of turpentine. 
Attention to the diet is important. In cases attended with local or general 
excitement, the patient should be confined to gum-water and farinaceous drinks. 
If debilitated, he may take rennet-whey,। or diluted milk. Milk with lime- 
water sometimes answers an excellent purpose. In great debility, as when 
the hemorrhage is passive, animal broths, jellies, egg beat with wine, and 
sometimes milk punch may be employed. When the stomach rejects every- 
thing, the patient must be supported by nutritive enemata. In convalescence, 
only the lightest and most digestible animal food should be allowed. 
The prophylactic measures adapted to haematemesis are to be inferred from 
the remarks already made relative to the general preventive treatment of he- 
morrhage ; and anything which may be peculiar to this particular form, will 
readily suggest itself to the reflecting practitioner. 
Article VI. 
HEMORRHAGE OF THE BOWELS, or MELINA. 
Hemorrhage of the bowels, though not unfrequent as an incident of various 
organic affections, is somewhat rare as an original functional disease. In the 
latter case, it generally assumes the form of melaena; the blood having under- 
gone, after, or in the act of extravasation, such changes as to give the stools 
the black appearance characteristic of that affection. The name melaena has 318 
[PART II. 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
been rather loosely applied, and ought to be abandoned as designative of a 
disease. In its most extensive sense, it would include all black discharges 
from the bowels, whether of vitiated bile or altered blood. In this applica- 
tion of the term it is improper, as it combines two distinct affections under 
one designation. If confined to hemorrhage, it is inadequate; for there are 
many instances of intestinal hemorrhage in which the discharges are not 
black; and there appears to be no good reason for making a mere difference 
in colour the basis of an arrangement into distinct varieties, especially as 
every diversity of shade is presented in different cases, from bright arterial 
redness of the stools to pitchy blackness. 
Discharges of dark and altered blood from the bowels are often a mere 
attendant upon haematemesis, and not necessarily connected with intestinal 
disease. A portion of the blood extravasated in the stomach passes the 
pylorus, and, being changed by admixture with the contents of the bowels, 
and their chemical reaction upon it, escapes in the form of black stools. Such 
a result may take place, even without vomiting; the whole of the effused 
blood passing downward. Again, the black evacuations may be derived di- 
rectly from the intestinal mucous membrane, though the patient may at the 
same time vomit blood; and this is probably often the case; as the causes 
which produce haematemesis act, in many instances, with scarcely less energy 
upon the bowels than on the stomach. Still another case is that in which, 
though vomiting and purging of blood may exist, the seat of the hemorrhage 
is exclusively in the bowels; the blood rising, as bile is often known to do, 
from the duodenum into the stomach. It is, therefore, by no means always easy 
to decide, in any particular case of bloody evacuations from the alimentary 
canal, whether or not intestinal hemorrhage, strictly so called, really exists. 
In forming a conclusion, we must be influenced by the character of the ante- 
cedent and attendant symptoms. According as these point more especially 
to the stomach or bowels, will be our inference as to the seat of the hem.or- 
rhage; and, if they equally embrace both, we may fairly conclude that the 
hemorrhage also is from both sources. The quantity and colour of the blood 
discharged will have some influence on our judgment. When it passes by 
stool copiously, or without great alteration, it is, in all probability, of intes- 
tinal origin. In some cases, however, it is impossible to arrive at a certain 
conclusion. Happily, this is of the less importance; as thecauses and nature 
of the hemorrhage from the two sources are so analogous as to give a certain 
character of identity to the affection, in reference to treatment. 
Symptoms.-In most cases of intestinal hemorrhage, the discharge of blood 
is preceded by evidences of disease. Often, this disease is of a well known 
and marked character, as enteritis; dysentery, enteric fever, scurvy, purpura, 
&c., of all of which hemorrhage from the bowels is an occasional concomitant. 
But frequently also the preliminary symptoms are less definite. Feelings of 
oppression, weight, distension, or other uneasiness in the abdomen, pains in 
the hypochondriac regions, occasional tenderness upon pressure, a furred 
tongue, deficient or disordered appetite, constipation or diarrhoea, a pale, sal- 
low, or dingy complexion, dejection of spirits, languor, weakness, and more 
or less disorder of the circulation, indicate a derangement of health of some 
duration, of which visceral disorder and impaired digestion are the most pro- 
minent ingredients. A patient in this condition is unexpectedly affected with 
griping pain, nausea, increased paleness, and more or less giddiness, faintness, 
depression of pulse, and coolness of the extremities, attended by a discharge 
from the bowels, which, on examination, proves to be blood of a black colour, 
very offensive, and otherwise altered in character. Occasionally a diarrhoea CLASS III.] 
INTESTINAL HEMORRHAGE.-MEL2ENA. 
319 
has existed for some days with more or less of the same symptoms, without, 
however,.occasioning much uneasiness, until attention is accidentally called to 
the bloody nature of the stools. In some instances, again, the hemorrhage 
comes on without any premonitory symptoms; and the evacuation from the 
bowels, and its attendant depression, are the first obvious signs of disease. 
This depression is sometimes extreme, and the patient may even sink below the 
point of reaction. Sudden prostration and death have occurred without any 
evacuation, and the cause has remained concealed until dissection has revealed 
a vast collection of blood, fluid or coagulated, in the small intestines. In 
cases of sudden prostration, intestinal hemorrhage may be suspected, when 
the previous symptoms were those of portal congestion, or organic disease of 
the bowels, and when tumefaction of the abdomen with dulness on percus- 
sion, not before existing, is discovered upon investigation. But cases of so 
much violence, whether with or without discharge from the bowels, are com- 
paratively rare. Very generally the system rises out of the temporary de^ 
pression, or the affection may even run its whole course without any serious 
evidences of prostration. Occasionally the bloody evacuations are attended 
and preceded by excruciating pain, which, however is to be ascribed to some 
organic disease of the bowels. Quite as often there is little or no pain. 
The character of the blood discharged is very various. The quantity is 
sometimes scarcely more than sufficient to stain the fecal evacuations, while 
in other instances it may amount to pints or quarts. The colour may be 
bright-red; but is much oftener dark or almost black. The consistence of 
the blood may be fluid, or grumous from broken coagula, or thick, semi-liquid, 
and tar-like. It is sometimes mixed with the intestinal secretions, fecal mat- 
ter or bile, and sometimes as pure as if drawn from the arm. It is almost al- 
ways very offensive. In certain cases, it is black, like soot or coffee-grounds, 
consisting of an insoluble dark matter floating in a colourless liquid; but, 
when of this condition, it can scarcely be called blood; as it has probably un- 
dergone some change in its passage from the vessels. This kind of discharge 
is not necessarily offensive, and exhibits neither the red colour of blood nor 
the yellowness of bile, when viewed in thin layers. The black colour, so com- 
mon in the different hemorrhagic discharges from the bowels, is not an indica- 
tion that the blood comes from the veins; but is generally ascribed to the 
chemical influence of the intestinal fluids and gases. 
The nature of the evacuations may lead to plausible inferences as to the 
seat and character of the disease. If the blood is bright-red, it has probably 
come from the large intestines; if dark-red, copious, and pure, from the small 
intestines, and from no very great extent of surface. If tarry or pitch-like, 
the inference is that it has proceeded from an ample surface, by a slow exuda- 
tion, giving it an opportunity to be intimately mingled with the secretions. 
If of the appearance of coffee-grounds, it has probably issued from a mem- 
brane disorganized by inflammation or malignant ulceration, as in yellow fever 
and cancer of the bowels. A small discharge of bright blood, mingled with 
mucus, would imply that there was active inflammation, as in dysentery. If 
the blood is dark, and either imperfectly or not at all coagulable, it indicates 
that it was depraved while still in the circulation, as in malignant fevers and 
purpura. If black, tarry, and exhibiting, in thin layers, both a red and bilious 
tinge, it may possibly, as maintained by Dr. Ayre to be generally the case in 
melsena, have proceeded from the liver. 
The course of the disease is altogether uncertain. The hemorrhage, as 
already stated, may prove immediately fatal; but this result is rare. Gene- 
rally, the bleeding is diminished or suspended for a time, to return again and 320 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
[PART II. 
again; and the disease may go on for weeks or months, with alternations of 
amendment and relapse, until at length it ceases, or wears out tha patient. 
But, if not complicated with serious organic derangement of the bowels or 
other viscera, it will generally yield with sufficient facility to remedies; though, 
even after a cure, the predisposition is too apt to remain, and lead to a return. 
Homething depends upon the age as to the result. In the old,, the disease is 
mu' h more apt to end fatally than in youth or middle life, perhaps because 
the result of a longer continuance of organic disorders, and a general breaking 
up of the health. When not complicated with such affections, or with deep 
depravity of the blood, it has usually, in the experience of the author, proved 
a manageable complaint, whether in the aged or the young. If considerable, 
it adds greatly to the dangers of diseases with which it may be associated. 
It need scarcely be stated that the general symptoms attending hemorrhage 
from the bowels are so exceedingly variable, from the variety of disease with 
which it is connected, that no one description will embrace them. 
Anatomical Characters.-Blood is always found in the bowels, of a cha- 
racter bearing some analogy with that discharged. The mucous membrane is 
frequently stained by imbibition. Both it and the veins leading from it are 
often found congested; but the congestion of the capillaries appears to have 
been sometimes relieved by the hemorrhage, and the membrane is unusually 
pale. The orifices of the mucous follicles are occasionally seen distended with 
black coagulated blood, looking like sooty specks upon the surface. Dissec- 
tion has in general afforded no ground for the notion that the blood proceeded 
from a ruptured or eroded vessel. The mucous membrane has been examined 
with the greatest care, without exhibiting any vascular solution of continuity. 
This is not the place to detail the numerous morbid changes of structure, 
belonging to the diseases of which the hemorrhage is frequently but a symptom. 
Diagnosis.-On the occasional confusion of this hemorrhage with haemate- 
mesis enough has been already said. It may be distinguished from the black 
bilious discharges which are frequently met with as a form of diarrhoea, by 
viewing the two liquids in thin layers, or by diluting them. The blood, 
under this management, usually assumes its proper red, and the bile its yellow 
hue. Common salt, when added to dark blood, is said to redden it, and does 
not produce the same effect with bile. The microscope may be resorted to in 
doubtful cases. Sometimes true melanotic matter is discharged from the 
bowels, and might be mistaken for hemorrhage. It probably proceeds from 
the breaking up of a melanotic tumour, and is very rare. It wants the redness 
of blood. (See Melanosis.') For the distinction between the hemorrhage under 
consideration, and that from the rectum or hemorrhoidal vessels, the reader is 
referred to the subsequent article. 
Causes.-These are so much the same as in haematemesis, that a particular 
enumeration of them is unnecessary. Whatever is capable of producing irri- 
tation, congestion, inflammation, or ulceration of the intestinal mucous mem- 
brane, may occasion this form of hemorrhage. Among the direct irritants it 
will be sufficient to allude to drastic cathartics, which, in cases of predisposition 
to this disease, would be very apt to bring on an attack. The remarks made 
in relation to the various pathological conditions which lead to haematemesis are 
also applicable here. Inflammation and ulceration of the mucous coat, as in 
enteritis, dysentery, invagination, &c.; disease of the liver and spleen; can- 
cerous and other malignant ulcerative affections; solid tumours; aneurisms; 
organic affections of the heart; suppression of the menses; malignant fevers, 
purpura, and scurvy; are all occasionally attended with hemorrhage from the 
bowels. The mosbeommon pathological condition in this, as in gastric hemor- 
rhage, especially in the form of melaena, is probably congestion of the portal CLASS III.] 
321 
INTESTINAL HEMORRHAGE.-MELINA. 
system, dependent on torpor or organic disease of the liver, or enlargement of 
the spleen. Hence its occasional occurrence in protracted intermittents, and 
association with abdominal dropsy. Enteric or typhoid fever, uniting occa- 
sionally the two conditions of a hemorrhagic state of the blood, and an in- 
flamed and ulcerated state of the bowels, is liable to very serious and often 
fatal complication with intestinal hemorrhage. 
Treatment.-In the treatment of this hemorrhage, reference must always 
be had to the pathological state in which it originated, and which may sustain 
it. To this state the remedies are to be addressed. If the hemorrhage be not 
abundant, no other treatment will, in general, be required. Most commonly 
the liver or spleen, or both, are in fault, especially in melama. If the hepatic 
affection is merely functional, an alterative course of mercury, as recommended 
by Dr. Ayre, will generally prove effectual. One-sixth of a grain of calomel, 
or from half a grain to a grain of the mercurial pill, may be given every hour 
or two, until from one to three grains of the former, or from three to nine of 
the latter, have been taken during the day. If the case is not urgent, the 
mercurial may be omitted on alternate days; if otherwise, it should be pushed 
steadily until the passages assume a healthy appearance, or the gums are 
touched. It may generally be very advantageously associated with opium and 
ipecacuanha in minute quantities, say one-twelfth or one-sixth of a grain of 
the former, and twice as much of the latter, with each dose of the mercurial. 
Advantage will often accrue from alternating the mercurial with a mild laxa- 
tive, as rhubarb or magnesia. When mercury cannot be given, or has been 
given ineffectually, nitromuriatic acid may be substituted. 
Sometimes, however, the discharge is so profuse as necessarily to be the 
prominent object of attention. It must be arrested or diminished, to avoid 
the risk of fatal exhaustion, no matter what may be the disease with which it 
is associated. Under these circumstances, astringents should be combined 
with the other remedies. Acetate of lead is, on the whole, the most effectual, 
but the vegetable astringents, particularly kino and rhatany, may also be ad- 
vantageously given. The latter are sometimes administered, in the form of 
pill, in connexion with the acetate of lead; and, though this is decomposed, 
the resulting tannate of lead is probably not less useful. Sulphuric acid, in 
the form of elixir of vitriol sufficiently diluted, or of compound infusion of roses, 
is also sometimes advantageous, but should not be given simultaneously with 
the salt of lead. Much may be expected from ergot, with or without opium, 
in the arresting of the hemorrhage. When the hemorrhage is of the passive 
character, oil of turpentine is perhaps the most effectual remedy. It may 
be given in the quantity of from five to twenty drops every hour or two, and 
may often be beneficially associated with a little laudanum. Dr. H. L. Byrd, 
of Savannah, Geo., obtained very speedy success in several cases of this hemor- 
rhage, complicated with intermittent fever, from the combined use of oil of 
turpentine and nitrate of silver. He gave about eight minims of the former 
every two hours, and one-half a grain of the latter every three hours, each 
combined with an opiate. (^Charleston Med. Journ. and Rev., vii. 164.) When 
the skin is cool, and the capillaries of the surface generally inactive, the hot 
bath, or the warm salt-bath, repeated daily, will be highly serviceable. 
In the form of the disease associated with amenorrhoea, purging has been 
recommended, to be followed by remedies addressed especially to the men- 
strual disorder. I have never ventured upon active purging in this affection. 
Sometimes, perhaps, where the hepatic secretion is arrested, a purgative dose 
of calomel maybe safe and advantageous; but generally, when the bowels are 
loaded with blood or feces, I prefer their evacuation by the mildest laxatives. 
There may be cases in which, from the activity and strength of the pulse, 322 
[part ir. 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
and the plethoric state of the circulation, bleeding may be called for; but this 
is seldom requisite in cases of intestinal hemorrhage, unless associated with 
inflammation. Cups or leeches and fomentations to the abdomen may be in- 
dicated in certain cases, and external derivatives are often useful. 
It is frequently necessary to support the strength by nutritious* food, and 
sometimes by stimulants. This is especially the case in the hemorrhage 
attending low fevers. When there is nausea, milk mixed with lime-water 
will, on the whole, be the most suitable article of diet. The preparations of 
sago and tapioca, with nutmeg and a little wine, may also be given. Some- 
times it will be necessary to resort to animal broths and jellies. Should 
stimulation be advisable, it may be most safely effected by wine-whey. In 
cases attended with general excitement, the lightest and least stimulating 
kinds of food should be employed, such as are applicable to the active hemor- 
rhages generally. Care should be taken to allow no article of food which 
would be likely to pass undissolved through the stomach. Hence liquid 
aliment is generally preferable, and fresh vegetables of difficult digestion 
should be excluded. 
The patient should be kept at rest mentally as well as bodily, should 
breathe a cool fresh air, and should be allowed refreshing drinks, in small 
quantities at a time. 
After the hemorrhage has ceased, a strict attention should be paid to the 
general health, and such a course of remedial or hygienic treatment adopted 
as the case may seem to call for; one grand rule being always kept in view, 
to avoid everything likely to irritate the intestinal mucous membrane. 
Article VIL 
HEMORRHAGE FROM THE RECTUM. 
Syn.-Hemorrhoidal Flux.--Hemorrhoids.-Bleeding Piles. 
Hemorrhage from the rectum, though most frequently connected with piles, 
is by no means necessarily so, but may proceed from the mucous membrane 
in a perfectly healthy state of the hemorrhoidal vessels, and may depend on 
the same pathological conditions as the other hemorrhages. 
Symptoms, Course, &c.-Before the appearance of blood, the patient fre- 
quently experiences a sensation of fulness, weight, aching, or other uneasiness 
in the region of the sacrum, with heat about the anus, indicating a congested 
state of the mucous membrane ; but the hemorrhage may also take place with- 
out premonitory symptoms. The blood escapes by stool, sometimes without 
effort, sometimes with more or less straining, and is generally but not always 
attended with feculent discharges. Not unfrequently the hemorrhage first 
appears after the expulsion of hardened feces. In the great majority of cases, 
it is an accompaniment of hemorrhoidal tumours, either without the sphincter, 
or protruded at the time of stool. Occasionally it comes in a full stream, 
without any antecedent or attendant circumstances to explain the accident. 
The quantity of blood may be not more than sufficient to stain the feces or 
the linen after the discharge, or it may be very great, so as to produce much 
exhaustion. Its appearance is much diversified, being sometimes dark, when 
proceeding from a ruptured vein or venous cyst, or long retained in the rec- 
tum, and sometimes bright, when from a ruptured artery. It may be ob- 
served upon the surface of the feces, or mingled with them in streaks, or 
altogether unmixed. Sometimes, moreover, it is more or less coagulated, and 
is not unfrequently mixed with mucus, or with purulent or sanious liquids. CLASS III.] 
HEMORRHAGE FROM THE RECTUM.-BLEEDING PILES. 
323 
The hemorrhage is, in general, quite irregular in its occurrence and dura- 
tion, owing to the various local causes which provoke it. But there are cases 
in which it seems disposed to return at certain intervals, and sometimes it is 
decidedly periodical. In females it occasionally comes on monthly, as a sub- 
stitute for the menses, or along with them.; and even in men it has been ob- 
served to assume the same regularly periodical character. 
The bleeding may be inferred to depend upon piles, when tumours are ob- 
vious, or can be detected upon a close examination. It is not always possible 
to determine whether it proceeds from the rectum, or a higher portion of the 
bowels. But, when the blood is pure, or mixed only in distinct streaks with 
the feces, and when its discharge has been preceded, for some time, by unea- 
siness in the sacrum, without any sign of disorder of the upper bowels, the 
probability is that it is from the rectum. When intimately mingled with the 
ordinary contents of the bowels, and of a black tar-like aspect, it may be in- 
ferred to proceed from some higher position. Occasionally, upon close in- 
spection, the point from which it issues, may be seen, upon a protrusion of 
the mucous membrane as in defecation. 
Hemorrhage from the rectum is seldom dangerous. In most cases, it is of 
little or no account, being merely an insignificant attendant on other affec- 
tions. Sometimes it is beneficial by relieving general plethora, portal con- 
gestion, or determination of blood to other parts, especially to the head. It 
may even, by its long continuance, become essential to health, so that a sud- 
den interruption of it may be dangerous. When copious and frequent, it may 
induce an alarming condition of anaemia; and cases of this kind, which are 
apt to be accompanied with great labour of the heart, have sometimes been 
mistaken for plethora and general excitement, and very injuriously treated by 
depletion. In some rare instances, life is endangered immediately by the 
abundance of the hemorrhage. 
Causes.-The causes of hemorrhage, in general, are all capable of produc- 
ing this particular form of it. Among them may be ranked whatever occa- 
sions irritation, congestion, or inflammation of the mucous membrane of the 
rectum, and whatever is capable of wounding this tissue. Of this kind are 
falls upon the sacrum; hardened feces; straining at stool; drastic cathartics, 
or others having a peculiar affinity for the rectum, as aloes; medicines which 
have a tendency to the pelvic viscera generally, as cantharides and oil of tur- 
pentine ; congestion of the portal circle from disease of the liver or spleen, or 
from other cause; and suppression of the menses and other habitual dis- 
charges. Of all these, portal congestion is probably the most frequent. They 
are of course much aided by a hemorrhagic state of the circulation, whether 
consisting in plethora, or an altered constitution of the blood, or in both. In- 
flammation of the mucous membrane of the rectum is frequently attended 
with the discharge of blood, which is, however, in this case, note often copi- 
ous. But by far the most frequent source of this hemorrhage is in hemor- 
rhoidal tumours. The blood may possibly, in some instances, proceed by 
exudation from the surface of the tumours; but much more frequently the 
hemorrhage results from a rupture of the dilated vein, or the hemorrhoidal 
cyst, from an abrasion or tearing of the investing mucous membrane, or from 
the division of a small vessel that may ramify in the memb^ne. In the last- 
mentioned case, the blood may sometimes be seen issuing from the point of 
rupture. Relaxation of the mucous membrane, leading to prolapsus, may 
give occasion to the hemorrhage; as may also fissures or small wounds in the 
folds of the anus. Cancerous and other ulcers of the rectum, are often at- 
tended with it, the former dangerously so. Like other hemorrhages, this 
may exist in the passive form, proceeding from vascular relaxation, and de- 
praved blood, as in malignant diseases. 324 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
[part II. 
Treatment.-When attendant upon hemorrhoidal tumours, this affection 
requires, in general, no other treatment than that which is extended to the 
main affection. (See Hemorrhoids, vol. i. page 668.) It may, however, be 
so copious as to demand especial attention, and then is to be treated as if it 
proceeded from other causes. Should plethora exist with general and local 
excitement, it may be proper to employ the lancet, with cups or leeches to 
the sacrum; but these remedies are not often necessary. Rest, a cooling and 
laxative regimen, cold water or ice applied to the sacrum or fundament, or 
introduced into the rectum, and, if these should fail, the injection of a solu- 
tion of alum or acetate of lead, or of a vegetable astringent infusion, will 
generally be found sufficient to arrest the hemorrhage. An enema consisting 
of three or four fluidounces of a solution of alum, made in the proportion of 
twenty grains to the fluidounce, and mixed with forty drops of laudanum, 
repeated daily or twice a day, has almost always answered, in my experience. 
When the hemorrhage proceeds from a single point, pressure may be employed 
by means of a bougie, or a piece of prepared hogs' intestine closed at one end, 
introduced into the rectum, then injected with cold water, and tied at the 
other end. The effects of constipation should, if necessary, be obviated by 
laxatives of the most unirritating character; and, if there be plethora or 
excitement, the saline cathartics, such as bitartrate of potassa, sulphate of 
magnesia, Seidlitz powders, &c., should be preferred. Congestion of the portal 
circle should be corrected by an alterative course of mercury alternated with 
laxatives, and by other means calculated to promote hepatic secretion. Some- 
times a full dose of calomel may be found useful. Relaxation of the mucous 
membrane of the rectum should be treated as directed under the head of pro- 
lapsus ani. When the affection is supplementary to the menses, efforts should 
be made to restore the uterine function. If there should be evidence of deter- 
mination of blood to the head, the hemorrhage should be checked with much 
caution; and, if measures for this end are employed, danger to the brain 
should be obviated by depletion, low diet, &c. The same caution should be 
observed in correcting a hemorrhoidal flux which has become habitual and 
constitutional. It is a good rule, under these circumstances, to establish a 
revulsion towards some point of the surface by means of setons or issues, and, 
at the same time, to prevent plethora by attention to the diet, occasional pur- 
gation with salts, and, if symptoms of a determination of blood to some vital 
organ be observed, by the use of the lancet. Passive hemorrhages must be 
treated by cold applications, astringent injections, and the use of measures 
calculated to support the system, and improve the blood. In these cases, 
some good might, be expected from oil of turpentine, copaiba, cubebs, &c., 
taken internally; and the same remedies maybe found useful in chronic cases 
of hemorrhage, originally active, when all signs of general and local excite- 
ment have ceased. 
Article VIII. 
HEMORRHAGE FROM THE URINARY ORGANS, 
or HEMATURIA. 
Syn.-Bloody Urine. 
The term haematuria is conveniently applied to the discharge of blood from 
the urinary passages, no matter from what portion of these passages the 
hemorrhage may proceed. Considered, however, in reference to its origin 
(aiya, blood, and ovpw, I urinate), it would not embrace bleeding from the CLASS III.] 
325 
HEMATURIA.-BLOODY URINE. 
mucous coat of the urethra; for the blood from this source escapes without 
any effort of the patient similar to that of micturition. In this place, the 
term is employed in its most general acceptation. The complaint is by no 
means common, except as an attendant upon inflammation of some portion of 
the membrane lining the urinary passages, and, in this case, is seldom so 
considerable as to claim particular attention. 
Symptoms.-The discharge of blood is sometimes preceded by sensations 
indicating irritation or inflammation of the part affected, and sometimes takes 
place without preliminary symptoms. When it proceeds from any other part 
than the urethra, the blood is expelled by the contraction of the bladder, in 
the same manner as the urine. Occasionally the discharge is without uneasi- 
ness; but, in other cases, there are symptoms similar to those of dysury; the 
patient having a disposition to micturate frequently, with bearing down sen- 
sations, ardor urinae, and pain, in a greater or less degree, at the neck of the 
bladder and along the urethra. In some instances, no blood escapes, in conse- 
quence of that which had been effused into the bladder having coagulated, 
and thus closed the entrance of the urethra. In such cases, there is a feeling 
of weight and painful distension above the pubes, and the other phenomena 
are presented which characterize retention of urine. 
The quantity of the blood discharged is altogether indefinite, being often 
not more than sufficient to tinge the urine, and in some rare cases so con- 
siderable as to endanger life. Its appearance, moreover, is exceedingly diver- 
sified. Sometimes it comes away of a bright-red colour, and nearly or quite 
pure, especially when the hemorrhage is copious; and afterwards coagulates. 
It may also escape unmixed drop by drop, owing to the blood issuing from 
the urethra, or the bladder near its orifice. Most commonly it is more or 
less mixed with the urine, which is sometimes merely tinged by it of a red, 
brownish-red, or blackish colour, sometimes turbid from the partial coagu- 
lation of the blood, which floats at first in irregular flocculi through the liquid, 
but soon subsides in the form of a soft grumous mass. Occasionally small 
worm-like coagula are observed in the urine, more or less deprived of their 
colouring matter. These are supposed to be formed in the ureters. When the 
blood coagulates in the bladder, its liquid portion first escapes with the urine 
tinged with the red corpuscles, and afterwards the coagulum broken up into 
a grumous mass. Thus the urine may continue to be bloody several days 
after the internal hemorrhage has ceased. Besides blood, various other mat- 
ters of a mucous or purulent character, and occasionally fetid, are mixed with 
the urine in some cases of organic disease of the bladder or kidneys. 
The blood may proceed from the kidneys, ureters, bladder, or urethra; but 
it is not always possible to decide with certainty upon its precise source in 
particular cases. It may be supposed to come from the kidneys, when the 
hemorrhage has been preceded by pain, heaviness, or other uneasiness in the 
loins, continued or not along the course of one or both ureters to the groin; 
when it has followed a blow or fall upon the back; when it is an attendant 
upon obvious nephritis or other organic disease of the kidneys, or upon calculi 
in the pelvis of that organ; and, finally, when the blood is mixed intimately 
with the urine, or presentsitself partly in the form of those cylindrical coagula 
believed to be formed in the ureters. In relation to these coagula, if some- 
what bleached, there can hardly be a doubt that they have come from one of 
the ureters; if soft and of a full-red colour, they may have been moulded in 
the urethra. The diagnosis of hemorrhage from the ureters is almost necessa- 
rily uncertain. It may be presumed to exist, when the escape of the blood 
has been preceded by the very painful passage of a calculus through one of 
these tubes. It is probably a very rare occurrence, unless in this condition 326 
[PART II. 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
of things; and, even then, it is scarcely possible to be certain that the blood 
did not proceed from the kidney. The bladder is probably the seat of the 
hemorrhage, when, before or along with it, the patient has experienced uneasi- 
ness over the pubes or in the perineum, or has received a blow or had a fall 
upon one of these parts; when he is known to have stone in the bladder; when 
the emission of the blood is attended with symptoms of dysury, and there is 
no reason to suppose the existence of a large coagulum in the bladder; when, 
in finfe, the blood comes away unmixed or but little mixed with urine. In 
cases of malignant fungus at the neck of the bladder, when hemorrhage gene- 
rally follows the introduction of a sound, the source of the blood may be con- 
fidently referred to that organ. When hemorrhage takes place from the 
urethra, it is generally known by the escape of the blood either drop by drop, 
or in a small stream, without any effort of the patient as in micturition, and 
without his ability to control the flow except by pressure upon the passage. 
The blood, too, is usually unmixed; and, when the patient micturates, the 
urine, though it may be slightly tinged at first, soon passes unchanged; the 
hemorrhage showing itself again after the cessation of the act. Injury to the 
urethra, or inflammation of that passage, would also lead to the inference that 
it might be the source of the blood. Occasionally, however, blood from the 
urethra, in consequence of a calculus or of some other obstruction in the 
passage, flows back into the bladder, and thus tends to confuse the diagnosis. 
The course of this hemorrhage is altogether uncertain, depending on the 
various pathological conditions with which it is associated. Of itself, it is 
very seldom dangerous, though death has occurred from a profuse loss of 
blood from the urinary passages, without any discoverable organic lesion. 
It is not unfrequently serious as a sign of other affections; and is sometimes 
troublesome and even hazardous by its consequences, as when it fills the blad- 
der and ureters with coagulated blood, and thus obstructs the escape of the 
urine. The worst form of' it is that which attends malignant diseases, and 
others characterized by a dark, feebly coagulable blood. 
Diagnosis.-In certain morbid states of the urinary organs, or of the sys- 
tem, the urine sometimes assumes so nearly the appearance of that mixed 
with blood, that some, care is requisite to distinguish them. Thus, it may 
be deep-red, or reddish-brown, or blackish, may be turbid, and may deposit 
a dark sediment somewhat like that produced by blood. In gravel, it is 
sometimes so concentrated, and so abundant in the reddish salts which mark 
the predominance of uric acid, that it might without difficulty be mistaken 
for hemorrhagic urine. It is also reddened by certain kinds of food, as the 
red beet, the prickly pear, &c., and the same effect is produced by madder. 
Bloody urine may usually be distinguished by the following properties. It 
is in general turbid when discharged, and afterwards becomes clear by sub- 
sidence; the matter deposited is not dissolved when the urine is heated; the 
clear portion, containing the serum of the effused blood, is, to a certain ex- 
tent, coagulable by heat; linen dipped in it is stained of a red colour. On 
the contrary, the coloured urine, above alluded to, is often transparent when 
discharged, and becomes turbid upon standing; re-dissolves the deposit when 
heated; is not coagulable; and stains linen yellow, or orange, or brown, but 
seldom blood-red. The discovery of blood corpuscles by means of the micro- 
scope, and of albumen by the usual tests, would, be decisive as to the nature 
of the fluid. The urine of females is sometimes tinged by the menstrual 
fluid, and by blood from the uterus or vagina; but there can be little diffi- 
culty in distinguishing this from the urine of haematuria, if the attention of 
the practitioner be directed to the circumstances of the case. CLASS III.] 
HEMATURIA.-BLOODY URINE. 
327 
Causes.-Blows or falls, violent horseback exercise, or the jolting of a 
rough carriage; violence in severe or protracted labours; venereal excesses; 
calculi in the pelvis of the kidney, ureters, bladder, or urethra; certain sub- 
stances which irritate the urinary passages when taken internally, as eantha- 
rides and oil of turpentine;* drastic cathartics which occasion much tenesmus; 
acrimony of the urine from great concentration, such as occurs in hot cli- 
mates, where the liquid parts of the blood are carried off by perspiration; 
translation of gouty or rheumatic disease; suppression of the menstrual, he- 
morrhoidal, or other habitual discharge; all these, and whatever other causes 
are capable of inducing irritation and congestion of the urinary organs, may 
give rise to hmmaturia, especially when, from plethora or the constitution of 
the blood,'there is a predisposition to hemorrhage. When there is a predis- 
position to this particular hemorrhage, from the state of the urinary organs, 
anything capable of stimulating the circulation, or giving the hemorrhagic 
character to the blood, may bring on an attack. Sex and age have some 
influence in forming such a predisposition; at least it is more common in 
men than women, and in adults than young children; though the cause of 
this may be less a peculiar condition of the constitution in the former, than a 
greater exposure of the parts affected to injurious influences. 
Pathological States.-Cases of haematuria no doubt occur, in which the 
affection depends merely upon an irritation or congestion of the bleeding 
surface, connected with a general hemorrhagic predisposition, and without 
the coexistence of other diseases. But such cases, even including among 
them those which are vicarious to the menses or hemorrhoidal flux, are very 
rare; and it is highly probable that a considerable proportion, supposed to be 
of this character, are actually dependent on some other concealed cause, 
perhaps a calculus which has escaped detection. The affection with which 
the hemorrhage is probably most frequently associated is inflammation, with 
or without ulceration of the mucous membrane. When merely inflammatory, 
it is seldom considerable; but, when connected with ulceration, it may be 
copious, though it is not easy nor always possible to discriminate between 
such cases during life. Bright's disease of the kidneys is often attended 
with bloody urine. Calculous disorder is a frequent source of this hemor- 
rhage, sometimes by directly wounding the surface with which the concretion 
is in cotttact, sometimes by merely irritating or inflaming it. Carcinomatous 
disease of the parts concerned, generally, at some stage of its progress, gives 
rise to bloody urine. When the introduction of a catheter is always or gene- 
rally followed by hemorrhage, this disease may be suspected in the neck of 
the bladder. Malignant fevers, as typhus, the plague, smallpox, measles, 
and scarlet fever, and other diseases' characterized by a depraved condition of 
the blood, as scurvy and purpura haemorrhagica, are sometimes attended with 
copious haematuria of the passive kind. 
Treatment.-When not involved in the treatment for associated affections, 
this should be conducted upon the principles applicable to hemorrhages in 
general. Rest, abstinence, cooling mucilaginous or other demulcent drinks, 
bleeding -when required by the pulse, and leeches or cups to the loins, hypo- 
gastrium, or perineum, as auxiliary to the lancet or as- a substitute for it, 
when there are signs of decided local irritation, are the remedies applicable 
to the early stage of active haematuria. When the hemorrhage is very co- 
* I have known bloody urine to result from inhalation of the vapours of oil of tur- 
pentine. The case was that of a patient in the Pennsylvania Hospital, who had been 
one of the crew of a vessel loaded with turpentine, among which he had worked and 
slept for several days. He informed me that two others of the crew were similarly 
affected. (Note to the second edition.} 328 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
[part II. 
pious, ice or ice-water may be applied over the part from which the blood 
proceeds; when it is moderate, and attended with much irritation, warm fo- 
mentations or emollient cataplasms would be preferable. In the former case, 
cold water, in the latter, laudanum, may be advantageously injected into the 
rectum. I have found great and almost immediate advantage from the ace- 
tate of lead, in small and often repeated doses. In the more advanced stages, 
other astringents, including uva ursi, may often be usefully employed; and 
oil of turpentine is an excellent remedy in chronic and passive conditions of 
the disease. The bowels if disposed to constipation, should be kept soluble 
by mild laxatives or enemata. It may sometimes be advisable to inject as- 
tringent solutions or infusions into the bladder; but this should always be 
done with caution. When coagulated blood in the bladder obstructs the 
discharge of urine, or resists the action of that liquid in breaking up and 
removing it, a sound should be carefully introduced so as to divide the co- 
agulum, or warm liquids thrown up so as to aid in washing it out. In 
urethral hemorrhage, a bougie may be introduced, after cold, rest, astrin- 
gents, &c., have failed. In passive haematuria, the general rules for the 
treatment of hemorrhage of this character are applicable; and the same may 
be said of the prophylactic treatment. 
Article IX. 
HEMORRHAGE OF THE UTERUS. 
The term uterine hemorrhage embraces all bloody discharges from the 
uterus, whether dependent on functional or organic derangement, and whether 
occurring in the impregnated or unimpregnated state of the organ. In this 
place, however, those only will be considered which are unconnected with 
gestation; the others being more appropriately treated of in works upon 
midwifery. 
The term menorrhagia has a somewhat less extensive signification. Its 
origin month, and I break) would confine it, in strictness, to 
an increased flow of the menses; but, as the menstrual discharge is now 
generally thought to be blood, and uterine hemorrhage, occurring in the un- 
impregnated state of the uterus, to be a mere increase of the menses, the term 
is extended so as to embrace that affection. They who consider the menses 
as a secretion, and not a hemorrhage, make the want of coagulability of the dis- 
charge its chief distinctive character. Though the menses usually appear every 
four weeks, continue for three or four days, and amount, on the average, to 
about five or six ounces, yet the interval may be much shorter, the continu- 
ance longer, and the quantity much greater, without being morbid, or requir- 
ing medical interference. No excess beyond the usual average, in any of these 
respects, would be entitled to the name of a disease, unless productive of in- 
jury to the health. Now an excess, to this degree, is very rare without being 
attended with unaltered and coagulable blood; and Dr. Dewees states, in his 
work on the diseases of females, that he has known only one instance of the 
kind. It is, therefore, scarcely worth while to make a distinction between 
morbidly superabundant menstruation and the hemorrhage which occurs at 
the same periods; especially as the treatment of the two affections would be 
conducted upon the same principles. But hemorrhage connected with' preg- 
nancy, or dependent upon organic disease of the uterus, could scarcely Be in- 
cluded, with propriety, under the title of menorrhagia, having no relation, 
Syn.-Uterine Hemorrhage.-Menorrhagia. 329 
CLASS III.] 
UTERINE HEMORRHAGE.-MENORRHAGIA. 
whatever, to the menses. By the term, therefore, is here understood only 
that form of uterine hemorrhage which occurs simultaneously with the menses, 
or which, originating from mere functional derangement of the organ, may be 
considered as somewhat analogous to menstruation in its character. 
Menorrhagia has been divided into the active and passive. There is a real 
foundation for this division, though not recognized by all authors. The dif- 
ference is simply this, that, in the former, the blood is extravasated in conse- 
quence of an irritation or increased action in the vessels themselves; in the 
latter flows through unresisting orifices merely upon the principle of gravi- 
tation, or under the impulse of the general circulating force. But it does not 
follow that all cases of hemorrhage attended with general debility are passive; 
and the probability is, that, in most of the instances in which menorrhagia is 
so considered, it is really active. Whenever the hemorrhage occurs at certain 
intervals answering to those of menstruation, and, even under apparently 
similar exciting causes, does not occur at other periods, it is probably active; 
for it is only in consequence of a certain vital exaltation or irritation in the 
organ, that the current of blood is at these times especially directed or invited 
to the uterus. The general forces which circulate the blood are quite passive 
in relation to its peculiar direction. Nevertheless, it is important to attend 
to the strength of the patient; for cases accompanied with debility, even though 
the uterine action may have the character of irritation, require a very differ- 
ent treatment from those occurring in an opposite state of the system. True 
passive menorrhagia is that which, in a weakened state of the system and of 
the uterine vessels, may occur at any time under the influence of exciting 
causes. It may be the result either of an atonic, relaxed condition of the 
vascular walls, consequent or not upon previous excitement, or of a certain 
hemorrhagic condition of the blood, which disposes to a passive extravasation, 
such as takes place in malignant diseases. 
Symptoms.-Menorrhagia usually occurs at the regular periods of men- 
struation, or, if in the interval, at such stated times as to justify the conclu- 
sion, that it is in some degree under the influence of the causes which regulate 
the menstrual function. That this is the case may be inferred also from the 
fact, that the disease seldom occurs before puberty, or after the age at which 
the system has become quite accommodated to the abolition of this function. 
In most instances, various premonitory symptoms are observable, sometimes 
as much as two or three days before the appearance of the hemorrhage. Such 
are a feeling of weight, fulness, or heat in the region of the uterus, pains in 
the loins, bearing down sensations, slight swellings of the external parts of 
generation, tumefaction and uneasiness of the mammae, more or less derange- 
ment of digestion, heat of mouth, giddiness or headache, excitement of the 
pulse, and mental depression. If the hemorrhage occur at the regular monthly 
period, the first discharge, according to Dr. Dewees, generally has the charac- 
teristic properties of the menstrual fluid, but is soon followed by blood, as 
shown by the clots or stringy coagula which attend it. The flow of blood 
frequently relieves the preceding symptoms of turgescence or excitement. 
After the first gush, it sometimes gradually subsides, and the patient expe- 
riences no further difficulty on the particular occasion ; but not unfrequently, 
after partial subsidence, it returns again and again, and does not cease until 
it has considerably reduced the strength; leaving the patient pale, languid, 
and with a feeble pulse. Sometimes the hemorrhage is so profuse as to pro- 
duce a condition of acute anaemia (see page 251), and even to involve life in 
apparent danger. Upon the cessation of the discharge, the patient gradually 
recovers her strength, until the recurrence of the monthly period brings back 
the same routine of preliminary excitement, hemorrhage, and exhaustion. 330 
[part it. 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
Occasionally, the intervals are not longer than two or three weeks. The 
general health gradually gives way. The blood becomes deteriorated in 
quality; and the symptoms of chronic anaemia are at length established. 
The patient is extremely pale, and suffers much from palpitation, faintness, 
giddiness, tinnitus aurium, and violent neuralgic headaches. The pulse is 
feeble, and is rendered very frequent by slight exertion. The returns of the 
hemorrhage become more irregular, and its duration longer. The discharge 
of blood is followed by that of coloured serum, and this not unfrequently by 
a profuse leucorrhoea. The slightest causes are sufficient to induce an attack. 
At length the patient is scarcely ever free from hemorrhage, which varies only 
from the extravasation of coagulable blood to that of a thin bloody serous 
liquid. The general symptoms are still further aggravated. Sallowness of 
complexion or excessive pallor, great emaciation, a very feeble and excitable 
pulse, a short and hurried respiration, edematous extremities, and sometimes 
a general dropsical tendency, with derangement of the digestive and nervous 
functions, mark the extreme prostration of the system. Occasional profuse 
discharges, sometimes attended with syncope, aggravate the danger. If the 
patient is not relieved, she sinks under the exhaustion, or yields to some acci- 
dental disease which her system in ordinary health would have resisted. A 
fatal termination, however, is rare; as the disease is almost always within the 
reach of remedies; and the course above described is often cut short, at various 
points, either by the interposition of art, the cessation of the cause, or the re- 
sources of the system. 
In some instances, a condition of debility, similar to that produced by a long 
continuance of the hemorrhage, arises from other causes in a healthy condi- 
tion of the menstrual'function. The peculiar causes of menorrhagia, now 
occurring, superadd this affection. The attacks of hemorrhage, under these 
circumstances, are less apt to be heralded by premonitory symptoms, and are 
less regular in their recurrence than in a more vigorous state of system; and 
the affection speedily assumes the character above described, as belonging to 
the advanced stage. There are, moreover, between the two extremes of vigour 
and debility, all conceivable grades; so that it is not always easy to decide to 
which category any particular case may belong. 
Either in the induced, or in the original debilitated state of the general 
health, it is possible that the hemorrhage may assume the truly passive 
form; the vessels of the womb having lost, to a greater or less extent, their 
power of resisting the forces that tend to extravasate the blood. But true 
passive menorrhagia is probably more frequent as the result of a depraved 
character of the blood itself, in which it no longer retains the power of sup- 
porting the organic contractility of the tissues. In such cases, any cause that 
may direct the blood with more than usual force, or in more than usual quan- 
tity, to the uterus, will bring on a discharge; but the blood instead of pre- 
senting its ordinary appearance, is apt to have a dark colour, and little tend- 
ency to coagulate. 
Women subject to menorrhagia are less apt to become pregnant, and, when 
they become so, are more liable to abortion, than others not thus affected. 
Dr. Locock has also "frequently remarked that those who have suffered much 
from menorrhagia, are peculiarly liable to uterine hemorrhage after abortion 
or parturition at the full time." (Cyc. of Pract. Med., Article Menorrhagia.) 
Besides menorrhagia, women are subject to other forms of uterine hemor- 
rhage. Inflammation of the womb is sometimes attended with a considerable 
flow of blood. The same thing occurs frequently from ulcers of the uterus, 
and from polypous tumours and other excrescences, which sustain a constant 
state of irritation and turgescence. Indeed, whenever frequent attacks of CLASS III.] 
UTERINE HEMORRHAGE.-MENORRHAGIA. 
331 
uterine hemorrhage occur, at altogether irregular intervals, even during the 
menstruating period of life, some organic derangement may be suspected, and 
an examination should be made. Carcinoma of the uterus is almost always 
productive of hemorrhage. About the period of life at which menstruation 
ceases, irregularities of this function are very common; and occasional excess 
of discharge, or even copious hemorrhage, may occur without serious disease 
of the organ. But, as cancer is apt to be developed about the same time, 
such hemorrhage is always a subject of suspicion. Should the hemorrhage 
come on after the menses have ceased entirely, and then occur irregularly, 
with lancinating pains in the region of the uterus, the grounds of suspicion 
are much stronger. In all such cases, an examination per vaginam will de- 
termine the question. 
Causes.-The predisposing causes of this hemorrhage are such as affect 
the system at large, or operate especially upon the uterus. Among the first 
are all those calculated to induce a plethoric or otherwise hemorrhagic state 
of the blood. The causes most operative in the production of plethora in 
women, are, perhaps, sedentary habits, the free use of stimulating food and 
drink, confinement in hot rooms, and over indulgence in sleeping, especially 
in hot beds. A contrary set of causes, as scanty and unwholesome food, bad 
air, exposure to cold, privations of all kinds, and diseases which impair the 
digestive functions, sometimes predispose to passive menorrhagia by impover- 
ishing or depraving the blood. The time of life has also some influence. 
Women appear to be most subject to menorrhagia at the period when the 
menses, in the natural course of things, are about to cease. Of the causes 
which act locally, many are occasionally exciting as well as predjsposing; in 
one instance inducing a tendency to the hemorrhage, and in another bring- 
ing an existing predisposition into action. Such are tight lacing, habitual 
constipation, congestion of the portal circulation from disease of the liver or 
spleen, long-continued leucorrhoea, and the frequent occurrence of abortion. 
Anything may act as an exciting cause which is capable of irritating the 
uterus, directly or indirectly,or sending towards it a current of blood. Of 
this nature are the ordinary menstrual effort, great exertion, inordinate danc- 
ing, straining, blows or falls, mechanical violence of all kinds, medicines cal- 
culated to affect especially the pelvic viscera, as cantharides, oil of turpentine, 
savine, and aloes, drastic cathartics in general, hardened feces in the rectum, 
sexual indulgence, lascivious thoughts, exciting passions, piles, and irritating 
diseases of the bladder and urinary passages. 
Treatment.-In acute cases, the patient should be kept at rest in a hori- 
zontal position, upon a firm bed or mattrass, and carefully guarded against 
causes of excitement, whether general or local. Everything having a tend- 
ency to invite the blood to the uterus, or to confine it there, should be re- 
moved. The dress, therefore, should be quite loose; constipation, if existing, 
should be obviated by laxative medicine or an enema; any irritation of the 
urinary organs or rectum which may occasion dysury, tenesmus, or bearing 
down efforts, should be quieted by an opiate injection; and, if there be con- 
gestion of the portal circle, dependent on hepatic torpor or obstruction, it 
should be corrected by an alterative mercurial treatment. These are general 
directions, to be put in force in all cases presenting the requisite indications. 
But it is highly important, in conducting the treatment, to consider the state 
of system, in relation to the degree of elevation or depression. 
When the disease is recent, the circulation plethoric, the pulse full and 
strong, and the evidences of uterine excitement obvious, blood may be taken 
from the arm. After bleeding, and in cases which do not require the lancet, 
should symptoms of considerable local congestion of the uterus exist, much 332 
[PART II. 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
good may be derived from a few cups to the sacrum, or leeches over the 
pubes, to the vulva, or on the inner and upper parts of the thighs. Deple- 
tion, however, of this direct character, is comparatively seldom necessary. A 
saline cathartic to remove any existing constipation, the use of refrigerant or 
nauseating diaphoretics, rest, cool drinks, and a diet restricted to farinaceous 
liquids, will generally be sufficient to meet the constitutional indications in 
active cases. Small doses of tartar emetic or ipecacuanha, repeated so as to 
induce slight nausea, without vomiting, will often have a happy effect in 
relieving vascular excitement, and controlling the hemorrhage, while they do 
not exhaust the resources of the system. Emetics have been recommended; 
but, though good might result from the relaxation which precedes and follows 
their operation, there would be some risk of increased hemorrhage, from the 
straining and consequent compression of the pelvic viscera which attend the 
act of vomiting. They must, therefore, be looked upon as a doubtful remedy. 
Should there have been little or no vascular excitement originally, or should it 
have been subdued, great advantage may be expected from opium and ipecacu- 
anha, given in the form of pill, or that of Dover's powder. Directing power- 
fully to the skin, this combination acts revulsively upon the uterus, while it 
quiets the various irritations general or local which often so strongly contri- 
bute to sustain the discharge. The patient may be kept constantly under its 
influence by a full dose every eight hours; or it may be administered at night, 
while other remedies are given through the day. When the stomach is very 
irritable, the remedy may be administered by the rectum, in twice or thrice 
the ordinary dose. Tincture of hemp has been found useful by Dr. Maguire, 
in this form of hemorrhage; and its efficacy is attested by Dr. Churchill, who 
gives it in the dose of five drops three times a day. {Braithwaite's Retrospect, 
xix. 329.) 
Should the hemorrhage be considerable, efforts should be made to arrest it 
directly by producing contraction of the bleeding vessels. This indication is 
admirably fulfilled by acetate of lead, which may be given in doses of two 
or three grains every hour, two, or three hours, until the hemorrhage is 
checked, or until from thirty to forty grains have been taken. It may often 
be happily combined with the opium and ipecacuanha, and the different indi- 
cations thus simultaneously answered. If the salt of lead should fail, or be 
objectionable, recourse may be had to ergot, which is peculiarly adapted to 
hemorrhages of the uterus, and, in consequence of its sedative action upon the 
circulation, may be used in cases attended with some excitement. When the 
hemorrhage is alarmingly copious, it is necessary in addition to employ local 
measures. Of these, cold is one of the most efficient, and best adapted to 
this condition of the disease. Cloths wrung out of very cold water or spirit, 
or bladders containing ice, may be applied about the pelvis, over the pubes, 
or to the loins and back; the patient may be placed in a cold hip-bath; cold 
water maybe injected into the rectum; or ice introduced into the vagina. 
Care, however, must be taken that the vital actions, already, perhaps, de- 
pressed by the hemorrhage, be not reduced too low by the long continuance 
of the remedy. Should cold not prove effectual, the measure still remains of 
plugging the vagina, which, in the ordinary state of the uterus, can scarcely 
fail. The following observations upon this point are made by Dr. Locock. 
"A dossil of lint, or a fine cambric handkerchief may be gradually introduced 
into the vagina up to the os uteri, so as to fill the vagina firmly throughout 
its whole extent. Many prefer soaking the material previously in some strong 
astringent liquid, and this is, perhaps, still more efficacious. If a plug pro- 
duce pain, it must be withdrawn, and at all events it should not be allowed to 
remain more than twenty-four hours, because it is apt to become very offen- CLASS III.] 
MENORRHAGIA. 
333 
sive and irritating from the putrefaction of the discharge. On withdrawing 
it, unless it be done very gently and gradually, a fresh discharge of blood is 
apt to be occasioned; but it can easily be restrained by another plug, or some 
of the other remedies." (Cyc. of Pract. Med., Article Menorrhagia.') Dr. 
J. Henry Bennet, of London, in very obstinate cases, plugs the os uteri, in- 
stead of the vagina. Bringing the part into view by the speculum, he intro- 
duces two or three small pieces of cotton tied to a thread, and wedges them 
firmly into the os uteri, and then covers the cervix with larger pieces before 
withdrawing the instrument. (Lond. Lancet, Feb. 1852.) 
When the case is originally attended with symptoms rather of general de- 
pression than elevation, or when it has become somewhat chronic, and as- 
sumed the condition usually considered as passive, other astringents besides 
acetate of lead may be employed with advantage. Among these, kino, catechu, 
rhatany, and pure tannic acid, from the vegetable kingdom; and alum, sul- 
phate of zinc, sulphate of iron, tincture of chloride of iron, and sulphuric acid 
from the mineral, are perhaps most esteemed. Gallic acid has been of late 
strongly recommended; and Dr. T. H. Tanner, of London, has found tincture 
of cinnamon, in the dose of a drachm, every six hours, very efficacious. (See 
Med. Exam., N. S., ix. 781.) The solution of arsenite of potassa has also 
been recommended. Oxide of silver, eulogized by Dr. Lane, has also been 
employed with great success by Dr. J. J. Thweatt, of Petersburg, Virginia. 
He gives it in doses varying from half a grain to two grains twice or three 
times a day, and always combines it with a little opium or morphia. (Am. 
Journ. of Med. Sci., N. S., xviii. p. 70.) Astringent injections, consisting 
of alum dissolved in the infusion of kino or catechu, or of solution of acetate 
of lead, may be thrown into the vagina; and similar injections have even 
been introduced directly into the cavity of the uterus, by means of a male 
catheter passed through its orifice, though death is said to have resulted from 
the latter plan in more than one instance. 
In cases still feebler, where the system and the uterus are both relaxed, 
and the hemorrhage appears to be sustained by the relaxation, it becomes 
necessary, in addition to the measures above recommended for arresting the 
discharge, to employ others with the view of giving tone to the various or- 
gans, and invigorating the general organic contractility. These measures are 
not to be confined to the periods of discharge, but continued also in the inter- 
val. The different bitters and chalybeates are now indicated. Sulphate of 
zinc, in the dose of two grains, and sulphate of copper, in that of one quarter 
of a grain, repeated three or four times a day, are occasionally of advantage. 
The tonics may sometimes be beneficially associated with an aromatic tincture, 
as that of cinnamon, or of ginger. In old cases, where the uterus is very 
feeble and relaxed, remedies calculated to stimulate that organ directly have 
been recommended, such as a blister to the sacrum, aloetic preparations, and 
even savine and cantharides; but these must be employed with caution. 
Oil of turpentine has sometimes a very happy effect. If the bowels are cos- 
tive, they should be kept open by rhubarb with soap. 
The diet should consist of nutritious and easily digestible substances; and 
the malt liquors, or a little wine may be allowed for drink. A cold bath, or 
cold hip-bath, may be employed for a few minutes, night and morning, if, 
upon cautious trial, the system is found to react well under its use. Moderate 
exercise, of a passive kind, will sometimes be useful, by improving the general 
health; but all jolting or jarring, and all active exertion should be carefully 
avoided. Among the most efficacious remedies is a journey to some of the 
chalybeate springs, and a free use of the waters. The occasions should be 
preferably seized for exercise, when the hemorrhage has been suspended. 334 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
[PART II. 
Much of the good effects of this remedy may be somewhat more safely obtained 
by means of friction with the flesh-brush. 
Much may be done, in the intervals of the hemorrhage, to ward off the 
attacks. The treatment adapted to the period of discharge, in the passive 
variety, is generally applicable also to that of suspension; the line between 
these two conditions being frequently but indistinctly drawn. This treatment 
has been already sufficiently detailed. In active cases, the accession of the 
hemorrhage may sometimes be usefully anticipated by a saline cathartic, and 
a reduction of the diet. At all times, in the interval, the diet should be 
moderate, and stimulant drinks avoided. Due activity should be imparted to 
the secretory and nutritive processes by means of exercise, so as to prevent 
an undue accumulation of blood in the circulation. All the functions should 
be maintained, as far as possible, in a healthy state; and particular attention 
should be paid to the liver and bowels. In those cases in which the menses 
are postponed beyond the regular time, and are attended with hemorrhage, 
efforts should be made to bring them back to the proper period. For this 
purpose, a warm hip-bath, and copious draughts of warm herb teas may be 
resorted to about the regular menstrual period, preceded, if the pulse be full 
and strong, by the loss of a little blood. 
In all forms and circumstances of the affection, the causes should be care- 
fully studied, and, if possible, removed. An irritable state of the nervous 
system, which is apt to attend the complaint, and may aggravate it, should 
be corrected by such narcotics and antispasmodics as may not be contraindi- 
cated by existing symptoms. Of these, opium or some one of its preparations 
is most effectual. Occasion may arise, also, for the use of hyoscyamus, cam- 
phor, assafetida, valerian, and compound spirit of sulphuric ether. 
Article X. 
HEMORRHAGE FROM THE SKIN, 
Hemorrhage from the skin in a sound state, with the cuticle entire, is 
exceedingly rare. Cases, however, have been observed. The blood is said to 
have escaped, in some instances, from the whole or large portions of the sur- 
face like sweat; but usually the hemorrhage is confined within a small space, 
as to the palms of the hands, soles of the feet, roots of the nails, nipple, 
navel, face, front of the chest, arm-pits, and groins. The blood oozes out like 
dew upon the surface, and, if wiped off, reappears in the same manner. The 
skin beneath is in some cases qilite healthy in its aspect, in others is red, as 
if congested or inflamed. 
This form of hemorrhage is stated to have resulted sometimes from violent 
exertion or straining, and from strong mental emotions, especially of fear. 
But these causes could scarcely have induced it without a strong predisposi- 
tion, dependent probably upon the condition of the blood. It is occasionally 
vicarious to other discharges, healthy or morbid, and particularly to the 
menses. When from this cause, it has been observed to be periodical in some 
instances. Women are much more subject to it than men. 
But, though exudation of blood through the cuticle is rare, hemorrhage 
beneath the cuticle, and in a morbid state of the skin, is not uncommon. 
Bleeding from blistered or ulcerated surfaces, and from scratches, or other 
very slight injuries, often occurs in persons strongly predisposed to hemor- 
rhage; and effusions in the cutis, in the form of petechias, and beneath the 
cuticle, in the form of bloody blisters, are common attendants upon scurvy, CLASS III.] 
HEMORRHAGE FROM THE SEROUS MEMBRANES. 
335 
and other diseases in which the blood is depraved. The consideration of 
hemorrhage from wounds belongs to the province of surgery. It may not, 
however, be amiss to mention here that the bleeding from leech-bites, espe- 
cially those of the European leech, is often profuse, and in children sometimes 
dangerous, particularly when there is a tendency to hemorrhage. 
The treatment in all these cases, so far as regards the cutaneous hemor- 
rhage, is very simple. In many instances, the affection is slight and disap- 
pears spontaneously, or subsides with the general disorder in which it had its 
origin. If so copious or protracted as to demand remedial measures, it may 
be treated with cold applications, astringent lotions, or compression. In the 
case of leech-bites, I have found a piece of cotton, wet with a saturated solu- 
tion of alum in boiling-hot water, and then pressed upon the wound just 
before the salt begins to crystallize, a very effectual remedy. Another plan 
is to introduce the fine point of a piece of lunar caustic into the bite; and 
still another, to take a thin piece of caoutchouc, and, having heated it till it 
becomes soft and adhesive, to press it over the point of hemorrhage, and retain 
it there until it is firmly fixed. 
Article XL 
HEMORRHAGE FROM THE SEROUS MEMBRANES. 
This sometimes occurs, though very rarely, as a functional derangement, 
from causes similar to those which produce hemorrhage from the mucous 
tissue. It is more common as the result of inflammation. In very many 
cases of serous inflammation, more or less blood is effused with other liquids; 
but this scarcely deserves to be considered as hemorrhage. To be entitled 
to this name, the blood should escape from the vessels in considerable quan- 
ties, and with little admixture. This sometimes happens in persons pre- 
disposed to hemorrhage; and is a not unfrequent attendant upon pleurisy, 
pericarditis, and peritonitis, occurring in scorbutic individuals. (See Scurvy.) 
Other sources of hemorrhage into the serous cavities are the bursting of 
aneurisms, the erosion of blood-vessels by ulceration, and their rupture in 
consequence of external violence. 
Though the effused blood is sometimes in quantity sufficient to produce 
fatal syncope, it is more commonly injurious by compressing the neighbouring 
vital organs, or by producing inflammation in the membrane. 
The diagnosis in these cases is often obscure; and not unfrequently the 
affection is first discovered after death. It may be suspected when, without 
Sufficient pre-existing disease to explain the result satisfactorily in another 
manner, there suddenly occurs great prostration, with the symptoms of acute 
anaemia; and, at the same time, the functions of some one of the organs in- 
vested by a serous membrane, are deranged in a mode implying compression. 
The diagnosis is aided by the fact that, very generally, when there is hemor- 
rhage from a serous membrane, independent of organic disease, there is simul- 
taneously hemorrhage from a neighbouring mucous membrane also ; the causes 
which occasion the former being so general in their influence as almost neces- 
sarily to involve a tissue, so much disposed to this affection as the mucous. 
If, by the aid of percussion or auscultation, a fluid can be discovered in one of 
the serous cavities, the evidence is strengthened. 
These hemorrhages are not necessarily fatal. If the effused blood is not 
very copious, it coagulates, and, producing inflammation in the contiguous 
membrane, occasions the exudation of coagulable lymph, which may form an 336 
LOCAL DISEASES.-CIRCULATORY SYSTEM. 
[part II. 
organized cyst around the mass, and ultimately remove it by absorption. Or 
the coagulum may itself become organized, and form a new structure not in- 
compatible with the life of the patient. Art has little to do in such cases but 
to look on, and occasionally aid the efforts of nature by correcting derange- 
ments in the general health. Should the symptoms afford reason to think that 
the hemorrhage is still going on, and that it may be the result of an irritative 
transudation, it would be proper to endeavour to check it by bleeding, carried 
as far as the strength of the patient will admit; and if he be already reduced 
too far for this remedy, cold may be applied externally, as near the seat of the 
hemorrhage as possible. When the effusion is very abundant, nothing offers 
a chance of safety but the evacuation of the blood through an artificial open- 
ing ; and the chance from this source is very slight. 
Hemorrhage of the pleura is one of the most frequent of the serous hemor- 
rhages. It may be suspected when shortness of breath, great debility and 
faintness, and bloody expectoration, occur suddenly and simultaneously; while 
the chest affords, by percussion and auscultation, evidences of a liquid within 
the pleura, not previously existing there. It is generally fatal when consider- 
able. Paracentesis has been performed in cases attended with large effusion, 
but not with very encouraging results. Dr. Karawagen, of Cronstadt, per- 
formed the operation in four cases of hemorrhagic pleuritis, attendant on an 
epidemic scurvy which prevailed at that place in 1839, and in all with relief 
to the patients, though without ultimate success. 
Effusion of blood into the pericardium, when it occurs, is generally conse- 
quent on rupture of the heart or one of the large blood-vessels; but cases have 
been recorded in which it appeared to be the result of transudation; as no 
solution of continuity could be found upon the most careful examination. 
Such cases have come under the notice of Baillie, Chomel, Carson, and Bur- 
rows. In Chomel's case, the affection continued several days, and was at- 
tended with orthopnoea, an unequal and irregular pulse, the absence under 
the hand of any impulse of the heart, general oedema, and reddish expecto- 
ration. (JDict. de Med., xv. 173.) Dr. Karawagen performed the operation 
of paracentesis in two cases of hemorrhagic pericarditis, accompanying scurvy, 
in one with relief to the symptoms, in the other with complete success, the 
patient having ultimately recovered; and this was the only case of recovery 
out of thirty affected with the disease. Three pints and a half of bloody liquid 
were extracted. (See Med. Examiner, iv. 525.) The same operation has 
been frequently performed by Dr. Kyber. In most cases, it merely served to 
protract life without preserving it; but, in four, a radical cure was effected. 
(See Ranking's Abstract, vii. 64.) 
Hemorrhage of the peritoneum, independent of inflammation or organic 
disease, though rare, has been occasionally noticed. Sudden and very severe 
abdominal pains, nausea and vomiting, coldness of the surface, extreme 
feebleness of the pulse, a haggard countenance, and delirium, have been the 
prominent symptoms. The presence of blood in this cavity, whether from 
transudation or other cause, is probably less fatal than in the pleura; isolation, 
and ultimate absorption, organization, or elimination of the blood, being of 
occasional occurrence. 
The phenomena and effects of hemorrhage of the arachnoid will be detailed 
under diseases of the brain and spinal marrow. As to the tunica vaginalis 
testis and the synovial membranes, little need be said. Hemorrhage in these 
membranes is almost always the result of violence, though it may sometimes 
occur from transudation in persons of a strong hemorrhagic diathesis. Blood 
has been found effused into the joints in scurvy. CLASS III.] 
HEMORRHAGE OF THE CELLULAR TISSUES. 
337 
Article XII. 
HEMORRHAGE OF THE CELLULAR AND PARENCHYMATOUS 
TISSUES. 
Extravasation of blood in the cellular tissue is a common result of a general 
predisposition to passive hemorrhage. In scurvy, purpura, and malignant 
febrile affections, as well as in cases of constitutional predisposition to hemor- 
rhage, it is among the most constant phenomena. The extravasation takes 
place immediately under the skin, forming ecchymosis; beneath the mucous 
and serous membranes, producing elevated red patches in parts obvious to in- 
spection ; and among the muscles, giving rise to tumours, often of considera- 
ble size. In short, there is no portion of this tissue in which the effusion 
may not occur. The blood in these cases, if the patient survive the disease 
in which the hemorrhage originates, is either gradually absorbed, or becomes 
organized, and forms new structure, which ultimately disappears. The hemor- 
rhage itself is seldom an object of treatment; the efforts of the practitioner 
being directed towards the general affection. 
Effusion of blood in the cellular tissue is a frequent result of external vio- 
lence, and, in persons with a constitutional tendency to hemorrhage, is pro- 
duced by the slightest causes. Large ecchymoses and bloody tumours are thus 
occasionally formed under the skin. They almost always, however, disappear 
gradually by absorption, if not tampered with. Evaporating lotions, as tinc- 
ture of camphor, may sometimes hasten the process; and it is possible that 
gentle pressure may occasionally do good, though it must be used with caution. 
If attended with inflammation, they should be treated with cold water, or 
saturnine lotions. 
Hemorrhage into the tissue of organs is of no unfrequent occurrence, though 
it probably results much oftener from an inflammatory or other organic lesion, 
or from external violence, than from mere transudation consequent upon irri- 
tation or congestion. It sometimes attends upon affections characterized by 
a hemorrhagic state of the blood. In most of the organs its existence can be 
known only after death. In the lungs and brain, however, it occasions cha- 
racteristic phenomena which indicate it in many cases with sufficient clearness. 
It is almost never by the mere loss of blood that it does harm, but by inter- 
fering with the functions of the organ. In this way it is almost always 
serious, and very often fatal. Apoplexy and palsy result from such effusions 
in the brain, and pulmonary apoplexy in the lungs. (See Apoplexy, and 
Hemorrhage of the Lungs f 
SECTION V. 
DISEASES OF THE ORGANS OF SECRETION. 
This section might embrace all the diseases of all the secreting tissues, in- 
cluding the serous, cellular, and mucous membranes, the skin, and the con- 
glomerate glands; but many of these are more conveniently considered under 
other functions, in the execution of which the tissues perform an essential 
part; as, for example, the complaints of the alimentary mucous membrane 
under digestion, and of the bronchial under respiration. I shall treat here 
onlsy of the diseases of the serous and cellular tissues, the skin, the salivary 338 
LOCAL DISEASES.-SECRETORY SYSTEM. 
[part II. 
glands, the liver, the kidneys, and the appendages of these several organs. 
No arrangement of diseases can be so precise, that the different divisions will 
not occasionally trench upon one another. 
SUBSECTION I. 
DISEASES OF THE SEROUS AND CELLULAR TISSUES. 
In consequence of the connexion of these tissues with other functions than 
the secretory, all of their diseases are considered elsewhere, except dropsy, 
which, being generally a disease of secretion, would appear to fall naturally 
into this division. 
Article L 
DROPSY. 
Dropsy may be defined to be a morbid accumulation of watery or serous 
fluid in the cellular tissue or serous cavities. A certain portion of such fluid 
is essential to the healthy state of these parts. It is only when the wants of 
the tissues are exceeded, and an accumulation takes place productive of more 
or less inconvenience or injury, that it can be said to be morbid, and thus to 
constitute dropsy. Nor do I here include, under this term, the serous collec- 
tions that sometimes take place in mucous cavities, in cysts or hydatids, or 
even in the bursae and synovial sacs. Though there is a certain analogy be- 
tween these and dropsy, and though the name is not unfrequently applied to 
them, they differ in this respect, that they are generally quite local, and do 
not, like dropsy, depend upon causes which may produce a simultaneous effect 
in all the ordinary seats of the affection. Thus, we may have serous effusion 
into the cellular tissue, the peritoneum, and the pleurae, at the same time, and 
from the same cause; but this does not extend into the mucous or encysted 
cavities, and seldom to the joints. The affections usually originate under dif- 
ferent circumstances, obey different laws, and require different treatment. It 
is even most convenient to separate certain cases of effusion in serous cavities 
from the general category, and either to treat of them under the head of the 
organs which they severally affect, as when the discharge is a mere attendant 
upon inflammation, or to refer them to the surgeon, as in the case of hydro- 
cele. The only localities of dropsy here considered are the cellular tissue, 
the arachnoid, the pleurae, the pericardium, and the peritoneum. When the 
effusion takes place in the cellular structure, it is denominated, if extensive, 
anasarca, if limited to one part, oedema,; when it affects the arachnoid, it is 
called hydrocephalus, or dropsy of the brain ; when the pleurae, hydrothorax, 
or dropsy of the chest; when the pericardium, hydropericardium, or dropsy 
of the heart ; when the peritoneum, ascites, or abdominal dropsy. The name 
of general dropsy is given to the affection when it occupies all or most of 
these positions, to a greater or less extent, at the same time. The complaint 
will be first treated of in its general relations, and afterwards in the several 
localities alluded to. 
Dropsy is rather a symptom or result of morbid action than itself a dis- 
ease. Nevertheless, it usually holds this rank in practical treatises, and, from 
its own striking characters, and the frequent obscurity of the true pathologi- 
cal condition in which it originates, will probably always continue to do so. CLASS III.] 
339 
DROPSY. 
The danger in which it frequently involves life, and the consequent necessity 
of employing measures for its removal, without reference to its source, are 
other considerations which entitle it to a place in the catalogue of distinct 
diseases. 
Pathological Condition. 
The first inquiry in delation to dropsy should be directed towards the pa- 
thological condition upon which the liquid accumulation depends, and which 
constitutes the true disease. This is not the same in all cases. Very differ- 
ent, and, indeed, opposite derangements of function or structure are the 
sources of dropsy. They may all be included under the following heads. 
1. Irritation, Active Congestion, or Inflammation.-The serous and cel- 
lular tissues pour out an increased quantity of fluid when excited. The ex- 
citement may amount to inflammation. That dropsical effusion is sometimes 
associated with this condition of the membrane from which it proceeds, is 
evinced by the symptoms during life, and the results of examination after 
death. Pleuritic and abdominal pains with fever occasionally precede hy- 
drothorax and ascites ; and, in some cases of anasarca, pressure upon the 
edematous part occasions considerable uneasiness. Indeed, inflammation of 
the serous tissues is generally attended with a fluid exudation, a portion of 
which has the serous character. When this is speedily absorbed, after the 
subsidence of the acute symptoms, it is not considered dropsical; but if it 
continue long, and especially if it increase and become complicated with ex- 
ternal oedema, it is unhesitatingly admitted to that rank. Dissection after 
death, in such instances, often exhibits decisive evidence of pre-existent or 
persisting inflammation. In most cases, the inflammation is chronic; and it 
is not unfrequently complicated with tubercles, which serve to sustain it. 
But, though inflammation sometimes lies at the foundation of dropsy, the dis- 
ease is more frequently the result of mere irritation with vascular turgescence. 
The very act of effusion relieves the vessels, and inflammation is prevented by 
the occurrence of dropsy. 
2. Debility or Relaxation.-An opposite condition of the tissues to that 
just mentioned may be productive of the same result, in relation to dropsical 
effusion. The vessels in debility sometimes become so relaxed, that the more 
liquid portions of the blood are allowed to pass through their walls, almost 
without resistance. We observe the same thing in the vessels of the skin, 
by which the watery part of the blood is often poured out abundantly in very 
feeble states of the system, in the form of colliquative sweats. The results 
of injection after death confirm this view of the pathological condition in cer- 
tain cases of dropsy. Dr. Horner, late Professor of Anatomy in the Univer- 
sity of Pennsylvania, stated that, in fine injections of whole dropsical subjects, 
scarcely any resistance is offered by the blood-vessels; the injected fluid es- 
caping from them by their lateral porosities as fast as it can be thrown in. 
(Am. Journ. of Med. Sci., i. 265.) 
3. Passive Congestion.-Distension of the blood-vessels, unattended with 
irritation, frequently results in serous effusion. If water be injected into the 
veins of an animal in considerable quantity, death takes place with symptoms 
of cerebral and pectoral oppression, and watery fluid is found, upon dissection, 
in one or more of the serous cavities, and in the cellular tissue. If, previ- 
ously to the injection, blood has been abstracted, and the quantity of water 
employed be merely sufficient to supply the loss, the same consequences do 
not follow. Distension, therefore, is the immediate cause of the effusion. 
Su^h distension frequently occurs, in various degrees, from a derangement of 
the proper balance between absorption and secretion, and from other causes. 340 
LOCAL DISEASES.-SECRETORY SYSTEM. 
[PART II. 
It is only when considerable, or, from the nature of its cause, lasting, that 
dropsy is produced. It may be said that the distension produces irritation 
or increased action of the capillary vessels, and that the effusion is the result 
of an active process. This is no doubt often the case; but frequently also 
there is reason to believe that it is wholly or in great measure passive, as all 
evidences of excitement are wanting; and the effusion is most apt to take 
place when the blood is watery, and the tissues relaxed. It is not improbable 
that many cases are of a mixed character; the extravasation being ascribable 
partly to irritation, partly to mere mechanical transudation. 
The preternatural fulness of the blood-vessels may be general, affecting the 
whole circulation, or it may be confined to the venous system, or to some por- 
tion of it, as to the portal circle, for example, or to a single limb. When 
partial, it is apt to be the result of some impediment to the return of the 
venous blood. The character of such impediments will engage our attention, 
under the causes of dropsy. The extent and position of the dropsy will of 
course be influenced by the locality of the congestion. 
4. Altered Condition of the Blood.-1There is little doubt that an altered 
composition of the blood is occasionally the true pathological condition in 
dropsy. What is the precise nature of the change has not been certainly 
determined. It is well known that anemic patients are occasionally attacked 
by dropsy; and it has been supposed that a watery state of the blood favours 
the occurrence of the disease. In repeated instances, examination of anemic 
patients who have died of dropsy has detected no organic lesion whatever, to 
which the disease could be ascribed; and a fair inference is that the blood 
was in fault. Two such cases are recorded by M. Castelnau in the Archives 
Generales (4e ser., v. 141). According to Andral, the dropsical tendency is 
connected not with a deficiency of fibrin or red corpuscles, but of albumen in 
the blood. (Patholog. Haematology, Am. ed., 108, &c.) MM. Andral and 
Gravarrat always detected albumen in the urine, in dropsical cases in which 
they found a deficiency of that principle in the serum. (Arch. Gen., 4e ser., 
v. 168.) This accounts for its deficiency in the blood, without the necessity 
of admitting that this deficiency was the cause of the dropsy. Dr. Rees, in 
many examinations of the blood of dropsical patients, never discovered a 
diminution in the proportion of albumen. (Ibid., 169.) In the two cases de- 
tailed by M Castelnau, there was no albumen in the urine, and the inference 
is drawn by the author that it was not wanting in the blood, which was very 
watery and deficient in red corpuscles. Watery blood may, therefore, cause 
dropsy without any special deficiency of albumen; but there can be little doubt 
that such a deficiency really does contribute to the dropsical tendency. The 
fact is, that further experiments are required to decide what is the precise 
alteration in the blood which disposes to dropsy. In the present state of our 
knowledge, we can only say that it is in general apparently more watery than 
in health. How it is that this state of the blood induces effusion is equally 
uncertain. It may be that the greater tenuity of the liquid facilitates its 
escape through the pores of the capillaries; it may be that these pores them- 
selves become relaxed from the want of due stimulus from the blood; or, 
finally, both these causes may operate. It is highly probable, also, that ac- 
cumulation in the blood of urea and other unhealthy constituents, consequent 
upon diminished secretion of urine, may give rise to an irritant property in 
the circulating fluid, which, acting on the serous and areolar tissues, may oc- 
casion increased secretion, and thus cause dropsy. 
5. Deficient Absorption.-In health there is a constant exhalation from the 
serous and cellular tissues, and an equally constant absorption of the effused 
fluid; and the two processes so far balance each other that no injurious accu- CLASS III.] 
341 
DROPSY. 
mulation takes place. It is obvious that dropsy may arise from an irregular 
condition of either or both of these functions; from an excess of exhalation, 
while absorption remains unchanged, from a deficiency of absorption, exhala- 
tion continuing as in health, or from an increase of exhalation and diminution 
of absorption combined. No sufficient proof has been adduced that dropsy de- 
pends exclusively on deficient absorption. It has been inferred to do so from 
the fact, that obstruction of the absorbent vessels is sometimes followed by 
oedema of the limb below; but this is not a necessary consequence ; for even 
the thoracic duct has been found obstructed without giving rise to dropsy. 
Nor has it been shown that the action of the absorbents is at all diminished 
in most cases of the disease. On the contrary, rapid loss of flesh often at- 
tends the progress of dropsy ; and the lymphatics running from dropsical parts 
have been sometimes observed to be greatly enlarged, as if they had been 
more than usually active. Besides, we have no proof that the fluid exhaled 
in dropsy is identical with that exhaled from the same tissues in health ; and 
the probabilities are that it is not so; for albumen, which is found in dropsi- 
cal fluid, is not usually a constituent of the normal secretions. But it is now 
generally believed that the veins are concerned in the process of absorption. 
Obstruction in these vessels, by producing congestion in the venous radicles 
below, must prevent the admission of fluid from without, and thus interfere 
with absorption, so far as the veins are concerned. The experiments of 
Magendie would appear to place this fact beyond doubt. They demonstrate 
that, when the venous system is artificially distended by the injection of 
water, absorption is impeded greatly, if not quite arrested. It is highly pro-' 
bable, therefore, that a deficiency of absorption in consequence of congestion 
of the veins is one of the pathological conditions upon which dropsical accu- 
mulations depend; but it is equally probable that this is never the sole, nor 
even the original cause; for, in all such cases, effusion is greatly increased in 
consequence of the distended state of the vessels. The fact, before stated, of 
the enlargement of the lymphatics in such cases, goes to show that absorption 
is not diminished in the ratio of the increased effusion; a portion of the duty 
of the veins being performed by the absorbents, which thus labour, though 
not in all instances effectually, to remedy the inconveniences arising from the 
venous congestion. 
The pathological conditions, above enumerated, are all that occur to me as 
being the immediate sources of dropsical accumulations. They constitute the 
true diseases of which the dropsy is a symptom. It is certain that various 
organic or functional derangements not yet mentioned are remotely the source 
of dropsy, but they all act by inducing one or more of these conditions, and 
will be more appropriately considered under the head of the causes of the dis- 
ease. Two or more of the above conditions are often united. Thus, irritation 
may supervene upon a watery condition of the blood, and congestion of the 
vessels; and it will be readily understood that, in such cases, the liability to 
the affection must be much greater than when either of the morbid states exists 
alone. We can thus explain why, in frequent instances, one of these states 
occurs without dropsy, while in other instances, being reinforced by one or 
both of the other conditions, it is attended with the complaint. 
The symptoms which characterize dropsical effusion will be more conve- 
niently detailed under the particular forms of dropsy. The affection some- 
times comes on suddenly, with more or less febrile action, indicated by in- 
creased frequency and force of pulse, warmth of skin, furred tongue, &c. 
Sometimes it is gradual in its approach, advances slowly, and is associated 
Symptoms, Course, Termination, &c. 342 
LOCAL DISEASES.-SECRETORY SYSTEM. 
[part II. 
with general debility, and depressed rather than excited vascular action. In 
the former case, it is sometimes called acute of febrile dropsy, in the latter 
chronic. But there is no definite line of demarcation between these varieties. 
Dropsy with feeble action sometimes makes its attack suddenly, and cases 
characterized by excitement may be slow in their progress; while others 
beginning with febrile action may end in debility. It is important that the 
practitioner should be aware that the disease is attended with these different 
states of the system; but little good can result from any attempt at classi- 
fication on such a basis. Cases of excitement sometimes manifest obvious 
marks of inflammation, such as thoracic and abdominal pains in hydrothorax 
and ascites, and tenderness of the cellular membrane on pressure in anasarca. 
More generally, however, the local symptoms are those rather of irritation 
than of positive inflammation. In dropsy with debility, the skin is usually 
very pale, the pulse feeble, and the general condition of the patient not un- 
frequently anemic. In many instances, neither symptoms of excitement nor 
those of depression are very obvious. 
The urine is almost always scanty. In this, dropsies of whatever character, 
and from whatever cause, generally agree. It is not, however, always easy 
to determine exactly what constitutes scanty urine. The quantity of this 
secretion varies exceedingly in different persons, and in the same person under 
different circumstances, and within the limits of health. The average in 
twenty-four hours, in healthy individuals, may be stated at two or three pints. 
In dropsy it is often not more than a pint in the same time, and sometimes 
is much less. In some rare cases of the disease, the urine remains undimi- 
nished, and is even increased, especially in the advanced stages. These are 
generally cases of debility, in which the serous portion of the blood finds a 
ready outlet through the relaxed vessels, whether of the kidneys, or the- serous 
or cellular tissue. 
The character of the urine is variable. In different cases, it is deep-brown 
like beer, deep-red and lateritious, bloody, bilious, pale, light-yellow or red- 
dish, turbid, somewhat opalescent, limpid, and quite healthy in appearance. 
In febrile dropsy, it is generally dark-coloured and turbid, more or less albu- 
minous, and of a specific gravity less than in health. In cases dependent on 
disease of the liver, it is often very high-coloured and bilious, and is said to 
have the odour of honey. In renal cases, it is sometimes dark-brown or 
tinged with blood, generally more or less acid and albuminous, and often 
abounds with epithelium thrown off by the tubuli uriniferi of the kidneys, 
and not unfrequently contains fibrinous casts of the tubes, discoverable by the 
microscope. Since the publication of Blackalls work on dropsy, considerable 
attention has been paid to albumen as a constituent of urine; and the determi- 
nation of its presence or absence, and relative quantity, is considered impor- 
tant as an aid to diagnosis. The subject has acquired additional importance, 
from the researches of Dr. Bright and others. It will be treated of more ex- 
tensively, when we come to the consideration of renal disease as a cause of 
dropsy. It will be sufficient here to point out the modes by which the pre- 
sence of albumen may be detected. 
Tests of albumen in the urine.-One of the most convenient tests is heat. 
The urine, if turbid, should be first filtered, and, if alkaline to test paper, 
should be neutralized; as alkalies counteract the coagulating property of heat, 
and, moreover, sometimes occasion a precipitation of the earthy phosphates in 
urine when heated, though it may contain no albumen. The urine should 
also always be examined before it has had time to undergo decomposition; as 
the albumen may be changed along with the other principles, and thus no 
longer be sensible to the usual tests. When prepared for examination, the CLASS III.] 
343 
DROPSY. 
urine may be exposed in a glass tube, closed at one end, to the flame of a 
spirit-lamp, or simply heated in a silver spoon, or other convenient recipient, 
over the fire. According to the proportion of albumen present, will be the 
amount of insoluble matter produced. If it be very small, there will be a 
mere whitish cloudiness in the urine; if larger, thep will soon be a sensible 
precipitation of whitish, curdy flakes; if very largd, the whole mass of urine 
may gelatinize. The last result is rare. The proportion of the precipitate 
varies, from the smallest appreciable quantity, to a bulk which occupies nearly 
the whole of the fluid. 
Another test usually employed is nitric acid. This added to albuminous 
urine produces a flaky precipitate. But it cannot be relied upon alone, as it 
sometimes, in the absence of albumen, occasions a precipitation of uric acid, 
and sometimes of nitrate of urea, when this latter principle is in excess in the 
urine. Such precipitates, however, are redissolved upon the application of 
heat. It has before been stated that heat may cause a deposition of the earthy 
phosphates in alkaline urine. These are redissolved upon the addition of 
nitric acid. Thus it appears that these two tests separately employed are 
liable to fallacies; but conjointly, their evidence may be considered certain. 
They should both be tried in every case at all doubtful. According to Dr. 
II. Bence Jones, the presence of a little acid may prevent the coagulation of 
albumen by heat; as a compound of the acid and albumen, though insoluble 
in dilute acid, is soluble in a larger proportion of pure water, hot or cold. 
He therefore advises that, before this test is tried, the tube should be washed 
thoroughly clean. (Lancet, March 16, 1850.) Additional proof is afforded 
of the albuminous nature of the urine, if acetic acid should not precipitate the 
coagulum produced by heat and nitric acid, when dissolved in solution of 
caustic potassa. It may be proper to observe that albumen, in very minute 
proportion, is capable, when coagulated, of rendering a clear liquor turbid, 
and that its bulk after precipitation is greatly disproportionate to its weight. 
Dr. Christison never found more than 27 parts in 1000 of urine, and states 
that, in the proportion of one part in 100, it gives to the urine almost the 
appearance of a thin pulp. When in considerable proportion, it coagulates 
at 160°, but if much diluted requires the heat of boiling water. 
Perspiration is generally deficient in dropsy. The bowels are often costive, 
and sometimes very insusceptible to purgative medicine, even of the most 
powerful kind. In some cases, however, the disease is complicated with 
chronic intestinal inflammation; and then the patient is apt to be affected 
with diarrhoea. When this occurs without any amelioration of the dropsical 
symptoms, and especially in the advanced stages, or when dropsy supervenes 
during its prevalence, it is usually an unfavourable sign. 
Thirst is often a prominent symptom. It is not confined to the febrile 
form of the disease, but may attend the most feeble cases. 
The fluid effused in dropsy appears generally to consist of the serum of the 
blood, more or less altered. Though not absolutely identical under different 
circumstances, it usually possesses closely analogous properties, being, for the 
most part, limpid, colourless, or slightly yellowish, and without smell. It is 
occasionally tinged with blood, especially when the dropsy is dependent on 
obstruction of the veins. In cases of inflammation, it is sometimes milky, 
and contains flakes of coagulated matter, and may also be mixed with pus. 
Its specific gravity is variable, but always exceeds that of water. It consists 
chiefly of water, but contains various principles existing in the blood. Albu- 
men is almost always present, but in very different quantities. In sixteen 
cases examined by Andral, he found proportions varying from four tt forty- 
eight parts in 1000 of the fluid, and uniformly less than in the serum of the 344 
LOCAL DISEASES.-SECRETORY SYSTEM. 
[part it. 
blood. The proportion was greatest in those cases in which the health ap- 
peared least impaired. {Pathol. Haematol., Am. ed., 115.) Besides albumen, 
Marcet found a peculiar animal principle which he named muco extractive 
matter, and which was also in variable proportion. Urea was found in large 
proportion by Dr. Corrigan in the fluid of a case of ascites with symptoms of 
disease of the kidneys. {Dub. Joum. of Med. Sci., March, 1842.) M. Dela- 
harpe, of Lausanne, discovered fibrin, in several instances, in the fluid of 
abdominal dropsy, in such quantity that the liquid coagulated after being 
withdrawn. {Arch. Gen., Be ser., xiv. 174.) According to Marcet, the salts 
are in singularly uniform proportion, in whatever part the fluid is effused. 
They consist of chlorides of sodium and potassium, sulphate of potassa, soda 
either free or carbonated, and phosphates of lime, iron, and magnesia. 
The dropsical effusion may occupy any one of the serous cavities, or any 
portion of the cellular tissue, whether in the interior of the body, or beneath 
the skin. Gravitation, and consequently the position of the patient, have 
much effect in determining the position of the fluid, whether in the cavities, 
or the cellular tissue. In the latter, the communication between the cells 
allows it to traverse the body with little difficulty. Hence, the swelling in 
anasarca is usually first observed, and is greatest in the feet, ankles, and legs. 
Hence too, in the cellular tissue of the lungs, the effused fluid generally occu- 
pies the lower portion, in consequence of the erect position of the patient, 
most common towards the decline of life. It occasionally undergoes a spon- 
The disease is confined to no time of life. It is not unfrequent in infancy, 
is frequent in old age, and occurs at all intervening periods. It is, however, 
taneous cure. In such cases, the disappearance of the effusion is generally 
coincident with an increase of some one or more of the secretions; with the 
occurrence, for example, of a profuse diuresis, perspiration, or diarrhoea. 
Most of the disagreeable symptoms in the progress of the complaint, arise 
from the deranged functions of the various organs, consequent upon the pres- 
sure of the effused fluid. Its greatest danger is from the same source. Thus, 
respiration and the action of the heart are embarrassed from the pressure of 
liquid in the thorax; and convulsions, coma, palsy, and apoplexy occur from 
a similar cause within the cranium. CEdema of the glottis sometimes occa- 
sions the most serious consequences. The pressure of the distended fluid in 
the extremities not unfrequently occasions inflammation of the skin, termi- 
nating in gangrene, and ultimate exhaustion. More frequently, however, the 
fatal result in dropsy is owing to the organic diseases in which it originates, 
as those of the liver, kidneys, and heart. Inflammations, such as pleurisy, 
bronchitis, and gastro-enteritis, not unfrequently occur in the advanced stages, 
and carry off the patient. In some instances, the effused fluid is entirely 
absorbed towards the close, and the patient dies exhausted, when the inex- 
perienced practitioner might be indulging the hope of a favourable issue. 
Causes. 
I consider as causes of dropsy those which produce the several pathological 
conditions upon which the effusion depends. In the first place may be men- 
tioned all those capable of inducing irritation or active congestion of the se- 
creting tissue. Of these one of the most common is exposure to pold, espe- 
cially in a state of profuse perspiration. If, in this condition, the kidneys, 
from excess of excitement, or other cause, fail to perform the vicarious office 
that is thrown upon them, the irritation may be directed to the serous or 
cellular tissue, and dropsy result. In general, however, inflammation rather 
than dropsical irritation ensues; and, in order to the production of the latter, 
there must be a peculiar predisposition, consisting either in the state of the 345 
CLASS III.] 
DROPSY. 
blood, or of the capillaries, or in some other and unknown condition. Some- 
what similar in their effect to cold, are the retrocession of cutaneous eruptions, 
or of gouty and rheumatic irritations, and the suppression of accustomed dis- 
charges, whether healthy or morbid, as of the urinary and menstrual secre- 
tions, hemorrhoidal flux, &c. The condition of system which follows delivery 
is said sometimes to favour the occurrence of dropsy, probably in consequence 
of a want of due accommodation of the general excitement, incident to the 
pregnant state, to the new order of things. Pregnancy itself may sometimes 
produce dropsy, as an effect of its attendant vascular fulness and excitement, 
in cases where a predisposition to the disease exists. Certain febrile diseases, 
especially the exanthemata, often leave behind them a tendency to that sort 
of irritation of tissue which occasions dropsy. .The same is not unfrequently 
the case with protracted intermittent fever; though, in this instance, the pa- 
thological condition is probably rather an anemic state of the blood, or venous 
congestion from disease of the liver and spleen, than vascular irritation. The 
presence of tubercles in the tissues affected is another cause of dropsical irri- 
tation, and one of those least capable of being obviated. 
Secondly, in the catalogue of causes may be ranked those which operate 
by relaxing and debilitating the tissues, and impoverishing the blood. These 
are frequently coincident. Among them are insufficient or unwholesome food, 
insufficient clothing, habitual exposure to damp, cold, and impure air, im- 
paired digestion, excessive secretion, great loss of blood, the intemperate use 
of alcoholic drinks, and long continued and exhausting diseases, as irregular 
gout, scrofula, cancer, and scurvy. Dropsy is often the closing scene of such 
affections, and its occurrence may generally be regarded as a sure evidence of 
the breaking up of the constitution. The abuse of mercury is said sometimes 
to have produced dropsy; but I have not witnessed this result. It has been 
already stated that protracted intermittents may rank in this class of causes. 
Chronic disease of the spleen is very frequently associated with the anemic 
state of the blood so favourable to dropsy, and very probably contributes to it. 
From what has been said before, it will be inferred that whatever favours the 
escape of albumen by the kidneys, and diminishes that ingredient in the blood, 
may predispose to dropsy. 
Still another, and probably the most frequent set of causes, are those 
which obstruct, or in any way retard the return of the blood by the veins, 
and thus occasion venous congestion. These may act on portions of the 
venous system, or on the whole. Simple debility may, to a certain extent, 
operate in this way, by retarding the returning current of blood from de- 
pending parts. It will be apt to do so if aided by posture. Long standing 
sometimes induces dropsical effusion in the lower extremities of feeble indi- 
viduals. Pregnancy, uterine tumours, and enlarged ovaries, are thought to 
produce the same effect, by pressure on the veins. Inflammation and con- 
sequent obliteration of the veins themselves occasion serous effusion in the 
parts from which the blood is conveyed by them; and, when the great trunks 
are the seat of the affection, the dropsy may be very extensive. Organic dis- 
eases of the liver and spleen, and of the heart, act in a similar manner, and 
are among the most frequent causes of dropsy. The same result has been 
ascribed to obstruction in the lungs, impeding the flow of blood from the right 
to the left cavities of the heart. Some of the English writers consider dropsy 
as a not unfrequent result of pulmonary inflammation, whether of the bron- 
chial membrane, or the parenchyma; and there can be no doubt that the 
affections are sometimes associated. It may be a question, however, whether 
they are npt the mere effects of a common cause. One would suppose that 
dropsy must: be a frequent result of those chronic pectoral affections, in which, 346 
[part II. 
LOCAL DISEASES.-SECRETORY SYSTEM. 
either from a loss of substance or consolidation of tissue, free scope is not 
given for the passage of the blood of the pulmonary arteries. We should 
say a priori that the right side of the heart, and consequently the whole 
venous system must become congested, and dropsical effusion follow; but this 
result really happens much less frequently than might be imagined, probably 
because, in these chronic affections, the mass of blood is diminished, so as to 
correspond to the diminished capacity of the lungs. Emphysema of the lungs 
is more frequently than other pulmonary affections followed by dropsy; be- 
cause the general condition of the system is comparatively little impaired, as 
much or nearly as much blood is required as in health, and, the lungs being 
unable to transmit the whole with due rapidity, a general venous plethora 
takes place. Compression of the heart and of the great veins, by large drop- 
sical collections in the serous cavities, is thought sometimes to induce anasarca 
by impeding the return of blood from various parts of the body. 
Besides the above causes, disease of the kidneys and of the lymphatics is 
yet to be mentioned. The first is among the most common, and has recently 
attracted great attention. There will be occasion to recur to it directly. Of 
the latter, it is only necessary to say that dissection, in cases of dropsy, has 
sometimes shown the lymphatic glands, especially those about the great ves- 
sels, enlarged and indurated; and that a diseased condition or extirpation of 
the glands in the groin or axilla has been followed by oedema of the corre- 
sponding extremities; facts which tend to show that obstruction in the absorb- 
ents may be the cause of dropsy; but much more-frequently the glands are 
found diseased or have undergone extirpation, without any such result. 
Before closing the subject of the causes of dropsy, it will be convenient to 
consider certain forms of the complaint in reference to the diseases in which 
they have their origin; as the nature of the connexion, in these cases, gives 
rise to pathological peculiarities of greater or less importance in a practical 
point of view. The forms alluded to are, dropsy following fever, and those 
dependent on intestinal, hepatic, cardiac, and renal disease. 
Scarlet Fever as a Cause of Dropsy.-The form of dropsy which follows 
scarlet fever, does not seem in any degree connected with the grade of the 
previous disease. The mildest cases are probably as often succeeded by dropsy 
as the most severe, and judging from my own observation more so. It would 
seem that the poison had not been completely eliminated in these mild cases, 
and remained to exert an irritant influence upon the serous and cellular tis- 
sues, and on the kidneys, as before upon the skin. There is no regular 
period at which the dropsical symptoms make their appearance. Sometimes 
they occur almost immediately after the cessation of the fever, sometimes as 
late nearly as a month. Perhaps the most frequent period is from ten to 
twenty days after the occurrence of desquamation. It has been supposed 
that the dropsy is induced by the action of cold upon the delicate skin. This 
may be true to a certain extent, though my own observation would not have 
led me to this conclusion. The caution, however, is not amiss, to avoid ex- 
posing a patient, during or immediately after the process of desquamation, 
unnecessarily to the cold air. 
Anasarca is the most frequent form of the disease; but effusion not unfre- 
quently also takes place into the serous cavities. The complaint is usually 
inflammatory, with an accelerated pulse, furred tongue, diminished appetite, 
scanty urine, and constipation of the bowels. Occasionally it is attended with 
evidences of meningitis, or of thoracic inflammation. Headache, flushed face, 
dilated or contracted pupil, heaviness, stupor, convulsions, and palsy mark 
different stages of the first affection; pain in the chest, cough, dyspnoea, irre- 
gularity of pulse, and sometimes great oppression, indicate the second. Both CLASS III.] 
347 
DROPSY. 
are complicated with effusion before their close, and, if neglected in their 
early stages, are highly dangerous. Either the pleura, or the pericardium, or 
both may be affected. The peritoneal cavity is also frequently the seat of 
effusion. But the most constant pathological condition, and the one upon 
which the affection probably in chief depends, is active congestion or inflam- 
mation of the kidneys. Evidences of this are presented not only upon post- 
mortem examination, but also by the condition of the urine during life, which 
is scanty, highly albuminous, and often bloody, and, when inspected by the 
aid of the microscope, exhibits abundance of epithelial cells and cylindrical 
fibrinous casts of the uriniferous tubules. Indeed, in any case of convales- 
cence from scarlet fever, when the urine is albuminous and materially dimin- 
ished in quantity, dropsy may be apprehended. More will be said in a sub- 
sequent paragraph, and under the head of Bright's disease of the kidneys, of 
the influence of morbid states of this organ in producing dropsy. 
The anemic state in which the system is sometimes left after severe scar- 
latina favours the occurrence of dropsy, and occasionally this cause co-operates 
with the renal affection in the production of the disease. The dropsy fol- 
lowing scarlatina, in the great majority of cases, yields readily to judicious 
treatment. 
Miasmatic Fever as a Cause of Dropsy.-One of the most common sources 
of dropsy, in this country, is the state of system following our ordinary inter- 
mittent and remittent fevers, and especially the former. These affections 
often leave the system extremely anemic, with a condition of the blood highly 
favourable to serous transudation. The copious night-sweats which occur 
under these circumstances are familiar to every practitioner. I have often 
found the urine in the ensuing dropsies highly albuminous; though it is by 
no means invariably so. The albumen thus drained out by the two emunc- 
tories, becomes deficient in the blood, and the condition most favourable to 
dropsical effusion takes place. Any cause which represses the action of the 
kidneys and skin, may now determine the production of the disease. The 
visceral disease consequent upon these fevers is probably another source of 
the dropsy. Enlargement of the spleen is a very frequent attendant, and 
seems to be in some way connected with the impoverished condition of the 
blood, not improbably, indeed, as one of its causes. Disease of the liver ope- 
rates in a manner explained further on. The dropsy following intermittents 
and remittents is most frequently anasarcous, though sometimes general, and, 
when the liver is especially involved, abdominal. It will almost always get 
well under judicious management. 
Dysentery as a Cause of Dropsy.-Chronic ulcerative affections of the 
bowels, whether coming under the denomination of diarrhoea or dysentery, 
but especially the latter, are frequently associated with dropsy in their ad- 
vanced stages. Not unfrequently bowel complaints come on in the course of 
renal dropsy, and are sometimes extremely obstinate, and tend much to em- 
barrass the treatment. But it is not to these that allusion is here made. 
There may be no special predisposition to dropsy, and no disease which is at 
all likely to end in it. In this condition of the system, an attack of dysen- 
tery may occur, which shall run on to a chronic form, and at last give rise 
to anasarca, with or without effusion into the peritoneum. The dropsy is 
the result of the dysentery, and of that alone. It is probably by inducing an 
impoverished or watery state of the blood, through its interference with the 
digestive process, that the latter disease acts in producing the former. If, 
under these circumstances, the bowel affection can be removed, the dropsy 
will either get well spontaneously with the improvement of the blood, or will 
readily yield to remedies. 348 
[part II. 
LOCAL DISEASES.-SECRETORY SYSTEM. 
Disease of the Liver as a Cause of Dropsy.-Disease of the liver may give 
rise to dropsy in two ways. The enlarged viscus may press upon the ascend- 
ing vena cava, and diminish its caliber so as to produce venous congestion in 
all its ramifications. In this case, we should probably have anasarca and 
ascites together. The same condition of the liver may lessen the caliber of 
the vena portarum and its branches; or changes in its interior structure, with- 
out enlargement, may interfere with the capillary circulation of the same set 
of vessels. In either of these events, there will be congestion of the whole 
venous system of the abdomen, and ascites may result. When obstinate 
abdominal dropsy exists, with yellowish conjunctiva, sallowness of the skin, 
and a jaundiced urine, without any sensible enlargement of the liver, there 
may be reason to apprehend scirrhus, cirrhosis, or extensive tuberculation of 
that organ. It is more frequently found enlarged in dropsical affections of 
hepatic origin than otherwise. This does not prove that the diseases which 
augment the volume of the liver more frequently occasion dropsy than those 
which derange its interior structure without enlarging it; but only that they 
are more common. Cases of the former kind are, in general, more easily 
curable; because the hepatic affection, being most frequently chronic inflam- 
mation, itself more readily yields to remedies. Dropsy does not generally 
occur as a consequence of hepatic disease,,until the latter has been of long 
continuance. It is, therefore, very frequently attended with debility. The 
urine is scanty, high-coloured, and often bilious, but, unless when the hepatic 
disease is complicated with a morbid state of the kidneys, is not albuminous. 
Disease of the Heart as a Cause of Dropsy.-Organic disease of the heart, 
whether seated in the valves, or in the muscular tissue, very frequently re- 
sults in dropsy. The effusion is ascribed to congestion arising from irregu- 
larity in the circulation. Constriction at the valvular openings, by checking 
the current of blood, causes it to accumulate in the vessels behind; and inac- 
curate closure of the valves may cause the force of the heart's impulse to 
receive a direction contrary to nature, and thus similarly to retard the cur- 
rent. Let us take, for example, disease of the left auriculo-ventricular valve. 
If the orifice be narrowed, the onward flow of blood in the pulmonary veins 
is impeded; the resistance is propagated through the capillaries to the ramifi- 
cations of the pulmonary arteries, the right ventricle is thus overloaded and 
consequently enlarged, and the whole venous system becomes congested. If, 
on the contrary, the valve do not close accurately, the force of the ventricle 
is exerted on the pulmonary veins, and the same evil consequences are ex- 
tended through the capillaries to the pulmonary arteries, the right ventricle, 
and the veins of the body generally. An undue activity arising from hyper- 
trophy, or feebleness from dilatation, in one of the sides of the heart, must of 
course disturb the equable distribution of the blood, and congestion in one 
portion or another of the circulation must ensue. But this mechanical ex- 
planation of the agency of the heart in producing dropsy may be carried too 
far. Due weight should be given to the influence of a constantly excited cir- 
culation in developing irritation of the tissues. There can be little doubt 
that hypertrophy of the heart sometimes produces dropsy in this way. Be- 
sides, a watery condition of the blood is a very frequent accompaniment of 
dilatation and other organic derangements of the heart, whether as cause or 
effect; and very probably contributes largely to the production of dropsy in 
these cases. 
There is nothing in the character of the dropsy itself, which will serve as 
a means of diagnosis between this and other cases having a different origin. 
In every instance of dropsy not obviously traceable to a different source, the 
heart should be suspected, and its condition examined. If it should be found CLASS III.] 
349 
DROPSY. 
to have been long organically affected, the inference will be justifiable, that 
it has been mainly instrumental in the production of the disease; though it 
not unfrequently happens that other causes have co-operated, as hepatic or 
renal affections, or an anemic condition of the blood; and in some instances, 
probably, the heart is wholly innocent; for dropsy is by no means a constant 
or necessary consequence of its organic diseases. 
As might be concluded from the nature of its cause, dropsy of cardiac origin 
is usually general. Commencing with anasarca, which for the most part shows 
itself first in the lower extremities, and gradually extends over the whole body, 
it invades also the serous cavities, and sometimes even the cellular tissue of 
the lungs, giving rise to protracted and complicated suffering, from which, 
though the patient may be temporarily relieved by treatment, he is generally 
in the end rescued only by death. The disease is seldom attended with active 
inflammatory symptoms. The urine has been sometimes observed to be albu- 
minous in cases which, after death, have exhibited no signs of renal disease; 
but in general it is not coagulable. 
Disease of the Kidneys as a Cause of Dropsy.-Whatever disables the 
kidneys from secreting a due amount of urine may occasion dropsy. De- 
bility, irritation or congestion, inflammation, and disorganization of various 
character, may have this effect. The excess of liquid in the blood-vessels, 
not escaping, as usual, by these organs, seeks another outlet, and, if the per- 
spiratory function be now arrested by cold or other cause, it finds this outlet 
sometimes through the serous and cellular tissues. But diseases of the kid- 
neys of different kinds, even to the extent of complete disorganization, may, 
and frequently do exist, without giving rise to dropsy; and the particular 
circumstances which occasion the complaint to be developed in one instance, 
while in others of a similar character, so far as the kidneys are concerned, 
no such result is experienced, have not been clearly ascertained. Some ad- 
vance, however, has recently been made towards a solution of the difficulty. 
Under the name of Bright's disease, certain organic affections of the kidneys 
have, within a few years, attracted much attention, as being very frequently 
associated with, and probably the cause of dropsy. Of the nature of these 
affections, a particular account will be given hereafter. (See Bright's Disease.) 
It will here be sufficient to say that recent investigations have determined at 
least two distinct renal derangements as having been confounded under the 
title just mentioned; one a peculiar desquamative inflammation of the tubuli 
uriniferi of the kidneys, and the other a fatty degeneration of the same struc- 
ture, both of which have the effect of interfering with the proper secretory 
function of the organ, and thus diminishing the quantity, as well as of alter- 
ing the quality of the urine. One of the most prominent of the changes 
in the urine is the abnormal presence of albumen. So characteristic has 
this symptom been supposed to be, that, when it has been observed in dropsy, 
some have been inclined to believe that it afforded sufficient evidence of a 
renal origin of that affection. Observation, however, has shown that albu- 
minous urine is not invariably present in Bright's disease, that when it occurs, 
it is not invariably attended with dropsy, and that it is frequently met with 
in dropsy and other affections independently of any known disease of the kid- 
neys. Indeed, cases are on record of death from dropsy with albuminous urine, 
in which no disease of the kidneys could be detected by post-mortem exami- 
nation. The action of mercury on the system is said to be sometimes attended 
with coagulable urine. I have repeatedly seen it in anasarca, consequent upon 
intermittent fever, in which there was no reason to suspect the kidneys. It 
is said sometimes to occur under the influence of blisters from cantharides. 
It will, of course, be found whenever blood exists in the urine, whether de- 
1 ' a J 350 
[part II. 
LOCAL DISEASES.-SECRETORY SYSTEM. 
rived from the kidneys, or any part of the urinary passages. It occasionally 
occurs in pregnancy; and, finally, it has been asserted that albuminous urine 
has been observed in health. The association, therefore, between Bright's 
disease of the kidneys, albuminous urine, and dropsy is not essential. Never- 
theless, it is so frequent that there must be some bond of connexion between 
them, some relationship of cause and effect, which it is desirable to be able to 
understand. It has been supposed that the dropsy might be the cause, and 
the renal derangement an effect. But this cannot well be; as the latter often 
precedes for a considerable time the dropsical effusion. It has been said that 
the dropsy is consequent merely upon the diminished flow of urine; and this 
may have some effect in producing it; but it cannot be the sole cause; for, in 
the advanced stages of the kidney disease, the quantity of urine sometimes 
exceeds the healthy average. The probability is that, in consequence of sus- 
pended function and obstruction in the uriniferous tubules, produced in a 
manner which will be explained under Bright's disease, the return of blood 
from the Malpighian bodies is impeded, congestion of these bodies is induced, 
and the serous portion of the blood escapes, if not the blood itself, in conse- 
quence of this congestion. Hence the albuminous and often bloody urine. 
The blood being thus deprived of a considerable proportion of its albumen 
becomes more watery and tenuous, and escapes more readily through the ex- 
halant pores of the serous and cellular tissues. Another higlily probable cause 
of the dropsy is the retention in the blood of the urea and other substances, 
which the kidneys now cease to eliminate in due proportion, and which pro- 
bably stimulate the secretory function of the different dropsical tissues. 
It is important to be able to form a correct diagnosis between dropsies 
depending on this affection of the kidneys, and those proceeding from other 
causes. This can generally be done by exercising an accurate scrutiny into 
all the circumstances of the case. The dropsy is almost always anasarcous 
in the beginning; and, throughout, though one or more of the serous cavities 
may become involved, there is generally a predominance of the cellular effu- 
sion. The complaint is very seldom indeed confined exclusively to the chest 
or abdomen. The absence of any other known source of the disease would 
tend to fix suspicion upon the kidneys. If the heart, lungs, and liver were 
sound; if intermittent or remittent fever had not immediately preceded the 
affection; if it had not occurred suddenly from exposure to cold, the checking 
of some wonted secretion, or the retrocession of a cutaneous eruption; if, finally, 
it could not be traced directly to debilitating causes, such as the loss of blood, 
the scorbutic diathesis, or the long prevalence of exhausting diseases; there 
might be strong reason for referring the origin of the complaint to the kidneys. 
This would be greatly strengthened by the previous occurrence of accidents, 
which might be supposed to affect the kidneys, such as blows upon the back, 
or by the previous existence of symptoms, which might be immediately re- 
ferred to these organs, as dull or acute pain in the lumbar region. If conse- 
quent on scarlet fever, the complaint may generally be referred to the kidneys, 
as at least one of its sources. 
But the evidence afforded by the urine is most to be relied on. This is 
scanty in the beginning, and is always diminished when acute symptoms 
supervene upon those of the chronic form of the complaint. In the advanced 
stage, as before stated, it is sometimes natural in quantity or even in excess; 
and, if this condition of urine exist without the use of diuretics, and at the 
same time the dropsical symptoms increase or remain undiminished, the pre- 
sumption is strong, though by no means positive, that the kidneys are affected. 
The urine varies in relation to colour, the presence or absence of turbidness, 
the disposition to deposit a sediment or otherwise, as in other forms of dropsy; CLASS III.] 
DROPSY. 
351 
and sometimes it is not unhealthy, in either of these respects. One striking 
character, however, not so frequently observed in other cases, is the presence 
of blood, which sometimes merely tinges the urine, sometimes exhibits itself 
in the shape of a dark reddish-brown or blackish deposit. This bloody state 
of the urine is especially common in the earlier stages, and acute forms of 
the complaint. A disposition to froth readily, and the unusual permanence 
of the froth when produced, resulting from the presence of albumen, have 
also been observed. 
From what has been before said, it will be inferred that the mere fact of the 
coagulability of the urine by heat or nitric acid is not in itself sufficient proof 
of the renal origin of the dropsy. Taken in connexion, however, with the 
foregoing circumstances, it would go far to establish the fact; and, if the albu- 
minous impregnation persist for a long time, or show itself in large quantity, 
the evidence may be considered as almost conclusive. But the most decisive 
proof is that afforded by the microscope, which, by the detection of epithelial 
cells of the uriniferous tubes and fibrinous casts of the same, gives indisputable 
evidence of desquamative inflammation of the kidneys, or, by showing the 
existence of cells containing oil, indicates fatty degeneration of those bodies. 
Much importance has also been attached to the specific gravity of the urine 
as a diagnostic character. This is almost invariably diminished in Bright's 
disease. The sp. gr. of healthy urine, according to M. Solon, is from 1.020 
to 1.024. In the complaint in question, it is gradually reduced as the disease 
advances, being at first little different from health, and sinking, in the last 
stages, as low as 1.008, and sometimes even much lower. Solon, in one 
instance, observed it as low as 1.003, but states the mean at 1.013. But, in 
drawing inferences from the specific gravity, reference must be had to the 
amount secreted; for the elimination of water by the kidneys may be increased 
without a corresponding increase of solid matter. The larger the quantity of 
the urine, the less will be its specific gravity. When, therefore, the quantity 
and specific gravity sink together, the evidence is strong of a morbid state of 
the kidneys. The reduction of the specific gravity has no direct relation to 
the presence of albumen. On the contrary, the albumen is in general most 
abundant early in the disease, diminishes with its progress, and is sometimes 
entirely and permanently wanting before its close. It also not unfrequently 
disappears for a time, and fatal cases have occurred in which it has never 
been observed. In such instances, the specific gravity assists much in the 
diagnosis. If, for example, the urine in dropsy contain no albumen, or but 
little, and have at the same time a low specific gravity, the presumption 
would be in favour of the existence of the kidney affection. If, having been 
coagulable, it should cease to be so, and, instead of reacquiring the healthy 
density, should remain light, or become lighter, the quantity not being in- 
creased, there would be evidence that the disease of the kidneys, so far from 
having yielded, was persisting, and probably advancing. 
A necessary inference from the diminished specific gravity of the urine, 
even when albumen is present, is that the other solid constituents are below 
the average in health. This has been ascertained by experiment to be actually 
the case. The quantity of urea and of saline matter, which constitute the 
chief solid constituents of healthy urine, has been found to be greatly re- 
duced ; according to Dr. Christison to one-fifth, and sometimes even as low as 
one-twelfth; the urea and saline matters being diminished in about the same 
proportion. The average quantity of urea in healthy urine is stated at three 
or four per cent., of saline matter at two or three per cent. It has been 
observed that, when the urea diminishes in the urine, it may sometimes be 
detected in the blood, where no trace of it can be found in health; so that 352 
[part II. 
LOCAL DISEASES.-SECRETORY SYSTEM. 
the result is not owing to a conversion of this principle into albumen; but 
simply to the fact, that it is not separated by the kidneys from the circulating 
fluid, and is thus allowed to accumulate in the latter. Under the same cir- 
cumstances, it has been found in the dropsical fluid of the serous cavities. 
The blood, while it thus gains urea, loses a portion of its albumen and red 
corpuscles; and not unfrequently a strongly anemic condition is at length 
established. Hence, in part, a sallow or dingy paleness of complexion, which 
is often a striking feature of this variety of dropsy. 
There is nothing very peculiar in the character of the dropsical symptoms, 
or in their progress. When the disease of the kidneys is acute, the anasarca 
usually appears at an early period; and, even in its more chronic forms, the 
commencement of the effusion, or its increase, is apt to be coincident with the 
supervention of inflammation or febrile excitement. This form of dropsy is 
peculiarly liable to be complicated with symptoms of cerebral derangement, 
such as headache, drowsiness, stupor, delirium, paralysis, apoplexy, and con- 
vulsions. They come on usually towards the close of the complaint, and are 
among the most frequent modes of its fatal issue. It has been observed that 
a marked diminution, or even total suspension of the secretion of urine, gene- 
rally precedes their appearance. They are sometimes owing to dropsical effu- 
sion within the encephalon, as proved by their occasional coincidence with 
the increase of the general dropsy, and by the discovery after death of serum 
in the ventricles, and in the tissue of the pia mater. But, in some instances, 
no such effusion is detected; and the cerebral affection must be ascribed to the 
altered state of the blood, consequent upon the diminished secretion of urine. 
Another frequent complication of renal dropsy is internal inflammation, most 
commonly of the serous membranes, and especially of the pleura. This very 
much increases the danger of the complaint, and is probably often the imme- 
diate cause of death. Organic disease of the heart is also frequently asso- 
ciated with the affection of the kidneys; whether as cause or effect, or as the 
result of some common cause, has not been determined. The same is the 
case, though less frequently, with organic disease of the liver. Indeed, it is 
very rarely that the alteration of the kidneys is found, upon dissection, uncom- 
plicated with other morbid structural changes. 
For information upon various other points connected with this renal affec- 
tion, the reader is referred to the disease of the kidneys. I have aimed at 
considering it here only in its connexion with dropsy. No age is exempt 
from this variety of dropsy, though it is most common in adults. Men are 
more subject to it than women. In its early stages it is often curable; but 
it may always be regarded as a formidable disease; and, when the structural 
derangement of the kidneys has become considerable, though the dropsical 
symptoms may disappear, a restoration to health can scarcely be expected. 
Numerous cases are on record of the spontaneous cure of dropsy; and M. 
Mondi^re, as well from observation, as from the result of his researches into 
the medical annals, has come to the conclusion, that such a termination of the 
disease is not very rare. (Arch. Gen., 3e s6r., xiv. 461.) Sometimes the 
cure is very sudden, being effected in the course of a few days, and even a 
few hours. In general it appears to be the result of a great increase in one 
of the normal secretions ; as, for example, of urine, of perspiration, or of the 
intestinal fluids. Instances are cited, in which profuse vomiting of serous 
fluid has speedily cured protracted cases; and the crisis by diarrhoea is not 
uncommon. M. Mondi^re relates a number of cases in which the critical 
discharge was from sources which would be considered less probable; as from 
Prognosis. CLASS III.] 
DROPSY. 
353 
the salivary glands, the nasal or vaginal mucous membrane, and even from 
accidental secretory surfaces. Dr. Watson relates a case, in which hydrotho- 
rax was greatly relieved by the copious expectoration of a limpid fluid. The 
tendency to exhalation, instead of taking an external direction, is sometimes 
thrown upon another internal part, and a sort of metastasis of the dropsy takes 
place. Thus, the swelling may suddenly leave the extremities, and symptoms 
of compressed brain or lungs come on, in consequence of effusion into the 
ventricles or into the pleural cavities. In some instances, the dropsy has 
been known to disappear without any increased evacuation whatever. 
Dropsy very often also yields readily to remedies. Within my own expe- 
rience, it has very generally proved curable when not dependent on tubercu- 
lous inflammation of the tissues affected, or upon organic disease of the viscera, 
as the heart, liver, and kidneys. Even in these cases, the dropsical symptoms 
will often disappear under appropriate treatment, and if, at the same time, 
the organic affection be cured, will not return. Thus, permanent cures are 
not unfrequently effected of ascites dependent on chronic inflammation and 
engorgement of the liver; and the same is true of renal dropsy, in the earlier 
stage of the affection of the kidneys. Occasionally, even when the original 
disease remains, and marches steadily onwards towards a fatal issue, the dropsy, 
after having been removed by treatment, does not again makes its appearance. 
But much more frequently, under such circumstances, it returns, and consti- 
tutes one of the greatest sources of distress to the patient towards the close 
of his life. Sometimes it may be removed, and will return several times, 
before it finally gets the mastery; and, where the physician cannot cure, he 
can often do very much to relieve. The great difficulty which he encounters 
is, that finally the strength of the patient gives way, and he is then precluded, 
even though he may call in the aid of supporting treatment, from the use of 
those evacuating remedies upon which he has previously relied. 
In a disease so various in its origin and character, no one plan of treatment 
will be generally applicable. The remedies must necessarily be adapted to 
the particular circumstances of each case. Nevertheless, there are certain 
indications which should always be kept in view. These are, 1. to correct, 
as far as practicable, the particular pathological condition upon which the 
effusion may immediately depend; 2. to remove by absorption, or otherwise, 
the effused fluid; 3. to remedy any disease, whether cardiac, hepatic, or renal, 
which may act as the remote cause of the dropsy; and 4. to support the 
strength of the system, when this may be necessary, under the exhausting 
influence of the disease, or of the medicines employed. The same remedy will 
often answer more than one of these objects; and, where two or more reme- 
dies are required, they may very generally be given conjointly; so that, in 
detailing the treatment, the several indications cannot be exactly followed, 
without ceaseless repetition. They will, however, be borne in mind in the 
succeeding observations, as they always should be in practice. 
When there is reason to believe that the effusion is the result of an inflam- 
matory or highly irritated condition of the exhaling tissue, and the general 
symptoms are those of active febrile excitement, or, even in the absence of 
fever, should the pulse be full and strong, blood-letting may sometimes be 
employed with much benefit. It not only diminishes the secretory irritation, 
and thus checks the effusion, but disposes to the absorption of the effused 
fluid, according to the well-established principle, that the fulness of the blood- 
vessels and the activity of absorption are in an inverse ratio to each other. 
The amount taken must be regulated entirely by the condition of system. If 
Treatment. 354 
[PART II. 
LOCAL DISEASES.-SECRETORY SYSTEM. 
the patient is vigorous, and the pulse full and tense, from twelve to eighteen 
ounces may be taken at first, and the operation repeated once, or oftener, 
under similar circumstances. This remedy is sometimes adequate alone to 
the cure of dropsy. But the cases are few which require or will support 
copious depletion; and much more frequently the remedy is not only not 
called for, but strongly contraindicated. The plan of promoting absorption, 
in all cases, whether in a vigorous or debilitated state of system, by the fre- 
quent repetition of small bleedings, while, in cases of debility, the general 
strength is supported by rich food and strong stimulants, is, I think, highly 
objectionable; for, though it may relieve the patient for a time, it will be apt 
to leave him still more disposed to the disease than at first, with the additional 
disadvantage of a susceptibility more or less worn out by needless stimulation. 
It is well known that frequent losses of blood have been the cause of dropsy, 
by inducing anaemia. It is only, therefore, in cases presenting a decided ele- 
vation in the grade of general action, and an unimpaired state of the general 
forces, that bleeding is admissible. A buffy state of the blood, under these 
circumstances, will favour the repetition of the remedy, as marking the exist- 
ence of inflammation. In cases of the same general character as those above 
alluded to, with little or no increased activity of the circulation, it would be 
safer, as a general rule, to trust to the refrigerant diuretics and hydragogue 
cathartics without bleeding; this being employed only when clearly indicated. 
When the disorder of the serous tissue assumes the grade of inflammation, it 
will generally be proper, in addition to the depletory measures mentioned, to 
apply cups or leeches to the vicinity of the affected part. Of these two reme- 
dies, cups are usually preferable as most effective. They may be applied to 
the chest or abdomen when these cavities are diseased; and will sometimes be 
found useful to the temples or back of the neck, when stupor or other evi- 
dence of determination to the brain is exhibited. Blisters are also useful 
under similar circumstances. Should the inflammatory action refuse to yield 
to these means, recourse may be had to calomel and opium, pushed to a 
moderate affection of the gums. 
When, instead of irritation of the secreting tissues, we have relaxation or 
debility, with an impoverished condition of the blood, perhaps a scarcely less 
frequent pathological condition than the former, a wholly different treatment 
is required. The indication now is to improve the condition of the blood, 
and give tone and increased contraction to the tissues. For this purpose, the 
preparations of iron, and those of Peruvian bark, are, upon the whole, the 
most efficient remedies. Five grains of the pill of carbonate of iron, of the 
U. S. Pharmacopoeia, conjoined with sulphate of quinia, may be given three 
or four times a day; and it will often be found convenient to unite in the same 
mass any diuretic or alterative medicines which the case may require, such 
as squill, digitalis, calomel, or the mercurial pill. The preparations of iron 
may be varied to meet the circumstances of the case. The tincture of chloride 
of iron, and the solution of the iodide would seem to be peculiarly appro- 
priate ; as they add diuretic to their tonic and astringent properties. Nor 
need the practitioner confine himself to the tonics mentioned. Almost any 
other of the class may be used, if any particular circumstance in the case 
should seem to call for it. The pure bitters are much used. Among the 
remedies occasionally employed is the decoction of pipsissewa, which is, at the 
same time, mildly tonic, astringent, and diuretic, and is admirably adapted to 
mild cases of this kind, requiring a gentle impression very long continued. 
Iceland moss has also been commended. To fulfil the same end of improving 
the condition of the blood, a diet of the most nutritious and digestible animal 
food, should be recommended, and porter or ale may be given for drink. CLASS III.] 
355 
DROPSY. 
The pathological condition which consists in passive venous congestion, may 
be complicated with one or the other of the above conditions, or may present 
no symptom of either, and, so far a? the system is concerned, must be treated 
accordingly. When there is no evidence of excitement, and none of debility 
or anaemia, we may leave the general state of health out of the question, 
and address our remedies to the removal of the cause of congestion, and the 
promotion of absorption. In every case, we should endeavour to ascertain 
whether any obstruction to the circulation exists in any portion of the veins, 
and, if discovered, to remove it. 
Conjointly with attention to the general condition of the system, whereby 
we may check the disposition to excessive exhalation, we should endeavour to 
fulfil the second indication, that, namely, of removing the effused liquid. This 
is done most effectually by promoting the secretions. We thus diminish the 
amount of circulating fluid, and proportionably favour absorption. At the 
same time, the tendency to exhalation is incidentally diminished; and, if in- 
flammatory excitement of the tissues exist, it is relieved by the depletion 
effected, and by a revulsive direction of excitement from the seat of disease 
to that of the stimulated function. 
Diuretics.-The symptoms strongly invite attention to the secretory function 
of the kidneys, as the one which especially demands stimulation. The urine 
is almost always scanty; and the progress of the effusion not unfrequently 
bears a close and direct relation to its diminution. To increase the action of 
the kidneys would, therefore, seem to afford a probable chance of relieving 
the disease; and experience has abundantly confirmed the deduction. No 
remedies, upon the whole, prove more effective in the cure of dropsy than diu- 
retics. When they can be brought to act freely, the disease is almost always 
moderated, if not removed. Of the diuretics, I have, within my own expe- 
rience, found bi-tartrate of potassa, or cream of tartar, most successful. When 
no organic visceral disease or tuberculous deposition has been at the root of 
the malady, and when the strength of the patient has been sufficient to hold 
out under the continued use of the remedy, I have generally been able to cure 
dropsy by this diuretic, with or without adjuvants, according to the apparent 
requisitions of the case. But, in order to produce the greatest effect, it must 
be given properly, and in sufficient quantity. Attention is frequently not 
paid to the comparative insolubility of the cream of tartar, and the patient 
takes only the liquid which may have been directed as the vehicle, leaving 
most of the medicine at the bottom of the vessel. Many practitioners con- 
tent themselves with directing half an ounce or an ounce to be taken at one 
dose, every day or every other day. The medicine thus given, acts as a purge, 
and, being removed from the bowels, is not absorbed, and consequently does 
not reach or affect the kidneys. A better plan is to direct a certain quantity 
of the salt to be added to a pint of water or other vehicle in a bottle, and the 
whole to be taken, in wineglassful doses, at certain intervals, in the course of 
twenty-four hours; the caution being always strictly observed to shake the 
bottle thoroughly before pouring out the dose, and then to swallow this 
quickly before the salt has had time to subside. The quantity must vary 
with the case, and if, upon trial, that first employed should make no impres- 
sion, it should be gradually increased until it operates actively upon the kid- 
neys. Half an ounce in the course of the day will, in some rare instances, 
be sufficient; but much more frequently it will be necessary to increase to an 
ounce, an ounce and a half, or even two ounces, in the same period of time. 
If the patient should be much purged, it may be proper to administer a little 
laudanum occasionally, so as to check the alvine discharges, and give the 
remedy a direction to the kidneys. Should dyspeptic symptoms be induced, 356 
[PART II. 
LOCAL DISEASES.-SECRETORY SYSTEM. 
they may often be counteracted by employing as a vehicle for the salt, instead 
of water, an infusion of juniper berries, or wild carrot seed, which are at 
once gently stimulant and diuretic; and some aromatic, as cardamom, fennel, 
or ginger, may be added if circumstances seem to require it. When, however, 
such additions are made, the infusion should be separately prepared and 
strained before being used as a vehicle; as, if the salt and its adjuvant be 
mingled together in infusion, the whole of the former cannot be taken with- 
out swallowing the solid residue of the latter, and it is, therefore, left in the 
vessel. Should the dyspeptic symptoms continue notwithstanding these 
means, the cream of tartar should be omitted for a time, and afterwards re- 
sumed if deemed advisable. I have given these somewhat minute directions 
from an experience of their usefulness, and the disadvantages which often ac- 
crue from their neglect. It has been stated above that, in all cases of dropsy 
not dependent on visceral disease or tubercles, nor complicated with too great 
debility, a cure might be hoped for from this remedy. I believe it to be pe- 
culiarly adapted to cases in which the pathological condition is inflammatory 
irritation of the exhaling tissue. But, even in the exceptional varieties of 
dropsy above mentioned, the cream of tartar, though it may not effect a per- 
manent cure, will often produce great relief, and not unfrequently cause the 
complete disappearance, for a time, of the dropsical effusion. The only cases 
in which it is positively contraindicated are those of great debility. If the 
strength of the patient, no matter what may be the form of the disease, should 
be observed to give way under the continued use of the salt; and if the addi- 
tional employment of sulphate of quinia, with a nutritious diet and malt 
liquors, or a little wine, should fail to counteract its debilitating effects, it 
must be omitted altogether. 
Various other saline diuretics are employed with more or less success. 
Among them nitrate of potassa probably ranks next in efficacy to the bitart- 
rate. Like that salt, it is especially indicated in inflammatory or febrile 
dropsy; but, being even more sedative in its general influence, and more apt 
to induce gastric irritation, it is applicable to a less extensive range of cases, 
and should not be used when there are evidences of debility, or any suspicion 
of inflammation of the stomach. It is generally employed as an adjuvant to 
other more efficient remedies, though in some instances of itself sufficient to 
cure the disease. Little good, however, can be expected from it unless freely 
given. Until recently, fears have been entertained of its poisonous operation 
in large quantities. It has, however, been ascertained that, if sufficiently 
diluted with water, it may be administered safely in doses much beyond those 
formerly thought proper. As a remedy in dropsy, not less than two drachms 
should be given in twenty-four hours. This quantity should be dissolved in 
at least a pint of water, or of some mucilaginous or diuretic infusion, and 
given in doses of from ten to twenty grains at suitable intervals. 
Acetate of potassa was formerly thought so efficient in its action on the 
kidneys as to have received the name of sal diureticus, or diuretic salt. It 
is comparatively little used at present. The same may be said of soluble 
tartar and Rochelle salt, both of which have had some repute in the cure of 
dropsy. They are not without effect, but have given way to the more diu- 
retic salts above mentioned. Carbonate and bicarbonate of potassa are still 
occasionally used, and sometimes with benefit. They are peculiarly advan- 
tageous in cases attended with excess of acid in the primm vise, or in the 
urine; and will generally correct the lateritious sediment in that secretion, 
denoting the presence of the urates. Though less effective as antacids than 
the corresponding salts of soda, they are better adapted to dropsy by their 
greater diuretic power. They may be advantageously associated with bitter CLASS III.] 
DROPSY. 
357 
tonics, such as quassia or columbo, when these are indicated. Such com- 
binations have repeatedly proved adequate to the cure of dropsy. The bicar- 
bonate is preferable to the carbonate in consequence of its milder taste. 
Squill is an active diuretic, much employed in this disease. It is in fact 
among the remedies in which the profession have the highest confidence. Be- 
ing somewhat stimulating, it should not be given in febrile and inflammatory 
cases; and it usually fails when the urine is strongly coagulable. It is more- 
over unsuited, in consequence of its nauseating and emetic properties, to cases 
of irritable or inflamed stomach. Under all other circumstances, it may be 
employed with the hope of benefit. It is considered by Blackall as peculiarly 
useful in dropsy of the chest, with scanty, high-coloured, and uncoagulable 
urine, which deposits a sediment on standing. In the dose of two grains, 
two or three times a day, in which it is commonly recommended, it will often 
entirely fail of effect. This may be a suitable dose to begin with, but it 
should be quickly increased, either in quantity or frequency of repetition, until 
it produces decided nausea. As this effect is desirable merely as a test of the 
activity of the medicine, the dose should be somewhat reduced after it has been 
attained, and subsequently kept just within the nauseating point. I have 
often found it necessary to give two grains every two hours, before any de- 
cided effect could be obtained. If it purge, it should be combined with a 
little opium. Calomel is often most advantageously associated with squill, 
in cases which demand at once diuresis and the mercurial influence. 
Digitalis is another most valuable remedy in dropsy. Though it occasionally 
fails in materially increasing the flow of urine, yet in many cases it operates 
with great power, producing and sustaining a copious diuresis, and completely 
eradicating the complaint. A knowledge of the circumstances favourable to 
its action would be very desirable; and various attempts have been made to 
indicate the cases to which it is peculiarly adapted. Dr. Withering, to whom 
the profession is mainly indebted for its introduction into regular practice, 
was of the opinion that it was better adapted to patients of feeble constitution, 
with a pale complexion, lax fibre, and edematous limbs pitting easily on 
pressure, than to the vigorous and florid, with a strong pulse and firmness of 
limb. It has also been stated to prove peculiarly efficacious in the dropsy of 
intemperate individuals. Dr. Blackall found it most successful in cases at- 
tended with coagulable urine, especially when the secretion was scanty, high- 
coloured, bloody, or disposed upon cooling to deposit a branny or lateritious 
sediment. He considered it an almost certain remedy in the anasarca fol- 
lowing scarlatina, when the urine is albuminous, and no fatal disorganization 
of parts exists. The same author thought caution necessary in its use, in 
cases attended with pale and copious urine, even though coagulable. This 
condition of the urine indicates frequently an advanced stage of organic dis- 
ease of the kidneys, in which few remedies can be of service, and the system, 
already greatly debilitated, might easily be prostrated below the point of re- 
action. Dr. Blackall states that, when it operates favourably, the urine be- 
comes gradually less coagulable; and that, even when it removes the swelling, 
unless it occasions this change in the urine, it produces no permanent good. 
My own experience has been to a considerable extent confirmatory of the ob- 
servations of Dr. Blackall. I have met with much more success from the 
remedy in cases attended with albuminous urine than in others. Two in- 
stances of general dropsy of this kind are prominent in my recollection, in 
which, after a long continuance of the disease, and the fruitless employment 
of a great variety of means, complete success followed the use of digitalis. Its 
beneficial influence, however, is by no means confined to such cases. In 
dropsy depending on disease of the heart, it often affords great relief; and it 358 
LOCAL DISEASES.-SECRETORY SYSTEM. 
[part II. 
may be resorted to in any case in which the system is not too far worn out 
by organic disease, or the vital actions too feeble from other causes to resist 
so potent a sedative. Any tendency which digitalis may have to purge should 
be counteracted by opium, which is also a useful adjuvant, in some instances, 
by obviating the sedative effects of the remedy, without interfering with its 
diuretic action. The best mode of administering it is in substance or infu- 
sion. A tablespoonful of the officinal infusion, in which a drachm of the 
leaves is employed to nine fluidounces of menstruum, though it is the dose 
usually directed, much exceeds in amount a grain of the powder, which is the 
usual dose in the latter form. It would be best to begin with only one-half 
the quantity, repeated twice or thrice daily, and to increase it gradually until 
some symptoms of its action are observed. The dose may in this way be 
augmented to ten or fifteen grains, or its equivalent. In whatever form or 
dose digitalis is employed, its effects should be closely watched, and the ap- 
pearance of a decided impression of any kind should be the signal for a sus- 
pension of the remedy, or a diminution of the dose. Great increase of the 
urinary secretion, reduction in the frequency and force of the pulse or inter- 
missions in its beat, nausea and vomiting, purging, faintness, giddiness, and 
a tensive pain of the head, sometimes over one eye, as noticed by Blackall, 
are among the signs of the action of the medicine which should not be over- 
looked. The tendency which digitalis has to accumulate, and, after having 
been given for some time without apparent effect, to break forth suddenly 
from its quiescence into violent action, must also be borne in mind. The 
dropsical patient to whom this remedy is administered should, as a general 
rule, be visited by his medical attendant every day. Powdered digitalis has 
also been employed externally. MM. Brera and Chrestien, of Montpelier, 
have succeeded, by friction with the powder upon various parts of the body, 
in bringing on copious and salutary diuresis. (Diet, de Med., xvi. 34.) 
Tobacco has properties closely resembling those of digitalis, and like it oc- 
casionally proves powerfully diuretic. It was employed by Dr. Fowler with 
considerable success in dropsy; and Dr. Darwall speaks of it as " particularly 
useful in dropsy connected with enlargement of the liver and spleen, but little 
to be relied upon when the principal disease is situated in the chest." He 
also states " that he has never seen any evil effects resulting from its use." 
(Cyc. of Pract. Med., Article Dropsy.) It was given by Fowler in the form 
of an infusion, made by pouring a pint of boiling water on an ounce of the 
leaves, macerating for an hour, straining off fourteen ounces, and adding two 
ounces of alcohol. The dose was at first thirty drops three times a day, to be 
gradually increased until diuresis was produced, or the effects of the medicine 
upon the stomach or head were felt. 
Numerous other diuretics of greater or less power are occasionally employed, 
either as remedies in chief or as adjuvants. The spirit of nitric ether may be 
usefully added to other remedies when there is not too great inflammatory 
excitement, and especially when the disease is complicated with nervous de- 
rangement. The infusion of juniper berries is much used as a vehicle and 
adjuvant, and will sometimes, unaided, remove moderate dropsical effusion; 
such, for example, as is apt to come on towards the close of chronic pectoral 
affections. The compound spirit of juniper is a good addition to diuretic 
mixtures or drinks, in cases of debility. Infusion of buchu has been strongly 
recommended in connexion with the alkaline bicarbonates. (Braithwaite's 
Retrospect, Am. ed., xvii. 33.) Infusion of wild-carrot, parsley-root, and the 
different species of erigeron or flea-bane, are occasionally administered with 
benefit, though never solely relied on. Dandelion in decoction or extract is 
peculiarly adapted to cases of dropsy, connected with chronic disease of the CLASS III.] 
DROPSY. 
359 
liver. Pipsissewa, in the same way, proves useful where a gentle tonic and 
astringent are indicated in conjunction with a diuretic. Various liquid pre- 
parations of colchicum were formerly used, and, though nearly abandoned in 
dropsy, might prove serviceable in those instances, not very uncommon, in 
which the disease is associated with gout or rheumatism. Various stimulating 
substances, with diuretic properties, may be employed in chronic cases, and 
others attended with great debility. Such are horseradish, mustard, onions, 
garlic, buchu, copaiba, oil of turpentine, and cantharides.* The two last- 
mentioned substances have been recommended in great insensibility or paraly- 
sis of the kidneys, with a more or less complete suppression of urine. Sul- 
phate of copper was formerly employed in cases of debility ; but is little used 
at present. Besides those mentioned, a long list of substances might be 
enumerated, which have enjoyed more or less credit as diuretics in dropsy; 
but, having been mostly laid aside after experience of their inefficacy, they 
scarcely merit notice. It is, however, desirable to have at command, in a dis- 
ease so frequently obstinate and protracted, numerous and diversified reme- 
dies, though of very unequal power. The caprices of the stomach, the pre- 
judices and anxieties of the patient, and the frequent failure of even the most 
efficient remedies, render changes necessary; and, without a long catalogue, 
we should be compelled to stop for want of sufficient material. Besides, 
diuretics are notoriously uncertain, so that upon failure with one, it is neces- 
sary to resort to another; and not unfrequently a persevering trial of the 
means at command is at length repaid by success, when the physician has 
almost ceased to hope for it. Much may also be effected by the combination 
of these remedies. Advantage has sometimes accrued from two or more 
diuretics mixed together, which had before severally failed. Numerous 
formulae of this kind have been proposed by different authors, which it would 
be useless to repeat; as each practitioner acquainted with the list of remedies, 
and their several qualities, can just as efficiently arrange them for himself. 
The combination of diuretics with tonics is highly advantageous in cases of 
debility. Thus, squill and the saline diuretics may be given in connexion 
with the infusion, tincture, or extract of the simple bitters, as gentian or 
quassia, with the preparations of cinchona, or with the salts of iron. Chaly- 
beates are of great advantage in anemic cases, particularly those following 
miasmatic fevers; and sulphate of manganese is said to have proved effectual 
under similar circumstances. Nux vomica has also been recommended as an 
adjuvant to the diuretics in atonic dropsy. 
Cathartics.-Scarcely less efficient than diuretics are the medicines belong- 
ing to the class of cathartics. They operate upon the same principles, of pro- 
moting absorption by diminishing the amount of fluid in the blood-vessels, 
and of calling off irritation from the morbidly secreting surfaces to the seat of 
their own action. In the latter respect they are even more efficient than the 
diuretics. But they debilitate much more by an equal amount of depletion, 
and are, therefore, not so well adapted to cases of an asthenic character. 
There is very frequently, moreover, a degree of stomachic or intestinal irri- 
tation in dropsy, which renders their steady employment hazardous; and, in 
gouty cases, they might prove injurious by inviting the disease from some 
safe exterior position to the alimentary canal. With a due regard to these 
considerations they may be employed safely, and often with great effect. Dis- 
* The following formula for a stimulating diuretic infusion was much employed by 
the late Dr. Parrish, and I have used it myself with advantage in long-standing dropsy 
with debility. Take of juniper berries, mustard seeds, ginger root, each, bruised, ; 
horseradish, parsley-root, each, bruised, §ij ; hard cider, Oiv; a wineglassful to be 
taken four times a day, and gradually increased. 360 
[part II. 
LOCAL DISEASES.-SECRETORY SYSTEM. 
crimination is necessary in their selection. Those should obviously be pre- 
ferred which produce copious serous exhalation from the bowels, in other 
words, the hydragogue cathartics; and even among these there is much room 
for choice. In febrile and inflammatory cases, the saline cathartics should be 
employed in consequence of their refrigerant properties. The best of these, 
for the purpose, are perhaps the bitartrate and tartrate of potassa, and the 
tartrate of potassa and soda. These should be given, not in small and re- 
peated doses, as when administered with a view to diuretic effect, but in large 
purgative doses, at distant intervals. When not of themselves sufficiently 
powerful, they should be combined with some one of the hydragogue vegeta- 
ble cathartics, such as senna, or jalap. A mixture of jalap and cream of tar- 
tar has long enjoyed high credit in the treatment of dropsy. In chronic 
cases, when the bowels are torpid, and the whole system exhibits rather a 
want of due susceptibility to impressions than actual debility or prostration, 
recourse may be had to the drastic hydragogues. Scammony, black helle- 
bore, buckthorn (rhamnus catharticus), gamboge, croton oil, and elaterium, 
are those which enjoy the highest reputation. Of these, gamboge and elate- 
rium are probably the most efficient. Dropsy not unfrequently yields to the 
judicious employment of these remedies alone. Gamboge, being apt to irri- 
tate the stomach, should generally be given in small doses, say from half a 
grain to two grains, repeated at intervals of one, two, or three hours, till it 
operates. Advantage will also accrue from combining each dose with a drachm 
or two of cream of tartar. The effects of elaterium are sometimes surpris- 
ingly prompt and powerful. I have known great distension of the abdomen 
to yield to two doses of this medicine. In consequence of its violence it must 
be administered with caution; and, if symptoms of gastro-intestinal inflam- 
mation should occur under its use, it should be at once suspended. 
There is a set of emeto-cathartic medicines, possessing diuretic properties, 
which have been occasionally used in dropsy with good effect. Such are the 
broom (scoparius), hedge hyssop (gratiola officinalis), the inner bark of different 
species of sambucus or elder, the juice of the root of black elder, cahinca, and 
the root of our indigenous apocynum cannabinum. In relation to the dose 
and proper mode of administration of these, and of the other medicines above 
named, the reader is referred to the Dispensatories. 
The frequency of repetition of the cathartic must be regulated by the 
strength and susceptibility of the patient. When the constitution is vigorous, 
and the bowels not peculiarly sensitive, it may be given every day. In few 
cases can much permanent good be expected from it, if repeated less fre- 
quently than twice or three times a week. The purgative, as in the case of 
the diuretic, may be combined with the bitter tonics or chalybeates, when 
these medicines are indicated; and, if the patient should be very feeble, ad- 
vantage might accrue from the use of the purgative tinctures, as those of 
senna, jalap, and black hellebore, in connexion with other preparations. 
Diaphoretics.-In some instances, diuretics will not act, and purgatives are 
contraindicated, or have been tried without effect. Here diaphoretics may 
be resorted to, and will occasionally produce cures; though, upon the whole, 
they must be admitted to be much less efficient than medicines of the two 
preceding classes. The best diaphoretic in dropsy is probably the officinal 
powder of ipecacuanha and opium. It is asserteu. that dropsy has been cured 
by large doses of opium alone; but its efficacy is much increased in this com- 
bination. To do good, it must be used freely, and the patient kept for a con- 
siderable time under its influence, so as to sustain a copious and continued 
perspiration. In febrile cases, with a strong pulse, preference should be 
given to the antimonials and refrigerating diaphoretics, as citrate of potassa CLASS III.] 
361 
DROPSY. 
and acetate of ammonia, with which the spirit of nitric ether may sometimes 
be combined. During the course of the treatment, the patient should be 
kept in bed. The effect of the diaphoretic may be much increased by exter- 
nal means. When the skin is hot and the circulation active, the warm bath 
should be used. But in other instances, the vapour bath, or dry hot-air bath, 
might be found more effective. I have known one almost desperate case of 
general dropsy to yield to an energetic use of Dover's powder and the hot 
bath, after failure with diuretics. The excessive sweating induced by tempo- 
rary confinement in an apartment heated considerably above the temperature 
of the body, would probably prove highly serviceable in some cases of dropsy. 
Even friction to the surface is said to have effected cures. 
Emetics.-When the strength of the patient is sufficient to bear the ex- 
hausting effect of repeated emetics, it is probable that they might be advan- 
tageously used, as they are well known powerfully to promote absorption. 
The antimonial emetics were recommended by Sydenham in this disease. 
At present, however, neither these nor other medicines of the same class are 
much used in the treatment of dropsy. 
Mercury.-This is occasionally very efficient. Its power of increasing se- 
cretion and absorption would appear to render it applicable to dropsy in 
general; while its antiphlogistic action would render it especially useful in 
the advanced stages of those cases which have originated in inflammation, 
whether of the serous and cellular tissues, or of some important organ, as the 
liver or the heart. Hence, it is often most happily combined with other 
remedies, whether diuretic, diaphoretic, or purgative, increasing the powers of 
these remedies, at the same time that it exerts an independent influence of its 
own. The medicines with which it is most frequently associated in dropsy 
are squill and digitalis. Calomel, the blue pill, or corrosive sublimate may 
be employed, according to the circumstances of the case. A combination of 
squill and calomel is considered as one of the most efficacious remedies in 
dropsy, especially when associated with chronic visceral inflammation. It has 
been customary to administer pills composed of two grains of squill and one 
of calomel three times a day. This quantity of squill, as the medicine is 
commonly found in our shops, is too small. The dose should be repeated 
every two or three hours unless it nauseate too much. That of the calomel 
is probably rather too large. Considering the excessive susceptibility of some 
dropsical cases to the influence of mercury, it would in general be better to 
commence with a smaller dose, and increase as the occasion may require. 
Perhaps the worst instance of salivation which I have personally witnessed, 
and in which the patient barely escaped with life, arose from six grains of 
calomel given in doses of a grain each as above recommended, in a case of 
general dropsy. It is said that the system is peculiarly susceptible to this 
influence in the renal variety of dropsy, and mercury is consequently dreaded 
by some physicians in that affection. But cures of the dropsy sometimes fol- 
low these excesses of the remedy, which would probably, therefore, prove use- 
ful by a more moderate action; and strict caution would sufficiently guard 
against inconvenient results. Mercury is decidedly contraindicated in cases 
of pure anaemia or great debility, and in those in which the dropsy depends 
upon some incurable organic affection, as scirrhus and tubercles of the liver, 
or a tuberculous condition of the dropsical tissue. 
Mechanical Means.-When the measures above detailed prove inadequate 
to the removal of the effused liquid, and the distension becomes painfully 
inconvenient, recourse may be had to mechanical means of relief, such as 
punctures with a sharp lancet, acupuncture, and tapping. Great relief is 
obtained by these means, and occasionally they seem to prepare the way for 362 
[part II. 
LOCAL DISEASES.-SECRETORY SYSTEM. 
the efficient action of remedies which had failed before, probably by removing 
that compression which may have cramped absorption. It has occurred to 
me repeatedly to see the kidneys brought in this way into efficient action, 
and the health of the patient restored when almost despaired of. These 
measures, however, require to be used with caution. The particular circum- 
stances which justify or forbid their use will be most conveniently detailed 
under the different forms of dropsy considered in relation to their position. 
Remarks upon the subject of blisters as depletory agents in dropsy will be 
best postponed to the same occasion. 
It remains to treat of the measures of relief peculiarly adapted to those 
cases of dropsy which depend on certain organic affections. 
In the cardiac dropsies attention must be paid to the disease of the heart, 
which, if incurable, must be palliated by appropriate remedies. It is espe- 
cially important, in all cases, that the patient should use no active exercise. 
When the dropsy is associated with chronic inflammation of the organ, great 
relief, if not a cure, may be hoped for from local depletion and blisters, and 
a moderate mercurial impression sustained for a considerable time, in connex- 
ion with suitable remedies for the removal of the effusion. In the choice of 
these remedies, reference must be had, as in other cases of dropsy, to the state 
of the system; and similar auxiliary means must be employed to reduce 
excessive, and support deficient action. It is indispensable that any anemic 
condition of the circulation should be corrected, as this has a powerful effect 
in increasing the cardiac disease. Of the diuretics, digitalis is peculiarly 
applicable in consequence of its double action on the heart and the kidneys; 
and, combined with squill and calomel, or the blue mass, in cases calling for 
the mercurial influence, is sometimes productive of the best effects. The pre- 
parations of colchicum are also peculiarly adapted to cardiac dropsies, from 
their control over the rheumatic or gouty irritation in which the affection of 
the heart has not unfrequently originated, and by the continuance or recur- 
rence of which it is aggravated or sustained. Though effectual cures of dropsy 
originating in this cause can seldom be expected, much may be done for tem- 
porary effect; and, by a judicious employment of remedies, and regulation of 
the patient's habits, not only may his comfort be greatly promoted, but his 
life frequently much prolonged. 
Whatever is peculiar in the treatment of hepatic dropsy will be more con- 
veniently considered under ascites, which is the form of dropsy most fre- 
quently originating in disease of the liver. 
Renal dropsy, connected with active congestion or inflammation of the 
kidneys, sometimes requires, in its earlier stages, the application of cups to 
the small of the back, which may be repeated if the state of the circulation 
permit. Care, however, must be taken not to push depletion too far, in con- 
sequence of the strong disposition to anaemia which characterizes the affection 
in its more advanced periods. Some advantage may also be hoped for from 
counter-irritation to the loins by means of solution of ammonia, tartar-emetic, 
or issues. Blisters, though recommended by some, are of doubtful propriety, 
from their tendency to produce strangury. Purgatives are peculiarly adapted 
to this variety of dropsy; the indication being to divert excitement from the 
congested or inflamed kidneys. Upon the same principle diaphoretic measures 
promise favourably. Theory would certainly suggest these two means of 
evacuation, at least in the earlier stage of the disease, as preferable to diu- 
retics, the stimulant action of which is directed especially to the kidneys, and 
which might, therefore, endanger an increase of the very affection supposed 
to lie at the root of the whole disorder. But our knowledge on this subject 
is yet too indefinite to justify the rejection, upon the ground of theoretical CLASS III.] 
DROPSY. 
363 
inference, of any measure that may have experience in its favour; and cer- 
tainly there is strong weight of testimony in support of the usefulness of at 
least two diuretics in this variety of dropsy; viz., cream of tartar and digi- 
talis. I have, indeed, found them the most effectual remedies, as regards the 
dropsy, and productive of no observable injury to the kidneys. They may, 
therefore, be resorted to at any stage of the complaint, unless that of greatest 
debility. The same cannot be said of the more stimulating diuretics, which 
should be employed only under circumstances decidedly calling for their sup- 
porting influence. Perhaps, on the whole, the best plan would be first to try 
cathartics and diaphoretics, connected with direct depletion, in an obviously 
inflammatory condition of system, and, failing with these, to have recourse to 
the two diuretics alluded to, with others of a similar character. Mercury 
must be looked upon as of doubtful propriety. It is asserted of itself occa- 
sionally to give rise to coagulable urine, and is believed to have a direct influ- 
ence in impoverishing the blood; effects which, as they are in some degree 
characteristic of renal dropsy, would seem to exclude their cause from the 
list of its remedies. Nevertheless, instances have occurred in which salivation 
was followed by permanent benefit; and, if the affection of the kidney be 
regarded as inflammatory in its character, the powerful antiphlogistic agency 
of this remedy would seem to be indicated. If employed, it should be so with 
much caution, in consequence of the peculiar susceptibility of patients in this 
disease to be violently affected by it; and its use should not be extended into 
the latter stages. It should never be used in the cases of renal dropsy de- 
pendent upon fatty degeneration of the kidneys. In these cases, along with 
the diuretics referred to, recourse must be had to means calculated to improve 
the blood, and invigorate the system. (See Bright's Disease.') 
Diet and Drink.-1The free use of drinks was formerly denied to dropsical 
patients, under the impression that they served to supply additional stimulus 
to secretion, and at the same time additional material for the function. This 
theoretical ground of exclusion still continues, with the superadded reason, 
afforded by recent investigations, that fulness of the blood-vessels is the 
greatest impediment to absorption. Nevertheless, experience has decided 
against these hypothetical deductions; and nature, by the frequently urgent 
thirst which attends dropsy, and the extreme distress if it be denied gratifica- 
tion, throws the weight of her indications into the same scale. Practitioners 
now generally leave their patients to their own discretion in relation to the 
quantity of drink. A good rule is that the liquids should be taken cold, and 
in small quantities frequently repeated, rather than in large draughts at once. 
Thirst is thus as effectually relieved, while the stomach and blood-vessels are 
not so much overloaded. The choice of the drink must depend upon circum- 
stances. Cold diuretic infusions sometimes satisfy the patient, and are better 
than cold water alone. In cases not inflammatory, old cider sometimes answers 
well; and, when spirituous liquors are indicated on account of previous habits 
or debility, gin should be preferred. The infusion of horseradish, mustard, 
juniper, &c., in hard cider, as given in page 359, is sometimes useful. No 
general rule can be given in relation to diet. The practitioner will, in this 
respect, be guided by the particular circumstances of each case, enjoining an 
antiphlogistic regimen in inflammatory cases, nutritious food in the anemic 
and debilitated, an easily digestible diet in those complicated with enfeebled 
digestion, and in all avoiding unnecessary interference with the habits and 
preferences of the patient. 364 
[part II. 
LOCAL DISEASES.-SECRETORY SYSTEM. 
Article IL 
ANASARCA. 
This term, derived from the Greek ava, through, and <rap§, flesh, signifies 
dropsy of the exterior cellular or areolar tissue. It is not usually extended 
to effusions into the cellular tissue of the interior organs considered separately, 
as, for instance, into the parenchyma of the lungs, or the submucous struc- 
ture. Nor is it customary to apply it to dropsical effusions of the exterior 
cellular tissue when of very small extent and quite local; these being desig- 
nated by the term oedema. 
The first symptom of anasarca is usually a swelling of the feet and ankles, 
appearing towards evening, and diminishing, if not quite disappearing, before 
morning. It is distinguished from other swellings by pitting under pressure, 
that is, by retaining for a considerable time the indentations made by a com- 
pressing body. This tumefaction of the lower extremities does not imply that 
the effusion of fluid has been confined to these parts. The cells of the areolar 
tissue communicate, so that fluid passes readily from one part of the body to 
another. In anasarca, the effusion generally takes place in various portions 
of the body, sometimes probably throughout the whole exterior structure. 
During the day the fluid gravitates into the feet, which are the lowest part, 
and at night is again diffused over the frame in consequence of its horizontal 
position. Sometimes, however, the effusion actually takes place first in the 
feet and legs; as in cases of debility, in which the want of energy in the cir- 
culation allows the blood to accumulate in the veins of the extremities, and 
thus to induce a condition favourable to the transudation of serum. In some 
instances, the tumefaction is first observed in the face, particularly about the 
eyes. This is apt to happen in febrile dropsy, in which the liquid is more 
quickly effused, and does not appear to travel so rapidly, and in certain con- 
ditions of diseased heart, in which the greatest stress of the circulation is upon 
the upper part of the body. Another condition in which the effusion is 
likely to appear originally in the face, neck, or upper extremities, is that of 
obstruction in the veins which reconvey the blood from these parts, as in the 
descending vena cava. Cases of this kind have occurred, in which the dropsy 
was confined to one arm. In certain rare instances of extremely rapid effusion, 
the dropsical swelling has shown itself simultaneously over the whole body. 
The swelling of the feet and ankles, in most instances, gradually increases, 
extends up the legs and thighs, encroaches upon the abdominal and thoracic 
parietes, and at last reaches the head and upper extremities, so that the whole 
body becomes bloated, and sometimes to an enormous extent. The parts in 
which the cellular texture is loose suffer tumefaction in the greatest degree. 
Hence, the backs of the hands and tops of the feet, the eyelids and neigh- 
bouring parts, the scrotum and cellular tissue of the penis in males, and the 
labia pudendi in females, become greatly distended. The swelling of the 
privates is often so great as to occasion much inconvenience, and in the male 
even to interfere with micturition. The lower extremities are often enor- 
mously increased in bulk, and the skin stretched, tense, and shining. Some- 
times the cuticle rises in the form of blisters, or the skin itself gives way; an 
erysipelatous inflammation invades the integuments; the cellular tissue 
sloughs; and sores are formed, which become the outlets of great quantities 
of serous fluid, and thus afford much relief to the patient. Instances have 
occurred, in which permanent cures have been effected in this way; but more 
frequently, though the patient may obtain some ease to his oppression, the CLASS III.] 
ANASARCA. 
365 
conjoined exhaustion and irritation are more than his enfeebled system can 
support, and the case terminates fatally. 
Most frequently the anasarca when extensive is attended with effusion into 
the serous cavities, which greatly increases the danger, and often proves the 
immediate caUse .of death. In some instances, however, the disease runs its 
course without such complication. Sometimes the anasarcous swelling sud- 
denly disappears, and, by a sort of metastasis, is succeeded by effusion into 
the ventricles of the brain, or into the thoracic or abdominal cavity. 
This form of dropsy is liable to all the diversities of character which have 
been described under the head of dropsy in general. It may be acute or 
chronic, sthenic or asthenic, febrile and inflammatory, or anemic. When it 
is of a febrile character, and dependent on irritation of the secreting tis- 
sue, the swelling is more firm and elastic, and the impressions made by the 
finger are sooner effaced than in other forms of the disease. In some in- 
stances, the excitement of the tissue amounts to inflammation, and disagree- 
able sensations are experienced in the affected part, with tenderness on pres- 
sure. The febrile forms of anasarca are occasionally, moreover, attended 
with inflammation of some interior structure, especially of the serous mem- 
branes, and of the kidneys. In cases of the disease dependent on general 
debility, or a watery state of the blood, or upon organic affections of the 
heart, the tumefaction is usually soft, and pits easily under the fingers. 
Anasarca is usually attended with much loss of flesh, and, in those por- 
tions of the body not occupied by the effused fluid, the emaciation is some- 
times extreme. This condition is very striking in old cases, in which a sud- 
den absorption of the dropsical fluid takes place. 
The diagnosis of the affection is scarcely ever doubtful. Sometimes there 
may be difficulty for a time in deciding whether an edematous state of the 
feet and legs is merely local, and dependent on inflammation of the cellular 
tissue from gout, rheumatism, or other cause, or whether it is properly drop- 
sical. But, in the latter case, the progress of the disease will in general 
soon settle the question. General emphysema might possibly be confounded 
with dropsy; but the crackling under the fingers in the former affection will 
sufficiently distinguish it. 
After death from anasarca, the cellular tissue is found greatly distended. 
That beneath the skin is usually most so, but the effusion is observed also in 
the deeper structure, and even in the substance of the muscles and of organs, 
which are softened, pale, and disposed to speedy putrefaction. Sometimes 
the serum is observed to have accumulated in the tissue subjacent to the 
mucous membranes, which are elevated, and assume a somewhat jelly-like 
appearance. Indeed, one of the causes of death in dropsy is the serous 
effusion beneath the mucous lining of the air-passages. 
In relation to the causes and general treatment, there is nothing so pecu- 
liar as to require particular notice. The reader is, therefore, referred to the 
subject of dropsy in general. A few observations, however, in relation to 
the local treatment of the disease will be in place here. Bandages to the 
limbs have been recommended. In most cases they can be of no service. 
But, when the affection is confined to the feet and legs, either originally, or 
towards the close of a more extensive affection, a well-regulated pressure may 
prove useful by promoting absorption. In some instances, too, of very great 
distension, it is possible that some good may be effected by careful bandaging, 
in obviating inflammation, ulceration, and sloughing, 
Blisters to the extremities have sometimes been employed to promote the 
discharge of the effused serum, and they may undoubtedly afford relief in 
this way. But their advantages are far overbalanced by the danger of ob- 366 
LOCAL DISEASES.-SECRETORY SYSTEM. 
[PART II. 
stinate ulceration, erysipelatous inflammation, and gangrene from their use; 
and they have now been universally abandoned. I have seen one striking 
case, in which an enormous ulcer on each leg followed the application of 
blisters; and, though the dropsical symptoms entirely disappeared, the patient 
died under the combined irritation and exhaustion produced by them. Still 
less admissible are the actual cautery, and the seton, which are said to have 
been formerly recommended. 
Small punctures may often be made with advantage in cases of great dis- 
tension. The quantity of liquid which escapes even from a few of these 
minute wounds is sometimes astonishing, and the relief to the patient inde- 
scribable. But they are not without hazard. Even in robust patients they 
are often attended with more or less inflammation, and sometimes end in ob- 
stinate sores, though fatal effects very rarely ensue; but in the feeble, in 
whom the powers of life are already nearly exhausted, they not unfrequently 
seem to hasten the close. The inflammation extends rapidly over the limb, 
sinks into the cellular tissue, and occasionally gives rise to extensive gan- 
grene, preceded by severe pain. I have repeatedly known patients to die 
from the effects of these punctures, after having been greatly relieved for a 
time by the discharge of the effused fluid. They should, therefore, always 
be practised with caution, and never in the very feeble, unless the symptoms 
of oppression should be so excessive as to threaten immediate death. Under 
these circumstances, they may, perhaps, be considered as the less of two evils. 
In young or middle-aged patients, with considerable vigour of constitution, 
they may be resorted to whenever the distension becomes very distressing, 
and has resisted the usual diuretic and purgative remedies. The punctures 
should be made with a very sharp lancet, and not deeper than merely through 
the skin. They should never be numerous, and frequently three or four in a 
limb will be sufficient at one time. They are most effectual for the discharge 
of the fluid when made on the top of the foot, or in the leg above the ankle; 
but are thought to be safest in the thighs. When the scrotum and penis, or 
labia pudendi, are very much swollen, they may often be punctured in the 
same way with much advantage. It is said that slight incisions, half an inch 
or an inch in length, merely through the cuticle, answer a good purpose, and 
are less liable to be followed by mischievous consequences. Acupuncture has 
been of late recommended as less hazardous than incision, though this also is 
not without its danger. The punctures should be made with a sharp, highly 
polished, and fine needle, should never be so deep as to penetrate a fascia, and 
should not be nearer to each other than an inch and a half or two inches. 
Incision would probably be preferable to puncture by very coarse or three- 
sided needles, which have been advised, as there would be less contusion, and 
probably less danger of inflammation. 
When the extremities become inflamed in dropsy, whether spontaneously 
or in consequence of wounds, the patient should lie in bed with the limb 
somewhat elevated; lead-water or flaxseed mucilage should be applied to the 
inflamed surface; or the parts should be enveloped in an emollient poultice, 
to which, in case of gangrene and sloughing, a solution of creasote may be 
added with advantage. 
Article III. 
DROPSY OF THE BRAIN, or HYDROCEPHALUS 
The term hydrocephalus is, in this work, considered as embracing only those 
cases of serous effusion within the#cranium which are independent of in- CLASS III.] 
HYDROCEPHALUS. 
367 
flammation. The affection usually denominated acute hydrocephalus is nothing 
more nor less than meningitis, either simple or tuberculous, and owes little 
or nothing of its symptoms or result to the effused liquid, which may or may 
not exist in any particular case. It has been questioned whether there is 
such an affection as proper acute hydrocephalus, in the sense in which the 
word is here used. The affection is undoubtedly rare; but there seems to be 
no rational ground for denying its existence; as cases have been reported in 
which death has occurred after a brief illness, with symptoms of cerebral dis- 
ease; and serous fluid in abnormal quantity has been found within the cranium, 
without any other appreciable lesion. Yet there are no signs by which such 
an affection, occurring after a complete formation of the cranium, could be 
distinguished with certainty from apoplexy, or meningitis affecting the base 
of the brain; and it is unnecessary, in a practical point of view, to give it a 
distinct consideration. The following observations, therefore, apply only to 
cases in which the disease is slowly developed. 
The effused liquid in hydrocephalus may occupy the ventricles, the cavity 
of the arachnoid, the tissue of the pia mater, or the substance of the brain, 
which is infiltrated with it. In the last two situations, however, the quantity 
of the liquid is always small; and its influence in producing the symptoms so 
doubtful that it may be left out of view. By some pathologists the situation 
is indicated by the name; the disease being denominated hydrocephalus in- 
terims when the effusion is seated in the ventricles, and hydrocephalus exter- 
nus when in the cavity of the arachnoid. 
The disease may be congenital or acquired. The congenital cases are almost 
always connected with organic defect in the encephalon, such as a partial or 
entire want of brain; and, ending fatally either during labour, or within a 
short period after birth, scarcely merit the notice of the practitioner. It is 
only the acquired disease with which we are concerned. 
This occurs chiefly in the young, especially in infants before the closure of 
the fontanels; but may happen at any period of life. Yet, in relation to cases 
in which the cranium is incapable of expansion, there must always be some 
doubt; as the only certain criterion of the presence of water is the increased 
size of the head. Various organic diseases of the brain, of a chronic charac- 
ter, are capable of producing symptoms closely analogous to those of hydroce- 
phalus; and any diagnosis that may be formed in such cases must be more or 
less conjectural. All that can be said with propriety is, that, when a case exhibits 
the ordinary hydrocephalic signs, with the single exception of the expanded 
cranium, after the complete union of the bones of the head, there may very 
probably be dropsy of the brain. 
Symptoms, Course, &c.-The most obvious phenomenon in hydrocephalic 
patients is the enlarged, or gradually enlarging head. The expansion takes 
place usually in all parts of the bony case of the brain, except the base; but 
it is generally most conspicuous in the frontal, parietal, and occipital regions; 
the top of the head being comparatively little affected. As the face is in 
general not larger than usual in health, the forehead and sides of the cranium 
are made to project very much, and give to the child a peculiar aspect. In 
some instances, it is said that the face undergoes a corresponding developement, 
and the whole head appears gigantic. The enlargement is sometimes irregular, 
affecting especially the forehead, or the parietal region, and much greater on 
one side than the other, so as to occasion great deformity. The fontanels ex- 
pand very much, the sutures not unfrequently open, and the bones of the 
cranium seem in some extreme cases to be almost floating upon a surface of 
liquid. Fluctuation can be perceived between them; and the interosseous 
spaces are either at the level of the surface, or project somewhat above it. In 368 
LOCAL DISEASES.-SECRETORY SYSTEM. 
[part II. 
some cases in which the collection of water is very great, the head appears 
somewhat translucent, if placed between the eye and the light. 
After a length of time, which is exceedingly variable, if the patient survive, 
the interosseous spaces are gradually converted into bone, and the cranium 
becomes entire; but it is no uncommon event for the fontanels to remain 
open in hydrocephalic patients for many years. After the complete ossifica- 
tion of the cranium, the head ceases to expand; and, unless there should also 
be a cessation of the gradual increase of the effusion, severe symptoms soon 
make their appearance. While the bones yield readily to the accumulating 
liquid, and no great pressure is exerted upon the brain, it not unfrequently 
happens that the general symptoms are not striking. When the disease 
attacks children whose fontanels have closed, the expanding force is some- 
times sufficient to reopen them, and this event has happened as late as the 
eighth or ninth year. 
The size which the cranium is capable of attaining in this complaint is 
enormous. Thus, the circumference of the head in a child two years old, 
under the notice of Willan, was twenty-nine inches; and in another of four- 
teen months, seen by Barthez and Billiet, nearly twenty-three inches. In 
general, however, the size is much less, and it varies by every gradation from 
the least visible expansion to the largest dimensions mentioned. 
The first signs of the evil effects of the accumulated fluid are not easily 
defined. They consist usually in some deficiency or irregularity of nervous 
action. Certain symptoms are to be ascribed, in part at least, to the increased 
weight of the head. The child walks with a somewhat tottering or uncertain 
gait; and not unfrequently falls. He either holds his head stiffly and watch- 
fully erect, so as to prevent its falling on either side, or supports it by his 
hand, or upon some object in his vicinity. In bed, he usually lies upon his 
back. The limbs are frequently affected with tremors. There is occasion- 
ally pain in the head or limbs, which appears to be paroxysmal, and, when 
most violent, causes the child to scream. The expression of face is usually 
sad, sombre, or stupid. The acuteness of the special senses is diminished. 
Dimness of vision occurs, which in some instances increases to blindness, 
while in others the patient can see to the last. The skin becomes more or 
less insensible ; and the smell and taste are sometimes affected. Hearing is 
usually the last of the special senses to fail. The intellect is seldom mate- 
rially deranged in the earlier stages; though the memory is obviously en- 
feebled, and not unfrequently a certain dulness or hebetude of mind is obvious. 
The digestive function often remains long unimpaired. Indeed, the appetite 
is sometimes keen, and, unless some other disease complicates the case, the 
patient may even increase in flesh. But more frequently he emaciates, not- 
withstanding that he may take more than the usual* quantity of food. The 
bowels are costive throughout, and the urine scanty. A disposition to copious 
secretion of tears and of saliva has been noticed. At length symptoms of 
more profound cerebral lesion appear; such as occasional vomiting, contrac- 
tion of the flexors of the limbs, muscular rigidity, strabismus, grinding of 
the teeth, epileptic convulsions, partial palsy, and mental imbecility, with a 
disposition to drowsiness or stupor. These symptoms are soon followed by 
complete loss of consciousness, abolition of the senses, especially of vision, in- 
voluntary discharges from the bladder and bowels, a small, feeble, irregular, 
and frequent pulse, stertorous respiration, and death. 
The duration of the disease is uncertain. Most of those affected die in in- 
fancy. Some live on for many years, and now and then one to adult age, 
and, it is said, even to old age. 
Anatomical Characters.-The quantity of liquid found in the ventricles CLASS III.] 
HYDROCEPHALUS. 
369 
varies greatly. It may be only a few ounces, or it may be pounds. Dr. 
Bright has reported a case in which seven or eight pints were taken from the 
head of a man who had been affected with the disease from infancy, and died 
when near thirty. The ventricles are often expanded into one great cavity. 
The consistence of the brain may be natural, though in some instances hard- 
ened, and in others softened to a greater or less depth from the surface of the 
ventricles. The brain is sometimes spread out, in the form of a layer, per- 
haps not more than half an inch or an inch in thickness, upon the inner sur- 
face of the cranium; the shape of the hemispheres being lost, and the convo- 
lutions obliterated. 
Instead of the ventricles, the arachnoid sometimes contains the liquid, in 
which case, instead of being unfolded into a sort of bag, the brain is appa- 
rently compressed into the bottom of the cranial cavity, with the liquid above 
it. In this case, the form of the brain is preserved, and the convolutions are 
not effaced. The head is thought not to be susceptible of so great an enlarge- 
ment as when the effusion has taken place in the ventricles. 
In other instances, the cavity of the ventricles and that of the arachnoid 
are thrown into one by the opening of the commissures of the brain, of which 
the central portions now present upward, and the hemispheres appear as if 
folded back. 
It might be supposed that, compressed as the brain is by the liquid, it 
would be diminished in weight. But this does not seem to be the case in 
the varieties just described, at least not to any considerable extent. 
The liquid is usually perfectly colourless and limpid; but sometimes, espe- 
cially in the cavity of the arachnoid, it appears like a bloody serum, and is 
partially coagulable. It generally contains a minute proportion of albumen, 
sometimes a little ozmazoine, and various saline substances, such as chloride 
of sodium, phosphate of soda, &c., also in very small proportion. 
The bones of the cranium are sometimes as thin as paper, and very fragile, 
sometimes of a thickness not disproportionate to the size of the head, and in 
other instances much thickened, even to the extent of nine or ten lines. In 
the last case, they are usually spongy as in rachitis, and, when otherwise, 
owe their developement, perhaps, to the deposition of bony matter upon the 
inner surface, to supply the deficiency resulting from the partial absorption 
of the effused liquid. 
Causes.-It is possible that the same condition of the blood and of the ex- 
treme vessels, which induces dropsy in the cellular tissue and the serous cavi- 
ties, may operate in the brain so as to occasion hydrocephalus, especially when, 
from a want of union between the bones of the cranium, little resistance is 
offered to the accumulation. But, in the greater number of cases, the effusion 
appears to be owing to tumours in the substance of the brain or cerebellum, 
and especially to tubercles, which press upon the veins, and thus induce effu- 
sion, exactly as tumours in the abdomen give rise to ascites. It is stated that 
tumours are not apt to produce this effect until they have attained considera- 
able size, and they are more apt to produce it when seated in the cerebellum, 
or near the base of the brain, than elsewhere. 
Diagnosis.-There would seem to be little difficulty in distinguishing cases 
of hydrocephalus, when attended at once by enlargement of the head, and the 
general symptoms indicative of cerebral lesion. It is necessary, however, for 
the practitioner to be on his guard, not to mistake for this disease cases 
of naturally large heads, and those in which the cranium is thickened and 
spongy, as sometimes happens in rachitis. Hypertrophy of the brain, occur- 
ring at the same period of life, may be attended with increased dimensions of 
the cranium, and with signs of cerebral lesion; but, in this affection, there is 370 
[PART II. 
LOCAL DISEASES.-SECRETORY SYSTEM. 
perhaps less of evident cerebral disease in its progress, until the acuter symp- 
toms come on which terminate fatally, and there is also less tendency to pro- 
duce local derangements, as in a particular limb or muscle; but it must be 
confessed that the diagnosis is obscure. This affection, however, is compara- 
tively very rare. 
Prognosis -The prognosis is generally unfavourable. When dependent 
on mere functional derangement, this form of dropsy may end in recovery as 
well as any other form ; but most frequently it is connected with irremovable 
causes, and necessarily ends in death. When consequent upon scarlatina or 
other febrile disease, it may be considered as probably independent of organic 
lesion, and its cure may be hoped for. When associated with an obvious 
tuberculous diathesis, it may be considered as almost desperate. But, gene- 
rally speaking, it is impossible to determine its precise origin; and a guarded 
prognosis should always be given. 
Treatment.-This consists essentially in the production of the mercurial 
impression, and the use of diuretics and cathartics. In addition, when the 
child is scrofulous or anemic, the chalybeates, preparations of iodine, decoc- 
tion of pipsissewa, and cod-liver oil may be used. Revulsion to the scalp by 
means of blisters, croton oil, oil of turpentine, or other irritant substances, 
has also been recommended. Care must be taken, in the use of the remedies, 
not to exhaust the strength of the patient. For producing the mercurial 
impression, small doses of calomel or the blue pili may be given internally; 
and mercurial ointment rubbed upon the inner surface of the limbs, and on 
the scalp. Of the diuretics, squill, spirit of nitric ether, bitartrate of potassa, 
and perhaps digitalis may be used, though the last always with caution. 
Cream of tartar, combined, when the patient is somewhat vigorous, with 
jalap, would be the best cathartic. Of the preparations of iodine, iodide of 
potassium is usually preferred. 
The following is the plan employed by Golis, for which he claims great 
success. The head is to be kept constantly covered with a woollen cap, and 
every night one or two scruples of mercurial ointment mixed with an ointment 
made from juniper-berries, are to be rubbed upon the scalp. Calomel is to be 
given in doses of one-quarter or one-half of a grain, twice a day; care being 
taken that too much purging is not produced. For young infants, the best 
diet is the mother's milk, or that of a healthy nurse; for older children, meats, 
eggs, and coffee made from roasted acorns. Fat substances, and all alcoholic 
liquids are to be excluded. In pleasant weather, the child should be as much 
as possible in the open air. In winter, the temperature of the chamber should 
be about 68° or 70° F., and the child should lie on a mattrass, and be care- 
fully guarded against currents of air. Golis asserts that this plan, duly per- 
severed in, has produced complete and lasting cures in many instances. Should 
no improvement be perceived at the end of two months, he advises the use of 
diuretics, such as acetate of potassa and squill, in connexion with the former 
medicines, and the insertion of an issue in the neck or arm, which is to be 
kept discharging for several months. Should inflammatory symptoms super- 
vene, the antiphlogistic treatment is to be employed. After the commence- 
ment of recovery, advantage sometimes accrues from small doses of quinia. 
Dr. Watson relates the following mode of cure as having been effectual in 
two cases. It was employed at the suggestion of Dr. Gower, and succeeded 
after the blue pill, diuretics, purgatives, &c., had been used without effect. 
Ten grains of metallic mercury were rubbed with conserve of roses; five 
grains of fresh squill were added; and the whole made into pills with pow- 
dered liquorice root. This quantity was taken three times a day, for nearly 
three weeks. It acted powerfully as a diuretic, without salivation, but with CLASS III.] 
371 
HYDROTHORAX. 
great reduction of strength and flesh, and gradual relief to the symptoms. It 
was continued for two weeks longer, at first twice, and afterwards once daily; 
at the end of which time the cure was complete. The strength was restored 
by the use of iron, and the cure was permanent. 
Compression and tapping of the head have been frequently employed in 
cases of chronic hydrocephalus, and sometimes with asserted success. Mr. 
Barnard's method of compression, which has proved successful in several 
instances, is to apply strips of adhesive plaster, about three-quarters of an 
inch wide, completely round the head, from before backward; then to carry 
cross strips from one side of the head to the other over the crown, and lastly, 
one long strip from the root of the nose over the vertex to the nape of the 
neck. This plan is applicable only to cases in which the bones are loose, and 
the general powers feeble, as shown by paleness of the surface, flabbiness of 
the muscles, &c. ( Watson's Lectures.} Should the symptoms be aggravated 
by the pressure, it should be relaxed, or abandoned. 
The operation of tapping has been employed by many, and with variable 
success. In some instances, temporary relief has been obtained; in others, 
the operation has appeared to aggravate the symptoms and hasten death; and 
in others again, though comparatively few, a complete cure has been effected. 
The operation should never be resorted to until all other measures have 
failed, and the case is considered desperate. The opening should be made 
by a small trochar, introduced perpendicularly, " at the edge of the anterior 
fontanel, so as to be as much as possible out of the way of the longitudinal 
sinus, and the great veins emptying therein. The instant that the pulse 
becomes weak, or the dilated pupil contracts, or the expression of the child's 
countenance manifestly alters, the canula should be withdrawn, and the aper- 
ture in the skull closed. Gentle compression should be carefully made to 
compensate, in some degree at least, the pressure that has been removed with 
the fluid." (Watson's Lectures.) Should inflammation follow, it must be 
treated by the usual antiphlogistic means. 
Article IV. 
DROPSY OF THE CHEST, or HYDROTHORAX. 
Though generally applied at present exclusively to dropsical collections in 
the pleura, the term hydrothorax may, from its origin (■vSwp, water, and 0apa|, 
chest), be appropriately extended to any case of serous effusion, within the 
thoracic cavity; and in this enlarged acceptation I shall here employ it. 
There are three positions which may be severally or jointly occupied by this 
affection; the cavity of the pleura, that of the pericardium, and the pulmo- 
nary parenchyma. 
More or less serous fluid is very often found in the pleural cavities after 
death, without having given rise, during life, to any disturbance of health. 
This may be the result of effusion occurring, like copious sweats, in the dying 
state, or may be purely cadaveric, or may have existed unnoticed during life. 
To constitute dropsy, the effusion must be so considerable as to derange in 
some degree the healthy functions. When it exists to this extent, it produces 
more or less difficulty of breathing, which is increased by any bodily exertion, 
especially running, or ascending heights, and is greater in the horizontal than 
in the erect position. The dyspnoea is slight at first, but increases as the 
1. Pleural Dropsy. 372 
LOCAL DISEASES.-SECRETORY SYSTEM. 
[PART II. 
disease advances, and often becomes excessive before its close, bearing a close 
relation to the amount of the effused liquid. The patient lies preferably on 
the side most affected, generally with his head and shoulders elevated; and 
in the advanced stages is often unable to lie down at all, maintaining day and 
night continuously the sitting posture. The pressure upon the lungs impedes 
the pulmonary circulation; and, as a consequence, the face has often a livid 
or purplish hue, and the lips are sometimes almost black in bad cases. This 
disease is often associated from the commencement with anasarca; and, when 
this is not the case, oedema of the face in the morning, and of the feet and 
ankles towards night, is very apt to make its appearance before the close. 
The chest is usually more prominent at the part where the liquid is col- 
lected. The projection is often obvious to the eye, and may be demonstrated 
by measurement with a tape. When the effusion is very copious, the ribs 
are further separated than in health, and the intercostal spaces lose their 
ordinary depression, and sometimes even appear to bulge outward. The 
heart too is displaced, being pressed towards the opposite side. It is asserted 
that, if the body be shaken, the agitation of the fluid may be heard; but this 
can happen only when there is also air in the cavity of the pleura. The vi- 
bration felt by the hand applied to the chest of an individual while speaking, 
is less sensible on the side affected with dropsy than on the other. Sometimes, 
when the effusion is very abundant, fluctuation can be perceived, if one hand 
be laid upon the chest, and slight percussion be made by the other upon the 
intercostal spaces in the same vicinity. Bichat speaks of the increased dys- 
pnoea resulting from pressure upon the abdomen as a useful diagnostic symp- 
tom. This, however, is experienced in so many other affections of the chest 
as to be of little value. It may assist the diagnosis when one pleural cavity 
only is dropsical; as the pressure produces a much greater effect when applied 
on the sound, than on the diseased side. 
But the most certain evidences are those afforded by percussion and auscul- 
tation. There is always dulness on percussion, proportionate in a great de- 
gree to the amount of effusion. This dulness is usually first perceived in the 
lower part of the chest, and gradually mounts upward, with the increase of 
the effusion, until in extreme cases it extends over the whole half of the thorax, 
except the portion corresponding with the root of the lungs. When the effusion 
is less extensive, the dulness changes its position with that of the patient, and 
thus shows clearly that it is owing to the presence of a movable fluid in the 
pleura. If, for example, the instrument be applied upon the front of the 
chest, near the highest limit of the dulness, in the erect position, and the 
patient then be made to lie on his back, any decided difference between the 
sound emitted upon percussion, before and after the change of posture, will 
leave no doubt as to the existence of a liquid in the cavity. 
In the early periods of the disease, the peculiar resonance of the voice 
called aegophony, is sometimes perceived upon applying the ear over the seat 
of effusion; but this disappears with the increase of the affection. The respi- 
ratory murmur is feeble at first, and at length ceases to be heard, in some 
bad cases over almost the whole chest. But, unless the collapse of the lung 
is complete, if the patient be placed upon his face, both aegophony and the 
respiratory murmur may be sensible in the posterior part of the chest, when 
they have ceased anteriorly. 
The only affections with which pleural dropsy is likely to be confounded 
are consolidation of the lung from pneumonia or other cause, and the presence 
of pus or blood in the cavity. From the former, dropsy may be distinguished, 
in moderate cases, by the changing position of the dulness and the ausculta- 
tory signs, with the change of posture by the patient; and, in severe cases in CLASS III.] 
HYDROTHORAX. 
373 
which the whole cavity is full, by the obvious expansion of the chest, the en- 
largement of the intercostal spaces, and the effacement of their regular depres- 
sion. Besides, in pneumonia percussion is not usually so dull as in dropsy, 
the respiratory sounds are not so distant, the vibratory movement of the chest 
is increased instead of being diminished, and the condition of the sputum is 
quite characteristic. Empyema is distinguished with greater difficulty. The 
diagnostic signs of this affection are chiefly such as indicate the previous or 
coincident existence of inflammation • though it is not impossible that, even 
with these, the liquid effused may be merely serum, and, therefore, if long 
continued, entitled to be considered as dropsical. Empyema is more apt than 
dropsy to be confined to one side, and is much less apt to be accompanied with 
oedema of the face and extremities. Should the signs exist of a communica- 
tion between the cavity of the pleura and the lungs, the effusion may be looked 
on as certainly purulent. The existence of blood in the pleural cavity may 
be inferred, if the effusion has succeeded any violence, or has come on sud- 
denly in cases of a hemorrhagic tendency, as in purpura and scurvy. 
Pleural dropsy is often only a portion of general dropsy, and is, in most 
instances, associated with more or less anasarca. Occasionally, however, it 
exists alone; and this is especially the case when it arises from inflammation 
or active congestion of the pleura. Under the same circumstances, it is some- 
times confined to one side; but more generally it exists in a greater or less 
degree in both cavities. In the latter case, however, it is very frequently in 
a greater degree upon one side than the other. When arising from disease of 
the lungs, it occurs most frequently on the affected side, and when from dis- 
ease of the heart, according to Dr. Williams, upon the right side. Its course 
is very uncertain. Sometimes it comes on suddenly, and soon proves fatal; 
but much oftener it is chronic, lasting for a long time, sometimes better and 
sometimes worse, now yielding to treatment, and again returning, until at 
length the patient succumbs, either under the disease in which the dropsy 
originated, or from the effects of the dropsy itself. When originating from 
a general dropsical diathesis, or from a mere irritation of the pleura, it is 
often radically cured. Not unfrequently, however, it ends in death, because 
dependent upon incurable affections. 
Upon examination after death, the lung is found more or less compressed, 
and forced inward and backward towards the mediastinum and spine. Occa- 
sionally old partial adhesions of the pleura are observed to restrain, in some 
measure, this change of position. In very bad cases, the bronchial tubes ap- 
pear almost entirely obliterated, and the lung had evidently quite ceased to 
admit air .in respiration. But, even in such cases, it expands if air be blown 
into it through the trachea. The pleura is often quite free from disease, but 
sometimes exhibits traces of preceding inflammation. The liquid is sometimes 
limpid and colourless, but more frequently yellowish or brownish, or tinged 
with blood, and occasionally offers flakes of coagulated fibrin or albumen, or 
is turbid from a similar impregnation. The quantity is exceedingly variable. 
It generally amounts to several pints, sometimes in bad cases to one or even 
two gallons, though the last mentioned quantity is very rare. 
The causes of pleural dropsy do not differ from those of the general disease. 
It originates most frequently in organic affections of the heart, the great blood- 
vessels or the lungs, and is apt to be associated with tubercles in their earlier 
stages. As in all other forms of dropsy, the effusion may depend upon in- 
flammation of the secreting membrane. Some authors consider the serous 
effusion arising from this cause as distinct from dropsy; but fail to assign a 
good reason for the distinction. When the effusion is simply serous, it must 
be considered dropsical whatever may be its origin. The cases considered as 374 
[PART II. 
LOCAL DISEASES.-SECRETORY SYSTEM. 
idiopathic hydrothorax are probably, in most instances, the result of a high 
irritation of the membrane, which has not reached the point of inflammation 
simply because the blood-vessels have relieved themselves by effusion. Some- 
times the disease results from a sudden transfer of the morbid process, what- 
ever it is, from the cellular tissue to the pleura; the anasarca disappearing as 
the hydrothorax occurs. 
In relation to the treatment, little need be added to what was said under 
general dropsy. When there is reason to believe that the effusion depends 
upon an inflammatory condition of the pleura, very great advantage may be 
expected from occasional cupping, and repeated and long continued blister- 
ing. Of the internal remedies, perhaps most reliance is to be placed upon a 
combination of squill and calomel; the latter being carried to a slight ptyalism. 
Paracentesis may be resorted to with some hope of benefit, when there is 
reason to believe that the disease has originated in inflammation or mere 
vascular irritation of the pleura. In other cases, it would be a desperate 
resort, at most calculated to afford but temporary relief at the hazard of pro- 
ducing fatal inflammation. Nevertheless, when the danger of death from suffo- 
cation is imminent, the practitioner would be justified in resorting to it as a 
temporary expedient. In no case should it be employed until other means 
have failed. 
2. Pericardial Dropsy.-Hydropericardium.-Dropsy of the Heart. 
A certain quantity of serum in the pericardium does not appear to be in- 
compatible with health ; at least, it is frequently found after death, without 
any previous symptoms that could have led to a suspicion of its existence. 
As in the pleura, the probability is, that the effusion is partly an attendant 
on the last agony, or merely cadaveric; but it can scarcely be doubted that, 
in many cases, it has existed during life. How much may be considered as 
constituting disease cannot be exactly determined; for the effects from the 
same quantity vary greatly with the rapidity of its accumulation. A small 
portion effused quickly will embarrass the heart more than a much larger 
quantity collected slowly, so as to allow that organ to be gradually accus- 
tomed to its presence. Corvisart considered six or seven ounces as on the 
average sufficient to indicate a morbid state; and it is probable that less will 
sometimes interfere with the circulation and respiration. 
As in pleural dropsy, there is much difficulty in distinguishing the symp- 
toms produced by the effusion from those of coexisting diseases, especially of 
the heart; and not unfrequently the same symptoms have their origin in both 
affections. Besides, hydropericardium is frequently associated with dropsy of 
other cavities, or with general dropsy, which very much complicate the phe- 
nomena. A small, feeble, irregular pulse, dyspnoea, inability to retain the 
horizontal position, a livid or purplish hue of the face, deepest in the lips, 
and sometimes extending to the arms, are symptoms which result from dropsy 
of the pericardium; but they also frequently exist in diseases of the heart 
without this complication. Corvisart pointed out a characteristic symptom, 
observable in some rare cases of very copious effusion. In two instances of 
this kind, the heart could be felt beating at different spots at different times; 
the pericardium being so much distended as to allow that organ to float about 
in the liquid with which it was surrounded, in obedience to any impulse 
which it might receive. An elevation of the point at which the heart's pul- 
sation is felt, and its removal further towards the left, are other occasional 
signs of pericardial effusion. A preternatural prominence of the thorax in 
the region of the heart, obvious to the eye, and oedema of the face and ex- 
tremities, are still more important signs. But no certain evidence of the CLASS HI.] 
375 
HYDROTHORAX. 
existence of the disease is offered except by percussion and auscultation. Dul- 
ness in a greater degree, and over a greater extent of the cardiac region than in 
health, is the result of considerable effusion into the pericardium. This same 
phenomenon is presented by dilatation of the heart; but it may be inferred to 
depend on effusion, if observed to vary in extent, either gradually increasing 
or gradually diminishing within a moderate length of time. This alteration 
may be appreciated by marking the limits of the dulness at any given time, 
by means of lunar caustic or other substance capable of imparting a durable 
stain to the cuticle, and comparing them with a similar outline at another 
time. The impulse imparted to the ear and to the hand in hydropericardium 
is somewhat obscure, as though conveyed through a liquid, and not superficial 
as in dilatation; and the sounds of the heart seem more distant in the former 
than in the latter case. Besides, the respiratory murmur can be heard over 
the dilated heart, in situations in which it would be inaudible in distension 
of the pericardium. But these signs only indicate the existence of a liquid 
in the pericardial cavity. Whether it is dropsical or not must be inferred from 
attendant circumstances. If accompanied, or immediately preceded by the 
state of system, and the physical signs which indicate pericarditis, it may be 
considered as the sero-albuminous or puruloid product of that affection; if 
occurring in a hemorrhagic state of system, it may consist of blood; in other 
cases it would probably be dropsy. 
This form of dropsy, when dependent on inflammatory irritation of the 
pericardium, or on a general dropsical diathesis, is susceptible of cure; but 
too frequently it is quite incurable, in consequence of the incurable nature of 
its cause; and it is generally of this character when very abundant. 
The liquid is found on dissection very similar to that effused in pleural 
dropsy. The quantity is sometimes very considerable; and a case is on record 
in which eight pounds were extracted. The pericardium sometimes exhibits 
signs of former inflammation; but frequently it is entirely free from them; 
being paler than usual, and otherwise differing from the normal state only by 
an occasional greater thickness, consequent, as is not unfrequently the case 
with other hollow structures, upon the stimulus of distension. 
In relation to the causes of pericardial dropsy, it is scarcely necessary to 
add anything to what has been already stated. In its serious forms, it is 
most frequently the result of disease of the heart, great blood-vessels, or 
lungs. It has been traced also to a tuberculated condition of the pericardium. 
As the other kinds of dropsy, it may depend upon simple irritation of the 
membrane, or upon those conditions which give rise to general dropsy. 
Nor is there anything peculiar in the treatment. The therapeutical remarks 
on dropsy of the pleura are applicable to this affection. Paracentesis, how- 
ever, must be resorted to with still greater reserve. Scarcely anything would 
justify it short of the most imminent danger to life. No case, I believe, is on 
record of a favourable result of the operation. 
This name is applied to serous effusion in the parenchyma of the lungs. 
It may occupy the extra-vesicular cellular tissue, or the air-cells, or both. 
When considerable, it occasions great dyspnoea, hurried breathing, and fre- 
quently cough, with the copious discharge of a thin, colourless, frothy liquid. 
There is more or less dulness upon percussion, which is most evident when 
the two lungs are unequally or one exclusively affected, the contrast between 
the two rendering the want of resonance in the dropsical lung more obvious. 
The respiratory murmur is diminished, but not altogether lost, unless in parts 
of the lungs in bad cases. Both the dulness on percussion, and the indistinct- 
3. Pulmonary (Edema.-Dropsy of the Lungs. 376 
LOCAL DISEASES.-SECRETORY SYSTEM. 
[PART II. 
ness of the respiration, are most decided in the lower and back portion of the 
chest. There is a subcrepitant rale during inspiration, resembling that of 
pneumonia, but not so fine, and attended with the mucous rale, indicative of 
liquid in the larger bronchia, The affection is very frequently accompanied 
by oedema of the face or extremities, and even general anasarca. 
From pleural dropsy it is distinguished by the absence of movement in the 
liquid, by the less decided dulness and loss of respiration, and by the inter- 
costal depressions not being effaced even when the chest is distended, as it 
sometimes appears to be in the lower part, by the great engorgement of the 
lungs. Another diagnostic sign is the increase of the costal vibration under 
the voice in pulmonary oedema, while it is diminished or quite lost in pleural 
effusion. Pneumonia, which it resembles in some of the earlier signs of that 
affection, differs by its febrile symptoms, the local pain which generally attends 
it, and its peculiar very viscid rusty or bloody sputum, strikingly different 
from that of oedema of the lungs. It has been stated that the crepitation is not 
so fine as in pneumonia, and more indicative of a thin liquid in the bronchial 
tubes. Congestion of the lungs presents phenomena not unlike those of 
oedema; but the expectoration is more viscid in the former, and apt to be 
tinged with blood; while the external dropsical symptoms which usually ac- 
company the latter will aid in the diagnosis. 
The affection is sometimes rapid, and terminates fatally in a few days; but 
more frequently it is chronic, and runs a long and variable course, together 
with the diseases of which it is a part or an effect. It may frequently be 
cured when dependent on causes which are not themselves irremediable. 
After death, the lungs do not collapse upon the opening of the thorax, have 
a yellowish colour, pit on pressure, and are less crepitant and heavier than in 
health. When they are cut, serum flows out, or may be pressed out, like 
water from a sponge. 
The causes of oedema of the lungs are the same as those of dropsy in gene- 
ral, and need not be repeated here. It not unfrequently accompanies pleural 
dropsy; and is apt to be found in old cases of disease of the heart, with anemic 
symptoms. There is nothing special in the treatment. If curable, it will 
yield to the diuretics, purgatives, &c., employed in general dropsy. 
Article V. 
ABDOMINAL DROPSY. 
The term ascites is now confined to dropsy of the peritoneum. Serous 
cysts within the abdomen often produce great distension, and imitate ascites 
in some of its most prominent symptoms; but they constitute a different affec- 
tion, having a different origin, and requiring a different treatment. They are 
usually designated as encysted dropsy, or, when connected with the ovaries, 
ovarian dropsy. Though not strictly belonging to the present category in a 
correct nosological arrangement, they will be most conveniently considered in 
this place, from their apparently close relation to ascites. 
1. Ascites. 
This is a frequent form of dropsy; but my own observation does not accord 
with that of the authors who make it the most frequent. It commences 
usually with an uneasy feeling of fulness in the abdomen, to which the atten- 
tion of the patient is first called by finding his clothes too tight. The dis- 
tension is first observable in the lower portion of the abdomen when the CLASS III.] 
ASCITES. 
377 
patient is in the erect position, and disappears when he lies down. But it 
gradually extends, and, when the complaint is at its height, the whole belly 
is uniformly, and often very greatly swollen. The character of the tumefaction 
is known by the wave-like impulse imparted to the hand placed in contact 
with the side of the abdomen, when slight percussion is made with the fingers 
of the other hand upon the opposite side. The sensation produced is quite 
distinctive, and can scarcely be mistaken. But, when the quantity of water 
is very small, the fluctuation cannot be made sensible in this way. In such 
a case, it is sometimes rendered evident, in the manner recommended by M. 
Tarral, by making slight percussion a few inches only from a finger placed 
upon the abdomen, or by applying the thumb and middle finger of the same 
hand upon the surface, and percussing by the index finger between them. 
The sound, moreover, yielded by percussion aids the diagnosis. This is flat 
over the region where the liquid is collected; and the extent of the liquid 
may sometimes be measured by the extent of the dulness; as the portions of 
abdomen unoccupied by it are resonant in consequence of the presence of air 
in the intestines. As, in consequence of the air which they contain, the 
bowels are specifically lighter than the liquid, those portions which are loose 
have a tendency to occupy the part of the abdomen which is uppermost. 
Consequently the resonance will be strongest over the upper part of the cavity 
in the erect position, and about the umbilicus when the patient is on his back. 
Exceptions to the latter statement will be found in the instances, noticed by 
Dr. Watson, in which the bowels are bound down to the back of the abdomen 
by adhesions, or in which the distension is so great that the attachments of 
the intestines are too short to allow them to reach the surface of the liquid. 
Another circumstance which indicates the nature of the complaint is the 
swelling or bulging out of the sides of the abdomen, with depression of the 
anterior surface, in the supine position. 
Besides the characters enumerated, the disease is attended with various 
symptoms, either belonging to dropsy in general, or the result of the organic 
derangements in which it originates. Of the former, are frequently thirst, 
scanty urine, a dry skin, more or less edematous or anasarcous swelling, and, 
when this is absent, general and sometimes extreme emaciation. The latter 
vary, of course, with the organic affection, and do not require to be mentioned 
here. Various functional disturbances result from the great mass of the effused 
fluid. Not to speak of the disagreeable feeling of distension and weight, and 
the inconvenience of movement, the patient often experiences great dyspnoea 
from the upward pressure of the diaphragm; nausea, colicky pains, and flatu- 
lent disturbance from the compression of the stomach and bowels; and, in 
the advanced stages, anxiety, occasional disposition to faintness, and feeble 
irregular pulse, from interference with the action of the heart. The tumefac- 
tion of the abdomen often becomes enormous; and is sometimes apparently 
increased by an anasarcous condition of the parietes. Occasionally, the skin 
at the umbilicus is stretched and everted so as to form a small projecting 
pouch. The veins on the surface of the abdomen are much enlarged in con- 
sequence of the compression of the venous trunks within. Instances have 
occurred, in which the skin of the pouch alluded to has ruptured, and the 
fluid been discharged externally. A communication has also been known to 
take place between the cavity of the abdomen and the bowels, so as to allow 
the escape of the liquid in this direction. In unfavourable cases, the debility 
becomes at length extreme, the action of the heart fails, drowsiness some- 
times occurs, and the patient dies from syncope, or with symptoms of op- 
pressed brain. 
Dissection often exhibits a bleached appearance of the abdominal contents, 378 
[PART II. 
LOCAL DISEASES.-SECRETORY SYSTEM. 
as if from maceration in the effused liquid. Evidences of former inflammation 
of the peritoneum are also often presented, in whitish opaque or thickened 
patches, a granulated surface, various abnormal growths upon the membrane, 
and adhesion and bands from organized fibrin. The liquid is of various 
character, transparent and colourless; turbid and either whitish, brown, or 
reddish, with albuminous flakes or purulent admixture; thin, or viscid like 
syrup, or almost gelatinous; and sometimes fetid. The quantity differs from 
a few pints to several gallons. 
The affections with which ascites might possibly be confounded are preg- 
nancy, tympanites, an enormously distended bladder, and encysted dropsy. 
In ordinary cases of pregnancy there can be no difficulty. But when the 
uterus, as sometimes happens, is greatly distended with serous fluid, so as to 
impart a decided sense of fluctuation to the hand, or when pregnancy is 
complicated with ascites, the diagnosis is occasionally embarrassing. In 
pregnancy, however, the abdomen remains more prominent when the patient 
is on her back, and does not so much bulge out laterally; the uterus, rising 
up anterior to the intestines, renders percussion dull at the umbilicus in the 
same position; and, when ascites coexists, the fluctuation is more distinct in 
the upper portion of the cavity, at the hypochondria, for example, than in 
the lower portion which is occupied by the womb. Some aid may also be 
derived from the history of the case, and the presence or absence of the 
menses; though the frequent suppression of this discharge in dropsy often 
deprives the sign of its value. The detection, by means of the stethoscope, 
of the action of the foetal heart would be quite decisive. Should other 
methods fail, an examination per vaginam by an experienced accoucheui' 
would settle the question. After all, however, it is not so much the difficulty 
of the diagnosis, as the liability to form a hasty decision, without particular 
examination, and from the mere statements of the patient, that requires 
notice. Ludicrous, if not serious, mistakes have sometimes resulted from a 
want of thought on the part of the practitioner. 
Nothing is easier than the diagnosis between dropsy and pure tympanites. 
The absence of fluctuation, and the universal resonance in the latter affection 
are sufficient distinctions. But the two affections are often complicated, and 
in such a manner as to rende'r it somewhat difficult to decide how much of 
the distension is tympanitic, and how much dropsical. Dr. Chapman has 
known ascites so often preceded by tympanitic distension as to have suggested 
to him the idea, that an aeriform secretion is sometimes converted into a 
liquid. (Am. Journ. of Med. Sci., i. 161.) The relative degree of fluctua- 
tion, and of resonance on percussion, must decide the question as to the rela- 
tive amount of liquid and air present. Fluctuation, and flatness on percussion 
must be sought for in the most depending parts of the abdomen. 
In relation to the distended bladder, it is only necessary that the young 
practitioner should be alive to the possibility that it may be mistaken for 
ascites, and to the fact that such a mistake has been made, in order to avoid 
it. The history of the affection, its attendant symptoms, the regular outline 
of the dulness in the lower part of the abdomen, and the pain on pressure, 
would sufficiently distinguish the distended bladder; and, if there should still 
be doubt, it would be at once removed by the introduction of the catheter. 
The diagnosis between ascites and encysted dropsy will be given, when 
the latter affection is considered. It is said that the dropsical effusion is 
sometimes confined to the inner laminse of the omentum, and that a large sac 
has been formed by the unfolding and dilatation of its cavity. But such 
cases are exceedingly rare; and could be recognized only after death. 
It is often important to decide, in cases of abdominal dropsy, whether it CLASS III.] 
379 
ASCITES. 
has arisen from organic derangement, and if so, what is the nature of that 
derangement. In forming his judgment, the practitioner will be guided by 
the symptoms, mingled with those peculiar to dropsy, which characterize the 
various affections that give origin to this disease. A careful examination of 
the abdomen will often throw light upon the subject. From abnormal hard- 
ness under the hand, circumscribed dulness on percussion, tenderness upon 
pressure, movements within the abdomen corresponding with changes of the 
position of the body, even from irregularities in the outline of the abdomen, 
the practitioner will be enabled occasionally to draw important inferences as 
to the existence of an enlarged or indurated organ, or some morbid structure, 
concerned in the causation of the disease. Dr. Watson speaks of a sensation 
experienced when sudden pressure is made by the points of the fingers in a 
direction perpendicular to the surface, a sensation neither to be described nor 
mistaken, as of the displacement of a liquid, and the impinging of the fingers 
upon a solid substance. This is a valuable aid in the detection of enlarge- 
ment of the liver or spleen, ovarian tumours, and other morbid growths com- 
plicated with ascites. 
Causes.-Both in relation to the pathological condition and causes of 
ascites, there is little to be added to what has been said on general dropsy. 
When connected with pathological conditions of a general nature, or depend- 
ent on causes having a general action, such as debility, a morbid state of 
the blood, and organic affections of the heart and kidneys, it is most com- 
monly associated with external oedema or anasarca. It is less frequently 
than anasarca of renal origin. When unaccompanied with dropsical effusion 
elsewhere, it depends, for the most part, either on a special irritation or in- 
flammation of the peritoneum, or upon some impediment to the portal circu- 
lation, inducing venous congestion of all the abdominal viscera. The latter 
is the most frequent origin of exclusive ascites. That it occasionally arises 
from peritoneal inflammation is proved by the abdominal pain and tender- 
ness, and the febrile symptoms, which have sometimes been observed to pre- 
cede its appearance, and by the phenomena exhibited upon dissection. It 
is more frequently the result of chronic than of acute inflammation. It is 
probable that tubercles in the membrane itself, and various abdominal tu- 
mours sometimes occasion ascites by sustaining an irritation or inflammation 
of the peritoneum. The same causes may also act by impeding the flow of 
blood in the ramifications of the veins, and thus inducing congestion. Ob- 
struction or remora of the portal circulation may arise from a stricture of the 
vena portarum, or a diminution of its caliber in consequence of pressure 
from without it. This is most frequently met with in the liver, and hence 
hepatic disease is generally recognized as the most frequent cause of ascites. 
Enlargement of the liver from chronic inflammation or degeneration, cirrho- 
sis, scirrhus, and tubercles, all produce it. Those conditions of the viscus 
are most effective, which pervade its whole substance, and consequently 
everywhere compress the ramifications of the portal veins. Hence, cirrhosis 
is one of its most frequent and fatal causes. The enlarged spleen and mesen- 
teric glands, scirrhus of the pylorus, diseased pancreas, and other tumours 
may possibly act in the same way, by diminishing the capacity of the portal 
vein or its tributary branches; but, as before stated, they probably also act 
quite as much by sustaining irritation of the peritoneum. 
Prognosis.-Ascites, when dependent upon the same causes as external 
dropsy, and associated with it, is very often cured. When it exists exclu- 
sively, it is apt to be much more obstinate, because connected with affections 
of an intractable or incurable character. But even in this form, those writers 
go too far who affirm that it rarely gets well. It is true that, in very many 380 
LOCAL DISEASES.-SECRETORY SYSTEM. 
[part it. 
cases, it is altogether unmanageable, and ends sooner or later in death. It is 
true also that, even in cases in which the fluid may be removed by general 
treatment, it often returns, because the root of the disorder has not been 
reached. But, nevertheless, instances of recovery are not uncommon. They 
have repeatedly occurred within my own observation. This result may be 
looked for with some confidence when the effusion depends upon simple peri- 
toneal irritation from checked perspiration, repelled eruptions, &c.; and it not 
unfrequently happens in cases of tumefaction of the liver, from simple chronic 
inflammation. Occasionally a spontaneous cure takes place by the re-esta- 
blishment of the urinary secretion, or the occurrence of copious discharges 
from the skin or bowels. A case is recorded in the London Lancet (March, 
1842), in which a radical cure was effected by profuse sweating from the 
abdomen, which came on spontaneously. M. Dalmas witnessed the cure of 
ascites, in an infant, from the rupture of a pouch which had formed at the 
umbilicus. {Diet. de Mid., iv. 202.) 
Treatment.-This is to be conducted according to the plan detailed under 
general dropsy. Perhaps the most efficient remedies for the removal of the 
fluid are the hydragogue cathartics. Elaterium will sometimes act like a 
charm. But the debilitating effects of purgatives cannot always be borne, and 
it is necessary to resort to the diuretics. Bitartrate of potassa often answers 
an admirable purpose. But, whatever remedy is employed for the evacuation 
of the serum, it is often essential to conjoin with it the use of mercury, espe- 
cially when the disease originates in chronic inflammation of the liver. The 
mercurial should be cautiously employed, so as but slightly to affect the gums, 
and should be persevered in for a long time, occasionally for months. Some 
recommend, under similar circumstances, the use of iodide of potassium ; but 
this should never be relied on to the exclusion of mercury. Frictions with 
iodine ointment daily, or twice a day, over the region of the tumefied liver, 
may be employed. When the liver is affected with tubercles, cancer, or cir- 
rhosis in its advanced stage, little good can be expected from these or any 
other remedies; but, in the uncertainty as to the precise condition of that 
viscus, it would be best to give the mercurial a fair trial, in the hope that the 
affection might be of a nature amenable to its influence. 
Dr. Christison and other practitioners of Edinburgh, imitating the practice 
of MM. Brera and Chrestien, of Montpelier, in France, have made use of 
digitalis externally with great benefit. A convenient mode of using it is to 
apply over the abdomen a cloth of spongy texture, soaked with an infusion of 
the leaves, made in the proportion of one ounce to twenty fluidounces of boiling 
water. The cloth should be worn steadily, and the evaporation of the liquid 
may be prevented by a covering of oiled silk. Its diuretic effect is usually 
produced in a few days. {Ed. Month. Journ. of Med. Sci., Oct. 1850, p. 312.) 
Should symptoms qf inflammation exist, cups and blisters to the abdomen 
should be resorted to; and a large blister will sometimes be found advan- 
tageous under other circumstances. Care, however, should be taken not to 
apply it in cases of great debility, or enormous anasarcous distension, for fear 
of gangrene. 
Well regulated compression of the abdomen by means of bandages has 
sometimes been of undoubted advantage. It is applicable to the earlier 
stages, before the distension has become so great as much to embarrass respi- 
ration. Dr. Gerhard has found this remedy, combined with the warm bath, 
very effectual. {Med. Exam., v. 209.) According to Dr. Dubini, in cases 
not encysted, and not attended with edematous extremities, it will, in the 
majority of instances, remove not only the effused liquid, but its cause; and 381 
CLASS III.] 
ASCITES. 
he has often succeeded admirably with its aid, in cases in which remedies had 
previously been ineffectual. (Braithwaite's Retrospect, Am. ed., xxi. 32.) 
Tapping has been much employed, and various opinions have been ex- 
pressed of its advantages. While some allow it only as a last resort, merely 
to obtain temporary relief when all ordinary means have failed, others have 
recommended it as a remedy, capable, in some instances, of effecting cures. 
There can be no doubt that permanent cures have, in some rare cases, followed 
this operation ; and the opinion held by some, that, by removing pressure 
from the kidneys, it favours the action of diuretics, is probably not entirely 
without foundation. Nevertheless, it very generally fails to do more than 
yield temporary relief; and the liquid accumulates again, often even more 
rapidly than before, so as to render a frequent resort to the operation neces- 
sary. The quantity of serum which has been drawn off, and the number of 
times that tapping has been repeated in some instances, are astonishing. In 
a case of Storck's, twelve and a half gallons were evacuated at one operation: 
Dr. Beall, of Missouri, records a case, in which the operation was performed 
ninety-six times in the course of a few years, and the whole amount drawn 
off was two hundred and seventy-five gallons and a half; and a case was 
reported by M. Lecanu to the Paris Royal Academy of Medicine, in which a 
woman was tapped eight hundred and sixty-six times, and ultimately recovered 
under compression of the abdomen. (Dunglison's Notes to Cyc. of Pract. Med.') 
Nor is paracentesis without danger. Leaving out of the question the instances 
in which the intestines or uterus have been wounded, and an artery divided, 
there is occasional danger from inflammation of the peritoneum, and the ope- 
ration has repeatedly been followed by fatal effects. It is probable, moreover, 
that, in most of those cases in which cures have followed it, the same result 
might have be.en obtained from other treatment. On the whole, it seems 
most advisable to resort to paracentesis only when it becomes necessary, from 
the failure of purgatives, diuretics, compression, &c., to afford the patient 
relief from great oppression, or to postpone for a period the fatal termination. 
In the performance of the operation, it is highly important, as the fluid 
escapes, to make compression of the abdomen by means of a bandage, so as 
to supply artificially the pressure of the viscera to which the patient has been 
so long habituated, and the sudden withdrawing of which has repeatedly 
proved fatal when this precaution has been neglected. 
The evacuation of the fluid by means of acupuncture has been recom- 
mended, and is said to have been sometimes very successful. It is stated 
that the fluid escapes from the cavity of the peritoneum into the external 
cellular tissue, and is there absorbed. Dr. Pritchard employs a grooved 
needle, and has found it less painful than the ordinary trochar, and not less 
effectual. But for particulars as to the mode of performing the operation, 
the reader is referred to the works upon surgery. 
The plan of injecting stimulants into the cavity of the abdomen, as in the 
radical cure of hydrocele, has been recommended; but the hazard of fatal 
inflammation greatly overbalances the slender prospect of benefit. A pupil 
of the author, however, Dr. John B. Sherrerd, formerly of Belvidere, New 
Jersey, recorded, in his inaugural essay (January, 1845), a case of appa- 
rently desperate abdominal dropsy in a female, in which Dr. Clark, of the 
same place, after tapping, injected a decoction of oak bark into the cavity of 
the abdomen, with the result of effecting a perfect cure. A case was reported 
by M. Leriche, of Lyons, in which the injection of an ounce of tincture of 
iodine, and a drachm of iodide of potassium, with eight ounces of water, into 
the abdominal cavity, immediately after tapping^ in a case of ascites, was fol- 
lowed by perfect recovery (Med. Times, May 29, 1847); two other cases were 382 
[part II. 
LOCAL DISEASES.-SECRETORY SYSTEM. 
afterwards treated successfully, in the same way, by the same practitioner 
{Arch. Gen., 4e s6r., xxiii. 78); and the operation has since been repeatedly 
performed by different practitioners with variable results. It is contra- 
indicated in all cases in which the abdominal dropsy depends on causes 
operating on the system at large, or through the heart, kidneys, or liver. 
In this affection, the liquid, instead of occupying the cavity of the perito- 
neum, is contained in cysts morbidly developed within the abdomen, and 
gradually increasing in size until tumefaction becomes obvious to the eye, 
and fluctuation is discoverable upon examination in the usual manner by the 
hand. These cysts are produced either in the substance or upon the surface 
of the organs, and are supposed sometimes to originate as hydatids. Their 
most common attachment is to the ovary, or some of the uterine appendages, 
as, for example, to the broad ligaments; and in such cases the name of ova- 
rian dropsy is applied to the affection. 
The cysts which spring from the ovary are either the morbidly dilated 
Graafian vesicles, or new formations within the substance, or upon the surface 
of that organ. In some instances, it seems as if the whole ovary had under- 
gone this process of dilatation, and been converted into a sac with numerous 
cells. The cyst has sometimes only a single cavity, sometimes several, which 
may either communicate or be quite distinct; and occasionally it appears to 
consist of two or more distinct sacs which have coalesced. It may either be 
unconnected, except at the place of its origin, or may have formed adhesions 
with the contiguous structures. The cyst sometimes attains an enormous 
magnitude. Cases are on record in which the fluid contents are stated at 
from 100 to 120 pounds, and one in which the cyst is affirmed to have mea- 
sured six feet in circumference. The contents are exceedingly diversified in 
colour and consistence. They may be colourless, yellowish, hrown, or milky; 
limpid like water, or turbid; thin and serous, or slimy, ropy, and gelatinous. 
They are described also as occasionally puruloid, bloody, oleaginous, even 
cretaceous or cheesy in consistence, and variously resembling the lees of wine, 
coffee-grounds, and molasses. It sometimes happens that the different cells 
of the same cyst have different contents. 
The affection is usually slow in its progress, and for a long time attended 
with little disturbance of the general health, though the menses are often 
irregular, and, when both ovaries are affected, are said to be almost invariably 
suppressed. Sometimes it continues for thirty years or more before it termi- 
nates fatally, and persons affected with it not unfrequently attain a tolerably 
advanced age. But in other instances it is much more rapid in its progress, 
and destroys life in a few years. This is said to happen most frequently when 
it attacks the young and robust. The age at which it is most common is 
about that of the cessation of the menses. Married women are said to be 
more frequently attacked than the single; but this difference may be only 
apparent, and dependent on the much greater number of the former. 
In its advanced stages it is apt to be attended with oedema of the extremi- 
ties, consequent on the interruption of the venous circulation by the bulk of 
the tumour. It may prove fatal by impeding respiration, by exciting perito- 
neal inflammation, or by an inflammatory action in the cyst itself, ending 
sometimes in suppuration, ulceration, and fistulous openings. Occasionally 
the cyst opens externally, occasionally into the cavity of the peritoneum; in 
either case generally terminating unfavourably, though spontaneous cures are 
said to have resulted in some rare instances of this kind. In one instance, 
2. Encysted Dropsy.- Ovarian Dropsy. CLASS III.] 
ENCYSTED DROPSY. 
383 
the cyst was ruptured from external violence, and its contents poured into 
the peritoneal sac, where they were absorbed, and the patient recovered. 
In other cases of encysted dropsy, the cyst springs from the liver, spleen, 
or some other portion of the peritoneal surface. In this case, it often pro- 
bably originates in hydatids. I once witnessed the post-mortem examination 
of a case of this kind, in which the abdomen had become, in the course of 
many years, enormously distended, and, upon being opened, was found filled 
with numerous cells of various sizes, the walls of which were in every stage 
of developement, from the state of delicate translucent membrane to that of a 
thick, rough, opaque, fleshy structure; and, in some of the cells, small trans- 
parent hydatids were found of various magnitude. 
Diagnosis.-The most important point for the practitioner, in relation to 
encysted dropsy, is to be able to form a correct diagnosis between it and 
proper ascites. This is not always easy when the former affection is in an 
advanced stage, and the cyst single, and distended so as to fill the abdominal 
cavity. But in general there is little difficulty. At an early period, the dis- 
tension, as well as the dulness on percussion, is confined to one portion of the 
abdomen; being observed, in ovarian dropsy, in the iliac fossa upon one side, 
and, when the cyst is of hepatic origin, in the upper part of the cavity. When 
the cyst is loose, it varies its position somewhat when the patient moves from 
side to side; but does not spread out uniformly, like free liquid, in obedience 
to the laws of gravitation. In ascites, the distension is first observed in the 
pubic region in the erect posture; but, in the recumbent, passes to the back 
portion and sides, which, when the effusion is considerable, swell outward, 
while the prominence of the abdomen is depressed. This lateral distension 
on both sides is not observed in encysted dropsy. In the advanced stage of 
the latter affection, the surface of the abdomen is generally uneven and some- 
what tuberculated, from the unequal developement of the cells of the cyst. 
The fluctuation is usually much more obscure than in ascites. But percus- 
sion affords, perhaps, the best means of diagnosis. In encysted dropsy, par- 
ticularly the ovarian, the intestines are pushed to one side, or crowded into 
the back part of the abdomen; while, in ascites, they float on the top of the 
liquid. Hence, in the former, the percussion will be dull upon one side and 
in front of the abdomen, while it may be resonant on the other side, and will 
generally be so in the back of the abdomen. In the latter, the resonance 
should be in the upper part of the abdomen when the body is erect, upon the 
anterior surface about the umbilicus when it is horizontal. Exceptions to 
the latter fact are the instances before alluded to, in which the distension is 
so great that the intestines cannot reach the surface, and in which the bowels 
are bound to the back part of the abdomen by adhesions. 
Some value also belongs to the constitutional symptoms. In encysted 
cases there is, for a long time, little of that disturbance of the functions which 
usually attends dropsy. There is, for example, no peculiar thirst, dryness of 
the skin, or scantiness of urine. The patient retains a better appetite, and 
undergoes less emaciation than in ascites. The inconvenience arises chiefly 
if not exclusively from the mere distension. 
Treatment.-Little need be said upon this point. All the remedies found 
useful in dropsy, have been tried in this affection, and proved of little avail. 
The object of the practitioner should be to render the patient as comfortable 
as possible. Inflammation in the sac will be obviated by leeches, blisters, fo- 
mentations, emollient poultices, and cathartics, while the pain will be relieved 
by anodynes. Sometimes a gentle mercurial course may prove useful; and 
the preparations of iodine have been recommended. Frictions with iodine 
ointment over the tumour, steadily persevered in a for a long time, may pos- 384 
LOCAL DISEASES.-SECRETORY SYSTEM. 
[PART II. 
sibly be productive of benefit. When the distension becomes very great, and 
exceedingly inconvenient if not dangerous, tapping may be resorted to. The 
operation must be performed in the centre of the most prominent portion of 
the abdomen, unless there may be reason to fear the division of an artery. 
This is necessary in consequence of the frequently cellular character of the 
cyst. But the operation is not without danger, and is never more than pal- 
liative, requiring in general, to be frequently repeated, as the cavity rapidly 
fills up. The dangers are of effusion into the peritoneal cavity, of inflamma- 
tion of the cyst itself, of wounding some important organ, or of opening an 
artery. The operation should not, therefore, be inconsiderately resorted to. 
In some cases, cures take place in consequence either of the bursting of the 
cyst from violence, and the absorption of its contents, or of inflammation of 
its inner surface, correcting the tendency to secretion, or giving rise to adhe- 
sion of its surfaces, and obliteration of the sac. Mr. Bainbridge, of Liverpool, 
effected a cure of this affection by making an incision into the cyst through 
the abdominal parietes, and keeping it open by means of a plug until sup- 
puration was established; and he subsequently published the history of eigh- 
teen cases, which had been treated successfully by various practitioners upon 
the same principle. (See Am. Journ. of Med. Sei., N. S., xiv. 231.) In 
1846, Dr. Allison, of Spencer, Indiana, cured a case of ovarian dropsy by 
injecting a solution of iodine into the sac. (Med. Examiner, N. S., iii. 459.) 
Dr. Simpson, of Edinburgh, has since repeatedly performed the operation, 
employing the undiluted tincture of iodine of the Edinburgh Pharmacopoeia, 
of which two or three ounces were usually thrown into the cyst. No serious 
constitutional symptoms followed, and in general little pain was suffered. Tn 
two or three cases the operation appears to have been successful; but it failed 
in a large proportion. (See Am. Journ. of Med. Sci., N. S., xxviii. 259.) 
In October, 1852, Dr. Boinet addressed a memoir oh the subject to the French 
Academy of Medicine, in which he recommended the operation as always 
safe if properly performed, often successful in the cure of the affection, and, 
when this cannot be effected, always palliative. (Arch. Gen., 4e ser., xxx. 483.) 
SUBSECTION II. 
DISEASES OF THE SKIN. 
The diseases of the skin described by medical writers are very numerous. 
Almost every diversity of morbid action in this tissue is obvious to examina- 
tion ; and various affections, which, judged of by their general effects alone, 
would appear identical, exhibit to the eye sufficient evidence of diversity to 
authorize or require a distinct consideration. Were the diseases of the mucous 
membranes susceptible of the same close inspection, they might possibly be 
found equally numerous. Perhaps authors have carried their nicety of dis- 
crimination somewhat too far in relation to cutaneous affections; as the multi- 
plicity of names and distinctions tends to embarrass the learner, without 
always being of practical advantage. The treatment is governed not so much 
by trivial differences in the appearance of an eruption, as by the condition of 
the system, and intimate nature of the disease, which are not unfrequently the 
same, when the obvious phenomena differ. In the following remarks, there- 
fore, I shall lay little stress upon many of the varieties which have been de- 
scribed, though, in accordance with general custom, I may deem it proper to 
notice them. 
But many of the cutaneous affections will be omitted in this place. Cer- CLASS III.] 
DISEASES OF THE SKIN. 
385 
tain functional derangements, such as excessive and deficient perspiration, and 
morbid heat and coldness of surface, occur almost always as symptoms of 
other diseases, to the history of which, therefore, an account of them properly 
belongs. Several highly important diseases of the skin are merely parts, 
though essential parts, of certain febrile movements; and, therefore, fall into 
the division of idiopathic fevers. Such are all the febrile exanthemata, as 
scarlatina, measles, smallpox, and not unfrequently erysipelas. Again, there 
are many skin disorders which are usually treated of in surgical works, the 
consideration of which in treatises on the practice would be useless repetition. 
Such are local erysipelas, furuncles, anthrax, cancer, and the different external 
developements of syphilis. All these will be omitted. 
In the classification and nomenclature of complaints of the skin, I shall 
follow chiefly Willan and Bateman, though their arrangement is in some 
measure defective, as indeed every arrangement must be, until we become 
much better acquainted than we are with the nature and cause of these com- 
plaints. But no better system of classification has been proposed; and, in 
regard to nomenclature, it is much better to retain the old, though not alto- 
gether acceptable, than to embarrass the learner by new names, which after 
all might not be deemed worthy of adoption. 
The cutaneous diseases may be arranged in the classes of 1. rashes; 2. 
pimples; 3. vesicles, including bullae; 4. pustules; 5. scales; 6. tubercules; 
7. discolorations; and 8. cryptogamous affections. To these, in order to in- 
clude certain diseases which do not belong to either of the above categories, 
it is convenient to add a division of unclassifiable complaints. 
Rashes are characterized by a red, superficial efflorescence, diffused or in 
patches, disappearing under pressure, and commonly ending in desquamation. 
They are by some authors denominated exanthemata ; but this term has also 
been applied to various other cutaneous eruptions, especially those attended 
with fever, and in the later sense is employed in this work. 
Pimples (papulae) are small, somewhat conical elevations, pointed at the top, 
containing neither lymph nor pus, and ending usually in a scurf. 
Vesicles (vesiculae) are circumscribed elevations of the cuticle, containing 
lymph either limpid and colourless, or more or less opaque and whitish or 
pearl-coloured. When large, and consisting of a clear fluid separating the 
cuticle from the true skin, they are called bullae, blebs, or small blisters. 
Pustules (pustulae) are circumscribed elevations of the cuticle, containing pus. 
Willan and Bateman make four varieties; viz., l.phlyzacium, large, on a hard 
circular base of a vivid red colour, and followed by a thick, hard, dark scab; 2. 
psydracium, small, often irregularly circumscribed, but slightly elevated, termi- 
nating in a laminated scab, often clustering and confluent, and, after the dis- 
charge of pus, pouring out a thin watery humour, which frequently forms an 
irregular incrustation; 3. achor, small, pointed, containing a straw-coloured 
matter of the appearance and nearly the consistence of strained honey, and 
succeeded by a thin, brown or yellowish scab; and 4. favus, containing a 
more viscid matter than achor, with a frequently irregular and slightly in- 
flamed base, and ending in a yellow, semi-transparent, and sometimes cellular 
scab, like a honeycomb. But, in fact, the favus of Willan, as will be seen 
under the head of Porrigo, is no pustule at all. 
Scales (squamae) are hard, thickened, whitish, opaque laminae of cuticle. 
Tubercules (tubercula) are small, hard, superficial, circumscribed, permanent 
tumours. They must not be confounded with the scrofulous or consumptive 
tubercles.* 
* To distinguish these two kinds of bodies, which have nothing in common but 
their condition as small tumours, I have, in the present edition, adopted the spelling of 386 
LOCAL DISEASES.-SECRETORY SYSTEM. 
[part II. 
Discolorations (maculae) are changes in the colour of the skin produced by 
modifications of the colouring matter independently of any other affection. 
Cryptogamous affections are those which depend essentially on the presence 
of microscopic fungi. 
It is important that the learner should bear in mind, that the nosological 
divisions of cutaneous diseases are more or less abstractions. They will not 
by any means always be found in nature of the same precise and definite 
character as stated in the books. Certain striking cases may correspond 
sufficiently with the definitions; but, in numerous instances they run into 
one another, so as to render discrimination difficult or impossible. Thus, the 
rashes are often mingled with papulous, vesicular, or pustular elevations; 
these latter are not unfrequently conjoined in the same case; and, in some 
diseases, the regular progress of the eruption is through the different states 
successively of pimple, vesicle, and pustule. 
Article I. 
RASHES. 
To this division belong, Rubeola, Scarlatina, Erysipelas, Erythema, Ro- 
seola, and Urticaria. By many writers, purpura is also included, but, for 
reasons before given, I consider that affection as belonging to diseases of the 
blood, and not to the cutaneous eruptions. Of the above-mentioned rashes, 
rubeola, scarlatina, and erysipelas belong to the idiopathic fevers Only 
erythema, roseola, and urticaria are here considered. 
1. ERYTHEMA. 
This rash is characterized by superficial redness, generally in irregular 
patches of greater or less extent, sometimes nearly continuous, and not con- 
tagious. It may or may not be attended with constitutional disturbance. 
When strictly local, it arises from some direct source of irritation, as the 
contact of acrid secretions or excretions, continuity with inflamed mucous 
membrane, the friction of contiguous surfaces, continued pressure upon any 
portion of the body, and the application of rubefacient substances. In this 
form, it differs from local erysipelas mainly in its more superficial character, 
inferior intensity, and less disposition to spread. When produced by the 
friction of contiguous surfaces, it takes the name of intertrigo. This is apt 
to occur in the groin and axilla, in the cleft of the nates, beneath the mammae, 
and between the folds of the integuments in the neck and upper part of the 
thigh, in very obese adults after exercise, and in fat infants, especially when 
not frequently washed. The irritated parts often exude a thin viscid fluid, 
of a disagreeable smell, and in the end not unfrequently suffer excoriation, 
with much itching, heat, and other disagreeable sensations. Another kind 
of local erythema, is that which results from dropsical distension of the lower 
extremities. It is in smooth, shining, uniform patches, more or less con- 
fluent, and is sometimes so considerable as to induce febrile action. In very 
feeble persons, it is apt to assume a purplish hue, and even to end in gan- 
grene. It is the erythema leeve of Willan. . 
tuber cute for the cutaneous affection, retaining the old name for the scrofulous tubercle; 
so that the reader may understand at once the meaning of the two terms respectively 
when he meets with them, without the necessity of being, on each occasion, specially 
guarded against mistake. (Note to the fourth edition.') CLASS III.] 
387 
RASHES.-ERYTHEMA. 
In the cases of erythema arising from constitutional causes, the affection 
generally occupies the face, limbs, or breast, but may occur in any other part, 
or even extend over nearly the whole body. It appears usually in irregularly 
circumscribed patches, sometimes quite distinct, but more frequently running 
more or less together, and occasionally quite continuous over an extensive 
surface. It is accompanied with a sense of heat, and sometimes with tingling; 
but seldom with burning or severe pain. There is usually little or no eleva- 
tion of skin; but the contrary is sometimes the case; and, in one variety, the 
patches of redness rise into hard eminences of considerable size, which are 
not unfrequently tender and even painful. The affection is often unattended 
with any obvious general disorder, though probably as often consequent upon 
some previously existing disease, and not unfrequently complicated with fever. 
In some instances, it is preceded or accompanied with depression of spirits, a 
feeling of debility, pains in the limbs, a frequent irritated, pulse, and other 
evidences of nervous disturbance; and its sudden, retrocession may give rise 
to various internal derangements. I have seen hemiplegia apparently result 
from this cause. It is irregular in its duration, sometimes lasting only two or 
three days, more commonly a week or two, but seldom becoming chronic. Oc- 
casionally it disappears and returns; and this may happen frequently, espe- 
cially when it is connected with intermittent or remittent fever. It is some- 
times distinctly intermittent, independently of any connexion with a regular 
fever of that type. Upon retiring, it generally leaves more or less desquama- 
tion, and, if it has occupied the scalp, the hair is apt to fall out. 
Willan and others make the following varieties; viz. 1. Erythema fay ax, 
with irregular patches, appearing successively on the arms, neck, breast, and 
face, and disappearing in a short time; 2. E. loeve, above described as attend- 
ing dropsy of the lower extremities, though sometimes appearing in the limbs 
without oedema; 3. E. marginatum, in which the patches are bounded on one 
side by a hard, raised, tortuous, red border, sometimes obscurely papulous, 
without regular limits to the redness on the other side, uncertain in its dura- 
tion, and generally connected with some internal disorder; 4. E. circinatum, 
of a circular form, spreading at the circumference, and fading in the centre; 
5. E. papulatum, consisting of small, definitely bounded and slightly promi- 
nent spots, somewhat papular in appearance, about as large as a small split pea, 
scattered upon the arms, neck, and breast, of a bright-red colour for the first 
few days, afterwards assuming a bluish hue, especially in the centre of the 
patches, and continuing for about two weeks; 6. E. tuberculatum, differing 
from the preceding mainly in the size of the patches, which are larger and more 
elevated, and subside in a week, leaving the redness, which becomes livid 
and disappears in another week, the affection being attended with fever, and 
much restlessness and irritability; and 7. E. nodosum, characterized by large, 
oval, imperfectly defined patches upon the anterior parts of the legs, with their 
long diameter corresponding with the direction of the tibia, slowly rising into 
hard painful protuberances, afterwards softening, and subsiding in 8 or 10 
days without suppuration, assuming a bluish colour as if bruised, and gene- 
rally preceded or attended with febrile and nervous symptoms. Dr. Begbie 
considers this last form of erythema as closely analogous to rheumatism. (Ed. 
Month. Journ. of Med. Sci., May, 1850, p. 487.) It would require no great 
violence to reduce these varieties to three, E. fugax, E. papulatum, and E. 
nodosum; E. leeve being omitted as a mere local effect of distension of the 
skin. 
M. Biett observed another variety, which he denominated E. centrifugum, 
and which is characterized by the mode of its extension, beginning by a point 
somewhere in the face, and gradually spreading in all directions, till it covers, 388 
LOCAL DISEASES.-SECRETORY SYSTEM. 
[part it. 
perhaps, the whole cheek. In some instances, however, it occurs in distinct 
patches, more or less circumscribed, red, and prominent. It is without local 
sensation, unless when acute, and is then attended with heat and pain. It is 
generally chronic, lasting, with various changes, sometimes for years. On 
disappearing, it leaves a permanent cicatrix, or depression in the skin, but 
without preceding ulceration. It is a very rare disease, and is at present 
ranked by Cazenave with Lupus, to one of the varieties of which it would 
seem to belong. (See Lond. Med. Gaz., Nov. 1851, p.-858.) 
Diagnosis.-The complaints with which erythema is most liable to be 
confounded are erysipelas and roseola. From the former it may be distin- 
guished by occurring more in patches, and being attended with less elevation 
or swelling of the skin, less burning and pain, and in general much less 
fever. It is also a much less serious affection. Roseola differs from it by 
its brighter rose-colour, the different arrangement of the eruption, which is 
often punctate, especially at the commencement, and not so much in continu- 
ous patches, and by the more frequent accompaniment of fever. Scarlet fever 
and measles have a somewhat similar eruption; but erythema wants the pe- 
culiar course and accompaniments of these affections, and is not like them 
contagious. Its rash, moreover, is not crescentic like the rubeolous, nor punc- 
tuated, as that of scarlet fever is very apt to be in the beginning. When raised 
into wheals, erythema bears some resemblance to urticaria, from which, how- 
ever, it is at once distinguished by the absence of the intense itching which 
characterizes the latter. The papulous form of it might be confounded with 
some varieties of lichen; but the smaller, rounder, firmer, and paler papulae 
of the latter, with the intense itching that often attends it, would sufficiently 
distinguish them. Care must be taken not to confound erythema with 
syphilitic eruptions. The greater duration of the latter, their coppery or 
grayish hue, and the general course of the disease of which they are a symp- 
tom, will serve as criteria. 
The causes of erythema are not always evident. It is generally connected 
with a disordered state of system. It is apt to occur during dentition, and 
is occasionally produced by irritating substances in the stomach. Fevers and 
bowel complaints are occasionally attended with it during their course, or in 
the convalescence; and it not unfrequently accompanies certain exanthema- 
tous fevers, such as smallpox, spreading over the skin in the intervals of the 
proper eruption. It is said also occasionally to have some connexion with a 
deranged state of the menses. During the years 1828 and 1829, an epi- 
demic (acrodynia') prevailed at Paris, of which an erythematous eruption, 
with a thickening and desquamation of the cuticle, was one of the most pro- 
minent symptoms. I have seen a striking case of erythema in an individual 
affected with metastatic abscesses. The disease does not appear to be confined 
to any age, and occurs in both sexes. 
Treatment.-The treatment in local cases must be somewhat varied with 
the cause. If the erythema depend on acrid secretions, care must be taken 
to prevent as much, as possible their contact with the skin, which should be 
protected by mild unctuous preparations, as the ointment of rose-water, sper- 
maceti ointment, &c. If the inflammation be considerable, lead-water may 
be applied. In cases of intertrigo, perfect cleanliness, frequent washing with 
cold water, separating the surfaces by a soft linen rag or otherwise, dusting 
the parts with some mild absorbent powder, as starch, tutty, calamine, or 
prepared chalk, the application of Goulard's cerate, or weak solutions of ace- 
tate or subacetate of lead, sulphate of zinc, or acetate of zinc, and, if the 
inflammation be considerable, mucilaginous or emollient applications, or 
what is, perhaps, the most efficacious, a strong solution of nitrate of silver, CLASS III.] 
389 
RASHES.-ROSEOLA. 
are the appropriate remedies. If the erythema proceed from pressure, this 
must be obviated by mechanical contrivances, and the skin protected by the 
common lead-plaster. Washing with spirit, or with a solution of alum in 
brandy, often modifies the condition of the skin so as to prevent this unplea- 
sant effect of pressure. In chronic cases, especially when there is excoriation, 
collodion may be usefully employed. It acts by excluding the air. 
When the local affection is connected with a morbid state of the system, 
or of the internal organs, little treatment is required, except what may be 
necessary to correct the disease in which it originates. The antiphlogistic 
regimen, antacid or saline laxatives, and, when there is fever, the refrigerant 
diaphoretics, as the antimonials and neutral mixture, are all that is required. 
Sometimes, when the pulse is very strong, it may be proper to take a little 
blood; but this is seldom requisite. Dr. Begbie has found quinia successful 
in E. nodosum. If the local affection be hot and painful, demulcent lotions, 
and the warm bath may be used. I have usually employed saturnine lotions 
in E. nodosum of the extremities. It is possible that leeches near the inflamed 
part might be useful in obstinate cases. When the sudden retrocession of 
the eruption has occasioned unpleasant or alarming symptoms, a sinapism, 
blister, or other active external irritant should be applied to the portion of 
the surface which it had occupied. 
2. SCARLET RASH, or ROSEOLA. 
This is defined to be a rose-coloured efflorescence, variously figured, with- 
out wheals or pimples, and not contagious. 
Roseola sometimes appears as a distinct exanthematous fever; sometimes 
as a mere symptomatic eruption. In the former case, it commences with 
slight febrile symptoms, which are attended with more or less gastric derange- 
ment, continue one, two, or three days before the appearance of the rash, and 
subside along with it. The eruption commences usually upon the face, neck, 
and breast, with specks or small patches, which sometimes remain distinct, 
but more frequently coalesce in a greater or less degree; and occasionally the 
whole surface of the body, or large portions of it, are covered with an almost 
uniform redness. The patient frequently complains of itching and tingling 
in the affected parts. The fauces are often reddened, and the papillae of the 
tongue appear through a slight coating of fur. Sometimes there is a feeling 
of roughness and even soreness of throat. The eruption is generally of short 
continuance, sometimes lasting only a day or two, sometimes running on to 
the fourth or even fifth day, before it entirely disappears. It fades gradually, 
and is commonly followed with little or no desquamation. 
The efflorescence differs considerably in appearance. In some cases, it 
bears a close resemblance to that of scarlet fever in its punctuated character 
or general diffusion, and in its bright redness. In other cases, it is more like 
measles, with distinct, somewhat regular, slightly-elevated patches, of a 
darker hue. The patches vary in size from a mere speck to half an inch or 
even an inch in diameter. Occasionally they have the form of rings, with 
sound skin in the centre; but this is comparatively rare. 
Sometimes the eruption disappears and returns, and, thus alternating, con- 
tinues for a week or more before taking its final leave. When it recedes sud- 
denly, symptoms of internal irritation occasionally appear, such as disordered 
stomach, headache, giddiness, faintness, pains in the limbs, and dejection of 
spirits, which are relieved by the recurrence of the rash. In some instances, 
these symptoms, and especially obstinate nausea and vomiting, precede for a 390 
[part II. 
LOCAL DISEASES.-SECRETORY SYSTEM. 
time the appearance of the eruption, after which they subside immediately. 
The affection has been known to assume a chronic form; the efflorescence 
coming and going at uncertain intervals, or fading in the morning to revive 
towards night; but such instances are rare. The itching and tingling which 
generally attend the eruption, are sometimes wanting. A roseolous efflores- 
cence occasionally also occurs without fever. In no case is the affection con- 
tagious, and one attack does not secure against a second. 
Dr. Willan, with an unnecessary nicety, has made seven distinct varieties 
of roseola, founded either on the season at which the disease is most apt to 
occur (R. aestiva and R. autumnalis), on the form of the eruption (JR. annu- 
lata), on the age of the patient (R. infantilis), or on the disease of which it 
is an attendant (JR. variolosa, R. vaccini, and R. miliaris). 
The affection originates in a great diversity of causes. It often accompanies 
dentition. The vicissitudes of heat and cold in summer, the sudden checking 
of profuse sweat, the drinking of cold water during perspiration, are thought 
sometimes to cause it. It often results from gastric and intestinal irritation, 
and hence sometimes attends the bowel complaints of children, and dyspeptic 
affections in adults, and follows the introduction of irritating substances into 
the stomach. There is reason to think that it is occasionally provoked by 
gastric acidity. Copaiba sometimes produces a similar eruption, and I have 
seen it result apparently from the free use of dandelion. It is not uncommon 
in smallpox whether natural or inoculated, and in varioloid, preceding the 
proper eruption in these complaints, sometimes covering almost the whole 
surface, and disappearing in two or three days. In the varioloid, it is sup- 
posed to prognosticate a favourable character in the chief disease. I have 
seen it occur in that complaint very profusely, and be followed by only a 
single pustule; and have reason to think that it has sometimes entirely re- 
placed the legitimate eruption. It has occasionally also been observed in the 
vaccine disease, appearing on the ninth or tenth day. Enteric or typhoid 
fever is sometimes attended with a roseolous efflorescence, which, in such 
cases, is apt to be mingled with miliary vesicles. I have witnessed a case in 
which these two eruptions occupied jointly almost the whole surface of the 
body; and both, in this case, came on after profuse sweating. The patient 
recovered, though attacked with pleurisy upon the disappearance of the rash. 
Roseola sometimes attends rheumatism and gout, and has been repeatedly 
observed in epidemic cholera, in the stage of reaction. It has been observed 
also in chronic pericarditis, but was probably an accidental complication. It 
sometimes occurs epidemically, and I have always noticed it most frequently 
during the prevalence of measles and scarlet fever. 
Diagnosis.-Roseola sometimes closely resembles erythema, and there is 
reason to believe that the two affections often scarcely differ either as to their 
cause or nature. In decided cases, however, they may be readily distinguished 
by the signs mentioned under erythema. It is more important to distinguish 
the complaint from scarlet fever and measles, with which it is often con- 
founded, and the more frequently from the circumstance that it is apt to pre- 
vail at the same time. It is probable that, in many of the cases in which 
scarlatina and rubeola are said to have occurred more than once in the same 
individual, roseola was mistaken for them. The two former complaints are 
contagious, the latter is not. The precautions which are sometimes highly 
necessary in the one case, are superfluous in the other. Roseola is a compa- 
ratively trifling disease, and seldom need occasion anxiety; scarlatina is not 
without great apprehension of danger, either primarily or secondarily, even 
in its mild forms. In decided cases of the three complaints, there can be 
little difficulty in the diagnosis. Scarlet fever is attended with sore-throat, CLASS III.] 
RASHES.-URTICARIA. 
391 
measles with catarrh, and roseola generally with neither. The fever and dis- 
turbance of system in the latter is much less, as a general rule, than in the 
former, especially scarlatina. The eruption of roseola is usually brighter, 
and the patches, while they are more regular than in scarlatina, are less so 
than in measles, and seldom have the crescentic character sometimes observed 
in the last-mentioned complaint. Nevertheless, it is often impossible to dis- 
criminate between mild cases of scarlatina and roseola, especially when the 
latter is accompanied with sore-throat; and, if it should be accidentally asso- 
ciated with catarrh, there might be the same impossibility to distinguish it 
from measles. It is only after the doubtful complaint is over, that a correct 
inference may be drawn from a general survey of its cause, course, and effects. 
Treatment.-This is very simple. The complaint will almost always ter- 
minate kindly without medical interference. In the severer cases, confinement 
to the house or chamber, a spare, cooling regimen, saline laxatives, magnesia 
if there is suspicion of acid in the stomach, antimonials or the neutral mixture 
if there is much fever, and the warm bath if the cutaneous irritation is con- 
siderable, are all that is requisite. Gentle friction with rye meal may also 
be used to relieve the itching and tingling. Should the eruption recede, and 
unpleasant symptoms result, it should be recalled to the surface by external 
irritants, or the hot bath. At the commencement of the attack, should the 
suspicion of scarlet fever be strong, an emetic of ipecacuanha may be given, 
and the bowels freely evacuated. At the worst, the treatment would be 
merely superfluous. In chronic cases, mineral acids and sea-bathing are said 
to have proved useful. 
3. NETTLE-RASH, or URTICARIA. 
This is a non-contagious affection, characterized by the cutaneous elevations 
called wheals, which are usually surrounded by a diffused redness, and uni- 
formly attended with itching, tingling, or other disagreeable sensation. Wheals 
are circumscribed swellings of the skin, of various shape and size, usually 
roundish or oblong, more or less hard, generally whiter, but sometimes redder 
than the healthy skin, containing no liquid, and having no tendency to sup- 
puration. An example of them is offered in the small elevations which follow 
the application of nettles to the skin. Willan made six varieties of urticaria, 
of which three are recognized by Biett. There does not appear to be a neces- 
sity for any other division than into acute and chronic. 
The acute form of the disease QU. febrilis of Willan) generally commences 
with some fever, which precedes the eruption for two or three days, and is 
often complicated with signs of gastric and nervous disorder, such as head- 
ache, nausea and vomiting, pain in the epigastrium, anxiety, languor, faint- 
ness, and slight rigors. These symptoms commonly disappear upon the occur- 
rence of the rash, which presents itself usually in the form of erythematous 
patches of a vivid redness, with wheals rising irregularly in the midst of them. 
Being attended with excessive itching, it causes the patient to rub or scratch 
the skin, and thereby very much to increase the eruption, which will often, 
under this kind of irritation, break out upon apparently sound portions of the 
surface. It may attack any part of the body, but is generally most abundant 
upon the inside of the forearm, and about the shoulders, loins, and thighs. It 
often also attacks the face, and is said sometimes to appear on the inside of 
the mouth. The eruption comes and goes irregularly, often declining in the 
day, and returning in the evening, with slight febrile exacerbation, and coming 
on with peculiar violence when the patient undresses, and gets into bed. It 392 
LOCAL DISEASES.-SECRETORY SYSTEM. 
[part II. 
has been said that the affection of the skin is aggravated by cold, and alle- 
viated by warmth. The reaction produced in the surface after being cooled, 
no doubt often provokes the eruption; but I do not think that heat has any 
favourable influence upon it. The wheals last sometimes only a few minutes, 
at other times for several hours; and, on disappearing in one place, often 
return in another. In some instances they coalesce, giving rise to great tume- 
faction, tension and irregular hardness of the skin, and almost universal red- 
ness (JJ. conferta of Willan). The attack generally lasts a week or ten days, 
with frequent remissions and exacerbations of the cutaneous affection, and 
the occasional occurrence, during its course, of various disturbances of sys- 
tem, such as have been mentioned as preceding the eruption. These are 
sometimes distressing, and even alarming upon a complete retrocession of the 
rash, and disappear upon its return. At the close of the attack, a slight 
desquamation of the cuticle usually takes place. 
In many instances, the eruption makes its appearance without previous 
fever. This happens especially when the disease proceeds from something 
taken into the stomach. In such cases, about an hour or two after the sub- 
stance has been swallowed, epigastric pain or uneasiness, with nausea, vertigo, 
anxiety, &c., come on, and are soon followed by the eruption, which is occa- 
sionally very violent. The face, neck, and chest, sometimes even the whole 
surface of the body, are much swollen, with an almost universal erythematous 
redness, interrupted here and there by single or clustered wheals; and the 
patient, along with an intolerable heat, itching, and tingling of the skin, suf- 
fers occasionally from oppressed breathing, which almost threatens suffoca- 
tion. This violence continues only for a few hours, after which the complaint 
gradually subsides, and terminates usually in one or two days. In some 
cases, there is only redness of the skin, without the wheals. In the course 
of the affection, the patient often experiences severe pain in the stomach, 
nausea, anxiety, general distress, faintness, &c., alternating with or attend- 
ing the eruption. The symptoms usually vanish very speedily after the sto- 
mach has been completely evacuated by means of an emetic or otherwise. 
Occasionally acute urticaria assumes a decidedly intermittent character, 
occurring in regular paroxysms every day, or every other day, either as an 
attendant on intermittent fever, or as an original affection. 
In the chronic form, there is no fever, and the eruption is not persistent, 
but appears and disappears irregularly (CC evanida of Willan); being some- 
times absent for a considerable interval, and recurring from slight causes, as 
after violent exercise, or indulgence in the pleasures of the table. The wheals 
are usually whitish, and less apt than in the acute form to be surrounded by 
a red efflorescence, though attended with the tingling, itching, and stinging 
sensations characteristic of the disease. The patient often suffers more or less 
with the gastric and nervous symptoms before described. The duration of 
the complaint is very variable and uncertain, sometimes not exceeding a few 
days, and sometimes extending to months or years. 
Occasionally the wheals increase rapidly, and attain a considerable magni- 
tude, forming tumours in the loins, limbs, &c., sometimes as broad as the 
hand, and interfering with movement. These tumours are sometimes hot, 
tender, and painful, occur usually at night, and subside after continuing for a 
few hours, leaving behind them sensations as if the patient had been bruised 
or fatigued. This form of urticaria is the U. tuberosa. 
In other cases, the wheals, instead of lasting only a few hours or a day, 
persist for two or three weeks after the redness has disappeared, retaining 
more or less of their characteristic sensation, and at length gradually subside. 
They constitute Willan's U persistans. CLASS III.] 
RASHES.-URTICARIA. 
393 
It sometimes happens that the sensations bear no just relation to the amount 
of eruption; and Willan noticed a variety, which he called U. subcutanea, in 
which the patient suffers much from severe stinging pains as if needles were 
run into the skin, without any visible affection whatever, except an occasional 
eruption of wheals, which continue for two or three days, and then disappear 
without any relief to the morbid sensations. 
Diagnosis.-Urticaria is often mingled with other eruptive affections, such 
as erythema, roseola, lichen, and impetigo; and it is not always easy to de- 
termine which is the prominent disease. But, when distinct, there is little 
difficulty in its diagnosis. The peculiar sensations which attend it, and the 
appearance of the wheals are, in general, sufficiently characteristic. Lichen 
urticatus, however, might without care be confounded with it, having both 
wheals, and the itching and tingling of nettle-rash. But the tumours in that 
complaint are smaller, less prominent, of a deeper colour, firmer, and much 
more persistent; and are always attended with true papulae, which cannot well 
be mistaken. ( Cazenave and Schedel.') The tumours of erythema nodosum, 
though somewhat similar to the large wheals sometimes seen in urticaria, are 
more durable, and without their disagreeable itching. , 
The nettle-rash, though a very disagreeable and often troublesome com- 
plaint, is scarcely ever dangerous. Cases of death have been recorded, when 
the disease has arisen from substances taken into the stomach; but it would 
be difficult to determine how far the result depended on the urticaria alone, 
and how far on gastric inflammation or other internal disorder produced by 
the same cause. 
Causes.-The most frequent causes of urticaria are internal irritations, 
especially of the stomach and bowels. It often attends dentition, and the 
bowel complaints of children. Acid and other irritant matters in the stomach 
frequently occasion it. Certain kinds of food have been long notorious as the 
occasional cause of nettle-rash. Of these, shell-fish, as lobsters, crabs, shrimps, 
and especially muscles of different kinds, are most apt to produce it. Salt 
and smoked fish have been accused by some writers; and it has been supposed 
that some fish are more poisonous at certain seasons than at others, as, for 
example, at the time of spawning. Particular parts of fish have also been 
supposed to be more noxious than others; and Autenrieth concluded, from his 
researches, that the irritant principle exists in connexion with the fatty mat- 
ter. Other kinds of food, which have been enumerated as occasionally pro- 
ducing urticaria, are pork, mushrooms, honey, oatmeal, bitter almonds, rasp- 
berries, strawberries, and green cucumbers. The worst case of the disease 
which I have seen occurred in a woman from eating raspberries. She had 
been twice before attacked in the same manner from the same cause. The 
face, neck, and extremities were greatly swollen, and the respiration in the 
highest degree embarrassed; but immediate relief was obtained by an emetic 
of ipecacuanha. Certain medicines also occasionally produce it, among which 
are mentioned valerian, copaiba, and the turpentines. I have seen it result 
also from pipsissewa (chimaphila umbeTlata). This susceptibility to urticaria 
from particular kinds of food or medicine is not general, but an idiosyncrasy 
of individuals; and the food which will produce it in one person will often not 
produce it in another, each person being liable to be affected by some particu- 
lar substance. 
Over-exercise, strong mental excitement, indulgence in eating rich and 
high-seasoned food, and the intemperate use of stimulating drinks, sometimes 
produce attacks of urticaria. It is said to be most prevalent in the spring 
and summer; yet some authors consider exposure to cold as a more frequent 
cause of it than heat. This can be readily understood, when it is recollected 394 
LOCAL DISEASES.-SECRETORY SYSTEM. 
[part II. 
how much the face and hands of some persons swell and tingle during the 
reaction which follows exposure to cold. 
Peculiar delicacy of skin predisposes to the disease; and some persons who 
have this character of surface are affected with it from the slightest causes. 
It is a not unfrequent attendant upon other diseases, especially fevers and 
febrile complaints; and I believe that it is one of the forms in which those 
protean diseases, gout and rheumatism, occasionally show themselves. It is 
said sometimes to have prevailed epidemically. 
The disease occurs in all ages, from infancy upwards; but it is most com- 
mon in infants, and in young persons of the sanguine temperament, and 
attacks women more frequently than men, probably because their skin is more 
delicate, and less hardened by exposure. 
Treatment.-Little medical treatment is required in most instances. The 
avoidance of stimulating and indigestible food and drinks, and of everything 
especially which may be known to have disagreed with the patient, conjoined 
with rest and mild aperients, will, in general, be quite sufficient. As excess 
of acid in the stomach is often the source of the complaint, or at least serves 
to aggravate it, magnesia may be very properly employed as the laxative, 
either alone, or combined with one of the saline cathartics. Cool drinks 
should be given; but lemonade, as recommended by some writers, is of doubt- 
ful propriety. When the fever is considerable, the neutral mixture, or small 
doses of tartar emetic may be used; and it is possible that the lancet may 
sometimes be requisite. In gouty or rheumatic individuals, wine of colchicum, 
in moderate doses, might be added to the other remedies. Should retroces- 
sion take place, with severe or alarming internal irritation, the disease should 
be invited again to the skin by stimulant applications and the hot-bath. In 
cases of great nervous disturbance, advantage may accrue from camphor water, 
Hoffmann's anodyne, or other nervous stimulant. 
When the disease proceeds from any article of food, the stomach should be 
immediately evacuated by ipecacuanha, and the bowels afterwards by a dose 
of sulphate of magnesia or castor oil; and, in severe cases of uncertain origin, 
it would be proper to employ the same treatment, as the offending cause would 
very probably be found in the stomach, and the emetic would at any rate have 
the probable effect of moderating the cutaneous affection. 
In chronic cases, which are sometimes very obstinate, Willan advises that 
the patient should abstain successively from the different kinds of food and 
drink which he had been in the habit of using, in the hope that the offending 
cause might thus be found and removed. In this way he had frequently 
succeeded in tracing the disease to its source, which, in some, was malt 
liquors, in others spirit, in others wine, in others, again, vinegar, or fruit, or 
sugar, or fish, or raw vegetables. (Bateman's Synopsis.') 
When the disease is very obstinate, and the habit of the patient plethoric, 
great advantage may be expected from the occasional loss of blood, and a 
rigid diet of bread and milk, so as to change the character of the circulating 
fluid. This treatment, however, should not be hastily adopted. 
In intermittent cases, sulphate of quinia will quickly effect a cure. Full 
doses of the same medicine, continued for two or three days, are said to have 
proved promptly effectual in some of the worst forms of the disease, even 
when not periodical. 
Attention should, in chronic cases, always be paid to the general state of 
health. If the digestion is feeble, and the system debilitated, the simple 
bitters or sulphate of quinia may be used, associated, if there be acidity of 
stomach, with one of the alkaline carbonates. In other cases, the mineral 
acids have been found useful. Where other means fail, good may be hoped 
for from the arsenical solution. A most obstinate case of Urticaria tuberosa. CLASS III.] 
395 
PIMPLES.-STROPHULUS. 
which, for four years, had resisted various treatment, yielded, in the Hos- 
pital Saint-Louis, under M. Biett, to this remedy. (Cazenave and Schedel.) 
A gentle course of mercury might also be rationally employed in cases of 
unusual obstinacy and continuance. It might be the means of removing 
some lurking internal inflammation, or of altering the character of the blood, 
and thereby removing the cause of the disease. 
The local treatment should be very simple in acute cases. Rubbing the 
skin gently with rye meal sometimes affords partial relief. Cold lotions, as 
of spirit and water, vinegar, lemon-juice, and lead-water, should be very cau- 
tiously used, for fear of sudden retrocession. A case is related by Prank, in 
which fatal metastasis to the brain took place in consequence of cold applied 
to the surface. The warm-bath, however, is safe, and may sometimes be ad- 
vantageously employed. Repeated daily in chronic cases, it is considered one 
of the most effective remedies. Alkaline baths, however, prepared with car- 
bonate of potassa or soda, are said to be still more useful; and vapour baths, 
or the vapour douche, have been highly recommended. 
Article II. 
PAPULOUS DISEASES. 
Syn.-Pimples, or Papulae. 
These have been generally considered as papillae, enlarged and somewhat 
indurated by inflammation. Erasmus Wilson believes them to consist in 
inflammation of the secretory orifices, whether sudoriferous or sebiferous. 
Plumbe thinks that they are the result of an effusion of coagulable lymph 
beneath the cuticle. Simon found them, under the microscope, to consist of 
slight elevations of the cutis, with the blood-vessels engorged with red corpus- 
cles, and the tissue infiltrated with a colourless fluid, more consistent than 
serum. In other words, they are the result of inflammation of minute isolated 
portions of the cutis. Willan and most writers after him, describe three papu- 
lous diseases : viz., strophulus, lichen, and prurigo. Some unite strophulus 
and lichen, considering the former as a mere variety of the latter. There is, 
indeed, no great difference between them; but, as strophulus belongs exclu- 
sively to infancy, there is a convenience in treating of them distinctly. None 
of the papulous affections are contagious. 
1. STROPHULUS. 
This is commonly called red gum when the eruption is florid, white gum 
when it is pale or whitish. It occurs usually in infants before or during the 
first dentition. The eruption is seated most frequently in the parts of the 
surface most exposed, as on the face, neck, arms, and hands; but it also fre- 
quently occupies other parts, and sometimes extends over the whole body. 
In its most common and simple form, it appears in minute florid pimples 
irregularly dispersed, with occasional specks or patches of redness without 
elevation, and sometimes a few small vesicles, especially on the extremities, 
which usually dry up without breaking. This is the £ intertinctus of Willan, 
and is observed most commonly in infants under two months. Sometimes, 
along with these red papulae, are mingled others of a whitish colour; and, 
when the irritation is slight, or the skin less than ordinarily vascular, the 
w7hole of the papulae have this appearance. Willan distinguishes two varie- 
ties of them, one which he calls £ albidus, characterized by minute, hard, 396 
[part II. 
LOCAL DISEASES.-SECRETORY SYSTEM. 
slightly elevated whitish specks, with a little redness at the base, the other, 
S. candidas, having larger pimples, with a white shining surface, and no red- 
ness. In worse cases of the complaint (N. confertus of Willan), the eruption 
is more abundant, forming large, irregular patches, and sometimes rendering 
the whole surface occupied by it of a uniform redness. Occasionally there 
are, in these cases, much itching and pain, with more or less excoriation, 
especially when the eruption is seated in the thighs or lower part of the body, 
so that the affection resembles intertrigo. In another variety (N. volaticus 
of Willan), the eruption appears in small, circular, bright-red patches or 
clusters, which appear and disappear successively on different parts of the 
body, each patch turning brown, and beginning to exfoliate in about four 
days, and the whole continuing for three or four weeks. 
Strophulus is, with few exceptions, an acute disease, generally beginning 
to exfoliate and disappear in one or two weeks, and seldom continuing longer 
than a month. It is rarely attended with fever, and often occurs without any 
observable disturbance of health. When febrile symptoms do occur, it is not 
always certain whether they are essentially associated with the eruption, or 
proceed from some other cause. Sometimes the papulae, when numerous, ap- 
pear to occasion much distress to the child by their heat and itching, and these 
sensations are increased when the surface is kept warm. 
The affection probably often depends upon causes acting directly upon the 
very irritable and vascular skin of the infant. Too great exposure to heat, 
rough flannel next the skin, the accumulation of filth upon the surface, 
whether from without or from the infant's own secretions, are causes of this 
kind. It is sometimes associated with disorder of the stomach and bowels, 
and often occurs as one of the results of dentition. But, in many instances, 
it is not possible to trace the affection to any known cause. 
Strophulus is almost always an innocent complaint. Its retrocession is 
thought sometimes to have been followed by serious internal irritations; but 
it is very difficult always to determine, in such cases, whether the disappear- 
ance of the eruption is cause or effect. 
Treatment.-Very few remedies are required, and, unless the child appear 
to suffer, or the health to be otherwise disturbed, it would be better to do 
nothing, except to remove any obvious cause of the affection. The surface 
should be kept clean by frequent warm ablutions, the clothing should be of 
an unirritating character, and the infant should not be overheated. The diet 
also should be attended to; and, if the case is obstinate, it may be proper to 
change the nurse. When there seem to be much heat and itching of skin, 
relief may be given by the application of tepid milk and water, or mucila- 
ginous liquids, and the occasional use of the warm bath. The stomach and 
bowels should be attended to, and acidity, if existing, corrected by magnesia, 
the alkaline carbonates, or prepared chalk; one or the other of these remedies 
being employed according to the state of the bowels. Attention should also 
be paid to the condition of the gums. Cold applications to the surface should 
be avoided, lest they might occasion a sudden disappearance of the cutaneous 
irritation, and its translation to some interior organ. In the event of such 
translation, the warm bath, rubefacient lotions, and a few drops of aromatic 
spirit of ammonia internally, may be resorted to. In severe cases of stro- 
phulus, advantage is said to have accrued from an emetic. 
2. LICHEN. 
Willan defines this to be " an extensive eruption of papulae, affecting adults, 
connected with internal disorder, usually terminating in scurf, recurrent, not CLASS III.] 
PIMPLES.-LICHEN. 
397 
contagious." But this definition is defective; for the complaint frequently 
affects children beyond the age of infancy, and is by no means invariably con- 
nected with internal disorder. Willan enumerates seven varieties; and this 
number might be doubled, if every diversity of form were a sufficient ground 
for a nosological distinction; but for all purposes of practical advantage, they 
may be included under the three following. 
1. Lichen simplex.-This consists of small red pimples, about as large as 
the head of a pin, appearing usually on the hand, forearm, neck, face, and 
breast, but not unfrequently also elsewhere, and sometimes over almost the 
whole .surface of the body. They are attended with heat, tingling, and itch- 
ing, in various degrees. Upon the face, they are often larger than elsewhere, 
andon the extremities are sometimes obscurely vesicular. Having continued 
stationary for several days, they begin to decline, and terminate usually with 
a slight scurf in one or two weeks. Sometimes, however, the attack is of 
much shorter duration; and sometimes, by the occurrence of successive crops 
of eruption, is prolonged for several weeks, and even for months. In their 
course, the papulae frequently exhibit small bloody scabs upon their surface, 
arising from its abrasion by scratching. In the more chronic forms of the 
complaint, they often scarcely differ from the skin in colour, but are always 
readily discovered by passing the fingers over the part affected. In these 
chronic cases, there is frequently much more desquamation, with some thick- 
ening of the skin; and the disease sometimes very much resembles psoriasis. 
When produced by the high temperature of summer, the complaint is com- 
monly called prickly heat, the L. tropicus of nosologists, which, however, is 
identical with the variety above described. It occurs in this country very 
frequently among boys, affecting especially their arms, neck, and breast. In 
tropical latitudes it is much more severe, most frequently attacking strangers 
from temperate climates, but by no means sparing the natives. The sensa- 
tions of tingling, itching, stinging, &c., which attend it, are described as 
scarcely supportable, giving rise to an almost irresistible propensity to scratch- 
ing and locomotion, which only aggravate the irritation; and the best means 
of counteracting it are patience, quietness, and keeping cool, both physically 
and mentally. 
Sometimes the papulae occur chiefly or exclusively at the roots of the hairs, 
constituting the L. pilaris of Willan. ' In persons of scorbutic habit, or he- 
morrhagic constitution, they are apt to have a purplish or livid hue, which has 
given rise to the designation of L. lividus by the same author. 
Occasionally the papulae have a disposition to assume a circular arrange- 
ment, forming patches which are called ringworms in the language of the 
common people, and L. circumscriptus in that of the learned. These patches, 
at first small, gradually increase by the eruption of new pimples at the cir- 
cumference, while those in the centre fade and exfoliate. In some cases, they 
disappear spontaneously in a week or two; in others, continue for several 
weeks, slowly enlarging, and often running together. Willan states that this 
form of lichen is sometimes produced in adults by vaccination. Biett has 
described another form, which he names L. gyratus, in which the papulae 
are arranged in the shape of a somewhat tortuous band of considerable 
length. In a case of this kind, alluded to by Cazenave and Schedel, the 
pimples, arranged in small groups, formed a kind of riband, which, setting 
out from the anterior surface of the chest, gained the inner part of the arm, 
and descended to the extremity of the little finger, following exactly the 
course of the cubital nerve. 
Lichen simplex is sometimes preceded for a short time by febrile symp- 
toms, which disappear when the eruption breaks out. Pains in the head or 398 
[PART II. 
LOCAL DISEASES.-SECRETORY SYSTEM. 
stomach, and other symptoms of internal disorder, also sometimes vanish 
under the same circumstances. But, in numerous instances, there is no con- 
stitutional disturbance whatever. 
2. Lichen agrius.-This variety commences with fever, which subsides 
upon the occurrence of the eruption, though it does not always wholly disap- 
pear. The papulae are small, very numerous, red and inflamed, and clustered 
in large patches, which are surrounded, often to a considerable extent, by an 
erythematous redness of the skin. Occasionally small vesicles are intermingled 
with the pimples; but they soon disappear. The eruption is usually more 
limited than in the milder form of the disease, and is very seldom general. 
It occupies preferably the outer surface of the limbs, differing in this respect 
from eczema, to which, in the advanced stage, it sometimes bears a close re- 
semblance. It sometimes also occurs in the cheek. The sensation of itching 
and tingling, general in lichen, is in this variety combined with burning and 
smarting pain, which is aggravated by the heat of the bed, and by everything 
which has a tendency to excite or irritate the surface. The affection com- 
monly remits in the morning, and undergoes exacerbation towards evening. 
After a few days, the tops of the pimples become slightly excoriated or 
ulcerated, and pour out a sero-purulent fluid, which concretes into small 
scabs. These are succeeded by minute scales, of a furfuraceous character, 
upon the separation of which the complaint may terminate, having run a course 
of two weeks or somewhat less. But often the surface remains more or less 
moist, or the scales fall and are replaced by others, or the eruptive affection 
vanishes for a time to return again; and thus successively for a period of 
several weeks, until at length the complaint exhausts itself, the sero-purulent 
discharge gradually diminishes, a dry furfuraceous surface succeeds, and the 
skin returns to a healthy state. In the moist state alluded to, the eruption 
resembles eczema or impetigo; and it is supposed by Willan, after repeated 
attacks, to terminate occasionally in the latter affection, though this is denied 
by others. During the progress of the complaint, the skin is often thickened, 
chapped or fissured, and very painful upon being rubbed or otherwise dis- 
turbed. L. agrius sometimes occurs originally in this form, and is sometimes 
a mere aggravation of the milder affection. 
3. Lichen urticatus.-1This variety is distinguished by the occurrence of 
small tumefactions, which are rather inflamed wheals than pimples, and 
resemble those produced by the bites of poisonous insects, or the sting of the 
nettle. These, however, subside in a day or two, and are followed by true 
papulm; while other wheals appear, to be in their turn succeeded by papulae; 
so that at length the whole surface may become covered with the pimples, 
which are more or less confluent. Both the wheals and papulae are accom- 
panied with extreme itching. The affection is usually obstinate. Bateman 
says that it is peculiar to children, occurring sometimes soon after birth, and 
continuing many months. Others have observed it in adults. It occasionally 
follows vaccination, and is ascribed by parents to that operation; but the 
association is probably quite accidental. It sometimes disappears and again 
returns, and ultimately terminates in desquamation. 
Causes.-One of the most frequent causes of lichen is heat. Hence, it 
commonly occurs in the warm seasons, and in hot climates. Some persons 
are liable to a return of it every summer. It is brought on by exposure to the 
sun, by severe exercise, and by the use of stimulating drinks and condiments. 
The .contact of certain stimulating powders with the skin may also induce it. 
Causes which disturb the general health, such as long watching, bad diet, 
and the abuse of alcoholic liquors, are thought sometimes to predispose to it; 
but it probably more frequently occurs in persons in robust health. Like CLASS III.] 
PIMPLES.-LICHEN. 
399 
many other cutaneous affections, it is occasionally associated with irritations 
of the alimentary canal, evinced by disordered digestion, nausea or vomiting, 
and diarrhoea. It is sometimes a sequela of acute fevers. It affects persons 
of all ages, and of both sexes, but is most frequent in adults. In its milder 
forms, it would receive in suckling infants the name of strophulus. 
The diagnosis of lichen is often very difficult; as there are numerous cuta- 
neous affections to which, in some one of its forms or varieties, it bears a more 
or less close resemblance. It has been mistaken for measles and scarlatina ; but 
a moderate attention to the well known characteristics of these several affec- 
tions would leave no room for doubt. Sometimes it appears to be mingled 
with these exanthemata. Enough has already been said of its relation to 
strophulus. The distinctive characters of prurigo, to which it bears a close 
analogy, will be mentioned under that head. L. urticatus might be con- 
founded by careless observers with papulous erythema and urticaria, the 
diagnosis of which has been given under the heads of these complaints re- 
spectively. The occasional resemblance of lichen to eczema, impetigo, and 
psoriasis has already been pointed out. From the intense itching which 
attends it, and the frequent appearance of little bloody scabs upon the tops of 
the papulae in L. simplex, produced by scratching, it might be mistaken for 
the itch. In its ringworm form, it might without care be confounded with 
Herpes circinatus. For the diagnosis between lichen and these several com- 
plaints, the reader is referred to their respective titles in this work. Finally, 
this complaint, in the form of L. urticatus, bears some resemblance to certain 
syphilitic eruptions. The latter are distinguished by their copper colour, the 
absence of inflammation, their much less degree of itching, their greater per- 
manence, and the circumstance that they are very frequently accompanied, or 
were preceded by other characteristic symptoms of syphilis. 
Treatment.-Little general treatment is required in the ordinary acute 
forms of the disease. It is chiefly important to avoid the causes. The patient 
should remain as much at rest as possible, avoid exposure to the sun, dress 
rather lightly in hot weather, and live moderately as regards food and drink, 
shunning rich meats, stimulating condiments, and all kinds of alcoholic liquid. 
All substances which may have directly irritated the skin, should be guarded 
against. If febrile symptoms attend the complaint, saline laxatives and 
refrigerant medicines may be given, though profuse diaphoresis is contraindi- 
cated. In all cases, the bowels should be kept regularly open. In Lichen 
agrius, it may sometimes be advisable to take blood once or twice from the 
arm, and to apply leeches in the vicinity of the inflamed part. A strict anti- 
phlogistic diet should be enjoined in the early stages of this variety. 
In the advanced stages of lichen, when the complaint has become chronic, 
and even at the commencement, if the system is feeble, as in L. lividus, 
it may be proper to give tonic medicines, as the mineral acids, sulphate of 
quinia or infusion of Peruvian bark, and the chalybeates; and the diet should 
now be nutritious. In very obstinate cases of long duration, some one of the 
arsenical preparations may be resorted to; and Fowler's solution, Pearson's 
solution, and the Asiatic pills have all been recommended. Pevergie strongly 
recommends the tincture of cantharides, and has employed the alkaline reme- 
dies, both internally and externally, with much success. 
The local treatment is quite as important as the general. In the early 
stages irritant applications should be avoided; nor should cold be too freely 
employed, from the fear of retrocession, and the production of internal dis- 
order. Plumbe has observed an acute disease with great heat and thirst, fre- 
quent pulse, vomiting, pain in the bowels, headache, and delirium, follow 
imprudent exposure to cold in this complaint. The best local applications 400 
[part II. 
LOCAL DISEASES.-SECRETORY SYSTEM. 
are demulcent washes, such as infusion of flaxseed, slippery elm, or sassafras 
pith, and emulsion of bitter almonds. The last-mentioned preparation is 
thought to be more effective in consequence of its hydrocyanic acid; and this 
acid itself, much diluted, has been recommended as a lotion. Lime-water, 
and solution of acetate of ammonia have also been found useful; and lotions 
of diluted vinegar sometimes yield relief. In the severer forms, the blandest 
oleaginous substances should be used, such as the ointment of rose-water, or 
pure and perfectly sweet almond oil. Glycerin is also a good application. 
Powdered starch may be employed. Wilson has derived benefit, in Lichen 
agrius, from the application of collodion; and still better, as it contracts less 
in drying, is a solution of gutta-percha or caoutchouc in chloroform. The 
warm bath is very useful; but care must be taken that it is not so hot as to 
be in any degree stimulating. 
When the disease has become chronic, sulphurous or alkaline baths may 
be substituted with advantage for the simple warm bath. For the preparation 
of the alkaline bath, carbonate of potassa or carbonate of soda may be dis- 
solved in water, in the proportion of an-ounce to the gallon. These salts may 
also be used in the form of lotion or of ointment; two or three drachms to 
the pint of water being employed in the former shape, and from ten to fifteen 
grains to the ounce of lard in the latter. The sulphur vapour-bath has been 
recommended by Plumbe. When the eruption has reached the furfuraceous 
state, and continues obstinate like psoriasis, stimulating applications may be 
employed, as ointments of calomel or protiodide of mercury, of corrosive sub- 
limate in the proportion of fifteen or twenty grains to an ounce of lard, 
citrine ointment, and especially tar ointment. Erasmus Wilson has found 
greatest benefit from a tincture of the seeds of Croton Tiglium, made in the 
proportion of an ounce of the seeds to four fluidounces of alcohol. 
A papular eruption, attended with intolerable itching, and often inter- 
mingled with vesicles and pustules, and sometimes with erythematous patches 
or ulcerations, has been observed in Germany, as occurring in persons who 
pick gooseberries when ripe, or are exposed to the bushes. Jahn has found 
that this affection is owing to the attacks of minute insects of the genus Leptus. 
It is readily cured by washing the affected part with soap and water, or a 
solution of hepar sulphuris. (See Am. Journ. of Med. Sei., N. S., xx. 191.) 
3. PRURIGO. 
This is an eruption of papulae, having nearly the same colour as the healthy 
skin, and attended with excessive itching. It is closely analogous to lichen, 
and might, perhaps, without violence, be considered a modification of that 
disease. From the ordinary forms, however, of lichen it differs in the absence 
of redness, in the generally somewhat larger and less pointed pimples, though 
these are not unfrequently very small, and in the greater intensity of the 
itching. Lichen is, moreover, most commonly acute, and often attended with 
fever; prurigo, on the contrary, chronic and without fever. Neither of the 
complaints is contagious. Willan makes three varieties of prurigo; namely, 
P. mitis, P. formicans, and P. senilis. The first two differ only in degree; 
the last has some peculiarities which entitle it to distinct notice. 
The eruption in prurigo is sometimes confined to one spot, sometimes attacks 
several distinct parts at the same time, and occasionally, though very seldom, 
affects the whole surface. Its favourite seats are the neck, shoulders, back, 
and outer surface of the limbs. It is rare in the face, unless in severe chronic 
cases, and almost always spares the feet and palms of the hands. CLASS III.] 
PIMPLES.-PRURIGO. 
401 
From their want of colour, the pimples are often not observed; the atten- 
tion being chiefly directed to the small black scabs scattered here and there 
over the affected parts. These are produced by the concretion of the bloody 
exudation from the tops of the papulae, abraded by the violent rubbing, or 
scratching, to which the patient is irresistibly impelled. But the papulae are 
readily distinguished by running the fingers over the surface. They are occa- 
sionally mingled with temporary wheals, and small inflamed pustules, pro- 
duced by friction. In severe cases, along with the itching is a sense of for- 
mication and painful prickling, as if insects were crawling over the surface 
and stinging it, or as if the skin were pierced with hot needles. These sensa- 
tions are almost incessant, but are aggravated by heat, and by sudden expo- 
sure to cold, as in undressing. They are often so distressing after the patient 
has become warm in bed, as to prevent sleep for several hours. 
Under proper treatment, the disorder sometimes disappears in two or three 
weeks, usually with a slight desquamation; but it is very apt to become 
chronic, persisting for months, and sometimes, with occasional remissions or 
suspensions, even for years. Dr. Willan says that, in its milder form, it is 
sometimes ultimately converted into contagious scabies; but this is extremely 
improbable, and, when the latter affection has supervened, it has most pro- 
bably arisen from causes independent of the previously existing prurigo. The 
severer form is said by the same author to end occasionally in impetigo. 
In very old cases, of years' duration, the papulae become much enlarged, 
hardened, and sometimes confluent; the skin is thickened and often inflamed; 
the characteristic eruption is mingled with vesicles, pustules, and even boils; 
febrile symptoms and various internal disorder complicate the complaint; and 
the patient is reduced to a condition of indescribable wretchedness, too often 
beyond the reach of remedies. The want of sleep, arising from the incessant 
itching of the skin, must have a tendency to impair the general health. 
Plumbe ascribes the obstinacy of these cases to an organization of the enlarged 
papulae, consequent upon the long-continued inflammation. 
In the Prurigo senilis of Willan, the eruption is of the same kind as in the 
ordinary forms, though perhaps rather flatter, and somewhat less abundant; 
but the variety is chiefly characterized by its occurrence almost exclusively in 
the old, by the extreme severity and permanence of the itching, and by the 
obstinacy of the complaint, which often resists every variety of treatment. 
Another distinguishing feature is its tendency to generate pediculi, which are 
sometimes very numerous and troublesome. It occurs most frequently in the 
feeble, and those exposed to the privations of extreme poverty. 
Causes.-Prurigo occurs at all periods of life, and in both sexes; but is 
most common in youth and old age. It is apt to make its attacks in the 
spring and beginning of summer, though not confined to any season. Some- 
times it appears to be connected with gastric or intestinal disorder. It has 
been ascribed to rich and stimulating food, to intemperate drinking, to the 
use of various irritating or indigestible articles of diet, as salt meats, certain 
kinds of fish, pickles and vinegar, and finally to the various circumstances of 
poverty which tend to deteriorate the health, among which may be mentioned, 
confined air, unwholesome food, and mental depression. Want of personal 
cleanliness, and of the proper change of clothing, is probably one of its most fre- 
quent causes. Its source, however, is not unfrequently altogether unknown. 
In relation to the diagnosis, nothing is necessary in addition to what has 
been said under lichen. 
Treatment.-Internal remedies have little direct efficacy in this complaint. 
The first object should be to correct any existing disorder, whether of a par- 
ticular organ or of the system. Hence, the state of the stomach, of the 402 
[part it. 
LOCAL DISEASES.-SECRETORY SYSTEM. 
bowels, and of the liver should receive attention, and the menstrual condition 
should not be overlooked. If the patient is debilitated, he should be invigor- 
ated by tonics and nutritious food. The diet should be regulated. Indigesti- 
ble, irritating, and highly stimulating substances should be avoided. Bread 
and milk would be very suitable, as a substitute for meats, in plethoric indi- 
viduals. The medicines most highly recommended are sulphur and the alka- 
line carbonates, separate or combined. The compound decoction of sarsaparilla 
is also thought to have been useful. In cases of debility, the vegetable and 
mineral tonics sometimes prove serviceable. Bateman states that he has seen 
considerable benefit from solution of chlorine; and nitromuriatic acid might 
be advantageous. In a complaint so obstinate, all the ordinary alteratives 
have of course undergone a trial; but little can be said in their favour. 
"Strong purgatives, or a course of purgation, appears to be injurious; anti- 
monials and mercurials are useless; and active sudorifics aggravate the com- 
plaint." (Bateman's Synopsis.) In obstinate cases, recourse may be had to 
iodine, arsenic, or the compound solution of these two with mercury, known 
as Donovan's solution. Anodynes are often necessary to allay the sufferings 
of the patient, and to procure sleep. Dr. Burgess recommends, as peculiarly 
efficacious, the internal use of strychnia, and of phosphorus dissolved in ether. 
(See Ranking's Abstract, Am. ed., ix. 83.) 
The external treatment is more important than the internal. In mild cases, 
cures may generally be effected by frequent ablutions with warm water, or the 
persevering use of the warm-bath, though this is said at first somewhat to 
aggravate the eruption. Cleanliness of person, and a frequent change of the 
clothing are essential. Sulphurous baths are still more effectual than the sim- 
ple warm bath; and, in the advanced stages, advantage is said to accrue from 
the external employment in this way of the alkaline carbonates. (See page 
400.) Sea-bathing has also been recommended. 
Lotions of spirit, diluted vinegar, solution of acetate of ammonia, glycerin, 
liquid or unctuous preparations of aconite, weak hydrocyanic acid, and the 
liquid preparations of opium sometimes afford considerable alleviation. In 
the more obstinate and chronic cases, as in P. senilis, the applications may 
be more stimulating. A solution of corrosive sublimate or nitrate of silver 
in the proportion of two or three grains to a fluidounce of water, and the oil 
of turpentine diluted with olive oil, have been recommended as useful, not 
only for the relief of the eruption, but also for the destruction of the pediculi 
by which the skin is infested. Fumigation with cinnabar is employed for the 
same purpose. Mercurial ointment, and the ointment of nitrate of mercury 
may be used; but with care not to salivate. The ointments of sulphur, iodine, 
iodide of sulphur, tar, creasote, and oxide of zinc, have been employed with 
various success. Erasmus Wilson excites a new action by the tincture of 
croton seeds (see page 400), or the tincture of iodine. In cases so obsti- 
nate and long continued as those of P. senilis, abundant opportunity is offered 
for a great variety of remedies. Dr. Bellingham has found creasote more fre- 
quently useful than any other local remedy. He uses it in the form of lotion 
or of ointment, but prefers the latter. The ointment is made in the propor- 
tion of ten or twenty drops to the ounce of lard, the lotion in that of twenty 
or thirty drops to eight fluidounces of water, a little alcohol or acetic acid being 
added to render it more soluble. The application should be made every night 
at bedtime. (Dublin Med. Press, Sept. 8, 1847.) When ointments are used, 
care should be taken not to allow the skin to become uncleanly. Plumbe 
recommends that, when the papulae have become enlarged and organized, they 
should be destroyed by the application of caustic to each one separately. Dr. 
Tournie has found the most successful application, in cases of pruritus of the CLASS III.] 
PIMPLES.-PRURIGO.-PRURITUS. 
403 
genital, anal, and axillary regions, whether dependent on this or other forms 
of eruption, or even without apparent eruption, to be an ointment made of one 
part of calomel and six of lard, to be followed by a powder consisting of one 
part of camphor and four of starch, which is to be sprinkled on the part. 
(See Am. Journ. of Med. Sci., N. S., xxii. 226.) 
Sympathetic Pruritus.-Under the head of prurigo are usually considered 
certain affections characterized by severe itching of the skin, with very little 
or no papulous eruption. The itching, in many of these cases, is merely 
sympathetic of internal irritations, especially when seated near the termina- 
tions of the mucous passages. Thus, itching about the nostrils is often de- 
pendent upon worms, or some other irritating matter in the stomach or 
bowels; about the anus, upon ascarides in the rectum; about the end of the 
urethra, upon irritation of the bladder or its neck; about the labia pudendi, 
upon disorder of the uterus or vagina. Occasionally, a general pruritus, or 
one affecting different parts of the surface at different times, occurs without 
eruption, and dependent entirely upon some internal derangement of func- 
tion. Such cases are sometimes mistaken for prurigo or psora, in conse- 
quence of the small bloody scabs which attend them, and which, though the 
mere consequence of slight excoriations by the nails, are apt to be looked 
upon as marks of abraded pimples or vesicles. It is highly important to form 
a true diagnosis; for the attention will then be directed to the real source of 
the evil, and those measures adopted by which alone relief can be obtained. 
Of course, the remedies must be adapted to the peculiar condition of system, 
or the special derangement of function which may be found in any particu- 
lar case, and must, therefore, be left to the discretion of the practitioner. 
Sometimes local pruritus is produced by disordered secretion of the part 
affected, or its immediate neighbourhood. Such is the case occasionally with 
itching of the prepuce, which depends on derangement of the sebaceous secre- 
tion around the corona glandis. Not unfrequently also it proceeds from in- 
sects, especially when it affects the parts about the genitals. In the former 
case, it will be cured by occasional lotions of the salts of zinc or lead; in the 
latter, by shaving the parts, and keeping them perfectly clean, or by the use 
of mercurial ointment, or a weak solution of corrosive sublimate. 
In other instances, the itching cannot be accounted for; no disordered 
secretion, no eruption, and no disease of neighbouring internal organs being 
discoverable. The affection is purely nervous, and analogous to neuralgia. 
It may sometimes possibly be one of the forms in which a gouty or rheu- 
matic diathesis displays itself. Affections of this kind, attacking the anus 
and external genitals, both in males and females, are in some instances exceed- 
ingly distressing, depriving the patient of sleep, impairing his health, and 
almost excluding him from society, by the impossibility of abstaining from 
rubbing or scratching the part affected. One of the evil consequences is 
occasionally the production of a habit of masturbation, and a consequent de- 
terioration of the moral sense. Few affections are more distressing than some 
of the cases of this kind recorded by writers. In attempting to relieve them, 
remedies should be addressed to the general system, calculated to alter the 
character of the nervous actions; such as narcotics, the chalybeates in large 
doses, sulphate of quinia, and in short, all those means which are considered 
useful in neuralgia. Various local measures have also been recommended. 
The applications before mentioned as employed in protracted cases of Prurigo 
senilis may also be used here. It is unnecessary to repeat them. Leeches, 
emollient poultices, demulcents, and narcotic lotions, ointments, or cata- 
plasms, will sometimes afford relief. Scrupulous attention should be paid to 
cleanliness. 404 
[PART II. 
LOCAL DISEASES.-SECRETORY SYSTEM. 
I have not deemed it necessary to describe the pruriginous affections under 
the distinct names which writers have attached to them; such as Prurigo 
pudicis, P. pudendi muliebris, P. pubis, P. praeputii, &c. It is sufficient 
to have given a general etiology and principles of treatment, which may 
readily be applied to any particular case. 
Article III. 
VESICULAR DISEASES. 
1. HERPES. 
Before the reform introduced by Willan into the nomenclature of cutane- 
ous diseases, this term was applied vaguely to various very different affections. 
At present, writers in general follow that dermatologist in restricting it to a 
vesicular eruption, occurring in circumscribed patches, upon an inflamed base, 
which extends somewhat beyond their margin, leaving portions of sound skin 
between them. It may or may not be associated with constitutional dis- 
turbance. In the severer cases, the eruption is generally preceded or attended 
by more or less fever, but not so in those of a milder grade. There is almost 
always a greater or less degree of burning pain, itching, and tingling; and 
sometimes the local suffering is very considerable. The complaint usually 
runs its course in a period varying from one to three weeks, and is very rarely 
chronic. The lymph in the vesicles, at first perfectly limpid, gradually be- 
comes milky and opaque, and at length concretes into scabs, which fall off, 
leaving a temporary redness of the skin. In some cases, a copious serous 
exudation takes place, the patches become superficially ulcerated, and even 
gangrene may ensue. But such cases are comparatively rare. In all its 
forms the disease is essentially mild, and never terminates unfavourably, 
unless accompanied with some vice of constitution, which would impart ma- 
lignancy to the gentlest affection. 
In its severer forms, herpes bears some resemblance to erysipelas, which is 
in like manner often attended with a copious vesicular eruption upon an in- 
flamed surface; but the former disease may be readily diagnosticated by its 
distinct clusters, with skin of the natural colour intervening. 
The causes of herpes are very obscure. Sudden exposure to cold in a state 
of perspiration from heat or over-exertion, the direct action of irritants, and 
strong mental emotion, have been enumerated among its occasional causes; 
but they probably operate only by calling a pre-existing disposition into action. 
It is said to have sometimes occurred epidemically. It is most frequent in 
the young, and in persons with a delicate skin. 
The following are the varieties generally recognized. They differ chiefly 
in the mere position or form of the vesicular patches. 
1. Herpes zoster.-Zona.-Shingles.-In this variety, the clusters are 
situated upon one side of the trunk, and are arranged in succession, so as to 
form an irregular band, with one extremity directed towards the spine, the 
other towards the sternum or linea alba. This band often extends one-half 
round the body, sometimes in a direct course, sometimes obliquely, and, in 
the latter case, though beginning on the trunk, it occasionally terminates 
either upon the thigh, or the arm. In some instances, the clusters commence 
in the middle of this line and extend at each extremity; sometimes they 
occur first at opposite points of the trunk, and approach each other in the 
middle. It is a singular fact, that in the great majority of cases they occupy CLASS III.] 
VESICLES.-HERPES. 
405 
the right side, and that they very rarely pass the median line of the body. 
It is, indeed, asserted by some writers that the eruption never transcends 
these limits; and that, when it has appeared to do so, it was Herpes phlyctae- 
nodes and not the shingles. But this is making the phenomena of a disease 
bend to a definition. There can be no doubt that the shingles sometimes extend 
more than half round the body, and cases have been observed in which they 
have extended quite round it. The popular notion that such cases are ne- 
cessarily fatal, is without the least foundation. Sometimes the row of clusters 
occupies the neck, or the side of the head, instead of the trunk; but in this 
case, also, it observes the general law of stopping at the middle line. 
Each cluster consists of numerous roundish vesicles, which are very minute 
at first, but when mature are generally of the size of pearls, and sometimes 
as large as a split pea or larger. They are often confluent, sometimes over 
a considerable surface. The red margin extends but a short distance beyond 
the vesicles. The clusters are irregular in shape and size, generally somewhat 
longer in the direction around the body, and varying from one to three inches 
in diameter. They do not in general all occur at once, but succeed each other, 
and one has sometimes begun to fade before another is completely formed. 
The limpid fluid of the vesicles becomes opaque in three or four days, when 
they gradually decline, and the scabs usually fall off about the twelfth or 
fourteenth day; but as the clusters appear successively in point of time, and 
each runs its own course, the whole duration may extend to three weeks or 
more. Sometimes, from the friction of the clothes, or other causes, the 
patches ulcerate, and tedious sores result. 
The eruption is usually preceded for two or three days by febrile symp- 
toms, with anorexia, general uneasiness, lassitude, &c., which are sometimes 
relieved when the clusters appear, sometimes continue in a greater or less 
degree in consequence of the irritation of the local affection. The patient 
often suffers considerably from the burning and smarting pain of the erup- 
tion; and not unfrequently experiences severe shooting pains more deeply 
seated in the trunk. 
In relation to the causes of shingles nothing need be added to what has 
been said of those of herpes in general. Its diagnosis is never difficult. 
2. Herpes phlycteenodes.-The clusters of this variety of herpes are irregu- 
lar, and have no fixed position. They occur most frequently on the cheek, 
neck, arms, or breast, more rarely on the lower extremities. Sometimes 
commencing on the breast, they spread successively over the whole trunk. 
When the eruption is thus extensive, the vesicles are usually very small. 
When larger, as in shingles at maturity, the clusters are very few, not often 
exceeding two or three in number; and sometimes there is only one. The 
affection runs a rather shorter course than shingles. Each cluster usually 
completes its series of changes in a week or ten days; and the whole duration 
of the attack seldom exceeds two weeks. In some very rare cases, the affec- 
tion assumes a chronic character, and it has been known to run on for months. 
In such instances, the clusters are very few or quite solitary. The general 
symptoms, and local sensations, do not materially differ from those of Herpes 
zoster, though on the whole somewhat more moderate. 
3. Herpes circinatus.-Ringworm.-The distinguishing character of this 
variety of herpes is the occurrence of the vesicles in circular patches. In 
the common form of it, the vesicles appear at the circumference, forming a 
ring with a portion of skin in the centre free from eruption. Hence the popu- 
lar name of ringworm, which it shares with other eruptive affections having 
a similar shape. The seat of it is usually in the upper portions of the body, 
as the face, neck, arms, and shoulders, and more rarely on the lower extre- 406 
[PART II. 
LOCAL DISEASES.-SECRETORY SYSTEM. 
mities. The vesicles are usually very small, sometimes so as to require a close 
examination, in order to be detected. They rise upon an erythematous ground, 
though the surface is perhaps less vividly red than in the other varieties men- 
tioned. The vesicles usually break in three or four days, forming minute 
scabs, which fall off in about a week. But, as the clusters appear successively, 
the complaint often has a course of two or three weeks. It is seldom attended 
with fever or other constitutional disorder; and the local sensations, amount- 
ing generally only to a moderate tingling and itching, are less severe than in 
II. zoster and H. phlyctaenodes. This variety of ringworm occurs most fre- 
quently in children; and sometimes under circumstances which have encou- 
raged the notion of its contagious nature, several members of the same family 
being affected at the same time. But this is owing not to contagion, but to 
similarity of exposure. 
Care is sometimes required to distinguish this affection from Trichosis fur- 
furacea (Porrigo scutulata of Willan), and Lichen circumscriptus, which have 
a similar form, and are also called ringworm in popular language. Trichosis 
furfuracea is a cryptogamous affection, and will be more particularly described 
hereafter. Lichen circumscriptus is papulous, and has no vesicles. In the 
herpetic ringworm, though the vesicles are often very minute, either they or 
their remnants maybe detected upon close examination. Besides, the borders 
are more inflamed than in lichen, and the central portion, which in the latter 
is usually filled with pimples in the earlier stages, exhibits in the former either 
a sound state of the skin, ora slight redness, and only becomes somewhat fur- 
furaceous when the affection is declining. 
Occasionally this variety of herpes takes on a much more aggravated cha- 
racter. The patches, instead of disappearing as the first ring of vesicles de- 
clines, is enlarged by a new crop at the circumference, and this, in its turn, 
is followed by another, and thus the circle goes on widening, until it embraces 
a large extent of surface. In some cases, the vesiculated surface ulcerates, 
even to a considerable depth, and the complaint exhibits a succession of belts 
in this state, an outer one forming as fast as the inner heals. This would 
fall under the title of Herpes exedeus, which has been given to the affection 
when it assumes an ulcerative character, with a disposition to advance. It is 
sometimes very obstinate. 
The cases described by Bateman under this head, as consisting of circles 
filled with crowded vesicles, surrounded by an inflamed border, occurring 
successively upon various portions of the body, and attended with much burn- 
ing pain, and more or less fever, would seem to belong properly to 11. phlyctee- 
nodes, from which they differ merely in the regularity of the circumference 
of the patches. 
Another form of herpes, first noticed by Bateman, and denominated by him 
Herpes Iris, exhibits circular patches, consisting of concentric rings of differ- 
ent shades of colour; an arrangement from which it derived its name. It 
occurs usually upon the hands or arms, and sometimes on the instep. The erup- 
tion first appears as an efflorescence, which soon becomes distinctly vesicular, 
the central vesicle being yellowish-white, the ring immediately around it brown- 
ish-red, the second ring nearly of the same colour as the centre, the third 
narrower and dark-red, and the fourth of a light-red hue, forming a kind of 
areola, which gradually fades into the colour of the skin. The patches are 
small at first, and increase till they are three-quarters of an inch or more in 
diameter. They arrive at their height in a week or nine days, are stationary 
for about two days, and occupy a week more in their decline. They are at- 
tended with no constitutional disorder. The affection is slight, and very rare. 
It may, without violence, be placed with H. circinatus. ' CLASS III.] 
VESICLES.-HERPES. 
407 
4. Herpes labialis.-This is distinguished merely by its locality, occurring, 
as its name implies, about the lips, of which it occupies a greater or less por- 
tion, being sometimes confined to a part of one lip, or to an angle of the 
mouth, sometimes extending from one angle to the other along the upper or 
lower lip, and sometimes surrounding the whole mouth, by a succession of 
clustered vesicles. There is first a burning sensation, with redness, which is 
soon followed by vesicles; and the lip becomes hard, swollen, and often very 
painful. The lymph of the vesicles gradually becomes opaque, and sometimes 
purulent scabs begin to form in three or four days, and the disorder disap- 
pears entirely in ten or twelve days, or a shorter time. Sometimes the erup- 
tion occurs as an original affection with febrile symptoms, and occasionally 
soreness in the fauces, which, upon examination, exhibit vesicles similar to 
those upon the lips. More frequently, however, it is an attendant upon other 
complaints, such as catarrhal, intermittent, remittent, and typhoid fevers, and 
the different phlegmasiae, in which its occurrence may be considered as a 
favourable sign, as it generally marks the commencement of convalescence. 
5. Herpes preeputialis.-The peculiarity of this, like the last-mentioned 
variety, consists merely in its position, which is upon the prepuce, either upon 
its outer or inner surface. The clusters are very small, consisting each of five 
or six minute vesicles, which, if undisturbed, run the ordinary course, and get 
well in ten or twelve days. When on the inner surface, from the delicacy of 
the epithelium, they are apt to break, and end in superficial ulcers, which, 
from the irritation of the secretions of the part, the motions of the prepuce, 
or improper applications made under the impression of their syphilitic origin, 
become sometimes obstinate sores. This affection is distinguishable from 
syphilis by its vesicular origin, its occurrence in clusters, and, after ulceration, 
the superficial character of the ulcer, and the absence of those abrupt and 
hard edges, and that adhesive yellowish-white exudation on the surface, which 
characterize chancre. 
Treatment.-As herpes almost uniformly runs a favourable course, unless 
interrupted by disturbing causes, all that is, in general, requisite in the treat- 
ment is to guard against the operation of such causes, and to relieve the symp- 
toms when severe and painful. In reference to the first indication, stimulating 
food and drink should be avoided; the patient should remain at rest when the 
eruption is considerable, and especially when attended with constitutional 
symptoms; and care should be taken to prevent irritation of the inflamed sur- 
face by the friction of the clothes, or by stimulating applications. When the 
eruption is seated in the face, the patient should avoid exposure of the part 
to the sun, or to a hot fire. 
If the complaint should be attended with febrile symptoms, cooling acidu- 
lous drinks, a strictly antiphlogistic diet, saline laxatives, and refrigerant dia- 
phoretics, may be directed. When the pain is severe, opiates may be added; 
and the best preparation is probably Dover's powder. Should the local affec- 
tion show a tendency to gangrene, from a scorbutic state of system, or general 
debility, as sometimes happens in old people, the strength must be supported 
by tonics, moderately stimulating drinks, and nutritious food. 
The local treatment is, in general, not less simple. When the inflammation 
is considerable, and the sensations of the part distressing, recourse may be 
had to cooling or demulcent lotions, as flaxseed tea, infusion of slippery elm, 
and weak solution of acetate or subacetate of lead; and, if the eruption is 
extensive, relief will be obtained by the occasional use of the warm-bath. It 
has been proposed to destroy the vesicles by nitrate of silver; but this is 
unnecessary in a complaint so favourably disposed, and of so short a duration. 
In mild cases, it will be sufficient merely to protect the affected surface, when 408 
[part II. 
LOCAL DISEASES.-SECRETORY SYSTEM. 
upon the trunk or extremities, by soft and fine linen. Should the surface be 
moist or ulcerated, it should be dressed with simple cerate, or spermaceti 
cerate, to prevent the adhesion of the clothes. When the ulcer appears indis- 
posed to heal, G-oulard's cerate may be applied, at first somewhat diluted with 
simple ointment, and afterwards, if necessary, undiluted. . Collodion, and 
solutions of gutta percha or caoutchouc in chloroform, have also been usefully 
employed, with the view of protecting the surface from the air. Cazenave 
recommends the application of a powder composed of one part of oxide of zinc 
and fifteen of starch. Should the case become chronic, and especially if the 
ulceration seem disposed to advance, it may be necessary to make use of mild 
caustic remedies, such as nitrate of silver or sulphate of copper. 
In II. circinatus, no internal remedies are, as a general rule, required. 
The tingling and itching may be relieved by very weak solutions of sulphate of 
zinc, sulphate of iron, sulphate of copper, alum, or elixir of vitriol; and these 
applications appear to shorten the duration of the complaint. Ink is often 
popularly employed for the same purpose, and the frequent application of 
saliva is recommended by some writers. Alkaline lotions are also recom- 
mended. In the ulcerative and spreading variety, the caustic treatment above 
advised may be cautiously tried, and especially the use of nitrate of silver. 
H. labialis requires only the cooling or slightly astringent lotions above 
mentioned. Relief may here often be obtained by anointing the lips fre- 
quently with fresh cream cooled by ice, or with glycerin. 
II. prseputialis may be treated by the same astringent lotions, care being 
taken that they are not made too strong; but generally it will be sufficient to 
guard the part against irritation from the clothing, or the frequent motion of 
the prepuce. When the eruption is seated on the inner surface, it will be 
proper to introduce some dry lint to prevent the contact of the opposite sur- 
faces, and to absorb irritant secretions. Should the irritation be considerable, 
it may be proper to inject demulcent liquids carefully beneath the prepuce, 
and to employ emollient applications without. 
The various irritant substances recommended by different authors in her- 
petic eruptions have reference to other and more obstinate affections, which 
were formerly confounded under the title of herpes. 
2. ECZEMA. 
This name was given by Willan to a non-contagious eruption, consisting 
of minute vesicles crowded together in irregular patches, with or without 
surrounding redness. It may be most conveniently considered under the 
two conditions of acute and chronic eczema. 
Acute Eczema.-In its mildest form (Eczema simplex'), this appears in 
patches of very minute, closely crowded vesicles, glistening and transparent, 
with little or no intervening redness, without fever, and with no other local 
sensations than a disagreeable itching and tingling. In a short time, the 
serum in the vesicles becomes turbid or lactescent, and is either absorbed, or 
exudes and forms a minute scale, which soon separates, leaving the skin per- 
fectly sound. The whole course of the eruption occupies from one to three 
weeks ; but, as the crop of vesicles is sometimes renewed, the affection may 
continue much longer. 
In a severer form (Eczema rubrum), the eruption is generally preceded 
and always accompanied by inflammation and redness of the skin. The 
vesicles show themselves at first like glistening points, which can scarcely be 
seen to contain a liquid, unless by the aid of the microscope. These enlarge, 
and when fully developed have about the size of a pin's head. In the mildest CLASS III.] 
VESICLES.-ECZEMA. 
409 
cases, the vesicles dry up in about a week, and are succeeded by desquama- 
tion, after which the surface remains of a reddish colour for a few days, and 
then resumes its healthy appearance. In the severer cases, the preceding and 
attendant inflammation is of a higher grade, with much heat, some swelling, 
and a vivid redness. Instead of drying up, many of the vesicles break, and a 
serous fluid exudes, often very copiously, which irritates and excoriates the 
skin, and thus increases the exuding surface. After a time, the secretion dimi- 
nishes, and the extravasated liquid concretes into thin soft scales, which, upon 
separating, are followed by others several times successively; the surface of 
the skin after each separation being still red and inflamed. If a favourable 
termination is to take place, the exudation gradually ceases, the scales become 
firmer and more adherent, and upon separating leave the skin less inflamed; 
and, at the expiration of two or three weeks, the diseased surface resumes its 
healthy appearance. But frequently new crops of vesicles show themselves, 
either upon the part previously affected, or upon the surrounding healthy skin, 
so as to extend, in some instances very greatly, the limits of the disease. When, 
by the successive eruption of new vesicles, the affection is kept up for two or 
three months, it may be considered as having assumed the chronic form. 
In other cases (Eczema impetig inoides), the eruption, though at first vesi- 
cular, assumes afterwards a pustular form, similar to that of impetigo. The 
liquid in the vesicles becomes opaque, yellowish, and apparently purifornK^ 
and, upon concreting, gives rise to soft yellowish scabs. These soon separate, 
leaving inflamed surfaces, that exude a reddish liquid, and again cover them- 
selves with scabs or scales, to go through the same process as those which 
preceded them. Gradually, however, the surface becomes less inflamed, the 
scales thinner and drier, and the skin returns to its healthy state in the 
course of two or three weeks, unless the disease degenerate into the-chronic 
form. It is worthy of note that, in E. impetiginoides, though most of the 
eruption may have this apparently pustular form, yet very frequently some 
of the proper eczematous vesicles may be seen either upon the margin of the 
patches, or within them. 
In either of the above varieties, the affection may be confined to a single 
surface of variable extent, or may spread, in successive patches, more or less 
extensively over the body. Sometimes it happens that, when the affection 
becomes general, some of the patches may be renewing and extending them- 
selves by successive crops of vesicles, while others are healing. When the 
disease is extensive, it is very apt to give rise to fever. In all its forms, it 
is attended with disagreeable,.sensations, such as itching, tingling, burning, 
&c.; which, in severe cases, are almost intolerable. 
In young and healthy persons, with a fair and delicate skin, though the 
eruption may rise more quickly to its height, it yet declines more rapidly, 
and leaves at last no observable traces behind it. But in the old, and those 
with dark, dry, and harsh skins, the inflammation is apt to extend to the sub- 
cutaneous tissue; the denuded surface becomes fissured ; the healing process 
is slow and interrupted; and, when the disease has disappeared, it leaves 
behind a brown or brownish colour of the affected part, which continues for 
years, and often for life. (BietE) 
Chronic Eczema.-This results from repeated and successive crops of the 
vesicular eruption, appearing before the effects of those preceding them have 
ceased. The vesicles soon break, and the serous exudation sustains a con- 
stant inflammation. The skin becomes excoriated and fissured; covers itself 
with scales or scabs, which fall and are replaced by others; and, when the 
disease spreads extensively over the body, presents a great diversity of appear- 
ances at the same time in different parts of the surface. Thus, in one spot 
are the forming vesicles; in another, the excoriated and perhaps bleeding sur- 410 
LOCAL DISEASES.-SECRETORY SYSTEM. 
[PART II. 
face; in a third, scabs or scales in various stages of developement or decline: 
in a fourth, loose cuticle, as if separated by a blister; and, almost everywhere, 
except in portions of the skin which remain sound, marks of more or less ini 
flammation, with redness, swelling, and tenderness. The quantity of liqunT 
poured out from the ruptured vesicles and excoriated surfaces is sometimes 
very great, saturating the clothes of the patient, and not unfrequently causing 
them to adhere in places, so as to tear the skin, and occasion bleeding when 
they are separated. The tenderness of the inflamed skin is sometimes such 
as to render the pressure of the body very painful in lying. If the excoriated 
surfaces be examined, they will exhibit numerous small pores, from which 
liquid constantly oozes. When the loose cuticle or concrete scales are removed, 
the surface sometimes appears covered with a whitish cheesy exudation. While 
in the moist state, the skin exhales a peculiar, stale, disagreeable odour. The 
sensations of the patient are often in the highest degree tormenting. It is not 
severe pain of which he complains, but excessive burning and itching, which 
render it impossible for him to refrain from violently scratching and almost tear- 
ing the skin with his nails; and the sensation of pain, with the loss of blood thus 
produced, affords temporary relief. At length the inflammatory susceptibility of 
the skin appears to be exhausted; the vesicles cease to be renewed or are much 
diminished; the liquid exudation gradually dries up; and there is left behind 
pendency to the constant and successive production of scales upon the dis- 
eased surfaces, which, at first soft, yellowish, and thickish, become gradually 
dryer, thinner, and whiter, and at last assume the form of the exfoliations 
in psoriasis, or even the furfuraceous appearance of pityriasis. Finally, these 
scales become fewer and fewer till produced no longer; the surface of the skin 
beneath them loses its red colour, and returns slowly to its natural state; and 
the patient recovers his health after many months, perhaps years of suffering. 
Parts affected.-Dermatologists are not agreed as to the precise seat of the 
disease. Bayer and others place it essentially in the cutaneous follicles; Biett 
in the superficial layer of the skin, the office of which is to secrete the epidermis. 
The eruption may appear upon any portion of the surface; but there are 
certain parts which it especially affects. The parts covered with hairs, as 
the scalp, pubes, &c., are very apt to be attacked by it. It occurs also not 
unfrequently in the flexures of the joints. It may be confined to one single 
patch, or may consist of distinct clusters, scattered more or less extensively, 
sometimes in one region of the body, and sometimes, though more rarely, 
over the whole surface. 
In the scalp, it may be partial or general. In the latter case, it is apt to 
spread to the nape of the neck, the ears, and the face. In the earlier stages, 
the hair is matted together by the copious exudation. In the more advanced 
stages, scales or scabs are formed; and the singular phenomenon is presented, 
of a large number of hairs penetrating one scab, which has concreted around 
their base, and is raised with them as they grow above the level of the skin. 
The disease is often complicated with bleeding wounds from the nails of the 
patient, small subcutaneous abscesses, swelling of the glands of the neck, 
scabs from intermingled impetiginous pustules, and innumerable pediculi. In 
time, the ichorous discharge ceases, and the affection becomes scaly or furfura- 
ceous ; and, before recovery, the hair is sometimes permanently lost from por- 
tions of the scalp. The complaint has frequently been mistaken for impetigo 
and porrigo, from which it is distinguishable by the vesicular character of the 
eruption. It often occurs in infants and children during dentition; and is 
thought by some to be rather favourable to health, by giving an external 
direction to the irritations incident to that period of life. Children have been 
noticed to be in good general health during the continuance of the eruption, 
and to suffer upon its removal. CLASS III.] 
VESICLES.-ECZEMA. 
411 
From the head it sometimes descends to the face, where it undergoes similar 
changes, ^nd constituiesjme of the affections referred to By writers under the 
name of prustfi lactea. W may originate also in this position. When hi the 
face, it i^ apt to pass tg the conjunctiva; producing^phthalmia, ancMuto the 
nostrils and mouth, caarang.inffimmation i.n.tlie linitm membram^nd a copious 
serous Secretion. It »m«1^e£'destroys tbe eyebrows \nd_j2ydmshes. The 
ears, when attacked by iff swell verySmuch both externally and within the 
meatus, which sometimes becomes the seat of small abscesses, and a very ob- 
stinate purulent discharge. 
In middle-aged men, the disease is disposed to attack the inner and upper 
part of the thighs, the genitals, and arms, where it keeps up an irritation and 
excessive itching, which k inconceivably harassing. Women also suffer much 
from the disease in the s®ne situations, and in them it occasionally attacks the 
inner surface of the labiproducing effects which, without careful examina- 
tion, may be mistaken for leucon-hcea or gonorrhoea. The excessive itching, 
however, would lead to the suspicion of eczema, and the discovery of some 
vesicles upon inspection would determine the nature of the affection. 
In the flexures of the joints, in the axilla, the groin, the bend of the 
elbow and of the knee, it i* «Qen ^ry troublesome, producing in the end a 
thickened state of the skin, with cracks or fissures, and a scaly condition of 
the surface, which obstinately resists treatment. 
It occurs not unfrequently flpon the arm, forearm, and hand, and between 
the fingers, where it may be mistaken for the itch. Sometimes, though rarely, 
it affects the palms, where it is somewhat modified by the thickness of the 
cuticle, which prevents the escape of the serum. 
Causes.-These^are-generally such as act through the constitution ; for, 
though local irritants will sometimes excite the disease, it requires a peculiar 
predisposition to give the irritation this particular form. Among the causes 
acting through the system are, in children, the unhealthy milk of nurses, and 
dentition; in adults, derangements of menstruation, pregnancy, the parturient 
condition, and the change of'Jife in women, and intemperance in both sexes. 
Inheritance and epidemic influence are also among the causes. The mercurial 
influence is said occasionally to produce it; and a variety of the disease has 
received its name (Eczema mercurials') from this supposed origin. I have 
been, during my whole professional life, in tjae habit of prescribing mercury, 
both in private and hospital practice, and do'not recollect to have seen a case 
of eczema from that cause. There can, however, be no doubt that it has often 
appeared during a mercurial course; and the circumstance that it has disap- 
peared upon the cessation of the mercurial action would seem to prove, that 
the presumed is, in some instances at least, the real cause. 
Among the local excitant causes are the direct rays of the sun, long expo- 
sure of any portion of the surface to artificial heat, blisters and rubefacients, 
and various irritants to which the hands of certain artisans are peculiarly ex- 
posed, as cooks, bakers, sugar refiners, dyers, and workers in metals. A dis- 
tinction, however, must be made between this disease and the vesicular eruption 
produced by certain irritant substances, as occasionally by Burgundy pitch, 
croton oil, &c., which subsides as soon as the irritant is withdrawn, and never 
runs through the protracted course of eczema, in itb more obstinate forms. 
Willan gave the name of E. solare to the, eruption .produced by exposure to 
the sun upon the face, hands, &c. It may be doubted how far this properly 
belongs to the disease under consideration. As often seen, the vesication 
from exposure to the sun is only a sligh^Jaffection which yields immediately 
upon the removal off the causef^nd the application of demulcents. It is 
possible, however, that the heat of the sun, like other irritants, may call a 
predisposition into action, and thus give rise to the genuine disease. There 412 
[part II. 
LOCAL DISEASES.-SECRETORY SYSTEM. 
is no reason to think that eczema is contagious. Instances are mentioned in 
which it appears to*have been communicated by contact; but they are few; 
and the secretion in these cases probably acted on ajf existing predisposition, 
like any'other irritant. The time of life E^pears to have no effect as a pre- 
disposing cause; for all ages are liable to the disease, from birth upward; but 
it has some influence in fixing the seat of the affection. Infants and young 
children are peculiarly liable to have it in the scalp and face; adults in early 
or middle life, upon the arms, the trunk, or about the genitals; and old per- 
sons, upon the lower extremities. 
Women are more frequently affected than men, perhaps in consequence of 
the disturbing influence of their peculiar sexual functions. The disease is 
more apt to appear in spring and summer, than in autumn or winter. 
Diagnosis.-In its three different stages, eczema is liable to be confounded 
with three different kinds of eruption; namely, with the vesicular affections, 
such as herpes, the miliary eruption, and scabies, in its early or proper vesi- 
cular stage; with lichen agrius and impetigo, in its stage of excoriation and 
puruloid secretion; and with pityriasis or psoriasis, in its last, or scaly stage. 
But in herpes, the vesicles are larger and more hemispherical, the patches 
are surrounded by a broader margin of, redness, and there is not the same 
disposition to the copious effusion of serum. The miliary eruption, though 
widely diffused, is isolated, and not in patches, and is besides attended with 
much more violent constitutional derangement. For scabies, the complaint 
is particularly liable to be mistaken when between the fingers, or in the 
flexures of the joints; but the diagnosis will be better given when that com- 
plaint is treated of. From lichen agrius it may be distinguished by the ex- 
istence of some vesicles on the borders, or even within the limits of the patch, 
while in lichen, any eruption which may be observed is papular. Eczema, 
even when most like impetigo, differs from it in the vesicular character of 
the eruption as it first appears, in the continued occurrence of some vesicles 
even in the advanced stage, and in its thinner and firmer scales. The same 
occasional appearance of vesicles, even in the most advanced stage, will suffi- 
ciently distinguish it from the proper scaly diseases, especially if opportunity 
has been afforded of ascertaining its early vesicular character, and its suc- 
cessive changes before attaining the scaly form. 
Prognosis.-In its lighter forms, eczema is a trivial affection, getting well 
in a week or two, without other inconvenience than a disagreeable itching. 
Even the severer forms of it, though distressing while they last, often termi- 
nate favourably in two or three weeks. In its chronic state, it is sometimes 
very obstinate, continuing occasionally for years, and proving a source of in- 
expressible discomfort; but it is without danger, is often attended, even in its 
worst condition, with surprisingly little disorder of the constitution, and al- 
most always ends in recovery. During dentition, it may sometimes be looked 
upon as a safeguard to the system, and caution is necessary in the employ- 
ment of repellent measures. When accompanied, in the female, with de- 
ranged menstruation, it will often refuse to yield during the continuance of 
that disorder. When attendant upon pregnancy, it is said seldom to disap- 
pear until after delivery. There may be some risk in curing very old cases 
of the disease; and an instance of insanity is recorded which resulted from 
such a cure. The inference is, that when attempts are made to subvert a 
very old eczema, its place should be supplied by a seton or issue. <• 
Treatment.-I shall first speak of the general, and afterwards of the local 
treatment. In mild acute cases, no other general remedies are required than 
gentle purgation with the saline cathartics; the use of small doses of the 
antimonials and neutral mixture, with refrigerant drinks, when the pulse is 
somewhat excited; a light and easily digestible diet; and a careful avoid- CLASS III.] 
413 
VESICLES.-ECZEMA. 
ance of all known exciting or predisposing causes. Sometimes a purgative 
dose of calomel may be advantageously given to children. In the severer 
cases, with considerable general excitement, or much local inflammation, it 
may be proper to take blood from the arm; to employ the antimonials and 
refrigerant cathartics more freely, and to restrict the diet to vegetable food. 
Acetate of potassa, in the dose of thirty grains, three times a day, has been 
employed with the happiest effects, producing cures in many cases in one or 
two months. (Easton, Ed. Month. Journ. of Med. Sci., May 1850, p. 422.) 
To procure rest, it is necessary sometimes to have recourse to opiates, or 
some other narcotic, as the extract of hyoscyamus or conium, with which it 
will be proper, if there is fever, to combine ipecacuanha or tartar emetic. 
In the chronic form of the disease, various remedies have been recom- 
mended. The mineral acids, the carbonates of potassa and soda, and the 
decoction of dulcamara, have each had their advocates. In the very old cases, 
recourse must be had to more powerful alteratives. Tincture of cantharides 
is said to have proved very efficient, given at first in moderate doses, and 
gradually increased as the patient could bear it. Biett places great reliance, 
in such cases, upon the use of the preparations of arsenic. The solution of 
arsenite of potassa may be used; but he prefers the arsenate of soda and that 
of ammonia, which he gives in the dose of of a grain dissolved in water, 
and gradually increased to the jg or | of a grain. In old cases, however, in 
which it is necessary to persevere long with the remedy, even for years in 
some instances, the smaller dose should be adhered to. The influence of 
mercury is sometimes found useful; but the mildest preparations should be 
employed, and profuse salivation avoided. A yery slight effect, maintained 
for a long time, is indicated. Iodine may also be tried with some hope of 
benefit; and recourse may be had to Donovan's solution, as combining the 
three last-mentioned powerful remedies in one. Solution of chloride of cal- 
cium has been recommended in scrofulous cases. In the advanced stages, 
my own experience has been decidedly in favour of Fowler's solution, with 
decoction of dulcamara. From three to five drops of the solution, and two to 
four fluidounces of the decoction should be given three times daily, and con- 
tinued if necessary for several months, with occasional intermission, if either 
of them should be found to affect the system too strongly. 
The local treatment is important. In the acute cases, mucilaginous liquids 
and emollient cataplasms are indicated; to which, when there is considerable 
inflammation, a solution of acetate of lead may be added. Care should be 
taken to avoid everything irritant in these applications. Hence,.all the in- 
gredients should be quite free from mustiness or rancidity. Perhaps the best 
mucilage is that of the slippery elm, and the best poultice that made of bread 
and milk. Glycerin is also an excellent, and at the same time convenient 
application. Should the inflammation be severe, leeches may be applied in 
the neighbourhood. When the disease is extensive, warm and mucilaginous 
baths should be substituted for the more limited emollient, and the patient 
should continue in them for an hour at a time. 
To relieve the excessive itching, recourse may be had to anodyne and 
soothing applications, such as emulsion of bitter almonds, decoction of dul- 
camara or of poppy heads, and infusion of opium or solution of the salts of 
morphia; care being taken that this latter application be not so strong as 
materially to affect the system. 
Cauterization by nitrate of silver or other escharotic has been employed in 
the early stage, but with variable results; and, upon the whole, this class of 
remedies is not deemed advisable. Nevertheless, I have seen a case of the 
complaint yield quickly to tincture of iodine applied to the diseased surface. 414 
[PART II. 
LOCAL DISEASES.-SECRETORY SYSTEM. 
In the chronic affection, while the fresh crops of vesicles continue to appear, 
recourse should continue to be had to the measures above mentioned. In the 
state of excoriation, the cerate of subacetate of lead may be applied with the 
hope of benefit. The effect of excluding the air by the application of solu- 
tions of gutta percha or caoutchouc in chloroform may be tried. Ointments 
of oxide of zinc and of magnesia have sometimes effected cures. The same 
oxide may also be used in the form of powder, mixed with fifteen parts of 
starch. The lime liniment of the pharmacopoeias has been recommended. 
In the more advanced stages, when the affection has become scaly, the hot 
bath, vapour bath, or hot douche may be substituted for the warm bath. 
Solutions of the alkaline carbonates, in the proportion of two or three drachms 
to a pint of water, are thought to have proved useful as local remedies. They 
may be applied by means of linen compresses. Similar solutions may be used 
in the form of a bath, which may contain from four to eight ounces of the 
carbonate of potassa or of soda. Sulphur baths are said to have sometimes 
proved beneficial. Certain stimulant ointments are often highly useful. 
Among them, the ointments of calomel, iodide of mercury, nitrate of mer- 
cury, and iodide of sulphur, have, perhaps, the highest reputation. They 
should be employed first in a diluted state, and their strength gradually in- 
creased as circumstances seem to require. Tar ointment is sometimes very 
efficient. I have seen the disease, after a duration of several months, yield 
immediately to this application. It must be recollected, however, that it is 
adapted exclusively to the scaly stage. The oil of cade has recently been 
recommended in Europe. It acts no doubt like tar, being prepared in a 
similar manner. 
3. SCABIES. 
This is a contagious vesicular eruption, in which the vesicles are some- 
what acuminate, generally distinct, and always attended with more or less 
itching. 
By some writers the disease has been ranked with the pustules; and the 
fact is, that the vesicles sometimes take on the pustular character, or become 
mingled with pustules; but such instances are exceptional; and the essential 
vesicular nature of the affection is now generally admitted. 
Bateman makes several varieties of scabies; but these have been discarded 
by recent authors, nor does there appear to be any sufficient ground for their 
retention; as the disease in all its forms has but one cause, and requires the 
same treatment. 
All parts of the body are liable to be affected, unless perhaps the face, 
which appears to be nearly if not quite exempt; and the disease is very rare 
in the scalp. The parts most frequently attacked are the flexures of the joints, 
contiguous surfaces, and those corresponding with the motions of flexion ; pro- 
bably because the cuticle is most delicate in these positions. Hence, the 
eruption is apt to appear between the fingers, in the cleft of the nates, in the 
bend of the elbow, in the axilla, groin, and ham, upon the anterior part of the 
wrist and forearm, and on the surface of the abdomen. The hand is more 
liable to be affected than any other part, being most exposed to the cause. 
It is said that anything which tends to harden the hand renders it less sus- 
ceptible to the contagion. 
The disease is often confined to one spot, as to the space between the 
fingers, the hand, or the wrist, and in most instances occupies only a surface 
Syn.-Itch.-Psora. CLASS III.] 
VESICLES.-SCABIES. 
415 
of moderate extent. Sometimes, however, it spreads into all parts of the 
body, choosing especially the seats already mentioned. 
Symptoms.-The first sign of the disease is an itching sensation, which, 
upon examination, is found to proceed from a minute, acuminated, reddish 
eruption, with a transparent viscid liquid at the summit. The vesicles are 
almost always distinct; and not clustered like those of eczema. Sometimes 
they are very few, and spread slowly; in other instances numerous, and 
quickly diffused. Being torn by the nails of the patient, they are soon 
covered with small scales from the concretion of the effused liquid; and 
among them are generally interspersed little red bloody points, or scratches, 
from the same cause. Pustules are also sometimes formed, which end in 
scabs; and several of them running together, occasionally give rise to exco- 
riated surfaces, from which pus exudes. The affected parts itch exceedingly, 
especially at night in bed, or after the use of stimulating drinks or exciting 
condiments; and the patient cannot refrain from scratching, which, indeed, is 
sometimes a source of positive pleasure. 
The complaint is said to be most rapid in its progress in persons whose 
skins are delicate, and at the same time full of blood; and to be slow in the 
feeble and cachectic. It is said also to be checked, and even for a time 
almost to disappear, upon the supervention of an acute internal disease. 
The proper' vesicles of scabies are often associated with papular eruptions, 
eczematous vesicles, pustules of ecthyma and impetigo, small furuncles, &c., 
which are thought to be engendered by the irritation of the existing disease, 
of the scratching, or of the remedies used in the cure, and which sometimes 
tend greatly to obscure the diagnosis. 
The itch, if not cured, continues indefinitely for years or even a lifetime ; 
but it has no fatal tendencies, and is never dangerous. The affection is en- 
tirely local; and any disorder of constitution that may attend it is accidental. 
It has long been known that a minute insect might occasionally be found 
in or near the vesicles of scabies; but, though its existence has been re- 
peatedly demonstrated, yet, as many failed to discover it after the most care- 
ful search, some doubt appeared to rest upon the subject, until, in the year 
183-1, the point was conclusively settled by M. Renucci, a young Corsican in 
Paris, who had learned in his native island the art of extracting the little ani- 
mal. It appears that the insect does not reside in the vesicle, but at a little 
distance from it. About the fourth of a line from the vesicle, a white speck 
may sometimes be seen, and, upon the removal of the cuticle by a pin, the 
animal becomes visible, and may be extracted upon the point of the instru- 
ment. But more frequently, there is a furrow of one or two lines in length, 
which may be seen running from the vesicle either straight or somewhat tor- 
tuously ; and at the further end of this furrow the insect may be found. It 
was originally known by the name of Acarus scabiei ; but M. Raspail, who 
described and figured it, has proposed the title of Sarcoptes hominis. It is 
not found in the vicinity of all the vesicles. 
Cause.-Contagion is the only cause of scabies, and this acts only by con- 
tact. The disease may be received either directly from the individual af- 
fected, or indirectly through articles that may have been contaminated, such 
as clothes and bedding. Neither age, sex, season, nor climate, affords ex- 
emption from it. Yet certain causes favour the influence of the contagion. 
It is most effective among a crowded and filthy population; and hence to be 
attacked with it has generally been looked upon as somewhat disgraceful, 
though no degree of care or cleanliness can under all circumstances guard the 
person effectually. The disease is more common with children than adults, 
with men than women, in summer than in winter, and in hot than in cold 416 
LOCAL DISEASES.-SECRETORY SYSTEM. 
[PART II. 
climates. Persons whose trades render it necessary for them to handle old 
clothes are peculiarly apt to be attacked. The period at which the complaint 
appears, after exposure to the cause, differs with the age and the season, being 
shorter in proportion to the greater delicacy of the skin, and the warmth of 
the weather. In children it varies from two to five days, in adults from one 
to three weeks, in old persons it is still longer. (Cazenave and Schedel.') 
From the knowledge of the existence of the acarus, it was a very natural 
conjecture, that this insect would prove to be the real agent in the communi- 
cation of the disease. Against this idea was advanced the fact, that the 
acarus can be found only in a few comparatively of the whole number of 
vesicles. But the difficulty has been removed by the discovery, that the 
female insect, which burrows in the skin in order to deposit her eggs, often 
leaves her hole at night, and makes a new nest elsewhere. M. Bourguignon 
has determined the question, by proving that the disease cannot be communi- 
cated by inoculation with the matter from the vesicles, while a transplanted 
acarus will give rise to the true vesicle of scabies. 
Diagnosis.-Though this is generally easy, there are cases in which much 
difficulty is experienced, even by the most skilful. The circumstance that the 
characteristic eruption, in this as in various other itching affections, is often 
changed by scratching, and a certain resemblance thus given to very different 
diseases, is one of the sources of embarrassment. Another is the not unfre- 
quent intermixture, to a greater or less extent, of other affections. The cu- 
taneous diseases which are most liable to be confounded with scabies, are 
different forms of prurigo and lichen among the papulous, and eczema among 
the vesicular. In relation to the two former, it will be found, upon a close exa- 
mination, that, though there may be occasionally a vesicle, yet the predomi- 
nant eruption is a small, solid pimple, without liquid contents. Besides, they 
appear most commonly on the outer surface of the limbs, while scabies prefers 
the inner; they are often clustered in patches, while this is almost always dis- 
tinct ; and, though they excite itching, yet it is also of a burning, or tingling 
character, very different from the unmingled sensation which has given its name 
to the more vulgar eruption. The circumstances in which the affection origi- 
nated must also be taken into account, scabies being always contagious, and 
the others never. In eczema, the vesicles are rounded or flattened instead of 
being acuminate, occur usually in patches instead of distinctly, occasion a 
more painful sensation, and may sometimes be clearly traced to a non-conta- 
gious, but never to a contagious origin. 
Treatment.-The treatment of scabies is exceedingly simple. Being exclu- 
sively local, it requires no constitutional remedies; though Biett recommends 
that some blood should be taken from the robust and plethoric. This, how- 
ever, can very seldom be requisite. In all instances, it is best to obviate 
costiveness if it exist; not so much in reference to the cure of the cutaneous 
affection, as upon the general principle of keeping the functions in a healthy 
state under all circumstances. 
Upon the whole, the most effectual, and safest remedy for the itch is sulphur 
ointment. This appears to be a specific in the disease ; and it is very seldom 
that any other remedy is required. The ointment of the U. S. Pharmacopoeia 
should be used, though its disagreeable odour may be corrected, if deemed 
advisable, by a few drops of the oil of bergamot to the ounce. The applica- 
tion should be made once or twice daily, and if the disease is extensively 
diffused, to the whole surface of the body. The patient should be stripped 
naked at bed-time, thoroughly anointed in a warm apartment, and allowed to 
remain all night with the ointment upon him. In the morning, he should 
be washed clean by means of a bath or otherwise, and put on perfectly clean 
clothing. Four or five applications of this kind will almost always cure the CLASS III.] 
VESICLES.-SCABIES.-MILIARY ERUPTION. 
417 
disease. Sometimes it may be necessary to continue the treatment for ten 
days, oi' two weeks, in obstinate cases. 
A great number of substances have been proposed as adjuvants of the sul- 
phur; but few that increase its efficacy. Biett, after trying numerous plans in 
the Hospital Saint-Louis, at Paris, adopted the following as the most effectual. 
Of an ointment composed of two parts of sublimed sulphur, one of carbonate of 
potassa, and eight of lard, he directed half an ounce to be applied, morning and 
evening, to all the affected parts; the patient receiving a bath every day or 
every other day. The mean duration of the treatment was twelve days. This 
ointment is much weaker in sulphur than that of the U. S. Pharmacopoeia. 
Sulphur baths, and the vapour of sulphur, have also been much used; but 
are less effectual than the ointment. A lotion was employed by Dupuytren, 
which, though also less efficient than the ointment, may be used when the 
patient is averse to inunction, or the application of the remedy may be in- 
convenient. The lotion consists of four ounces of sulphuret of potassium 
dissolved in a pint and a half of water, with the addition of half an ounce of 
sulphuric acid. It is to be applied twice daily to the affected part. It is not, 
however, all skins that will bear an application so irritant. 
The smell of sulphur has always constituted a strong objection to its use 
with many persons; and on this account numerous substitutes have been tried. 
Among these, the preparations of mercury have proved efficient. The mer- 
curial ointment, calomel ointment, citrine ointment, ointment of iodide of 
mercury, and solution of corrosive sublimate have been employed successfully; 
but a great objection to these preparations is their liability to salivate. 
White hellebore has enjoyed considerable reputation. The officinal oint- 
ment of this root may be used. Biett found it to cure the disease, upon the 
average, in about two weeks, and without injury to the patient. The ointment 
of sulphuric acid, of the old Dublin Pharmacopoeia, weakened by an equal 
proportion of lard, has also been used with success. Inunction with lard and 
oil, without medicinal impregnation, is said by M. Bazin to cure the itch, in 
from four to six applications. (See Am. Journ. of Med. Sci., N. S., xxi. p. 
485.) M. Bourguignon, in experimenting on substances poisonous to the 
insect, found iodide of sulphur and solution of iodide of potassium the most 
energetic, and next to these a solution of the alcoholic extract of stavesacre. 
The last is preferable as a remedy for the itch, because less irritant to the skin. 
He, therefore, employs an ointment made by digesting over a vapour bath, for 
twenty-four hours, three parts of stavesacre in powder with five parts of lard, 
and then straining. This ointment will cure the disease in four days. {Ed. 
Month. J. of Med. Sci., July, 1852, p. 63.) I do not repeat the numerous 
other applications which have been recommended; because none of them are 
equal to those already mentioned. 
It is a caution which should always be observed, in relation to the clothes 
of persons affected with the itch, that, before being touched, they should be 
thoroughly fumigated with sulphur. By speedily and carefully washing the 
hands in soap and water, after touching a patient with the disease, the re- 
ception of it may almost always be prevented. 
4. MILIARY ERUPTION. 
This name is given to minute vesicles, not exceeding a millet seed in size, 
which are scattered in great numbers over different parts of the body, usually 
as an attendant upon certain febrile diseases. 
Syn.-Sudamina. 418 
[PART II. 
LOCAL DISEASES.-SECRETORY SYSTEM. 
Symptoms, Course, &c.-At first the vesicles are so small as scarcely to be 
visible unless upon close inspection; and attention is often called to them, in 
consequence of a feeling of roughness which they impart to the fingers when 
the skin is touched. If the surface is now viewed obliquely, it may be seen 
to be thickly studded with little glistening vesicles, almost as transparent as 
water, and looking very much like minute, almost microscopic drops of clear 
sweat upon the skin. They gradually enlarge, become hemispherical, .and 
assume a pearly aspect, in consequence of the liquid within them becoming 
somewhat opaque and milky. Sometimes they are formed on a red base, and 
consequently have a reddish tinge {Miliaria rubra'); sometimes rest upon 
the skin in a perfectly natural state as regards colour, and are either trans- 
parent or whitish (Miliaria alba}. They are usually quite distinct, and 
irregularly scattered over the surface, though occasionally crowded together 
in spots so as to present a clustered appearance, and, in some instances, co- 
alescing into the form of bullae of considerable size. They may be dispersed 
over all parts of the body, but are most abundant upon the neck and trunk, 
and are rarely found in the face. In some instances, they are attended with 
itching or tingling, in others occasion no peculiar sensation. Each vesicle 
soon dries up, seldom lasting longer than from two to five days, though suc- 
cessive crops of them are often produced. They are followed by a slight, and 
often scarcely perceptible desquamation. 
A distinction has been made between sudamina and miliary vesicles; the 
latter name being given to the eruption when formed upon a red base, at- 
tended with itching, of a conical shape, and ultimately becoming opaque and 
pustular; the former, to the vesicles when of a semi-globular form, and not 
preceded or attended with redness or itching. The distinction, however, will 
not hold ; for the two often appear together, and one form may run into the 
other. Nor does there seem to be a good reason for confining the title of 
sudamina to the vesicles when they occur as a mere epiphenomenon of dis- 
eases, and for calling those only miliary which are supposed to be characteristic 
accompaniments of one peculiar disease, denominated miliary fever. They 
are probably the same under whatever circumstances they occur; and it is at 
least doubtful whether they can, with propriety, be considered as character- 
istic of any disease. 
Cause.-Miliary vesicles or sudamina almost always occur in connexion 
with febrile complaints, which, however, they do not appear in any degree to 
affect, as regards either their course or result. Nor are they restricted to 
any grade or form of fever, but may occur equally in the mild and malig- 
nant, the inflammatory and the typhous. Thus, we meet with them in the 
typhus and typhoid or enteric fevers, in scarlatina, as a precursor of the 
eruption of smallpox, in the milk fever of puerperal women, in phthisis, in 
rheumatism, and in many of the phlegmasiae. The only known condition 
that favours their production is copious and continued sweating. In what- 
ever febrile disease that phenomenon is presented, we may look for sudamina, 
though they will by no means be invariably found. Nor is this condition 
absolutely necessary to them. We often meet with them in enteric fever and 
typhus, when there has been no sensible perspiration. They are said some- 
times to appear in health, after severe exercise in warm weather, which has 
provoked copious sweating. 
It would appear that epidemic influence occasionally gives a tendency to 
sudamina in different diseases; for there are occasions when they are more 
than usually prevalent, and, without any obvious cause, are met with as an 
attendant upon complaints, in connexion with which they are on other occasions CLASS III.] 
419 
VESICLES.-MILIARY ERUPTION. 
seldom seen. There is not the least reason to suppose that they are contagious. 
They are said to occur more frequently in summer than winter. 
Diagnosis.-The only other eruption with which the miliary can be con- 
founded is eczema; and there is generally little difficulty in distinguishing 
them. Eczema is more disposed to appear in patches, is attended with much 
more itching and irritation, is of much longer duration, and is not apt to occur 
as an attendant on severe fevers. 
Prognosis.-The miliary eruption is itself quite insignificant. It is some- 
times, however, useful as a sign in diagnosis, especially in enteric and typhus 
fevers. The idea has been entertained that its sudden retrocession is accom- 
panied with danger. We can readily understand that the sudden supervention 
of a severe internal phlegmasia may cause the retrocession of the eruption; 
but in such a case its disappearance is an effect and not a cause. 
Treatment.-The miliary eruption demands no special treatment. It may, 
indeed, without injury, be quite overlooked in the management of the several 
diseases which it accompanies. The copious sweating which favours its pro- 
duction, if it be not the cause of it, may be advantageously treated in some 
instances by refrigerant remedies, and the mineral acids. 
Miliary Fever.-Sweating Miliaria.-Sudor Miliaris.-Miliaris 
Sudatoria. 
Though not disposed to admit the existence of a peculiar disease, of which 
the miliary eruption is a characteristic, as the variolous pustules are of small- 
pox ; yet I do not doubt that a peculiar epidemic fever has sometimes pre- 
vailed in different parts of Europe^ to which the names above given have 
been applied, and which is often attended with the eruption alluded to. But 
the sudamina are admitted not to be essential to the affection, and, indeed, 
are often wanting; and they are probably more frequent in this than most 
other fevers, chiefly if not exclusively because the disease is attended with 
copious sweats. It may be proper to give a brief sketch of the disease. The 
following account of it is condensed chiefly from Bayer. 
It occurs in diversified forms, which may all be included in the two, of 
mild and malignant. The milder variety commences abruptly, or after the 
shorter or longer continuance of various precursory symptoms, such as lassi- 
tude, pains over the eyes, anorexia, epigastric pains, and feelings of general 
heat. The period of attack is marked by the occurrence of sweating, or 
rather of hot vapour steaming from the skin, at first from one portion of the 
body, but very soon from the whole surface. There is at the same time ex- 
treme weakness, with a tendency to syncope, a singular constriction of the 
chest, and a soft, frequent, intermitting pulse. (Cazenave and Schedel.') The 
tongue is furred, the appetite feeble or quite wanting, the respiration op- 
pressed, and the bowels costive. After these symptoms have continued two, 
three, or four days, with sweating all the time, the eruption makes its appear- 
ance, and spreads with different degrees of rapidity over the body, presenting 
the characters which have been already described. Rayer states that the 
sweating is a more constant symptom than the eruption. It is very copious, 
and has an odour like that of rotten straw. The disease gradually declines, 
and ends in complete recovery by the eighth, ninth, or tenth day. 
'The malignant variety is characterized by the occurrence of violent inflam- 
mation in some of the interior organs, especially the stomach, lungs, kidneys, 
and brain, and appears to owe its danger to these complications. It some- 
times proves fatal in two or three days, but more frequently ends in about a 
week, and sometimes runs on for two or three weeks. 
No other cause for the disease is known than epidemic influence. Rayer 420 
LOCAL DISEASES.-SECRETORY SYSTEM. 
[part II. 
thinks it contagious, but offers no convincing proof. On the contrary, he 
states thaii-. the disease cannot be conveyed by inoculation with the liquid 
from the vesicles. 
The mild variety is not dangerous, and always ends in recovery under an 
expectant treatment. The malignant forms are sometimes extremely fatal. 
The treatment of the disease must be conducted upon the principles applica- 
ble to fevers in general. 
5. PEMPHIGUS. 
Syn.-Pompholyx. Willan. 
Pemphigus belongs to that section of cutaneous diseases which consist in 
the eruption of bullae, blebs, or small blisters. In this particular affection, 
the bullae are usually large, contain a yellowish transparent fluid, and termi- 
nate in the formation of thin scabs. The disease is acute or chronic. 
Acute Pemphigus.-In its mildest form, this occurs without fever, and 
with little or no inflammation. Bullae, from the size of a pea to that of a 
chestnut, appear in succession upon the face, neck, or limbs, and, having 
continued for three or four days, break, and soon afterwards heal. This is 
the Pompliolyx Lenignus of Willan, and is quite a trivial affection. It occurs 
most frequently in children, and appears to be connected with dentition, or 
disordered digestion. 
A much severer form of the disease, attended with fever and inflammation, 
is described by writers on dermatology, and, though not admitted by Willan 
and Bateman, and certainly rare, has too much testimony in its favour to be 
rejected. It usually commences with more or less constitutional disturbance 
of a febrile character, which continues from one to three days, before the ap- 
pearance of the eruption. This shows itself in circular spots of inflammation, 
at first bright-red, but afterwards becoming dusky, and varying from a few 
lines to two inches or more in diameter. Upon each of these a blister speed- 
ily forms, either covering the whole inflamed surface, or occupying a portion 
in the middle, leaving a circle of redness around it. Some of the red spots 
never form blisters, though the cuticle may be readily detached. The bullae 
vary from the size of a pea to that of a hen's egg. The skin between them 
is perfectly sound. They quickly attain their full size, and are then trans- 
parent and yellowish. In the course of one, two, or at most three days, they 
begin to decline, and most of them break; the serum contained in them hav- 
ing previously become somewhat turbid, and occasionally reddish. They are 
followed by thin yellowish-brown scabs which separate in a short time, leaving 
surfaces of a dusky-red colour. Should the cuticle by any accident be re- 
moved before becoming dry, excoriations are produced, which are sometimes 
painful, but usually heal without much difficulty. The whole course of each 
bulla is completed in about a week; but, in consequence of successive erup- 
tions, the disease may be prolonged to three weeks. 
The bullae may appear on one part of the body exclusively, or may extend 
more or less thickly over the whole surface. 
During their continuance, the constitutional disorder is often so slight that 
the patient is not confined to bed; but, in some instances, there is much 
fever, with delirium and other alarming symptoms. 
The Pompholgx solitarius of Willan may be attached to this variety of the 
disease. It is characterized by the appearance, after some tingling of the 
skin, of one large blister, which rapidly increases so as to contain several 
ounces of liquid, and, breaking within forty-eight hours, leaves an excoriated CLASS III.] 
421 
VESICLES.-PEMPHIGUS. 
surface. Another bulla rises, in a day or two, in the same vicinity, and, pur- 
suing the same course, is in its turn sometimes followed by two or three 
others, so as to make the whole duration of the eruption eight or ten days. 
Chronic Pemphigus.-Pompholyx diutinus (Willan).-This is distinguished 
from the acute only by its longer continuance, and the absence of the early 
febrile symptoms, which characterize the most prominent form of the preced- 
ing variety. The eruption is usually preceded for a considerable time by 
signs of constitutional disorder, and smarting oi' prickling sensations are felt 
in the part before the bullae appear. These run the same course individually 
as the acute, but, as they decline, others appear; and the disease is thus 
maintained for months, and sometimes for years. Not unfrequently the bullae 
may be seen in all stages upon different parts of the surface at the same time. 
They may be confined within a space of three or four inches, may occupy a 
distinct part of the body, as a leg, an arm, or the face, or may spread over 
the whole surface. In the last case the body may be at times almost covered 
with crusts; but this is rare. Painful excoriations are sometimes produced, 
which disturb the rest, and, when much multiplied, may occasion a slight 
febrile paroxysm at night. This form of the disease is often associated with 
a general depravation of health, which gives rise to various internal inflamma- 
tions, and in the end not unfrequently to dropsy. 
Causes.-These are obscure. The acute variety; which is confined chiefly 
to children, has been ascribed to dentition, errors of diet, exposure to the sun, 
&c. The chronic disease attacks chiefly the old, and men more frequently 
than women. It is in general probably dependent upon an impaired state of 
the constitution resulting from disease, bad living, intemperance, excessive 
fatigue, exposure, &c. 
Diagnosis.-1There can be little difficulty in distinguishing pemphigus when 
in the state of bullae. The only affection with which it could be confounded 
is rupia. When in the scabby state, it bears some resemblance to certain 
forms of impetigo. For the diagnostic signs the reader is referred to these 
diseases. 
Prognosis.-So far as regards the mere eruptive affection, the prognosis is 
almost always favourable. The febrile symptoms which attend the acute 
variety in infants are said sometimes to be serious. In the chronic disease, 
it is the vitiated state of health that has given rise to the pemphigus, and not 
that affection itself, from which fatal results are to be apprehended. 
Treatment.-The acute disease requires in general nothing but a cooling 
regimen, and saline laxatives. In its severer forms, when the pulse is strong, 
and the constitution vigorous, it may be proper to take some blood from the 
arm, and to apply leeches in the vicinity of the severest inflammation. The 
warm bath is also useful. Care should be taken to avoid rubbing off the 
cuticle from the blistered surfaces, and, when excoriations occur, they should 
be protected from*the air by dressings of simple cerate. 
In the chronic form, the treatment must be addressed to the state of the 
constitution. If this is vigorous, and especially if the disease is associated 
with internal inflammation, the antiphlogistic plan should be pursued; con- 
sisting of a low diet, saline purgatives, refrigerant drinks, the warm bath, 
and sometimes general or local bleeding. Alkaline baths are also recom- 
mended. In the opposite condition of health, tonics are indicated; and re- 
course may be had to the mineral acids, chalybeates, simple bitters, quinia, 
and a generous diet. Attention should be paid to the digestive organs. 
Opiates or other narcotics are often requisite to procure sleep, and relieve the 
distressing sensations of the local disease. For the same reason, soothing 
applications should be made to the excoriations; and, when these are indis- 422 
[part II. 
LOCAL DISEASES.-SECRETORY SYSTEM. 
posed to heal, the cerate of subacetate of lead may be employed. Rest is 
necessary, to avoid injury to the blistered surfaces. In very obstinate cases, 
recourse should be had to the internal use of arsenic. 
6. RUPIA. 
Rupia is characterized by flattish, distinct bullae, containing a serous, puru- 
lent, or dark sanious fluid, and followed by thick scabs, easily separated and 
soon renewed, or by ulcers. 
There seems to be some doubt whether this may not be the same disease as 
ecthyma; as the two are often together, and the pustules of the latter affec- 
tion sometimes appear in the form of mere purulent bullae, or blisters con- 
taining pus. 
In its mildest form (Rupia simplex, Bateman), the disease first breaks out 
in bullae, without preceding inflammation. These are about an inch in diameter, 
and contain a fluid, which is at first thin and transparent, but soon thickens, 
becomes purulent, and dries into brownish rugged scabs, thicker in the centre 
than at the borders. The scabs are easily detached, and leave ulcerated sur- 
faces, which either cicatrize, or form new scabs successively several times, 
until the morbid tendency »is exhausted, and the surface heals. A livid red- 
ness is usually left behind for a longer or shorter time. 
In a severer form (Rupia prominens, Bateman), there is usually at first an 
inflamed surface, on which the bulla forms with greater or less rapidity. The 
liquid it contains is apt to become opaque and blackish. Sometimes the blis- 
ters disappear without scabbing; but generally scabs form very rapidly, ac- 
cording to Bateman, in one night. These subsequently receive additions 
beneath, and at their circumference by the vesication and scabbing of succes- 
sive borders of the surface around them, until they attain their full size, which 
is generally larger than that of the milder kind. From their mode of forma- 
tion, the scabs have a conical shape, and exhibit circular marks of the several 
additions made to them, giving them the appearance of certain small oyster 
shells. Sometimes the scabs adhere for a considerable time, sometimes sepa- 
rate, leaving ulcerated surfaces, which are either covered with new scabs, or 
remain as unhealthy and occasionally deep circular ulcers. These, however, 
at length heal, leaving purple stains upon the skin, which last for a long time. 
Still more severe is the Rupia, escharotica of Bateman, which consists of 
bullae formed upon a livid surface, small at first, but gradually and irregularly 
enlarging, with a blackish opaque liquid, and ending in ulcers. These spread 
and deepen, are surrounded by a red inflamed border, and are covered with a 
fetid, excoriating pus or sanies. Many of them appear successively. They 
are attended with pain, restlessness, want of sleep, and fever; and either heal 
at last, after a very protracted duration, or end in death in the course of a 
week or two. Sometimes eschars form, which leave deep pits in the skin 
after recovery. 
The different forms of rupia appear preferably on the lower extremities, or 
about the loins and nates; but they also break out in other parts of the body. 
They occur generally in persons debilitated by old age, intemperance, bad 
living, and the various privations of poverty, or by previous disease, especially 
smallpox and scarlatina. They may occur at all periods of life. The R. 
escharotica is apt to appear in new-born children, or during the period of the 
first dentition, and is especially disposed to attack those badly fed and badly 
clothed, and with health depraved by various causes. 
Diagnosis.-Pemphigus and ecthyma are the only complaints from which CLASS III.] 
RUPIA.-ECTHYMA. 
423 
there can be any difficulty in distinguishing the bullae of rupia. From pem- 
phigus they differ in the circumstances, that their contents are generally 
opaque and sanious; that the scab is often conical, thick, and fluted, and sur- 
rounded by a vesicated border; and that they leave behind them ulcers which 
are often deep, foul, and difficult to heal. The diagnosis between this com- 
plaint and ecthyma, belongs to the latter disease. (See Ecthyma.') 
Prognosis.-It is only the R. escharotica which is dangerous. The others 
are sometimes tedious and troublesome, but they get well sooner or later; and, 
if death takes place in the course of them, it is not from the skin affection, but 
from the general state of health which gave rise to it. 
Treatment.-It is highly necessary to attend to the state of the constitu- 
tion, and endeavour to correct the general health. The digestive organs, and 
the state of the blood especially require attention. A diet of light, nutritious, 
and easily digested food, both animal and vegetable, is generally indicated ; 
as are also frequently the tonics, as quinia, the mineral acids, malt liquors, 
wine, &c. The alterative influence of mercury, with sarsaparilla, may be tried 
in obstinate cases. I have found iodide of potassium to act like a charm in 
curing, or apparently curing, the disease. 
In relation to external remedies, warm baths, or alkaline baths, may be 
employed, and emollient applications may be made to the inflamed eruption. 
In the state of ulcers, it sometimes becomes necessary to apply something 
capable of changing the action of the diseased surface. For this purpose 
nitrate of silver is, perhaps, the best remedy, being applied, in the form of the 
solid stick, more or less strongly according to the severity of the local disease. 
Other stimulants or escharotics maybe used; as nitric and muriatic acids, and 
the ointments of red oxide of mercury, nitrate of mercury, iodide or biniodide 
of mercury, &c. It is probable that iodide of potassium may prove useful in 
the form of cerate. 
The gangrenous variety must be treated by tonics and stimulants to sup- 
port the strength, and the warm-bath or emollients externally, until the 
severe constitutional symptoms disappear; after which the same course may 
be pursued as in the other varieties. 
Article IV. 
PUSTULAR DISEASES. 
1. ECTHYMA. 
The name of ecthyma was appropriated by Willan to an eruption of phly- 
zacious pustules, generally distinct, non-contagious, and without fever. 
The affection may occur either in an acute or a chronic form. This appears 
to me the only essential distinction. In the former, the eruption appears, 
runs its course, and disappears, without return. In the latter, the disease is 
kept up by constantly renewed crops of pustules. 
Symptoms.-lu the acute variety, the eruption is often preceded by symp- 
toms of constitutional disturbance, such as lassitude, pains in the limbs, epi- 
gastric uneasiness, loss of appetite, and irregularity of bowels, which continue 
in a greater or less degree until the pustules have run their course. These 
first make their appearance as distinct, conical elevations, of the size of a split 
pea or smaller, of a bright-red colour, and often very painful. They occur 
most frequently on the neck and shoulders, and sometimes on the extremities, 424 
LOCAL DISEASES.-SECRETORY SYSTEM. 
[PART II. 
but seldom if ever upon the face or scalp. They enlarge, and spread at the 
base, and, in the course of three or four days, or sooner, exhibit pus at their 
summit, and present an appearance not unlike that of small boils. The little 
abscesses break after a while, and, discharging their pus, form brown, closely 
adherent scabs, which fall off in a week or two from the commencement of 
the eruption, and leave dark-red surfaces of six or eight lines in diameter, 
with occasionally a slight superficial scar in the centre. (Rayer.') These 
stains gradually disappear. Sometimes two of the pustules join, and thus 
acquire greater size, and an irregular form. The inflammation is occasionally 
sufficient to produce a painful sympathetic swelling in the neighbouring lym- 
phatic glands. Young persons are peculiarly subject to this form of ecthyma. 
It is the E. vulgare of Bateman's synopsis. 
In the chronic form, some vice of constitution sustains the morbid tend- 
encies of the skin, and crop after crop of the pustules arise, protracting the 
disease often for several months. Not unfrequently, too, the local affection 
is of an aggravated character; the pustules being more numerous, more ex- 
tensively diffused, and severally larger, more depraved, and more obstinate. 
Sometimes, instead of pus at the summit of a conical elevation, with a border 
of inflammation, the whole reddened surface throws out a purulent fluid, 
forming a sort of bulla, not unlike that of rupia, after its contents have 
become turbid. In some instances, a portion of the pustules undergo a sort 
of resolution; the pus being absorbed, and its place supplied by a mere scale, 
instead of a scab as in ordinary cases. This happens most frequently upon 
the hands and feet. Now and then the scabs, when separated either by acci- 
dent or spontaneously, leave ulcers, which may be deep, unhealthy, painful, 
and very slow in healing. This is said to be especially the case in those 
instances of the disease which follow smallpox and scarlet fever. 
In persons of vitiated health, the old, the intemperate, and those worn out 
by various privations and fatigue, the pustules have a dark-red or purplish 
base, are unusually large, and spread over almost the whole body, except the 
face. In eight or ten days they break, and discharge a sanious or bloody 
matter, which leaves a deep excavation. This fills up with a dark scab, which 
appears as if firmly set in the skin, and is surrounded by a swollen, hard, 
and dark-red border. In this state the affection remains for many weeks, or 
for months, unless the scab is forcibly removed, when an ill-conditioned, and 
obstinate ulcer is formed, exuding an offensive sanies. This is the Ecthyma 
luridum of the synopsis. 
In other cases, occurring also in depraved constitutions, the eruption 
attends a febrile condition of the system, with various disorder of the func- 
tions, and presents an appearance closely resembling certain forms of cuta- 
neous syphilis. Though most abundant in the lower extremities, it may 
occupy any portion of the surface, even the face and scalp, which are usually 
spared by the disease in its other forms. 
In consequence of the appearance of a new set of pustules before the old 
have completed their course, the surface often has a very diversified aspect, 
exhibiting the affection at the same time in all its stages, of inflamed eleva- 
tion, matured pustule, scab, ulceration, and lurid or purple stain. 
From what has been said, it will be inferred that ecthyma may be confined 
to one part of the surface, or may extend over the whole. It appears to have 
a predilection for the lower extremities, though it not unfrequently also occurs 
upon the arms, shoulders, neck, and breast. The parts which are the least 
frequently affected are the face and scalp. Sometimes the eruption is scat- 
tered, sometimes more or less clustered. 
Causes.-Certain irritants produce an eruption of the ecthymatous cha- CLASS III.] 
425 
PUSTULES.-ECTHYMA. 
racter by contact with the skin. Tartar emetic has this effect. Artisans 
whose hands are exposed much to acrid substances are apt to be affected, as 
workers in metals, dyers, and persons who handle sugar, spices, &c. But 
generally the disease depends upon causes acting through the system. Hence, 
infants who are badly or insufficiently fed, and otherwise neglected, are espe- 
cially liable to be attacked. The depraved condition of health arising from 
intemperance, the filth and various wretchedness of extreme poverty, sensual 
excesses, and depressing moral causes, predisposes to the disease. It occa- 
sionally follows the eruptive fevers, especially scarlatina and smallpox. Other 
cutaneous affections, by their irritant influence, not unfrequently cause the 
developement of ecthyma, by which they are then complicated. Such are, 
especially, lichen, prurigo, and scabies. The disease is said also to occur 
from the sympathy of the skin with internal irritations. 
Diagnosis.-The inflamed and elevated base of ecthyma generally serves 
to distinguish it from other pustular affections. The disorders with which 
it may sometimes be confounded are rupia, scabies, and syphilitic eruptions. 
One of its forms closely resembles rupia, when the contents of the bullae have 
assumed a purulent character; and there is, indeed, reason to think that they 
may be essentially the same affection, as they occur sometimes together, and 
from the same cause. But if the bulla has the vesicular character at any 
period of its course, it may be considered as rupia. There can be no difficulty 
in the diagnosis between rupia and the ordinary form of ecthyma. Scabies, 
even when associated with ecthymatous pustules, may generally be distin- 
guished by the presence of some of its own acuminate vesicles, or the more 
pointed form of the eruption, if it has assumed the pustular character. In 
relation to the syphilitic affection, the copper colour of the diseased surface, 
and the history of the case, are sometimes the only diagnostic signs. 
Prognosis.-So far as the eruption alone is concerned, though ecthyma 
is sometimes protracted for several months, it may always be looked on as 
curable. The only danger is from the frail state of general health, in which 
the local affection originates. 
Treatment.-In the acute disease, little treatment is necessary. Saline 
laxatives, a light and digestible diet, the avoidance of all stimulants, and the 
removal of the cause, when discoverable, are the only requisite measures. 
Warm or mucilaginous baths may be employed as adjuvants. In young and 
robust individuals, if the inflammation is considerable and very painful, blood 
may be taken from the arm, and a low diet enjoined. 
In chronic cases, the chief care must be directed to the constitution. The 
digestive organs should be attended to, and the disordered state of the blood 
corrected. It is often advisable to have recourse to tonics, especially the sim- 
ple bitters, quinia, the chalybeates, and the mineral acids. Nitromuriatic 
acid sometimes exerts a favourable influence in these cases. The preparations 
of sarsaparilla have been employed as alteratives. But the most efficient 
medicine is probably iodide of potassium, which should be employed espe- 
cially in the ulcerative cases. Iodide of iron may be substituted when the 
blood is anemic. Opiates or other narcotics are often necessary to quiet un- 
easiness, and procure sleep. In the old cases, baths rendered somewhat sti- 
mulant by alkaline, ioduretted, sulphuretted, or saline impregnation may be 
used. The common salt-bath has been recommended. Attention must also 
be paid to the cause. A wholesome and nutritious diet, and suitable clothing, 
should be secured to the patient. In children at the breast, it is sometimes 
important to change the nurse. Of course, strict temperance in all things 
must be enjoined. 
In relation to local measures, while the eruption is inflamed, emollient ap- 426 
[part II. 
LOCAL DISEASES.-SECRETORY SYSTEM. 
plications should be employed; in the advanced and ulcerative state, nitrate of 
silver, the diluted mineral acids, ointment of iodide of potassium, solution of 
chloride of lime, or other stimulant alterative. 
2. IMPETIGO. 
Impetigo consists of an eruption of small psydracious or achorous pustules 
(see page 385), generally set closely together, forming thick, yellowish scabs, 
without contagious properties, and without fever. 
The varieties of this affection may be reduced to three, namely, I. figurata, 
I. sparsa, and I. larvalis. The first two are known commonly as the moist or 
running tetter, the last is the crusta. lactea of the older authors. 
1. Impetigo figurata.-Moist tetter.-This may appear upon any part of 
the body, but is most frequent upon the face, and especially on the cheek. 
The eruption is sometimes preceded by general uneasiness, headache, or signs 
of gastro-intestinal irritation, but frequently appears without any previous 
disorder. It occurs in clusters of minute yellow pustules, of the size of a 
pin's head, or less, closely crowded upon a circumscribed red and inflamed 
portion of the skin ; the redness extending a little beyond the pustules, and 
the whole patch being slightly elevated above the surrounding surface. 
There may be one of these patches, or several. In the latter case, they are 
usually smaller, and, extending by their borders, not unfrequently coalesce. 
Sometimes they are preceded by an inflammation notunlike that of erysipelas, 
from which, however, the affection (Z erysipelatod.es') may very soon be dis- 
tinguished by the appearance of the pustules. In this case, there may be a 
slight fever when the disease spreads extensively over the face and neck. 
In two or three days, the pustules break and discharge their contents, leav- 
ing a red, shining, somewhat excoriated surface, which exudes'large quantities 
of an ichorous fluid from numerous minute pores. The affection is attended 
with very disagreeable sensations of itching, heat, and smarting. 
The exudation soon concretes into yellowish, or greenish-yellow, brittle, and 
translucent scabs, from beneath which a liquid matter continues to ooze. It 
is in this state that the complaint generally first comes under the notice of the 
physician. He detects its character, not only by the peculiar appearance of 
the incrustation, but also by a few pustules which generally show themselves 
upon the borders of the circumscribed patch. The countenance of the patient 
is completely altered, so as scarcely to be recognizable, when the eruption is 
somewhat extensive on the face. 
In three or four weeks, the disagreeable sensations and the quantity of fluid 
discharge lessen, and the scabs, becoming dry, fall off, and leave the skin 
red, somewhat thickened, rough, and brittle; so that slight causes of irrita- 
tion may occasion fissures and excoriations, with renewed discharge and 
scabbing, and thus greatly protract the complaint. But, should such sources 
of injury be avoided, the diseased surface may gradually resume the healthy 
condition, though it still remains for some time red and shining, with a very 
delicate cuticle. The cure generally begins in the centre of the patches, and 
extends towards the circumference. This may be considered as the acute form 
of impetigo. 
But the disease is often much protracted, and may then be considered 
chronic; though, in fact, the acute character still frequently remains, as the 
successive crops of pustules which sustain it appear with the same properties, 
and go through the same changes as at first. Sometimes these renewed erup- 
tions appear upon the original surface, thereby at length producing a deep CLASS III.] 
427 
PUSTULES.-IMPETIGO. 
affection of the skin. In other cases, they take place upon the borders of the 
patch, extending it in all directions, while the interior remains covered with 
a scaly or scabby incrustation, constituting one of the varieties of ringworm. 
At length, however, the affection becomes truly chronic, presenting dry scabs 
or scabby surfaces, the origin of which may generally be known by the occur- 
rence now and then, about their edges, of a few characteristic pustules. 
When a cure takes place, the itching ceases, liquid is no longer secreted, the 
scabs become thinner and thinner, and at length disappear, and the skin re- 
sumes its healthy character, though long somewhat discoloured. 
It has been already stated that this variety of the disease occurs most fre- 
quently in the face. It may cover the whole of one or of both cheeks, and 
may even extend downward to the neck; but occasionally it is confined to 
some one limited spot, as to the eyelid, the ala of the nose, or the upper or 
lower lip. When upon the eyelid, it is apt to induce ophthalmia. It occurs 
also on the limbs, and is said to be usually of smaller extent in the upper 
than the lower extremities, in the latter of which it sometimes forms several 
large patches. 
2. Impetigo sparsa.-This differs from the preceding variety only in the 
arrangement of the pustules. These are of the same character, and go through 
the same series of changes ; but, instead of being in well-defined patches, they 
are scattered irregularly over the part affected. The disease is in this form 
more apt to become chronic. It is also much more frequent in the lower 
extremities, affecting especially the flexures of the joints. It may be con- 
fined to a portion of one limb, or may spread more or less over the whole of 
it, or may even occupy more than one. In some instances, by the occur- 
rence of successive crops of eruption in the intervals of the preceding, before 
these have terminated in health, large portions become continuously diseased; 
and the whole of a limb is sometimes enclosed in a firm yellowish incrusta- 
tion, which has been compared to the bark of a tree. In this state, the dis- 
ease constitutes the Impetigo scabida of Willan. The leg from the knee 
downwards, and the arm from the elbow to the wrist, may thus be encased 
in a scabby covering, which renders motion difficult and painful. Now and 
then the crust splits, admitting an ichorous matter to flow out, which in its 
turn concretes, and adds to the thickness of the covering. When the scabs 
are removed, the surface appears excoriated, but soon covers itself over with 
a new crust, by the concretion of the liquid discharge that takes place. Some- 
times the disease extends to the fingers and toes, causing a separation of the 
nails, which, when afterwards renewed, are apt to be notched and misshapen. 
Obstinate ulcers occasionally form in the impetiginous limb, which is also not 
unfrequently greatly distended with edematous effusion. This is peculiarly 
apt to happen in old and feeble individuals, with health broken or depraved 
by intemperance, bad living, and various diseases. 
This variety of impetigo is said to occur most frequently in the autumn, 
while the I. figurata is most partial to the spring. Some persons are attacked 
by the former every autumn, and do not get rid of it until the recurrence of 
warm weather after the close of winter. 
It should be recollected that there is no precise line between these two 
forms, but that they are connected by cases presenting every diversity of 
shade, and in fact constitute one and the same disease, depending upon the 
same causes, and requiring the same treatment. 
3. Impetigo larvalis.-Porrigo larvalis (Willan).- Crusta lactea.-This 
affection has been removed by the recent French writers on dermatology from 
porrigo, to which it was attached by Willan and Bateman, and placed with 
impetigo. It differs from porrigo essentially in the circumstance of its want 
of contagiousness, as well as in its pustular character. 428 
[part II. 
LOCAL DISEASES.-SECRETORY SYSTEM. 
This variety of impetigo is confined chiefly to infancy, and, though it may 
appear on different parts of the body, occurs most commonly upon the face 
or scalp. Its specific name is derived from the circumstance, that it some- 
times covers nearly the whole face with a scabby incrustation, as with a mask. 
It differs much in its extent, the degree of inflammation that attends it, the 
thickness of the crusts, &c. The eruption consists of numerous very small, 
whitish, achorous pustules, which cause much itching, and soon break, either 
spontaneously or from scratching. A purulent fluid escapes, which concretes 
into soft, yellowish, or greenish-yellow scabs. As the pustules spread, the 
scabby surface extends, and is at the same time thickened by the concretion 
of matter which forms beneath the crust. Beginning in the forehead or 
cheek, it thus spreads till it sometimes covers the whole face, with the excep- 
tion of the nose and eyelids. In some instances, it is confined to particular 
parts of the face. Thus, it may cover the chin only, or may form a crust 
completely around the lips, very much interfering with their motions. If the 
crust is removed, the surface is seen to be red, inflamed, and excoriated; and 
it sometimes discharges fluid so copiously that scabs cannot form. In other 
instances, little fluid secretion takes place, and the crusts are dry, brown, and 
adherent. 
At the same time that it thus chiefly affects the face, patches of the erup- 
tion not unfrequently appear on the breast, arms, or other parts of the body. 
It affects also the ears and scalp; and the lymphatic glands of the neck some- 
times become inflamed and enlarged. The disease is also occasionally com- 
plicated with inflammation of the eyes, and purulent discharge from the audi- 
tory meatus. 
In consequence of repeated renewals, or the long continuance of the dis- 
ease, the skin becomes fissured and excoriated, though it is said that, when 
the parts are restored to health, no scars are left, unless in consequence of 
wounds made by the fingers. 
In the scalp it may be confined to the back part, or pervade the whole. 
The viscid fluid that is poured out agglutinates the hairs, which are consoli- 
dated with the scabs into extensive crusts. From beneath these matter con- 
tinues to exude; and innumerable vermin find a congenial residence in the 
filthy mass, which is unspeakably offensive as well to the nostrils as to the 
eye. It is only, however, in cases in which no regard is paid to cleanliness 
that the affection assumes so repulsive an aspect. If the hair is cut off, and 
the scabs removed, the surface appears red, and exhibits numerous exuding 
points, while here and there are frequently to be seen small subcutaneous 
abscesses. In old cases, the hair partially falls, but, as the bulbs are not 
destroyed, it grows again; in which respect the disease differs from porrigo. 
When the pustules are distinct in the scalp, they sometimes terminate in 
scabs which join several hairs together, and which, upon separating from the 
skin, become hard, unequal, irregular, and of a brown or dark-gray colour, 
and remain interspersed in great numbers among the hair, giving it a pecu- 
liar appearance. This is the affection described by Cazenave and Schedel as 
the Impetigo granulata. 
The affection is attended with much itching and irritation, which renders 
the child fretful and restless, and interferes with sleeping. In this way the 
general health may at length become affected, and sometimes internal dis- 
eases occur, which carry off the patient. This, however, is not common. In 
general, the health is little impaired; and there is reason to believe that the 
affection, which is peculiarly apt to occur during dentition, sometimes serves 
as a useful outlet to the morbid tendencies of that period. 
The complaint is often tedious, and sometimes cannot be cured permanently CLASS III.] 
PUSTULES.-IMPETIGO. 
429 
while teething continues. Sooner or later, however, it gets well; the secretion 
ceasing, the scabs diminishing, and the skin gradually returning to the healthy 
state, though it continues long red, delicate, and marked with deep lines, and 
the cuticle repeatedly exfoliates. According to Dr. Bateman, fissures are not 
apt to be produced in the skin, as in other forms of impetigo. 
Causes.-The causes of impetigo are not always obvious. Dentition ap- 
pears to dispose to it, as do various conditions in the female connected with 
the menstrual function, as change of life, amenorrhoea, and sometimes gesta- 
tion. Young persons of fresh and delicate skins are said to be peculiarly 
liable to its attacks. Among the exciting causes are enumerated violent exer- 
cise, sensual excesses, vehement passions, and various local irritants to which 
artisans are exposed, as dyers, workers in metal, bakers, &c. One of the most 
frequent causes of its obstinacy is the untimely application of stimulant medi- 
caments, which are unsuitable to the early stage. 
Diagnosis.-1The complaints with which impetigo is most likely to be con- 
founded are eczema and porrigo. From eczema it is distinguished by its pus- 
tules, and by its thick, rugose, yellowish or greenish-yellow scabs. If, along 
with minute pustules, there are also vesicles, succeeded by thin laminated or 
scaly crusts, the complaint may be referred to eczema impetiginoides; though 
it is by no means impossible that the two affections may be conjoined. The 
diagnosis between impetigo and porrigo will be given under the latter com- 
plaint. It has been already stated that the latter is, and the former is not 
contagious. There can be no difficulty in distinguishing the disease from 
scabies in its ordinary forms. The pustules, the patches, the profuse liquid 
discharge, the copious thick scabs, and the want of the contagious quality, 
are sufficiently diagnostic. In the advanced stages, it is possible that impe- 
tigo might sometimes be confounded with the scaly diseases; but the history 
of the cases will serve to distinguish them, and, besides, by careful watching, 
some pustules may generally be detected at times among the patches of impe- 
tigo, even when in its most chronic state. 
Prognosis-This disease is very seldom dangerous. Even in those cases 
of infants' who perish while labouring under it, the cause of death must 
almost always be sought for in some merely coincident disease. It is possi- 
ble that the cutaneous affection may sometimes add the last drop that is 
wanting to make the cup overflow. But there is reason to believe, that it 
much more frequently acts as a safeguard by giving the morbid tendencies 
an external direction. Though a cure may be counted on sooner or later, 
yet it is impossible to determine how soon; for, even .when the complaint is 
disappearing, we cannot be certain that a new crop of pustules may not break 
out. It may get well in a few weeks, or may continue many months. 
Treatment.-In the early stages, this should always be soothing. In rela- 
tion to general treatment, little is requisite. In cases of vigorous constitu- 
tion, when there is much local inflammation, it may be proper to take a little 
blood generally or locally; but this is seldom requisite. It will usually be 
sufficient to diminish the diet, to give cooling drinks, and to administer now 
and then a gentle laxative, as magnesia, one of the neutral salts, or a mixture 
of sulphur and cream of tartar. An occasional purgative dose of calomel may 
be useful in infantile cases of unusual severity or obstinacy. 
The local treatment, in the same stage, should be confined to the keeping 
of the part perfectly cleansed from all filth, whether extraneous or from its 
own secretions, and to the use of demulcent or emollient applications. The 
pus should be carefully wiped away with a very soft sponge, or linen rags, 
and the surface frequently washed with warm water, milk and water, infusion 
of bran or slippery elm, almond emulsion, or other similar liquid; and, in the 430 
[PART II. 
LOCAL DISEASES.-SECRETORY SYSTEM. 
intervals, may be protected by some mild unctuous substance or liniment, 
such as thick cream, ointment of rose-water, spermaceti ointment, or glycerin. 
When the disease affects the scalp, the hair should be cut close, and emol- 
lient poultices applied to remove the scabs, after which the demulcents may 
be used as above. Sometimes anodyne applications may be made to relieve 
the irritation; but great care must be taken not to poison the infant through 
the skin. The liquid preparations of opium, digitalis, hydrocyanic acid, &c., 
which have been recommended, should be used with caution. When the 
surface is excoriated, the cerate of subacetate of lead, or ointments made with 
calamine, or oxide of zinc may be tried. Benefit may sometimes accrue from 
solutions of gutta percha or caoutchouc in chloroform, which leave a pellicle 
on the surface, and thus exclude the air. Absorbent powders may be used 
for the same purpose, as well as to obviate the effects of the acrid secretion. 
Cazenave employs oxide of zinc mixed with fifteen parts of starch, the surface 
having been previously well washed with a weak alkaline solution and dried. 
When the disease is more advanced, other measures should be resorted to. 
In relation to constitutional treatment, much good may sometimes be done 
by a proper attention to the general state of health, and by the use of certain 
alteratives. Should the patient be feeble, recourse should be had to the 
tonics. Of these the nitromuriatic acid sometimes acts very happily, from 
its effects in improving a depraved blood. Should the digestive system or 
hepatic secretion be disordered, these should be restored to a sound state. 
As alteratives, iodine, mercury, sarsaparilla, and arsenic may be tried; but 
they should not be used except in decidedly chronic and obstinate cases, and 
in these always with caution. The waters of sulphur springs may also be 
used. Solution of chloride of calcium has been recommended in scrofulous 
cases; and cod-liver oil may be employed under similar circumstances. 
Locally, recourse may now be had to stimulant applications; their strength 
being graduated to the circumstances of the case. It is best to begin with 
the mildest, and advance, if necessary, to the more active. The mineral 
acids very much diluted, weak solutions of the alkaline carbonates, magnesia 
in an unctuous form, a very dilute solution of nitrate of lead, or ointment of 
nitrate of mercury weakened with six or eight times its weight of lard, may 
be used. Should these prove insufficient, and the parts not be irritated by 
them, trial may be made of nitrate of silver, or the mineral acids of such a 
strength as to be very slightly caustic, ointment of iodide of sulphur, undi- 
luted ointment of nitrate of mercury, or the other stimulant preparations of 
the same metal. Sanguinaria is said to have proved beneficial. In cases 
attended with thick incrustation, jets of warm aqueous vapour, or the hot 
water douche, may be used in connexion with emollient poultices to soften 
and remove the scabs; after which some of the applications above mentioned 
may be used, beginning with the ointments of zinc or lead, and resorting 
afterwards if necessary to the more stimulating. In the scaly stage, I prefer 
tar ointment to all others. A blister to the diseased surface has been recom- 
mended. Alkaline and sulphuretted baths are said to have proved beneficial; 
and the salt-water bath has sometimes effected cures. 
3. ACNE. 
There are several pustular affections which have this in common, that they 
are seated in the cutaneous follicles, but differ so much in appearance as to 
merit distinct names. Such are the complaints called severally acne, rosacea, 
and sycosis. The first two are included under acne by Willan, Bateman, CLASS III.] 
PUSTULES.-ACNE. 
431 
Biett, and others. Rayer considers them separately, and his example is here 
followed. Mr. Plumbe has shown that they consist essentially of inflamma- 
tion of the follicles, or at least has rendered the fact in^the highest degree 
probable. Willan and Bateman place them among the tubercules; but they 
are now universally admitted to be truly pustular; the tuberculated condition 
■which they sometimes assume being secondary. 
Acne (from ax^, vigour of life) is a chronic eruption of scattered pustules, 
with inflamed and hardened bases, terminating frequently in tubercules, and 
seated probably in the sebaceous follicles. It occurs upon the face, neck, 
shoulders, and anterior and posterior portions of the chest, sometimes extend- 
ing down the back almost throughout its whole length. The upper and pos- 
terior part of the back is probably, as a general rule, most affected. Some- 
times the pustules appear on the back of the arms. They very rarely occur 
upon the lower part of the trunk, and almost never upon the lower extremi- 
ties, though said sometimes to affect the follicles of the scrotum. They are 
usually first observed upon the face, especially the forehead, nose, and region 
of the masseters, though they may have previously existed between the 
shoulders unnoticed. 
At first small pimples are seen, entirely distinct, generally red at the base, 
but without pain, and with little or no uneasiness of any kind. The system 
at large is not perceptibly affected. In some instances, the pimples appear in 
small numbers and successively; in others they break out abundantly, and 
almost cover the face. The skin between them often has an oily appearance. 
At first about the size of a pin's head, they gradually enlarge and become red, 
shining, and somewhat painful to the touch. Suppuration takes place slowly, 
and it is often a week or more before pus is formed. This is usually small 
in quantity, and quickly dries into a minute scab, which, upon separating, 
leaves a small, red, somewhat elevated spot, that ultimately disappears. The 
whole process occupies about three weeks. The pustules are renewed at inter- 
vals for an indefinite time, and in some cases are never quite wanting. This 
is the simplest form of the affection, answering to Acne simplex of Willan. 
The complaint often occurs in a severer form, denominated Acne indurata 
by Willan. The follicles are more inflamed, the pimples are larger, and sup- 
puration takes place more slowly, occurring at various periods from ten days 
to three weeks. Sometimes several neighbouring follicles appear to unite, 
and form a small tumour of the size of a large pea, or even of a hazlenut. 
After suppuration, the pustule, instead of subsiding entirely, often leaves a 
hard tubercule of a violet red colour, which is long in undergoing resolution. 
The inflammation extends in spots to the subcutaneous cellular tissue, which 
becomes hardened here and there, and gives irregularity to the surface. Some- 
times only a few of these tubercules appear; sometimes they are numerous, 
covering particular portions or nearly the whole of the face. Between the 
tubercules are numerous smaller prominences, some in the state of pimple, 
some in that of pustule, others with minute scabs; and interspersed among, 
these are also the red spots left by the retroceding eruption, and whitish ob- 
long scars resulting from former tubercules. Besides these various appearances, 
there are very often not only in this, but also in the simpler form, numerous 
black points, surrounded by a more or less prominent circle of cuticle, which 
are the orifices of sebaceous follicles, distended with their peculiar secretion. 
From these the sebaceous matter may be pressed out in the form of small 
worms with a black head; and, not unfrequently, the escape of this matter is 
preceded by a gush of pus through the same orifice. The affection, when pre- 
senting this appearance, is denominated Acne punctata by Willan. In some 
instances, the sebaceous matter is exuded so abundantly as to produce crusts 432 
[part II. 
LOCAL DISEASES.-SECRETORY SYSTEM. 
over considerable portions of the surface, forming the Acne sebacea of Biett. 
AU the phenomena above described, constituting different stages or degrees 
of follicular inflammation or excitement, may appear at the same time upon 
any of the parts frequented by the disease, and when on the face give it a 
very disagreeable and even repulsive aspect. 
The affection, in this form, often continues for months or years, varying 
more or less in degree, sometimes, perhaps, disappearing, and again returning, 
until at length the constitutional tendency to it seems to be exhausted, and 
the patient slowly recovers, retaining, however, not unfrequently, indelible 
marks of the disease. At no time is it necessarily attended with any consti- 
tutional disorder. 
Causes.-The chief cause of acne is probably some modification of the vital 
processes, during the period which intervenes between puberty and full ma- 
turity of growth. At this period, when the functions are gradually settling 
down from a state of high activity into the regularity of mature age, excesses 
or irregularities in the vital actions not unfrequently occur, which find an 
outlet in various local diseases, of which one of the safest is" undoubtedly that 
now under consideration. Hence, young persons of both sexes are peculiarly 
liable to the disease, which is most common from the seventeenth or eighteenth 
up to the twenty-fifth year, though it not unfrequently happens as late as 
thirty or even thirty-five. The notion is, I think, altogether gratuitous, and 
highly injurious to the good name of the young, which ascribes the disease to 
secret and vicious indulgences. On the contrary, it frequently occurs in per- 
sons of health in all other respects perfectly sound, and of the most correct 
characters; and I have certainly not noticed it as peculiarly attendant upon 
cases in which such vices have been acknowledged. 
It is no doubt true that, in those predisposed to the affection, it is induced 
by intemperance in eating and drinking; and it is very intelligible that, in 
females, it should be more apt to occur when the menses are retained or sup- 
pressed, than in the healthy state of that function. It is supposed to be 
caused in some instances by disordered digestion. Local irritation may also 
sometimes call the predisposition into action. 
Diagnosis.-Acne may in general be easily distinguished. The only affec- 
tions which are liable to be confounded with it are ecthyma, and syphilitic 
pustules and tubercules. The pustules in ecthyma are larger and more super- 
ficial than those of acne, have a much thicker scab, and do not, like the latter, 
leave chronic tubercules behind them. Nor are they accompanied with thick- 
ening and induration of the subcutaneous cellular tissue. The syphilitic pus- 
tule and tubercule are apt to be surrounded with a copper-coloured areola, 
appear on other parts of the body as well as in the ordinary seats of acne, and 
are besides preceded or accompanied with other symptoms which sufficiently 
indicate their nature. Besides, the syphilitic tubercules are often ulcerated 
at top. Nor are they interspersed with those enlarged sebaceous follicles, or 
attended with that greasy state of the skin, so characteristic of acne. 
Prognosis.-The simple form of the disease is often of brief duration; but 
it is often also obstinate and persistent; and the severer form sometimes lasts 
for many years. It is impossible in any case to prognosticate with accuracy 
the period of recovery. The patient, however, may be assured that he will 
get well in time; for it almost never happens that, with a proper attention to 
regimen and modes of life, the disposition to the disease does not spontane- 
ously cease, with the changes which the system undergoes. 
Treatment.-Very little should be done in the milder cases. In those of 
greater severity, the physician, even if disposed, cannot resist the appeals con- 
stantly made to him by the very excusable regard of the patient for his per- CLASS III.] 
PUSTULES.-ACNE. 
433 
sonal appearance. But he should always bear in mind that this affection may 
be a safe outlet for tendencies to irritation, and should, therefore, be guarded 
in the measures employed. 
In relation to general remedies, it is usually sufficient, in the early stages, 
to obviate costiveness by saline laxatives, to restrict the patient to a moderate 
and easily digestible diet, and to forbid strictly all stimulating drinks and 
high-seasoned food. Any disorder of menstruation, digestion, or other im- 
portant function, should be corrected by the appropriate means. Should the 
inflammation be severe, and the patient vigorous or plethoric, it would be pro- 
per to take blood both from the arm, and by leeches from the neighbourhood 
of the affected part, as, for example, from behind the ears in acne of the face. 
Under the same circumstances, the diet may be still further reduced, and a 
dose of sulphate of magnesia occasionally administered. The habitual use of 
the warm bath may also be advantageous. Should the patient, on the con- 
trary, be feeble, it may be necessary to support his strength by mild tonic 
measures, adapted to the circumstances of his case. Among these the cold 
bath is one of the best. In the advanced stages, when the disease has become 
quite chronic, recourse may be had to the alterative influence of iodide of 
potassium, iodide of iron, compound syrup of sarsaparilla, &c. Mr. Startin 
has obtained great success, in the Hospital for diseases of the skin, in London, 
by the conjoined use of the preparations of iron and saline aperients. (Med. 
Times and Gaz., vi. 24.) 
The local treatment should at first be soothing. Emollient or demulcent 
lotions may be used occasionally through the day, such as infusion of bran or 
slippery elm, emulsion of bitter almonds, warm milk, cream, glycerin, &c. 
When considerable extents of surface are affected, demulcent baths may be 
useful. An emollient poultice, as of bread and milk, mashed potatoes, mush, 
&c., may be applied to the face at night. Wilson has found advantage from 
the application of collodion, so as to protect the surface from the air. A 
solution of gutta percha or caoutchouc in chloroform is still better. As the 
complaint advances, and the eruption assumes a more indolent character, dis- 
posed neither to suppuration nor to resolution, gently stimulant applications 
may be made; such as alcohol, diluted with one of the aromatic waters; di- 
luted spirit of lavender, bay-rum, or Cologne water; a solution of corrosive 
sublimate in alcohol or water, in the proportion of from half a grain to two 
grains to the pint, &c. Dr. Neligan thinks that the best method of preventing 
acne is to wash the face, in the morning, with a solution of carbonate of soda 
instead of soap, and afterwards with a lotion consisting of two drachms of oil 
of lemon and half a drachm of oil of rosemary, dissolved in half a pint of alco- 
hol. (Dub. Quart. Journ. of Med. Sei., xi. 330.) Mr. Plumbe strongly 
recommends that each tubercule, as soon as it assumes a bluish hue indicative 
of suppuration, should be opened by a lancet, and the matter pressed out. 
The same end may often be effected by pressure alone without puncture. At 
a still later period, the ointment of nitrate of mercury, of ammoniated mer- 
cury, or of iodide of sulphur should be used. Biett praises highly the last- 
mentioned preparation, made in the proportion of from twelve to twenty-four 
grains of the iodide to an ounce of lard. At this stage, too, it is that lotions 
of one of the natural sulphur waters, or the douche of hot vapour or hot 
water, continued for fifteen or twenty minutes, have been found beneficial in 
exciting the languid tubercules into a more rapid action. The use of vapour 
baths, and sulphur baths, has also been recommended. A blister applied to 
the diseased follicles has sometimes had a powerful influence in promoting 
their resolution. In despair of benefit from other means, nitrate of silver, 
and the strong mineral acids have sometimes been employed with a view to 434 
[part II. 
LOCAL DISEASES.-SECRETORY SYSTEM. 
their caustic effect. I should prefer a trial of the tincture of iodine applied 
repeatedly to the diseased surface. When any of the above measures occasion 
much inflammation, they should be suspended for a time. 
4. ROSACEA. 
Syn.-Acne rosacea (Bateman, CazenaDe and Schedd).-Gutta rosea.-Couperose 
(French'). 
This is strikingly peculiar in its appearance. An affection sometimes 
occurs in the young, consisting of isolated and scattered pustules of acne, 
upon a broad, hard, and violet-red base, which, though described by authors 
under this head, appears to be intermediate between acne and rosacea, and, 
from the circumstance that it occurs at the same age, might properly be refer- 
red to the former complaint. If it be so referred, it would be entitled to the 
name of Acne rosacea. Rosacea, as the term is here understood, is confined 
almost exclusively to persons in middle or advanced life. 
The disease usually appears first upon the nose, especially the end of it, 
though it may begin also in other parts of the face. The skin in the part 
affected assumes a deep-red colour, most commonly after some excess in 
drinking or eating. The redness disappears after a time, but returns upon 
some similar occasion, and this may happen several times, until at length the 
colour becomes permanent. Pustules now appear upon the surface, and, by 
their yellowness, sometimes offer a striking contrast with the purple redness 
around them. The skin swells unequally, the part affected often enlarges con- 
siderably, and deeper-red or bluish streaks, caused by the enlarged capillaries, 
meander over the surface. In some instances, the affection continues con- 
fined to the nose, but in others it extends to the cheek, forehead, chin, and 
even to the whole face, which is then all over red, though with unequal inten- 
sity in different spots. The redness is deepest about the pustular eminences, 
which often assume a tuberculated condition, neither inclined to suppuration 
nor to resolution. The whole surface affected is unequal, rugose, and of a 
peculiarly disagreeable and repulsive appearance. 
Cause.-This affection is generally the result of intemperate drinking or 
eating, or of both. It is also said to be produced by excessive mental labour 
with confinement, and especially when combined with the indulgences of the 
table. Disorder of the digestive process is apt to accompany, and may pos- 
sibly promote it. Individuals have been observed to be peculiarly prone to 
it, whose parents have been affected in the same way. Women are especially 
liable to it about the period of the cessation of the catamenia. 
Prognosis.-The complaint often ceases for a time, but it is very apt to 
return; and, when of long standing, is exceedingly obstinate, if not quite 
incurable. The prognosis is favourable inversely in proportion to the age of 
the patient, and the duration of the disease. When it depends upon intem- 
perance, there may be more hope of cure from a change of habits, than when 
it arises from constitutional peculiarities. 
Treatment.-There may be cases of the disease in which th'e general health 
is so vigorous as to admit of bleeding; but they are rare. Occasional 
leeching near the part affected may be useful in some cases. The measure 
upon which most depends is a complete change of habits. If the patient, 
upon the occurrence of the disease, can be prevailed on to adopt a temperate 
course of life, there is reasonable ground to expect a cure. A bland diet of 
boiled meats, milk, and digestible vegetables and fruits, should be enjoined. 
The course of general treatment must be conducted in reference to the state CLASS III.] 
435 
PUSTULES.-ROSACEA.-SYCOSIS. 
of system, without particular regard to the local affection. It is said that 
good has resulted from the nitro-muriatic acid foot-bath; and the alterative 
influence of mercury, or iodine, or of both conjoined, may be tried. Dono- 
van's solution has been specially recommended. 
In relation to the local treatment, the remarks made under acne are exactly 
applicable here. In the early and more inflammatory stage, the emollient 
plan should be adopted, and should afterwards be exchanged gradually for 
the stimulant, as the affection becomes indolent. 
5. SYCOSIS. 
The term sycosis is derived from ovxov, a fig, probably from a supposed 
resemblance between the disease which it designates, and the rough interior 
of that fruit. The complaint differs from the two preceding by affecting 
especially the hair follicles of the face. It may occupy the chin, upper lip, 
eyebrows, submaxillary region, or that part of the cheek where the whiskers 
grow. In other words, it is confined to the hairy portions of the face. It 
is sometimes also seated in the scalp, and in Bateman's synopsis, is named 
/Sycosis capillitii when in this position, and & menti when in the chin. But 
the division is unnecessary, as the affection is identical in the two positions. 
Sometimes it is limited to one portion of the face, sometimes affects all the 
hairy parts at the same time. 
Sycosis does not usually make its attack without previous warning. The 
patient is for a long time affected now and then with an eruption, to which, 
however, he pays little attention. At length some portion of the chin or 
upper lip is affected with redness, heat, and painful tension, followed by an 
eruption of pimples, which in one, two, or three days, are converted into 
pustules of various sizes, but not generally exceeding* that of a millet seed. 
Each pustule is usually penetrated by a hair. They are sometimes isolated, and 
sometimes in clusters, and may occur over a considerable space at the same 
time, or, beginning at a point, may gradually extend thence in different direc- 
tions. In six or seven days they break, and form brownish scabs. In ten 
days or two weeks, these scabs separate, and the particular pustules have run 
their course. But others appear, the skin becomes inflamed, and the inflam- 
mation extends to the subcutaneous tissue, producing partial swelling and 
induration. The parts are now red, painful, and deformed; exhibiting pus- 
tules intermingled with large yellowish or greenish-brown scabs, which mat 
the beard together, and with tubercules of various sizes, sometimes as large 
as a pea or cherry, which suppurate very slowly. Plumbe says that a little 
pus is contained in the centre of every tubercule; but this statement has been 
found to be too general. Sometimes a small spot only is affected, and pre- 
sents a dark-coloured, prominent scab, which has a very peculiar appearance. 
In some old cases, the hair falls from particular spots, though it grows again, 
and ultimately acquires the same appearance as it had originally. When the 
part returns to health, there is a gradual diminution of the swelling and in- 
duration, the existing tubercules are resolved, new pustules cease to appear, 
and the disease ends by a desquamation of the cuticle. It is very uncertain 
in its duration, and its course cannot be predicted. Sometimes it speedily 
yields to remedies, at other times it resists them obstinately, and runs on for 
years with various vicissitudes. Some persons are attacked every winter, and 
become free from the disease in summer. 
Causes.-These are not well understood. A predisposition appears to be 
Syn.-Mentagra.-Tinea Sycosa (W. Jenner). 436 
LOCAL DISEASES.-SECRETORY SYSTEM. 
[PART IT. 
generated by intemperance, and low debauchery and filth; but it occurs also 
in the temperate, and in those exemplary in all respects. Disorder of diges- 
tion, gouty or rheumatic irritation, or other derangement of health, is some- 
times associated with it, and probably in the relation of cause. The scrofulous 
diathesis is thought to predispose to the affection. It occurs most frequently 
in young adults, though old age is not exempt. Local irritation, and what- 
ever induces an habitual flow of blood to the face, are said to act as exciting 
causes. Hence, the disease has sometimes been ascribed to cosmetics ; and 
persons whose faces are necessarily much exposed to the fire, as cooks, smiths, 
&c., are said to be peculiarly prone to it. Some ascribe attacks of it occa- 
sionally to the use of a razor previously used in shaving a diseased person. 
M. Foville saw a number of the insane inmates of the hospital of Rouen at- 
tacked by it successively, after having been shaved by the same razor. It is 
doubtful, however, whether the proper sycosis is contagious. It is not im- 
possible that there may be an analogous complaint capable of being communi- 
cated in this way; and Mr. G-ruby, of Vienna, has described such an affection, 
which he considers to be essentially a cryptogamous vegetation seated in the 
beard, and capable of communication by the transfer of the sporules. (Notes 
to Royer on Dis. of Skin, Am. ed., p. 186.) M. Bazin considers ordinary 
sycosis to be the result of this microscopic plant, which grows in the hair 
follicle between the hair and the capsule; and, in accordance with this view, 
proposes for it the name of Tinea sycosa; having adopted Tinea as the generic 
title of the cryptogamous affections of the scalp. . . 
Diagnosis.-This affection may be confounded with ecthyma, impetigo 
figurata, and some forms of syphilitic eruption. Ecthyma has larger pustules, 
and larger, thicker, and more adhesive scabs; and is not attended with tuber- 
cules, nor with subcutaneous thickening or induration. In impetigo figurata, 
the pustules are small, flat, in crowded groups, and at their height on the 
third or fourth day; while those of sycosis are prominent, often pointed, gene- 
rally distinct, and do not break till the sixth or seventh day. In the former 
disease there is more fluid discharge, and larger, thicker, and yellower scabs 
than in the latter. Impetigo is without tubercules. The syphilitic pustules 
are without the heat and pain of those of sycosis, are also flatter, slower in 
their march, surrounded, by a copper coloured border, and situated in other 
portions of the face besides the hairy parts. 
Treatment.-It is important to attend to the state of the general health, 
and to correct it by measures corresponding with the indications. The habits 
and pursuits of the patient should be regulated so that they may not act as causes 
of the disease. Bleeding may be employed both generally and locally, when 
there is much inflammation, and the patient is robust. Moderate purging, 
continued for a long time, at such intervals as not to debilitate the patient, is 
recommended; and the blue mass or calomel in small doses, followed by or 
connected with one of the saline cathartics, may be employed for the purpose. 
In chronic cases, tonics are occasionally useful, especially the preparations 
of iron. M. Biett has employed the chloride of gold, with great asserted 
advantage, by rubbing it upon the tongue. Mercury and iodine may be used 
as alteratives; and, in very obstinate cases, a careful trial may be made of 
Donovan's solution. 
The patient should avoid the use of the razor, and should remove his beard 
by means of a very sharp curved pair of scissors. The same local treatment 
is required as for acne. (See page 433.) In the view of the cryptogamous 
nature of the complaint, a watery solution of sulphurous acid, or an acetous 
solution of one of the alkaline sulphites, might be employed with the reason- 
able hope of effecting a cure. Plumbe recommends that every tubercule CLASS III.] 
SCALY DISEASES.-PSORIASIS. 
437 
should be opened in its advanced state, and the hair plucked from every 
pustule when it can be done without pain. ' 
Article V. 
SCALY DISEASES. 
Four scaly diseases are usually classed together; namely, psoriasis, lepra, 
pityriasis, and ichthyosis. Of these, the first two are so analogous in symp- 
toms, character, and treatment, that they might, without impropriety, be con- 
sidered as varieties of the same disease; and ichthyosis is so different from the 
others as to have been separated from them by Rayer, and treated of under 
hypertrophy of the skin. Without stronger reasons, however, it is perhaps 
best not to disturb an arrangement established by the great English derma- 
tologist, and in which authors generally seem disposed to acquiesce. 
1. PSORIASIS. 
This term, derived from the Greek word 4<jpa, which signifies a cutaneous 
eruption supposed by some to be scabies, was applied by Willan to a disease 
of the surface, characterized by slight elevations of the skin, surmounted by 
whitish scales, and not depressed in the centre. It appears in several forms, 
which, however, are often only different stages of the same affection. 
Symptoms, Course, &c.-In the mildest form [Psoriasis guttata of Willan), 
it appears first in small papulous elevations often not larger than a pin's 
head, the summit of which is soon covered with a slight scab. Many of 
these break out at the same time. They gradually increase in size till they 
have attained a diameter of from two to four lines; continuing quite distinct, 
and appearing somewhat like isolated drops of liquid scattered upon the skin. 
Their form is irregularly circular; and, when freed from their scales either 
spontaneously or by the nails in scratching, they present a bright red, some- 
what painful, and slightly elevated surface, which quickly again covers itself 
with scales. They may occur upon all parts of the body, but are most fre- 
quent on the back and limbs. They are attended with some itching, espe- 
cially when the patient is warm in bed. 
Sometimes, instead of having the distinct form just described, the little 
red elevations occur so numerously, and so near together, that they neces- 
sarily coalesce as they grow, and thus form large irregular surfaces, which 
are covered with scales of various thickness and adhesiveness, and sometimes 
exhibit remains of the original papulous elevations within their boundaries. 
This is the Psoriasis diffusa of Willan. When freed from the scales, the 
patches are red, rough, and chapped. They are often very large, sometimes 
covering the whole anterior surface of the leg, or posterior surface of the fore- 
arm, and especially affect the knee and elbow. Occasionally the patches are 
seen without any elevation, merely presenting irregularly circumscribed sur- 
faces, covered with minute thin scales. Though most frequently observed 
upon the extremities, they sometimes show themselves on the back and abdo- 
men, and may indeed occur in any part of the body, but are not common in 
the face. They are attended with burning, tingling, and a very troublesome 
itching, especially when the patient is near a fire. Sometimes they become 
inflamed, the surface is more elevated, the scales thicken, and the skin cracks 
into fissures, which are painful, and bleed upon movement. 438 
[part it. 
LOCAL DISEASES.-SECRETORY SYSTEM. 
A still worse form of the disease (Psoriasis inveterata of Willan) results 
from long neglect, from the continued operation of the cause, or from the 
peculiar constitution of the patient, as in the old, the intemperate, and per- 
sons broken down by bad habits of life, or by hardships and privations. In 
this, the skin is inflamed, thickened, and intersected in all directions with 
furrows, which are often deep, and filled by a white powdery matter. Im- 
mense quantities of scales are produced, which readily separate, so that the 
bed is sometimes found full of them in the morning. In some instances, the 
surfaces are nearly destitute of scales, red, rough, and unequal. The affec- 
tion may be confined to the limbs; but sometimes extends to the whole sur- 
face, except, perhaps, the face, palms of the hands, and soles of the feet; and 
occasionally the body seems as if furnished with a complete scaly case. In 
this form of the disease, the motions are often much constrained and painful, 
producing cracks and fissures in the vicinity of the articulations, which fre- 
quently bleed, and become very sore and tender, so that the patient is com- 
pelled to keep chiefly to his bed. 
In another, but very rare form of the disease (Psoriasis gyrata of Willan), 
the eruption, instead of assuming the shape of broad irregular patches, or small 
circles, appears in narrow strips, sometimes nearly straight, sometimes con- 
torted and vermicular, and occasionally in rings. 
Not unfrequently, psoriasis is quite local, occupying a limited space and 
only that, and receiving different names according to its position. Sometimes 
it appears exclusively on the face (P. facialis'), especially on the forehead, 
nose, and back part of the cheeks, where it forms thin scales of considerable 
size, upon red and somewhat painful surfaces, which are often little if at all 
elevated; and the scales, instead of being white, are often of a light yellowish- 
brown, or tawny hue. It may be confined to the vicinity of the eye (P. 
ophthalmicai), where it is seen in the form of minute scales at the angles of 
the eyelids, and upon the lids themselves, rendering them stiff on movement, 
and inducing more or less inflammation of the conjunctiva. Another seat of 
the disease is the lips (P. labialis), around which it sometimes forms a circle 
of about half an inch in width, with furrows converging towards the mouth, 
so as to give it a puckered appearance. The epithelium forms thick scales, 
which frequently exfoliate, and'the lips are apt to be affected with fissures, 
which bleed and occasion pain when the part is moved. In the palm of the 
hand (P. palmaria'), it appears either in distinct, red, and elevated spots, 
which coalesce and exfoliate; or as a single patch, inflamed, hot, and some- 
what painful, which covers itself with a white scale, and extends, by additions 
to its circumference, till it occupies the whole palm, and even the anterior 
surface of the fingers; while the central portion, exfoliating, shows a purplish- 
red, thickened, stiff, and tender surface, with deep furrows and fissures, ren- 
dering every movement of the fingers painful. Another form of the disease 
upon the hands is that vulgarly denominated grocers' itch (P. dorsalis), which 
is situated upon the back of the hand and fingers, causing large, hard, and 
dry scales, and deep and painful cracks about the knuckles. The nails, when 
affected by the disease in their matrix (P. unguium), become distorted, lamel- 
lated, rough, unequal, and of a yellowish colour, exhibit a whitish powder 
about their roots, and sometimes give place to irregular scaly incrustations. 
The disease is occasionally confined to the prepuce or scrotum (P. prseputii, 
and P. scrofalis), rendering the skin of these parts rough, scaly, cracked, and 
inexpansible, and, in the prepuce, sometimes giving rise to phymosis. . 
In the milder forms, and in those confined to particular parts, there is little 
or no constitutional disturbance; and the general health is often very good. 
The severer forms are sometimes preceded by general uneasiness, feverishness, CLASS III.] 
SCALY DISEASES.-PSORIASIS. 
439 
headache, &c., which disappear when the eruption is established. In the inve- 
terate variety, the mucous membranes sometimes become inflamed, especially 
that of the bowels; though, even in this form, the appetite is not unfrequently 
unimpaired, and the strength wonderfully preserved for many years. 
When the disease terminates favourably, there is a gradual subsidence of 
the symptoms; the patches begin to return to the healthy state in the centre; 
the circumference is often broken into fragments by the advancing cure; and 
at last the whole surface returns to the natural state, except that a yellowish- 
brown stain is often left for some time. 
Causes.-These are for the most part obscure. It is admitted on all hands 
that the disease is not contagious. There appears to be in some a hereditary 
tendency to it. From the circumstance that it occurs most frequently among 
the wretchedly poor, it is supposed that its attack is favoured by the priva- 
tions, hardships, and uncleanly habits incident to extreme indigence. Never- 
theless, the disease also occurs among persons who live well, and pay the 
strictest attention to cleanliness. It has been thought that the use of certain 
kinds of food, as salt meat and fish, vinegar, sour fruits, and acescent vege- 
tables, has produced it in certain individuals. It seems to have been some- 
times called into action by strong emotions, and by cold water taken by 
persons greatly overheated. It occasionally alternates or is associated with 
gout and rheumatism. The local varieties are induced by local irritants, as 
in the instance of psoriasis of the hand, which is ascribed to the irritation of 
powdery substances frequently applied to that part. The time of year seems 
to have some influence; as the complaint occurs most frequently in the spring 
and autumn; and it has been observed that certain mild cases are apt to leave 
the patient upon the approach of very hot and very cold weather, and to return 
again at the former seasons. Both sexes and all ages are liable to the disease. 
It is most frequent in adults, though children, particularly those in the hum- 
blest stations of life, are occasionally attacked, and Willan has a distinct 
variety of the disease under the name of P. infantilis. 
Diagnosis.-The diagnosis between this complaint and leprosy, as well as 
pityriasis, will be considered under these two diseases. From lichen circum- 
scriptus, psoriasis is distinguished by its want of pimples, some of which may 
almost always be seen in the former complaint. A scaly eruption of a syphilitic 
character, which bears some resemblance to psoriasis guttata, may be distin- 
guished by its copper colour, the absence of scales or their extreme minute- 
ness, and by concomitant symptoms. 
Prognosis.-1This is always favourable in the milder forms, under proper 
treatment. The disease often speedily gets well; but it must be acknowledged 
that it is sometimes very obstinate. The inveterate form, especially in con- 
stitutions broken down by old age or other causes, but too frequently resists 
every variety of treatment. Sometimes psoriasis gets well spontaneously, and 
sometimes is superseded by other diseases, as by measles or erysipelas. It 
often runs on for years. It is never fatal unless complicated with internal 
disease, as gastro-intestinal inflammation. In this way it is sometimes fatal 
in the old. It is very liable to return after having been apparently or really 
cured. 
Treatment.-In the threshold of the treatment, it should be borne in mind 
that repellent remedies, in the early stages and acute varieties, may do harm 
by inducing internal disease. I have seen a case in which pericarditis seemed 
to follow even the cautious application of tar ointment. It is safest, there- 
fore, to trust the disease at first to general remedies and the mildest local mea- 
sures. I shall consider the general and local remedies separately. 
Should the patient be vigorous, with a strong pulse, and considerable in- 440 
[part II. 
LOCAL DISEASES.-SECRETORY SYSTEM. 
flammatory excitement in the eruption, it might be advisable to bleed mode- 
rately from the arm. Purgatives may be employed with advantage. A mode- 
rate dose of sulphate of magnesia, or other saline cathartic, may be given twice 
or three times a week, and continued for a considerable time, unless it should 
too much reduce the strength, or irritate the alimentary mucous membrane. 
In the cases of children, calomel in doses of from two to four or six grains, 
followed by castor oil, and repeated occasionally as the strength will permit, 
is among the most efficacious remedies. Should the bowels be torpid, re- 
course may be had to the more active purgatives, as senna, jalap or its ex- 
tract, compound extract of colocynth, croton oil, &c.; and the compound 
cathartic pill, which combines several of these, is an eligible preparation. 
Purging is useful not only as a depletory remedy, but probably still more by 
revulsion. Acetate of potassa, in the dose of half a drachm three times a 
day, has been found very useful. (Easton, Ed. Month. Journ. of Med. Sei., 
May, 1850, p. 423.) The diet, under the same circumstances, should con- 
sist of vegetable substances, or of these with milk. Everything stimulant 
should be avoided, and cooling drinks, and rest as far as possible, enjoined. 
In connexion with this antiphlogistic course, the decoction of dulcamara 
may be employed internally. Half a pint in divided doses may be given at 
first during the day, and gradually increased to a pint. I have used this 
remedy frequently, and it has appeared to contribute much to the cure. 
Among its effects are a general reduction of the force of the circulation, and a 
particular reduction of the capillary circulation of the skin. It is, therefore, 
calculated to produce the very effect desired of reducing cutaneous irritation. 
The remedy should be persevered in for weeks. 
In co-operation with the above measures, the warm bath should be employed 
daily, and it will be still more effectual, if rendered demulcent by the addi- 
tion of bran, flaxseed, or slippery elm. 
In old and feeble individuals, the above course cannot be adopted. For 
these it is sometimes necessary to employ tonics, and a nutritious, though not 
stimulating diet, in order to correct the condition of the blood, the vitiation 
of which has probably contributed to the disease. 
When the complaint has resisted the above measures, and certain local 
means to be mentioned directly, and the system has been sufficiently reduced, 
recourse may be had to alterative medicines such as experience has proved to 
be useful. Among these, the preparations of arsenic are, according to my 
own observation, incomparably the most efficacious. It is very seldom that 
the most obstinate case will refuse to yield to this remedy, if properly employ- 
ed, and duly persevered in. I have known it to fail in no instance in which 
I have had an opportunity of doing it full justice. A case of fifteen years 
duration, in which almost the whole surface was thickly covered with the 
eruption, yielded to the remedy. The patient began to improve soon after taking 
it, and recovered perfectly in about six months. I usually employ the Fow- 
ler's solution in the dose of from three to five drops three times a day, giving 
at the same time about a pint of the decoction of dulcamara daily, and 
employing warm mucilaginous baths, and, in very chronic cases, tar ointment, 
or ointment of iodide of sulphur, as a local remedy. Other preparations of 
arsenic have been used, among which are Pearson's solution, and arseniate 
of ammonia. The remedy should be suspended, if it occasion gastric uneasi- 
ness, oedema of the face, or muscular weakness, and resumed when these symp- 
toms cease. To be successful it should be persevered in for a long time, 
even for several months, with occasional interruptions. 
Another powerful remedy is tincture of cantharides. It has been found 
very effectual by M. Biett. From six to ten drops of the U. S. tincture, which CLASS III.] 
SCALY DISEASES.-PSORIASIS.-LEPRA. 
441 
is only about one-fourth as strong as the French, may be given twice a day, 
and gradually increased to forty or sixty drops, care being taken to suspend it 
should irritation of stomach or of the urinary passages result, and to resume 
it in smaller doses when this has subsided. It must be persevered in, with 
occasional intermissions, for months if necessary; but a cure, it is stated, may 
be expected from it in six or eight weeks. (Cazenave and Schedel.') 
Neither tincture of cantharides nor arsenic should be administered in cases 
attended with inflammation of the stomach. 
Numerous other remedies have been recommended, and most of them pro- 
bably possess some efficacy. Among them are the officinal solution of potassa, 
in the dose of twenty drops three times a day, carbonate of ammonia, corro- 
sive sublimate with compound syrup of sarsaparilla, the antimonials, the pre- 
parations of iodine, sulphur, sulphuret of sodium, tar and turpentine, meze- 
reon, burdock root, rhus radicans, and galium aparine. (See U. S. Dispensa- 
tory, 10th ed.) Iodide of potassium has been specially recommended. Bate- 
man says that the mercurial influence is injurious. In very obstinate cases, 
the practitioner would be justified in resorting to Donovan's solution. 
Of the local measures, it is best, in the early stages, to be content with de- 
mulcents and emollients, in the form of cataplasms, when the disease is suf- 
ficiently local, and of lotions consisting of warm water, milk and water, 
almond oil, almond emulsion, glycerin, &c., when it is more general. Exclu- 
sion of the air by means of collodion, or a solution of gutta percha or gum 
elastic in chloroform, will often be productive of advantage. 
Should the disease not yield, and should the constitutional measures men- 
tioned as applicable to the early stages have been sufficiently tried, the prac- 
titioner may then employ tar ointment, which ought at first to be diluted 
with lard, and applied to a portion only of the diseased surface. Afterwards, 
if found to do good and no harm, it may be gradually increased in strength, 
and applied to the whole surface. So far as my observation has'gone, this 
application is one of the most efficient in removing psoriatic eruptions. 
The ointment of iodide of sulphur, may also be used, having been employed 
very successfully. It may be made in the proportion of twelve or fifteen 
grains to an ounce of lard; and the quantity may be increased to thirty 
grains. 
Sulphur lotions, and sulphur baths have been favourably spoken of. The 
vapour bath is sometimes highly useful. Various irritant applications have 
been employed, with asserted advantage. Such are lotions of corrosive sub- 
limate, and ointments of nitrate of mercury, calomel, and the mercurial iodides. 
Blisters to the part have been used beneficially in some very obstinate cases. 
Some of these applications answer an excellent purpose in the local varieties 
of the disease ; but I repeat that none have proved so effectual in my hands 
as tar ointment. In psoriasis of the scrotum, fumigations with sulphur and 
with cinnabar have been specially recommended. 
Whatever course of treatment may be adopted, it is all important that the 
causes of the disease should be avoided; and consequently that the patient 
should relinquish all habits of living, or particular pursuits of business which 
may be thought to have been instrumental in producing it. 
2. LEPRA, or LEPROSY. 
Lepra is a Greek term, which was wrongly applied by the earlier modern 
writers to different cutaneous diseases, but was restored by Willan to its 
original signification, and is now generally employed to designate a scaly 
affection, characterized by circular patches, depressed in their centre. 442 
[PART II. 
LOCAL DISEASES.-SECRETORY SYSTEM. 
The disease may occur in any part of the body, but usually commences 
upon the extremities, whence it extends to the trunk, and not unfrequently to 
the head. 
Symptom^.-The eruption begins with minute solid eminences of a reddish 
colour, smooth at first, but in the course of a day or two, covering themselves 
with extremely delicate scales. These occur quite distinctly, and at consid- 
erable distances. Each one is quickly surrounded with others of a similar 
kind, thus forming a small circular patch, singularly regular in its shape. The 
patches are covered with glistening, tough, grayish or pale-yellowish, translu- 
cent scales, and have a red slightly elevated margin, which gives them the 
appearance of being somewhat depressed in the centre. The scales fall and. 
are renewed, but accumulate and overlay each other upon the border; where 
they sometimes form a prominent incrustation, of a whitish colour. When the 
scales are removed, the surface is red, shining, and in this stage of the disease 
quite smooth. These circular patches enlarge often with considerable rapidity; 
still preserving their regular form, and retaining their red prominent margin; 
while the central portions frequently return to the healthy state, so that the 
eruption presents the appearance of a ring of greater or less width surround- 
ing a portion of sound skin. 
The size which the patches may attain is not definite. Often about an inch 
in diameter, they sometimes greatly exceed these dimensions, and in some 
cases reach even a foot or more. But, in thus expanding, neighbouring 
patches often coalesce, lose in some measure their distinctive shape, and form 
large patches, in which, however, the remains of the circular outline may still 
be seen. This is especially apt to happen in the vicinity of the joints. When 
the scales are removed from these old patches, instead of the smooth surface 
originally presented, there are often deep lines or furrows, intersecting each 
other, and giving to the part a reticular appearance. 
It has been stated that the eruption usually first appears on the limbs. It 
especially affects the parts in which the bones are most thinly covered, and 
like psoriasis shows a peculiar predilection for the neighbourhood of the 
joints, as the knees and elbows. It most frequently appears on both legs or 
both arms at the same time. From the limbs it spreads to the trunk, not 
unfrequently reaches the scalp, and sometimes covers irregularly almost the 
whole surface of the body, sparing only the face and hands. Even these do 
not always escape ; though the face is very seldom affected, unless upon the 
forehead and temples, near the insertion of the hair. 
The disease i's liable to some diversities. In some instances, especially in 
children, the patches never exceed a few lines in diameter, appear only or 
chiefly on the extremities, and are covered with whiter scales than in the 
common variety. In this form, the affection was denominated Lepra al- 
phoides by Willan, while to the ordinary form of it he gave the name of Lepra 
vulgaris. 
Cazenave and Schedel describe a peculiar form of the disease, characterized 
by one, two, or three large circles upon the trunk, especially on the back, a 
foot or more in diameter, consisting of an elevated margin a few lines in 
breadth, wholly without scales, bordered within and without by a fringe of 
redness, and enclosing a central portion of perfectly sound skin. The nature 
of the disease was shown by the simultaneous appearance upon the limbs of a 
few of the characteristic patches. 
Some rare instances of the disease have been noticed with the patches of a 
dark-livid colour. These were denominated by Willan Lepra nigricans. 
A scaly affection is sometimes met with, consisting of circular patches less 
than an inch in diameter, upon which the scales, instead of disappearing from CLASS III.] 
SCALY DISEASES.-LEPRA.-PITYRIASIS. 
443 
the centre as in ordinary lepra, seem to accumulate one upon another, the 
topmost one, which is smallest, being pushed upward by the larget produced 
beneath, so as to form a very low cone with a relatively very broad base; and 
many of the patches thus formed, clustering together, cover sometimes a con- 
siderable extent of surface. This eruption might be considered as a form of 
either lepra or psoriasis; but its regular circular shape may perhaps be con- 
sidered as ranking it most appropriately with the former. If specially de- 
signated, it should receive the name of Lepra prominens. 
The duration of lepra is indefinite. It occasionally disappears spontane- 
ously ; but is very apt to return, and, if not interrupted by treatment, will 
frequently continue for many years. The general health is, during all this 
time, scarcely disturbed; and the only inconvenience usually experienced is 
an itching when the patient is warm in bed, or heated by violent exercise. 
Bateman states that the itching is sometimes excited by certain states of the 
weather. In bad and inveterate cases, there is occasionally much soreness, 
stiffness, and pain upon motion ; and the joints have become, in some in- 
stances, so stiffened by the disease of the skin, as to prevent walking, and to 
confine the patient to his bed. 
When recovery takes place, it begins in the centre of the patches, and 
gradually extends towards the circumference, which is penetrated here and 
there, and broken into fragments, before it entirely disappears. 
Causes.-These, so far as known, are precisely the same as those of pso- 
riasis, and need not, therefore, be repeated here. The disease occurs more 
frequently in adults than in children, in men than in women, in autumn than 
in winter. It is sometimes hereditary; and never contagious. 
Diagnosis.-From Psoriasis guttata, the disease is distinguished by the 
smaller patches of that affection, their less regularly circular form, and their 
want of depression in the centre. Even in the form in which the patches of 
lepra coalesce, there are sections of circles to show its peculiar character, and 
almost always, in some part or another of the body, circles may be seen which 
have retained their integrity. 
Porrigo scutulata presents occasionally some resemblance to lepra, when 
the surfaces of the patches have been deprived of their crusts, and a red circle 
only remains; but the characteristic pustules and scabs of the complaint will 
not long be absent; and the destruction of the hair in porrigo, is another 
diagnostic sign. 
Syphilitic eruptions sometimes assume the circular shape, but, on close in- 
spection, it will be seen that the ring is formed by little tubercules arranged 
side by side, and that, if there be any scales, they are much smaller than 
those of lepra, and not continuous, covering as they do only a small portion 
of each of the minute elevations. Besides, the concomitants of the syphilitic 
affection are sufficient to distinguish it. 
Prognosis.-Lepra is never dangerous, but often extremely obstinate; and 
when relieved is very apt to return. It may, however, almost always be ame- 
liorated, and often permanently cured, if the patient can be induced to avoid 
the causes, and adhere to the regimen and mode of life prescribed. 
Treatment.-This is exactly the same as that of psoriasis, to which, there- 
fore, the reader is referred. 
3. PITYRIASIS. 
Pityriasis (from ^Irvpov, liran') is a title generally given to a superficial 
inflammation of the skin, attended with a continued exfoliation of minute 444 
LOCAL DISEASES.-SECRETORY SYSTEM. 
[part II. 
bran-like scales, which are renewed as fast as they are thrown off. This de- 
finition is extended by Rayer, so as to embrace superficial inflammation with 
foliations, as well as furfuraceous desquamation, occurring in spots or patches; 
and there are certainly cases of cutaneous disease, which cannot be properly 
classified unless this extension, or a similar one for psoriasis, be admitted. 
The disease is sometimes confined to the head, where it occupies especially 
the parts covered by hair; but it may occur also upon any portion of the 
surface; and, in some instances, spreads extensively over the body, disap- 
pearing in one part when it fixes on another. 
Symptoms.-In some cases, the disease makes its appearance without any 
observable preceding redness, the first phenomena presented being surfaces of 
variable extent, covered with minute, dry, whitish scales, partially separated 
from the skin, often arranged in an imbricated manner, and easily detached 
in great numbers by scratching or rubbing the part. Sometimes the affected 
surface is covered by a uniform incrustation,divided into innumerable minute 
sections, which may be separated in the form of bran-like particles. Not un- 
frequently several of these minute scales may thus be successively detached 
by the nail from the same spot, before the reddened speck of skin is exhibited 
which supplies them. This form of the disease is apt to occur in the head, 
where it affects chiefly the parts covered with hair, and especially the scalp. 
In this situation it was denominated Pityriasis capitis by Willan. 
In most instances, when the disease appears on other parts of the body, it 
begins in the form of small red erythematous spots or blotches, which ulti- 
mately enlarge into patches of various shape and dimensions. The redness 
is sometimes attended with swelling of the subcutaneous cellular tissue. In 
a few days the cuticle exfoliates, generally in the form of white furfuraceous 
scales, so as to give the surface an appearance as if covered with meal or bran. 
When these are separated, their place is rapidly supplied with others, and the 
quantity produced increases with the duration of the complaint; so that, in 
some old cases, they may be detached by the nails almost in clouds. But not 
unfrequently, instead of these bran-like scales, portions of cuticle are detached, 
varying from two or three lines to nearly an inch in diameter; and these also 
are renewed as fast as removed. The affected surface is usually dry and rough 
to the touch, but occasionally soft from a kind of oily exudation. (Cazenave 
and Sckedel.') When the scales are separated, the skin is quite red, and 
sometimes sore and slightly painful. According to Rayer, when the patient 
scratches the part severely, a serous yellowish fluid exudes from the denuded 
surface, sometimes so abundantly as to soak the clothing, and to give to the 
affection a certain resemblance to eczema. The form of the disease described 
in this paragraph, belongs to the Pityriasis rubra of Willan. 
Rayer states that the disease is less severe, and the exfoliation finer, on the 
inner than the outer surfaces of the limbs, and on the breast than the back. 
About the olecranon and patella, and in the palms of the hands and soles of 
the feet, broader and thicker laminae are separated than elsewhere. On the 
scalp, and in the face, it is generally powdery. A brief notice of the com- 
plaint in different positions will close the account of the symptoms. 
In the scalp it occurs frequently in very young infants, and occasionally 
also in adults and old people. It is in this situation commonly called 
dandriff. About the forehead and temples a mealy scurf may generally be 
seen, and, by slight scratching with a comb, the hair may be filled with the 
minute scales. But sometimes, upon the scalp, the epidermis is detached in 
scales of considerable size. In some instances, along with the production of 
scales, there is an exudation of an adhesive fluid, which agglutinates the hair 
with the scales, and forms a complete covering for the head, which has been CLASS III.] 
SCALY DISEASES.-PITYRIASIS. 
445 
compared to a cap of asbestos. Upon removing this, the surface is seen to 
be vividly red in numerous points. (Rayerd) The eyebrows are sometimes 
alone affected. Occasionally also the disease is confined to the lips, the red 
surface of which throws off a constant succession of translucent laminae, which 
sometimes leave the surface beneath them redder than in health, and somewhat 
painful. This affection is usually worse in winter than in summer. Though 
not serious, it is often very troublesome. I have known it to last for many 
years. The palms of the hands and soles of the feet are also liable to be 
affected, in which, instead of the solid elevations of psoriasis, there are merely 
red spots, which gradually spread, and constantly detach laminae of thickened 
and yellowish epidermis. 
All the varieties of pityriasis are attended with itching, tingling, or prick- 
ing sensations, which are sometimes very intense, and cause the patient to 
scratch severely, so as to increase the inflammation, and, as before stated, 
produce a serous exudation. There, is seldom any constitutional disturbance. 
Occasionally, however, the disease appears to attack the mucous membrane, 
as well as the skip, producing the ordinary phenomena of gastro-enteric inflam- 
mation or irritation. 
Pityriasis versicolor.-Under this name, Willan described an affection, which, 
though it has some of the characters of this genus of scaly eruptions, is also 
in some respects peculiar. In former editions of this work, considering it 
essentially a disease of the colour-producing function of the skin, I ranked it 
with the maculae, under the name of ephelis ; and Erasmus Wilson, with a 
similar view of its nature, gives it the title of chloasma. In the present state 
of our knowledge, its best position is, I think, that given to it by Willan; 
as it is attended with some irritation of the skin, and the exfoliation of the 
cuticle in very minute scales. It first appears in the form of small grayish 
or dull-reddish stains of the skin, which soon assume a yellowish or brownish- 
yellow or tawny colour. They are seated usually on the anterior part of the 
neck and chest, the abdomen, the back, or the inner surface of the thighs, 
but may occur in any part of the skin. These spots enlarge and coalesce, 
forming large irregular patches, which sometimes cover extensive portions of 
the surface; so that, in some instances, the impression is given that they are 
of the natural colour of the skin, and that the unchanged parts are morbidly 
discoloured. There is no elevation of the surface, no constitutional derange- 
ment of any kind, and no other inconvenience than a moderate itching, 
which is increased by whatever excites the surface, as the warmth of the 
bed, and the use of stimulating food and drinks. The affection sometimes 
goes off in a few days, sometimes persists for months or years. It is ac- 
companied with a slight mealy desquamation, which is, however, much less 
conspicuous than in proper pityriasis. Eichstedt has demonstrated the exist- 
ence of a microscopic fungus among the scales, consisting of round cells, and 
of fine filaments, short, serpentine, and rarely branched. What part this 
plant performs in the origination or progress of the affection, has not yet 
been determined; whether it is the cause, or whether a mere attendant, find- 
ing a genial soil in the diseased epidermis. We may at least reasonably 
conclude that it is the cause of the peculiar colour; and, if observations made 
upon cases under the care of Mr. Startin, in London, which seem to show that 
the affection is contagious (Med. Times and Gdz., vii. 630), be confirmed, 
they will go far to prove that it is of cryptogamous origin. The affection 
has been ascribed to exposure to the sun, irritating articles of food, the 
abuse of spices and alcoholic drinks, derangements of the menses, and the 
suppression of hemorrhoidal discharges. It is apt to occur in women at the 
approach of the menstrual period, and to disappear when it is over. It 446 
LOCAL DISEASES.-SECRETORY SYSTEM. 
[part II. 
sometimes also occurs in pregnant women, especially upon the face, and may 
either disappear after a short continuance, or persist during the period of 
pregnancy. It is possible that some of these causes may predispose to the 
affection by giving to the skin a condition favourable to the growth of the 
parasitic fungus; but this is probably the essential cause. 
The discoloured surfaces referred to above have, in some very rare in- 
stances, been observed to have a blackish colour, which has given rise to the 
name of Pityriasis nigra, applied to these cases in the works of Bateman, 
and of Cazenave and Schedel, and to that of Melasma in the treatise of Erasmus 
Wilson. The complaint is probably of the same nature as the P. versicolor. 
Causes.-The causes of pityriasis are obscure. As it occurs upon the 
scalp of infants and old men, it has been ascribed to the scantiness of the 
hair, affording an insufficient protection to the surface. Upon the chin, it is 
supposed sometimes to result from shaving. Among the exciting causes have 
also been enumerated the heat of the sun, exposure to the fire, vicissitudes of 
temperature, the influence of hot climates, the use of spices and other stimulat- 
ing condiments, and of alcoholic drinks, and certain articles of diet, as mush- 
rooms. The association between these supposed agencies and the disease has 
probably been, in general, less that of cause and effect, than of mere coinci- 
dence. The disease occurs at all times of life, and in both sexes. Rayer 
thinks it is sometimes connected with amenorrhoea. 
Diagnosis.-There is in various cutaneous affections more or less of a fur- 
furaceous exfoliation, like that of pityriasis; but it may almost always be dis- 
tinguished by the presence of some peculiarity of those eruptions, such as 
the appearance of pimples, vesicles, or pustules, or the shape of the diseased 
surface. Psoriasis and lepra are distinguished by the shape of their patches, 
and the elevation of the skin in the affected parts, not to speak of the fissures 
and indentations which attend inveterate cases of these diseases. 
Prognosis.-Though often easily cured, pityriasis is liable to return, and in 
some cases is very obstinate. It may even be dangerous if associated with 
gastro-intestinal irritation, though such cases are very rare. 
Treatment.-In the milder forms of the disease little general treatment is 
required. To keep the bowels open with saline laxatives, to obviate acidity 
by the alkaline carbonates, and to avoid stimulating articles of diet, are all 
that is necessary in most cases. Sometimes, when there is considerable cuta- 
neous inflammation, and the patient is vigorous, it may be proper to take 
blood from the arm; and the saline cathartics may be employed more freely. 
The antimonials may here also be useful. In cases attended with debility, it 
may, on the contrary, be necessary to give tonics. The alterative vegetable 
diaphoretics, as represented by the compound decoction or syrup of sarsapa- 
rilla, may be used; and Bateman states that he has employed the tincture of 
white hellebore advantageously in small doses. Baths are probably more 
efficient than internal remedies. When there is inflammation, the warm or 
mucilaginous bath should be preferred. In other cases, vapour, alkaline, or 
sulphur baths may be employed. 
As local measures, it will often be sufficient, as the disease occurs in the 
head of children, to keep the part perfectly clean by frequent ablutions. 
Should it refuse to yield, spirituous or alkaline lotions may be employed; 
and, these failing, recourse may be had to unctuous preparations of alum, 
acetate of lead, sulphate of zinc, ammoniated mercury, &c. When there is 
no inflammation, I have found the tar ointment very useful. It often excites 
a little inflammation, upon the subsidence of which, the tendency to exfolia- 
tion diminishes or disappears. Solution of chloride of lime has been recom- 
mended ; and the vapour douche is a favourite remedy with many. In the CLASS III.] 
SCALY DISEASES.-ICHTHYOSIS. 
447 
affection of the lips, the surface should be protected against the drying effects 
of the winter air, by some simple unirritating lip salve; and the ointments of 
subacetate of lead, oxide of zinc, and calamine, may be tried with a view to a 
remedial impression. 
In relation to P. versicolor, local applications will generally effect a cure. 
I have long employed a solution of sulphate of zinc, in the proportion of two 
or three grains to the ounce of water, and found it, if diligently applied, 
uniformly successful. The same is said of a solution of corrosive sublimate 
containing a grain to the fluidounce. If cryptogamous, the affection should 
yield to sulphurous acid, as proposed by Dr. W. Jenner, or one of the sulphites 
dissolved in diluted vinegar. Mr. Winzar, of Salisbury, England, states that 
he has found a most efficacious remedy in sulphuret of potassium, dissolved 
in the proportion of one drachm to three ounces of water. (Land. Lancet, 
Oct. 1853, p. 360.) 
4. ICHTHYOSIS. 
This affection is characterized by a hardened, thickened, rough, almost 
horny state of the cuticle, which breaks into small irregular scale-like pieces, 
apparently boupded by the natural furrows of the skin, little disposed to ex- 
foliate, but soon replaced by others of a similar character when removed, and 
quite unattended with inflammation. 
The disease may be confined to a particular portion of the body, or may 
occupy at the same time almost the whole surface. It is most frequently con- 
genital, but sometimes acquired. 
In the congenital cases, the child is not born with the disease fully deve- 
loped. The skin is thick, harsh, and of a dirty colour; but the epidermis 
retains its integrity. In a few months, however, the surface assumes the 
condition which is afterwards to continue during life. In the mildest form, 
there is merely a dry state of the skin, with the appearance of small furfu- 
raceous scales, as in the desquamation which follows certain exanthematous 
eruptions. When the disease is of a severer character, the thickened epider- 
mis breaks into scales of various shapes and sizes, often representing the natural 
cuticular lozenges, but sometimes embracing several of them in one. These 
little sections of the cuticle are dry, hard, occasionally shining and pearly, 
somewhat elevated like warts, and often surrounded by a blackish circle. They 
are generally detached for a greater or less extent of their circumference. In 
certain parts of the body they appear sometimes to be imbricated. They give 
to the skin a roughness to the fingers, which has been compared to that of a 
file, or of the roughest shagreen, or of the surface of a fish. The true skin, 
upon their removal, exhibits no redness or other sign of inflammation; and it 
is only some of the larger scales, which, adhering rather firmly, occasion any 
uneasiness when they are detached. The furrows of the corium are somewhat 
deeper than in health, and the follicles are often greatly developed. (Rayerd) 
There is another variety in which minute portions of the epidermis are sepa- 
rately hypertrophied, and project sometimes considerably above their base. 
The colour is usually dark. I have seen the case of a boy in England, in 
whom almost the whole surface of the body was covered with little, slender, 
hard, movable prominences, about a line in length, closely crowded together, 
of a dark-brown somewhat olive hue, and in the bend of the elbow as fine as 
hair, so that, when the arm was extended, it had the appearance of the pile of 
velvet, or the short fur of an animal. The boy was at the time about fourteen 
Syn.-Fish skin Disease. 448 
LOCAL DISEASES.-SECRETORY SYSTEM. 
[part II. 
years old, was quite healthy, and exhibited himself as a show. He had been 
affected with the complaint from early infancy. 
Though the disease may affect, more or less, almost the whole surface, cer- 
tain parts are much less liable to it than others. Among these are the surfaces 
which perspire freely, as the palms and soles, and those in which the skin is 
most delicate, as in the groin and axilla, upon the inner surface of the limbs, 
and upon the face, especially the eyelids. On the contrary, the outer parts 
of the limbs, the convex surface of the knee and elbow, the posterior and upper 
portion of the chest and the neck, having a thicker cuticle, are most liable to 
be severely affected. 
The disease is attended with no constitutional derangement; and the general 
health is often remarkably good. Nor does the patient suffer the least itching 
or pain. The skin is very dry; and it might be supposed that injury must 
result from the suppression of the perspiration; but either the office of the 
skin is vicariously supplied by other emunctories, or the excessive secretion 
which sometimes takes place from certain parts, as the palms and the soles, 
compensates for the general deficiency. 
Occasionally it appears that ichthyosis is favourably modified by the super- 
vention of other diseases attended with inflammation of the skin; but the 
effect is only temporary. In some instances, the diseased epidermis is said 
to exfoliate in the summer; but the same condition returns with the return 
of cold weather. 
Belonging to the same class of cuticular hypertrophy, is the affection cha- 
racterized by the developement, on the skin, of horn-like excrescences, consist- 
ing of layers of hardened epidermis, which have-sometimes, though erro- 
neously, been called horns. Of a similar nature was the noted porcupine 
disease, which affected several members of the same family in England. 
Bateman calls this affection I. cornea, while he designates common ichthyosis 
as I. simplex. 
Causes.-The disease is sometimes hereditary, and sometimes occurs in 
several children of the same parents without having previously existed in 
the family. In the latter case, it has been attributed by some to impressions 
made on the mind of the mother during pregnancy. It is said to occur more 
frequently than usual among persons who live near certain parts of the sea- 
coast, where they are exposed to dampness and offensive exhalations, and eat 
tainted fish. But all this is very problematical. Both sexes are liable to 
the complaint; but of the persons who applied at the Hospital of St. Louis 
in Paris, under the charge of M. Biett, only one-twentieth were women. 
Diagnosis.-There is seldom any difficulty in distinguishing ichthyosis. 
Some cases attended with a furfuraceous exfoliation might possibly be con- 
founded with pityriasis; but the disposition of the latter affection to occur 
in patches, the itching and other unpleasant sensations which attend it, and 
the existence of some inflammation of the skin, however slight in certain 
cases, are sufficiently diagnostic. 
Prognosis.-The disease is exceedingly obstinate. When congenital, it 
may be considered as incurable. The acquired variety is sometimes cured, 
but generally resists treatment long, and often altogether; and, when com- 
pletely developed, is apt to continue, in a greater or less degree, during life. 
Treatment.-This, in the congenital cases, must be purely palliative; and 
consists in the frequent use of the warm or vapour bath so as to soften the 
diseased epidermis, and to enable the patient to remove it with the fingers. 
Frictions to the surface by means of a piece of flannel may be conjoined with 
the bath. This plan was recommended by Willan, though he states that the 
layer of cuticle which remained was harsh and dry, and the skin did not re- CLASS III.] 
ELEPHANTIASIS OF THE GREEKS. 
449 
cover its softness. Bateman knew an instance in which the skin was cleared 
by sulphurous bathing and friction; but it did not regain a healthy condi- 
tion; and the scales returned. 
Different remedies have been proposed for the affection when accidental. 
Willan placed some confidence in the internal use of tar; and several cases 
of cure by that remedy are reported, among others, one by Dr. Elliotson, 
who conjoined with the internal remedy the free use of oleaginous applica- 
tions externally. But neither Biett nor Rayer met with any success with 
the remedy. It must be given largely and long. A scruple should be given 
at first three times a day, in pills, and the quantity gradually increased, 
until the whole amount each day shall reach half an ounce. Bateman effected 
a cure in one case with Fowler's solution, though he failed in two others. 
But local treatment is probably more efficacious than constitutional. I 
should, in such a case, use the tar ointment liberally and perseveringly, con- 
joined with emollient, warm, hot, or vapour baths. Biett cured a case of 
local ichthyosis by repeated blistering. Mr. Plumbe cured two cases of the 
disease in the leg, by strapping the part tightly with adhesive plaster, and 
keeping a muslin roller upon the limb constantly wet with cold water. The 
strips were renewed every fourth or fifth day, and each time brought away 
with them much of the diseased cuticle. A. cure is also recorded by Mr. 
Colson, effected by the use, first of a wash of corrosive sublimate, and after- 
wards of a liniment made with half an ounce of nitrate of mercury and an 
ounce of olive oil, applied three times daily. (Rayer on Diseases of the Skin, 
Am. ed., p. 350.) Dr. Banks, of Dublin, reports a cure effected by the 
sedulous use of cod-liver oil internally and externally, continued for three 
months. A vapour bath was applied every night, upon coming out of which, 
the patient, a girl of thirteen years, was well rubbed over the whole body with 
the oil, flannel being constantly worn next the skin. (^Dub. Quart. Journ. of 
Med. Sci., Aug. 1851, p. 81.) 
Article VI. 
TUBERCULATED DISEASES. 
1. ELEPHANTIASIS OF THE GREEKS 
Syn.-Lepra Tuberculosa.-Leontiasis.-Satyriasis. 
Two entirely distinct diseases are known by the name of elephantiasis; 
one essentially a tuberculated affection of the skin; the other a hypertrophied 
and altered condition of the subcutaneous tissue. The former is the e/e- 
phantiasis of the Greek writers, the latter that of the Arabian writers; and 
they are thus distinguished in most modern works. As they are both ex- 
ceedingly rare in this country, a very brief description of them will be suf- 
ficient. Not belonging to the tuberculated affections, the elephantiasis of 
the Arabs will be noticed in a subsequent article. 
The Greek elephantiasis is characterized by an eruption of irregular tu- 
mours, of a size from that of a pea to that of a walnut or larger, somewhat 
soft, smooth, shining, and of a colour at first dusky-red or livid, but in the 
end yellowish-brown or like bronze. These tumours are usually preceded by 
patches of an erythematous appearance in white persons, but darker than the 
natural colour of the skin in the blacks. Sometimes they are developed 
rapidly, sometimes very slowly. The skin between the tumours is also 
thickened and discoloured, the subcutaneous tissue often swells, and the part 450 
LOCAL DISEASES.-SECRETORY SYSTEM. 
[part II. 
affected becomes greatly deformed. In this state of developement, the tu- 
mours are often very tender, so that the effect of pressure upon them has 
been compared to that produced by unexpectedly hitting the nerve at the 
elbow against hard objects. 
The disease may occur upon any part of the body, and sometimes extends 
over almost the whole surface. The part most frequently affected is the 
face. When this is fully occupied by the disease, it presents a revolting and 
even hideous aspect. Knotty, irregular prominences are exhibited here and 
there over its surface, separated often by deep furrows; the skin is much 
hypertrophied and rugose upon the cheeks, forehead, chin, &c.; the lips, ears, 
and aim of the nose, are enormously thickened; the nostrils are distended, and 
the brows overhanging; the eyebrows, eyelashes, and beard have fallen off; 
and the whole face is enlarged, uneven, oily, and of a peculiar dusky livid 
hue. The face of a boy, whom I saw with the disease, was that of advanced 
life; and it was difficult to look at the child and not believe that it was a little 
old man who was before me. The countenance has been compared by writers 
to that of a lion or other beast; and hence the designation of leontiasis. The 
disease extends at length to the mucous membranes, and tubercules are often 
developed in the mouth, fauces, and larynx, and the eyes become inflamed. 
Sometimes, instead of the whole face, only a single feature is affected, as 
the nose or ears, which become enormously enlarged. 
When the lower extremities are the seat of the eruption, it is apt to appear 
especially on the inferior portion of the thigh and about the ankle; but, what- 
ever part it attacks, exhibits the same coarse, exaggerated, unequal, and 
revolting aspect, with the prominences, furrows, and livid or bronze hue 
characteristic of the disease. 
In the advanced stages, there is usually a great diminution or total loss of 
special sensibility. The parts affected become insensible or nearly so to im- 
pressions; the smell and taste are greatly impaired or quite lost; the sight 
and hearing also are affected; the voice is husky or extinguished. The moral 
qualities and powers are equally changed. The patient is careless, indifferent, 
or dejected, and loses all mental energy. A very common opinion has been 
that the sexual propensities are morbidly increased; but this is denied by 
many writers; who have observed 'exactly the opposite result. Perhaps the 
condition of the patient may be different, in this respect, in the early and 
advanced stages. 
For a long time, the general organic functions are not materially impaired; 
and the patient retains a tolerable degree of health, with the exception of his 
local disease, for many years. In some instances, however, gastro-intestinal 
inflammation is developed; and this appears to be generally the case, in a 
greater or less degree, in the advanced stages. The local affection now also 
undergoes a change. Inflammation is developed in the tumours, which 
ulcerate, exude an ichorous matter, and form black scabs, or open running 
sores. Sometimes the morbid tendency extends also to the deeper structures; 
the bones become softened and carious; the soft tissues slough; the nose 
sometimes falls in; and it is said that the smaller joints occasionally separate 
by mortification. The progress of the tumours is not uniformly destructive. 
Sometimes they appear to undergo absorption; and the ulcers in which they 
are apt to terminate sometimes heal; but, while an apparent amelioration 
takes place in one part, the disease is advancing in another; and death comes 
at last as a relief to the patient and all those around him. 
There appear to be two varieties of the affection, which, though frequently 
mingled, are frequently also distinct; the tuberculated as above described, and 
the anxsthetic. In the latter, in place of tumours, vesicles appear on the CLASS III.] 
ELEPHANTIASIS OF THE GREEKS. 
451 
extremities, succeeding each other as in pemphigus, and after breaking leave 
sores, which cover themselves with white scabs. The limbs, at first, per- 
haps, excessively sensitive, gradually lose their sensibility, and become stiff 
and inflexible, having sometimes a purplish and glazed appearance. The soft 
parts swell, suppuration takes place, and the small bones of the hands or feet, 
having been long diseased, are now separated and thrown off; and the patient 
at length perishes, sometimes after a period of fifteen or twenty years of varied 
suffering, and progressive depravation of health with occasional remissions. 
The tuberculated variety is of shorter duration, seldom continuing longer than 
twelve years. (See Lond. Med. Times and Gaz., v. 549, and vii. 446 and 470 ) 
Examination, after death, besides the obvious disease of the skin, reveals 
signs of gastro-intestinal inflammation, and often also tuberculous disease in 
the lungs and mesentery, and a soft and spongy state of the bones. The mu- 
cous membrane is everywhere of the same bronze hue as the skin; the pecu- 
liar tubercules of the disease are traced into the larynx and oesophagus, and 
various parts of the chest and abdomen; the mucous membrane of the stomach 
is found softened, and thinner than in health; that of the bowels, softened, 
thickened, and ulcerated ; and the glands of Peyer are occasionally diseased. 
The tumours are formed by the deposition of a peculiar matter, which has also 
been observed surrounding and infiltrating the nerves, thus explaining the 
anaesthetic character of many of the cases. The matter deposited is whitish 
or yellowish, with a disposition to be softened and thrown off, analogous in 
this respect to tubercle, and differing from cancer in the absence of blood- 
vessels, and in the mode of increase, which is rather by further deposition 
than by growth. 
Causes.-Little is known with certainty of the etiology of the disease. It 
has been ascribed to contagion, but on insufficient grounds. Some have sup- 
posed it to be dependent upon syphilitic contamination, but altogether without 
proof. There is little doubt that it is often transmitted by inheritance. It 
appears sometimes to have been epidemic in certain parts of Europe. It is 
endemic in hot latitudes all over the globe ; but it exists also in high 
northern latitudes, being prevalent in certain parts of Norway, in one of the 
provinces of Sweden (Arch. Gen., 5e ser., i. 515), and, within very narrow 
limits, in the British Province of New Brunswick, among the descendants of 
the French Acadians. (Bost. Med. and Surg. Journ., xlvi. 29 and 169.) A 
residence in low marshy neighbourhoods, miserable living and uncleanly 
habits, and a diet of salt provisions, and especially of pork, have been accused 
of producing it; but these causes often exist where the disease is unknown. 
It is thought to have been occasionally induced, in the predisposed, by the 
intemperate use of alcoholic drinks, violent emotions, and menstrual derange- 
ments. No age and neither sex is exempt; but men are probably more fre- 
quently attacked than women, and the young than the old. 
Prognosis.-This is always a very serious, and generally, sooner or later, a 
fatal disease. In some instances, however, it undergoes a favourable change; 
the tumours either disappearing by resolution, or the ulcers in which they 
terminate, healing under the scabs, and leaving permanent scars behind them. 
Some hope of a favourable issue may be indulged, when the patient is young 
and vigorous, and the disease in its early stage, and not extensive. 
Treatment.-The great liability to gastro-enteric inflammation in this dis- 
ease, renders the internal employment of remedies, fitted to produce a favour- 
able effect upon it, somewhat hazardous. The substances which have been 
found most efficient in the modification of the cutaneous affection, are those 
which exercise some irritant influence on the alimentary canal. The calo- 
tropis gigantea (modar or mudar) is said to have been usefully employed in 452 
[part II. 
LOCAL DISEASES.-SECRETORY SYSTEM. 
the East Indies. Similar effects might be expected from the different species 
of asclepias growing in this country. The hydrocotyle asiatica, a plant of 
South Africa and the E. Indies, has recently been strongly recommended. 
(See U. S. Dispensatory, 10th ed.) The alterative diaphoretics, such as sarsa- 
parilla, mezereon, and sassafras, are thought to have been sometimes useful, 
conjoined or not with the antimonials. Iodide of potassium, or other prepa- 
ration of iodine should always be employed, if not forbidden by the state of 
the stomach and bowels. Dr. Danielson, of Bergen, in Norway, has found 
more advantage from this medicine, and from iodide of iron, than from any 
others, preferring the latter in the anaesthetic cases. Biett recommends the 
employment of tincture of iodine and the preparations of arsenic. Mercury 
has been tried without benefit. Perhaps cod-liver oil might be serviceable. 
When the alimentary canal is inflamed, a soothing treatment should be em- 
ployed, consisting of demulcent drinks, light, easily digestible food, and the 
use of opiates. Nitrate of silver with opium might be useful in these cases. 
Externally, the vapour douche, the vapour bath, rubefacient liniments, 
frictions with ointment of iodide of potassium, repeated blistering, and cau- 
terization have been recommended. 
2. LUPUS. 
This is a chronic disease, manifested usually by dull-red or livid indolent 
tubercules, having a tendency either to destroy, or deeply alter the neighbour- 
ing tissues, with or without ulceration, and ending generally in indelible cica- 
trices. It was known to the ancients, and in its ulcerous form is the noli me 
tangere. of surgical writers. There are two prominent varieties of it, distin- 
guished by the titles of Lupus exedens and Lupus non exedens, which deserve 
separate notice. Cazenave has described a third variety, in which the skin 
is diseased in patches, without elevation, and which has no claim, therefore, 
to be ranked with the tubercules. As it is attended with redness of the skin, 
like erythema, it has been proposed to denominate it erythematous lupus. 
The disease usually attacks the face, especially the nose and lips, but is 
sometimes met with elsewhere, and has been specially noticed in the vicinity 
of the anus, and the vulva in women. It is happily a rare affection. 
Symptoms, Course, &c.-Lupus usually commences with one or more 
tubercules, circular or oval, about two lines in diameter, of a dull-red colour, 
somewhat translucent, soft or hard, and seated in the superficial portion of 
the skin. They usually remain stationary for some time, but at length in- 
crease in numbers and size, and take on new characters. 
In the ulcerous variety (^Lupus exedens) they either spread from a central 
point, producing a superficial ulceration of the skin, or sink deeply, causing 
considerable destruction of the parts beneath and about them. In the former 
case, the tubercule becomes inflamed and forms a scab on the top, upon the 
removal of which an ulcerated surface appears, which soon covers itself with 
another scab; additional tubercules rise around the first, and undergo similar 
changes; and the affection thus spreads sometimes over a considerable extent 
of skin; the central portion cicatrizing as the circumference extends. Not 
unfrequently the ulceration returns again upon the cicatrized portion; and 
this course may be repeated more than once. When at length the surface 
approaches health, it is either rough, appearing as if sprinkled over with 
minute dull-red tubercules, or covers itself with thin scales, ending in an 
indelible white scar. Instead of pursuing this superficial course, the disease 
frequently sinks more deeply. Underneath the first scab an ulcer is formed, CLASS III.] 
LUPUS. 
453 
which deepens and spreads, and, as scabs are successively formed and thrown 
off, appears to have extended further and further, until at length much de- 
struction is produced, not only of the soft parts, but also of the cartilages in 
its vicinity. Thus, beginning on the nose, it may to a greater or less extent 
destroy that feature, which is reddened and swollen, may spread thence to 
the adjacent parts of the cheek, and may even involve the palate and the 
gums. The ulcer of lupus has thick red edges, with an irregular surface, 
covered with patches of white lymph, or studded with fungous granulations, 
and exudes a fetid, ichorous, puruloid matter, often in considerable quantities. 
It generally, however, heals at last, leaving an unsightly cicatrix remarkable 
for its white corrugated bands. There can be no doubt that ulcerated lupus 
has often been mistaken for cancer, and that the credit obtained by some 
empirical preparations in the cure of the latter affection, has resulted from 
their successful use in the former. 
In the variety without ulceration {Lupus non exedens'), the tubercules are 
softer than in the preceding, are but slightly prominent, and often form patches 
of considerable extent, and usually of a circular or annular shape. The in- 
tervening skin and cellular tissue swell, and at length, in some instances, the 
entire face becomes swollen, exhibiting here and there dull-red points, which 
are the summits of the embedded tubercules. The lips in these cases are much 
enlarged, the nostrils closed with the tumefaction, the eyelids everted, and the 
whole countenance of a hideous aspect. 
Of the erythematous lupus, described by Cazenave, three prominent forms 
have been noticed. 1. In the simplest form, it appears on the forehead or 
cheek as a circular patch of redness, about as large as half a dollar, some- 
what raised above the sound surface, gradually extending by its circumference, 
without itching or pain unless sometimes when pressed, and at length sub- 
siding, and leaving behind, without other change, a superficial scar like that 
of a burn. 2. In a second form, which is more frequent, the redness shows 
itself usually at first on the end of the nose, and subsides and reappears, per- 
haps several times, before becoming fixed. There is some swelling, but little 
or no pain except on exposure to sudden changes of temperature, or on the 
occasion of some intemperate indulgence, when a smarting sensation is expe- 
rienced. At length the redness disappears, a superficial exfoliation takes 
place, and the skin is left thin, smooth, and shining. 3. The third form is 
marked by a more rapid exfoliation, one lamina after another of the skin 
separating, without ulceration, until the tissue is nearly or quite destroyed, 
when the morbid tendency ceases, a cicatrix being left behind. {Land. Med. 
Gaz., N. S., xiii. 858.) 
In all the varieties, indelible marks of the disease are left behind, and the 
cicatrix is destitute of the natural sensibility of the skin. 
The progress of lupus, though sometimes rapid, is usually slow, and the 
sufferings of the patient less than might be imagined; the sensibility in the 
parts affected being diminished from the first. The complaint sometimes 
continues for years, sometimes for life; but is seldom if ever fatal. It is 
often extremely obstinate under treatment, and is generally so in proportion 
to its duration. 
Causes.-1These are not well known; but there is reason to believe that a 
scrofulous habit, and intemperance in drinking, predispose to the disease. It 
attacks the young preferably, and is most common between the ages of puberty 
and full maturity. It occurs in infants, but seldom after forty. Both sexes 
are equally liable. It is not contagious. Cazenave states that the erythema- 
tous variety is most frequently brought on by cold. 
Treatment.-The general treatment is precisely that adapted to scrofula 454 
LOCAL DISEASES.-SECRETORY SYSTEM. 
[PART II. 
(see vol. i.,page 739); the most prominent remedies being cod-liver oil, and 
the preparations of iodine. The arsenicals and mercurials have also been used, 
but with more doubtful results. Nevertheless, Rayer recommends red iodide 
of mercury as the most efficacious remedy, and Erasmus Wilson has obtained 
the best results from a prolonged use of Donovan's solution. 
More is thought to depend on local measures. For the non-ulcerous form 
of the disease, Mr. Wilson prefers the acetum cantharidis to any other appli- 
cation. Both for this and the ulcerous form, the appropriate remedies are 
escharotics, of which many have been employed. Among them may be 
mentioned the mineral acids, chloride of zinc, chloride of gold, red iodide of 
mercury, and arsenious acid or some other preparation of arsenic. These 
should be more or less diluted when applied. Nitrate of silver or sulphate of 
copper may be employed to favour the healing of the ulcers. For the erythe- 
matous variety, moderate stimulation in the advanced stage is the most ap- 
propriate treatment. Cazenave uses ammoniacal lotions and the vapour 
bath. 
3. MOLLUSCUM. 
This name was given by Bateman to a complaint characterized by the ap- 
pearance of numerous tubercules, varying in size from that of a pea to that of 
a pigeon's egg, spherical, or flattened, sometimes pedunculated and pendulous, 
and either of the colour of the skin, or somewhat brownish. They have little 
sensibility, and no tendency to inflammation or ulceration. According to 
Bateman, they contain an atheromatous matter. They are apt to be station- 
ary, and continue indefinitely without affecting the general health. 
A variety denominated by the same authoi' Molluscum contagiosum, from 
its supposed contagious nature, has been ascertained to be a disease of the 
sebaceous follicles, and has been placed by M. Caillault, who has written 
an elaborate dissertation on the subject, among the varieties of Acne. {Arch. 
Gen., 4e ser., xxvii. 47, Sept. 1851.) The affection had been previously 
noticed and described by Dr. Patterson, of Leith, Erasmus Wilson, and 
several other writers. It occurs most frequently in children, and is seated 
preferably in the face or neck. The little tumours vary from the size of a 
millet seed to that of a pea, are somewhat translucent, and are either sessile, 
or attached by a very short peduncle. But their distinctive character is 
the existence at the top, or on one side, of a small orifice, which allows the 
escape, spontaneously or under pressure, either of a milky fluid, or of the 
ordinary sebaceous matter. Sometimes they become inflamed, discharge 
their contents, and form ulcers, which cover themselves with scabs, and 
ultimately heal, leaving sometimes a surface perfectly natural, sometimes 
a scar not unlike that of the vaccine disease. Another mode of cure is their 
separation from the skin by the ulceration of the peduncle by which they are 
sometimes attached. A third termination is in small flabby excrescences, 
resulting from the withering of the tubercules. As the tumours make their 
appearance successively, it follows that, in the same case, may sometimes be 
seen all their different states above referred to. The milky liquid which ex- 
udes from the tubercules appears, under the microscope, to consist of nucle- 
ated epithelial cells, diffused through a great quantity of fat. 
The affection is mild, and is not known to have produced fatal results in 
any case. Its chief disadvantage is the disagreeable appearance of the face 
which it occasions. Bateman noticed tumefaction of the small cervical glands 
in the vicinity of the tubercules. CLASS III.] 
455 
MOLLUSCUM.-FRAMBCESIA. 
Little is known of the cause. It has been stated that Bateman believed 
the affection to be contagious. This mode of origin has been denied by sub- 
sequent writers; but some facts are adduced by Caillault, which would appear 
to render it highly probable. It is not impossible that the cells generated 
in the hypertrophied follicles may have the property, when transferred to 
another individual, of self-propagation in their new position. Such a transfer 
may readily take place by means of a pillow or towel, which may have re- 
ceived a portion of the milky fluid from the face of a person affected. 
The treatment of these little tumours, as of other cases of excessive and 
retained sebaceous product, consists in exciting the skin to the proper per- 
formance of its function by friction with a rough towel, and by gently stimu- 
lant applications, such as Cologne water, or a weak solution of corrosive 
sublimate, or of sulphate of zinc. The tumours may also often be advantage- 
ously emptied of their contents by pressure. Bateman employed Fowler's 
solution internally, with supposed benefit, in a case of his contagious mollus- 
cum; but this remedy can scarcely be necessary. 
4. YAWS, or FRAMBCESIA. 
This disease is characterized by an eruption of tuberculous excrescences, 
bearing some resemblance to the raspberry, whence it derived the title of 
framboesia (from framboise, the French for raspberry); and yaws, the name 
by which it is known in the West Indies, is said to have a similar significa- 
tion in one of the dialects of the western coast of Africa. 
The complaint is said to be indigenous in Africa, and to have been con- 
veyed thence into tropical America. 
The parts in which the eruption is most abundant and largest, are the face, 
axilla, groins, and vicinity of the pudenda and anus; but it may appear on 
any portion of the body, and is not uncommon in the scalp. 
Symptoms.-In some instances, the eruption occurs without any prelimi- 
nary disorder, in others, is preceded by febrile symptoms, with languor, pains 
in the limbs, &c. It appears first as small red points, like flea-bites, which 
soon rise into pimples, not larger than the head of a pin. These rapidly in- 
crease in size, until they become from half an inch to an inch in diameter. 
In a week or more the tubercules exude a fluid at top, by the concretion of 
which they are covered with scabs. Beneath these a fungous growth springs 
up, having a granulated surface, like that of a raspberry, to which fruit they 
bear some resemblance also in colour, size, and shape. From one to three 
months elapse before these fungous excrescences are fully formed. In the 
mean time another crop of the eruption not unfrequently rises, which under- 
goes the same changes; so that the patient exhibits the disease in its different 
stages at the same time upon his body. When the number of the excrescences 
is great, their size is usually small; when few, it is apt to be larger. They 
are without pain, except when they occur upon the palms of the hands, anti 
upon the soles of the feet, where, in consequence of the pressure made by the 
firm cuticle, they sometimes occasion so much soreness as to prevent the 
patient from walking. Their colour in vigorous subjects is reddish, in the 
feeble and cachectic sometimes whitish. They do not produce healthy pus, 
but discharge an ichorous fluid, which concretes into crusts. The hair in the 
parts affected loses its colour, and becomes white. 
When the eruption has attained its height, it continues long without much 
change. Among the excrescences, one is generally observed larger than the 
others, being an inch or more in diameter, which is called the master or mother 456 
[PART II. 
LOCAL DISEASES.-SECRETORY SYSTEM. 
yaw. This becomes depressed, while the others remain elevated, and assumes 
the form of an ulcer, with a foul surface, from which an acrid fluid exudes 
that excoriates the neighbouring skin. 
After a variable length of time, which is shorter in children than in adults, 
and in the vigorous than the infirm, the tumours begin to decline, gradually 
sink to the level of the skin, and ultimately disappear, leaving only in a few 
instances any scar or depression. When a scar occurs, it is usually somewhat 
larger, but more shallow, than that left by the vaccine disease. The mother 
yaw generally leaves a scar. The complaint appears, like the eruptive fevers, 
to run a certain course, which varies in length, in different individuals, from 
six or eight months, to one, two, or three years; being usually from six to 
nine months in children, and a year or more in adults. 
The yaws does not appear to be a dangerous disease; though, in persons of 
bad constitution, it is said that ulceration of the fauces and falling of the nose 
take place, with caries of the bones. But may it not be, that syphilis, in such 
cases, has mingled with the framboesia ? 
Causes.-The only known cause of the disease is contagion. This does not 
operate through the atmosphere, but, like the vaccine virus, only by the con- 
tact of the matter of the sores with an excoriated or wounded surface. Like 
the exanthematous contagious diseases, it attacks the same individual as a 
general rule but once. Children are most susceptible to the contagion; and 
negroes are said to be more so than whites. The period of incubation appears, 
from the experiments and observations of Dr. Thomson, to be about two 
months. (Rayer on Dis. of the Skin, Am. ed., p. 418.) 
Treatment.-It is the general opinion of practitioners in the West Indies, 
that the best plan is to allow the disease to run its course until it has at- 
tained the period of decline, and then to interfere only in order to support the 
strength of the system, and thereby enable the patient to throw off the re- 
mains of the complaint. At first, therefore, they content themselves with 
prescribing a wholesome regimen, cleanliness, &c.; and, at the proper period 
for acting, direct the use of tonics and alterative diaphoretics, as quinia, the 
mineral acids, the chalybeates, the compound decoction of sarsaparilla, the 
antimonials, and sulphur. Mercury is also sometimes moderately employed 
in this stage. Different opinions are entertained as to the value of this remedy 
in the yaws. Some of the French West India practitioners recommend it as 
highly efficacious; the English, on the contrary, declare that, though it will 
sometimes remove the eruption for a time, it is sure to return, and with in- 
creased violence. The latter, therefore, only use it as a gentle alterative to- 
wards the close of the complaint. Under the same circumstances, especially 
when there might be ulcers indisposed to heal, it is probable that the iodide 
of potassium would prove successful. During this course of medicine, the 
diet should be nutritious and of easy digestion, the patient should be warmly 
clad, to protect him against the changes of temperature from day to night, 
and his health should be promoted by moderate exercise. 
As to the local treatment, little is at first required besides cleanliness, and 
emollient applications when inflammation is developed. In the latter stages, 
caustic sometimes becomes necessary, in order to alter the action of the ulcer- 
ated surfaces, and to destroy obstinate excrescences. For this purpose, nitrate 
of silver, red oxide of mercury, chloride of zinc, or the mineral acids may be 
used. The arsenical paste of Frkre. Come is recommended by Cazenave and 
Schedel, as having been employed advantageously by M. Biett in this and 
other cases of obstinate ulceration, and never with any injury. But the 
caution was used, not to apply it at one time over a portion of surface larger 457 
CLASS III. 
KELOID. 
than about half a dollar.* Biett once employed the actual cautery success- 
fully, when other means had failed. 
5. KELOID. 
This is a peculiar affection of the skin and subcutaneous tissue, named, 
according to some, from its shape like that of a lobster or crawfish the 
claws of a crab), according to others, from its resemblance in appearance to 
the scar of a burn (xtflas, a spot as if made by a burn). It was first fully de- 
scribed by Alibert. It is in the form of an excrescence, somewhat flat at top, 
square, oval, oblong, or cylindrical, but usually more or less irregular, with 
processes shooting out from the main body, giving it a fancied resemblance to 
various objects, as to a lobster, a bird with expanded wings, &c. It is usually 
of a deep rose colour disappearing momentarily under pressure, smooth and 
shining upon the surface, hard and resistant to the touch, and marked with 
tendon-like lines stretching across the surface. • Very small at first, it gra- 
dually extends to the length of one or two inches or more. The extension 
is effected by the projection of claw-like processes, which produce, apparently 
by contraction, a puckered state of the skin, which, with the shining and 
smooth surface, gives to the tumour an appearance somewhat like that of the 
cicatrix of a burn. Sometimes there is only one tumour, which is situated 
preferably on the middle of the anterior part of the chest, nearly in a line 
with the nipples; but not unfrequently there are several, and they are some- 
times found on the neck, back, arms, thighs, and even on the face. When 
numerous, they are usually small. Their growth is generally attended with 
heat in the part, itching, prickling, and sometimes lancinating and burning 
pains, which cause great suffering to the patient; but occasionally no other 
uneasiness is experienced than a feeling of stiffness or tension of the skin. 
The disease continues for a long time with little change, almost never ulcerat- 
ing, and seldom undergoing resolution. Instances, however, have occurred 
in which the tumours have spontaneously disappeared, leaving a firm white 
scar behind. They are not malignant, and do not materially affect the gene- 
ral health. Examined by the microscope, they have been found to be of a 
fibrous nature, as if a hypertrophy or outgrowth of the true skin, though 
they are said to begin in the subcutaneous tissue, and to involve the skin 
secondarily. That the affection is constitutional is inferrible from the fact, 
that persons predisposed to them are apt to have them developed in the cica- 
trices of ordinary ulcers. The cause is unknown. They are not contagious, 
and have not generally been considered hereditary; though Dr. W. J. Burnett, 
of Boston, has recorded one instance in which the disease seemed to descend 
from a father to his children. (Am. Journ. of Med. Sci., N. S., xxvi. 370.) 
Treatment has been found of little avail. The use, however, of iodine or 
its preparations, both internally and locally, would seem to be indicated. The 
tumours have been repeatedly extracted by the knife; but have generally, if 
not uniformly, returned. 
Dr. Addison, of London, has described under the name of " true Keloid," 
another affection, different from Alibert's disease, but in his opinion better 
meriting the title, as it much more exactly resembles the scar of a burn, from 
Syn.-Cheloidea.-Keiis.-Keloide, Fr.-Cancroide, Fr. 
* This paste is made by mixing with water a powder containing ten grains of arse- 
nious acid, two scruples of sulphuret of mercury, and ten grains of powdered animal 
charcoal. 458 
LOCAL DISEASES.-SECRETORY SYSTEM. 
[part II. 
which the name originated. This has its seat in the subcutaneous tissue, 
and first appears in the form of a smooth, round or oval, white spot, scarcely 
elevated, without pain or uneasiness, and surrounded by a zone of redness. 
The spot increases, and after a time acquires a faint yellowish or brownish 
tint, and a mottled aspect. As the disease advances, a sense of pain and 
constriction is experienced, and the parts become hard and rigid, so that, 
when a limb is the part affected, its motions are much restrained. At a later 
period, the surface assumes a reddish or yellowish colour, or that of a dead 
leaf; and a disposition to superficial ulceration is evinced, in the absence of 
which, nodular elevations are exhibited; and the whole surface closely resem- 
bles the remains of an imperfectly cicatrized burn. Reddish claw-like pro- 
cesses sometimes proceed from the boundary of the discoloured surface into 
the neighbouring skin, very like those of the keloid of Alibert. The cause 
of the affection is unknown; and time has hardly yet been allowed to trace 
it to its termination. No treatment has been found to produce any effect, 
except the use of iodine, which has appeared to produce a favourable impres- 
sion. (Lend. Med. Times and Gaz., March, 1854, p. 244.) 
Article VIL 
DISCOLORATIONS, or MACULA. 
Discoloration of the skin connected with diseases of other parts of the sys- 
tem, or of the skin itself, if attended with any prominent change besides that 
of colour, are not included under the present heading. It is to idiopathic dis- 
colorations, if the term is admissible in that application, that allusion is here 
made. They are the result of some change in the production of the colouring 
matter of the skin, and have their seat in the rete mucosum, or lower epi- 
dermic layers', though the real pathological condition is probably an altered 
action of the superficial portion of the corium. As the colour of the skin 
depends on the presence of the pigment cells, it may be deepened or rendered 
lighter by an increase or diminution in the quantity of these cells, and in 
other ways changed by an alteration in their character. In either case, 
maculae are produced, which may be only in spots of variable size, or may 
occupy large and continuous portions of the surface. The following are 
varieties recognized by dermological writers. 
1. Lentigo.-Freckles.-From ancient times, the name of lentigo has been 
applied to those small, yellowish, brownish-yellow, or greenish-yellow, irre- 
gularly roundish spots, which are denominated freckles. They are not elevated 
above the general surface, and are unattended with itching, or other abnormal 
sensation. They exist most abundantly on the parts most exposed to the 
light, as the face, neck, hands, &c., and especially on the face; but are found 
also on other parts of the body. They are congenital,, or appear very soon 
after birth, and may continue through life, or disappear at puberty. It is a 
question whether they are generated in subsequent life. Spots which in no 
respect differ from them in appearance are frequently produced, in certain 
persons, on exposure to the sun's light; but these disappear in the absence 
of the cause, while the others are permanent, or only change with some 
general change of system in the progress of growth. In those affected with 
them from early life, they are deepened and increased by exposure to the 
sun. They are found generally in persons of fair complexion, with light and 
especially sandy hair. Congenital lentigo cannot be removed by remedies; 
though it may, when aggravated by any special cause, be advantageously CLASS III.] 
MACULAE. 
459 
treated by gently stimulant applications, such as those mentioned under the 
following head. 
Ephelis.-This term has been variously applied, by some as synonymous 
with lentigo, by others to an affection closely analogous if not identical with 
pityriasis versicolor. The origin of the term (sna and sun) would con- 
fine it to discolorations produced by exposure to the sun. Perhaps we may 
be justified in extending it to all those brown patches depending on mere 
excess of colouring matter, by whatever cause produced, which have consider- 
able extent; while the smaller spots may be considered as belonging to the 
freckles. When produced by exposure to the sun, the affection appears in 
parts unprotected by the dress, and especially in persons of fair and delicate 
skins, as in women and children. It occurs generally in summer, and dis- 
appears in cold weather. Perhaps under this head, rather than under that 
of pityriasis, may be ranked the discolorations which sometimes appear in 
women during pregnancy, or in the menstrual period, and disappear when 
these processes have ceased. Similar changes sometimes occur without any 
assignable cause, occupying either large portions of the skin, so as to give it 
a pied appearance, or even the whole surface of the body. In these cases, 
which are very rare, the discoloration is without elevation, desquamation, or 
abnormal sensation of any kind, and is apt to be permanent. । Erasmus Wil- 
son calls the affection melanopathia. 
In those forms of lentigo and ephelis which depend on exposure to the 
sun, the treatment consists in obviating the cause, and in soothing or sedative 
applications to the affected surface, as the emulsion of sweet or bitter almonds, 
tbe ointment of rose-water, a mixture of lime-water with olive or almond oil, 
and weak lead-water when there is considerable heat or irritation. In other 
forms of the two affections, advantage is sometimes derived from gently 
stimulant applications, as a weak solution of corrosive sublimate or of sulphate 
of zinc (gr. ij to f^i), lime liniment with a little ammonia, the mineral acids 
very much diluted (f^j to Oj of water), weak solution of citric acid or diluted 
acetic acid, &c.; and it might sometimes be advisable to apply one of these 
irritants, or some other of similar character, in connexion with the ointment 
of rose-water, or almond emulsion. 
Pigmentary Naevus.-This is a congenital dark discoloration of the sur- 
face, occurring in spots, usually small, but sometimes many inches in diameter, 
with little if any elevation, often covered with hairs, and in vascularity and 
sensibility not differing from the healthy skin. They are permanent, but 
quite harmless, and altogether different from the vascular naevi, which some- 
times increase, and require the interference of the surgeon. 
Albinism.--Albinismus.-Leucopathia (E. Wilson).-In the affections just 
referred to, there is an increase of the pigmentary matter of the skin. The 
one now under consideration consists in a diminution or total absence of this 
matter. Persons extensively affected in this manner are called albinos. 
They are found among people of all countries; but the affection is most 
striking in the black races, in consequence of the greater contrast. Not only 
is the colouring matter of the skin wanting, but also that of the hair, and of 
the choroid coat of the eye, which is thus rendered extremely sensitive to 
light, so that the individual can see better at night than in the day. The 
affection is usually congenital; but sometimes it is accidental, occurring at 
various periods after birth. In the latter case, it is more apt to be partial, 
giving the surface a pied appearance. The colour of the affected portions of 
the skin is a dead white. When congenital it may be considered as irreme- 
diable ; but cases of partial albinism, occurring accidentally, may sometimes 460 
[part II. 
LOCAL DISEASES.-SECRETORY SYSTEM. 
be relieved by local stimulants and general tonics, which have the effect of 
exciting the colour-producing function of the skin. 
Vitiligo.-This term, said to have originated from a supposed resemblance 
of the surface affected to the colour of veal (yitulina'), has received various 
applications. Celsus. embraced under it different forms of what are now 
known as lepra and psoriasis, and another affection which is probably identical 
with the lupus non exedens of modern writers. Willan and Bateman em- 
ployed the term in this latter acceptation, though considering the affection as 
distinct from lupus. Erasmus Wilson considers it as a mere synonyme of 
the variety of lupus referred to. Cazenave uses the term to signify the par- 
tial albinism above described; but also embraces, in the same description, 
an affection of the scalp which appears to be the same with that described in 
this work as Trichosis decalvans. In this confusion of meaning, it would be 
better to abandon the name, especially as nothing seems to have been included 
under it which has not received some other distinct designation. 
Article VIII. 
CRYPTOGAMOUS AFFECTIONS. 
Under this head I include two affections which, not belonging to any one 
of the divisions of cutaneous disease hitherto noticed, and originating as I 
believe in vegetable cryptogamous growths, may with propriety be arranged in 
a group distinguished by the nature of the cause. They are here treated of 
by the names of Porrigo and Trichosis, for reasons which will be given when 
each is distinctly considered. Besides their fungous origin, they have this 
also in common, that they are both contagious. There are at least two other 
cutaneous diseases which have strong claims to be admitted into this division; 
namely, sycosis, and pityriasis versicolor ; but further observations are de- 
sirable, before dislocating them from their old attachments in the systems of 
dermatology. 
1. PORRIGO, or FAVUS. 
Syn.-Scald-head.-Tinea capitis.-Tinea favosa (Bazin). 
This is a peculiar cryptogamous affection, characterized by scab-like, cup- 
irhaped elevations, distinct or confluent, and of a contagious nature.* It was 
at one time considered as a pustular eruption, and was described as such in 
former editions of this work. At present, however, it is universally admitted 
that, though pustules occasionally accompany it, they are merely accidental, 
and the proper disease has no essential connexion with them. Willan, and 
after him Bateman, confounded under the title of porrigo several distinct af- 
fections, having no affinity for each other. Besides the disease here referred 
to, they described varieties of impetigo, eczema, and pityriasis, under the 
names Porrigo favosa, P. larvalis, and P. furfurans. Later dermatologists 
have corrected this arrangement, and, referring the noncontagious affections 
to other classes, restrict the term porrigo to the disease now under considera- 
tion. Of this Biett makes two varieties, which differ only in the arrangement 
of the eruption; namely Porrigo favosa, in which the scabs are distinct and 
* The favus of Willan, which he described as a pustule, is undoubtedly the same 
affection as the cryptogamous crust described in the text, in its earliest stage, and is in 
no degree pustular. CLASS III.] 
461 
PORRIGO. 
without any regular grouping, and Porrigo scutulata, which appears in some- 
what circular patches. The eruption is precisely the same in both. 
1. Porrigo favosa.-Favus dispersus (Bayer).-Porrigo lupinosa (Willan). 
-This is the most common form of scald-head. The eruption occurs much 
more frequently on the scalp than elsewhere; but it occasionally appears also 
on other parts of the body, as the face, neck, limbs, &c., to which it is pro- 
bably in general transferred, either from the head by the nails of the patient, 
or from some extraneous source by direct contact. 
It shows itself first in the form of specks, of a sulphur-yellow colour, like 
minute crusts, scarcely rising above the surface, and appearing as if set in 
the skin. There is usually but little redness about them. They are scat- 
tered irregularly, without any special arrangement, and not unfrequently 
continue permanently distinct; but sometimes they are so crowded as to 
cover portions of the surface continuously. Very generally they are seated 
at the root of the hairs, one of which passes through the centre of the crust. 
The eruption is attended with more or less itching. 
When one of these crusts is examined by the microscope, it is seen to be 
depressed in the centre, or cup-shaped. They gradually enlarge, sometimes 
to the diameter of five or six lines or more, still retaining the circular form 
and central depression, which are now obvious to the eye, and constitute one 
of the striking features of the case. With this increase in diameter they 
also become thicker, and gradually rise more and more above the surface of 
the skin, until they are sometimes at length very prominent. The slight 
redness at first surrounding the eruption spreads and becomes deeper, in con- 
sequence of increased irritation of the skin. 
When the crusts are numerous, they often meet at their circumference, so 
as to form a continuous incrustation of greater or less extent. In such cases, 
their rounded circumference is pressed into a somewhat hexagonal shape; and, 
the cup-like depression in the several crusts remaining, the surface presents 
an appearance somewhat analogous to that of the honey-comb, which has 
given origin to the name of favus. Sometimes the scabs are so much 
broken up on the surface as to lose their peculiar aspect; in which case, by 
removing the superficial parts of the incrustation, the characteristic form 
often again becomes obvious. The portions of the scalp not affected frequently 
exhibit a furfuraceous desquamation; and ecthymatous or impetiginous pus- 
tules occasionally form, arising from the irritation of the surface, and are 
mingled with the proper eruption. Sometimes the whole scalp is covered, as 
by a closely fitting cap. 
If permitted to remain undisturbed, the crusts continue to adhere for 
months or years, but undergo a kind of disintegration on the surface, ex- 
changing their yellow for a whitish colour, becoming brittle, and breaking 
into small powdery fragments, compared to the crumbling mortar falling from 
old walls. In the isolated eruption this change begins in the centre, and 
gradually approaches the edges, which break down, so as to change the con- 
cave for a convex surface. The crusts have now entirely lost their charac- 
teristic shape. A partial separation of them often takes place spontaneously, 
after which a new eruption is developed, and new incrustations form. 
The hair upon the diseased surface, in this advanced stage, generally falls; 
and either none afterwards appears, or that which is produced is of an altered 
character, being downy and destitute of colour. 
When want of cleanliness co-operates with the disease, insects are often 
generated beneath the crusts, intense itching is induced, and the patient is 
unable to resist his propensity to scratch the parts, sometimes even violently, 
thus tearing off the scabs, causing here and there bleeding and excoriated 462 
[PART II. 
LOCAL DISEASES.-SECRETORY SYSTEM. 
spots, and adding greatly to the inflammation. In this state of the scalp, there 
is usually an extremely fetid odour, said to resemble that of the urine of cats. 
With proper cleanliness, and upon the removal of the scabs, the odour is less 
disagreeable, but still stale and nauseous. (Cazenave and SchedeH.} 
When, in the earlier stages, the crusts are carefully removed, nothing is 
seen but smooth concave depressions, somewhat red, but without abrasion. 
In the worst cases, such as above described, after removal of the incrustation 
by poultices, or other emollient applications, the surface appears full of small 
excoriated or ulcerated depressions, which sometimes give it a reticulated ap- 
pearance, and in very old cases occasionally penetrate to the periosteum, or 
even to the bone, which may become carious. From these spots a fetid, 
ichorous discharge takes place, which concretes into irregular scabs, alto- 
gether unlike the genuine cup-shaped favous crusts. These are never repro- 
duced except by the occurrence of a new eruption, which runs through its 
regular course. This not unfrequently happens. 
Along with the proper eruption, small subcutaneous abscesses occasionally 
form in the scalp; and the cervical glands are not unfrequently swollen and 
somewhat painful. The disease, when long established, is thought to retard 
the developement of the system, and to have a debilitating effect upon the 
intellectual faculties. A tendency to scrofulous disease is also occasionally 
shown; and its developement is favoured by the eruptive affection. The 
nails, in old cases, are said to be sometimes thickened, elongated, and rough- 
ened, and to become of a yellow colour. (Rayerh) 
The duration of the complaint, if left to itself, is indefinite. It may con- 
tinue for many years, a source of much distress to the patient, and of disgust 
to those about him; but it is seldom if ever directly fatal. When it ends 
favourably, under proper treatment, new crusts are no longer formed upon 
the removal of the old ones, pustules cease to show themselves, and the skin, 
though it may have been apparently disorganized, returns gradually to its 
normal condition, with only some redness left, which ultimately disappears. 
The hair, however, is sometimes never reproduced, and, when it comes forth, 
has usually for a long time an unnatural appearance. Still, this also in time 
may be perfectly restored, and generally is so, when an early cure is effected. 
2. Porrigo scutulata (Biett),-Favus confertus (Bayer).-Ringworm .of the 
scalp.-1This variety also chiefly affects the scalp, though sometimes found on 
the forehead, face, neck, and other parts of the body. The character and 
progress of the crusts are precisely as in the preceding variety; but, instead 
of being disseminated, they cluster into circular patches. At first a small red 
surface may be seen, upon which the minute crusts appear, thickly crowded, 
especially near the circumference, where they are most abundant. These 
soon exhibit the characteristic cup-shaped surface; and, upon their removal, 
the surface appears red and shining, and is soon covered with a new eruption. 
The patches extend by the formation of additional crusts upon their circum- 
ference; and at length not unfrequently meet, and become confounded toge- 
ther over a greater or less extent of the surface. Sometimes the whole scalp 
is covered with a thick crust, and almost entirely deprived of hair, except a 
narrow border at its confines. Still, the peculiar character of the variety 
may be known by the arcs of circles which appear at the circumference of 
the incrustation. In the middle, the several circles are completely confused, 
and the crusts have lost their peculiar colour and shape, being whitish, brit- 
tle, and crumbly, and presenting the appearance of old mortar, referred to as 
occurring in the former variety. 
When the clusters are numerous, and have not yet coalesced, they may 
appear in different parts of the scalp in all their different stages; the incipient CLASS III.] 
PORRIGO. 
463 
circle of redness, the group of yellow specks, the scabby incrustation, and 
the final white and hairless patch. In the disposition to indefinite duration, 
and in the results of efficient treatment, this variety resembles the former, 
and is probably identical with it in nature. 
Causes.-Both varieties of porrigo are undoubtedly contagious; being 
caused by the direct contact of the morbid product. It has, indeed, been 
imparted by inoculation. A very common mode of propagation is the em- 
ployment of a comb which has been used for the hair of a diseased individual. 
The complaint is said also to arise sometimes without contagion. Persons of 
feeble constitution, of a lymphatic temperament, badly fed and clothed, with 
filthy habits, and confined to low and damp places, as in prisons, are thought 
to be peculiarly liable to it. No age and neither sex is exempt, but children 
between the ages of six and ten are most frequently affected. Some persons 
appear to be insusceptible to it, and escape, though the contagious cause may 
be directly applied to them. 
Nature.-Most authors seem to agree with M. Baudelocque in the belief, 
that the disease is seated in the hair follicles. Within a few years, it has 
been ascertained that the peculiar crusts of porrigo have a vital organization. 
To Schbnlein, of Berlin, is due the credit of having first detected in them a 
peculiar microscopic fungus, named, in honoi' of its discoverer, Achorion 
Sehonleini. His observations have been confirmed and extended by others, 
among whom may be mentioned Gruby, Bennet, and Lebert. When the 
favous crust is removed, and examined before it has become disintegrated, it 
is perceived to consist of a cup-shaped capsule, concave at top, convex at bot- 
tom, having a cavity within, and composed of epidermic scales. The interior 
surface of the walls is covered with a finely granular mass, from which sprout 
countless cylindrical tubes, branching dichotomously, and terminating in 
round or oval globules, of which several are often arranged together like a 
row of beads. These tubes are jointed at regular distances, and frequently 
contain minute granules. The central portion of the capsule is filled with 
masses of spherical or oval corpuscles, mingled with fragments of the tubes, 
and more or less of the granular or molecular matter noticed on the inner sur- 
face. The branching tubes are the plant, and the corpuscles are thought to 
be the sporules, formed and thrown off at their extremities. May not these 
supposed sporules be, as supposed by Dr. Griffith (Land. Med. Gaz., Feb. 
1851, p. 275), merely the smaller joints of the fungus produced by germina- 
tion ; and the molecular granules found among them be real sporules, as suggest- 
ed by Lebert (Physiol. Pathol., p. 480) ? In this way all the constituents of the 
capsules might be accounted for; the walls being composed of the epidermic 
scales, while the contents are altogether products of the parasitic growth. 
The hairs passing through the capsules are stated by Dr. Bennet to contain 
the same jointed tubes, which run through them longitudinally, and render 
them very brittle. (Monthly Journ. of Med. Sci., July, 1850, p. 51.) As the 
hair follicle is much more deeply seated than the favous crust, it may probably 
remain unaffected by the disease; so that, though the hair is destroyed by it 
for a time, it may in the end be regenerated. Lebert observed attached to the 
hair in the seat of the disease, minute brownish bodies, round, pear-shaped, 
or irregularly elongated, and filled with granules, which he conjectures to be 
very young receptacles of the true favous plant. 
It is probable that the disease is propagated by the transplantation of the 
sporules of this plant, which, arrested at the entrance of the hair follicles, 
are detained in this situation, and propagating, penetrate the epidermis, and 
make themselves a nest of its scales. When the epidermis is abraded, the 
same sporules may probably find access into it in any situation ; so that the 464 
[PART II. 
LOCAL DISEASES.-SECRETORY SYSTEM. 
disease is not essentially connected with the hair follicles. That these are not 
otherwise interested than as just stated would seem to result from the fact, 
that the favous crust, when removed, leaves only a superficial depression in 
the skin, without abrasion, which soon rises to the general level, and shows 
no appearance of disease. 
Dr. Bennet thinks that a scrofulous condition of system, or some analogous 
depravation of health is necessary to the propagation of the disease, and that 
the finely granular matter in the capsules is a product analogous to the gran- 
ules of tubercles, and serves as a soil for the fungus to take root in. But 
though, in the cases noticed by that author, such a defect of constitution ex- 
isted, it is by no means so generally observable in the cases which appear 
among us, and Lebert states that the disease occurs as well in healthy as un- 
healthy children. 
Diagnosis.-There is generally little difficulty in distinguishing this from 
all other diseases, upon a close examination. The complaint with which it 
is most likely to be confounded is impetigo. But the somewhat prominent 
form of the pustule in that affection, its inflamed base, the frequent liquid 
exudation, the comparative thickness, softness, and looseness of the scab, the 
continuance of the hair even in the advanced stages, and the utter want of 
contagious properties, will in general be sufficient to distinguish it from por- 
rigo; which is characterized by its flat crust, set as it were in the skin, with 
little redness at the base, its cup-shaped surface differing from that of all 
other eruptive diseases, the white powdery appearance of its last stages, the 
loss of hair which attends it, and its contagiousness. The circular form of 
the patches of porrigo scutulata, gives this variety a superficial resemblance 
to various affections of the scalp which assume the same form, as impetigo 
figurata, herpes circinatus, and lichen circumscriptus; but a close examination 
of their elements cannot but lead to a correct diagnosis. 
Treatment.-It is always proper to attend to the condition of the general 
health in this complaint; but rather in order to prevent evil from the removal 
of an inveterate disease to which the constitution may have become habituated, 
than with a view to its cure. A blister, issue, or seton in the arm, which has 
been recommened in obstinate porrigo, may be useful in this way. Should 
evidences of a scrofulous state of system be presented, cod-liver oil should be 
exhibited, with or without the preparations of iron or iodine, as the symp- 
toms may or may not call for these medicines. But no remedy, not directly 
addressed to the part, can have any material effect in the cure of the eruption, 
the treatment of which must be mainly local. 
If the disease occupy the scalp, the hair should first be removed from the 
affected part by cutting it closely with a pair of scissors, or by shaving it. 
The scabs should then be removed by means of emollient poultices or fomen- 
tations, and thorough washing with soap and water; and, throughout the 
treatment, attention should be sedulously directed to the keeping of the sur- 
face clear from incrustation. One cause of the aggravation of the complaint 
is thus removed, and access allowed for our remedies to the seat of the dis- 
ease, without which they can be of little avail. The next step is to apply 
substances capable of subverting the morbid action in the part, or destroying 
the microscopic fungus on which it probably depends. 
Should the disease be in its early stage, and confined to narrow limits, it 
may be proper to attempt to arrest it at once by the application of nitrate of 
silver, in stick, or saturated solution. This plan will often prove effectual; 
and a single application is generally sufficient. But the remedy may be 
thought too severe for the occasion, and is not adapted to cases which have 
acquired any considerable extent. CLASS III.] 
PORRIGO. 
465 
Judging from the cases which have fallen under my observation, I should 
be disposed,, in all instances, whether in the early or advanced stages, to make 
a thorough trial of tar ointment, after having obtained a clear surface. This 
often acts very happily, and of itself effects cures. It should be kept applied 
to the part steadily for a long time. I believe that the pitch caps which 
were formerly recommended, in order to extract the hair by their removal, 
operated more in the relief of the disease by their alterative than their me- 
chanical influence. Should the tar ointment fail when applied alone, it may 
be mixed with an equal proportion of sulphur ointment. Should this mix- 
ture also fail, recourse may be had to the ointment of iodide of sulphur, as 
recommended by Biett, or to some one of the numerous remedies mentioned 
in the books, which may be employed successively, if necessary, until the 
disease gives way. The excessive pertinacity of the complaint renders it de- 
sirable to have a long list of remedies at command. Those deemed the most 
effectual are enumerated below. 
Much stress is laid by some writers upon the necessity of extracting the 
hairs. This is readily understood, when it is recollected that the hair often 
contains the plant, and consequently, serves to propagate it to the neighbour- 
ing epidermis, though the whole of the disease withiu reach of the remedy 
applied may have been destroyed. Rayer says that "in old cases of favus 
of the scalp, any method of treatment into which the evulsion of the hair 
does not enter as an element is incomplete, and not worthy to be entitled 
curative." The old plan of effecting this by means of adhesive caps has been 
abandoned as barbarous. The object may be effected by removing the hairs 
one by one with a pair of tweezers. But a much more rapid plan is to employ 
a depilatory application; and the carbonate of potassa or of soda, is said to an- 
swer this purpose, while it exercises a favourable influence directly in the dis- 
ease. Either of these may be used in the form of an ointment made by mixing 
one or two drachms with an ounce of lard. This should be rubbed upon the 
part every day for six or eight minutes; and at the same time a wash may be 
used, containing two drachms of either salt in a pint of water. 
The hairs having been removed by this, or some other method, if the dis- 
ease has not given way, one of the following substances may be applied twice 
daily; namely, in the form of lotion, the mineral acids in the proportion of 
a drachm to a pint of water, and solutions of sulphuret of potassium, chloride 
of lime, sulphate of iron, zinc, or copper, nitrate of silver, and bichloride of 
mercury; in the way of inunction, ointments of nitrate of mercury, red oxide 
of mercury, dried alum, calomel, oxide of manganese, cocculus indicus, white 
hellebore, and cantharides. Dr. Bennet makes use of cod-liver oil as a local 
as well as a general remedy. 
The ointment of nitrate of mercury (citrine ointment) is probably among 
the most efficient. Mr. Startin has obtained great success with a compound 
sulphur ointment, consisting of sulphur, ammoniated mercury, ethiops mine- 
ral, and creasote, with lard and olive oil. (See Med. Examiner, N. S., x. 445.) 
Some have recommended a blister to be applied over the diseased part, and 
it sometimes appears to have done good. Dr. Wigan speaks with the utmost 
confidence of the efficiency of concentrated acetic acid. He applies the acid 
for three or four minutes to the diseased spot by means of a fine sponge, tied 
to the end of a stick, or in a pair of silver sugar-tongs. One application, he 
says, is sufficient to effect a cure. Cauterization with nitrate of silver, or the 
strong mineral acids, may be employed as a last resort in the advanced stages. 
Dr. Wm. Jenner has found a strong solution of sulphurous acid very efficient, 
having employed it as a poison to the parasitic fungus. (Land. Med. Times 
and Gaz., vii. 183.) 466 
LOCAL DISEASES.-SECRETORY SYSTEM. 
[part ii. 
2. TRICHOSIS. 
This name was employed by Dr. Good to express disease of the hair. It 
is here applied to two affections, ranked by Willan with porrigo, but consist- 
ing essentially of an abnormal state of the hair, producing baldness in the 
part attacked, and dependent probably upon a parasitic fungus. 
1. Trichosis furfuracea (Erasmus Wilson).-Porrigo scutulata (Willan). 
- Herpes tonsurant (Cazenave).- Teigne tondante (Mahon).- Tinea ton- 
surans (Bazin).-Ringworm of the Scalp.-This affection is seated in the 
hairy part of the scalp. It consists of one or more circular patches, usually 
covered with minute furfuraceous scales, and exhibiting the remains of hairs, 
which rise usually a line or somewhat more above the skin, though of very 
unequal length, and are ragged at their ends as if eaten off by an insect. 
According to Willan, the surface about to become the seat of the disease, 
is first covered with very small pustules, which afterwards break and form 
minute scabs, followed by a furfuraceous exfoliation. Cazenave maintains 
that the affection commences with little vesicles, which advance at the circum- 
ference of the patch, and are followed by a desquamation occupying the 
centre. Hence, he considers it a species of herpes, and is confirmed in his 
views by the occurrence, in the greater number of cases, of patches of herpes 
circinatus on the neck and forehead. Erasmus Wilson says that there is 
first a layer of scurf, consisting of separate scales around each hair, or patches 
including several hairs. The probability is, that the visible disease begins 
sometimes in one of these methods, sometimes in another; as the cutaneous 
affection is the mere result of an irritation extended from the diseased hair, 
which, according to its degree, or the peculiar susceptibility of the individual, 
may occasion a vesicular or a pustular eruption, or a mem exfoliation of 
epidermic scales. The only characteristic appearances are the dry furfura- 
ceous surface from which the finger nail easily separates a fine powder, little 
papillary elevations about the hair follicles sensible to the sight and touch, 
and the broken irregular stumps of the hair, which are variously bent or 
twisted, and have a tow-like aspect. 
In old and neglected cases, the incrustation becomes thicker, and appears 
broken up into small angular compartments, separated by white lines. Some- 
times impetiginous pustules result from the irritation of the skin; but they 
are not essential attendants on the disease. 
The circular patches may occupy any part of the scalp, but are said to be 
most common upon the side of the head and the occiput. Their size varies 
from a few lines to that of a dollar, and increases with the duration of the 
complaint, until, by the confluence of neighbouring circles, they sometimes 
cover nearly the whole scalp, leaving only a narrow fringe of uninjured hair 
around the head. 
The only complaint with which this could be confounded is pityriasis, 
from which it is readily distinguished by the perfect state of the hair in the 
latter affection. 
It is without danger, but is extremely obstinate, lasting for months, and 
sometimes for years, and, if left to itself, may end in complete and incurable 
baldness. But, if properly managed, it may be entirely removed; and the 
hair may grow again of its natural texture. 
Nature and Cause.-This complaint probably depends essentially upon a 
cryptogamous growth in the interior of the hair. When examined microscopi- 
cally, each hair is found to be much thickened, and to contain, immediately CLASS III.] 
TRICHOSIS. 
467 
beneath its outer cortical portion, a layer of nucleated cells, and within these 
longitudinal filaments, undulated in their course, and interrupted here and 
there by the nucleated cells, which are also distributed between them. Gruby 
considers these cells as a cryptogamous growth, capable of propagation. Upon 
this view of their nature, the contagious character of the complaint, almost 
universally admitted, can be readily understood. The sporules may be con- 
veyed by means of combs, towels, hats, &c., from the head of one person to 
that of another. Bateman says that the disease seems to originate spontane- 
ously in ill-fed and uncleanly children, of feeble health, and is afterwards pro- 
pagated by contagion; but it appears to me that, if its dependence on a pecu- 
liar vegetable parasite be admitted, the probability is altogether in favour of 
its exclusive origin in that cause, though filthy habits and depraved health 
may facilitate its transfer and propagation. The disease occurs chiefly if not 
exclusively in children. 
Treatment.-The general state of health should be attended to, and cor- 
rected if in any way impaired. Particular attention should be paid to hygi- 
enic circumstances, such as cleanliness, proper clothing, wholesome diet, and 
exercise in the fresh air. The mineral acids, chalybeates, or vegetable tonics 
may be given in cases attended with debility, and cod-liver oil in those ex- 
hibiting a scrofulous habit. But local measures are most important. These 
are essentially the same as those directed for porrigo. The part should first 
be deprived of its scaly coating by washing with soap and water, and then 
rubbing with a towel, or by the application of some stimulating liquid, such 
as the vinegar or tincture of cantharides; and should afterwards be treated with 
some ointment or wash, which may alter the nature of the diseased action, or 
destroy the vegetable parasite. Probably no one is more efficient for this 
purpose than tar ointment, which should be applied at first diluted with lard 
or suet, and, when the skin ceases to be irritated by it, of the full strength. 
It should be kept in constant contact with the patches, except when the head 
is washed with soap and water, which should be done once at least every day. 
Should this fail, other applications may be tried, as ointments of nitrate of 
mercury, red oxide of mercury, iodide of sulphur, or sulphate of zinc, or solu- 
tions of the last-mentioned salt, sulphate of copper, or corrosive sublimate. 
Solution of sulphurous acid may be tried, as peculiarly noxious to cryptoga- 
mous plants. Each of these substances should at first be used weak, and its 
strength gradually increased. If the part become too much irritated, it may 
be dressed with cerate of subacetate of lead. The hairs should be removed if 
possible, or should be kept closely cut down to the scalp. 
2. Trichosis decalvans (Willis).-Porrigo decalvans (Willan).- Tinea de- 
calvans (Bazin).-This consists of patches of baldness more or less circular, 
without any essential eruption on the surface. The portion of the scalp 
affected is smooth, shining, remarkably white, and quite hairless, while all 
around it the hair is perfect. At certain stages of the complaint, small papu- 
lous elevations of the skin appear at the openings of the hair follicles. The 
circles gradually enlarge, sometimes become confluent, and may at length de- 
nude almost the whole scalp. The affection is of considerable duration, but 
gradually subsides, and is followed by a new crop of hair, which is softer and 
lighter coloured than before, and, in persons somewhat advanced in life, is 
apt to be gray. 
Gruby found in the hair which falls in these cases a microscopic fungus, 
seated in the epidermis of the root, branching, with sporules on its sides, 
forming a sort of sheath about the hair, and at last penetrating into the 
neighbouring epidermis. (Arch. Gen., 4e ser., xxiv. 341.) When the hair 
is quite destroyed and lost from the part affected, the parasite ceases to find 468 
LOCAL DISEASES.-SECRETORY SYSTEM. 
[part it. 
the circumstances essential to its support, and, in all probability, gradually 
perishes. Whether this affection is propagated by contagion has not been 
determined. Bateman states that it has appeared where no communication 
could be traced. It is not confined to any age. 
Supposing the disease to depend on a parasitic fungus, the treatment should 
consist in the application of one or more of the substances mentioned as useful 
in the preceding form of trichosis. Washing with soap and water, and rub- 
bing with a towel, may have the effect of rendering the epidermis penetrable, 
and of thus bringing the remedy into contact with the remains of the fungus 
about the follicle. ' The application may also be useful by stimulating the 
atrophied follicle itself. When the hair begins to reappear, if the patch be 
frequently shaved, and some excitant liniment or lotion applied, it will gradu- 
ally resume its original quality. The most effective local remedies are such 
as prove efficacious in other vegetable parasites, especially applications of a 
terebinthinate character. Liniments made from tar, creasote, Canada tur- 
pentine, oil of turpentine, &c., may be employed. More agreeable prepara- 
tions may be made by dissolving two fluidrachms of the oil of cloves or of 
nutmeg in four fluidounces of alcohol, with or without a little camphor. It 
is sometimes necessary to continue the treatment for several months. 
Article IX. 
UNCLASSIFIED SKIN DISEASES. 
1. ELEPHANTIASIS OF THE ARABIANS. 
In the earlier editions of the present work, this complaint was, for the sake 
of convenience, ranked with the Greek elephantiasis, with which, however, it 
has nothing in common but the name. Being quite peculiar in its character, 
it obviously belongs to the group of unclassified affections. 
The elephantiasis of the Arabians is a chronic indurated swelling of the 
subcutaneous tissues; with more or less alteration of the skin itself, and great 
deformity of the part affected. 
It occurs most frequently in the lower extremities, especially in the leg, 
above the ankle; and the enormous size which the limb sometimes acquires 
has no doubt given rise to the name of the disease. The next most frequent 
seat of it is probably the scrotum. Dr. G. R. B. Horner, in his description 
of the disease as it prevails in Rio Janeiro, states that it occurs almost as 
often in the scrotum as the leg. {Med. Topog. of Brazil, p. 107.) The arms 
are also occasionally attacked; as, in fact, are most other parts of the body, 
among which may be particularly mentioned the face, neck, female breast, 
and anterior part of the abdominal parietes. 
Symptoms.-As described by Dr. Hendy and M. Alard, the disease appears 
usually to begin with acute inflammation of the lymphatic vessels. Pain is 
felt in the part, and, when the complaint occurs in the leg, a hard knotty 
cord runs up from the ankle or knee, along the course of the absorbents, to 
the groin, where it terminates in the swollen glands. At the same time, 
there is frequently erysipelatous inflammation of the surface, with more or 
less subcutaneous swelling. These local symptoms are attended with fever, 
headache, sometimes delirium, and frequently vomiting. After a few days 
the attack subsides, and goes off entirely with the exception of a slight tume- 
faction in the limb. But, after a length of time varying from a month to 
Syn.-Barbadoes Leg. CLASS III.] 
ELEPHANTIASIS OF THE ARABIANS. 
469 
several years, the attack is renewed; and the paroxysms, being frequently re- 
peated, and, on each occasion leaving more and more of the swelling behind, 
produce at last the enormous tumefaction characteristic of the disease. 
Sometimes the swelling is uniform, sometimes in successive portions, sepa- 
rated from each other by deep furrows. It may be confined to the part ori- 
ginally affected, or may extend to others in the neighbourhood. The only 
parts of the limbs which escape are the palms of the hands and soles of the 
feet. In some instances, the skin is white, smooth, and tense; in others vari- 
ously altered, exhibiting prominent veins and varicose tumours upon the sur- 
face which give it a violaceous hue, or pouring out a liquid exudation which 
concretes into scabs, or covering itself with scales as in ichthyosis, or finally 
deformed by fissures, ulcers, or soft fungous excrescences. The sensibility of 
the surface is not lost in this, as in the other form of elephantiasis. Occa- 
sionally the glands suppurate, or portions of the limbs slough, and discharges 
of fetid pus contribute to exhaust the patient. The complaint is said some- 
times to end spontaneously in health; it often continues for many years in an 
indolent state; but finally, if not carried off by some supervening disease, the 
patient is worn out, and dies of a low irritative fever. 
When the scrotum is affected, the size which it sometimes attains is enor- 
mous. Dr. Horner states that he saw two instances in which the tumour was 
four feet in circumference. 
Though, in the disease as above described, the lymphatics appear to be the 
primary seat, yet cases have been reported by MM. Bouillaud, Rayer, and 
Fabre, in which the original cause was probably obstruction of the veins 
leading from the part affected. (Rayer on Diseases of the Skin.') 
Causes.-Little can be stated positively as to the causes of the disease. It 
is not contagious, and does not appear to be hereditary. It attacks all ages, 
but adults more frequently than children; both sexes indifferently; and per- 
sons in all situations in life, though more frequently the poor than those in 
comfortable circumstances. Climate has undoubtedly some influence in pro- 
ducing the disease; as it is almost confined to hot countries. It appears to 
be peculiarly prevalent in certain districts within the tropics, as in Barbadoes, 
Rio Janeiro, Ceylon, &c. Some have ascribed it to sudden changes of tem- 
perature. Dr. Ilorner attributes the disease, as it occurs in Rio Janeiro, to 
the heat and moisture of the climate, and the exhalations by which the air is 
contaminated; and, in support of this view, states that it has become less 
prevalent in that city, since greater attention has been paid to the removal of 
the sources of foul exhalations. 
Treatment.-Advantage may be hoped from treatment in the earlier stages. 
The paroxysms should be encountered by bleeding, purging, the antiphlo- 
gistic regimen generally, rest, elevation of the limb, and leeching, with emol- 
lient applications to the inflamed part. Blisters might be expected to do 
good in removing the tumefaction left behind by the paroxysms. 
In the chronic state of the disease, internal remedies have little effect. 
They should be employed only so far as they may be proper to meet general 
indications. Mercury has been tried without effect. Something might be 
hoped from the influence of iodine upon the absorbents. Of local measures, 
steady compression, the occasional use of the vapour douche for fifteen or 
twenty minutes, and frictions with the ointment of iodide of potassium, pro- 
mise most fairly. If the surface of the limb should be inflamed, it should be 
treated with emollient cataplasms. A medicine denominated assacou has 
been employed, in Brazil, with asserted advantage in this complaint. It is 
the product of the Hura Brasiliensis; and either the milky juice of the plant, 
or an infusion or decotion of the bark is used. (See U. S. Dispensatory, 9th 470 
LOCAL DISEASES.-SECRETORY SYSTEM. 
[part II. 
or 10th ed.) The alterative medicines mentioned under Elephantiasis of the 
Greeks may also be tried. (See page 451.) Dr. H. D. Bulkley, of New 
York, in a note to his edition of Cazenave and Schedel's work on diseases of 
the skin (A. D. 1852, page 334), states that he has found the local applica- 
tion of the vapour of sulphur and iodine, with iodide of iron internally, suc- 
cessful in a ease which had come under his notice. A complete and perma- 
nent cure of elephantiasis of the leg was effected by Dr. J. M. Carnochan, of 
New York, by tying the femoral artery. (W. 17 Journ. of Med., N. S., ix. 168.) 
2. PELLAGRA. 
Pellagra (frorft pellis, skin, and eegra, diseased), though unknown in this 
country, merits a brief notice from its extensive prevalence and great fatality 
in certain parts of Europe. It is met with more or less throughout the North 
of Italy, but abounds most in the low lands of the Milanese, where it is very 
destructive. It has been noticed also in the South of France, and in a certain 
district in Spain. The existence of the disease in Lombardy can be traced 
back no further than to the early part of the eighteenth century; and it is 
generally believed to be of modern origin. It was first described by Frapolli, 
one of the physicians to the hospital of Milan, in a publication which appeared 
in 1771. The cutaneous affection, in this complaint, is only an accompani- 
ment of the much more serious constitutional derangement, which may, indeed, 
exist after the disease of the skin has quite disappeared. 
Symptoms, Course, &c.-The disease is chronic, generally lasting two or 
three years, and sometimes much longer. The cutaneous affection usually 
makes its appearance at the commencement of warm weather in the spring, 
but is invariably preceded, for a longer or shorter period, by symptoms of 
disorder of the system. Of these, general uneasiness, feelings of weakness, 
depression of spirits, an anemic aspect, and various signs of digestive derange- 
ment are the most prominent. The occurrence of the eruption in the spring 
is thought to be determined by exposure to the sun; as it appears especially 
in the parts of the body which are uncovered, such as the back of the hands, 
the forearm, the neck and breast, the feet and lower parts of the legs, and 
sometimes the forehead and cheeks. Patches of a dark, obscure, erythema- 
tous redness, sometimes semi-circular or elliptical, first show themselves on 
these parts. In some instances, there is a mere chocolate-coloured darkening 
of the skin, with subsequent desquamation, and without redness, pain, or 
itching. In others, the affection approaches the erysipelatous character, with 
vesicles or blisters, and a burning pain, which, when the surface is no longer 
exposed to the sun, end in an exfoliation of the cuticle, followed by a smooth, 
shining, darkened spot, in the place of the original eruption. During the 
progress of the skin affection, the general symptoms continue; but there is 
no relation between them in the degree of intensity. The appetite is wanting 
or morbidly excessive; the bowels are obstinately constipated, or loose with 
variously unhealthy discharges; the lips are livid, and the mucous membrane 
of the mouth pale or ulcerated; and all the signs point unmistakably to dis- 
order of the digestive system, and a depraved state of the blood. With the 
advance of the season a remarkable remission takes place in the symptoms, 
both general and local, and, at the beginning of autumn, scarcely any traces 
of the disease remain. This amendment continues, more or less, until the 
next spring, when the symptoms again make their appearance, and, so far as 
regards those of a constitutional character, in an aggravated form. Disorder 
of the nervous system is now superadded, as evinced by disturbances of CLASS III.] 
PELLAGRA.-DISEASES OF THE SALIVARY GLANDS. 
471 
hearing and vision, headache, spinal pains, cramps and convulsive movements, 
muscular weakness amounting almost to palsy, especially in the lower limbs, 
mental dejection, fearfulness, and sometimes delirium or mania. The disease 
of the digestive system is aggravated, the general cachexia deepens, and the 
skin frequently becomes callous and marked with deep fissures. Other dis- 
eases often supervene, as various internal inflammations, an'd tuberculous 
deposition ; and many patients die at this stage. But more generally another 
remission takes place with the approach of cool weather, though much less 
decided than on the former occasion. After this the affection becomes' again 
aggravated, fever of a typhoid character often sets in, the debility is extreme, 
the breath offensive, the functions generally depraved, the senses blunted; and 
the patient, if he do not die of phthisis, dysentery, or other intercurrent affec- 
tion, or sink under the prostration of the disease itself, often becomes maniacal, 
and, on recovery from this condition, is left with incurable dementia or idiotcy. 
Dissection shows various lesions from the intercurrent affections; but 
nothing of a special character has been noticed, except an extraordinary 
atrophy of large portions of the small intestines, especially of the ileum, first 
particularly described by Dr. P. Labus, in a treatise on the disease published 
at Milan in 1847. (See Ed. Month. Journ. of Med. Sei., Nov. 1851.) 
Causes.-It is generally admitted that pellagra is the result of causes cal- 
culated to deprave the blood, and depress the powers of the system, such as 
bad and insufficient food, crowded and ill-ventilated dwellings, inadequate 
clothing, and mental anxiety and distress, all of which have been operating, 
with steadily increasing force, upon the wretched and oppressed agricultural 
population of those rich and beautiful regions where the disease prevails. 
Special influence has been ascribed to the use of maize as a common article 
of diet; but that there is nothing unwholesome in this kind of food is proved 
by the fact, that millions of our own population employ it largely and 
habitually, without any injurious effect upon the health. It is not impos- 
sible that the use of Indian corn of a bad quality may contribute to the 
result; and the opinion of Dr. Balardini, who ascribes the disease mainly to 
this article of food, altered by the presence of a parasitic fungus, which he 
names Sporisorum maidis, may very possibly be correct. In this case, there 
would be a strong analogy between the occurrence of pellagra, and those 
fatal prevalences of disease in certain parts of Europe which have been 
attributed to the use of ergotted rye. 
Treatment.-Little need be said upon this point here. No specific remedy 
and no plan of treatment specially applicable to the disease have yet been 
discovered, Proper hygienic measures, as regards diet, clothing, lodging, &c., 
have been found effectual in the way of prevention, and have even proved 
curative, if applied in the earlier stages. In relation to other remedial 
measures, they are simply such as the symptoms themselves would indicate. 
Unfortunately they are too often ineffectual, when applied for the first time 
to the disease already fully established. 
SUBSECTION III. 
DISEASES OE THE SALIVARY GLANDS AND PANCREAS. 
Most of the diseases of these glands come under the care of the surgeon, 
and will, therefore, not be noticed in this work. Those which require the 
attention of the physician may be included under functional derangement 
and inflammation. The former may consist either in an increase, diminu- 472 
LOCAL DISEASES.-SECRETORY SYSTEM. 
[part II. 
tion, or alteration of the secreted fluid; the latter maybe of the ordinary cha- 
racter, or specific. The pancreas is so similar in structure and product to 
the salivary glands, that its diseases may, with propriety, be considered in the 
same category; and I shall, therefore, treat of them under the present head. 
Article I. 
FUNCTIONAL DISEASES OF THE SALIVARY GLANDS. 
Increased Secretion.-Salivation.-Ptyalism.-When salivation is so co- 
pious as to be deemed morbid, the liquor usually flows out of the mouth, or 
is discharged by spitting. The affection can be confounded only with the 
discharge of a similar liquid from the stomach; and this mistake is not un- 
frequently made by patients; but there can be little difficulty in forming a 
correct diagnosis, when it is recollected that, in the latter case, the liquid is 
brought up by an effort like that of eructation. Perhaps the most frequent 
cause of an inordinate flow of saliva is inflammation or irritation in some 
portion of the mouth or throat. It is in this way that the acrid substances 
denominated masticatories act. The chewing of tobacco is a frequent cause 
of salivation; and the discharge is sometimes so copious as to prove detri- 
mental to the health. Certain substances taken internally have a specific 
power of promoting the salivary secretion. This is especially the case with 
mercury. Nausea is often attended with a profuse flow of saliva; and various 
other gastric disorders have occasionally the same effect. A disposition to 
ptyalism sometimes accompanies pregnancy, and is frequent in certain dis- 
eases, as scurvy, hysteria, some states of mania, and especially hydrophobia, 
in which the patient, in some instances, spits almost incessantly. Ptyalism 
generally subsides with the removal of the cause in which it originates, with- 
out special treatment. In some cases, it may be proper to employ measures 
directly to suppress it. For this purpose, the use of astringent solutions or 
infusions, as washes to the mouth, is most efficient. The vegetable astringents 
may be first employed, and, if these do not succeed, recourse may be had to 
alum, acetate of lead, or sulphate of zinc. 
Deficient Secretion of saliva is not an uncommon affection. It is marked 
by clamminess or dryness of the mouth. It is most common in low forms of 
fever, in which there is a general failure of the secretions, and is important 
chiefly as a sign of the condition of the system; the return of saliva in the 
mouth being frequently a signal of the decline or disappearance of the disease. 
It seldom requires any direct remedial measures; but, when an original affec- 
tion, may sometimes be advantageously treated by local sialagogues, such as 
tobacco, horseradish, mustard, mezereon, pellitory, &c. 
Alteration of the Saliva, is not unfrequent in various diseases. It some- 
times becomes acid, and thus proves injurious to the teeth; sometimes offen- 
sive to the smell, and consequently very inconvenient both to the patient and 
those in his vicinity. The latter condition is apt to occur in scurvy, in mer- 
curial ptyalism, and various anomalous derangements of digestion, or of the 
blood. When acid, it may be corrected by the internal use of the soluble 
antacids, especially the carbonate or bi-carbonate of soda, which readily enters 
the circulation. When fetid, it may sometimes be sweetened by means cal- 
culated to improve digestion, and alter the blood, among which a diet consist- 
ing, in due proportion, of fresh vegetables, milk, and fresh meats, is probably 
the most efficient. The local and internal use of creasote, nitromuriatic 
acid, the alkaline chlorides, and charcoal, may also prove useful. These CLASS III.] 
INFLAMMATION OF THE SALIVARY GLANDS. 
473 
substances may at least correct the fetor of the contents of the alimentary 
canal, and thus prevent the absorption of offensive substances, and their sub- 
sequent elimination by the salivary glands. 
Article II, 
INFLAMMATION OF THE SALIVARY GLANDS. 
When the parotid only is affected, the complaint is denominated parotitis; 
but very frequently the causes which produce this operate equally upon the 
submaxillary and sublingual glands; and the whole are more or less involved. 
Inflammation of these glands is marked by pain, heat, and swelling, which, 
in the parotid, are attended with stiffness of the jaws in the beginning, and 
sometimes a total inability to open the mouth in the progress of the com- 
plaint. The surrounding cellular tissue and the skin, usually participate in 
the inflammation; and, in some severe cases, the whole neck and face are 
swollen, the head becomes painful, and difficulty of deglutition, and even of 
respiration is experienced. The attending fever is often considerable. It is 
not always easy to distinguish inflammation of these glands from that of the 
cellular tissue exclusively, or of the lymphatic glands; though a careful ex- 
amination of the seat of the pain and tumefaction, and of the progress of the 
affection from the beginning, will almost always lead to a correct conclusion. 
In the instance of the parotid, the prominence immediately beneath the ear 
gradually diminishing downward, the comparative immovableness of the tu- 
mour, and its less accurately defined outline, will sufficiently distinguish it 
from an inflamed lymphatic gland. The disease, if well treated, generally 
ends in resolution; but occasionally it runs on to suppuration, and is said 
sometimes to have ended in gangrene. When the parotid suppurates, the com- 
plaint is often tedious and very troublesome. The pus is generally discharged 
externally, but sometimes finds an outlet through the external auditory meatus, 
leaving a fistulous opening; sometimes makes its way down the neck, dissect- 
ing the muscles as it proceeds; and has even been known to be discharged 
into the oesophagus and trachea. The glands are also liable to chronic inflam- 
mation, either original, or as a consequence of the acute. This may be dis- 
tinguished from scirrhus by the greater hardness of the latter, its more 
unequal surface, and the character of the pain. 
The disease may proceed from cold or mechanical injury; but is more fre- 
quently the result of inflammation of the mouth or fauces, as when occasioned 
by decayed teeth, or by tonsillitis. The parotitis arising from decayed teeth 
is sometimes very troublesome, ending in a painful and tedious suppuration. 
The mercurial influence is another, and among the most frequent causes of 
inflammation of these glands, which, however, in such cases seldom proceeds 
to suppuration. Parotitis is an occasional attendant upon other complaints. 
It may accompany scrofula and partake of its nature. It occurs in the course 
and towards the close of low fevers, especially the enteric, in which it is re- 
garded by many as a favourable sign, though it may also, when considerable, 
add to the danger. In these cases, the inflammation is of a rather feeble 
character, and very prone to suppuration; and sometimes enormous abscesses 
are formed. It occurs not unfrequently as a sequela of scarlatina, and some- 
times of other exanthematous fevers, and in these cases also tends to the 
formation of pus. 
In the treatment of this inflammation, it is often sufficient to confine the 474 
[part II. 
LOCAL DISEASES.-SECRETORY SYSTEM. 
patient to an exclusively vegetable diet, to keep him at rest, and to operate 
upon the bowels with saline cathartics ; but, when the inflammation is con- 
siderable, and the fever high, blood may be taken from the arm, and after- 
wards from the tumour by leeches; and the latter remedy may sometimes be 
advantageously resorted to, when the want of general strength forbids the 
former, or the moderate character of the disease renders it unnecessary. 
When there is much fever, the patient should be confined to bed, and treated 
with antimonials, and other refrigerant diaphoretics. Cold applications to 
the tumour are not generally deemed advisable. Liniments of camphor 
and laudanum may be employed to relieve the pain; and it is usually recom- 
mended to keep the parts warm. If a tendency to suppuration is obvious, it 
should be promoted by emollient poultices; and the abscess should be opened 
as soon as fluctuation becomes very evident. 
Article III. 
Syn.-Specific Inflammation of the Salivary Glands.-Parotitis.-Cynanche Parotidasa. 
MUMPS. 
Though named by nosologists from the parotid, this affection does not con- 
sist essentially in inflammation of the salivary glands; as is sufficiently proved 
by the tendency to metastasis, and the contagious origin of the complaint; 
both of which point to some change in the blood, or the presence in that fluid 
of some morbific agent, as the probable cause of the local affections. 
Mumps usually begin with a feeling of stiffness about the joint of the jaws, 
which is followed by pain, heat, and swelling beneath the ear, but with little 
or no redness of the skin. The swelling rapidly extends in all directions, 
sometimes considerably down the neck; and the other salivary glands are not 
unfrequently involved. The skin is somewhat tense ; but the tumour is not 
very hard or elastic. When the swelling is at its height, there is often great 
difficulty in opening the mouth, and sometimes deglutition is painful; though 
the latter symptom is frequently quite wanting, and the complaint may thus 
be distinguished from angina or cynanche tonsillaris. There is generally 
more or less fever; but in most cases not sufficient to confine the patient. 
Sometimes, however, it is very high, with a furred or dry tongue, loss of ap- 
petite, heat of skin, and even some delirium. The inflammation usually 
reaches its highest point in two days, continues unabated until the end of the 
fourth, and then gradually declines, disappearing in about a week, with a 
disposition to perspiration in the neighbouring parts, and sometimes over the 
whole surface of the body. The gland very seldom suppurates. I do not 
remember to have witnessed a case in which this result has occurred. When 
it does occur, the suppuration is said to be superficial. Sometimes only one 
parotid is affected, but more generally both, either simultaneously or succes- 
sively. Not unfrequently the inflammation of the salivary glands suddenly 
subsides, and the testicle or mamma becomes painful and swollen. A metas- 
tasis has taken place. This I have noticed to occur especially in young males 
approaching manhood. When only one parotid has been affected, the testicle 
or mamma of the corresponding side is generally the seat of the translated 
disease. The labia pudendi in females are said sometimes to be attacked. 
Generally the new inflammation subsides in three or four days, without show- 
any tendency to suppuration. In some instances, it suddenly returns to the 
parotid, leaving the mamma or testicle sound. Translation may also take CLASS III.] 
MUMPS. 
475 
place to other organs. There is reason for the conjecture, that the pancreas 
is sometimes affected. That a metastasis to the brain occasionally happens is 
well known. This is, indeed, the chief danger of mumps, and sometimes ends 
in death. In some rare instances, after the inflammation has left the parotid, 
the irritant cause produces alarming constitutional disturbance and prostration 
of system, which disappear when the inflammation becomes established in its 
new locality. Mumps are usually a mild affection, and almost never termi- 
nate fatally unless under the circumstances above referred to. 
Contagion is a frequent cause of mumps; but there is reason to believe that 
the disease also sometimes originates from epidemic or endemic influences in- 
dependently of contagion, though, when thus produced, it is equally capable 
of self-propagation as if it had arisen in the ordinary way. It occurs most 
frequently in the young, and more frequently in males than females. Like 
most contagious affections, it seldom attacks the same individual more than 
once. Occasionally, however, it does so. Many escape it altogether. 
In most cases of mumps, little treatment is requisite. It is usually sufli- 
cient for the patient to live low, and avoid exposure to cold and wet. Should 
the bowels be confined, refrigerant laxatives, as the Seidlitz powder or small 
doses of one of the neutral salts, should be given occasionally. All repellent 
applications to the tumour should be avoided, for fear that a metastasis may 
take place. It is indeed advisable to keep the parts warm, so as to prevent 
the repellent influence of the external cold, and to favour perspiration. This 
measure is peculiarly appropriate, in consequence of the absence of all dispo- 
sition to the suppurative process. Singed tow is a popular and very suitable 
application; but carded wool or cotton, or a piece of soft flannel may be sub- 
stituted. If the inflammation should be considerable, and fever exist, the 
saline cathartics may be given more freely; and, if the fever should be high 
enough to confine the patient to bed, the antimonials, and other refrigerant 
diaphoretics may be added to the other measures. Occasionally it may even 
be advisable to take blood from the arm; but this is seldom necessary. Should 
the inflammation be translated to the mamma or testicle, the same general 
treatment may be employed, while the part affected is in like manner to be 
kept warm. But, if the local affection is considerable, leeches should be freely 
applied, especially to the testicle. In the cases of young and vigorous men, it 
is sometimes proper to bleed generally as well as locally. The patient should 
be confined to the horizontal posture, the testicle should be sustained by a 
suspensory bag or other means, and emollient applications should be made 
after leeching. At the same time, it is advised to endeavour to recall the in- 
flammation to the parotid by some stimulating application, as a sinapism or 
blister over the gland. In case of metastasis to the brain or other vital organ, 
antiphlogistic measures should be energetically employed, as in inflammation 
of these organs from other causes. 
When chronic inflammation of the gland is left behind, which, according 
to Dr. Good, is apt to happen in elderly persons, and especially in females 
about the cessation of the menses, it should be counteracted by occasional 
leeching and blistering, the internal and external use of iodine, and, if other 
measures fail, by a very careful use of mercury. Dr. Good, who states that 
such cases are disposed to run on slowly to suppuration, and sometimes end 
in very obstinate and even fatal ulceration, recommends antimonial emetics 
as highly useful. 476 
LOCAL DISEASES.-SECRETORY SYSTEM. 
[PART II. 
Article IV. 
DISEASES OF THE PANCREAS. 
From the deep-seated position of the pancreas, the vicinity of other im- 
portant organs which almost always suffer along with it, and the want of any 
sure characteristic mark of derangement of its function, it is scarcely ever 
possible to distinguish its diseases with certainty. As its secretion is very 
similar to that of the salivary glands, which this organ also resembles closely 
in structure, it has been conjectured that the colourless discharges which 
occasionally take place from the stomach and bowels, as in pyrosis and serous 
diarrhoea, might, in some instances, be of pancreatic origin. But, though 
the fact may possibly be as supposed, yet it is altogether insusceptible of 
satisfactory proof; and, in relation to the functional diseases of the pan- 
creas, we may be said to be wholly in the dark. Its organic affections are 
somewhat better known; their results being seen after death, and the symp- 
toms thus verified, leading, in other cases, to probable inferences as to the 
seat and character of the disease. But even in these affections the diagnosis 
is very uncertain. A brief notice of them will, therefore, be sufficient. 
Some experiments and speculations of M. Bernard, in reference to the 
proper function of the pancreas, have an important bearing on the diagnosis 
of the diseases of that organ. It has been ascertained by that physiologist 
that the pancreatic secretion has a strong emulsive and saponifying power in 
relation to oleaginous matters, which, when mixed with it, are quickly brought 
into the state of a milky fluid, not unlike chyle in appearance. From these 
and other observations, he inferred that it is the exclusive office of the pan- 
creatic juice to act on the fatty matters in digestion, and bring them into 
a state suitable for absorption into the lacteals. If this view be correct, 
disease of the gland, interfering with the due performance of its function, 
should be attended with evidences of the want of digestion of oleaginous sub- 
stances used as food; and the truth is that, in various cases of pancreatic dis- 
ease, proved to have been such by examination after death, undigested fat has 
been noticed in the evacuations from the bowels. Though it would be pre- 
mature at present to admit any necessary connexion between these events as 
an established fact, though cases of pancreatic disease have occurred in which 
no fat could be found in the evacuations, and though the conclusions of Ber- 
nard, in relation to the exclusive office of the pancreas, have been somewhat 
invalidated by the experiments of Frierichs and Lentz, who found fatty sub- 
stances to be thoroughly digested and absorbed, without the aid of the pan- 
creatic juice (dm. Journ. of Med. Sci., N. S., xxiii. 222), yet the results 
referred to are not without interest, and should be borne in mind in the diag- 
nosis of affections which may be supposed to have their seat in this organ. 
Inflammation of the Pancreas.-Pancreatitis.-If we are to rely on post- 
mortem examination alone, it must be admitted that this affection is very rare; 
but it is highly probable that, when of an ordinary grade, it very generally 
ends in resolution, and, from the mildness and uncertainty of its symptoms, 
runs its course undiscovered. The following symptoms have been observed 
in cases in which dissection has proved the existence of inflammation of the 
pancreas. A fixed pain, increased by pressure, with or without heat, anxiety, 
or tension, is felt deep in the epigastrium, extending even to the back, and 
sometimes from one hypochondrium to the other. It is sometimes obtuse, 
sometimes acute and even pungent, and is occasionally increased by distension CLASS III.] 
DISEASES OF THE PANCREAS. 
477 
of the stomach, as after a meal, by a full inspiration, and by a position upon 
the back or the left side. This effect of position may be ascribed to the 
■weight of the stomach, in the former case, and of the liver, in the latter, 
pressing upon the diseased gland. In a few instances, a firm, somewhat 
elastic, fixed, and circumscribed tumour may be felt in the epigastrium. 
The patient is apt to be affected with gastric derangement, exhibited in the 
forms of acid eructations, pyrosis, gastrodynia, nausea, and vomiting, which 
are apt to come on a few hours after the taking of food. Aortic pulsation in 
the epigastrium, often visible, and increased by pressure, is given by Professor 
Seibert, of Jena, as a characteristic symptom. It probably sometimes attends 
the affection, as the aorta would be very likely to be irritated by an inflam- 
mation so immediately in its own neighbourhood; but it also often arises 
from other causes, and cannot be relied on in the diagnosis. The bowels 
are almost always deranged, being either constipated, or affected with diar- 
rhoea. In the latter case, the stools, though at first fecal, become afterwards 
colourless, like saliva; and a somewhat similar fluid is discharged from the 
stomach. Jaundice has been observed in some instances, arising probably 
from pressure upon the common duct of the liver and gall-bladder. Fever- 
also, of various grades, attends'the affection. In chronic cases, the pain is 
less severe, there is little or no fever, and the tumour in the epigastrium 
occurs more frequently, and is more obvious. The appearance of undigested 
fat in the alvine discharges may be considered as a probable evidence of the 
existence of the disease. This probably ends generally in resolution; but 
sometimes it runs on to suppuration, and even to gangrene, though the latter 
result is very rare. 
Dissection exhibits the gland, in acute cases, reddened and softened, in the 
more chronic, enlarged, hardened, or more dense than in health, of a reddish 
or yellowish-white colour, and with its surface sometimes adhering by means 
of false membranes to the neighbouring organs. When suppuration has 
taken place, pus is found either infiltrated in the parenchyma, or collected 
into an abscess, which has been known to fill the investing capsule, with the 
complete destruction of the glandular substance. Occasionally the pus has 
made its way into the stomach or bowels, the cavity of the abdomen, or be- 
tween the layers of the mesocolon. 
The causes of pancreatitis are obscure. The general causes of inflammation 
are probably capable of producing it. The disease has been ascribed to the 
influence of mercury, and the excessive use of tobacco. It probably arises 
more frequently from sympathy with the salivary glands, or a metastasis of 
irritation from these glands. Thus, inflammation of the parotid has been 
followed, upon its sudden disappearance, by the symptoms of pancreatitis, 
which have in their turn given way on the occurrence of swelling of the tes- 
ticle. When the disease has been observed upon dissection, it has been most 
commonly in connexion with inflammation of a neighbouring organ, as the 
stomach, duodenum, or liver, which has in all probality been primarily affected. 
It has been noticed also in hydrophobia and some idiopathic fevers. 
There is nothing peculiar in the treatment. In acute cases, general and 
local bleeding, refrigerant diaphoretics, warm fomentations or cataplasms, and, 
after a sufficient reduction of excitement, blisters to the epigastrium, are the 
chief remedies. The whole antiphlogistic regimen must be observed. Chronic 
cases may be treated with occasional leeching, blistering or pustulation, and, 
if they do not yield, a cautious use of mercury or iodine. The vomiting and 
diarrhoea are to be controlled by suitable measures (see Vomiting and Diar- 
rhoea), and pain and restlessness by opiates or other narcotics. 478 
[PART II. 
LOCAL DISEASES.-SECRETORY SYSTEM. 
Noninflammatory Organic Affections.-The pancreas has been found 
hypertrophied and atrophied; but these conditions are very rare. Softening 
without inflammation has also been observed, especially in scorbutic and scro- 
fulous patients. The gland is sometimes indurated without other change; 
and this condition has been considered as the commencing stage of scirrhus, 
though probably upon insufficient grounds. It has been known to undergo 
the fatty and cartilaginous degenerations, and occasionally becomes the seat 
of calculous concretions, cysts, tubercles, cancer, and melanosis. Of these 
organic affections, melanosis is the rarest, and cancer probably the most fre- 
quent. The latter disease has often been noticed upon dissection, and, inde- 
pendently of inflammation, is the one which chiefly demands attention. 
Carcinomatous or cancerous disease of the pancreas is observed most fre- 
quently in the form of scirrhus. The disease may be confined to the gland, 
or involve the parts about it. In either case, the functions of these parts may 
become deranged, in the first case from sympathetic irritation or undue pres- 
sure in consequence of the magnitude of the tumour, in the second by their 
own disorganization. These secondary phenomena often completely cover and 
mask the symptoms of the pancreatic affection, so that it cannot be detected, 
and may even escape suspicion. There is no end to the diversity of functional 
disturbance thus produced. Almost every conceivable variety of stomachic 
derangement, from mere dyspepsia to the most obstinate vomiting, arising 
from obstruction of the pylorus or duodenum; haematemesis and intestinal 
hemorrhage; diarrhoea and constipation; jaundice from a stoppage of the 
choledoch duct; cough and other pectoral symptoms from affection of the 
diaphragm; dropsy from pressure on the great venous trunks; countless nerv- 
ous irregularities from encroachment on the spinal column; these and other 
analogous phenomena, some in one case and some in another, attend the pain- 
ful progress of the disease, through hectic fever and great emaciation, to a 
fatal issue. The diagnostic characters, upon which most reliance can be placed, 
are the seat and character of the pain and of the tumour. The former is often 
lancinating and intolerably severe. It is deep seated in the epigastrium, some- 
times almost seeming as if it occupied the spinal column, and often shooting 
irregularly into various parts of the abdomen and chest. It has, in some in- 
stances, been observed to be aggravated by the erect posture, and the patient 
seeks relief by bending forward. The gland is generally enlarged, and some- 
times enormously so. It forms a hard, deep, fixed, incompressible tumour 
between the pit of the stomach and umbilicus, generally less superficial than 
that produced by scirrhus of the pylorus, and not always readily detected. It 
has been recommended, in doubtful cases, to place one hand over the epigas- 
trium, and the other upon the corresponding part of the back, and then to 
make pretty strong pressure, which will occasion a deep-seated pain, and im- 
part the sensation of the presence of a hard body, if the pancreas should be 
affected with scirrhous enlargement. Undigested fat in the stools would now 
be a confirmatory symptom. After all, an accurate diagnosis is of no great 
importance, as it cannot lead to efficient treatment. Nothing more can be done 
than to palliate the symptoms, and retard somewhat the progress of the dis- 
ease, by obviating irritation and inflammation, without materially lessening 
the strength. Vomiting, constipation, diarrhoea, and hemorrhage are to be 
treated as elsewhere directed; inflammation, when it is obvious, may occa- 
sionally be met by leeches, revulsives, and a mild diet; and pain and nervous 
irritation must be controlled by opiates or other narcotics, and by antispas- 
modics. When there is any reason to think that the tumour may not be of 
a malignant character, mercury or iodine may be resorted to with some hope 
of benefit. CLASS III.] 
HEPATITIS. 
479 
SUBSECTION IV. 
DISEASES OF THE LIVER AND ITS APPENDAGES. 
Article L 
INFLAMMATION OF THE LIVER, or HEPATITIS. 
Inflammation may affect the substance of the liver, its investing peritoneal 
membrane, or both, or may involve the whole organ or only a part; and in 
each of these cases presents certain characteristic symptoms, which may lead 
to a more or less accurate diagnosis. Hepatitis varies also greatly in its 
degree of violence and rapidity; being sometimes acute, sometimes chronic, 
and not unfrequently of intermediate grades; so that it is not always easy to 
classify its diversities in these respects correctly. 
Symptoms, Course, &c. 
It -will be most convenient, in the description of hepatitis, first to treat of 
it generally, and afterwards to indicate the characters which mark its several 
varieties, so far as these can be distinguished. The grades and forms of it 
which cannot be properly classified will thus receive their due share of attention. 
The most characteristic symptoms of the disease are pain and tenderness in 
the region of the liver, including the right hypochondrium and epigastrium, 
and, when the organ is enlarged, a greater or less extent of the umbilical and 
lumbar regions, the left hypochondrium, and the chest. The pain varies in 
degree and nature with the seat and grade of the inflammation; being some- 
times severe and acute, sometimes dull and aching; in certain cases confined 
to one spot, in others extensively diffused; stationary or wandering; con- 
tinued or periodical; and occasionally either quite wanting, or amounting 
only to a slight and vague uneasiness. It is almost always increased by pres- 
sure over the part affected. Force applied over the false ribs or in the epi- 
gastrium will generally occasion uneasiness; but inflammation of the stomach 
and rheumatism of the intercostals yield the same sign; and the most effective 
mode of employing this means of diagnosis is to make pressure upon the under 
surface of the liver. The patient being placed upon his back, with the knees 
drawn up and the shoulders elevated, the ends of the fingers are to be pushed 
first directly backward beneath the edge of the ribs, and then upwards with 
their joints flexed. The liver is thus compressed against the diaphragm, and 
tenderness is detected, whether the interior or surface is inflamed. I have 
thus been able to demonstrate the existence of hepatitis, when all other evi- 
dences have been equivocal. In this manner we are often also able to dis- 
criminate between tenderness of the colon and of the liver, the former being 
evinced by pain when the points of the fingers are pressed directly backward, 
the latter when they are turned upward. Should the liver extend much below 
the ribs, this method of diagnosis is neither applicable nor requisite. 
A deep inspiration increases the pain by the descent of the diaphragm on 
the liver, and, when the convex surface is acutely inflamed, the patient often 
suffers from the same cause, even in ordinary respiration. 
Pain is also frequently experienced in other parts. Thus, pain in the right 
shoulder has long been considered diagnostic of hepatitis. It is not found in 
every case; but, when it exists in connexion with tenderness in the right 
hypochondrium, it may be considered as a strongly confirmatory symptom. 480 
[part II. 
LOCAL DISEASES.-SECRETORY SYSTEM. 
The sensation is rather aching than sharply painful, and often extends to the 
subscapular and clavicular regions, and sometimes down the arm even to the 
wrist. It must not be confounded with the pain of rheumatism, which often 
affects the same parts, and, if not discriminated, might sometimes lead to a 
mistaken diagnosis. The pain may be considered rheumatic, when increased 
materially by movement of the shoulder or neighbouring muscles, or by pres- 
sure on the part. When dependent on hepatitis it is purely sympathetic, and 
is often increased by pressure on the liver. It is thought to indicate inflam- 
mation of the right lobe, and especially of the convex surface. When the left 
lobe is inflamed, the sympathetic pain is said to be felt in the left shoulder. 
Fains are also occasionally experienced in other parts, as on both sides of the 
chest, in the head, the loins, and the lower extremities; and in these situa- 
tions are sometimes more severe than in the seat of the disease. 
It must be borne in mind that neuralgic pains are often felt in the region 
of the liver, when that organ is perfectly sound. These are generally con- 
nected with a rheumatic or gouty diathesis, and care must be taken not to 
confound them with such as are truly inflammatory. They may usually be 
distinguished by the absence of the other signs of hepatitis. I have known a 
female patient, otherwise in good health, affected with such pains almost 
steadily for thirty years, with only an interval of two or three years, during 
which she suffered with insanity. 
The decubitus is of some significance in this affection. The patient gene- 
rally lies on the right side, or on the back somewhat inclining to the right. 
A position upon the left side is often attended with a painful dragging sensa- 
tion from the right towards the left hypochondrium, arising probably in part 
from the greater tenderness of the folds of the peritoneum by which the liver 
is suspended, and partly from the increased weight of that organ, increasing 
the tension of the ligaments. It is possible also that, when the liver is greatly 
enlarged, it may occasion uneasiness by pressure upon the stomach. But this 
symptom is by no means constant; and sometimes the patient prefers lying 
upon the left side. In acute cases, the sitting posture, with the body bent 
forward, is' occasionally found to be the least painful. 
Increase of the bulk of the liver is another frequent though not uniform 
attendant upon hepatitis. In the healthy state it seldom extends beyond the 
sixth rib upwards, or the lower edge of the false ribs downward, and is scarcely 
to be detected in the left hypochondrium. Beyond these dimensions, it may 
generally be considered morbid. In some instances, especially in chronic 
disease of the organ, it becomes enormously enlarged; and cases have occur- 
red in which it has reached as high as the third rib, has descended into the 
iliac fossa, and occupied almost the whole left hypochondrium. 
But, in estimating this diagnostic symptom, we must bear in mind that the 
liver is liable to be displaced, and that it may be observed in wholly abnormal 
positions without any enlargement. Thus, it may be pressed upwards in the 
chest by abdominal tumours and dropsy, and may fall much below the ribs 
in consequence of relaxation or stretching of the suspensory ligaments. Four 
cases have come within my own observation, in which the liver, though itself 
in all respects healthy, could be distinctly felt occupying the lumbar region, 
and could even be taken between the thumb and fingers of the examiner. In 
one, the descent could be traced to a very large scrotal hernia, which had 
existed in early life, in another it was probably owing to adhesion formed 
between the lower surface of the liver and the uterus from an injury, and con- 
sequent peritoneal inflammation, during pregnancy. In both, the symptom, 
connected as it was with occasional uneasiness in the side and epigastrium, 
occasioned much solicitude, which was relieved when the nature of the affec- CLASS III.] 
HEPATITIS. 
481 
tion was understood. In the third case, the result was ascribable to a fall, 
which had probably ruptured the suspensory ligament. In this instance, the 
liver, in its false position, was mistaken for an abdominal tumour, and caused 
great mental uneasiness to the patient, until informed of the nature of the affec- 
tion. The same solicitude existed in the fourth case, which, however, though 
clearly of like character with the others, I could not trace to any special cause. 
Such displacements may be detected by placing the patient on the back, when 
the liver either retires, or may be readily pushed within its proper limits. 
Percussion, moreover, by marking its outlines both above and below, will 
demonstrate that the phenomena are ascribable not to its enlargement, but to 
its abnormal position. 
Increased bulk of the liver may often be rendered obvious to the eye by 
stripping the patient, and comparing the two sides. The lower ribs on the 
right side will be observed to bulge outward and forward considerably be- 
yond their proper outline. Any inequality of the sides will be most easily 
discovered by standing at the foot of the patient, and running the eye up- 
ward along the body, as suggested by Mr. Twining. When below the ribs, 
or the due boundary in the epigastrium, the outline of the liver may be usu- 
ally felt by the fingers, especially when the patient is thin, and the abdominal 
muscles not very rigid. To facilitate the examination, the lower limbs should 
be drawn up, and the shoulders elevated, so as to relax the abdomen; or the 
patient may sit up with his body bent forward, or he may be placed upon bis 
elbows and knees, so as to throw the liver forward. But various circum- 
stances often interfere to obscure the diagnosis, such as fat, tumours in the 
abdomen, ascites, &c.; and the aid of percussion may in such cases be advan- 
tageously resorted to. The sound yielded by the liver differs greatly from 
that of the ordinary contents of the abdomen below, and the lungs above. 
The extent of the liver is usually commensurate with that of the continuous 
flatness from the middle of the hypochondrium in all directions. Below is 
the clearer sound of the intestines and the stomach, above and at the left 
extremity, that of the lungs. It should be recollected, however, that a por- 
tion of the lung intervenes between the liver and the ribs, gradually increas- 
ing in thickness upward, so that the hepatic sound is somewhat modified, 
and in a gradually increased degree, by the pulmonic, as fab as the sixth or 
seventh rib, when the latter should be exclusively heard. If the dulness 
extend below the edge of the false ribs posterior to the angle, or considerably 
below it anterior to the angle, or beyond the mesial line towards the left side, 
or above the sixth rib, the liver, unless displacement should be obvious, may 
be considered as enlarged. Tumours in the abdomen, pleuritic effusion in 
the right side, and consolidation of the lung from pneumonia, might interfere 
with the diagnosis. But, in the first case, there would generally be observed 
a clearer sound between the liver and the tumour, which, moreover, might 
often be detected by being movable; in the case of pleurisy, the outline of 
the dulness changes with the position of the patient; and, in pneumonia, the 
sound is scarcely so dull as that of the enlarged liver, and at all events there 
are other signs, both physical and rational, which sufficiently mark the dis- 
tinction, and which are indicated under inflammation of the lungs. Some- 
times a thin edge of the liver extends below the ribs, over the intestines and 
the stomach; in which case the flat hepatic sound is modified by the hollow 
organ beneath; but in this case there is still some dulness, the lower limits 
of which will mark the extent of the liver. A comparison between the ex- 
tent of the hepatic sound downward and upward will show whether the liver 
is enlarged or merely displaced. 
According to Dr. Malcolmson, auscultation affords a sign indicative of 482 
[part II. 
LOCAL DISEASES.-SECRETORY SYSTEM. 
hepatic encroachment upon the lungs; a loud sound, namely, between a cre- 
pitant rale and a bleating, owing, as he supposes, to the thin edge ofJthe 
lung being compressed by the enlarged liver against the pleura. This sound 
is audible to the patient and even the bystander, and attended by a vibration 
of the thoracic parietes sensible to the hand. {Thomson on Dis. of Bil. Or- 
gans.) Dr. Walshe states that the sound occurs only in inspiration, near the 
end of the act, and requires a forced expansion of the chest for its develope- 
ment. (See ylm Journ. of Med. Sci., N. S., xx. 484.) 
The consistence of the liver is frequently altered. In the healthy state, 
though much firmer than that of the intestine, it has a certain degree of yield- 
ingness and elasticity, which may give place, especially in chronic inflamma- 
tion, to a greater or less degree of induration, readily detected by examination 
with the hand. But neither enlargement nor induration can be considered as 
necessarily indicative of inflammation, unless attended with other symptoms, 
as they may result from organic changes of a different character. 
Cough is a frequent symptom, generally short and dry, but sometimes at- 
tended with expectoration. It may arise from pressure upon the lung, from 
the sympathetic propagation of irritation, or from the pulling down of the 
diaphragm by the weight of the liver. In acute cases, it comes on generally 
within a day or two from the commencement. Occasionally it appears to de- 
pend upon bronchial inflammation occurring simultaneously with the hepa- 
titis, and probably from the same cause. Dyspnoea, and palpitation sometimes 
result from the encroachment of the liver upon the lungs and pericardium. 
The stomach is very apt to be disordered; and gastric distress, nausea, and 
vomiting sometimes of bilious matter, and sometimes of mucus or the ordi- 
nary contents of the stomach, are not uncommon. 
The bowels are in some cases constipated, in others affected with looseness; 
and the stools are generally unhealthy, evincing, by an excess or deficiency 
or perverted state of the bile, a derangement of the secretory function of the 
liver. Now and then also dysenteric symptoms appear, with mucous or bloody 
stools. Hiccough is an occasional symptom. 
The eyes, and the skin upon the upper part of the body, are often yellow- 
ish, the urine is also deep-yellow or orange-coloured, the fur on the tongue 
is yellowish, with a bitterish taste in the mouth, and sometimes the patient 
is completely jaundiced. But these symptoms are often wanting, and pro- 
bably occur only when the parenchyma of the liver, or the biliary ducts are 
the seat of disease. 
Depression of spirits, a gloom sometimes amounting to insanity, headache, 
delirium, and coma occasionally evince the sympathy of the brain. These 
symptoms may also be ascribed to a morbid state of the blood, arising from 
defective hepatic secretion. Whatever may be the cause, hepatitis both acute 
and chronic is frequently attended with a melancholy, morose, or hypochon- 
driacal state of the mind. 
There is generally more or less fever, and almost always in the acute form. 
It is usually ushered in with rigors, and does not differ from that which re- 
sults from inflammation of other important organs. (See Fever.) It is of 
every grade, from a mild febricula, showing itself in a moderately accelerated 
pulse with heat of skin, occurring towards evening, and subsiding in the night, 
up to a continued and tumultuous vascular disturbance, with all the other 
phenomena which characterize this form of disease. In most instances, the 
febrile action is sthenic; but sometimes it assumes the typhoid character, 
especially in the advanced stages. It is not, however, an essential accompa- 
niment; for hepatitis has been known to run its whole course to the forma- 
tion of an abscess, without the least sign of febrile disturbance. CLASS III.] 
483 
HEPATITIS. 
The course of the disease and its duration are exceedingly various. It may 
last only a few days, or continue for weeks, months, or years; and may ter- 
minate in resolution, or run on to suppuration, induration, or gangrene, though 
there is reason to believe that the last termination is very rare. Under pro- 
per treatment, resolution may be generally effected. The febrile action sub- 
sides, the pain and tenderness gradually diminish, the tumefaction disappears, 
and the patient is restored to health. But, if due measures be not employed, 
and especially if the original cause continue to operate, suppuration is very 
apt to ensue, either quickly or after a shorter or longer delay, according to 
the degree in which the case is acute or chronic. Not unfrequently, under 
similar circumstances, the acute subsides into the chronic form, which may 
ultimately yield to proper remedies, or, after numerous alternations, may at 
last end in abscess, or other organic change of a not less serious character. 
This is especially liable to happen in hot climates, where the original cause 
operates unceasingly, and the patient is in constant danger of a new accession 
of disease, before the original attack has been completely subdued. In the 
variety of hepatitis which attends dysentery, and which is apt to occur, in 
certain states of the system, whenever there is a suppurative focus in any 
part of the body, the tendency to suppuration is very strong; so that this 
may ensue in the course of two or three days from the first appearance of 
disordered hepatic symptoms, and sometimes even without any previous symp- 
toms whatever that have called attention to the liver. 
The occurrence of suppuration is often marked by general rigors or chilli- 
ness ; increased frequency of pulse, which is usually, according to Twining, 
above 105, though softer and weaker than before; relaxation of the surface 
with a tendency to perspiration; and a feeling of weight or throbbing in the 
side, with a diminution of pain, if this was previously acute. After the pro- 
cess has been fairly established, copious sweats are apt to occur during sleep, 
and sometimes complete hectic fever sets in, with great debility and exhaus- 
tion. Upon examining the side, it will sometimes be observed that, in place 
of the general intumescence, there is a more or less circumscribed swelling, 
which has at first a soft pasty feeling, and at length yields obvious signs of 
fluctuation, indicative of the presence of pus. This gradually advances to- 
wards the surface, and, if adhesion take place between the hepatic and parietal 
peritoneum, may ultimately be discharged by the spontaneous or artificial 
opening of the abscess. The opening may take place at any point in the 
vicinity of the liver, whether below or between the ribs, anteriorly or poste- 
riorly, or in the epigastrium. When between the ribs, the abscess is marked 
by a bulging of the intercostal spaces, which, in connexion with the fluctua- 
tion of the tumour, and its circumscribed character, is one of the most certain 
diagnostic symptoms. The pus, in abscess of the liver, most frequently takes 
the external direction; and, as the right lobe is most frequently the seat of 
inflammation, and its convex surface presents externally, the liquid will gene- 
rally, unless in cases of great enlargement, seek an outlet between the ribs. 
Death from the combined exhaustion and irritation frequently occurs before 
the abscess opens, and the same causes may lead to a fatal issue after this 
event; but the patient is almost always relieved by the discharge, and is often 
restored to health. One great source of danger is the breaking of the abscess 
into the cavity of the peritoneum, in consequence of the want of adhesive in- 
flammation between the opposite surfaces of that membrane, or the insufficiency 
of the adhesion that may have taken place. The patient is, under these cir- 
cumstances, generally carried off speedily by peritoneal inflammation; though 
this event does not necessarily follow; as the pus, if small in quantity, may 
remain circumscribed, and, becoming ultimately confined in the form of an 484 
LOCAL DISEASES.-SECRETORY SYSTEM. 
[PART II. 
abscess by the inflammation excited by its own presence, may seek its way 
externally, either through the intestines or the surface of the body. 
But the external direction, though the most frequent, is not the only one 
taken by hepatic abscesses. When the abscess is at the convex surface of the 
liver, the diaphragm becomes necessarily involved in the adhesive inflamma- 
tion that precedes the progress of the pus, which, making its way through 
that muscle, may be discharged into the cavity of the pleura, if the opposite 
surfaces of this membrane should not have been united, thus constituting 
empyema. But much more frequently this union takes place, and the pus 
is either discharged externally between the ribs, as already noticed, or makes 
its way into the substance of the lungs. Even in this case, it may still reach 
the surface by the consolidation of the lung, the adhesion of the pulmonary 
to the parietal pleura, and the gradual march of absorption towards the skin. 
But, instead of taking this direction, it is sometimes discharged into the 
bronchial tubes or pulmonary tissue, where it may either produce suffocation 
by overwhelming the lung, or excite fatal inflammation of that organ, or ulti- 
mately escape by expectoration. In the latter case, the purulent matter 
coughed up is often tinged with bile; and even pure bile is said to have been 
sometimes expectorated. The affection has been named hepatic phthisis, and, 
though always dangerous, is by no means necessarily fatal; as many instances 
of recovery are on record. 
When the abscess is seated near or upon the lower surface of the liver, it 
sometimes finds a safe outlet through the stomach and intestines, the perito- 
neal investment of which becomes agglutinated to the hepatic. When the 
pus enters the stomach it is usually discharged by vomiting, when the colon, 
by stool, when the duodenum, by one or the other mode. It is therefore 
highly desirable, when hepatic abscess is suspected, that the matter discharged 
by vomiting or purging should be inspected. If at any time a copious dis- 
charge of pus should suddenly occur, there will be reason to suppose that the 
abscess has opened, and to hope for a favourable issue. 
It is thought that the pus sometimes penetrates the biliary ducts, and thus 
finds a passage into the duodenum, without disturbing the integrity of the 
hepatic or intestinal investments. In some very rare instances, it has escaped 
from the liver by other routes, as into the pericardium, vena cava, and pelvis 
of the kidney. There is reason to believe that it is sometimes absorbed, the 
abscess being gradually filled up by granulations, and leaving only a cicatrix. 
Some have supposed that the pus which has been occasionally discharged by 
urine, and from the bowels, in cases of hepatic disease which have afterwards 
recovered, has' been absorbed from the abscess of the liver, and been thrown 
off again by these emunctories after having entered the circulation. But this 
hypothesis is inadequately supported by facts. 
It is important to distinguish between abscesses and other morbid collec- 
tions of fluid, such as serous cysts, hydatids, and especially distended gall- 
bladder. For the diagnostic characters of these affections, the reader is 
referred to the heads of non-inflammatory organic diseases of the liver, and of 
diseases of the biliary passages. 
Hepatitis is a fruitful source of other morbid affections. Of these one of 
the most serious is dropsy, and especially ascites. It is said that the affection 
of the liver which leads most frequently to this result is the organic degene- 
ration denominated cirrhosis; but I have so often seen dropsy of the abdomen, 
connected with disease of the liver, yield to appropriate treatment directed to 
that organ, that I cannot doubt of its occasional origin in ordinary hepatitis. 
Various diseases of the alimentary canal have occasionally the same origin, 
as dyspepsia, bilious colic, diarrhoea, and dysentery; and, when it is consi- CLASS III.] 
HEPATITIS. 
485 
dered how close is the sympathetic relation between the liver and that canal, 
and how intimately the two structures are connected in their circulation, it 
would seem scarcely possible that one should be extensively diseased, without 
interfering in some degree with the functions of the other, if not with its 
organization. Disease of the spleen is also frequently dependent on that of 
the liver; and jaundice is so common a result, as to be ranked among the 
symptoms of hepatitis. It is not improbable that other organic affections of 
the liver itself may occasionally either directly result from inflammation of 
the viscus, or be called into action by its influence upon an existing predis- 
position. 
Reference has already been made to different forms of hepatitis. The fol- 
lowing deserve attention; and it must be understood that, in their descrip- 
tion, only those modifications of the phenomena already enumerated are no- 
ticed, which are somewhat peculiar to the several varieties, and essential in 
their diagnosis. 
Acute Hepatitis.-This, though a very frequent disease within the 
tropics, is comparatively rare in cold and temperate latitudes. It is also a 
much more violent and fatal disease in the former than in the latter situation. 
In severe cases, it is usually ushered in with great pain, tension, or feelings 
of oppression in the region of the liver, sometimes attended with difficult re- 
spiration. Simultaneously, or somewhat subsequently, the patient is affected 
with chills, followed by the symptoms of severe pyrexia, among which nausea 
and vomiting or other gastric disorder are usually prominent. In sqme in- 
stances, the febrile symptoms precede any striking local evidences of the dis- 
ease. The pain is sometimes sharp and almost lancinating, at others obtuse, 
heavy, and aching. In milder cases, the onset of the disease is less sudden, 
the pains less severe, and the fever more moderate; and sometimes only a de- 
gree of hypochondriac or epigastric uneasiness is felt, preceding, for a time, 
and afterwards accompanying the phenomena which mark the sympathy of 
the system at large, and especially of the stomach, with the hepatic disorder. 
The bowels are usually constipated, though sometimes relaxed, and the urine 
is scanty, high-coloured, and often bilious. The disease runs a brief course; 
and a week rarely elapses before a tendency to resolution or suppuration be- 
comes evident. Not unfrequently the severe symptoms yield very quickly to 
active treatment; but the inflammation remains unsubdued, and, if remedial 
measures should be suspended, or too soon relaxed, will be apt to advance to 
suppuration, or at best to assume the chronic form. The symptoms of acute 
hepatitis vary with the part of the liver affected. 
When the peritoneal coat is inflamed, the pain is sharp, and usually much 
more severe than when the disease is seated in the substance of the organ. 
The pain upon inspiration, and the consequent difficulty of breathing, are also 
much greater; and neighbouring organs are more apt to suffer sympatheti- 
cally. The locality of the inflammation may often be conjectured from the 
effect upon contiguous parts. Thus, when the convex surface is inflamed, the 
irritation extends more readily to the diaphragm and pulmonary organs ; and 
the cough is consequently more troublesome, while inspiration is more pain- 
ful than under other circumstances. On the other hand, inflammation of the 
lower surface affects especially the stomach and bowels; the gastric symptoms 
being most prominent when it is seated in the left lobe, and the intestinal 
when in the right. It rarely happens, however, that the peritoneal coat is 
much inflamed, without involving also the substance of the liver to a greater 
or less depth. Hence, the symptoms characteristic of the inflamed parenchyma 
are apt to be mingled with those of the membranous affection. 
The substance of the liver is known to be inflamed when the pain is obtuse 486 
LOCAL DISEASES.-SECRETORY SYSTEM. 
[PART II. 
and aching, the size of the organ considerably augmented, the conjunctiva and 
skin considerably jaundiced, and the urine loaded with bile. The yellowness 
of the skin, being ascribable to a deposition of colouring matter from the over- 
loaded blood, must result from some cause which interferes with the secretion 
or excretion of the bile, especially the former; and this consequence is much 
more likely to ensue from disease of the secreting parenchyma than of the 
investing membrane. 
The locality of the parenchymatous inflammation may be inferred from the 
position and limited extent of the pain and tenderness, and from the peculiar 
sympathetic phenomena evolved. Thus, inflammation of the right lobe occa- 
sions pain and tenderness in the right side, and pain in the right shoulder; 
of the left lobe, pain and tenderness in the epigastrium, and pain in the left 
shoulder. The pulmonary symptoms may be expected to predominate when 
the inflammation is limited to the upper portion of the right lobe; the intes- 
tinal, when to the lower portion of the same lobe ; and the gastric, when to 
the left lobe. According to Twining, a greater tension of the right rectus 
muscle than of the left, or of other parts of the abdominal parietes, indicates 
a tendency to inflammation and abscess in the substance of the right lobe; 
and the same author has observed a similar condition of the left rectus in 
patients who have afterwards died of abscess of the left lobe. {Diseases of 
the Liver and Spleen, by Wm. Twining.) 
Chronic Hepatitis.-Chronic inflammation very generally affects the 
substance of the liver. It is not unfrequently a sequela of acute hepatitis, 
but is, perhaps, still more frequently an original affection. It often comes on 
very insidiously, and may, indeed, run its whole course to suppuration or a 
cure, without any symptoms which would strongly call attention to the seat 
of the real disease. When, therefore, the slightest cause of suspicion exists, 
a careful examination should be made of the condition of the liver, which, if 
inflamed, will evince the fact by some degree of tenderness upon pressure, or 
some increase of its bulk. The phenomena in these masked cases are often 
almost precisely those of dyspepsia, attended, as that complaint frequently is, 
by derangement of the hepatic secretory function. In most instances of the 
disease, however, the obvious symptoms are more characteristic. These it is 
unnecessary to repeat in much detail, being the same as those already men- 
tioned as belonging to hepatitis in general, only moderate in degree. The 
pain is seldom acute or very severe, unless when the disease is complicated 
with neuralgia or cancer. Occasionally, instead of positive pain, there is only 
a vague uneasiness, or sense of weight or distension, and sometimes not even 
these. There is, however, almost always tenderness upon strong pressure, 
especially if directed upwards under the ribs. Enlargement and some degree 
of induration are not uncommon. Sometimes the liver is contracted. Dis- 
ordered stomach, occasional vomiting, irregular bowels, unhealthy alvine 
evacuations, a bitter or otherwise disagreeable taste, a tongue somewhat 
furred, a turbid or jaundiced hue of the eyes and skin, a harsh, dry surface, 
high-coloured, bilious, and acrid urine, which often irritates the urethra as 
it passes, a short, dry cough, depression of spirits, slight febrile excitement 
towards night, and general emaciation, constitute an epitome of symptoms, 
which, variously grouped, and in different degrees, not one of them being 
uniformly present, are, in connexion with those above mentioned, sufficiently 
characteristic of the affection. Chronic hepatitis, like the acute, not unfre- 
quently ends in suppuration; but it may prove fatal by interfering with the 
various vital functions, and gradually wearing out the strength, without 
reaching that process. When not complicated with peculiar organic disease, CLASS III.] 
HEPATITIS. 
487 
or sustained by the continuance of its cause, it will generally yield to suitable 
treatment. 
Anatomical Characters. 
As hepatitis is rarely fatal in its first stage, the physician seldom has an 
opportunity of examining its earlier anatomical characters. It is only in 
cases of death from some other disease, in the course of which the patient 
has been attacked with inflammation of the liver, that this opportunity is 
presented. When the investing coat is inflamed, it is redder and more vas- 
cular than usual, somewhat thickened, and often covered with an exudation 
of coagulable lymph, either semi fluid, or so consistent as to glue together 
the contiguous surfaces. This exudation in time becomes vascular, and the 
foundation is thus laid for those permanent adhesions which are occasionally 
observed between the liver and neighbouring organs. When the parenchyma 
also is inflamed, the viscus is found partially or wholly congested with blood, 
more or less enlarged, generally softer and more friable than in health, pre- 
senting, when torn, a granular aspect, a brighter and deeper colour than 
natural, and a considerable oozing of blood. "Upon making a section of 
the viscus with a very sharp scalpel, and wiping with a sponge the cut sur- 
faces, these present a lighter-coloured reticulum or mesh, studded with red 
or brick-red granulae, and the divided ends of blood-vessels and biliary ducts." 
(Annesley.') Sometimes effusion of blood is observed, either diffused through 
the parenchyma, or filling distinct cavities, which it appears to have hollowed 
out in the substance of the organ. The outer surface is, in some instances, 
variously shaded with "red, brown, brick-coloured, greenish-brown, and even 
with almost black spots and streaks." (Annesley.') In the advanced stages, 
especially in the chronic form of the disease, the liver is sometimes indurated 
and enlarged from the coagulable lymph exuded into its tissue, and this in- 
duration may occupy either a part or the whole of the organ. Sometimes, 
along with the induration, there is diminution of bulk instead of enlargement. 
This may be explained by the contraction of the fibrin which had been exuded 
around the vessels, and the consequent diminution or obliteration of their 
caliber, giving rise to atrophy from want of blood. But more frequently, 
instead of induration, we find softening, either partial or general; and this is 
sometimes very great, so that the texture of the organ is completely broken 
up, and the parenchyma reduced almost to a pulpy mass. In the chronic 
indurations, the colour, instead of being darker or redder than in health, as 
is usually the case in the inflammatory softening, is apt to be light, and even 
yellowish-white. 
But among the most frequent appearances presented by the liver, in ad- 
vanced and fatal cases of hepatitis, are abscesses occupying either the sub- 
stance or surface of the organ. When situated in the parenchyma, they 
appear to have been formed by a softening of the part affected, the subse- 
quent infiltration of a sero-purulent fluid, and the gradual solution or absorp- 
tion of the softened tissue, while the production of pus increases. The parts 
about the forming abscess are more vascular than natural. Sometimes there 
is only one abscess, sometimes two or more, and occasionally they are very 
numerous. They are of all sizes, from that of a filbert or less, up to that 
of one of the lobes, or even of the whole organ. Cases are on record in which 
the liver appears to have been converted into a purulent mass, enclosed in the 
investing membrane. The pus of one of these abscesses has been known to 
weigh eleven or twelve pounds. They are more apt to occupy the right than 
the left lobe. Sometimes they are encysted, that is, surrounded by a smooth 
membranous sac, resulting from the exudation of coagulable lymph; some- 488 
[PART II. 
LOCAL DISEASES.-SECRETORY SYSTEM. 
times the pus is contained in a cavity which appears merely to have been 
hollowed out of the substance of the liver, the parenchyma of which forms 
its walls. The pus is either genuine, as in ordinary abscesses of the cellular 
tissue, or is variously altered, being sometimes contaminated with bile, or the 
remains of the disorganized substance of the liver, and presenting very differ- 
ent qualities of colour and consistence. Thus, it may be reddish, greenish, 
or blackish, and either as thin almost as water, semi-liquid, or nearly concrete. 
Abscesses have also been observed upon the surface of the liver, produced 
either by the deposition of pus beneath the peritoneal coat, or in cavities 
formed by adhesions between that coat and contiguous surfaces. 
Cicatrices of abscesses occasionally exist upon the surface and in the inte- 
rior of the liver, at least, portions of fibrous or cartilaginous matter have been 
noticed, with radii extending to a greater or less distance from the central 
point, which have been taken for cicatrices, and with the greater probability, 
as they have been found in persons who had been suspected, during life, of 
having been affected with hepatic abscess. {Thomson on Diseases of the 
Liver and Biliary Passages.') 
Instances of undoubted gangrene of the liver, following inflammation, have 
been recorded; but they are very rare; and most of the cases which have 
been considered as gangrene, were probably mere softening, as the fetid 
odour was wanting. 
Causes. 
The most frequent cause of hepatitis is long-continued exposure to heat. 
Hence, the disease is much more common within the tropics than in cold or 
temperate latitudes, and is generally prevalent in proportion to the degree 
and continuance of the heat, though this is not uniformly the case. An ele- 
vated temperature probably operates as a diiect stimulus to the liver, and 
either excites it into inflammation, or sustains it in a state of excessive action, 
which strongly predisposes it to take on that condition, when exposed to the 
influence of any other cause. It is probable, also, that the liver is kept, in 
hot climates, in a constant state of exaltation by the duty of discharging from 
the system the excess of carbon, thrown upon it in consequence of an insuffi- 
cient elimination of that substance through the lungs. 
Among the agencies which co-operate with heat, one of the strongest is 
probably that exercised by vicissitudes of temperature; by changes, for ex- 
ample, from hot and dry to cold and damp weather, or by exposure to cold 
in any mode when heated and perspiring from over-exertion. 
Miasmatic influence is also probably among the frequent causes of hepatitis. 
That it is capable of producing this effect indirectly, through the agency of 
the morbid processes which it sets up in the system, admits of no doubt; for 
inflammation of the liver is one of the recognized accompaniments and results 
of bilious remittent and intermittent fevers. But there is also strong reason 
to believe that it is capable of immediately deranging the hepatic actions, 
and, under favouring circumstances, of producing hepatic inflammation. How 
otherwise can we explain the greater prevalence of all ordinary morbid affec- 
tions, having their origin in the liver, in hot miasmatic regions than in those 
which are at the same time hot and dry ? 
Hepatitis is said to have been sometimes epidemic; but it is highly pro- 
bable that, where this has been thought to be the case, a closer examination 
would have discovered some local cause sufficient to account for the result, 
as, for example, miasmatic exhalation. 
Many other causes of this affection have been enumerated; as direct injury 
to the liver by falls, blows, &c., or by the presence of gall-stones; violent CLASS III.] 
489 
HEPATITIS. 
and fatiguing bodily exertion ; excess in the use of rich animal food; intem- 
perate drinking; the abuse of mercury; the translation of gout or rheuma- 
tism ; the suppression of accustomed discharges, especially from the hemor- 
rhoidal vessels; paroxysms of violent emotion, as of anger, terror, &c.; 
and continued mental depression from grief, disappointment, or anxiety. 
Perhaps the most fruitful of these is habitual intemperance, which, in a vast 
number of instances, even in temperate latitudes, lays the foundation of 
chronic disease of the liver. That alcohol taken into the stomach should 
act with special energy upon the liver will be readily understood, if the pre- 
valent opinion be admitted, that it enters the circulation by the route of the 
portal veins, and must, therefore, be distributed through the liver before it 
can reach the system generally. Much stress too has been laid, by some 
writers, upon the abuse of mercury, especially of calomel, given in such un- 
stinted measure as it often has been, in the treatment of bilious fevers, and 
other diseases incident to hot seasons and climates. The late Dr. Chapman, 
of the University of Pennsylvania, expressed, in decided terms, his opinion 
to this effect, and his experience entitles that opinion to great weight. The 
well-known excitant influence of mercury upon the hepatic functions, would 
of itself render the production of inflammation from an excess of its action 
a highly probable result. I cannot, however, say, though much in the habit 
of using mercury as a remedy, that I have myself witnessed such an effect; 
but the reason may be that I have generally been very careful to use it 
moderately. 
The liver is undoubtedly often inflamed through the agency of morbid con- 
ditions of other parts of the system. Diseases of the heart which impede the 
flow of blood into its right cavities, and diseases of the lungs which produce 
indirectly the same result, frequently disturb the hepatic functions, and favour 
the production of chronic inflammation, by occasioning congestion of the 
ascending cava, and consequently of the liver. Tumours pressing upon the 
vena cava may have the same effect. Disorders of the stomach and intestines 
notoriously affect the liver. Between these structures so close a sympathy 
exists, that some derangement of the one might be expected as an almost 
necessary result of serious disease in the other. It is supposed that irritation 
or inflammation of the orifice of the ductus communis choledochus may travel 
to the liver, and thus excite hepatitis. But the chief source of disorder of 
the liver, consequent upon disease of the alimentary canal, is probably the 
change in the quantity and character of the blood sent into the former organ 
through the portal vessels. How frequently must hepatic congestion result 
from an over-active circulation in the stomach and bowels! Besides, the 
noxious contents of the alimentary canal, whether introduced from without, 
or resulting from morbid secretion or chemical changes in the canal itself, are 
frequently absorbed into the portal vessels, and carried by its ramifications 
through every part of the liver before they can enter the system. Upon this 
organ, therefore, their injurious influence must be first exerted. Hence, dys- 
pepsia, chronic gastritis and enteritis, dysentery, colic, &c., are not unfre- 
quently associated with hepatitis, especially in its chronic forms, either as 
cause or effect. Probably sedentary habits favour the production of chronic 
hepatitis chiefly by their primary influence on the alimentary canal. Diseases 
of the brain have also frequently been observed in connexion with hepatic 
inflammation, but whether in the direct relation of cause and effect has not 
perhaps been so clearly demonstrated. Abscesses in the liver, as the result 
of fatal injuries of the brain, have often attracted the notice of pathologists; 
and many have ascribed them to a direct sympathy between these organs. 
But similar abscesses have been observed after surgical injuries elsewhere, 490 
[part II. 
LOCAL DISEASES.-SECRETORY SYSTEM. 
such as amputation of a limb; and it is well known that the liver is pecu- 
liarly apt to feel the influence of those diseases in which the blood may be 
supposed to suffer under peculiar contamination, such as cancer and fungus 
haematodes. It is now, therefore, supposed that hepatic abscesses, following 
extensive injuries, are the result rather of phlebitis and the consequent intro- 
duction of pus into the circulation, or of a purulent infection of the blood 
from some other cause, than of mere sympathy. A similar origin is ascribed 
by Dr. George Budd to the abscesses of the liver, so frequently found con- 
nected with ulcerations of the stomach and bowels, particularly of the large 
intestines in dysentery. The ulcer is the source of some acrid product, which, 
admitted into the blood-vessels, induces that condition of the blood which 
tends to the formation of metastatic abscess. (See Metastatic Abscess or Puru- 
lent Infection.') Dr. Budd thinks also that hepatic abscesses sometimes ori- 
ginate, on similar principles, from ulcers of the gall-bladder. {Diseases of the 
Liver, 2d ed., p. 84.) 
Finally, age and sex are supposed to have some influence in the causation 
of hepatitis; and it has been said that children and females are less liable to 
the disease than adults and males: but if this difference really exist, it is 
probably much more owing to difference in exposure to the causes, than to 
any peculiar susceptibility of constitution. 
In acute hepatitis, when the pulse is strong, and the constitution unim- 
paired, blood should be taken from the arm in quantities proportionate to the 
severity of the disease. Bleeding is especially demanded when there is reason 
to believe that the peritoneal surface is affected; but it is highly important 
also in the exclusively parenchymatous inflammation. The amount taken 
should be limited only by the effect upon the symptoms and the circulation. 
It is so altogether uncertain that no definite rule can be given. In urgent 
cases the bleeding should be copious, and may be repeated once and again if 
apparently called for. Even in cases less strikingly developed, it may still 
be important to resort to this remedy; but always with reference to the pre- 
vious habits of the patient, and the general condition of his system. It is 
said not to be borne so well in hot as in temperate climates. 
Local bleeding is an excellent auxiliary to the lancet, or substitute for it 
when forbidden. It is very rarely indeed that, in acute hepatitis, blood cannot 
be taken with propriety from the vicinity of the disease. Some recommend 
preferably bleeding from the hemorrhoidal vessels; but I believe that, in 
inflammation of an interior organ, no position is upon the whole so favourable 
for local depletion as the surface of the body immediately over the part 
affected. Theory may indicate another point as having a closer vascular con- 
nexion with the inflamed organ; and it may be difficult to account, in the 
present state of our knowledge, for the extraordinary influence of the loss of 
blood from the surface: but speculation should yield to an experience almost 
universal, and which appears to me to hold as well in this as in other instances. 
Cups or leeches may be employed. The latter are preferable when there is 
great tenderness upon pressure, and should of course be used when blood is 
to be taken from the anus. But, other circumstances being equal, cups are 
preferable to the side, and especially over the ribs, in consequence of the con- 
siderable revulsion they produce in addition to their depletory effect. 
Purgatives are useful, in acute hepatitis, both by their revulsive action, and 
by the depletion they indirectly produce from the portal veins. Mercurials 
are especially indicated, in consequence of their property of increasing the 
hepatic secretion, and thereby directly unloading the congested vessels of the 
Treatment. CLASS III.] 
HEPATITIS. 
491 
liver. From five to fifteen grains of calomel should be given at the com- 
mencement of the treatment, and followed in a short time by one of the saline 
cathartics, or by the infusion of senna with salts. In the cases of individuals 
liable to suffer great irritation of stomach and bowels from calomel, an equiva- 
lent quantity of the mercurial pill may be substituted. Sometimes it may be 
proper to administer the mercurial in connexion with a quicker cathartic, as 
jalap, scammony, &c.; but this plan is often forbidden by irritability of the 
stomach. Calomel in smaller doses, from one to three grains, for example, 
may afterwards be given at bedtime, and followed in the morning by a saline 
aperient, so as to have the bowels well opened every day. The saline ca- 
thartics should be largely diluted with water, so as to render them as little 
irritant as possible. It will often be found advantageous, when the first vio- 
lence of the inflammatory excitement has been subdued by depletion, or earlier 
in cases not requiring depletion, to combine with the calomel at night a grain 
of opium, and, if there is no irritability of stomach, an equal or double quan- 
tity of ipecacuanha. By this plan pain and irritation are allayed, the patient 
rests at night, and the secretory function of the liver is sustained; while, at 
the same time, the foundation is laid for a full mercurial course, should the 
disease not appear disposed to yield without it. 
Should the skin be hot and dry, and the stomach not irritable, tartar emetic 
in solution may be given in small doses, at short intervals, alone, or combined 
with nitre or the neutral mixture. If the patient is affected with nausea or 
vomiting, the effervescing draught would be preferable as a refrigerant dia- 
phoretic. Under the same circumstances, the Seidlitz powder will be found 
useful as an aperient ; and, should no indication exist either for diaphoresis or 
purging, the sickness of stomach may be controlled by small draughts of car- 
bonic acid water, and external fomentations or revulsives. 
When depletion, along with the measures proposed, fails to subdue the in- 
flammation, the mercurial impression should be unhesitatingly resorted to. 
In ordinary cases, it is unnecessary to do more than to produce a very slight 
effect upon the gums. For this purpose, the calomel before given only at 
night, may be repeated in smaller doses, say from half a grain to a grain, 
every two, three, or four hours, until it begins to produce some obvious effect 
upon the mouth ; or the mercurial pill may be substituted in double or triple 
the dose. When the mouth is affected, the remedy should be omitted for a 
time, and resumed when found necessary to sustain the impression, which 
should be continued until all signs of the inflammation are subdued, or until 
it shall be found that mercury is inadequate to this effect. When the sto- 
mach and bowels do not bear the mercurial well, or the system resists its in- 
fluence, recourse may be had to the external use of the mercurial ointment. 
In severe and rapid cases of the disease, such as are apt to occur in tropical 
countries, the remedial means must be proportionably more energetic. In 
these calomel may be given more freely as a cathartic, and afterwards pushed 
more speedily in reference to its general effects upon the system; while its 
operation is aided by mercurial frictions or dressings. In common hepatitis 
of an acute or sub-acute character, two or three days or more may be given 
to the depletory method, before attempting to establish the general influence 
of mercury; in the more alarming cases, the two plans should be carried into 
effect simultaneously. 
While the measures already mentioned are in operation, they should be 
assisted, in the early stages, by fomentations or poultices to the side, and, 
after the violence of the inflammatory excitement has subsided under the 
lancet and purgation, by large blisters. These, in connexion with mercury, 
often serve to complete the cure, and prevent the degeneration of the disease 492 
LOCAL DISEASES.-SECRETORY SYSTEM. 
[PART II. 
into the chronic state. Advantage will often accrue from a more or less fre- 
quent repetition of the blister, one being allowed to heal before another is 
produced. In some cases, it may be advisable to dress the blistered surface 
with mercurial ointment. 
Should evidence of suppuration be presented, both the depletory and mer- 
curial plans should be omitted, or at least very much relaxed. The indica- 
tions now are to hasten the suppurating process, to favour its tendency to the 
surface, and to support the general strength. If any advantageous specific in- 
fluence over the liver can be substituted for the mercurial, which would now 
be too exhausting, it should also be resorted to. These indications are best 
met by the nitro-muriatic acid, which operates both as a tonic, and an hepatic 
alterative, and by emollient cataplasms to the side; while irritation is calmed 
by opiates, or other narcotics, as hyoscyamus and coniuin. In many cases, it 
will be advisable to superadd the use of quinia and the fermented liquors. 
Recourse may also be had to other mineral acids, as the nitric, sulphuric, and 
muriatic, in order to vary the tonic impression. 
In the early stages, the patient should be allowed cooling drinks, and con- 
fined to a very low diet, consisting chiefly of farinaceous and mucilaginous 
liquids. As convalescence advances, the diet may be gradually improved as 
in other inflammatory affections. During suppuration, also, it is often necessary 
to allow thejjatient nutritious food, such as preparations of milk, broths, soft 
boiled eggs, oysters, &c., in order to sustain the strength. 
Chronic hepatitis requires a somewhat modified treatment. This is essen- 
tially the same, whether the complaint is a mere residue of an acute attack, 
or was originally of the chronic form. General bleeding is now seldom ne- 
cessary or admissible; but occasional advantage may be derived from local 
depletion by cups or leeches. Our main reliance, however, so far as medi- 
cines are concerned, must be upon a moderate mercurial course, sustained for 
a considerable time. It is highly important that both these modifications 
should be attended to. Merely to salivate, and then to suspend the mercurial, 
is altogether insufficient to remove a disease, often of long standing, and at- 
tended with great organic derangement. A powerful impression will exhaust 
the strength of the system, and render a continuance of the treatment impos- 
sible, while the effect produced is partial and temporary. Many of the fail- 
ures in the treatment of chronic hepatitis are probably owing to a too energetic 
employment of mercurials in the first place, and a too hasty abandonment of 
them under slight discouragements. The slightest effect on the gums is suffi- 
cient, and this is desirable only as a proof that the mercurial is acting, and 
may be very properly dispensed with, if the case appears to be going on 
favourably without it. The mercurial or blue pill is decidedly the most suit- 
able of the mercurials in this case. It should be given in small doses, 
repeated several times a day, and combined or not, according to the circum- 
stances of the case, with other medicines. Thus, should the bowels be con- 
stipated, it may be given with rhubarb, or aloes, or both; should they be too 
loose, with opium or small doses of Dover's powder, and sometimes with one 
of the cretaceous preparations, where there are symptoms of acid in the sto- 
mach and bowels; and, should the digestion be feeble, with extract of gentian 
or quassia, or small doses of sulphate of quinia. Should opium be contra- 
indicated, and the patient complain of pain, restlessness, or other form of 
nervous irritation, conium, hyoscyamus, or stramonium may be combined 
with the mercurial. Sometimes it may be better to use very small doses of 
calomel, or even to depend upon mercurial frictions, especially when the sto- 
mach and bowels are very irritable. A mercurial plaster worn constantly on 
the side will be found a useful remedy in some very susceptible constitutions, CLASS III.] 
HEPATITIS. 
493 
and may be used as an adjuvant in any case, when the side is not otherwise 
occupied. The impression on the system should be maintained for weeks or 
months, if the patient appear on the whole to improve under it; care being 
always taken, if the mouth should be inadvertently made decidedly sore, to 
suspend the remedy until this inconvenience has been removed. 
During the mercurial course, revulsion to the side should be made by rube- 
facients, repeated blisters, pustulation with croton oil or tartar emetic, setons, 
or issues, according to the severity of the symptoms. When the liver is en- 
larged and indurated, advantage maybe expected from frictions over the side 
with iodine ointment, repeated daily or twice a day, and continued for a long 
time. 
Should the mercurial plan fail, or circumstances forbid its employment, nitro- 
muriatic acid should then be resorted to, and employed both internally, and 
externally by pediluvium, general bath, or lotion to the side. The two reme- 
dies, however, should never be administered at the same time internally, as 
they are chemically incompatible, and might produce serious mischief. The 
same adjuvants may be given, if requisite, in connexion with the nitro-muria- 
tic acid as with mercury. The former remedy is especially adapted to cases 
in which suppuration has commenced, and in which the mercurials should not 
be given, at least as a general rule. 
Other alteratives have enjoyed more or less reputation in the treatment of 
chronic hepatitis. Perhaps the one most highly esteemed is taraxacum. This 
may be given as an adjuvant to the mercury or nitro-muriatic acid, and, in 
consequence of its aperient and slightly diuretic properties, is especially adapted 
to cases in which there is a tendency to constipation, and to dropsical effusion. 
The alkaline carbonates sometimes appear to exercise a happy influence over 
disordered hepatic actions, and alkaline baths have been highly recommended. 
Some German practitioners have considerable confidence also in the alterative 
properties of muriate of ammonia. 
Attention, throughout the treatment, should be paid to the state of the 
stomach, bowels, and skin, which should be kept in as healthy a condition as 
possible. (See Dyspepsia, Diarrhoea, Constipation, &c.) 
The regulation of the diet is highly important. Without being stimulant, 
it should in general be nutritious and easily digestible. Milk and farinaceous 
substances, with a moderate allowance of the lighter kinds of animal food, 
especially of boiled meats or poultry, are generally admissible. But the phy- 
sician should modify the regimen, according to the greater or less degree of 
inflammatory excitement or general debility. 
Moderate exercise of the passive kind is often useful; but fatigue, or violent 
exercise calculated to agitate the liver, as riding on horseback or in a rough 
vehicle, should be avoided. 
Among the most efficient remedies in chronic hepatitis is a change of cli- 
mate. After failure by medical treatment, if the patient reside within the 
tropics, he should be sent to some mountainous region, or colder latitude; if 
in a city or miasmatic district, within temperate latitudes, to some cool ele- 
vated, and healthy spot, which experience has proved to be favourable, or to 
the sea-shore, which is almost always salutary in such cases. 
Many natural mineral waters have enjoyed some reputation in the cure of 
chronic hepatitis, and probably co-operate with the exercise, pure air, cheerful 
society, and exemption from cares, incident to watering-places, in producing 
a favourable impression. The waters of Vichy in France, Cheltenham in 
England, and Saratoga in this country, have been especially recommended. 
The combination of chalybeate and aperient properties should be sought for, 
when the stomach is feeble, and the bowels costive. In a different state of 494 
LOCAL DISEASES.-SECRETORY SYSTEM. 
[PART II. 
the bowels, the purer chalybeate springs may be preferred. Advantage has 
also undoubtedly accrued, in chronic liver affections, from the sulphur springs, 
such as those found in the interior of Virginia, Kentucky, and New York. 
These may be employed both internally and externally. In reference to the 
former mode, it is necessary to be careful that no phlogosis of stomach, or 
general inflammatory excitement exist. The hot springs of Virginia have also 
been found very useful, employed in the form of bath. 
In cases of abscess of the liver, advantage may sometimes be derived from 
an artificial opening; but care should be observed that the abscess is suffi- 
ciently advanced; and the operation should not be performed, unless there is 
good reason for believing that adhesion has taken place between the perito- 
neum of the liver and that of the abdominal parietes; as otherwise the pus 
might escape into the cavity, and occasion fatal peritonitis. When evident 
fluctuation is presented, the integuments obviously thinned, and the skin 
over the tumour reddened, it may be inferred that adhesion has taken place; 
and a trochar or lancet may be safely introduced. Plans have been proposed 
to effect the desired adhesion, when it is doubtful, by the application of caus- 
tic, and by incision through the parietes. It appears, however, from dissec- 
tions, that these plans have often failed. Mr. Twining, who often opened 
hepatic abscesses by caustic, states that, upon examination after death, adhe- 
sion of the peritoneal surfaces had very rarely been found. Dr. Graves pro- 
posed incision through the integuments over the tumour, the division of some 
layers of muscle, and afterwards stuffing the wound with lint. But neither 
has experience shown this method to be effectual. A plan proposed by M. 
Begin, is to cut down to the peritoneum, open this carefully as in the opera- 
tion for*bernia, and then, if adhesion be found not to have taken place already, 
to apply common dressings to the wound in the hope that the consequent in- 
flammation may lead to the requisite consolidation of parts. The late Dr. 
Horner, of the University of Pennsylvania, in an operation for opening an 
hepatic abscess, having found a want of adhesion upon cutting through the 
abdominal parietes, stitched the liver to the side by means of a crooked needle 
armed with a kid-skin ligature, and then plunged a trochar and canula into 
the abscess. No signs of peritonitis followed, and, though the patient died, 
apparently in consequence of the previous exhaustion, yet, upon examination 
after death, adhesion was discovered immediately around the wound, which 
had proved sufficient to prevent the entrance of pus into the abdominal cavity. 
(Ami. Journ. of Med. Sei., xiv. 87.) Perhaps the dangers of the want of 
adhesion have been somewhat exaggerated. Dr. Thomson states that, in the 
cases on record in which hepatic abscesses have been opened, though there is 
reason to believe that in many of them there was no adhesion, yet there is no 
evidence of the pus having, in any one case, entered the abdominal cavity; 
and Dr. Murray expressly declares, in the Madras Quarterly Medical Journal 
(July, 1839), that he has opened many hepatic abscesses, in which there was 
no adhesion between the liver and abdominal parietes, and that in none did 
any matter escape into the peritoneal cavity after the operation. (Dis. of the 
Liv. and Bil. Passages, by Wm. Thomson, M. D.) Two modes of opening 
the abscess have been proposed, one by caustic potassa, the other by a cutting 
instrument. The latter is now almost universally preferred. A trochar and 
canula may be employed; but sometimes the contents of the abscess are so 
thick that they will not readily flow out through the instrument, in which 
case, a larger opening may be made by the knife. Dr. Budd has suggested 
a danger from opening abscesses, which had previously scarcely been taken into 
account. The substance of the liver being firm, the walls of the abscess may 
not collapse when the pus is evacuated; air consequently enters; and the CLASS III.] 
ORGANIC DISEASES OE THE LIVER. 
495 
pus, undergoing decomposition, becomes acrid and thus tends to sustain irri- 
tation in the organ. (Diseases of the Liver, 2d ed., p. 116.) This is less an 
objection to the opening of the abscess, than to any subsequent measure for 
forcing out the pus to a greater extent than would be spontaneously effected 
by the collapse or contraction of the surrounding tissues. 
Article IL 
NON-INFLAMMATORY ORGANIC DISEASES OF THE LIVER. 
These are very numerous, and generally difficult, often impossible to dis- 
tinguish from chronic inflammation during life. They are, indeed, very fre- 
quently attended by inflammation in their course, which serves to mask, in 
some degree, any peculiar phenomena by which they may be characterized. 
It is not improbable that some of them have their origin, at least occasionally, 
in the inflammatory process or its results. In most of them, the only treat- 
ment, from which any good is to be expected, is some modification of that 
adapted to chronic hepatitis. It would seem, therefore, that no great practical 
benefit could accrue from their distinct consideration. In the formation, 
however, of a just prognosis in hepatic affections, they must be taken into 
account; and even the partial knowledge of them we may possess may lead 
to some modification of the treatment, founded upon the impossibility of ulti- 
mate success. It will be proper, therefore, to give a brief sketch of such of 
them as have been well ascertained. It may be observed, in general, that in 
consequence of their interference with the functions of the liver, and the free 
flow of blood through that organ, they necessarily give rise to the same phe- 
nomena as those resulting from inflammatory disorganization, such as stomachic 
and intestinal derangement; a frequently jaundiced colour of the skin, eyes, 
and secretions; mental depression, heaviness, stupor, and other marks of cere- 
bral oppression; and finally dropsical effusion, either general, or exclusively 
abdominal. With the exception of cancerous formations, they are attended 
with little or no pain; and, when pain does occur, it is of an obtuse character, 
and probably dependent in general upon the developement of inflammation. 
Of course those of them which are attended with enlargement of the liver, 
give rise to all those signs of pulmonary oppression, cardiac derangement, and 
disorder of the abdominal viscera, which result from mechanical encroachments 
upon the two great cavities, and compression of their contents. An interesting 
fact in relation to these non inflammatory organic affections is, that they are 
proportionally much more common in temperate than hot climates; so that they 
do not appear to be subject to the same kind of causality as common hepatitis. 
Hypertrophy.-This is an overgrowth of the liver, consequent upon an 
increase of its proper structure, and entirely independent of inflammatory 
depositions, or the developement of new and accidental tissues or products of 
any kind. It may affect a part or the whole of the organ, giving rise, in the 
former case, to great alteration of its form. It is probably most common in 
children from the circumstance that the excessive nutrition of the liver, which 
constitutes its normal state in the foetus, may not be diminished in the due 
proportion after birth, so that the viscus may retain in a greater or less de- 
gree its original preponderance. It is a rare affection in such a degree as to 
be considered morbid. There is no symptom by which it can be certainly 
distinguished, during life, from other cases of enlargement of the liver. 
Atrophy.-This is exactly the reverse of the preceding affection, being 
characterized by a diminution of the natural structure of the organ, so as to 496 
LOCAL DISEASES.-SECRETORY SYSTEM. 
[part II. 
leave its several constituents in their due proportion and relation; a condition 
such as might result from a defective nutrition, or too active interstitial ab- 
sorption. Every case of shrinking of the liver is not one of atrophy; for 
the texture may be merely condensed, and the weight greater even than in 
health. In true atrophy, both the bulk and weight are diminished. It is 
said that the characteristic structure of the liver sometimes suffers atrophy, 
while the cellular tissue is increased; so that there is no diminution of bulk. 
Cases are on record, in which the liver has been reduced to the size of the 
fist. An accurate diagnosis of this affection during life is not possible. 
Induration.-The liver often acquires increased density and hardness 
from depositions or new formations in its substance; but it occasionally also 
undergoes an induration of its parenchyma without such cause, and without 
other observable change. In such instances, it is firmer to the touch than in 
health, is torn with greater difficulty, and yields a sound under the scalpel. 
The hardness may be connected with increased or diminished bulk of the 
liver; but the latter is much the more common of the two. It may be either 
general or partial. It is observed most frequently as a complication of other 
affections, and may possibly result from long-continued irritation, approaching, 
but not reaching the inflammatory state. It cannot be distinguished during 
life from hardness proceeding from other causes. 
Softening.-This is a frequent result of inflammatory action; but it 
may also occur without that cause. Louis describes a variety of softening, 
observed by him in typhoid fever, which he designates by the term friability. 
The liver breaks with the slightest force, and crumbles, as it were, into a sort 
of powdery mass. Another kind, which may be distinguished as the moist 
softening, is marked, in extreme cases, by a pasty or semi-liquid consistence 
of the liver, the organization of which is completely destroyed in the affected 
part, but without the offensive odour of gangrene. Softening may, or may 
not be attended with signs of congestion. Sometimes the liver has merely 
an increased flaccidity, being throughout as soft as the spleen. This condi- 
tion was noticed by Dr. Baillie, especially in old people. 
Cirrhosis.-Granular Degeneration of the Liver.-This affec- 
tion was described by Br. Baillie under the name of " common tubercle of the 
liver." It was afterwards investigated by Laennec, who named it cirrhosis 
(from xippoj, yellow), in accordance with his peculiar views of its nature. It 
consists in the developement, upon the surface and through the substance of 
the liver, of innumerable corpuscles, of various sizes, from that of a pin's 
head to that of a hazelnut, or even larger. The viscus is usually diminished 
in bulk, sometimes considerably so ; is harder and denser than in health, and 
rough upon the surface, in consequence of the projection of these little bodies, 
and the shrinking of the surface between them. In some instances, the bulk 
of the liver, instead of being diminished, is even increased, and its substance 
softer instead of firmer than in health. This is supposed to be the first stage 
of the affection ; and, in cases of the kind, I have noticed that the corpuscles, 
or rather morbid subdivisions of the gland, are much larger than when the 
liver is smaller and firmer. The colour of the corpuscles is yellow of different 
tints, sometimes a bright canary-yellow, sometimes brownish or greenish, and 
occasionally of a reddish hue; and, when pressed upon white paper, they 
impart to it a yellow stain. When the liver is cut, the surface, at first sight, 
appears uniform and yellow or brownish-yellow, but, more closely examined, 
is found to be studded with these minute bodies in countless numbers. Ac- 
cording to Cruveilhier, each corpuscle, as observed upon the surface, is distinct, 
with its own investing membrane, and connected with the other parts only by CLASS III.] 
CIRRHOSIS. 
497 
a vascular foot-stalk; and a similar distinctness of position exists in the inte- 
rior of the viscus. 
Very different views have been taken of the nature of the affection. Laen- 
nec considered the corpuscles consist of a peculiar accidental product, 
somewhat analogous to tubercle, and, like that, capable of being softened, and 
converted ultimately into a greenish-brown, inodorous, and somewhat adhe- 
sive mass. Others have viewed them as resulting from alteration of the 
proper structure of the liver, or of one of its constituents. By some anato- 
mists it is believed that the liver consists of two substances : " one apparently 
formed by the ramification of the capillary vessels, and presenting a reddish 
appearance, the other yellowish-white, and supposed to be chiefly concerned 
in the secretion of the bile." In accordance with this notion, Bouillaud 
maintains that the corpuscles are nothing more than the secretory granules of 
the liver, undergoing gradual organic change, in consequence of the oblitera- 
tion of the vascular plexus, and the interruption thus offered to the hepatic 
circulation. Andral also believes that they are the hypertrophied yellow 
constituent of the liver, predominating over the atrophied red constituent. But 
those who, with Mr. Kiernan, deny the existence of these two distinct struc- 
tures, must resort to another hypothesis; and Cruveilhier suggests that cirrhosis 
may consist in an excessive developement of a portion of the granules of the 
liver, consequent upon atrophy of the remainder. According to Dr. Carswell, 
the disease is essentially atrophy of the lobular structure, produced by a con- 
tractile fibrous tissue, originating in inflammation of the capsule of Glisson, 
which is the cellular envelope surrounding the blood-vessels of the liver, and 
ramifying with them through the viscus. Something like this appears at 
present to be the opinion prevalent among English pathologists. They con- 
ceive that a fibrous tissue has formed in the spaces occupied by the blood- 
vessels and areolar tissue around the acini, which may be seen, in a section 
of the liver, forming white lines around the granules, and which by its con- 
traction causes compression of the secretory cells, and general atrophy of the 
liver. By some this fibrous matter is considered as the product of inflam- 
mation, by others as a peculiar abnormal product, resulting from a peculiar 
non-inflammatory exudation, which may be placed in the same category with 
the tuberculous, the atheromatous, and cancerous formations, though possessed 
of distinct characters of its own. This view is ingeniously maintained by Dr. 
Hanfield Jones, who designates this formation as a fibroid degeneration, closely 
analogous to what is frequently seen in blood-vessels and other parts, and 
called cartilaginous degeneration, from its cartilage-like appearance. (Brit, 
and For. Medico-Chirurg. Rev., July, 1854, p. 28.) Against the opinion 
of Laennec are the facts, first, that each morbid corpuscle, as stated by Cru- 
veilhier, when cut through, exhibits under the microscope the same arrange- 
ment as the healthy parenchyma, and, secondly, that the granules appear to 
be capable of secreting bile, as the quantity of this liquid produced in cirrhosis 
is often scarcely less than in health. The opinions based upon the double 
structure of the liver are now entertained by few. That the affection is not 
essentially inflammatory follows, I think, from its course, and the utter in- 
sufficiency of antiphlogistic measures in its cure. The hypothesis which 
ascribes it to the formation of a new fibroid tissue is plausible; but there are 
difficulties in the way of its reception, and among them the facts, that around 
many of the corpuscles no confining or compressing tissue can be detected, 
and that instead of being compressed, the affected acini would seem to be 
enlarged. Some modification of the view of Cruveilhier seems to me to 
explain the phenomena most satisfactorily; though it must be admitted that 
any view which can be taken, in the present state of our knowledge, must 498 
[PART II. 
LOCAL DISEASES.-SECRETORY SYSTEM. 
be regarded as mainly conjectural.* The name of cirrhosis has recently been 
extended by some pathologists, so as to embrace the condition of the liver 
characterized by increase of density and diminution of bulk, with fibrous for- 
mation, even though the peculiar tuberculated aspect may be wanting. Some 
have even gone so far as to apply the name also to a supposed similar state 
in other organs, as in cirrhosis of the lungs, which is characterized by a fibrous 
infiltration into the tissue of the lungs, solidifying and contracting it. Cir- 
rhosis is sometimes associated with fatty or waxy degeneration, and sometimes 
exists without either. 
The symptoms of cirrhosis are not strongly marked, and its existence is in 
general rather to be inferred by the way of exclusion, than to be positively 
demonstrated. There may be some dull pain or sense of discomfort in the 
* In order to understand the nature of cirrhosis, it is necessary to be acquainted with 
the intimate structure of the liver. That viscus consists essentially of an aggregation of 
minute lobules, called acini, separated from each other by areolar tissue, through which 
pass the branches of the portal vein and hepatic artery conveying blood to the acini, as 
well as those of the hepatic vein and the biliferous tubes which carry the blood and the 
bile from them. In these acini are performed the offices of the liver, the secretion, 
namely, of the bile, and the preparation of the blood brought by the portal vein for the 
purposes of the general economy. 
According to the researches of Mr. Kiernan, of London, and of Dr. Joseph Leidy, of 
Philadelphia, these acini are made up chiefly of a network of minute tubes, consisting 
of a basement membrane, lined internally with epithelial cells, the arrangement of 
which was first demonstrated by Dr. Leidy. Between and around these tubules ramify 
minute branches of the portal vein and hepatic artery; while, in the centre of each 
acinus, a branch of the hepatic vein arises, which receives the blood after it has been 
submitted to the secretory and elaborative action of the cells, and carries it into the 
vena cava. It is believed that, as in other secretory functions, the epithelial cells of 
these tubules of the acini are the real agents by which the secretion of bile is effected, 
and the blood rendered fit for its purposes in the system. 
The most probable explanation of cirrhosis appears to me to be, that the cell-action 
is disordered, the cells themselves being abnormally multiplied, and at the same time 
congested with abnormal matter derived from the blood. The tubules are thus dis- 
tended, and the bulk of the acini greatly increased; while the vascular ramifications 
within the latter, being unduly compressed, are probably in a greater or less degree 
obliterated. The enlarged acini, pressing upon others either less diseased than them- 
selves, or altogether undiseased, cause their absorption; while the areolar tissue sur- 
rounding the several absorbed acini becomes consolidated about those which are hyper- 
trophied, thus giving rise to the fibrous structure which separates and isolates the 
little bodies, and which has been taken for a product of inflammation or of abnormal 
exudation. In this condition, the liver, as is believed to be the case, may be enlarged 
and soft in the early stage, while the corpuscles themselves are often of considerable 
magnitude. But, the blood-vessels being gradually obliterated by the pressure of the 
enlarged acini, cease to supply to these sufficient blood to support their hypertrophied 
condition. They consequently shrink more and more, and the whole organ becomes at 
length'much diminished, and at the same time hardened. It must be admitted, how- 
ever, that this view is like the others quite hypothetical. 
The flow of blood through the organ is impeded, the secretion of bile is diminished) 
and congestion of the portal circle with consequent abdominal dropsy takes place; 
while, the blood which passes into the vena cava not being duly elaborated, the whole 
system suffers. According to Bernard, the liver elaborates glucose or grape sugar for 
consumption in the respiratory function, and fat and fibrin for the general purposes of 
nutrition. If his views be correct, these functions must suffer in cirrhosis. 
Intemperance is thought to be one of the most common causes of this disease. With 
the views above given, this is easily explained. Alcohol taken into the stomach enters 
into the portal vein, and is first distributed through the liver, which, therefore, feels 
the full force of its stimulation. The secretory epithelial cells are excited by it into 
inordinate action, undergo in consequence excessive multiplication, and, not being 
washed away like the analogous diseased cells in the kidneys by a current of watery 
fluid, necessarily accumulate in their tubules, with all the results which have been 
above referred to as characterizing the disease under consideration.-[Note to the third 
and fourth editions.') CLASS III.] 
499 
CIRRHOSIS.-FATTY LIVER. 
region of the liver; but often there is none, and pressure occasions no un- 
easiness. When, along with the ordinary accompaniments of disordered 
hepatic function, such as more or less yellowness of skin or urine, gastric and 
intestinal derangements, depression of spirits, &c., there is also abdominal 
dropsy either without or preceding external oedema, and a diminished bulk 
of the liver, evident upon percussion, we have every reason to think that 
cirrhosis exists, especially if the symptoms have obstinately resisted all the 
remediate measures, or, if relieved for a time, have again returned with equal 
force. Should the liver be within reach of the touch, as sometimes happens 
when a full inspiration is taken, so as to depress the viscus below the edge 
of the ribs, and should the surface then have a rough granular feel, the exist- 
ence of the disease may be considered as almost certain. Sometimes a fric- 
tion sound may be heard, arising from the rubbing of the rough surface against 
the walls of the abdomen. The characteristic phenomena, it thus appears, 
are abdominal dropsy, exclusive or original, a diminished size of the liver, 
and a granular state of the surface. The disease may exist without these 
characters, but cannot then be recognized with an approach to certainty. In 
consequence of the impeded circulation through the liver, and resulting 
portal congestion, there is sometimes enlargement of the superficial veins 
of the abdomen, and the patient is, in some cases, affected with occasional 
attacks of hemorrhage from the stomach and bowels. The duration of 
the disease is uncertain; as it is difficult to ascertain the precise period of 
commencement. It may end in a few months, or last a year or more. 
So far as known, its termination is uniformly fatal. Towards the close of 
the disease, the pulse, before nearly natural, becomes frequent and irregular; 
the skin, usually dry and of the natural temperature, becomes cold; emacia- 
tion takes place, some oedema of the lower limbs is observed, the strength ut- 
terly fails, and the patient dies of debility, evincing usually before death more 
or less mental disorder. 
Little is known in relation to its cause. It often occurs in drunkards, but is 
by no means confined to that class of persons; and a considerable proportion 
of the patients who have come under my own notice have been of temperate 
habits. In one case it was coincident with granular disease of the kidneys. 
In regard to its treatment nothing more satisfactory can be said than of its 
causes. So far as is known it is a necessarily fatal disease; but it may very 
possibly have happened that cases have yielded to treatment in their earlier 
stages, without the nature of the complaint being recognized. It is proper 
always to combat the symptoms, as they appear, by such means as are 
usually employed for similar symptoms in other hepatic complaints. Cir- 
rhosis is one of the most common of the fatal diseases of the liver in tem- 
perate climates. 
Fatty Liver.-There appear -to be two forms of fatty liver, one in 
which the oil accumulates in the organ from over-production, as in the liver 
of the goose when over-fed, the other in which the oil takes the place of the 
healthy tissue, and which is the true fatty degeneration. Dr. Hanfield 
Jones states that, in the former, the oil globules are found in excess within 
and without the cells, being everywhere distributed through the liver; in the 
latter the oil drops are not in distinct cells, nor generally distributed, but 
are confined to the margin of the lobules, where they appear to have replaced 
the cells. Another important distinction, noticed by the same observer, is 
that sugar was found in the merely over-fat liver, while none could be detected 
in that in which the true fatty degeneration had taken place ; showing that 
the function is destroyed in the latter, but not necessarily in the former. (Land. 500 
LOCAL DISEASES.-SECRETORY SYSTEM. 
[PART II. 
Medico- Chirurg. Trans., xxxv. 249 ) Yet we know of no external marks by 
which the affections can be distinguished. 
In the adipose degeneration of the liver, this viscus is usually, though not 
always, enlarged, and sometimes is very much so. It has been known to fill 
almost the whole abdominal cavity. The weight is not increased in a degree 
corresponding to the enlargement. The characteristic hue of the fatty liver 
is a pale-yellow or cream colour, diversified by brownish, deep-orange, or reddish 
spots or points. The organ is generally softer than in health, but not always, 
and it is sometimes said even to be harder. When cut, it has a brownish or 
pale-yellow colour, which is usually modified by innumerable red points. It 
has an unctuous feel between the fingers, greases the knife, makes a greasy 
stain on bibulous paper, and, when heated moderately, furnishes much oily 
matter. The augmentation of volume probably depends upon an increase 
of the oily deposit. Along with this there appears to be a greater or less 
atrophy of the other portions of the parenchyma, possibly dependent upon 
pressure. Sometimes the deposit of fatty matter is partial. We have no 
means of forming an accurate diagnosis of this complaint. It may be sus- 
pected when the liver is considerably enlarged in phthisis, or in Bright's 
disease, without the attendant pain and tenderness of inflammation. The 
causes are quite as obscure as the diagnosis. From the well known effect of 
close confinement and excessive feeding in developing fatty matter, with 
enormous increase of bulk, in the liver of the goose, it might be suspected 
that the same causes are capable of producing the disease under considera- 
tion in man. But we have no positive proof to that effect. Fatty liver is 
frequent in phthisis, and exists in other chronic complaints, especially 
Bright's disease. Louis found it in one out of three of all the cases of 
phthisis which he examined after death; and of 49 cases of fatty liver which 
he observed in the course of three years, 47 occurred in consumptive patients. 
According to the same observer, it is much more frequent in women than 
in men. Dr. George Johnson states that of 21 cases of fatty liver observed 
by him, 17 occurred in combination with fatty degeneration of the kidney, 
which is the ordinary chronic form of Bright's disease. {Medico- Chirurg. 
Trans., xxix. 12.) Nothing satisfactory can be said of its treatment. An 
obvious inference from what has been stated would be, that, in individuals 
suspected to have this complaint, sedentary habits and over-eating, especially of 
food containing oily matter, should be avoided. Nevertheless, I am disposed 
to think that cod-liver oil may prove beneficial by favourably modifying the 
nutritive function in the liver. 
Waxy Liver.-Brawny Liver.-Scrofulous Liver.-1This has usually 
been considered a variety of fatty liver, and not unfrequently confounded with 
it. Pathologists now believe it to be the result of a peculiar degeneration or 
deposition, having no resemblance whatever to fatty matter, ft has been 
specially examined by Dr. Geo. Budd (Diseases of the Liver, 2d ed., p. 304), 
and by Dr. W. T. Gairdner (Ed. Monthly Journ. of Med. Sci., Feb. 1854, p. 
186). The liver is much enlarged, sometimes enormously so, and at the same 
time denser than in health. It is usually pale or fawn-coloured, but some- 
times red from congestion, and sometimes mottled. It is of a tough texture, 
and when cut presents a uniform, compact, smooth, somewhat shining or trans- 
lucent surface, pale or yellowish, and not unlike bacon or' yellow wax, both 
of which have given it names. Under the microscope, the entire structure 
seems to have been changed, and the epithelial cells appear compressed, irre- 
gular, with atrophied nuclei, and sometimes aggregated in masses. The affec- 
tion has been noticed especially in scrofulous and syphilitic patients, and, ac- 
cording to Dr. Gairdner, is the most frequent hepatic lesion in phthisis, more CLASS III.] NUTMEG LIVER.-TUBERCLES.-HYDATIDS. 
501 
so even than the fatty liver, with which it appears to have been confounded 
by Louis. Hypertrophied livers are very frequently of this character. Not- 
withstanding the extent of disease in the organ, there is often no deficiency 
of bile, and the chief inconvenience arises from its bulk and consequent pres- 
sure. The patient usually dies of other coincident diseases. 
Nutmeg Liver.-This name has been applied to the liver, when it ex- 
hibits, in its cut surface, a veined appearance, produced by two distinct colours 
conspicuously intermingled, as seen in the section of a nutmeg. These colours 
are usually red and yellowish or whitish, and are owing, the former to san- 
guineous congestion, the latter probably to the impermeability of portions 
of the tissue, from destruction or occlusion of the blood-vessels. The limits 
of the colours are often well defined, and the contrast not unfrequently striking. 
The condition does not depend on any one lesion, but may result from what- 
ever produces degeneration of the tissue in closely neighbouring minute sec- 
tions, irregularly intermingled with unaltered parts. The degeneration may 
be fatty, or waxy, or possibly fibrous; and hence the nutmeg liver may be- 
long to either of these affections. The colours are most strikingly contrasted 
when circumstances exist which produce intense venous congestion. The 
most marked case of the kind which I have seen, occurred this winter (185-1-5) 
in the Pennsylvania Hospital, in a drunkard who died of disease of the heart, 
with insufficiency of the mitral valves, great dilatation of the right ventricle, 
distended and throbbing jugulars, and universal venous congestion. The liver 
was somewhat enlarged, dense, tough, of a blackish redness externally, and 
intense venous redness upon its cut surface, beautifully veined everywhere 
with a fine distinct yellowness. There was no fatty feel, or greasy appearance 
on the knife; and, when a small portion of the yellow matter was scooped out 
and examined under the microscope, it exhibited masses of irregular cells, 
containing granular matter, either without visible nuclei, or with indistinct 
ones; the condition ascribed to the cells of the waxy liver, of which I have 
no doubt this was a commencing example. 
Tubercles.-This term is employed here, as in general elsewhere in 
this work, exclusively to designate that morbid deposit, which, when existing 
in the lungs, constitutes genuine phthisis. Tumours are occasionally found 
in the liver, having all the proper tuberculous characters, and in all the dif- 
ferent stages. Such tumours have been described by Portal and Baillie. 
Cruveilhier, however, never saw tubercles in the livers of adults affected 
with phthisis or tuberculous disease of the abdomen; and Louis observed 
only two instances in the numerous cases of phthisis which he dissected. 
They must, therefore, be considered as comparatively rare. But, according 
to Cruveilhier, it is not uncommon to find in the livers of tuberculous chil- 
dren thousands of minute, hard, semi-transparent granules, like millet- 
seed ; and I have myself examined the liver of an adult, dead of pulmonary 
consumption, the cut surface of which appeared completely studded with 
minute oval, hard, transparent corpuscles, which could be readily isolated 
from the parenchyma in which they were imbedded, and bore an exact re- 
semblance to the miliary tubercles of the lungs. 
Serous Cysts and Hydatids.-Cysts containing watery fluid have 
frequently been observed in the liver. These are of two kinds, one consisting 
of a single sac, the other of a sac containing within it one or more additional 
sacs. The former variety is a mere derangement of the natural structure, the 
latter is supposed to be a distinct organization, a peculiar kind of parasitic 
animal, to which the name of -hydatid or acephalocyst has been given. The 
proper serous cyst is very rare. It has, however, been found both in the 
interior and upon the surface of the liver, in the latter case sometimes par- 502 
LOCAL DISEASES.-SECRETORY SYSTEM. 
[part II. 
tially embedded in its substance. There may be one only, or several may 
exist at the same time. The cysts are of various sizes, and sometimes very 
large. When upon the surface, they may break, and occasion fatal peritonitis 
by the escape of their contents. They are liable to become inflamed, to sup- 
purate, and thus to be converted into abscesses. Their origin is uncertain. 
Hydatids are not unfrequent. They are, indeed, more common in the liver 
than in any other organ. The cyst which contains them is often thick and 
fibrous, and is probably the product of inflammation excited by the presence 
of the parasitic body. From one to four of these cysts have been found at 
the same time in the liver, which is usually enlarged, though not necessarily 
so. Sometimes, though rarely, there is only one hydatid sac, which is in 
contact with the inner surface of the cyst, and forms a lining for it. Much 
more commonly, this inner sac, which maybe considered as the mother hydatid, 
contains a progeny of smaller sacs or young hydatids, which are of all sizes, 
from that of a millet-seed up to that of the fist, and are sometimes very 
numerous. They float in a serous liquid, usually of a yellowish colour. In 
some instances, the cysts attain an enormous size, occupying a large portion 
of the liver, and containing many pints of liquid. They may remain for a 
long time without material change, and with little disturbance to the health. 
But generally, sooner or later, they become the seat of a morbid activity, and 
undergo various changes, which sometimes probably reconduct to health 
through the agency of absorption, and sometimes end in products, which are 
described as resembling variously steatomatous, atheromatous, melicerous, and 
tuberculous deposits. Not unfrequently they inflame and suppurate, thus 
forming abscesses which contain the remains of the hydatids mixed with the 
pus. These abscesses sometimes pursue a course similar to those resulting 
from ordinary hepatitis, gradually approaching the surface of the organ, and 
forming, through the agency of adhesive inflammation, a passage exterrrally, 
or into some one of the different contiguous cavities. Instances of recovery 
have repeatedly occurred in such cases, though the danger of extensive inflam- 
mation and consequent exhaustion is always great. Dr. Theophilus Thomp- 
son, in his "Lectures on Pulmonary Consumption" (Am. ed., p. 33), relates 
a case in which hydatids of the liver were coughed up, and the patient at the 
period of the report was in a fair way to recovery. 
There is no mode by which hydatids can be distinguished during life, until 
their fluctuation becomes evident; and then they may be readily mistaken for 
common abscess. Such a mistake has been occasionally made, and hydatids 
have been opened with fatal results. The most striking diagnostic characters 
are the greater resistance of hydatids to pressure, their greater elasticity, and 
their more definite outline. According to M. Piorry, a cyst containing nume- 
rous hydatids yields, under percussion, a peculiar quivering sensation which 
is quite characteristic. Skoda says that a good idea of it may be obtained 
by tapping a repeater held in the hand, or percussing a stomach completely 
filled with water, and held in the air. He states, also, that it may be ob- 
served in cases of peritoneal effusion when the abdomen is tense, and the walls 
not very thick, and that it must be rarely observed in hydatid cysts. 
Notwithstanding the fatal consequences which have ensued from the punc- 
ture of hydatid cysts by mistake, it has been proposed to open them with a 
view to the discharge of their contents, and the institution of a curative pro- 
cess in the sac. It is asserted that this has been done successfully in several 
cases by M. Recamier. His plan is to apply caustic over the most prominent 
point of the integuments, to divide the slough, again to apply the caustic 
through the opening, and to repeat the process, until at length a slough opens 
into the cavity. It is supposed that before the separation of the slough, the CLASS III.] 
503 
HYDATIDS.-MALIGNANT AFFECTIONS. 
contiguous surfaces of the peritoneum will have been united by adhesive in- 
flammation. To prevent the entrance of the air, the evacuated cavity is filled 
with an emollient liquid, and is kept full during the progress of the cure, which 
is measured by the diminution of the quantity of liquid necessary for the 
object. The injected fluid may be rendered slightly stimulant or antiseptic, 
in cases attended with indolence or fetor of the cavity. 
Malignant Affections.-The liver is peculiarly liable secondarily to 
all the malignant formations to which the human body is incident. It is 
also sometimes attacked by them primarily. Thus, genuine scirrhus, me- 
dullary carcinoma, and melanosis, are all occasionally met with in the liver as 
original affections. These tumours may make their attack either at a single 
point, and thence extend upon all sides, or at several points simultaneously. 
When separate tumours occur, they are very apt to be upon the surface of 
the organ, and may thus sometimes be recognized during life. They form a 
number of unequal prominences, which are at first rounded, but, as they ad- 
vance, become depressed towards the middle in consequence of the occurrence 
of softening or ulceration. While thus superficially distinct, they ultimately 
coalesce in the interior of the organ so as to pervade its substance. The 
tumours are of all sizes. The liver is generally much enlarged, and is some- 
times found to weigh fifteen or twenty pounds, or even more. The proper 
substance of the viscus is sometimes wasted; but sometimes, on the contrary, 
undergoes a kind of hypertrophy ; so that very variable phenomena, connected 
with the condition of the hepatic functions, are observed in different cases of 
this malignant affection. The patient is very apt to be attacked by jaundice, 
and by abdominal or general dropsy, which probably in part depend upon 
the pressure of the tumours on the biliary ducts, or on the large venous trunks, 
in part upon the organic changes of the liver interfering with its secretory 
function, and with its power of transmitting into the general circulation the 
blood sent to it from the abdominal viscera. 
Malignant diseases of the liver usually give rise to the phenomena of chro- 
nic inflammation of that organ, and indeed are not unfrequently attended with 
more or less of that condition. The lancinating character of the pain some- 
times serves as a diagnostic symptom; but it cannot be relied on; because this 
kind of pain may occur in affections which are not malignant, and the malig- 
nant affections sometimes occasion little or no pain. The existence of nume- 
rous prominences on the liver, sensible to the touch, and the subsequent dis- 
appearance of these prominences upon the occurrence of softening, is another 
highly characteristic symptom. But the absence of such superficial tumours 
is no proof that the case is not malignant; and their presence, when they do 
exist, is sometimes concealed when the liver is covered by the ribs, or the 
abdomen distended by dropsical effusion or intestinal accumulations. The 
first positive proof, therefore, of the character of the hepatic affection is 
afforded by the examination of the body after death. 
No particular precepts are required for the treatment of these diseases. 
Until the nature of the affection in each particular case is ascertained, it will 
be managed in the same manner as if it were one of chronic hepatitis. After- 
wards, our efforts will be limited to the relief of pain by opiates or other ano- 
dynes, and to the palliation of the other symptoms. 
Besides the organic derangements above referred to, the liver is subject 
also to others, which, however, are very rare, and demand no special precepts. 
Among them may be mentioned the production of a peculiar vascular erectile 
tissue, enlarged blood-vessels, worms contained in cysts, osseous deposits, and 
various anomalous tumours. 504 
LOCAL DISEASES.-SECRETORY SYSTEM. 
[PAET II. 
Article III. 
FUNCTIONAL DISEASES OF THE LIVER. 
Under this head I propose to treat of the disorders of the liver unattended 
with inflammation or other organic derangement. They are all perversions 
either of the nervous, circulatory, or secretory processes. 
Neuralgia.-1The only known affection of the liver coming exclusively 
under this head is neuralgia. Pains are not unfrequently felt in the right 
hypochondrium and the epigastrium, wholly unconnected with any appreciable 
change in the healthy structure of the organ. They are sometimes obtuse, 
sometimes acute and lancinating; and vary exceedingly in their duration and 
periods of recurrence. They may be ephemeral, irregularly remittent, inter- 
mittent, or continuous, and may vanish in an instant, or endure for variable 
periods, even for months or years. I have before mentioned the case of an 
elderly lady, who was affected with pains of this kind almost constantly during 
a great part of her life. They are probably connected in general with a gouty 
or rheumatic diathesis, or at least have appeared to be so in cases which have 
come under my notice. They may be distinguished from the pains of inflam- 
mation by the absence of all the other signs of that affection, especially of the 
tenderness upon pressure. Instead of being increased, they are often relieved 
by compression of the organ. There is usually no loss of appetite, no disorder 
of bowels, unless, perhaps, occasional constipation, no jaundice, and no febrile 
disturbance. The treatment is the same as that of neuralgia elsewhere. (See 
Neuralgia.') Combinations of colchicum with opiates or other narcotics, and, 
in the intermittent form, sulphate of quinia in the intervals, will probably be 
found the most efficient remedies. 
1. Nervous Disorder. 
2. Circulatory Disorder. 
Congestion.-Hypersemia.-This consists in a preternatural fulness of the 
blood-vessels of the liver, and a consequent general or partial distension of 
the organ. 
It may be attended with a sense of fulness, tension, weight, or oppression 
in the region of the liver, diminution or loss of appetite and a furred tongue, 
constipation or looseness of bowels, deficiency or excess of biliary secretion, 
and a bilious tinge of the eyes, skin, and urine. None of these symptoms, 
however, are constant. There is very commonly a feeling of general uneasi- 
ness, languor, dulness, drowsiness, or depression of spirits; the patient being 
conscious of something wrong in himself, and disposed to see nothing right 
in things about him, and yet wholly unable to explain the cause of his sensa- 
tions. Sometimes there is a disposition to make frequent deep inspirations, 
as if to relieve the congestion by the pressure of the diaphragm. The pulse 
is not unfrequently irregular. The symptoms vary somewhat according as 
the congestion is active or passive, the former being frequently attended with 
a degree of general vascular excitement, the latter wholly without it, and 
sometimes even marked by a languid circulation. If the hypochondrium be 
carefully examined, especially with percussion, the liver will often be found 
to extend beyond its normal limits. In some instances, the symptoms come 
on quickly and as quickly disappear; in others, they are more lasting, and if 
not relieved end in serious disease. In the efforts of nature to unload and CLASS III.] 
505 
FUNCTIONAL DISEASES OF THE LIVER. 
relieve,the liver, either directly by increased secretion or hemorrhagic de- 
pletion from the organ, or indirectly by depletion from the blood-vessels of 
the alimentary canal, she not unfrequently carries her salutary operations to 
the point of disease, and induces an attack of cholera morbus, diarrhoea, me- 
laena, or hemorrhage from the bowels or rectum. Should her efforts be un- 
successful, gastric or intestinal inflammation, colic, or hepatitis may ensue 
from the congested state of the portal circulation. 
When the liver of a person who has died of some other complaint during 
congestion of that viscus is examined, it is found to be enlarged either wholly 
or partially, to bleed when cut into, and to present throughout the seat 
of congestion either a uniform deep-red colour, or a mottled appearance of 
red and yellow or yellowish-white. This mottled aspect is ascribed by those 
who believe in two distinct constituents of the liver to the injection of one 
of these constituents, while the other remains in its natural state; but by 
those who do not admit this constitution, to the circumstance that the con- 
gestion is confined to one of the two sets of vessels, the hepatic and portal, 
which convey blood to the viscus. Sometimes the liver is observed to be 
softened, and sometimes blood to be effused into its parenchyma. 
Causes.-Whatever excites irritation in the liver may occasion active con- 
gestion, the causes of which are essentially the same as those which produce 
inflammation. (See Hepatitis.') In its more passive forms, the congestion 
may arise either from obstruction or deficient activity in the capillaries of the 
liver, which prevents them from passing as rapidly as usual the blood brought 
to them by the portal vein, or from some impediment to the return of blood 
to the heart, as in cases of obstruction in the hepatic vein or ascending cava, 
tumours pressing upon the latter vessels, or organic diseases of the heart and 
lungs, which oppose the entrance of the blood into the right auricle and vent- 
ricle. An increased circulation in the stomach and bowels, without a corre- 
sponding increase of the circulation through the liver, must lead to the same 
result. The affection under consideration occurs most frequently in summer 
and autumn, and is not an unusual precursor of the more serious diseases of 
the season, as cholera morbus, diarrhoea, dysentery, and the autumnal fevers. 
Treatment.-When the complaint is accompanied with arterial activity and 
general plethora, it may be proper to take blood moderately from the arm; 
but this is not often requisite. An emetic will sometimes operate very effect- 
ually and speedily in removing the congestion, partly by producing compres- 
sion of the liver, partly by stimulating the secretory function. Generally, 
however, all that is required is a pretty brisk purge, containing a proportion 
of calomel or the blue mass. The compound cathartic pill of the U. S. Phar- 
macopoeia is a very suitable combination. If deemed preferable, the mercurial 
may be given first, and followed in a few hours by some quicker cathartic, as 
sulphate of magnesia, infusion of senna with salts, or castor oil. By this 
method, depletion is effected directly from the vessels both of the bowels and 
the liver. The patient- may continue to feel uncomfortable until the day after 
the operation of the medicine, when he generally experiences complete relief. 
If the congestion, or a disposition to it should continue, a blue pill, alternated 
with a mild laxative every day, or every other day, will soon effect a cure. 
It is necessary, however, that the diet should be attended to; and, if the pa- 
tient is plethoric, and the pulse strong or excited, to restrict him for a few 
days to vegetable food, or to this combined with milk. The above plan of 
treatment will answer whether the congestion arise from irritation or torpor 
of the liver; though in the latter case bleeding can scarcely be requisite, and 
animal food, as a general rule, need not be prohibited. Should the cause of 
the affection be mechanical, the practitioner will be guided by the nature of 506 
[part II. 
LOCAL DISEASES.-SECRETORY SYSTEM. 
the impediment, which he will endeavour to remove or to palliate; and, when 
this is impossible, temporary relief may still be obtained by the occasional use 
of mild purgatives with mercurials. 
3. Secretory Disorder. 
The secretion of the liver may be excessive, deficient, or depraved. In 
either case, the affection generally ends in complaints which are treated of 
distinctly; as diarrhoea, cholera, jaundice, constipation, and melaena, to which 
severally the reader is referred. There is, however, a stage of the hepatic de- 
rangement, before either of the above-mentioned complaints is decidedly pro- 
duced, which deserves attention, as, if it be opposed by proper treatment, the 
more serious consequences may generally be averted. This is indicated by the 
state of the alvine evacuations, which, in the absence of the symptoms of hepatic 
congestion, yield the only certain evidence of the derangement. 
Excessive secretion may be inferred from the deep bilious colour of the 
stools, often connected with abdominal pains or uneasiness, and sometimes 
with loss of appetite, nausea, and slight vomiting of bile. If not arrested, or 
if violent from the onset, it occasions bilious diarrhcea or cholera morbus. 
It may arise from any cause capable of stimulating the liver, as heat, mias- 
mata, gastric or intestinal irritation, congestion of the portal circle, &c. (See 
Hepatitis.') The liver appears, in hot climates, to act vicariously for the 
lungs in carrying off from the blood the excess of carbonaceous matter. It is 
a well-established fact, that less carbonic acid is produced by respiration at 
elevated than at low temperatures; and, consequently, if the same diet be 
employed, an excess of carbon must ensue, unless carried off by some other 
emunctory; and none is known capable of performing this office so efficaciously 
as the liver. This organ, therefore, secretes more profusely; the direct stim- 
ulus under which it acts being probably that of the carbonaceous principles 
accumulated in the blood. It is not improbable that the hepatic secretory 
function is thus frequently excited to excess. 
The treatment, in this early stage, should consist chiefly in the removal, 
as far as possible, of the cause, and in assisting nature to throw off the effete 
matter which is offending her. The means are a mild diet, cool and unstimu- 
lating drinks, bodily repose, the avoidance, as far as practicable, of exposure 
to heat, and the use of mild cathartics, such as castor oil, the Seidlitz powder, 
or a small dose of sulphate of magnesia, to remove the bilious matter from 
the bowels. Should these measures fail, a small dose of some mild mercurial, 
such as the blue mass or calomel, followed by a laxative, will prove useful by 
unloading the liver. If the disease has advanced to bilious diarrhoea or 
cholera morbus, the case should be treated as recommended under the heads 
of these complaints. 
Deficient Secretion.-The liver may either secrete less than usual, or cease 
for a time to secrete altogether. In the former case, the stools will often 
be scanty or light-coloured, or both. At first they often assume a light- 
yellow colour, as in infants, and, if the affection continue, gradually become 
lighter and lighter, until at length they no longer exhibit the appearance of 
bile, and are either clay-coloured or whitish. I have also noticed that the ob- 
vious deficiency of bile as indicated by the whitish discharges, is occasionally 
preceded immediately by black or blackish stools. This deficiency of bile 
may be attended with constipation; or, in consequence of portal congestion 
arising from the suppression of the biliary secretion, diarrhoea or dysentery 
may ensue, the stools being in the former case copious and whitish or nearly 
colourless, in the latter small, mucous, and without bile. When the stools 
are thus destitute of bile, it may generally be inferred that the hepatic secre- CLASS III.] 
507 
FUNCTIONAL DISEASES OF THE LIVER. 
tion has been diminished greatly, or suspended, unless indeed the symptoms 
of obstruction of the biliary passages are presented. Along with the condi- 
tion of the evacuations alluded to, there is usually more or less intestinal un- 
easiness, gastric derangement, and mental depression; although these are by 
no means essential concomitants. Diarrhoea and dysentery have been men- 
tioned as consequences of this kind of hepatic disorder. Jaundice is also 
among its frequent results. 
The causes of this inactivity of the liver are not always obvious. It may 
result from an excessive stimulation, followed as this condition often is by a 
proportionate torpor. It may depend also upon a diminished quantity of the 
materials for bile in the blood. But it probably more frequently proceeds 
either from the embarrassment which an overloaded condition of the organ 
may occasion in the due performance of its function, or from some direct or 
indirect sedative agency, as mental anxiety, bodily inactivity, sympathy with 
an enfeebled stomach, the diversion of nervous energy elsewhere, the revulsive 
influence of other affections, and general impoverishment of the blood. 
The principles of treatment are simple. The remedies must be such as are 
calculated to stimulate the secretory function of the liver, care being taken 
also to remove the causes, as far as this can be done. Alterative doses of 
mercury,, combined with chalybeates or the bitter tonics when the stomach is 
enfeebled, and with mild cathartics, as rhubarb and aloes in small doses, when 
constipation exists, are by far the most effectual. Sometimes it may be pro- 
per to commence the treatment with a purgative dose of calomel or the blue 
pill, accompanied or followed by a laxative; but generally it will be sufficient 
to give, every evening or every other evening, a grain of calomel or a blue 
pill, to be followed by a laxative in the morning; and this treatment is to be 
continued until the discharges assume a decided bilious character. Caution 
should be observed never to allow the mouth to become sore. Nitro-muriatie 
acid may be resorted to if mercury fail or cannot be given. Should diarrhoea, 
dysentery, or jaundice ensue, they must be treated as elsewhere directed. 
Should too much intestinal irritation result from the bile secreted under the 
mercurial influence, it will generally be arrested by from five to ten drops of 
laudanum, or a fluidrachm of paregoric. Aloes and dandelion have some 
reputation also as cholagogues, and may be employed as adjuvants of the 
other more efficient remedies. 
Vitiated Secretion.-The bile is often much vitiated. Sometimes it be- 
comes very acrid, producing violent gastric and intestinal pains, and even 
spasms. Such is the case frequently in bilious diarrhoea and cholera morbus, 
when the secretion has undergone no obvious change of colour. But not 
unfrequently it is also much altered in appearance. Thus it may be green, 
dark-brown, or blackish. The greenness of the bile sometimes discharged 
from the stomach and bowels is often owing to acids in the alimentary canal; 
but there is reason to believe that the bile is occasionally green when secreted. 
There can be little doubt that black bile is often discharged from the bowels. 
I have repeatedly noticed it of a deep-brown almost black colour after large 
doses of calomel. Some consider the black tarry stools of melaena as result- 
ing exclusively from intestinal or gastric hemorrhage. I have no doubt that 
they are also the consequence of hemorrhage or perverted secretion of the 
liver; as the same material has been found after death in the biliary ducts 
and gall-bladder. Bile may, moreover, be vitiated by the loss of one or more 
of its characteristic ingredients. It is asserted to have been produced of a 
white colour, and albuminous. 
The causes of this perverted action of the liver cannot always be traced. 
Generally they are not distinguishable from those which occasion a mere in- 508 
[part II. 
LOCAL DISEASES.-SECRETORY SYSTEM. 
crease or diminution of its function. Sometimes the affection may be ascribed 
to a vitiated state of the blood, as in scurvy and low fevers. 
The treatment is essentially the same as that required by deficient secre- 
tion. When the affection assumes the form of melaena, it must be managed 
as directed under that disease. * 
The importance of attending to these functional disorders of the liver, in 
their earlier stages, cannot be too strongly impressed on the young practi- 
tioner. At this period, they may generally be arrested with the utmost facility, 
and thus prevented from running on into diseases which are not only trouble- 
some and painful, but also frequently dangerous, and sometimes fatal notwith- 
standing the most energetic treatment. Whenever there is any reason what- 
ever to suspect deranged hepatic function, the alvine evacuations should be 
inspected, and, if not healthy, should be corrected. 
Article IV, 
DISEASES OF THE BILIARY PASSAGES AND GALL BLADDER. 
1. Inflammation of the Ducts and Gall-Bladder. 
The biliary ducts, like all other similar passages, are liable to inflammation 
of their mucous membrane, which becomes swollen so as in some measure to 
impede the flow of bile. The deficiency of this fluid in the stools, and the 
consequent bilious tinge of the skin and urine, are the only symptoms by 
which the affection can be recognized; as pain is generally very slight or quite 
wanting, and the inflammation is not sufficiently extensive to call into play 
those sympathies which act so important a part in hepatitis. Nor can these 
symptoms be depended on, arising as they do from many other pathological 
conditions, and from some much more frequently than the one in question. 
The inflammation may occupy a portion or the whole of the ducts, and may 
even extend to the tubuli biliferi, and thus produce symptoms of obscure 
hepatitis. Sometimes it ends in softening and ulceration of the membrane, 
and even perforation of the coats has been known to occur, followed by the 
escape of bile into the peritoneal cavity, and fatal peritonitis. Such a result, 
however, is exceedingly rare, unless as a consequence of obstruction of the 
duct, or obliteration of its cavity at some point. Occasionally the ulcers heal, 
and, by their contraction, produce stricture or obliteration of the passage. 
The same consequence may flow from a permanent thickening and induration 
of the coats from chronic inflammation. 
The gall-bladder is not unfrequently inflamed. Either the peritoneal cover- 
ing, or the mucous coat may be affected. In the former case, adhesions are 
apt to be formed with the contiguous surface of the liver, or with the peri- 
toneal investment of neighbouring viscera. The affection, when exclusive, 
might be indicated by acute pain, confined to one spot, beneath the edge of 
the false ribs, and behind the right rectus muscle; but the diagnosis must 
always be uncertain. Still more obscure are the symptoms of inflammation of 
the mucous membrane. It probably generally ends in resolution without any 
observable sign, unless perhaps a dull pain or sense of uneasiness in the part. 
Sometimes, however, the membrane ulcerates, and the bladder may become 
filled and distended with pus, though this can happen only when the outlet is 
closed. Cases have occurred, in which the distended bladder has been per- 
forated, and its contents have escaped with fatal effect into the abdominal cavity. 
The .affection has sometimes pursued a safer course, exciting adhesive inflam- 
mation in advance of the ulceration, and thus enabling the purulent and bilious CLASS III.] 
BILIARY CALCULI. 
509 
matters to escape at the surface, or into some one of the hollow viscera, com- 
municating externally. 
The coats both of the biliary passages and gall-bladder are also liable to an 
interstitial deposit of lymph or pus, and to various alterations of structure, 
which more or less tend to interfere with the course of the bile. The capsule 
of Glisson appears sometimes to be thickened, and thus made to press upon 
the contained vessels and ducts; and Mr. Twining refers to two small bodies, 
which he considers as absorbent glands, one seated near the junction of the 
gall-bladder and the cystic duct, the other in the upper portion of the common 
duct, and which sometimes become so much enlarged by inflammation as to 
obliterate the passage. 
The causes of these affections, so far as they are peculiar, are probably the 
propagation of inflammation from the duodenum or liver, and the presence of 
acrid bile, and of biliary concretions. 
The treatment, in those cases in which a probable diagnosis can be made 
out, must be conducted upon the same principles as that of inflammation of 
the liver, though the means requisite will be much less energetic. It is only 
in inflammation of the gall-bladder, that opportunity for treatment in the 
earlier stages will in general be presented. In the other cases, the inter- 
ference of the practitioner is seldom required, unless to correct the effects, 
such as jaundice and bilious accumulations. 
2. Biliary Calculi, or Gall-stones. 
This name is given to concretions which form in the gall-bladder, and the 
hepatic and biliary ducts. They differ in number, size, and position. There 
may be only one, or there may be thousands. They may be of the minutest 
size, or large enough to fill the whole cavity of the gall-bladder. They are 
found in the gall-bladder, tubuli biliferi, and biliary ducts, and occasionally 
also in the bowels. Concretions of very great size have been observed in the 
last-mentioned position; and it has been made a question, whether they 
originated in the intestines, or were carried into them through the biliary 
passages. I have seen them so large as to fill the caliber of the bowel, and 
moulded exactly to its shape. In one case* of this kind, they occasioned all 
the symptoms of obstruction of the bowels, which were relieved upon their 
expulsion. They were clearly too large to have passed through the ductus 
communis, and must have either entered the bowels while yet small, and have 
grown by accretion, or must have been formed in the latter position. Some- 
times, when they cannot pass the ducts, they produce inflammation and 
ulceration, and thus make their way into the bowels; but no satisfactory 
reason can be given, why bile which has entered the alimentary canal, may 
not deposit solid matter and thus increase or form concretions. Sometimes 
several calculi become impacted into a mass in the bowels, and produce ileus 
by obstructing the passage. 
Gall-stones are usually of a yellowish, brownish, or brownish-yellow colour, 
of a rather soft consistence, and of various shapes, but generally with several 
irregular faces, and rounded angles, produced by their mutual pressure and 
attrition. Their composition is various; but they consist most frequently of 
cholesterin and bilious colouring matter. Bile in a solid state, or other con- 
stituents of it besides those mentioned, are said occasionally to form these 
concretions; and calculi, consisting chiefly of phosphate and carbonate of 
lime, have been found in the gall-bladder or biliary passages. 
The concretions are probably formed in general by deposition from the 
bile around a solid nucleus, which may be insoluble matter precipitated from 
the bile, coagulated blood, fibrinous exudation, or solidified mucus. What- 510 
LOCAL DISEASES.-SECRETORY SYSTEM. 
[part II. 
ever impedes the flow of the bile favours their production. The character of 
the secretion no doubt also has considerable influence; a thick, viscid bile, in 
which the liquid solvent is saturated with the solid constituents, being more 
likely to form calculi, than the same liquid in its ordinary state. It is pos- 
sible that a deficiency of alkali in the bile may have the same effect. Accord- 
ing, to Dr. Powell, gall-stones are comparatively rare in hot countries. Is this 
ascribable to a more liquid consistence of the bile ? 
The calculi often remain in ,the gall-bladder long without causing incon- 
venience, and are first discovered upon examination after death. They may 
even lie in the ducts without producing any considerable uneasiness. It is 
when in the course of expulsion, or when so large as to occasion distension or 
obstruction, that they become sources of trouble. If accumulated in the gall- 
bladder, they may sometimes be detected by a dull crepitation, produced when 
pressure is made so as to cause them to move on one another. 
One of their ordinary effects is severe pain. Putting the coats of the tube 
upon the stretch, they cause it probably to contract spasmodically, especially 
at or near the orifice by which the common duct enters the duodenum. The 
pain is sometimes exceedingly violent. It usually comes on suddenly in the 
epigastrium or toward the right side, being felt especially at a point corre- 
sponding with the orifice of the common duct, and thence shooting to the 
back. It occurs in paroxysms, though there is commonly a persistent dull 
pain in the intervals. It is often attended with a pale skin, a small and feeble 
pulse, nausea and vomiting, anxiety and restlessness, hurried respiration, 
faintness, and great prostration. The paroxysms may occur several times an 
hour, and the attack usually continues from a few hours to two or three days, 
though the case is sometimes much longer protracted. The calculus at length 
generally escapes into the bowels, and passes along with the stools, in which 
it may be discovered upon inspection. Relief is experienced the instant that 
it enters the duodenum. 
Another morbid effect of gall-stones is inflammation. This may arise from 
the irritation of their presence, from their direct pressure or distending force, 
or from the bilious accumulations which they occasion. The inflammation 
sometimes ends in suppuration, ulceration, and, through the medium of adhe- 
sions between the contiguous peritoneal surfaces, the discharge of the calculus 
externally or into one of the open cavities. Recovery sometimes takes place 
under these circumstances. 
A third effect worthy of notice is obstruction. A duct may be distended 
by one of these concretions so as to produce spasm, inflammation, and ulcera- 
tion, without a complete stoppage of the flow of bile, which may find its way 
alongside of the calculus. But, even in this case, there may be undue accu- 
mulation of bile behind the impediment; and, when the obstruction is com- 
plete, as occasionally happens, the accumulation is sometimes enormous; its 
precise seat depending upon the position of the stone. If this be in the hepatic 
duct, the distension will be in the tubuli biliferi, and the liver may become so 
much enlarged, and so full of fluid as to yield a sense of fluctuation upon 
being examined externally. If the cystic duct be obstructed, the gall-bladder 
only will be distended; if the common duct, both the gall-bladder, and all 
the biliary ducts behind the point of obstruction. The absence of bile in the 
alimentary canal, the consequent derangement of digestion, and general jaun- 
dice, are other results of this affection; and, if the obstruction should not be 
removed in due time, inflammation, ulceration, and perforation must ultimately 
ensue, with the escape of the bile into the cavity of the peritoneum, or exter- 
nally, or into some portion of the alimentary canal; death being a necessary 
consequence in the first case, and a very probable one in either of the others. CLASS III.] 
DISEASES OF THE GALL-BLADDER. 
511 
In the treatment of biliary calculi, the first indication is to obviate their 
effects, the second to cause their expulsion or solution, and to prevent their 
formation. The effect which most urgently calls for interference is the spas- 
modic pain. For the relief of this, opiates in large doses are incomparably 
superior to all other means. One, two, or three grains of opium, or an equi- 
valent quantity of one of its liquid preparations, may be administered every 
hour or two, and sometimes even at shorter intervals, either until the patient 
experiences some relief, or narcotic symptoms are produced. Should the 
stomach reject the opiate, it may be administered by the rectum. Perhaps 
advantage might be derived from the inhalation of ether or chloroform. If 
the patient is of a plethoric habit, and especially if the case is complicated 
with inflammation, blood should be taken from the arm; but venesection is 
often contraindicated by the existing debility. The warm bath and warm 
fomentations to the seat of pain are excellent adjuvants. Ice has been applied 
to the epigastrium, and is said sometimes to have afforded speedy relief. The 
tobacco enema has been recommended, but should be used, if at all, with 
great caution, and only in cases in which the general strength is unimpaired. 
Emetics are also a doubtful remedy. They may sometimes remove the ob- 
struction by forcing forward the calculus, and relieve the spasm by the relaxa- 
tion attendant upon the nausea they produce; but nature usually provides in 
a sufficient degree these means of relief; and the superadded action of an 
emetic might endanger rupture of the distended gall-bladder or ducts. In 
cases of alarming faintness and prostration, recourse may be had to the aro- 
matic spirit of ammonia and the ethereal preparations internally, and a mustard 
cataplasm to the epigastrium. Any inflammation that may ensue must be 
counteracted by the usual remedies. 
The second indication is best met by the free use of alkaline medicines, 
and the employment of a regulated diet, from which fats, and an excess of 
animal food should be excluded. By the first measure there may be some 
hope of dissolving the calculous matter, or at least of preventing its depo- 
sition by increasing the solvent power of the bile; by the second, of prevent- 
ing the production of an excess of the material out of which the concretions 
are most commonly formed. There would seem also to be an indication for 
the use of remedies calculated to increase the amount of biliary secretion, 
which may thus have a greater solvent power. Hence, mercurials may be 
conjoined, in alterative doses, with the alkalies. Another remedy, proposed 
by M. Durande, of Dijon, which had at one time considerable repute in Eu- 
rope, was a mixture of two parts of sulphuric ether and three of oil of tur- 
pentine, given in the dose of thirty minims or a fluidrachm. This was sup- 
posed to have the power of dissolving the calculus. Any benefit which it may 
have produced is probably more justly ascribable to its antispasmodic action. 
This may result from various causes. The most frequent are such as pro- 
duce obstruction in the common duct, as gall-stones, inflammation acute or 
chronic with its results, and tumours of various kinds. In this case, bile is 
the distending fluid; and the accumulation has sometimes been enormous, 
amounting to twelve pounds or even more. Obstruction of the cystic duct is 
followed by distension only in cases in which inflammation of the mucous 
membrane of the gall-bladder has been excited by calculi or other cause, pro- 
ducing a copious secretion of purulent fluid. Paralysis of the bladder is 
another cause of its distension. 
In all these cases, the chief danger arises from the rupture or perforation 
of the coats, and the escape of the bile or pus into the abdominal cavity; 
3. Distension of the Gall-bladder. 512 
LOCAL DISEASES.-SECRETORY SYSTEM. 
[part II. 
though, as before mentioned, the liquid may sometimes find a safer outlet by 
an ulcerated opening into the bowels, or through the skin. In many c^ses, the 
obstruction is removed, and the distension disappears without ultimate injury. 
It is very necessary, therefore, not to confound such distension of the gall- 
bladder with abscess of the liver; for by opening the former, through mistake 
for the latter, fatal effects may be produced in cases in which nature or 
remedial measures might effect a cure. 
The distension occasions a fluctuating tumour observable externally; but 
this tumour has usually a fixed situation beneath the false ribs and-behind 
the right rectus muscle, has come on, probably, without preliminary symp- 
toms of inflammation, and presents in all parts of its surface an equable 
fluctuation, obvious from the commencement, with a definite boundary, and 
without surrounding oedema or hardness; while, in abscesses, the position is 
variable, the first appearance is usually preceded by symptoms which might 
lead to its anticipation, the fluctuation comes on gradually, is most observable 
in the centre of the tumour, and, for the most part, either passes insensibly 
into the softness of oedematous effusion, or is bounded by the hardness of 
effused and coagulated fibrin. 
The remedies applicable to the relief of the distended gall-bladder are not 
numerous. Gentle and equable pressure may be tried, especially when the 
distension depends upon paralysis. An emetic might prove useful; but is 
somewhat hazardous. Appropriate measures must be employed for the re- 
moval of any existing obstruction when this is remediable; as in the case of 
inflammation or spasm of the ducts. It has been made a question, how far an 
operation for opening the gall-bladder is justifiable. When the distended 
bladder has been opened by mistake for an abscess, the result has been gene- 
rally fatal. Cases, however, are on record, in which the operation has resulted 
successfully. According to M. Petit, it may be tried when the symptoms 
are threatening, and when immovability of the tumour, and redness of the 
skin over it evince that adhesion has taken place between the peritoneal coat 
of the bladder and that of the parietes of the abdomen. 
Article V. 
JAUNDICE. 
This is an affection in which the skin, eyes, and urine are of a yellow or 
yellowish colour, from the presence of bilious matter. The existence of 
whitish or clay-coloured stools usually enters into the definition; but is here 
excluded, as not always present, and not essential. 
In certain conditions of the system, the skin becomes of a yellowish hue, 
independently of the bile or of bilious matter, as, for example, after bruises, 
and in cases of cancer, especially cancer of the womb; and the same result 
occasionally takes place, where it has been doubted whether the bile has any 
part, as in malignant fevers, and the bites of poisonous serpents. These 
cases are excluded from the definition. 
The colour in jaundice is in all cases a mere symptom. The essential 
pathological condition is probably an excess in the blood of bile, or of its 
yellow colouring principle, which, not finding a sufficient outlet through the 
liver, is thrown off by other emunctories. It is not maintained that bile 
ready-formed exists in the circulation. Like urine, sweat, and saliva, it is a 
complex fluid, resulting from the combination of various proximate principles, 
Syn.-Icterus.-Morbus regius.-Morbus arquatus.-Aurigo CLASS III.] 
JAUNDICE. 
513 
some of which certainly pre-exist in the blood, some are probably created in 
the secretory process out of elements furnished by that fluid. It is nearly 
certain that the colouring matter of bile is among the former principles. 
Formed in the blood in the process of assimilation, and noxious if allowed to 
accumulate there beyond a certain amount, it is thrown off by the liver among 
the other constituents of the bile, as urea is thrown off by the kidneys. It 
was detected in the blood by Lassaigne (Diet, de Med., xvi. 207), and is pro- 
bably the principle which very frequently gives a yellowish tinge to the serum 
in health. Of the excess of this yellow matter in the blood, constituting the 
true pathological condition in jaundice, there may be three sources, viz., ex- 
cess of production, absorption, and deficiency of elimination. 
1. Excess of production.-This probably happens in some instances of 
bilious fever, cholera, and diarrhoea, in which, along with a yellow colour of 
the skin, eyes, and even urine, there is bilious vomiting or purging. The 
same cause that produces the disease, may occasion an increased production 
of the yellow principle, which, though escaping by the usual emunctory, is 
not thrown off in that way with a rapidity corresponding to the exigencies of 
the system, and therefore finds other outlets. The same excess may some- 
times occur as an original affection; and then we shall have an attack of 
idiopathic jaundice, with bilious stools. 
2. Absorption.-This is believed by most to be an ordinary, and, by many, 
the exclusive source of jaundice. An obstruction takes place in some portion 
of the biliary passages, which prevents the excretion of the bile. An accumu- 
lation of this fluid necessarily takes place in the gall-bladder or biliary pas- 
sages behind the seat of obstruction; and even the tubuli biliferi of the liver 
sometimes become greatly distended. It has been supposed that the bile is now 
either absorbed and conveyed into the circulation, or regurgitates directly into 
the venous radicles by which it was thrown out, and thus becomes excessive 
in the blood. Such obstructions do undoubtedly sometimes exist in jaundice, 
and serve as the cause of it. But whether the bile re-enters the circulation, 
after having been once thrown out, is not so certain. The late Dr. Chapman, 
of the University of Pennsylvania, denied that this event takes place, and I 
am disposed to believe that it is comparatively rare, and of small account. Do 
we find a common tendency in surfaces to absorb the peculiar liquid they 
secrete, or which passes them in its exit from the system ? Is mucus 
absorbed when it accumulates in the mucous cavities? Is urine absorbed 
in cases of distended bladder? If pus is occasionally taken up in small 
quantities, is not the contrary more frequently the case in abscesses? Be- 
sides, if absorption takes place so rapidly as is implied by the theory that 
it occasions the symptoms of jaundice, how does it happen that the accumu- 
lations of bile are sometimes so enormous in cases of obstruction ? Cases are 
alleged to have occurred, in which great distension of the gall-bladder has oc- 
curred, with whiteness of the stools, in consequence of obstruction, and yet no 
jaundice has taken place. (Thomson on Dis. of Liver, Am. ed., p. 35.) It 
is, indeed, stated that Tiedemann has observed bile in the lymphatics of the 
liver, in cases of artificial obstruction of the biliary passages; and the possi- 
bility of absorption must, therefore, be admitted. (Diet, de Med., xiv. 206.) 
But this fact does not invalidate the arguments above stated, which only go 
to render improbable this result to any very considerable extent. That the 
bile should re-enter the circulation by regurgitation, implies a reverse ac- 
tion of the secreting cells, which is scarcely admissible in the present state 
of our knowledge. A much more probable supposition is that, in cases of 
obstruction and consequent accumulation, the pressure made by the accumu- 
lated fluid upon the vessels impedes the process of secretion, and thus pre- 514 
[PART II. 
LOCAL DISEASES.-SECRETORY SYSTEM. 
vents the due elimination of the yellow colouring matter from the blood. 
"While, therefore, I am willing to admit that absorption may contribute to 
the production of jaundice in cases of obstruction, I am also inclined to the 
opinion that, even in such cases, deficiency of secretion is a more effective 
agent. 
3. Deficiency of elimination.-Should the view taken of the existence of 
the yellow colouring matter of bile in the blood in health be correct, it follows 
that, when the secretory action of the liver is either suspended, or diminished 
in a degree greater than that in which the colouring principle is produced, its 
accumulation in the circulation, and its elimination by other emunctories, are 
necessary consequences. Such, I believe, is most commonly the origin of 
jaundice. This view was maintained by myself, in a paper published in the 
N. Am. Med. and Surg. Journ., for Oct. 1826, to which the reader is referred 
for a statement more at large of the arguments by which it may be supported. 
The theory may be given in a very few words. The liver is in part an emunc- 
tory by which noxious matters in the blood are thrown off. Among these 
noxious substances is the yellow principle upon which the colour of bile de- 
pends, and which is probably formed in the circulation. Through some morbid 
agency, the secretory function of the liver is impaired or suspended. The 
yellow matter consequently accumulates in the blood, and, if not thrown off 
by some other avenue, would derange the vital processes. Nature has pro- 
vided a remedy for this evil by rendering almost all the other secretory 
functions sensible to the stimulus of the yellow matter in excess, and capable, 
under this stimulus, of separating it from the blood. Hence, it passes off by 
the skin and kidneys, and is deposited in the various tissues, giving its own 
colour to the secretion and to the tissue; while the want of colour in the fecal 
evacuations shows its absence from the bowels. The deficiency of bile in the 
stools may be owing either to its deficient secretion, or to some obstacle to its 
passage after it has been secreted; though, even where the latter cause exists, 
it is still probable that the jaundice, in great measure, results directly from 
the former; the obstacle to excretion operating to suspend or impair the 
secretory process. But, in the great majority of cases, there is no reason 
whatever to suspect the existence of any obstruction. Dissections of persons 
labouring under jaundice at the time of their death have repeatedly shown 
the biliary passages to be perfectly free, and the liver exempt from organic 
disease. Under these circumstances, the obstruction has been ascribed to 
spasm of the ducts. But no proof of the existence of such spasm is offered. 
The patient often experiences no pain. The disease frequently comes on 
gradually and continues long, which would not happen were it dependent on 
spasm. Inspissated mucus or bile, which is thought to be a cause of obstruc- 
tion, cannot have been so in these cases; for it would have been detected on 
examination. Besides, in jaundice not connected with inflammation or or- 
ganic disease of the liver, there is in general no discoverable distension of the 
gall-bladder or liver, such as would necessarily accrue from obstruction with 
a continuance of secretion. In the absence of all proof of such obstruction, 
and in the face of contrary evidence, we have no right to assume its existence ; 
especially when the phenomena can be otherwise even more satisfactorily 
explained. The result of treatment is another evidence of the correctness 
of the views here given; for the most efficient remedies are those which pro- 
mote the secretion of bile; and effective means, which were considered empiri- 
cal under the former views of the pathology of the disease, now fall within 
the limits of rational therapeutics. 
With these preliminary considerations, I proceed to a detail of the symp- 
toms, causes, and treatment of jaundice. CLASS III.] 
515 
JAUNDICE. 
Symptoms, Course, &c.-In most cases, the appearance of the characteristic 
phenomena of jaundice is preceded by symptoms indicative of functional dis- 
order of the liver, and derangement of the digestive organs generally. Such 
are diminution or loss of appetite, sometimes nausea and vomiting, a vague 
and indescribable uneasiness in the epigastric and hypochondriac regions, a 
sense of sinking in the abdomen as if the bowels wanted support, a tendency 
to constipation, furred tongue, double or otherwise disordered vision, general 
disquietude, great and apparently causeless depression of spirits, and a dispo- 
sition to gloomy views of all subjects. These are not all present in all cases; 
and, in some instances, most of them are wanting. If, after their appearance, 
the stools be examined, they will be found lighter than natural, perhaps at 
first of a light yellow hue as in healthy infants, but afterwards whitish or 
grayish like potter's clay. 
At length the yellowness of the surface makes its appearance. In some 
instances, this is the first observable symptom, and perhaps is generally the 
first after the patient has been seen by the physician. The colour usually 
shows itself first in the eyes and face, afterwards upon the neck and upper 
part of the chest, and ultimately extends over the whole body, being most 
intense in those parts where the skin is thinnest, and the perspiration most 
apt to appear, as upon the front of the trunk, and on the insides of the ex- 
tremities. But there are great diversities in these respects. Sometimes the 
parts which are commonly the first to be discoloured are the last to be so. 
Sometimes the yellowness is quite local, and it is even said to have affected 
one half of the body longitudinally, while the other half retained its healthy 
hue. Different shades of colour are said occasionally to appear at the same 
time on different parts of the body. At first the colour is usually a light-yel- 
low, sometimes a lemon-yellow, which gradually deepens, and at length, if 
the disease continues, is apt to assume an intense golden or deep-orange hue, 
and this often covers the whole surface. Occasionally the yellowness is modi- 
fied by a greenish tinge; and, in some comparatively rare cases, the colour is 
so deep as to approach to blackness; a result which is probably owing in 
general to a depraved condition of the blood, such as occurs in scurvy. The 
affection thus characterized is sometimes called green or black jaundice. In 
ordinary cases, the yellow hue is often modified by the natural complexion of 
the patient, being lighter in the fair, and deeper in the brown. The discolora- 
tion of the skin is occasionally attended with a very troublesome itching. 
The urine, which is at first little changed, after a time becomes yellowish or 
orange-coloured, but with varying degrees of intensity; being sometimes little 
deeper in its tint than in health, but generally much darker, like a rather 
strong infusion of saffron, and occasionally deep-brown or blackish. The 
darker hues are usually owing to a greater amount of the colouring matter; 
for the urine, if diluted, becomes bright-yellow. The urine of jaundice may 
be distinguished from that of nephritic affections by imparting to white linen 
a bright-yellow stain, which is rendered green by muriatic acid. 
All the other secretions are occasionally more or less tinged with bile, espe- 
cially the perspiration, which often stains yellow a towel rubbed upon the 
skin. The milk, however, is rarely affected, and the same may be said of 
the mucous secretion. The coating of fur on the tongue is often yellowish, 
and the patient frequently has a bitter taste. Though the conjunctiva is 
almost always deeply stained, the vision may remain unaffected. Sometimes, 
however, the colouring matter appears to be deposited in the humours of the 
eye; and then all objects are seen of a yellow hue. 
After the appearance of the yellowness of skin and urine, I have often 
observed that the preliminary symptoms diminish, though they still con- 516 
LOCAL DISEASES.-SECRETORY SYSTEM. 
[part II. 
tinue in a greater or less degree. The patient is still in general affected with 
epigastric uneasiness, more or less disorder of digestion, depression of spirits, 
general languor and indisposition to exertion, and other signs of nervous 
disorder. The bowels are usually costive, though sometimes regular, and in 
general readily moved by purgative medicine. The stools are in the great 
majority of cases whitish, gray, or clay-coloured, from the absence of bile. 
Though the stomach is frequently disordered, and even nausea and vomiting 
sometimes occur, yet this is by no means invariably the case; the appetite 
being in some instances quite natural, and the digestion unimpaired. The 
tongue is sometimes furred, sometimes nearly or quite healthy in appearance. 
The skin is usually harsh and dry. The pulse varies much, being either 
quite natural, irregular, or excited and even febrile, according as the affection 
is complicated or not with inflammation or active congestion of the liver or 
other organ. In some cases, the patient complains of more or less pain, ten- 
sion, &c., in the epigastric or hypochondriac region. This may be either 
heavy and dull, as when parenchymatous hepatitis or mucous duodenitis 
exists, or severe, acute, and spasmodic, as when the jaundice is dependent on 
the presence of gall-stones in the biliary ducts. But, in the great majority 
of cases, the local uneasiness does not amount to pain, and is not of an in- 
flammatory character. In the progress of the complaint, a greater or less 
degree of drowsiness is not uncommon, probably in consequence of the direct 
influence of the bilious matter upon the brain. As jaundice may be asso- 
ciated with a great number of organic diseases of the liver or other neigh- 
bouring organs, its symptoms must be modified accordingly; and its appear- 
ance should always be the signal to the practitioner for a careful investigation 
into the condition of the abdominal viscera. 
A depraved condition of the blood is a not unfrequent accompaniment of 
jaundice. Sometimes this appears to be simply of an anemic character, some- 
times is attended with a hemorrhagic disposition. Both of these conditions 
may occur with or without organic affection of the liver. Nor is it difficult 
to explain them. Bile has been ascertained to have a solvent power over 
the blood corpuscles. (Carpenter's Hum. Physiol., Am. ed., 1850, p. 120.) 
This explains the anaemia. With the excess of bile in the blood there must 
be an excess of alkali also, which tends to dissolve the fibrin. Besides, from 
the experiments of Bernard, it would appear that one of the offices of the 
liver is to elaborate fibrin out of the portal blood. But a deficiency of fibrin 
in the circulation is considered as constituting a predisposition to hemorrhage. 
Hence, jaundice, the existence of which implies an excess of bile in the blood 
and deranged hepatic function, may readily be conceived to be occasionally 
attended with hemorrhage. This complication, however, is not frequent 
relatively to the whole number of cases of jaundice. 
The course of the disease is exceedingly various. Sometimes rapid in its 
attack and as quickly disappearing, it not unfrequently runs on for weeks and 
months, and, in some obstinate cases, may even persevere for years. In the 
vast majority of cases, it either gets well spontaneously, or yields sooner or 
later to appropriate treatment. Indeed, fatal cases of jaundice are exceed- 
ingly rare, unless when it is complicated with incurable organic disease of 
the liver or adjacent viscera. The first sign of a favourable change is usually 
the reappearance of the healthy colour of the stools, indicating a restoration 
of the secretion or excretion of bile. Simultaneously with this change, there 
is usually a great improvement in the symptoms of digestive and nervous 
disorder, indicated by a return of appetite, a disappearance of the epigastric 
uneasiness, and restored cheerfulness. This amelioration is often experienced 
before the discoloration of surface has been materially diminished. Gradually, CLASS III.] 
517 
JAUNDICE. 
however, the yellowness of skin, eyes, and urine disappears; in general re- 
ceding last from the parts first attacked. The urine at this period frequently 
deposits a delicate reddish sediment. An itching of the surface, and a slight 
eruption followed by desquamation, are said sometimes to accompany the dis- 
appearance of the yellowness. The symptoms which indicate a fatal termina- 
tion are usually those which mark the last stages of organic hepatic diseases. 
(See Hepatitis and Organic Diseases of the Liver.) Sometimes, however, 
fatal consequences appear to have ensued from an excessive accumulation of 
the excrementitious bilious principles in the circulation, producing on the 
brain effects analogous to those which result from a too highly carbonized 
blood; such as delirium, profound coma, and apoplectic phenomena. The 
black and green jaundice may sometimes, perhaps, be fatal from this cause; 
but more frequently their malignancy depends on the profound organic dis- 
eases, or total depravation of the blood, with which they are associated. 
Anatomical Characters.-Uncomplicated jaundice is so seldom fatal, that 
few opportunities of examination after death are offered, and those, for the 
most part, in cases in which the patient has died from some accidental cause 
during an attack of this complaint. In such instances, a yellow colour has 
been found pervading more or less almost all the tissues of the body, even 
the bones. The fat is especially apt to be discoloured. The substance of the 
brain is said to be least subject to the bilious deposition, and sometimes re- 
mains white when the meninges are yellow. These phenomena are found 
without organic lesion, and without obstruction of any kind in the biliary 
passages, whether structural, or from inspissated bile or mucus. Of course, 
in complicated cases, dissection reveals the organic lesion upon which the 
jaundice may depend. Of such lesions sufficient has been said elsewhere. 
Causes.-According to the views of jaundice already given, it may be pro- 
duced by any cause which materially diminishes, or suspends altogether, the 
secretory function of the liver, whether by producing a torpor or a sort of 
paralysis of the organ, or by overwhelming its powers through the means of 
active congestion. The agents capable of giving rise to these effects have 
been sufficiently treated of under other heads. (See Functional Diseases of 
the Liver, and Hepatitis.) Among the most frequent may be mentioned con- 
tinued heat, miasmata, tbe depressing emotions, any sudden and violent pas- 
sion, hysterical excitement, errors of diet, and gastric or duodenal affections 
operating through sympathy. The disease is said also to have sometimes pre- 
vailed epidemically.* 
These causes may exist independently of any lesion of the liver, or any 
impediment or obstruction to the flow of bile in the ducts. But such lesions 
and obstructions are admitted also to produce jaundice. Organic diseases of 
the liver may act either by simply changing the condition of secreting cells, by 
obstructing a greater or less number of the tubuli biliferi or the larger ducts, 
or by destroying the substance of the organ. Obstruction of the biliary pas- 
sages results from inflammatory thickening of the coats of the ducts, pressure 
upon them by tumours from without, and gall-stones or worms in their caliber. 
Solid accumulations in the colon, and the pressure of the gravid uterus, are 
thought sometimes to occasion jaundice by pressing upon and closing the 
ducts. Inflammation of the duodenum is believed by some modern patholo- 
gists to be a frequent cause of jaundice, and is thought to operate by closing 
* Dr. Hiram Corson, of Montgomery County, Pennsylvania, informs the author 
that an epidemic of jaundice has recently prevailed in his neighbourhood. Within a 
limited district, not more than a mile long by about one-quarter of a mile broad, occu- 
pying a hilly ridge, he had attended in a short time twenty-seven cases. The disease 
was mild; and all his patients recovered. (Note to the fourth edition.) 518 
LOCAL DISEASES.-SECRETORY SYSTEM. 
[PART II. 
the mouth of the common duct, or by the extension of the inflammatory action 
to the mucous membrane of the passages, and even to the liver. The disease 
is also thought to have originated, in some instances, from paralysis of the 
ducts. It is said to attack males more frequently than females, and adults 
than children. 
Nevertheless, there is a variety of jaundice to which very young infants are 
liable, and which from that circumstance has been named icterus neonatorum. 
It comes on usually a few days after birth, and disappears in a short time, 
without any other observable disorder of system, unless perhaps a more than 
ordinary degree of drowsiness. It has been variously ascribed to pressure of 
the accumulated meconium upon the common duct, to obstruction of the duct 
by meconium or inspissated mucus, and to irritation or congestion of the liver 
sympathetic with an irritation of the alimentary canal; but its cause is not 
certainly known. Some, indeed, seem disposed to deny its claim to be con- 
sidered as a variety of jaundice, ascribing it to the congested state of the sur- 
face at birth, which terminates in a change of colour, analogous to the yellow- 
ness following a bruise. It gives way almost always to gentle laxatives. 
Treatment.-In simple jaundice, the most obvious indication is to promote 
the hepatic secretion; and, in the great majority of cases, nothing more is re- 
quired. As soon as it is discovered, by an inspection of the alvine evacua- 
tions, that the bile has begun to flow, and that its flow can be sustained, a 
speedy cure may in general be calculated on with much certainty. 
In order to meet the indication properly, it should be ascertained, if prac- 
ticable, whether the liver is in a state of active congestion or irritation, or 
whether it is torpid. If there be pain or a sense of fulness in the side, with 
tenderness on pressure, the former may be inferred; and, if the pulse is full 
and moderately strong, blood should be taken from the arm, or by cups or 
leeches near the tender part, or in both ways conjointly, as circumstances 
may seem to require. Free purgation with mercurial and saline cathartics, 
and, if the disease do not now yield, a very moderate alterative course of mer- 
curials, will generally be sufficient to complete the cure. 
But much more frequently there are no evidences of inordinate excitement 
of the liver, and the want of secretion must be ascribed to mere torpor, or a 
state of passive congestion. In this case, the treatment must be directed to 
the stimulation of the hepatic function. For this purpose a purgative dose of 
calomel should be given, to be followed in due time by a dose of castor oil. 
Some recommend a mixture of castor oil and oil of turpentine, in the propor- 
tion of half a fluidounce of each; but I have never found the latter substance 
necessary. Instead of calomel alone, a combination of this with other active 
cathartics may be employed, as in the compound cathartic pill of the U. S. 
Pharmacopoeia. Sometimes the more energetic action of an infusion of senna 
may be found advisable. After this, if the strength of the patient remain un- 
impaired, and the constipation with clay-coloured stools continue, the cathar- 
tic may be repeated at intervals of two, three, or four days, until the flow of 
bile is established; but, generally speaking, the alterative use of mercury alter- 
nated with laxatives will be preferable, as equally efficient and less exhausting 
to the patient. From half a grain to three grains of calomel, or one or two 
blue pills, may be given every night or every other night, and followed in the 
morning by two drachms or half an ounce of sulphate of magnesia or bitar- 
trate of potassa, or an equivalent quantity of some other saline cathartic; the 
object being, in every case, to produce a slight stimulation of the liver, and 
a gentle action on the bowels, without any observable effect upon the gums, 
or any exhaustion of the strength. The disease will often yield to this 
simple plan. Should no evidence of a return of biliary secretion be observed CLASS III.] 
JAUNDICE. 
519 
in the course of a week or two, or should the symptoms at the commence- 
ment be urgent, it will be proper to resort to other measures. An emetic 
will often prove serviceable by compressing the liver, and, through its sympa- 
thies with the stomach, rousing it into action. Tartar emetic is preferable 
for this purpose. This remedy, however, is disagreeable, and may generally 
be dispensed with. 
The alkalies are often efficient adjuvants to the alterative course of mercury, 
probably by stimulating the secretory function of the liver; though by those 
who believe that the disease arises from obstruction consequent on an inspis- 
sated state of the bile, they are thought to act by modifying the condition of 
that secretion. I have usually preferred the bicarbonate of soda, which may 
be given in carbonic acid water, in the dose of half a drachm or more three 
times a day. The carbonate of soda and the carbonate and bicarbonate of 
potassa may also be employed. The salt of tartar has been a favourite remedy. 
Soap has also had some reputation, and may be advantageously combined with 
tonic and laxative pills. Castile or almond soap should be preferred. 
Small doses of various emetic medicines also prove serviceable by stimulat- 
ing the liver to secretion. Tartar emetic, precipitated sulphuret of antimony, 
ipecacuanha, sanguinaria, and squill have all been used. They would be pe- 
culiarly applicable to cases in which there is slight febrile action, especially 
the antimonials and ipecacuanha. Advantage will occasionally accrue from 
combining them in the same formula with other medicines useful in the dis- 
ease, such as the mercurials, antacids, and laxatives. 
There are other remedies supposed to have the cholagogue property, which 
may be used either as adjuvants of the mercurials, or as substitutes. The 
most efficient of these is nitro-muriatic acid, which may be used externally 
during the alterative mercurial course, and internally after it has been for 
some time suspended. The dandelion and soapwort have some reputation of 
the same kind, and are occasionally used. Aloes, in purgative doses, is 
thought by many to stimulate the liver directly, and is certainly a useful 
remedy in jaundice. With some individuals, it is more efficient than any 
other remedy in restoring the bilious secretion in a torpid state of the func- 
tion. Electricity may also be employed to rouse the torpid viscus. 
Not unfrequently the torpor of the liver is associated with a feeble and 
languid state of the stomach, which probably aggravates the hepatic affection, 
if it does not lie at its foundation. In such cases, tonics are highly useful. 
These may be combined very advantageously with purgatives and antacids, 
and given in conjunction with the alterative doses of mercury, or afterwards. 
Such combinations prove peculiarly beneficial in sustaining the hepatic func- 
tion, after it has been excited into action by the mercurials. The simple 
bitters, as gentian, quassia, columbo, and sabbatia, should be preferred. Their 
extracts, along with aloes, rhubarb, soap, and sometimes a little blue mass or 
calomel, form excellent combinations. In some cases, particularly those of 
an anemic character, the chalybeates should be associated with or substituted 
for the vegetable tonics. The mineral acids are also sometimes useful by pro- 
moting appetite and stimulating the stomach. 
The narcotics are often highly beneficial by relieving nervous disorder, 
and producing sleep. Of these, hyoscyamus and conium should be preferred 
to opium, which has a tendency to restrain the secretion of bile. They may, 
in general, be used quite freely; but should not be employed when the head 
is materially affected. They may be used, among other purposes, for the 
alleviation of the disagreeable itching, which may also be allayed by gentle 
friction with rye meal. 
Various remedies have been recommended somewhat empirically in jaun- 520 
[part it. 
LOCAL DISEASES.-SECRETORY SYSTEM. 
dice. Dr. Chapman has found cider and lemonade serviceable. {Dis. of 
Thorac. and Abdom. Viscera, 363.) A mixture of sulphuric ether, and oil of 
turpentine, has been highly praised. (See page 509.) Ammoniac and assa- 
fetida are recommended by the German writers. Sulphate of manganese is 
said to have proved useful. Certain remedies originally introduced, upon the 
doctrine of signatures, on account of their colour, have continued to hold a 
place in the books; as celandine, agrimony, and madder. The popular repu- 
tation of the yolk of raw eggs probably had a similar origin. A mixture of 
the yolk with sulphuric ether has been supposed to possess peculiar efficacy. 
The most whimsical remedies have occasionally found popular advocates; 
and I have known the excrement of geese to be strongly recommended. It 
is probable that the credit enjoyed by many reputed cures for jaundice, 
has been owing to their employment at a period when the disease was 
about to subside spontaneously. Dr. Peebles, of Petersburg, Virginia, has 
found nitrate of silver a very efficient remedy. He believes it to act by curing 
chronic inflammation or other disease of the stomach, which may have caused 
or sustained the hepatic affection. (Am. Journ. of Med. Sci., N. S., xviii. 59.) 
The treatment applicable to those painful cases in which jaundice is con- 
nected with the passage of gall-stones, has been already treated of. (Seepage 
508.) When the disease is associated with organic affections of the liver or 
its appendages, the remedies suited to these affections must be resorted to. 
When jaundice exists along with bilious stools, indicating a probable excessive 
production of the colouring matter of bile in the circulation, the treatment 
should consist in the use of mercurial and saline cathartics, and a vegetable 
diet. 
In obstinate cases of jaundice, and for completing the cure of those which 
have partially yielded to remedies, the greatest advantage may be expected 
from a visit to the watering-places, especially to those in which the waters 
combine chalybeate and purgative properties. I have known the happiest 
effects from a short residence at the Saratoga springs. 
The diet must be accommodated to the circumstances of each case. When 
excitement exists, it should be confined to vegetable food or to this with milk; 
but, in most cases, animal fogd is not only admissible but required. In all 
cases, indigestible food should be scrupulously avoided. The regimen suited 
to dyspepsia, is also, as a general rule, the best in jaundice not complicated 
with inflammation. (See Dyspepsiad) 
SUBSECTION V. 
DISEASES OF THE SPLEEN. 
The propriety of considering diseases of the spleen in this place may well 
be doubted, as it has not yet been satisfactorily shown that this organ has 
any peculiar secretory function. But in the uncertainty as to its proper office, 
and from the considerations that it often appears to suffer in common with 
the liver, and may possibly be concerned in preparing the blood for the secre- 
tory action of that gland, I have thought it best to consider the diseases of 
the two organs in connexion. 
Much uncertainty exists in relation to the diseases of the spleen, arising 
partly from our ignorance of its true function, partly from its low degree of 
sensibility, and the close vicinity of other highly important organs, which 
render an accurate diagnosis sometimes very difficult. It is probable that CLASS III.] 
521 
DISEASES OE THE SPLEEN. 
original affections of this viscus are rare, and that, in by far the larger pro- 
portion of instances, when diseased, it is so secondarily, in consequence of 
disease existing elsewhere. While, from its remote position and comparative 
insensibility, it is little exposed to morbid impressions from without, it is 
peculiarly liable to suffer from derangements of the system itself. It is com- 
posed chiefly of blood, of which its tissue seems to have been intended as a 
receptacle, and of which it contains variable proportions under varying cir- 
cumstances, so that it is susceptible of considerable differences of size without 
any deviation from health. Indeed, a probable conjecture in relation to one 
at least of its offices appears to be, that it is intended as a diverticulum, for 
the reception of blood under circumstances which may render the temporary 
withdrawal of a portion of that fluid from the circulation, or from other organs, 
desirable. If this opinion be correct, the spleen must be peculiarly liable to 
suffer indirectly from causes which derange the circulation, or impair the 
quality of the blood. Thus, if the forces which move the blood fail, if the 
heart act too feebly, or the capillaries of the liver refuse to forward the blood 
of the portal vein, accumulation must take place in the spleen, which becomes 
congested if not inflamed. Hence, it is apt to become enlarged in asphyxia, 
and the cold stage of fevers, in cases of hepatic torpor or congestion, and in 
diseases generally of feeble action, as in malarious cachexy and scurvy. But 
if the blood which it thus receives in excess is diseased, it must suffer also 
peculiarly from this cause; and hence, possibly, the soft disorganization to 
which it is liable in malignant fevers, and scorbutic affections. But when 
disease of the spleen is evident, it may be very difficult to form an accurate 
judgment of its nature from the symptoms, and sometimes even from dissection. 
Thus, it is often impossible to decide, in a case of enlarged spleen, whether 
the disease is simple congestion, or inflammation, or abnormal nutrition, or 
specific organic derangement; all these affections having certain symptoms in 
common, and those which ordinarily characterize the inflammatory state being 
obscure, in this case, from the defective sensibility of the viscus. It is equally 
impossible, in some instances of post-mortem examination, to determine the 
precise nature of the lesion discovered; whether, for example, the enlarge- 
ment is inflammatory, or merely congestive, and whether the softening, so often 
observed, is the result of inflammation, of the morbid condition of the blood, 
or of a process analogous to gangrene. The fact is interesting, though as yet 
not traced out in all its pathological relations, that in many cases of sudden 
and unexpected death, the spleen has been observed to be enlarged and soft- 
ened. In the present state of our knowledge on the subject, it will be most 
convenient first to treat of those splenic diseases which may be referred to the 
heads of acute and chronic inflammation, and afterwards to take a brief view 
of others, which have no claim or only a very doubtful one to be considered 
inflammatory. It must be borne in mind, however, that there is no distinct 
line between acute and chronic splenitis; and that cases frequently occur, which 
it would be impossible to assign to either division. 
Attention has recently been directed to the office of the spleen, and various 
researches have been made, the general tendency of which has been to show 
an important connexion between that viscus and the process of sanguification; 
but sufficiently definite results have not hitherto been obtained to serve as a 
basis for any practical conclusions. That a diseased condition of the spleen 
and an anemic state of the blood often coexist has long since been ob- 
served; and it has of late been discovered that, in many instances, the anaemia 
is, under these circumstances, of a peculiar character, being distinguished by 
a great excess of white corpuscles, which has given origin to the name of leuco- 
cythemia attached to it. But it is yet undetermined whether the splenic 522 
[PART II. 
affection or that of the blood is the original disease, or whether they may not 
both originate in some other concealed deviation from health. (See Leucocy- 
themia, p. 257.) 
LOCAL DISEASES.-SECRETORY SYSTEM. 
Article I. 
ACUTE SPLENITIS. 
The peritoneal eoat, or the parenchyma of the spleen may be separately 
inflamed, or both simultaneously; and the symptoms are somewhat different, 
though an accurate discrimination during life would be difficult. Such a dis- 
crimination, however, is of no great practical importance; for the treatment 
will be directed less by the exact seat of the inflammation than by the grade 
of the local symptoms, the state of the circulation, and the previous condition 
of the patient's constitution. In general terms, it may be said that inflamma- 
tion of the outer coat may be suspected, when the pain is acute, and the fever con- 
siderable; of the parenchyma, when the pain is obtuse, and the viscus enlarged; 
of both conjointly, when sharp pain and enlargement exist at the same time. 
Symptoms, Course, &c.-The most characteristic symptom of acute splenitis 
is pain deep in the left hypochondrium, sometimes sharp or throbbing, some- 
times vague and dull, occasionally extending to the left shoulder, or shooting 
into the neighbouring parts of the abdomen, and almost always increased by 
pressure over the region of the spleen. It is also generally increased by 
coughing, and by a deep inspiration; and is most troublesome when the patient 
lies upon the affected side. In some cases, instead of pain, there is only a 
feeling of weight, fulness, or tension; and even this may be absent, so that 
the disease can be detected only by a close examination, which will generally 
reveal the existence of tenderness under pressure, and a certain degree of en- 
largement. But, as the tumefaction of the spleen is much greater and more 
striking in the chronic than in the acute form of the disease, it will be more 
conveniently treated of under the former head. 
The onset of the disease is usually marked by a chill, followed by fever, 
which may have the continued, remittent, or intermittent type. It is a ques- 
tion whether the splenitis is ever the original affection when the fever is 
distinctly intermittent. Generally, it is no doubt secondary under such cir- 
cumstances; but cases are on record in which the fever has been intermittent, 
though the inflammation of the spleen was the result of local violence. Never- 
theless, even these cases may not have been exceptions to the general rule; 
for there may have been a predisposition to fever and ague, which the injury 
called into action. 
Besides the phenomena mentioned, there are often others dependent on 
derangement of the neighbouring organs. Epigastric uneasiness, nausea, and 
vomiting are not uncommon; and, in very severe cases, the vomiting is inces- 
sant, and constitutes one of the most prominent symptoms. In consequence 
of the extension of irritation to the diaphragm and lungs, or of the upward 
pressure of the enlarged viscus, the patient is sometimes affected with cough, 
dyspnoea, and hiccough ; and irregular action of the heart or palpitation may 
occur from a similar cause. The bowels are usually costive; but sometimes 
they become involved in the irritation, and diarrhoea or dysentery results. 
Vomiting and purging of blood are also ranked among the occasional symp- 
toms of the disease. The liver is often functionally deranged, and the occur- 
rence of urinary disorder evinces sometimes a sympathetic irritation of the 
kidneys. Depression of spirits, headache, and delirium are mentioned among 
the occasional symptoms. 523 
CLASS III.] 
ACUTE SPLENITIS. 
The condition of system may be sthenic or asthenic. In the latter case, 
the splenitis is generally secondary, connected with low and malignant fevers, 
or with a depraved condition of the blood, as in scurvy. Its symptoms have, 
moreover, in general, little prominence; and often nothing occurs during life 
to call attention especially to the spleen, which after death is found com- 
pletely disorganized. In such cases, the grade of inflammation is low; and 
it is even doubted whether there is anything more than a mere congestion, 
with a dissolution of the tissue consequent upon its feeble vitality. 
In the great majority of cases, simple inflammation of the spleen, under 
proper treatment, terminates favourably in resolution. Sometimes, however, 
it is otherwise, and violent cases may end fatally in a week or ten days, or 
even a shorter time; death being preceded by hiccough, tympanites, diarrhoea, 
delirium, and general collapse. Other cases run on to suppuration, which 
usually takes place in eight or nine days, and is marked, though obscurely, 
by a diminution or alteration of the pain, by rigors, relaxation of the surface, 
and a disposition to sweat at night. The patient may die before the pus is 
discharged, or he may get well in consequence of its absorption. But occa- 
sionally the pus escapes from the spleen, and is either discharged into the 
cavity of the peritoneum, producing fatal inflammation of that membrane, or 
makes its way posteriorly or anteriorly into or through the abdominal parietes, 
or finally penetrates into the lungs, stomach, or bowels, and thus finds an 
external outlet. In either of these latter events, recovery may take place, 
though it is always doubtful and tedious. 
From the contiguity of various important organs, splenitis is liable to be 
confounded with other diseases, especially with inflammation of the left lobe 
of the liver, of the stomach, of the pleura, of the colon, and the kidneys. 
Even rheumatism of the muscles in the vicinity may be mistaken for it without 
care. But, when the spleen is in its natural position, a close observation of 
the seat of pain and tenderness, taken in connexion with the signs which 
indicate enlargement of the viscus, as well as those which characterize the 
several inflammations alluded to, will generally enable the practitioner to 
come to a just conclusion. What tends more than anything else to embarrass 
the diagnosis, is the simultaneous existence of high irritation or inflammation 
of one of the organs referred to, which obscures and sometimes completely 
masks the splenic disease. Perhaps the affection most liable to be confounded 
with splenitis is pleurisy, seated in the lower angle of the chest. The pain, 
increased upon inspiration, the cough and dyspnoea, and the dulness on per- 
cussion extending further upward than in health, which attend splenitis, 
especially when it occupies the upper surface of the viscus, are all likewise 
found in pleurisy. But the absence of egophony and the pleural friction 
sound, the extension of the dulness downward into the abdomen, and its un- 
varying limits with every change of position, and the occasional decubitus on 
the left side, will serve sufficiently to characterize the affection of the spleen. 
Kheumatism will, in general, be readily distinguished by th£ pain which 
accompanies the movements of the trunk. 
Anatomical Characters.-When the patient dies early, the spleen is found 
larger than in health, of a dark-red or blackish colour, and very soft or friable, 
so that it yields readily to pressure with the finger. Here and there may be 
observed lighter spots indicative of commencing suppuration. If death has 
been delayed until after this process has been established, pus is discovered 
either infiltrated through the tissue of the viscus, or collected in isolated cavi- 
ties, which vary much in number and size. When there is only one abscess, 
this is sometimes very large, occupying the greater part, or even the whole of 
the spleen, and in the latter case filling completely the investing capsule. 524 
LOCAL DISEASES.-SECRETORY SYSTEM. 
[PART II. 
The pus is often intimately mixed with blood. Sometimes marks of gangrene 
are presented, though these are very rare; what was formerly taken for gan- 
grene being nothing more than a black softening of the tissue, without putre- 
factive smell. Sometimes the surface of the spleen is covered with coagulable 
lymph, and in old cases it is found adhering to the neighbouring viscera. 
Causes.-External violence; severe and continued muscular exertion, as in 
running for a long time; metastasis of other diseases, as of gout, rheumatism, 
and various affections seated in the skin; suppression of hemorrhoidal, men- 
strual, and other habitual discharges; sudden mental emotions of a depressing 
nature, as terror; and the extension of inflammation from contiguous organs; 
are ranked among the causes of acute splenitis. Whatever produces sudden 
portal congestion may have the same effect, by retarding the return of the 
blood from the spleen. Tn this way it probably is, that miasmatic and malig- 
nant fevers produce splenitis; the blood accumulating in the viscus during 
the chill. Hepatic congestion and inflammation operate in the same way. 
Treatment.-The treatment must be directed upon the same general prin- 
ciples as in other inflammations. Bleeding, general and local; active purga- 
tion, first with combinations of calomel and other cathartics, and afterwards 
with saline purgatives or senna; warm fomentations or cataplasms, and the 
warm bath; and, after these, blisters, repeated if necessary, are the remedies 
adapted to open and well developed cases of the disease, with a strong and 
accelerated pulse. The whole antiphlogistic regimen must be at the same 
time observed. If there should be nausea and vomiting, the effervescing 
draught may be employed, with or without opiates, as circumstances may seem 
to require. Should the stomach, on the contrary, be retentive, and at the 
same time the fever considerable, the antimonials may be prescribed in diapho- 
retic doses. Incidental symptoms, as those of diarrhoea and dysentery, must 
be encountered by methods suitable to the several affections they indicate. 
But, in many cases, the condition of system will not admit of a decided 
depletory course. Here leeches or cups should be substituted for the lancet; 
and the purgatives employed should be of the less exhausting kind, as rhu- 
barb and aloes, with or without calomel, according as the hepatic function 
may be impaired or otherwise. 
Mercury, as an antiphlogistic remedy, is less applicable to this than to 
most other visceral inflammations. When, however, a frank attack, in a 
patient of vigorous constitution, does not yield to the usual antiphlogistic 
remedies, I should have no hesitation in employing mercury carefully, with 
a view to its impression upon the system. But in the disease as it, perhaps, 
more frequently occurs, with a depraved state of the general health, and 
especially of the blood, mercury might prove injurious by still further break- 
ing down the vital forces, and thus favouring congestion of the spleen. 
Should the disease be associated with intermittent fever, sulphate of quinia 
should be resorted to, without further delay than such as is requisite for the 
clearing out 6f the bowels. By arresting the paroxysms, and thus preventing 
that periodical congestion of the spleen which occurs with every chill, it will 
prove much more serviceable in arresting the inflammation, than it possibly 
can prove injurious by its stimulant action. There is no incompatibility 
whatever, in such cases, in the joint employment of quinia and the lancet, or 
other depletory measures, should the latter be indicated. CLASS III.] 
CHRONIC SPLENITIS. 
525 
Article IL 
CHRONIC SPLENITIS. 
Under this head I include those chronic enlargements of the spleen which 
frequently attend intermittent fevers, and are commonly called ague cakes; 
for, though it is not certain that they are always inflammatory, yet that they 
often are so in their origin or progress is undisputed, and it is impossible in 
any one instance, during life, positively to deny them this character. 
Symptoms, Course, &c.-Chronic splenitis occasionally occurs with so few 
symptoms as altogether to escape notice, and it is first known to have existed 
upon post-mortem examination. In general, however, it is sufficiently charac- 
terized by its phenomena. There is often a feeling of weight, tension, or 
other uneasiness in the left hypochondrium, sometimes amounting to positive 
pain, which is almost always increased by pressure, and is usually greater 
when the patient lies upon the right side. As in the acute inflammation, it 
is also sometimes felt in the left shoulder. But the most characteristic symp- 
tom is enlargement of the viscus. This is often obvious to the most superfi- 
cial examination, and, when not so, may usually be detected by percussion. 
This enlargement occasions various inconveniences, not only incommoding the 
patient by its weight, so as occasionally to produce an inclination towards the 
left side in standing, and to influence the gait in walking, but embarrasses 
very much by its pressure the functions of the neighbouring organs, as the 
lungs, heart, stomach, and intestines, as well as from sympathetic irritation. 
Hence, the complaint is often accompanied by cough, dyspnoea, palpitations, 
or other irregular action of the heart, impaired digestion, and consequent 
general emaciation. The hepatic and renal functions are also frequently de- 
ranged. The skin is apt to be sallow, and sometimes has a dusky or greenish 
hue. If to these symptoms we add a frequent tendency to irregular febrile 
action, and to hemorrhage, especially from the stomach, lungs, and nostrils, 
we have a tolerably full picture of the complaint. If not relieved, it pro- 
duces a gradual exhaustion of the vital powers, with hectic symptoms or 
dropsical effusion, and at length death, amidst the usual phenomena of fatal 
abdominal diseases, such as vomiting and purging, stomachic and intestinal 
hemorrhage, anxiety, restlessness, and delirium. 
The disease is of very variable duration, lasting only a few months, or run- 
ning on for years, and sometimes continuing, in its milder and more inert 
forms, even to the end of a long life, without any very great inconvenience. 
In miasmatic countries, many individuals are affected with enlarged spleens 
or ague cakes, without seeming to heed them. In such cases, the tumour 
appears to be quite indolent, though capable of being roused into dangerous 
activity by causes calculated to induce acute splenitis, especially by blows, or 
falls on the side, or other external violence. According to Mr. Twining, 
children are not so well able to support the disease as adults, and perish under 
a degree of it which might be resisted by more hardened constitutions. 
As chronic splenitis prevails in miasmatic regions, it is often associated 
with a peculiar cachectic condition of system, with a depraved constitution 
of the blood; though it is difficult to say how far this state of health bears 
to the splenic disease the relation of cause or effect, and how far they are both 
coincident results of the same morbid cause acting upon the whole economy. 
It is, on the whole, probable that both the disease of the spleen and the 
cachectic state of system are common effects of the same cause, though they 526 
LOCAL DISEASES.-SECRETORY SYSTEM. 
[PART II. 
may tend to sustain and aggravate each other. The constitutional affection 
alluded to is characterized by a pale anemic condition of the skin, which is 
also sallow, dry, and shrunken; by general lassitude, inertness, muscular 
weakness, and mental depression; by great liability to hemorrhages, and to 
sloughing ulcers of the legs from slight injuries; by pains in the extremities, 
sometimes followed by collections of pus; by amenorrhoea in the female; and, 
in general terms, by all the symptoms which mark a scorbutic diathesis.* 
The enlargement of the spleen occurs in various degrees. Sometimes it 
scarcely projects beyond the lower edge of the ribs, and can then be detected 
only by the flatness upon percussion, which extends further upwards than in 
the normal state of the viscus. Most commonly, however, the tumefaction is 
very obvious, reaching beyond the ribs various distances into the lumbar, 
umbilical, and epigastric regions, and sometimes descending as low as the 
iliac fossa and hypogastrium, and occupying nearly the whole cavity of the 
abdomen. In this condition, the spleen is usually in the form of a hard, 
smooth, oblong, and somewhat movable tumour, rounded on the outer side, 
and presenting on the inner a more or less attenuated edge, running down- 
ward from the epigastrium or near it towards the left flank, and often some- 
what notched. This is the ordinary state of the tumour in very chronic cases, 
in which there has been much organic change. In others which approach 
more nearly to the acute form, and in which the swelling is probably depend- 
ent chiefly upon congestion, the tumour is less oblong and more rounded, is 
softer to the touch, and yields more readily to treatment. 
Sometimes other tumours are mistaken for enlarged spleen, and a mere 
displacement of this viscus by fluid distending the pleura, may give rise to 
the impression that it is larger than in health. The affections most liable to 
be thus mistaken are tumours of the omentum, peritoneum, and abdominal 
parietes, and enlargement of the left lobe of the liver. But by bearing in 
mind the shape of the diseased spleen, the normal position of that viscus, and 
its relation to the neighbouring viscera, as well as the ordinary course of chro- 
nic splenitis, and the characteristic phenomena of the other affections alluded 
to, the practitioner will almost always be able to arrive at a correct conclusion. 
Dissection.-The peritoneal coat of the spleen is often found adhering to 
that of the stomach, colon, or kidneys; and the proper coat to have assumed, 
in patches more or less extensive, a cartilaginous or osseous character; and 
these degenerations sometimes follow the capsule in its cellular extensions 
through the interior of the viscus. The spleen itself is enlarged in various 
degrees, sometimes enormously so, weighing from ten to twenty pounds, or 
even more. The parenchyma exhibits various changes of structure, not un- 
frequently even in the same case, being indurated, hypertrophied, or con- 
gested, sometimes softened with purulent infiltration or collections, and some- 
times presenting cavities filled with effused blood, or variously coloured liquids 
which appear to have originated in such effusion. 
Causes.-Chronic splenitis sometimes succeeds the acute; but is more 
frequently original. Its most common cause is intermittent fever, of which 
it is a very frequent result, when that disease is long continued. The spleen 
becomes congested during the chill, is partially relieved upon the occurrence 
of the fever, is again congested in the subsequent paroxysm, and thus goes 
* The coexistence of the anemic state of the blood and enlarged or hypertrophied 
spleen, so often observed, may in some degree be explained upon the hypothesis that 
one of the offices of the spleen is to destroy the red corpuscles; an hypothesis strongly 
supported by the observations of Mr. Henry Gray, that the blood leaving the spleen is 
much less rich in these corpuscles than the blood entering it. (On the Structure and 
Use of the Spleen, Lond., 1854.)-Note to the fourth edition. CLASS III.] 
CHRONIC SPLENITIS. 
527 
on alternately distended with blood and incompletely unloaded, until at length 
organic change and permanent enlargement take place. The disease also 
sometimes follows bilious remittent fevers; and it is thought occasionally to 
result directly from the miasmatic influence, without the intervention of fever. 
Retention or suppression of the menses is believed to favour its production. 
In fact, anything capable of maintaining a continued portal congestion may 
serve as a cause of chronic splenitis; and most of the agents already enume- 
rated, as producing the acute form, may produce also the chronic when acting 
more moderately and for a longer time. 
Treatment.--General bleeding is seldom required or admissible, unless 
when acute inflammation supervenes upon the chronic. Local bleeding by 
cups or leeches should be employed when there is pain or tenderness in the 
side, without an anemic or very debilitated state of system, and especially if 
fever exist. In some instances, it may be advantageously repeated several 
times in the same case. Most frequently, however, the complaint is associated 
with a state of health which is incompatible with much direct depletion. The 
French authors recommend leeches to the anus. 
Purging is, in general, a safer and more efficient measure. Medicines 
should be preferred which are capable of producing a powerful revulsion to 
the alimentary canal, without greatly debilitating. Jalap and cream of tartar, 
senna, rhubarb, and especially aloes, may be employed, the latter being useful 
by its action upon the hemorrhoidal vessels. The compound extract of colo- 
cynth is an excellent combination, when the bowels are somewhat indolent. 
Tartar emetic is sometimes advantageously combined, in small doses, with the 
purgatives, to promote their action, and is especially applicable when there is 
fever. If the liver should not act sufficiently, calomel should be added to the 
other cathartics. In debilitated cases, the purgative tinctures, as those of 
aloes, senna, and jalap, may be added to or substituted for the medicines in 
their ordinary form. The cathartic may generally be repeated every second 
or third day. When given in moderate doses, so as to act rather as a laxative 
than a purgative, it may be repeated daily. Of course, in cases complicated 
with diarrhoea, cathartics must be employed cautiously if at all. 
The mercurial impression is less useful in this than in most other instances 
of chronic inflammation. Calomel, the mercurial pill, or iodide of mercury, 
may be resorted to in minute alterative doses, when the hepatic action is de- 
ficient or deranged; but care should be taken that it be not carried so far as 
to affect the gums. Though, in some cases in which the general health is 
not materially impaired, the impression of mercury on the system might 
prove useful; yet the disease is so often associated with a depraved or cachec- 
tic state of system that it would generally prove injurious by increasing the 
debility, and still further depreciating the character of the blood. This has 
been sufficiently proved by observation; and the employment of mercury, 
formerly recommended in this disease as in hepatitis, is now deprecated by 
the most experienced practitioners. 
Upon the whole, the most efficient remedies, in connexion with purgatives, 
are tonics and astringents. Sulphate of quinia is highly useful. In cases 
complicated with intermittent fever, it often speedily effects a cure by removing 
the cause. But in malarious cases, in which there has been no fever, or the 
fever has been subdued, sulphate of quinia has still exerted a most favourable 
influence, continued for a considerable time, in doses of from six to twelve 
grains in twenty-four hours. Other bitter tonics may be substituted, when 
the indication is especially to improve the digestion. It is probable that nux 
vomica would prove useful, as, among the effects which have been observed 
to follow its poisonous action in animals, a marked diminution in the size of 528 
[PART II. 
LOCAL DISEASES.-SECRETORY SYSTEM. 
the spleen has been observed. The chalybeates have a high and merited 
reputation in chronic splenitis. They not only act by improving digestion, 
correcting the anemic condition of the blood, and thus producing a tonic im- 
pression on the general system; but they are believed also to have a direct 
effect upon the spleen, which they are asserted to diminish in bulk in health, 
and still more when morbidly congested. The salts of manganese may also 
be employed, as having a similar influence on the blood; and the sulphate 
has been particularly recommended. 
These remedies may be variously combined in the same prescription, so as 
to suit the circumstances of each case. Thus, aloes, extract of jalap, or com- 
pound extract of colocynth, and protocarbonate of iron may be given in pill, 
to which sulphate of quinia, or extract of gentian or quassia, and one of the 
mercurials, may be added if requisite; or, if it be desirable to administer the 
medicines in a liquid form, senna or aloes may be combined with one of the 
bitters and some aromatic in infusion, and one of the soluble or liquid prepa- 
rations of iron, as the sulphate, tincture of the chloride, or solution of the 
iodide, may be added; and the whole rendered more stimulating, if thought 
advisable, by one or more of the purgative, tonic, or aromatic tinctures. A 
preparation of this kind is recommended by Mr. Twining, as having proved 
efficient in the chronic splenitis of Bengal.* 
Another remedy which seems strongly indicated in chronic splenitis is 
iodine; and it has sometimes been employed with much apparent advantage. 
It may be used internally, or externally, or both. Perhaps for internal use 
the iodide of iron would, on the whole, be the best preparation; though the 
compound solution, or compound tincture of iodine, the iodide of potassium, 
or the iodide of mercury may be substituted, when circumstances seem pre- 
ferably to call for any one of them. The ointment of iodine should be rubbed 
freely, daily or twice a day, upon the abdomen over the whole surface of the 
tumour. 
Piorry states, as the result of his observations, that common salt (chloride 
of sodium) has the property of diminishing the bulk of the spleen whether 
in its normal state or hypertrophied. He gives from two to six drachms dis- 
solved in ten times the weight of water. {Arch. G^n., 4e ser., xxviii. 344.) 
Other local measures may be resorted to. Repeated blistering is some- 
times serviceable; but the remedy should be used with caution; and not at 
all in those cachectic and scorbutic cases in which there is a tendency to 
slough. With the same restrictions, setons, issues, or pustulation with tartar 
emetic may be employed. Friction over the abdomen is sometimes useful; 
and a broad flannel roller should be worn around the body, in order to sus- 
tain a proper temperature of the surface, and to afford mechanical support. 
Warm bathing should be used in cases attended with fever. 
The diet should be regulated by the state of the system. In some febrile 
cases, it may be proper to restrict the patient to vegetable food; but much 
more generally a nutritious animal diet is requisite, in order to support the 
strength and repair the character of the blood. In doubtful cases, milk may 
be added to the vegetable food. In all cases, the food should be of easy di- 
gestion. (See Dyspepsia.} 
* R.-Pulv. Jalap., Pulv. Rhei, Pulv. Colombas, Pulv. Zingiberis, Potassas Bitartratis, 
aa gj ; Ferri Sulphatis ^ss; Tinct. Sennse fgiv; Aq. Menth. Sativ. f^x. Misce. The 
dose is a fluidounce and a half for an adult, repeated twice a day, at 6 A. M., and 
11 A. M., to be reduced proportionably for children, so as to produce three or four 
stools daily. This is to be continued for three or four weeks or longer, if necessary, 
with occasional intermissions when found to disagree with the patient. Should the 
patient be feverish, it is to be omitted until this state is corrected. CLASS III.] 
NON-INFLAMMATORY DISEASES OF THE SPLEEN. 
529 
Moderate exercise, attention to the clothing, and a pure air are valuable 
adjuvants in the treatment. All that has been said, under chronic hepatitis, 
in relation to watering-places, may be considered as applicable here. 
Various other remedies besides those enumerated have been employed. In 
Bengal, where the disease prevails, the natives use garlic and expressed oil 
of mustard with chalybeates and aloes. They also employ the actual cautery, 
and practice acupuncturation of the spleen with very long needles. Nitric 
and nitro-muriatic acids have been recommended in combination with purga- 
tives. Muriate of ammonia in large doses is favourably spoken of in Eberle's 
practice, as is also tartar emetic used in small quantities in weak solution as 
drink. Repeated emetics are said to have sometimes succeeded in reducing 
enlarged spleens, and cataplasms of tobacco leaves over the enlarged viscus 
have been advised. Mechanical methods, such as gentle percussion and 
kneading of the spleen with the hand, have had their advocates; but they 
are obviously applicable only in the absence of all tenderness, and when 
there is reason to believe that the viscus is indolent rather than inflamed. 
Article III. 
NON-INFLAMMATORY DISEASES OF THE SPLEEN. 
Congestion.-The spleen is peculiarly liable to become engorged with 
blood, either from irritation in the viscus itself, or from causes operating from 
without. When active, the congestion is often but the incipient stage of 
inflammation; and probably, even when passive, it produces in time a low 
and imperfect grade of that affection, which may end in serious organic 
changes of the viscus, as in intermittents. Sometimes, however, congestion 
exists without any evidence whatever of inflammation. 
The symptoms during life are not very obvious, and the affection not un- 
frequcntly entirely escapes notice. There may be a feeling of fulness, weight, 
or tension in the side, with oppression of the chest, and possibly sometimes 
prostration from the sudden withdrawal of blood from the general circula- 
tion; but, in most cases of debility connected with congested spleen, the 
state of system is dependent on other causes, and is itself the cause rather 
than the consequence of the congestion; the blood accumulating in the spleen, 
because the heart has not force enough to carry it forward as fast as it is re- 
turned by the veins. Along with the sensations alluded to, a close exami- 
nation will detect enlargement of the viscus; and the absence of pain or 
tenderness will render it probable that the enlargement is not inflammatory. 
In some instances, the spleen has been ruptured by its excessive distension, 
especially when previously more or less disorganized; and the blood, escaping 
into the cavity of the abdomen, has produced suddenly the symptoms of se- 
vere and fatal peritonitis. 
All prostrating influences may occasion congestion of the spleen in an 
ordinarily full condition of the blood-vessels. Hence it takes place in faint- 
ing, and in the cold stage of fevers, especially those of miasmatic origin; and, 
in the latter case, the distension is sometimes enormous, especially in ma- 
lignant intermittents and remittents. Any impediment to the transmission 
of the blood of the vena portarum through the liver, or any obstruction to 
the entrance of the blood into or its transmission through the right cavity of 
the heart, may have the same effect. Rapid running, and excessive muscu- 
lar exertion of any kind are liable to produce congestion of the spleen; and 
that viscus is said to have sometimes been ruptured from this cause. 530 
[PART II. 
LOCAL DISEASES.-SECRETORY SYSTEM. 
Upon dissection, the spleen is found to be considerably enlarged, of a deep- 
brown almost black colour, and engorged with blood. Sometimes the blood 
is extravasated, and exists infiltrated into the tissue, or collected in one or 
more cavities as in apoplexy. Occasionally, in old cases of splenic disease, 
cicatrices and fibrous cysts have been observed, which are supposed to be the 
remains of similar lesions; the effused blood having been absorbed or become 
organized. 
Congestion of the spleen is very seldom fatal or even serious of itself; and, 
in the fatal cases in which it has been observed, death has usually resulted 
from other causes. It may, however, prove injurious by laying the founda- 
tion of inflammation, or disorganization of some other nature; and -when dis- 
covered, therefore, merits attention. If it be of an active character, bleeding 
may be employed. In other cases, emetics will be found very efficient, and 
these should be followed by cathartics. In debilitated states of the system, 
tonics may be employed as mentioned under chronic splenitis, and the chaly- 
beates with sulphate of quinia are the most efficient. 
Softening.-The texture of the spleen is softened by acute inflammation; 
but there is another kind of softening, which is not attended by inflammatory 
symptoms during life, and exhibits, on dissection, no other evidence of this 
process than its own existence. It is generally associated with congestive 
enlargement of the spleen, but not universally so. The increase of bulk is 
various in degree, and never so great as in many cases of enlargement with 
induration and hypertrophy. The viscus seldom much exceeds three or four 
times its usual size, though occasionally it has attained the weight of seven or 
eight pounds. The degree of softening is also very different in different 
cases. Sometimes the consistence is but slightly altered : sometimes the 
whole parenchyma is converted into a liquid or semi-liquid disorganized mass, 
like a loose clot of blood contained in a membranous bag. In the latter case, 
the spleen will even break or tear if lifted in the hand; and the finger can be 
run through it in all directions, almost without resistance. The interior mass 
is sometimes a black gore, sometimes a pulpy matter like mud, varying in 
its shades of colour, from a light gray to a dark almost blackish brown. In 
some instances, the fibrous tissue which gives its cellular structure to the 
viscus remains; in others, this also is disorganized. 
This affection occurs in the course of various diseases, in which the blood 
is altered, especially scurvy, and low forms of fever. It is a very frequent 
accompaniment of typhoid fever. The nature of the softening is not well 
understood. It may be ascribed to a feeble inflammation which the vitality 
of the tissue could not resist; but opposed to this supposition is the fact 
stated by Louis, that, in all the cases observed by him in typhoid fever, he 
found the whole tissue of the spleen affected, without any marks of inflam- 
mation of the peritoneum, and without pus. It is more probably owing to 
the diseased state of the blood, which, accumulated and retained in the spleen, 
cannot sustain the feeble vitality of the tissue, and therefore acts in some 
measure the part of a solvent. 
No therapeutical measures are required in this affection other than such as 
are indicated in the treatment of the diseases with which it is associated. 
Hypertrophy and Atrophy.-The spleen is sometimes enlarged by excessive 
growth, without any material alteration of its structure. This may be owing 
to a gentle irritation, not exceeding the nutritive point, sustained by an undue 
supply of blood. It is said sometimes to occur in intermittents; but there 
are no symptoms by which it can be distinguished from other enlargements of 
the viscus attended with organic derangement. The spleen is also occasion- 
ally found much diminished in size; and instances have occurred in which it CLASS III.] 
531 
NEPHRITIS. 
was little larger than a walnut. The diminution is generally attended with a 
loss of colour, and a comparatively bloodless condition. The causes of this 
extreme atrophy are unknown. In some instances of a more moderate kind, 
it may be supposed to be owing to a contraction of the capsule of the spleen, 
consequent upon inflammation or other organic change. 
Tubercles have been noticed in the spleen, but they are rare. Cysts and 
hydatids, undergoing the same changes as in the liver, sometimes exist, but 
are also rare. The same may be said of carcinoma, or cancer. Out of up- 
wards of nine thousand cases of this disease which occurred in the department 
of the Seine, in France, in ten years, according to the table of M. Tanchou, 
only thirteen were in the spleen. (Lebert, Malad. Cancer, p. 92.) Melanosis 
is asserted to have occasionally occurred. The fatty and waxy degenerations 
have also been noticed; and, in the waxy spleen, the new matter has been 
observed to yield a blue colour with iodine and sulphuric acid; a reaction 
characteristic of cellulose. (Ed. Month. Joum. of Med. Sci., April, 1854, 
p. 381.) Calculous concretions have also been found. But none of these 
affections are of practical importance; as, independently of their rarity, they 
present no signs by which they can be detected in life. The spleen is some- 
times displaced from its natural position by the pressure of abnormal growths 
or collections of fluid in its neighbourhood; and has been known to be entirely 
dislocated without any assignable cause. An example of the latter affection 
is noticed by Dr. Dunglison, in which the viscus was found resting on the 
brim of the pelvis, retaining its peritoneal and vascular connexions, and freely 
movable in all directions. (Cyc. of Pract. Med., Philadelphia, 1844, Article 
Diseases of the Spleen.') 
SUBSECTION VI. 
DISEASES OF THE URINARY ORGANS. 
Article I. 
INFLAMMATION OF THE KIDNEYS, or NEPHRITIS. 
Inflammation of the kidneys, in its different grades and varieties, is not 
uncommon. It may be seated in the investing coat of the gland, in its sub- 
stance, in the mucous membrane lining its pelvis or calyces, or in two or 
more of these parts conjointly. The capsule is seldom inflamed unless in 
connexion with the parenchyma. The part most frequently affected is pro- 
bably the pelvis with the calyces. Rayer has given different names to the 
disease occupying these different sites. Inflammation of the substance of the 
gland he calls nephritis, of the pelvis and calyces pyelitis, of the coat perine- 
phritis, and of the glandular parenchyma and pelvis conjointly pyelonephritis. 
But this refinement of nomenclature is of little practical importance. It sel- 
dom happens that one part is much inflamed without some participation of 
another; and an exact diagnosis is very often difficult if not impossible. The 
treatment, moreover, is directed much more according to the violence of the 
symptoms, and the origin of the disease, than its precise locality. Nephritis 
has also been divided into varieties in reference to its causes; as into the 
simple when produced by the ordinary causes of inflammation, the calculous 
when resulting from urinary concretions, and the gouty when of an arthritic 
origin. But there is no such practical or essential difference in these cases as 532 
LOCAL DISEASES.-SECRETORY SYSTEM. 
[PART II. 
to call for distinct designations. The most important division is probably into 
the acute and chronic, though these two conditions of the disease are often 
very indefinitely separated. 
Symptoms of Acute Nephritis.-The most prominent symptom of acute 
nephritis is usually a deep-seated pain in the small of the back, upon one 
side or upon both; sometimes sharp and severe, sometimes heavy, obtuse, 
or burning; often extending downward, in the direction of the ureter, to the 
groin, neck of the bladder, scrotum, or even the inside of the thigh; in- 
creased by firm pressure over the region of the kidney, sudden jars, quick 
change of position, bending forward in the sitting posture, severe coughing 
or sneezing, or a full inspiration from any cause; and frequently accompanied 
with a retraction of the testicle, with some tenderness of that organ. It is 
said that when one kidney only is affected, the patient lies most comfortably 
on the opposite side. Along with the pain, there is occasionally a feeling of 
numbness in the thigh. If the patient lie on his face with the knees drawn 
up, the kidney may in thin subjects be grasped by the hands, and will gene- 
rally be found tender, and, in cases of inflammation of the parenchyma, some- 
what enlarged. 
The patient basin general a disposition to micturate frequently, though the 
reverse is sometimes the case. The urine passed is very scanty, usually 
high-coloured and more or less mixed with blood, sometimes albuminous 
even when it contains no blood, and not unfrequently contaminated with 
mucus, and with calculous matter, which is deposited upon standing. In 
some instances, however, when the substance of the kidney is exclusively 
affected, or when the urine which escapes is derived from the sound kidney, 
in consequence of obstruction upon the diseased side, the secretion is clear 
and of a healthy colour. When both kidneys are affected, the urine is 
sometimes almost or quite suppressed; and then comatose symptoms are apt 
to supervene. 
Acute nephritis is almost always attended with fever, the antecedent rigors 
of which, in severe cases, set in simultaneously with the pain, or even before 
it. In other cases, the pain and signs of urinary disorder occur before the 
constitution has begun to sympathize. Sometimes the fever is very high, with 
headache, furred tongue, thirst, a hot dry skin, and a strong pulse; sometimes 
it is slight. It is generally remittent, and is asserted occasionally to have 
the intermittent form. 
The stomach is almost always disordered in bad cases. Nausea and vomit- 
ing are very frequent; and it is said that the vomited matter sometimes has a 
urinous smell. The bowels are in most instances constipated. 
When the substance of the kidney is exclusively affected, the urine is free 
from obvious mucus, and usually from gravelly deposit. If, upon examination 
by the microscope, it be found to contain fibrinous casts of the uriniferous 
tubes, the inference is highly probable that the cortical portion is inflamed. 
The gland is also more tender under pressure in proper nephritis, than when 
the mucous cavities only are diseased. 
In the pyelitis of Rayer, or inflammation of the pelvis and calyces, the tes- 
ticle is more frequently retracted than in the other case, the renal secretion is 
not so much diminished, and is never quite suppressed, the urine is more or 
less mixed with mucus, and in the advanced stages with pus, and when the 
diseaseis associated, as it generally is, with gravel, the same liquid frequently 
abounds also in calculous matter. In some instances, however, in which the 
concretion serving as the source of irritation consists of oxalate of lime, the 
urine is free from calculous matter, though loaded with mucus. 
When nephritis is of calculous origin, the pain is often very acute and CLASS III.] 
533 
NEPHRITIS. 
spasmodic, suffering exacerbations with the movements of the calculus in the 
pelvis of the kidney, and sometimes excited into excruciating violence upon 
its entrance into or passage through the ureter. The presence of calculous 
deposit in the urine, the sudden cessation of pain evincing the entrance of a 
stony concretion into the bladder, and the escape of such a concretion from 
the urethra, are further proofs of the peculiar nature of the affection. 
The gouty form of nephritis may be known generally from the constitu- 
tional habit of the patient, and is sometimes strongly characterized by occur- 
ring upon the retrocession of the disease from some external part. It may be 
recognized also by the character of the urine, which is high-coloured, and, 
while in the other varieties it is usually deficient in uric acid, and either neutral 
or alkaline, in gouty nephritis usually abounds in that principle, which it de- 
posits copiously upon cooling in the shape of earthy or sandy gravel. 
In its more acute forms, nephritis is often very rapid, either ending in reso- 
lution, or evincing signs of suppuration, or other unfavourable phenomena 
in the course of a week. In the first case, the pains diminish, the urine be- 
comes more copious, and blood is sometimes discharged from the urethra, the 
fever abates, the skin relaxes, the stomach is composed, the tongue begins to 
clean, and health returns sometimes in four, five, or six days. Occasionally, 
the disease subsides without disappearing, and runs into the chronic form. 
The occurrence of suppuration is marked by rigors, some change in the 
character of the pain, a weaker pulse, a relaxed skin, and sometimes sweats 
at night. In some instances, the urine becomes at first turbid, and then 
gradually yellowish and opaque, obviously owing to the presence of pus. In 
others, the pus appears suddenly in the urine after a certain continuance of 
the signs of suppuration. The former symptom indicates inflammation of the 
mucous membrane, the latter an abscess of the glandular substance, which has 
broken into the pelvis of the kidney. In either case, the patient may gra- 
dually recover, or the disease may continue long, even during the whole residue 
of life, in the chronic form. This is especially the case when calculous mat- 
ter, or small concretions are occasionally discharged with the purulent urine, 
proving the existence or production of these substances in the kidney. The 
presence of pus in the urine may be known by the change which takes place 
with solution of potassa; the yellowish cream-like deposit becoming viscid 
and glairy, like ropy mucus, on the addition of that reagent. When other- 
wise doubtful, it may be detected by means of the microscope. 
Pus in the kidney may be disseminated, or in the form of an abscess in the 
glandular substance; or, it may exist in the pelvis, or in one of the distended 
calyces, in consequence of obliteration or obstruction of the ordinary outlet, 
either by coagulable lymph or calculous concretions. It has been already 
stated that the abscess sometimes breaks into the pelvis, and the pus is dis- 
charged with the urine. It sometimes also happens that the obstruction 
offered by a calculus in the ureter is partially or wholly removed, and pus 
and urine, often mingled with calculous matter, escape by the natural outlet. 
But in both these cases a different result sometimes occurs. The purulent 
collection goes on increasing, so as occasionally to produce large tumours, 
which can even be felt through the walls of the abdomen. This is especially 
the case with those which result from obstruction or obliteration of the ureter, 
and consequent distension of the pelvis of the kidney. In these, the pus is 
mixed with the secreted urine of which the escape is cut off, as well as with 
calculous deposition; and these collections sometimes attain an immense size, 
stretching out the substance of the kidney into a thin layer, and presenting 
an evident fluctuation to an external examination. These abscesses or collec- 
tions sometimes open into the peritoneal cavity, producing certain death. 534 
LOCAL DISEASES.-SECRETORY SYSTEM. 
[part it. 
They have been known also to be evacuated through the colon, with a scarcely 
less fatal, though more protracted issue. Cases are on record, in which the 
matter has been discharged into the cellular tissue of the loins, and found its 
way outward through the skin; and, if the patient has resisted the first shock, 
pus, alone or mixed with urine and calculous matter, has continued to escape 
for a long time through the fistulous opening. Even under such circumstances, 
recovery has taken place, though seldom. Another and much rarer outlet 
has been through the diaphragm into the lungs, with the expectoration of pus 
and urine, and ultimate death. It is asserted that a favourable issue has re- 
sulted, in some of these tumours, in consequence of a complete destruction of 
the substance of the gland, so that urine or pus was no longer produced, and 
an opportunity was offered for the removal of their contents by absorption, 
and for their consequent contraction and ultimate obliteration. 
But suppuration is not the worst evil in acute nephritis. Sometimes a 
total suppression of urine takes place, with the occurrence of cerebral symp- 
toms, as delirium, coma, and convulsions. In such cases, the urea and other 
principles usually thrown off by the kidneys accumulate in the blood, and act 
injuriously upon the brain. In other instances, the accompanying fever 
assumes a typhoid form, with dark-coloured, turbid, ammoniacal urine, which 
comes away involuntarily, and towards the close is blackish or quite suppressed, 
while the breath and perspiration are fetid. Both these forms of the disease 
are almost always fatal. Again, gangrene sometimes though very rarely occurs, 
marked by a sudden' cessation of pain and universal collapse of the system. 
It necessarily ends in death. 
Symptoms of Chronic Nephritis.-The conditions already described as 
occasionally following suppuration of the kidneys, may be considered as ex- 
amples of a chronic form of the disease consequent on the acute. Occasion- 
ally the symptoms of acute nephritis gradually subside into those of a lower 
grade of inflammatory action, without previous suppuration ; and the case 
becomes chronic. But the symptoms are sometimes also from the com- 
mencement those of the chronic form. There is little or no fever, and the 
pain in the lumbar region is slight, so much so occasionally as scarcely to be 
observed unless the attention of the patient is directed towards it. Strong 
pressure usually aggravates it, or renders it sensible if not previously noticed. 
It does not, as in the acute form, extend to the groin or thigh, and there is 
no retraction of the testicle. The urine is diminished in amount, and passed 
more frequently than in health. It soon loses its natural acidity, becoming 
neutral or alkaline, assumes a turbid appearance, and deposits sediments con- 
sisting chiefly of the calcareous and ammoniaco-magnesian phosphates, some- 
times mixed with urate of ammonia. Much stress is laid by Rayer on the 
alkalinity of the urine as a sign of inflammation of the organ. Should the 
disease advance, the pain increases, the urine sometimes assumes a purulent 
appearance, and a frequent pulse, night sweats, and emaciation mark the 
developement of hectic fever, under which the patient sinks if not relieved. 
When the urine remains free from pus, the inference is that the substance of 
the kidney is the exclusive seat of inflammation. But more frequently the 
pelvis is the part originally affected, or at least participates in the disease, and 
the urine, at first mucous, becomes purulent or muco-purulent in the end. In 
chronic, as in acute nephritis, the blood may become contaminated from the 
want of due purification by the kidneys; and various secondary affections may 
thus originate, which will be more particularly noticed under Bright's disease. 
Diagnosis.-The complaints with which acute nephritis is most liable to 
be confounded are nephralgia, lumbago, inflammation of the psoas muscle, and 
partial peritonitis. In relation to most of these, it might be sufficient to say CLASS III.] 
NEPHRITIS. 
535 
that they are without the scanty and disordered urine, the disposition to fre- 
quent micturition, the retraction of the testicle, and the pain shooting ob- 
liquely downward from the region of the kidney to the groin, which cha- 
racterize nephritis. But nephralgia is sometimes attended with all these 
phenomena; and is to be distinguished only by the greater violence and more 
spasmodic character of the pain, and the total absence of fever. The pain in 
diseased psoas is situated somewhat as in nephritis, and the testicle is some- 
times retracted; but the other symptoms above mentioned are wanting, as 
well as the gastric disturbance so common in the renal affection; and the in- 
crease of pain in the muscle resulting from a voluntary movement of the thigh 
on the pelvis, is another diagnostic symptom. In lumbago, the pain is more 
superficial, and is greatly increased by certain motions, especially by attempt- 
ing to rise from the sitting posture. In peritonitis there is vomiting; but the 
urinary symptoms and peculiar direction of the pain are absent, there is greater 
tenderness on pressure, the pulse is small and corded, and the expression of 
countenance peculiarly anxious. Chronic nephritis is liable to be confounded 
with inflammation of the bladder, which gives rise to the same mucous or 
purulent character of the urine; and the diagnosis is extremely difficult when 
the two affections, as sometimes happens, are coexistent; for the pains in the 
region of the kidney, if experienced at all, are apt to be overlooked in the 
more decided evidences presented of the disease of the bladder. In such 
cases, the lumbar uneasiness, which a close examination may detect, and the 
pain developed by pressure upon the kidney, will serve to indicate disease of 
the latter organ. Rayer considered an alkaline state of the urine, which 
he believed never to attend pure cystitis, as a good diagnostic character; 
but, according to Dr. Golding Bird, this liquid may be alkaline, and loaded 
with phosphates, from disease limited to the bladder alone. In the case of 
a fistulous opening in the lumbar region, the urinous smell of the discharged 
matter will prove its connexion with the kidney. 
Dissection.-When death has taken place at an early stage, the kidney is 
found enlarged and congested, of a reddish-brown colour, especially in the 
cortical portion, with dispersed red points, and occasional spots of extravasated 
blood. It is sometimes four times as large as in its healthy state. The tis- 
sue is usually softened, though parts of it are said to be sometimes indurated, 
especially in the tubular portion. The mucous membrane of the pelvis is 
usually reddened and thickened, and the investing coat more easily separable 
than in the healthy state. At a later period, pus is observed in the glandular 
structure, either disseminated, or collected in small cavities, and sometimes 
also in the pelvis, along with fibrinous exudation. In some rare instances, 
blood and pus have been seen, interspersed among the broken down tissue of 
the gland; the whole having a fetid odour, indicating gangrene. Sometimes 
the mucous membrane of the pelvis and calyces exhibits evidences of disease, 
without a corresponding affection of the parenchyma, being reddened, ecchy- 
mosed, and, in the advanced stages, softened, ulcerated, and even gangrenous. 
Occasionally patches of coagulable lymph exist upon the surface, which in 
some instances close the ureter. When obstruction of the ureter has occurred 
from fibrinous exudation, calculous concretion, or other cause, the pelvis is 
found to be distended with urine, mixed with blood, pus, and amorphous or 
crystalline deposits. In chronic cases the kidney is sometimes larger, but 
usually rather smaller than natural, more or less hardened, often rough, gran- 
ular, or lobulated on the surface, and of a pale colour mottled with red. In 
old cases of suppuration, the substance of the gland is mostly destroyed; the 
interior parts being reduced to a disorganized pasty mass, into which the re- 
mains of the blood-vessels and excretory tube may be seen to run in the form 536 
[part II. 
LOCAL DISEASES.-SECRETORY SYSTEM. 
of fibrinous cords. The mucous membrane is thickened, sometimes pale, at 
other times reddish-brown with slate-coloured patches, and occasionally ulcer- 
ated. In the cases in which dilatation of the pelvis has taken place, pouches 
of great size are sometimes found, the walls of which consist partly of the 
thickened mucous membrane, partly of the distended substance of the kidney, 
the outer surface of which has formed adhesions with the neighbouring vis- 
cera. The contents of these pouches, when not opened by ulceration, are 
usually mixtures of urine, pus, and blood with occasionally one or more cal- 
culi, which have probably been the cause of the mischief. An instance is on 
record of a tumour of this kind weighing sixty-eight pounds. Instead of the 
large tumours, the fistulous passages are sometimes to be seen by which they 
have discharged their contents in the various directions already noticed. 
Causes.-Mechanical violence, as from blows, falls, concussions, or penetrat- 
ing wounds; exposure to cold and wet; the drinking of cold water when over- 
heated and perspiring; various substances which have the property of irritat- 
ing the kidneys, as cantharides both internally and externally used, oil of 
turpentine, and corrosive sublimate in poisonous doses; and the abuse of 
alcoholic drinks, have been enumerated among the causes of nephritis. An- 
other very frequent, and perhaps the most frequent cause, is the presence of 
calculi, or' gravelly matter, in one of the calyces, in the pelvis, or in the ureter. 
In such cases, both kidneys are apt to be affected. These concretions pro- 
duce inflammation in two ways, either by the direct irritation of their irregu- 
lar surfaces, or by obstructing the outlet of the fluids and thus occasioning 
distension. In the former of these modes of action, they are much aided by 
whatever produces in them sudden and violent movement, as horseback riding, 
the jolting of a rough carriage, jumping, running, &c. Other substances in 
the kidneys besides calculi sometimes cause inflammation of the organ. Such 
are cysts, hydatids, and various morbid deposits in the glandular tissue, in- 
cluding the tuberculous and carcinomatous. Still another cause, which is not 
unfrequently associated with the preceding is gout. This sometimes operates 
by giving rise to the deposit of calculous or gravelly matter in the kidney; 
and sometimes by a direct influence; as where the disease has been translated 
from some other part. Gout not unfrequently constitutes a predisposition to 
nephritis, which is then brought on by cold, and excesses of various kinds. 
Other diseases serve as occasional causes of nephritis. Any affection of the 
urinary organs capable of producing retention of urine may have this effect, 
in consequence of the distension of the pelvis of the kidney which results. 
Hence strictures of the ureter, morbid growths of the bladder closing the 
opening of the excretory duct into it, enlarged prostate, and affections of the 
spinal cord or brain producing paralysis of the urinary organs, may give rise 
to nephritis. It may occur also in consequence of the propagation of irrita- 
tion from an inflamed portion of the urinary passages, whether the ureter, 
bladder, or urethra, to the pelvis of the kidney; and it is not improbable 
that the sympathy which connects an organ with the outer extremity of its 
excretory duct may act in this case, thus producing nephritis as a result of 
gonorrhoea, or other urethral inflammation. Various structures in contact 
with the kidneys are capable of imparting to them their own inflammation, as 
the enlarged liver and spleen, and the peritoneum. Nephritis sometimes occurs 
as an incident in the course of febrile diseases, especially those of a typhoid 
or malignant character. Certain persons appear to be predisposed to it by 
inheritance; probably through a tendency to gout or calculous complaints. 
Old age also constitutes a predisposition; for the disease is most common in 
declining life. It is more frequent in childhood than after puberty, or in the 
vigour of manhood. CLASS III.] 
537 
NEPHRITIS. 
Treatment.-In severe cases, in which there is reason to believe that the 
substance of the kidney is affected, and the pulse is vigorous, blood should be 
taken freely from the arm; and the bleeding should be repeated again and 
again, if the symptoms do not yield, and the strength of the patient permit. 
In many instances, however, especially of inflammation of the mucous mem- 
brane, such as results from uric acid gravel, for example, the grade of action 
is not sufficiently high to call for copious depletion. A moderate bleeding, 
or the application of cups to the loins is all that is necessary; and sometimes 
even these may be dispensed with. It is, however, a good general rule to 
take blood when the inflammation is sufficient to occasion fever. When the 
arterial excitement has been sufficiently subdued by the lancet, should decided 
symptoms of inflammation continue, local depletion by cups or leeches should 
be resorted to, and repeated if deemed advisable. 
After the first bleeding, the bowels should be well evacuated. A loaded 
state of the colon must act very injuriously; and purging is moreover indi- 
cated both as a depletory and revulsive measure. As the stomach is often 
irritable, calomel is, perhaps, the best cathartic to begin with, being one of 
those most certainly retained. Should it not operate efficiently, it should be 
followed either by some mild purgative, as sulphate of magnesia, or castor 
oil, or by copious enemata. When the pain is very acute, and especially if it 
be of a spasmodic character, opium should be given with the calomel, in doses 
large enough to make a decided impression on the' system. From one to 
three grains is not too large a dose in many instances; but perhaps the better 
plan would be to give a moderate dose both of the opium and calomel, and 
repeat it if necessary. Thus, from three to four grains of calomel and one of 
opium may be given every two hours until three doses have been taken, unless 
relief is previously obtained. This combination often has the effect of com- 
posing the stomach, so that it will receive more kindly the saline or oleagi- 
nous cathartic, which, under these circumstances, should never be omitted. 
Should the system be rebellious to opium and its preparations, the extract of 
henbane may be substituted. Independently of their aid in cleansing the 
bowels, copious enemata of warm water, or warm mucilaginous fluids, are 
thought to be useful as internal fomentations. 
The bowels having been well evacuated, it will be advisable to aid the 
depletory measures by warm cataplasms or fomentations to the loins, the hip- 
bath, or the full warm bath; care being taken that the patient is protected 
against cold. The warm bath is peculiarly applicable to the cases of children. 
At this stage, great advantage will also frequently accrue from the use of opiate 
enemata at night. From forty to sixty drops of laudanum, in a wineglassful 
of mucilage or thin starch, thrown up the rectum, not only affords relief to 
the pain and restlessness, but also frequently quiets the stomach, and enables 
it to receive medicines kindly. Should the stomach be retentive, instead of 
an anodyne enema at bedtime, a grain of opium, with an equal quantity of 
ipecacuanha, and a grain or two of calomel, may be substituted, and the bowels 
opened upon the following day by a mild cathartic. 
To quiet irritation of stomach is often a prominent indication. Should it 
not yield to the anodyne, small doses of the effervescing draught, or repeated 
draughts of cold carbonic acid water will frequently afford great relief; and 
a sinapism may be applied to the epigastrium, should these remedies fail. 
Creasote has been recommended, but is of doubtful propriety, unless in the 
advanced stages. 
When the stomach is retentive, free dilution by mucilaginous drinks, as 
gum-arabic water, barley-water, flaxseed tea, &c., will often be useful by 
diluting the urine, and rendering it less irritating. They are, however, pecu- 538 
LOCAL DISEASES.-SECRETORY SYSTEM. 
[part it. 
liarly applicable to cases of mucous inflammation, without much disease of the 
substance of the kidney. In the declining stages, chicken, mutton, or veal 
water, or rennet whey, may be substituted for the mucilages. 
At any time, if the skin is hot and dry, citrate of potassa, in the form 
either of the neutral mixture or effervescing draught, will be found an excel- 
lent adjuvant; and tartar emetic, in very small doses, may be added if the 
stomach is not at all irritated. 
When the disease is connected with calculous deposition, especially of 
uric acid or the urates, bicarbonate of soda is an invaluable remedy. If, 
therefore, the urine should deposit a lateritious sediment, or should be high- 
coloured, and prove strongly acid upon the application of test paper, let half 
a drachm of the bicarbonate be given three or four times a day, in three or 
four fluidounces of carbonic acid water, with or without syrup, care being 
taken to avoid the acidulous syrups. The same remedy is also useful, though 
less strikingly so, in the phosphatic depositions. 
In gouty cases, in addition to the measures already proposed, attempts 
should be made to call the disease to the extremities by sinapisms to the legs 
or ankles, or bathing the feet in hot water, rendered more stimulating by red 
pepper or mustard. Colchicum is also an excellent adjuvant, given so as to 
keep up a moderate and steady influence on the secretions without nauseating 
the stomach. It may often be usefully combined with morphia. 
In the more advanced stages, benefit will accrue from irritation to the loins. 
Blisters are recommended by some, but they are hazardous in consequence of 
their tendency to produce strangury. Revulsion is more safely effected by 
ammoniacal lotions, sinapisms, pustulation with tartar emetic or croton oil, or 
by setons, issues, or even moxa. But these latter measures are best adapted 
to chronic cases. 
Should the disease be of the chronic grade at the commencement, it will be 
proper to treat it at first by some of the remedies already enumerated, but em- 
ployed with much more restraint. The occasional application of a few cups 
or leeches, possibly in some instances a moderate bleeding; attention to the 
state of the bowels and urine, which should be kept as nearly normal as pos- 
sible (see calculous disease)' revulsive applications to the loins; the wearing 
of flannel next the skin; and a careful avoidance of the exciting causes, are 
the most important measures. But, when the disease is advanced, whether 
originally chronic or consequent upon an acute attack, and the urine is loaded 
with mucus or pus, indicating disease and possibly ulceration of the pelvis of 
the kidney, another system of measures becomes necessary. Attempts should 
now be made to act directly upon the diseased surface by medicines which pass 
through the kidneys. Among these uva ursi has long been prominent, and 
should be employed freely in the form of decoction. Pipsissewa has analogous 
properties, and is probably not less efficient. The turpentines and balsams 
have long been employed in these cases with obvious benefit. Oil of turpen- 
tine and copaiba are the most convenient, and probably the most effectual. 
Even cantharides may be here employed, as a stimulant impression upon the 
diseased surface is often highly useful; but great caution should be observed 
in its use. Diosma and pareira brava have enjoyed much credit in this stage 
of the disease. Should any of these remedies produce much irritation, they 
should be suspended, and recourse be had to demulcent and emollient measures. 
In the mean time, it is necessary to support the general health. For this 
purpose, some of the milder tonics may be occasionally used with advantage, 
especially the chalybeates and pure bitters. Wild cherry bark is well adapted 
to cases complicated with hectic fever. Moderate exercise and pure air are 
highly important. If a resident of cities, the patient should, therefore, be CLASS III.] 
NEPHRITIS.-BRIGHT'S DISEASE. 
539 
sent into the country during the summer. Certain mineral waters have been 
found beneficial, especially those combining a chalybeate with alkaline salts 
and carbonic acid impregnation. 
The diet should be adapted to the stage and grade of action. In the early 
stage of the acute disease, it should be exclusively mucilaginous or farinaceous, 
and should be employed usually in the liquid form. When the disease is 
advanced, weak animal broths may be added; and, in cases of debility with a 
tolerably sound state of the digestive function, a full allowance of the ordinary 
food may be permitted ; indigestible and acescent substances being scrupulously 
excluded. In the chronic disease, with symptoms of local or general excite- 
ment, it is best to restrict the patient to vegetable food, with the addition of 
milk in doubtful cases. But, when suppuration is fairly established, and the 
general strength begins to fail, the diet should be nutritious, though still mild 
and digestible. 
When coma supervenes upon affections of the kidneys, little additional can 
be done. The attention of the physician is still to be directed to the disease 
of the urinary organs, and the restoration of the suspended secretion should 
be the object chiefly aimed at; as it is upon this probably that the cerebral 
symptoms depend. It must be remembered, however, that in the acute, dis- 
ease no good can accrue from the stimulating diuretics. They would only 
aggravate the difficulty. The cerebral symptoms may be combated by cold 
fb the head, and leeches to the nape of the neck or the temples. Typhoid 
cases must be treated upon the principles applicable to low forms of fever in 
general. 
In all cases where the symptoms do not appear disposed to yield, and the 
remedy is not prohibited by a cachectic state of system, mercury so exhibited 
as but slightly to touch the gums, promises some chance of good. 
Article II. 
BRIGHT'S DISEASE. 
Syn.-Granular Degeneration of the Kidneys.-Fatty Degeneration of the Kidneys.- 
Desquamative Inflammation of the Kidneys.-Albuminuria.-Albuminous Nephritis. 
Attention was first called by Dr. Bright, of London, to the peculiar asso- 
ciation of symptoms, connected with a disordered state of the kidneys, which, 
for the want of a name fitted to express its precise pathological character, is 
generally called Bright's disease, in honor of its original observer. This name 
it will be most convenient to retain, until opinion shall have become settled 
upon the exact nature of the affection. In the course of the following obser- 
vations, it will be rendered obvious that neither of the names given above as 
synonymes, has a just claim to exclusive adoption. The statements put forth 
by Dr. Bright, in 1847, were afterwards confirmed and extended by other 
observers, among whom Drs. Christison, Gregory, and Osborne, of Great Britain, 
and MM. Solon and Rayer, of France, are the most prominent ; and recently 
many valuable microscopic observations have been contributed by Professor 
G-luge, of Brussels, Dr. George Johnson, of London, and several others. It 
is due to Dr. Christison to state that, in drawing up the following account of 
the disease, I have availed myself of his lucid essays on the subject. 
There are two forms of the disease, which are sometimes distinct in their 
origin and course, sometimes appear to be merely different stages of the same 
attack, and which may be distinguished by the epithets of acute and chronic. 
I shall first describe them separately, so far as may be necessary to characterize 540 
LOCAL DISEASES.-SECRETORY SYSTEM. 
[PART II. 
each of them; and then dwell more at large on those points which maybe con- 
sidered as belonging to the disease in general. 
Symptoms of the Acute Form.-This is less frequent than the chronic. 
It comes on with symptoms closely resembling those of ordinary nephritis. 
There is usually pain in the loins, sometimes severe and acute, but more fre- 
quently moderate and obtuse, occasionally extending downward to the groin or 
testicle, and usually increased by firm pressure. Micturition is often frequent, 
and sometimes painful; and the urine, of which the quantity is in general much 
diminished, is highly albuminous, and not unfrequently bloody. In some 
cases, there is tenderness of the epigastrium with or without nausea and vomit- 
ing. Fever is a uniform accompaniment, and is often ushered in with rigors 
at the commencement of the attack. Very soon, sometimes in a day or two, 
edematous effusion takes place, and dropsy, of the kind usually denominated 
inflammatory, is developed. All these symptoms, however, are not present 
in every case. Thus, the pain is'sometimes very slight or even wanting, and 
the disease occasionally runs its course without the occurrence of dropsy. 
The urine is often very greatly diminished, and sometimes is quite sup- 
pressed, or comes away only by drops. It is in some cases so abundant in 
albumen, that it is converted by the coagulation of that principle into a uni- 
form jelly; and the deposit, upon standing twenty-four hours after coagula- 
tion, seldom occupies less than one-third of the bulk of the fluid.* Other 
diseases are occasionally attended with coagulable urine; but in none is the 
albumen so copious or so continuous, and so durable in its prevalence. In 
consequence of its presence, the urine froths much when shaken. In other 
respects, it varies greatly. Sometimes it is clear, sometimes blood-red; and, 
in severe cases, blood is occasionally discharged almost or quite unmixed. 
The urine is often turbid or opalescent from the presence of oily matter, of 
opaque mucus, or of the cast off fragments of the mucous epithelium, which 
are recognizable by the aid of the microscope.f Minute cylindrical tubes are 
also sometimes discoverable in it, which are coagula of fibrin moulded in the 
uriniferous tubules of the kidneys; and with these more or less of the epi- 
thelial cells of the tubules. Upon standing, the urine, even when at first 
nearly clear, usually deposits a fleecy sediment, and sometimes lithic and 
phosphatic salts. It occasionally putrefies and becomes ammoniacal; but this 
is a rare event. Its specific gravity is nearly as in health, though generally 
somewhat lowered. In a few instances, it has been found considerably heavier 
than the normal standard, owing to the great abundance of albumen. The 
other solid ingredients do not vary greatly from their due proportion. From 
the diminution in the quantity of urine, whilst most of its solid ingredients, 
as urea and the salts, are in the healthy proportion, it follows that the whole 
amount of these substances eliminated is much lessened. 
* The reader is referred to the article Dropsy, page 342, for an account of the best 
mode of testing the urine for albumen. Dr. Christison states that, if the Coagulated 
albumen be separated, washed, and dried, it will weigh sometimes as much as 27 grains, 
and seldom less than 10, in 1000 of urine. In testing for albumen, allowance must be 
made for that which necessarily attends the presence of blood or pus in the urine ; and, 
if the quantity discovered is very small, the absence of the corpuscles of these fluids 
must be shown by the microscope, before the urine can be pronounced to be albuminous. 
f Dr. George Johnson states that, in the healthy condition of the urine, no renal 
epithelium is contained in it. Consequently, the presence of the epithelial cells of the 
uriniferous tubules is an evidence of a morbid desquamation of this structure. The 
epithelial cells of the secreting tubules differ from those of the straight tubules and of 
the mucous passages, in being rounded instead of flattened, and in having a granular 
and opaque appearance. Occasionally they contain an oil globule, but Dr. Johnson 
thinks this is rare in the perfectly normal state of the epithelium. (fond. Med. Times 
and Gaz., iv. 284 and 335.) CLASS III.] 
bright's disease. 
541 
Blood drawn from the arm is very often sizy and even strongly cupped. 
The serum sometimes appears milky, in consequence of the presence of oily 
matter. Its specific gravity is reduced, sometimes from 1.029, which is 
about the average in health, even to 1.018; and it coagulates loosely by heat. 
Both these circumstances are owing to its deficiency in albumen, consequent 
upon the secretion of that principle by the kidneys. On the other hand, the 
fibrin of the blood is somewhat increased, and urea has been discovered in 
the serum. The proportion of the red corpuscles is not materially altered at 
first, but diminishes as the disease advances. 
Besides dropsy, which has been mentioned, the disease is apt to be asso- 
ciated in its course with various other affections, among which have been 
enumerated inflammation of the serous membranes, bronchitis, pneumonia, 
and diseases of the heart, liver, and brain. When the attack terminates 
unfavourably, it is generally through some one or more of these associated 
affections; and among them coma and apoplexy are probably the most fre- 
quent. More will be said of them hereafter. There is reason, however, 
to believe that, in its acute form, the disease generally terminates favourably; 
and, when this is not the case, it not unfrequently runs into the chronic form. 
Symptoms of the Chronic Form.-Though occasionally preceded by the 
acute form, this has much more frequently its characteristic grade from the 
commencement. The symptoms are in the beginning very obscure. The 
disease may have been in existence for months, nay even for a year or more, 
without the consciousness on the part of the patient of any material departure 
from health. He may have been sensible of a growing weakness, of some 
derangement of digestion, of an occasional tendency to frequent micturition, 
of some obscure or fugitive pain in the lumbar region; he may even have 
observed a diminution in the quantity of his urine, or some irregularity in its 
appearance; but these symptoms were perhaps insufficient to call his serious 
attention, or excite alarm. The first thing which occasions anxiety, and 
leads to an application for medical aid, is usually the occurrence of edematous 
swelling, commencing often in the face and extending rapidly over the body. 
The physician is consulted on account of the dropsical symptoms, and the 
previous existence of the phenomena above mentioned is ascertained upon 
inquiry. At the same time he discovers, perhaps, some tenderness upon 
strong pressure over the region of the kidney, and, on examining the urine, 
finds not only that its quantity is considerably less than the ordinary healthy 
average, though much less reduced than in the acute form, but that its den- 
sity is diminished, and that it is more or less albuminous. If dropsy has 
not been developed, the gradual increase of stomachic disorder, general weak- 
ness, emaciation, and perhaps lumbar pain, engages the attention of the 
patient, and leads him to seek relief. There is now danger that the physician 
may overlook the real disease; but, if upon his guard against mistake, he will 
investigate the condition of the urinary organs and of the urine, and will find 
the condition above described. The complaint, unless arrested, slowly ad- 
vances. The constitutional symptoms mentioned are aggravated, nausea and 
frequent vomiting are occasionally added to the other dyspeptic phenomena, 
the patient complains of great thirst and occasional drowsiness, the surface 
becomes dry, and at the same time pale and nearly bloodless, and a general 
anemic condition sets in, which is one of the most striking features of the 
case. Instead of paleness, there is sometimes a purplish hue of the surface, 
and not unfrequently the patient has a dusky aspect. Exposure to cold or 
some other cause occasionally brings on an acute attack, with fever, an in- 
crease of uneasiness in the back, a still further diminution in the amount of 
urine, and a greater degree of albuminous impregnation. These symptoms 542 
[part II. 
LOCAL DISEASES.-SECRETORY SYSTEM. 
may subside under treatment, and the complaint resume its chronic march. 
At length other diseases supervene, and either carry off the patient, or leave 
him, upon their subsidence, more exhausted than before. The system-seems 
to be peculiarly susceptible to inflammatory attacks, whether acute or chronic, 
such as pleurisy, peritonitis, pericarditis, bronchitis, and pneumonia. De- 
rangement of the alimentary canal is not uncommon. Frequent and very 
obstinate vomiting has been noticed as a prominent symptom in this stage. 
Though generally constipated, the bowels are sometimes affected with an 
exhausting diarrhoea. Organic diseases of the heart, lungs, and liver, either 
previously existing, or developed during the progress of the complaint, very 
often aggravate the danger, and render a fatal termination almost certain. In 
the ordinary course of the complaint, if it end unfavourably, death is pre- 
ceded by comatose symptoms, sometimes amounting to apoplexy. 
The urine differs greatly in different cases, and at different periods of the 
same case. The only invariable circumstance in relation to it is a reduction 
of its specific gravity, owing to the diminished proportion of its solid con- 
stituents, especially the urea and salts. This is the most characteristic phe- 
nomenon of the chronic form of the complaint. Though the density of the 
urine is generally somewhat below the healthy average in acute attacks, the 
reduction is trivial compared with that which takes place in the chronic. 
According to Prout, the specific gravity of healthy urine is from 1.015 to 
1.025, according to Solon, from 1.020 to 1.024. It has been diminished in 
this complaint to 1.003, though the average is considerably higher than this. 
The density goes on diminishing with the progress of the complaint, and is 
not materially increased by the supervention of an acute attack. 
The urine is very generally, though not uniformly albuminous; and the 
quantity of albumen varies. It is always much less than in the acute disease, 
except when an acute attack supervenes upon the chronic. The coagulum 
produced by heat or nitric acid, instead of occupying one-third of the volume 
of the urine, below which it seldom falls in the acute, is diminished to a 
quarter or even an eighth. In the advanced stages, it sometimes wholly dis- 
appears for a time, and sometimes the usual tests occasion only a slight opal- 
escence. Towards the close of the case, this may happen even though the 
urine is but small in quantity; but it also sometimes occurs at an earlier pe- 
riod, when the secretion is more than ordinarily copious.* 
The quantity of urine is also very variable. Sometimes it is very small, 
sometimes natural, sometimes increased; and the augmentation is occasion- 
ally so great as to constitute diuresis. It diminishes upon an acute invasion, 
and near the close of the complaint, when the daily discharge is often reduced 
to one or two ounces. The colour of the urine may be yellowish, or blood- 
red, or dark-brown, or even quite natural; but it is usually much paler than 
in health, and the secretion is in some instances almost colourless. It is 
generally more or less turbid or opalescent, from the same cause as in the 
acute form. The fleecy matter which communicates the partial opacity, gradu- 
ally settles towards the bottom of the vessel, without in all instances completely 
* Dr. G. Owen Rees has generally found one of the extractive matters of the blood-, 
in these cases, along with the albumen. After separating all the albumen by brisk boil- 
ing and filtration, so that the urine yields no sign of the presence of this fluid, he has 
been able to obtain a copious precipitate with tincture of galls, showing a strong analogy 
between the liquid eliminated by the kidneys, in these cases, and the effusions from 
serous surfaces. He has noticed the same extractive matter in the urine of cardiac ana- 
sarca without disease of the kidneys, and in chlorotic anaemia, and believes that its 
escape from the blood contributes much- towards the impoverishment of that fluid, and 
the production of debility in such affections. It diminishes along with the albumen in 
convalescence. (Lend. Med. Gaz., July, 1851, p. 136.)-Note to the third edition. CLASS III.] 
bright's disease. 
543 
separating. In microscopic examinations, therefore, the lower portion should 
be selected where there is no solid sediment. In this insoluble matter are 
found, in various proportions, and on different occasions, blood or pus corpus- 
cles, oil globules, epithelial cells variously altered, cylindrical casts of the 
uriniferous tubules, and occasionally the urates and phosphates. 
A singular circumstance, considered in connexion with the state of the 
urine, is the rapid diminution of the colouring matter of the blood. It has 
been stated that, in the acute stage, the proportion of this constituent is but 
slightly changed, while the serum of the blood loses much of its albumen, 
in consequence of the rapid separation of this principle by the kidneys. 
But as, in the chronic stage, less albumen is discharged with the urine, the 
serum nearly reacquires the proportion which it has in health. The salts and 
fibrin of the blood are not materially changed in quantity; and urea, which 
is not appreciably present in health, has often been found in the serum in 
Bright's disease; an event which might be looked for from the diminished 
amount secreted. All this is what might be expected from the condition of 
the urine. But the disappearance of the colouring matter of the blood is 
not so readily accounted for. All due allowances being made for the effects 
of artificial bleeding, and of occasional hemorrhage from the kidneys, the 
red corpuscles are sometimes reduced to one-third of their healthy proportion 
under the direct influence of the disease alone. The diminution goes on until 
the close of life; and the whole surface of the body consequently often ac- 
quires before death a waxen, yellowish-white, almost cadaveric hue. To what 
is this loss of the red corpuscles to be ascribed ? Is it owing to the failure of 
the digestive process? In reply to this question, it is asserted that the phe- 
nomenon occurs in cases in which the digestion is apparently unimpaired. 
Can it be that the colouring matter is changed into albumen by the kidneys? 
This is not probable. The fact that the proportion of albumen in the urine 
is smallest in the advanced stage, when the decolorization of the blood is going 
on most rapidly, is wholly incompatible with this notion. The most probable 
explanation appears to be, that there is some failure in the vigour of the as- 
similating processes, dependent probably on the same cause which has predis- 
posed the kidneys to the morbid change going on within them; and that the 
two effects, instead of having any mutual dependence, are merely coexisting 
results of the same concealed agency. It has been suggested that the effect 
might depend on a solvent power of the urea over the red corpuscles, or a 
poisonous influence upon them leading to their disintegration. 
Associated Disorders.-Dropsy is the most frequent and important of the 
affections associated with Bright's disease. It has, indeed, been considered 
as one of its essential phenomena. But this is an error. It is not only often 
absent during long periods in the progress of the disease, but is sometimes 
wanting throughout its whole course, especially in the acute form. Nor are 
all cases of dropsy with albuminous urine, as has been supposed by some, 
associated with this particular disease of the kidney. But when along with 
dropsy, in any particular case, there is scanty and highly albuminous urine, 
and when the specific gravity of that secretion is decidedly and steadily below 
that of health, at the same time that the quantity is at times at least reduced 
below the natural standard, and especially if there is evidence in lumbar pains 
of the existence of renal disease, there is no longer room for doubt. The 
dropsy has been ascribed, in acute cases, to the diminution of albumen in the 
blood, and, in chronic cases, to this combined with deficiency of red corpuscles, 
whereby the liquid portions of the blood are allowed more readily to pass 
• through the vascular walls. There is probably some truth in this suppo- 
sition ; but it appears to me that, in the acute form, it comes on too speedily 544 
[part II. 
LOCAL DISEASES.-SECRETORY SYSTEM. 
after the first evidence of kidney affection, to be ascribable, at least exclusively, 
to any alteration of the blood dependent on that affection. In such cases, a 
more probable origin is irritation of the serous or cellular tissue, resulting 
from the same cause as that which gives rise to the inflammatory congestion 
of the kidney. This form of. dropsy has been already sufficiently considered 
in all its practical relations. (See page 349.) 
The British writers upon Bright's disease speak of a strong tendency which 
it has exhibited, within their observation, to favour the developement of 
inflammation in other parts of the body, especially the serous membranes. 
The pleura, peritoneum, and pericardium are attacked, in relation to fre- 
quency, in the order in which they are here placed; and the arachnoid is 
sometimes affected. Bronchitis is not unfrequent, and is apt to be very 
obstinate. Pneumonia has also been noticed in some cases. Chronic rheu- 
matism is said to be very frequent and obstinate in the chronic disease of the 
kidney. These inflammations are liable to occur upon slight exposure to 
cold, or to cold and wet combined; and may be ascribed to the condition of 
the blood, rendered impure by the defective state of the most important 
emunctory. But their origin is somewhat obscure. 
Cardiac and hepatic diseases are very frequent associates of Bright's ma- 
lady. Out of one hundred cases recorded by Dr. Bright himself, there were 
only twenty-seven in which no cardiac affection could be detected, and in 
fifty-two instances the heart was in a state of hypertrophy. In eighteen of 
these there was valvular disease, in eleven the aorta was affected, and in the 
remaining twenty-three, the hypertrophy could not be traced to any other 
organic affection of the heart or the large blood-vessels. (See Watson's Leet., 
Am. ed., p. 785.) The inference is obvious that, where the disease originated 
in the course of the renal affection, it must have been owing to the existing 
anaemia, which, by an obvious mode of action, is one of the most powerful 
agents in the production of hypertrophy and dilatation of the heart. But 
not unfrequently the cardiac precedes the renal disease; and it is not at all 
unlikely that the two have one common cause. The same may be said of 
the disease of the liver, which occasionally accompanies Bright's disease, and 
very greatly increases its danger. The most frequent hepatic affections under 
these circumstances are fatty degeneration, and that usually denominated 
cirrhosis. The affections both of the heart and the liver tend very strongly 
to increase the dropsical effusion, which is supposed to have its origin in the 
renal disease. 
Dyspeptic symptoms are extremely common, and often very troublesome. 
Dr. C'hristison lays great stress on The chronic vomiting frequently attendant 
upon the complaint of the kidney, and apt to be peculiarly distressing towards 
its close. It sometimes occurs daily upon the awakening of the patient in 
the morning, sometimes frequently in the course of the day; and in some 
cases all the food taken into the stomach is rejected. It is highly probable 
that the cardiac disease has some influence, perhaps the chief influence in 
producing this state of the stomach. So far as regards the latter organ, it 
appears to be merely functional. The inference is obvious, that it must greatly 
contribute to exhaust the patient and hasten the fatal issue. The frequent 
attacks, of diarrhoea incident to the disease have been before alluded to. Some- 
times this affection is useful by relieving the dropsy, sometimes it is the 
immediate cause of death by the exhaustion it produces. It may in some 
instances be purely functional; but is more frequently dependent on chronic 
inflammation and ulceration of the bowels. 
In this catalogue of associated affections, the cerebral must not be over- 
looked. They are indeed of very great significance; as it is through the brain CLASS III.] 
bright's disease. 
545 
that a fatal issue of the disease very frequently takes place. Coma may, indeed, 
be considered as the regular termination of a fatal case of Bright's malady. 
In some acute cases, it is the immediate consequence of a total suppression of 
the urine; and the patient is carried off without the supervention of dropsy, 
or any other secondary affection. When dropsy is developed, comatose symp- 
toms frequently make their appearance, and are always a signal of danger. 
In chronic cases, one of the most characteristic phenomena is occasional drow- 
siness, sometimes disappearing and again recurring, but on the whole gradually 
deepening as the complaint advances, until at length it sinks into profound 
coma shortly before death. In some instances, the brain shows evidences of 
more active disorder, in the occurrence of apoplexy, convulsions, or delirium. 
Amaurosis has repeatedly been noticed as an associate of Bright's disease, 
and violent headaches are another occasional attendant. It is customary to 
ascribe the drowsiness, coma, and other cerebral phenomena to the accumu- 
lation of urea in the blood. In all probability, either this or other impurities 
remaining in the circulation from the closure of their usual outlet, are the 
cause of the symptoms by directly poisoning the brain. It is a frequent ob- 
servation that the drowsiness is increased when the urine becomes very scanty, 
and is relieved by an increase of the renal secretion. Total suppression of 
the urine is almost constantly followed by coma. But, in opposition to these 
views, it may be urged that urea is in all cases defectively eliminated, and if 
it be the cause of coma in one instance, it should be so universally. But the 
objection is met by the fact, that this and other noxious principles are elimi- 
nated with the dropsical fluid, in which, in fact, urea has been asserted to 
have been rendered evident by chemical tests. Thus, the occurrence of dropsy 
may be considered as in some degree a safeguard. According to Frerichs, 
•whenever these cerebral symptoms are exhibited, the blood will be found to 
contain not urea only but carbonate of ammonia, which is supposed to result 
from the decomposition of the former principle, and is conjectured to be the 
immediate cause of the morbid phenomena. Frerichs supposes that, for the 
decomposition of the urea, some agent must be present in the blood capable 
of acting on this principle as a ferment, and, according as such an agent is 
present or absent, there will or will not be produced the poisonous effects 
ascribed to urea. But there are probably other sources of the coma. Some- 
times it increases with the increase of the dropsy, and diminishes with its 
diminution. In such cases, it probably depends upon the effusion of serum 
into the ventricles, and is relieved by the absorption of that fluid. The 
anemic state of the blood may possibly also occasion drowsiness, from the 
want of the stimulating properties requisite to keep the brain in action. 
Again, the cerebral symptoms are probably owing, in some instances, to san- 
guineous congestion of the brain, or meningeal inflammation, consequent upon 
the same state of system which occasions inflammations elsewhere; and it can 
scarcely be doubted, that this organ participates not unfrequently in that 
tendency to fatty or other degeneration, which affects so many other organs, 
and is often indeed the primary cause of the affection of the kidney itself. 
Course of the Disease.-When the acute cases are about to terminate 
favourably, which they often do after an uncertain duration, the lumbar pains 
cease, the urine increases greatly in quantity, and the dropsical symptoms 
with the tendency to drowsiness gradually diminish, until health appears to 
be restored. Should the urine continue to be albuminous, the apparent re- 
covery must be looked on as delusive, and the practitioner should persevere 
in his curative measures, or be prepared to encounter a return of the symp- 
toms. In unfavourable cases, the disease runs a variable course. Sometimes, 
without dropsical symptoms, a comatose or apoplectic state comes on speedily, 546 
LOCAL DISEASES.-SECRETORY SYSTEM. 
[PART II. 
and after a few days carries off the patient. This is apt to happen when the 
urine is exceedingly scanty, or altogether suppressed. In some instances, 
the coma is the first symptom which causes alarm; the local affection of the 
kidney having escaped attention, and being, perhaps, first discovered upon 
examination after death. Much more frequently dropsy takes place, either 
exclusively anasarcous, or involving also the serous cavities; and the patient 
perishes of some intercurrent inflammation, or dies comatose in the ordinary 
progress of the complaint, or, after partial and temporary ameliorations, falls 
at length into the chronic state of the disorder. 
The usual course of a chronic case in its earlier stages has already been 
described. In this form, the disease, when once established, either runs 
slowly onward with a steady aggravation of the symptoms, or undergoes 
various changes from the occurrence of secondary diseases, the occasional 
supervention of acute attacks of the' renal affection, and from remissions or 
ameliorations from natural causes, or under the influence of treatment, with 
subsequent exacerbations. Sometimes the complaint appears to be quiescent 
for a considerable time. The dropsy yields wholly or in part, the intercurrent 
inflammations are relieved, and the patient is apparently well; but fresh ex- 
posures bring on renewed attacks, or the local affection, which has remained 
quiescent, becomes again active, and the complaint resumes its march with an 
accelerated pace. Should the patient not perish with an acute or chronic 
inflammation, or in one of the supervening attacks of the disease in the acute 
form, he becomes weaker and weaker, more and more anemic, more and more 
dropsical,' and at length sinks into a fatal coma, or perishes of the compli- 
cations incident to dropsy in its last stage; incurable organic affections of 
the heart or liver not unfrequently superadding their influence to that of the 
renal disease. It has been said that apparently favourable changes take place 
under remedies, which promise fairly, but not unfrequently deceive the hopes 
of the practitioner. Such indications are ^never to be relied on, unless the 
urine resumes and retains for some time the healthy character. It must not 
only become natural in appearance and quantity, and free from albumen; 
these changes not unfrequently occur without any real improvement; it must 
also regain the healthy density, showing that the kidneys are capable of per- 
forming their part in the purification of the blood; and the favourable change 
must persist for a long time, before it will justify confidence in the really 
sound condition of the kidneys. 
Diagnosis.-After the description of the symptoms above given, little need 
be said under this head. In every case where there is any reason to suspect 
the possible presence of Bright's disease, the urine should be examined. It 
is not enough that this should merely contain albumen to prove the existence 
of that disease. Various other morbid affections, both of the kidneys and 
other organs, are occasionally attended with coagulable urine. But this phe- 
nomenon, along with the quantity and density of the urine, and especially 
when dropsical or obvious renal symptoms are present, will afford sufficient 
means for a very probable diagnosis. Thus, should the urine be scanty, highly 
albuminous independently of the presence of blood, and little reduced in specific 
gravity, and should the patient be at the same time febrile, it may be taken 
for granted that he is labouring under an acute attack, or is in the early stage 
of Bright's disease. When the urine, whether scanty or otherwise, is mode- 
derately albuminous, or, though free from albumen at times, is generally con- 
taminated with it, and when, at the same time, its specific gravity is consider- 
ably and steadily diminished, there can be little doubt of the existence of the 
disease in its chronic form. The conjunction of dropsy with these symptoms 
will render the diagnosis almost certain. The evidence of the microscope, as CLASS III.] 
bright's disease. 
547 
■will be soon shown, aids greatly in the decision as to the character of the 
affection. 
Dissection.-Authors describe, as the result of the examination of the kid- 
neys, after death with the above symptoms, various organic derangements, 
among which are tubercles, simple atrophy of the organ, and cartilaginous 
hardness. These, therefore, are affections which, though probably distinct 
from Bright's disease, cannot always be discriminated. But they are rare, and 
a mistake in diagnosis could lead to no evil result. The genuine malady pre- 
sents the following anatomical characters in its different stages. In the early 
stage of the acute form, the kidney is found greatly congested and enlarged, 
weighing twice, thrice, or even four times as much as in health. It is also 
flabby and soft, though the softness is stated to be different from that ordinarily 
produced by inflammation. Signs of vascular congestion are also presented in 
visible arterial ramifications, and reddish points upon its outer and inner sur- 
faces. The colour externally is dark, with spots here and there still darker. 
Internally, the organ appears engorged with blood, and exhibits small patches 
of ecchymosis. The cortical part, which is chiefly and sometimes exclusively 
affected, is of twice or thrice its ordinary thickness. These phenomena might 
be considered as those merely of the early or congestive stage of ordinary acute 
nephritis; but another circumstance, which constitutes the peculiarity of the 
case, is that, in the midst of this congested parenchyma, there is often an 
apparent granular formation, which, though in this stage of the same colour as 
the neighbouring structure, is proved to be distinct by the fact, that it is im- 
pervious to the finest injection, which therefore surrounds and defines it. The 
quantity of this matter appears to increase with the progress of the disease, 
and is abundant in cases which have continued several weeks. 
Sufficient records are wanting of the appearances presented in the early 
stage of the disease, when of the chronic form from the beginning. When 
somewhat advanced, it exhibits the following phenomena. The kidney is some- 
times enlarged and flabby, sometimes shrunken and indurated, and sometimes 
of the natural size. The outer surface is paler than in health, mottled with 
yellowish or grayish patches, and often granular to the touch. The cortical 
portion internally has the same yellowish marbled aspect, the natural striae 
being obliterated or deranged, and has also a rough or granular feel. In a 
more advanced stage, the whole cortical portion, including that which dips 
between the tubuli, has lost its natural reddish-brown colour, and assumed a 
yellowish hue, which is the more striking from its contrast with the healthy 
colour of the tubular structure, which is little affected. If a minute exami- 
nation be now made, small granulations will often be observed, of a whitish 
colour, and about as large as the head of a pin, scattered through the sub- 
stance or on the surface of the cortical part, and sometimes clustering so as 
to give the appearance of patches. Sometimes, however, the new matter is 
quite homogeneous over considerable spaces. That it is different from the 
ordinary structure of the kidney is proved by the fact, that it cannot be in- 
jected. Still further onward in the disease, the surface of the kidney, while 
it has the same mottled appearance, is irregular, often tuberculated, or lobu- 
lated, probably from the absorption of the healthy tissue between the masses 
of new deposition, and the consequent shrinking of the surface. The whole 
kidney is often greatly shrunk, and sometimes very hard. Internally there 
are few remains of the healthy striated cortical portion. If the kidney remain 
of the natural size, the place of the cortical parenchyma is completely usurped 
by the new matter in a granular or homogeneous form, and portions of it are 
also found even amidst the tubular structure; and at length even this structure 
almost entirely disappears, leaving, perhaps, only a single tubulus. When the 548 
LOCAL DISEASES.-SECRETORY SYSTEM. 
[PART II. 
kidney has contracted, the new matter itself appears to have undergone absorp- 
tion, partial or complete, the cortical portion is shrunk, the tubuli also are 
shrunk and deranged in position; and, in some very old cases, the whole kid- 
ney has been reduced to a shrivelled, flabby, almost membranous structure, in 
which little or nothing remains either of the proper glandular parenchyma, or 
of the new deposit. Occasionally, but very rarely, suppuration has been no- 
ticed in the kidneys; and small cysts are not unfrequently found on the 
surface or in the substance of the organ, which are sometimes very numerous, 
and are ascribed to distension of the tubules produced by obstruction below 
the point of dilatation. The supra-renal gland is usually hardened. It is 
unnecessary to detail the morbid phenomena which are occasionally found 
in other organs. They are such as might be inferred from the phenomena 
during life. 
Nature.-It was only with the aid of the microscope, that any hope could 
be entertained of ascertaining the precise nature of those changes in the 
kidneys, upon which the appearances offered to the unaided senses, as well 
as the consequences of the nephritic disease, depend. Such researches have 
been diligently made; and the result has been the discovery of two affections 
of the kidneys, wholly distinct in their nature, though sometimes associated, 
which constitute the real organic lesions in Bright's disease, in at least a great 
majority of cases. These are 1. an inflammation affecting especially the uri- 
niferous tubules, and called by Dr. George Johnson desquamative inflamma- 
tion of the kidneys, and 2, fatty degeneration consisting mainly in a great 
excess of oil in the epithelial cells of the tubules. 
Desquamative Inflammation.-This may be acute or chronic, and may 
originate in either form, or pass from one into the other.* It occupies at first 
the cortical portion of the kidney, and is believed to be seated especially in 
the uriniferous tubules, though producing the general congestion of the kidneys 
which has been noticed in the acute disease. One of the effects of the inflam- 
mation is to cause a more or less rapid production and separation of the epi- 
thelial cells, while at the same time fibrin is exuded so as to form a pseudo- 
membranous lining to the tubules, and the ordinary products of the secretion 
are greatly diminished or cease to appear. The accumulation of the exfoliated 
cells and exuded fibrin produces distension of the tubules, which are thus made 
to compress the vascular rete around them, and consequently to produce con- 
gestion of the Malpighian corpuscles, which in this condition throw out serum 
and sometimes blood itself, but less water than in health. The fluid extra- 
* In order to understand this subject, it is necessary that the student should have an 
idea of the intimate structure of the kidney as recently made known. The cortical 
portion of the gland consists, in great part, of a congeries of tortuous, uriniferous tu- 
bules, which, on leaving this structure, become straight, and combine to form the cones 
which project into the renal pelvis. These tubes, both in their tortuous and straight 
course, are lined with epithelial cells, which, in the former, are believed to be the agents 
of the true urinary secretion, separating the urea, uric acid, saline matters, and other 
characteristic constituents of the urine from the blood. Here and there in the cortical 
tubules, as ascertained by Mr. Bowman, or at the end of each tubule as stated by 
Frerichs, an expansion may be observed, in which is admitted one of the Malpighian 
corpuscles, invested by a very delicate epithelial coating, which separates it from the 
cavity of the tubule. These little bodies are formed by the convolutions or ramifica- 
tions of a branch of the renal artery, terminating in a vein, which leaves the corpuscle 
where the artery enters, and then itself ramifies so as to form a network of vessels about 
the neighbouring tubules. The office of the Malpighian bodies is believed to be to 
separate from the blood its watery part, which, passing down through the tubules, 
washes away the characteristic urinary matters eliminated by the cells, and, mixing 
with or dissolving them, forms urine. The cells are believed to derive the materials of 
their secretion from the blood of the venous network by which they are surrounded. CLASS III.] 
bright's disease. 
549 
vasated from the Malpighian bodies washes down the contents of the tubules, 
and together with these passes out of the body as urine. This, therefore, while 
it contains little urea or saline matter, must be more or less albuminous, and 
contain epithelial cells, fibrinous casts of the tubules, and not unfrequently 
blood. 
Fatty Degeneration.-In this condition, which was first investigated by 
Gluge, and afterwards independently by Johnson, oil globules are deposited 
in great excess in the epithelial cells, distending them, and causing their 
detachment from the walls of the tubules, which become at points so much 
dilated as to burst, and allow the escape of the fatty cells into the neighbour- 
ing tissue. Similar effects are produced in this as in the preceding case upon 
the proper secretion, and, by pressure, on the blood-vessels and the Malpighian 
corpuscles. In the urine the main difference is that, instead of the ordinary 
epithelial cells and fibrinous casts of the tubules, we observe detached cells 
loaded with oil globules, and casts of the tubes containing the oil-bearing cells 
embedded in them. 
In some cases the two affections are combined, the desquamative inflam- 
mation coexisting with the fatty degeneration; and in such the urine will 
contain cells and casts with and without the oil. The presence of a few oil 
globules in the epithelial cells is said by Frerichs to be normal; but Dr. 
Gairdner maintains that the least trace of it indicates a diseased state of the 
kidney, and Dr. Geo. Johnson, who anticipated Frerichs in his statement, 
has subsequently been induced to change his opinion on this point.* The 
coincidence of inflammation and fatty degeneration is in no degree extraor- 
dinary; for the fibrin exuded in the former state may, as the powers of the 
part fail, undergo a change into oil; and, as suppuration is seldom observed 
in this affection, it seems highly probable that the fatty degeneration may be 
substituted for it; the two conditions having this in common, that they ori- 
ginate under similar conditions of the vital forces. 
The characteristic appearances of the kidneys may be readily accounted for 
upon the basis of the above facts. In both forms, the kidneys may be at 
first increased in bulk, in the one from general congestion and exudation of 
fibrinous matter in the tubules, in the other from the copious deposition of 
oil. In both, the granular consistence may be given by the aggregation into 
small masses of the separated epithelial cells. In the fatty kidney, the colour, 
whether uniformly yellow or mottled, is owing to the fatty matter, which in 
the former case is uniformly diffused, in the latter is in isolated spots. The 
shrinking of the gland in the progress of the disease is what might be anti- 
cipated. Pressure on the blood-vessels causes their obliteration; the Mal- 
pighian bodies, not receiving blood, wither; and, as the deposition producing 
the atrophy is irregularly distributed, the shrinking is also irregular, giving 
a granular, tuberculated, or lobulated character to the surface. As the urini- 
ferous tubules are deprived of their cells, the denuded basement membrane 
becomes wholly incapable of performing the proper function of secretion, 
though it may permit the watery portion of the blood to pass more or less 
albuminous, so that, in the advanced stages of the disease, there may be a 
considerable quantity of watery urine, with or without albumen. The func- 
tion of the kidney being thus impaired, the atrophy continues to increase 
from this cause; till at length the gland may become completely wasted. 
In relation to the atrophied kidney, Dr. Geo. Johnson maintains that it is 
not owing to an absorption of the fatty deposition, but is either a chronic 
* See Brit, and For. Medico-Chirurg. Rev. (Am. ed., April, 1852, p. 219) ; also Bond. 
Med. Times and Gaz. (iv. 283). 550 
LOCAL DISEASES.-SECRETORY SYSTEM. 
[part II. 
condition of the acute desquamative inflammation, or a chronic affection from 
the commencement, dependent on a desquamative disposition of the glandular 
epithelium, which is gradually separated, leaving the tubules bare, and thus 
unable to perform their function. Hence atrophy ensues. (Brit, and For. 
Medico-Chirurg. Rev., Am. ed., Jan. 1853, p. 48.) 
Another view has recently been taken not only of this, but of all other 
forms of Bright's disease, by Drs. Ogle and Handfield Jones, the latter of 
whom maintains that the affection consists essentially in a kind of fibroid 
degeneration, in which, in consequence of the morbid state of the fibrin of the 
blood, an unhealthy plasma is thrown out, which, being incapable of normal 
organization, either degenerates into fat, or undergoes an imperfect organiza- 
tion into unhealthy epithelium, whence all the consequences flow. (Ibid., July 
1853, p. 27, and July 1854, p. 41.) . 
Causes.-The views just given of the pathological condition of the kidney 
throw much light upon the causes. It is obvious that whatever is capable 
of exciting inflammation of the cortical portion of the kidneys, with a special 
direction to the uriniferous tubules, may give rise to one variety of the disease. 
Hence, cold occasionally acts as a cause, especially when aided by anything 
calculated to irritate the secreting structure of the gland. Attacks of the 
disease have also been ascribed to blows or falls on the back. But it is 
probable that the most efficient agents are those which operate through the 
blood, and are thus brought to bear immediately upon the seat of the affec- 
tion. To this source is traced by many the influence of scarlatina, the dropsy 
following which is now generally recognized as an example of the acute in- 
flammatory form of Bright's disease. By some it is supposed that the direct 
cause in this case is the scarlatina poison, not thoroughly eliminated in the 
progress of the fever, and seeking an outlet through the kidneys. The abuse 
of alcohol may possibly operate in this manner, by a constant over-stimulation 
addressed to the secreting function of the kidneys. 
But the causes of the variety depending on fatty degeneration are very 
different. It is not over-excitement in this case, but a deficiency of vital power 
or activity that must be looked to. As taught in the early part of this 
work, fatty degeneration, wherever found, is probably the result of the pre- 
dominance of chemical over vital influences. Not only the kidneys, but other 
organs also suffer in the same way. It has been before stated that Bright's 
disease is very often attended with fatty liver. Organic disease of the heart 
is another frequent attendant, and this sometimes has its origin in atheroma- 
tous disease of the valves or endocardium, which is an example of fatty dege- 
neration. Phthisis is another not unfrequent associate; and so also is cirrho- 
sis of the liver. It can scarcely be doubted that there is some common origin 
for all these affections; some state of system in which the powers of life are 
impaired, and particularly those concerned in the elaboration of the blood. 
What that particular condition is remains yet to be determined. Intemper- 
ance is probably among the most efficient agencies in its production. 
In the cases which unite the two forms of renal disease, there may be a 
mere accidental superaddition of inflammation to an already existing fatty 
degeneration; or there may have been a predisposition to the latter, which any 
cause inducing the former may have brought into operation. Cold, diverting 
action from the skin to the kidneys, or substances which directly stimulate 
the latter organ, as oil of turpentine and cantharides, may operate in this 
way. It has been stated, in a previous paragraph, that the inflammation is 
not improbably often the first step, which the fatty degeneration follows, as 
the result of the depreciation of the vital forces, and a sort of substitute for 
suppuration. The notion that the action of mercury is sometimes attended CLASS III.] 
bright's disease. 
551 
with albuminous urine has induced a suspicion that it might be a predisposing 
or exciting cause of the disease; but no proof of the fact has been adduced. 
The puerperal state is thought to favour it. All ages appear to be liable to 
the complaint; and, if persons are more frequently affected in middle life, it 
is probably because they are more apt to be exposed to cold and wet, and 
most addicted to intemperance, which are thought to be the most powerful 
known agents in inducing the complaint in one or the other of its forms. 
Prognosis.-Now that the pathology of Bright's disease has become better 
understood, we are able to form more accurate estimates of its degree of 
danger, and the probabilities of a favourable termination than was formerly 
possible. I have always been convinced, from the results of my own observa- 
tion, that the acute form of the disease is generally curable. As this is ad- 
mitted at present to be essentially inflammatory, there can be no difficulty in 
adopting this favourable view. Indeed, there can be little doubt that, treated 
at an early stage, or before the structure of the kidneys has been so far de- 
stroyed that not enough remains to perform the functions essential to life, 
it may very generally be cured by the use of efficient means. In relation 
to the cases dependent on fatty degeneration, the prognosis is less favour- 
able. At an advanced stage, the complaint is often incurable in consequence 
of the extent to which the kidneys have been destroyed; and not unfrequently, 
moreover, it is associated with organic diseases which are themselves incura- 
ble. But, when not thus accompanied, if treated in the early stage, or while 
enough of the renal structure remains to answer the purpose of purifying 
the blood, I have no doubt that a cure is often possible. All that is neces- 
sary is to obviate the further deposition of the fatty matter. That which has 
been deposited may be removed by absorption or elimination. In other cases, 
where the destruction has been greater, there may be a partial restoration; 
but the health will be uncertain, and the patient liable to frequent disturb- 
ances arising from vitiated blood. In all cases, a relapse will be more to be 
apprehended than an original attack in a healthy individual. The test of 
perfect recovery is a steadily favourable condition of the urine. If, after the 
patient is apparently well, this should continue to exhibit the characteristic 
signs of the disease, or if it should reacquire after having lost them, a return 
of other symptoms may be expected. Dr. Christison considers the danger 
of the disease to be in proportion to the reduction of the daily discharge of 
solids in the urine. He states that, when this is so low as one-third of the 
natural average, the patient may live long in comfortable health; when one- 
fourth, troublesome secondary symptoms are to be apprehended; and a greater 
reduction is soon followed by serious disorder, and usually by drowsiness 
terminating in coma. In the acute form, when there is complete suppression 
of urine with decided coma, the case may be considered hopeless. The same 
may be said of the chronic form without suppression, when drowsiness has 
gradually deepened into coma, notwithstanding the employment of suitable 
remedies. The dropsy and inflammations which attend the complaint fre- 
quently, nay, generally get well under appropriate treatment, though liable 
to recur. The anemic state may be regarded with apprehension, not only 
for itself, but because it aggravates if it does not originate hypertrophy and 
dilatation of the heart. Organic cardiac affections, or cirrhosis associated 
with Bright's disease, are for the most part inevitably fatal. 
Treatment.-As dropsy is the visible affection which is most frequent and 
most prominent in connexion with the disease of the kidney, it usually first 
engages the attention and efforts of the practitioner. But, in relation to its 
treatment, nothing could be said in this place different from what has been 
already said under the head of dropsy in general, to which, therefore, the 552 
LOCAL DISEASES.-SECRETORY SYSTEM. 
[part II, 
reader is referred. The various inflammatory affections which may occur in 
the course of Bright's disease, are to be treated as when they occur under other 
circumstances, reference being had to the exhausted strength and anemic con- 
dition of the patient, in the advanced stages of the chronic complaint, and to 
the liability to be injuriously affected by mercury. On the present occasion, 
therefore, I shall treat only of the measures called for by the renal affection, 
without reference to the secondary complaints. 
In the acute form of the disease, blood should be taken freely once or 
oftener from the arm, followed by cups or leeches to the loins, and by emol- 
lient cataplasms when convenient. Should the fever be high, with a hot dry 
skin, recourse should be had, in the first place, to the refrigerant diaphore- 
tics, including antimonials when there is no nausea, and afterwards, when 
excitement has been somewhat reduced, to the warm-bath or vapour-bath, 
aided by Dover's powder repeated every six or eight hours. In cases not 
attended with much fever, or in which the fever has been in great measure 
subdued, purgatives may be employed with much benefit. Bitartrate of 
potassa, given to the amount of from half an ounce to two ounces daily, is 
probably the most efficient. Should the bowels be torpid, this may be com- 
bined with jalap, or the neutral salts and senna may be substituted. But 
care must be taken not to carry purgation so far as to exhaust the patient; 
and, should his strength appear to fail, the remedy should be suspended or 
omitted. The diet should be strictly antiphlogistic, and cool demulcent and 
acidulous liquids should be given for drink. When excitement has been 
subdued by these means, but the state of the urine still indicates the con- 
tinuance of the renal disease, counter-irritation should be made upon the 
loins by means of ammonia, croton oil, tartar emetic, setons, issues, or moxa. 
Cantharides should be employed with hesitation, unless in the most advanced 
stages of the complaint. 
The same treatment may be applied to cases in which an acute attack su- 
pervenes upon the chronic disease; but bleeding should be employed much 
less liberally, in consequence of the anemic tendency or condition, which is 
aggravated by the loss of blood. 
Mercury, so useful in most inflammatory affections, is here generally con- 
sidered of doubtful utility, if not positively injurious. The system is brought 
under its influence with extraordinary facility; and small quantities some- 
times occasion severe ptyalism. One of the worst cases of mercurial sore- 
mouth which I have ever witnessed, resulted from six to nine grains of calo- 
mel, in a case of general dropsy, probably of this character. Mercury is said 
of itself sometimes to produce albuminous urine, and upon this ground has 
been feared in Bright's disease. But I believe that it is only in the cases of 
fatty degeneration that mercury is contraindicated. There it would probably 
prove injurious, as in scrofulous and other cachectic affections, by still further 
reducing the vital forces, and impairing the blood. In the inflammatory cases, 
whether acute or chronic, I would employ it without hesitation should other 
means fail. Happily, it is now in our power, through recent microscopic dis- 
coveries, to diagnosticate such cases with tolerable certainty. When epithelial 
cells and their nuclei, with entire or broken-down casts of the uriniferous 
tubules, consisting of epithelial cells, their nuclei, and blood corpuscles, united 
by coagulated fibrin into the form of minute cylinders, are visible in the urine, 
without oil globules or but few in the cells, the inference is fair, that the case 
is inflammatory, and that the employment of mercury is justifiable, unless 
obviously contraindicated by an anemic or otherwise impoverished condition 
of the system. 
In cases strictly chronic, the applications already mentioned to the loins, CLASS III.] 
bright's disease. 
553 
including cups or leeches where there is lumbar pain or tenderness, Dover's 
powder and the hot or vapour bath, and the bitartrate of potassa, may be 
used with much benefit. I believe that some of the diuretics are here also 
useful by their direct action upon the kidneys, altogether independently of 
their anti-hydropic effects. In the dropsies with albuminous urine, digitalis 
has been long known to have a most favourable effect, not only in removing 
the effusion, but in effecting a permanent cure. This it can do only by 
modifying in some way the condition of the kidney, possibly by producing an 
absorption of the morbid deposit which is the root of the evil. It is no doubt 
capable of producing the same effect in a similar condition of the kidney with- 
out dropsy ; and should, therefore, be tried in all cases of the disease after due 
depletion. Its use may often be advantageously combined with that of the 
bitartrate of potassa. Other remedies having a peculiar influence upon the 
kidneys may also be tried in chronic cases, the more stimulating substances 
being restricted to the more advanced stages and debilitated conditions. Such 
are squill, uva ursi, and pipsissewa, colchicum, horseradish, mustard, copaiba, 
oil of turpentine, and cantharides. The last-mentioned medicine is asserted 
to have done good in advanced and debilitated cases, to which alone it is ap- 
plicable. Objection has been made on theoretical grounds to the use of diu- 
retics in this complaint. It is said that the secretory structure is already too 
much irritated, and can only be injured by additional excitement. But ex- 
perience is decidedly in favour of these remedies; and in dropsical cases they 
have been, in my hands, incomparably the most efficacious, both in relieving 
the dropsical symptoms, and in permanently curing the complaint. Like all 
other remedies, they require to be adapted to the stage and character of the 
affection; the refrigerant being used especially in the stage of local excitement, 
and the more stimulating only when the disease has become decidedly chronic, 
or is of a low grade from the beginning. We know well that a part chroni- 
cally inflamed is often most efficiently treated by the special stimulants of 
the part; and if the fatty degeneration be, as I believe it to be, the result of 
a low vital action, excitants appear to be specially indicated. On the whole, 
no two remedies within my experience, have been so effectual as digitalis and 
bitartrate of potassa, combined with treatment addressed to the state of the 
system. 
When the system is feeble, and in all instances of fatty degeneration of the 
kidneys unaccompanied with acute inflammation, recourse should be had to 
measures calculated to promote the general strength, and improve the blood. 
The chalybeates, quinia, and the mineral acids, especially the nitric and nitro- 
muriatic, may often be used advantageously in connexion with a nutritious 
diet. The preparations of iron are of incalculable advantage in some of these 
cases connected with anaemia. Gallic acid also has been recommended. I 
have used cod-liver oil with apparent benefit, notwithstanding the seeming 
contraindication of oleaginous substances in cases of fatty degeneration. But 
I have before expressed my belief that this remedy does not act merely as an 
oil, but that, in some unknown manner, it improves the quality of the blood, 
and favourably modifies the nutritive function. 
Diarrhoea must be treated by remedies addressed to the existing state of 
the bowels, varying with the precise cause of the affection. As a general 
rule, acetate of lead, kino, extract of rhatany, and tannic acid, combined with 
a little opium, will be found most effectual; but alteratives, such as sulphate 
of copper or of zinc, copaiba, or oil of turpentine, may be required in cases 
attended with ulceration ; and small doses of the mercurial pill or calomel, in 
others characterized by deficiency or perversion of the bilious secretion. 
The disorder of stomach sometimes calls urgently for relief. It may be 554 
LOCAL DISEASES.-SECRETORY SYSTEM. 
[PART II. 
treated in the same manner as recommended in dyspepsia. The remedies 
elsewhere advised for vomiting (see Vomiting, vol. i. page 563) may be em- 
ployed for the same purpose in this affection. Creasote in the dose of a drop 
or two is said to be peculiarly efficacious. 
Should coma occur, the practitioner must be guided by the state of the 
pulse, and the general strength. If these permit, he will bleed freely 
both from the arm, and locally from the temples or behind the ears. A 
blister should be applied to the back of the neck, the patient should be purged 
with a dose of calomel, or some one of its, combinations, and efforts should be 
made to restore the action of the kidneys by the free use of bitartrate of 
potassa, and other diuretics. In the coma of the advanced stages, the last- 
mentioned remedies are chiefly to be relied on. 
It is highly important, both in the course of the treatment, and after appa- 
rent cure, that the patient should avoid all known causes of the disease. Fie 
should, therefore, carefully guard against cold by wearing flannel next his 
skin, and shunning all unnecessary exposure to vicissitudes of weather, and 
should also scrupulously avoid alcoholic drinks, high seasoned and stimulating 
food, and all kinds of sensual excess. A nutritious, mild, and digestible diet, 
pure air, and moderate exercise will tend to confirm the Cure, or to protract 
life in incurable cases. 
Article HI. 
NONINFLAMMATORY ORGANIC DISEASES. 
The kidneys are liable to most of the morbid alterations of structure found 
in other organs. A particular description, however, of these affections would 
be of no practical importance; as they can very seldom be recognized during 
life by peculiar symptoms. Their phenomena are generally those presented 
by the more common renal diseases, and often those of chronic inflamma- 
tion, which, indeed, not unfrequently attends them. Occasionally congenital 
malposition of the kidneys has been observed. Thus, the gland has been 
found in the pelvis, and in the iliac fossa. The two kidneys have been 
known to be connected by renal structure running across the spine, con- 
stituting what has been named the horse-shoe kidney. It has been before 
stated that, in consequence of obstruction from calculous concretions or other 
cause in one of the calyces or the ureter, distension sometimes takes place; 
and, in extreme cases, the substance of the kidney is reduced by absorption 
or distension to a sort of membranous bag. Generally this violence to the 
structure of the organ is attended with inflammation; but, if very gradually 
induced, ft may go on to a great extent, even so as to produce a tumour per- 
ceptible from without, and yet offer no signs of irritation. 
Hypertrophy is sometimes observed without other organic change than that 
which consists in a mere over-growth. The kidney may in this way be aug- 
mented to double its natural size. The cause appears to be an increased 
stimulation from the blood, insufficient to induce inflammation; and the affec- 
tion generally occurs when one gland is under the necessity of performing a 
double duty, in consequence of the destruction of the other by disease, or of 
its congenital deficiency. Sometimes the hypertrophy is partial, affecting 
only one of the constituent structures, or some one portion of the organ. It 
is attended by no striking symptom, unless, it may be, an increased secretion 
of urine, as in diabetes. 
Atrophy of the kidneys, in a greater or less degree, is a not unfrequent CLASS III.] 
ORGANIC DISEASES OF THE KIDNEYS. 
555 
attendant on other complaints, especially chronic inflammation and Bright's 
disease. There is reason to believe that it may also be, in some rare instances, 
an original affection, dependent on deficiency in the supply of blood, or of 
other influences necessary to the due performance of the nutritive process. 
As in the case of hypertrophy, it may affect a part or the whole of the gland; 
and instances are not wanting in which, while one constituent or portion of 
the gland, or one whole gland, has been atrophied, another constituent or por- 
tion, or the other gland has been in the opposite state. There are no symp- 
toms by which atrophy of the kidney can be known during life. Deficiency 
of secretion depends on too many other causes to lead even to the suspicion 
of the existence of this affection. 
Softening of a peculiar kind, differing wholly from the inflammatory, is 
sometimes met with. It is marked by flaccidity or flabbiness rather than want 
of cohesion. The gland is deficient in firmness, but cannot be readily torn. 
The cause is unknown. The opposite state of induration is not very unfre- 
quent; but it can generally, if not always, be traced to some other organic 
affection, such as chronic inflammation, undue compression, or scirrhus. 
Osseous and cartilaginous degeneration sometimes occurs in isolated masses 
in the interior of the gland, but more frequently in patches in the investing 
membrane, or the subjacent cellular tissue. The whole kidney has been 
known to be enclosed as in a shell of bone or cartilage. The origin of this 
degeneration is not in all instances known; but it is probably, sometimes at 
least, dependent on chronic inflammation; as it has been found associated 
with ulceration and suppuration of the gland. 
Fatty degeneration of the kidneys has generally been considered of rare 
occurrence; but, if Dr. Johnson's views of the nature of Bright's disease be 
received, it must be allowed to be a common affection. (See page 549.) As 
in other organs, there may be two kinds of fatty accumulation in the kidneys, 
one consisting in oil more or less dispersed through the substance of the 
kidney, but not entering the epithelial cells, and not attended with alteration 
of tissue; the other in which the oil is found as well in the cells as elsewhere, 
and replaces the legitimate constituents of the gland. The latter is the true 
fatty degeneration, and is attended with atrophy of the proper renal tissue. 
Cysts occasionally exist, either with or without other organic derangement. 
They consist of a membranous bag, analogous to serous tissue, enclosing 
serum, mucus, pus, fatty matter, and even urine. They are of all sizes, from 
the minutest visible vesicle to a magnitude sufficient to occupy the greater 
part of the gland. Sometimes they are very numerous, and fill almost the 
whole kidney, the proper substance of which disappears. In this form they 
are sometimes found in Bright's disease, and have been differently ascribed to 
distension of the tubules in consequence of obstruction, and to the generation 
of abnormal cells, which have become developed into these little structures. 
The cyst is sometimes of the hydatid character. 
Tubercles of the kidney, though not frequent, are occasionally met with in 
consumptive cases, occupying either the substance of the gland, its investing 
coat, or the lining membrane of the pelvis and calyces. They are of different 
sizes, and have been found in all their stages, from perfect solidity, through 
softening, to suppuration and ulceration. Their contents have even been 
discharged, as in ordinary renal abscesses, into the intestine or adjacent cel- 
lular tissue. They sometimes produce albuminous urine, and during life can 
scarcely be distinguished from Bright's disease. 
Cancer or Carcinoma.-Of the organic renal affections, the carcinomatous 
are probably next in importance to nephritis and Bright's disease. They are, 
however, less frequent in the kidneys than in the liver or alimentary canal. 556 
LOCAL DISEASES.-SECRETORY SYSTEM. 
[part II. 
Sometimes they offer, during life, no peculiar symptoms "by which they can 
be distinguished from chronic inflammation. In other cases, a probable diag- 
nosis may be formed. When the pain is very severe, lancinating, and long 
continued, though with intervals, and there is no special reasofi for referring 
it to the passage of calculi; when blood comes pure or nearly pure from the 
kidney, forming coagula in the urine, and frequently returning; when a tumour 
can be felt through the abdominal parietes; when in addition to these symp- 
toms, the patient, as he wastes away, exhibits the peculiar pallid hue of face 
that belongs to cancer, there is strong ground for suspecting the existence of 
that complaint. In its advanced stages, it is often complicated with symptoms 
arising from derangement in the functions of the neighbouring organs which 
may participate in the disease. Towards the close, dropsical effusion is apt to 
occur in the abdomen and lower extremities. 
Dissection exhibits the affection in all its varieties and stages, sometimes in 
the form of yellow medullary carcinoma, sometimes of fungus hsefnatodes, 
sometimes of scirrhus; and occasionally these different conditions are com- 
bined. The absorbent glands in the vicinity are often affected, as well as other 
neighbouring structures; and the disease is asserted sometimes to involve the 
emulgent vein and vena cava, filling them with its brain-like matter. Indeed, 
in most instances, evidence is afforded that the complaint has travelled to the 
kidney from some other organ, connected with that gland by function or con- 
tiguity, as the bladder, testicle, or liver. 
Renal cancer is most common in middle and advanced life, affects men 
rather than women, and is said to be most frequent in the right kidney. 
The treatment can be only palliative. To relieve pain, opiates must be 
given by the stomach or rectum, or endermically. Other narcotics may be 
conjoined or temporarily substituted, especially hyoscyamus and conium; but 
none are so much to be relied on. If there should be general excitement, 
the most suitable measures would be rest, a restricted diet, and moderate 
catharsis with the neutral salts; and, if symptoms of inflammation should be 
superadded, leeches or cups might be applied to the loins. Haematuria must 
be checked by perfect quiet, opiates, acetate of lead or other mild astringent, 
and cold to the loins. The dropsical symptoms should be combated by mild 
diuretics, and hydragogue cathartics, especially cream of tartar. 
Article IV. 
INFLAMMATION OF THE BLADDER, or CYSTITIS. 
Though the several coats of the bladder may be inflamed separately, yet 
it seldom happens that one is long affected, in the acute form of the disease, 
without one or more of the others being involved; and it would be a useless 
refinement to treat of the inflammation of each coat as a distinct affection. 
There is, however, a form of cystitis so peculiar in its character as to have 
received a distinct name, and to merit a separate consideration. This is 
chronic inflammation of tbe mucous coat, commonly called catarrh of the, blad- 
der. The following observations, therefore, will be included under the two 
heads of acute and chronic cystitis. 
Acute Cystitis.-Symptoms, Course, &c.-Acute inflammation of the 
bladder is characterized by pain above and behind the pubes, much increased 
on pressure in the hypogastrium, by frequent and painful micturition, and by 
fever, usually commencing with a chill, and either preceding for a short time, 
accompanying, or very speedily following the first signs of the local affection. CLASS III.] 
CYSTITIS. 
557 
In some instances, there is little pain at the commencement; but generally it 
is severe, often attended with a burning sensation, and occasionally extending 
to parts without the bladder, as to the glans penis, the perineum, the anus, 
the upper part of the thighs, the loins, and in the more advanced stages to the 
abdomen. At the same time, there is a frequently returning, and sometimes 
almost incessant desire to void urine, which is discharged in small quantities, 
in some instances drop by drop, and often with much pain, heat along the 
urethra, and straining. The rectum is sometimes sympathetically affected, 
and the dysury is attended with tenesmus. A feeling of tension and fulness 
over the pubes is often experienced from distension of the bladder, consequent 
upon retention of the urine. The abdomen itself occasionally becomes tense, 
swollen, and very tender. Epigastric uneasiness, nausea, and vomiting are 
not unfrequent. The patient has an anxious expression of countenance, 
is very restless, and experiences great mental distress from his incessant and 
ineffectual efforts to relieve the bladder. In a few days, if relief be not ob- 
tained, the system begins to sink. The pulse becomes small, very frequent, 
irregular, and feeble; the tongue dry, with extreme thirst; the extremities 
cool; the abdomen tympanitic; hiccough is not unfrequent; delirium sets in, 
sometimes followed by coma or convulsions; and the patient dies in six or 
seven days, or during the course of the second week. Death occasionally re- 
sults from gangrene of the bladder, in which case the pain ceases entirely, 
some time before the close. 
When the disease is less violent, the symptoms may gradually subside, and 
the inflammation terminate in resolution; the amendment being sometimes 
attended by a copious discharge of mucus with the urine. In other instances, 
suppuration takes place, indicated by the appearance of the urine, which be- 
comes torpid and yellowish, and acquires a purulent odour. Generally, in all 
probability, the pus proceeds from the mucous membrane, in which case the 
urine gradually assumes the appearance characteristic of the presence of that 
fluid. Sometimes abscesses form in the walls of the bladder, into the cavity 
of which they open, and the urine thus becomes suddenly contaminated. The 
pus of these parietal abscesses occasionally takes an external direction, and 
escapes into the rectum or vagina, or shows itself in the perineum or vicinity 
of the anus. Cases of this kind may assume a chronic form, and the patient 
may be long afflicted with purulent urine, or discharges of pus, and sometimes 
probably of pus and urine through fistulous openings. 
In some cases of acute cystitis, occupying the vicinity of the orifice at which 
the ureter enters the bladder, these ducts appear to be closed, and urine is 
thus accumulated in the pelvis of the kidney, producing results which very 
much complicate the disease. 
As above described, cystitis is a very formidable disease; but not unfre- 
quently it is much milder, producing only a moderate degree of pain, tender- 
ness, and dysury, and yielding readily to depletion and the avoidance of causes 
of irritation. 
The bowels are usually constipated; but, in the advanced stages, sometimes 
relaxed. ' The urine is at first little altered, or, as in most other acute inflam- 
mations, is rather scanty and high-coloured, with acid reaction, and, though 
clear on being discharged, deposits a sediment upon standing. It afterward 
becomes alkaline, and opalescent or turbid from the presence of mucus, albu- 
minous flakes, or pus; and, in the advanced stages, is sometimes offensive. 
Throughout the complaint, it is liable to be contaminated with blood. When 
it becomes coagulable, without the presence of pus or blood, it may be very 
probably conjectured that the inflammation has extended to the kidneys. 
The symptoms of the disease are somewhat different, according to the coat 558 
[PART II. 
LOCAL DISEASES.-SECRETORY SYSTEM. 
or particular portion of the bladder which may be primarily or chiefly affected. 
Thus, when the pain is burning, the disposition to pass urine almost constant, 
the discharge small and attended with ardor urinae and painful spasm, and 
mucus present in considerable quantity in the urine, it may be inferred that 
the disease is chiefly in the mucous membrane. When there is severe pain, 
and great tenderness above the pubes, and the contraction of the bladder is 
either very painful or impossible, so as to give rise to retention of urine, while 
there is little or no dysury or strangury, the probability is that the peritoneal 
coat, and perhaps the muscular, are affected. Severe dysury, excessive pain 
upon the introduction of the catheter, and tenderness in the perineum, with 
little or none in the hypogastrium, are signs that the neck of the bladder is 
especially diseased. The occurrence of tenesmus indicates that the inflamma- 
tion is in the posterior part of the bladder, and of abdominal pain and tender- 
ness that it is in the summit. Sometimes the disease runs into the chronic 
form, and continues for months, or years. 
Dissection.-The mucous coat exhibits the usual signs of inflammation of 
that tissue; being reddened in irregular patches, softened, and sometimes par- 
tially disorganized. Portions of the surface are sometimes covered with puri- 
form or fibrinous concretion, bearing some resemblance to ulcers. Not unfre- 
quently ulcers exist, which penetrate to the muscular coat. Pus is some- 
times found infiltrated in the muscular tissue, or occupying small cavities in 
the walls of the bladder; and the sinuous passages may occasionally be traced, 
by which the contents of similar abscesses have escaped. The cellular tissue 
of the bladder is infiltrated with serum, coagulable lymph, or pus. In some 
cases, portions of the bladder which had been inflamed are found gangrenous. 
Causes.-Mechanical causes frequently produce cystitis. Such are wounds, 
falls and blows, the careless introduction of the catheter, severe labours in the 
female, and stone in the bladder. The last-mentioned cause most frequently 
induces a chronic inflammation of the mucous coat; but sometimes, aided by 
rough and sudden movements, as, for example, riding upon a rough horse, it 
gives rise to an acute attack. Irritating injections into the bladder, disten- 
sion from retained urine, and the action of certain substances which, when 
swallowed, have a tendency to pass off by the kidneys, such as cantharides 
and the oil of turpentine, may produce cystitis. Exposure to cold after being 
heated is a fruitful cause, especially when a predisposition exists. Among 
the causes are also enumerated, the suppression of habitual discharges, the 
translation of gout or rheumatism, the retrocession of cutaneous eruptions, 
and the direct propagation of inflammation from continuous or contiguous 
structures, as the prostate gland and urethra, the peritoneum, rectum, and 
womb. The disease is not confined to any age, or to either sex, but is most 
common after maturity. 
Treatment.-When the strength permits, blood should be taken freely, 
and, if necessary, repeatedly, by venesection; and leeches should be applied 
copiously above the pubes or in the perineum. In severe cases, a calomel 
purge should be given at the commencement, followed in due time, should it 
not act freely, by castor oil; and the bowels may afterwards be kept open by 
the saline cathartics. Emollient cataplasms or warm fomentations, and the 
warm bath are useful adjuvants. Large demulcent enemata have been re- 
commended, under the impression that they may make a useful emollient 
impression; but any advantage of this kind would probably be more than 
counterbalanced by their pressure on the tender bladder. The free use of 
cold mucilaginous drinks is generally considered useful by increasing the 
secretion of urine, and rendering it less irritating; and such is probably the 
case when the mucous membrane chiefly is affected; but, when the inflamnia- CLASS III.] 
CHRONIC CYSTITIS. 
559 
tion is seated in the muscular and peritoneal coats, so as to prevent contraction 
of the bladder, and thereby induce retention of urine and consequent dis- 
tension of the viscus, an augmentation of the secretion is scarcely desirable. 
Under such circumstances, it would be proper that the patient should take no 
more liquid than is necessary to satisfy urgent thirst, and that what he may 
swallow should be tepid, so as to direct action rather to the skin than the 
kidneys. In general there is a decided indication for the promotion of dia- 
phoresis. In the earlier stages, this may be done by the use of citrate of 
potassa, acetate of ammonia, and the antimonials when there is no nausea. 
Should the stomach be irritable, the effervescing draught would be preferable, 
from its anti-emetic as well as diaphoretic property. The action of these 
medicines may be favoured by the vapour-bath. After depletion, Dover's 
powder should be preferred. Great advantage will often accrue from anodyne 
enemata, in all stages of the disease, after the bowels have been thoroughly 
evacuated. They not only relieve the distress, but are positively therapeuti- 
cal by preventing in some measure those violent efforts at micturition, which 
cannot but aggravate the complaint of the bladder. They sometimes greatly 
facilitate the evacuation of the urine. In case of distension of the- bladder, it 
becomes necessary to draw off the urine by the catheter, which, however, 
should be used with caution, and never officiously, for fear of irritating the 
inflamed membrane unnecessarily. 
If the disease has followed the disappearance of external gout or rheuma- 
tism, attempts should be made by stimulant applications, such as mustard, 
Cayenne pepper, ammonia, hot wtiter, &c., to bring back the disease to its 
original seat; while, in addition to the ordinary measures for the cure of 
cystitis, one of the preparations of colchicum should be administered inter- 
nally. When a repelled or retroceding cutaneous eruption has been followed 
by the disease, frictions with croton oil or tartar emetic may be found useful, 
by substituting another eruption for that which has disappeared. 
In the advanced stages of the disease, fly blisters over the pubes, or on the 
upper and inner part of the thigh, have been advised; but, in consequence of 
their liability to produce strangury, they should be used cautiously if at all, 
should not be allowed to remain on more than from four to six hours, and 
should be followed by emollient poultices. But, on the whole, blistering by 
solution of ammonia would be preferable; and, if a permanent rather than a 
hasty impression be desirable, anftimonial pustulation, or the use of a seton or 
issue may be better than either. 
Should the disease resist depletion, mercury may be employed with a view 
to a moderate impression on the system. Calomel combined with opium, and, 
if the stomach is not irritable, with ipecacuanha, is perhaps the best prepara- 
tion for the purpose. One or two grains of calomel with a grain of opium 
may be given every four, six, or eight hours, according to the urgency of the 
case. 
The diet should in the early stages be of the mildest kind, consisting ex- 
clusively of farinaceous, mucilaginous, or saccharine drinks. When the dis- 
ease is more advanced, and suppuration has set in, more nutritious food may 
be given, and, in some cases, is absolutely required. Porter or ale may be 
allowed when the debility is great. 
Chronic Cystitis.- Chronic Mucous Inflammation of the Bladder.- 
Cystirrhoea.- Catarrh of the Bladder.-Though in acute cystitis there is often 
a flow of mucus from the bladder, yet this is a much more striking phenome- 
non in the advanced stages of the disease, when it may be considered as having 
assumed the chronic form; and, in many cases, the grade of inflammation from 
the commencement is such that the affection may be considered as of that form 560 
LOCAL DISEASES.-SECRETORY SYSTEM. 
[PART II. 
throughout. Catarrh of the bladder is, therefore, treated of here as a chronic 
disease. 
Symptoms.-The complaint sometimes comes on gradually, so that it is 
impossible for the patient to fix precisely the period of its commencement. 
In other instances the onset is more abrupt. The symptoms are, for the most 
part, those of acute cystitis in a greatly mitigated form. There is more or less 
uneasiness, dull or shooting pain, or sense of morbid heat in the region of 
the bladder; also frequently a feeling of weight in the perineum, and irrita- 
tion about the rectum and anus. With these is always associated a disposition 
to pass urine more frequently than in health. Sometimes this desire is very 
urgent, while the discharge is attended with straining, spasm of the bladder, 
and burning and shooting pains along the urethra. The patient often com- 
plains also of a feeling of' weakness in the loins. There is usually a slight 
fever, with anxiety, restlessness, and general distress. 
But the distinguishing feature of the complaint is the altered character of 
the discharge from the bladder. Soon after the occurrence of the symptoms 
mentioned, and sometimes without them, the urine assumes a whitish, some- 
what turbid. appearance, owing to mucus and the epithelial scales, the deposi- 
tion of whicu leaves it again nearly clear. The mucus increases, sometimes 
readily mixing with the urine, sometimes separating from it, upon standing, 
in the form of a viscid tenacious matter, which cannot be made to mix with 
it again. The quantity of this mucous discharge is often very great, amount- 
ing, according to Prout, in some cases, to several pints daily. Not only does it 
now come away with the urine, but it occasionally also passes nearly or quite 
unmixed, and is sometimes so thick as to be moulded by the urethra as it 
escapes, and even to obstruct the passage for a time. In this state, it is some- 
times so irritating as to occasion severe burning pain in the urethra. Its 
consistence is such that, when the vessel containing it is inverted, it still keeps 
its place. At first the mucus is whitish or opalescent; but at length it be- 
comes yellowish or greenish and quite opaque, obviously from the presence 
of pus. The urine itself is at length changed, being turbid even after stand- 
ing, albuminous, and alkaline. Occasionally blood appears in it from the be- 
ginning in small quantities. Large quantities of the phosphates are sometimes 
precipitated by the alkaline secretion from the bladder, so as, when mixed with 
the mucus, to give the urine a purulent appearance, though no pus corpuscles 
may be detected by the microscope. In such cases, crystals of the phosphate 
of magnesia and ammonia may be seen by placing a portion of the urine be- 
tween plates of glass, and submitting it to microscopic inspection. This con- 
dition may be readily distinguished from the purulent by the reaction of 
liquor potassae, which does not affect the phosphates, while it produces with 
pus a viscid, glairy, mucous-like substance. The urine, under these circum- 
stances, may also have an offensive odour. (Golding Bird, Urinary Deposits, 
Am. ed., p. 154.) In the advanced stages, when there is reason to believe 
that ulceration has occurred, considerable hemorrhage from the bladder is not 
very uncommon. 
If the disease continue to advance, the pains are increased and extended to 
neighbouring parts, especially to the anus and down the thighs; the dysury 
also increases; the mucus is in great measure replaced by pus; the general 
strength gives way; rapid emaciation takes place; and the patient dies in a 
hectic state, worn out by irritation and the exhausting discharge. Not un- 
frequently the fatal termination is preceded by a period of comparative ease. 
Towards the close, the urine assumes the appearance of the washings of flesh, 
being deep-coloured, albuminous, and alkaline, with an ammoniacal odour. 
But at the very last, the quantity both of urine and muco-purulent matter CLASS III.] 
CHRONIC CYSTITIS. 
561 
discharged is greatly diminished; and the urine sometimes recovers its natu- 
ral acidity, probably because it ceases to be contaminated with secretions 
from the bladder. 
Dissection.-In old fatal cases, the mucous membrane is often much dis- 
organized. In some instances, it exhibits dark-red or purplish irregular 
patches, in others, is little discoloured. It is extensively softened, ulcerated, 
and sometimes almost wholly destroyed. The muscular coat is often much 
thickened, contracted, and of a firm consistence, probably in consequence of 
the incessant efforts at micturition. In such cases, the mucous membrane, 
which cannot so readily change its dimensions, is thrown into folds, occasion- 
ally forming a species of sac, in which calculous matter is deposited, while 
the prominent ridges are reddened and abraded. Sometimes the ulceration 
penetrates through the parietes of the bladder into neighbouring organs. Not 
unfrequently the ureters are enlarged, and signs of inflammation are observed 
in the pelvis of the kidneys. 
Causes.-Most of the causes of acute cystitis are capable of producing this 
affection, when operating in a less degree, or upon a less inflammatory con- 
stitution. It is unnecessary to repeat them. Besides those already enume- 
rated, the irritating properties of the urine sometimes secreted by diseased 
kidneys, and excessive venereal indulgences, may be mentioned. In most 
instances in which the disease has been induced by some exciting cause, it is 
probable that a predisposition has existed which has given effect to its action. 
Such a predisposition is supposed sometimes to be inherited, as when it is 
found in scrofulous or gouty individuals; and is sometimes induced by cer- 
tain influences long continued, as by a residence in cold and damp climates, 
the abuse of alcoholic drinks, the undue use of high-seasoned animal food, 
and by sedentary habits, especially when combined with vicious indulgences. 
Cystirrhoea is frequently associated, either as effect or cause, with inflamma- 
tion of other neighbouring parts, especially the prostate gland, the urethra, 
and the lower extremity of the rectum. Stricture in the urethra probably 
sometimes acts as a predisposing cause. The disease is more common in men 
than in women, and in the old than the young. 
Prognosis.-Cystirrhoea will generally get well under proper treatment in 
the early stage, unless there be some strong constitutional predisposition, or 
the causes which produced it continue to operate. In some instances, recovery 
appears to take place in consequence of the supervention of an acute attack 
of disease elsewhere, as of bronchitis or gastritis. After suppuration has 
been fairly established, the chances are diminished, though still the patient 
may often get rid of the disease with due care. It is very apt, however, even 
when it does not destroy life, to continue for a long time, occasionally for 
many years, greatly distressing the patient, and sometimes even rendering 
existence burthensome. Gangrene is necessarily fatal. 
Treatment.-Depletion is seldom requisite, unless occasionally by leeches 
applied over the pubes or in the perineum, near the commencement of the 
disease, or after some fresh accession of inflammation in its course. The 
bowels should always be kept soluble, and sometimes, when there is fever, 
moderate purgation with the saline cathartics is desirable. As laxatives, 
magnesia, castor oil, the lenitive electuary, or sulphur may be used. Those 
cathartics which especially irritate the rectum should be avoided. Dover's 
powder at night, and the frequent use of the warm bath are often beneficial. 
Anodynes are almost indispensable to control the excessive irritation which 
is apt to attend the complaint. Opium as a suppository, or some one of its 
liquid preparations given as an enema, is perhaps the most effectual. But, 
when this narcotic is from any cause contraindicated, hyoscyamus, conium, 562 
[part II. 
LOCAL DISEASES.-SECRETORY SYSTEM. 
lactucarium, extract of hemp, or camphor may be substituted, either sepa- 
rately or variously combined. In very protracted cases, it may be advisable 
to alternate one or more of these narcotics with opium, so that the system 
may not lose its susceptibility to the latter drug. 
When the disease is decidedly chronic, and especially in its advanced stages, 
remedies may be resorted to which have the property of passing off by the 
kidneys, and thus impregnating the urine. Many of these have been used 
with more or less success. The turpentines or their volatile oil are among 
those most employed. In Europe, the Venice, Chian, or Strasburg turpen- 
tine has been given; in this country, the oil of turpentine is usually preferred. 
Of the latter, from ten to thirty drops may be given three or four times a 
day. Copaiba and its volatile oil have similar properties, but are more apt 
to offend the stomach. Buchu has been much commended, and has the ad- 
vantage of not nauseating. Other remedies of analogous character are cubebs, 
balsams of Tolu and Peru, tar-water, and creasote. Certain tonics and as- 
tringents, supposed to have a peculiar action on the urinary passages, have 
enjoyed considerable credit. Such are especially uva ursi, pipsissewa, and 
pareira brava. Other tonics, having no such peculiar influence, are also occa- 
sionally useful. Hops are sometimes advantageous both as a tonic and nar- 
cotic. Sulphate of quinia, the mineral acids, and the preparations of iron 
have also been commended. The tincture of the chloride of iron is supposed 
to be. peculiarly useful, from its tendency to the urinary organs. The tonics 
may often be advantageously combined with some one of the narcotics above 
mentioned. In gouty cases, colchicum may prove useful. Measures must 
be employed to correct any irritating condition of the urine arising from un- 
healthy action of the kidneys. (See Lithiasis.') Dilute phosphoric or other 
mineral acid, or benzoic acid may be given when the bladdei' is loaded with 
the earthy phosphates.* Recourse should be had to mercury upon the failure 
of other means of cure, unless some strong objection exist from the state of 
the constitution in any particular case. No remedy is more powerful than 
this in chronic mucous inflammations. 
Local measures should not be neglected. Though less efficient than in 
more recent cases, counter-irritation may be resorted to 'with some hope of 
benefit. This may be effected in the manner recommended under the pre- 
ceding head. M. Chopart strongly advises the use of injections, and they 
have frequently been employed by others. It is necessary, however, that 
much caution should be exercised in their use, in order not to irritate the 
bladder. The liquid injected should be introduced very slowly, almost drop 
by drop; and violent distension should be most carefully avoided. A double 
catheter has been recommended, so that the liquid which enters the bladder 
through one passage may escape from it by the other. In the earlier stages, 
only demulcent or emollient liquids should be thrown up, such as barley- 
water, flaxseed-tea, decoction of marsh-mallow, &c.; but in the more advanced 
stages, astringent and mildly stimulating substances may be used; the caution 
being observed always to begin with the solution very weak, and gradually to 
increase the strength as the organ is found to bear it. At first, two or three 
grains of sulphate of zinc or acetate of lead, or one grain of corrosive subli- 
* Dr. G. Owen Rees, however, believing that the phosphatic deposition depends on 
the alkalinity of the mucus secreted, and that this was intended by nature to obviate 
the irritating properties of the acid urine as it comes from the kidneys, prefers the use, 
along with demulcent drinks, of alkaline salts, such as the citrate and tartrate of po- 
tassa, which render the urine from the kidneys alkaline, and, diminishing in this way 
its irritating property, remove one impediment to the cure of the inflammation. (Lond. 
Med. Gaz., July, 1851, p. 35.) CLASS III.] 
563 
DISEASES OF THE PROSTATE. 
mate or nitrate of silver, may be thrown up dissolved in four fluidounces 
of pure water. Solution of nitrate of silver has been of late especially re- 
commended, having been found successful in several cases. The strength 
may be increased gradually from one to four grains to the fluidounce of water, 
and the injected solution may be allowed to remain about a minute. Nitric 
acid in the proportion, to begin with, of one minim to two fluidounces of 
water, is employed by Brodie, the bladder being first washed out with warm 
water, and the diluted acid suffered to remain not more than half a minute 
after injection. Acid injections are peculiarly useful when the urine contains 
the insoluble phosphates. Dr. Golding Bird has seen cases of this kind yield 
to these injections, after resisting all other treatment. He employed muriatic 
acid in the quantity of ten minims, with twenty minims of wine of opium, 
thrown into the bladder daily with a sufficient quantity of barley water. 
(^Urinary Deposits, Am. ed., p. 157.) Tar-water and a weak solution of 
creasote have also been used in the same way. M. Bretonneau injects four 
or five grains of calomel rubbed up with mucilage. The injection may be 
repeated at first every other day, and afterwards, when the bladder becomes 
habituated to the impression, daily. In acute cases, or even in chronic cases 
upon which acute symptoms have supervened, I should fear even the mildest 
injections, lest more harm should result from their mechanical irritation than 
good from any alterative or demulcent effect. 
The diet should be mild and nutritious, and such as can have no tendency 
to occasion urinary deposits. The farinaceous substances, milk, and boiled 
meats in moderate quantity may be used; but, upon the supervention of acute 
symptoms, animal food should be for a time suspended. Stimulating condi- 
ments, and alcoholic drinks should be avoided, unless in cases of considerable 
debility, and where the system has been long accustomed to them; and, even 
in the latter case, it would be best that they should be gradually withdrawn. 
Mucilaginous drinks are upon the whole most suitable. Moderate exercise 
and fresh air are desirable, for the sake of the general health; but fatigue 
and all jolting or jarring motion, and exposure to cold and wet should be 
avoided. To guard against vicissitudes of weather, the patient should wear 
flannel next his skin. Advantage will often accrue from the use of the natu- 
ral mineral waters, especially those which are mildly chalybeate and laxative; 
and sea-bathing is said to have done much good. A residence in a warm 
climate during the winter is also considered advantageous. 
Article V, 
DISEASES OF THE PROSTATE. 
1. Acute Inflammation.-Prostatitis.-This disease comes on with 
a feeling of weight and tension in the perineum, soon followed by a heavy, 
pulsative, or burning pain, which is increased by pressure in the perineum, by 
the sitting posture, and by the act of evacuating the bowels. Indeed, the 
uneasiness during defecation is so great that the patient is usually indisposed 
to go to stool, and the bowels are consequently apt to become costive. Very 
soon after the first occurrence of pain, a disposition to pass the urine more 
frequently than in health begins to be felt, which gradually increases until it 
becomes very urgent and almost incessant. But much difficulty is experienced 
in the act of micturition; and at length the urine escapes only by drops, often 
high-coloured, sometimes mixed with mucus or blood, and usually producing 
a severe burning pain in its passage. Not unfrequently complete retention 564 
[part II. 
LOCAL DISEASES.-SECRETORY SYSTEM. 
takes place, and the bladder suffers a very painful distension. Along with 
these symptoms there is generally fever, which is sometimes of a high grade, 
with a strong full pulse, hot skin, loss of appetite, a furred tongue, &c. 
If an examination be made by the finger in the rectum, the prostate will 
be found considerably enlarged, and painful to the touch. A catheter in- 
troduced into the urethra meets with some resistance when it reaches the 
position of the gland, and if now pushed forward excites violent pain and 
burning, and enters the bladder with difficulty. 
The disease under proper treatment not unfrequently subsides, and goes off 
by resolution; a glairy discharge sometimes taking place from the excretory 
ducts. But the termination is not always so favourable. Sometimes the in- 
flammation travels to the bladder, and the dangers of cystitis are added to 
those of the original complaint. Sometimes it only partially recedes, and the 
gland is left in a state of chronic inflammation. More frequently, if not 
arrested, it ends in suppuration. The occurrence of this is sometimes marked 
by rigors; and the existence of an abscess may be occasionally ascertained by 
the feeling of fluctuation imparted to the finger in the rectum. At length 
the abscess opens, most frequently into the urethra, sometimes into the blad- 
der or rectum, and now and then also, though rarely, through the skin of the 
perineum. Brodie states that the route by the perineum is the most frequent, 
but other surgeons of high authority, among whom are Velpeau and Amussat, 
make a different statement. When the abscess presents towards the urethra, 
it is not unfrequently ruptured by the introduction of a catheter; when towards 
the rectum, it gives rise to much uneasiness in the rectum and the anus, and 
so presses upon the intestine, that a stool is for the time impossible, and even 
moderate injections are refused admission. Even the point of th^. syringe 
sometimes occasions extreme suffering. After the opening of the abscess, the 
patient becomes quite easy, and is generally soon restored to health. The 
whole course of the disease is usually completed in a week or ten days. 
Causes.-The most frequent cause of this disease is gonorrhoea, the inflam- 
mation of which passes by continuous propagation to the prostate. It is as- 
serted by Velpeau that this is peculiarly apt to take place, when heating 
remedies, such as cubebs and copaiba, are employed in the treatment of the 
urethral complaint. Other causes are cold suddenly applied to the perineum, 
falls or blows upon the same part, and the unskilful introduction of the catheter, 
in the cases of chronic enlargement of the gland so common in advanced life. 
Cathartics, such as aloes, which act especially on the pelvic viscera, venereal 
excesses, masturbation, intemperate drinking, and violent riding on horseback, 
are also considered as among the predisposing or exciting causes of the com- 
plaint. It seldom occurs before puberty, and not often in old age, unless by 
supervention upon an already enlarged prostate. 
Treatment.-Bleeding, leeches to the perineum, emollient poultices, the 
warm hip-bath, mucilaginous drinks, rest, and a rigid antiphlogistic diet, are 
the chief remedies in the early stages. Opiates either by the stomach or 
rectum may be employed to relieve pain and procure sleep. When the dis- 
tension of the bladder is very considerable, attempts must be made to obtain 
relief by the catheter, though the introduction of the instrument is exqui- 
sitely painful. Should an abscess have formed, it should be opened as soon 
as possible, wherever it can be ascertained to present. But this is a point 
for the consideration of the surgeon. 
2. Chronic Enlargement.-This affection is very common in old age. 
As it usually occurs, it comes on gradually, without pain; and the first symp- 
toms which attract attention are those which arise merely from the bulk and 
position of the tumour. Sometimes there is a vague feeling of uneasiness CLASS III.] 
DISEASES OF THE PROSTATE. 
565 
about the rectum or perineum, ceasing and returning at intervals, but scarcely 
noticed by the patient, until the occurrence of dysury leads him to apprehend 
mischief, and seek advice. The first prominent symptom is a disposition to 
frequent micturition, which is at the same time somewhat difficult. Some time 
often elapses after the desire is felt before the patient can relieve himself, and 
then the stream of urine, instead of being projected to a considerable distance, 
as in health, is apt to fall almost perpendicularly from the urethra, especially 
the last portions of it. The dysury increases, strangury frequently sets in, 
and at length the patient loses almost entirely the power of evacuating his 
bladder, even with the most violent efforts. But, though the patient loses his 
control over the function, and the bladder often becomes much distended, yet 
the retention is not always complete, as involuntary stillicidium of urine is 
apt to take place, especially during sleep, by which a partial relief is effected. 
In the diagnosis of this affection, the practitioner is much assisted by the 
age of the patient. The disease scarcely ever occurs in the young; and symp- 
toms analogous to the above, showing themselves in early life, would almost 
invariably be ascribable to some other cause. But, if a man fifty years old 
or upwards should be attacked as above described, and at the same time should 
be free from pain in the glans penis, and suffer no inconvenience from sudden 
jars, as in jumping or rough riding, it may be inferred that in all probability 
he is labouring under enlarged prostate. 
An examination by the rectum and urethra will now set the question at 
rest. In the former, the finger will detect a tumour much exceeding the ordi- 
nary size of the prostate; in the latter a catheter or sound of full size, which 
would not pass a stricture of the urethra, first meets with some impediment 
when it reaches the site of the gland, yet by skilful management may be made 
to pass on into the bladder, thus proving that the cavity of the urethra itself 
has not been diminished. The difficulty in the passage of the instrument 
arises from the change in the route of the urethra, consequent upon the irre- 
gular projection of the surface of the prostate. 
In itself this complaint is not usually dangerous. Without anything malig- 
nant in its character, without tending to suppuration or ulceration, consisting, 
in fact, of a mere hypertrophy of the gland, it often continues with little 
change for many years, and in some instances, after attaining a certain mag- 
nitude, ceases to increase. It is only by its interference with the excretion 
of the urine that it generally becomes serious. In consequence of the dif- 
ficulty in passing the urine, this fluid accumulates in the bladder, which is 
thus stimulated to unwonted efforts. As a consequence of this over-exertion, 
it sometimes becomes much thickened and contracted. In other cases, yield- 
ing to the distending force, it is much thinned, and at length loses its power 
of contracting altogether. The urine retained undergoes chemical changes 
which render it highly irritating; inflammation of the mucous membrane of 
the bladder is thus excited; and cystirrhoea, one of the most common attend- 
ants upon enlarged prostate, is thus established. Even acute cystitis is some- 
times excited; and the irritation, ascending to the kidneys, joins these organs 
in a common bond of disease with the whole urinary passages. Occasionally 
ulceration of the neck of the bladder, urethra, and prostate takes place, giving 
rise to a complication of distressing symptoms which render life burthensome. 
Yet the disease, with proper care, continues long without fatal consequences; 
and persons die at a good old age, of other complaints, after having for many 
years suffered with this. 
Treatment.-Little is to be expected from medicine in the treatment of this 
disease. The usual antiphlogistic remedies are scarcely of any avail, unless 
to control acute inflammation when it may happen to supervene. The reme- 566 
LOCAL DISEASES.-SECRETORY SYSTEM. 
[PART II. 
dies from which most good may be expected are mercury and iodine. These 
may be employed internally and externally, separately or in conjunction, 
according to the circumstances of the case, and the views of the practitioner. 
Calomel or the blue mass is the most suitable preparation of the former, and 
iodide of potassium of the latter, unless the iodide of mercury, which com- 
bines the two, may be considered preferable. To be of effect, they must be 
used moderately, and persevered in for a long time. Fischer, of Dresden, 
has employed muriate of ammonia, in large doses, with extraordinary success. 
He begins with fifteen grains every two hours, and gradually increases until 
nearly half an ounce is taken daily; diminishing the dose if disorder of the 
stomach, or scorbutic symptoms should appear. (See Brit, and For. Medico- 
Chirurg. Rev., Oct. 1852, p. 557.) Issues in the upper and inner part of 
the thighs are said to have done some good. The bowels should be kept in 
a soluble state, so as to prevent the hardened feces from irritating the gland 
in their passage. No irritating cathartic or diuretic should be allowed. 
Various mechanical remedies have been proposed, as compression, cauteriza- 
tion, incision, &c.; but these fall exclusively under the charge of the sur- 
geon. The patient should be cautioned against straining in the evacuation 
of his urine, and to control, as far as possible, the disposition to frequent 
micturition. If he should be unable to evacuate the bladder, it will be neces- 
sary to resort to the catheter, the use of which then becomes important not 
only for present relief, but to check the progress of the complaint, by pre- 
venting the distension of the bladder. It is a question for the surgeon to 
decide whether the catheter is to be left always in the urethra, or whether it 
is to be introduced three or four times daily. One plan is best adapted to 
certain cases, the other to others. There is often much difficulty in intro- 
ducing the catheter, requiring a dexterous operator. 
In some instances of chronic inflammation of the prostate, there is an exces- 
sive flow of its secretion, which gives rise to a very obstinate variety of gleet. 
This is apt to happen as a sequela of gonorrhoea. The disease is most effect- 
ually treated by the application of nitrate of silver to the surface of the 
urethra, where it is embraced by the gland. 
3. Other Organic Affections.- Calculous concretions occasionally 
form in the ducts of the prostate and acquire great dimensions. These are 
properly objects for the care of the surgeon. Tubercles are said to have been 
noticed in the prostate. But there is no sign by which during life they could 
be distinguished from other chronic affections of the gland. The prostate is 
also subject to scirrhus, either as an original affection, or by propagation from 
neighbouring parts. The hardness of the gland, the communication of the indu- 
ration to the structures about it, the lancinating character of the pain, and the 
peculiar cachectic complexion of the patient, are the chief diagnostic symptoms. 
The treatment can be only palliative, and must consist chiefly in the free use 
of narcotics, and the avoidance as much as possible of all irritating influences. 
Article VL 
FUNCTIONAL DISEASES OF THE URINARY ORGANS. 
Under this title are here included all the diseases of the urinary organs not 
consisting in organic derangement; consequently all their states of irritation 
or depression, whether merely nervous, or involving also the blood-vessels, 
and all the deviations from the healthy performance of their functions, whether 
secretory or excretory. These diseases may be conveniently arranged in two CLASS III.] 
567 
CALCULOUS NEPHRALGIA. 
divisions; the first including affections purely nervous, the second disorders 
of secretion and excretion. 
1. Nervous Affections. 
1. Neuralgia.'-The kidneys, bladder, and urinary passages in general, 
are liable to attacks of pure neuralgia. These are characterized by pain, gene- 
rally very acute, without any evidence whatever of inflammation or consider- 
able vascular excitement, and without spasm. They are not attended with 
material derangement of the urine, with pain or other irregularity in its 
evacuation, or with fever; and, if nausea and vomiting sometimes occur, it is 
merely in consequence of the close sympathetic connexion between the sto- 
mach and urinary apparatus. The pains are usually in irregularly recurring 
paroxysms, sometimes only remitting, sometimes quite ceasing in the inter- 
vals. Occasionally they assume a regular periodical form. When they 
occupy the kidney, they generally shoot downwards towards the groin, as in 
nephritis; and in this position the complaint may be denominated nephralgia. 
When seated in the bladder, they are felt above and behind the pubes or in 
the perineum, and occasionally extend to the penis. 
The causes are the same as of neuralgia elsewhere. The complaint proba- 
bly in some cases originates in the nervous centres, whence the organs receive 
their immediate supply of nervous influence; in others may depend on the 
action of miasmata or upon general debility; and in others, again, may be 
traced to a gouty or rheumatic diathesis, in constitutions not vigorous enough 
to rise readily to the point of inflammation. Occasionally it appears to be 
connected with hysteria. 
The treatment is the same as that of neuralgia seated elsewhere, and is 
given under the general heading of that disease. It may not be improper, 
however, to mention here that, when regularly intermittent, it will generally 
yield to anodynes during the paroxysms, and large doses of quinia in the in- 
tervals. It is referred to at present less in relation to therapeutics than to 
diagnosis. The practitioner should be especially cautious not to confound it 
with inflammation; as the two affections require a quite different treatment. 
2. Calculous Nephralgia.-Spasm of the Ureters.-.Nephritic Colic. 
-This is one of the most painful affections to which the human frame is 
liable. It depends upon the passage through the ureter of a calculus or other 
solid body, coming on when this enters the duct upon leaving the pelvis of 
the kidney, and rarely ceasing entirely until it is discharged into the bladder. 
The pain is probably excited immediately, either by the roughness of the cal- 
culus wounding the mucous membrane, or by its size producing distension. 
There is reason to believe that concrete organic matter, as blood or fibrin, may 
sometimes give rise to the affection. 
During an ordinary attack of gravel, or in the midst of apparent health, 
a severe pain is suddenly felt in the loins, shooting to the groin, testicle, or 
thigh, and often extending into the abdomen, where it imitates colic. Occa- 
sionally it is felt chiefly or exclusively in and about the hip. The space be- 
tween the ilium and umbilicus is sometimes acutely sensible to pressure. The 
pain occurs usually in irregular and excruciating paroxysms, having all the 
characters of spasmodic attacks, with intervals of comparative ease. During the 
severity of the paroxysm, there is often nausea or vomiting, and sometimes a 
small and very feeble pulse, great apparent prostration, a cool pale surface, 
and profuse sweat. A desire to pass urine frequently, but with little success 
when the effort is made, is another symptom. The patient is usually restless, 
rising frequently from bed, and seeking relief, though in vain, from every 
change of position. At length the calculus escapes into the bladder, and the 568 
[PART II. 
LOCAL DISEASES.-SECRETORY SYSTEM. 
pain suddenly ceases. Not unfrequently, however, it is renewed after some 
hours or a few days, in consequence of another concretion entering the ureter, 
and pursuing the same course. Occasionally it appears to go off entirely with- 
out the expulsion of the calculus, returns again after a considerable interval, 
and at length finally ceases upon the escape of the offending cause. It is im- 
portant that the calculus should be seen in the urine; as otherwise there might 
be reason to fear lest it should still be lurking in the pelvis of the kidney after 
vain efforts to enter the ureter, or, being detained in the bladder, should be- 
come the nucleus of a stone. Hence the propriety of examining the urine, 
and, if the calculus should not be found, and especially if there should be 
signs of its presence in the bladder, of directing the patient to retain his urine, 
drinking freely at the same time of cool liquids, until the bladder should be 
filled, and then to discharge it in a full stream with his body bent forward. 
Should it still remain in the bladder, or be caught and fixed in the urethra, 
the aid of the surgeon should be called in. 
This affection is different from nephritis, and requires a different treatment. 
The pain comes on before there has been time for the developement of inflam- 
mation, and does not in any degree necessarily depend on that cause. Should 
the calculus, however, be detained long, inflammation will ensue; and then 
the two affections will coexist. The total absence of fever, while that affec- 
tion always attends acute nephritis, is generally sufficiently diagnostic of the 
nature of the complaint. Its sudden commencement, and its equally sudden 
and often complete departure, are other evidences of its nature. In the ne- 
phralgic disease, moreover, the kidney would not probably exhibit an equal 
sensibility to strong pressure as in nephritis. 
The origin of the pain in the loins, its course along the ureter, the occa- 
sional retraction of the testicle, the disordered micturition, and the frequent 
presence of sandy or amorphous deposit in the urine, are usually sufficient to 
distinguish this complaint from colic and peritoneal enteritis, the former of 
which, moreover, is in general more decidedly paroxysmal, and more exempt 
from abdominal tenderness, while the latter is accompanied with high fever. 
Occasionally most of the symptoms above described occur without the pass- 
age of a calculus at the time, or, so far as can be discovered, afterwards. It 
is possible that, in such cases, they may be owing to coagulated organic mat- 
ter which has subsequently been broken up in the bladder; or there may be 
in the ureter a power of idiopathic painful contraction analogous to spasm. 
Treatment.-The prominent indications are to relieve the suffering of the 
patient during the passage of the calculus, and to render this passage as 
speedy as possible. If the pain should not be very severe, the bowels should 
first be evacuated by a full dose of castor oil or other mild yet quick cathartic, 
so as to prevent irritation from feculent accumulation. The cathartic may 
be aided, if it do not operate speedily, by a purgative enema; and, in cases 
attended with much irritability of stomach, the latter remedy may be em- 
ployed to the exclusion of the former. After the bowels have been emptied, 
opiates should be given promptly and freely. When the pain is extremely 
violent, it is best not to wait for the action of cathartic medicine, but imme- 
diately to administer opium, while an attempt is made, at the same time, to 
evacuate the lower bowels by an enema containing a portion of oil of turpen- 
tine, with other milder ingredients. One or two grains of opium, or an 
equivalent dose of laudanum, black drop, or one of the salts of morphia, 
should be given at first, and repeated at intervals of half an hour, hour, or 
two hours, according to the urgency of the pain, until this is somewhat alle- 
viated, or the patient exhibits signs of narcotic influence. Should the stomach 
be irritable, the opiate may be administered with as powerful and prompt CLASS III.] 
SPASM OF THE BLADDER. 
569 
effect by the rectum, in double or triple the dose. From forty to sixty or even 
eighty drops of laudanum may thus be given in a wineglassful of thin starch, 
and repeated if necessary. If relief should not be afforded by these measures, 
the patient should be immersed in a warm bath, and kept in it for an hour 
or more if he bear it well. Indeed, it will generally be proper to have the 
bath prepared immediately, and used as soon as ready, while the other mea- 
sures are in progress. Hot fomentations to the abdomen and loins may also 
be employed. In vigorous individuals, should relief not be quickly obtained, 
it will be proper to bleed from the arm, both in order to favour the passage 
of the calculus by producing relaxation, and to obviate inflammation. This 
is one of the affections in which great advantage may be expected from the 
inhalation of ether or chloroform. 
The means calculated to prevent the return of the disease depend, in great 
measure, upon the character of the urinary deposits, and the nature of the 
calculus. The subject will, therefore, be most conveniently treated of under 
lithiasis. 
3. Spasm of the Bladder.-This is marked by violent pain, with a 
feeling of constriction in the region of the bladder, which is sometimes con- 
tracted into a hard ball. The pain often extends to the penis producing 
erection, to the rectum producing tenesmus, and even to the kidneys, with 
symptoms like those of the nephralgic paroxysm. Sometimes the contraction 
is so great and so permanent as to close the orifice of the ureters, and thus to 
occasion an apparent suppression of urine, which, however, accumulates in 
the pelvis of the kidney, and leads to serious irritation of that organ. During 
the paroxysm the patient is sometimes affected with cold perspiration, paleness 
of surface, feeble pulse, and great restlessness and general distress. Often, 
however, the spasm is less violent and continuous; and the affection altogether 
much more moderate. From cystitis it is distinguished by the absence of 
fever, the want of pain on pressure, and its paroxysmal character. 
Spasm of the bladder may proceed from stone, from acrid urine or other 
morbid renal secretion, from similar morbid secretions of the bladder itself in 
a state of organic disease, from the direct irritation of cantharides or other 
acrid diuretic taken into the stomach, from sympathetic irritation occasioned 
by ascarides in the rectum, from gout and hysteria, and finally from exposure 
to severe cold. When connected with long continued organic affections of 
the kidneys or bladder in old people, it is sometimes the immediate cause of 
death by its shock upon the already exhausted nervous system. It is almost 
always susceptible of relief when idiopathic, and often ceases without the in- 
tervention of remedies. 
Treatment.-It is obvious that, when it is dependent on any discoverable 
source of irritation, this must be removed if possible. So far as regards the 
spasm itself, it is most effectively treated with opiates, especially in the form 
of enema, and freely administered.. Warm fomentations, and the warm bath 
are excellent adjuvants. Sinapisms above the pubes are sometimes useful; 
and the effect of a stream of cold water poured from a height out of a pitcher 
upon the hypogastrium may be tried. In robust individuals, blood may be 
taken from the arm, and, should the disease be complicated with inflamma- 
tion, both this and leeching would be called for. If the spasm has ensued 
upon the disappearance of gout, colchicum should be given with the opiate, 
and the disease invited to its original seat by rubefacients. If it be purely 
nervous, the antispasmodics may be employed, such as assafetida, Hoffmann's 
anodyne, camphor, musk, and valerian, separate or combined; and advantage 
may accrue from the simultaneous use of tonics. Ethereal inhalation has 570 
[PART II. 
LOCAL DISEASES.-SECRETORY SYSTEM. 
been found to afford speedy relief to the sufferings of the patient, and the 
same result may be expected from chloroform. 
4. Irritable Bladder.-This name has been applied to states of the 
bladder, however various, in which that organ shows, by an increased fre- 
quency of action, either a morbidly increased susceptibility to the stimulus of 
the urine, or an altered and more stimulating condition of the urine itself. 
Thus employed, however, it is obvious that the name cannot be considered as 
expressive of a peculiar disease, but rather of an association of symptoms be- 
longing to several distinct pathological conditions. These symptoms are a 
disposition to frequent micturition, more or less uneasiness if the urine is 
retained, and inability to retain it long, and often only a partial relief when 
the desire is yielded to. Now this state of things may be dependent on acri- 
mony of the urine, arising from organic or functional disease of the kidney, 
or from spontaneous decomposition in consequence of being retained too long 
in the bladder; on unhealthy secretions, other than urine, from either of these 
organs; on organic disease of the bladder itself; on irritation propagated to it 
sympathetically from neighbouring parts, as the kidney, prostate, urethra, and 
rectum; or finally on an exalted susceptibility, which renders it morbidly sen- 
sible even to ordinary impressions. In all these cases, except the last, the 
irritability is secondary, and is to be considered in connexion with the various 
pathological conditions in which it originates. Nevertheless, it is highly 
important as a sign, sometimes the first or almost only very obvious sign of 
important diseases, which, but for it, might long escape observation. When- 
ever it occurs, therefore, it should lead to a close investigation of the various 
organs connected with the urinary apparatus by function or position, and espe- 
cially of the kidneys, and prostate. The urine should always be examined; 
as its condition may lead to important discoveries in relation to renal disease. 
The urethra too should be examined, in order that it may be ascertained 
whether a stricture exists, which might alone explain the symptoms. 
But the affection to which the name of irritable bladder should be confined, 
as expressive of a distinct disease, is that last mentioned in the above list; 
viz., an increased susceptibility which renders it morbidly and even painfully 
impressible by healthy urine, or other natural and wholesome stimulus. This 
is often a purely nervous complaint, connected sometimes with debility, some- 
times with hysteria, and sometimes with a disordered condition of the brain, 
spinal marrow, or other nervous centre. It may be merely the first step 
towards inflammation of the bladder, and dependent on the various causes of 
that affection, acting in a less degree, or upon a less impressible system. 
(See Cystitis.} It is, in general, distinguishable from other affections by the 
healthy state of the urine, and by the absence of fever, of pain or tenderness 
in the region of the bladder, of the symptoms of stone, of stricture of the 
urethra, and of other signs indicative of organic renal or cystic disease. 
In the treatment of this idiopathic irritability, it is necessary to consult 
the state of the system. If the patient is robust and plethoric, the loss of a 
little blood, a dose of sulphate of magnesia, the warm bath, and an antiphlo- 
gistic regimen, employed separately in different cases, or all together, as the 
grade of symptoms may require, will generally remove the complaint, and 
probably prevent the developement of acute or chronic cystitis. Should the 
affection be painful, an anodyne enema may be administered. The patient 
should drink freely of mucilages, and the bowels should be kept loose, though 
all aloetic or stimulating cathartics should be avoided, and only the mildest 
laxatives employed. If the complaint be connected with debility, mild tonics 
and astringents should be used, such as uva ursi, pipsissewa, pareira brava, 
the simple bitters, the mineral acids, and the tincture of the chloride or the CLASS III.] 
DEBILITY OF THE BLADDER.-STRANGURY. 
571 
solution of the iodide of iron. ' Occasionally, when there is no pain, the more 
stimulating diuretics may be advisable, as buchu, the balsams, the turpen- 
tines, wild carrot, &c. The occasional use of local or general cold bathing or 
the shower bath will also be advantageous. In hysterical affections, the anti- 
spasmodics may be conjoined with other remedies. Counter-irritation to the 
spine is also sometimes useful. 
5. Paralysis, or Debility of the Bladder.-It often happens that, 
from the want of due sensibility or muscular power, the bladder is unable to 
perform its office, or performs it but imperfectly. The symptoms vary with 
the part affected. When the neck of the bladder is exclusively concerned, 
incontinence of urine results. If the bladder in general is affected, we have 
retention of urine, in consequence of insensibility to its presence, or inability 
to contract upon it. These conditions may exist in very different degrees, 
from mere nocturnal incontinence on the one hand, or slight difficulty of mic- 
turition on the other, up to a constant flow of urine from inability to retain 
it, or a degree of retention sufficient greatly to distend the bladder, and 
endanger life. There is seldom, however, complete retention, the urine es- 
caping in small portions, by an involuntary stillicidium, especially when the 
patient sleeps, and thus giving rise to very great inconvenience. 
This partial or complete palsy may arise from a direct diminution of nervous 
energy, as in the gradual decay of strength incident to old age, and in spinal 
and cerebral disease, producing palsy elsewhere as well as in the bladder; or 
it may come on as a result of excessive or long continued excitement, as from 
venereal excesses, or those organic diseases of the kidneys, prostate, &c., which 
sustain an incessant irritation of the bladder, exhausting at once its sensibility 
and power. In low fevers, this condition of the bladder is a not unfrequent 
concomitant of the general diminution of nervous energy. It occurs, also, 
occasionally in hysteria, as a consequence of the irregular distribution of 
nervous influence characteristic of that complaint. 
When the affection depends upon cerebral or spinal lesion, or upon organic 
complaints of the urinary apparatus, it must be remedied, if at all, by ad- 
dressing our measures to the real seat of disease. When the consequence of 
excessive indulgences, it can be relieved only by a change of habits. In 
cases associated with general debility, the vegetable tonics, the chalybeates, 
and the mineral acids, with the cold bath, are the appropriate remedies. 
Stimulation of the bladder by medicines having a tendency to the pelvic 
viscera, such as oil of turpentine and cantharides, or by electricity, will some- 
times be of great utility in cases in which the affection is purely local. Strych- 
nia, or some other preparation of nux vomica, is strongly indicated. Hys- 
terical cases must be treated by the means applicable to the same kind of dis- 
order elsewhere. It often happens that much may be done, in restoring power 
to the bladder, by inducing the patient to exert his own will vigorously. 
This is especially true in hysteria, in which a diseased will has often much to 
do with the complaint. In such cases, caution must be used not to resort 
too hastily or too freely to the catheter; but, generally speaking, in this 
disease, it is of great importance not to allow the bladder to become unduly 
distended; and to prevent this, it is necessary frequently to draw off the urine. 
6. Strangury.-Perhaps this should be considered rather in the light 
of a symptom than a disease. There is, however, a more or less general irri- 
tation of the urinary passages, which is short of inflammation, and cannot, 
perhaps, be more appropriately designated than by this term. It is exhibited 
in a frequent and irresistible desire to pass water, of which very little escapes, 
with burning and cutting pains at the neck of the bladder, along the urethra, 
and at the end of the penis, during and immediately after the passage. The 572 
[part II. 
LOCAL DISEASES.-SECRETORY SYSTEM. 
pains often extend to the bladder, up the ureters, and even into the kidneys 
themselves; and sometimes the rectum becomes involved, and tenesmus is 
induced. The symptoms are those of inflammation of the whole urinary pas- 
sages ; but the affection is often so transient, and yields so immediately to 
suitable remedies, that it can hardly be considered of that character. It is 
caused, most frequently, by irritating substances in the urine, and is a com- 
mon attendant on the different forms of lithiasis. The most frequent cause 
of it, however, is beyond all comparison, the Spanish fly, either taken inter- 
nally, or applied as an epispastic. As resulting from this cause, it is often 
most exquisitely painful, and imperiously calls for relief. Oil of turpentine 
and other stimulating diuretics sometimes have the same effect. 
The treatment is very simple. After the removal of the cause, so far as 
possible, an injection of from forty to sixty drops of laudanum in a wineglassful 
of mucilage will almost always afford complete relief, if not at first, at least 
upon being repeated. As auxiliary measures, mucilaginous drinks should be 
given freely. In mild cases it may be sufficient to employ these with mode- 
rate doses of camphor in the form of camphor water. Warm fomentations, 
emollient poultices, and the warm bath or half-bath may also be used; and, 
should any objection exist to opiate enemata, other narcotics may be sub- 
stituted, though none are nearly so effectual. 
2. Disorders of Secretion and Excretion. 
The kidneys are undoubtedly emunctories, by which injurious substances 
accidentally present in the circulation, effete matters resulting from the per- 
petual renewal of the organization, and any excess in the wholesome principles 
of the blood, are thrown off from the system, and thus prevented from inter- 
fering with its healthy actions. In performing this office, they appear to 
permit the passage of certain substances with little or no change, as water, 
urea, and various salts, while they occasionally decompose others, and elimi- 
nate the results of this decomposition in new forms of matter, probably not 
pre-existent in the body. From this view of the function of the kidneys, it 
is obvious that the urine may vary greatly, both in quantity and constitution, 
not only in different individuals, but even in the same individual under differ- 
ent circumstances, and yet still remain within the limits of health. Thus, it 
is more or less copious according to the quantity of liquid drank, and the 
state of other emunctories, especially of the skin. One of the most important 
offices of the kidneys is to preserve the amount of fluid in the blood in due 
proportion to the wants of the system. The quantity of urine will, therefore, 
be increased with an excess in this proportion, and diminished with a de- 
ficiency. Consequently, other things being equal, the individual who drinks 
more largely than another will pass a greater amount of urine in the same 
time, and the same difference will be observed in the same individual at differ- 
ent times, according to his habits in this respect. Again, the urinary and 
perspiratory functions are so related that when one is unusually active, the 
other is, in general, proportionably inert, and whatever promotes or impedes 
the one has an opposite effect upon the other. Hence, the urine is more copious 
in winter than in summer, after the use of cold than of hot drinks, and during 
the day than when the patient is warm in bed. 
The quality of the urine is not less various than its quantity. A full rich 
diet of animal food, supplying more nutriment to the blood than the wants 
of the economy require, is attended with an excess of the solid ingredients of 
the urine; while a purely vegetable diet, which leaves the blood somewhat 
deficient, necessitates a diminished elimination of nutritive matter, and pro- 
duces, consequently, an opposite state of the secretion. The urine imme- CLASS III.] DISORDERED URINARY SECRETION AND EXCRETION. 
573 
diately following a meal in which liquids have been taken freely, has long 
been noticed to be very different from that which occurs after digestion has 
been accomplished, and the rich chyle is poured into the circulation. The 
former, sometimes called urina potiis, is abundant and watery; the latter, 
denominated urina sanguinis, is moderate in quantity, but loaded with solid 
matters. Whatever promotes activity in the general organic processes of the 
system, as vigorous exercise, for example, and whatever renders it necessary 
that the system should live upon itself, as starvation and febrile diseases, pro- 
mote a loaded condition of the urine, because the effete matters are in propor- 
tion to the activity of the organic changes. Even the morning urine, which 
upon the whole may be considered as offering the truest criterion of the normal 
state of the function, because least interfered with by disturbing causes, is 
more or less diversified in character. 
Ingredients not ordinarily existing in the urine, are occasionally added to 
it, in consequence of the use of certain articles of food or drink. Thus, 
asparagus, horseradish, and garlic impart to it peculiar odorous principles; 
and saccharine matter and oxalic acid are asserted to have been found in it, 
after a free use of sugar in the one case, and of sorrel or rhubarb pies in the 
other. These foreign impregnations cannot be considered morbid, unless pro- 
ductive of some injury in the economy. On the contrary, their presence is 
probably the result of a preservative process. 
It follows, from what has been said, that it is impossible to indicate any 
precise condition of the urine, whether as to amount or quality, which can be 
considered as the healthy standard. All that can be done is to make some 
approximation to such a result. It is not surprising that very different opin- 
ions have been given by writers. The conclusions here presented are those 
which have appeared to the author most probable, after a comparison of the 
various statements upon the subject. 
In relation to the quantity of urine passed daily, the mean for a healthy 
man, in temperate weather, and without the operation of any extraordinary 
causes, may be stated at two or three pints. Women generally pass less, 
because less active and more abstemious. 
The density of the urine, which indicates, though somewhat indefinitely, 
the proportion of its solid ingredients, is exceedingly variable, being sometimes 
as low as 1.005, sometimes as high as 1.033; and both these points may be 
passed in their respective directions, without a necessary deviation from 
health. Prout, in the last edition of his work on renal diseases, states the 
average specific gravity at from 1.015 in summer to 1.025 in winter. Willis 
thinks that the general average is for adults about 1.015, and, if children are 
included, 1.012. Dr. Gregory gives, as the result of numerous observations, 
1.0225; and Dr. Christison considers even this too low, and places the average 
for a robust healthy man of moderate habits at 1.0252. But it is obvious that 
the results obtained by different investigators must vary according to the 
habits of the people among whom they live. The density would be much 
greater with a population living chiefly on meat than with another whose diet 
is exclusively vegetable. 
The quantity of the urine, or its density, affords alone no indication of the 
loss of solid matter to the system, which is often an important problem to 
solve. The urine may be very copious, and yet contain so little solid matter 
as to abstract less than the ordinary average from the blood; or it may be 
very dense, and yet so small in amount as to lead to the same result. To 
come at the truth, the density and quantity must be considered together. In 
the healthy state, a diminished density is usually compensated by an increased 
quantity, and vice versa, so that the average of solid matters daily discharged 574 
LOCAL DISEASES.-SECRETORY SYSTEM. 
[PART II. 
is about the same, whatever may be the amount of urine. This average is, 
according to Christison, under the most favourable circumstances, nearly two 
ounces and a half, and is seldom short of one ounce and a half, which ought, 
therefore, to be the daily yield of urine of the ordinary quantity and specific 
gravity. 
The constituents of healthy urine are usually water, urea, colouring and 
extractive matters, uric acid, lactic acid, lactate and perhaps urate of ammo- 
nia, muriate of ammonia, chlorides, and salts of phosphoric and sulphuric 
acids with ammonia, potassa, soda, lime, and magnesia. Berzelius found 
also a minute proportion of silica, and traces of fluate of lime. A little mucus 
is usually present, derived from the membrane lining the urinary passages. 
In the healthy state, the urine has generally an acid reaction, indicated by 
the reddening of litmus paper. These several ingredients may vary greatly 
in proportion without deviation from health, so that no one analysis of urine 
can be expected to agree exactly with another. The table given in the note, 
and taken from Prout's work on Urinary Diseases, exhibits the results of 
one of the most recent and carefully conducted analyses.* Though urine in 
health has usually an acid reaction, it is always changing in the degree of its 
acidity, which, according to Dr. H. Bence Jones, is greatest before eating, 
and diminishes immediately after, especially when animal food is eaten, in 
* Table, representing in English weights 'and measures the mean normal Quantity, 
Specific Gravity, and Composition of the Urine, in the different Sexes, as deduced from eight 
analyses (four in each Sex) by M. Alfred Becquerel. (Semeiotique des Urines, p. 7.)f 
Male. 
Female. 
General Mean. 
Quantity, Specific Gravity, and Composition 
of the Urine. 
Urine in 
24 hrs. 
Compo- 
sition of 
1000 
parts. 
Urine in 
24 hrs. 
Compo- 
sition of 
1000 
parts. 
Urine in 
24 hrs. 
Compo- 
sition of 
1000 
parts. 
Quantity of urine 
Specific gravity of urine ..... 
General composition {^mattera 
44 fl.oz. 
1818.9 
18949.6 
609.9 
1000.000 
968.815 
31.185 
48 fl. oz. 
1015.12 
20642.8 
528.0 
1000.000 
975.052 
24.948 
46 fl. oz. 
1017.01 
19T96.2 
568.9 
1000.000 
971.935 
28.066 
02 
Water 
Urea . 
Lithic acid (uric acid) . . . . . 
18949.6 
270.7 
7.6 
968.815 
13.838 
0.391 
20642.8 
240.4 
8.6 
975.052 
10.366 
0.406 
19796.2 
255.5 
8.1 
971.935 
12.102 
0.398 
,ils of Analys 
Organic f Lactic acid \ 
matters in- Lactate of ammonia 
separable -! Colouring matters J- 
from each | Extractive matters 
other. ( Muriate of ammonia J 
181.1 
9.261 
149.0 
8.033 
165.0 
8.647 
Deta 
Fixed salts') ™, .. (Lime ) 
indecomposa- 1 ^sp£ates 1 Soda 1 . 
.holt a J SulPhates [MagnesiaJ 
150.5 
7.695 
130.0 
6.143 
a 140.3 
b 6.918 
19559.5 
1000.000 
21170.8 
1000.000 
20365.1 
1000.000 
t 15.434 grs. Troy = 1 gramme; 437.5 grs. Troy = 1 fl. oz. I have omitted the fractions of the fl. oz. as 
of no importance to the general statement. 
Composition of the entire quantity of fixed salts voided in 24 hours; and in 
1000 parts of urine. 
Chlorine 10.17 
Sulphuric acid 17.33 
Phosphoric acid 6.44 
Potash 26.36 
Soda ) 
Lime >- . 79.97 
Magnesia ) 
140.27 
a. Fixed salts voided in 24 hours. 
Chlorine 502 
Sulphuric acid 855 
Phosphoric acid 317 
Potash 1.300 
Soda 1 
Lime > ..... 3.944 
Magnesia J 
6.918 
6. Fixed salts in 1000 parts CLASS III.] 
DISORDERED URINARY SECRETION AND EXCRETION. 
575 
which case it may even become alkaline. This seems to be owing to the con- 
centration of acid in the stomach during digestion, and its consequent diver- 
sion from the kidneys. The acidity of urine has generally been ascribed 
mainly to uric acid; but the very difficult solubility of this acid renders the 
point somewhat doubtful; and Dr. W. Marcet has recently demonstrated the 
presence of two animal substances with an acid reaction, which had pre- 
viously escaped the notice of chemists, one colourless, the other rose-coloured, 
both soluble in ether, and both crystallizable. (See Chern. Gaz., x. 347.) 
The urine becomes alkaline by the use of alkalies, and of alkaline salts with 
vegetable acids, especially tartrate of potassa. Hence, this condition is some- 
times observable after the use of various acidulous fruits, in which these salts 
are contained largely. The acid is decomposed in the process of digestion or 
sanguification, and the alkali is thrown off by the kidneys. When alkaline 
from other causes, the urine must be considered as unhealthy, indicating, 
according to Dr. Rees, either disease of the spine, dyspepsia, or inflammation 
of the mucous membrane of the urinary passages. (Med. Gaz., July 4, 
1851, p. 29.) 
With so great a diversity in the character of healthy urine, it can be con- 
sidered morbid only when its deviation from the ordinary condition is attended 
with some obvious derangement of health, or when it is known from experience 
that such derangement, though concealed for a time, must sooner or later ap- 
pear if the deviation continue. There are two modes in which the secretion 
may become morbid. In the first place, in consequence of a diseased state of 
the system, noxious matters may originate in the blood or be thrown into it, 
which the kidneys are called on to eliminate; and, secondly, the kidneys them- 
selves may be disordered in their function from organic disease or deranged 
innervation. In either case, the perverted renal function may itself become 
the source of serious mischief, either to the system by the exhaustion from 
excessive or the depravation from deficient evacuation, or to the urinary pas- 
sages from the irritating or otherwise injurious character of the fluid secreted. 
It will be most convenient to give a hasty view of the several perversions to 
which the urine is liable; and afterwards to dwell more fully on those which, 
from their importance or peculiarity of character, may deserve to be considered 
as distinct diseases. 
Sometimes the urine becomes morbidly excessive in quantity, retaining its 
ordinary solid constituents in their ordinary relative proportion, only more 
than usually diluted. Sometimes, along with this excess in quantity, is a 
striking change of character, consisting either in a superabundance or defi- 
ciency of one or more of its constituents, or in the addition of a new ingre- 
dient not ordinarily found in health. These derangements constitute the 
different forms of diuresis and diabetes. 
The secretion may be morbidly deficient in quantity, or altogether sup- 
pressed; and in this case also, provided any urine be discharged, it may be 
altered in character merely by concentration, or may be deranged in various 
ways by the addition of new, or the altered relation of old constituents. This 
form of urinary disease will be treated of under the title of suppression of 
urine or ischuria. 
Not unfrequently there is an excess or deficiency of the solid constituents 
of the urine, exceeding the limits pf health. The degree of this excess or 
deficiency is measured with sufficient accuracy by the specific gravity, which 
is of course above the healthy mean in the former, and below it in the latter. 
Thus, the density of the urine is sometimes as high as 1.055, and in other 
instances so low as hardly to exceed that of water. In the former case, it is 
apt to deposit its constituents before being discharged, and then gives rise to 576 
LOCAL DISEASES.-SECRETORY SYSTEM. 
[PART II. 
various complaints of the urinary passages, such as nephritis, cystitis, hsema- 
turia, nephralgia, gravel, stone in the bladder, dysury, strangury, and reten- 
tion of urine, all which affections are separately considered. In the latter, 
it is usually vastly increased in quantity, constituting a species of diuresis. 
The daily amount of solid matters discharged with the urine is also liable to 
wide deviations from the standard of health. Thus, the quantity has in some 
instances been increased to two pounds, and in others reduced to a few grains. 
It is obvious that great danger from exhaustion must exist in the former case, 
and of poisoning the system in the latter. We have examples of these results 
in diabetes and ischuria. 
The proportion of the several solid constituents of the urine is liable to morbid 
changes. Thus, urea, which is the characteristic ingredient of the secretion, 
is sometimes in great excess, sometimes deficient or altogether wanting. Both 
of these conditions are apt to be attended with diuresis, and constitute varieties 
of that complaint. Uric acid, free or combined, is often morbidly abundant, 
so much so as to be deposited when the urine cools, or even while it is still 
in the course of excretion, thus producing a variety of gravel and of stone. 
The same thing happens from an occasional excess of the lactic, muriatic, or 
phosphoric acid, which decomposes any existing urate, and throws down the 
uric acid. On the contrary, the alkaline and earthy bases may be super- 
abundant, in which case, the earthy phosphates are precipitated, and another 
form of gravel is produced. All these affections are more fully treated of 
under lithiasis. 
Very frequently ingredients are found in morbid urine which do not exist 
in the healthy secretion. It is scarcely necessary here to allude to that kind 
of impregnation which arises from the absorption of certain stimulating sub- 
stances when swallowed, and their elimination by the kidneys. This becomes 
morbid only when sufficient to irritate or inflame the urinary passages, as from 
the use of the turpentines and cantharides. But there are other urinary im- 
pregnations of the highest importance. Oxalic acid is sometimes secreted, 
and, uniting with lime, forms a precipitate which constitutes one of the hardest 
and most insoluble of all the calculous concretions. (See Lithiasis.'') Albumen, 
which does not ordinarily exist in the urine in health, enters into it as a con- 
stituent in various diseases, and as an almost constant ingredient in Bright's 
disease of the kidneys. (See Bright's Disease.} The albuminous impregna- 
tion is an occasional result of the action of mercury on the system, of the 
poisonous action of arsenic, of the strangury from blisters, of acute nephritis 
or nephritic congestion from any cause, of pneumonia in certain stages, of 
various fevers either in their course or at their close, of epidemic cholera, of 
pregnancy, and of violent mental emotions. It will of course be found, when 
blood or pus, and, in a slight degree, when the seminal fluid exists in the urine. 
In itself, and when a mere result of functional disorder, it is of little import- 
ance, but becomes of the greatest when considered as a sign^f organic renal 
disease. Dr. Arthur Hassal has shown that a species of fungus, denominated 
penicilium glaucum, is frequently developed in albuminous urine, when acid- 
ulous, and exposed to the air. (Medico- Chirurg. Trans., xxxvi. 42.) Suga.r 
in the urine, which is a characteristic of true diabetes, is of fatal significance. 
This affection will be fully treated of in the following pages. Oil is an 
occasional ingredient of morbid urine. It is generally in the form of an 
emulsion, combined with albuminous or fibrinous matter, and giving a milky 
appearance to the secretion. In some instances, it is found in considerable 
quantities, even floating in distinct globules upon the surface. It does not 
appear to be associated with any particular form of disease; but probably 
depends on the abnormal presence of oily matter in the blood. It is owing CLASS III.] 
DISORDERED URINARY SECRETION AND EXCRETION. 
577 
to such an impregnation of the urine that it has been sometimes supposed to 
contain milk. Bayer never could detect the milk globule in the urine, except 
in one instance, in which it was obvious that milk had been added to it. 
Starch granules have been found in the urine, but their presence was acci- 
dental or fraudulent. Fibrin, in connexion with oil and albumen, is in some 
rare cases so abundant as to render the urine spontaneously coagulable. This 
is the case in the chylo-serous urine of Dr. Prout, which, as it scarcely rises to 
the rank of a distinct disease, and is too obscurely connected with any known 
derangement of system to be attached as a symptom to any other disease, will 
be most conveniently considered in this place, as an occasional derangement 
of the urine. 
Chylo-serous urine (Prout), oleo-cdbuminous urine (Willis), or chylous diu- 
resis (Venables), is a curious and rare affection, first described minutely by 
Dr. Prout, but subsequently noticed by various writers. The characteristic 
qualities of the urine are a whitish or milky opacity, and spontaneous coagu- 
lability. The milkiness varies in different specimens from a mere opalescence 
to perfect opacity; and the amount of coagulum is proportionate, being small 
in the former case, while in the latter it occupies the whole bulk of the urine, 
having the shape of the vessel, and an appearance not unlike that of blanc 
mange. When the coagulum is placed in a position favourable for draining, 
it separates into two portions, one a thin, opalescent, or whitish liquid, which 
upon standing becomes covered with a whitish creamy layer, and the other a 
fibrinous mass of small relative bulk, which is either whitish, or somewhat 
tinged by the colouring matter of- the blood. Dr. Prout observed that the 
urine passed a few hours after a full meal, and when the chyle might be sup- 
posed to be entering the circulation, was quite opaque, while that passed after 
long abstinence was merely opalescent. Sometimes the milky urine is mixed 
with a good deal of blood, which gives it a red colour. If agitated with ether, 
it becomes transparent, at least in some instances; and the ethereal solution 
yields an oil or fatty matter on evaporation. It is to this oil, therefore, form- 
ing a white emulsion with the other matters, that the urine owes its milkiness. 
The liquid portion, remaining after the separation of the coagulum, is proved 
to be albuminous by coagulating with heat. The solid spontaneously coagu- 
lated portion is fibrin. Urea and the salts of the urine are found in the liquid, 
which does not materially vary in density from healthy urine. 
This affection is sometimes attended with an increase of the urinary secre- 
tion, so great as to have induced some to rank the complaint with the different 
forms of diabetes. But this is not a necessary symptom. In severe cases, 
the patient is occasionally troubled with difficult micturition, in consequence 
of the coagulation of the urine in the bladder. There is sometimes uneasiness 
in the back and loins, with slight excitement of the circulation, a dryish and 
furred tongue, thirst, torpid bowels, and a dry skin; and occasionally the diabetic 
symptoms of extreme thirst and hunger, emaciation and debility, are presented. 
In other cases, little or no depravation of the general health is observed. The 
disease does not appear to be very dangerous; at least patients live long under 
it, and, when death has occurred, it has resulted, unless in one instance, from 
some other disease. In that instance, the patient died of exhaustion, after 
having had the complaint twenty years. The characteristic condition of the 
urine sometimes disappears spontaneously, and returns after a long interval. 
In several instances, recovery has taken place, and the patients have remained 
well up to the last period of inquiry. In the case of an individual affected 
with the disease who died of some other complaint, the kidneys were found 
healthy. This state of the urine, therefore, does not depend on organic renal 578 
LOCAL DISEASES.-SECRETORY SYSTEM. 
[PART II. 
disease. Prout ascribes it to the production of an imperfect chyle, -which 
does not readily become assimilated with the blood, and is, therefore, thrown 
off by the kidneys. But it is probable that the kidneys are also in fault, as 
the colouring matter of the blood not unfrequently escapes with the other prin- 
ciples. It is not necessary to resort to the chylous theory to explain the pheno- 
mena. Oil is often found in the blood, which contains also albumen and fibrin; 
and these are the prominent constituents of the milky urine. A relaxation 
of the renal vessels such as to permit the passage of these constituents of the 
blood, without or with but little of the red corpuscles, is sufficient to account 
for the phenomena. 
The causes of the complaint are obscure. Residence in a hot climate appears 
to predispose to it; for it is said to be much more frequent within the tropics 
than in temperate latitudes. In more than half the cases which had come 
under the notice of Dr. Prout, the patients had either been born, or had long 
lived in hot countries. Exposure to cold, extreme fatigue, luxurious living, and 
the action of mercury, have been mentioned as exciting causes; and yet Prout 
states that, in one instance, he noticed the disappearance of the chylous symp- 
toms during a severe mercurial ptyalism. The disease is confined to no parti- 
cular age, and to neither sex. It is very rare. Only thirteen cases came under 
the notice of Dr. Prout, either in his own practice, or that of his professional 
friends. 
The treatment is quite unsettled, and must, therefore, be left to the guid- 
ance of general principles. In the earlier stages, when there is some uneasi- 
ness in the region of the kidneys, and some general excitement, the lancet, 
cups to the back, and the antiphlogistic regimen may be expected to do good. 
The skin should be kept warm with flannel, and a tendency of the circulation 
to the surface promoted by the warm or vapour bath, aided by the powder of 
ipecacuanha and opium. In chronic cases, the digestive organs should be 
attended to, and their functions corrected if deranged. Astringents have been 
employed, but generally with no great advantage. In a case, however, reported 
by Dr. H. Bence Jones, the disease disappeared entirely for a considerable 
time under the use of gallic acid, given in the quantity of a drachm daily; 
and, though the affection returned subsequently on several occasions, it was 
each time benefited by the remedy. In the relapses of this case, Dr. Jones 
increased the quantity of the acid from twenty grains up to forty grains three 
times a day. Tannic acid was also tried, but produced disorder of stomach 
and headache, with little effect on the disease. (Lond. Med. Times and Gaz., 
n. 653.) In another case, the same practitioner obtained great advantage from 
the tannate of alumina. The most convenient method of preparing this he 
found to be, to dissolve a drachm of tannic acid and a drachm of alum in 
three fluidounces of distilled water, the whole of which was given in divided 
doses through the day. {Ibid., vii. 494.) Of course, all causes which tend 
to disturb the condition of the kidneys, or promote disease in these organs, 
should be avoided. 
The extractive matters of the blood are often eliminated by the kidneys, 
and, according to Dr. G. 0. Rees, are always found in albuminous urine. 
Their presence is ascertained by first boiling the urine so as to coagulate all 
the albumen, and- afterwards testing the clear liquid by tincture of galls, 
which throws down the extractive. They are also found in certain cases 
marked with debility, unattended with albuminuria, as in chlorotic anaemia, 
and anasarca with disease of the heart. The presence of extractive is import- 
ant, as indicating a drain from the circulation, and will sometimes account 
for general debility and impoverished blood, the cause of which might other- 
wise be obscure. (Med. Gaz., July 25, 1851.) CLASS III.] 
DISORDERED URINARY SECRETION AND EXCRETION. 
579 
Bile, or its colouring principle, is very often present in urine, giving it a 
deep-yellow, yellowish-brown, or almost black colour. For an account of 
the circumstances under which this impregnation is most apt to occur, the 
reader is referred to the article on jaundice. A mode of detecting the pre- 
sence of bilious colouring matter has been given under that head. Another, 
which may be mentioned here, is to pour some urine into a shallow white dish, 
and then to add nitric acid. If the colouring principle of bile be present, 
there will be a beautiful play of colours, among which the green, blue, pink, 
violet, and bright yellow may be noticed. 
Carbonate of ammonia is among the occasional abnormal ingredients of 
the urine. In this case, the urine has an ammoniacal odour, and, upon the 
addition of an acid, will give out carbonic acid if heated. It appears that urea 
is sometimes changed, either in the blood, or by the chemical action of the 
kidneys, into carbonate of ammonia; for the former is often wanting when 
the latter is present. That the ammoniacal salt is not, in all cases, the result 
of a putrefactive process, is proved by the fact, that in low fevers, scurvy, &c., 
its presence has been detected in the urine immediately after secretion. It 
is true that, in certain chronic diseases of the bladder attended with more or 
less retention of urine, the diseased mucus appears to act as a ferment, and to 
bring on the putrefactive fermentation accompanied with the production of 
ammonia. But in this case the urine has an excessively fetid along with the 
ammoniacal odour; while, in those instances in which the carbonate of am- 
monia appears to have been secreted by the kidneys, there is no fetor; the 
smell being merely compounded of that proper to the urine and that of the 
volatile alkali. The presence of free ammonia in the urine appears sometimes 
to arise from the decomposition of the ammoniacal salts of that fluid, by the 
fixed alkali secreted with the mucus in inflammation of the urinary passages. 
QG. 0. Rees.} The fixed alkalies in the urine may be distinguished by 
leaving a permanent impression on test-paper, which, when rendered blue by 
ammoniacal urine, is reddened again on drying. 
Ferrocyanuret of iron has been found in some very rare instances in the 
urine, giving it a blue colour. 
The xanthic, uric, or lithic oxide, of which some very rare urinary calculi 
are composed, and which is supposed to have the same composition as uric acid, 
less one equivalent of oxygen, is occasionally deposited by the urine, though 
it has hitherto escaped detection as an ingredient of that fluid. ( Willis.} 
Cystine or Cystic oxide, also an ingredient of urinary calculi, has been ob- 
served in certain urinary deposits, and in the urine itself, either dissolved, in 
suspension, or forming a film on the surface. Its presence may be suspected 
when the urine has a greenish-yellow colour, a peculiar odour, as of the green 
brier mixed with that of fetid urine, and an oily, slightly turbid appearance. 
The chemical characteristics of this substance are insolubility in acetic, citric, 
and tartaric acids, and solubility in diluted muriatic acid, and in the solutions 
of potassa and soda, from which it is thrown down by bicarbonate of ammo- 
nia. It emits a peculiar odour when heated. 
Nitric acid appears to exist sometimes in the urine. Thic acid generates 
by reaction with lithic acid peculiar products, which, by reaction with ammo- 
nia, give rise to a red colouring matter, considered by Prout as a combination 
of a peculiar acid, denominated purpuric, with ammonia. It is the murexide 
of recent chemistry. To this compound Prout ascribed the pink or red colour 
of certain urinary deposits; but the opinion does not appear to have been con- 
firmed by direct analysis, and has the authority of Berzelius against it. 
Phosphorus, in a free state, is asserted to have been observed in urine, ren- 
dering it luminous in the dark. 580 
[part it. 
LOCAL DISEASES.-SECRETORY SYSTEM. 
The colour of the urine is occasionally changed, assuming, under different 
circumstances, a deep-yellow, green, blue, red, dark-brown, and black hue. 
The causes of these changes are not always known. The admixture of bile 
gives a deep-yellow, brown, and sometimes almost a black colour. A green 
colour may arise from the same source. The blue colour has in one or two 
cases been traced to Prussian blue. Chemists have discovered one or more 
proximate principles, probably modifications of the hematin of the blood, to 
which the blue, deep-brown, and black urine sometimes owes its colour. The 
blue colour, which, when dependent on an organic principle, is usually seen 
only after the exposure of the urine to the air, has been found by Dr. A. H. 
Hassal to belong in general to a substance chemically identical with indigo, 
which results from the oxidation of a brown extractive matter. The indigo 
appears only in pathological conditions; but the nature of these conditions has 
not been satisfactorily ascertained. (Plulosoph. Mag., Sept. 1853.) The urine 
is thought to owe its ordinary hues to two colouring matters, one yellow, and 
the other red, either of which may predominate, and both of which have an 
affinity for urate of ammonia, being separated with it when deposited from 
the urine. For the red principle, Dr. Golding Bird proposes the name of 
purpurine. It is the uro-erethrine of Simon. When it is largely present in 
the urine, that fluid, if not already high-coloured, becomes of a fine rose or 
purple colour on the addition of muriatic acid; and, when a deposit of urate 
of ammonia takes place from such urine, it has a colour " varying from a pale 
pink to the deepest carmine?' Purpurine is soluble in alcohol, which sepa- 
rates it from the urate of ammonia. Dr. Bird considers its presence in excess 
as a certain evidence of functional or organic disease of some organ connected 
with the portal circulation. (Urinary Depos., Am. ed., pp. 57 and 93.) 
The odour of the urine is sometimes very much changed. Its occasional 
ammoniacal smell, and the fetor arising from its putrefaction have been already 
noticed, as have also the effects produced upon it by certain substances taken 
into the stomach. Even the odour of ordinary kinds of food may now and 
then be detected in it, in cases of feeble digestion. But it is sometimes ex- 
tremely offensive, as secreted, without any obvious source of the fetor. Un- 
der such circumstances, it may be inferred that there is some concealed mor- 
bid action, probably affecting the constitution of the blood; and a fair indication 
is offered for the internal use of creasote, the alkaline chlorides, and perhaps 
of nitro-muriatic acid. 
To complete this view of the morbid states of the urine, it is proper to refer 
to the additions derived, not from the renal secretion, but from the mucous 
coat of the passages, or some other source communicating with them. 
Mucus exists in small proportion in healthy urine. It is sometimes very 
much increased in consequence of irritation or inflammation of the membrane 
lining the bladder, pelvis of the kidney, &c. A slight cloudiness may often 
be observed dependent on multitudes of minute scales of the mucous epithe- 
lium, which is thrown off and removed like the cuticle in ordinary health. 
This desquamation, like the secretion of mucus, may be excessive. The mu- 
cus appears to be in different states in the urine. Sometimes it is dissolved, 
giving to the liquid a ropiness, and tendency to froth on slight agitation. In 
this state it is distinguished from albumen by not coagulating with heat. In 
other cases it forms a cloudiness, which gradually separates and falls to the 
bottom as a loose sediment. In another form it is thick and tenacious, so as 
occasionally to retain its place in the vessel when inverted. In this state, it 
is sometimes discharged in great quantities in catarrh of the bladder. 
Pus is not unfrequent in the urine as a result of mucous inflammation or 
ulceration of the kidneys or passages, or of abscesses formed in their walls or CLASS III.] 
581 
DIURESIS. 
in adjoining parts, and opening into the passages. According to Mr. John 
Hamilton, of Dublin, it may be known to be from the latter source, when the 
urine containing it continues acid after having stood several hours. (Dub. 
Quart. Journ. of Med. Sei., xi. 311.) Sometimes the pus passes out nearly 
pure with the urine, and sinks to the bottom of the vessel upon standing. In 
this case it has a yellow colour, is readily miscible with the urine, from which 
it again soon separates, and, when examined by the microscope, exhibits the 
pus corpuscle. Very often, however, the discharge is more or less mixed 
with mucus, and presents the appearance of that transition state from mucus 
to pus, which marks a certain stage of inflammation of the open passages. 
When urine contains pus, it is always albuminous. This is an important fact 
in diagnosis. 
The prostatic and seminal fluids sometimes exist in urine. The presence 
of the latter is known by the spermatozoa or spermatic animalcules, which 
may be detected by the microscope. 
Of blood, in the urine, which is not an uncommon impregnation, sufficient 
is said under hsematuria. 
Article VIL 
DIURESIS. 
Under this term are included all the complaints consisting in an excessive 
urinary secretion, with the exception of that which is characterized by the 
presence of sugar, and to which, following the example of Dr. Prout, I pro- 
pose confining the term diabetes. These complaints have been commonly 
designated by authors as Diabetes insipidus ; but this name does not express 
the fact, as the urine is not always tasteless. Diuresis may be simply a mor- 
bidly increased discharge of urine, differing from that of health only in being 
more dilute; or it may be attended with a material and permanent alteration 
in the character of the secretion. 
Simple Diuresis.-Hydruria (Willis).-A temporary increase in the 
secretion of urine, depending on an excess of liquid swallowed, exposure to 
cold, mental anxiety, the use of diuretic articles of food or drink, &c., with- 
out any disturbance of health, or considerable inconvenience, can scarcely be 
looked upon as morbid. Perhaps we may consider in the same light the co- 
pious discharges of pale, watery urine, which frequently attend the hysterical 
paroxysm, and to which persons of an irritable, nervous constitution, are 
occasionally liable. Dr. Willis found, upon examination, that, though the 
specific gravity of the urine was very low, sometimes even as low as 1.002, 
and consequently the solid constituents small in proportion, yet these several 
constituents bore to each other about the usual relation. 
But instances of diuresis are not unfrequently met with of a more perma- 
nent character, affecting the comfort of the individual by the frequent and 
harassing calls to evacuate his bladder, often at the most unseasonable times, 
interrupting his rest at night, occasioning troublesome thirst, and, if not 
arrested, producing at length a greater or less degree of debility, and loss of 
flesh. Such cases are apt to occur in individuals of excitable or nervous tem- 
perament, and especially in dyspeptics, who are sometimes greatly alarmed 
lest an attack of real diabetes may have set in. They are, moreover, not un- 
common in people who have passed the middle life, and whose bodily powers 
have begun somewhat to fail. The affection, in such instances, is apt to be 
considered as mere irritation of bladder; but, upon examination, it will be 582 
[PART II. 
LOCAL DISEASES.-SECRETORY SYSTEM. 
found that the amount of urine daily evacuated is much above the healthy 
average. Now and then cases occur of profuse diuresis of a very permanent 
character, without any known cause; and the statements on record of the 
amount of urine passed, and water drank daily, in some of these instances, 
during a long succession of years, are almost incredible. Thus, a man aged 
fifty-five was admitted, for an accident, into the Hotel-Dieu, at Paris, who, 
during his stay, passed daily, on an average, thirty-four pounds of urine, and 
drank thirty-three pounds of water. The account states that this individual 
had been affected in a similar manner ever since his fifth year, and that, from 
the age of sixteen upwards, he had daily consumed not less than two bucket- 
fuls of water, and discharged a commensurate quantity of urine. ( Willis on 
Urinary Diseases.) It is sometimes difficult to determine, in these cases of 
excessive thirst ^polydipsia) with profuse diuresis, which of the two affec- 
tions is primary. The singularity is, that the system should support so long 
such an enormous excess of one of its functions, without greater evidence 
of suffering. Nevertheless, though in some instances the affection may be 
borne with impunity, and the vital actions accommodate themselves to the 
great strain upon them, yet there must be considerable danger in the process; 
and the kidneys at least must be liable to serious organic disease from the 
continued functional disturbance. They may, therefore, be -considered as 
proper cases for medical interference. 
The urine in profuse diuresis is usually pale or colourless, quite transparent, 
and of very low density, sometimes scarcely exceeding that of water. Its low 
specific gravity, the absence of a sweet taste, and the fact that it will not ferment 
with yeast, are sufficient evidences that it is not of the true diabetic character. 
The treatment of simple diuresis must be directed chiefly to the regulation 
of the habits of the patient, and the improvement of his general health. In 
the first place, his own will should be brought to the aid of the physician. It 
is probable that occasionally the affection may have originated in, or at least 
may be sustained by a habit of excessive drinking. The patient should, there- 
fore, be induced to take as little drink as may be at all consistent with his 
comfort, and should avoid altogether liquids calculated especially to stimulate 
the kidneys. The diet, too, should be of a kind least likely to provoke thirst; 
and salt food, and the use of much salt as a condiment, should be avoided. 
In order to divert action from the kidneys, all the other emunctories should 
be sustained in full operation. The liver, if torpid, should be stimulated by 
nitro-muriatic acid; the bowels should be kept regular by rhubarb and aloes, 
compound extract of colocynth, sulphur, &c., the saline cathartics being pro- 
hibited; and efforts should be especially made to promote the functions of the 
skin by the frequent use of the flesh-brush, by the warm or vapour bath every 
day or every other day, by woollens next the skin, and by moderate exercise. 
Nervous irritability should be controlled by narcotics and tonics. Opium 
often has a very happy effect, and is preferable to the salts of morphia, which 
I have sometimes known to stimulate the kidneys actively. It may be advan- 
tageously given combined with an equal proportion of ipecacuanha at bedtime, 
so as to obtain at once its diaphoretic and narcotic effect. Of the tonics, the 
mineral acids, chalybeat.es, and simple bitters, including the preparations of 
Peruvian bark, may be employed. In some instances, the disease appears to 
be connected with laxity of the kidneys, and may be treated with astringents. 
In such cases, I have seen the oil of turpentine apparently very efficient. 
As dyspepsia is not unfrequently the basis of the disease, the whole regi- 
men and course of treatment adapted to that affection should be employed. 
Complicated Diuresis.-Several varieties of diuresis have been described, 
in which, along with the excess in the quantity of urine, there is superabund- CLASS III.] 
DIURESIS. 
583 
ance or deficiency of one of its solid constituents, or the addition of some new 
principle not usually contained in it. Mere occasional derangements, how- 
ever, of this kind, can scarcely be considered as morbid. It is by a certain 
degree of persistency that they acquire a claim to be thus regarded. The 
varieties hitherto noticed are those connected with an excess or deficiency of 
urea, the presence of albumen, or that peculiar derangement known as the 
chylous or chylo serous urine. 
Ureous diuresis, the azoturia of Willis, is characterized by an excess of 
urea. The attention of the profession was first called to it by Drs. Bostock 
and Prout. The urine is generally pale and transparent, but sometimes 
brownish, has an acid reaction when first discharged, and is, perhaps, some- 
what heavier than in health, having a specific gravity varying from 1.015 to 
1.035, and averaging generally about 1.020. It soon undergoes decomposi- 
tion, and becomes alkaline. Nitric acid added to it usually occasions, after a 
short time, crystallization with the urea, either without a previous concentra- 
tion of the urine, or with a degree of concentration too slight to afford the 
same result in the healthy state of the secretion. An excess of urea is thus 
indicated. But it may also be in excess even should the test fail; for the 
quantity of urine is so much increased, that more than the daily average of 
urea may be discharged, though the degree of impregnation should even be 
less than in health. From half a gallon to a gallon or more of urine is 
passed daily; and, even where the amount is not greatly increased, it is liable 
to be so by slight causes which would scarcely be felt in health. It is said 
that the daily discharge of urea has equalled nine and a half ounces, while, 
in the healthy state, according to Becquerel's analysis, it is only about half 
an ounce, and to that of Berzelius, somewhat more than an ounce. With this 
character of the urine, there is often much thirst, sometimes an increased 
appetite, a sense of weight or dull pain in the back, a sinking, gnawing, or 
other uneasiness at the pit of the stomach, and more or less debility and ema- 
ciation, with an anxious expression of countenance. But the skin is not dry. 
and parched, nor is the thirst so insatiable as in the saccharine diabetes. 
The causes of this complaint are unknown. Dr. Prout mentions as pro- 
bable predisposing causes, hereditary influence, intemperance and the abuse 
of the sexual propensity in early life, mental anxiety, and mercurial action. 
It is apt to attack persons of spare habit and nervous temperament, and gene- 
rally occurs in those of middle age, and in men more frequently than women. 
Children are not exempt from it, and, there is reason to think, occasionally 
perish under it without the cause being known. In the case of a young man, 
a patient in the Pennsylvania Hospital, in whose urine, which was about nor- 
mal in quantity, nitric acid produced a copious crystallization of nitrate of 
urea, the patient was dyspeptic, anemic, and considerably emaciated. No 
other disease could be detected. The affection seemed to be either a too rapid 
disintegration of the tissues, or a defective assimilation of the food. He 
improved under the use of nitro-muriatic acid and cod-liver oil. 
The disease is said to be an occasional precursor of diabetes, with which, 
moreover, it sometimes alternates or co-exists. If taken early, it is thought 
to be generally curable. 
The treatment must be regulated upon general principles. If there is pain 
in the back, cups may be applied; but depletion is not usually required. To 
support the digestive process and the general strength by tonics, to keep the 
bowels regular by means of laxatives, to divert to the skin by the warm-bath, 
Dover's powder, and warm clothing, and to control the general irritability and 
excessive renal action by opiates, are the prominent indications. Saline 
cathartics, and all other substances calculated to irritate the kidneys are ob- 584 
[part II. 
LOCAL DISEASES.-SECRETORY SYSTEM. 
jectionable. The patient should take moderate exercise, and follow the same 
regimen generally as in dyspepsia. 
Anureous diuresis, the anazoturia of Willis, is marked by the very copious 
secretion of a colourless or straw-coloured urine, of a density scarcely exceed- 
ing that of water, of a faint odour, a weak acid reaction when first discharged, 
but becoming slightly ammoniacal upon standing, and containing very little 
urea. The attendant symptoms are thirst, a parched mouth, a craving appe- 
tite, gnawing in the epigastrium, constipation, dryness of skin, depression of 
spirits, debility, and emaciation. Such is the description given of this affec- 
tion; but it does not appear to me to be sufficiently distinguished from simple 
diuresis. If the daily amount of urea is greatly deficient in some cases, it is 
not very strikingly so in relation to the other solid constituents. Dr. Willis 
believes the disease to be not unfrequent among the children of the poor. Dr. 
Christison considers it as the form of diuresis which is sometimes met with in 
the advanced stages of Bright's disease. The treatment recommended does 
not differ materially from that considered applicable to the preceding variety. 
Albuminous diuresis sometimes occurs in the advanced stage of Bright's 
disease. The presence of albumen has probably nothing to do with the in- 
creased secretion of urine; but it serves, in connexion with the low specific 
gravity, to indicate the origin of the complaint in organic disease of the kid- 
neys. It is alluded to here merely as one of the varieties of the so called 
tasteless diabetes. (See Bright's Disease.') 
According to Dr. G. Owen Rees, large quantities of the extractive matter 
of the blood pass with the urine in certain cases of diuresis. It may be 
detected by means of the tincture of galls, in the manner indicated in page 
578. The affection serves as a great drain upon the system, and is the 
occasional source of anaemia and general debility. (London Med. Gaz., July, 
1851, p. 137.) 
The term chylous diuresis may be used to designate the increased secretion 
which sometimes attends the chylo-serous urine. This has been already suffi- 
ciently described. (See page 577.) 
Article VIII. 
DIABETES. 
Syn.-Diabetes Mellitus.-Honey Diabetes.-Saccharine Diabetes.-Glucosuria.-Mel- 
lituria (Willis). 
This disease is characterized by an excessive discharge of saccharine urine. 
It consists essentially in the production and elimination of glucose or grape 
sugar, the diuresis being merely incidental, and dependent on the existence 
of that principle in the blood. Indeed, there is reason to suppose that the 
saccharine state of the urine may at least sometimes precede the excessive 
secretion; and it is known often to remain after the diuresis has for a 
time disappeared. A disease so distinct merits a distinct designation; and 
hence it is proposed in this work, in imitation of Dr. Prout, to appropriate 
to it exclusively the name Diabetes, before applied to all diseases indiscrimi- 
nately in which a great excess of urine is a prominent symptom. Dr. Thos. 
Willis, who lived in the time of Charles II. of England, is generally admitted 
to have been the first who noticed the saccharine character of diabetic urine. 
The complaint is not frequent in this country. It is probably more so in 
Great Britain; as Dr. Prout states that in twenty-five years he saw more than 
five hundred cases. CLASS III.] 
585 
DIABETES. 
Symptoms, Course, &c.-Diabetes is almost never recognized at its very 
commencement; and it is not usually until after the lapse of a considerable 
time that the attention of the physician is called to it. The symptom which, 
in general, first attracts the notice of the patient is the frequency of his calls 
to evacuate the bladder, by which lie is often disturbed several times in the 
night. He soon also observes that the quantity of the urine is much increased, 
and accident sometimes leads him to the discovery of its sweet taste. The 
physician is now consulted, and finds, in addition to the symptoms mentioned, 
thirst, a clammy state of the mouth and fauces, a coating of frothy mucus or 
white fur upon the tongue, constipated bowels, a dry, harsh skin, a sense of 
weariness or dull pain in the back, loins, and lower extremities, frequent, and 
in some cases almost constant chilliness, a general feeling of lassitude, weak- 
ness and indisposition to bodily or mental exertion, and a daily increasing 
emaciation. Dyspeptic symptoms are also frequently exhibited; such as sour 
eructations, oppression or weight in the epigastrium, burning sensations about 
the praecordia, &c. The appetite, however, is seldom impaired, but on the 
contrary often increased. Thus affected, the patient may be considered as in 
the first stage of the disease. If this should continue to advance, the symp- 
toms assume a more violent character. The discharge of urine is increased, 
and the craving for drink, and often for food, becomes inordinate and insatia- 
ble. From twenty to thirty, or even forty pints of water are sometimes drank 
daily, and enormous quantities of food consumed; and yet the patient is never 
satisfied, nay, sometimes feels the craving increase with the means used to 
gratify it. Along with this excessive thirst and hunger, and probably con- 
tributing to them, are a parched state of the mouth and fauces, and a sensa- 
tion of hollowness or sinking, with faintness, at the pit of the stomach. The 
food, notwithstanding the quantity consumed, produces no increase of flesh. 
On the contrary, a steadily progressive emaciation is almost always noticed, 
with increasing debility both of body and mind. The sexual propensity is 
lost, the spirits depressed, the temper soured, or peevish and fretful, and the 
memory and intelligence impaired. The lungs and surface of the body exhale 
a sweetish odour, generally compared to that of hay. The feces are said to 
be destitute of their characteristic offensiveness, and to be scanty and very 
dry. The tongue is now either red at the edges and furred in the middle, or 
uniformly red and smooth. The gums assume a dark-red or purplish hue, 
are soft and spongy, bleed easily, and often separate from the teeth, which are 
thus loosened. With this scorbutic state of the mouth, the breath, instead of 
retaining the sweetish odour before mentioned, becomes offensive. Occasion- 
ally a redness like that of the mouth is observed at the orifice of the urethra, 
and a sensation of heat is experienced along the urinary passages. Serious 
organic disease is now apt to set in. Tubercles are often developed in the 
lungs, with the usual attendant symptoms. Sometimes Bright's disease of 
the kidneys occurs, indicated by an albuminous impregnation of the urine. 
At this stage, the patient sinks rapidly, the emaciation and debility become 
extreme, the fauces assume a dark-red or aphthous appearance, the extremi- 
ties swell, the urine diminishes, loses its saccharine character, and at last is 
almost wholly suppressed, and the patient dies exhausted and comatose. 
The urine in diabetes is of a pale-yellow or greenish-yellow colour, a faint 
sweetish odour, which has been compared to that of fresh hay or milk, and a 
sweet taste, which, however, is not always very distinct.* The quantity dis- 
* Diabetic urine is said sometimes to contain a tasteless kind of sugar, which, accord- 
ing to Bouchardat, corresponds in all its chemical properties with ordinary diabetic sugar, 
having the property of fermenting, and being converted into sweet sugar by the acids. 
(Simon's Chem., ii. 293.) 586 
LOCAL DISEASES.-SECRETORY SYSTEM. 
[PART II. 
charged varies much, but almost always greatly exceeds that of health, aud is 
sometimes enormous. From ten to twenty pints are usually passed daily, 
often thirty pints, and occasionally forty or fifty pints or even more ; and this 
average is maintained for weeks and months together. Contrary to what might 
have been anticipated from the quantity of the urine, its density is undimi- 
nished, and often much increased. The sp. gr. is seldom below 1.020, and is 
sometimes as high as 1.055, or even higher. The average is probably about 
1.040. The ordinary solid ingredients of urine, as the urea and salts, 
though smaller in proportion to the liquid part than in health, are yet undi- 
minished if reference be had to the whole daily discharge. The urea is some- 
times increased beyond the healthy standard.* The uric acid is said to be 
almost invariably deficient. The increased density, therefore, must be as- 
cribed to a new ingredient. This is sugar, of the variety known to chemists 
by the name of glucose or grape sugar. It may be obtained separate in the 
crystalline state without difficulty. A portion of the saccharine matter, how- 
ever, appears to be uncrystallizable. 
As the saccharine taste is not always very obvious, and the application of 
this test at best not very agreeable, it is important to possess some other 
means of detecting the presence of sugar. This may be done by a very sim- 
ple process. Like other liquids containing sugar, diabetic urine is capable 
of undergoing the vinous fermentation, upon the addition of yeast, and at a 
suitable temperature. No such change takes place in healthy urine, under 
the same circumstances. To test the urine, therefore, nothing more is neces- 
sary than to add yeast, and expose the mixture to a temperature of 70 or 80°. 
If it be diabetic, an effervescence will speedily commence, gas will escape, and 
the liquor will acquire a vinous odour. Dr. Christison says that he has thus 
detected one part of diabetic sugar in 1000 parts of urine. By collecting the 
carbonic acid over mercury, and measuring it, we can ascertain also with tole- 
rable accuracy the proportion of sugar present, allowing for every cubic inch 
of the gas about one grain of sugar. Another test, proposed by Runge, is to 
dry a drop or two of urine upon a surface of porcelain, and to let fall upon 
the spot a drop of sulphuric acid, diluted in the proportion of one of acid to 
six or eight of water. If sugar is present, a blackish colour will be developed. 
( on Urinary Diseases.} The reaction of grape sugar with the salts 
of copper at an elevated temperature, and the effect of the alkalies upon it, 
offer the methods of testing it at present most relied on.f If diabetic urine 
* Simon states that the ratio of urea to the other solid ingredients is always less than 
in health, and that it is diminished in proportion to the increase of the sugar. 
f Frommer's test, which is based on the reaction of the salts of copper, is applied in 
the following manner:-Add enough solution of sulphate of copper to the urine to give 
it a faint blue tint. A little phosphate of copper generally falls. Then add solution of 
potassa in great excess. The oxide of copper precipitated at first is re-dissolved in the 
excess of the alkali, producing the peculiar blue of ammoniated copper. If the liquid 
be now gently heated, a red suboxide of copper falls if diabetic sugar is present. 
Moore's test depends upon the property of sugar of being converted into a brown sub- 
stance (melassic or sacchulmic acid) under the action of an alkali. To two fluidrachms 
of the urine in a test tube, nearly a drachm of liquor potassm is to be added, and the 
mixture boiled for a minute or two over a spirit-lamp. If sugar is present, the urine 
will assume an orange-brown or bistre tint according to the quantity. In applying this 
test, it is necessary to bear in mind a fact ascertained by Dr. G. 0. Rees, that solution of 
potassa, kept in white glass bottles, sometimes contains so much lead as to produce a 
brown colour in albuminous urine, which might be mistaken for the effects of sugar. To 
guard against this fallacy, the solution of potassa should be tested for lead by hydrosul- 
phuret of ammonia, before being used. {Ranking's Abstract, v. 286.) 
M. Maumene, of Rheims, proposes the following test, which he finds extremely deli- 
cate. A strip of white merino, or other tissue not affected by chloride of tin, is dipped CLASS III.] 
DIABETES. 
587 
be allowed to stand, without addition, in a moderate temperature, it will 
undergo spontaneous decomposition, ultimately becoming acid, and having 
the smell of sour milk. (Ibid.') Dr. Arthur Hassal has ascertained that 
the yeast fungus is developed in diabetic urine freely exposed to the air, if 
an acid be present; and that in this way a quantity of sugar may be de- 
tected, with the aid of the microscope, too small to give any evidence of its 
presence by the ordinary chemical tests. (Medico- Chirurg. Trans., xxxvi. 75.)* 
From tables, prepared by Dr. Henry, of the amount of solid matters con- 
tained in urine of different densities, it appears that, in a case in which only 
one gallon is discharged daily of the average sp. gr. of 1.040, the amount of 
solid matters discharged at the same time would somewhat exceed a pound 
troy; and this is sometimes doubled, tripled, or even quadrupled for many 
successive days or even weeks. The whole quantity of solids thus eliminated 
often considerably surpasses that of the dry food taken into the system.f 
The urine in diabetes is sometimes albuminous, as shown by the tests of 
heat and nitric acid. Sometimes also it is tinged with blood; and Dr. Prout 
states that he has seen it mixed with a whitish fluid like chyle, which sank 
to the bottom of the vessel, and appeared to act the. part of yeast; as the 
urine underwent a spontaneous vinous fermentation. Occasionally, in con- 
sequence probably of an excess of urea, diabetic urine putrefies and exhales 
ammonia; but this result is not common. 
Hij^lric acid has been found by several chemists in diabetic urine. 
The quantity of urine discharged in a given time is asserted to be some- 
times much greater than that of all the ingesta, including food and drink, 
even though to the weight of the latter, the loss of weight by the body be 
added. This statement has been denied; and, though the experiments of 
in a strong solution of that salt, and dried. A few drops of the suspected urine, placed 
upon the strip thus prepared, and exposed to a heat from 260° to 300° F., immediately 
produce a black or dark-brown stain. [Med. Gaz., April, 1850, p. 604.) 
Sometimes urine containing cystine undergoes a species of viscous fermentation, end- 
ing in the appearance of much ropy mucus, which might be mistaken for the saccharine. 
The odour, however, is ditferent, being disagreeable and sulphurous, instead of vinous., 
(Bird on Urin. Dis., Am. ed., p. 198.) 
* It is asserted that sugar occasionally appears in the urine, when there is no reason 
to suspect the existence of diabetes. M. Reynoso, in a report made to the French 
Academy, states that he has found the urine saccharine in persons who have been under 
the influence of chloroform and ether, also in cases of tuberculosis, pneumonia, chronic 
bronchitis, asthma, asphyxia, hysteria, and epilepsy, and after the use of various medi- 
cines, as opium and other narcotics, quinia, mercury, &c. He is disposed to think 
that whatever interferes with the respiratory process, whether directly, as diseases of 
the chest, or indirectly through the nervous centres, as nervous affections and narcotics, 
may produce this effect. M. Dechambre, in a report made to the Academy of Medicine 
of Belgium, announces that he has detected sugar in the urine of a large number of 
old persons whom he has examined, and considers it as a normal result of old age. 
Uhle, Schrader, and others have repeated the experiments of Reynoso, and with different 
results; and Dr. Frick, of Baltimore, states (Am. Journ. of Med. Sei., N. S., xxiv. 77), 
that, though he has tested the urine in some hundreds of cases of disease, he has never 
detected sugar unless where diabetes existed or ensued. Still, taking all the various 
statements into consideration, there cannot, I think, be any doubt that the urine may 
sometimes become in some degree saccharine, in other cases than in those of diabetes; 
but this event is relatively so rare, and so temporary, that, whenever sugar is found in 
the urine, and persists for any length of time, there is reason to apprehend that, if dia- 
betic symptoms do not exist at the time, they will sooner or later make their appear- 
ance. (Note to the fourth edition.) 
f Dr. Christison gives the following formula for ascertaining the amount of solid mat- 
ter in urine, which Mr. Day, editor of the Sydenham edition of Simon's Chemistry, has 
found in numerous observations to be the most correct. Multiply the excess of the spe- 
cific gravity over 1000, by 2.33, and the result is the number of parts of solid matter 
in 1000 of urine. (Simon's Chern., ii. 290.) 588 
[part II. 
LOCAL DISEASES.-SECRETORY SYSTEM. 
Bardsley, McGregor, and others, would seem scarcely to leave room for doubt 
upon the subject, yet such experiments are exposed to so many sources of 
fallacy, that the apparent result must be received with hesitation ; especially 
as other observations, in which the greatest care has been taken to avoid 
error, have determined, in relation to the cases examined, that the whole 
amount of liquid discharged from the body in diabetes was exactly equal to 
that taken into the stomach.* In the supposition that the occasional excess 
referred to really exists, it has been explained upon one of two hypotheses, 
either that water is absorbed through the skin or lungs, or that it is produced 
by the combination of hydrogen and oxygen within the body. 
The symptoms of diabetes above given are by no means uniform in all cases. 
This disease presents a very great diversity in its secondary phenomena. Dr. 
Prout states that, in relation to the minor and concomitant symptoms, he has 
seen no two cases alike. The thirst, however, is almost never absent during 
the course of the complaint, and usually increases with indulgence. Hunger 
is a more variable symptom, and, in some instances, the appetite is rather 
deficient. Both thirst and hunger are sufficiently explained by the enormous 
drain of liquids and solids. Constipation of the bowels, and dryness of the 
skin, though very frequent, are not constant symptoms. Instead of the chil- 
liness which characterizes most cases, there is sometimes febrile heat. The 
debility and emaciation are probably invariable when the complaint is of very 
long duration ; but they differ greatly in degree in different cases ; adl^corpu- 
lent persons sometimes retain their obesity with little apparent diminution 
for a considerable time, and either recover, or perish from other diseases 
without becoming emaciated. 
The disease is generally very slow in its progress, lasting sometimes for 
years, nay for many years, before a fatal termination. Occasionally it appears 
to cease entirely, either spontaneously or under the influence of remedies, and 
again returns with equal or increased violence. Not unfrequently it assumes 
a remittent form. In the great majority of instances, the patient dies of 
phthisis. Sometimes he is carried off by organic disease of the kidneys, as- 
suming the characters of Bright's disease. Organic affections of other struc- 
tures, as of the brain, liver, or stomach, may also be the immediate cause of 
death. He is, indeed, constantly exposed to fatal effects from causes which 
but slightly disturb the system in health. Dropsical effusion or colliquative 
diarrhoea, in some instances, precedes the fatal issue. In other cases, death 
appears to be the direct result of exhaustion and debility, produced by the 
excessive discharges. The sudden withdrawal of food or drink has sometimes 
occasioned fatal prostration. Perhaps the overloading of the stomach, under 
the influence of a ravenous appetite, has led more frequently to the same 
fatal result by a direct embarrassment of the vital processes. Though the 
disease is generally chronic, acute cases sometimes occur, running their whole 
course in a few weeks, or even in a few days. The author has known of a 
case in which a man was attacked with excessive micturition in apparent 
health, and died almost immediately from the consequent prostration. 
Anatomical Characters.-When any organic disease has supervened upon 
diabetes, the marks of it are of course found in the body after death; but dis- 
section has revealed nothing calculated to throw light upon the nature of the 
complaint, except that it is not necessarily connected with any organic lesion, 
and is, therefore, in all probability, purely functional. It is true that the 
kidneys are often found enlarged and flabby, and sometimes congested, with 
* See, for the result of experiments by Th. von Dusch, of Manheim, Archives Gene- 
rates, February, 1854, page 222. CLASS III.] 
DIABETES. 
589 
the tubuli unusually permeable, and the blood-vessels dilated; but these are 
results which might be anticipated from the excessive work which is thrown 
upon these organs; and, in some instances, their structure has been observed 
to be quite healthy. Occasionally the same morbid appearances are found in 
their cortical portion as those which characterize Bright's disease. But this is 
a mere supervention of organic affection in the kidneys, like that of tubercles 
in the lungs, and is much rarer than the latter form of morbid deposition. As 
might be conjectured, the mucous membrane of the stomach and upper bow- 
els is sometimes congested or inflamed; but in other cases it is quite sound. 
The stomach is often much enlarged. A congested state of the veins which 
contribute to the portal circle is very frequent; and the nervous centres some- 
times exhibit marks of disease. 
Nature.-1The excessive discharge of saccharine urine in diabetes is not the 
disease itself, but only a result of that pathological condition in which the 
disease consists. The production of sugar, which, in the healthy state, exists 
neither in the blood of the general circulation nor in the urine, and which is 
found even when not the least particle of saccharine matter is swallowed, is 
obviously the main character of the affection. The first point, then, in the 
course of a pathological investigation, is to ascertain where the sugar is gene- 
rated. Is it in the kidneys? This is not probable. These organs have been 
ascertained to be much more efficient as mere separatories than producers of 
the matters they discharge. Thus it is with the urea, and in great measure 
with the saline matters, which are the healthy ingredients of urine; and thus 
also it has been shown to be with the albumen and oil occasionally existing 
in it in disease. The same is the case with the sugar. This principle is 
merely separated from the blood by the action of the kidneys. But has it 
been shown to exist in the blood? For a long time it escaped the researches 
of the most skilful chemists; and for an obvious reason, viz., that the least 
quantity in the circulation proves offensive to the constitution, and it is, there- 
fore, thrown off almost as fast as it enters. It is not by the kidneys only that 
it escapes. It was detected in the saliva by McGregor, in expectorated mat- 
ter by Dr. Francis, and in the sweat and stools by Dr. Charles Frick, of Bal- 
timore, who states that all the secretions which can be examined afford evi- 
dence of its presence. (Am. Journ. of Med. Sei., N. S., xxiv. 66.) Patients 
are said often to have a sweet taste in the mouth; and the odour of their 
breath, and that exhaled from the surface of the body, are other evidences 
of the same kind.* But we have positive proof. Sugar was found in the 
serum of diabetic blood by Ambrosioni, Maitland, and McGregor, and has 
subsequently been detected by many other chemists. Dr. McGregor evapo- 
rated diabetic serum to dryness, boiled the residue in water, and added yeast 
to the decoction after filtration and concentration. Vinous fermentation re- 
sulted, proving the presence of sugar. It may also be detected in the serum 
by the tests for sugar already mentioned. (See note at page 586.) But what 
is the origin of the sugar? So far as experiment has determined, only two 
sources are known. McGregor ascertained that sugar is formed in the sto- 
mach of a diabetic patient, during chymification, even when no saccharine 
matter has been swallowed. This happens to a certain extent, though the 
patient may have been confined to animal food exclusively. Two individuals, 
one in health and the other diabetic, were vomited and purged, then fed on 
beef and water exclusively for three days, and at the end of that time were 
* Bernard maintains that the proper salivary secretion is not saccharine. If the 
fact be so, the sugar ascribed to the saliva must really exist in the mucus mingled with 
that fluid. 590 
[PART II. 
LOCAL DISEASES.-SECRETORY SYSTEM. 
again vomited with sulphate of zinc, administered about three hours after a 
meal. The contents of the stomach, properly prepared and concentrated, 
were submitted to the test for sugar. The matter thrown up by the healthy 
person showed no signs of fermentation, that of the diabetic patient fermented 
briskly, though less so than in another case, in which the diet was of the 
ordinary character. Sugar, then, is produced in the stomach of diabetic in- 
dividuals, during the process of digestion. Some matter is probably secreted 
with the gastric juice, which disposes to the generation of sugar out of aliment- 
ary substances, as diastase disposes to its production out of starch in the pro- 
cess of germination.* The sugar thus generated* may enter the duodenum, 
and, escaping the assimilating powers exercised in the small intestines, may 
pass with the current of the chyle, or through the portal system, into the 
circulation, and mix with the blood. M. Bernard, in his beautiful experi- 
ments upon the functions of the liver, has pointed out another source of the 
diabetic sugar. From these experiments, it appears that no sugar is in health 
found in the portal vessels proceeding towards the liver, but that it exists 
abundantly in the venous blood proceeding from the liver to the heart, and 
passes with this into the lungs, where it is consumed in the process of respira- 
tion ; as none can be detected, in the healthy state, in the arterial blood of the 
pulmonary veins. Now if the liver produce the sugar in excess beyond the 
consuming power of respiration, or if, from disease in the lung, the normal 
quantity produced in the liver be not consumed, in either case, the sugar must 
enter the general circulation. From whatever source derived, being admitted 
into the circulation, it stimulates the kidneys to excessive action, and is thrown 
off with an increased amount of the other constituents of the blood, which 
escape the vigilance of the renal function, occupied with its great duty of 
eliminating the noxious matter. The vast discharge of fluid and solid matters 
provokes thirst and hunger, which, by leading to distension of stomach, increase 
probably the original digestive disorder; and the vital actions of assimilation 
and secretion thus go on in a vicious circle, which draws at length all the 
functions of the economy into its fatal vortex. The derangements already 
enumerated among the symptoms of diabetes are thus readily explained. 
Dryness of the skin necessarily follows the concentration of secretory action 
in the kidneys. Emaciation and debility tread naturally in the steps of au 
evacuation, beyond the reparative powers of the nutritive function. The 
depravation of the blood leads to organic derangements, such as tuberculous 
deposit in the lungs, and granular disease in the kidneys. At length the 
overtasked renal powers give way; the secretion of urine ceases; effete matters 
accumulate in the circulation; and, if life has not fled by some one of the 
numerous avenues before opened, it goes at last through the brain, which is 
paralyzed or oppressed by the impoverished or poisoned blood. 
Causes.-These are quite obscure. It appears to be generally admitted 
that hereditary tendencies, and certain natural or acquired conditions of the 
constitution in persons whose parents had never been affected with the dis- 
ease, act as predisposing causes. Prout states that he has seen it more fre- 
quently in persons of light-reddish hair, and strumous constitution, than in 
others. A residence in cold damp situations, and in miasmatic districts, an 
impoverished diet, venereal excesses, and the abuse of mercury, are said some- 
* The theory of the digestion of amylaceous matters, at present generally admitted, 
is that starch in the stomach passes first into dextrin, then into grape sugar, and ulti- 
mately into vegetable acid or carbonic acid. This theory being admitted, the supposi- 
tion is that, in diabetes, the series of changes is arrested by some unknown cause after 
the production of the sugar, which therefore accumulates. CLASS III.] 
DIABETES. 
591 
times to have placed the system in a condition favourable to the occurrence 
of diabetes. The same is said of the excessive use of sugar. Among the 
exciting causes have been mentioned, exposure to cold, blows or other violence 
on the back, the drinking of cold water when over-heated, anxiety or grief, 
and various diseases, especially rheumatism and gout, cutaneous eruptions 
repelled from the surface, and carbuncle or its allied affections. Dr. Prout 
states that, so far as his experience goes, carbuncle is always accompanied with 
diabetes. It must be confessed that all our knowledge of the causes of this 
complaint is exceedingly vague and unsatisfactory. It is most frequent in 
middle life, and is rare in infancy and old age. Sex appears to have no in- 
fluence over it. Should further investigations prove the accuracy of the ex- 
periments by which the origin of the diabetic sugar may be traced to a defect 
in the process of digestion, as inferrible from the observation of McGregor, or 
to abnormal action of the liver or lungs, as suggested by the experiments of 
Bernard, we shall have advanced one step towards an understanding of the 
etiology of the disease. M. Bernard found that, by irritating the olivary 
bodies of the medulla oblongata, he could at any time increase the production 
of sugar, and cause its appearance in the urine. We may, therefore, look to 
the nervous system, as well as to the stomach, liver, and lungs, as possible 
seats of the true disease in diabetes. In a fatal case occurring subsequently 
to the promulgation of the observations of Bernard, two dark spots were found 
in that part of the medulla oblongata, the wounding of which had been fol- 
lowed by the extraordinary effect above mentioned. (See Am. Journ. of Med. 
Sci., N. S., xix. 185.) It is very certain that the affection is often associated 
with organic disease of the liver and lungs. 
Prognosis.-This is generally unfavourable. When the .disease is sub- 
mitted to treatment in its earlier stages, there may be some hope of affording 
permanent relief, though, when apparently cured, the patient is liable to a 
renewed attack from comparatively slight causes, and constant watchfulness 
is necessary during the remainder of life. Though the disease is cured, the 
predisposition remains. In many cases, where complete cures cannot be 
effected, much may be done towards moderating the symptoms and prolonging 
the life of the patient. In the advanced stages, treatment is of little avail. 
Upon the whole, though numerous instances of asserted cure are on record, 
the cases are remarkably few in which individuals, after having once had the 
disease and been restored to apparent health, are positively known to have 
continued exempt from it during their after life. Favourable symptoms, in 
any particular case, are a diminution in the quantity and saccharine quality 
of the urine, a density not exceeding 1.035, the appearance of uric acid in the 
secretion, a moderation of the thirst and hunger, improved spirits, and a gain 
in flesh. Unfavourable symptoms are excessive and unremitting diuresis, pale 
or albuminous urine with a density exceeding 1.035, insatiable thirst and 
hunger, extreme emaciation, and, above all, the evidences of organic disease 
of the lungs or kidneys. Any one of these symptoms is of serious import; 
the occurrence of many or all of them may be considered as rendering the 
case desperate. In no case should the disease be considered as cured, while 
the saccharine quality of the urine remains, even though all the other symp- 
toms should have disappeared. 
Treatment.-In conformity with the pathological views above given, the 
indications of treatment are first to prevent the formation of saccharine mat- 
ter, which appears to lie at the very foundation of the disease; secondly, to 
diminish the amount of urine discharged, which, independently of its peculiar 
character, tends, by its excess, to impoverish and deprave the blood, and to 
produce emaciation and debility; and thirdly, to alter the condition of the 592 
LOCAL DISEASES.-SECRETORY SYSTEM. 
[part II. 
blood itself, which is probably the direct source of much of the functional and 
organic derangement which marks the progress of the disorder. 
1. To prevent the formation of sugar, we must alter the functional action 
of the stomach and of the liver by which it is produced, or must prevent the 
entrance into the system of materials out of which it may be elaborated. The 
first is obviously the most important object, and if accomplished would 
leave little more to be done. Unhappily, we are yet ignorant in what the 
gastric derangement consists, and therefore cannot strike at its root. By some 
it is considered a species of dyspepsia; but, in general, there does not appear 
to be a want of solvent power, and large quantities of food are often disposed 
of with little inconvenience. The most reasonable view appears to be that 
the secretory function of the stomach is perverted; and that, instead of the 
ordinary healthy gastric juice, or along with it, there is produced some sub- 
stance which, acting like a ferment, disposes to the generation of sugar out of 
the different forms of aliment, as the diastase, generated during the germina- 
tion of the potato, disposes to the production of sugar out of starch. It is 
reasonable to suppose that this perverted secretion may originate in a want of 
due gastric energy; and hence tonics are often employed, and sometimes not 
without apparent advantage. The simple bitters, quinia, and the chalybeates 
have had the highest reputation. These may be resorted to in any case, in 
which the stomach exhibits no evidence of vascular irritation or inflammation. 
The preparations of iron are perhaps most suitable. Any one of these may 
be selected which agrees well with the stomach. The pill of carbonate of 
iron, the tincture of the chloride, or the solution of the iodide, will usually 
answer well. The iodide and the phosphate have been recommended as hav- 
ing peculiar efficacy; but this is doubtful. Cod-liver oil has been employed 
with apparent advantage, and may be supposed to act favourably by invigorat- 
ing the assimilative functions. At the same time, the bowels should be kept 
regularly open; and, for this purpose, aloes and rhubarb, or the compound 
extract of colocynth, may be employed, either combined with the chalybeate, 
or given separately, as circumstances may render most convenient. The acrid, 
and saline purges, should, in general, be avoided; the former as too irritating 
to the bowels, the latter as endangering an increased diuresis. Castor oil has 
been recommended; but few stomachs will bear it, with that frequency of 
repetition which is often necessary. Emetics have sometimes been thought to 
do much good; and cures are asserted to have been effected by them. It is 
possible that, occasionally repeated, they may tend in some unexplained way 
to correct the gastric perversion; but experience has not spoken with suffi- 
cient decision to justify a reliance upon them. The opinion has been ad- 
vanced, that the acids, which are not unfrequently present in the diabetic 
stomach, may dispose to the conversion of other principles into sugar, as some 
of the same class of substances are known to do out of the body, when aided 
by sufficient heat. Whether this be so or not, the alkaline remedies are 
among those which are thought to have done the most good. Magnesia and 
carbonate of ammonia, separate or together, have probably been most effectual, 
and cures have been repeatedly ascribed to them. Dr. Trotter, who found 
pure magnesia peculiarly useful, gave it in the quantity of two drachms daily. 
Five grains of the carbonate of ammonia may be given four times daily, and 
gradually increased to eight or ten grains. Bicarbonate of soda has been 
highly recommended in the dose of half a drachm, increased to a drachm, 
three times a day. Lime-water, has also enjoyed much reputation, and is 
sometimes given with milk as drink and food. To be effectual, the alkaline 
plan must be continued for weeks or months. It should be persevered in, so 
long as the quantity and saccharine quality of the urine appear to diminish CLASS III.] 
DIABETES. 
593 
under its use. If, on the contrary, the urine should appear to be increased 
by any one of the antacids used, it should be changed for another, or the plan 
abandoned. 
Experience has not yet taught us what measures may be expected to cor- 
rect the diseased action of the liver, which, according to the observations of 
Bernard, is so much in fault in the production of diabetes. The success as- 
serted to have been obtained bjT the use of ox-gall in diabetes may be con- 
jecturally ascribed to its influence on the hepatic function. A case of cure is 
recorded, effected in four weeks by the use of twenty ourices of this medicine. 
(See Nordamerik. Monatsbericht, &c., i. 23.) 
But, while the above measures are in operation, it is highly important to 
attend to the second object under this indication; namely, to prevent the 
access to the stomach of those substances which are most liable to be con- 
verted into sugar. The regulation of the diet is indeed absolutely essential. 
It is necessary gradually to restrain within moderate limits the quantity of 
food and drink taken, so as not to weaken or irritate the stomach by over 
distension, or over dilution. Little drink should be taken at meals, at least 
no more than is indispensable for the comfort of the patient. The urgent 
sensation of thirst may often be as well appeased by washing the mouth and 
throat with cold acidulated drinks as by swallowing them. Some recommend 
that the drinks be taken warm, in order to remove the temptation to excessive 
indulgence. Pure water or carbonic acid water, and, in cases of debility, good 
sound porter, diluted or otherwise, may be used. Milk diluted with lime- 
water forms a good drink for meals. Excess in eating must be equally 
avoided. Death, in one or more instances of this disease, has been traced 
immediately to undue indulgence of a ravenous appetite. 
The quality of the food is all important, and, without attention to this point, 
cures can scarcely be effected. Those substances*only should be allowed which 
are least capable of conversion into sugar. Dr. Rollo was the first to carry 
out effectually the plan of confining the patient to a diet exclusively of animal 
food. The plan was found highly beneficial, and, with some modifications, 
is now almost universally admitted to be essential. Numerous cures are on 
record effected in this way. It is true that Dr. McGregor found sugar in the 
diabetic stomach, even after a diet of beef and water continued for three 
days, and Bernard ascertained that, with a similar exclusive diet, the liver 
still produced glucose; but the quantity was much less than under other cir- 
cumstances, at least in McGregor's experiments; and there can be no doubt, 
as well from our knowledge of the chemical relations of the organic proximate 
principles, as from extensive and careful observation, that an exclusively animal 
diet is a powerful corrective of the morbid production of sugar, and will very 
often diminish, if it do not altogether correct the saccharine impregnation of 
the urine. To be effectual, however, as>a curative measure, it must be long 
persevered in, so that the stomach or liver may lose the morbid habit which 
it had previously acquired. It often happens that a single violation of the 
exclusive rule, on the part of the patient, leads to a return of the complaint; 
and, even after cures have been apparently effected, a long and careful watch- 
fulness over the diet is necessary to prevent a relapse. The particular arti- 
cles of diet admissible are the easily digestible meats, cream, cheese, butter 
and oil, soft-boiled eggs, fish, and oysters. Milk has generally been allowed; 
but Bouchardat, who has had great experience in the treatment of this com- 
plaint, forbids it. Salt meats are to be excluded as liable to provoke thirst. 
But a diet exclusively of animal food is generally distasteful, and often be- 
comes at length absolutely disgusting to the patient, so that it is almost 594 
LOCAL DISEASES.--SECRETORY SYSTEM. 
[PART II. 
impossible for him to adhere to it; and very few will be found who will not 
occasionally resort to other food. Some practitioners permit the use of bread; 
but, as this contains a large proportion of starch, which is one of the sub- 
stances most easily converted into sugar, it is obviously improper; and ex- 
perience has shown that the animal diet, with this latitude, seldom proves 
effectual. Bouchardat employs a bread made from the gluten of wheat flour, 
after the starch has been washed out. It requires, in order to be made into 
light bread, to be mixed with about one sixth of its weight of flour; and the 
addition of bran would probably be useful by dividing the nutritive matter, 
and at the same time acting as a laxative.* The green vegetables, such as 
spinage, celery, parsley, and more especially those belonging to the cruciferae, 
as cabbage, water-cress, sea-kale, and the young tops of the radish and turnip, 
are said not to be liable to the saccharine change, and to be eaten with impu- 
nity by diabetic patients. These, therefore, may be tried in connexion with 
the animal food, and persevered in if not found to be injurious. Coffee and 
tea, without milk or sugar, have been recommended from their highly azo- 
tized composition; but their known injurious influence in dyspeptic cases 
renders them of doubtful applicability here. Bouchardat recommends the 
lighter wines, particularly claret, which he gives very freely. On the same 
authority, beer and the acid drinks are objectionable. The patient should 
eat and drink slowly, masticating his food thoroughly. Such exercise as the 
strength will permit is important, in order to sustain a due vigour of digestion. 
2. Were the measures employed to meet the first indication speedily suc- 
cessful, there would be no occasion for further treatment; for, the root of the 
evil being eradicated, all the resulting derangements would cease of course, 
and the patient be restored to health, unless incurable organic disease should 
have set in. But, unfortunately, the operation of these measures is often 
slow, and by no means uniformly successful even with time; so that it be- 
comes necessary to control the secondary morbid actions, and obviate the mis- 
chief that must otherwise ensue. Hence arises the second indication, that, 
namely, which points to the diminution of the amount of urine. For this 
purpose, as well as in reference to the condition of the stomach, the regu- 
lation of the drinks becomes necessary. The attempt should not he made to 
reduce these at once to the lowest ultimately desirable point; for serious in- 
jury might result to the constitution from the sudden disturbance of a sort of 
equilibrium, which nature has established. But the end should be accom- 
plished by slow degrees, and here it is highly important that the patient 
should honestly and zealously second the views of the practitioner. Of course 
all diuretic drinks should be immediately abandoned. 
Of the medicines calculated to diminish the discharge of urine none is so 
efficacious as opium. The great advantages to be derived from this remedy 
are admitted by almost all. It not only very frequently diminishes the-flow 
of urine; but also quiets the nervous irritation of the patient, and renders 
him much more comfortable. It does not, however, alter the saccharine cha- 
racter of the urine, and is, therefore, of itself inadequate to the cure of the 
complaint. It is only one of the most valuable, perhaps the most valuable of 
the secondary means. It should be given so as to keep the system mode- 
rately under its influence, and care should be taken to prevent a too rapid 
* A bread containing no starch has been made from potatoes, and used with asserted 
advantage. The following is the recipe. Take sixteen pounds of potatoes, previously 
rasped and washed free from starch, three-quarters of a pound of mutton-suet, half a 
pound of fresh butter, twelve eggs, half an ounce of carbonate of soda, two ounces of 
diluted muriatic acid. Mix the ingredients; divide the mass into eight cakes, and bake 
quickly until browned. (See Am. Journ. of Pharm., xxi. 242.) CLASS III.] 
DIABETES. 
595 
increase of the dose, or the establishment of a bad habit on the part of the 
patient. It is, therefore, best to administer it in such combinations as to 
conceal its character, and to lead to unpleasant sensible effects if it should be 
abused. These purposes are answered by the addition of ipecacuanha or tartar 
emetic, which, while in overdoses it would be apt to excite nausea or vomiting, 
will in the proper quantity be found directly useful by giving the medicine 
a direction to the skin. From half a grain to a grain of opium with an equal 
quantity of ipecacuanha, or one-sixth of the quantity or less of tartar emetic, 
may be given at intervals of six or eight hours. Sometimes it may be thought 
best to give from ten to twenty grains of Dover's powder at bedtime, and none 
in the course of the day. 
Another means of meeting the second indication is to excite action in the 
surface, and restore, if possible, the perspiratory function. This should be 
attempted by the wearing of flannel next the skin, by friction with the flesh- 
brush, by the warm or hot-bath, vapour bath, or hot air-bath, by bodily exer- 
cise, and by the use of diaphoretics. Of the diaphoretics none is so efficacious 
as the Dover's powder already mentioned. Carbonate of ammonia is some- 
times useful. The saline diaphoretics, such as citrate of potassa, acetate of 
ammonia, and nitrate of potassa, are of doubtful propriety, in consequence of 
an occasional tendency to excite the kidneys. 
To answer the same indication, astringents have often been employed, and 
sometimes with supposed advantage. Kino, catechu, krameria, alum, the 
•sulphates of iron, zinc, and copper, and the acetate of lead may be tried. It 
is highly probable that the excessive diuresis may be sometimes at least de- 
pendent upon a relaxation of the kidneys; and substances having a directly 
stimulant action on these organs may prove beneficial. Upon this principle 
it probably is, that the turpentines and cantharides sometimes lessen the flow. 
Cures of diabetes have been ascribed to the latter of these medicines. Crea- 
sote, also, has been highly recommended. In one severe case, I have seen it 
exercise apparently considerable influence over the amount of secretion; but 
it had no effect in checking the disease. 
3 By the loss of its water and salts through the kidneys, as well as by the 
imperfect assimilation of the nutriment thrown into it, the blood becomes de- 
praved, having an excess probably of the fibrinous and colouring ingredients ; 
as the fluid absorbed scarcely keeps exactly even pace with that discharged. 
Hence, probably, the scorbutic phenomena; and hence too the tendency to 
various organic derangement, which marks the advanced stages. Bleeding 
is the best palliative for this state of the blood. It tends to restore the equili- 
brium of the constituents; for the place of the blood abstracted is supplied 
with water and salts in larger proportion than with the animalized products. 
Nor does it materially weaken the patient. The vigour of the appetite, and 
the nutritious character of the food used, serve to obviate this result. The 
consequences are usually great relief to the uncomfortable feelings of the 
patient, a diminution of any inflammatory symptoms that may exist, and a 
reduction in the quantity of the urine. The bleeding may be repeated occa- 
sionally to the amount of ten or twelve ounces, as the system may be found 
to bear it. The remedy is not applicable to the latter stages of the complaint, 
nor to cases attended with marked debility from the outset; and should be 
abstained from if found to weaken the patient. 
The above treatment is that which experience has pointed out as the most 
efficient, and which the nature of the affection appears to call for. Various 
other remedies have been recommended. Mercury has had its advocates; but 
the general opinion is at present decidedly adverse to it, unless as a mere 
alterative when the hepatic function is deranged. The alkaline sulphurets 596 
LOCAL DISEASES.-SECRETORY SYSTEM. 
[PART II. 
were employed by Rollo, but have not been found peculiarly useful upon sub- 
sequent trial, and have been abandoned. Hydrocyanic acid and camphor 
have enjoyed credit with some, and are probably not without utility in the 
control of irregular nervous symptoms. Phosphate of soda is said to have 
cured the complaint, but at best must be considered as a doubtful remedy. 
It may possibly be useful by supplying the loss of saline matter by the blood. 
Strychnia, colchicum, iodide of potassium, permanganate of potassa, and sul- 
phuret of arsenic are also among the medicines which have been proposed. 
Dr. Frick, who tried the effect of various remedies in relation to the quantity 
of sugar, found strychnia to diminish it far more than any other, while cod- 
liver oil increased it, in whatever mode administered. (Am. Journ. of Med. 
Sei., N. S., xxiv. 72.) 
Dr. James Gray, of Glasgow, has employed rennet with success; and the 
practice has been imitated with asserted advantage; but it has generally failed 
altogether. The object in using this remedy was to convert the sugar formed 
in the primae vise into lactic acid; an effect which it has the property of pro- 
ducing out of the body. (Ed. Month. Journ. of Med. Sei., Jan. 1853, p. 31.) 
Under the similar idea that the vinous and acetous fermentations might be 
excited in the stomach, and the sugar there existing in excess be converted 
into acetic acid, I employed yeast, in a case which occurred to me in the 
Pennsylvania Hospital, with great temporary benefit; and similar advantage 
was subsequently obtained by my friend Dr. Wm. Pepper in another case; but 
no permanent impression was produced upon the disease in either instance. 
(Trans, of Col. of Phys, of Phila., N. S., i. 390.) The dose of the rennet 
was a teaspoonful three times a day. From one to four fluidrachms of yeast 
may be given as often. 
It may be useful to recapitulate briefly the course of treatment recommended, 
without the distraction of accompanying explanation. The prominent reme- 
dial measures are bleeding; opium, especially combined with ipecacuanha; 
means calculated to direct action to the surface, as exercise, warm clothing, 
friction, hot bathing, and diaphoretics; alkaline substances, especially mag- 
nesia and the carbonate of ammonia; tonics, especially quinia, the chalybeates, 
and cod-liver oil; a proper regulation of the quantity of drink and food; and, 
above all, a strict adherence to an exclusive animal diet, with the exception 
of certain green herbaceous products, which may be tried in connexion with 
meats, and persevered in if not found unsuitable. 
Occasional symptoms must be controlled by remedies which general prin- 
ciples would suggest. Thus, when the stomach is tender and painful, leeches 
may be applied to the epigastrium, followed, if necessary, by blisters, antimo- 
nial pustulation, or other means calculated to produce counter-irritation. The 
same remedies may be applied to the loins, should symptoms of nephritic 
inflammation show themselves. All causes of general disturbance to the sys- 
tem, and especially such as are calculated to affect the urinary organs, should 
be sedulously avoided. The patient should never expose himself to sudden 
variations of temperature; should avoid severe mental or physical exertion, 
and all excessive sensual indulgences; should take moderate exercise in the 
open air; and should endeavour to give a cheerful direction to his thoughts, 
and maintain, as far as possible, an equable condition of feeling on all occa- 
sions. He should never be considered cured until the urine has not only 
been sufficiently reduced in quantity, but has lost all trace of sugar; and even 
then should be watchful over his mode of living, and be ready to resume a 
rigid course upon the least return of the symptoms. CLASS III.] 
SUPPRESSION OF URINE. 
597 
Article IX. 
SUPPRESSION OF URINE. 
By suppression of urine, as the title of a distinct affection, is here meant 
either a complete cessation of the secretory action of the kidneys, or a dimi- 
nution of it so considerable as to be clearly morbid. It is undoubtedly in 
general, perhaps always, a mere symptom or effect of some other disease; 
but instances occur in which no other affection is obvious; and in these it 
must, in the present state of our knowledge, be considered as idiopathic. 
Besides, a mere symptom or effect, when it constitutes the most prominent 
feature of the case, and the chief source of discomfort or danger, is often most 
conveniently named and treated as a disease; as in the instances of diarrhoea, 
dropsy, and the hemorrhages. Such is the case with the affection under 
consideration. 
It is difficult to determine at what point of reduction the renal secretion 
can be considered as morbid. The quantity of urine is often very much 
diminished in health, and sometimes only a few ounces are passed daily for 
a considerable time, without serious inconvenience. The best rule, perhaps, 
is to treat every case as morbid in which the secretion is reduced, for any 
length of time, much below the healthy standard of the individual, without 
obvious cause, such as excessive perspiration, or extraordinary abstinence 
from drink. Though morbid results may not always follow immediately, 
there is danger that they may occur; and the practitioner, if he err at all, 
will err on the right side by attempting to increase the secretion. Cases in 
which the suppression is entire, or nearly so, should receive immediate 
attention. 
The most prominent sign of suppression is the diminution or suspension 
of the passage of urine; but it is by no means unequivocal. It may be the 
result of a retention of the urine in the bladder, ureters, or pelvis of the 
kidneys. The first object, then, of inquiry, is in relation to the existence of 
the latter affection. This would be indicated, if in the bladder, by feelings 
of uneasiness, fulness ovei' the pubes, dulness on percussion, or more certainly 
still by the introduction of the catheter, which would be followed by a flow of 
urine. If in the ureter or pelvis of the kidney, it would be likely to be 
attended with the symptoms of nephralgia, the passage of a little bloody 
urine, or of a calculus, and, if long continued, by marks of distension in the 
region of the kidney, or inflammation of that organ. There is, however, a 
case of retention, from obstruction or obliteration of the upper end of the 
ureter, or large accumulation of calculous matter in the pelvis of the kidney, 
in which the pressure of the accumulated urine seems to produce a cessation 
of secretion, and thus to give rise to all the phenomena of suppression. The 
entire want of urinary discharge is exceedingly rare in what may be denomi- 
nated renal retention; for both sides are seldom simultaneously involved, 
and, though the quantity of urine might be diminished by sympathetic irrita- 
tion, it would continue to flow more or less from the kidney not affected, 
unless it had been destroyed by previous disease. The presumption, there- 
fore, in such absence of urinary discharge, without signs of retention in the 
bladder, would be strongly in favour of the existence of suppression. 
A rare form of suppression, occurring apparently as an idiopathic affection, 
was described by Sir Henry Halford, and has been occasionally met with by 
Syn.-Ischuria renalis.-Anuria (Willis). 598 
[part it. 
LOCAL DISEASES.-SECRETORY SYSTEM. 
other practitioners. A person in apparently full health observes that he 
passes little or no water, but suffers at first no other inconvenience than a 
feeling of restlessness and anxiety, with perhaps a little uneasiness in the 
lumbar region. After a day or two he is seized with a chill, or, finding the 
urinary affection unabated, becomes somewhat uneasy and applies for medical 
advice. There is no fulness or pain over the pubes or in any part of the 
abdomen, no febrile action, no symptom whatever calculated to call attention 
decidedly to the kidneys, except simply that of the great deficiency or absence 
of urine. No effort on the part of the patient is of any avail in increasing 
the discharge, and the introduction of the catheter into the bladder is followed 
by the escape of only a few drachms of a pale somewhat turbid urine, usually 
coagulable by heat, and of little density. In a short time, however, nausea 
comes on, and increases until vomiting results; and this continues afterwards 
to be one of the most troublesome symptoms. The patient becomes dull and 
torpid, and, when roused, seems surprised at the concern apparently felt by 
the physician. The pulse, so far from being excited, is usually less frequent 
than in health. The urine, if not completely suppressed from the commence- 
ment, now becomes so. A urinous odour is sometimes exhaled from the 
surface. The dulness increases to drowsiness, with occasional signs of mental 
wandering or incoherence. Eructations and hiccough are not unfrequent 
symptoms. In about four or five days from the occurrence of complete sup- 
pression, the patient sinks into coma, and dies soon afterwards in the midst 
of repeated convulsions. Should small quantities of urine continue to be 
secreted, the disease may run on for weeks; but, unless relieved, it terminates 
at last in a gradually deepening coma. Dissection has revealed, in these 
cases, various conditions of the kidneys. In general, they have been more 
or less congested, sometimes atrophied, or enlarged, or indurated; and occa- 
sionally the seat of disease has proved to be in the surrounding adipose tissue, 
which has been found congested, inflamed, and even gangrenous. Effusion 
has been observed in the ventricles and on the surface of the brain, and the 
liquid has emitted a urinous smell. Urea has been detected in the blood in 
some cases of complete suppression. The affection has generally been con- 
sidered to be a paralysis of the kidney. It probably has its origin, for the 
most part, either in some disease of the nervous centres, which prevents the 
due innervation of the kidneys, or in vascular congestion of these organs, 
overwhelming their secretory powers. Exposure to cold has beeu accused as 
the exciting cause. In elderly people the affection is sometimes ascribed to 
gout, and in children to dentition. It occurs most frequently in persons 
beyond middle age, and is especially apt to attack men of a somewhat robust 
or corpulent habit. It occasionally affects infants. 
But suppression of urine is much more frequent as an attendant and result 
of other diseases. Inflammation or intense vascular irritation of the kidneys 
is often accompanied with great deficiency of the secretion, which is then of 
a fiery redness, highly acrid, and scalding in its passage through the bladder 
and urethra. Sometimes .only a few drops of this kind of urine pass at a 
time; and in some very rare cases it is quite suppressed, with the most 
serious consequences. A species of febrile ischuria, which not unfrequently 
occurs in infancy, and sometimes in old age, may be considered of this cha- 
racter. The same may be said of that which results from poisonous doses of 
acrid substances, such as cantharides and corrosive sublimate. G-out, too, is 
often the cause of this species of ischuria. The urine which passes in these 
cases is apt to be loaded with uric acid. 
Another kind of suppression is that which in a greater or less degree 
attends acute inflammations, and idiopathic fevers. The urinary appears to CLASS III.] 
SUPPRESSION OF URINE. 
599 
participate in the torpor or constriction which affects the other secretory func- 
tions. In consequence of its great concentration, the urine is often of a deep- 
red colour. Suppression more or less complete occurs in certain forms of 
dropsy, and is sometimes the immediate cause of death both in the early and 
the last stages of Bright's disease. Calculous concretions in the pelvis of the 
kidneys, and obstruction of the ureter, have before been alluded to as causes of 
this affection. It is occasionally among the innumerable complications of hys- 
teria, and has been known to follow severe surgical operations with fatal effect. 
Sometimes, too, it may be traced to cerebral or spinal disease. In the epidemic 
cholera, there is occasionally a total absence of urine for days together. 
From whatever cause proceeding, suppression of urine is usually charac- 
terized by the general symptoms before enumerated as occurring in the idio- 
pathic affection. If it be complete for several days, and coma supervene, it 
is almost certainly fatal. The cause of death is generally considered to be 
the depressing and poisonous action upon the brain of the urea accumulated 
in the blood, in consequence of its being no longer eliminated by the kidneys. 
It is surprising, however, under how small a daily discharge life may be pro- 
longed, and ultimately preserved. In some instances, too, other organs appear 
to take on a vicarious office, and to relieve the system by throwing off the 
urea. Thus, in epidemic cholera, in which the urinary secretion is sometimes 
entirely arrested, the brain remains remarkably clear, in consequence, no doubt, 
of the copious discharges from the skin and alimentary mucous membrane. 
Numerous cases are on record in which the urinary secretion has been wholly 
arrested for days, weeks, or months, without serious disturbance of health. In 
these, there have generally been liquid discharges from the stomach, bowels, 
or skin, which have sometimes had a urinous smell.* Repeated instances 
have also occurred in which pints or quarts of fluid, smelling like urine, are 
said to have been discharged from the mouth, axilla, external auditory meatus, 
umbilicus, and mammae. Accounts, apparently well authenticated, have been 
given of persons who have passed no urine for a long time, perhaps not from 
birth, and yet have not seemed to suffer. In these last cases, however, it.is 
probable that, from disease or malformation, the kidneys have communicated 
with the bowels, and the urine escaped with the feces. In the other cases, it 
is difficult to pronounce a positive opinion. They have generally occurred in 
females; and there can be no doubt that the observers have often been deceived 
by the insane cunning, with which some hysterical women are prone to impose 
upon the credulity of those about them, in relation to affections of the urinary 
and sexual organs. Instances have occurred in which such deception, after 
having been long successful, has been detected at last by careful watching; 
and it is fair to presume that others of a similar character have existed, which 
have either not been thoroughly scrutinized, or have eluded the scrutiny. 
Nor is this sort of insanity, or disposition to deceive for purposes of conve- 
nience, confined to females. Male malingerers are not unfrequent in hospitals. 
Yet, making all due allowances for these cases, it would be difficult to deny cre- 
dence to some of the published accounts of vicarious urinary discharges; and 
d priori there is no more reason to doubt the possibility of life being saved, in 
cases of suppression of urine, by the discharge of urea through some other 
than its normal emunctory, than that a similar result should take place in 
jaundice, in relation to the colouring matter of bile. An explanation of the 
* From experiments by MM. Bernard and Barreswil on animals, it appears that, after 
extirpation of the kidneys, salts of ammonia may be detected in the intestinal secre- 
tions, and that, while they continue to be present, the animal exhibits no evidence of 
the poisonous effects of urea. The inference is that urea is thrown out into the bowels, 
and there decomposed into salts of ammonia. (Note to the second edition.') 600 
[part II. 
LOCAL DISEASES.-SECRETORY SYSTEM. 
variable results from the accumulation of urea in the blood, is afforded by the 
doctrine, recently advanced by Frerichs, that it is not the urea which produces 
the poisonous effects, but the carbonate of ammonia resulting from its decom- 
position, and this decomposition may or may not take place, according as 
there may or may not be a substance in the blood capable of acting as a fer- 
ment upon the urea. Now, without admitting necessarily that carbonate of 
ammonia is the real morbific agent, we may admit the general theory that the 
effects flow not from the urea, but the products of its decomposition. 
Treatment.-In idiopathic suppression, it is important to begin with treat- 
ment early in the case, when there may be good hope of saving the patient. 
Blood should be taken from the arm as freely as the strength will permit; 
and afterwards by cups from the small of the back. At the same time, brisk 
purgation should be effected by jalap and cream of tartar, senna and Epsom 
salt, or other cathartic combinations having a tendency to act as well on the 
kidneys as on the bowels. A small addition of elaterium or gamboge, if ad- 
missible by the stomach, would probably be advantageous. Vigorous diuretics 
should then be administered. Perhaps the most efficacious is bitartrate of 
potassa, given in the quantity of an ounce or two in divided doses during the 
day. But digitalis, squill, nitre, and the spirit of nitric ether, may also be 
given in various combination, and in as large doses as the system will tolerate. 
As the case advances, a large blister may be applied upon the small of the 
back, on each side of the spine, and repeated when the surface ceases to dis- 
charge. Some have recommended the more stimulating diuretics, as oil of 
turpentine and cantharides; and they may possibly prove useful when there 
is no inflammatory congestion of the kidneys; but it should be borne in mind 
that these very substances, in overdoses, are capable of producing suppression. 
Emetics, the warm bath, vapour bath, or hot air bath, and Dover's powder, 
have also been recommended; and, by effecting a vicarious discharge from 
the skin, may sometimes postpone the occurrence of coma, while they at the 
same time relieve congestion of the kidneys, and thus enable these organs to 
feel the impression of remedies more especially directed to them. While 
these measures are going on, the patient should be allowed to drink mucila- 
ginous liquids, rendered diuretic by suitable additions, as juniper, wild carrot, 
spirit of nitric ether, and the like. Should the urine be scanty, high coloured, 
and loaded with lithic acid, no medicine will be found more efficacious than 
bi-carbonate of soda, which may be given to the amount of two or three 
drachms in twenty-four hours, as drink, dissolved in a large proportion of car- 
bonic acid water. The diet should, in acute cases, consist of vegetable food 
exclusively. 
Similar measures are required in cases of suppression, attended with clear 
evidences of inflammation of the kidneys or the urinary passages. In many 
of these, however, especially when the local excitement scarcely passes the 
boundaries of high irritation, it may not be necessary to push the depletory 
measures so far. The saline cathartics, and alkaline bi-carbonates, aided by 
the spirit of nitric ether, or other mild diuretics, with the free use of muci- 
laginous drinks, will often be sufficient. The affection, as it occurs in infants, 
will in general yield readily to this treatment. 
When the disease may seem to depend upon affections of the brain or 
spinal marrow, remedies should be addressed to these parts especially; and, 
besides the general plan above recommended, local bleeding and blistering 
should be employed as near as possible to the seat of the disease. 
In those instances of suppression which occur in the last stage of disor- 
ganization of the kidneys, whether from ordinary inflammation or Bright's 
disease, little good can be expected from remedies; and the physician will 
confine his efforts to palliation. CLASS lit.] 
601 
LITHIASIS. 
Article X. 
LITHIASIS. 
Lithiasis (from the Greek a stone) is characterized by the deposition 
from the urine, within the body, of insoluble matter, in the form of impalpa- 
ble powder, minute crystalline particles like sand, or solid concretions of va- 
rious magnitude, with irritation or inflammation of the urinary passages. 
In its most healthy state, the urine is transparent when discharged, except 
a slight cloudiness from mucus and epithelium scales, and remains so after 
cooling, until decomposition begins. But not unfrequently, from slight ex- 
cesses in eating or drinking, some peculiarity of diet, or some fugitive impres- 
sion that can scarcely be considered morbid, the urine, though transparent 
when evacuated, becomes turbid on cooling, and deposits a sediment of amor- 
phous or imperfectly crystalline matter. When temporary, or productive of 
no considerable inconvenience, this is not looked on as a disease. It is, on 
the contrary, a method by which the system frees itself from superfluous 
matters, which might otherwise occasion trouble. But, when the deposition 
continues long, or recurs frequently, and especially if the urine should be 
turbid at the time of discharge, it should be regarded as suspicious, even 
though no present inconvenience may be experienced; for, so long as this 
state of urine remains, there will be liability to gravelly or calculous deposi- 
tion within the body, and consequent disease of the urinary organs. 
The sediment may be either 1. an amorphous powder without grittiness, 
2. a sandy matter consisting of minute crystalline grains, of a gritty feel, but 
not distinctly visible, or 3. of amorphous or crystalline concretions, sufficiently 
large to be readily distinguished by the eye, and denominated calculi. Mor- 
bid effects in the urinary passages proceed in general only from the two latter 
kinds of sediment. The presence of an impalpable powder in the urine is of 
consequence merely as it indicates a disordered state of system or of the uri- 
nary organs, or a liability to the occurrence of the other forms of deposition, 
or as confirmatory of other evidence of the existence of a calculus in the 
body, and affording the means of ascertaining the character of the calculus. 
The chemical nature of the sediment is very different in different cases. 
All the deposits, however, may be arranged under the three heads of 1. uric 
acid, or the. urates; 2. the phosphates ; and 3. oxalate of lime. As each of 
these is consequent upon a peculiar state of system or of local disease, and 
attended, in a certain degree, by peculiar symptoms, they will be most ad- 
vantageously treated of separately, so far as regards the deposition itself and 
its causes. The morbid effects of the several deposits, as closely analogous, 
will be treated of conjointly, and the same course will be adopted in relation 
to the treatment. The carbonate of lime, and cystic oxide or cystine deposits, 
are too rare to require particular notice in this place. 
Uric Acid Lithiasis.-Lithic Gravel.-Lithuria (Willis).-This is 
much the most common form of gravel, and is highly important as in most 
instances the foundation of stone in the bladder. Different opinions have 
existed at different times as to the precise nature of the deposit. At first 
supposed to be amorphous uric acid, it was afterwards, on the authority of Dr. 
Bird, believed to consist mainly of urate of ammonia, and is now determined 
by Lehmann, Heintz, and others, to be urate of soda, mixed with a very little 
of the urates of lime and ammonia. The probability is that it varies much 
Syn.-Gravel.-Calculous Disease. 602 
[PART II. 
LOCAL DISEASES.-SECRETORY SYSTEM. 
with the condition of the urine, and that uric acid, or either of the urates men- 
tioned may, under varying circumstances, be the predominent ingredient. The 
urate of potassa has also been noticed. These substances, when quite pure, are 
colourless; but, as deposited in the urine, they have almost always some shade 
of yellow or red; being frequently salmon-coloured like brickdust, and therefore 
called lateritious, sometimes yellowish, and sometimes, though more rarely, 
pink. So constant is this association, that the reddish colour of the deposit is 
one of the characteristic signs of the uric acid lithiasis. The colour is owing 
to certain organic colouring principles in the urine, which appear, in some way 
not yet satisfactorily explained, associated with uric acid and its compounds. 
It is not certainly ascertained in what state the uric acid itself exists in urine. 
According to Prout, one part of this acid requires one thousand parts of water 
at 60° for solution; and the highest solubility which has been allowed to it 
will not account for the proportion in which it is often found in the urine. 
Dr. Prout supposed that it was held in solution by combination with a propor- 
tion of ammonia insufficient to prevent its acid reaction, and yet sufficient con- 
siderably to increase its solubility, the urate of ammonia being much more 
soluble than the uncombined acid. There can scarcely be a doubt that the 
urine does sometimes contain this salt. But there is reason to think that the 
acid is often also held in solution in consequence of its affinity for the colour- 
ing matter of the urine; as it is frequently deposited without ammonia, and it 
has been ascertained that, though almost insoluble in pure water, it is dis- 
solved by water to which the colouring matter has been added. (See Willis 
on Urinary Diseases.') But, whatever may be the state in which uric acid 
exists in the urine, the fact appears to be, that it is precipitated by the addi- 
tion of other acids. Urate of soda is occasionally observed in urinary deposits 
nearly colourless; but it is comparatively rare in this state. The deposit may 
be considered as belonging to the uric acid class, when it is readily dissolved 
by solution of potassa, and is insoluble in dilute muriatic acid. Should an 
ammoniacal odour be developed during the action of potassa, it would indicate 
the presence of urate of ammonia. Dr. Gr. 0. Rees mentions, as a test of 
uric acid, that it is dissolved by nitric acid with effervescence, and, when 
the solution is carefully evaporated to dryness, yields a pink colour, which 
assumes a violet tint upon the addition of ammonia. (Analysis of' the Blood 
and Urine, Am. ed., p. 73.) 
The urine, during the existence of the complaint, is usually high-coloured, 
and more or less diminished. It is often very scanty. Its density does not 
upon the whole vary much from that of health. Dr. Willis found the sp. gr. 
frequently between 1.020 and 1.022; but in some cases of very scanty urine 
it is much greater, reaching even to 1.033, when the urine abounds in urea, 
as well as in uric acid or urate of ammonia. When first passed, the urine is 
often clear; and sometimes the deposition takes place, after cooling, without 
much if at all disturbing its transparency. But generally it becomes turbid 
on standing, and not unfrequently, when heavily loaded, comes away more 
or less turbid from the bladder. The deposit sometimes, though rarely, con- 
sists exclusively of crystalline sand. More generally this is mixed with a 
large proportion of amorphous impalpable matter; and now and then small 
concretions of the size of a pin's head or larger may be observed. 
The deposition which takes place out of the body, when the urine cools, is 
owing to the saturated state of the solution, and the diminished solvent power 
at a reduced temperature. But this cannot be the cause of deposition in the 
body; as the temperature does not vary. It has been stated that the addition 
of an acid to urine, in this complaint, produces precipitation of uric acid. It 
is highly probable that such an addition occasionally takes place in the kid- CLASS III.] 
LITHIASIS. 
603 
ney, which, after having secreted urine saturated with uric acid into the 
tubules, may throw out from the Malpighian bodies lactic or free phosphoric 
acid, which may then act as the precipitant. A crystalline deposit having 
once occurred, serves as a nucleus which may sustain a precipitation in the 
saturated fluid, without the further addition of an acid. 
It is obvious, therefore, that whatever produces an excess of uric acid in 
the circulation, or occasions the secretion by the kidneys of another acid when 
the urine is saturated with uric acid or urate of ammonia, or neutralizes any 
alkali which might otherwise be secreted by the kidneys and render the uric 
acid more soluble by combining with it, may serve as the cause of an attack 
of this variety of gravel. Whatever materially diminishes the quantity of 
urine may have the same effect, by rendering the solution too concentrated. 
Hence the frequent association of scanty and high-coloured urine with the 
disposition to deposit uric acid or the urates. Among the causes which act 
most powerfully in producing an excess of uric acid is the use of much high- 
seasoned animal food, conjoined with indulgence in wine or other alcoholic 
drink, and at the same time with habits of indolence. An amount of azotized 
matter is thus introduced into the system beyond its wants, and the prelimi- 
nary process of digestion is stimulated into over-exertion, so that the food, 
instead of being thrown off by the stomach or bowels, is carried into the blood. 
Thus overloaded, and not relieved by the demands which vigorous exercise 
usually makes upon it, the blood must find some other outlet for its excess 
of azotized matter, which therefore escapes by the kidneys, in part at least, 
in the shape of uric acid or urate of ammonia. It was formerly supposed that 
an exclusive vegetable diet predisposed to this disease; but the contrary has 
been established by the experiments of Magendie and others. Yet, in an 
individual whose urine is loaded, from the causes already mentioned, with a 
superabundance of uric acid, acescent vegetable food, especially connected 
with a dyspeptic state of stomach, may strongly aid in inducing an attack of 
gravel. This it does by the generation of an acid, probably the lactic, phos- 
phoric, or muriatic, which, entering the circulation, may be secreted by the 
kidneys, and thus cause a precipitation of the uric acid, or may neutralize 
any alkali in the blood, which might otherwise pass out with the urine, and 
maintain the uric acid in solution. Hence, attacks of uric acid gravel may 
be very frequently traced to the use of indigestible and acescent food or 
drink, such as heavy dumplings, pastry, cheese, sour fruits or vegetables, 
acescent wines, &c., combined with an excess of rich meats, stimulating 
drinks, and deficient exercise. 
But there is also not unfrequently a strong constitutional tendency to the 
disease, which occasions it to appear in certain individuals from causes which 
have no effect on others; so strong, indeed, in some instances, that the com- 
plaint appears, notwithstanding the most studious care to shun its exciting 
causes. This tendency is often hereditary, and often apparently associated 
with gout. Indeed, there seems to be a close connexion between the gouty 
and uric acid diathesis. Uric acid gravel is exceedingly common in gout, and 
the deposition of urate of soda in the joints is another evidence of the strong 
tendency, in that complaint, to the generation of an excess of uric acid. The 
similarity, one might say, the identity of the causes of the two affections, is 
another proof of their close relationship. It is said that infants whose parents 
have suffered from gout are apt to be attacked with this form of gravel or 
calculus. 
Fevers of a sthenic character, and inflammations producing fever, are fre- 
quently attended with a scanty, high-coloured urine, which, as the complaint 
passes off, is apt to deposit a copious lateritious sediment. This may readily 604 
LOCAL DISEASES.-SECRETORY SYSTEM. 
[part II. 
become the origin of an attack of gravel; and the complaint does in fact fre- 
quently originate in a febrile condition of the system. An inflammatory 
condition or vascular irritation of the kidneys, is apt to induce scantiness of 
urine, and to develope gravel in those predisposed to jt. The probability is 
that the result flows chiefly from the great concentration of the urine. But 
it may also depend upon the decomposition of the tissues which takes place 
during febrile disease, when the digestive organs almost cease to perform 
their functions, and the system lives upon itself. Chronic organic disease of 
the urinary organs, on the contrary, produces a tendency to the phosphatic 
deposition. Dr. Prout thinks that inflammation of the liver and the heart 
are peculiarly apt to be accompanied with uric acid sediment in the urine. 
Age appears to have some influence. Thus, the disease has been noticed 
to be most common in infancy, and on the commencement of the decline of 
life. In the former case, it lias been ascribed to an exclusive diet of milk, 
at once highly azotized and acescent; in the latter to a diminution of exer- 
cise, without a corresponding reduction in the indulgences of the table. 
The disease is also more prevalent in certain districts of country than in 
others. This may be owing partly to differences in the habits and diet of the 
population, partly to differences in the character of the climate; damp places, 
and those much exposed to vicissitudes of weather, being considered most 
liable to renal affections. 
Exposure to cold, and injury to the kidneys from external violence, some- 
times act as exciting causes of uric acid gravel. They may produce the effect 
by giving rise to irritation of the urinary organs, and consequently to a scanty 
and highly charged urine; while cold probably operates additionally by check- 
ing cutaneous exhalation, and thus directing to the kidneys acid matter which 
usually escapes by the skin. 
The prognosis in this form of lithiasis is generally favourable. It may 
almost always be relieved when merely in the form of gravel; though, if the 
original predisposition has been strong, it may not be possible to prevent occa- 
sional returns of the complaint. 
Phosphatic Lithiasis.- Ceramuria (Willis).-This is much less fre- 
quent than the preceding variety of gravel. The salts of which the deposit 
consists are the double phosphate of magnesia and ammonia, and the phos- 
phate of lime, either separate or mingled. Unmixed phosphate of lime is 
rare; the double salt is less so; and the two together are most frequent. 
These salts are very insoluble, but in healthy urine are held in solution by 
an excess of acid. They appear in the sediment sometimes in the form of 
white, shining, crystalline grains, which are, however, almost always mixed 
with a much larger quantity of a whitish or grayish impalpable powder; and 
the latter is often present alone. The phosphatic deposit is distinguished by 
its whiteness, its insolubility in solution of potassa, and its ready solubility in 
dilute muriatic and acetic acids. In the early stages, it is sometimes attended 
with a yellowish sediment of urate of ammonia; but this diminishes if the com- 
plaint continues, and in the advanced stages almost disappears. 
The urine is usually more copious than in health, and of a pale colour 
when passed. It is sometimes clear at first, at other times turbid, and, in 
the former case, lets fall a sediment upon cooling, and sometimes also upon 
being heated to the boiling point, probably on account of the escape of car- 
bonic acid. From this latter property it might be mistaken for albuminous 
urine; but it may be readily distinguished by the solubility of the coagulum 
in an excess of nitric acid. Another characteristic is the frequent appear- 
ance of an iridescent pellicle of the phosphates on the surface of the urine, 
when it has been allowed to stand for some time. This pellicle is gradually CLASS III.] 
LITHIASIS. 
605 
deposited. Phosphatic urine frequently presents beautifully crystalline forms 
under microscopic examination. In the beginning, the urine is sometimes 
feebly acid, but more frequently neutral; in the end, it is always alkaline. 
Its sp. gr. varies much, according as more or less of it is evacuated. Willis 
has found it as low as 1.004 in the morning when the urine was copious, and 
as high as 1.033 at night when it was comparatively scanty. The urine be- 
comes putrescent, with exhalation of ammonia, more speedily than in uric 
acid lithiasis, or than in health; and, when it assumes this condition, the 
phosphatic deposition is greatly increased. It is much less liable to be at- 
tended with crystalline deposit within the body than the uric acid urine; and 
hence true phosphatic gravel is comparatively a rare disease, though the urine 
often abounds in the salts. 
The causes of the phosphatic sediment are such as produce an excess of the 
salts, or an alkaline state of the urine. The phosphates being held in solu- 
tion in the urine by an excess of acid, are of course deposited when the acid 
is neutralized, or an alkali predominates. This is probably much the most 
frequent source of the phosphatic deposition. It has been observed that a dis- 
position to an over-production of the phosphates is apt to accompany a nervous 
and irritable condition of system, marked by general debility, paleness of com- 
plexion, impaired digestion, and a frequent, irritated and easily excited pulse.* 
The dyspeptic symptoms are sometimes very prominent, with irregular bowels, 
and deranged hepatic secretion. There is often uneasiness, seldom amounting 
to pain, in the lumbar region. This condition is found among the poor, as a 
consequence of unwholesome food, exposure to cold and privation, and wretch- 
edness of all kinds. It occurs also in those whose systems have been worn 
out by profligate habits, or by over-exertion, whether bodily or mental. In 
its worst forms, there is often loss of appetite, a listless state both of mind and 
body, peevishness or acerbity of temper, general debility, emaciation, and a 
sunken, haggard appearance of the face. It is often associated with chronic 
organic affections of the urinary organs, uterus, rectum, or spinal marrow. 
Injuries of the kidneys, bladder, &c., from local violence, occasionally pre- 
cede the developement of the phosphatic lithiasis. Whatever induces chronic 
inflammation of the urinary organs disposes to the affection. The diseased 
mucus which results, has been thought to act as a ferment, and thus induce 
putrefaction in the urine while still in the bladder. Dr. Gr. Owen Rees, how- 
ever, believes that the alkalinity of the urine, in cases of inflammation of the 
mucous membrane of the kidneys and urinary passages, is owing to the alka- 
linity of the mucus itself, and not to any decomposing effect it may exert on 
the urea. (Lend. Med. Gaz., July, 1851, p. 33.) The alkaline condition 
* Dr. Bence Jones states, as the result of an observation of 100 cases of disease, and 
of many hundred quantitative analyses, that acute affections of the nervous substance, 
either organic or functional, are the only diseases in which an excess of the phosphatic 
salts, earthy and alkaline, can be proved to exist in the urine. Connecting this fact 
with the discovery of Mulder, that in inflammation the fibrin of the blood is oxidized, 
he thinks it probable that, when the nervous substance of the brain is inflamed or irri- 
tated, its phosphorus is converted into phosphoric acid by oxidation, and thus gives 
rise to the excess of phosphates alluded to. {Lancet, July 29, 1847.) Dr. G. Owen 
Kees believes that the phosphatic deposition, in many of these cases, is attributable to 
an alkaline condition of the urine resulting from a dyspeptic state of the stomach, in 
which the acids usually thrown off by the kidneys are secreted with the gastric juice. 
He admits, however, that disease of the spinal marrow occasions alkaline urine, and 
consequently phosphatic deposition, from defective innervation; but in these cases is 
disposed to ascribe the result to a secondary inflammation of the mucous membrane of 
the urinary organs, which is well known to cause alkalinity of the urine. {Lond. Med. 
Gaz., July, 1851, p. 31, &c.) 606 
LOCAL DISEASES.-SECRETORY SYSTEM. 
[part II. 
thus produced strongly favours the deposition of the phosphates, which often 
form an abundant sediment under these circumstances. 
Occasionally, grief or other depressing emotion, exhausting mental appli- 
cation, or debilitating excesses, induce an attack, which subsides upon the re- 
moval of the cause. But too frequently the prognosis is unfavourable, in con- 
sequence of the organic mischief which lies at the foundation of the urinary 
disorder. The worst cases are said to be those in which the phosphate of lime 
alone is deposited, as this is apt to be associated with organic disease of the 
bladder.* Much advantage, however, may be expected from treatment in 
cases which do not depend upon incurable structural lesions. 
Oxalic Lithiasis.- Oxaluria.-In this affection the urine is in gene- 
ral tolerably clear, or exhibits only a slight sediment on cooling. In some 
instances, deposits of oxalate of lime are said to have been noticed, bearing 
some resemblance to the phosphates in appearance; but they are rare. Upon 
the whole, it is the absence of sediment, in connexion with internal symptoms 
of calculus, or certain constitutional symptoms, that excites suspicion of the 
existence of this affection. The suspicion is confirmed, when crystalline or 
amorphous concretions, found in the urine, prove upon trial to be insoluble 
in acetic acid, or solution of potassa, soluble in dilute nitric acid, and very 
slightly so in dilute muriatic acid. Effervescence with dilute acids, after cal- 
cination, but not previously, is another character by which the oxalic deposit 
may be detected. 
Oxalate of lime in the urine may be recognized by the transparent octohe- 
dral crystals which it exhibits when examined under the microscope. Some- 
times also the crystals have the form of a dumb-bell, and sometimes are circular 
or oval. The dumb-bell crystals, according to Dr. J. W. Griffith, consist of 
minute needles, aggregated, and radiating from a common centre. (Loud. Med. 
Gaz., Dec. 1850, p. 1088.) The dumb-bell form of crystals, at one time con- 
sidered as characteristic of oxalate of lime, has been found in so many different 
ingredients of the urine, as to have very much lost its value in diagnosis. Dr. 
Golding Bird first called attention to the fact, that minute crystals of that 
salt often float in the urine, which ordinarily escape notice on account of their 
transparency, and close approach in specific gravity to that of the liquid. By 
gently heating the liquid, and thus diminishing its specific gravity, the crystals 
are deposited. They also slowly subside, if the urine is allowed to stand; 
but their absence should not be inferred from their not being observed in the 
sediment, until at least twenty-four hours after micturition. If any substance 
capable of acting as a nucleus be present, the crystals are apt to cluster around 
it; and they generally fall in connexion with any other matter which may be 
deposited from the urine, as, for example, uric acid, or the phosphate of mag- 
nesia and ammonia. According to Dr. Bird, there is generally an excess of 
urea in the oxalic acid urine. 
Little is known of the cause of oxalic lithiasis. The system is not obvi- 
* Dr. Rees explains this fact in the following manner. A slight inflammation of the 
urinary mucous membrane occasions a feeble alkalinity of the urine, and consequently 
a decomposition of the ammoniacal salts by means of the fixed alkali eliminated. The 
ammoniaco-magnesian phosphate is produced; and its precipitation indicates there- 
fore, a feeble alkalinity and feeble inflammation. But in the cases in which the mucous 
membrane is more deeply affected, there is a greater quantity of fixed alkali produced, 
which, after decomposing all the ammoniacal salts, remains in excess in the urine, and 
now precipitates the phosphate of lime. The ammoniacal alkalinity of the urine can be 
readily distinguished by the circumstance, that litmus paper, rendered blue by it after 
being reddened by an acid, resumes its red colour on becoming dry in the air, in conse- 
quence of the escape of the ammonia. This is not the case when the alkalinity is owing 
to an excess of one of the fixed alkalies. (Lond. Med. Gaz., July, 1851, p. 33.) CLASS III.] 
LITHIASIS. 
607 
ously much deranged before the attack. Dr. Prout believes that the predis- 
position consists in a peculiar morbid condition, which is at first of a somewhat 
inflammatory character, but afterwards evinces itself by general debility, nervous 
irritability, dyspepsia, and a tendency to carbunculous affections, and scaly or 
impetiginous eruptions. According to Dr. Bird, individuals in whom the oxalic 
urine exists are apt to be irritable and extremely sensitive, dyspeptic, feeble, 
emaciated, and full of hypochondriacal notions and gloomy apprehensions. 
Dr. H. A. Johnson states that, in a number of instances in which he had found 
oxalate of lime in the urine, the patient was subject to severe attacks of neu- 
ralgia. (Bost. Med. and Surg. Journ., xlix. 184, from North- Western Med. 
and Surg. Journf) Contrary to what has generally been thought in relation 
to the prevalence of oxalic acid lithiasis, Dr. Bird expresses his belief that, 
in London, the cases in which oxalate of lime exists in the urine are far more 
frequent than those in which there is deposition of the earthy phosphates. 
The immediate cause of production is probably some defect in the assimilative 
processes; and, in almost all instances, a close investigation will reveal serious 
functional derangement of the digestive organs.* Some relation appears to 
exist between the state of system predisposing to this deposition and that 
which occasions the deposition of the urates; for it has frequently been ob- 
served that the disappearance of one is apt to be followed by the other. 
It is highly probable that the use of sorrel, and of the footstalks of rhubarb 
leaves, as articles of diet, favours the production of the oxalic deposit; as both 
of these vegetables contain oxalic acid combined in excess with potassa.f It 
is probable also that, when a predisposition exists, the free use of sugar may 
tend to give it effect. The complaint sometimes occurs in infancy; is most 
common between the ages of fifteen and fifty; and is rare in old age. 
Silicious lithiasis is an apocryphal affection. It is true that sand and sili- 
cious concretions are asserted to have been discharged from the bladder; but, 
when the cases are accurately investigated, they invariably prove to be decep- 
tive. The patients are generally females; and the effort at imposition is prob- 
ably the result, in most instances, of that singular variety of insanity which 
is occasionally associated with hysteria, and is especially directed towards the 
* The fact that uric acid is converted, by the agency of oxide of lead, into urea, 
oxalic acid, and allantoin, has led to the supposition, that the acid might undergo a 
similar metamorphosis in the system. To ascertain this point, Wohler and Frerichs 
performed some experiments upon animals, the result of which was, that, when one of 
the urates is introduced into the system, either oxalate of lime, or an abnormal amount 
of urea, or both, are found in the urine. Urate of ammonia, given to a man in the 
evening, was followed in the morning by a sediment in the urine consisting chiefly of 
oxalate of lime, while the urine itself was of high specific gravity, indicating the prob- 
able presence of urea in large proportion. This fact may possibly be found of some use 
in the explanation of the morbid assimilation which characterizes oxaluria. (See Che- 
mical Gazette, June 15, 1848, p. 231.) 
j- In an interesting paper by Dr. Charles Frick, of Baltimore, contained in the Ame- 
rican Journal of Medical Sciences (N. S. xvi. 281), the views of Dr. Bird are confirmed 
by the detail of several cases. Dr. Frick has been led to the conclusion, that the oxalic 
acid deposit is among the most common of those requiring medical interference. In two 
cases, the patients complained that they had never eaten tomatoes without suffering an 
aggravation of their symptoms; and, as this fruit contains a large proportion of oxalic 
acid, the inference is obvious, that the use of it as a vegetable may contribute to the 
production of this variety of urinary disorder. (Note to the second edition.) 
Dr. H. Bence Jones has so often found oxalate of lime in the urine of persons in good 
health, that he does not consider it as indicating the existence of any serious disease, 
scarcely more so, indeed, than urate of ammonia. (London Lancet, Feb. 23, 1850.) 
Professor Lehmann has also frequently found oxalate of lime present in normal urine; 
and it may now be considered as pretty well established that the presence of this salt 
in the urine, unless in considerable quantity, or attended with othei' signs of deranged 
health, is of very little significance. (Note to the fourth edition.) 608 
LOCAL DISEASES.-SECRETORY SYSTEM. 
[part II. 
urinary or genital organs. In many cases, the substances asserted to have 
been discharged with the urine have been obviously of external origin, such 
as common sand and pieces of pebbles, glass, or quartz. I once received from 
a physician in the country a small box full of hard bodies which he had ex- 
tracted from the urethra or vagina of a female. One of these was a true 
calculus, and had been the first extracted. The others were fragments of 
glass, pebbles, quartz, &c., and had clearly been introduced by the female 
herself. It is necessary that the practitioner should be constantly on his guard 
against this species of deception. 
Effects of Morbid Urinary Deposits.-These differ according to the cha- 
racter of the deposit, and the portion of the urinary organs upon which it acts. 
It has been before stated that, in the form of impalpable powder, the sediment 
produces no material effect in its passage. In the form of sand, it often excites 
very considerable irritation throughout the urinary passages, from the pelvis 
of the kidney where it is deposited, to the termination of the urethra. In that 
of calculus, it gives rise to peculiar phenomena in the several positions which 
it may occupy, as the kidneys, the ureter, and the bladder. I shall treat of 
these two forms distinctly. 
The commencement of an attack of gravel, in which the sediment is in the 
form of sand so fine that no mechanical impediment is offered to its passage, 
is frequently marked with febrile symptoms, either as a part of that condition 
of system which leads to the deposition, or as a consequence of the irritation 
of the kidney produced by the deposited matter. There is an excited pulse, 
furred tongue, headache or vertigo, heat of skin, heaviness, and general dis- 
comfort, with not unfrequently more or less pain in the back, which is, how- 
ever, dull and aching rather than acute. After these symptoms have continued 
for a day or two, a discharge of sandy matter takes place with the urine, pre- 
ceded by scalding or cutting pains in the course of the ureter, and at the neck 
of the bladder, and attended by itching or painful sensations at the outlet of 
the urethra, with frequent and urgent desires to make water, and a good deal 
of straining in the effort. These sensations are much modified in different 
cases, in some rising to the most violent strangury, in others scarcely exceed- 
ing a moderate burning with a little uneasiness along the passages. After a 
short time, the symptoms become milder or cease for a while, to return 
in renewed paroxysms, until at length the morbid tendency seems to give 
way, and the patient is restored to health; or the affection assumes a 
chronic form, and runs on for a long time, perhaps indefinitely, with irre- 
gular alternations of remission and exacerbation. Not unfrequently it ap- 
pears at first with milder features, and becomes aggravated as it advances. 
In the great majority of cases, the discharge is of the uric acid character, 
especially when attended in the commencement with febrile symptoms, 
and always when associated with gout. In the phosphatic variety, the suf- 
ferings from the mere deposition are so mixed up with those incident to 
the organic disease in the urinary organs, that it is not always easy to de- 
termine how much is to be considered as the effect of the proper litbiasis. 
One of the painful paroxysms or exacerbations, attendant upon the evacuation 
of sandy matter, is usually called a fit of the gravel. 
When concretions form so large as to come under the designation of calculi, 
the effects are much more serious. They are different, according as the calcu- 
lus is in the kidney, ureter, or bladder. 
Calculi are almost always formed originally in the kidney. Crystalline 
particles are often observed in the tubuli uriniferi, and small concretions are 
occasionally seen sticking in the point of the papillm, and partly projecting 
into the infundibula. Not unfrequently they are detained in the pelvis or CLASS III.] 
609 
LITHIASIS. 
calyces, sometimes singly, but occasionally also in considerable numbers. They 
are of various sizes, generally small, often not larger than the head of a pin, 
and seldom larger than a pea. Occasionally, however, they attain a great 
magnitude, filling the pelvis and calyces of the kidney, and weighing two or 
three ounces. In many instances, they produce little obvious effect, and are 
carried for a long time without serious inconvenience. There may be occa- 
sional uneasiness in the lumbar region, and embarrassment in the passage of 
the urine, with the discharge of calculous matter; but the symptoms are not 
such as would lead to the suspicion of the existence of renal calculi. Often, 
however, it is otherwise. There is much pain in the region of the kidney, 
with all the other symptoms of nephritic inflammation, such as frequent 
micturition, scanty, high-coloured, or bloody urine, nausea and vomiting, and 
sometimes pains shooting towards the groin or down the thigh, with retraction 
of the testicle, &c. (See Nephritis.') Sudden jars or concussions of the body 
from a false step, jumping, rough riding, &c., are apt to excite uneasiness and 
even acute pain; and rest is attended with greater relief than in inflammation 
of the kidneys from other causes. The occasional discharge, moreover, of 
calculous matter by urine serves to direct attention to the nature of the case; 
and the particular character of the renal calculus may often be told from the 
nature of the substance discharged. The symptoms, though somewhat relieved 
by treatment, are apt to return in consequence of the continued presence of 
the irritating matter, until at length, after an attack of nephritic colic, such 
as attends the passage of a calculus through the ureter, one or more small con- 
cretions escape with the urine, and the complaint often ceases for a time, or 
disappears altogether. The continued presence of calculi in the kidney some- 
times leads to very serious organic disease, such as abscess, absorption of the 
glandular structure, and great distension consequent upon obstruction to the 
flow of urine. (See Chronic Nephritis, and Organic Diseases of the Kidneys.) 
Sometimes also it gives rise to fatal suppression of urine, probably by com- 
pression of the secreting vessels, either directly, or through the intervention 
of the accumulated and retained secretion. 
When the calculus enters the ureter it produces a double injury; first, by its 
rough surface or sharp angles, wounding the mucous membrane, and, secondly, 
by its magnitude distending the coats of the tube, and thus inducing excessive 
irritation. The pain which attends its passage is sometimes excruciating, and 
perhaps equals any to which the human frame is liable. It is usually more 
or less paroxysmal, and has therefore been called nephritic colic. The affec- 
tion has been already sufficiently described under the title of nephralgia, to 
which the reader is referred. After a variable duration of the severest suffer- 
ing, the patient is often suddenly relieved by the escape of the calculus into 
the bladder, and it is said that the relief is sometimes preceded by a paroxysm 
of unusual intensity, in consequence of the greater sensibility of the extremity 
of the duct. In some instances, the calculus is detained in the ureter, either 
producing complete obstruction, and consequent accumulation of urine, with 
distension, ulceration or rupture, or renal ischuria, or so arranging itself in the 
end as to allow the urine to flow past it, and thus producing directly no other 
mischief than inflammation in its immediate neighbourhood. In relation to 
the effects produced by the different kinds of calculi in the ureter, it is pro- 
bable that the oxalate of lime concretions produce the severest pain from their 
roughness and hardness, and the phosphatic the least because less generally 
crystallized. The latter, however, are comparatively rare; as the phosphates 
are little disposed to form original concretions, and are generally produced by 
deposition about a nucleus. The uric acid concretions are greatly more numerous 
than both the others together. The character of the calculus may be conjee-* 610 
[part II. 
LOCAL DISEASES.-SECRETORY SYSTEM. 
tured from that of the urine. If uric acid or the urates are copiously deposited, 
the concretion may be supposed to be of the same nature; and so also of the 
phosphates; while the absence of all deposit, or the presence of oxalic acid in 
any state in the urine, especially if the nephralgic paroxysms are unusually 
severe, would lead to the suspicion that the offending cause might be the 
oxalate of lime. 
In the bladder, a small calculus does not necessarily occasion much un- 
easiness. The immediate relief experienced upon its escape from the ureter 
is so great, that the patient is scarcely sufficiently upon his guard against the 
ultimate consequences. Generally, the calculus passes readily through the 
urethra; as this tube is of larger caliber than the ureters. In some instances 
it sticks in its passage, causing painful pricking sensations, and a more or less 
complete obstruction of the urine. This is a case exclusively for the surgeon. 
Not unfrequently, however, from want of due attention at the time, it remains 
in the bladder, and becomes the nucleus of a stone. It is probable that calculi 
seldom originate in the bladder. A nucleus, generally of uric acid, sometimes 
of the oxalate of lime, and sometimes, though rarely, of other matters, enters 
through one of the ureters, and then receives accretions, either of its own or 
a different nature, according to the state of the urine. Should the phosphatic 
condition prevail, in consequence either of the general state of the constitu- 
tion, or the alkalinity of the urine from local causes, the additions will consist 
of the phosphates. Not unfrequently, alternate layers of different deposits 
are found in the stone. Occasionally, instead of a nucleus of uric acid, or the 
oxalate of lime, the deposition will take place around a portion of coagulated 
blood or fibrin, or any foreign body that may have accidentally entered the 
bladder. Sometimes the calculus remains long in the bladder, and increases 
greatly before it produces much inconvenience. Generally, however, its pre- 
sence is indicated by a disposition to frequent micturition, an occasional sud- 
den stoppage of the stream of urine, painful spasmodic contractions of the 
bladder, the discharge of blood from the urethra, and itching and painful 
sensations in the glans penis, which lead, especially in children, to a frequent 
pulling and great elongation of the prepuce. These symptoms are gradually 
increased. The disposition to pass water becomes at length extremely urgent 
and almost incessant, and the spasms of the bladder exquisitely painful. The 
least jar occasions severe suffering, so that riding in a rough vehicle becomes 
almost impossible. Vesical mucus is discharged in great quantities, the urine 
becomes offensive, and copious deposition of the phosphates often takes place. 
The general health at length gives way. Hectic fever ensues, with great 
debility and emaciation; and at last death from inflammation and disorganiza- 
tion of the bladder relieves the patient. These symptoms, however, though 
strongly characteristic, should not be exclusively relied on in forming a diag- 
nosis. Sounding is the only infallible method of determining the existence 
of stone in the bladder. Sometimes the stone is encysted; and then the 
symptoms are much more obscure. To the physician it is chiefly important 
to know that calculus in the bladder exists, in order not to confound it with 
other complaints; and to be aware of its composition, in order that he may 
administer suitable palliative remedies. The latter knowledge is to be ob- 
tained exclusively by the examination of the urine, and the matters discharged 
with it. 
Treatment of Lithiasis.-The means of relieving the effects produced upon 
the kidney, ureters, and bladder by calculous depositions, are treated of else- 
where. (See the articles Nephritis, Nephralgia, and Cystitis.} The measures 
which require attention here, are those calculated to prevent the deposition 
from taking place within the body, and to remove the deposited matter. As CLASS III.] 
LITHIASIS. 
611 
the mode of treatment is influenced by the character of the calculous matter, 
it will be proper to give separately the treatment adapted to the three promi- 
nent forms of lithiasis already described. 
1. In the uric acid variety, the indications are, 1. to render the uric acid 
more soluble in the urine; 2. to increase the solvent power of the urine 
itself; 3. to correct the constitutional tendency to excess in the production 
of uric acid, or of any other acid which may have the property of precipi- 
tating it from its solution; and 4. to remove from the body any calculus 
which may have been already deposited. 
To render the uric acid more soluble, recourse must be had to the alkalies 
or alkaline earths. These are, indeed, by far the most efficient remedies in 
this variety of lithiasis. The bicarbonate of soda or of potassa should be 
preferred, as less liable than the caustic alkalies, or even their carbonates, to 
injure the stomach. Either of these bicarbonates may be given for a long 
time without injury. I have always employed the bicarbonate of soda, and 
seldom found it to fail in correcting, for the time, a tendency to the deposition 
of uric acid or the urates. It is less unpleasant than the corresponding salt 
of potassa, and probably not less efficacious. By rendering the urine alka- 
line, these salts enable it to hold the uric acid in solution. They have the 
additional advantage of increasing the secretion of urine, and thus meeting 
the second indication. It is obvious that they do not correct the excessive 
production of the acid; but they afford relief to the symptoms, and prevent 
injurious results, while other means are employed for effecting a radical cure. 
When the cause of the excess of uric acid is temporary, it often happens that 
no other remedies are necessary. The bicarbonates have still another advan- 
tage, that they are capable of dissolving the phosphates as well as uric acid, 
and consequently do not occasion the deposition of these salts, as the carbo- 
nates and caustic alkalies are accused of doing. They should be used freely, 
and dissolved in a large quantity of liquid. The best solvent for them is car- 
bonic acid water, as it is usually very acceptable to the stomach, and at the 
same time supplies any deficiency of carbonic acid which may exist in the 
salt. Half a drachm of bicarbonate of soda may be given, dissolved in from 
four to eight fluidounces of carbonic acid water, with or without ginger syrup, 
four times a day. It should be continued until the urine ceases to yield any 
sediment on cooling, passes freely, and recovers its natural colour; and, if 
omitted, should be resumed immediately upon the recurrence of the symp- 
toms. The natural mineral waters, most useful in calculous complaints, are 
those containing bicarbonate of soda. Such are the celebrated waters of 
Vichy, in France. Solution of potassa, the alkaline carbonates, magnesia, 
lime-water, and soap, have all been employed to meet the same indication, 
and all to a certain extent with the same effect. There might be circum- 
stances under which one of these antacids would be preferable ; as lime-water, 
for example, in cases of chronic nausea and vomiting; but, as a general rule, 
they are inferior to the bicarbonates. 
Borax and phosphate of soda have been recommended in this variety of 
gravel, in consequence of their solvent power over uric acid. Benzoic acid 
was also suggested by Dr. Alexander Ure; but the supposition upon which 
the suggestion was founded, that this acid has the property of converting the 
uric into soluble hippuric acid in the system, has not been sustained. Upon 
another principle, however, as will be seen directly, it proves useful in phos- 
phatic depositions. 
To meet the second indication, that, namely, of increasing the solvent 
power of the urine, means must be employed to increase its quantity. 
Hence, the patient should drink freely of cool diluent liquids, such as gum 612 
[PART II. 
LOCAL DISEASES.-SECRETORY SYSTEM. 
arabic water, flaxseed tea, and the infusion of slippery elm, sassafras pith, 
and benne leaves. Carbonic acid water is sometimes a useful beverage in 
these cases. Benefit will now and then accrue from adding some diuretic 
substance to the drink, especially in chronic cases in which moderate stimu- 
lation may not be objectionable. Such additions are the oil of juniper, wild 
carrot, and the spirit of nitric ether. It has been stated that the alkaline 
bicarbonates serve also to fulfil this as well as the first indication. 
In order to correct the tendency to an excessive production of uric acid, we 
must remove its causes. The patient, therefore, should be restricted to a 
vegetable diet in the acute form of the complaint; and, even in chronic cases, 
should employ animal food with moderation. Alcoholic drinks should be 
forbidden. To prevent the generation or accumulation of any other acid in 
the system, which may tend to precipitate the uric acid, acescent articles of 
food should be avoided, as well as substances of difficult digestion, which may 
favour the production of acid in the stomach by diminishing its solvent powers. 
The alkalies also meet this indication by neutralizing any excess of acid pro- 
duced. Other means calculated to prevent accumulation of acid in the cir- 
culation, are such as excite the skin or the bowels to increased action, and 
throw off the acid through these emunctories. In the febrile state, the neu- 
tral cathartic salts may be used as purgatives, and the citrate of potassa and 
acetate or citrate of ammonia as diaphoretics. The latter salts are best given 
in the state of effervescence. They have the additional advantage, that, by 
the decomposition of their acid ingredient in the process of digestion, they 
increase the alkalinity of the blood, and impart this property also to the urine. 
In the absence of fever, combinations of opium with ipecacuanha or tartar 
emetic will be useful, especially at bedtime. Recourse may also be had to 
the warm bath. Flannel should be worn next the skin. Moderate exercise 
is advantageous, both by enabling the system to appropriate the food admitted 
into it, without the necessity of throwing off the excess in the form of urea 
or uric acid, and by sustaining the eliminating function of the skin. 
The fourth indication is to be fulfilled by means directed to the solution, 
disintegration, or mechanical expulsion of the calculus. These are to be re- 
sorted to whether the calculus is in the kidney or the bladder. To effect its 
solution, no means are so efficacious as a very free and long-continued use of 
the alkaline bicarbonates. The urine should be brought into the alkaline 
state by these salts, and kept so for months if necessary. Instances are re- 
corded, in which there is good reason to think that even stones in the bladder 
have been completely removed in this way. Renal calculi are supposed to 
have been sometimes disintegrated, and thus rendered capable of expulsion, 
by the use of stimulating diuretics, such as oil of turpentine, copaiba, and 
cantharides. It is certain that sometimes, after the free use of these sub- 
stances, large quantities of calculous matter have been discharged with the 
urine, to the great relief of previous uneasiness in the lumbar regions, and 
other morbid symptoms. But their mode of action is not so certain. It may 
be that, by their stimulant influence upon the kidneys, they enable the tubuli 
uriniferi more thoroughly to discharge the calculous matter contained in them, 
than under the influence of ordinary diuresis. It may be also that the calcu- 
lous matter alluded to is the result of a stimulated secretion, and the relief 
owing to its elimination from the system. 
When there is reason to think that calculi are fixed in the kidneys, it is 
possible that the concussion of emetics, united with the relaxing influence of 
the nausea they produce, may cause their dislodgment; and horseback riding, 
or the motion of a jolting carriage, has been recommended with the same 
view j but these measures must be employed with great caution. CLASS III.] 
613 
LITHIASIS. 
Of the measures calculated to facilitate the passage of the calculus into the 
bladder, sufficient has been said elsewhere. (See Nephralgia.') After it has 
reached the bladder, means should be immediately employed for its expulsion, 
if it do not pass out spontaneously. This is of the utmost importance; as it 
is by such precaution that the formation of stone in the bladder is to be pre- 
vented. When, therefore, there is good reason to believe that a calculus has 
escaped from the ureter, the patient should be directed to retain his urine as 
long as he conveniently can, drinking in the mean time freely of water or 
mucilaginous fluid, and, when the bladder is quite full, to bend his body for- 
ward so as to make the entrance of the urethra the lowest part, and then to 
discharge his urine in a full stream. The urine should be carefully examined 
to ascertain whether a calculus has passed. If not, the above process should 
be repeated time after time. Sir B. Brodie recommends that, previously to 
the discharge of the urine, a large bougie should be introduced into the 
bladder, and withdrawn at the moment of the effort of micturition. The cal- 
culus sometimes follows the bougie immediately. During the employment of 
these methods, attempts to dissolve, or at least prevent the increase of the 
calculus should be made by a free use of the alkaline bicarbonates. Should 
the calculus become lodged in the urethra, the aid of the surgeon will be 
necessary. Should none be discharged, and yet all symptoms of its presence 
in the bladder cease, there will be reason to think that it may have been dis- 
solved ; and, in the course of two or three weeks, the efforts for its solution or 
expulsion may be omitted. 
It has been said that persevering efforts should be made to effect the solu- 
tion of stone in the bladder by the internal use of the alkaline bicarbonates. 
Should this object not be obtained, and, when the stone is of any considerable 
size, success is hardly to be expected, still much good may possibly be done 
by preventing further deposition, and thus obviating increase of bulk and 
roughness of the surface. The solution of stone in the bladder by the injection 
of certain fluid menstrua has been frequently attempted. Sir B. Brodie suc- 
ceeded, in one instance, by the injection, every two, three, or four days, of 
water acidulated with nitric acid in the proportion of two and a half minims 
to the ounce. (Lond. Med. Gaz., viii. 355.) This injection is adapted to 
the phosphates. In the case of uric acid calculus, a solution of the alkaline 
bicarbonates should be employed. This apparently very rational mode of 
treating vesical calculi has not been sufficiently tried. By the use of a double 
catheter, a constant stream into and out of the bladder may be kept up as 
long as may be considered desirable. Galvanism has been proposed as a 
means of effecting the solution or disintegration of the stone; and an instru- 
ment has been devised by Mr. Charles Phillips, by which the influence of a 
galvanic current, and at the same time that of a current of liquid having a 
chemical action upon the stone, may be brought to bear upon it. 
2. In the phosphatic variety of lithiasis, the most important indications are 
1. to prevent the production of an excess of the phosphates, and 2. to prevent 
their deposition. Their production in excess being associated with dyspepsia, 
general debility, and nervous disorder, it is important to obviate these several 
conditions by tonics, attention to the state of the bowels and the hepatic 
secretion, a proper regulation of diet and exercise, and a judicious use of nar- 
cotics. The whole treatment applicable to dyspepsia may be employed. (See 
Dyspepsia.) In relation, however, to exercise, care must be taken, if a calculus 
already exists within the body, that it be not too violent. Opium is admitted 
by all to be an invaluable remedy in this variety of lithiasis. It not only 
quiets the irritation of the urinary organs, and the general irritation of the 
nervous system, and thus greatly increases the comfort of the patient; but it 614 
[PART II. 
LOCAL DISEASES.-SECRETORY SYSTEM. 
controls also the secretion of urine, which it tends to keep in the proper state 
both as to quantity and quality. Thus, it is asserted that no means are more 
efficacious in maintaining the healthy acidity of urine than the use of opium. 
The patient should be kept under its moderate influence during the parox- 
ysms. The dose may be from half a grain to a grain, two, three, or four times 
a day. When opium disagrees with the patient in all its forms, some other 
narcotic, as camphor, hyoscyamus, conium, or dulcamara may be resorted to. 
Strychnia has been recommended in reference to its operation on the spinal 
marrow, derangement of which is supposed to be a fruitful source of alkaline 
urine, and consequently of the phosphatic deposition. 
The deposition of the phosphates would be best prevented by rendering the 
urine acid. On this account the mineral acids were at one time highly re- 
commended, under the impression that they might be secreted with the urine, 
and supersaturate the alkali. But it has been ascertained that these acids do 
not enter the urine in their free state, and it is asserted that they have not 
been found to correct the alkalinity of this secretion. This is probably true 
in many cases. When the alkalinity depends upon causes acting in the 
urinary organs, as upon the secretion of unhealthy mucus, the acids cannot 
affect it, as they do not reach these organs in their free state. But when it 
depends upon the state of the blood, or the general condition of the system, 
they may probably do good by neutralizing alkali which might otherwise find 
its way into the urine. At any rate they are excellent tonics, and peculiarly 
adapted to the condition of system characteristic of the phosphatic diathesis. 
Either the sulphuric, nitric, muriatic, or nitromuriatic acid may be employed. 
The last would be peculiarly appropriate in cases of disordered hepatic secre- 
tion. Some of the vegetable acids appear to have done good occasionally in 
lithiasis. Thus, cures are asserted to have been frequently produced by the 
use of hard cider. At least this remedy is worthy of being tried in the phos- 
phatic variety of the disease. Benzoic acid has the effect of rendering urine 
acidulous, probably by conversion into hippuric acid, and may be given, 
therefore, in the phosphatic lithiasis with great effect, so far as concerns the 
prevention of the deposition.* 
But it appears to be now generally admitted, contrary to former opinion, 
that the alkaline bicarbonates are the most efficient medicines in preventing 
the deposition, and effecting the solution of the phosphatic, as well as of the 
uric acid sediments. It is only the bicarbonates, however, that have this 
effect. The carbonates and pure alkalies increase the deposition. 
No advantage accrues from an increase of the secretion of urine. It is 
indeed frequently too copious, and sometimes requires repression. As the 
disease is often associated with chronic inflammation of the mucous membrane 
of the kidneys and bladder, and probably owes its obstinacy to this cause, 
remedies which produce an alterative impression upon these organs are occa- 
sionally useful. Hence, the turpentines or their volatile oil, copaiba, buchu, 
uva ursi, pareira brava, &c., may sometimes be advantageously administered. 
* Dr. G. Owen Rees thinks that the indication in this affection is not, as has been 
supposed, to render the urine acid. He believes, that acid urine irritates the mucous 
membrane, and has the effect of sustaining the inflammation in that membrane, which he 
considers to be the most frequent cause of alkalinity of the urine, and of the consequent 
pbosphatic deposit. He rather advises the use of alkaline medicines and demulcents, 
by which, the irritating acid being neutralized, the secretion is rendered blander, and 
the inflammation is allowed to subside, or may yield to other treatment. He advises 
especially the alkaline salts, as the citrate and tartrate of potassa, which have a power- 
ful influence in rendering the urine alkaline, in consequence of the decomposition of their 
organic acid. (Land. Med. Gaz., July, 1851, p. 35.)-Note to the third edition. CLASS III.] 
615 
RETENTION OF URINE. 
By correcting the secretion of mucus, they obviate the cause of the alkalinity 
of the urine, and consequently the phosphatic deposition. It is hardly neces- 
sary to observe that the patient, in this as in the preceding variety of lithi- 
asis, should be clothed in flannel. He should especially avoid the use of 
hard water as drink. Both the sulphate and carbonate of lime, often con- 
tained in such water, probably dispose to the phosphatic sediments. Stone 
in the bladder is peculiarly abundant in lime-stone regions. 
The remarks made in relation to the treatment of stone in the bladder, in 
the uric acid variety of the complaint, are also applicable here. 
3. In the treatment of the oxalic lithiasis, the practitioner must be guided 
by the general condition of the system. Sometimes it may require a mode- 
rate antiphlogistic treatment, sometimes the reverse. Dr. Prout recommends 
mineral acids, particularly the nitric, combined with other tonics, in order to 
change the diathesis to that in which the disposition is to deposit uric acid. 
But as soon as any tendency to the latter sediment is observed in the urine, 
the treatment should be suspended. Of the acids, Dr. Bird prefers the nitro- 
muriatic, but recommends sulphate of zinc, when great nervous irritability 
exists, and in anemic cases, the chalybeates. He has found advantage from 
colchicum in some obstinate cases. The shower bath is also useful. The 
nitromuriatic acid has proved very efficacious in my experience. All articles 
of diet containing oxalic acid, or readily converted into it, should be forbidden. 
The patient should, therefore, avoid sorrel, whether of the genus oxalis or 
rumex, as a salad, should never eat rhubarb pies, and should partake very 
moderately of sugar. Indigestible substances generally should be excluded 
from the diet, and no fermented liquor allowed. Dr. Bird considers a very 
small quantity of brandy and water at meals as the best beverage. Flannel 
should be worn next the skin. The dietetic and general hygienic rules 
adapted to dyspepsia are applicable to this form of lithiasis. Little or no- 
thing can be done to dissolve the oxalate of lime when deposited. So far as 
regards mechanical measures for expulsion, the same rules are applicable as 
to the uric acid calculi. 
Article XL 
RETENTION OF URINE 
When urine is secreted, but not evacuated, it is said to be retained, and 
the affection is denominated retention of urine. This may occur in the kid- 
neys, or in the bladder. 
1. Renal Retention.-This is not always easily distinguishable from 
suppression of urine, in which the secretory function is suspended or abolished. 
In both, the discharge of urine either greatly diminishes, or entirely ceases; 
and in both, the signs which indicate fulness or distension of the bladder are 
wanting, and little or no urine escapes upon the introduction of a catheter. 
In retention, however, there is much more pain than in suppression. There 
is, also, in the former a distressing sense of weight, or distension in the lum- 
bar region; great uneasiness is produced by strong pressure in the loins ; and 
it is asserted that the ureters and kidneys have sometimes been so much dis- 
tended as to form a fluctuating tumour, discoverable from without. Besides, 
the retention is seldom complete. Occasionally there may be a considerable 
discharge of urine, consequent upon a partial removal of the obstruction; 
and, even if no urine pass the obstructed point, still a portion may enter 
the bladder from the opposite kidney, and escape by the urethra. In sup- 616 
[PART II. 
LOCAL DISEASES.-SECRETORY SYSTEM. 
pression, there is either no discharge, or the quantity is very small, and 
liable to little diversity. 
The consequences of renal retention, unless the obstruction be speedily 
removed, are very serious. If the obstruction exist in the upper part of the 
ureter, the pelvis of the kidney, and even the kidney itself, become greatly 
distended; and the renal structure has sometimes been so much stretched out 
as to form a sort of membranous bag. When the lower part of the ureter is 
closed, this tube becomes also vastly dilated above the point of obstruction. 
In some instances, there is reason to believe that suppression is induced in 
consequence of pressure upon the secreting surfaces, and death speedily 
results from this cause. In other cases, inflammation, suppuration, and com- 
plete disorganization of the kidney take place, with rupture, and all thh fatal 
consequences of effused pus and urine. 
The most frequent causes of renal retention are calculi in the ureter, or 
at its origin in the pelvis of the kidney. Coagula of blood or fibrin may 
produce the same effect. Obstruction of the passage may also arise from 
inflammatory thickening of the coats of the ureter, or the pressure upon it 
of tumours from without. 
2. Vesical Retention.-Retention of urine in the bladder is, in 
general, very easily distinguished. The occurrence of inability to make 
water leads to an examination of the bladder, which is felt above the pubis, 
forming a roundish, well-defined, and sometimes visible tumour. Occasion- 
ally, however, in very fat persons, or in tympanitic states of the abdomen, 
it cannot be easily distinguished by the touch. In this case, the dulness 
upon percussion over the whole region which it occupies, contrasting with 
the resonance of the surrounding space, will be sufficiently diagnostic. A 
complication of ascites with retention might cause some embarrassment; but 
the peculiar pain produced by pressure on the distended bladder, or, if this 
fail, the introduction of a finger into the rectum, or of a catheter into the 
bladder, will soon decide the question. The distension goes on increasing 
with the continuance of the retention; and the bladder sometimes acquires 
enormous dimensions, reaching to the umbilicus, or even, in some rare in- 
stances, as high as the scrobiculus cordis. It has, under these circumstances, 
been mistaken for ascites. 
There are two conditions of retention materially differing in their symptoms; 
one, in which the affection is suddenly induced, the other, in which it comes 
on gradually. In the former, there is usually much pain in the hypogastrium 
and perineum, with a constant and distressing desire to pass water, but in- 
effectual notwithstanding the strongest efforts. The pain is much increased 
by pressure over the pubes. If the affection continues, the patient becomes 
feverish, restless, anxious, and exceedingly distressed, until at length a por- 
tion of the bladder or urethra gives way, and the urine escapes either into the 
peritoneum with inevitably fatal results, or more frequently, into the neigh- 
bouring cellular tissue, producing inflammation, sloughing, and generally 
death. When the retention is partial, and the accumulation in the bladder 
gradual, this viscus accommodates itself to the pressure, and may be greatly 
distended without much uneasiness. The ureters, and even the pelvis of the 
kidney, sometimes participate in the distension. Sooner or later, however, 
unless relieved, the same symptoms are apt to come on as in the acute form, 
and with the same fatal result. 
The causes of vesical retention are twofold, namely, obstruction of the 
urethra, and a loss or diminution of the contractile power of the bladder. 
Obstruction may arise from inflammatory swelling of the mucous membrane 
and cellular tissue at the entrance of the urethra; and, in this case, the CLASS III.] 
RETENTION OF URINE. 
617 
symptoms of irritable or inflamed bladder are added to those properly be- 
longing to the retention. It may also arise from spasmodic contraction of 
the sphincter fibres, under the influence of cold, direct irritation, inflamma- 
tion, or nervous disorder, especially hysteria. Other causes of obstruction 
are a pendulous tumour falling upon the entrance of the urethra, tumours of 
the uterus or vagina, the gravid uterus pressing on the neck of the bladder, 
and more frequently still, especially in old people, enlargement of the pros- 
tate. But the most frequent obstruction of all, is that from stricture of the 
urethra. Diminished contractility of the muscular coat may arise from the 
debility of old age, the deficient innervation of low fevers, and cerebral or 
spinal disease, attended with paralysis. In these cases, the retention is not 
complete. When the bladder is to a certain degree distended, even though 
it may have lost all muscular power, its elasticity is sufficient to overcome 
the feeble resistance of the sphincter, and a portion of the urine escapes, in 
general, involuntarily. This happens especially at night; and there is some 
danger of mistaking the affection for incontinence, unless the practitioner is 
on his guard. In states of system in which the patient is insensible, as in 
typhoid fevers, there is peculiar liability to this mistake, which may lead to 
serious consequences. This state of the bladder is often very annoying. All 
voluntary power of evacuation is lost, but, with every movement which causes 
gravity to favour the discharge of the urine, and with every unusual degree 
of pressure on the bladder, as in coughing or sneezing, a portion of the urine 
escapes involuntarily, producing irritation, and even excoriation of the skin 
with which it comes in contact, and an excessively disagreeable odour about 
the person. Such cases are a combination of retention and incontinence. 
The very act of distension has the effect of debilitating the muscular coat, 
and, in the end, if continued, of entirely destroying its contractile power. 
Hence, the habit of resisting the desire to evacuate the urine may, if long 
enough continued, gradually induce retention. 
Treatment.-Renal retention, if consequent upon inflammation, must be 
treated by means adapted to the cure of nephritis; if upon calculi or coagula 
in the ureter, by those which are recommended under lithiasis and nephralgia. 
In vesical retention, when proceeding from inflammation at the neck of the 
bladder, bleeding, leeching, saline cathartics, antimonials, emollient cataplasms, 
and the warm bath are suitable remedies, and will seldom fail. To attempt 
to relieve the complaint with the catheter would in general only aggravate the 
irritation. The instrument should be resorted to in this and the following 
case, only when rendered absolutely necessary in order to relieve very painful 
or dangerous distension. When spasm is the cause of retention, an anodyne 
enema will often be found an effectual remedy; and the inhalation of ether 
or chloroform will probably answer the same purpose, the former of the two 
being preferable as the safer. Tobacco or lobelia cataplasms to the peri- 
neum may also prove useful. In these cases, too, the tincture of chloride 
of iron, and the alcoholic solution of ammoniated iron have been recom- 
mended. Should the spasm be hysterical, or the retention depend upon hysteria 
in any other way, the remedies applicable to this disease must be employed, 
and especially cups or leeches, with subsequent blistering or pustulation over 
the spine. But care should be taken, in such cases, not hastily to resort to 
the catheter; for, if once used, it is again and again called for, and becomes 
at length a necessary source of relief. When the obstruction is purely 
mechanical, as from stricture of the urethra, enlarged prostate, &c., the 
catheter becomes indispensable, and if this cannot be introduced, the bladder 
must be punctured. Such cases, however, belong to the surgeon. 
Retention arising from deficient power in the muscular coat must be treated 618 
[part II. 
LOCAL DISEASES.-SECRETORY SYSTEM. 
according to the circumstances in which this loss of power originated. If the 
seat of disease is in the spine, cups, blisters, antimonial pustulation, and setons 
or issues to the back are appropriate remedies; and some have recommended 
moxa and even the actual cautery. If the paralysis of the bladder is only a 
part of a general affection, dependent on disease of the brain, it must be 
treated accordingly. If quite local, or connected with general debility, it is 
to be encountered by tonic treatment addressed to the system, and stimulants 
to the bladder itself. The cold bath, and the cold douche to the perineum 
and pubes, are sometimes useful by rousing a salutary reaction. Strychnia 
or nux vomica, quinia, tincture of chloride of iron, uva ursi, pareira brava, 
buchu, cubebs, oil of turpentine, and cantharides have all been recommended, 
and may be tried successsively, or variously combined. Aloetic laxatives 
should be preferred in order to keep the bowels regular, unless the patient 
should be troubled with piles. Ergot has been used by M. Passot, of Lyons, 
under the impression that it acts upon the bladder in the same manner as on 
the uterus; and he reports a number of cases in which it is said to have proved 
effectual. (See Am. Journ. of Med. Sei., N. S., xxvi. 488.) Repeated blister- 
ing to the sacrum will occasionally prove useful, and electricity or galvanism 
may be tried with the hope of benefit. In these cases, the use of the catheter 
is important in order to prevent distension of the bladder, which has the effect 
of increasing its debility. It should be introduced at Ic^st twice a day, and, 
if more frequently used, so much the better. After recovery, the patient should 
be scrupulously careful to obey the call to pass water in due time, lest accu- 
mulation should take place and produce distension. 
Article XII. 
INCONTINENCE OF URINE. 
Syn.-Enuresis. 
In this affection there is a want of power to control the discharge of urine, 
which is evacuated involuntarily. There are two very different conditions of 
the urinary organs, both of which are attended with incontinence. In one, 
the bladder is so highly irritated that the sphincter, though in a healthy state, 
cannot resist the urgent desire of micturition; in the other, the sphincter is 
debilitated or palsied, and cannot contract sufficiently to retain the urine, in 
the ordinary state of the bladder. In the former, the bladder may be in- 
flamed or highly irritated, so as to be unable to tolerate the presence of heal- 
thy urine; or the urine may be morbidly acrid so'as unduly to excite the 
bladder, though this may have been previously in a normal condition. This 
sort of incontinence also frequently accompanies stone in the bladder. 
But it is the second condition which constitutes true incontinence. In this, 
the sphincter either relaxes under less than the ordinary stimulation from the 
urine, or is quite destitute of the power of contraction, so that no other im- 
pediment exists to the escape of urine than the pressure of the soft parts upon 
the channel of the urethra; a resistance which the slightest force is sufficient 
to overcome. 
Not unfrequently both these conditions exist in the same case; the bladder 
being irritated to more than its ordinary contraction, while the sphincter has 
less than the ordinary power of resistance. 
Under the influence of sudden emotion, especially of fear, involuntary dis- 
charges of urine sometimes take place. These can be considered as morbid 
only when they occur habitually, or from comparatively slight causes. CLASS III.] 
INCONTINENCE OF URINE. 
619 
The most frequent form of incontinence is that in which the sphincter 
retains considerable contractile power, but yields habitually to slight impulses 
when the will is not sufficiently on its guard, or when it is to a considerable 
degree inoperative, as in sleep. Involuntary discharge of urine at night is a 
frequent and very disagreeable affection. It is most common in children be- 
fore puberty, and is apt to cease spontaneously after this period, but is some- 
times prolonged into adult age. Though in itself of little importance in refer- 
ence to the health, it often becomes highly important in its moral influences, 
sometimes affecting the character and whole future life of the patient. The 
discharge during sleep frequently occurs in consequence of dreams; but often 
also it is altogether involuntary, without the least consciousness on the part of 
the patient, and dependent solely upon the relaxation of the sphincter under 
the stimulus of the urine. It is said that the position of the patient has some 
effect, and that he is more apt to make water when lying on the back than 
upon the face or side. I have, however, some doubts of the accuracy of this 
statement. Occasionally the incontinence is experienced also during the day, 
so that the patient cannot retain his urine so long as persons in ordinary 
health. This affection is often attended with an acrid condition of the urine, 
which is high coloured, and loaded with uric acid in solution, or even with 
sediments of the acid or its salts. In this case, there is a combination of irri- 
tation of bladder with debility of the sphincter. More frequently, however, 
the urine is pale and watery, and secreted in unusual quantity. The affec- 
tion appears to be hereditary, or at least occurs frequently in several members 
of the same family. 
A variety of incontinence analogous to the above occasionally arises from 
irregular nervous action, especially in hysterical cases. There is in these 
cases less a positive debility of the sphincter, than an irregularity of inner- 
vation, which is as often excessive as deficient. 
But the most deplorable cases of incontinence are those connected with 
complete paralysis of the sphincter, or a total loss of power in the muscular 
fibres thus denominated, in consequence of mechanical injury, as from the 
operation of lithotomy in females, and from severe labours. The paralysis 
of the sphincter may not extend to the muscular coat of the bladder gene- 
rally, in which case the urine will be occasionally discharged in a jet, when 
from position or other cause it has accumulated considerably; or the blad- 
der may share the same loss of power, and then incontinence may become 
involved with retention; the bladder being frequently full or distended, while 
the urine dribbles away whenever the elasticity of the coats is sufficient to 
overcome the slight resistance of the urethra, or gravity favours the discharge. 
This condition of things is most common in the old, and is sometimes asso- 
ciated with disease of the prostate. The disease, like retention from a similar 
cause, may be quite local, or may be associated with paralysis of other parts 
from disease of the brain or spinal marrow. 
Treatment.-The variety of incontinence connected with an irritated state 
of the bladder, or an acrid condition of the urine, must be corrected by re- 
moving its cause. The proper remedies will be found under the heads of 
irritable bladder, cystitis, nephritis, and lithiasis. An anodyne enema is 
among the most effectual means of affording present relief. In the cases 
dependent on debility of the sphincter, such as nocturnal incontinence, the 
indications are to restore tone to the system at large, if debilitated, and to 
stimulate the sphincter. The first object is to be accomplished by the bitter 
tonics, mineral acids, chalybeates, sea-bathing, the cold bath, and due attention 
to clothing, diet, and exercise. For the latter purpose, astringents or tonics 
having a peculiar reference to the urinary organs may be first tried, such as 620 
LOCAL DISEASES.-NERVOUS SYSTEM. 
[PART II. 
uva ursi, pipsissewa, and pareira brava; and these may be aided by the cold 
douche to the sacrum, perinaeum, or pubes. Should these remedies fail, 
recourse may be had to the more active urinary stimulants, as buchu, cubebs, 
oil of turpentine, or cantharides. On the whole, I have found no one remedy 
so effectual as cantharides, pushed so far as to produce slight irritation of the 
urinary passages. In bad cases, blisters to the sacrum may be employed. 
Strychnia and ergot have been recommended, in reference to a supposed power 
of stimulating the sphincter; and much may be hoped for from the former 
remedy. Narcotics have also been found useful, probably by diminishing the 
susceptibility of the neck of the bladder. Belladonna has answered an excel- 
lent purpose in the nocturnal incontinence of children. The patient himself 
should be induced to aid the efforts of the practitioner. Much may be done 
by firm resolution on his part. Yet a resort to chastisement, recommended 
by some writers, in cases in which the will is not concerned, is not only cruel 
but nugatory; as the fears excited have of themselves a relaxing effect on the 
sphincter. Little or no drink should be allowed in the latter part of the day 
or evening; the patient should fully evacuate the bladder before going to 
sleep; and a good plan is to awaken him for the same purpose late at night, 
before the period at which lie usually wets the bed. Any method which will 
serve to break the habit will often be found serviceable. When the com- 
plaint is connected with hysteria, the peculiar treatment adapted to that 
affection must be employed. 
In paralytic cases, remedies addressed to the spine, as mentioned under 
retention, will sometimes prove useful. The stimulating diuretics already 
enumerated may also be employed when the affection is local. Strychnia or 
nux vomica has been highly recommended, and electricity, or electro-mag- 
netism should not be neglected. Advantage is sometimes derived from power- 
ful irritants, as cantharides or nitrate of silver, applied by means of bougies 
directly to the upper part of the urethra. But very often all our remedies 
are of no avail, and wTe are compelled to content ourselves with measures to 
render the complaint as little inconvenient as possible. Pressure upon the 
urethra by means of a spring-pad of moderate firmness, and the use of urinals 
at night, and water-proof bags in the day, to receive the urine as it dribbles 
from the patient, include about all the justifiable means at our command. 
SECTION VI. 
DISEASES OF THE NERVOUS SYSTEM. 
SUBSECTION I. 
DISEASES OF THE BRAIN.* 
Article I. 
INFLAMMATION OF THE BRAIN AND ITS MEMBRANES. 
Under this head I propose to consider all the inflammatory affections of the 
parts contained within the cranium. Great difficulty has been experienced in 
* Cerebral Auscultation.-In the year 1833, a paper was read by Dr. John D. Fisher, 
before the Boston Society for Medical Improvement, upon a peculiar sound called by CLASS III.] 
621 
DISEASES OF THE NERVOUS SYSTEM. 
arranging these affections. There would seem to be a propriety in treating 
separately of each distinct portion of the encephalon; of the several membranes, 
for example, of the brain itself, and the cerebellum; but, so far as our know- 
ledge at present goes, the signs of inflammation in these different parts, as 
well as its causes, and the treatment which it requires, are so much alike, that 
it is almost impossible, and happily at the same time of little practical im- 
portance, to discriminate accurately between them. 
It is true that inflammation may exist separately in the meninges and the 
substance of the brain. Dissection has demonstrated this fact. But the 
cases are rare, in which any considerable portion of one of these structures is 
affected without the other. This, indeed, is what might be inferred from their 
him the cephalic bellows sound, which he had observed to accompany certain diseases of 
the brain. In a subsequent communication, made in 1838, he very much extended his 
former observations, and gave an account of the normal sounds heard upon auscultation 
over the brain, and of the modification produced in them by certain cerebral diseases. 
This dissertation was published in the American Journal of Medical Sciences for August 
of the same year (xxii. 278). In a subsequent volume of the Journal (Oct. 1843, N. S., 
vi. 281), is a communication upon the same subject by Dr. S. S. Whitney, of Newton, 
Massachusetts, in which the observations of Dr. Fisher are confirmed, and somewhat 
extended. The subject appears to me worthy of attention ; and, accordingly, a brief 
abstract is herewith given of the statements made by the writers above mentioned. 
Dr. Fisher recommends that the patient when ausculted should be in the horizontal 
position, that the head should be covered by a soft napkin, and that, in cases of children, 
the act should be performed during sleep. The sounds may be heard at any part of the 
surface of the cranium, but are most distinct at the summit. They are somewhat dif- 
ferent before and after the closure of the anterior fontanelle. The auscultation is best 
performed by the naked ear, applied to the surface of the cranium. 
Four distinct sounds are observed in health; 1. the cephalic sound of respiration, pro- 
duced by the passage of the air through the nasal cavities; 2. the cephalic sound of the 
heart, of a soft mellow character, seeming as if proceeding from a distance, and corre- 
sponding with the action of the heart; 3. the cephalic sound of the voice ; and 4. the cephalic 
sound of deglutition, produced by the act of swallowing. 
The most prominent abnormal sound is a modification of the cephalic sound of the 
heart, which Dr. Fisher calls the cephalic bellows sound. It is closely analogous to the 
cardiac murmur after which it is named. Dr. Fisher observed it in chronic hydroce- 
phalus, in congestion of the brain, in acute meningitis with effusion, in abscess of the 
brain, in induration of that organ with effusion into the ventricles and at the base, and 
in compression of the brain from without. Dr. Whitney has noticed it also in inflam- 
mation of the brain without effusion, in ossification of the cerebral arteries, in aneurism 
of the basilar artery, and in certain hydrocephaloid conditions of the brain connected 
with anemia. The explanation of this sound, given by Dr. Fisher, is that it is produced 
in the arteries at the base of the brain, and is consequent upon the diminution of their 
caliber, resulting from pressure upon them by the effused fluids, congestion, &c., within 
the cranium. Dr. Whitney thinks that it is also generated by disease of the arteries 
themselves, as when their coats are altered by inflammation, or in aneurism. 
Another modification of the cephalic sound of the heart, noticed by Dr. Fisher, occurred 
in several cases of apoplexy. Instead of proceeding from a distance, it seemed to be 
near the ear, and was characterized by an impulse, as if the brain were suddenly raised 
against the cranium. He designates it as the impulsive cephalic sound of the heart. 
An abnormal modification of the cephalic sound of the voice, was noticed by Dr. Whit- 
ney, resembling almost precisely the aegophony of pleurisy, and arising from a similar 
cause; from a thin stratum of liquid, namely, between the surface of the brain and the 
internal surface of the cranium. It is called by Dr. Whitney segophony of the brain. 
The same observer notices two modifications of the cerebral bellows murmur, one of 
which occurred in aneurism of the basilar artery, and the other in anemic conditions of 
the brain. The first he describes as harsh, rough, and attended with a purring or vibra- 
tory thrill, that seemed to be communicated to the whole brain. It appeared to be of 
the same character with a whizzing noise which the patient complained of as a con- 
stant and annoying attendant on his disease. The second was a cooing, chirping, or 
musical sound developed in the brain of anemic patients, and varied exceedingly by dif- 
ferent degrees of pressure on the carotids. (Note to the second edition.) 622 
LOCAL DISEASES.-NERVOUS SYSTEM. 
[part II. 
anatomical relations. The delicate arachnoid, so closely connected as it is 
with the pia mater, can scarcely suffer without involving that membrane; and 
the very office of the pia mater, which is in part at least to supply blood to 
the cortical portion of the brain, would appear to render the propagation of 
inflammation from one of these tissues to the other almost unavoidable. Nor 
is it easy to conceive, how any considerable portion of the periphery of the 
brain could become inflamed at once, except through the instrumentality of 
the investing membrane, through which alone a vascular communication is 
maintained between its distant parts. It seems improbable that general cere- 
britis could exist without a simultaneous meningitis. 
All attempts have failed to establish an accurate diagnosis between inflam- 
mation of the meninges of the brain and its substance. There may be ex- 
treme cases in which probable inferences may be drawn from the symptoms; 
but, even in these, dissection has not always confirmed the decision of the 
judgment. It is only through their influence upon the cerebral functions, 
that the membranes can make their diseased condition known. Pain and 
fever, which are probably their sole independent effects, are common to so 
many diseases, that they could be considered alone as in no degree diagnostic. 
The delirium, convulsions, stupor, and coma, which serve to indicate menin- 
gitis, are cerebral phenomena, which might equally result from inflammation 
of the cortical substance, without that of the membranes. Both affections, 
therefore, express themselves, to a considerable extent, in the same manner. 
This at least is true of general or diffused inflammation of the two tissues. 
Nature thus appears to have made one disease of the affection, and is consist- 
ent with herself in requiring the same means of relief, in whichever position 
the disease may be prominently or exclusively seated. I cannot see the pro- 
priety of separating what she has put together, and shall, therefore, treat of 
general inflammation of the membranes and of the brain conjointly. There 
are frequent cases of local inflammation which may be traced pretty confi- 
dently to the cerebral substance, whether the membranes may be involved or 
not. These I propose to consider separately. 
There has been much confusion of nomenclature in relation to the cerebral 
inflammations. It is of little consequence what terms are used, provided they 
are employed with a fixed and definite meaning. In applying the name menin- 
gitis to the diffused inflammation, and cerebritis to the local, I wish it to be 
understood that the former does not exclude inflammation of the brain, nor 
the latter that of the membranes. I prefer these designations, partly because 
they are much used, and partly also because they serve to imply the fact, that, 
in the one complaint, the meninges are most prominently, and perhaps, in 
general, primarily affected, and, in the other, the proper tissue of the brain. 
There is a peculiar form of meningitis, which is so strongly characterized by 
the nature of its cause, and by its result, as to merit well to be distinctly 
treated of. It is that in which the inflammation is excited by the existence 
of tubercles, and which has, therefore, received the name of tuberculous 
meningitis. In these three divisions will be included all the forms of disease 
belonging to the present article. 
1. MENINGITIS. 
Syn.-Phrenitis.-Meningoencephalitis.-Encephalo-meningitis.-Encephalitis.- 
Arachnitis. 
The reader will distinctly understand, that, by this term, is here signified 
diffused inflammation of the cerebral membranes, either alone, or conjoined, CLASS III.] 
623 
ACUTE MENINGITIS. 
as it generally is, with more or less inflammation of the brain itself. I am 
not sure that the old name of phrenitis is not better, as it would not be liable 
to mislead. Arachnitis, which was at one time popular, is wholly inappro- 
priate; as the disease is seldom, perhaps never confined to the arachnoid; and, 
indeed, judging from its appearance upon dissection, as well as from its ex- 
treme delicacy, that membrane would seem to serve little other purpose in 
the disease than merely to admit the passage of the morbid products through 
its pores. Meningitis may be either acute or chronic. 
Acute Meningitis.-This disease, as it occurs in children, is still fre- 
quently classed with acute hydrocephalus, though by far the greater number 
of the cases, usually called by that very inappropriate name, belong to tuber- 
culous meningitis. 
Symptoms, Course, &c.-The attack may be quite sudden, or it may be pre- 
ceded by various preliminary symptoms, such as vague uneasiness, depression 
of spirits, wakefulness, vertigo, tinnitus aurium, and defective appetite. Along 
with the usual febrile phenomena which usher in acute inflammation, are con- 
joined intense headache, redness of the face, suffusion of the eyes, an excited 
or wild expression, giddiness, buzzing or roaring in the ears, and painful sen- 
sitiveness to light and sound, especially the former, so that the patient often 
closes his eyes forcibly, and the pupils, when they are open, are seen to be 
contracted, sometimes almost to the size of a pin-hole. Extreme restlessness, 
jactitation, and want of sleep, are not uncommon symptoms; convulsive and 
spasmodic movements frequently occur; and sooner or later delirium generally 
sets in, sometimes calm, but, in the greater number of instances, more or less wild 
or violent. The pulse is frequent, hard, occasionally irregular or tumultuous; 
the respiration hurried; the skin hot, but often moist; and the tongue covered 
with a whitish fur, and sometimes clammy. Vomiting very often attends the 
complaint from the commencement, and is among its most characteristic symp- 
toms. The bowels are usually constipated, though not invariably so. 
After a length of time, differing greatly in different cases, unless the dis- 
ease is interrupted, a new set of phenomena appear. The delirium yields 
gradually to drowsiness or stupor, from which the patient can at first be roused, 
giving vague and imperfectly articulated replies, but which deepens at length 
into coma. The pupils become dilated; sight and hearing are impaired; liquids 
often lie in the mouth without being swallowed, or are permitted to run out 
of it; strong irritants make little impression on the nostrils; and the sensi- 
bility of the skin is much diminished. Convulsions, though less violent than 
in the early stage, are still not unfrequently experienced. But rigidity of the 
muscles, and contraction of one or more of the limbs, are apt to take the place 
of the general convulsive movements; and subsultus tendinum, with picking 
at the bed-clothes, or at supposed objects in the air, is not uncommon. The 
pulse, instead of being frequent as at first, often becomes slower and inter- 
mittent; and the respiration is interrupted with deep sighs. The urine is 
sometimes retained, and sometimes dribbles away without the consciousness of 
the patient; but, even in the latter case, it may accumulate so as greatly to 
distend the bladder. 
At length signs of great exhaustion are added to those of cerebral oppres- 
sion; the spasmodic contractions often give way to partial palsy or are mingled 
with it; the pulse becomes feeble, frequent, and thread-like; the skin cool, 
pale, and bathed in sweat; the features sunken and haggard; the sphincters 
relaxed; and the patient dies in a state of profound insensibility. 
This is the more common course of the disease; but many of the symptoms 
are often absent; and diversities in the mode of their succession are not un- 
frequent. In many instances, the attack is ushered in with convulsions, upon 624 
LOCAL DISEASES.-NERVOUS SYSTEM. 
[PART II. 
the suspension of which the patient may either remain comatose, or reacquire 
consciousness; and these convulsions may be frequently repeated. In others, 
stupor or coma is the predominant symptom from the commencement. Occa- 
sionally the case begins with delirium, which may be at first moderate, and 
gradually increase in intensity, the patient walking about for some days before 
being confined; or may be violent or even furious from the outset. Sometimes 
severe pain is the only cerebral phenomenon connected with the fever, during 
the greater part of its continuance; and there are now and then cases in which 
it precedes the general symptoms for a considerable time. In some rare 
instances, the disease has been known to commence with a sudden loss of 
speech. Finally, there have been cases so entirely destitute of peculiar ce- 
rebral symptoms, that examination after death has given the first evidence of 
their nature. 
Before leaving the subject of the symptomatology of the disease, it will be 
proper to make a few observations on some of the prominent phenomena. 
Perhaps the most constant of all the symptoms is pain in the head. It is 
seldom entirely absent from the commencement to the close, except when 
the brain becomes insensible from coma. Even when the patient is in a 
state of stupor, he will often, if roused, evince signs of cerebral uneasiness. 
In infants it is indicated by their moans and cries, the contraction of their 
brow, the putting of the hand to the head, the rubbing or pressing of the head 
against the breast of the mother, the rolling of it from side to side, &c. It 
sometimes seems to occupy the whole head; sometimes is seated more espe- 
cially in a particular part, as the forehead, the parietal region, or the occiput; 
and occasionally shoots from one part to another, or seems to come deeply from 
the interior of the brain. It is not unfrequently in some degree paroxysmal, 
being more acutely violent at certain times, and probably coming on like the 
darting pains of neuralgia, as evinced by the quick sharp screams sent forth 
by children, though immediately before quite tranquil. 
Vomiting is also a frequent and highly characteristic symptom, beginning 
often with the disease, and continuing more or less till the brain becomes 
torpid. It is wholly independent of disease existing in the stomach itself, 
and is undoubtedly in most instances cerebral. It, is distinguished from 
mere gastric irritability, by the obstinacy with which it often resists all the 
means usually found effectual in allaying vomiting. It sometimes alternates 
with the pains in the head, and appears to relieve them. 
Delirium does not generally come on until some time after the develope- 
ment of the disease, though occasionally it begins along with it, and even 
precedes all the other symptoms. In adults it is apt to be violent in the 
early stage, and is sometimes even furious, so that force is necessary to re- 
strain the patient. Not only the intellect, but the senses also are frequently 
perverted, and the patient perceives unreal sights, sounds, and odours. He 
flies rapidly from thought to thought, talks almost incessantly, raves and 
screams, throws about the objects near him, and often attempts to rise from 
his bed, so as to require constant watching. In other instances, the delirium 
is more tranquil; but, in almost all cases, it is strikingly distinguished from 
the delirium of drunkards by the absence of fear. In the advanced stage, it 
is superseded by coma, but still frequently exhibits itself, though in a more 
depressed form, when the patient is roused. 
The convulsions which occur at an early period are usually general, affect- 
ing all the limbs, and the muscles of the face. But in the more advanced 
stages, when the substance of the brain may be supposed to be more espe- 
cially involved, they show frequently a partial tendency; affecting one-half 
of the body, one limb, or particular muscles, as those of the face, those which CLASS III.] 
625 
ACUTE MENINGITIS. 
move the tongue, or those concerned in deglutition. Hence the grinding of 
the teeth, the stammering, the thrusting of the tongue out of the mouth, and 
the occasional difficulty of swallowing, which attend the complaint. Not 
unfrequently there is a persistent spasm, or rigidity of the muscles in this 
stage, and a tendency to contraction or flexion of the limbs. Towards the 
close, the involuntary movements take the form of subsultus, and carphologia; 
and complete relaxation or palsy of particular portions of the body not un- 
frequently occurs before death. 
The course and duration of the disease are very uncertain. Heath some- 
times takes place within the first twenty-four hours, more frequently between 
the fourth and seventh days, but still more frequently at a period varying 
from one to three weeks. The disease very seldom passes the seventh week. 
In the speedily fatal cases, death is usually preceded by convulsions. In 
these it has been observed that the brain is much less altered than often in 
old cases, in which the symptoms have been comparatively mild. The brain, 
like most other organs, has the power of accommodating itself to considerable 
change in its structure; but each increment of the new condition must be 
small, in order to be made with impunity. A strong sudden impression often 
completely paralyzes the organ, though the amount of physical effect may be 
very small, compared with that which the brain bears well, when made by a 
great number of successive slight impressions. 
The disease may often be arrested in the first stage, or that of excitement, 
which sometimes runs on for ten days, two weeks, or more, but, in general, 
begins to give way to symptoms of collapse at the end of a week. In the 
second stage, marked by stupor, with rigidity of the muscles and diminished 
frequency of pulse, the chances of safety are much lessened. In the last 
stage, or that of profound coma, with or without paralytic affection, there is still 
less ground for hope. Recoveries are said to take place more frequently from 
secondary meningitis, occurring as an attendant upon other diseases, than 
when the complaint is original. It is a singular fact, noticed by several 
authors, that the disease sometimes assumes a regular intermittent form, hav- 
ing paroxysms daily or every other day, and ending at last like the ordinary 
form in coma. This may easily be accounted for when the patient resides in 
a miasmatic region; but it is said to occur in situations where there is no 
reason to suspect the existence of such a cause. The explanation, under the 
latter circumstances, myst be sought for in the general law which governs the 
production of intermittent diseases. (See vol. i. p. 194.) 
Anatomical Characters.-1The dura mater is very seldom found to partici- 
pate in the inflammation, unless the result of violence, or propagated from 
disease in some portion of the bony parietes. In such cases, it is detached 
from the cranium, which is whiter than natural; is reddened, thickened, ulcer- 
ated, or gangrenous; and is sometimes covered with a layer of coagulable 
lymph or pus. The same products are also found between it and the arach- 
noid, sometimes extending for a great distance. The arachnoid itself in acute 
inflammation undergoes singularly little change. Only here and there does 
it exhibit signs of a fine sanguineous injection. It is not unfrequently opaque 
or opalescent, and is said to be sometimes thickened, and to present numerous 
projecting points which render it rough to the finger. But Rilliet and Bar- 
thez state that, in several cases which they examined, this membrane retained 
its smoothness, gloss, and transparency, even when bathed with pus upon 
both sides. If the patient has died rather early, liquid pus is sometimes 
found spread over the surface of the membrane, which, at a later period of 
the disease, becomes concrete, resembling false membrane. (Rilliet et Bar- 
thez.') It can scarcely be doubted that layers of coagulable lymph are some- 626 
[part II. 
LOCAL DISEASES.-NERVOUS SYSTEM. 
times found in the same situation. But more frequently the effusion is ob- 
served beneath the arachnoid, in the tissue of the pia mater, which is infiltrated 
with serum or pus, in the former case appearing as though covered with a 
coating of gelatinous matter. The serum, however, escapes when the trans- 
parent arachnoid is punctured, and thus betrays the true nature of the phe- 
nomenon. The pus in the pia mater is sometimes liquid, and sometimes con- 
crete, in the latter case appearing like yellow bands or patches. When freed 
from these liquids, the tissue of the pia mater is seen to be reddened. The 
membrane often adheres with considerable firmness to the brain, so that even 
portions of the cortical substance are torn away with it. The ventricles 
generally contain more or less fluid, which, when the inflammation has been 
slight, is usually perfectly limpid; but, when the lining membrane of the 
cavity has been much inflamed, is apt, to be turbid with albuminous or fibrin- 
ous flocculi, or opaque and greenish from an admixture of pus. Sometimes 
blood is effused into the ventricles, or the general cavity of the arachnoid. 
The quantity of fluid in the ventricles, and in the meshes of the pia mater, 
varies from a few drachms to six or eight ounces or more. It is this pheno- 
menon that has caused the disease, occurring in children, to be ranked with 
hydrocephalus. But the liquid is not unfrequently wanting. 
In some instances, the brain appears to be perfectly sound; but much more 
frequently exhibits signs of having participated in the inflammation. Occa- 
sionally it appears as if swollen, the convolutions being enlarged and flattened ; 
and, when cut into, it is found to be congested with blood. The cortical por- 
tion is reddened, and sometimes much softened, so that parts of it are removed 
with the pia mater; and the cut surface of the medullary portion is thickly 
dotted with red spots, or diversified with small streaks or stains of blood. 
Parts of the medulla are also softened, though, in some instances, this tissue 
is said to be rendered more dense than in health. The cerebellum exhibits 
phenomena altogether analogous to those presented by the brain. 
Attempts have been made to point out the symptoms which indicate espe- 
cially inflammation of the membranes in this affection, and those which depend 
upon lesions of the brain. Pain, fever, delirium, and general convulsions are 
supposed to be meningeal symptoms, arising from irritation propagated to the 
cerebral substance; and the coma and diminished or abolished sensibility of 
the advanced stages, have been ascribed to the pressure of the effused pro- 
ducts ; while muscular rigidity, contraction of the limbs, and partial palsy 
have been referred to inflammation of the brain itself. There can be no doubt 
that the meningeal symptoms above referred to may be the result of inflam- 
mation of the membranes alone; but they may also proceed from the same 
disease in the brain ; and, though the contractions and palsy are often cere- 
bral, there can be no reason that I can understand why they may not also 
spring from a partial pressure by the effused fluid, or a partial irritation 
extended to particular portions of the cerebral mass, without any positive 
inflammation of the latter structure. 
Causes.-The predisposing causes of meningitis are numerous. One of 
them, common to this and other inflammations, is a rich plethoric state of the 
blood. Persons of a sanguine temperament, and those of a short neck, and 
choleric temper, are said to be more liable to it than others of a different con- 
stitution. There is every .reason to believe that a tendency to the disease is 
sometimes inherited. Age has considerable influence over the predisposition. 
Early infancy, and vigorous manhood are supposed to promote it. The dis- 
ease is not uncommon in new-born infants, and in those under two years. 
After that age, the susceptibility appears to diminish until about the period 
of puberty, when it again increases, not to decline until the commencement CLASS III.] 
ACUTE MENINGITIS. 
627 
of the decline of life. Acute meningitis is asserted to be most frequent be- 
tween fifteen and forty-five. It is singular that the tendencies to tuberculous 
meningitis are exactly the reverse, being greatest between two and fifteen. 
Guersent states, as the result of his own observation, that the proportion of 
cases of ordinary meningitis to the tuberculous, at this period of life, is as two 
to twelve. (Diet, de Med., xix. 411.) Males are much more liable to the dis- 
ease than females. MM. Parent and Martinet give the proportion of males 
to that of females as four to one. This is a greater disparity than can be 
accounted for from accidental causes, and must have its foundation in some 
inherent difference between the two sexes. The occupation and habits of the 
individual contribute much to modify the susceptibility to cerebral inflamma- 
tion. Professions which demand excessive mental exertion, or occasion great 
mental anxiety, or necessarily expose much to the sun, act as predisposing 
causes. The same may be said of intemperance in drinking and eating. Hot 
climates have a similar effect. Hypertrophy of the left ventricle of the heart, 
especially when dependent on obstruction in the aorta below the origin of the 
carotids, necessarily keeps up an active congestion of the brain, and predis- 
poses it to inflammation. The disease has sometimes occurred epidemically. 
Exciting causes are blows, falls, &c., upon the head, especially among 
children; exposure of the head unprotected to the direct rays of the sun, or 
to an intense artificial heat; an habitually dependent position of the head; 
violent mental excitement or disturbance of any kind; excessive bodily exer- 
tion; abuse of alcoholic drinks ; venereal excesses; the irritation of teething; 
the translation of gout or rheumatism J the suppression of accustomed dis- 
charges; the retrocession of cutaneous eruptions; and various febrile diseases, 
especially typhoid fever, erysipelas, and scarlatina. Meningitis is a not very 
unfrequent .sequela of the last mentioned disease. Erysipelas may produce it 
by a direct propagation of irritation through the skull, or up the auditory or 
nasal passages. Among the frequent causes of it, deserving of a particular 
attention, are caries of the bones of the ear, of the ethmoidal bone, and of the 
cranium itself. It is not uncommon for disease of the ear to be extended to 
the brain with fatal effects. A case of death from cerebral inflammation 
occurred to me, which depended upon caries of the interior bones of the nose. 
In all these cases, an irritation is extended to the dura mater by the diseased 
bone in its vicinity, and from that membrane is propagated to the other mem- 
branes, and to the brain. The meningeal seizure may generally be known 
by the occurrence of a chill, followed by fever, vomiting, delirium, convul- 
sions, and ultimately coma; and I have known more than one instance, in 
which repeated chills, with trembling, occurring irregularly, have marked 
the early stage of the cerebral affection. These symptoms are usually pre- 
ceded by severe and sometimes excruciating headache. 
Diagnosis.-The disease most liable to be confounded with simple menin- 
gitis, is tuberculous meningitis. The diagnosis between them will be given 
when the latter disease is considered. 
Many fevers, also, in their early stages, bear considerable resemblance to 
the complaint under consideration. This is especially the case with enteric 
or typhoid fever and smallpox. Fever, headache, and delirium are some- 
times, for a period, the only striking symptoms of meningitis; and they are 
all frequently present in the disease just alluded to. In some instances, it 
is impossible for a time to discriminate accurately between them. But, gene- 
rally speaking, in each affection, these common phenomena are mingled with 
peculiar symptoms which serve as the basis of a probable diagnosis; and, when 
this is not the case, such symptoms soon become developed in the progress of 
the disease, and remove all doubt. It would be repetition to detail these 628 
[PART II. 
LOCAL DISEASES.-NERVOUS SYSTEM. 
diagnostic symptoms here. The reader is referred to the several diseases 
alluded to. The absence of the characteristic phenomena of other febrile 
affections, the severity and persistence of the headache, the obstinate vomiting, 
the not unfrequent convulsive movements, the contracted pupil and exagge- 
rated sensibility, will generally serve to distinguish meningitis in its early 
stages. At an advanced period, the symptoms become so obvious as scarcely 
to admit of mistake. 
But there is another condition of the brain which it is still more important 
to distinguish from acute meningitis. I allude to a state of delirium which 
sometimes shows itself in debilitated conditions of the system, and, so far 
from being essentially connected with inflammation, is in fact dependent upon 
the want of due energy in the cerebral functions. Such a condition occurs in 
the delirium of drunkards. (See Delirvu'n} Tremens.} It comes on sometimes 
also in individuals, exhausted by the loss of blood, by starvation, by long 
continued diarrhoea, or by other debilitating diseases. I have seen it occur 
in the course of exanthematous affections, in which it is attended with a dis- 
appearance of the eruption, and might readily be mistaken for cerebral inflam- 
mation, consequent upon a retrocession of the cutaneous affection; whereas, 
this subsides, in such cases, solely in consequence of the prostrated state of 
the circulation. The delirium may have the appearance of greater or less 
violence, or it may be of a low character. It may be followed by symptoms 
of coma, with dilated pupil, insensibility to light, &c.; or this may be the 
original form which the cerebral affection may assume. It is important not 
to mistake this condition for acute meningitis; because it demands an exactly 
opposite treatment, and often yields readily to stimulants, which would prove 
fatal in that complaint. It may generally be distinguished, in connexion with 
the previous state of the patient's health, by the paleness of face, the frequent 
collapse of the features, the coolness and inactivity of the surface, the feeble- 
ness of pulse, the tremors of debility, and the want of that fearlessness so 
characteristic of the delirium in acute meningitis. 
Treatment.-It is of the utmost importance to begin the treatment early. 
By energetic measures at this period, the patient can generally be saved. Be- 
yond all comparison the most effectual remedy is bleeding. The pulse is 
usually tense, and the loss of blood is' well borne. The quantity taken must 
be regulated by the constitution of the patient, and the effects produced upon 
the pulse. It is always safe to continue the bleeding until the pulse begins 
perceptibly to flag, except only in the case of hypertrophy of the left ventricle 
of the heart. From twelve to twenty-four ounces may be taken from an adult 
at one operation, and the bleeding repeated once, twice, thrice, or even oftener, 
in as many days, if the pulse remain tense, and the active cerebral symptoms 
unabated; but the quantity abstracted at the subsequent bleedings should 
generally be less than at the first. After a decided impression has been made 
upon the pulse by general bleeding, cups or leeches to the temples, behind 
the ears, or to the scalp, should be freely employed. Leeches are preferable 
to cups, as they generally disturb the patient less when skilfully applied. 
They are peculiarly adapted to infantile cases. Some writers, especially the 
French, strongly recommend leeches to the anus. I believe they are more 
effectual upon the head. A good plan is to shave off the hair, and apply 
them to the scalp. I would repeat that a vast deal depends, as to the result 
of treatment in simple acute meningitis, upon early and vigorous bleeding, 
both general and local. 
Active purging is also highly useful; more so perhaps in this than in most 
other inflammatory affections. Calomel is especially adapted to the disease, 
in consequence of being thrown off from the stomach with greater difficulty CLASS III.] 
629 
ACUTE MENINGITIS. 
than most other cathartics. It should be given in full purgative doses; and 
its operation should be promoted by the subsequent administration of the 
infusion of senna with Epsom salt, or other similar combination. This plan 
is peculiarly suited to young children. For adults, combinations of calomel 
with other active cathartics, as the extract of jalap, or the compound extract 
of colocynth, may be preferable in some instances, by insuring a more speedy 
action. The purging should be continued afterwards, every day or every 
other day, by means of one of the saline cathartics, or of these with senna 
tea. Croton'oil sometimes answers an excellent purpose, when there is diffi- 
culty in administering medicines in large doses. Elaterium has been recom- 
mended when there is reason to suppose that effusion has taken place. 
In the intervals of the above treatment, if the stomach is retentive and not 
nauseated, tartar emetic may be given in doses varying from the eighth to 
the quarter of a grain every two hours. The production of some nausea is 
not objectionable, as it tends powerfully to lessen the force of the cerebral 
circulation, and is the means which nature herself very frequently takes to 
procure relief. Positive emesis is not desirable, unless when the stomach 
may happen to be overloaded; as, in the act of vomiting, cerebral congestion 
is produced, and there may be some danger of aggravating the inflammation. 
Local measures in this stage, are also very useful. The hair should be 
removed either by the razor, or scissors, and cold applications made to the 
scalp. To be effectual, the cold must be steadily applied; as, if employed 
intermittingly, it might produce as much harm by the reaction it occasions, 
as good by its primary sedative influence. Some have recommended evapor- 
ating lotions, as of alcohol or ether. But these are not sufficiently energetic; 
and, in this stage, the inhalation of the vapours might prove seriously detri- 
mental. The best application is ice, pounded or in small fragments, and con- 
tained in a large bladder or caoutchouc bag, only partly filled, so that it 
may be fitted to the head. Care must be taken not to continue- the applica- 
tion so long as to endanger the loss of life in the skin. It should, therefore, 
be removed for a time, especially if painful to the patient, and reapplied be- 
fore reaction takes place. Should ice not be attainable, very cold water may 
be substituted, and may be applied either by means of linen cloths folded 
several times, and renewed as fast as the water with which they are soaked 
becomes warm; or of a large sponge, hollowed out so as to fit the head, and 
kept saturated with the liquid. Another plan of employing cold water, said 
to be very efficient in controlling cerebral excitement, is to direct a slender 
stream of the liquid, cooled by ice, from the height of two or three feet, upon 
the scalp; care being taken by a suitable arrangement of oiled silk about the 
neck and breast, to protect them from the wet. By contriving a gutter in 
the silk, the water may be conveyed off as fast as it falls. The depressing 
influence of this remedy is so great, that the practitioner should always 
superintend its application, at least until the attendants shall have acquired 
the requisite skill. It may be continued from fifteen minutes to an hour at 
a time, and renewed as occasion may require; but in the intervals the scalp 
should not be allowed to become hot or turgid from reaction. Some recom- 
mend a constant dropping of cold water, which may be effected by pouring it 
upon a sponge placed in a funnel, suspended over the head of the patient. 
While cold is thus employed to the head, the feet may be soaked in hot 
water, or sinapisms applied to the legs, more especially when the extremities 
have a disposition to be cool. In infantile cases, the warm bath is often bene- 
ficial by its sedative effects. It should be only tepid and not hot; as in the 
latter state it is too stimulating. Sometimes advantage may accrue from cold 
to the head, while the body is immersed in the bath. 630 
[part II. 
LOCAL DISEASES.-NERVOUS SYSTEM. 
Another method of lessening the flow of blood to the head has been pro- 
posed. It consists in making pressure upon the carotids, so as to diminish 
the amount of blood passing through them. It is said that this measure 
sometimes has a very striking effect in abating cerebral excitement. To be 
of any permanent benefit, it must be repeated frequently, and would require 
the constant presence of the practitioner, with a skill in manipulation which 
is not always possessed. It may be useful sometimes in cases of obstinate 
convulsions, which refuse to yield to the ordinary means. 
Unfortunately opiates cannot be employed with propriety in the early stage 
of meningitis, in consequence of their property of stimulating the brain; and 
the same objection applies to most of the anodyne narcotics. 
During the treatment, the patient should lie in a cool well ventilated apart- 
ment, with his head somewhat elevated. For the first day or two, his diet 
may be restricted to gum-water, and, throughout the stage of excitement, 
should be of the lowest kind. 
The remedies above recommended are applicable to the stage of excitement, 
while the pulse is still active, and headache, delirium, convulsions, &c., indi- 
cate irritation of the brain. There is one other which has not yet been men- 
tioned, because adapted rather to the intermediate stage between excitement 
and collapse, than to the first stage. I allude to mercury in reference to its 
constitutional influence. Should depletion have failed to subvert the disease, 
or should the case not be seen until too late for the effectual use of that mea- 
sure, mercury should be used both internally and externally, so as to bring 
the system as quickly as possible under its influence. Calomel or the mer- 
curial pill should be given in small and frequently repeated doses, and mer- 
curial ointment freely rubbed upon the inside of the limbs, and applied to 
blistered surfaces, should any such exist. The remedy should be suspended 
as soon as its effects become evident in the mouth. 
Coincident with the use of the mercurial, it may be found advisable to sub- 
stitute an emollient poultice to the scalp for cold applications. When symptoms 
of depression begin to appear, marked by a diminished frequency of pulse, 
coolness of the surface, and a disposition to stupor, with dilated pupil, &c., 
recourse should be had without hesitation to a blister to the scalp. I believe 
this to be a very efficient remedy in simple meningitis, when properly timed; 
perhaps the most efficient, after bleeding, purging, and mercury. It is gene- 
rally postponed too long, and, being applied when no remedy can be of much 
avail, has of course failed. I am quite certain that I have often seen it pro- 
duce the most happy effects, under the circumstances alluded to. There is 
much more danger of deferring it too long than of employing it too early. 
It may be resorted to as soon as the continuance of depletion becomes im- 
proper, from the weakness of the pulse, or other signs of depression. To do 
good, moreover, it must be large, so as to cover the whole scalp; and must 
be kept on from twelve to twenty-four hours. Small blisters serve only to 
vex the patient if still sensible. They exert little influence over the disease. 
Nor have I seen much good from them applied to the back of the neck in 
acute meningitis. The scalp, and the whole scalp is the proper seat for them. 
Mercury and blisters are the remedies chiefly to be relied on, in the stage of 
the disease intermediate between that of excitement and that of collapse. 
Should the complaint be connected with the retrocession of a cutaneous 
eruption or of external gout or rheumatism, hot water, rubefacients, or blis- 
ters to the former seat of disease are especially indicated. If the external 
affection was of an eruptive character, it may be best to attempt to imitate it, 
as nearly as possible, by pustulation with croton oil or tartar emetic. 
Occasionally symptoms of great prostration ensue upon the cure of the CLASS III.] 
CHRONIC MENINGITIS. 
631 
inflammation, requiring the use of tonics, stimulants, and nutritious food, to 
prevent fatal results. The symptoms of this state may, in some measure, 
simulate those of profound cerebral disease, which mark the closing stage of 
the worst cases. The inference is, that, when the signs of great debility are 
present in the last stage, stimulants may be resorted to; as, if the symp- 
toms are organic, death must necessarily take place, so that they can do no 
harm; while, if merely functional, they may be the means of saving life. 
Opiates, though entirely forbidden in the early stage, may sometimes be 
safely and usefully employed to control the restlessness remaining after the 
inflammation has gone. A mixture of chloroform and camphor may be used 
for the same purpose. 
Throughout the complaint, attention should be directed to the bladder, and 
the urine drawn off by a catheter, if necessary. 
Much may be done in the way of prevention. Thus, the existence of chronic 
otitis or ozrena should lead to measures for the cure of these affections, so as 
to obviate this source of cerebral inflammation. Attention to the gums during 
teething is also particularly required, in those who may be suspected of the 
least predisposition to meningitis. (See Morbid Dentition.} A consideration 
of the various causes of the disease will suggest other preventive measures, 
under similar circumstances of constitutional tendency. As relapses are pe- 
culiarly-dangerous, great care should be taken, during convalescence, to prevent 
premature exposure to these causes. 
Chronic Meningitis.-Chronic meningitis, uncomplicated with tuber- 
cles, has not yet been fully investigated. The most detailed account that I 
have seen of its symptoms and anatomical characters, in the form which it 
ordinarily assumes, is that given by Bayle. The disease may either be 
original, or the consequence of acute meningitis. The phenomena which it 
usually presents, when commencing in the chronic grade, are those of insanity. 
At first there is generally some exaltation of the cerebral functions. The 
patient exhibits an extraordinary eagerness in some particular pursuit, or is 
under the influence of some exaggerated passion, as pride, vanity, or ambition; 
and is very apt to be possessed by some monomaniacal notion or propensity. 
He is generally restless, talks and gesticulates much and rapidly, has a flushed 
face, and often some excitement of the pulse. In other instances, he is apa- 
thetic, dejected, or gloomy, and not unfrequently tormented with imaginary 
apprehensions. In this stage of the disease, the general functions are little 
impaired; the appetite is often good; and the patient, unless emaciated by 
the wearing effects of want of sleep, may even gain flesh. 
After a longer or shorter period, this state of exaltation is followed by a 
failure both of the physical and mental powers. This is usually first shown 
in the muscular movements. A not unfrequent phenomenon, even in the 
early stage, is some hesitancy of speech, and a kind of stammering when the 
patient attempts to pronounce certain words. Afterwards a degree of stiff- 
ness or uncertainty may be noticed in the motions, as if the muscles were 
somewhat rigid. Paralysis at length shows itself, and gradually increases. 
The lower limbs are especially affected, and lose in the end both sensibility 
and power of motion, so that the patient is confined to his bed. At the same 
time, the muscles concerned in speech are so much affected that he can scarcely 
articulate intelligibly. The sphincters finally give way, and involuntary dis- 
charges follow. The mental imbecility keeps pace with the failure of physical 
strength, and before death the patient is often reduced to the lowest condition 
of idiocy and paralysis. Sometimes, in the course of the disease, he is affected 
with spasms, and even with regular epileptic convulsions. 
In some instances, the chronic affection appears chiefly in the form of 632 
[part II. 
LOCAL DISEASES.-NERVOUS SYSTEM. 
epilepsy; and this happens especially when the disease follows an acute attack. 
In others, there is reason to believe that symptoms of chronic hydrocephalus 
are the result of this grade of cerebro-meningeal inflammation. 
The duration of the affection is very uncertain. Sometimes it runs its course 
in a few months, sometimes continues for years. It is always dangerous; and, 
in the advanced stage, is generally hopeless. In its early stage, it may proba- 
bly very often be cured by appropriate treatment; at least, patients exhibiting 
all the characteristic symptoms of the complaint often get well; though it is 
impossible to decide with certainty, under these circumstances, whether or not 
meningitis really existed. Sometimes the patient is carried off by a super- 
vening acute attack. 
The anatomical characters as observed by Bayle are the following. The 
arachnoid upon the convex surface of the brain, and on the inner surface of 
the hemispheres, is opaque and thickened, sometimes as thick even as the 
dura mater, and resembling parchment soaked in water. In some cases, 
patches of false membrane, of various thickness, either opaque or translucent, 
may be seen adhering both to the cerebral and the parietal surfaces of the 
arachnoid. Adhesions between the opposite surfaces of this membrane, are 
not very uncommon, especially in the great fissure. The pia mater of the 
convolutions is red and thickened, and more or less loaded with bloody or 
serous effusion. Sometimes it adheres to the cortical portions so firmly, that, 
when torn away, it brings portions of the latter along with it. This mem- 
brane is also thickened in the ventricles, where it is not unfrequently rough 
with numerous projecting points like grains of sand; and similar minute pro- 
minences occasionally appear on the convex surface. The ventricles almost 
always contain an abnormal quantity of serum, which is also in excess in the 
general arachnoid cavity, and in the tissue of the pia mater. The quantity 
of fluid is sometimes six or eight ounces, and entitles the case to be consi- 
dered as hydrocephalic.* 
It is somewhat singular that the cerebellum very seldom participates in the 
inflammation. The serous membranes throughout the body are very apt to 
be inflamed, and the disease is often complicated, before its close, with gastro- 
enteric inflammation, the marks of which are obvious after death. 
Of the treatment of chronic meningitis, it is necessary to say little in this 
place. As the disease generally exhibits itself by symptoms of insanity, it is 
under that affection that the remedies must be particularly considered. It is 
sufficient now to state, that the general principles which govern the treat- 
ment of the acute disease are applicable to this also, though the measures 
must be more moderately used. In addition to general or local bleeding, 
purgation, mercury, blisters, setons, &c., recourse must now be had to moral 
agencies, which are often the most effectual remedies for a chronically dis- 
eased brain. 
There is another form of chronic meningitis, which has recently been par- 
ticularly described by Dr. R. H. Goolden, of London. It is analogous to 
external periostitis, and may be associated with syphilis, though it has no 
necessary connexion with that disease. Pain in the head is the most promi- 
nent symptom, usually at first paroxysmal, and occurring especially at night, 
but at length becoming more or less constant. It is often very severe. If 
it be not arrested, weakness of the lower limbs comes on, ending in paralysis, 
epileptic convulsions occasionally take place, and the patient becomes despondT 
ing, emaciated, and affected with night-sweats. The disease yields to iodide 
* For cases of this affection recorded at length, the reader is referred to a valuable 
paper by Dr. Pliny Earle, of the Bloomingdale Asylum, N. Y., in the American Journal 
of Medical Sciences (N. S., xiii. 333). CLASS III.] 
633 
CEREBRITIS. 
of potassium with sarsaparilla, opiates at night, and a blister to the head. 
(London Lancet, May 16 and Aug. 23, 1851.) 
Syn.-Partial Inflammation of the Brain. 
2. CEREBRITIS. 
As it is scarcely possible that general inflammation of the brain should 
exist without involving the membranes extensively, and thus coming under 
the preceding head, the term cerebritis is here confined to partial or local 
inflammation of the cerebral substance, in which, though portions of the 
membranes are sometimes concerned, yet they are so secondarily and quite 
locally, and are of comparatively little account either in the symptoms or the 
result. 
Symptoms, Course, &c.-The symptoms vary considerably with the extent 
of brain affected, the degree of the inflammation, and the greater or less rapid- 
ity of its progress. It might be supposed also that they would differ with 
the part of the brain inflamed; but it is surprising how little can be learned 
from the symptoms in relation to the precise position of the disease. In con- 
sequence, however, of the decussation of the fibres from the opposite hemi- 
spheres, before leaving the cranial cavity, the appearance of the exterior 
effects of cerebral inflammation upon either side of the body exclusively, may 
be considered as a proof that the inflammation is situated in the opposite side 
of the brain; and, when both sides of the body are affected, it may be inferred 
that both portions of the brain are inflamed, or at least that, if the inflamma- 
tion be confined to one side, it is sufficiently near the median line to extend 
a powerful irritation to the other. 
The symptoms, as they ordinarily occur, may be divided into three stages, 
which, however, are often confused, or follow each other at irregular inter- 
vals, and sometimes appear, in rapid cases, almost concentrated into one. 
First stage.-Headache is a very frequent attendant on the early stage of 
cerebritis, and often precedes, for a considerable time, all other symptoms. 
The patient complains of a severe pain, occurring paroxysmally, sometimes 
in one, sometimes in another part of the head, but usually feeling as if it 
came from the very centre. Along with this symptom, either from the com- 
mencement, or after a variable length of time in different cases, other de- 
ranged sensations are experienced, as vertigo or dizziness, occasional faint- 
ness, temporary dimness or perversion of vision, buzzing or roaring in the 
ears, nausea or loss of appetite, and feelings of slight tingling in different 
parts of the body. There is very often upon the countenance an expression 
of seriousness, sadness, or self-concentration; or the patient is restless, agi- 
tated, and unable to sleep; or he may be morose or irascible, or disturbed 
by mental illusions. After a time, the sensations above referred to become 
more decided and characteristic. Neuralgic pains, or the tingling and for- 
mication which are usually intimated when we say that a part is asleep, or 
feelings of numbness are experienced in some particular portion of the body, 
as a limb, for example; and the patient is not unfrequently affected with 
convulsive movements, which may be either general, or confined to one side. 
Occasionally there is fever, with accelerated circulation, heat of skin, flushed 
face, furred tongue, &c.; but more frequently the pulse, so far from being 
excited, is quite as slow as in health, or even slower; being in some instances 
not more than fifty or sixty in a minute, and at the same time feeble and 
irregular. This irregularity is occasionally a striking symptom. At one 
moment the pulse will be very slow, then more frequent; and this alternation 634 
LOCAL DISEASES.-NERVOUS SYSTEM. 
PART II. 
may recur at short intervals, as often even as several times in a minute. The 
surface, too, is rather cool and pale, and the face usually pale, though liable 
to be flushed suddenly, especially upon the occurrence of a spasmodic parox- 
ysm. This condition of the circulation and of the surface is the more im- 
portant, as it may mislead the practitioner, if not upon his guard, and induce 
him to attribute the phenomena to debility. The cause of the depression is 
probably the loss of power in the inflamed cerebral mass, which prevents it 
from sending forth the influences requisite to preserve the organic actions in 
their healthy state. 
Through all these symptoms the headache continues with unabated vio- 
lence; still, however, occurring somewhat paroxysmally, and, even in cases 
in which it is seldom or never quite absent, being at one time much more 
violent than at another. It is very frequently associated with vomiting, 
which is a characteristic symptom of the disease. I have often observed, in 
these cases, that, during the continuance of the nausea and vomiting, or a 
tendency to them, the headache is less severe, and in some instances ceases 
for a time. 
The symptoms above enumerated may be considered as marking the first 
stage of the disease, that probably of inflammatory congestion. The complaint 
may often be arrested in this stage by appropriate remedies, or, if the portion 
of brain affected be extensive, or the inflammation violent, may terminate in 
a speedy death, preceded by convulsions or coma, or by both. 
Second stage.-If the disease continue, other phenomena make their ap- 
pearance. A certain rigidity or continuous spasm is often observed in the 
muscles of some part of the body, of one limb, for example, or of both limbs 
on the same side; or possibly it may be confined to a single muscle; and the 
flexors are almost always preferably affected, so that the hand is fixedly bent 
on the wrist, or the forearm upon the arm, or the leg upon the thigh. Attempts 
to overcome this spasm are resisted by the muscles, and often occasion severe 
pain to the patient, so as to extort cries from him, even though in a partially 
comatose state. Along with this tonic spasm, there are not unfrequently 
sudden startings or twitchings of the muscles, or convulsive movements of 
one side of the body or of both, with sensations of numbness or tingling, and 
a want of control over the limb. The face, eyes, tongue, or throat, may be 
the seat of these disorders of sensation and motion; and hence occasional dis- 
tortion of the features, squinting, stammering, or other defect of speech, and 
difficulty of swallowing. The pupils are little sensible to light, and are often 
largely dilated; and there is not unfrequently a want of correspondence be- 
tween them; one being dilated, while the other is natural, or possibly some- 
what contracted. The sight of one eye, moreover, may be affected while that 
of the other remains unimpaired. 
Though the patient is seldom affected with violent delirium, yet the mental 
faculties are obviously deranged. Sometimes he is sombre, morose, or indif- 
ferent to everything around him, as if absorbed in his own sufferings. There 
is often forgetfulness, especially of particular words, with confusion and inco- 
herency of thought, or a tendency to drowsiness, and sometimes temporary 
unconsciousness. 
These symptoms are supposed generally to indicate the occurrence of soften- 
ing in the cerebral substance. The most characteristic of them are the rigid 
contractions of the flexors, and a commencement of paralysis both of sensation 
and motion. The contractions alluded to are not, however, present in all in- 
stances. The disease may prove fatal at this period, without advancing into 
the third stage. In this case, either a convulsive paroxysm may carry off the 
patient, or he may sink into a state of collapse, with a very feeble and fre- CLASS III.] 
CEREBRITIS, 
635 
quent pulse, counting sometimes 140 or 160 in the minute, a cold skin, and 
slow respiration, soon followed by death. 
Third staye.-The third stage is that of paralysis, with a more decided 
disposition to stupor. The portion of brain affected has become completely 
disorganized, having probably fallen into the last stage of softening, or dis- 
solved into pus. The limb or limbs, before perhaps partially contracted and 
partially paralyzed, now lose all sensation and power of motion ; other parts 
of the body become involved in the same loss of power; the senses of sight, 
hearing, &c., fail; the sphincters give way; and the patient dies at last, having 
been reduced, both mentally and bodily, to the lowest condition of helplessness. 
The duration of the disease, and the course of its symptoms, are liable to 
great diversities. Sometimes when the inflammation is violent or extensive, 
and especially when the cineritious portion of the brain is affected, the pro- 
gress is very rapid. Convulsions may carry off the patient in two or three 
days from the first attack; or a short period of febrile excitement, headache, 
delirium, &c., may be followed by coma, with or without the muscular con- 
tractions and paralysis, and prove fatal within one, two, or three weeks. But 
more frequently the disease runs on much longer, and often continues for 
months, and sometimes for years, before completing its course. 
The sketch above given is very general, and does not aim to include all the 
derangements of function which occur in the progress of the complaint, or all 
the diversities of association or succession which the symptoms enumerated 
exhibit in different cases. Such elaborate minuteness is incompatible with 
the limits of this work, and is unnecessary for all practical purposes. One or 
two of these varieties it may be proper to notice. 
Like the form of cerebral inflammation denominated in this work menin- 
gitis, the one now under consideration is disposed to assume the remittent form, 
and is occasionally to all appearance regularly intermittent, having a paroxysm 
daily or every other day, at the same hour. The violent headache, delirium, 
convulsions, or coma, constituting the paroxysms, vanish entirely during the 
intermission; and it would seem impossible that a patient, bearing so nearly 
the aspect of health, should be labouring under inflammation of the brain. 
Sooner or later, one of the paroxysms unless interrupted proves fatal, and dis- 
section reveals softening, or an abscess in the brain. The explanation given 
of intermittent meningitis is equally applicable to this affection. 
In some instances, the course of the disease is affected by the supervention 
of a diffused inflammation of the meninges. When, after a period of violent 
headache, vomiting, and more or less of the local effects already described, 
without much disturbance of the circulation or of the mental faculties, there 
comes on suddenly a condition of high febrile excitement, with a frequent 
pulse, heat of skin, flushed face, active delirium, and a tendency to convul- 
sions, there is good reason to suspect that an inflammation, commencing in 
the cerebral substance, has extended to the membranes. 
Anatomical Characters.-In cases which have eventuated in a speedy death, 
nothing more may be found than congestion, more or less intense, of a portion 
and sometimes an extensive portion of the brain. Such cases, however, are 
almost always connected with meningeal inflammation. 
In pure cerebritis, the texture of the cerebral substance is usually changed. 
Sometimes the alteration is confined to one spot, sometimes is found in two 
or more. It may be either at the circumference or towards the centre; but is 
most frequent in the cortical or cineritious portion. The character of the 
alteration is different, according to the stage at which the disease may have 
proved fatal; and it also presents somewhat different appearances, according 
as it occupies the cineritious or white structure. 636 
LOCAL DISEASES.-NERVOUS SYSTEM. 
[part II. 
In the earlier stage, when the part affected is divided by the scalpel, and 
especially when it belongs to the cortical substance, the cut surface exhibits 
innumerable red points mingled with the natural colour, or stains of a rosy, 
violaceous, or reddish-brown hue, imparting to it a marbled appearance. The 
consistence is considerably softer than in health, and the structure may rea- 
dily be broken up into a soft pulp, of a reddish colour. Sometimes, however, 
instead of being softer, the part is firmer than in health, though at the same 
time more brittle. The colour is owing to the incorporation of blood in dif- 
ferent degrees with the cerebral matter, and thus various shades are presented 
of deep red, rose-colour, violet, brown, &c. This appearance is denominated 
the red softening. 
In a more advanced stage, pus may be seen infiltrated into the cerebral 
tissue, and mixed in various proportions with the blood, which, according to 
some pathologists, is converted into it. The structure is now completely 
softened, of a semi-liquid consistence, and as if dissolved in the purulent 
liquid. The colour is modified by the pus, and presents various shades of 
brown, chocolate, greenish, gray, &c., until at last the colour of blood is en- 
tirely lost, and only the yellowness of the pus remains. In this state the 
appearance is denominated yellow softening. Both the red and yellow softening 
may sometimes be seen in the same brain. Not unfrequently small extrava- 
sated portions of blood exist in the altered tissue, of a dark-red or nearly 
black colour, and varying in dimensions from the size of a shot to that of a 
small cherry, or larger. The softening may also be gangrenous, of a grayish 
or brownish colour, sanious, and very fetid. 
Occasionally it happens that .pus is found infiltrated in the cerebral tissue 
unsoftened. Sometimes it forms cavities or abscesses in the brain; the proper 
tissue having been completely broken down, and absorbed or dissolved in the 
pus. These cerebral abscesses are very apt to follow inflammation from inju- 
ries of the head. They are sometimes formed with great rapidity, even in the 
course of three or four days, or a shorter time. They differ greatly in size, 
occupying spaces varying from a few lines in extent, or a single convolution 
of the brain, to a whole hemisphere. There may be several of them or only 
one. The pus may be perfectly well formed and inodorous, or it may be floc- 
culent, ichorous, or fetid; and not unfrequently portions of the cerebral blood- 
vessels, and fragments of the cerebral tissue are mixed with the pus of the 
abscesses. These may open into the ventricles, or on the surface of the brain, 
and have sometimes even made their way externally through the mastoid 
cells, or the petrous portion of the temporal bone. 
In some of these abscesses, there is no sign whatever of inflammation in 
the substance of the brain about them, and none of the usual symptoms of that 
affection have existed during life. In such cases, it has been supposed that 
the pus, as in the metastatic abscess in other parts, may have been deposited 
from the blood-vessels without inflammation in the part, being either the 
result of phlebitis, or absorbed from some exterior source. The reader, how- 
ever, is aware that a somewhat different view of the formation of such 
abscesses is entertained by the author. (See Purulent Infection, page 244.) 
Abscesses are sometimes found enclosed in a sort of cyst of false mem- 
brane, and it has been ascertained that this is produced after the deposition 
of the pus. The liquid being thus isolated, is prevented from exercising its 
disorganizing influence on the brain; so that the cyst is no doubt in this 
situation as elsewhere, the result of a self-protective effort of nature. 
The symptoms produced by abscesses are the same as those which result 
from softening of the brain. 
Instances of softening have been observed in which no pus could be dis- 
covered. CLASS III.] 
CEREBRITIS. 
637 
A variety of softening has been noticed, especially.in the medullary por- 
tion of the brain, in which the diseased part was of a milky whiteness, and 
of a shining satin-like appearance, without signs of either blood or pus. Dr. 
Abercrombie considered it as in some instances the product of inflammation, 
and as the result of gangrene consequent upon the interruption of the circu- 
lation by that process. This appearance has been distinguished by the name 
of white softening. 
The extent of the softened parts varies greatly. It may be less than an 
inch, it may be several inches, or it may be commensurate with one of the 
hemispheres. 
It is a question whether softening of the brain is always the result of in- 
flammation. In most instances, it undoubtedly is so; but it appears to be 
generally admitted, as maintained by Rostan, that the white softening may 
occur without inflammation. Instances are now and then observed, in which 
no unequivocal mark of inflammation can be discovered in the neighbourhood 
of the affected part, and no sign whatever of cerebritis existed during life. It 
is especially apt to occur in cases of ossified blood-vessels, and has been as- 
cribed to gangrene resulting from that cause. As proved by Hasse, it some- 
times depends on obliteration of the cerebral arteries, consequent on coagu- 
lation of the blood. (Archives Generales, 4e s£r., xiv. 217.) It has followed 
the tying of the carotid arteries. Dr. W. Senhouse Kirkes relates several 
cases, in which the brain was extensively softened in consequence of the 
plugging of the cerebral arteries by clots of fibrin, apparently detached from 
the surface of the cardiac valves, where they had been formed. But we can 
readily conceive of softening as the result of.a depraved nutrition, which in 
its turn may be owing to defects in the blood; and the phenomenon has been 
observed especially in anemic persons. From recent researches of Mr. Paget 
and others, there is reason to believe that this non-inflammatory softening 
may sometimes be the result of fatty degeneration, or at least that the two 
conditions are coincident.* Infiltration with serum produces also a softening 
of the brain, without inflammation, as in cases of sub-arachnoid and ventri- 
cular effusion. 
The microscope affords the means of distinguishing, after death, the in- 
flammatory from the non-inflammatory softening. In the former, numerous 
granules and granular corpuscles, resulting from the exudations of the inflam- 
matory processs may always be detected, while they are absent in the latter. 
Professor Bennett, of Edinburgh, in all cases of softening examined by him- 
self, in which the symptoms of cerebritis existed during life, found the evidences 
just referred to after death; while in the cases of softening which exhibited 
none of these granules or granular corpuscles, the symptoms of inflammation 
had not been noticed. (Ed. Month. Journ. of Med. Sci., April, 1851, p. 365.) 
* Dr. Duparcque, of France, records cases of softening occurring in the brain in 
children, which, upon the closest examination, exhibited no appearance of inflamma- 
tion after death, and the symptoms of which diifered from those of any recognized 
variety of cerebral inflammation. The attacks occurred in children of precocious or 
highly cultivated intelligence, whose minds had been fatigued by intellectual labour, 
or subjected to profound or vivid emotions. The prominent symptoms were headache, 
vomiting, slight somnolency, trembling, iiitegrity of the intellectual functions, and 
exaltation of special sensibility, without fever, increased frequency of pulse, convul- 
sions, rigidity of the muscles, or paralysis. Death occurred rather suddenly, with 
general prostration, and slight convulsive movements. (Arch. Gen., 4e ser., xxviii. 
163.) In the non-inflammatory softening produced by obstructed vessels, the most 
prominent symptom is ordinarily paralysis, with more or less headache and vertigo, 
and without the muscular rigidity which characterizes the lesion when dependent on 
inflammation. 638 
LOCAL DISEASES.-NERVOUS SYSTEM. 
[part II. 
Softening of the brain has been investigated with great assiduity by recent 
pathological anatomists, among whom Rostan is most conspicuous, though 
much is due also to the observations of Abercrombie, Andral, and others. 
But the attempt to make of it a distinct affection, marked by certain character- 
istic phenomena during life; to elevate it, in other words, into the rank of a 
distinct disease, has not been successful. It would appear to me as reasonable 
to make distinct diseases out of softening of the lungs, the stomach, and the 
heart. This condition is not itself a disease, but merely the result of morbid 
processes. 
It is true that, in the brain, it is often attended with a certain train of phe- 
nomena, during life, which indicate its existence with some degree of proba- 
bility. Such especially is the rigid contraction of the flexor muscles of the 
limbs, associated with or followed by paralysis. But softening sometimes 
exists without producing these symptoms, and the symptoms have been found 
to proceed from other causes; so that there is no necessary connexion between 
them. The fact appears simply to be, that, in the progress of inflammation 
of the cerebral tissue, there is a point at which, before its destruction, it is 
capable of expressing its irritation by a tonic involuntary contraction of cer- 
tain muscles; while, after its complete disintegration, all its power is lost, 
and complete palsy of the muscles results. 
Instead of softening, induration of the cerebral structure is sometimes 
found, as a consequence probably of chronic inflammation. In certain cases, 
the affected part is more than usually injected and vascular; and its consist- 
ence has been compared to that produced by immersing the brain in dilute 
nitric acid; in others, it is of a pearly whiteness, with less blood than in 
health, and as hard nearly as wax. It has been noticed that, though convul- 
sive movements attend this species of lesion, paralysis is less common than 
in softening; owing undoubtedly to a less complete disorganization of the 
cerebral tissue. 
True gangrene is sometimes observed in the brain as a result of inflamma- 
tion. It may occur on the circumference, or in the interior of the cerebral 
substance. It is marked by a livid appearance and softening of the tissue, a 
fetid odour, and the presence of a greenish, sanious, very offensive liquid. 
Ulcers have also occasionally been noticed upon the cerebral surfaces. 
It would seem rational to expect, as each muscle, and each organ of sense, 
probably has a nervous centre which presides over its function, and nervous 
cords connecting it with that centre, that the particular seat of a cerebral 
lesion found after death, taken in connexion with the external part of the 
function affected during life, might afford us the means of tracing the relation 
between the centres and their several dependent structures and functions, 
with some degree of precision; so that, by observing the muscle or organ of 
sense diseased, or the mode of its disease, we might fix upon the morbid point 
in the nervous tissue. But experience has not yet confirmed such anticipa- 
tions. "We possess," says Calmeil, "examples of circumscribed softening 
of one of the corpora striata, one of the optic thalami, the anterior lobe, the 
middle lobe, the posterior lobe, a deep point in the white substance, a cerebral 
convolution, a whole hemisphere;' in each of these cases, it would have been 
impossible to assign before death the special seat of the softening. Nothing 
in the pronunciation, in the derangement of movement in the arm or the leg; 
nothing in the state of the intellectual functions, permits a suspicion as to the 
limits of the softened part. The local softening of the cerebellum gives rise 
to the same symptoms nearly as softening of the brain; nevertheless, the 
persistence of pain in the back of the head, the absence of delirium or dis- CLASS III.] 
CEREBRITIS. 
639 
turbance of the principal intellectual functions, the occurrence of erection, a 
tumultuous state of the movements preceding paralysis, as well as the trouble 
of vision, might give cause to fear the formation of cerebellic softening." 
{Diet. de Med., xxvii. p. 213.) 
Causes.-The causes of local inflammation of the brain are essentially the 
same as those of meningitis. It is also not unfrequently produced by solid 
bodies in the brain, as carcinomatous, and fibrous or fibro cartilaginous tumours, 
scrofulous tubercles, hydatids, and collections of effused blood. It is even 
more apt than diffused meningitis to result from local injuries. 
Diagnosis.-This affection may be confounded with tuberculous meningitis, 
apoplexy, and certain cases of hysteria, to the account of each of which the 
reader is referred for the diagnostic symptoms. From meningitis, as already 
described, the disease is distinguished by a very uncertain line. There are 
instances in which the diagnosis is not difficult. Thus, in a case attended 
with decided fever, frequent pulse, headache, delirium, general, convulsions, 
and ultimately coma, without rigid spasm or local paralysis, we might be safe 
in ascribing the symptoms to meningitis; while wo should be equally safe in 
considering as cerebritis an affection, in which, without frequency of pulse, 
acute delirium, or general convulsions, the prominent phenomena should be, 
in the beginning, severe headache and vomiting, at a more advanced period, 
tonic spasm in a certain limb, with some degree of palsy, and, in the last 
stage, complete palsy. But very frequently the symptoms are so intermingled 
that a positive decision is impossible, and the physician must be guided by 
probabilities alone in the forming of his opinion. One of the marked differ- 
ences between the two affections is the more frequently protracted duration 
of cerebritis. 
Prognosis.-This is always a dangerous disease. Traumatic cerebritis is 
less so than that which arises spontaneously, probably on account of the pre- 
dispositions which have favoured the production of the latter, and continue to 
operate in sustaining it. I have no doubt, however, that local inflammation 
of the brain, though arising without violence, may generally be cured by 
efficient remedies employed in the early stage. After the appearance of the 
tonic contractions of the limbs, the chances are diminished, and still more so 
after complete local paralysis. Still, if the portion of brain disorganized be 
not very extensive, there may be some hope for the patient. There is the 
chance that the softened part, supposing this to be the true state of the lesion, 
may be converted into an abscess, that this may be enclosed in a cyst, and 
thus, being in some measure cut off from the system, may cease to occasion 
serious symptoms, and may even in time undergo absorption. 
Treatment.-This does not differ materially from that directed for menin- 
gitis; and it is wholly unnecessary to go again into a detailed account of the 
remedies. As a general rule, cerebritis does not admit of so copious a de- 
pletion as the former disease; because the actions of the system are already 
considerably depressed by the want of the due supply of nervous power, and 
there may be some danger, by very ample bleedings, of depressing them 
below the point necessary for the support of life. Nevertheless, in the acute 
cases, and before decided evidences of softening have been offered, bleeding 
should be carried to whatever extent the patient can bear; and the practi- 
tioner, in judging of the quantity to be taken, must be influenced less by the 
pulse than by other signs. If the pulse were the sole guide, so Jittle excited 
and so weak is it, in many instances, that stimulation rather than depletion 
might be deemed necessary. Should it be found that, during the flow of 
blood, the patient shows no signs of faintness or nausea, the operation may be 
continued till the usual quantity directed in inflammatory diseases has been 640 
[part II. 
LOCAL DISEASES.-NERVOUS SYSTEM. 
taken; and, if no greater general prostration ensue, while the symptoms of 
the disease continue, the operation should be repeated until some decided im- 
pression is made. 
In the more chronic cases, bleeding must be more sparingly employed, 
especially if the disease has advanced to the second stage; for in that case, 
as a long reparative process may be necessary, the strength of the system 
should be in some measure husbanded. Under these circumstances, after a 
single moderate bleeding, the practitioner should be content with local deple- 
tion from the temples, scalp, or back of the neck. From two to four or six 
ounces of blood may thus be taken every third or fourth day; to be increased 
or diminished according to the obvious strength of the patient. With this 
treatment moderate purgation should be combined every other day, or more 
active purgation at somewhat longer intervals, as may seem best to the judg- 
ment of the practitioner. A constant succession of blisters, three or four 
inches by six for an adult, should be kept upon the back of the neck, and 
between the shoulders; and means should be taken to direct the current of 
the circulation as much as possible from the brain. The blisters may in very 
chronic cases be superseded by a seton in the back of the neck, or issues 
between the scapulae. While this treatment is going on, a moderate mercurial 
impression should be made with the blue mass, or small doses of calomel, so 
as simply to touch the gums in the slightest degree; and this should be sus- 
tained for a long time. 
The diet in this stage must be exclusively vegetable; the mind should be 
kept as tranquil as possible; and perfect rest should be enjoined. By this 
treatment, with the accessories which the judgment of the practitioner may 
suggest, in relation to any existing disorder of function, the disease may often 
be controlled in the first stage, and a complete cure obtained. 
The same plan should be continued in the second stage, but with a dimin- 
ished activity of depletion. Should the patient be feeble, milk may be added 
to the articles of diet. 
In the last stage, or that of palsy, little else remains for the practitioner 
than to guard the patient against injurious influences, and to give nature a 
fair chance for the work which she alone can accomplish. To guard against 
accessions of inflammation, a seton or issue may be kept open in the neck; 
and, should inflammatory symptoms occur, they should be obviated by a 
cautious use of the measures recommended in the early stage. 
The practitioner should endeavoui' to maintain all the functions as nearly 
as possible in their healthy state, so as to avoid the transmission of irritations 
to the brain from these sources. Hence, he should watch over the- stomach 
and bowels, liver, kidneys, and uterus. Should the patient be feeble, it may 
be necessary even to resort to tonics, and, in anemic cases, especially to the 
chalybcates. The diet, too, in this stage, should be improved, and the patient 
allowed the lighter kinds of animal food. It may even be proper, after the 
injury of the brain may be supposed to have been repaired, to use measures 
for directly stimulating the paralyzed parts, as nux vomica, electricity, and 
frictions; but the consideration of these remedies belongs to palsy. 
3. TUBERCULOUS MENINGITIS. 
This affection is characterized by inflammation of the membranes of the 
brain, and to a certain extent also of its substance, in connexion with tuber- 
cles in the pia mater. 
Syn.-Acute Hydrocephalus. CLASS III.] 
641 
TUBERCULOUS MENINGITIS. 
Under the name of hydrocephalus, two distinct diseases have until recently 
been confounded; one consisting essentially of an excessive production of 
serous fluid within the cavity of the cranium, independently of acute inflam- 
mation, and constituting strictly a dropsical affection;' the other a real phleg- 
masia of the brain and its membranes, often, it is true, attended with a copious 
effusion into the ventricles, but not unfrequently with little or none. The 
former of these affections has been treated of among the dropsies, the latter 
belongs to the present place. But the confusion in the use of the term hydro- 
cephalus does not stop here. By referring to the writings of British authors, 
it will be seen that in general they draw no very clear distinction between 
simple and tuberculous meningitis; and that these affections, as they occur in 
children, are in some degree confounded in their accounts of acute hydrocepha- 
lus. But the two complaints are very different in their nature; one being a 
frequently curable disease, the other, in the present state of our knowledge, 
essentially incurable. Indefinitely as the term thus appears to be used, it is 
best to abandon altogether its application to the cerebral phlegmasiae, and to 
limit its employment to its strict etymological meaning, as a synonyme of 
true dropsy in the brain. Such is the course pursued in this work. Of the 
two acute diseases above referred to, simple meningitis has been already con- 
sidered; and it now remains to treat of tuberculous meningitis; undoubtedly 
the affection, which, though until within a few years indefinitely known, has 
been mainly in the thoughts of writers when describing acute hydrocephalus. 
The existence of tubercles in the substance of the brain has been long 
familiarly known to pathologists; and writers have for many years occasionally 
noticed granulations of the membranes, as one of the anatomical characters 
of hydrocephalus. It was also a common observation that the disease was 
frequently associated with the scrofulous diathesis. Both of these facts were 
familiar to M. Guersent, who adopted, in 1827, the name of granular menin- 
gitis to designate those cases of meningeal inflammation in which the granula- 
tions existed, and taught, besides, that hydrocephalic patients were consump- 
tives, dying through the brain. (Diet. de Med., xix. 394.) But neither to 
M. Guersent, nor to any other pathologist up to that time, does it appear 
to have occurred that the granulations might be tuberculous, and the true 
cause of the meningitis. M. Papavoine, in two cases published in 1830, 
demonstrated that such was the nature of these small Bodies, and showed 
their concurrence with tubercles in other organs. (Barthez et Rilliet, Traits 
des Malad. des Enfants, iii. 550.) But it was only as a coincidence that they 
were thus proved to be present in cases of hydrocephalus. To our own coun- 
tryman, Dr. Gerhard, and to M. Rufz, who conducted simultaneously in the 
years 1832 and 1833, in the Children's Hospital, at Paris, their investiga- 
tions into the pathology of this disease, the credit certainly belongs of having 
first clearly shown its essential connexion with, and dependence upon tubercles 
of the pia mater. (Am. Journ. of Med. Sei., xiii. 313.) This discovery, 
though it has unhappily not led to any important therapeutical result, is in 
the highest degree interesting, and is so far satisfactory, as it has solved the 
mystery of the exceeding fatality of hydrocephalus, and given precision to 
the pathology of a complaint, in relation to which, previously, there was much 
vagueness and uncertainty. The conclusions of Drs. Gerhard and Rufz have 
been subsequently confirmed by numerous observers in relation to the disease 
as it occurs in children; and MM. Diberder and Valleix have established the 
same facts in the cases of adults. 
Tuberculous meningitis may occur at any period of life, from the earliest 
infancy to old age; but it is beyond all comparison most frequent in children, 
so that it is generally looked upon as a disease of childhood. 642 
[PART II. 
LOCAL DISEASES.-NERVOUS SYSTEM. 
Symptoms, Course, &c.-The complaint may be considered as acute or 
chronic, according to the light in which it is viewed. It is probable that the 
tubercles are gradually developed, and often exist for a long time before the 
occurrence of inflammation; but, when this has been once excited, its march 
is usually rapid. In relation, therefore, to the tubercles, the disease may be 
chronic, while, in relation to the inflammation, it is acute. 
In the greater number of cases, the active stage of the complaint, or that of 
clearly developed inflammation, is preceded for a variable length of time, some- 
times for many months, by symptoms indicative of deranged health; and 
these symptoms are often such as depend upon the existence of tubercles in 
other parts of the body. The child is affected with a dry cough, occasional 
fever, emaciation, paleness, listlessness, and want of spirits, and various signs 
of disorder in the digestive organs, such as irregular appetite, diarrhoea or 
constipation, and unhealthy discharges. Along with these there are also, in 
many cases, symptoms which belong to the affection of the brain. Occasional 
attacks of headache, with or without vomiting, are experienced, or the child 
exhibits other evidences of cerebral congestion. These spells occur usually 
at irregular intervals; but sometimes they come on at a certain time every day 
or every other day, with apparently good health between them, so as very 
much to resemble paroxysms of intermittent fever, for which they have occa- 
sionally been mistaken. These head affections may gradually deepen into the 
acuter form of the disease, so that it shall be impossible to decide when the 
latter precisely commences; but more frequently the inflammatory symptoms 
show themselves abruptly, and the transition from the comparatively latent 
state to that of excitement is obvious. 
Not unfrequently, moreover, the acute attack comes on in the midst of ap- 
parently perfect health, without any warning whatever from preliminary dis- 
order. In either case, it is marked with more or less of the following pheno- 
mena. There is in general a disposition in the disease to a certain succession 
of symptoms, which may be arranged into three successive stages, according 
to the example set by that close observer, Dr. Robert Whytt, who published, 
in 1768, the first very accurate description of the complaint. But it must be 
acknowledged that the distinction between these stages is not always well ob- 
served, and that they are frequently a good deal confused together. 
The prominent symptoms of the first stage are headache, vomiting, and con- 
stipation, with more or less febrile excitement. Not unfrequently the child 
is seized with a paroxysm of vomiting and pain in the head, without apparent 
cause, which disappears and returns daily, or two or three times a day, for two, 
three, or four days successively, before he is taken off of his feet. In other 
instances, the acute attack begins with chilliness or rigors, followed by fever, 
together with the local symptoms mentioned. After the disease is completely 
formed, the pain of the head is almost constant, in some degree, and seldom 
leaves the patient so long as sensibility remains. It is, however, much more 
severe at certain times than others; and every now and then sudden and vio- 
lent lancinating attacks of it seem to occur, extorting sharp, quick cries or 
screams from the patient, which are among the characteristic features of the 
disease. The seat of the pain is most frequently in the anterior part of the 
head, though it is sometimes referred to the temples or occiput. In very 
young children, it is exhibited, independently of their cries, by the frequent 
application of their hands to the head, or by pressing it against the breast of 
the mother. The vomiting is apt to occur simultaneously with the pains, or 
soon after them. Sometimes food only is discharged, but more frequently 
bile. This is always a suspicious symptom in children, when occurring re- 
peatedly without apparent cause. It does not usually continue longer than CLASS III.] 
643 
TUBERCULOUS MENINGITIS. 
four or five days, and sometimes ceases after the second or third. Occasion- 
ally, however, it lasts much longer, especially when the disease commences 
with isolated paroxysms of headache and vomiting. 
Constipation is very common in the early stage, and sometimes yields with 
great difficulty even to active medicines. The stools, when obtained, are 
usually green or dark-coloured, and sometimes black. They are seldom quite 
healthy. Occasionally the patient experiences abdominal pains. The pulse 
is usually more or less excited, sometimes considerably so; and there is 
generally some febrile heat. The face, usually rather pale, exhibits at times 
remarkable flushes of redness, which quickly disappear, and often coincide in 
their occurrence with the paroxysms of severe pain and vomiting. The tongue 
is moderately furred and quite moist. There is little or no thirst; and 
occasionally the patient exhibits even aversion for drinks. The eyes are 
painfully sensitive to light, so that they are usually kept forcibly closed, and 
the patient cries if attempts are made to open them. The pupils are in some 
instances contracted, in others dilated; and these conditions sometimes quickly 
alternate. The child often has a characteristic frown upon his brow, and an 
expression of pain, or vacancy, or as if he were stunned, upon his counte- 
nance. The character appears to have undergone a change, and the playful 
temper of childhood is replaced by peevishness, fretfulness, or irascibility, 
without obvious cause. He is seldom, however, delirious at this period, but, 
if old enough, sometimes shows sagacity by his answers. Not unfrequently 
several days thus elapse, before he is quite confined to the bed. 
The second stage is characterized by the supervention of more decided nerv- 
ous symptoms, and of diminished frequency with irregularity of the pulse. 
The period at which the change takes place is altogether uncertain. It may 
come on in a day or two, or be postponed for a week. The symptoms not 
unfrequently also mingle with those of the first stage, so that no distinction 
of stages can be made. The pulse gradually diminishes to 80, 70, or 60 in 
a minute; and Guersent states that he has known it to descend even to 48. 
At the same time it is rather full, and more or less irregular, being faster at 
one time than another, now large and then small, and almost always inter- 
mittent, either at fixed or uncertain intervals. The respiration also becomes 
irregular both as to the succession and length of inspirations, is occasionally 
broken by deep sighs or yawnings, and is in some instances so long inter- 
rupted as to suggest the fear that it may not return. It is slower than in the 
first stage. The heat of skin diminishes, and the patient is often affected 
with partial or general sweats. The paroxysmal flushes of the face continue. 
A disposition to drowsiness or stupor comes on, during which the patient 
grinds his teeth, and if roused, has a look of idiocy or intoxication, answers 
with difficulty questions that may be asked, and immediately relapses into 
sleep. In this state he often moans, and occasionally sends forth sharp cries, 
probably marking attacks of pain. Instead of stupor, he is sometimes affected 
with delirium, which in a few instances is wild and restless, but is generally 
calm, and attended with low mutterings. This seldom continues more than 
two or three days, and then gives way to coma. The eyes are closed or par- 
tially open, and the patient seems unable to command the movements of the 
lids, which only partially obey the will when he wishes to raise them. The 
pupils are usually dilated, in some instances equally, in others unequally, and 
are little sensible to light; vision is impaired or disordered; and strabismus 
often takes place, sometimes in a converging, and sometimes a diverging 
direction. The hearing is less affected than the sight. The tongue remains 
moist, the vomiting ceases, the constipation is less obstinate and yields to 
purgatives, and the abdomen is singularly retracted. There seems to be no 644 
LOCAL DISEASES.-NERVOUS SYSTEM. 
[PART II. 
disgust for food, and the patient swallows what is given him. This period 
often continues a week or ten days. In the course of it, a remarkable remis- 
sion of almost all the symptoms occasionally takes place, giving to the inex- 
perienced strong hopes of convalescence. There is sometimes, under these 
circumstances, no other sign of the disease remaining than irregularity of the 
pulse, and an unnatural expression of countenance. But the amelioration soon 
disappears, and the symptoms return with others still worse. 
In the third stage, signs of a more profound cerebral lesion are presented. 
A disposition to tonic spasms is evinced in some part of the body. The 
flexors of one of the extremities, especially of the arm, contract somewhat 
rigidly, and attempts to straighten the limb are resisted, and appear to pro- 
duce pain. The jaws are sometimes stiffly closed, the muscles of the back 
become rigid, and the head is occasionally drawn backward. Painful contrac- 
tion of the cervical muscles is a very frequent symptom, and may often 
be noticed before the supervention of the last stage. The rigidity is in cer- 
tain rare cases so extensive that the body seems as stiff as a board, and can 
be raised by the head and feet without bending. Along with these spastic 
contractions, there are occasional convulsive movements, more or less exten- 
sive. The patient is affected with subsultus, carphologia, and sometimes with 
a cataleptic state of the limbs. Partial palsy at length takes place in one or 
more of the extremities; the surface becomes insensible to the touch, and the 
eyes to light; hearing gives only vague evidences that it still exists; the 
patient sinks into profound coma; the pulse becomes regular, and more and 
more frequent, rising sometimes to 120, 140, or 160, in a minute, or even 
still higher, being at the same time very feeble; the face often assumes a vio- 
laceous hue, and is utterly expressionless; the eye is quite dim and as if 
covered by an opaque film; the surface becomes cold; involuntary evacuations 
take place; and the patient dies, often in convulsions. 
But this is not the uniform course of the disease; and the symptoms enu- 
merated occur sometimes with great irregularity. Thus, in some instances, 
the attack begins with delirium. In others, convulsions take place at an 
early period; but, according to Barthez and Rilliet, only in cases in which 
there are tubercles in the substance of the brain. Cases have occurred in 
which there was a total want of drowsiness until near the close. Others have 
exhibited coma at the commencement, and throughout the course of the dis- 
ease. Instead of constipation at the beginning, there is sometimes diarrhoea, 
in consequence of complication with enteric inflammation. Occasionally the 
attack is made insidiously. The patient has some of the preliminary symp- 
toms enumerated, but not such as to rouse the attention of his attendants to 
the danger, when all at once the acute symptoms come on with great violence. 
The approach of the disease is, in other instances, concealed by scarlatina, 
smallpox, or other febrile affection; and it is not suspected until it comes 
forth under full sail from the mist which had enveloped it. 
The duration of the attack, counting from the first appearance of the vomit- 
ing and headache, is usually from one to three weeks; though death may 
take place in a shorter time, even so early as the third or fourth day, and 
may be postponed for six weeks or two months. The greatest number of 
patients probably die in the course of the third week. 
Anatomical Characters.-The chief characteristic anatomical peculiarity of 
this disease is the existence of minute bodies, round or sopewhat flattened, 
translucent or opaque, gray or whitish or yellow, from the size of a grain of 
sand to that of a pin's head, dispersed here and there over the surface of the 
brain and cerebellum, and situated beneath the arachnoid, in the substance 
of the pia mater. They are found upon all parts of the surface, the convex CLASS III.] 
645 
TUBERCULOUS MENINGITIS. 
and lateral portions, as well as the base, in the anfractuosities of the convolu- 
tions, and in the fissures. They may be on both sides of the brain, or only 
upon one side; and may be confined to a single spot, or may exist in several; 
and all this without any appreciable bearing upon the symptoms of the case. 
From a table of cases given by Barthez and Rilliet, it would appear that, 
contrary to what had been previously supposed, they are more frequent upon 
the convex surface of the brain than at the base. They are much more 
abundant upon the brain than the cerebellum. They are often isolated, but 
sometimes grouped in patches, and are apt to be arranged along the veins of 
the pia mater. In number they vary exceedingly. Sometimes not more than 
four or five of them can be detected, sometimes they are scattered in countless 
numbers through the pia mater. When the brain is exposed by the removal 
of the dura mater, they may be seen like yellowish specks through the trans- 
parent arachnoid, scarcely rising above the general surface. Sometimes, in 
order to see them distinctly, it is necessary to separate the membrane, and 
hold it up to the light. These bodies are altogether identical with the granu- 
lations found in other parts of the body, in tuberculous cases. In some in- 
stances, larger tubercles are found, from the size of a millet-seed to that of a 
filbert, and occasionally several miliary tubercles aggregated together, with 
portions of the pia mater included in their substance. In such cases, the 
number of the separate tubercles is always small. 
The free surface of the arachnoid exhibits few signs of inflammation. The 
membrane has now and then an opalescent appearance in particular situa- 
tions, and not unfrequently is somewhat viscid upon the surface. More rarely, 
it is in places thicker and firmer than in health, and capable of being removed 
along with the pia mater without tearing. Occasionally there is a little serum 
in its cavity, but very seldom either coagulable lymph or pus. 
The pia mater almost always exhibits marks of inflammation, being in- 
jected, thickened, and infiltrated with a serous, gelatinous, or turbid liquid, 
but very rarely with fluid pus. But very often a concrete yellowish matter 
is seen deposited in its tissue, sometimes soft and inelastic, sometimes firmer, 
elastic, and somewhat shining, and supposed to consist of concrete pus, or 
coagulable lymph. This yellowish matter is either in patches, or deposited 
in lines bordering the blood-vessels; and is much more commonly seen at the 
base of the brain than upon its summit; as is the case also with the other 
signs of inflammation in the membrane. Miliary tubercles are often inter- 
spersed in the midst of the gelatinous and yellowish deposit. The latter 
sometimes covers almost the whole base of the brain in a continuous layer. 
But there is no precise relation between the numbers of granulations, and 
this product of inflammation; nor do they necessarily occupy the same por- 
tions of the surface. Sometimes the tubercles are seen with only a slight 
redness or infiltration around them, scarcely amounting to inflammation. 
The brain itself exhibits morbid appearances. The convolutions are much 
flattened, and sometimes quite effaced, either by the cerebral turgescence, or 
the amount of fluid in the ventricles. The cortical portion is reddened, and 
sometimes softened in the vicinity of the inflamed patches. The medullary 
portion, when cut, appears often as if sanded over with red specks. 
The ventricles usually contain an abnormal quantity of serum, either per- 
fectly colourless and limpid, or somewhat turbid, probably from the products 
of inflammation in the ventricular walls, as supposed by Abercrombie, or 
from the softened tissue of the brain itself, as suggested by Barthez and Ril- 
liet. The amount of fluid varies from a few drachms to four, six, or eight 
ounces, and sometimes even exceeds the last mentioned quantity. Occasion- 
ally, however, there is no increase whatever beyond the healthy amount of 646 
LOCAL DISEASES.-NERVOUS SYSTEM. 
[part it. 
serosity; and yet the symptoms during life are not materially different, show- 
ing that the effusion is not an essential feature in the disease, which has, 
therefore, no claim to a place among the dropsies. 
The medullary substance which bounds the ventricles is much softened, 
sometimes to the consistence of cream. This change is especially observable 
in the septum lucidum, and the fornix. It may be of moderate extent, or 
may involve the whole of the walls of the ventricles; and the amount of it 
bears no fixed relation to the quantity of fluid. Some writers, with Dr. Aber- 
crombie, ascribe this softening to inflammation; others, taking into considera- 
tion the absence of all other marks of this kind of affection, consider it as 
resulting from the infiltration of the medullary substance by the effused serum, 
in which it undergoes a kind of solution. Abercrombie gives cases in which 
the same softening was observed without any effusion. 
In almost all cases of tuberculous meningitis which have been examined, 
tubercles have been found in other parts of the body, as in the substance of 
the lungs, the bronchial glands, &c., showing that the cerebral disease is the 
result of a general tuberculous diathesis. 
The mucous coat of the stomach is frequently in a softened state. 
Causes.-This disease is often hereditary in the same sense as other tuber- 
culous diseases; that is, the general diathesis or predisposition is derived from 
the parent, and circumstances afterwards give it one or another direction. The 
meningitis can scarcely be said to be itself hereditary; as persons affected with 
it very seldom live to be parents. Nevertheless, children are certainly born 
not only with a general tuberculous diathesis, but also with a particular tend- 
ency to this disease; as proved by the fact, that in some families almost all 
the children die with it, one after the other, without any appreciable external 
cause, and solely in consequence of some peculiarity in their organization. 
It is possible that the diathesis may be created, after birth, by the operation 
of those various causes which have been detailed under the head of tubercu- 
losis, external scrofula, and phthisis, and which it is unnecessary to repeat 
here. But the probability is, that the predisposition is much less frequently 
created than in the case of consumptive patients, because the early age at 
which this form of meningitis comes on frequently precludes, to a very great 
extent, if not entirely, the operation of the predisposing causes. 
Among the influences which give a special tendency of the tuberculous 
predisposition to display itself in the brain, the most powerful is that of age. 
What it is in early life that leads to this result is not so certain. Some have 
ascribed great influence to the process of dentition; but it appears from recent 
researches that, though the disease is frequent during the period of the second 
dentition, it is rare during the first, which is so much more frequently the 
source of other diseases. Some other agency must, therefore, be sought for, 
and none appears to be so probable as the greater activity of the brain at this 
period of life, when not only more ideas are received than at any other period, 
but the necessities of a very rapid physical developement require and sustain 
a constant excitement of the nervous centres. The time of life in which the 
disease is most frequent, is said to be between the fifth and tenth year. It is 
not uncommon from the second to the fifth year. Before the second, and after 
the fifteenth year, it is comparatively rare. 
Neither sex nor season appears to have any peculiar influence over the 
disease. 
Numerous causes have been accused of exciting the disease, or calling the 
diathesis into action. It is probable that whatever irritates the brain may 
tend to this result. When the tuberculous predisposition exists, whatever 
over-excites the vessels of a part, and disposes to exudation, must endanger CLASS III.] 
647 
TUBERCULOUS MENINGITIS. 
the elimination of tuberculous matter in that part. It is not surprising, there- 
fore, that falls upon the head, or other local injury should have the effect of 
producing attacks of tuberculous meningitis. Perhaps too much stress may 
have been laid upon this cause, but I do not think its occasional efficiency can 
be denied. Other exciting causes are direct exposure to the sun's rays, vio- 
lent emotions as of anger or fright, a premature or too powerful exercise of 
the brain in the processes of education, the disappearance of -cutaneous erup- 
tions, worms and other causes of irritation in the alimentary canal, various 
febrile diseases, and probably sometimes dentition, which, though it may not 
be sufficient to cause the disease before the predisposition to it is formed, is 
no doubt capable, in some instances, of acting as an exciting cause. 
Nature.-Some doubt has been entertained whether the tubercles, in these 
cases, are the causes or the results of the inflammation. When the consist- 
ence of some of these small bodies, which are hard and resistant to pressure, 
is considered, it seems improbable that they should have been very rapidly 
produced; and, as they have been found without any attendant inflammation, 
or any signs of its previous existence, it is clear that this process is not essen- 
tial to their formation. The inference is not unfair, that they are sometimes 
at least the result of a slow, and probably uninflammatory deposition, and that, 
after attaining a certain degree of developement, they may either directly ex- 
cite meningitis, or may keep the membranes in a state of irritation, which may 
be excited into inflammation, by slight accidental causes. But, at the same 
time, it is in the highest degree probable that an irritation or inflammation in 
the brain of a child, predisposed to this disease, may occasion the deposition 
of tuberculous matter; and that thus a scrofulous predisposition, without the 
present existence of tubercles in the meninges, may give a fatal character to 
accidental inflammation. 
It appears that, in many cases, there is a peculiar yellowish deposition, 
like concrete pus, within the meshes of the pia mater, which differs from the 
results of ordinary inflammation, observed in cases in which there are no 
tubercles in other parts of the body, and consequently no proofs of a scrofu- 
lous diathesis. The differences between this deposition and that which attends 
inflammation in persons without tuberculous tendency, as pointed out by 
Barthez and Rilliet, are, that the former is almost always solid, the latter al- 
most always liquid; the former occurs more especially at the base of the brain, 
the latter upon the convex surface; the former is of limited extent, especially 
when on the convex surface, the latter may spread over the greater portion of 
the surface of the brain; and, finally, the former attacks almost exclusively 
the pia mater, while the latter occurs habitually in the great cavity of the 
arachnoid. (^Trait. des Malad. des Enfants, iii. 487.) This matter may be 
associated with tubercles in the pia mater, or may be wholly independent of 
them. When tubercles exist in this membrane, the deposition may occupy 
the same parts as the tubercles, or may be found in others. It is not, there- 
fore, necessarily the direct result of the irritation of the tubercles; and must 
be ascribed to a peculiar influence exerted upon the nature and results of the 
inflammation by the scrofulous or tuberculous diathesis. It may possibly be 
the product of such an acute action of the vessels as, if chronic, might produce 
proper tuberculous matter. 
It appears, then, that, though tubercles in the meninges are commonly 
present in tuberculous meningitis, and serve as the exciting cause of the in- 
flammation; yet the scrofulous diathesis, as evinced by tuberculous deposition 
in other parts of the system, is capable of producing the same kind of inflam- 
mation of the membranes of the brain, without the existence of granulations, 
or other form of tubercle within the cranium. 648 
[part II. 
LOCAL DISEASES.-NERVOUS SYSTEM. 
Diagnosis.-The disease from which it is most difficult to distinguish the 
one under consideration is simple meningitis; and there can be little doubt 
that the two affections, as they occur in children, are very often confounded. 
Among the most certain criteria is the existence or non-existence of signs of 
scrofulous or tuberculous disease elsewhere. If the child has an obstinate 
cough, tumid abdomen and diarrhoea, or the marks of external scrofula, there 
is every reason to fear that the meningitis is tuberculous. In the absence of 
all such signs, the hope may be indulged that it will turn out to be simple. 
There are, however, points in which the two affections generally differ; though 
there may be individual cases which cannot be distinguished. In simple 
meningitis, the febrile excitement in the early stage is higher, with more 
heat and thirst, more delirium, and greater acuteness in all the symptoms. 
The vomiting is more frequent, the headache more continuous and less parox- 
ysmal, and the patient is sooner compelled to take to his bed. The march of 
the diseasS is more rapid, the agitation and wildness in the course of it are 
more striking, and comatose symptoms appear more quickly. Simple menin- 
gitis often terminates in less than a week; the tuberculous generally continues 
till the close of the second, or some time in the third week. The time of life 
should also be taken into account. Tuberculous meningitis seldom occurs be- 
fore the end of the second year; the simple inflammation often. 
The various febrile diseases may for a time, in certain stages, be mistaken 
for tuberculous meningitis, especially the enteric or typhoid fever; but the 
mistake cannot be of long duration. A careful study of the characteristic 
symptoms of each disease will guard against a continuance of the error. The 
violent and paroxysmal pains in the head; the vomiting without obvious cause; 
the sudden sharp screams; the pulse at first somewhat excited and afterwards 
slow, intermittent, and irregular; the irregular respiration, with deep sighs 
and yawns; the constipation, dark-green or black discharges, and retracted 
abdomen; the dilated, contracted, or oscillating pupil; the strabismus; the 
tonic and clonic spasms; and the final partial palsy, will, in general, be suffi- 
cient to distinguish the meningeal affection. Occasionally almost all the 
peculiar symptoms of the disease are imitated by mere functional derange- 
ment, sympathetic with disease in the alimentary canal or elsewhere; and, in 
cases of this kind, dissection after death has revealed, to all appearance, a 
perfectly sound state of the encephalon. In such cases, however, there is 
generally some one characteristic wanting, either in the symptoms or the 
course of the disease, upon which a probable diagnosis may be founded. Thus, 
the patient may be affected with most of the prominent symptoms of tuber- 
culous meningitis, but may want the characteristic condition of the pulse, some- 
what excited at first and regular, then slow and intermittent, and finally rapid 
and again regular. 
Prognosis.-This is almost always unfavourable. It is scarcely possible 
that recovery should take place with the pia mater loaded with irremovable 
tubercles. Dr. Whytt states that he never cured one of his patients. MM. 
Barthez and Rilliet never saw a case recover. M. Guersent, who witnessed 
a great multitude of cases, considers the disease as scarcely curable in any 
instance in the second stage, and quite incurable in the third. He is dis- 
posed to think that he has been successful with some cases in the first stage, 
but admits that the precise character of these is always doubtful. Very dif- 
ferent accounts, however, are given by other practitioners of their success. Dr. 
Golis, of Vienna, who had charge of an institution for children in that city, 
states that he has witnessed 41 recoveries. Dr. Odier, of Geneva, states that 
one-third of the cases of acute hydrocephalus in that city get well. Formey 
ciyed nearly all whom he had the opportunity to treat in the early stage. It CLASS III.] 
TUBERCULOUS MENINGITIS. 
649 
is quite obvious that these statements have reference to different diseases. Many 
of the cases cured were undoubtedly either simple meningitis, or mere imita- 
tive functional derangements of the brain. It is impossible otherwise to ac- 
count for the different success of skilful practitioners, with plans of treatment 
not essentially different. • 
I have occasionally seen cases of cerebral disease recover, which appeared 
to me to present the characters of acute hydrocephalus, as this complaint was 
formerly defined; but I have never seen a well marked case of tuberculous 
meningitis end favourably. 
Still, the practitioner should not be discouraged, and should never intermit 
his efforts. There is always the hope, in the early stage, when the patient is 
not obviously tuberculous, that the disease may be simple meningitis, and 
consequently curable. There is the hope, too, that even though the subject 
may be scrofulous, the tuberculous matter may not have been absolutely 
deposited in the brain, and the timely application of remedies may prevent 
the deposition. Even in the second or third stage, there is still the fact, that 
patients presenting the same symptoms have recovered; and the inference 
may be drawn, that possibly the diagnosis in the case under treatment may 
not be correct, and that the event may be equally fortunate. 
Treatment.- It has been recommended by some writers to be sparing in 
the use of depletory remedies in tuberculous meningitis; as it is well under- 
stood that whatever lowers the grade of vital power, and deteriorates the blood, 
favours the deposition of tubercle. This is undoubtedly true as a general 
fact; but the inference is not, I think, just, in relation to this particular dis- 
ease. It is admitted that, if tubercles are already formed in the membrane^ 
of the brain, sufficient to induce the symptoms of acute meningitis, there is 
scarcely any ground for hope. The disease, it is thought, must almost inevit- 
ably prove fatal. The most that can be expected is to protract life a short 
time, and with it the sufferings of the patient. Now this is scarcely desira- 
ble; and even this little will fail to be gained in the vast majority of cases. 
Abstinence from active measures has, therefore, little to recommend it. But, 
if the practitioner should have made a wrong diagnosis, or if the case should 
be one of those in which tubercles are not yet formed, but only in danger of 
being formed should the inflammation continue, it is obvious that the expect- 
ant plan surrenders a case as hopeless, in which great good may be expected 
from energetic measures. The inference from this is, that active treatment 
can do little or no harm, even if unsuccessful, while it may possibly be the 
means of rescuing the patient. It appears, then, to be the duty of the physi- 
cian to treat such cases with all the energy that the strength of the system 
will admit. 
Whatever danger there may be accrues, in nearly all instances, immediately 
from the inflammation; for even where tubercles are present, it is through 
this process that they almost always work out their fatal results; and, where 
they are not yet formed, it is this which most strongly disposes to their depo- 
sition. It is'inflammation, therefore, that is to be combated. The treatment 
recommended for simple meningitis is exactly that required, upon the princi- 
ples above stated, for the tuberculous variety. It is even more important in 
the latter, that the remedial measures should be early applied; for it is in the 
first stage especially that there may be some reason to hope that the tuber- 
culous deposition may be prevented. To give the treatment in detail in this 
place would be mere repetition. The reader is, therefore, referred to the 
article upon simple meningitis. General and local bleeding, active purgation 
with calomel and suitable adjuvants, cold to the head, revulsion by means of 
blisters over the scalp, and the introduction of mercury into the system both 650 
[part II. 
LOCAL DISEASES.-NERVOUS SYSTEM. 
internally and through inunction, so as to produce its constitutional impres- 
sion, are the remedies to be employed. Depletion should be pushed to what- 
ever extent the strength of the patient will permit. No precise directions 
can be given adapted to each case. As a general rule, this variety of menin- 
gitis does not bear bleeding so well as the simple; and, therefore, less blood 
must be taken. Calomel, however, as a purge, may be employed, in the cases 
of children, almost indefinitely. Enormous quantities have sometimes been 
given with impunity, and even with asserted benefit. But all that can be 
effected by these quantities can be gained from more moderate doses; as a 
great proportion of what is given lies inert in the bowels. From four to ten 
grains may be given at first to a child of two years or upwards, and, if it do 
not operate too actively, may be followed by the same quantity daily until 
the period for depletion is passed. After this time, it may be continued in 
smaller doses, frequently repeated, from one-quarter of a grain to a grain, for 
example, every hour, with a view to affect the system; while mercurial oint- 
ment is rubbed upon the insides of the limbs, and applied to a blistered sur- 
face over the scalp. When an impression is made upon the mouth, the mer- 
curial should be suspended. Instead of blisters to the scalp, and at the same 
period of the disease, pustulation by tartar emetic has been strongly recom- 
mended; and Dr. Hahn, of Aix-la-Chapelle, records several cases in which 
the remedy has proved effectual, though it sometimes induces disagreeable 
ulceration and even sloughing in the infantile scalp, which may last long, 
and leave indelible traces behind them. He recommends to pustulate a sur- 
face of five or six inches in diameter, avoiding with great care the fontanels. 
The tartar emetic ointment is to be rubbed for about ten minutes on the scalp, 
previously shaved; and the application is to be repeated every two hours, until 
the surface becomes decidedly affected. (Archives Gen., 4e ser., xx. 411, and 
xxi. 58.7 
One additional remedy should be employed in this form of meningitis, from 
its supposed influence over the scrofulous habit of body, and in the hope that, 
if it do not promote the absorption of the tuberculous matter, it may possibly 
prevent its deposition. I allude to iodine. I would commence with it in 
such doses as the stomach of the child could bear, and continue it through- 
out the treatment. The iodide of potassium, or the compound solution of 
iodine (U. S. Ph.) should be employed. Iodide of mercury might, with 
great propriety, be substituted for the calomel at the stage at which it is de- 
sirable to aim at the mercurial impression; and, in this case, the other pre- 
parations of iodine should be abandoned. 
In the last stage, when the strength of the patient declines, it should be 
supported by mild stimulating measures and nutritious food, upon the ground 
that, should the disease be of a less serious character than it seems, life might 
not be lost from sheer prostration. Instances have occurred of recovery under 
apparently quite desperate circumstances. There can be little doubt that, in 
these cases, the nature of the disease was mistaken; but the most skilful are 
liable to similar errors, and the patient should not be allowed to lose the 
benefit of this chance. 
Besides the remedies mentioned, many others have been employed, most of 
which, however, so far as regards any impression on the disease, are useless 
or worse than useless; and to repeat them would be unnecessarily to embar- 
rass the student. A few merit, perhaps, a brief notice. Digitalis has been 
employed, in the early stage, in order to reduce excitement. I believe that 
it is useless for this purpose; but, combined with calomel or iodide of mer- 
cury, it may be given in the second stage, to promote the absorption of the 
effused fluid. Other diuretics have also been proposed, as squill, colchicum, CLASS III.] 
651 
TUBERCULOUS MENINGITIS. 
spirit of nitric ether, and oil of turpentine ; but they are of little use. In the 
progress of the complaint, indications are often presented for the anodyne and 
composing influence of opium, or other narcotics. All these are obviously 
contraindicated in the early stages by the excitement existing in the brain. 
In the advanced periods, they may be used more safely, but always require 
caution. In cases which assume a somewhat chronic march, and especially 
when, with suspicious but not certainly characterized cerebral symptoms, there 
are evidences of a scrofulous state of system, cod-liver oil should be employed. 
I have seen the most threatening symptoms disappear under the use of that 
remedy. 
The functional or organic disorders, frequently occurring in the course of 
the disease, are to be combated by means which the general knowledge of 
the practitioner must suggest; reference being always had to the influence of 
such incidental measures upon the brain. Thus, vomiting is to be treated 
by small doses of effervescing draught, carbonic acid water, or lime-water and 
milk, internally, and by sinapisms, aromatic cataplasms, or other rubefacient 
applications, to the epigastrium; obstinate constipation, should it resist pur- 
gatives, by enemata of various kinds; diarrhoea, occurring in the advanced 
stages, or as a complication, by the cretaceous preparations, vegetable astrin- 
gents, and acetate of lead, &c.; abdominal pains with tenderness on pressure, 
by leeches, emollient poultices, and blisters; and convulsions, independently 
of the remedies addressed directly to the disease, by the warm bath, garlic 
poultices to the feet, and frictions with garlic and brandy, oil of amber, oil 
of turpentine, &c., along the spine. 
But prevention is of more importance in this affection than remedial treat- 
ment. When, from the previous death of one or more children in a family, 
there may be reason to apprehend that others may be predisposed to the 
disease, a plan of preventive treatment should be commenced at birth, and 
perseveringly maintained till the period of danger is passed. This plan must 
be directed to the 'counteraction of the tuberculous diathesis. The basis of 
it must be to maintain the general health in a vigorous state, but without ex- 
citement. Care should be especially directed to the formation of healthy 
blood. The child should receive its nourishment from a perfectly healthy 
nurse, in whom there can be no reason to suspect any scrofulous tendency. 
If the mother have not these requisites, she should surrender this part of her 
charge to another. After weaning, the child should be fed on a nutritious 
and easily digestible, but not a stimulating diet. Milk, farinaceous products, 
the more digestible fruits and vegetables, and meats in moderation may be 
used. Tea and coffee should be entirely forbidden. The child should not be 
shut up in close rooms, but exposed to the air, and encouraged to exercise 
himself out of doors, as soon as his age will permit; the precaution being 
always taken to keep him warmly clad, and to prevent the depressing effect 
of continued cold. The brain should never be overtasked; and mental edu- 
cation, though not entirely neglected, should be postponed to the physical. 
Long sitting in close school rooms would be highly injurious. Care should 
be taken to obviate the ill effects of dentition. If eruptive affections appear 
about the ears, too much solicitude should not be evinced for their removal; 
and, if any suspicion exist of a disposition to internal scrofulous affections, 
attempts should be made by blisters behind the ears, or upon the arm, by 
pustulation with croton oil in convenient situations, by a seton in the back of 
the neck, or some similar measure, to give the disease an external direction. 
These measures may be aided by the moderate internal use of cod-liver oil 
and the preparations of iodine. Children with such predispositions are apt 
to be injudiciously indulged, and every caprice attended to by the fond and 652 
[part II. 
LOCAL DISEASES.-NERVOUS SYSTEM. 
fearful parent, lest injury might result from the irritation produced by de- 
nial. No plan of treatment could possibly be worse. An excitable state of 
the brain is thus fostered and sustained, and the child, besides, made liable 
to constant injury from the violence of temper occasioned by accidental dis- 
appointment. The contrary course should be adopted. The child should be 
taught to control his temper, to be moderate in his desires, and to meet dis- 
appointments with equanimity. 
Article IL 
ORGANIC DISEASES OF THE BRAIN. 
For the sake of brevity, this designation is here employed to express organic 
affections of the brain not dependent upon inflammation, effusion, or rupture of 
the vessels. Strictly speaking, inflammation and hemorrhage, and the results 
of an abnormal collection of fluid within the cranium, are organic affections; 
but they are considered under other heads. This preliminary explanation is 
made in order to prevent misapprehension. 
Of softening and induration of the brain I have already sufficiently treated 
under cerebritis, to which they properly belong; as, though supposed to be 
sometimes independent of inflammation, they are certainly in the great ma- 
jority of instances the result of that process. 
1. Hypertrophy of the Brain.-This is an increase in the bulk of 
the brain from excessive nutrition, in other words an over-growth of the organ. 
Not unfrequently, upon opening the cranium and dura mater, in post-mortem 
examinations of patients who have died of cerebral disease, the brain bulges 
out more or less through the opening, in consequence of a real or apparent 
increase of dimensions from congestion, inflammation, hemorrhage, or effusion 
into the ventricles. But this is not the affection alluded to in the present 
paragraph. In proper hypertrophy, the dimensions of the brain are not in- 
creased by the afflux of blood, or the formation of cavities within it containing 
liquid, but by an excessive production of the cerebral matter. When it occurs 
before the closure of the fontanelles, so that the cranium may expand to cor- 
respond with the dimensions of the brain; or when the cranium is developed 
proportionably with the brain itself, the head may be so large as to occasion 
some inconvenience by its weight; but the affection can scarcely be considered 
as morbid. The case is much otherwise, when, as generally happens, the skull 
refuses to yield, and the brain is consequently compressed within dimensions 
which arc too narrow for it. Under these circumstances, it constitutes a serious, 
though happily a very rare disease. 
When the dura mater is divided, the cerebral mass projects through it, as 
if too large for its unyielding envelope. The convolutions appear flattened, and 
as it were " heaped upon one another;" the ventricles are obliterated; no serum 
is discoverable in any part of the cranial cavity; the membranes are remark- 
ably dry; the blood-vessels are empty; the cortical portions appear blanched 
nearly to the paleness of the medullary; no red points are seen when the 
brain is divided; the cerebral substance is firmer than in health; and the whole 
brain considerably heavier. It is obvious that fluids have been in great mea- 
sure excluded by the accumulation of the cerebral matter. The cerebellum 
is in general not involved in the disease. 
Symptoms.-The affection may exist long with little observable derange- 
ment of health. Among the first symptoms is usually headache, which occurs 
generally in paroxysms, and is often exceedingly violent. In some instances, CLASS in.] 
ATROPHY OF THE BRAIN. 
653 
these paroxysms are attended with vomiting. After a longer or shorter time, 
other symptoms appear, of which the most prominent are convulsions. These 
are sometimes of an epileptic character, sometimes partial, affecting one or 
more limbs, the face, or one-half of the body. At length, the senses become 
affected; dimness of vision or temporary blindness occurs, especially during 
the paroxysms of headache and vomiting; hearing and the sense of touch are 
impaired; and, though palsy may not take place, there is uncertainty in the 
movements of the patient, who obviously has not complete control over the 
muscles. The mind, at first little disordered, and sometimes correct to the 
last, generally fails more or less as the disease advances; and depression of 
spirits, indifference, loss of memory, and intellectual hebetude come on, end- 
ing in permanent delirium or imbecility. The organic functions suffer little 
in the progress of the complaint. With the exception of occasional vomiting 
during the paroxysms, the digestive organs are scarcely deranged; the skin 
remains cool; and the pulse, if in any respect altered, is somewhat slower than 
in health. At last, however, the convulsions become almost incessant; the 
bodily powers give way, and the patient, if not carried off by some incidental 
disease, dies with coma, convulsions, or syncope. The disease is often several 
years in running its course; during which, though there may be occasional 
remissions and partial amendment, the symptoms on the whole gradually be- 
come graver to the end. 
The chronic character of the affection distinguishes it from acute menin- 
gitis; and the want of local rigidity and paralysis, from cerebritis. This last 
character may also serve to distinguish it from tumours in the brain. With 
chronic meningitis, and chronic effusion into the ventricles, it might easily be 
confounded, especially with the latter, when unattended with enlargement of 
the cranium. Dr. West gives the following diagnosis between hydrocephalus 
and hypertrophy in children. The cerebral disturbance is much more marked 
in the former. In both the head is enlarged, and ossification of the skull is 
tardy, but the enlargement is less in hypertrophy, and the fontanelles and 
sutures not so widely open. Nor is there the tension or prominence of the 
anterior fontanelle as in hydrocephalus, but on the contrary an actual depres- 
sion in this position. The shape of the head is less rounded; the occiput being 
the first part enlarged in hypertrophy, and often continuing throughout to 
keep this predominance. When the forehead projects, the eyes remain deep 
in their sockets, and want the prominence and downward direction given to 
them by the pressure of the fluid in hydrocephalus upon the orbitar plates. 
The causes of hypertrophy of the brain are quite unknown. The affection 
is too rare, and comes under the notice of the physician at too late a period, 
to enable any very accurate investigations to be made. 
2. Atrophy of the Brain.-This term may be made, for the sake of 
convenience, to include cases both of diminution of the cerebral substance 
occurring after birth, and of congenital deficiency of the organ, though the 
latter affection is technically denominated cerebral agenesis. 
The deficiency may occur on one side or on both; but the former event is 
most common. The brain retains its natural consistence. The vacuity is 
usually filled up with watery fluid. Sometimes the cranium is depressed over 
the seat of the atrophy, giving a deformed appearance to the head. 
The affection may continue long without interfering materially with the 
organic functions; but it is generally attended with palsy of one or more 
limbs, or of one-half of the body, upon the opposite side to that in which the 
atrophy exists. In some instances, rigid contractions complicate the paralysis. 
Epileptic convulsions are frequent accompaniments. The senses are some- 
times affected, but rarely to any great extent. The mipd almost always suffers 654 
[PART II. 
LOCAL DISEASES.-NERVOUS SYSTEM. 
more or less. The memory is apt to be defective, the rational powers feeble, 
the passions irregular, and sometimes strong; and not unfrequently the patient 
is nearly or quite idiotic. 
The causes are little known. The congenital affection has been ascribed 
to accidents to the mother during pregnancy, but always with some uncer- 
tainty. The acquired variety is sometimes traced to convulsions occurring in 
infancy, or to injuries of the head received at the same period of life. 
The patient often lives many years; sometimes to old age; and death 
almost always accrues from some disease not immediately connected with the 
cerebral affection. 
3. Tumours in the Brain.-Most of the varieties of tumour which 
are found in other parts of the body, are occasionally also met with in the 
substance of the brain. Cysts, non-malignant tumours, the different forms of 
carcinoma or cancer, tubercles, and hydatids, are sometimes generated in the 
midst of the medullary or cineritious structure, and produce the most deadly 
effects. After attaining a certain degree of developement, it is of little conse- 
quence what the nature of the tumour may be. The effects are alike malig- 
nant. The progress of the symptoms may be more or less rapid; but there 
is a strong resemblance in their character; and their tendency is constantly 
towards death. While the tumour is yet small, it often happens that no in- 
convenience is experienced; and, in consequence of its frequently very gradual 
growth, the brain so far accommodates itself to the encroachment, that con- 
siderable magnitude has been sometimes attained without serious results. 
Thus, dissection after death from diseases in no way connected with the brain, 
now and then reveals cerebral tumours, the existence of which had never been 
suspected. But, when a certain magnitude has been attained, which is differ- 
ent in different cases, the circumstance that the brain occupies a cavity which 
cannot be enlarged, and cannot be much encroached on with impunity, gives 
to productions, elsewhere innocent, an influence scarcely less noxious than 
that of the most malignant. The ilLeffects of these tumours are such as 
arise from direct compression of the cerebral substance, from irritation of the 
brain generally, from inflammation with softening, suppuration, &c., of the 
structure in their vicinity, and from compression of the veins, producing 
effusion in the ventricles, or chronic hydrocephalus. The symptoms, there- 
fore, must be the same as those which characterize the several affections men- 
tioned. It is not the tumour which yields the signs directly, but the brain 
upon which it acts. 
Tubercles are the most frequent and most interesting of these products. 
As existing in the meninges they have been already noticed. (See Tuber- 
culous Meningitis.') Reference is here had only to those embedded in the 
cerebral substance. Their shape is usually spherical, and they are found of 
all sizes, from that of a millet-seed to that of a hen's egg, or larger. Their 
numbers vary from one to twenty or more; but they are much less numerous 
than usually in the membranes. Their consistence is that of the crude yellow 
tubercle. Sometimes masses of the translucent gray matter are found, with 
portions of the yellow within them. The larger are sometimes formed by the 
aggregation of smaller tubercles. They occur most frequently in the hemi- 
spheres, and are more common in the cerebrum than the cerebellum. The 
brain around them is often injected, softened, or suppurating. 
Symptoms.-Headache is very generally the first symptom observed. It 
is usually paroxysmal, and sometimes intensely violent. It may be general, 
or confined to a particular part of the head, though nothing can be inferred 
from its position, with an approach to certainty, in relation to the exact site 
of the tumour, unless, perhaps, we may consider its fixed location at the nape CLASS III.] 
655 
TUMOURS IN THE BRAIN. 
of the neck, as indicative of disease in the cerebellum. The pain often 
continues for a long time without any other prominent symptom, besides the 
vomiting which frequently attends it. Epileptic convulsions very often ensue, 
and continue subsequently throughout the complaint. Sometimes the spas- 
modic movements are confined to a particular part or parts of the body. 
More or less coma not unfrequently follows the convulsive paroxysms. Vision 
is apt to become deranged or impaired; and temporary blindness sometimes 
coincides with the cephalalgic and epileptic attacks. The local palsy, con- 
traction of the flexors, and muscular rigidity, which characterize cerebritis, 
are often experienced as the disease advances; and they have almost invaria- 
bly proved to be upon the side opposite to that occupied by the tumour. The 
mental faculties are usually at first little disturbed; but memory begins to fail 
after a time, sensation and perception are blunted, the rational powers are 
enfeebled, and a state approaching dementia not unfrequently ensues, before 
the close of the complaint. Such affections are seldom fatal under a year, and 
they sometimes continue many years. All the general symptoms of chronic 
hydrocephalus sometimes precede death, which usually occurs in the midst of 
coma or convulsions. 
The above symptoms are not all present in every case. Sometimes one, 
sometimes.another is more prominent; and not unfrequently, a few are asso- 
ciated to the exclusion of the remainder. 
Attempts have been made to establish a diagnosis not only between tumours 
and other diseases, but between the different kinds of tumour. But it is 
seldom more than conjectural; except when the cerebral symptoms may 
happen to coincide with some affection in other parts of the body, which may 
serve as a clue to that of the brain. Thus, any form of cancerous disease, 
within the reach of observation, would point to cancer as the probable cause 
of the cerebral phenomena; and the existence of tubercles in the brain might 
be inferred, with an approach to certainty, if the symptoms above enumerated 
should coexist with those of external scrofula, phthisis, or tuberculated mesen- 
teric glands. In relation to the tumours generally, the most diagnostic signs 
are the very gradual approach and advance of the symptoms, with the occur- 
rence of local rigidity and paralysis. As to the part of the brain occupied, 
all is uncertainty. Should the pain be confined to the back of the head, and 
the patient exhibit a peculiarly staggering gait, or the want especially of the 
power of properly associating his movements, there might be some grounds 
for suspecting the cerebellum as the seat of the disease. 
Treatment.-Unfortunately this can be of little avail. There is, however, 
one rule applicable to all these cases of organic cerebral disease. In most of 
them, there is so much uncertainty in the diagnosis, that we may be justified 
in ascribing the symptoms to chronic inflammation of the brain, and treating 
them accordingly. Should existing debility, therefore, not forbid, the measures 
recommended in cerebritis may be carried into effect; the caution being always 
observed not to use depleting remedies rashly, nor to prostrate the system 
irrecoverably. As a general summary of the treatment, may be mentioned, 
occasional leeching or cupping to the temples, or back of the neck; frequent 
moderate purging; revulsion by means of perpetual blisters, setons, issues, or 
pustulating applications behind the ears, at the back of the neck, or between 
the shoulders; a diet chiefly of vegetable food and milk, with the lighter kinds 
of flesh, when the strength appears to fail; and, finally, a moderate and sus- 
tained impression from mercury. These measures should be persevered in 
for months, and, if found productive of benefit, for years; with occasional in- 
terruptions, as circumstances may seem to require, especially in relation to the 
mercurial treatment. In conjunction with them, the utmost care should be 656 
LOCAL DISEASES.-NERVOUS SYSTEM. 
[part II. 
observed to guard the patient against causes likely to aggravate the disease, 
such as excessive mental or bodily exertion, emotional excitement, sudden 
vicissitudes of temperature, &c. 
In tuberculous cases, the antiphlogistic treatment must be used with more 
caution, and the mercurial omitted altogether. The constitutional remedies 
adapted to scrofula should be used, such as the preparations of iodine, the 
chalybeates, the mild vegetable tonics, moderate exercise, &c. 
In cases which are clearly cancerous, the measures should be palliative; 
and the same may be said of all the other cases, when the perseverance or 
aggravation of the symptoms, notwithstanding all the means employed, suf- 
ficiently proves the incurable nature of the malady. 
Article III. 
APOPLEXY. 
Apoplexy (artort^ca, from arto and I strike) is a disease charac- 
terized by the sudden loss, more or less complete, of sensation, voluntary 
motion, and consciousness, without a suspension of respiration and circulation, 
and depending on pressure upon the brain, originating within the cranium. 
It is necessary to include the immediate cause of the symptoms in the defini- 
tion ; as otherwise there are many affections, which, being attended with the 
phenomena above mentioned, would necessarily rank with apoplexy, without 
having any strict pathological relation to it. Such, for example, is the coma 
which sometimes marks the onset of certain malignant fevers, that resulting 
from various narcotic poisons, and that which occasionally accompanies ence- 
phalic inflammation, hysteria, and gastric irritation. Between these affections 
and true apoplexy, the real difference in character is so great, that they could 
not with any propriety be ranked in the same category. Pressure upon the 
brain enters essentially into the definition; and the pressure, moreover, must 
be somewhat sudden, and not the result of a slow organic growth, or very 
gradual liquid accumulation. Besides, it must originate within the cranium, 
as otherwise we should be compelled to rank compression of the brain, from 
fracture and depression of the bone, with apoplexy. 
By some writers the attempt has been made to identify the term apoplexy 
with cerebral hemorrhage. But, in the present state of our knowledge, it is 
quite impossible to determine, in very many instances, whether hemorrhage 
exists or not; and, if this definition of apoplexy were admitted, it would be 
necessary to include in the same category the most overwhelming stroke of 
the disease, as ordinarily defined, and the slightest local paralysis which might 
proceed from a little hemorrhage about some nervous centre. 
In all cases of true apoplexy, the symptoms are produced either by simple 
congestion of the brain, hemorrhage within the cranium, or sudden serous 
effusion ; and the disease has been distinguished by some writers, according 
as it is attended by one or the other of these pathological conditions, into the 
simple or nervous, the sanguineous, and the serous. But such a division is 
useless for practical purposes; for we are in possession of no means of diag- 
nosis which can be certainly relied on; and the treatment is determined not 
so much by our views of the exact pathological condition of the brain, as by 
certain exterior symptoms w'hich may equally belong to the three varieties, 
and are liable to the same diversity in all of them. 
Symptoms, Course, &c.-In many instances, the attack of apoplexy is pre- 
ceded by certain symptoms which prove that the brain is unsound. Among CLASS III.] 
657 
APOPLEXY. 
these are a feeling of weight or fulness in the head, vertigo, headache and 
vomiting, drowsiness, dim or perverted vision, noises in the ears or temporary 
deafness, defect of memory, confusion of thought, apprehensions of impending 
evil, flushings of the face, epistaxis, numbness or formication in some portion 
of the body, unsteadiness of gait, faltering speech, and other evidences of 
slight partial palsy. Many other symptoms are enumerated by authors, but 
most of them have only an accidental relation to apoplexy, and need not, 
therefore, be repeated. Of those above mentioned, there may be only one 
present in a particular case, or there may be several; and they may precede 
the attack, in greater or less degree and more or less continuously for months, 
or only for a few hours or even minutes. Great difference exists between 
authors, as to the proportion of cases in which the premonitory symptoms are 
observed. Rochoux declares that of 69 cases of which he has collected the 
history, 11 only presented precursory symptoms. (Diet, de Med., iii. 470.) 
But my own observation conforms much more nearly with the statement of 
Dr. Bennet, that apoplexy rarely occurs without premonitory symptoms, 
though they may occasionally be so slight as to escape notice. (Tweedie's 
Syst. of Pract. Medd) It is certain, however, that the stroke does sometimes 
approach without warning, and in the midst of apparently sound health. 
When attacked, the patient, if standing or sitting, usually falls, deprived 
of consciousness, and more or less completely of sensation and the power of 
motion. If a limb be raised and let go, it falls as if destitute of life. Pinch- 
ing the skin seems to occasion no uneasiness. Sight and hearing are sus- 
pended, and the patient is not roused by shaking, or by calling loudly in his 
ear. The countenance is marked with a total absence of expression, and is 
often turgid with blood. Throbbing of the carotids is not uncommon. The 
pulse is full, slow, strong, and sometimes intermittent. This condition of the 
circulation, though not universal, is yet so frequent that, when a similar pulse 
is met with in other affections, it is often said to be apoplectic. The respira- 
tion too is slow, and frequently stertorous. The pupil is in some instances 
dilated, in others contracted, but generally immovable, and insensible to light. 
The power of deglutition is usually much impaired, and sometimes lost. The 
bowels are generally constipated ; and the urine is either passed involuntarily, 
or accumulates so as to distend the bladder, and then dribbles away under 
mere gravitation or pressuror Though the limbs are usually motionless, there 
is sometimes spasmodic contraction or rigidity of the muscles, which is gene- 
rally confined to one side, while the other is quite relaxed. 
This condition of stupor continues variously from a few minutes to several 
days, sometimes even to the sixth or seventh day, when, if a fatal result does 
not take place, it slowly gives way, either spontaneously, or to the remedies 
employed. The patient, upon beginning to recover his consciousness, often 
has a peculiar expression of countenance, as if astonished. The symptoms 
may now all gradually decline, and health return without any remains of the 
disease. But this result is comparatively rare. Much more frequently it is 
observed, when the patient begins to exercise a little power over the muscles, 
that some part of the body, and generally one-half of it in the longitudinal 
direction, is more or less completely paralysed. Indeed, this condition of 
hemiplegia may often be seen at the very commencement of the attack; one 
side of the body retaining a certain degree of contractility and sensation, while 
the other appears quite insensible and powerless. Sometimes, however, the 
palsy is less extensive, affecting only a single limb, one side of the face, the 
tongue, &c. Generally both sensation and the power of motion are lost, but 
sometimes only one. The side affected is apt to be opposite to the one con- 
vulsed ; though, in some instances, the muscles which refuse to obey the will 658 
[part II. 
LOCAL DISEASES.-NERVOUS SYSTEM. 
contract spasmodically. The paralytic condition of the face is rendered 
obvious by the fallen and relaxed state of the features on the affected side; 
while there is a certain degree of contraction in the muscles of the other 
side, towards which the angle of the mouth is drawn. When the tongue is 
protruded, the point turns towards the paralytic side, because the muscles 
which draw it forward act only upon the other half of the organ. Very fre- 
quently, in consequence of this palsy of the tongue, the patient on recovering 
his consciousness is unable to speak, or articulates very imperfectly. 
These paralytic symptoms may disappear in a few hours or a few days, or 
may continue for months, or years, or to a greater or less extent during life. 
Upon the return of consciousness, the patient sometimes complains of head- 
ache, and symptoms of delirium not unfrequently appear. If these should 
be considerable or lasting, with wakefulness, an accelerated pulse, and some 
heat of skin, there would be reason to suspect the occurrence of inflamma- 
tion. After convalescence from the apoplectic symptoms, the palsy often 
remains for a long time; the mind appears not unfrequently weakened ; the 
patient is apt to shed tears upon slight occasions, or without any occasion; 
the memory is often defective, and words are miscalled, or one substituted 
for another of a wholly different meaning; and, in some instances, it is long 
before the patient recovers the power of speech after having lost it. After 
a time, however, which varies exceedingly in different cases, from a few 
months to several years, the apparently wrecked system is often gradually 
repaired by its own inherent powers; and the patient, though seldom as 
vigorous in mind or body as before the attack, regains a tolerable share of 
health, and is able to enter again into the routine of active duties. 
When the apoplectic attack is to end fatally, it seldom terminates before 
the lapse of three or four hours, and much more frequently not till the third 
or fourth day. Immediate death is very rare; and the patient seldom sur- 
vives the eighth day. Before death, the coma, if at first imperfect, becomes 
profound; the sphincters frequently give way; the pulse sinks in force and 
volume, and increases in frequency; the extremities become cold; the surface 
often covers itself with a cold sweat; and the respiration is performed at 
gradually lengthening intervals till it ceases. 
The above is a general sketch of the disease as it most frequently appears. 
But it is liable to numerous diversities. In some instances, instead of 
striking the patient down suddenly, it comes on by degrees, with a drowsi- 
ness increasing into stupor, and either ending in profound coma, or going off 
without a perfect loss of consciousness at any time. Even in the sudden at- 
tacks, there is not always an utter loss of sensation or consciousness; the pa- 
tient sometimes showing imperfect signs of intelligence when spoken to loudly. 
Occasionally hemiplegia, or palsy of some one part of the body, precedes the 
apoplectic symptoms; and the patient, before losing his consciousness, finds 
himself unable to speak, or to open and close one of his eyes, or to move the 
arm or the leg upon one side, or finally to move any portion of that side. 
Every now and then we meet with instances in which these paralytic symp- 
toms occur without a loss of consciousness at any time. In one winter no 
less than four or five hemiplegic cases were brought into the Pennsylvania 
Hospital, in which the patients had never lost their consciousness for a 
minute. These, however, are not cases of apoplexy; and the affection will 
hereafter be treated of under palsy. 
Instead of the flushed face, and the strong full pulse which ordinarily 
characterize apoplexy, there may be paleness of the countenance, and a small 
feeble pulse; and in these respects there is every possible grade between the 
two extremes. Sometimes we meet with instances in which the force of the JLASS III.] 
659 
APOPLEXY. 
blow seems to be at once overwhelming. The vital powers yield immediately, 
and the pallid features, cold skin, and scarcely perceptible pulse, indicate a 
condition of system closely resembling syncope. 
Dr. Abercrombie describes a form of apoplexy, commencing with sudden 
pain in the head, attended with paleness of face, faintness, nausea, and gene- 
rally vomiting. The skin is bloodless; the pulse is feeble, and frequent, or 
irregular; and the patient either falls, in a state approaching to syncope, 
with occasionally some degree of convulsion, or simply experiences slight and 
transient confusion of mind. In either case, the symptoms pass off, with the 
exception of the headache. After a variable interval, which may not exceed 
a few minutes or hours, or may extend to several days, comatose symptoms 
gradually come on, with or without "paralysis, and death ensues. In these 
cases, according to Dr. Abercrombie, there is always copious extravasation of 
blood; and the symptoms are of the worst possible augury. 
Before leaving the symptomatology of apoplexy, it will tend to render the 
subject clearer, if we consider successively the several phenomena which are 
most characteristic of the disease. 
The pulse, though commonly full, slow, and strong, and not unfrequently 
irregular or intermittent, is in some instances scarcely different from that of 
health, and in others small, feeble, and more or less frequent. 
There are two phenomena in the respiration which are worthy of notice, a 
stertorous or snoring sound in inspiration, and a peculiar noisy puffing out 
of the cheeks in expiration; the former probably arising from the torpid state 
of the velum pendulum, the latter from an equally torpid state of the bucci- 
nators, and other muscles of the face. Neither of them is present in every 
case. They usually indicate deep stupor, and the flapping of the cheeks is 
the worst sign of the two. The breathing is generally slower than in health, 
but is often irregular, and sometimes sighing or yawning. 
The face is most frequently flushed, more or less turgid, and of a red, pur- 
plish, or livid hue; but it is sometimes also pale, or of a yellowish or greenish 
tint; so that the colour is by no means to be relied on as a diagnostic symp- 
tom. There is always, however, a characteristic want of expression in the 
countenance, a deep soporose aspect, which serves to distinguish the affection, 
in many instances, from other forms of coma. 
The pupil is in bad cases quite immovable, being either contracted, or di- 
lated, or one pupil being in one state, while the other is in the other. When 
the apoplexy is not profound, it is often sensitive to light. 
It has been already stated that convulsive movements, when they occur, are 
generally upon the opposite side to the one paralysed, though sometimes they 
occupy the same side, and are occasionally general. In some instances, tonic 
spasms and muscular rigidity are observed. These involuntary contractions 
may precede, accompany, or follow the apoplectic attack. 
Paralpsis is present in the greater number of cases, and is thought to be 
very seldom wanting when there is hemorrhage. In some violent cases, all 
the limbs are paralysed; but generally the affection is confined to one-half of 
the body, having the form of hemiplegia. Sometimes only a single limb is 
affected; and, in this case, the arm is much more frequently paralysed than 
the leg. It is a singular fact, moreover, that, in recovery from hemiplegia, 
the leg almost always regains its powers and sensibility much before the arm; 
and it not unfrequently happens that the patient can walk, while the arm still 
hangs, like a dead weight, by the body. The paralysis may also be confined 
to the face, the tongue, the eyes or their lids, the oesophagus, or the larynx. 
In the face it produces, as already observed, inequality of the two sides; in 
the tongue, difficulty of articulation or inability to articulate at all, while the 660 
[PART II. 
LOCAL DISEASES.-NERVOUS SYSTEM. 
organ, when protruded, is apt to point towards the paralysed side; in the eye, 
want of vision, and often dropping of the eyelid, or its imperfect closure; in 
the oesophagus, inability to swallow, with symptoms of suffocation when the 
attempt is made; in the larynx, loss of voice. But the disease is very rare 
in the last two positions. In general the palsy affects both sensation and 
motion; but sometimes it is confined to one of these properties. 
Consciousness is affected in various degrees. As a result of pressure of 
the brain, there is every grade of stupefaction, from a slight confusion or 
vertigo, to profound coma. The case, however, scarcely meets the definition 
of apoplexy, unless consciousness is suspended, at least for an instant. It 
is said that, at the moment of attack, the patient sometimes has a feeling as 
if something were suddenly torn or rent in the interior of the head. 
After recovering in some degree from the proper apoplectic symptoms, the 
patient is liable to be attacked with those of cerebritis, consequent upon in- 
flammation excited in the cerebral substance by the presence of effused blood. 
Though the patient not unfrequently recovers entirely from one attack of 
apoplexy, and even from all its apparent consequences, he is yet very liable 
to returns of the disease, which in general, sooner or later, prove fatal. A 
third attack of the severer form of apoplexy is seldom survived. Of that 
milder kind, however, which depends on mere cerebral congestion, without 
effusion, the result is much less fatal; and it sometimes happens that a pa- 
tient has numerous attacks, which reduce him at length to a state of mental 
imbecility little short of idiocy. 
Anatomical Characters.-It is now generally admitted that death may 
occur with all the phenomena of apoplexy, without leaving any observable 
lesion in the brain. Such cases are denominated by some nervous apoplexy. 
They are very rare. The probability appears to me to be, either that some 
slight phenomena of congestion have been overlooked, or that the blood- 
vessels, violently distended within a moderate space, sufficient to paralyse the 
action of one of the nervous centres essential to life, have become emptied of 
blood before death, after the mischief had been produced. 
In other cases, nothing which could account for the symptoms is discovered 
but a highly congested state of the cerebral vessels, such, for example, as is 
sometimes produced by exposure of the head to the direct rays of a very hot 
sun, constituting what the French call a coup de soleil. 
It has been long known that patients sometimes die of apoplexy produced 
by the sudden effusion of serum into the ventricles, or the cavity of the arach- 
noid. The serum is sometimes limpid and colourless, sometimes turbid and 
reddish or yellowish. It may be wholly unattended with signs of inflam- 
mation or congestion, and apparently the result of a sudden extravasation of 
watery fluid, such as is occasionally observed in dropsy of the serous cavities. 
Such a case is related by Andral, in which a large quantity of perfectly trans- 
parent and limpid fluid was found in a cavity produced by the union of the 
two lateral ventricles with the third; the septum lucidum and fornix having 
been reduced into small fragments of white pulp, floating in the serosity. 
(Clin. Med., n. 95.) Sometimes the effusion is attended with distension of 
the veins and sinuses of the brain, or with general congestion of the organ. 
But hemorrhage within the cranium is the most frequent lesion. The 
blood may be effused between or upon the membranes, in the ventricles, or 
in the substance of the brain. A case is recorded by Dr. John Watts {Med. 
and Surg. Register of the New York Hosp., A. D. 1818, p. 145), in which 
blood was effused between the dura mater and the cranium, in consequence 
of caries of the inner table, of about the size of a sixpence, producing the 
rupture or erosion of a blood-vessel. It is more frequently found in the CLASS III.] 
661 
APOPLEXY. 
cavity of the arachnoid, diffused over the surface of the whole brain, or one of 
the hemispheres. Sometimes it occupies cysts made by lamina? of false mem- 
brane upon the free surface of the arachnoid. (See Arch. Gen., 4e ser., xxii. 
87.) It may occupy the lateral, the third, and the fourth ventricles, having 
sometimes been found in one or more of these cavities, and sometimes in all. 
In some instances, it has been found in the ventricles and the arachnoid cavity, 
communicating with a collection of blood in the cerebral substance. In such 
cases, it is supposed that the fluid has broken a passage from its source in the 
brain, through the substance of the organ, into the cavities. 
Beyond all comparison, the most frequent form of hemorrhage is that which 
occurs in the tissue of the brain. When this is met with after sudden death, 
it is usually accompanied with evidences of general congestion within the 
cranium; the sinuses of the dura mater being full, the pia mater infiltrated 
with blood, and the cut surface of the brain exhibiting numerous little drops 
of blood. The extravasated blood is sometimes apparently infiltrated into the 
cerebral substance; but much more frequently is collected in a cavity, which 
it has hollowed out for itself. The quantity found in such cavities varies 
from a few drops to six ounces or more. The situation of the cavity may be 
in any part of the brain or cerebellum, though, according to Rochoux, it is 
very seldom in the white substance. It is almost uniformly upon the side of 
the brain opposite to the side of the body affected with palsy. When the 
hemorrhage occurs on both sides of the brain, the palsy is apt to be on the 
side opposite to the larger cavity. There is a singular tendency to hemor- 
rhage in the substance or vicinity of the corpora striata, and optic thalami. 
Of 386 cases of cerebral and spinal hemorrhage compared by Andral, 202 
showed extravasation in the hemispheres on a level with these bodies, and at 
the same time in them; 61 in the corpora striata, and 35 in the optic thalami. 
Of the remainder, 22 were in the cerebellum, 8 in the spinal marrow, and 58 
in other parts of the brain. The greater disposition to hemorrhage in the 
corpora striata, optic thalami, and their neighbourhood, is ascribed to the 
greater vascularity of that part of the encephalon. 
The walls of the hemorrhagic cavity are for a depth of one or two lines 
deep red, very soft, and of an irregular surface. Beyond this layer is usually 
another, from one to three lines thick, which is also soft, almost as much so 
as cream, but is of a light-yellow colour, and blends at its outer circumference 
with the healthy substance of the brain, so that no accurate line of separation 
can be drawn. (Rochoux.) It is asserted that the cerebral substance is some- 
times also found perfectly healthy, immediately around the blood. 
The effects of time upon the effused blood have been examined with much 
care. A few days after the effusion, it is in the form of a blackish soft coag- 
ulum. This gradually loses its colour, and acquires increased firmness, be- 
coming pale-reddish, or yellowish, and is at last wholly absorbed, leaving a 
cavity with smooth sides, which, if the cavity is small, are in contact without 
adhering, but, if large, are connected by transverse and interlacing filaments, 
forming a sort of areolar tissue, the cells of which are filled with a yellowish 
or reddish liquid of various consistence. If the hemorrhage was on the sur- 
face of the brain, a depression is left of larger or smaller dimensions. The 
coagulum may entirely disappear in four or five months, or may continue a 
year or two before being absorbed. Effusions of serum are sometimes found 
in old cases of apoplexy, as are also circumscribed softenings; and it is pro- 
bable that these conditions contribute sometimes to the fatal result. It is 
thought by Rochoux that the effused blood always leaves a visible alteration 
of the cerebral tissue behind it; and that thus the number of attacks, which 
an individual may have experienced of proper sanguineous apoplexy, may be 662 
LOCAL DISEASES.-NERVOUS SYSTEM. 
[part II. 
ascertained after death. It is not uncommon to find two or three of these 
cicatrices, and M. Moulin and Dr. Abercrombie have each seen four in the 
same individual. M. Cruveilhier has seen fifteen. (Rochoux, Diet, de Med., 
iii. 485.) The cavities, however, filled by a yellowish coloured serum, which 
Rochoux considers the remains of apoplectic effusion, are, according to M. 
Durand-Fardel and others, the result merely of cerebral softening. 
The blood effused into the natural cavities is much less readily absorbed 
than that which has formed a cavity for itself in the substance of the brain. 
In some instances, it coagulates, then gradually loses its redness, and appears 
ultimately to undergo organization, and to be converted into a kind of false 
membrane. In other instances, it becomes encysted, and is enclosed in a sac 
which has the appearance of a newly formed serous tissue. 
Causes.-That there is a condition of the system, or of the brain, consti- 
tuting a predisposition to apoplexy, cannot be doubted. Among the causes 
which give rise to this condition, and which are, therefore, predisposing causes 
of the disease, inheritance is one of the most prominent. The complaint is much 
more likely, as a general rule, to attack individuals descended from apoplectic 
parents than others. Old age is another predisposing cause, and probably 
the most powerful. Apoplexy may occur at any age; but it is vastly more 
frequent in the old than the young. Indeed, the disease is very rare under 
twenty. It is true that hemorrhage into the arachnoid is not very uncommon 
in infants. But it is not marked by the usual apoplectic phenomena, and 
ranks, by the symptoms, rather with meningitis than with the disease at pre- 
sent under consideration. The age at which the predisposition is strongest 
is above fifty. Of sixty-nine cases collected by Rochoux, two were between 
20 and 30, ten between 30 and 40, seven between 40 and 50, thirteen between 
50 and 60, twenty-four between 60 and 70, twelve between 70 and 80, and 
one between 80 and 90. Thus, it appears that there were fifty cases beyond 
the fiftieth year, to nineteen short of it. When it is considered how much 
fewer are the numbers of persons living above fifty than below it, the dispro- 
portion, great as it is, will appear to be much increased. 
It was formerly supposed that a certain physical conformation predisposed 
to apoplexy. Persons with large heads, short necks, red and turgid faces, 
full habit of body, and generally of a sanguineous temperament, were looked 
upon as doomed victims of this disease. It is true that some individuals thus 
constituted suffer with apoplectic attacks; but the vast majority escape; and 
the number of patients who want these characteristics is probably much 
greater than those who possess them. It is no uncommon event for tall and 
thin persons, with pale faces and small heads, to die of apoplexy. 
Sedentary habits with high living have been also supposed to produce a 
predisposition to the disease by generating plethora. They undoubtedly fa- 
vour its developement, when the predisposition already exists; but in persons 
without any tendency to the complaint, it is very doubtful whether they would 
occasion it. 
It is probable that certain organic diseases of the heart and of the lungs, 
by producing and keeping up for a long time congestion, either active or 
passive, of the vessels of the brain, may so derange their organization as to 
dispose them to rupture, and may thus act as predisposing causes of apoplexy. 
They are, probably, however, more frequently merely exciting causes. The 
cardiac affection for which most influence of this kind is claimed is hypertro- 
phy of the left ventricle. It appears, at first sight, reasonable to suppose that 
the vastly increased force, sometimes given to the current of blood by this 
condition of the ventricle, must be exerted with peculiar effect upon the ves- 
sels of the brain; and there can be no doubt that, when these vessels are CLASS III.] 
APOPLEXY. 
663 
already weakened, they will sometimes yield to the increased impulse, and 
rupture sooner than they otherwise would have done. Hence, cases have been 
repeatedly noticed, in which apoplexy and hypertrophy of the left ventricle 
wera associated. But I believe that much more than the due importance has 
been attached by some writers to this cause. So far as my own observation has 
gone, comparatively very few cases of disease of the heart terminate in apo- 
plexy. Cardiac affections are very common in the Pennsylvania Hospital; 
and patients frequently die of their consequences; but, during the period of 
my attendance upon that institution, I cannot recall a case in which apoplexy 
resulted. M. Rochoux states that, of forty-two apoplectic patients whose 
bodies he examined, three only presented aneurism of the heart. (Diet. de 
Med., iii. 503.) Even in those instances in which the two affections have 
been found associated, it appears to me highly probable, as suggested by Dr. 
Watson, that they may have been quite as often merely coincident, as bearing 
to each other the relation of cause and effect. The same constitutional tend- 
encies which occasion disease in the valves and parietes of the heart, would 
be likely to affect also the blood-vessels of the brain, and predispose them to 
rupture. 
It is a highly interesting question, what is the state of the brain which 
gives it a tendency to apoplectic effusion. There can be little doubt that 
organic changes in the coats of the blood-vessels, such, for example, as ossi- 
fication, and atheromatous deposits or fatty degeneration, may so far lessen 
their power of resistance as to lead to rupture upon the application of any 
unusual force. Hence, perhaps, in part, the peculiar liability of old people 
to the disease. An aneurismal state of the cerebral vessels has been occa- 
sionally observed, and it is possible that this may sometimes be the cause of 
rupture, even when it escapes observation. The opinion appears to me very 
plausible, which ascribes the occurrence of apoplexy, in the greater number 
of cases, to a previous disease of the cerebral substance, predisposing it to 
hemorrhage. This opinion is ably supported by Rochoux, who considers 
hemorrhagic apoplexy, with effusion into the substance of the brain, as de- 
pendent in almost all cases upon a peculiar previous softening of the cerebral 
substance. Such a softening is almost always observed around the collection 
of blood; according to Rochoux in ninety-nine out of one hundred cases. 
(Ranking's Half-yearly Abstract, i. 204.) This softening he believes to be 
peculiar, and not dependent upon inflammation. It is true that other ob- 
servers, as Cruveilhier, Carswell, and Durand-Fardel, consider the softening 
as consequent upon the hemorrhage, and not antecedent to it. It is asked, 
why the attack of apoplexy is so seldom preceded by signs of cerebral dis- 
ease, if so serious an organic change has been going on in the substance of 
the brain? But this objection is met by the fact, that such changes have 
frequently existed in organs without any obvious signs during life, and have 
been first revealed by dissection. Besides, there often are preliminary symp- 
toms of a marked character; and it appears to me that the theory of M. 
Rochoux affords the best explanation of their occurrence. Admitting the 
previous existence, in many instances, of this hemorrhagic softening, we have 
been, until of late, completely in the dark as to its nature and immediate cause. 
But some observations of Mr. Paget, communicated to the London Medical 
Gazette in February, 1850 (page 229), render it in the highest degree pro- 
bable that, in many cases of apoplexy with cerebral softening, the previous 
condition of the brain is connected with, if it be not dependent on a fatty 
degeneration of the minute cerebral vessels. In such cases, even in the appa- 
rently healthy parts, minute particles of oil may be detected by the aid of the 
microscope, scattered in the substance of the vascular coats; while, in the 664 
LOCAL DISEASES.-NERVOUS SYSTEM. 
[part II. 
diseased part, the vessels are so beset with them that the healthy structure 
becomes wasted, and at length completely lost, so that the vessel ruptures with 
great facility, and of course permits hemorrhagic effusion. Still it cannot be 
considered as proved that, in this cerebral softening, the fatty degeneration is 
exclusively or essentially in the coats of the vessels. It may also be, and pro- 
bably is in the extravascular tissue. Sex appears to have some influence in 
the production of the apoplectic predisposition; at least men are more subject 
to the disease than women. Thus, of 2297 cases compared by M. Falret, 
1670 were in men, and only 627 in women. (Archives Generates, tom. ii.) 
The immediate or exciting causes of the apoplectic seizure are very nume- 
rous. It must be admitted that the attack not unfrequently occurs as the 
result of previous disease of the brain or its vessels, without any obvious excit- 
ing cause. Thus, it often happens that the patient is attacked while sitting, 
standing, or quietly walking, without the least unusual physical effort, and 
without any mental excitement or disturbance. Indeed, instances are not 
uncommon in which the seizure takes place during sleep. But in other in- 
stances, and those very numerous, the result can be clearly traced to some direct 
cause. Whatever is capable of increasing the force of the circulation, and 
especially of giving it a peculiar direction to the brain, and whatever impedes 
the return of blood from that organ, and thus produces congestion of its veins 
and sinuses, may act as the immediate cause of apoplexy. It is probable that 
such causes alone, without any peculiar predisposition, may produce the simple 
congestive form of the disease. It is even possible that they may occasion 
hemorrhage by transudation into the cavity of the arachnoid and ventricles, in 
a previously sound state of the brain. It is by no means certain that they may 
not also occasion rupture of healthy cerebral vessels, in the substance of the 
brain, when operating with peculiar violence. But the circumstance that apo- 
plexy so seldom occurs in the young, who are even more exposed than the aged 
to these exciting causes, proves conclusively that, without aid from other influ- 
ences, they are seldom alone adequate to the production of the disease. Among 
the causes alluded to may be enumerated, 1. strong muscular effort, as lifting 
heavy burdens, violent coughing or sneezing, straining at stool, the act of 
vomiting, playing upon wind instruments, excessive exertion of the voice, the 
act of coition; 2. any position favouring the accumulation of blood in the brain, 
as stooping, suspension by the feet, and turning the head strongly in a direction 
differing from that of the body, so as to compress the jugulars; 3. compression 
of the neck by tight cravats or other ligatures, and general compression of the 
trunk; 4. external stimulation immediately to the head, as by the direct rays 
of a hot sun, and the heat of an intense fire; 5. internal stimulation directed 
especially to the brain, as by violent emotion, and the use of alcohol or other 
cerebral stimulant; 6, increased force of the general circulation, from hyper- 
trophy of the left ventricle, indulgences of the table, the hot bath, &c.; 7. 
transfer of morbid action, from repelled eruptions, retrocedent gout or rheuma- 
tism, the healing of old ulcers, the suppression of accustomed discharges; and 
8. organic or other affections impeding the return of blood from, the head, 
including tumours pressing on the jugular veins, diseases of the heart, con- 
gestion of the lungs, &c. Excessive cold is said also to produce apoplexy, 
probably by concentrating the blood in the interior organs. 
Nature.-The definition of apoplexy given in this work implies that the 
essence of the disease is a sudden pressure upon the brain. The pressure is 
produced by an active or passive congestion of the cerebral vessels, by effusion 
of serum, or by hemorrhage. Active congestion may be the result of an irri- 
tation in the brain, inviting, or of an exterior force, compelling, an undue 
quantity of blood into the organ. Passive congestion is produced by whatever CLASS III.] 
665 
APOPLEXY. 
prevents the return of blood from the head. In the former, it is the arteries 
•which are loaded; in the latter, the veins and sinuses. The effusion of serum 
may be the consequence of obstruction of the veins by tumours, &c., of a 
general dropsical disposition in which the cerebral membranes may participate, 
or of a vascular irritation or inflammation of the arachnoid. Hemorrhage may 
be the result either of transudation, or of rupture of the vessels. The former 
may perhaps be the case, in general, when the blood flows primarily into the 
cavities, the latter when it collects within the substance of the brain. 
It has been questioned whether the brain is capable of being compressed. 
Observation has decided the question in the affirmative. In cerebral hyper- 
trophy, the organ after death expands considerably upon the opening of the 
cranium and dura mater, proving that it was previously in a state of com- 
pression. But, even allowing the essential incompressibility of the cerebral 
substance, there is little difficulty in explaining, to a certain extent, the effects 
of pressure in producing the symptoms of apoplexy. Every action of the 
brain, or any portion of it, requires a certain amount of arterial blood, either 
as a stimulus, or as furnishing materials essential to the action. If the sup- 
ply of fresh blood be unduly diminished, the actions also languish or cease. 
The brain can no longer perform its duty of receiving impressions, transmit- 
ting motive power, or generating thought. Palsy of sensation and voluntary 
motion, and the loss of consciousness are necessary results; and these are the 
symptoms of apoplexy. But in what manner is the supply of blood to the 
acting cerebral substance diminished in this disease? In the first place, in 
active congestion, as more blood is invited or forced into the arteries than 
legitimately belongs to them, the increased space thus occupied must be gained 
at the expense of all compressible spaces ; and the veins must therefore receive 
less, and consequently convey back the blood more slowly than in health. A 
stagnation in the capillaries is a necessary consequence, and the blood in them, 
soon becoming changed, can no longer afford the essential stimulus or ma- 
terial. In passive congestion, on the contrary, the gain by the veins must be 
supplied at the expense of the arteries, which are compressed, and less blood 
enters the capillaries than is essential to the due support of the cerebral functions. 
In serous and sanguineous effusion, it is obvious that the space occupied by the 
liquid is abstracted from that of the veins and arteries conjointly, and there is a 
consequent deficiency of the pabulum essential to action in the nervous centres. 
The above course of reasoning explains the phenomena so far as the centres 
are concerned. It is probable also that the apoplectic symptoms may arise, in 
part, from an interruption of the communication between the nervous centres 
and the external parts under their control. The connecting cords may be so 
compressed that influence is but imperfectly conveyed along them in either 
direction, or they may be ruptured, as in effusion of blood into the cerebral 
substance, and their function cease altogether. In the former case, there may 
be imperfect sensation and imperfect motion; in the latter, there must be a 
total want of both, so far as regards the. particular part to which the commu- 
nicating fibrils that have been ruptured run. Nor is it difficult to account, in 
the same way, for the absence of sensation alone in some cases, and of motion 
in others. All that is necessary to be supposed is, that the nervous cord which 
conveys impressions to the nervous centre is ruptured or compressed in the 
former cases, and that which carries the motor impulse in the latter. That 
respiration continues, during the deficiency of the other functions, must arise 
from the fact, that the centre which governs that funciion is less liable than 
the sensorial centres to the effects of the compression within the cranium. 
Lying near the great outlet of the cavity, it probably participates partly in the 
security of the nervous structure without the enclosure. Should the medulla 666 
[PART II. 
LOCAL DISEASES.-NERVOUS SYSTEM. 
oblongata be the immediate seat of the compression, life might cease imme- 
diately from the cessation of breathing; and this is probably the case, in some 
instances of sudden death, and in some of those in which great prostration is 
experienced at the commencement, with coldness of the surface, feebleness of 
pulse, and a failing respiration. 
Diagnosis.-Is it possible to distinguish the varieties of apoplexy, depend- 
ent upon difference in the compressing cause; or to determine the portion of 
the brain occupied by the effused blood, when that is the source of the pheno- 
mena? I believe not with any certainty or precision. Occasionally, how- 
ever, we may reach very probable conclusions. When the attack speedily 
subsides, .without producing palsy, or at least without leaving any paralytic 
phenomena behind it, and without any of those mental deficiencies which 
indicate a structural lesion of the brain, we may infer that it was congestive; 
and, whether active or passive, might be determined in some instances by the 
nature of the cause, and in most, with some degree of probability, by the 
symptoms which ordinarily distinguish the two conditions elsewhere; as a full 
strong pulse with a red flushing of the face, in the active, and a comparatively 
weak or natural pulse, and a livid hue of the countenance, in the passive. But 
it would be going too far, to say that no case could be one of mere congestion 
in which a paralytic effect remained, or that the affection must be necessarily 
congestive when unaccompanied with palsy. It is well known that congestion 
alone may produce palsy; and it is possible that the paralytic effect may con- 
tinue for some time after the cause of it has ceased; just as the palsy of an 
arm produced by pressure upon the nerve, often outlasts considerably the 
compressing cause. It is, moreover, not at all impossible that hemorrhage 
may exist without producing observable paralysis. 
It was formerly supposed that the existence of serous apoplexy was indicated 
by paleness of the face and feebleness of the pulse. Experience, however, has 
proved this notion to have been a fallacy. It is, indeed, impossible to diag- 
nosticate these cases with an approach to certainty. When the attack super- 
venes upon chronic disease of the brain, or accompanies an obvious dropsical 
diathesis, or is marked by the occurrence of general instead of local or partial 
palsy, it may be suspected to be of this nature. 
Hemorrhagic apoplexy may be diagnosticated when hemiplegia precedes the 
seizure, and generally, when this or any other form of palsy is left behind, 
after the apoplectic symptoms have disappeared. Should palsy of all the limbs 
result, the inference would be that the effusion of blood had been great. When, 
after a partial or complete loss of consciousness, the patient recovers, and soon 
afterwards becomes comatose with the ordinary symptoms of apoplexy, the 
case may be almost always regarded as hemorrhagic. 
In relation to the seat of the effusion, inferrible from the symptoms, all 
that can be said with an approach to certainty is, that hemiplegia or partial 
palsy upon one side of the body indicates the existence of hemorrhage upon 
the opposite side of the brain; and this is true also, as a general rule, when 
the cerebellum is the seat of the hemorrhage, although the fibres of that 
structure do not, like those of the cerebrum, decussate before passing out of 
the cranium. More will be said upon this point under the head of palsy. A 
connexion has also been observed between apoplexy of the cerebellum and dis- 
order in the sexual appetite; so that any unusual exaltation of this propensity, 
or striking loss of it, immediately before the apoplectic seizure, might lead to 
the suspicion that the Cerebellum was the seat of the disease. 
The diagnosis between apoplexy and coma occurring from other causes is 
not always easy. When the insensibility has occurred suddenly, and is at- 
tended with a flushed and turgid face, a full, strong and slow pulse, and a CLASS III.] 
667 
APOPLEXY. 
slow, stertorous breathing, the probabilities are strongly in favour of apoplexy; 
and the probability is converted into certainty by the simultaneous occurrence 
of hemiplegia, or palsy of any one portion of the body. But cases of apoplexy 
are not always marked by these symptoms. Sometimes stertor is absent, the 
face is pale, and the pulse feeble and perhaps frequent. Even in such a case, 
the existence of palsy would decide the question. But even this diagnostic 
character may be wanting; or the palsy may have pre-existed. Under such 
circumstances, the decision must be based upon the history of the case, and 
upon the absence of characters indicating the existence of other kinds of coma. 
For the diagnostic characters of these affections, the reader is referred to Func- 
tional Disease of the Brain, Epilepsy, Hysteria, Meningitis, and Cerebritis. 
There are, however, two or three conditions, which may with propriety be 
particularly noticed in this place. 
The coma produced by narcotic poisons, particularly such of them as may 
be denominated cerebral stimulants, sometimes closely resembles apoplexy. 
Profound intoxication from alcohol, and still more, perhaps, the stupor from 
opium, strongly simulate that disease. To distinguish them, the circum- 
stances under which they occurred should be ascertained, if possible; whether, 
for example, the patient had been drinking spirituous liquors, or had been in 
a situation in which he might be supposed to have been drinking; whether an 
empty laudanum bottle was to be found upon his person, or in his vicinity; 
whether any cause for the commission of suicide existed, &c. &c. The smell 
of the breath will often serve as a diagnostic character. The absence of palsy 
in any one portion of the body; the general capability of being somewhat 
roused in the earlier stages of narcotic poisoning; the extreme dilatation of 
the pupil from certain narcotics, as stramonium and belladonna; the gradual 
progress of the symptoms, from a state of more or less excitement, to drowsi- 
ness, stupor, and ultimately coma; these circumstances, when existing, should 
have their weight in influencing the decision. When apoplexy may have 
been induced by alcoholic drinks, the case becomes more complicated, and at 
a certain point in the affection, it might be impossible, in the absence of palsy, 
to decide the question. In the last stage of narcotic poisoning, when the coma 
is profound, the pulse has given way, and the general relaxation of the muscles 
is complete, the diagnosis must be based exclusively on pre-existing and at- 
tendant circumstances; and here the age of the patient would be of much 
assistance. In a young person, the presumption would be in favour of some 
other affection than apoplexy. The poisoning from irrespirable gases or 
vapours is generally known from the circumstances of its occurrence. In 
these cases, the pulse is apt to be weak, the surface cool, and the face, though 
it may be coloured, is rather livid than reddened. 
The effects produced upon the brain by an accumulation of urea and of 
bilious matter in the blood, sometimes bear a close resemblance to apoplexy; 
and, indeed, the suggestion has been advanced, that most of the cases of 
nervous apoplexy, as they have been called, might be referred to the exist- 
ence of Bright's disease of the kidneys. Two cases of this kind are recorded 
by Dr. J. A. Wilson. (See Diet, de Med., iii. 458.) The gradual progress of 
the symptoms, the general absence of palsy, the suppression or great diminu- 
tion of the renal secretion, with the presence of albumen in the urine, the 
existence of jaundice or-of white or clay-coloured stools, would be sufficiently 
diagnostic. It is quite evident that the disease differs wholly from apoplexy 
as here defined. The one depends upon a poison accumulated in the blood, 
the other upon pressure on the brain. 
Perhaps the affection most difficult to be distinguished from apoplexy is 
the coma of chronic cerebritis, or of cerebral softening whether inflammatory 668 
[PART IT. 
or not. The difficulty of decision, in these cases, arises chiefly from the 
association of partial palsy with both affections. But the preliminary symp- 
toms in cerebritis, especially the paroxysmal headache with vomiting, and 
the complication of the paralysis with rigid contraction of the flexor muscles 
of the extremities, will generally serve to distinguish it. In acute cases, the 
diagnosis is more difficult, and must rest chiefly on the greater tendency to 
muscular rigidity in the cerebral inflammation. Not unfrequently, the two 
affections are associated; apoplexy either supervening upon softening, or giv- 
ing rise to it after the effusion of blood has taken place. 
Prognosis.-Apoplexy is a very serious disease, though very often not 
immediately fatal. The cases consisting of congestion solely almost always 
recover under proper treatment. The patient may, indeed, survive numerous 
attacks of this form of apoplexy; but there is always danger that a congestive 
stroke may be followed by one of a hemorrhagic character; and when this 
danger is escaped, the disease, as already stated, is apt to leave traces behind 
it in an enfeebled condition of the memory and intellect. 
The hemorrhagic and serous forms of apoplexy are much more fatal. Ro- 
choux thinks that less than one-third of the number attacked perish from the 
immediate effects of the blow. Among the signs which threaten an unfavour- 
able issue, are convulsions, general paralysis, deep coma lasting two or three 
days, a gradual onset of the disease ending in profound coma and paralysis, 
complete immobility of the pupil, inability to swallow, flapping of the cheeks 
in respiration, foaming at the mouth, frequent yawning or sighing, repeated 
vomiting, involuntary evacuations, a frequent and irregular pulse, cold extre- 
mities, cold and clammy sweats, and a failure of the circulation succeeding 
great strength of pulsation, without any amendment in the other symptoms. 
The patient may survive the occurrence of any one of these phenomena; but 
they must always be regarded as dangerous signs; and, when several of them 
are presented in the same case, the hope of a cure is feeble. In judging of 
the probable result, reference must be had to the number of previous attacks, 
and to the age of the patient. The prognosis is more unfavourable in the old 
than in the young, and, upon the whole, in proportion to the age. A second 
attack is more apt to be fatal than the first; and a third than the second. 
Favourable signs are the absence of those above mentioned, and a general 
subsidence of the symptoms. In relation to the ultimate result, the prognosis 
is, on the whole, unfavourable. The individual once attacked with hemor- 
rhagic apoplexy, if he escape for the time, is very apt to die in the end, either 
of a fresh attack, or of a general failure of the vital functions, consequent 
upon the mischief done to the brain. 
Treatment.-The indications of treatment are to check the hemorrhage, or 
reduce the congestion, to prevent a renewal of either affection, to obviate in- 
flammation, and to promote the absorption of blood or serum that may have 
been effused. The same measures are calculated to meet most of these indi- 
cations. The patient should be placed in a recumbent position, with his head 
and shoulders somewhat elevated by pillows; everything which acts as a liga- 
ture, should be removed from the neck and chest; and the air of the chamber 
should be rather cool, and frequently renewed. Persons not concerned in the 
treatment should be removed from the apartment. 
If the strength of the pulse admit, blood should be drawn immediately 
from the arm, through a large orifice, and to an extent proportionate to the 
vigour of the patient, and the force of the circulation. But bleeding is not 
to be indiscriminately resorted to, or pushed to an unlimited extent. Much 
injury has probably been done in this disease by excessive bleeding. It is 
not, in the first place, inflammation that is to be subdued, but merely hemor- 
LOCAL DISEASES.-NERVOUS SYSTEM. CLASS III.] 
669 
APOPLEXY. 
rhage or congestion. The object of bleeding is not now so much to alter the 
character of the blood, as to check the current of it towards the head. If 
nature has already accomplished this purpose by a great reduction of the 
heart's impulse; if the pulse at the wrist, instead of being full and strong, as 
it generally is, should be small and feeble, there is no advantage to be derived 
from the further loss of blood at the commencement of the treatment. It 
should be remembered that, in the hemorrhagic and serous cases, the disease 
is not over when the effusion is suppressed. The brain has sustained a great 
shock, and a long series of actions in the organ will be necessary to repair the 
mischief done. It is bad practice to destroy the resources of the system, 
which may be necessary to sustain this course of action, by an inconsiderate 
and exclusive obedience to the first indication; that, namely, of arresting 
effusion, or correcting congestion. I would repeat, that the practitioner 
should be guided by the strength of the pulse whether he shall bleed or not; 
and by this, in connexion with the general state of the constitution, to what 
extent he shall bleed. From fifteen to thirty ounces may be taken from a 
robust patient at the first bleeding, should the pulse bear the loss well. But 
the operation should be checked as soon as the circulation shows evident signs 
of having slackened in force. The bleeding may sometimes be performed a 
second, third, or even fourth time, should the vigour of pulse continue ; the 
quantity taken being diminished each time. Allowance must be made for 
the pulse of hypertrophy of the left ventricle, which is sometimes full and 
strong almost to the last moment of existence. Very often a single bleeding 
will be found amply sufficient. 
After the circulation has been sufficiently reduced by general bleeding, 
and without that remedy should the pulse be feeble at the commencement, 
blood may be taken locally, by cups or leeches, from the temples or the back 
of the neck. From the great relief sometimes afforded to cerebral congestion 
by a moderate epistaxis, there would seem to be a propriety in applying 
some leeches to the interior of the nostrils. This situation for* local depletion 
would be especially indicated, if the attack should have succeeded a suppressed 
epistaxis. When the apoplectic attack has followed the suppression of hemor- 
rhage from the rectum or uterus, or of the menses, leeches should be applied 
to the anus or vulva. As the later bleedings are generally attended with the 
appearance of the huffy coat, signifying the existence of some inflammation 
in the brain, probably induced by the presence of the clot of blood, the local 
bleeding is especially indicated at this stage of the disease. 
Some authors have recommended emetics in apoplexy, and most continue 
to recommend them in cases which may have followed a full meal. I think 
that, in genuine hemorrhagic apoplexy, they can never be otherwise than 
injurious. If any one who may have vomited severely, will call to mind the 
feeling of intense distension in the temples, and general cerebral fulness, of 
which he has been sensible during the act, he would dread the thought of 
putting the vessels of the brain upon such a stretch, when already pouring 
out blood, or but just recovered from the hemorrhagic act. It seems to me 
that it could scarcely otherwise happen than that injury should result. If 
the stomach has been filled, it will gradually empty itself, even though the 
contents may be alcoholic; and, in the meantime, we have it in our power by 
means of the lancet, rest, position, &c., to control the force of the excited cir- 
culation. In those cases of coma from sympathetic irritation, which some- 
times follow the use of indigestible food, and which are anything but apo- 
plectic, an emetic is often of great service; but never probably in true apo- 
plexy; at least never with sufficient certainty to justify the hazard. Should 
the patient spontaneously vomit, or be affected with retching, it may be 670 
[part II. 
LOCAL DISEASES.-NERVOUS SYSTEM. 
proper to facilitate the process, and calm the stomach by free dilution with 
mild liquids; but this very seldom happens in genuine apoplexy. The late 
Dr. Parrish used to mention to his pupils the case of a young man who died 
of apoplexy, induced by the action of an emetic; and Andral relates a case, 
in which vomiting was obviously followed by a renewed attack, in a patient 
already apoplectic. {Clin. Meld., v. 102.) 
Purging is very useful in apoplexy. It acts not only by depleting, but also 
by a powerful revulsion from the head, along the whole track of the aliment- 
ary canal. Active purgatives should be used at first. If the patient is able 
to swallow without much difficulty, the infusion of senna with sulphate of 
magnesia is probably the best cathartic that can be given. When there is 
reason to think that portal congestion or torpidity of the liver is associated 
with the attack, a full purgative dose of calomel should be administered, and 
followed by castor oil or Epsom salt. If there is difficulty of deglutition, 
croton oil may be administered in the dose of a drop every hour or two till it 
operates. Sometimes it will be found the best plan to put a drop of this 
medicine upon the back part of the tongue, and allow it to remain until it 
excites the movement of deglutition. Should the throat be so far paralysed 
that the patient cannot swallow, strong infusion of senna, or some other active 
cathartic should be given by enema. 
In ordinary cases, cold should be applied to the head by means of cloths 
wet with iced water, or of bladders or water-proof bags filled with small pieces 
of ice. (See Meningitis, page 629.) But if the surface is cool, the face pale, 
and the pulse feeble, this remedy is contraindicated. Under these latter cir- 
cumstances, some recommend warm emollient applications. 
Revulsion to the extremities should be kept up by the occasional use of hot 
stimulating pediluvia, sinapisms, &c. 
When the force of the circulation has been sufficiently reduced by the above 
measures, and the comatose symptoms continue at the end of three or four 
days, the head should be shaved, and the whole scalp covered with a blister. 
A powerful exterior revulsion is thus effected, and any tendency to inflamma- 
tion of the meninges strongly counteracted. 
Lastly, should the disease not yield to these measures, the effect of a mer- 
curial impression should be tried. If unsuccessful, it can do no harm; if suc- 
cessfully brought about, it may prove useful in counteracting inflammation, 
and promoting the absorption of the effused blood, two of the indications above 
referred to. A very sore mouth, or profuse salivation should not be aimed at. 
A mercurial pill, or a grain of calomel may be given every two or three hours, 
and the operation assisted by gentle mercurial friction upon the inside of the 
thighs and arms. 
In the cases with depressed circulation, pale and cold surface, and collapsed 
rather than turgid countenance, should the debility not be in itself alarming, 
it may be proper to take some blood locally by cups or leeches from the tem- 
ples or back of the neck, or to make a small tentative bleeding from the arm. 
If, by the loss of a little blood, the pulse should acquire increased fulness 
and strength, it would be proper to proceed further; if, on the contrary, it 
should become somewhat more depressed, all thought of direct depletion 
should be abandoned, and the treatment should be confined to moderate pur- 
gation, revulsion towards the extremities, and to the surface of the scalp, and 
a gentle mercurial impression. Sometimes the debility approaches to syncope, 
and imperiously demands the employment of supporting measures. In such 
cases, an injection of oil of turpentine may be thrown into the rectum, blisters 
and rubefacients applied to the skin, and, if these should not sufficiently ex- 
cite the circulation, carbonate of ammonia, arnica, capsicum, oil of turpentine, CLASS III.] 
671 
APOPLEXY. 
&c., may be given by the mouth; care being taken to avoid stimulants dis- 
posed to act immediately upon the brain, such as the fermented or distilled 
liquids, unless under circumstances of the strongest urgency. 
During the treatment, attention should be paid to the bladder, and the urine 
drawn off regularly if requisite by the catheter. Upon the restoration of con- 
sciousness, the greatest care should be taken to avoid all disturbances whether 
moral or physical. The diet should be of the lowest kind in the early stages, 
consisting of farinaceous or demulcent drinks, when the patient can swallow. 
As the case advances, it should be improved, and, in convalescence, the milder 
forms of animal food may be allowed in great moderation, such as milk, a soft 
boiled egg daily, boiled fowl or mutton, &c., in connexion with vegetable sub- 
stances. All premature efforts on the part of the patient should be sedulously 
guarded against. In the prostrate cases, it may be necessary to give animal 
broths even at an early period. 
Should paralytic symptoms succeed those of apoplexy, the treatment must 
be conducted upon the plan recommended under the head of palsy. 
Prophylactic Treatment.-This is of great importance in apoplexy. After 
one attack, the patient should be considered as peculiarly prone to the disease, 
and put upon his guard at all points. His bowels should be kept regularly 
open once a day; and, if any tendency to constipation exist, he should take 
occasionally a small dose of sulphate of magnesia, or some other saline ca- 
thartic. Should vertigo or headache, with a flushed face, and a strong full 
pulse, come on at any time, no hesitation should exist in employing the lan- 
cet, or in taking blood locally from the head, or in the use of an active purge, 
according to the urgency of the symptoms. Care, however, should be taken 
not to confound merely nervous sensations from disordered digestion, hysterical 
tendencies, or other cause, with those resulting from sanguineous congestion. 
All the causes of the disease should be most carefully avoided. The diet of 
the patient should consist chiefly of vegetable food and milk, with the lighter 
meats, especially boiled meats, in moderation. Stimulating drinks and con- 
diments should be wholly proscribed. Even tea and coffee, if used at all, 
should be taken weak and in small quantities; and black tea should be pre- 
ferred. The object should be to avoid plethora on the one hand, and anaemia, 
which provokes excessive action of the heart, on the other. The patient should 
take moderate exercise, particularly of the passive kind; but should avoid 
all active muscular exertion, should never -strain under any circumstances, 
even at stool, should never walk fast, or run, or mount a flight of stairs hastily. 
He should always sleep with the head elevated, and, though taking care to 
keep sufficiently warm at night, should avoid the other extreme of excessive 
heat. In warm weather, a mattrass should be preferred to a feather bed. In 
the use of the bath, care should be taken that it be not heated above 98°. 
The hot bath produces often almost as powerful an impression on the brain 
as wine. The cold bath should also be used with caution. Though the patient 
might often employ it with impunity and even advantage to his general health, 
yet there is always the risk that the blood may be too suddenly concentrated 
in the brain. Nor is less caution necessary in watching over his mental con- 
dition. It should be the care of the patient's life to maintain an equable frame 
of mind, and never to allow himself to be excited into passion or strong 
emotion by any of the varying interests, or conflicts, or vexations of this 
world. Severe intellectual occupation, also, if previously the habit of the 
patient, should be abandoned for the remainder of life. In short, it should 
be his aim, and that of his medical adviser, to maintain in all things, in eat- 
ing, drinking, exercise, employment, pleasure, and pursuits of every kind, 
as well as in the state of the bodily functions, a wholesome moderation. 672 
[part ii. 
LOCAL DISEASES.-NERVOUS SYSTEM. 
Article IV. 
FUNCTIONAL DISEASES OF THE BRAIN. 
There are two points of view from which functional disease of the brain may 
be regarded; first, in relation to the pathological state of the organ ; secondly, 
in relation to certain symptoms or groups of symptoms, which, though in some 
instances they have the rank of diseases, are in fact only the effects of the 
true disease, and the signs by which it is made known. It will contribute to 
a clearer understanding of the subject, to consider it in both these lights. 
Before entering upon the special affections, there is one preliminary con- 
sideration which it is necessary to present to the student. A remarkable fact, 
familiar to all pathologists, is, that similar phenomena very often proceed from 
precisely opposite conditions of the brain; so that it is occasionally very dif- 
ficult to decide, from the symptoms alone, what is its real pathological state. 
To some pathologists this fact seems so difficult to be reconciled to a sound 
philosophy, that they have endeavoured, in the seemingly opposite states of 
the part, to discover some one action or influence of an identical character, to 
which the effects may be ascribed. Such an influence is supposed to have 
been found in pressure on the brain, which is said to be produced when the 
condition of the cerebral circulation is in any way disturbed. Thus, if too 
much blood is sent into the arteries, pressure upon the cerebral substance in 
their vicinity is the necessary result. If too little is sent, then, as the cranium 
is a plenum, always kept full by the pressure of the atmosphere, there must 
be a corresponding excess in the veins, so that pressure is exerted in their 
neighbourhood. But this explanation is unsatisfactory. In the first place, 
it does not meet those cases in which the blood is altered in quality only, 
nor those in which the morbid phenomena are purely nervous without any 
vascular change ; and, in the second place, assumes, as the result of pressure, 
symptoms which are very different from such as are known to proceed from 
that cause. Thus, stupor is well known to be produced by pressure; but I am 
not aware that morbid vigilance has ever been shown to be among its effects. 
But this peculiarity of cerebral disorder is really not so anomalous as at 
first sight it may seem to be. . The phenomena of electricity, analogous, in 
various respects, to those of nervous action, are not less so in the present case. 
We obtain effects, to ordinary observation precisely the same, from positive 
and negative electricity. Both produce attraction and repulsion, the electric 
spark, the shock, and chemical decomposition. It is not surprising, there- 
fore, that the brain, which is the great nervous battery, should exhibit similar 
effects from precisely opposite conditions. It is true that science can detect 
a difference between the effects of positive and negative electricity. It is 
highly probable that a similar difference will some time be detected also in 
the seemingly identical results of opposite cerebral disturbance. As it is, we 
can often, by a close observation, discover peculiarities which enable us to 
determine, with sufficient certainty, the particular pathological condition in 
which the phenomena, in any special case, may have originated. I do not 
wish it to be inferred that I believe the brain to act in the same manner as a 
galvanic battery. My object is simply to prove that, in the apparent contra- 
diction, there is in fact nothing opposed to the course of nature in other 
departments, and consequently nothing impossible, or really contradictory. CLASS III.] 
NERVOUS IRRITATION OE THE BRAIN. 
673 
I. PATHOLOGICAL CONDITIONS. 
These may be included under the divisions of 1. pure nervous irritation, 
without any necessary participation of the blood-vessels; 2. vascular irritation, 
or active congestion; 3. depression, whether nervous or vascular; and 4. 
mechanical or passive congestion. 
1. Nervous Irritation.-The brain is peculiarly susceptible to irrita- 
tation of an essentially nervous character; that is, without necessary partici- 
pation of the blood-vessels. Too exclusive an importance has, I think, been 
attached to the state of the circulation in this organ. All the morbid pheno- 
mena have been ascribed by some pathologists to too much or too little blood, 
or to its unequal quality or distribution. These are undoubtedly frequent 
sources of cerebral disorder; but the brain is also frequently excited into dis- 
ease without them. The nervous system has a mode of action of its own, in 
which, though blood may be necessary as an instrument, it is not the main 
operating principle. This action is susceptible of exaltation, depression, or 
depravation in itself, and from the influence of its own peculiar agents. The 
fact here stated is not of merely speculative interest. It is in the highest 
degree practically important; and a vast deal of mischief has been done by 
looking to the blood-vessels exclusively as the seat or source of cerebral dis- 
order. But, in thus asserting for the nervous functions a capacity of exclu- 
sive and independent disease, we must not forget that their irritation frequently, 
in the end, involves the blood-vessels; and that the affection, if not relieved, 
may terminate in active congestion or inflammation. 
Symptoms.-As the offices of the brain are numerous, so also must be the 
signs of its excessive excitation. To enumerate all these in the present place 
would be quite out of the question. Irritation in the brain obeys the general 
laws of that morbid affection. If moderate, it exalts the healthy functions 
without otherwise altering them ; if stronger, it more or less deranges the func- 
tions; in great excess, it entirely changes or abolishes them. Thus, sensation 
and perception maybe simply rendered more acute; or they may be deranged, 
producing vertigo, pain, and every variety of disorder in vision, hearing, touch, 
&c., from buzzing in the ears, unnatural colouring of objects, a sense of tin- 
gling, formication, &c., to complete hallucination. The intellectual faculties 
and the emotions may be excited into increased vigour, or may be completely 
perverted, as in delirium and insanity. The general overseeing faculty of the 
brain may be simply stimulated to increased vigilance, to a more ready and 
rapid response to all the intimations of its dependent functions; or it may be 
thrown into excessive disorder, evinced by restlessness, jactitation, obstinate 
sleeplessness, &c. The motor faculty may merely impart increased activity 
and energy to the muscles under the influence of the will; or it may throw off 
more or less completely subordination to that principle, and give rise to every 
variety of spasm and convulsion. Finally, all the functions above referred 
to may be overwhelmed by an excess of the irritation, and more or less com- 
pletely lost in stupor and coma. 
Not only the proper cerebral functions become deranged in this species of 
irritation, but to a certain extent, also, many, I might perhaps say, all those 
of organic life. Connected with the digestive function we often have nausea 
and vomiting; with the secretory, disorder of the liver and kidneys; with the 
respiratory, hurried and otherwise irregular breathing; with the circulatory, 
a frequent and agitated, though seldom full or energetic pulse. 674 
LOCAL DISEASES.-NERVOUS SYSTEM. 
PART II. 
Various special diseases either consist exclusively in some modification of 
cerebral nervous irritation, or frequently partake of that affection. Such, 
among others, are insanity, epilepsy, chorea, neuralgia, and hysteria. Fre- 
quently also, it is met with at the threshold of other diseases, in which the 
morbid action consists mainly in vascular irritation or inflammation. It exists, 
moreover, very often in its milder grades, without receiving any other name 
than the vague one of nervous disorder. 
Causes.-1The nervous temperament, great mobility of the nervous system, 
as in children and females, and debility or poverty of the blood predispose to 
this form of disease. Causes which, in a vigorous frame, might induce vas- 
cular irritation, are apt in debility to excite only the nervous. Anaemia 
operates especially as a predisposing cause. When the blood is not rich 
enough to supply the wants of the system, the cerebral centres receive inti- 
mation of the deficiency from every function, in order that the due influence 
may be transmitted to the heart, and are kept in a constant state of excite- 
ment, which itself often amounts to irritation, or readily becomes so by the 
addition of any new stimulus. 
The exciting causes are excessive intellectual action, violent emotion, strong 
impressions from without upon the senses, and almost every variety of local 
irritation elsewhere, especially in the gums, the stomach, the bowels, and the 
uterus. The headache accruing from acid in the stomach, the delirium some- 
times excited by excessive pain, the insanity from hepatic disease, the coma 
of uterine affections, and the convulsions from intestinal spasm in infants, are 
often examples of this kind. 
It is important, in reference to treatment, to make a correct diagnosis be- 
tween purely nervous and vascular irritation of the brain; but the distinguish- 
ing characters will be most conveniently given under the following head. 
Treatment.-It is only the general principles of treatment that can be 
given in this place. The indications are, 1. to remove the cause of irritation, 
whether predisposing or exciting; 2. to diminish the susceptibility, or directly 
to repress the excitement of the cerebral centres; and 3. to equalize the nerv- 
ous action, either by medicines calculated to stimulate the whole nervous sys- 
tem, or by revulsive impressions upon other parts of the body. 
To meet the first indication, the patient must be protected as far as possible 
from exterior sources of irritation; and a close scrutiny into the state of all 
the organs must be instituted, in order that any existing disease in any por- 
tion of the system may be corrected. As a debilitated and anemic condition 
of system predisposes to the complaint, such a condition, if present, should 
be removed by the chalybeates and other tonics, exercise, pure air, and a 
nourishing diet. 
The second indication is to be fulfilled by opium and other narcotics, as 
extract of hemp, hyoscyamus, belladonna, stramonium, conium, aconite, chlo- 
roform, tobacco, digitalis, and hydrocyanic acid; the most efficient, beyond all 
comparison, being opium in some one or other of its various forms of prepara- 
tion. When the cause is temporary, this narcotic will often at once most happily 
control the disease. Thus, I have seen the most violent delirium, depending 
upon temporary excitement, yield immediately to a full dose of that narcotic. 
But, in the use of these medicines, especially of such of them as possess 
stimulating properties, and the power of producing congestion of the brain, 
great care must be exercised not to mistake vascular irritation for the nervous. 
In relation to those which rather diminish than excite vascular fulness in the 
brain, including chloroform exhibited by the stomach, aconite, tobacco, digi- 
talis, and hydrocyanic acid, the caution is not equally necessary; though these 
are in general much less efficient for the end in view, and are liable to the CLASS III.] 
VASCULAR IRRITATION, OR ACTIVE CONGESTION. 
675 
danger of producing too great prostration. Under this indication may come 
also the use of the warm bath. 
The third indication is met by the nervous stimulants or antispasmodics, 
such as musk, assafetida, camphor, the ethereal preparations, valerian, and 
garlic, internally or externally used; by the tonics which operate with peculiar 
energy on the nervous system, as quinia, and the metallic tonics generally; 
and by revulsives to the surface, including hot pediluvia, rubefacients, blisters, 
setons, issues, &c. Blisters often have a most happy effect. It is not unusual 
for patients, restless, agitated, and wakeful, to be completely calmed, and to 
fall into a peaceful sleep under the operation of that remedy. 
Mental influences often operate like a charm in calming this variety of 
cerebral irritation, probably in chief by a kind of revulsive action within the 
brain; one function in excess being reduced by calling another into operation 
The principles of faith, hope, fear, the love of the marvellous, and the various 
affections, may be occasionally brought into play with great effect; and a strong 
or steady occupation of the imagination and reasoning faculties has occasionally 
a wonderful influence. 
Bleeding is seldom useful, and often injurious, by increasing debility or 
giving rise to anaemia; nevertheless, it may sometimes be called for by coex- 
isting diseases; and cases not unfrequently occur in which vascular congestion 
is mingled with, or supervenes upon the nervous, in such a degree as to 
require the lancet. More or less congestion is a frequent consequence of an 
irritation originally exclusively nervous; and, in such cases, even though there 
may be general debility, the local abstraction of blood often affords much 
relief; but the remedy should be resorted to with caution, especially in cases 
of long duration, lest its frequent repetition should do more harm by aggra- 
vating the disordered condition of system, than good by relieving the cerebral 
affection. 
2. Vascular Irritation, or Active Congestion.-It is supposed 
by some that, as the brain is incompressible, and the cranial cavity a plenum, 
the quantity of blood in the organ is the same under all circumstances. But 
it is not certain that the cerebral substance may not be somewhat compressed, 
even by the force which the heart is capable of exerting, and consequently 
that an additional quantity of blood may not be admitted. Besides, under 
an increased pressure from without, or an increased attractive force from with- 
in, it is very possible that portions of the cerebral substance, or of the serous 
liquid impregnating its tissue, and contained in its cavities, may be so far 
absorbed as to create space for the entrance of more blood. The arteries, more- 
over, may be distended, while the veins and sinuses are diminished in capa- 
city ; the compression of the latter being compensated by a more brisk current 
through them. At all events, there may be an increased rapidity of the cere- 
bral circulation in general; so that a more than ordinary amount of influence 
may bear, within a given time, upon the susceptibilities of the organ. Vascular 
irritation, therefore, has full scope for its display in the brain; and is, in fact, 
one of the most frequent modes of derangement. 
Symptoms.-The derangements of sensorial, mental, and motor function in 
the brain, already detailed as the effects of nervous irritation, may equally 
result from the vascular. Among the most common are a sense of fulness, 
weight, or distension in the head; giddiness; headache of every grade and 
variety; increased sensitiveness to sound, with buaeing, roaring, and other 
perversions of hearing; double, partial, luminous, painful, dim, or otherwise 
disordered vision, with muscae volitantes, scintillations, &c.; tingling, formica- 
tion, neuralgic pains, numbness, and partial or complete loss of sensation in 
various parts of the body; nausea and vomiting; morbid vigilance, or perhaps 676 
LOCAL DISEASES.-NERVOUS SYSTEM. 
[PART II. 
more frequently oppression, heaviness, drowsiness, and stupor in various de- 
grees; mental confusion, loss of memory, and delirium ; and finally subsultus, 
spasm, convulsions, or the opposite condition, indicated by muscular weakness, 
tremors, and temporary paralysis of motion. It is, of course, understood that 
all these symptoms are not present in any one case. They are, indeed, often 
contradictory, and could not exist together. There may be one only, or a few, 
or many variously grouped. 
Active congestion of the brain is sometimes of itself serious, and may prove 
fatal; but its greatest danger is as the precursor of inflammation of the brain 
or its membranes, or of apoplectic effusion. Another injurious result, com- 
mon to this and the preceding variety of cerebral disorder, is the establish- 
ment in the brain, under frequently renewed irritations, of a habit which may 
lead to the recurrence of the phenomena from slight causes, and even, in some 
instances, without any apparent exciting cause, as in epilepsy, some forms of 
hysteria, chronic headache, &c. It is a condition which requires attention; 
and by the proper management of which, at an early period, much subsequent 
suffering and danger may be prevented. 
Causes.-All the causes enumerated under the last head may produce vascu- 
lar irritation, when the system is predisposed to it; and, as before stated, it is 
very apt to he the result of the continuance of an irritation primarily purely 
nervous. But there are certain causes more especially operative, such as 
direct injury to the head by falls, blows, &c., exposure of the head to intense 
solar or artificial heat, external cold, alcoholic stimulants, the exciting passions, 
febrile diseases, translated gouty or rheumatic irritation, suppressed discharges, 
teething in children, hypertrophy of the left ventricle, and various intestinal 
and stomachic disorders. The sanguineous temperament, a plethoric state of 
the circulation, and an over-richness of the blood, may be considered as con- 
stituting predispositions to it. Men are probably more subject to it than 
women. It is common in infancy, at the age of puberty and from that up to 
maturity, and again in advanced life. 
Diagnosis.-It is sometimes highly important to distinguish active conges- 
tion of the brain from passive congestion, depression, or mere nervous irrita- 
tion. In relation to the two former of these affections, the reader is referred 
to the subsequent part of this article. From nervous irritation it is to be dis- 
tinguished chiefly by the state of the circulation. In active congestion, the 
face is usually flushed, the eyes suffused, and the whole countenance often 
turgid. If the patient is sensible, he is apt to complain of fulness, distension, 
or heaviness of the head ; and any vertigo or headache which he may have is 
much increased by stooping, with the head downward. The temporal and 
carotid arteries sometimes may be seen to throb. These symptoms are often 
wanting in the purely nervous irritation. The state of the pulse, too, is dif- 
ferent. In the former condition it may be small or large, accelerated, or slow, 
but it is almost always in a greater or less degree tense, hard, and strong. In 
the latter, it may be natural as to frequency, or very much excited, but is 
generally rather feeble, or at least destitute of tension. In nervous irritation 
there is often an aspect of a lighter, more fugitive affection, sinking less deeply 
into the sources of life, which an experienced eye can readily detect. In 
congestion, when considerable, there is more tendency to drowsiness or stupor; 
the expression of countenance is duller, or more changed; and the case ap- 
pears to approach nearer to the character of inflammation or cerebral hemor- 
rhage. 
Treatment.-1The treatment in this affection, independently of the measures 
necessary for the removal of the cause, which should never be neglected, is 
chiefly depletory, sedative to the circulation, and revulsive. Bleeding, gene- CLASS III.] 
677 
DEPRESSION OF THE BRAIN. 
ral and local, purging, the warm bath, the antimonials when the stomach is 
not irritable, other saline refrigerants, cold to the head and hot pediluvia, 
mustard, blisters, &c., to the extremities, with low diet, rest, and an elevated 
position of the head, are the principal remedies. Very often, in mild cases, 
the symptoms may be removed by a saline cathartic and attention to the diet. 
When serious, however, recourse should be had to the lancet. The inter- 
nal use of aconite has been highly recommended. It must be remembered 
that, though the warm bath may be useful, the hot bath might prove injurious 
by over-stimulation. But no permanent benefit can be expected while the 
offending cause remains. This, therefore, should be diligently sought for, and 
removed or corrected if possible. 
3. Depression.-In this condition the activity of the brain is diminished 
either by a directly depressing influence, or the withdrawing of an accustomed 
stimulus. 
The symptoms, so far as regards the disorder of sensation, consciousness, 
mental action, and motive power, are the same as those already mentioned as 
resulting from irritation of the brain. We have the same headache, vertigo, 
disordered vision and hearing, wakefulness, delirium, convulsions, and coma. 
There is not, as from the moderate influence of the other affection, increased 
cerebral energy; as indicated by greater acuteness of sensation, more brilliancy 
of imagination, a more rapid flow of just thought and expression. These can 
only result from a positive excitement of the brain ; but all the other derange- 
ments alluded to may be experienced. It may seem strange that obstinate 
wakefulness and violent convulsion, should be among the effects of cerebral 
depression; yet few facts in medicine appear to me to be better established. 
Thus, take away from the brain a stimulus to which it has been long accus- 
tomed, and one of the first results is morbid vigilance; and this condition is a 
not unfrequent attendant on the debility which succeeds exhausting acute dis- 
eases. The last vital act of the system, expiring under the loss of blood, is 
sometimes convulsions. It is well known that all the phenomena of advanced 
meningeal inflammation, or acute hydrocephalus, are sometimes imitated in 
children in the lowest stages of exhaustion from bowel affections; and the 
brain is found apparently healthy after death. The insanity which attends 
starvation might be adduced as another illustration of the resemblance be- 
tween the phenomena of an excited and depressed brain; but it is probable 
that, in this case, there is a real and powerful irritation of the cerebral centres, 
proceeding from the impressions sent up to it so urgently from all parts of the 
suffering system. 
After death from cerebral depression, especially in cases of chronic debility, 
serous effusion has sometimes been observed in the cavities of the brain, and 
has been misinterpreted into an evidence of inflammation; especially as soft- 
ening of the cerebral substance has been at the same time observed, resulting 
from the imbibition of the serum, and a sort of maceration, or possibly from 
some directly depressing influence. The presence of the effused fluid is no- 
thing more than what might reasonably have been anticipated from the pre- 
existing condition. The brain is not sufficiently nourished, or is not suffi- 
ciently supplied with blood, and, as the cranium does not admit of a vacuum, 
the loss of bulk is supplied by effusion of watery fluid from the blood-vessels. 
The causes of cerebral depression are long continued or excessive cold; the 
depressing passions, such as fear and grief; various sedative poisons, as tobacco, 
digitalis, hydrocyanic acid, and chloroform; the irrespirable gases, as hydrosul- 
phuric acid, carbonic acid, carburetted hydrogen, &c.; deficiency in the gene- 
ral amount of blood, or in its supply to the brain; an impoverished state of 
the blood; an excess of carbonaceous matter, and the presence of urea and 678 
[part II. 
LOCAL DISEASES.-NERVOUS SYSTEM. 
bilious matter in the blood; the withdrawing of an accustomed stimulus; 
and, secondarily, any excessive excitement when it ceases. Of course, all 
the modes of living, the kinds of exposure, the accidents, the diseases which 
produce any of the above conditions, may act as remote causes of cerebral 
depression. To enumerate them here would be only to occupy space with 
what is already familiar to the reader. 
An important point is to discriminate between depression and vascular 
irritation of the brain. The greatest practical evils have resulted from error 
upon this point. Bleeding has often been resorted to in diseases of pure de- 
bility, because convulsions, or delirium, or insanity, or morbid vigilance, or 
some other symptom occurring in cerebral exaltation, has been misinterpreted 
into a necessary sign .of that condition of the brain. The diagnosis is not 
always easy. But we can generally reach a tolerably just conclusion, by 
taking into consideration the cause of the affection, and the signs exhibited 
by the organic functions. When, for example, the effect can be clearly traced 
to a directly sedative agent, or to the withdrawal of a direct stimulus, or to 
an obviously debilitated condition of the system; when, at the same time, the 
pulse, though perhaps frequent, is less firm and strong than in health, the 
face pale, livid, or purplish, the capillary circulation slow, and the patient 
disposed to faintness upon exertion, there can scarcely be a doubt upon the 
subject. The aggravation of the symptoms upon rising from a stooping to an 
erect position is another valuable diagnostic sign. The difficulty is that, in 
cases of debility, an active congestion of the brain is sometimes induced by 
an irritant cause, and exhibits itself by cerebral symptoms similar to those of 
depression. But the nature of the cause will often enable us to decide justly; 
and a permanent flushing of the face, or other signs indicative of a steady 
determination of blood to the head, would very much aid the diagnosis. 
Another difficulty is sometimes presented by cases, in which a sudden and 
powerful irritant influence has overwhelmed the brain, and so far cramped its 
energies as to have induced a prostrate condition of the organic functions. A 
blow upon the head, an astounding piece of intelligence, the shock of a severe 
accident or surgical operation, or excessive pain in some structure, especially 
rich in sympathies, as in the stomach, bowels, kidneys, &c., occasionally 
produces such a result. Here too we are aided by a knowledge of the. nature 
of the cause; and, whenever there is good reason to suspect the existence of 
the condition of things alluded to, we should act cautiously in the applica- 
tion of stimulant measures, from the fear of subsequent reaction. 
Inflammation of the brain itself, or apoplectic congestion or effusion, by 
interfering with the ordinary influences of the organ, sometimes induces the 
same apparent signs of debility; but the previous symptoms and attendant 
circumstances will generally sufficiently evince the nature of the case. 
Treatment.-1Tonics, stimulants, external irritants, and a nutritious diet, 
with the means necessary to remove the causes of the affection, are indicated 
in this condition of the brain. In cases at all doubtful, those stimulants 
should be preferred which have the least permanent impression upon the 
brain, such as carbonate of ammonia, oil of turpentine, capsicum, musk, and 
assafetida; while external stimulation by means of rubefacients, blisters, the 
hot bath, &c., and the powerful influence of electro-magnetism, should be 
mainly relied on, when deemed sufficient to meet the exigencies of the case. 
Should the respiration have been suspended, it should be restored artificially. 
This is especially important in the cases of poisoning from irrespirable gases. 
The shock of cold water suddenly dashed upon the surface is sometimes very 
effective, by rousing the suspended sensibilities of the brain. CLASS III.] 
679 
HEADACHE. 
4. Mechanical or Passive Congestion.-This results from causes 
interfering with the return of blood from the cerebral vessels. The blood 
accumulates in the veins and sinuses; the capacity of the arteries is of course 
diminished; less arterial blood is admitted than is necessary for the support 
of the functions; and we have the double result of compression and depres- 
sion of the brain. 
The characteristic symptoms of this condition are a feeling of fulness, 
weight, and sometimes coldness in the head, an actual diminution of temper- 
ature in this part, a strong tendency to drowsiness or stupor, vertigo, faint- 
ness, impaired vision with muscae volitantes, forgetfulness of things or words, 
dulness of countenance, a livid or purplish hue of the lips and different parts 
of the face, with paleness, occasionally nausea, and depression in the func- 
tions of circulation and respiration. 
The causes are ligatures around the neck, tumours pressing upon the 
venous trunks, gravitation, and such an organic or functional derangement 
of the heart and lungs, as to impede the passage of the blood either into the 
right side of the heart, or from the right to the left side through the lungs, 
and consequently to produce accumulation in the descending cava. 
The treatment consists exclusively in the removal of the cause, and, when 
this is impossible, in the adoption of measures calculated to proportion, as 
nearly as may be, the calls of the system upon the cerebral centres to their 
diminished capacity. The avoidance of all kinds of excess, mental or phy- 
sical, is especially requisite. 
II. MORBID PHENOMENA. 
I do not propose to treat, in this place, of all the phenomena of functional 
disease of the brain. Most of them have been already, or will be hereafter 
fully considered, in connexion with special diseases, either consisting essen- 
tially of this kind of derangement, or associated with it. But there are cerr 
tain phenomena, which, though noticed elsewhere, and perhaps in various 
places, yet have not been presented so fully or so connectedly to the reader as 
their importance would seem to require; and others which, not essentially 
connected with any other special complaint, and scarcely meriting the rank 
of distinct diseases themselves, yet demand some attention, and may be most 
conveniently noticed under this heading. The phenomena, or affections 
alluded to, maybe included in the divisions of 1. sensorial disorder; 2. mental 
disorder; and 3. disorder in the motor power. 
This may embrace all the cerebral derangements having reference to the 
faculties of sensation and consciousness; and the morbid conditions which 
claim attention in this place may be arranged under the sub-heads of head- 
ache, stupor, and wakefulness. 
1. Headache, or Cephalalgia.-In the widest acceptation, this may 
be considered as embracing all kinds of uneasy sensation in the head. Very 
often it is wholly independent of the brain, being seated in the scalp or cra- 
nium. Such is the case with many instances of gouty and rheumatic head- 
ache, neuralgia, various inflammatory affections of the exterior coverings of 
the cranium or of its sinuses, and syphilitic affections of the periosteum or 
bony case itself. These do not belong to the complaint as here considered, 
which is exclusively cerebral. 
Headache is of every degree, and of every conceivable diversity of cha- 
1. Sensorial Disorder. 680 
LOCAL DISEASES.-NERVOUS SYSTEM. 
[part II. 
racter. It may be confined to one small spot, in which case it is sometimes 
called clavus, as if it might proceed from a nail driven into the head; it may 
occupy a particular region of the cranium, as the frontal immediately over 
one or both eyes, the temporal, the parietal, or the occipital; it may embrace 
one side of the head as in hemicrania; or it may be diffused, and of inde- 
finite extent. Sometimes it is fixed, sometimes changeable in its position. It 
may be apparently superficial, or felt in the depths of the brain. It is not 
less various in duration than in the other respects mentioned. It may con- 
tinue but for an instant, or may last for hours, days, or weeks. Indeed, in- 
stances have occurred in which it has never been absent, during consciousness, 
for months or years. Much more frequently, however, when so durable, it 
occurs in paroxysms with intervals of comparative or entire ease, the exacer- 
bations being quite irregular in their recurrence. Not unfrequently, how- 
ever, headache is regularly periodical, being either remittent or intermittent, 
and generally of the quotidian or tertian type, though the interval is some- 
times longer, and I have known it to occur regularly once in two weeks, 
without association with any natural periodical function. The pain may be 
simple, or may be mingled with various other perverted sensations, such as 
giddiness, fulness or distension, weight or lightness, emptiness, heat or cold- 
ness, hissing, buzzing, ringing or roaring in the ears, the sight of dark or 
luminous spots, scintillations, double vision, half-vision, dimness of vision, 
and temporary blindness. 
Headache may be the result of any one of the pathological conditions de- 
scribed in the beginning of this article, and is one of the most common of 
their effects. It appears to be the favourite sign by which nature makes 
known any deviation whatever from the normal state of the brain. Viewed 
in this light, it may be looked on as a safeguard, intended to give notice of 
disease which might otherwise escape attention, till too late to be remedied; 
and its indications should never be neglected. The physician, consulted for 
this affection, should not be content till he has traced it to its source, however 
hidden; for it is not the pain only that he is called on to relieve, but often 
the more serious affection of which it is a mere symptom. 
For the sake of convenience, we may consider headache as symptomatic 
when the result of some known disease, and idiopathic when the pathological 
state on which it may depend cannot be ascertained, or is not recognized 
among special diseases. It is obviously nothing more, strictly speaking, than 
a symptom in either case. 
Symptomatic headache is exceedingly common, and associated with a great 
number of diseases. It is an almost uniform attendant on the different forms 
of meningeal and cerebral inflammation; and is usually the first sign by which 
other organic affections of the brain, such as tumours, hydatids, and morbid 
growths or formations of all kinds, declare themselves. As the direct result 
of vascular irritation of the brain, it is one of the most common symptoms of 
all febrile diseases, whether idiopathic or symptomatic, and is a not unfre- 
quent precursor of apoplexy, and epileptic convulsions. Gout and rheumatism 
often show themselves in this guise. In the nervous form, it is very often 
sympathetic of disease of the stomach constituting sick headache, of hepatic 
disease constituting bilious headache, of worms, constipation, and other dis- 
orders of the bowels, of renal and uterine affections, and of spinal irritation. 
It is sometimes dependent on decayed teeth, even when these do not ache; 
and, in every obstinate case of cephalalgia, of uncertain origin, particular 
examination should be made into the condition of the teeth, and, if any one 
of these is found decayed and tender on pressure, it should be extracted. I 
once had a case of headache, which had continued for two or three months, CLASS III.] 
HEADACHE. 
681 
with varying degrees of violence, and had resisted numerous remedies, which 
yielded immediately upon the extraction of some decayed teeth. Diseases of 
the heart are very frequently, and those of the lungs somewhat less frequently, 
attended with headache, dependent either on the greater impulse with which 
the blood is sent into the brain, as in hypertrophy of the left ventricle, upon 
the insufficient supply of blood, as in pure dilatation and softening of the 
heart, mitral regurgitation, &c., or upon venous congestion consequent on 
impediment, either pulmonary or cardiac, to the passage of the blood from 
the venous to the arterial system. Anaemia and plethora are also affections 
which frequently occasion headache, though from opposite causes. 
Idiopathic headache is also not uncommon. It is usually distinguished by 
the name of nervous headache. It is exceedingly irregular in its modes of 
attack, duration, and recurrence, as well as in the character of the pain. 
Sometimes coming on suddenly in a state of apparently sound health, it pros- 
trates at once the mental as well as physical energies of the patient, and, after 
a longer or shorter period, leaves him as abruptly as it approached, and with 
all his powers restored. In other instances, it comes on slowly, heralded per- 
haps by unaccountable depression of spirits, or acerbity of temper, and gradu- 
ally increases for hours, perhaps for days, before it attains its acme and de- 
clines. In one patient, an attack is experienced at long intervals; in another, 
the pain returns frequently and quite irregularly; in a third, it is scarcely 
ever absent entirely for long periods of time; at least the individual never 
feels himself secure against it for a moment. Sometimes it interrupts and 
prevents sleep; but more frequently the patient, though tormented during 
the day, will go to sleep at the usual hour, and upon awaking find that the pain 
has left him for a time. More frequently than any other variety of headache, 
this assumes the regular periodical form. In most instances, probably, the 
pain is in the front of the head, over one or both eyes; but it is occasionally 
felt in the occiput, and is often diffused without a definite seat. Not unfre- 
quently it occurs in the form of hemicrania. It may be dull and grumbling, 
or heavy and throbbing, or sharp and lancinating like neuralgia. After con- 
tinuing a certain length of time, it not unfrequently provokes vomiting; but 
differs from sick headache in the circumstance, that the matter discharged from 
the stomach may be quite destitute of acid, bile, or any acrid property. Its 
duration is entirely uncertain. One attack seldom continues long; but the 
patient is liable to frequent returns of it, in many instances, for months or 
years, and in some even for life. It is purely functional, and leaves no traces 
in the brain after death. The headache itself never proves fatal; but it may, 
in the end, so far wear out the strength as to render the system less able to 
support the assaults of other diseases, and may thus contribute to shorten life. 
The causes of it are often obscure. One of the most common is, I believe, 
the use of coffee, tobacco, and strong tea. Sedentary habits, combined with 
much mental exertion, and loss of sleep, sometimes give rise to it, inde- 
pendently of any primary disease of stomach. It may now and then be traced 
to a disordered state of the blood, consequent upon defective renal, hepatic, or 
cutaneous secretion, upon the absorption of unwholesome matters from the 
alimentary canal, or upon some concealed vice in the processes of assimilation. 
Occasionally I have observed the breath to smell offensively. It has appeared 
to me that, in many instances, this variety of headache is nothing more than 
a form of nervous gout and rheumatism. 
Treatment.-For the treatment of symptomatic headache, the reader is re- 
ferred to the various diseases of which it is an accompaniment. Under the 
heads of nervous gout, sick headache, and neuralgia, he will find remedies for 
varieties of the disease in its nervous form. The treatment adapted especially 682 
LOCAL DISEASES.-NERVOUS SYSTEM. 
[part II. 
to liemicrania is detailed under the last named affection. It is only for the 
disease in its idiopathic form that the mode of treatment is here given. 
The first and most important point is to discover and remove the cause. 
In the first place, if the patient is in the habit of using either strong tea, cof- 
fee, or tobacco habitually, he should be advised to try the effect of abandon- 
ing it for three or four weeks, by way of experiment. Very often he will 
find the headache relieved by this simple measure, and then will be sensible 
of the propriety of abstaining from the poison altogether. Should this mea- 
sure fail, it will be necessary to seek for some other cause, and if there is any 
one suspicious article of diet, the same course should be pursued with that as 
with the substances mentioned. The patient should also sleep sufficiently and 
regularly, should not overtask his mind or allow himself to be worried and 
perplexed by business or other cause, and should exercise freely in a pure air. 
If a citizen, he should be advised to take a journey into the country. A long 
voyage is occasionally very useful. Sometimes a complete change of life, the 
substitution, for example, of the business of farming for that of a merchant or 
professional man in cities, has a most salutary effect. It need scarcely be 
added that the bowels should be kept regular, and the functions of the sto- 
mach, liver, kidneys, skin, and uterus, in a healthy state. 
The pain may almost always be temporarily relieved by opiates or other 
narcotics; and sometimes, when it is very severe, it becomes advisable to 
have recourse to these remedies; though their habitual use should be most 
sedulously guarded against. The nervous stimulants or antispasmodics also 
frequently afford relief. One of the best of these is Hoffmann's anodyne, of 
which a fluidrachm may be given; but, on the whole, I have found nothing 
more effectual than two or three cups of strong tea or coffee. When the dis- 
ease depends upon the use of tea or coffee, this remedy acts simply like ardent 
spirit in relieving the horrors of intemperance. It should, under these cir- 
cumstances, not be employed, as it aggravates the evil in the end. But in 
other cases it will be found a valuable resource. Ether applied in the hollow 
of the hand to the forehead, chloroform rubbed upon the scalp and then con- 
fined by a piece of oiled silk, lotions with spirit of lavender, Cologne water, 
or bay-rum, the application of a mustard plaster to the back of the neck or 
the temples, or blisters behind the ears, and the external use of tincture of 
aconite, are sometimes advantageous. The taking of several deep inspirations 
in quick succession is said occasionally to afford relief. It was suggested by 
M. Tavignot, under the impression that the affection might in some instances 
be connected with a stasis of blood in the cerebral sinuses, or insufficient 
change in the lungs. (See Am. Journ. of Med. Sei., N. S., xxi. 201.) 
In relation to the permanent cure, sulphate of quinia should always be em- 
ployed in intermittent cases, and may be tried with the hope of good in others. 
When there is any suspicion of gout or rheumatism, recourse should be had 
to occasional purgative doses of sulphate of magnesia and wine of colchicum, 
to which a full dose of sulphate of morphia may sometimes be added. The 
chalybeates should be used in anemic cases. In certain extremely obstinate 
cases, especially if paroxysmal, arsenic proves wonderfully efficacious. A 
patient of mine, who had been for many months a martyr to the disease, in 
whom quinia, iodine, mercury pushed to salivation, and other powerful reme- 
dies, including depletion, had been employed in vain, began to improve im- 
mediately under the use of Fowler's solution, and was effectually cured in two 
or three weeks. If the disease prove obstinate, the whole round of remedies 
recommended in neuralgia is at the command of the physician. 
2 Stupor and Wakefulness.-These opposite conditions are men- 
tioned here, not with a view to minute description, but chiefly in order to call CLASS III.] 
683 
STUPOR AND WAKEFULNESS. 
attention particularly to the fact, that they may each of them be the result of 
a depression or elevation of the cerebral actions. 
By stupor is meant that condition of the brain which consists in a suspen- 
sion more or less complete of the animal functions, while those of the organic 
life continue, and which bears a close resemblance to sleep, except in the cir- 
cumstances that it is much less under the control of the will, and depends 
upon some morbific cause. Under the name may be included various grades 
of the affection, from heaviness or slight drowsiness to absolute coma, in which 
all consciousness is lost, and from which the patient cannot be roused. It 
may be produced at any time by pressure upon the brain, whether proceeding 
from vital causes congesting the cerebral vessels, or giving rise to eflfusion 
within the cranium; or from mechanical causes, as depression of the bone, or 
impediment to a return of the blood from the head. Some appear to con- 
sider it as dependent upon pressure alone. But, as this cause operates merely 
by suspending certain functions, there is no reason why stupor, in its different 
grades, should not arise from other causes capable of interrupting the same 
functions, whether by an excess of excitement or a direct sedative impression. 
I have no doubt whatever, that it often results from both these causes, alto- 
gether independently of pressure. Thus, I have seen coma consequent upon 
a sympathetic irritation extended to the brain from the stomach loaded with 
indigestible matter, when the face was quite pale, the pulse was wholly undis- 
turbed, and there was no reason whatever to suspect congestion within the 
cranium. I have seen it, moreover, result apparently from the loss of blood, 
and consequent simple depression of the cerebral functions. A boy fell upon 
his head from a great height, and was affected immediately with symptoms of 
concussion, for which he was at the moment improperly bled. His system, 
however, reacted, and along with the reaction the coma with which he was 
originally affected began to give way. The excitement was thought to exceed 
the just limits, and leeches were applied to the temples. Immediately after- 
wards the coma increased; and it now became a question, whether this could 
be owing to an increased excitement of the vessels augmenting the pressure, 
or might be the result of an insufficient supply of blood to the brain. The 
weakened pulse, the paleness of face, and the diminished heat, induced his 
attendants to ascribe it to the latter cause. They administered stimulants and 
nutriment, and from the moment this plan was commenced, the child began 
to recover. He would probably have perished under other circumstances, and 
almost certainly had the bleeding bd®n repeated. The practitioner, therefore, 
must be upon his guard in cases of coma, and prepared to treat it upon the 
principle either of morbid pressure, of simple excess of irritation, or of de- 
pression. As the result of the last mentioned cause, it frequently follows the 
influence of sedative narcotic poisons, such as tobacco, digitalis, or hydrocyanic 
acid, or the admission of venous or carbonated blood into the arteries of the 
brain. Coma in children, with largely dilated pupils, and not ascribable to 
any obvious cause, may be conjecturally referred to narcotic poison, and, un- 
der circumstances favouring that supposition, may be treated with a gentle 
emetic. Hr. Dorsey was called to a child in this state, and saved his life by 
giving an emetic, which brought away a large quantity of stramonium seeds. 
Stroke of the Sun.-The coma which sometimes attacks individuals exposed 
to fatigue, in hot weather, and under a hot sun, and which is commonly de- 
signated as coup de sdleil, or stroke of the sun, though sometimes dependent 
on active congestion or apoplectic effusion within the cranium, is much more 
frequently the result of exhausting influences, acting probably on a previously 
enfeebled constitution. In such cases, bleeding, which is but too frequently 
employed, is always injurious, and there is reason to believe not unfrequeutly 684 
[part II. 
LOCAL DISEASES.-NERVOUS SYSTEM. 
fatal. Post-mortem examination has revealed a total absence of congestion 
of the brain ; and the symptoms during life, the pale and cool surface, and 
the feeble pulse, are indications of both general and cerebral prostration. The 
coma is often associated with convulsions, in the intervals of which muscular 
tremors not unfrequently occur, as in the delirium of drunkards. It often 
happens that, before collapse, the surface is hot and the circulation much ex- 
cited ; but this is the mere result of irritation in a weakened system, and 
tends to a speedy exhaustion. Instead of being slow, full, and strong, as in 
apoplectic cases, the pulse is, in this affection, frequent and weak, varying, 
according to Dr. H. S. Swift, of New York, who witnessed sixty cases, from 
100 to 160 in the minute. (W K Journ. of Med., N. S., xiii. 51.) In four 
cases, examined after death by Dr. Wm. Pepper in the Pennsylvania Hospi- 
tal, the heart was found pallid, flaccid, and softened; while the other muscles 
were florid and firm. (Transact. of the Col. of Phys, of Philad., iii. p. 100.) 
May not these be cases of fatty degeneration of the heart, which have sud- 
denly succumbed under fatigue and exhaustion, after a long previous existence 
of the affection? It is of the utmost importance to distinguish such cases 
from those of apoplectic congestion or effusion. The" remedies required are 
the ammoniacal and alcoholic stimulants, which should be administered by 
injection when the patient cannot swallow. Active rubefacients should also 
be employed externally. Dr. Swift states that convalescence is usually speedy, 
after the severity of the attack is passed; but, in the affection as seen by Dr. 
Pepper, it was apt to be slow, and was sometimes attended with mental aber- 
ration. The mortality of the reported cases has been about one-half; and it 
is stated that most who are. bled die. 
Wakefulness or morbid vigilance certainly proceeds, in many instances, from 
an over-excitement of the brain, whether merely nervous, or vascular. Thus, 
it is a frequent incident in the early stages of meningeal inflammation and 
insanity. It is well known, also, to be produced in many persons by coffee 
and tea, which powerfully stimulate the nervous system, with little effect upon 
the vascular; and is a. common attendant upon the excitement of joy, hope, 
or anticipation. It appears to be a lower grade of that vascular excitement, 
which, carried further, ends in stupor. 
Very commonly a depression of the vascular actions of the brain, or a purely 
nervous depression, produces some grade of stupor; but occasionally it may 
also give rise to morbid vigilance; and this I consider an important practical 
fact. We see it, as already observed, and as will hereafter be fully shown, 
proceeding from the suspension of the use of powerful stimulants (see Deli- 
rium Tremens); and it is a frequent result of great general debility, without 
being at all traceable to any irritant cause. What are the peculiar circum- 
stances which determine these opposite effects, as the consequences of appa- 
rently the same pathological condition, has not been determined. That the 
seeming anomaly is not without analogies in nature, has been already shown. 
(See page 672.) The student should be prepared to refer the symptom, when 
he may encounter it, to the true cause, whether of irritation or depression. 
His view upon the point will determine his practice. 
The remedies, whether for stupor or wakefulness, are to be addressed to 
the pathological condition, whatever that may be, and will be found detailed 
elsewhere. It may be stated here, that coffee and tea may often be advan- 
tageously used as powerful antihypnotics. 
2. Mental Disorder. 
To this head belong delirium, insanity, and certain less usual forms of de- 
rangement, of which those especially deserving of notice appear to be ecstasy CLASS III.J 
ECSTASY.-SOMNAMBULISM. 
685 
and somnambulism. Delirium in its different forms and relations Las been, 
or will be sufficiently treated of elsewhere. Being always a symptom, it has 
been considered, in its general relations, under- the head of Symptomatology 
(vol. i. page 192), and, specially, in connexion with the diseases which it at- 
tends, such as the different forms of fever, and of cerebral inflammation. One 
affection in which it constitutes a prominent character, namely, delirium tre- 
mens, will be treated of distinctly; and there will be occasion to refer to it 
also in connexion with other nervous affections which are yet to be considered. 
Insanity forms the subject of a distinct article. It remains, then, in this 
place, only to notice the two disorders above alluded to under the names of 
ecstasy and somnambulism. These are curious mixtures of sensorial and 
intellectual disturbance, which approach more nearly to delirium or insanity 
than to any other form of cerebral disease. 
1. Ecstasy.-This is an affection in which, with a loss of consciousness 
of existing circumstances, and insensibility to impressions from without, there 
is an apparent exaltation of the intellectual or emotional functions, as if the 
individual were raised into a different nature, or different sphere of existence. 
The patient appears wrapped up in some engrossing thought or feeling, with 
an expression upon his countenance as of lofty contemplation, or ineffable 
delight. Voluntary motion is usually suspended; and the patient either lies 
insensible to external influences, or, as in catalepsy, maintains the position in 
which he may have been attacked. Sometimes, however, the muscles obey 
the will, and the patient speaks or acts in accordance with his existing im- 
pulses. In these cases, the disease borders closely on somnambulism. The 
pulse and respiration may be natural, or more or less depressed; the face is 
usually pale; and the surface of the body cool. If the pulse is increased in 
frequency, it is usually more feeble also. The duration of the attack is very 
uncertain; in some instances not exceeding a few minutes, in others extend- 
ing to hours or days. 
Upon recovering from the spell, the patient generally remembers his thoughts 
and feelings more or less accurately, and sometimes tells of wonderful visions 
that he has seen, of visits to the regions of the blessed, of ravishing harmony 
and splendour, of inexpressible enjoyment of the senses or affections. After 
the attack is over, he may return entirely to his ordinary health, and ordinary 
pursuits, or he may exhibit some permanent change of character, as the re- 
sult either of the disease, or of the causes which produced it. 
The disease is usually brought on by causes which occasion a strain upon 
the mental functions; a profound exercise of thought, for example, or an over- 
whelming excitement of the emotions or affections. It is most frequent in 
persons of a nervous temperament, and women are peculiarly subject to it. 
The treatment is simple. During the continuance of the spell, little more 
is required than to take care that the patient is supplied with nourishment. 
Should symptoms of prostration appear, they should be counteracted by ex- 
ternal and internal stimulation. Should vascular irritation, on the contrary, 
threaten injury to the brain, it might become necessary to resort to the mea- 
sures already recommended for that condition. In obstinate cases, the most 
effectual remedy would probably be to shave and blister the head. After the 
attack, attention should be paid to the condition of the functions; and especial 
care should be taken to avoid all causes of excitement. 
2. Somnambulism.-This is a state of the system in which, with an 
apparently rational concatenation of thought, and the power of consistent action, 
the patient has completely lost the consciousness of his actual condition, and, 
in a greater or less degree, the susceptibility to ordinary exterior influences. 
As it occurs most frequently at night, during sleep, and as the patient is apt 686 
[PART II. 
LOCAL DISEASES.-NERVOUS SYSTEM. 
to rise from his bed, and walk about the house or abroad, persons affected with 
it are commonly called sleep-walkers. 
Symptoms.-The most striking phenomenon in the affection is the obvious 
unconsciousness of the patient of his real position. Like a dreamer, he fan- 
cies himself under circumstances which do not really exist, but, unlike the mere 
dreamer, has the power of acting in accordance with those circumstances. 
He rises from his bed, in pursuance of some course of action in which he sup- 
poses himself engaged, or to accomplish some purpose which his fancy has 
suggested, and all his movements are well concerted to those ends. He ap- 
pears to be utterly insensible to danger, and frequently puts himself in situa- 
tions, as upon the roofs of houses, or on the brink of precipitous heights, in 
which, if awake, he would incur great hazard, from the loss of all self-com- 
mand. It is said that somnambulists, suddenly awakened in such situations, 
have fallen and perished. There appears to be a somewhat different condition 
of the senses in different cases. The eyes are in some instances closed, in 
others widely open. If, in the latter case, a bright light be held before them, 
it occasionally happens that no impression seems to be made; and other per- 
sons in the immediate vicinity are not apparently recognized. Sudden and 
loud noises may be made near the ear without being heard, or at least noticed. 
In some cases, one kind of food has been substituted for another, without any 
apparent perception of the difference; and snuff has been replaced by saw-dust 
without a discovery of the imposition. Yet the somnambulist will perform 
offices which require the greatest delicacy.of vision; will frequently answer 
questions that may be put to him; and often proves himself possessed of an 
acute sense of touch. It is obvious, therefore, that it is not the senses, but 
the perceptive faculty that is defective. The patient seems to be able to ap- 
preciate impressions only from sources which have some relation to the object 
of his pursuit at the time; or at least which fall in with the existing current 
of his thoughts and feeling. In reference to such points his senses are often 
more acute than in health. Thus, a somnambulist will perform acts requir- 
ing the use of sight, in the midst of a darkness in which he becomes entirely 
lost if awakened. 
Occasionally the affection is associated with catalepsy. When aroused, the 
patient generally forgets the subject of his recent thoughts or actions; though 
he sometimes remembers them obscurely like a dream. It is asserted that, 
in some instances, the train of thought which had occupied the period of 
somnambulism, and which had been interrupted during the waking state, has 
returned upon the return of the paroxysm, and that this has happened in 
several successive alternations of the dreaming and waking state; memory 
being active in each condition in relation to its own incidents, while those of 
the other state are forgotten. If left to himself, the sleep-walker generally 
returns to his bed, sleeps naturally, and awakens at the usual time, quite un- 
conscious of the incidents that have taken place, though sometimes fatigued 
by his exertions. He can often be awakened by disturbing him considerably 
in any manner; but among the most effectual methods is to throw cold water 
upon the surface. 
Causes.'-The causes of somnambulism are not always obvious. Sometimes 
it appears to be connected with derangement of the alimentary canal, or of the 
uterus. Intemperance is said to have occasioned it. In very mild forms, it 
is not uncommon in children, but generally ceases before adult age. The 
severer forms of it are said to occur most frequently in men under the middle 
age. The affection is asserted to be hereditary. 
Artificial Somnambulism.-Animal Magnetism.-Mesmerism.-1This affec- 
tion bears a close analogy to the preceding, and, though it has been observed CLASS III.] 
687 
ARTIFICIAL SOMNAMBULISM. 
in a much greater variety of phases, is probably identical with it. The methods 
usually employed to bring individuals into this state are too well known to re- 
quire description. I believe that it is of very little consequence what manipu- 
lations are used, provided the mind of the patient be impressed in that peculiar 
manner which appears requisite to the production of the results. A steady 
look of the operator, with an expression of earnest conviction upon his face, 
as if he had that full power over the nervous system of the one acted on which 
he claims to have, will very often be sufficient. The subject of the operation 
soon begins to be sensible of a not unpleasant heaviness; the eyelids usually 
close; and, in a period of time varying from less than a minute to twenty 
minutes or more, a state of apparent sleep results. But examination shows 
that the condition is very different from that of ordinary sleep. Thus, a cata- 
leptic state of one or more of the limbs will sometimes be discovered on at- 
tempting to move them; and curious phenomena in relation to the power of 
muscular motion, or the loss of it, may be observed. Sensation is strangely 
modified. The patient is often quite insensible to painful impressions; so 
that a tooth may be extracted, or a surgical operation performed, without per- 
ceptible uneasiness. This has been too frequently tested to admit of reason- 
able doubt. But, while general sensibility is thus blunted, the special senses 
are often more acute than in health. The slightest sound, such as generally 
escapes notice altogether, is heard; touch is occasionally exquisitely sensitive ; 
and there is reason to believe that vision is also remarkably acute. As in 
spontaneous somnambulism, it appears that all objects do not make an equally 
strong impression; but it is impossible to determine what principle it is that 
regulates this diversity of the sensorial function. The patient loses all con- 
sciousness of his real situation; but evinces in various ways considerable, and 
sometimes extraordinary mental activity. Present events apparently excite 
trains of thought, which have no relation to the actual condition of the patient, 
but seem to be merely successive actions of» the cerebral machinery, mental 
vibrations as it were, necessarily following the impressions from without. 
Thus, an individual acquainted with craniology, upon feeling the touch of a 
finger upon the part of the cranium corresponding with one of the supposed 
organs, will often set off into a most ludicrous series of actions illustrative of 
the operations of that organ. A slight sound, which no one else notices, sug- 
gests a course of thought in accordance with the cause of that sound, which 
strikes spectators sometimes as little short of miraculous. This property of 
somnambulism, connected with a wonderful sharpening of the memory, so that 
things long forgotten, and even circumstances that at the time of their occur- 
rence seemed to make no impression, are recalled vividly, accounts satisfactorily 
for those phenomena, which, superficially viewed, have led to the most extra- 
vagant notions as to the mysterious powers imparted by this strange condition 
of the nervous system. The patient may often be induced to rise and walk 
about the apartment, and sometimes does so spontaneously, in order to act out 
the course of thought with which the mind may be occupied. The actions, 
corporeal and mental, appear to be under the guidance of principles entirely 
differing from those which characterize the individual in health; as if another 
spirit, with different views and feelings, had taken up a temporary residence 
in the body. Thus, I have seen a little girl, on all occasions diffident and 
even bashful in health, become in this morbid state pert and forward, joking 
with her elders and superiors, as if quite on a footing with them; and this 
change of character uniformly took place whenever the affection was produced. 
Along with the nervous phenomena above mentioned, there is a change in 
some of the organic functions, which if there were any doubt upon the reality 
of the state, would of itself be sufficient evidence. The pulse is accelerated, 688 
[PART II. 
LOCAL DISEASES.-NERVOUS SYSTEM. 
and there is an increased production of moisture, which is especially observa- 
ble in the hands. 
Very different opinions exist as to the nature and causes of this affection. 
Many suppose it to be a peculiar condition of the nervous system, produced 
by the influence of another nervous system, in a manner analogous to the 
electrical changes which take place, when an excited electric is placed in the 
near vicinity of other bodies. Now this is not altogether impossible. But 
I hold it to be unphilosophical to adduce a new principle in the explanation 
of phenomena, which admit of explanation upon principles already established. 
I see nothing mysterious in this magnetic or mesmeric state, as it has been 
called; at least nothing more so than in hysteria, catalepsy, epilepsy, &c., in 
all of which there is much that we cannot understand. It is merely one of 
the different phases of nervous disease, and is induced by the mental condi- 
tion of the individual affected; as an attack of hysteria is often induced by 
a fit of vexation. 
The subjects of the disease are usually persons of nervous temperament, 
and generally in a position of inferiority, either physically, mentally, or by 
position to the operator; who, therefore, has a greater influence over their ima- 
ginations. The mysterious manipulations, the peculiarity of the occasion, 
the steadfast gaze of the operator, appearing as if he had no doubt of his own 
powers, excite in the susceptible mind of the subject a feeling of the strange, 
the mysterious, perhaps even of the awful, which appears to unhinge some 
connexion in the brain necessary to keep the nervous machinery in its due 
order, and causes it to work for a while in a wholly new direction. Young 
women and children are most easily affected; and at each successive trial the 
effect is, in general, more readily produced; so that at last, in certain very 
susceptible individuals, a look is sufficient to throw them into the magnetic 
state; and, indeed, the patient may fall into the state voluntarily, or.spon- 
taneously without any exercise of will. I have met with one instance in 
which a boy, who had been frequently acted on, was attacked with an affec- 
tion in all essential respects similar, without apparent cause, and did not re- 
cover until, after two or three days of fruitless attempts by other means, a 
blister was at length applied over the whole scalp. 
Artificial somnambulism may sometimes be usefully employed as a remedial 
agent. Nervous headaches, neuralgic pains, morbid vigilance, great restless- 
ness, and various hysterical disorder may sometimes be removed, at least for 
a time, by bringing about this condition of system. The surgeon and dentist 
may also sometimes avail themselves of the insensibility to pain which it occa- 
sions, to perform their operations with less suffering to the patient. But, when 
it is understood that the person acted on is thrown into a condition, in which, 
while passions may be developed, control over the conduct, and the influence 
of habitual principle cease, the practice must strike the reflecting mind as 
extremely hazardous, and fraught with the possibility of so much unmitigated 
evil, that it can scarcely be justified as a remedy, and is altogether unjusti- 
fiable on any other score. Besides, the nervous system is rendered morbidly 
susceptible, and a tendency to diseases of this system consequently fostered, 
by the frequent repetition of the process. 
The morbid state, if left to itself, gradually subsides; but the restoration 
of the patient may be effected more speedily by artificial means. Among the 
most efficient apparently is a rapid motion of the hand near the patient, so as 
to bring a current of cool air in contact with the face. Probably a cup of 
cold water thrown upon the face would have a similar effect. In obstinate 
cases, it might be advisable to induce sound sleep by means of an opiate. 
This would imitate natural somnambulism, in which the individual, upon re- CLASS III.] 
689 
CONVULSIONS. 
turning to his bed, falls asleep again, and awakes as usual in the morning. I 
have already mentioned one case in which a blister to the head appeared to me 
to be requisite. In relation to the cure of natural somnambulism, something 
may probably be done by attending to the general health, correcting any de- 
ranged function, especially of the digestive organs, or the uterus, obviating 
plethora if it exist, and giving an equable action to the nervous system by the 
metallic tonics, as the preparations of copper, zinc, or iron. The nervous 
stimulants, or antispasmodics, may sometimes be used advantageously. A 
combination of mugwort (Artemisia vulgaris) and assafetida, has been recom- 
mended as especially efficacious. (Ed. Month. Journ. of Med. Sci., Nov. 1851, 
p. 480.) Should the affection return nightly, and no sign of congestion of 
the brain exist, opium in full doses, or some other narcotic of similar powers, 
might be tried, in the hope of breaking the morbid habit. It is recommended 
to avoid suppers, and not to sleep upon the back. 
3. Motor Disorder. 
The motor faculty may be deranged in two modes, independently of a morbid 
increase under the influence of the will, in which case it is the latter faculty 
that is affected, and the patient may be considered as insane. The two modes 
of derangement alluded to are involuntary contraction or spasm, and loss of the 
power of motion or palsy. To the latter subject a special article will be de- 
voted. Of spasm, there are several varieties. One distinction is into clonic 
and tonic spasm, the former consisting in rapidly alternating contraction and 
relaxation, as in subsultus tendinum and convulsions, the latter of contractions 
having a certain duration, and attended with rigidity or hardness of the muscle, 
as in common cramps, and in tetanus. The latter is usually painful, the 
former either not painful or but slightly so. The tonic spasm is sometimes 
also entitled spastic contraction. Another distinction is into, first, those con- 
tractions which bear no resemblance to ordinary voluntary motion, and would 
appear to be wholly independent of the cerebral machinery by which the will 
acts, as when an irritation, for example, is applied in the course of the motor 
cords or filaments, and, secondly, those in which the will seems to have been 
replaced by a new and morbid influence, acting through the same channels, or 
by the same instrumentality precisely, as happens in the movements of chorea 
and catalepsy. Of several special diseases in which these different kinds of 
spasm are exhibited, I have had occasion to treat already, or shall treat here- 
after under separate heads. Those only which require notice here are non- 
epileptic convulsions, and catalepsy. 
1 Convulsions.-Eclampsia.-These are clonic spasms of the muscles, 
producing visible motions of the limbs or other parts of the body, and gene- 
rally attended with unconsciousness. When the contraction is slight, feeble, 
and brief, so as to occasion a mere catching of the tendons, with very little 
observable movement of the parts into which the tendons are inserted, the 
affection is denominated subsultus tendinum. It may or may not be accom- 
panied with unconsciousness. It is an inferior degree of the same condition 
that exists in convulsions, often takes place under the same circumstances, 
and from the same causes, and is not unfrequently a precursor of them. It 
is exceedingly common in diseases of debility; and, except as an attendant 
on other complaints, scarcely requires notice. It is not, therefore, treated of 
here as a distinct affection. Should it become, in any case, the prominent 
object of attention, it must be treated upon the general principles laid down 
for the management of functional cerebral disease. 
It is not of convulsions, in all their relations, that I propose to treat in 
this place. As a symptom of cerebral inflammation, and febrile diseases of 690 
[part II. 
LOCAL DISEASES.-NERVOUS SYSTEM. 
all kinds, they have been sufficiently considered already. As occurring in 
epilepsy and hysteria, they will be the subject of consideration in separate 
articles. Puerperal convulsions belong especially to the department of ob- 
stetrical medicine. But isolated attacks of convulsions are frequently met 
with, which do not constitute an essential part of any other recognized dis- 
ease, and which, though they may in some instances arise from sources of 
irritation existing in various parts of the body, are yet the prominent object 
of attention, and that which especially demands practical interference. It is 
to these that the following remarks apply. 
Though occurring at all ages, they are incomparably more frequent in child- 
ren before the conclusion of the second dentition than at any subsequent age, 
and are most frequent in infancy. Hence they are often considered sepa- 
rately, as belonging especially to this period of life, under the title of infantile 
convulsions. But there is nothing absolutely peculiar in the convulsions of 
infants; and the following remarks upon their pathology and treatment, ex- 
cept when necessarily exclusive from reference to the peculiar circumstances 
of infancy, may be considered as of general application. 
Symptoms, Results, &c.-1The attack of convulsions may either be preceded 
by other signs of nervous disorder, or may come on abruptly, without warn- 
ing. The voluntary muscles of all parts of the body may be affected, or the 
spasms may be confined to one-half of the body, to a single limb, or to the 
features. There may be only a single attack, or several in more or less rapid 
succession. During the paroxysm, the face is sometimes pale, sometimes 
purplish or livid, the lips are bluish, the features often apparently swollen, 
the jugulars distended, the general surface more or less heated, and the pulse 
very frequent and often irregular. The abdomen is frequently swollen and 
tympanitic. Involuntary evacuations now and then take place. The dura- 
tion of the convulsions is exceedingly variable. It may be only a few mo- 
ments, or it may extend to hours or days; but, in the latter case, there is 
always some remission or intermission of the convulsive movements; though 
the comatose symptoms continue. Perhaps the average duration of each 
paroxysm may be stated at from five to fifteen or twenty minutes. In the 
prolonged cases there is apt to be more or less rigidity or tonic spasm of the 
muscles. Upon the subsidence of the paroxysm, the patient is generally dis- 
posed to sleep, and not unfrequently remains somewhat comatose for a longer 
or shorter period. In some infantile cases, however, the child is bright and 
lively immediately after the cessation of the spasms; in others, the convul- 
sions go off with vomiting. Occasionally, when the paroxysm is over, it is 
found that some serious cerebral or spinal lesion has taken place, as indicated 
by partial paralysis, strabismus, and various mental disorder; and sometimes 
the paroxysm is only the commencement of a series of subsequent attacks, oc- 
curring at irregular intervals, and constituting epilepsy. In these cases, the 
disease passes out of the category at present under consideration. 
Convulsions sometimes end fatally, though not often unless connected with 
other disease. Simple uncomplicated functional convulsions are seldom very 
dangerous. In fact, the affection is itself probably in many instances a safe- 
guard, by directing irritation from the nervous centres to the circumference. 
Nevertheless, convulsions may prove immediately the cause of death, by in- 
terrupting the due innervation of the lungs or heart; and they always demand 
a vigilant attention, as the possible evidence of very serious disease. 
After death from pure convulsions, there may be nothing discovered in the 
brain to account for the result. But, in the great majority of fatal cases, 
congestion, effusion, softening, tumours, or other signs of inflammation or 
organic affection of the brain or spinal marrow, prove that the convulsion was, CLASS III.] 
CONVULSIONS. 
691 
in these cases, merely a symptom of some pre-existing or coincident lesion; 
and very generally, evidences of the existence of such lesion are presented 
during life, quite independently of the convulsive movements. 
Causes.-The peculiar state of the nervous system in infancy and early 
childhood may be considered as a predisposing cause. Very impressible from 
the necessities of the organization at this age, it must of course feel more sen- 
sibly than at other periods of life the influence of disturbing causes. But 
there is also a great difference in children in this respect. In some the nervous 
system is peculiarly liable to this mode of derangement, either from inherit- 
ance, from powerful impressions, as some suppose, upon the nervous system 
of the mother during pregnancy, or from some inappreciable cause, which 
often determines, in all the children of certain parents, a predisposition of this 
kind. Nothing is more common than to see all or most of the children of 
one family peculiarly subject to convulsions, though the parents may have 
exhibited no such tendency in their own persons. Children thus predisposed 
show themselves more impressible than others by ordinary causes, start fre- 
quently, are unusually excitable, if not properly controlled are apt to be fret- 
ful or irascible, and occasionally exhibit great precocity. Among adults, 
females are, for the same reasons, more subject to convulsions than males. 
The predisposition to the disease may also be induced by impure air, un- 
wholesome diet, and whatever has a tendency to lower the general standard 
of health. For reasons explained elsewhere, the anemic condition strongly 
predisposes to convulsions. 
The exciting or immediate causes are very numerous. Strong, and sudden 
emotion, as fear, anger, surprise, &c., is a frequent cause. Insolation, excessive 
artificial heat, exposure to cold, over-exertion, and falls or other accidents, 
may induce convulsions. But they are much oftener the result of an irrita- 
tion transmitted to the brain from some other part of the body. One of their 
most frequent sources is the irritation of teething. Perhaps even more so is 
that proceeding from indigestible or acrid substances in the alimentary canal. 
Articles of food not readily dissolved by the infantile stomach are often the 
cause of convulsions. So also are acid in the stomach and bowels, intestinal 
worms, and the acrid secretions consequent upon disordered hepatic function. 
Whatever occasions spasm in the intestines may induce convulsions; for there 
is nothing which more powerfully discomposes the infantile nervous system 
than violent pain. A cause, perhaps not sufficiently appreciated, is the milk 
of the mother or nurse. This occasionally produces the effect even when the 
nurse is apparently healthy. It is said that agitating or exciting emotions 
will sometimes so affect the milk as to induce convulsions in the suckling. 
The use of certain articles of food or of medicine may have the same effect. 
I have known convulsions in the infant to be the apparent result of antimo- 
nial medicines taken by the mother. Irritating purgatives or other medicines 
have sometimes the same effect directly on the child. The practitioner can- 
not be too strongly impressed with the importance of looking to the gums, 
and to the alimentary canal of children, as the seat of the cause of convul- 
sions. The retreat of an habitual irritation from the surface of the body is 
another occasional cause. Hence, convulsions sometimes follow the disap- 
pearance of a cutaneous eruption. The irritation of hooping-cough sometimes 
provokes them. 
Too great vascular fulness or excitement may induce the disease in those 
predisposed to it; and if, at the same time, there should exist peculiar nervous 
disturbance, convulsions will be very apt to result. Hence their great fre- 
quency in febrile diseases. Some children never have an attack of fever 
without convulsions. They are peculiarly frequent in the exanthemata. 692 
[part II. 
LOCAL DISEASES.-NERVOUS SYSTEM. 
Diagnosis.-The most interesting point in the diagnosis of convulsions is 
to determine, whether they proceed from vascular irritation of the brain, or 
whether from mere nervous irritation, or depression. In the former case, 
depleting remedies are important, in the latter, anodynes and nervous stimu- 
lants; and what may prove very useful in the one, may be very injurious in 
the other. There are many cases in which the two conditions are.mingled; 
and in which it is not possible to determine what share each of them may 
have in producing the symptoms. But this does not diminish the importance 
of making a correct diagnosis when it is possible. It is by the symptoms 
connected with the organic functions, and by a consideration of the cause in 
any particular case, rather than by the purely nervous phenomena, that the 
judgment is to be decided. In the cases of vascular irritation or congestion, 
the face is usually flushed, the pulse strong and tense, the surface warmer 
than in health, and the tongue often somewhat furred. The attack is fre- 
quently preceded by febrile symptoms; and, upon the subsidence of the con- 
vulsion, the elevation of pulse, heat of skin, and tendency to coma which 
remain, evince the existence of an active focus of excitement in the brain. 
In the purely nervous cases, without vascular irritation, the face is generally 
pale, or, if coloured, is so in consequence not of any active determination to 
the head, but of the interference of the convulsions with respiration, and is 
rather of a livid hue than red. The pulse may be very frequent, but it is not 
stronger, and is generally feebler than in health, and subsides upon the sub- 
sidence of the paroxysm. Upon the cessation of the convulsion, the child, 
instead of being comatose, is at most simply disposed to sleep, and not unfre- 
quently appears as though nothing had happened, resuming his infantile 
occupation or amusements. Attention was strongly called to this fact, as 
affording an important diagnostic sign, by the late Dr. Joseph Parrish, who 
published an excellent paper on infantile convulsions from intestinal spasm 
in the N. American Medical and Surgical Journal, for January, 1827. The 
cause of the convulsion, and its frequent occurrence without preliminary cere- 
bral disturbance, afford other valuable signs. Thus, when the source of the 
attack is some non-inflammatory irritation, as spasm in the stomach or bowels, 
for example, it would be inferred that the cerebral disease was probably also 
merely nervous, especially if unattended with the ordinary marks of active 
congestion of the brain. I have repeatedly seen children in a state of appa- 
rently good health, except, perhaps, that some evidence of colicky disease 
had been presented, suddenly scream, throw themselves back with stiffened 
abdomen as if frdm severe pain in the bowels, and go off into a convulsive 
paroxysm; and, upon coming out of such paroxysms, I have seen them look 
smilingly about, and begin to play as if nothing had happened. In such 
cases, there can be no doubt that the cerebral affection is purely nervous. 
An anemic condition of system would afford another indication, though not 
to be certainly relied on. Convulsions, arising from a positively depressing 
influence, are generally recognizable by their causes. When they follow the 
excessive loss of blood, or the operation of a directly sedative poison, as 
digitalis, tobacco, hydrocyanic acid, or sulphuretted hydrogen, they may be 
confidently referred to a depressed state of the cerebral functions. When 
dependent upon passive congestion, they may be known by their origin in 
morbid states of respiration, or in some other cause impeding the return of 
blood from the head. 
Treatment.-This divides itself into such as may be proper in the convul- 
sion, and such as may be required after it has subsided. During the parox- 
ysm, whatever may be the precise pathological condition of the brain, the 
patient should be placed where he may breathe a fresh and pure air, of a CLASS III.] 
693 
CONVULSIONS. 
moderate temperature, and especially not too much heated; and every part of 
the dress which may act as a ligature, should be loosened. Hot water may 
be immediately directed for the feet, sinapisms may be got ready for the ex- 
tremities, and, if the head is at all heated or flushed, cold water may be 
applied in the manner before repeatedly directed to the scalp. In the mean- 
time, investigation may be made into the cause and precise nature of the 
affection. Should the pulse be full and strong, the face turgid with red 
blood, and the previous symptoms such as to point to the existence of active 
congestion, blood may be taken from the arm; and, should the same symp- 
toms in some degree persist, leeches may be applied to the temples; but, in 
the great majority of cases, there is no immediate urgency for these measures, 
and they may in general be omitted, or at least postponed until other means 
have failed. Hot pediluvia, sinapisms to the legs, arms, and over the epi- 
gastrium, care being taken not to allow them to be too strong with mustard, 
nor to remain too long in contact with the skin; cold water to the head; and 
a purgative enema; are usually sufficient in moderate cases of vascular irri- 
tation. Should the convulsion not yield to these measures, the patient may 
be placed in a warm bath, while cool applications are made to the head; and, 
if this should fail, and blood either not have been taken, or not sufficiently, 
the patient may be bled, or leeched, or both, as circumstances may seem to 
indicate. After failure with all these measures, a gentle emetic of ipecacu- 
anha, if the patient can swallow, will sometimes put an immediate end to the 
paroxysm; and, in cases of much cerebral fulness, this remedy always comes 
in better after depletion than at the commencement. 
Should the evidences of cerebral congestion not be decided, or the case 
appear to be one of mere nervous irritation, in connexion with the other reme- 
dies mentioned, the use of antispasmodics will be found advantageous. The 
feet may be enveloped in poultices of bread and milk or flaxseed meal, mixed 
with well-bruised garlic or onions; brandy heated with garlic, or a mixture 
of oil of amber, olive oil, brandy, and laudanum may be applied warm along 
the spine, and over the abdomen; and assafetida, musk, oil of turpentine, or 
oil of amber, may be injected into the rectum. 
Sometimes it will be proper to attempt the removal of the cause, even during 
the existence of the convulsions, though in general this is best effected in the 
intervals. Thus, if there is reason to believe that indigestible food or other 
irritating matter may exist in the stomach, it should be evacuated by means 
of ipecacuanha, if the patient can swallow it, aided, if necessary, by a feather 
introduced into the fauces. The happiest effects occasionally result from this 
expedient in some obstinate cases. When convulsions can be traced to intes- 
tinal irritation, some of the measures to be pointed out directly may be em- 
ployed with great benefit even in the paroxysm. If the gums are swollen, 
and apparently painful, they should be freely lanced. 
But it very frequently happens that the physician does not see the patient 
till the convulsion is passed; and, when he arrives in time, he generally finds 
the simplest measures sufficient for its removal. It is in the intervals, for 
the most part, that he is called on to act, and can act most efficiently. 
Here again the question as to the state of the brain comes up for decision. 
If vascular irritation exist, it is of great moment that it should be overcome; 
as an attack of meningitis, or an amount of cerebral lesion which might other- 
wise end in permanent epilepsy, may thus be prevented. If, therefore, there 
is fulness and strength of pulse, with stupor or headache, blood should be 
taken generally, or locally, or both ; and, in infantile cases, a full cathartic 
dose of calomel should be administered, to be followed in due time, if it do 
not operate thoroughly, by a dose of castor oil. In doubtful cases, the prac- 694 
LOCAL DISEASES.-NERVOUS SYSTEM. 
[PART II. 
titioner may be content with the cathartic, which should seldom be omitted. 
The head should be kept cool; any existing febrile excitement, met, by means 
of the antimonials or neutral mixture; and nervous disturbance, controlled by 
gentle antispasmodics, such as sweet spirit of nitre, Hoffmann's anodyne, or 
camphor water. At the same time, gentle revulsion should be maintained 
towards the extremities; the bowels should be kept in a soluble state by saline 
laxatives, and the diet should be restricted to farinaceous substances, or, in 
infants, to these with the milk of the nurse in moderation. Should there be 
a disposition to the return of the convulsions, more decided revulsion should 
be effected by means of blisters between the shoulders or to the extremities; 
and, in obstinate cases, after sufficient depletion, it may be proper to blister 
the whole scalp. 
In cases of pure irritation, besides removing the cause, it is proper to dimin- 
ish the nervous susceptibility, and to control the cerebral irritation by diffusing 
the excitement over the whole nervous system. To meet the first indication, 
narcotics may often be employed; and none is more efficacious than opium, 
which, to diminish its stimulant influence, may be combined in some instances 
with ipecacuanha. Hyoscyamus, lactucarium, or conium may be substituted, 
if on any account thought preferable. But, before resorting to these remedies, 
the practitioner must be very sure of his grounds. He must be quite con- 
vinced that it is nervous irritation, and not active congestion of the brain that 
he has to encounter. The second indication above alluded to is to be fulfilled 
by antispasmodics, administered by the mouth, the rectum, or the skin, and 
by the use of tonics, of which the metallic are deemed most efficient. Of 
these the oxide of zinc has perhaps enjoyed most reputation, though the chaly- 
beates should be preferred in anemic cases. Should the digestion be impaired, 
and the system at large feeble, the simple bitters or quinia might be preferable 
to the metallic tonics. These remedies may often be combined in the same 
prescription. Thus, opium or hyoscyamus, assafetida, and either oxide of zinc, 
carbonate of iron, sulphate of quinia, or extract of gentian or quassia, may 
very properly go together. The cold or shower bath, cautiously used, may 
also serve to strengthen the nervous system. Fresh air and a nutritious diet 
of easy digestion are important. 
In frequently recurring convulsions, resisting other measures, and threat- 
ening life, the practitioner would be justifiable in resorting to the inhalation 
of chloroform, which will often quickly quiet the spasms, and, if reapplied 
with each return, may obviate danger until the tendency is past. It has the 
advantage, moreover, over other narcotics, of not congesting the cerebral 
centres, though the danger of fatal prostration from its use must not be 
forgotten. 
Even when asphyxia or apparent death may have resulted from the con- 
vulsions, hope should not be abandoned; but efforts should be made, by arti- 
ficial respiration, to restore the function of the lungs, and consequently that 
of the heart. A case of recovery in an infant, by means of this measure, is 
recorded by Dr. A. W. Ely, in the New Orleans Medical and Surgical 
Journal (ix. 209). 
But an account of the treatment would be imperfect, without a more particu- 
lar reference to the mode of removing some of the more prominent causes. 
When the gums are in fault, they should be freely lanced; and, if the tend- 
ency to convulsions continue, a pair of blisters should be applied behind the 
ears. If the affection is connected with acid in the stomach and bowels, re- 
course should be had to the antacids, of which magnesia may be used when a 
laxative effect is desired; carbonate of lime, if diarrhoea exist; aromatic spirit 
of ammonia, when a stimulant effect is indicated; and one of the alkaline car- CLASS III.] 
CATALEPSY. 
695 
bonates or bicarbonates, when there is no special indication, and the extrica- 
tion of carbonic acid in the bowels is not feared. The existence of worms 
would lead to the employment of calomel as a purge, and of oil of wormseed, 
or oil of turpentine as an anthelmintic. 
Any derangement in the hepatic secretion should be carefully observed, and 
treated with minute doses of calomel, blue pill, or mercury with chalk. When 
the disease depends on intestinal spasm, great advantage will often accrue from 
the use of laudanum with assafetida or spirit of ammonia by the mouth, the 
injection of musk into the rectum, the application of a mustard cataplasm, or 
blister over the abdomen, and if, as often happens, the bowels are distended 
with flatus, from the introduction of a catheter into the colon, and drawing 
off tfle air by means of a syringe. This last measure is sometimes of great 
importance. It was recommended by Dr. Parrish in the paper above referred 
to, and I saw it employed with the happiest effects more than thirty years 
since. Should the disappearance of a cutaneous eruption have preceded the 
convulsion, efforts should be made to restore it by friction with croton oil, or 
other active irritant. In urgent cases, a blister might be produced by means 
of the strong solution of ammonia on the surface previously affected. Finally, 
great attention must be paid to the diet of the patient, in order that nothing 
irritating may enter the stomach; and, when there is any reason to suspect 
the milk of the mother or nurse, it should be changed for that of another and 
perfectly healthy woman. 
2. Catalepsy.-This term, derived from the Greek a seizure, 
is used to designate an affection, characterized by a loss more or less complete 
of consciousness, with a peculiar rigidity of the muscles, causing the body, 
and each portion of it, to retain the position in which it may have existed at 
the moment of attack, or in which it may afterwards be placed. The disease 
is seldom idiopathic or solitary; but is generally combined with some other 
affection, especially hysteria, somnambulism, and insanity. It may attack 
both sides of the body, one side only, or a single limb. Sometimes the attack 
is preceded by signs of nervous disorder, sometimes comes on without pre- 
monition. 
When the whole body is attacked, the patient becomes stiff like a statue, 
and remains standing, sitting, or lying, according to the posture at the time 
of seizure. Upon any attempt to move the limbs by another, though there is 
some degree of stiffness, they generally yield to the impulse, and afterwards 
retain the position in which they may be placed, however ludicrous or seem- 
ingly painful. The features are usually composed; though it is said that the 
muscles of the face obey the general law, and that the same expression of 
countenance is retained as may have been exhibited at the moment of attack. 
The pulse is variously affected, being in some instances healthy, in others 
accelerated, and in others diminished both in frequency and force. During 
the continuance of the attack, the evacuations are either suppressed or invol- 
untary. 
The duration is quite uncertain. It may be only a few minutes, or it may 
extend to hours and days. In some cases, the attacks are repeated with greater 
or less frequency, and in this way the complaint may continue for months or 
years. Upon the solution of the paroxysm, the patient often complains of 
headache, and a feeling of muscular soreness or fatigue; but is in general 
wholly unconscious of what has passed, and sometimes, it is said, resumes a 
conversation or action in which he may have been engaged when attacked, at 
the point at which it was interrupted. 
There is usually in the intervals some evidence of nervous disorder, very 
often connected with derangement of the alimentary canal, or, in the female, 
of the uterus. 696 
[part II. 
LOCAL DISEASES.-NERVOUS SYSTEM. 
The disease exhibits considerable diversity of symptoms. The rigidity varies, 
being occasionally so great as to resist strong efforts to overcome it, and in 
other cases so slight that the limb will not retain a new position, but falls 
slowly if elevated. Sometimes a degree of consciousness remains; and certain 
muscles may be moved under the influence of the will, while others are cata- 
leptic. Cases, too, have occurred, in which the patients upon recovery have 
declared that they were perfectly aware of their condition, and of all that was 
going on around them, but utterly unable to speak, or to move the voluntary 
muscles, even those of the eye. In some very rare instances, circulation and 
respiration have been so far reduced, as to be scarcely if at all observable; and 
the individuals have been supposed to be dead. But the expression of the 
face, the retention by the limbs of any new position in which they may be put, 
or an inflexibility greater than that of death, and the preservation of a certain 
degree of animal temperature, will generally serve to distinguish these cases 
if closely observed. It is probable also that some action of the heart would 
be discoverable by the stethoscope. A piece of cold clear glass held before 
the lips would detect any remains of respiration by the condensation of moist- 
ure. In itself the affection is generally innocent; but it is apt to be associated 
with cerebral disease, which may end in cerebritis, apoplexy, or insanity, and 
with serious organic disease of the viscera. 
Causes.-An excitable condition of the nervous system, analogous to that 
which exists in hysteria, constitutes a predisposition to this affection. Women 
and children are peculiarly liable to it. Any strong emotion, or unusual or 
protracted intellectual exertion, may serve as an exciting cause. Strong 
sexual desires, or excessive indulgence, are said to have brought on attacks. 
Paroxysms of the disease have also been ascribed to worms, to the retroces- 
sion of cutaneous eruptions, to menorrhagia, and to the cessation of habitual 
discharges. Probably the most frequent exciting causes are stomachic, intes- 
tinal, and uterine irritations. 
Treatment.-If the pulse appear to call for it, blood may be taken from the 
arm, and by leeches or cups, once or oftener, from the temples or back of the 
neck. Purging is also indicated, especially in cases of amenorrhoea, in which 
aloes should be employed in full doses. Cold should be applied to the head, 
if it be in any degree heated. The warm bath may be tried, though its utility 
is not universally admitted. All the organic functions should be maintained 
as nearly as possible in the healthy state. Any spinal irritation that may 
exist must be corrected in the usual manner. Should the paroxysms be peri- 
odical in their recurrence, quinia might be expected to prevent them. Anemic 
cases would require the chalybeates. Debility must be counteracted by tonics, 
the shower bath, or sea-bathing, exercise in the intervals of attack, and a nu- 
tritious easily digested diet. Advantage may sometimes accrue from the 
nervous stimulants; and oil of turpentine with aromatic spirit of ammonia, 
given several times a day, in connexion with the warm bath, was used suc- 
cessfully by Dr. Radcliffe in the case of a child who was very severely affected. 
(Arch Gen., 5e ser., i. 329, from the Lancet for 1852.) Should respiration 
be suspended, it should be restored artificially. 
Article V. 
INSANITY. 
Syn.-Madness.-Mental Derangement.-Lunacy, 
Insanity is a general term, including all derangements of the intellectual 
and moral functions, not forming a part of some other recognized disease, noi CLASS III.] 
697 
INSANITY. 
an ordinary physiological result of the time of life. The delirium of fever, 
the hallucinations of hysteria, the temporary cerebral irregularities from ex- 
cessive pain or functional disturbance in various parts of the body, the irra- 
tional confidence and hopes of phthisis, the equally irrational depression of 
dyspepsia, the stupor of apoplexy, and the imbecility of old age, can scarcely 
be considered as falling within the meaning of the term. Yet it must be ac- 
knowledged that the definition is imperfect; and perhaps necessarily so ; as 
our ideas of insanity are somewhat indefinite; and, when precision is wanting 
in our conceptions, it cannot be given by words. 
The disease is seated essentially in the brain. It is through that organ 
exclusively that we think, and experience emotion; and derangements in these 
two modes of mental exhibition, whatever may be their remote cause, are ne- 
cessarily cerebral disorders. But insanity is by no means a simple mental 
condition. The brain, if not a complex organ, certainly has complex func- 
tions ; and it may be deranged in the whole of these functions, or in one only, 
or in any number of them, and there is scarcely an end to the diversity of 
mental disorder which may thus arise. Some arrangement, however, is ne- 
cessary for the purpose of description; and I know of none better than that 
which divides the disease, primarily, into general and partial insanity, and, 
subordinately, into mania and dementia, belonging to the first division, and 
moral insanity, monomania, and insane impulse, belonging to the second. 
By general insanity is meant a derangement, in a greater or less degree, of 
all the cerebral functions connected essentially with mind; by partial insanity, 
a derangement of one or a portion only of these functions. Mania, is that 
form of general insanity in which there is an exaltation of the cerebral ac- 
tions ; dementia, that in which the brain is enfeebled, and the mental opera- 
tions all participate in its weakness. Partial insanity takes the name of moral 
insanity, when it affects only the emotional functions, as contradistinguished 
from the intellectual; of monomania, when, with a general soundness of thought, 
there is delusion upon some one point, or in some one direction; and of insane 
impulse, when, without reflection, and without any known perversion of the 
feelings or passions, the patient is irresistibly impelled to some insane act. 
Each of these modes of insanity requires a distinct description. 
It is necessary to guard against the mistake of supposing that all cases of 
insanity can be referred clearly to one or the other of these varieties. Each 
one of them is occasionally well characterized; but cases are constantly occur- 
ring, either intermediate in their nature, or combining the peculiarities of 
two or more of the varieties, so that it would be impossible to refer them to 
any one division; and the same case occasionally exhibits, in its different 
stages, all the different phases of the disease. 
As to the relative frequency of the several forms of insanity above referred 
to, it may be stated, in general terms, that the cases of general insanity, so 
far as can be inferred from the returns of hospitals, are more than one-half of 
the whole number. In relation to the subordinate varieties, mania and mono- 
mania are probably nearly equal. Esquirol, however, considers monomania as 
more frequent than mania; and the probability is, that of the insane who are 
not treated in the public institutions, much the larger proportion belong to the 
former class. The cases of mania greatly exceed in numbers those of dementia; 
and of monomania those of pure moral insanity, and of insane impulse.* 
* Of 2010 insane patients admitted into the Pennsylvania Hospital, since the separate 
existence of the insane department, 981 are classed under mania, 486 under melancholia, 
285 under monomania, 247 under dementia, and 11 under delirium. As monomania is 
defined in this work, it includes the cases of melancholia, so that the whole number is 
771, or about one-fifth less than those of mania. (Report of the Penn. Hosp, for the In~ 
sane, A. D. 1851, p. 13.) 698 
LOCAL DISEASES.-NERVOUS SYSTEM. 
[PART II. 
Symptoms, Course, &c. 
1. Mania.-This sometimes makes its attack suddenly, with little or no 
premonition; but much more frequently its approaches are very gradual, and 
often for a long time unperceived. After the nature of the case has become 
quite evident, the friends of the patient frequently call to mind traits of cha- 
racter and conduct, which had, perhaps, somewhat surprised them, which they 
had ascribed to eccentricity or whim, or which had given them uneasiness as 
evincing a failure of principle or customary prudence, but which they had not 
thought of referring to its true source, in commencing insanity. In this early 
stage, the patient sometimes evinces disorder only by a certain exaggeration 
in his feelings, views, expressions, and actions. He is apparently eager and 
enthusiastic, but generally unstable; flies from one object to another; and is 
found, perhaps, at last, to have been busied with trifles. He speaks much but 
vaguely, of his engagements, projects, and expectations; all of which come 
to nothing when examined. Not unfrequently he imagines evil of certain 
individuals; attributes to them impertinent interference in his own concerns, 
or some departure from general rectitude; and sometimes gains a partial be- 
lief from the unwary of his insane fictions in relation to their character and 
actions. His most intimate friends and relatives are often the subjects of 
these suspicions and charges. His feelings are morbidly excitable. He is 
irritated by slight causes; often speaks in a quick and elevated tone; is rest- 
less and anxious; loses much sleep; and not unfrequently rises from his bed 
at night, and walks about the chamber. At length, upon the occurrence of 
some unusual excitement, some opposition to his views or wishes, perhaps 
even of some unguarded and scarcely intended charge of insanity extorted by 
his singularities, he breaks out into violent and wholly irrational expressions; 
and his friends, convinced of the nature of the case, only wonder that it had 
not long before occurred to them. Not unfrequently, however, the increasing 
developement of the disease forces itself upon the attention, without any 
special and temporary occasion of excitement. 
Instead of this preliminary excitation, a wholly different character of feel- 
ing and deportment is sometimes exhibited. The patient is calm, but, if left 
to himself, is constantly imagining false facts, and forming false judgments 
of things and persons. The state of his mind is not at first obvious to others, 
because, when roused to exert himself, he can think correctly, and pursues 
his usual avocations, if with less energy, yet without any very visible want of 
judgment. In time, however, the affection increases, and his insanity be- 
comes quite evident. Sometimes a period of great mental dejection or anxiety, 
perhaps consequent upon external circumstances, perhaps without obvious 
cause, precedes the period of false excitement or illusion. 
Between the two extremes of mental condition above alluded to, as cha- 
racterizing the forming period of insanity, there is every possible gradation; 
and the modes in which the intellectual and moral aberration shows itself are 
diversified beyond all power of description. One prominent phenomenon, 
exhibited probably in the great majority of cases, before the occurrence of 
open and acknowledged insanity, is want of sleep. This is important, in a 
therapeutical point of view; as it cannot but exert an unfavourable influence 
over the progress of the disease, and affords an indication of treatment which, 
if attended to, may sometimes lead to effectual preventive measures. In 
women the preliminary symptoms are sometimes of an hysterical character. 
After an unusually violent paroxysm of crying, sobbing, laughing, and per- 
haps of temporary unconsciousness, the patient is found, upon the subsidence 
of the nervous phenomena, to have quite lost her reason. CLASS III.] 
INSANITY. 
699 
The initial or incubative stage of insanity varies greatly in duration. It 
may not exceed a few days, or it may extend to months and years. 
It has been stated that the disease sometimes comes on suddenly. In such 
cases, it is apt to have an acute form, and exhibits, in a greater or less de- 
gree, the phenomena of ordinary meningeal inflammation. Before the attack, 
the patient may complain of headache, vertigo, tinnitus aurium, &c., which 
disappear upon the occurrence of delirium. The pulse is increased in fre- 
quency and force; the face is flushed, the eyes are wild; the tongue is coated 
with a white fur; there are thirst, anorexia, constipation, scanty urine; the 
patient is restless, agitated, sleepless, often violent; he talks incessantly, 
raves, screams, laughs, flies from one thought to another, and is kept in bed 
only by force. The fever, however, is not usually so high as in common acute 
meningitis; there is less tendency to stupor; and the progress of the case is 
not so rapid. After a variable period of from one to three or four weeks, or 
longer, the symptoms either assume the character of cerebral oppression, and 
death ensues preceded by coma; or, what is much more common, a gradual 
amendment takes place, the febrile symptoms subside, the tongue cleans, the 
appetite returns, and the patient becomes convalescent, so far as the general 
health is concerned. It often happens that the delirium disappears with the 
other symptoms, and perfect recovery takes place. But often also the mind 
remains disordered, and a state of chronic insanity results. 
The degree of this febrile and inflammatory disturbance is very different 
in different cases. It is almost always greatest in the abrupt attacks. In 
those which have approached gradually there is often little of it observable. 
There may be a slight increase of the circulation and of the general tempera- 
ture, some fur upon the tongue, an offensive breath, and more or less loss of 
appetite; there may be some gastric or intestinal uneasiness; the skin may 
be dry; the menstrual flux in women, and any accidental discharge in men, 
may cease; some emaciation may take place; but the patient is not ill enough 
to be confined to bed, and not unfrequently continues upon his feet as if in 
health. In the great majority of cases, there is a tendency to constipation; 
and obstinate wakefulness is very frequent, continuing for many days, and, as 
some have asserted, occasionally for weeks and months. One of the peculiar- 
ities of the insane is an ability to support loss of sleep, with less injury than 
would be sustained from the same cause in ordinary states of health. What- 
ever may be the amount of derangement in the organic functions in the early 
stage, it generally subsides after a variable duration, and leaves the patient 
with little other observable disorder than the mental. Sometimes, indeed, it 
is scarcely sufficient to attract notice, even at the commencement; and, in cer- 
tain cases, the patient appears rather debilitated than physically excited; the 
pulse being slower and less vigorous than in health. 
One of the ordinary characters of mania is the tendency to paroxysms of 
violence, with intervals of comparative quietness and composure. These par- 
oxysms are so common a feature of this variety of insanity, as to have acquired 
for it the name of raving madness. They are of variable duration, lasting 
sometimes only a few hours, sometimes for days, or weeks. During their con- 
tinuance, the physical signs of disease are often increased as in the early stage; 
the pulse being accelerated, the tongue often furred, the appetite impaired, 
&c.; but it is not always easy to determine whether these are the effects of 
the excitement, or direct results of the same cause. They are probably in 
some cases the one, and in others the other. Thus, the paroxysm sometimes 
comes on spontaneously, without any discoverable cause of irritation, and pro- 
bably depends upon increased vascular action in the brain, which is sufficient 
also to induce a certain degree of fever. In other instances, it is caused by 700 
[PART II. 
LOCAL DISEASES.-NERVOUS SYSTEM. 
some real or imaginary source of provocation; as opposition, denial, compul- 
sory restraint, &c.; and, in such cases, the physical disturbance may be the 
direct result of the violence. 
Instead of merely remitting, mania is sometimes quite intermittent; the 
symptoms of insanity occurring at somewhat regular periods, daily, every other 
day, weekly, monthly, semi-annually, once a year, or even at still longer in- 
tervals; and leaving the patient perfectly sane upon their subsidence. Some- 
times they recur without apparent cause, sometimes are excited by an accidental 
cause, such as exposure to the sun, over-exertion, excitement of the passions, 
or the use of alcoholic drinks. Some individuals are aware of the approach 
of the paroxysms, and voluntarily submit themselves to the necessary restraint. 
An attempt to describe the various phases of mental disorder which mania- 
cal patients exhibit, would be quite out of place in a general treatise like the 
present. The reader is referred to the works upon insanity, among which 
those of Prichard and Esquirol merit especial notice. I shall only aim at a 
brief analysis of the phenomena. 
All the cerebral functions which express the state of the mind, whether 
active or passive, are deranged. There are undoubtedly various degrees of 
this derangement; but there is no one point, in relation either to the intellect, 
the feelings, the conscience, or the will, in which the patient can be said to 
be perfectly sound. 
In some instances, the character of the insanity, both in its intellectual and 
moral bearings, receives an impress from the natural peculiarities of the indi- 
vidual. Ambition leads armies, sits upon thrones, or usurps even the place of 
Deity; vanity decks herself in gewgaws and tinsel; love lavishes upon inani- 
mate objects the kindly affections once perhaps rejected by the living. But 
frequently also, the character is wholly changed. Suspicion takes the place 
of confidence, affection is turned into hate, and the modesty which forms one of 
the chief charms of woman, gives way to utter wantonness of manner, and the 
grossest obscenity of language. 
Sometimes, along with the wreck of the intellect, there is some one promi- 
nent passion or illusion in which the thoughts appear to centre. Such cases 
are a link connecting mania with monomania. 
The ordinary deportment of the patient, except when under excitement, 
jnay not vary greatly from that of health; but often it is much otherwise. 
Sometimes he is abstracted, as if absorbed in his own thoughts, stands or sits 
long in the same position, talks to himself, or is obstinately silent. Some- 
times, on the contrary, he walks about incessantly, speaks to every one who 
will listen to him, holds conversations with imaginary persons, occupies him- 
self about imaginary concerns, engages in some mechanical pursuit when the 
means are afforded him, paints, writes letters, makes speeches, flies from one 
subject to another, seldom completing a train of reflection, and seldom ad- 
hering long to any one course of action. 
In some maniacs, the feelings have a cheerful character; the imaginations 
are all agreeable, and calculated to flatter the natural ruling propensity, as 
they are probably the result of it. They are contented, cheerful, even happy 
in their illusions. But with the greater number it is very different. They 
are disturbed, sad, gloomy, discontented, or morose; usually have some fancied 
cause of complaint; apprehend some danger; suspect individuals, communi- 
ties, mankind in general, whom they consider as conspiring against them. 
But, in this species of insanity, when not of the character before alluded to 
as having some analogy with monomania, there is only a general tendency to 
elevation or depression, without any steady direction of the feelings towards 
a particular object; and, in many instances, the feelings vacillate between the CLASS HI.] 
INSANITY. 
701 
two conditions; the patient being at one time cheerful, at another time dull, 
now trustful and then again suspicious, the sport alike of every caprice of 
passion, and every vagary of the imagination. 
A striking peculiarity of mania, when fully formed, is the entire uncon- 
sciousness of the patient of his real condition. He has full faith, usually, in 
the correctness of his own judgments, and the reasonableness of his conduct; 
and, however much apparently the mere creature of impulse, is generally not 
without a motive in his acts, which he can sometimes explain after conva- 
lescence, though it is often obscure, shadowy, or absurd. He is even aware 
not unfrequently that others think him insane, and will sometimes control his 
own acts and expressions, and conceal his convictions, from the consciousness 
that they will tend to confirm an unfavourable opinion of his sanity. Occa- 
sionally, from the opposition between his own standard of sanity and that of the 
world around him, he fancies that other people are mad, and sometimes exhibits 
considerable ingenuity in proving it; like the insane editors of a journal in 
one of the asylums, who, having collected from the newspapers numerous in- 
stances of violence, lawlessness, and criminality, ended with the exclamation, 
" and this is the world which considers itself sane I" A natural consequence 
of his belief in regard to the state of his own mind is, that he expects to be 
treated like one possessed of his reason, and is often very sensitive to any 
want of due consideration. 
The above remarks have reference to the general tenor of the patient's 
deportment and mental habit. In the paroxysms already referred to, as 
occurring frequently and irregularly in the course of the complaint, the phe- 
nomena are peculiar. The brain is now obviously labouring under great 
excitement. The face is often flushed, the eyes are wild and fiery, and the 
temples throb with the increased current of blood. The patient talks loudly, 
rapidly, incoherently; flies from one topic to another, and finishes none; 
vociferates, screams, implores, threatens, curses; now shrieks as with the 
anguish of despair, and then breaks out into savage laughter; gesticulates 
violently, breaks everything fragile about him, strikes, throws, tears his 
clothes, rends in pieces the covering of his bed, strips himself naked, even 
bites his own flesh in his insane fury. Broken thoughts chase one another 
with fierce haste through his brain; every wild and evil passion, malice, fury, 
hatred, revenge, despair, struggle as if for mastery in his agitated features; 
his hair stands on end; every trait of his meagre countenance is distorted; 
even his intimate friends would scarcely recognize an acquaintance in the 
demoniac before them. It is not to be understood that every case of mania 
offers paroxysms so violent as this, nor that all the particular features are 
united in every violent case. In (some instances, the paroxysms are very 
feeble, consisting in nothing more than occasional aggravation of the ordinary 
symptoms under excitant influences. Nor is it to be understood that even 
the greatest violence is always so incoherent in its mode of expression. Oc- 
casionally, even maniacal patients confine themselves to one strain of feeling 
or thought. I have known a patient to rave, scream, and implore for an 
hour continuously, under the impression that he was surrounded by robbers 
who aimed at his life. After the subsidence of the paroxysm, the patient is 
weak, exhausted, pale, frequently gloomy and silent, or talks to himself, and 
apparently broods over his troubles. 
A short reference to the state of the individual psychological functions will 
close this description. Sensation is not in general materially deranged. 
Sight and hearing are sometimes more acute or sensitive in the early stages 
than in health; patients are occasionally extraordinarily insusceptible to 
extreme cold, and to painful impressions, or at least unmindful of them; and, 702 
[PART II. 
LOCAL DISEASES.-NERVOUS SYSTEM. 
in the advanced stages, there is often some decay of the senses, especially of 
hearing. But, until the affection lapses into dementia, morbid sensation is 
not a striking phenomenon. The perceptive faculty, moreover, is for the 
most part not very prominently affected. The patient usually recognizes 
persons and objects, appreciates sounds, and receives tolerably correct im- 
pressions through the senses of smell and taste. But this is not always the 
case. The perceptions are sometimes quite illusory. Imaginary sights are 
seen, imaginary sounds are heard, the patient converses aloud with imaginary 
persons, and there is reason to believe that his perceptions of odour and taste 
are different from those of health. One kind of misapprehension is not un- 
common. The patient, struck with some real or fancied resemblance between 
a stranger and one of his friends or relatives, a wife, a husband, a child, for 
example, mistakes the former for the latter, and lavishes upon the new per- 
sonage the attentions which the reality of the supposed relation would suggest. 
Even brute animals, or things without life, may become the objects of such 
attentions. Thus a bird, or a cat, may be gifted with the attributes of 
humanity; a pillow, or a stick of wood may be fondled as a child; and we 
may sometimes see a patient holding up a bed, or lifting up a flower-pot, to 
save the bedstead or the flower-stand from fatigue. But it is probable that 
mistakes like these arise more from a perverted mental action subsequent to 
perception, than from disorder of the perception itself. The reasoning faculty 
is always deranged. But it is not abolished. The patient can often follow 
out trains of ratiocination with considerable correctness, and sometimes even 
with much ingenuity. But he is apt to change abruptly from one course of 
thought to another before the first is completed; each idea that presents itself, 
however irrelative, becomes the starting point of a new succession, which is, 
in its turn, soon interrupted; and his intellectual action is thus broken up 
into disjointed fragments, fitted to no useful purpose. Again, the maniac 
may argue for a time with a show of reason; but he is apt to base his logic 
upon some ludicrously absurd assumption, of which he cannot perceive the 
folly, and therefore reaches equally absurd conclusions. He often, besides, 
mistakes some slight semblance, some mere shadow of association, a similarity 
of sound in a word, for example, for a legitimate link in a chain of reasoning, 
and thus, even when starting from correct premises, is led into the most egre- 
gious errors. The judgment is, perhaps, more perverted than any other 
faculty. It is the quality of mind which is most rarely perfect in health, 
and which might, therefore, be expected to be most defective in mental un- 
soundness. The maniac cannot duly appreciate his relations to the world 
around him, cannot shape his course in accordance with the various interests, 
opinions, and feelings of others, and is, therefore, constantly encountering 
difficulties and vexations, which aggravate his disease, and generally render 
confinement essential. The imagination in mania is often greatly excited, 
fruitful in its suggestion, not unfrequently brilliant in its illusive picturing; 
but always deranged. The pictures which it forms, like the workings of the 
insane reason, are without due connexion or relation of parts, mere jumbled 
assemblages of the grotesque, the ludicrous, the wild, the fearful; shifting, 
tbo, like dreamy phantasms, to which it is probable that they bear no slight 
resemblance. Memory is one of the faculties that suffers least in this variety 
of insanity. Maniacs can often vividly recall past events, whether relating 
to themselves or others; and they sometimes take a malicious pleasure in 
suggesting disagreeable recollections. Even the incidents which attend their 
illness they frequently remember with greater or less accuracy, and often, 
after recovery, have a vivid recollection of the kindness or harshness with 
which they may have been treated, and feelings such as these recollections CLASS III.] 
INSANITY. 
703 
are calculated to excite. The imitative quality is also retained by them in a 
considerable degree; and, like children, or some of the lower animals, they 
may often be induced, by the example of others around them, to regulate 
their deportment, and restrain their insane propensities. We may often most 
usefully avail ourselves of this property of the maniacal character in our 
course of treatment. It is a fact of some interest, that, in the cerebral ex- 
citement of mania, faculties which before lay dormant, have been sometimes 
called into existence, as, for example, those of music and painting; and a 
certain degree of wit or humour is not uncommon, either retained amid the 
ruin of nobler powers, or generated by the new stimulus to the brain. 
The emotional functions are not less disordered than the intellectual. In 
some cases, there is a morbid exaggeration of the natural qualities; in others, 
a complete change. In general, the maniac is more irascible than in health, 
surrenders himself more readily to every impulse, is often suspicious, revenge- 
ful, malicious; and the countenance is sometimes fearfully expressive of his 
uncontrolled passions. Among the most common results of the disease is an 
alteration of the natural affections. Connubial, parental, and filial love are 
not unfrequently exchanged for indifference, forgetfulness, even suspicion and 
hatred. The dislike of the insane for their former nearest and most intimate 
friends is almost proverbial; and the exhibition of such a dislike is sometimes 
among the first observable symptoms of the disease. Excesses of pride, am- 
bition, and vanity are frequently witnessed. But the kindlier emotions are 
occasionally also morbidly developed or directed. The insane not unfre- 
quently form irrational or whimsical attachments. Love, in its purest form, 
is sometimes exhibited, especially by women, who betray their insanity by 
openly lavishing marks of tenderness, which in their sane state they would 
have been most solicitous to conceal. Delicacy and the sense of shame appear 
often to be quite abolished. There is not unfrequently a strange propensity 
to go naked. Lascivious desires are expressed openly by language and ges- 
tures. Personal cleanliness is disgustingly neglected. Patients sometimes 
smear themselves with their own excrement. Notwithstanding the violence 
of maniacs, they are usually wanting in steady courage. It has been often 
observed that, if regarded fixedly and firmly, by a sane individual, especially 
one having official power over them, they will drop their eye, and yield for a 
time, though the moment before fierce and threatening. But this is not uni- 
versally true; and some caution is advisable not to trust too much to their 
presumed submissiveness. As with the thoughts in mania, so is it generally 
also with the feelings. They are exceedingly unstable. The patient passes 
rapidly from one state to its opposite. The mental cords vibrate in quick suc- 
cession with the whole gamut of the passions. 
The exaltation of the cerebral actions is exhibited strongly in the increased 
muscular power. In their paroxysms, the insane sometimes evince almost 
incredible strength and activity, and an amount of endurance altogether be- 
yond their capacity in health. 
After the subsidence of the first symptoms of physical disorder, if such 
symptoms existed, the general health does not usually appear to be much im- 
paired. The patient is liable to occasional attacks of the ordinary diseases; 
he is perhaps, for the most part, somewhat emaciated and of a squalid appear- 
ance; his stomach, bowels, and liver may be variously disordered; he may 
even suffer with accessions of acute cerebral symptoms; but in general there 
is little prominent derangement. 
The disease, if it continue, may now pursue one of two courses. Either it 
may pass gradually into the state of dementia, to be described directly, or may 
settle into confirmed mania, which thus becomes the habit of the mind, after 704 
LOCAL DISEASES.-NERVOUS SYSTEM. 
[PART II. 
a complete apparent restoration of physical health, and may continue for 
may years, or for life. In the latter case, the patient generally dies in the 
end not of the cerebral affection, in which the insanity may have originated, 
but of some accidental disease, as phthisis, or inflammation of the lungs, 
pleura, or alimentary canal. It has been supposed that insane persons are 
peculiarly exempt from ordinary diseases, that they are less liable to be affected 
by prevalent epidemics than the sane, and that the complaint affords a pecu- 
liar protection against phthisis. There may, possibly, be some truth in this 
belief; but the prophylactic influence of insanity has been much exaggerated; 
and the fact is, that evidences of serious disease of the lungs are sometimes 
revealed by dissection, which had escaped notice during life. On the whole, 
the probability is, that, independently of organic disease in the brain, mania 
has a tendency to shorten life, in consequence, in some measure, of the wear- 
ing influence of nervous excitement upon the organic functions, but still more 
from the injurious influences, partly necessary, partly accidental, to which the 
patients are often exposed, such as confinement, unsuitable diet, excesses of 
cold or heat, insufficient clothing, and various ill usage. 
Recoveries from mania often take place, especially within the first, second, 
or third year. After the latter period they become more and more rare; 
though cases are on record, in which the disease has been cured at various 
times between the tenth and twentieth year; and one is mentioned by Pinel, 
in which the patient recovered at the end of twenty-seven years. 
The cure is sometimes abrupt ; the patient passing at once from a state of 
insanity to the perfect possession of his faculties. It is said that the change 
is occasionally attendant upon the supervention of another disease, or the oc- 
currence of what have been considered critical affections, such as a diarrhoea, 
copious perspiration, various hemorrhages, abscesses, or cutaneous eruptions. 
Much more frequently the amendment is very gradual, liable to occasional 
interruptions, or partial relapses, but, on the whole, advancing towards per- 
fect sanity. One of the most favourable indications is the appearance of a 
consciousness, on the part of the patient, of his real condition. Not unfre- 
quently, too, headache or other cerebral uneasiness occurs upon the subsidence 
of the delirium. The convalescence usually occupies a period varying from 
two or three to six or eight weeks. In some instances it is perfect; in others 
the cure is only partial, the patient retaining some peculiarity of thinking or 
deportment for a long time, perhaps during the remainder of his life. Re- 
lapses are not unfrequent. Out of 2804 cases, as stated by Esquirol, there 
were 292 relapses, or about one-tenth. The number may, perhaps, vary from 
one-fifth to one-tenth, according to the completeness of the cure, and the sub- 
sequent position of the patient in relation to the causes of the disease. These 
remarks in reference to the cure of mania apply also to the other varieties. 
2. Dementia.-This, it will be recollected, is that form of general in- 
sanity in which the mental functions are enfeebled. It is a condition of 
mental imbecility, or of fatuity, differing, in its complete form, from original 
idiocy only in the circumstance, that, in the latter, there never has been in- 
tellect, and the mind appears to be a blank, while, in the former, the broken 
remains of a previous intelligence are generally discoverable. The affection 
is characterized, not by a want of ideas; but by an entire want of coherence 
between them. The passions, the conscience, the will, may not be quite 
obliterated; but their exhibitions are generally feeble, fragmentary, merely 
habitual. An imperfect memory of the past remains; but present objects 
and incidents make no impression; or are forgotten immediately. 
Dementia is not fully formed at once. It in general comes on gradually, CLASS III.] 
INSANITY. 
705 
and exists in various degrees; and there is every grade between the perfectly 
sane, or the maniacal condition of mind, and complete imbecility. 
When the result of previous mania or monomania, it makes its appearance 
by a gradual diminution of coherence in the thoughts, of apparent motive in 
the actions, of vigour in the will, memory, feelings, and passions. Paroxysms 
of violence still occur, but they are less frequent, more subdued, more mo- 
tiveless than before; the mere waves of a tempest which has subsided. . 
In some instances, the passage of mania or monomania into dementia is 
marked by the occurrence of paralytic symptoms indicative of organic disease 
in the brain. Even before the intellect is quite lost, evidence of commencing 
palsy are offered in the hesitating speech, the stiff or uncertain movements, 
the tottering walk, and false steps of the patient. With the progressive weak- 
ening of the mind, the palsy increases, so that ideas and the power of ex- 
pression appear to be nearly lost together. Along with the organs of 
speech, the lower extremities usually suffer most; walking becomes difficult 
or quite impossible; and the patient is confined to a chair, and finally to his 
bed, where the constant pressure is apt to occasion sloughing upon the back 
and hips. Involuntary discharges from the bladder and bowels now cohic on; 
and general sensibility is so much impaired, fhat little, if any uneasiness is 
produced by severely pinching the limbs. Occasionally, partial or general 
convulsions vary the progress of the disease. Death usually occurs in these 
cases, according to M. Bayle, at a period varying from three months to two 
or three years from the commencement of the stage of dementia. Dissection 
proves the existence of chronic inflammation of the brain and its membranes. 
In other cases, the passage of mania into dementia is not attended with 
this failure of the physical powers. On the contrary, as the wearing reaction 
of the cerebral excitement upon the general health ceases with its cause, the 
patient not unfrequently increases in flesh; the organic functions retaining 
their vigour amidst the decay of those belonging to the mental constitution. 
Dementia sometimes occurs as an original affection. It then first shows 
itself, as a general rule, in failure of the memory. The patient can usually 
recollect remote events; but those passing at the time make little impression, 
and are forgotten quickly. Words also are forgotten, or ludicrously misap- 
plied ; persons and things being frequently called by the wrong names. Some- 
times the patient appears to live in the past, and speaks of having recently 
visited old friends long since deceased, or of mingling in events which had 
perhaps occurred in his youth. The power of reasoning is gradually quite 
lost. The ideas may have a sort of concatenation depending on old associa- 
tions; but the mind is wholly incapable of a train of thought leading to any 
rational conclusion. The feelings, conscience, and will, undergo a similar 
decay. Former friends are seen without emotion ; the capacity for grief and 
for joy seems to be alike impaired or lost; only some former ruling passion, 
such as ambition or avarice, may yet exert an influence almost mechanical 
over the conduct. Patients in this state are not unfrequently capable of cer- 
tain habitual employments, which require no mental effort. They play at 
certain games, draw, paint, knit, and perform various domestic functions with 
considerable efficiency and regularity. But, in the progress of the affection, 
even these feeble powers are lost. There is a total want of comprehension 
and thought. The man is reduced to the state of a brute without its instincts. 
The lower animal functions still remain. Some patients exhibit much mus- 
cular activity, jump, run about, dance in circles, sometimes jabber incessantly, 
uttering words or parts of words rapidly and without discoverable meaning. 
Others are quite silent, sit crouching in the same position, which they change 
only under the guidance of others, and to which they return when uncon- 706 
[part II. 
LOCAL DISEASES.-NERVOUS SYSTEM. 
trolled, pay no attention to things or events about them, appear insensible 
alike to heat and cold, eat only when food is placed before them, are utterly 
inattentive to personal cleanliness or to decency in the offices of defecation 
and micturition, look at you with a meaningless stare, a vacant face, or an 
idiotic laugh. At last, scarcely any consciousness is evinced; and their con- 
dition is reduced to that of a mere vegetative existence, perhaps with the power 
of locomotion, perhaps deprived even of this by the supervention of paralysis. 
In all the stages, however, of this affection, the brain appears capable of being 
excited by temporary influences to a higher grade of activity. Some glim- 
merings of intellect, some excitement of the passions, some little show of 
sentiment may now and then appear, like ignes fatui in the darkness. Death, 
in dementia, may occur from the supervention of various acute or chronic 
disease, having no immediate connexion with the brain; or it may apparently 
depend upon the cerebral affection, life being terminated by an apoplectic 
seizure, or the slow progress of paralysis. 
It is a singular fact, that individuals who have long remained in a seeming 
state of vegetative existence, entirely silent, apparently attending to nothing, 
and caring for nothing, eating only what was given them, and wholly inatten- 
tive to their person, have suddenly thrown off this lethargy, and resumed 
their usual mental activity, with or without a complete return to reason. Dr. 
Earl relates the case of a young man brought for insanity into an asylum 
under his care, who had sunk into a state of lethargy and apparent dementia, 
without speech for several weeks, and without voluntary locomotion for many 
months. All at once he roused himself from his seeming fatuity; and the 
doctor was first made sensible of the change, by seeing him in the midst of a 
circle of the inmates of the house, convulsing them with laughter by his antics 
and witticisms. In such cases, the dementia may sometimes be only appa- 
rent, and the obstinate simulation of it the result of an insane determination. 
In the case, however, referred to, it was not so; for the patient subsequently 
relapsed, and fell into the same state of dementia as before. 
3. Moral Insanity.-The existence of derangement of the emotional 
functions, distinct from the intellectual, has been long admitted. Pinel called 
attention, in 1831, to a form of this disease, which he named "mania with- 
out delirium," or "reasoning insanity." Numerous examples of the affection 
are given by Dr. Rush, under the name of moral derangement, in his treatise 
on " Diseases of the Mind," published in 1812. But the subject has been 
most elaborately considered by Dr. Prichard, who gave to this variety of men- 
tal disease the title of moral insanity, and defines it to be " a morbid perver- 
sion of the feelings, affections, and active powers, without any illusion or erro- 
neous conviction impressed upon the understanding." There are numerous 
individuals mingling in society, and participating in the ordinary avocations 
of other men, whose sentiments and conduct are so peculiar as to attract 
general attention; but who can reason so well upon all subjects within their 
capacity, and whose intellect is often so clear, and, in many instances, even 
strong, that no one questions their sanity. They are simply said to be sin- 
gular or eccentric. Now the fact is, that such individuals are not unfre- 
quently as much under the control of their morbid feelings, act as irrationally 
in obedience to these feelings, and are morally as little responsible for their 
acts, as others who carry out in their conduct some false conclusion of the 
intellect. Such persons should certainly be considered as insane. It may 
not be easy to draw the line, in all of these cases, between sanity and insanity, 
to determine how far the deviation from the ordinary course may proceed 
without passing the limits of mere eccentricity; but the same difficulty is ex- 
perienced in defining with precision the boundary between health and disease CLASS III.] 
707 
INSANITY. 
in general. The case may be considered as coming within the province of 
insanity when the conduct of the individual materially interferes with the 
safety or comfort of other persons; and, in doubtful instances, the judgment 
may be very much aided by the consideration of the origin and causes of the 
peculiar state of mind. If there has been at any period a marked change in 
the feelings; if the individual affected was at one time like other men, and 
fell into the new condition after some great misfortune, or other circumstance 
calculated very much to disturb the mind; if the affection can be traced to 
an attack of illness, or has occurred in one previously affected with ordinary 
insanity, or descended from ancestors who had been insane, there would be 
little hazard of mistake in ascribing the peculiarities of the character to this 
disease. It must not be understood that the patient may not form erroneous 
judgments in moral insanity. Like all others under the influence of strong 
feelings of any kind, he is liable to be warped in the formation of his opinions; 
bnt these are not manifestly absurd, or of a character to exhibit any peculiar 
deficiency of reasoning power. 
The disorder may evince itself in the general condition of the feelings, or 
in reference more especially to a particular passion. Sometimes it appears to 
consist in a state of general excitement. The patient exhibits an excessive 
cheerfulness or hilarity without cause, cherishes confident hopes, forms magni- 
ficent projects, makes large purchases, enters into imprudent speculations, or 
lives in a constant state of spiritual exaltation. In other instances, there is 
an equally causeless depression, everything is viewed through a medium of 
gloom; the patient can see no pleasure in store for him; he is apt to be retir- 
ing, solitary, moody; and occasionally withdraws from all social intercourse, 
and shuts himself up in his apartments for months, or perhaps for years. 
Another form of moral insanity is that of excessive irascibility. The least 
opposition is apt to throw the patient into ungovernable rage, driving him to 
the commission of acts, of which in his cooler moments he repents, and for 
which he may be ready to apologize; but which are repeated again under 
similar circumstances. A regard for public opinion, or the fear of personal 
consequences, will often be sufficient to control the expression of these feel- 
ings; but, when no such restraint exists, they are allowed full sway, and the 
patient seems to take an insane delight in their indulgence. To abuse or 
even strike a fond parent, or other near relative or friend, to curse and revile, 
to pour out torrents of reproaches and accusations without foundation, and, 
when there is powerlessness at the same time, to scream and roar, and use all 
kinds of frantic gestures in the violence of impotent rage, are among the acts 
of persons affected with this species of insanity. Yet, towards the world at 
large, their conduct may be irreproachable; and, though often willing to ad- 
mit themselves in the wrong to the objects of their excitement, they find 
plausible excuses which deceive the multitude, and sometimes make them- 
selves appear to be persecuted individuals. 
The disease may take the form of suspicion or jealousy; or it may appear 
as a complete want of the moral sense, or conscience, so that the person affected 
shall be incapable of the feeling of wrong or criminality; but lie, defraud, and, 
if he dare, steal, without compunction, and even with a keen relish. Some- 
times it is revenge, hate, or mere cruelty that constitutes the insanity, and 
persons of this kind take a fiendish delight in the infliction of pain. The pas- 
sion of love, or the coarser sexual propensity, is liable to the same mad ex- 
cesses, and sometimes leads to the most fearful acts. As observed by Dr. Pri- 
chard, there is apt, in this kind of insanity, to be a disregard for the feelings 
of others, an extraordinary degree of selfishness, and at the same time a want 
of decent reserve, in many instances, in regard to the concerns of the patient, 708 
LOCAL DISEASES.-NERVOUS SYSTEM. 
[PART II. 
his domestic difficulties or relations, arising perhaps from an inability to ap- 
preciate the feelings of others, or to suppose that they are different from his 
own. An irresistible propensity to the abuse of alcoholic drinks, which is now 
and then met with in individuals paroxysmally, and quite independent of the 
mere habit of drinking, may be referred Jo this affection. 
This form of partial insanity, if not subdued, is very apt in time to end in 
monomania. The excess of a particular passion leads at length into some fixed 
illusion connected with the existing propensity; and the patient, before con- 
sidered merely eccentric, perhaps condemned for his excesses, perhaps punished 
as a criminal, is now acknowledged to be insane. 
4. Monomania.-This expressive title was proposed by Esquirol, who, 
however, confined it to those cases in which the insanity was limited to a sin- 
gle object, or a small number of objects, "with excitement, and the predomi- 
nance of a cheerful and expansive passion," while to that form of the disease 
in which the solitary or limited delusion was attended with "predominance 
of a melancholy and depressing passion," he gave the name of lypemania, 
synonymous with the melancholia of the ancients. But, though there are 
cases in which this difference in the state of the feelings is very obvious, yet 
others occur in which it would be very difficult to decide which of these dis- 
positions predominate; one, perhaps, prevailing at one time, and the other at 
another, or no peculiar tendency to either being exhibited. There does not 
appear, therefore, to be any ground for such a division in the essential nature 
of the affection ; and the term monomania, as here used, is applied to all cases 
of illusion upon one subject, or in one direction, without reference to the state 
of the feelings. The moral insanity of Dr. Prichard has been included by 
Esquirol under monomania; but surely there are cases in which the passions, 
the sentiments, the conscience are delirious without the reason; in which the 
moral as contradistinguished from the intellectual nature is the main seat of 
the affection. A proper view of this subject is important both in its thera- 
peutical and medico-legal relations; for, if intellectual delusion is made a 
necessary ingredient of insanity, many a curable patient will be allowed to 
pass, through neglect, into confirmed insanity; and many an unfortunate per- 
son will be sentenced to the gallows or the prison, who would be more appro- 
priately sheltered in a lunatic asylum. 
The statement that the monomaniac is quite sane upon all other points 
than in relation to the subject of his illusion must be received with some 
allowance. There may be such cases; but they are comparatively rare. In 
most instances, something peculiar will be discovered in his general mode of 
thinking and acting, something in which he differs from other men, and from 
what he himself was before the commencement of his insanity. He would 
be counted among eccentric individuals independently of his peculiar insane 
notion; and, in different monomaniacal cases, there is a gradation by insen- 
sible steps from this mere eccentricity, up to the limits where positive and 
undoubted mania begins. 
In the greater number of monomaniacal patients, the intellectual illusion 
is connected with a morbid exaltation of some one of the passions, and is pro- 
bably based upon it. The exaggerated passion places objects calculated to 
gratify it so frequently and so strongly before the imagination of the patient, 
that they appear at length to the mind's eye with all the distinctness and re- 
ality of an impression through the senses, a suggestion of the inner conscious- 
ness, or a conclusion of the judgment. He can no more refuse to believe 
them, than to believe in the existence of what he sees or feels, or in a self- 
evident truth. Hence it is that moral insanity so frequently ends in mono- 
mania. CLASS III.] 
709 
INSANITY. 
It is a singular fact, that, though quite confident of the truth of his insane 
notion, the monomaniac not unfrequently either has some imperfect con- 
sciousness of his want of sanity, or, what is more probable, is able to appre- 
ciate the opinions which others would be apt to entertain of it, were the real 
state of his convictions made known. Hence, he will frequently conceal it 
carefully from the knowledge of others; and, when at length his delusion has 
become so intense as quite to have got the mastery over his judgment, it will 
be found that he has long secretly cherished his insane notion, while mingling 
unsuspected in the world. 
The character of the insanity may depend on the previous dominant pas- 
sion, and will not unfrequently also be influenced by the original cause of 
the affection. A morbid pride or ambition will make the monomaniac a 
governor, a president, a nobleman, a king, a god; and sometimes even per- 
sonal identity is lost, and he becomes some particular great man who may 
happen to occupy largely the attention of the world. Thus, there were many 
Napoleons during the career of that great commander. It is highly probable 
that many of the pretenders to thrones who have been punished as criminals, 
were really monomaniacs, who had full faith in the justice of their claims. 
The peculiar tendency of the mind to cheerfulness or despondency will affect 
the nature of the convictions. Thus, the ambitious, cheerful monomaniac 
will imagine himself a monarch on his throne; a melancholy one, on the con- 
trary, though he may possess the same dignity, does so in a prison or in 
chains. From excess of avarice springs the belief, on the one hand, of im- 
mense wealth, on the other, of broken fortunes, and probable death in a poor- 
house. Vanity will plume herself on high fashion, or splendid dress, or will 
mourn over some beauty supposed to be extinguished, an eye, for example, 
that has lost its softness, or a form its grace. Love will be exquisitely happy 
in the exercise of its own sweet attachments, though the object may be ab- 
sent, or dead, a superior being, a brute animal, or a piece of inanimate mat- 
ter; or it will pine ovei' imaginary desertion, over vows that have been broken, 
or affections in the grave. Sometimes a supposed absence of all feeling will 
be alike the delusion and the distress of the monomaniac. A wife laments 
that she can no more love her husband or children, and feels as though a 
heart of stone were in her bosom. The conscience, or religious principle, 
when diseased, leads to convictions which are very diversified, according to 
the tendency of the feelings, and the circumstances in which the patient may 
be placed. One person will be in ecstacies from immediate intercourse with 
deity; another will be weighed down with the terrible despair of having com- 
mitted the unpardonable sin, or of being on some other account condemned 
to eternal misery. When the world believed in demons, monomaniacs pos- 
sessed with devils, or demoniacs, as they were called, were not uncommon; 
and, when witchcraft was in vogue, the victims of popular delusion not unfre- 
quently shared the public belief in their own supernatural powers. Jealousy 
imagines that the most sacred obligations have been violated, and fixing the 
charge, without the least show of reason, upon some innocent individual, 
pursues him with all the rancour of the most inveterate malice, or the most 
deadly revenge. Fear thinks itself pursued by justice, condemned to death, 
beset with enemies. 
In many instances, a morbid depression of mind gives rise to illusions, 
which are of the most diversified character. Allusion has been already made 
to several which appear to spring from some special passion. Not unfre- 
quently the insane notion has reference to the condition of the frame. The 
patient imagines himself afflicted with an incurable disease, as syphilis, can- 
cer, &c. He believes that there is a snake, lizard, or other disgusting or 710 
LOCAL DISEASES.-NERVOUS SYSTEM. 
[part II. 
horrible reptile in bis stomach or bowels. Some have the notion that they 
have been converted into a brute animal, the sounds and actions of which 
they imitate. Others entertain some whimsical notion as to their physical 
condition, believing themselves tea-pots, and assuming a position accordingly, 
or made of glass, and tremblingly fearful lest they should be broken, or 
enormously swollen, so that they cannot pass through a doorway. Instances 
are related in which the patient has even thought himself dead. 
The melancholy monomaniac is, in some instances, very excitable, easily 
impressed by slight causes, fretful and peevish or irascible, disposed to con- 
vert every new sound or sight into a source of discomfort, vexation, or alarm, 
restless and wakeful, and exceedingly communicative upon the subject of his 
trouble, his terrors, his despair. In other instances, on the contrary, he is 
obstinately silent, sad, gloomy, or morose, perhaps misanthropic, seemingly 
concentrated upon his own insane notion, scarcely sensible of changes that 
are going on around bim, and incapable of mental effort, from the apparent 
absorption of his faculties as well as feelings in the one overwhelming illusion. 
These are opposite extremes, which often mingle in various degrees, and 
sometimes alternate in the same individual. 
Hypochondriasis belongs to this branch of insanity. In its slighter forms, 
when consisting only in depression of spirits, connected with functional, hepa- 
tic, gastric, or intestinal disorder, and not yet associated with any intellectual 
illusion, its claims to this rank might be disputed. But, when the constant 
and morbid watchfulness over the health leads at last to some obviously 
irrational but fixed belief, such as above mentioned, in relation to the state 
of the body, the existence of animals within it, &c., there can be no doubt of 
its monomaniacal nature. The hypochondriac is affected with pains in the 
chest and abdomen, especially under the false ribs, which have given origin 
to the name of the affection. He is troubled also with dyspeptic uneasiness, 
flatulence, constipation, vertigo or pains in the head, perverted sensations in 
various parts of the body, imperfect digestion, a furred tongue, a cool and 
dry skin, a sallow or dingy complexion, cold feet, disturbed sleep, and various 
other symptoms real or imaginary. But the peculiarity of the affection is the 
importance attached to the slightest sign of disorder. His countenance has 
a melancholy or sombre expression; he is always dwelling upon his symp- 
toms; magnifies slight sensations into matters of great importance; imagines 
that he cannot live; speaks constantly of his health; perhaps goes to his bed, 
and remains there for weeks, or shuts himself up in his apartments; in short, 
torments himself and all around him by his unceasing complaints, and the 
obstinacy with which he resists all kinds of consolation. Nothing affronts 
him more than to make light of his disorder. At length he is affected with 
hallucinations, and entertains some ridiculous, or whimsically absurd notion 
of his personal transformation, of what is going on within him, &c., charac- 
teristic of true monomania. The affection is probably a mental disease, super- 
vening on neuralgic or otherwise deranged conditions of the digestive viscera. 
It is often remittent, occurring paroxysmally with regular intervals of com- 
parative health; and is often much aggravated by the abuse of stimulating or 
narcotic substances, as strong coffee, tobacco, opium, or alcohol. 
Sometimes the illusion is not so much one of the judgment or reason, as 
of the perceptive faculty. The patient has visions, sees persons and objects 
which have no existence, hears imaginary noises. His perceptions of things 
around him are different from those of health. For a time, perhaps, he may 
resist the novel impressions, may himself laugh at them, as singular, vision- 
ary, or absurd. When he believes them real, they become hallucinations, and 
he is insane. CLASS III.] 
INSANITY. 
711 
Not unfrequently the illusion leads to some particular course of action, 
which then constitutes the most prominent feature of the case. Some mono- 
maniacs abstain obstinately from eating, under an insane notion of duty, or 
an apprehension of evil. Thus, one will suppose that he must fast forty days 
in imitation of the Saviour, another that poison has been introduced into his 
food. Others for similar reasons are determinedly silent, having a revelation 
of duty to that effect, or apprehending some terrible evil, should they speak. 
A third set retain their excretions from similar absurd convictions, con- 
nected with their illusion. But worse than these are the tendencies not un- 
frequently evinced to suicide and murder. These latter forms of the disease 
are so common as to have received the designations of suicidal and homicidal 
monomania, and are so important as to merit a separate notice. 
Suicidal monomania is distinct from the insane suicidal impulse of which 
I shall treat directly. In the former there is always a motive. The proper 
maniac scarcely ever kills himself unless by accident. He may jump out of a 
high window, thinking he is escaping through a door, or may rush into some 
danger from the notion that he cannot be injured; but he seldom or never 
makes way with himself from settled purpose. 
The motives of the monomaniac are various, and cannot always be discovered. 
Some commit the act under feelings of despair, or in order to escape intolerable 
suffering. The monomaniac who believes that he has committed the unpar- 
donable sin, and is condemned to misery both in this world and the next, often 
kills himself, perhaps in the vague hope that he may better his condition, 
while he cannot make it worse. Some fly to suicide as a refuge from supposed 
disgrace, from the fancied pursuit of justice, from the burthen of real or ima- 
ginary guilt, from physical sufferings which they believe incurable, from the 
horrors of paralysed affections and a stony heart, from the overpowering dis- 
tress of crushed hopes, wrecked fortunes, violated confidence, and outraged 
honour. In these latter cases, though the sufferer may be in his sound mind 
in some instances, and perpetrate the act as a matter of calculation, he is 
probably more frequently in a state of monomaniacal delusion. Not a few 
destroy themselves under an impression of duty, being commanded to the 
sacrifice by an intimation from above, or by the consideration of some great 
good that is to accrue to individuals, or some great evil that may be averted 
from them, by their death. Sometimes an insane notion of revenge is the 
apparent motive. The purpose is accomplished in various ways; by hanging, 
drowning, the pistol, the razor, or poison. The constancy with which the 
monomaniac cherishes his suicidal intentions, and the skill and cunning which 
he sometimes evinces in deceiving the watchfulness of his attendants, and pro- 
viding the means of self-destruction, are truly surprising. Dr. Brigham 
states that, of 1181 patients received into the New York State Lunatic Asy- 
lum, 156, or between a seventh and an eighth of the whole number, were 
disposed to suicide. (Report, Feb. 1847, p. 37.) 
Homicidal monomania, though less frequent than the disposition to suicide, 
is yet not uncommon. In most instances, it is undoubtedly the result of cal- 
culation. The maniac sometimes kills another without cherished intention, 
perhaps without any intention whatever, in the mere violence of his insane 
fury. The monomaniac generally has a motive. Sometimes this is revenge 
for imagined injury, intense hatred, ambition, anger, or other evil passion. 
Sometimes it is fear, which leads him to kill another to escape a supposed 
dangei' from his victim. Very often it is a sense of duty. The mother kills 
her infant children to save them from the misery, or the guilt of this world, 
and to secure them a place in heaven. The religious enthusiast kills the 
supposed enemy of his faith; the political enthusiast, the supposed enemy of 712 
LOCAL DISEASES.-NERVOUS SYSTEM. 
[part II. 
his party, or his doctrines. Some, there is reason to think, obey an imaginary 
intimation from above. They suppose themselves mere instruments of a higher 
power. It is a well attested fact, that the monomaniac sometimes seeks his 
own death through that of another. Afraid to rush into the other world with 
an unrepented sin upon his conscience, he commits murder in order that he 
may be executed, with the chance of repentance in the meantime, and conse- 
quent forgiveness from heaven. Some kill from a principle of imitation, as a 
child will sometimes hang his companion after witnessing a public execution; 
some, probably, from a wish for notoriety. It is possible that a mere abstract 
disposition to kill or destroy may itself constitute the insanity of the patient, 
without any appreciable motive, and without illusion. This might be moral 
insanity, or insane impulse, but would not come under monomania as usually 
defined. 
Monomania may terminate in recovery, may continue indefinitely during 
the life of the patient, or may sink finally, either with or without the super- 
vention of mania, into dementia, paralysis, and death. 
5. Insane Impulse.-The existence of this form of insanity unconnected 
with moral insanity or monomania, has been doubted; but cases every now .and 
then occur which can be explained in no other way. Persons in the perfect 
possession of their intellect, with no predominant passion, are seized with an 
unaccountable propensity to do some insane act, without motive or object ap- 
preciable by themselves or others. Sometimes they rush headlong to the act 
in obedience to the impulse, which takes them as it were by surprise, so that 
they have apparently no time for resistance. In other instances, the impulse 
is less immediate and powerful, and the patient is able to resist it for a time, 
or even to conquer it altogether, or at any rate to hold out against it, until the 
morbid condition of brain in which it originates ceases spontaneously, or under 
the influence of remedies. Persons who have looked down over the brink of 
a high tower, or a precipice, and have experienced a shudder to come over 
them when the thought of voluntarily throwing themselves into the abyss 
beneath has forced itself upon their minds, can probably form some faint con- 
ception of the mental condition in cases of insane impulse. The tendency is 
not limited to any particular act, or any number of acts. But it is most 
striking when it takes, as it not unfrequently does, a violent or illegal direc- 
tion, as for example, to personal assault, homicide, self-destruction, arson, or 
theft. There is reason to believe that individuals have been frequently im- 
pelled to kill others or themselves by this cause. A father or husband, always 
affectionate and tender in his domestic relations, suddenly seizes an axe and 
kills his wife or child, and then attempts his own life, but survives long enough 
to declare that he had acted under a sudden and irresistible impulse, altogether 
unintelligible to himself. Dr. Woodward relates the case of a young man 
who consulted him on account of an extraordinary desire which frequently 
came over him to kill, and which was so strongly excited by the presence of 
near relations, for whom he had all proper affection, and not the least antip- 
athy, as to make him shudder. The propensity bad for a time quite disap- 
peared, upon his engaging in some laborious avocation, but had afterwards 
returned, and to such a degree that he was under the necessity of frequently 
leaving the company of a partner in business, to avoid yielding to his horrible 
propensity. (Am. Journ. of Insanity, i. 325.) The late Dr. Parrish used to 
relate the case of a young lady, to whom he was called several hours after she 
had taken a poisonous dose of opium. Though too late to save her, he suc- 
ceeded in producing a brief return to consciousness, when she assured him that 
she had no cause whatever for the act, but that she had been unaccountably 
seized with a disposition to suicide upon seeing a bottle of laudanum. I once CLASS III.] 
713 
INSANITY. 
attended a lady, who had taken laudanum to destroy herself, and who declared, 
after her recovery, that she had been led to the act by reading the account of 
a suicide by another lady of whom she had some knowledge. 
Anatomical Characters. 
Very commonly organic derangements of various kinds are found in persons 
who have died insane, which had no direct connexion with the cerebral affec- 
tion. Such marks of disease are observed most frequently perhaps in the 
lungs; but frequently also in the alimentary canal; and occasionally in the 
heart. According to M. Georget, more than half the maniacs who die in the 
Salp^tri^re, are carried off by phthisis. A singular anatomical phenomenon 
noticed by Esquirol in numerous cases of melancholy monomania, and by 
others after him, is an irregular position of the colon, which, instead of pass- 
ing across the abdomen as in health, descends perpendicularly behind the 
pubes. But, though most patients are destroyed by other affections than the 
cerebral; yet evidences are generally discovered of former or present disease 
in the encephalon. It is said that, in some instances, the brain is perfectly 
sound; and Esquirol relates the case of a young woman, killed accidentally 
in a state of recent mania, in whom no lesion was discovered in the brain or 
its membranes. But, since a closer attention has been paid to the patholo- 
gical condition of the brain in disease, the number of instances in which no 
lesion could be traced has diminished; and it is highly probable that many 
of those, formerly thought to be exempt, would have unfolded some morbid 
sign to the nice anatomy of the present day. 
Not to speak of the anatomical observations of Willis, Morgagni, Greding, 
Haslam, and Esquirol, which are somewhat contradictory, the results ob- 
tained by more recent pathologists, among whom may be mentioned Georget, 
Bayle, Calmeil, Delaye, Foville, Pinel-Granchamp, Parchape, and Webster, 
concur in authorizing the conclusion, that the cortical substance, or the mem- 
branes, or both, exhibit evidences of previous or existing inflammation in 
almost all cases of insanity; and, from the statements of Delaye, Foville, and 
others, it appears that, in those cases in which insanity is complicated with 
paralysis, besides the affection of the gray matter and the membranes, the 
medullary substance is preternaturally hard and white. 
The following is a summary of the most striking cephalic phenomena 
noticed in connexion with insanity. The cranium is sometimes thickened, 
and either dense and solid throughout like ivory, or soft and spongy. The 
cavity, though often quite regular, is in some instances misshapen. The 
membranes are often diseased. The dura mater is occasionally thickened and 
adherent. The arachnoid is thickened and opaque, with false membranes in 
various stages of developement within its cavity, and attached to its surface. 
The pia mater is swollen, injected, red, infiltrated with blood or serum, and 
often adherent to the brain, portions of which are carried away with it, when 
forcibly separated. The cortical substance, in recent cases, is reddened, 
sometimes uniformly and intensely, sometimes in spots or points, with minute 
infiltrations of blood. In old cases, whicft have assumed the form of demen- 
tia, the spots are of a violaceous hue. Dr. Ecker, of Utrecht, has found the 
minute cerebral vessels, as seen under the microscope, to be greatly enlarged. 
The consistence of this portion of the brain is altered, being, in general, pre- 
ternaturally soft throughout its depth, while it may be somewhat hardened 
on the surface, where it adheres to the pia mater. The white substance is 
indurated in paralytic cases. In the advanced stages, the bulk of the brain 
is sometimes diminished, and minute cavities are observable in the cortical 
substance, resulting, as supposed by M. Foville, from former extravasations, 714 
LOCAL DISEASES.-NERVOUS SYSTEM. 
[part II. 
but, according to Dr. Sims, from softening. Serous or sanguineous effusion 
is often noticed in the cavity of the arachnoid, the ventricles, and the tissue 
of the pia mater; and scrum exists in minute cavities in various parts of the 
encephalon; especially in the plexus choroides, which, as noticed by Esquirol, 
generally contains serous cysts resembling hydatids.* 
The general inference from a comparison of all the observations is, that 
the gray substance is almost always diseased in fatal cases of insanity; and 
that, in cases complicated with palsy, there is in addition the indurated state 
already mentioned of the white or medullary matter. 
Predisposing.-In the great majority of cases, insanity is produced by the 
influence of exciting causes acting upon a predisposition to the disease. In- 
heritance is the most frequent source of this predisposition, perhaps more 
frequent than all others put together. Even a particular form of insanity is 
often inherited; and it has been noticed that the attack is apt to come on at 
the same period of life in the parent and the offspring. The tendency to 
suicide not unfrequently descends from parent to child. It is thought that 
children born before the occurrence of insanity in the parent, are less liable 
to be affected than those born subsequently. 
Time of life has much influence over the susceptibility to insanity. Neither 
youth nor old age is very liable to the disease. The period of greatest sus- 
ceptibility, according to most European writers whom I have consulted, is 
between thirty and forty; at least that is the age at which the largest num- 
bers are admitted into the Hospitals in England and France. But the num- 
bers of the population are said by Prichard to decrease in greater ratio, with 
increasing years, than those of the insane, so that in fact these are more 
numerous in relation to the sane of the same age in advanced than in mid- 
dle life. In this estimate, however, Dr. Prichard includes senile dementia, 
which scarcely deserves to be considered as insanity. If this be omitted, it 
will probably be found that the disease comparatively seldom originates in old 
age. Under ten years, though insanity sometimes occurs, it is very rare. It 
is a singular fact, probably to be accounted for by the earlier period at which 
individuals of both sexes in this country enter into the business and excite- 
ment of active life, that the greater number of cases among us occur between 
the ages of twenty and thirty. This at least is the inference to be drawn 
from the reports of the Pennsylvania Hospital for the Insane, and the State 
Asylum of New York.f 
Causes. 
* Of 175 autopsies reported by Dr. John Webster, of London, there was infiltration 
of the pia mater in 145, turgidity of the blood-vessels in 127, effusion into the ventri- 
cles in 120, thickening and opacity of the arachnoid in 62, altered colour of the brain 
in 45, bloody points on the cut surface of the medullary substance in 32, and effusion 
of blood in 32, besides various other morbid alterations. (Lond. Medico-Chirurg. Trans., 
xxxii. 155.) 
f The following statements will serve to illustrate the text. Of 4409 patients ad- 
mitted into various establishments in France and England, 356 were between 10 and 
20; 1106 between 20 and 30; 1416 between 30 and 40; 861 between 40 and 50; 461 
between 50 and 60; 174 between 60 and 70; and 35 above 70. (Georget, Did. de Med., 
xiii. 252.) 
Of 2010 patients in the Pennsylvania Hospital, 4 were under 10 years; 233 were first 
attacked between 10 and 20 years of age; 770 between 20 and 30; 491 between 30 and 
40; 332 between 40 and 50 ; 129 between 50 and 60; 39 between 60 and 70; and 12 
above 70. (Kirkbride's Report for 1851.) 
Of 1181 in the New York State Asylum, 123 were first attacked under 20; 439 be- 
tween 20 and 30 ; 299 between 30 and 40; 186 between 40 and 50 ; 86 between 50 and 
60; 44 between 60 and 70 ; and 4 above 70. (Brigham's Report, Nov. 1846.) 
It will be seen that, in the first table, the age at the period of admission into the CLASS III.] 
INSANITY. 
715 
Sex does not appear, according to the Hospital returns, to have any very 
decided influence. From the researches of Esquirol it would seem that the 
proportion of women is rather greater than that of men in Europe; but 
more extensive returns subsequently collated indicate a slight predominance 
of males.* It is probable, however, that a much larger number of females 
are taken care of at their own homes than of males; so that the proportion of 
the former may be greater than it would appear to be from the returns. Men 
are probably more exposed to the direct causes of the disease; but it may be 
admitted that there is probably a greater predisposition in women, arising 
partly from their strongly nervous temperament, and perhaps still more from 
the influence of their peculiar sexual functions on the nervous system, as 
menstruation, pregnancy, and the puerperal state. 
The natural constitution of the individual often predisposes to insanity. 
Persons of the nervous and melancholic temperaments, are peculiarly liable 
to the disease. So also are those who have naturally any strong passion in 
excess, as ambition, pride, love of applause, &c. 
The rich and cultivated are more subject to it than the poor and ignorant. 
Their cerebral functions are, from their position and habits, more liable to over 
excitement; while the irregular movements of their nervous systems want the 
control of regular and constant occupation. 
Vicious education is a powerful predisposing cause. There may be error 
in two opposite directions. The brain may be prematurely stimulated to exer- 
tion by the ambition of the child or the parent; or the evil passions may be 
allowed to develope themselves unchecked through a weak and injudicious 
indulgence. In the former case, the cerebral functions are sometimes brought 
into a state of irritation which requires but a slight additional excitement to 
become decidedly morbid; in the latter, the character is left unprovided with 
the due safeguards against the temptations and necessary struggles of life, and 
the mind sometimes breaks down under the first serious conflict. Premature 
indulgence, moreover, in every pleasure, lawful or unlawful, wears out the 
susceptibility to enjoyment, and leaves the mind a prey to ennui, and pecu- 
liarly prone to morbid impressions. 
Celibacy appears to favour the inroads of insanity. It will be seen by re- 
ferring to the reports of hospitals, that the proportion of unmarried inmates 
is in general much beyond that of the same class of persons to the population 
at large. It is highly probable, that the agitations and frequent disappoint- 
ments of the tender affections to which celibacy is exposed, may have some 
influence in bringing about this result; but a still more powerful cause is 
probably the want of that perennial source of consolation and encouragement 
in all the reverses, disappointments, and struggles of this life, which is found 
in connubial affection. Perhaps, however, the proportion of the unmarried 
insane in hospitals may not properly represent their relative numbers in the 
community generally; for, being frequently without the conveniences of a 
home, and without near friends to take charge of them, they necessarily become 
inmates of the public institutions. 
The profession or business of men has great influence over the number of 
the insane. The proportion is vastly greater among the classes whose brains 
Hospital is given ; in the two latter tables, that at which the disease began. But, even 
when compared upon the latter basis, the numbers in this country will be found great- 
est between 20 and 80; for 644 were admitted into the Pennsylvania Hospital between 
those ages, while 531 only were admitted between 30 and 40. (Kirkbride's Report 
for 1851.) 
* From Hospital reports both in Europe and America, collated by Dr. Edward Jarvis, 
it appears that of 125,028 patients, 64,786 were males, and 60,242 females. (Ato. 
Journ. of Insanity, vii. 146.) 716 
LOCAL DISEASES.-NERVOUS SYSTEM. 
[PART II. 
are kept in a perpetual turmoil, either of passion or of intellect, than among 
those who pursue a tranquil course of moderate industry and enjoyment. 
Rulers, poets, artists, politicians, and professional men are peculiarly liable 
to insanity. The proportion of physicians in a community is perhaps one to 
five hundred; yet, in the report of the Pennsylvania Hospital up to the year 
1852 we find 22 of them out of 2010 patients, or 1 to about 90.* It has 
been observed that the number of the insane is greater in a community, in 
proportion to the political and religious freedom of the population ; that is, 
to the opportunity they enjoy of working out their own purposes, whether in 
relation to this world or the next, in the manner most agreeable to themselves. 
Excitement and powerful effort are always greatest, in such communities. 
Perhaps there is no country in the world in which the insane are proportion- 
ably more numerous than in our own. 
One attack of insanity is often a predisposing cause to another. 
Exciting Causes.-These are very numerous. Whatever disturbs the regu- 
lar supply of blood to the brain, or otherwise morbidly exalts or depresses the 
functions of that organ, may prove an exciting cause of insanity in the pre- 
disposed. A certain degree of these influences may occasion the result without 
peculiar predisposition. In some instances, the immediate cause of an attack 
is very obvious; in others it is altogether obscure; and it is probable that the 
original proclivity to the disease may be so strong in some, as to induce it 
in the natural progress of the organization towards maturity and decay, with- 
out the intervention of any special cause. The exciting causes are usually 
divided into the moral and physical, of which the former are much the more 
frequent, if the effects of other diseases in promoting insanity, such as apo- 
plexy, epilepsy, and febrile diseases, be left out of the question. 
Of the moral causes, excessive mental excitement, whether intellectual or 
emotional, is probably among the most common. Examples of this we have 
in severe study; perplexing metaphysical investigations; over-indulgence of 
the imagination; the struggles for power, influence, or wealth ; religious and 
political excitement; violent anger, and excesses of revenge, jealousy, or hatred; 
the agitations and perplexities which arise from the entanglements and re- 
morse of vicious or criminal indulgence; all kinds of erotic exuberance; the 
slow tortures of connubial disturbance ; and the occasional wearing solicitudes 
of family relationship and dependence. Nor are depressing causes without a 
powerful influence. Fear, disappointment, grief, and despair, have been fruit- 
ful sources of insanity. The reverses of business, the loss of friends, the 
triumph of enemies, abused confidence, betrayed affections, public disgrace, 
violated chastity, and general destitution, fearfully contribute to fill the asy- 
lums for the insane. Times of great public excitement, whether of business, 
war, politics, or religion, are usually attended with a marked increase of the 
disease. Independently of the rational agitations of such occasions, there is 
generally added a diseased, almost electrical enthusiasm, arising from the fric- 
tion of mind against mind, amid these tumultuous movements. The preva- 
lence of a speculative or gambling spirit in a community, with its sudden 
accessions of fortune, its unbounded hopes, its short-lived triumphs, its rapid 
fluctuations, and fearful reverses, leaves many a mental wreck behind, when 
it subsides. Revolutionary struggles, insurrectionary violence, and fearful 
* Perhaps this disproportion may be owing in part to the long established reputation 
of the Pennsylvania Hospital, and to the circumstance that most of the inmates pay for 
their support in the institution. But, in the comparatively new State institution of New 
York, the number is 10 out of 1181, or 1 to about 118. The number of attorneys is 14, 
or 1 to about 84, which is vastly beyond their proportion to the community at large, all 
dae allowances being made for the young and the old. (Brigham's Report, Nov. 1846.) CLASS III.] 
INSANITY. 
717 
political commotions, strew their course with the ruin of mind, as well as of 
body and estate. The terrors of false prophecy, and the enthusiasm of new 
religious creeds, sweep every now and then over communities, and whirl along 
many an excitable mind into the abysses of madness. The imitative principle 
often leads to insane acts, if not to insanity itself. The reading of murders 
and suicides, and all kinds of criminal violence, has tended, I have not the 
least doubt, vastly to augment the numbers of such deeds. 
The physical causes are insolation, injuries to the head, long watchings, 
vicious indulgences, excessive venery, masturbation, intemperance in drink- 
ing, the abuse of opium and tobacco, violent pain, the transfer of rheumatic 
or gouty irritation, the suppression of wonted discharges, the change of life in 
woman, the puerperal state, the retrocession of eruptions, the healing of old 
ulcers, and certain morbid states of the brain or other parts of the system, as 
apoplexy, epilepsy, fevers, hepatic and gastric disease, and various irritation 
of the intestinal mucous membrane. 
Of these causes some act in a peculiar manner, giving rise to certain forms 
of insanity rather than others, or impressing a peculiar character on that 
which they excite. Of the moral causes, those of a depressing nature are apt 
to induce dementia rather than mania, or at least to impress a tendency to 
this state of insanity upon the mind. Causes calculated to excite some par- 
ticular passion, as ambition, intense avarice, jealousy, revenge, love, &c., give 
an especial tendency to monomania; and the same may be said of the prin- 
ciple of imitation. 
Of the physical causes, those of an exhausting character, as venereal ex- 
cesses and masturbation; and those which derange the organization of the 
brain, as chronic meningitis, epilepsy, apoplexy, and tumours, occasion de- 
mentia either primarily or ultimately, and, in almost all cases, if they do not 
produce full dementia, give a taint of weakness to the cerebral disorder. 
Diseases of the stomach and liver dispose to the melancholy forms of mad- 
ness, and especially to hypochondriasis, or other gloomy condition of mono- 
mania. Nothing is more common than to see a depression of spirits approach- 
ing to mental derangement consequent upon functional disease of the liver; 
and the superaddition of a delusion or hallucination converts the affection 
into insanity. Such affections occasionally clear off like mists before the sun, 
under the use of mercurial alteratives. 
Alcohol, by its stimulant impression on the brain, may call a predisposition 
to the ordinary forms of insanity into action ; but there is a condition of brief 
and often violent madness, continuing for two or three weeks, and then sub- 
siding spontaneously, or under judicious treatment, which alcoholic drinks in 
excess almost uniformly induce in certain individuals. This is wholly differ- 
ent from delirium tremens, which so frequently results from the abuse of 
these liquors. The latter is consequent upon a suspension of their use, and 
is a debilitated condition of the brain; the former is the result of direct stimu- 
lation, and is a strongly excited condition of the organ. There is another 
morbid state of mind, connected with the use of alcohol, differing from either 
of the above. It is, however, not the result of the stimulant, but antecedent 
to its use on any particular occasion, and consists in a morbid and irresistible 
craving for it, coming on at times, and constituting a sort of monomania, or 
perhaps insane impulse. 
The name of puerperal insanity has been conferred upon the disease in 
women, when connected with child-birth. Pregnancy may serve as a cause 
of insanity, but rarely, except in those slight forms in which certain longings 
are so strong and whimsical as to merit the name. But the state which su- 
pervenes upon delivery is a not unfrequent source of the disease. It most 718 
LOCAL DISEASES.-NERVOUS SYSTEM. 
[part II. 
frequently occurs within a few days after the birth of the child, though it may 
happen at any time during lactation, and even after weaning. Of 92 cases 
referred to by Esquirol, 37 were within the first two weeks, 17 between this 
period and two months, 19 from the end of the second to that of the twelfth 
month, and 19 after the child was weaned. There is nothing peculiar in this 
form of insanity, except a greater tendency to general prostration than is 
ordinarily met with; so that the disease will seldom bear depletion, and gene- 
rally requires a supporting treatment. Dr. Hodge informed the author, that 
he had observed a groundless aversion to the nurse, to be among the first 
symptoms of insanity exhibited by women in this condition. 
Nature. 
In relation to this subject, the author wishes it to be understood that he 
believes fully in the existence of the soul, as something entirely distinct from 
the body, which is merely its instrument for the accomplishment of certain 
great purposes in the general economy. But, as this principle operates through 
the brain, and exhibits its derangements only through alterations in the state 
or actions of that organ, we may, without giving just grounds for the impu- 
tation of materialism, consider the various phases of disordered mental action, 
simply as morbid cerebral phenomena. Now there is good reason to believe, 
though the fact cannot yet be said to have been certainly demonstrated, that 
all the cerebral functions connected essentially with mind, are performed by 
the cineritious or cortical matter, while the white or medullary matter serves 
only as the medium of communication between this and the rest of the body, 
or between different portions of the cortical substance itself, thereby associat- 
ing its actions harmoniously. If this view be correct, all disorders in the 
primary mental phenomena must be connected with disorder in the cortical 
substance; and, at most, disease of the white matter can act only by derang- 
ing the associations of mental action, or in a greater or less degree impairing 
the communication of the mind with the system at large, and with the ex- 
terior world. It is, therefore, chiefly in the cortical substance of the brain 
that we are to look for the seat of insanity ; and the general tendency of cada- 
veric examinations has recently been, so far as mental derangement leaves 
any permanent signs, to discover them in the structure alluded to; while 
lesions of the medullary matter have been noticed especially in cases where 
the reciprocal action of mind and body had been interrupted, as in palsy of 
sense and motion. 
But what is the pathological condition of the cineritious structure which 
occasions the symptoms of insanity ? This is a question that cannot be fully 
answered, in the present state of our knowledge, because we are utterly igno- 
rant of the mode in which the brain acts in giving rise to mental phenomena. 
But we can advance a certain distance. One well established fact is, that 
most of the symptoms of deranged cerebral action are produced as well by an 
elevated as by a depressed condition of the organ, and that it is very often 
impossible to determine, by any peculiarity of the proper cerebral phenomena 
themselves, in which of these conditions they originated. (See page 672.) 
Such is the case with those derangements of function which are classed to- 
gether under the name of insanity. They may be mere symptoms of an 
excess or deficiency of action in the cortical substance. 
We might expect insanity, therefore, as a consequence of irritation or in- 
flammation of the cineritious structure; and both the symptoms in the early 
stage, and the results of dissection prove, that these conditions do frequently 
exist. Whenever insanity commences with delirium, fever, a furred tongue, 
anorexia, &c., and these phenomena cannot be ascribed to some coincident CLASS III.] 
INSANITY. 
719 
affection, the strong probability is, that either the cortical substance is itself 
inflamed, or that it is irritated by inflammation of the meninges. But the 
question now occurs, does this inflammation continue through the whole pro- 
gress of the case ? Are the symptoms of insanity which persist for months 
and years, and a whole lifetime, an evidence of still existing inflammation ? 
This question may be confidently answered in the negative. In some in- 
stances, the cerebral inflammation undoubtedly continues in a chronic form. 
But, in these cases, there is some other derangement than mere insanity. 
There is a rapid deterioration of the mental powers; the mania, or mono- 
mania, as the case maybe, passes speedily into dementia; and paralytic 
symptoms soon show that the disease has invaded the medullary tissue. But, 
in most instances, when the symptoms of physical excitement have subsided, 
the patient is left with his general health little impaired, and nothing mate- 
rial remains besides the psychological phenomena to indicate the existence of 
disease. Sometimes patients continue in this state, with little change, during 
the residue of a long life, and die at last of some disease unconnected with 
the brain. It is impossible that, during all this period, there should have 
been cerebral inflammation. The fact probably is, that the cerebral func- 
tions receive a wrong direction from the disturbance of the early stage; that 
some hinge in the mental actions becomes dislocated; and thus, as occasionally 
happens in machinery, the whole working of the instrument is deranged, 
though the original pathological condition may have ceased entirely. Some- 
thing like this we occasionally witness in other organs, which acquire a per- 
verted action during inflammation, that remains long after the inflammation 
has disappeared. That even a slight disturbance in the brain is capable of 
impressing a new character upon its actions, is shown by the total psycholo- 
gical change produced by various nervous affections, and especially that 
usually, though very erroneously, denominated the magnetic sleep. There- 
fore, though insanity may often begin with inflammation, or high vascular 
irritation of the cineritious matter of the brain, and though it may sometimes 
continue to be associated with that affection in a chronic form for months, or 
years, and at length terminate in death from cerebral lesions, yet much more 
frequently there is nothing but a perversion of the cerebral functions, left 
behind by the original affection. In general, the grade of the initial inflam- 
mation, when it exists, is moderate, bearing to ordinary acute meningitis a 
relation similar to that which subacute rheumatism bears to the acute, and 
seldom producing fatal disorganization in its acute form. 
But insanity is not always inflammatory, even its early stage. Many cases 
occur, in which little or no evidence is afforded of any reaction of the cerebral 
disease upon the system at large. The original cause of the malady has been 
sufficient, by its direct influence, and without an intermediate inflammation, 
to pervert the cerebral functions, as we see them perverted by similar influ- 
ences every day in hysteria and in artificial somnambulism, the difference be- 
ing that, in the latter affections, the perversion is temporary. They who have 
witnessed the various workings of the so-called animal magnetism, must have 
been sometimes struck with a certain resemblance to insanity, in those cases 
in which the patient is free from stupor; and no one would hesitate to pro- 
nounce such cases insanity, were they to become chronic. 
Even influences of a sedative or depressing character may produce mental 
derangement, without any attendant evidence of inflammation or even vascu- 
lar excitement, except the simple psychological disorder; and to admit this as 
a sufficient evidence of it would be to beg the question. 
The occasional sudden changes from long continued unmitigated insanity 
to a perfectly sane state of mind, though admitted to be rare, prove that, in 720 
LOCAL DISEASES.-NERVOUS SYSTEM. 
[PART II. 
such cases at least, there was mental disorder without inflammation; for it is 
impossible to conceive that a long-continued chronic inflammation should cease 
at once, and leave no trace behind it; and, if the existence of insanity without 
such complication be admitted in one case, it may fairly be considered as pro- 
bable in all which present no other evidence of inflammation. The decision 
of this question is of something more than speculative interest. It has, indeed, 
great therapeutic value; for one who believes that insanity is in all cases con- 
nected with cerebral inflammation, will scarcely be able to receive, with an 
unprejudiced mind, evidence in favour of those plans of treatment which con- 
flict with his theoretical views. 
Some have placed the seat of insanity in the viscera of the chest or abdo- 
men. It is highly probable, nay, it may be considered certain, that disease 
of these viscera sometimes induces insanity. Nor does this appear strange, 
when we consider that every part of the system is probably connected with 
some centre in the brain, which receives impressions from its altered state, 
and acts accordingly. It is only singular that the centres, which are thus 
the constant recipients of morbid impressions, should not in consequence be 
themselves more frequently disordered. But, though the cause of the cere- 
bral derangement may thus reside in some distant organ, the real pathological 
condition from which the insane movements directly proceed is undoubtedly 
cerebral, and exclusively cerebral. . Thought and emotion, so far as the ma- 
terial frame is concerned, are the products of the brain alone. 
Diagnosis. 
The complaint with which insanity, in the form of acute mania, may be 
most easily confounded, is ordinary acute meningitis. Indeed the two affec- 
tions scarcely differ in character, unless in the greater violence of the menin- 
gitis, and its more especial direction to the membranes of the brain. In 
meningitis, the disease probably commences usually in the membranes, and 
thence extends to the brain; in acute mania, probably in the cortical substance 
of the brain, whence it may reach the membranes. The former disease begins, 
as a general rule, more abruptly, exhibits greater violence of headache, more 
intolerance of light and sound, a higher degree of fever, more tendency to 
convulsions and coma, greater general prostration, and a more rapid course 
than the latter; and much oftener ends in speedy death, or speedy recovery. 
In the great majority of maniacal cases, the gradual advance of the symptoms, 
and the comparatively little disturbance of the constitution, leave no room for 
doubt. In some instances, it is impossible to decide with certainty until after 
the subsidence of the febrile symptoms, when, if derangement of mind remain, 
the case may be considered as insanity; if it disappear entirely, it may be 
ranked as simply acute meningitis. 
Between certain cases of insanity and chronic meningitis, there is absolutely 
no difference. When a case begins as mania or monomania, with some febrile 
excitement, then passes into dementia with paralysis, and ends fatally in the 
course of a few months, or at most two or three years, dissection will almost 
always reveal evidences of lesions in the meninges and cortical substance of 
the brain, with induration, probably, of the medullary structure. 
Another affection with which insanity may be confounded is the delirium 
of fever. Generally, there is little difficulty in the diagnosis. Fevers begin 
more abruptly than insanity, exhibit various other evidences of disease in the 
head and elsewhere before the appearance of mental derangement, have pecu- 
liar characters of their own by which they can generally be recognized, are 
attended with much greater prostration of the general strength, and run usu- 
ally a special course. The delirium of fever, moreover, is generally different CLASS III.] 
INSANITY. 
721 
from that of insanity. It is more frequently attended with disordered per- 
ception, is oftener complicated with stupor, and wants that expressiveness of 
countenance, which, in insanity, so strongly marks the fluctuating state of the 
thoughts and feelings. Nevertheless there is occasionally in febrile diseases 
a delirium which very closely resembles insanity; so that time alone can de- 
cide whether it may not belong to the latter affection. I have seen an attack 
of enteric or typhoid fever present so exactly the mental characters of insanity, 
that it seemed as if the fever must have supervened upon the latter affection; 
which, however, I was assured was not the case. 
It is sometimes important to distinguish insanity from delirium, tremens ; 
but the reader is referred to the latter disease for the diagnosis. 
The question as to the existence of insanity in a particular case is often 
difficult of solution; and sometimes it is impossible to come to a positive con- 
clusion, because no precise line can be drawn between sanity and insanity; 
the two conditions running into each other by insensible gradations. Space 
does not permit a consideration of this question in its medico legal relations. 
For medical purposes, the good sense of the physician will generally enable 
him to decide with sufficient certainty. A prominent consideration should 
always be, in doubtful cases, the previous condition of the patient. If the 
peculiarities which attract attention have characterized all his previous course 
of life, the presumption would be in favour of mere natural eccentricity; if 
they can be shown to have begun at a certain period, and especially if they 
have followed some great misfortune, or some great excitement, or an attack 
of acute disease, they may be referred with confidence to insanity. The 
knowledge whether the patient was descended from insane parents or grand- 
parents, and whether he had suffered from a previous attack of insanity, will 
also aid much in the diagnosis. • 
It has already been stated that monomaniacs often show great skill in con- 
cealing their insane peculiarities, when upon their guard. The physician is 
frequently called on to decide in these cases. My duty as one of the phy- 
sicians of the Pennsylvania Hospital was formerly to see each patient, sup- 
posed to be insane, before admission into the institution, and certify as to bis 
sanity. In doubtful cases, my plan was first to learn from the friends of the 
patient his peculiar insane notion, and then, in my inquiries, to keep his 
attention so long directed towards that particular subject, that he would find 
it impossible to resist the strong internal impulses, which prompted him to 
speak in accordance with his feelings or convictions. Thus, I once under- 
stood from the friends of a patient that his delusion consisted in supposing 
himself the possessor of high political office. He was thoroughly on his 
guard, and quite ready to speak with me on all subjects. I conversed with 
him at first on indifferent matters, then gradually approached the subject of 
the elections, and took occasion to ask him how he would like to be appointed 
to a political office. He answered very rationally that he would have no 
objection, if the people should think him competent. But, after a long con- 
versation upon subjects of this kind, to which I endeavoured to confine his 
attention, he at length assumed a confidential air, and informed me, that the 
existing president of the United States had no right to his station, as another 
person had been really elected; and finally ended by assuring me, in answer 
to my questions, that he was himself the chosen candidate. 
It should be remembered, in our inquiries as to the existence of insanity, 
that patients often have lucid intervals, in which it is difficult or impossible to 
detect any trace of their disease; and a decision, therefore, should be avoided, 
until they have been seen on different occasions; and sometimes it is neces- 722 
LOCAL DISEASES.-NERVOUS SYSTEM. 
[part II. 
sary for the physician, in forming his own judgment, to rely upon the testi- 
mony of others. 
In relation to moral insanity and insane impulse, a just decision is often 
still more difficult than in cases of monomania with one steady illusion. Men 
so often act insanely under the influence of misguided opinion and excited 
passions, that the physician should be very cautious in coming to a conclu- 
sion. When the tendencies of the irregular feeling or impulse are materially 
to injure the persons of others, or of the affected individual himself, the judg- 
ment should perhaps incline to insanity, so that the proper guard may be 
exercised; if the tendency be quite innocent, it may without harm pass for 
mere eccentricity of feeling. The question as to the origin of the peculiar 
state of feeling, and the circumstances of its first appearance, should in this 
form of insanity, as in monomania, be allowed some weight. 
The question as to whether insanity has been feigned or not, is so purely 
medico-legal, that it may be very properly left for works upon medical juris- 
prudence. 
Prognosis. 
Under this head may be considered the general mortality of the insane, 
the proportion of those who recover, and the circumstances which authorize 
a favourable or unfavourable prognosis in any particular case. 
In relation to the general mortality, it is very difficult to arrive at the 
truth from the reports of hospitals; because, in most of these institutions, 
the inmates are frequently changing, and few comparatively of the chronic 
cases remain till their termination in death. But there can be no doubt 
that, even where insanity does not directly destroy life, it has the general 
effect of shortening it by the depravation of system which it occasions in 
various ways. Esquirol estimates the mortality of maniacs to be one in 
twenty-five annually, of monomaniacs one in sixteen, and of those affected 
with dementia one in three. It may be doubted whether the proportion for 
the first division is not too small, and for the last too large. 
The proportion of recoveries from insanity, judging from the reports of 
the hospitals, varies from about one-half to one-fourth of the whole number. 
The proportion must differ in the different establishments, not only according 
to the mode of management, and the greater or less completeness of the 
proper arrangements, but very much also with the plan adopted in relation 
to admission and permanent residence; some receiving only those supposed 
curable, and dismissing them when beyond hope of favourable change, while 
others admit all indiscriminately, and retain them during life. This may 
account for the differences of proportion above stated. Of 19,516 patients 
admitted into different English hospitals, 5,918 were cured; of 12,592 
received at the Bicetre and Salpetriere in France, 5,075 were restored to 
reason. {Did. de Med., xiii. 321.) In the best English asylums, as in the 
Retreat near York, the proportion of cures is about one-half. Of 2010 
patients admitted into the Pennsylvania Hospital up to the year 1852, 950 
were cured; and, if 216 remaining at the date of the report, whose cases 
were not yet determined, be deducted from the whole number admitted, it 
will be perceived that the proportion of cures is more than one-half; without 
calculating a considerable number who left the hospital much relieved, and 
afterwards recovered. 
But these reports do not afford a just criterion of the real curability of 
insanity. A large proportion of the cases admitted are old, and quite beyond 
all hope of cure. It is now a universally admitted fact, that insanity is 
curable in proportion to the early commencement of a suitable treatment. CLASS HI.] 
723 
INSANITY. 
" Of all who are attacked with insanity, and subjected, during its early stages, 
to a judicious treatment faithfully persevered in, at least eighty per cent, will 
probably recover." (Kirkbride, Report of Penn. Hosp., A. D. 1846, p. 9.) 
Dr. Charles Evans, attending Physician of the Friends' Asylum for the Insane, 
near Philadelphia, informed me that, of the recent cases admitted into that 
institution during ten years, the recoveries averaged nearly eighty per cent. 
Many recoveries take place in the first year, fewer in the second, still fewer 
in the third, and each year afterward the number diminishes.* After ten years 
there is little to hope; though recoveries have taken place at a much later 
period; and efforts should never be abandoned; as cases apparently the most 
desperate have terminated favourably; and, where cures cannot be effected, 
much can be done to render the patient more comfortable, and widen the sphere 
of his enjoyments. The average duration of the curable cases of insanity is 
stated by Pinel at five months for mania, and six months for melancholy or 
monomania. Esquirol makes it somewhat longer, but under a year. 
Mania is more readily curable than monomania, and this than dementia. 
Puerperal mania, if it do not destroy life, ends favourably in the great ma- 
jority of instances. Debility is most to be dreaded in this form of insanity. 
Great prostration, a very frequent pulse, and much restlessness are unfavour- 
able symptoms. Moral insanity, without delusion, is apt to be very obstinate. 
When insanity appears to be merely an exaggeration of some striking natural 
peculiarity, the prognosis is not favourable. The insanity of epilepsy or apo- 
plexy, or that associated with paralysis, seldom ends in recovery. The young 
are more curable than the old. The most favourable age, according to Es- 
quirol, is between twenty and thirty, and few comparativelyrecover after fifty. 
Inherited insanity is less easily and permanently cured than that arising with- 
out such predisposition. Cases of sudden attack are in general more apt to get 
well than those in which the disease comes on slowly and insensibly. Relapses 
are said to be more difficult of cure than original cases. The re-establishment 
of health, with a tendency to grow fat, without any improvement in the mental 
symptoms, is unfavourable. 
Treatment. 
In relation to the treatment of insanity, a point of great importance, and 
one which must engage an early attention, is to place the patient under cir- 
cumstances most favourable for a cure. The question must be promptly 
decided, whether he is to remain under the immediate care of his family and 
friends, or to be placed in one of the public institutions, which the advancing 
humanity and civilization of the times have provided for the shelter and 
treatment of the insane. As a general rule, there can be no doubt that a 
residence in a well-conducted establishment of this kind is conducive both to 
the comfort and restoration of the patient. Persons affected with insanity 
are very apt to contract aversion for their nearest friends and relatives, and 
are consequently liable to perpetual irritation from their presence. Instead 
of being soothed by their kind offices and affectionate attentions, they are 
often excited into paroxysms of rage; and the best directed measures fail 
entirely, because counteracted by the injurious influence of those through 
whom they are administered. Besides, the patient often requires control. 
Opposition to his will is absolutely essential. But such opposition and con- 
trol from persons from whom he has before experienced nothing but kindness 
* Of 2005 cases considered curable in the Salpetricre, 604, according to Esquirol, 
were cured in the first year, 497 in the second, 71 in the third, and 46 in the seven years 
which followed, in all 1218 in ten years. (Esquirol, Des Malad. Merit ales, i. 92.) 724 
LOCAL DISEASES.-NERVOUS SYSTEM. 
[PART II. 
and perhaps submission, as his judgment cannot appreciate their motives, 
become sources of perpetual vexation, and sustain an excitement highly cal- 
culated to aggravate and fix his disorder. For these and other reasons, sepa- 
ration from family and former friends is almost universally recognized as one 
of the most essential rules of treatment, in relation to the greater number of 
cases. With the wealthy, such an isolation is often attempted in their own 
homes, or at least in a private manner. But this plan is liable to objections. 
The anxiety of affection is a never-failing temptation to break through the 
restrictions, which are therefore seldom well observed; and, even when they 
can be maintained, there is no little danger of abuse of power, on the part of 
the often mercenary and ignorant guardianship to which the patient is entrusted. 
Besides, it is of the first necessity to separate the patient from the causes of 
his disease, which are often connected with his own home, and from every- 
thing that may have a tendency to produce impressions, or awaken associations 
coinciding with the morbid feeling or train of thought. All these considera- 
tions indicate a public asylum as the proper abode of the lunatic. But there 
are others of great weight. It is only in such establishments, that all the mea- 
sures which experience has shown to be advantageous in the cure of the dis- 
ease can be brought efficiently into operation. Placed as they usually are 
under the care of experienced physicians, who have directed an especial at- 
tention to the subject of insanity, and whose whole time is devoted to the 
inmates of the institution, they afford peculiar advantages in relation to me- 
dical treatment. Much of the success in the management of insanity depends 
on a knowledge of the peculiarities of each case, and a proper adaptation of 
means to these peculiarities; a result which can generally be secured only by 
a degree of special attention unattainable in the ordinary course of medical 
practice. Another important consideration is, that, in these institutions, 
nurses and other immediate attendants upon the sick are trained to the busi- 
ness, and have learned to treat the insane with the least offence to their irri- 
table feelings, and to exercise the necessary control with the least amount of 
force. The powerful influence of the imitative principle of our natures, which, 
as before stated, is one of those that suffer least in insanity, can be most 
advantageously applied in these institutions. In no other situation can so 
effectual a guard be placed over the suicidal propensity, so common and so 
fatal among the insane. 
It is true that such institutions are liable to abuse; and, in former times, 
mad-houses were notorious as scenes of the most inhuman neglect or violence. 
But they were then looked on merely as receptacles of the insane, to keep 
them from injuring others, and in many instances were little better than pri- 
sons. Now, they are hospitals for the cure and comfort of their inmates. 
Open to public inspection, and with the watchful eye of self-interest upon 
them, they are much less liable to abuse than formerly. The interest of the 
superintendents is coincident with their duty. Stated reports make the con- 
dition of the institution known to the public, and a praiseworthy regard for 
the general good opinion, renders theii' directors solicitous of so managing 
the internal concerns of their respective establishments, as to be able to pre- 
sent a fair view of their efficiency to the world. 
But, in order that the greatest good may flow from asylums for the insane, 
it is desirable that the public should be impressed with the importance of 
sending the patient to them in the early stages of his disease, and of not re- 
moving him prematurely, before the cure is thoroughly accomplished. After 
the first two or three months of insanity, the longer a proper course of treat- 
ment is postponed, the less is the chance of success. While of those treated 
correctly from the beginning four-fifths may recover, only one-fourth, one- CLASS III.] 
725 
INSANITY. 
third, or at best a little more than one-half of the general average of admis- 
sions into the hospitals end favourably, because too often introduced at a late 
period of the disease. The cure of insanity is almost always slow and gradual, 
too much so often for the impatience of friends, who do irreparable mischief 
by a too speedy removal. The disease, moreover, is exceedingly liable to 
relapse, unless quite eradicated before the patient is again exposed to the 
dangerous influences of an unrestricted intercourse with the world. Conva- 
lescence should be decided, and all evidence of the existence of insanity should 
have ceased for weeks, as a general rule, before the patient should be per- 
mitted to leave the institution. 
But, while thus advocating a recourse to the public institutions, I do not 
wish to be understood as recommending it indiscriminately. On the con- 
trary, there are many cases which are best managed at home. In the acute 
stages of insanity, when there are evidences of inflammation of the brain, and 
constitutional disturbance enough to make it most prudent that the patient 
should keep his bed, the disease will be best left to the ordinary course of 
domestic nursing, and regular medical attendance. The necessary means 
can generally be effectively employed at home; while the exposure and 
agitation of a removal may be productive of serious injury. Should insanity 
remain after the inflammatory symptoms have subsided, resort may then be 
had to the public institutions. There are, moreover, not unfrequently cases 
of such a nature, especially among females, as rather to be benefited and 
cheered by the kindly influences of home and the society of friends, than to 
be injured; while the subdued and quiet character of the affection renders 
little or no restraint necessary. In such instances, the best situation for pa- 
tients is in the bosom of their family; and a residence among strangers might 
aggravate the disorder. 
Three prominent indications present themselves in the treatment of in- 
sanity; first, to remove the causes; secondly, to correct all discoverable phy- 
sical disease, whether in the brain or elsewhere; and, thirdly, to rectify the 
perverted cerebral function. 
1. Removal of the cause.-Immediate attention should be paid to the cause 
of the disease. This has sometimes ceased to act, and therefore requires no 
other consideration than as a knowledge of it may contribute to a better un- 
derstanding of the case. But very frequently it continues in full force, and 
by its influence serves to sustain and aggravate the disease; or, if the patient 
is removed by the violence of his insanity temporarily beyond its reach, lies 
as it were in wait for any returning glimpse of reason, prepared again to 
strike down its victim as he rises. Its removal, under these circumstances, 
should be one of the first cares of the physician. If this be impossible, the 
next object should be to withdraw the patient from its influence until his 
health is confirmed. If neither object be attainable, efforts should at least 
be made to obviate its influence as far as circumstances will permit. It occa- 
sionally happens that the mental wound heals immediately, when the thorn 
is extracted. Among the greatest advantages of separation from old associa- 
tion, and seclusion in an establishment for the insane are, that the patient is 
thus placed beyond the sphere of influences which had contributed to pro- 
duce and sustain his disease, and, if the cause consist in some personal vice 
or injurious habit, that opportunities are thus afforded of correcting the evil, 
which could not be commanded under the patient's own roof. It is unneces- 
sary to repeat here the particular circumstances requiring attention. They 
have already been sufficiently considered under the head of the causes. 
2. Removal of existing physical disease.-Whenever, in the early stages 
of insanity, the symptoms put on the characters of acute meningitis, there 726 
LOCAL DISEASES.-NERVOUS SYSTEM. 
[part II. 
should be no hesitation in adopting an antiphlogistic course, proportionate in 
degree to the apparent violence of the inflammation. The treatment should 
be in all respects that already recommended in the same pathological condition 
existing independently of fixed insanity. (See Acute Meningitis.) Bleeding, 
general and local, active purging, cold to the head, and, if the disease should 
tend to the comatose state, after due depletion, a blister over the whole scalp, 
and mercury given with reference to its influence on the system, are the chief 
remedies. Not only may a fatal termination of the disease often be averted 
by the energetic use of these measures, but, in cases which might possibly not 
prove immediately fatal if more leniently dealt with, the establishment of 
chronic insanity, with or without attendant chronic inflammation of the brain 
and meninges, may in some instances be prevented. I am confident that I 
have witnessed such results. 
But here it is necessary to place the reader upon his guard. There are 
comparatively very few cases of commencing insanity which present symp- 
toms of acute meningitis so violent as to require very energetic depletion. 
In the great majority of cases, if there be evidence of cerebral inflammation 
at all, it is comparatively mild, and requires corresponding mildness in the 
treatment. The proper therapeutical rule is to be guided by the condition of 
system, very much as though there were no symptoms of insanity, allowing 
to this phenomenon simply the weight of an indication, that the local cause 
of any general disturbance which may exist is probably in the brain. When, 
therefore, in the early stage of acute insanity, increased frequency and force 
of pulse, increased heat of skin, a furred tongue, anorexia, constipation, and 
other symptoms of febrile excitement exist, which can be reasonably referred 
to no other cause than the cerebral disease, the patient should lose more or 
less blood, should be purged more or less frequently, and treated in other 
respects more or less actively by the antiphlogistic method, according to the 
degree and energy of the excitement, independently of the mere mental de- 
rangement. Should the excitement be slight, bleeding may be dispensed with; 
and should no febrile action whatever exist, as not unfrequently happens, 
antiphlogistic measures may be altogether unnecessary. 
To bleed and otherwise deplete copiously for insanity alone, even in its 
early stage, is, I am convinced, a hurtful practice. Without having the least 
influence over the delusions of the patient, it lowers the grade of his vital 
force, and renders him less able to support the more or less wearing influence 
of the mental disease on the bodily health. It is even thought by some to 
dispose to a more rapid decline of mania or monomania into dementia; and to 
diminish the chances of a subsequent cure, or at least to protract the duration 
of the disease. Dr. Kirkbride, the intelligent superintendent of the Pennsyl- 
vania Hospital for the Insane, informs me, that depletion is in his estimation 
the great error in the primary treatment of insanity. It is not uncommon to 
mistake some frequency of pulse, which may be the result of mere functional 
disturbance of the brain, for an indication of active febrile excitement; and the 
violent maniacal paroxysms as proofs of cerebral inflammation. There can 
be no greater error than these. The pulse is often accelerated by the 
want of sleep, and the various agitation of the patient, without fever or in- 
flammation, and indeed may in many instances be most happily composed by 
opium and other cerebral stimulants, which under the contrary supposition 
could do only injury. The maniacal paroxysms, though frequently attended 
with signs of general excitement, occur as well in debilitated as in elevated 
states of the system, and may be quite compatible with a stimulating or sup- 
porting treatment. Instead of being relieved, they are in some instances ag- 
gravated by the loss of blood. The practitioner should draw his inferences as CLASS III.] 
727 
INSANITY. 
to the condition of the brain, whether inflamed or not, from other sources than 
these. To justify the use of depletory measures, the excitement of the circu- 
lation should persist in the intervals between the paroxysms in a greater or 
less degree; the pulse should be strong as well as frequent; and other signs 
should exist of the reaction of the inflamed brain upon the system, such as a 
furred tongue, deficient appetite, deranged secretion, &c. When the pulse is 
feeble and compressible, though frequent; when coolness or other marks of 
deficient capillary circulation in the extremities exist with general relaxation 
of the surface, and copious sweats; and when nervous tremors like those of 
delirium tremens are observed; however violent may be the phenomena of in- 
sanity, blood should either not be taken at all, or should be abstracted with 
great caution, and only by cups or leeches. 
Supposing that depletion has been called for by the existence of inflamma- 
tion or high vascular irritation of the brain, it should be abandoned as soon 
as the symptoms indicative of these pathological states have been subdued, 
though the insanity may remain unabated, and the patient exhibit, on fre- 
quent occasions, all the signs of maniacal fury which may have at any time 
marked the paroxysms. 
Very different opinions have been given by persons of great experience and 
high authority as to the propriety of bleeding in insanity. Thus, Haslam, 
Rush, and Foville strenuously advocate this remedy, while the equal authority 
of Pinel and Esquirol is against it. The inference is, that there is good and 
evil in the remedy; and that the difference of opinion has probably arisen from 
too exclusive a direction of the attention to one or the other of these qualities. 
Bleeding may undoubtedly often do much good. Reason and experience both 
abundantly prove that it is very often unnecessary, and may sometimes be essen- 
tially injurious. The rule will bear repetition, that the mere existence of in- 
sanity, however violent in its exhibitions, should never be admitted as a reason 
for bleeding, any more than delirium, coma, headache, or any other sign of 
cerebral derangement. It is only when the mental disorder is associated with 
signs of active vascular irritation or inflammation that the remedy should be 
appealed to; and then it should be employed with an energy proportionate to 
the violence of the symptoms. The reports of those hospitals, in which bleed- 
ing has been entirely abandoned, and in which great success is claimed for an 
opposite mode of treatment, must not be allowed undue weight in the decision 
as to the propriety of the measure. Cases have usually advanced beyond the 
period at which active depletion is advisable, before they are sent to these 
establishments. When doubts may exist as to the propriety of using the 
lancet, local bleeding may be substituted. 
Purging has always been a favourite remedy with some practitioners. It 
was much employed by the ancients, and the use of hellebore in insanity passed 
into a proverb. It is certainly a useful adjuvant of the lancet in cases attended 
with cerebral inflammation; and in those of a milder character, but still offer- 
ing some degree of general excitement, may with great propriety be employed 
as a substitute. Calomel, compound extract of colocynth, the compound ca- 
thartic pill, senna and salts, jalap and bitartrate of potassa, &c., may be used 
in the earlier stages and the severer cases; sulphate of magnesia, or some other 
saline cathartic, in those of a milder character, and when a frequent repeti- 
tion of the remedy is desirable. Many cases of commencing insanity may be 
advantageously trusted, during the stage of general excitement, to a dose of 
one of the purgative salts every day, every other day, or less frequently, ac- 
cording to the circumstances of the case, along with a proper regulation of 
the diet. Even in those instances in which no general excitement exists, or 
in which signs of debility may be evident, as constipation is a frequent attend- 728 
LOCAL DISEASES.-NERVOUS SYSTEM. 
[PART II. 
ant, and as the irritation of fecal accumulation acts injuriously on the brain, 
it is often best to employ cathartics; but, in such cases, the non-depletory 
laxatives should be preferred, such as rhubarb and aloes. 
In febrile conditions, with a hot dry skin, the antimonials and refrigerant 
saline diaphoretics may be used, in conjunction with the warm bath, which 
is here a valuable remedy. When, along with this febrile state, there is 
much paroxysmal violence, advantage will often accrue from nauseating doses 
of tartar emetic or ipecacuanha. The sensation of nausea has a powerfully 
repressing effect upon cerebral excitement. The highest fury of the insane 
paroxysm is not unfrequently quieted down into calmness under this influ- 
ence. One or two grains of tartar emetic, or from five to ten grains of ipeca- 
cuanha may be given every two, three, or four hours until no longer required; 
or smaller quantities may be employed if found to answer. 
Cold to the head is a valuable remedy in some cases of great vascular irri- 
tation or inflammation of the brain. The hair should be removed, and ice 
or cold water applied as mentioned under meningitis. Sometimes advantage 
accrues, especially in instances of violent maniacal excitement, from directing 
a small stream of cold water upon different parts of the scalp, through a flexi- 
ble pipe. The effect will be increased by immersing the feet at the same time 
in hot water, and thus producing revulsion towards the extremities.* 
Should the disease appear to take on the form of chronic inflammation of 
the brain or its membranes, after depletion general and local has been carried 
as far as circumstances appear to warrant, an attempt should be made to arrest 
its progress by blisters over the whole scalp, repeated if' necessary, and the 
production and maintenance, for a considerable time, of a moderate mercurial 
impression. Blisters to the scalp are especially useful when there is a strong 
tendency to stupor or coma. They are greatly preferable to the same remedy 
applied to the back of the neck, or between the shoulders. Small blisters 
placed upon the crown of the head can have little effect. To be really use- 
ful, they must cover the whole scalp. I have seen the greatest apparent 
benefit from the remedy in this state of insanity. Some recommend issues 
and setons; and an issue in the top of the scalp, over the sagittal suture, is 
thought to have been very beneficial in some instances of dementia with a 
comatose tendency. 
But there are other morbid states, besides that of cerebral inflammation, which 
complicate insanity. These should be carefully observed, and treated upon 
principles applicable to ordinary cases presenting the same characters. The 
digestive organs are often deranged. Dyspepsia and constipation sometimes 
require the use of mild tonics and laxatives, with a properly regulated diet, 
and exercise in the open air. Chronic gastritis or chronic enteritis may be 
coincident with the disease, and possibly contribute to sustain it. They should 
be treated as elsewhere directed for the same affections. The functions of the 
liver are very frequently impaired, and demand the use of the blue pill, nitro- 
muriatic acid, taraxacum, &c. A morbid dryness and inactivity of the skin 
require the use of the warm or hot bath, and frictions to the surface. Ex- 
cessive action of the heart should be controlled by digitalis, or medicines con- 
taining hydrocyanic acid. General debility should be corrected by tonics, the 
cold or shower-bath, exercise, and a nutritious diet. Anemic patients should 
be treated with chalybeates. Derangement of the menses should receive a 
careful attention; and, if suppressed, they should be restored by the use of 
* M. Briere de Boismont recommends, as extraordinarily effectual in the treatment 
of acute mania, the immersion of the body in a bath for five, ten, or even fifteen hours, 
combined with continuous cool irrigation of the forehead. By this plan he asserts that 
the disease may be cured in one or two weeks. [Braithwaite's Retrospect, xvii. 60.} CLASS III.] 
INSANITY. 
729 
the warm hip-bath, aloes, the chalybeates, or other measures that may be 
deemed appropriate. 
Want of sleep, which is one of the most distressing accompaniments of in- 
sanity, and contributes greatly to aggravate and sustain it, should never be 
neglected. When apparently connected with active cerebral congestion or in- 
flammation, it must be left to the remedies calculated to obviate these conditions. 
But, under other circumstances, it should be corrected by special remedies. 
Sometimes it will yield to blisters applied upon the extremities or epigas- 
trium. Fatiguing employment during the day will in some instances obviate 
the habitual nocturnal restlessness. Occasionally, the nervous stimulants, as 
assafetida, Hoffmann's anodyne, camphor, valerian, garlic, &c., may be used 
very advantageously. But nothing upon the whole is so effectual as opium; 
and this remedy should be employed, in some one of its forms, whenever the 
affection seems indisposed to yield to other means, and no decided contra-indi- 
cation exists in the congested or inflamed state of the brain. If found upon 
trial to be useful, it may be persevered in; if otherwise, it can be omitted; 
and no serious evil need be apprehended, with a moderate degree of caution. 
It will often most happily control the maniacal paroxysms. It must be given 
more freely than in the healthy state of the brain, in order to produce its 
legitimate effects. The requisite quantity must be ascertained by trial; but 
generally from one to three grains will be found sufficient for a dose, unless 
given so frequently that the system becomes habituated to it. Ipecacuanha 
or tartar emetic may often be added with advantage. When opium disagrees 
with the patient, other narcotics will sometimes be found to answer, such as 
hyoscyamus and conium; but they must be given in large doses to have effect. 
Chloroform might be tried in such cases, either by the stomach or in the way 
of inhalation, with reasonable hope of benefit; but its occasional fatal effects, 
when administered in the latter method, should preclude this use of it, unless 
under extraordinary circumstances. 
In other forms of systemic irritation, with frequent pulse, muscular tremors, 
relaxation of the surface, and more or less general disturbance of the functions, 
opium is often an admirable remedy, controlling these irregularities most hap- 
pily, when depletion would aggravate the mischief, and might produce great 
danger. This condition is not unfrequently met with in puerperal mania; but 
occurs also in other cases attended with general debility. The opium may 
here sometimes be advantageously combined with camphor, the ethereal pre* 
parations, assafetida, &c.; and occasionally the debility is so great as to call 
for alcoholic stimulants and quinia. 
The maniacal paroxysm has been very speedily relieved by ethereal inhala- 
tions; but care must be taken that, at the time of their employment, there is 
no active congestion or inflammation of the brain or its membranes. Perhaps 
chloroform might be safer in this respect, as rather sedative than stimulant in 
its action on the nervous centres. Much benefit may be expected from the 
use of this remedy internally, in connexion with camphor. 
Puerperal mania is to be treated upon the same general principles as the 
ordinary forms of the disease ; but almost all writers agree in considering it as 
requiring more caution in the use of depletion, and as seldom bearing the loss 
of blood from the arm. Opium and the various nervous stimulants, with due 
attention to the state of the digestive function, and, in cases of violent cerebral 
symptoms, local depletion, with cold applications and subsequent blisters to 
the scalp, are the chief physical remedies required. 
In excitement of the venereal propensity, some good may occasionally result 
from antaphrodisiac remedies, of which dulcamara, very freely employed, is 
perhaps among the most efficient. Grout or rheumatism, with which the in- 730 
LOCAL DISEASES.-NERVOUS SYSTEM. 
[PART II. 
sanity may have alternated, should be invited to its original seat by hot water, 
rubefacients, or blisters. If the disease has followed the disappearance of an 
eruption, attempts should be made by pustulation with tartar emetic, croton 
oil, or other irritant, to reproduce the cutaneous affection. Hemorrhoidal 
disease, which may have disappeared, should be restored by means of the hot 
hip-bath and aloes. 
Machines have been invented, the rotary motion of which, by giving a cen- 
trifugal direction of blood from the head towards the extremities, or producing 
that sort of nausea and attendant prostration which accompany sea sickness, 
has been supposed useful in the treatment of insanity. The effect, however, 
of these machines is necessarily temporary; and the danger is that, upon the 
cessation of the movement, there may be a reactive tendency of the blood to 
the brain, which shall more than counterbalance the previous benefit. It is 
possible that they may sometimes be usefully employed in controlling the 
violence of the paroxysm. 
In relation to diet and regimen generally, there are no special rules. They 
must be adapted to the existing state of health, without reference to the mere 
mental disorder. It is altogether unnecessary to go over the ground already 
so often trodden, and repeat the lessons of abstemiousness, rest, and the re- 
moval of all sources of excitement in inflammatory and febrile conditions ; of 
a nutritious diet in debility; of the importance of preserving, in the ordinary 
state of health, the proper balance between the supplying and expending pro- 
cesses, by adjusting the quantity and quality of food to the degree of exercise 
which circumstances may require or admit. Not unfrequently the insane re- 
fuse obstinately to eat, either with the purpose of committing suicide, or from 
some motive connected with their delusion. In such cases, they may some- 
times be tempted to take food, by leaving it constantly in their presence, with- 
out any attempt at persuasion or compulsion, which would arouse opposition 
and confirm their purpose. Something may be occasionally accomplished by 
allowing them no other drinks than such as are nutritious. They can bear 
hunger but not thirst. Should other means fail, recourse must be had to the 
injection of broths into their stomach by means of a tube introduced through 
the nostrils, or mouth, or to nutritious enemata.* 
Moral influences should be made to coincide with physical remedies; but 
they are most prominently useful in the fulfilment of the next indication, 
under which, therefore, they will be more particularly considered. 
Throughout the disease, symptoms of physical derangement, whether essen- 
tially connected with the insanity, or merely incidental, should be treated by 
measures appropriate to the particular circumstances of the case. 
3. The correction of the perverted cerebral functions.-In the foregoing his- 
tory of the disease, it has been maintained that, after the subsidence of the 
original physical disorder of the brain, it may be left with a perverted mode 
of action, without any inflammatory complication whether acute or chronic, 
or any other appreciable organic derangement. It is possible that the whole 
* The forcible administration of food, under these circumstances, often fails of the 
desired effect; and the propriety of the measure has been doubted. In a verbal com- 
munication to the College of Physicians of -Philadelphia, Dr. Charles Evans, physician 
to the Friends' Asylum near Frankford, stated his conviction that this refusal of food 
by the insane was generally owing to acute or chronic mucous gastritis. He strongly, 
however, advocated the injection of food into the stomach, but thought it should be 
administered in small quantities, and of a quality adapted to the condition of the organ; 
and expressed his belief that the failure to do good might be ascribed to the large quan- 
tities of rich soup usually injected, the effect of which was to aggravate the disease of 
the stomach instead of nourishing the patient. (Trans. of Coll, of Phys, of Phila., N. 8., 
i. 868.) CLASS III.] 
INSANITY. 
731 
complaint, from the very commencement, may sometimes consist in such a 
perversion. Now to reach this condition by physical remedies would seem to 
be impossible. We may by medicines excite and depress the brain, may irri- 
tate or calm it, may even sometimes restore its healthy action by removing 
the causes which disturb it; but how can mere matter, by entering the cere- 
bral vessels, regulate the fine operations of thought, awaken the sleeping con- 
science, or turn the perverted current of feeling into its proper channels ? The 
medicine of the mind must be mental. The recesses of the brain, where every 
movement is regulated by the presiding soul, must be approached through the 
soul. We may by physical means put the physical structure into order; we 
often must do so in order to fit it for the performance of its office; but when, 
after perfect repair, it continues to act wrongly, because its interrupted rela- 
tions with the moving spirit have not been duly renewed; we must enter its 
interior with that spirit, and through its intervention restore healthful and 
just movement to the organ. Through the senses, the intelligence, the me- 
mory, the affections, we must endeavour to touch those delicate cords which 
vibrate thought and emotion, and so touch them that they shall again produce 
their wonted harmony. Instead of leaving the operations of the mind to the 
caprice of accident, we must aim at so arranging exterior influences, that their 
suggestions shall be favourable to correct thought and feeling; at so clarify- 
ing the inner fountains, that there shall be a gentle welling up of healthful 
reason and impulse, instead of the turbid gushings of madness. 
There is, however, one physical remedy, or set of remedies, which aid us 
very much in the fulfilment of this indication. I allude to opium, and the 
narcotics of similar power. Independently of the advantageous influence 
exerted by these remedies in quieting irritation, controlling excessive nervous 
excitement, and producing sleep, they probably operate in another mode in 
the cure of insanity. When kept steadily under their influence, the brain is 
rendered in some measure insensible to those morbid impressions which have 
a constant tendency to disturb it. Though the patient may not be restored 
to reason, yet the irregular mental movements are much repressed, the pro- 
verbially cheering influence of the drug restrains the tumult of the feelings, 
and a condition of the brain is induced, in which a continued presentation of 
rational objects of reflection, and sources of a healthful interest, may gradu- 
ally accustom the organ to a sound mode of action; while the morbid trains 
of reflection, and the perversions of the passions are gradually obliterated from 
want of renewal. After the removal, therefore, of physical derangement, no 
medicine is so efficient as opium in favouring a return to a healthy state of 
function. It must be given in such quantities as to produce and maintain a 
decided impression, and must consequently be increased with its continued 
use. After the brain has been restored to a perfectly healthful state of action, 
the opium should be gradually diminished; and the patient should not be 
considered well until the medicine has been entirely dispensed with. This 
treatment should never be commenced during the continuance of active con- 
gestion or inflammation of the brain. It should be remembered, however, 
that mere nervous irritation or mental disorder, however violent, so far from 
constituting a contra-indication, is often relieved by it. I have known a pa- 
tient in a state of the most violent maniacal excitement, after being put asleep 
by a dose of opium, to awake in the morning quite composed and rational. 
Should the opium, upon trial, be found to aggravate the cerebral disorder, it 
should be omitted for a time. 
In the moral treatment of insanity, a proper regulation of ordinary personal 
intercourse is of great importance. The deportment towards the patient 
should be as much as possible the same as towards persons in health. He 732 
LOCAL DISEASES.-NERVOUS SYSTEM. 
[part it. 
should not discover, from the manner of those around him, that he is looked 
upon as insane. Instead of the tone or look of harshness or command, he 
should be addressed with gentleness and courtesy; nothing should be said to 
wound the self-love or self-esteem which he feels as strongly as other men; 
and whenever firmness and the exertion of authority become necessary, every- 
thing like an appearance of anger or violence should be banished from the 
voice and manner. The attendants should exhibit, in their deportment, a 
model for the insane to copy, not an imitation of the violence of insanity, 
which the patients will be the first to appreciate. 
The same rule should be extended to the whole treatment of the patient. 
There should be as much as possible of liberty, consistent with the safety of 
the patient and others; as little as possible of forcible restraint. Nothing 
that can be avoided should remind him of his difference from other men. 
His apartment, though well secured, should not look like a prison cell. In 
all his movements he should be carefully watched and guarded, when not 
well enough to be trusted to himself; but this should be done in a manner 
not to excite his suspicions. The attendance upon him should appear in the 
form of friendly care, companionship, or service, as the case may be, not of 
the watch of a jailer over his prisoner. Nothing more excites anger, and 
maintains a turbulent spirit in the insane, than violent restraint. Independ- 
ently of its positive discomfort, they feel it as an unprovoked and unwarrant- 
able injury. How is it possible for a brain to recover its regular and calm 
movements, when thus tortured by fierce excitement ? Happily, the days of 
chains, dungeons, the scourge, and starvation are passing away. But it is 
mournful to reflect upon the numbers formerly goaded into incurable mad- 
ness, or sunk into hopeless mental impotence, who, under judicious manage- 
ment, might have been restored to comfort and usefulness. 
In conversation with the patient, the subject of his insanity should be most 
carefully avoided. Unthinking persons sometimes amuse themselves with the 
peculiarities of the insane, and lead them purposely to the special subject of 
their illusion. This is cruelty. The sufferer might well exclaim : " it is 
amusement to you, but death to us." It is like irritating a wound that others 
are attempting to heal. It is, in general, altogether useless to argue with 
the insane, and to endeavour to convince them of their error. No impres- 
sion is produced upon their convictions, and their tempers are unnecessarily 
irritated. The aim of their physician and care-takers should be to turn their 
thoughts away from the subject of their false impressions, tef surround them 
with circumstances which should offer as little occasion as possible for the 
excitement of their perverted feelings. Regular occupation, physical and 
mental, should be provided. Nothing is more effectual in soliciting the mind 
back into a healthy mode of action. Ideas are presented in their due order, 
and steadily presented, so that the mind is accustomed to trains of connected 
thought. The broken threads of association, before hanging loose in the 
mental machinery, are thus fastened together; and the tendency to fly from 
one isolated thought to another is gradually corrected. Innocent amusement, 
too, and various recreation, should be provided, in order to arouse healthful 
feeling, and, in monomaniacal cases, to direct emotion towards other points 
than that morbid one in which it has a constant tendency to centre. 
In all these respects, public institutions have great advantages. They can 
provide occupation in gardening, farming, and the different mechanic arts; 
their patients may have the opportunity of taking long walks and drives, and 
of making diversified excursions of recreation, business, or instruction, under 
proper guardianship; they can arrange systematic courses of instruction by 
schools, lectures, and reading suitably regulated; in fine, they afford the means CLASS III.] 
733 
INSANITY. 
of various social amusements, such as balls, concerts, plays, and games of an 
innocent or useful tendency. Meetings for 'social conversation and worship, 
in which the most orderly afford an example wdiich the imitative tendency of 
the disorderly often induces them to copy, may be of much service. By all 
these modes the mental functions of the brain are duly medicated; calmed 
down when exalted, elevated when depressed, and rectified when crooked and 
perverse. Reason clearly points out such a course of proceeding as indicated 
by the circumstances of the case; and experience has recently abundantly 
confirmed its correctness, by the great success which has resulted everywhere 
from its adoption. 
The necessity is obvious of studying the peculiarities of each particular case, 
and applying proper measures to its special wants. The course that may be 
advisable for one kind, or stage, or degree of insanity may not be proper, may 
even be injurious, in another. In public institutions, it is often possible to 
classify the inmates according to their resemblance in these respects, and thus 
to bring particular plans to bear on numbers. The social principle which 
leads man to seek his fellow, and by a sort of elective affinity causes every 
individual in a crowd to fall into his proper place, is here sometimes highly 
useful in subduing the morbid propensities which, if indulged, might render 
exclusion from the circle necessary. Though some analogy in the condition 
of the patients should serve as the principle of association; yet those should 
not be brought together who may happen to labour under similar delusions; 
for their thoughts and conversation would inevitably cluster around these 
delusions, and the tendency would be to increase and confirm them. 
Allusion has already been made to the necessity of separation from former 
friends and accustomed scenes. In general, it is best, while the patient 
remains in the institution where he may be placed, that all former associations 
should be broken off; that the visits of friends should not be permitted ; and 
that all the circumstances around him should be new. Relaxation of this 
rule may occasionally be found advantageous; but of its general applicability 
to the cases of the insane there can be no doubt. 
Among remedial mental influences, the fine arts, and especially music, hold 
an important place. Independently of the very suitable occupation they 
afford, they often exert a soothing influence over mental irritation, operating 
sometimes with all the charm-like efficiency of the nervous stimulants in 
hysterical affections. I have seen the utmost paroxysmal violence of mania 
gradually calmed down by the sweetness of the female voice in singing, and 
terminate in a peaceful sleep under its influence. The power of David's harp 
over the insanity of Saul is familiar to every one. 
In hypochondriacal cases, good may sometimes be derived from appearing 
to accord fully with the patient, and so managing that the state or action upon 
which the delusion turned should seem to come to a natural termination. 
Thus, the experiment has often been tried, and sometimes successfully, with 
those who imagine a living animal to exist within them, of making a slight 
incision in the skin, and adroitly slipping into a vessel a real animal, which 
they were made to believe was extracted through the wound. Attempts, how- 
ever, of this kind are said occasionally to end unfortunately. Thus, I have 
seen somewhere the account of a hypochondriac, who confined himself to his 
chamber because convinced that he was too bulky to pass through the door, 
and who, having been forcibly pushed through, in order to destroy his illu- 
sion, fell dead under the powerful shock upon his imagination. The excita- 
tion of. a strong counter-feeling may sometimes be advantageous. Thus, a 
person believing himself dead, might perhaps be roused into life by being 
made to hear a conversation, which should ascribe to the departed certain dis- 734 
[part II. 
LOCAL DISEASES.-NERVOUS SYSTEM. 
graceful practices invented for the occasion. But these contrivances generally 
fail of any permanent effect. 
Though harsh proceedings of all kinds towards the insane should be avoided, 
it is necessary sometimes to employ restraint, in order to prevent them from 
injuring themselves or others. The camisole, or strait-waistcoat, and tempo- 
rary confinement to the bed or a chair by leather straps, arranged so as not 
to injure the skin, may be occasionally resorted to; and stiff leather gloves 
for the hands may become necessary to prevent the exercise of vicious per- 
sonal practices, or a disposition to break and tear everything that can be laid 
hold of. Some prefer, to such close personal restraint, the plan of shutting 
the violent patient up in a room, of which the walls and floor are covered by 
some soft, elastic material, calculated to prevent injury to the person from 
forcible contact with them. Something in the shape of penalty for violations 
of good order may also, in some instances, have a favourable influence in teach- 
ing the patient to control his propensities; but punishments should never be 
severe or disgraceful. Temporary seclusion, or the denial of some accustomed 
or expected gratification, is allowable; but chains, the dungeon, the whip, 
even the shock of a shower-bath, never. In the violence of the paroxysm, 
the shower-bath may be employed, sometimes very effectually, as a remedial 
or calming measure; but not as a punishment after the violence is passed. 
The patient should always be encouraged to keep himself clean in his per- 
son, and neat in his dress; and, if inattentive himself to these points, should 
have the office performed for him by others. The frequent use of the bath 
is essential. It will be impossible to restore a due degree of self-respect to 
the insane, while immersed in filth, and clothed in rags. 
An important rule in the application of these moral remedies, is never to 
consider a case as hopeless, but to treat every one, however old, and however 
low, as if there were some chance of improvement. The cares of the phy- 
sician are sometimes rewarded by recoveries in cases apparently the most 
desperate; and with almost all, if they cannot be cured, some improvement 
may be effected, or at least the circle of enjoyment enlarged. 
Travelling, with proper attendance, has sometimes a most happy influence 
on the insane, by the constant succession of novelties and of incidents which it 
offers, and the withdrawal of the attention from the subject of delusion or 
morbid feeling. The late Dr. Joseph Parrish used to relate the case of a 
patient, who, upon the occasion of descending a mountain in a journey, with 
a broad and novel landscape before him, suddenly exclaimed that he was well. 
Uis mind threw off the cloud which had oppressed it, as if in sympathy with 
the smiling and beautiful scene. 
Article 
DELIRIUM TREMENS 
Syn.-Mania & Potu.-Mania a Temulentia.-Delirium tremefaciens.-Dipsomania. 
This is the delirious affection which follows the suspension of the habitual 
use of alcoholic drinks or other stimulants. Its essential character consists 
in the cerebral debility consequent upon the cessation of an accustomed excite- 
ment. The most prominent symptoms are delirious hallucinations, the dread 
of impending evil, muscular tremors, and the want of sleep. The name of 
delirium tremens originated with Dr. Sutton, by whose tracts, published in 
1813, the attention of practitioners is said to have been first generally directed 
to the disease. It was, however, familiar to the physicians of this country CLASS III.] 
DELIRIUM TREMENS. 
735 
long before that period. In a paper published in 1820, Dr. Chapman speaks 
of the stimulating plan of treating mania d potu as having been the estab- 
lished practice of this city for upwards of half a century. (Phil. Journ. of 
Med. and Phys. Sei., i. 195.) 
Symptoms, Course, &c.-1The disease exists in various degrees, and with 
different complications, which give it a considerable diversity of appearance. 
It may be simple; it may be mingled more or less with the direct effects of 
alcohol upon the brain; or it may be connected with various accidental dis- 
eases. I shall consider it under each of these aspects. 
1. Simple delirium tremens.-The first effects of the suspension of the 
stimulus are feelings of great weakness or sinking of the whole system, with 
an indescribable anxiety and agitation, which are strongly expressed in the 
countenance and manner of the patient. He is troubled with frightful imagi- 
nations, vague alarms, and depression of spirits; his sleep is disturbed; his 
hand trembles; his mind is weak and confused, though without positive delu- 
sion; the pulse is soft, feeble, and often frequent; the extremities are cool; 
the whole surface is disposed to perspiration; and disorder of the digestive 
apparatus is shown by the frequently furred tongue, defective appetite, and 
tendency to constipation. This is the condition familiar to old drunkards 
under the name of the horrors. It is often experienced in a slight degree by 
intemperate persons in the morning, before the first dram. It almost always 
yields to the reapplication of the accustomed stimulus. 
Should circumstances, however, prolong the absence or privation, this pre- 
liminary condition becomes aggravated, and the disease is fully formed. The 
perceptive faculties are now disordered; and the patient receives false impres- 
sions through his senses, which he at first often recognizes as imaginary, and 
may even be disposed to smile at, but which soon acquire in his convictions 
all the force of reality. Not unfrequently it happens, for a time, that the 
phantasms seem real at night or in darkness, and either vanish, or are known 
for what they are by day-light. The patient sees the most grotesque, fright- 
ful, or disgusting objects; little hobgoblins of all possible shapes flying about 
the apartment, leering, hissing, threatening; serpents, toads, rats, mice, and 
other loathsome reptiles and vermin, crawling over his bed or person, or run- 
ning about his room; creeping insects, which he appears busied in searching 
for among his clothes or the bed covering. There is no end to the number or 
diversity of these hallucinations in different individuals. 
But with all this variety in the objects of delusion, there is one striking 
feature of the delirium which is seldom wanting. The patient is almost always 
fearful, and usually has some special object of terror, which influences most 
of his movements. One person is pursued by justice; another flies from a 
creditor or an avenging enemy; another is attacked by robbers or assassins. 
Voices are heard conspiring the destruction of the patient; he sees a gun 
pointed at him through the windows, or a knife glittering in an imaginary 
hand within his curtains. He hides from pursuit; defends himself against 
assault; struggles violently against persons aiming to seize or to bind him ; 
perhaps jumps out of a high window in order to escape; screams for aid, or 
implores pitifully to be spared; occasionally even seizes on a pistol or a sword, 
and commits manslaughter in supposed self-defence. In some instances, it is 
for others that he fears. Some violence is going on within his sight or hear- 
ing, and often of a revolting character, as of a child strangled by its parents, 
of a body beheaded or quartered, of a person falling a victim to assassins, &c. 
Most of the violences committed by the subjects of this disease, their occa- 
sional vociferations, their struggles, their attempts at flight, and even their 
assaults on others, originate in some notion of personal danger or disgrace to 736 
[PART II. 
LOCAL DISEASES.-NERVOUS SYSTEM. 
be avoided. There is seldom, if ever, any disposition to injure, any malignant 
feeling, as of revenge or hatred, to gratify. 
Very often the manner of the patient is quiet and gentle. He recognizes 
persons about him, receives his physician courteously, answers his questions 
without hesitation, and, if his attention is roused and strongly fixed, will give 
rational answers upon all points except such as are connected with his halluci- 
nations. The countenance, however, has usually a peculiar expression of ab- 
sence, vacancy, or pre-occupation; and a close examination will often detect 
evidences of fear in the manner, even when nothing is said by the patient on 
the subject. He will sometimes turn his head on one side, with a quick, 
alarmed look, as if dreading some danger from a particular direction ; or will 
have a listening ear, as if endeavouring to catch distant sounds of fearful im- 
port. He usually submits without hesitation to those who have the care of 
him, and readily takes the medicines that are offered. 
Morbid vigilance is one of the most characteristic symptoms. The disease 
begins with broken and disturbed rest, becomes confirmed with the occurrence 
of obstinate wakefulness, and ends when the patient is enabled to sleep pro- 
foundly. It frequently happens that not a wink of sleep is obtained for seve- 
ral days, and it is said sometimes not for one or even two weeks. 
Muscular tremors are also a very common, though not essential attendant 
on the complaint. The physician, in feeling the pulse, is struck with the 
trembling of the tendons, and, if not previously aware of the nature of the 
disease, has his suspicions awakened by this symptom. Though most percep- 
tible in the hands, the tremors will be generally found, upon close examina- 
tion, to affect the whole system. They are observable in the tongue when 
protruded; and the speech is not unfrequently affected by them. They some- 
times amount to convulsions. 
The pupil is often contracted, but there is no intolerance of light or sound. 
The pulse is sometimes quite natural, except, perhaps, that it may be softer 
and weaker than in health; but it is often frequent and feeble, and occasion- 
ally very frequent. The tongue is usually somewhat furred, though moist; 
the appetite is wanting; the bowels are generally constipated; and the stools, 
when procured, are dark and offensive. The breath is often fetid. The skin 
is generally moist; and profuse perspirations, attended with an unpleasant 
smell, are apt to break out, in consequence of great muscular exertion. The 
patient is, in most instances, able to be upon his feet, and dislikes confine- 
ment to the bed. There is sometimes great debility; the pulse being very 
feeble and frequent, the skin cold and clammy, the features pale or purplish; 
and death occasionally ensues from this cause, especially if the patient use 
much exertion. I once saw a person affected with delirium tremens jump 
from a public stage-coach, walk about a quarter of a mile, return to the coach, 
and die immediately from exhaustion. 
At the end of three or four days, though sometimes as late as a week or 
later, if no untoward event happens, the patient generally falls into a sound 
sleep, which may continue for twelve, eighteen, twenty-four, and it is said 
even for thirty-six hours. From this he awakes, feeble, pale, and trembling, 
but free from his illusions, and generally disposed to eat. Convalescence 
has now commenced, and, though some delirious symptoms may occasionally 
linger or recur for a day or two, they gradually disappear entirely, and the 
patient is restored to health. Not unfrequently, the first sleep is only for a 
few hours, and is followed by an amelioration of the symptoms, which sub- 
sequently disappear upon a return of rest. 
Instead, however, of this favourable course, cases improperly treated, or 
without treatment, sometimes lapse into what may be called the third stage, CLASS III.] 
DELIRIUM TREMENS. 
737 
which is characterized by great prostration. The delirium is now complete; 
the previous illusions give way to incoherence; extreme restlessness takes 
place, so that it is often necessary to confine the patient forcibly to his bed; 
the tremors are excessive; the pulse is extremely frequent and feeble; cold or 
warm sweats cover the surface; the features are sunken and haggard; the 
tongue is brown and dry; the pupils are much contracted or dilated; and 
subsultus tendinum, muttering delirium, coma, and convulsions, precede death. 
The successive stages of the disease do not always occur with regularity. 
Not unfrequently the complaint is arrested, as already stated, without reach- 
ing the second or third stage. In some instances, the first stage is wanting, 
and the patient passes at once into the fully formed disease; and instances 
occur in which the typhoid symptoms of the closing stage are presented at 
the commencement of the case. 
The whole duration of the complaint varies generally from three or four days 
to a week; but sometimes the delirium continues for ten days or two weeks. 
2. Complication with the immediate effects of the stimulant.-After a pro- 
tracted debauch, in which the inebriate has surrendered himself, with a sort 
of insane fury, to his propensity for days or weeks in succession, it sometimes 
happens that the brain or stomach, or both, are stimulated into inflammation, 
or a degree of vascular irritation bordering upon it; and a state of system is 
produced, in which the drinks either become disgusting, or can no longer be 
tolerated; or in which they are withheld by friends from a conviction of the 
absolute necessity of this course. The symptoms of morbid cerebral excite- 
ment, proceeding from the direct agency of the alcohol, now become mingled 
with those resulting from the want of the stimulus, or those characteristic of 
delirium tremens. The face is flushed and turgid, the lips intensely red, the head 
hot, the tongue furred or of a fiery redness, the appetite quite gone, the thirst 
extreme, and the pulse excited, full, and tense. The violent delirium of me- 
ningitis is mingled more or less with the hallucinations, the tremblings, and 
the wakefulness of delirium tremens; convulsions are not unfrequent; and, if 
not relieved, the symptoms are exchanged for those of stupor, coma, and fatal 
prostration. In some instances, a state of almost apoplectic stupor attends 
the case from the commencement; and the symptoms of delirium tremens are 
developed only upon the subsidence of the congestion. In others, excessive 
vomiting appears to keep the cerebral symptoms for a time at bay. 
3. Complications with accidental affections.-When the intemperate are 
overtaken by a serious injury, or attacked by a disease which takes away the 
appetite or opportunity for strong drink, the symptoms of delirium tremens 
very frequently become mingled with those of the accidental affection, and 
materially complicate the case. Severe surgical injuries, such as fractures, 
dislocations, and wounds, often owe their fatal termination in drunkards to 
the supervention of delirium. All the phlegmasiae are liable to the same occur- 
rence; and some of them are the more dangerous on this account, as the 
cerebral phenomena are apt to mask the symptoms of the original affection. 
This is especially the case in pleurisy and pneumonia. Genuine meningitis 
sometimes occurs in drunkards; and the two cerebral affections mingle, and 
modify each other, so as sometimes greatly to confuse the diagnosis. The 
severer idiopathic fevers seem to escape this complication ; for, though there 
is often great prostration in these diseases occurring in drunkards, the peculiar 
symptoms of the trembling delirium are not apt to occur. 
Anatomical Characters.-The opportunity is not often presented of ex- 
amining an uncomplicated case of delirium tremens after death; but, when 
such examination has been made, nothing has been discovered which could 
account for the symptoms. Sometimes an abnormal amount of serum has 738 
[part II. 
LOCAL DISEASES.-NERVOUS SYSTEM. 
been found in the ventricles, in the cavity of the arachnoid, and infiltrating 
the cerebral substance; but this may have been a mere result of the habitual 
state of the brain in drunkards, in whom there is often a strong tendency to 
serous effusion, as evinced by their bloated faces. It certainly does not account 
for the symptoms of the disease. In some instances, marks of congestion and 
inflammation have been noticed; but this only proves, what the symptoms in- 
dicate, that the drunkard is sometimes attacked with meningitis or cerebritis 
in consequence of the direct influence of the poison, or from other causes. 
As most patients, who die in delirium tremens, do so from other diseases 
upon which the delirium supervenes, it necessarily follows that the signs of 
these diseases will be discovered in their bodies after death. Hence, besides 
cerebral inflammation, dissection occasionally reveals marks of acute gastritis, 
pneumonia, pleurisy, &c. All the lesions, moreover, indicative of those nu- 
merous chronic affections resulting from intemperate habits, are liable to be 
met with; such as cirrhosis, fatty degeneration, and chronic inflammation of 
the liver, Bright's disease of the kidneys, chronic gastritis and enteritis, &c.; 
but these have no essential connexion with the complaint under consideration, 
which, so far as dissection throws any light upon the subject, must be regarded 
as strictly functional. 
Causes.-The essential cause of this species of delirium is the suspension 
of a stimulus to which the brain has been accustomed. In order that it may 
be produced, there must have been a certain continuance of the previous 
stimulation, so as to have formed a cerebral habit. The brain must have 
accommodated itself to the habitual excitement, which has thus become a part 
of its ordinary condition, and essential to its ordinary acts. Hence, steady 
tipplers, who always keep themselves under the influence of alcohol, without 
ever becoming absolutely intoxicated, are more liable to the disease, upon 
any interruption of this habit, than the occasional drunkard, who commits a 
debauch now and then, but allows intervals in which the brain may emerge 
from under the effects of the poison, and reacquire its healthy state. 
The disease is not confined to the use of any particular variety of alcoholic 
drink, though, for obvious reasons, most apt to result from the strongest. 
Hence its great prevalence in the United States, where the cheapness of 
spirituous liquors places at the command of every one an amount of stimu- 
lation, which would exceed the means of the majority of the population in the 
wine-drinking and beer-drinking communities of Europe. Happily, a moral 
influence has sprung up to counteract this facility of the means of intoxication; 
and the consequence is, that the cases of delirium tremens have much di- 
minished. This result is very obvious to those who have the superintendence 
of our hospitals and alms-houses. 
Persons of sedentary habits are much more easily affected than those who 
labour; because, under vigorous exercise, the stimulus is expended in the 
various functional operations of the system, instead of concentrating its whole 
force upon the brain. 
As already stated, the occurrence of an accidental injury, or of a violent 
disease, is apt to be the exciting cause of the delirium, by interrupting the 
use of the stimulant, causing its rejection by the stomach, or reudering the 
system for a time insusceptible to its influence. 
Nature seems to have provided that the condition of nausea and vomiting, 
which are not unfrequently induced by the abuse of alcoholic drinks, should 
avert the delirium, and sometimes afford the organs an opportunity of return- 
ing to theii' healthy state, without the intervention of this disorder. The con- 
dition of the brain under the influence of nausea, which is as much a cerebral 
action as any other sensation, is in a great measure incompatible with the CLASS III.] 
739 
DELIRIUM TREMENS. 
peculiar disturbance of its functions, such as occurs in delirium tremens. It 
is very common to see drunkards, labouring under an attack of cholera mor- 
bus, or other disease attended with nausea and vomiting, who, while in this 
condition, retain the full possession of their mental faculties, but, if the 
stomachic affection is interrupted, pass at once into the state of delirium. 
It is said that the abuse of other cerebral stimulants, and especially of 
opium, is liable to lead to the same affection, by a similar interruption of 
their employment. Though, from my position in the Pennsylvania Hospi- 
tal, I have for many years had frequent opportunities of witnessing cases 
of delirium tremens, I have never yet met with one which I could trace 
to the use of that drug. The affection, therefore, from this cause I presume 
to be very rare; and, even in cases which may be supposed to have had such 
an origin, it is not always easy to determine whether the patient may not 
have indulged also in alcoholic drinks. Dr. B. H. Coates, however, in an 
excellent treatise upon delirium tremens, published in the North American 
Medical and Surgical Journal, for 1827 (vol. iv. p. 34), states that he has 
seen well characterized cases, in which the disease resulted from the inter- 
mission of the use of opium. 
The late Dr. Chapman informed me that he had seen the disease, with all 
its essential features, result from the excessive use of tobacco; but, as this is 
sedative in its influence on the brain instead of stimulant, the delirium was 
the consequence of its direct operation, not a secondary result as in the case 
of alcohol, and ceased when the narcotic was omitted. 
The delirium which sometimes conies on in the temperate, after a severe 
injury or surgical operation, excessive mental exertion, or a long loss of rest, 
with fatigue and anxiety, has been considered by some as identical with that 
from the abuse of alcohol; but others deny the identity; and certainly there 
is sufficient difference in the symptoms and course of the affections to au- 
thorize at least, very strong doubts upon the subject. The excitement pro- 
duced by alcohol is peculiar; so, also, I think, is the depression which fol- 
lows the withdrawing of the stimulus 
Nature.-Little remains to be said upon this subject. The reader will 
before this have perceived that I consider delirium tremens as a disorder of 
the cerebral functions, immediately dependent upon the diminution of the 
degree of excitation necessary for the support of the brain in its ordinary 
actions. The brain is in a state at once of debility and depression. It may 
be objected to this view, that there is increased muscular effort amounting 
sometimes to violence; that, instead of reposing as in sleep, the brain is in 
perpetual action; in fine, that the phenomena are in general those of disturb- 
ance rather than depression of the animal functions. But we must recollect 
that the brain is not like other organs, and that its actions must be judged of 
by a different rule. One of its singularities, as already explained, is, that 
totally opposite conditions of the organ are attended with apparently similar 
effects. (Seepage 672.) 
Deduce the amount of healthy excitant influence, and we have disturbances 
in the various functions quite equal to those which would result from an 
excess of it. There is little doubt that, could we look into the interior ope- 
rations of the brain, in delirium tremens, we should see the springs of the 
organ everywhere relaxed, its machinery moving languidly and feebly ; and 
the streams of its influence sent forth scantily to their several destinations. 
The vacuum thus created in all parts of the system gives rise to disturbances, 
not unlike those arising from repletion of the same influence; just as the 
wind and the storm, in the exterior world, follow as well the: diminution of 
the sun's influence as its increase. But, though the phenomena are some- 740 
LOCAL DISEASES.-NERVOUS SYSTEM. 
[part II. 
what similar to those of over-excitement, there is yet a difference which is 
appreciable by close observation. The heart beats more rapidly, but it beats 
feebly; the muscles may be thrown into occasional violent action, but they 
tremble; the mind may be agitated, but it is with terror, and not with daring. 
A correct view of this subject is of practical importance; for the treatment 
depends upon it. If we believe the brain to be in a state of high vascular 
irritation or inflammation, we shall be disposed to deplete; if in the contrary 
state, we shall deem it necessary to stimulate.* 
Diagnosis.-The affections with which delirium tremens may possibly be 
confounded are febrile delirium, meningitis, and the different forms of in- 
sanity. In the well-marked cases of these several affections the diagnosis is 
very easy; but instances now and then occur in which a decision is difficult, 
and, for a time, even impossible. 
The delirium of fever is more incoherent than that from drink, does not 
usually generate the same fantastic hallucinations, is without its fears and its 
tremors, and is attended with greater apparent muscular prostration, with a 
wholly different expression of countenance, and with much more heat and 
dryness of skin. The last stage of delirium tremens bears considerable re- 
semblance to a certain stage of typhoid fever; and, if the case were seen only 
in this condition, there might be some doubt as to its nature; but the pre- 
vious history, if attainable, will almost always determine the question. 
Acute meningitis has greater violence of delirium, more febrile disturbance, 
and a stronger tendency to convulsions and coma, while it is without the co- 
herence, the imaginary terrors, and the muscular tremblings of the alcoholic 
disease; but not unfrequently the two affections are conjoined; and the cases 
of delirium tremens following immediately a prolonged debauch, and present- 
ing symptoms of cerebral congestion or inflammation, have somewhat of this 
complicated character. 
Insanity is usually much more gradual in its approach, less apt to see phan- 
toms, or to be haunted with terrors, less frequently attended with muscular 
tremors, and much more persistent. Mania is more incoherent, monomania 
more rational. The paralytic tremblings of dementia may bear some resem- 
blance to the tremors of delirium tremens; but the whole course of the disease 
is different. A case of the latter complaint, complicated with palsy, might 
sometimes be mistaken for the former; but the error must soon be corrected. 
Dementia is not so sleepless as delirium tremens. The case of greatest dif- 
ficulty is one in which real insanity has occurred in a drunkard, and become 
complicated with the symptoms of the disease under consideration. Such, 
probably, are those cases in which, after the subsidence of the peculiar symp- 
toms of delirium tremens, the patient continues insane. 
In forming a diagnosis, the physician will always be much aided by a know- 
ledge of the previous habits of the patient. Sometimes, however, a habit of 
intemperate drinking is concealed with great art, and the occurrence of an 
attack of delirium is the first event which excites suspicion. 
Prognosis.-Simple, uncomplicated delirium tremens is not a dangerous 
disease. It generally subsides spontaneously, and, under proper treatment, 
* The state of the urine, as examined by Dr. H. Bence Jones, affords additional evi- 
dence in favour of the view, that the action of the brain is depressed in delirium tre- 
mens. In acute inflammation of the brain, he has uniformly found an increased amount 
of the phosphates, which he ascribes to an active oxidation of the cerebral matter, con- 
sequent on an excessive action of the organ- In delirium tremens, on the contrary, 
there is a diminution of the phosphates, while the proportion of the sulphates and of 
urea is greatly increased, indicating, as Dr. Jones supposes, excessive activity, and of 
course oxidation of the muscles. (Lond. Med. Gaz., July, 1851, p. 81.) CLASS III.] 
741 
DELIRIUM TREMENS. 
almost always ends favourably. The chief danger is of death from debility, 
and especially from exhaustion after muscular exertion ; and, if this be 
guarded against, there is little else to apprehend. Sometimes, also, the pa- 
tient destroys himself; but very rarely with suicidal intention. 
But, when the disease is complicated with cerebral inflammation, or a high 
degree of active cerebral congestion, when it supervenes upon a severe injury, 
or occurs in the course of another serious disease, it adds no little to the 
danger; and such cases not unfrequently end in death. Stupor, convulsions, 
complete incoherence, muttering, subsultus, extreme frequency of pulse, a 
dry tongue, and a cold clammy surface, are unfavourable signs. 
Very few die of the earlier attacks. Each successive one becomes more 
dangerous, because usually occurring in a more debilitated constitution, and 
associated with a greater amount of organic disease. Yet some individuals 
recover from very numerous attacks, and die at last either of some accidental 
disease, or of the complicated organic derangements resulting from intemper- 
ance, independently of the delirium. 
Of 1241 cases of delirium tremens, in all its forms and stages, and of in- 
temperance expected to end in delirium, admitted into the Philadelphia Hos- 
pital (Blockley) from May 1834, to November 1839, and subjected to a variety 
of treatment, 121 cases proved fatal, or somewhat more than one in ten. 
(Gerhard, Tweedie's Syst. of Pr act. Med., Am. ed.) 
Treatment.-According to the view here taken of the pathology of delirium 
tremens, the indications of treatment are, clearly, first, to stimulate the brain 
up to the point essential to its correct action, and secondly, after having thus 
reinstated it in its normal functions, to withdraw gradually the artificial sup- 
port, and bring the organ safely back to a reliance upon the ordinary healthy 
influences. In almost all uncomplicated cases, these objects can be accom- 
plished without difficulty, provided the treatment has not been postponed so 
long, that the system has sunk beneath the lowest point of impressibility. 
The first question to be decided is in relation to the character of the stimu- 
lation to be employed. It appears obvious that, as the suspension of alcoholic 
drinks was the cause of the disease, the cure is to be effected by their resto- 
ration ; and experience has shown that there is no easier or more certain 
method than this, of removing the delirious symptoms, and restoring the pa- 
tient to his previous state of health. But here a high moral consideration 
interferes. It seems as though nature had kindly provided this affection, as 
a means of checking the drunkard in his downward career, and offering him 
an opportunity of retrieving his lost position. In the great majority of in- 
stances, if left to itself, the affection subsides, and the patient, though feeble, 
is in a condition of sanity, capable of reflecting on the past, and of securing 
himself by the exertion of a very possible self-control for the future. Is the 
physician to step in, and obviate this kind provision of nature by reapplying 
the original poison, and thus placing the patient in a situation, certainly not 
more favourable, it might, I think, with propriety be said, even more un- 
favourable, than before the occurrence of delirium ? It appears to me that, 
by stimulating with alcohol, we incur the risk of confirming the patient in his 
evil habit, and of hastening the last fatal result, which must come in one 
shape or another, if this h^bit be persevered in. The plan of alcoholic stimu- 
lation is safer in hospitals than in private practice; because, in the former, 
the patient may often be detained after his restoration to sanity, until the 
evil habit has been in some measure eradicated by a gradual withdrawing of 
the stimulus. But, even in this situation, the patient cannot be detained 
against his will in this country; and very frequently he demands his liberty, 
in order to satisfy his craving, long before the cure is accomplished. In pri- 742 
[part II. 
LOCAL DISEASES.-NERVOUS SYSTEM. 
vate practice, the plan is, I think, ruinous. No sooner is sanity restored, 
than the patient again becomes his own master, or rather the slave of his 
morbid inclination; and has lost all the benefit which abstinence, during the 
continuance of the attack, would have afforded him. 
It is, therefore, highly desirable to find some other stimulus, which may be 
sufficient to pupport the nervous system during the continuance of the disease, 
may occupy in some measure the cravings of the patient upon his first re- 
turning consciousness, and may be more readily withdrawn when it ceases to 
be essential. Happily such a stimulus we have in opium. It affords a gentle 
support to the brain, quiets nervous disturbance, favours the return of sleep, 
and, when no longer required, can be given in gradually diminished doses, if 
necessary without the knowledge of the patient, who feels himself, almost 
unconsciously, placed upon his feet, prepared to commence again the journey of 
life, it may be, with better purposes, and more power of will to carry them 
into effect. Much has been said of the directly injurious influence of opium on 
the brain, of its producing convulsions, and favouring congestion and inflam- 
mation. With a proper selection of cases, and a proper use of the medicine, 
these dangers need not be apprehended. It is certainly possible to give the 
patient with delirium tremens enough opium to destroy him, as it is possible 
to produce the same effect with any other poison. But there is not the least 
occasion for incurring any such danger. The object is not to force sleep at 
all events. It is not to pour in the narcotic in such quantities as completely 
to overwhelm the brain, and, if sound sleep cannot be induced, at least to 
bring about a state of coma. It is sufficient for the object to keep the patient 
moderately under the influence of the narcotic, so as to prevent his nervous 
powers from failing, and patiently to wait till the disease ceases in its ordi- 
nary course, and sound sleep returns. 
Sometimes, however, the debility is so great, that the moderate use of 
opium alone is not sufficient to counteract it. There is danger of fatal pros- 
tration unless the patient receive further support. In such cases, alcoholic 
'liquids should be allowed in quantities sufficient to sustain the vital functions. 
The least stimulating, the most tonic and nutritious of these should be pre- 
ferred. The malt liquors usually answer the purpose admirably well. In 
extreme debility brandy must be resorted to, if necessary to save life. But 
the rule should be to give no more than is requisite to sustain a due strength 
of pulse; and, as soon as the stimulus ceases to be essential to this purpose, 
to withdraw it. 
Upon these principles essentially the treatment of delirium tremens has 
been long conducted in the Pennsylvania Hospital, and with very satisfactory 
success. It is rarely that a case of the simple disease proves fatal, unless 
brought into the institution in the last stage of exhaustion. 
The particular plan of treatment which I usually pursue is the following. 
Two grains of opium, half a grain of sulphate of morphia, or an equivalent 
quantity of one of the liquid preparations of the drug, are given every two 
hours, and steadily persevered in, until sleep takes place, or a decided narcotic 
impression is evinced. This quantity is seldom exceeded. When, after one 
or two doses, the patient is found very susceptible to the influence of the nar- 
cotic, the interval should be lengthened to three or four hours or more, or the 
quantity diminished. Upon his awaking from the first sleep, should the least 
tendency to hallucination remain or return, the medicine is to be given in 
quantities sufficient to control the tendency, and to be gradually diminished 
or omitted as the occasion for its use lessens or ceases. 
Should the pulse be feeble, and the skin cool, the patient may be allowed 
from one to two bottles of ale or porter, or an equivalent quantity of wine, in CLASS III.] 
743 
DELIRIUM TREMENS. 
twenty-four hours; and, should the debility be alarming, recourse may be had 
to brandy, or other form of ardent spirit. But it must be remembered that 
the alcoholic stimulus is employed simply to support a due degree of strength, 
and to obviate the danger of fatal prostration. Tincture of hops or of lupulin, 
in the dose of half a fluidounce every three or four hours, sometimes answers 
a very good purpose; affording the requisite support to the system, while it 
co-operates with the opium in producing sleep. 
To obviate the tremors when excessive, and in cases which exhibit a tend- 
ency to convulsions, the nervous stimulants should be added to the other re- 
medies. Assafetida, and compound spirit of sulphuric ether, are those upon 
which I place most reliance. In slight cases, infusion or oil of valerian may 
be employed. 
In cases of violent excitement, advantage may be expected from the internal 
use of chloroform, which may be given in the dose of from forty to sixty 
drops, repeated at intervals of an hour or two, until its quieting or depressing 
effects are experienced. The most convenient mode of exhibition is that of 
emulsion with a little camphor, the yolk of an egg, and water. Care must be 
taken not to carry the remedy so far as to produce prostration. 
Should the patient, as sometimes happens, be seized with sudden and 
alarming prostration, sulphuric ether should be given in the dose of from two 
to four fluidrachms, repeated at short intervals, in connexion with powerful 
alcoholic stimulants. 
The condition of the organic functions should be attended to. If the bowels 
are constipated, cathartics should be administered, adapted to the circum- 
stances of the case; calomel or mercurial pill being added to the other medi- 
cines, when the hepatic secretion is deficient. Magnesia, castor oil, rhubarb, 
and aloes are generally preferable to the more active depletory purgatives. 
Senna may be employed when something more energetic is requisite. Irrita- 
bility of the stomach, if it exist, may be quieted by lime-water and milk, the 
effervescing draught, small draughts of carbonic acid water, aromatic spirit of 
ammonia, and a sinapism or blister to the epigastrium; and, should opiates be 
rejected from the stomach, they may be administered in twice the quantity 
by the rectum. 
Should the patient fall into the typhous condition, which very rarely hap- 
pens in the uncomplicated cases, his strength must be supported by carbonate 
of ammonia, brandy toddy, milk punch, egg beat up with brandy, essence of 
beef, &c., as in proper typhus fever. 
In very obstinate cases of sleeplessness, which resist the usual measures, 
and persist for a week or more, a blister over the whole scalp sometimes has 
a most happy effect. The same remedy should be resorted to when convul- 
sions occur, or a tendency to coma supervenes. When the disease has long 
resisted opium, sleep has repeatedly been induced by ethereal inhalation; and 
chloroform has been employed for the same purpose, but requires much cau- 
tion, for fear that its depressing influence may prove dangerous in the debili- 
tated state of the patient. Perhaps by combining ether and chloroform, as 
practised by Dr. Joseph Parrish, of Burlington, New Jersey, in a case recorded 
in the New Jersey Medical Reporter (i. 301), the great energy of the latter 
may be obtained, while its prostrating effects may be counteracted by the 
stimulant agency of the ether. 
Dr. James Grieve, of Dumfries, Scotland, has employed with advantage the 
extract of belladonna, as a local application, when the pupil was contracted, 
in order to expand it, and thus obviate the spectral illusions, which probably 
tend in some measure to prevent sleep. (Ed. Month. Journ. of Med. Sci., 
Nov. 1853, p. 430.) 744 
LOCAL DISEASES.-NERVOUS SYSTEM. 
[part II. 
Great caution should be observed not to interrupt the sleep of the patient, 
unless it should appear to assume the form of coma; or the occurrence of a 
cold clammy skin, with sinking of the pulse, should indicate the necessity for 
stimulant and nutritive substances. Upon awaking, the patient should be 
furnished with some gently stimulating and nutritious substance, to obviate 
exhaustion; and perhaps nothing is better for the purpose than the yolk of 
egg beat up with ginger and hot water, to which a little wine or-brandy may 
be added if deemed requisite. 
Some modification of the above treatment is necessary in those cases of pro- 
tracted debauch, in which symptoms of active congestion or inflammation of 
the brain, the direct result of the excessive stimulation, are mingled with the 
peculiar symptoms of commencing delirium tremens. Here it sometimes 
becomes necessary, in order to prevent disorganization of the brain, to take 
blood either generally or locally or both, to make cold applications to the 
head, and to administer an active purge. Should the symptoms of conges- 
tion disappear, and a pure case of the ordinary delirium be developed, the plan 
already detailed should then be carried into effect. But, if stupor or convul- 
sions continue, the whole scalp should be blistered with little delay; and the 
accruing debility counteracted by just as much stimulation as may be neces- 
sary to prevent the patient from sinking; the arterial and nervous stimulants, 
as carbonate of ammonia, capsicum, musk, assafetida, &c., being preferred to 
the alcoholic, until found to be insufficient to fulfil the indication. Oil of 
turpentine or assafetida may also be given by enema. 
In the complicated cases, the treatment must be modified according to the 
character of the complication. Should it be a surgical accident, the plan 
recommended for the simple cases should be carried out, and opium may be 
even more freely employed, unless the head be the part affected, and menin- 
geal and cerebral inflammation be apprehended. If the associated disease be 
one of debility, the necessity for alcoholic stimulants will be greater than 
under ordinary circumstances; and quinia will sometimes be found a most 
valuable auxiliary. But, beyond all comparison, the most frequent complica- 
tions are the phlegmasiae; and these offer to the physician one of his most 
perplexing therapeutical problems. The principles of treatment, however, 
appear to me to be pretty well determined. To prevent disorganization, the 
quality of the blood must be altered, and this can be effected in no way so 
satisfactorily as by bleeding. But the patient, already debilitated by his 
habits, will sink under this treatment, if his ordinary artificial support be 
withdrawn. It is, therefore, necessary to administer alcoholic drinks in such 
amount as may be requisite to sustain the functions, and control the delirium. 
When the relief of the inflammation can be accomplished by leeching or cup- 
ping, these should be preferred to the lancet; but there should be no hesita- 
tion in resorting to the latter, when the symptoms are very threatening, and 
the pulse tolerably strong. Blisters, too, should be freely employed in these 
cases. One of the most frequent of these local affections is gastritis, and 
leeches to the epigastrium may often be usefully applied, even when it is 
necessary to administer stimulants internally. Inflammation of the brain offers 
the most difficult question; as the force of the necessary stimulus bears in this 
instance especially upon the over-excited organ. The rule of treatment, how- 
ever, has been already stated; namely, to deplete as far as the strength will 
permit, to blister, and to use only that amount of stimulus absolutely neces- 
sary to support life, preferring such substances as have least tendency to 
operate especially on the brain. It not unfrequently happens that the delirium 
of drunkards conceals some serious local inflammation, which may be sapping 
the foundations of life, while the physician is directing his measures only CLASS III.] 
DELIRIUM TREMENS. 
745 
against the obvious symptoms. In every case, therefore, of delirium tremens, 
it is highly important that the several organs should be thoroughly investi- 
gated, to ascertain whether there may not be some phlegmasial complication. 
Should febrile symptoms attend the complaint, the presumption will be alto- 
gether in favour of the existence of such an affection. 
The question will early present itself, what course is to be pursued in rela- 
tion to the confinement of the patient. Is he to be forcibly kept in his bed ? 
to be shut up, as some have recommended, in a dark cell ? or to have a cer- 
tain amount of liberty of movement? I prefer the last-mentioned course. 
Forcible confinement often leads to excessive and exhausting struggles; while 
solitude and darkness exaggerate the terrors of the patient, and fix his hallu- 
cinations more firmly. The proper plan, I think, is to allow as much liberty 
of movement as may be compatible with the safety of the patient, and the 
convenience of his attendants, the most careful watch being kept over his 
actions, and all tendency to violence soothed or restrained. But when very 
weak he should be confined to his bed; as fatal syncope may result from a 
continuance in the erect position, especially if muscular exertion be used at 
the same time. In this prostrate condition, he should never be left without 
constant oversight. I have known death to result from a patient rising from 
his bed at night, during the absence of his attendants. 
The diet should be adapted to the circumstances of the case. In the ear- 
lier stages, when there is any local inflammation, it may be sufficient to give 
farinaceous substances; but ordinarily, the patient may use milk and the 
lighter kinds of animal food; and great debility must be counteracted by 
broths, animal essences, egg and wine, milk-punch, &c. 
The above is the course of treatment which coincides best with my own 
judgment and experience in this complaint; and it probably accords more or 
less closely with the views of the majority of practitioners. Other plans, 
however, have been proposed. 
Of these the most successful, so far as regards immediate results, is pro- 
bably the purely stimulant plan as advocated by Dr. Gerhard. Under this 
plan, the proportion of deaths from delirium tremens in the Philadelphia 
Hospital (Blockley), was reduced from one in eight, which it had been ori- 
ginally, to one in about thirty-three. Dr. Gerhard gives from one to two 
fluidounces of brandy every two, three, or four hours, according to the pre- 
vious habits and the degree of debility, alway employing the least quantity 
that will tranquillize the patient, and gradually diminishing as the occasion 
for the stimulus ceases. The largest quantity necessary at first, in each case, 
is seldom required longer than twenty-four hours. (Tweedie's Sy st. of Pratt. 
Med., Am. ed., Article Delirium Tremens.') I have already given my reasons 
for not thinking this plan generally the most expedient. 
Another mode of treatment is the emetic plan, originally proposed by the 
late Dr. Joseph Klapp, of Philadelphia. He was induced to adopt this treat- 
ment, from observing that the disease was apt to occur upon the cessation of 
an attack of vomiting in the intemperate, and that the spontaneous superven- 
tion of vomiting, during the disease, relieved the delirium. The fact that an 
attack of cholera morbus in an intemperate person, if arrested, is apt to be 
followed by delirium tremens, I can verify by repeated observation. The state 
of nausea appears to be, in some measure, incompatible with the cerebral con- 
dition peculiar to this disease. Dr. Klapp gave two grains of tartar emetic 
every fifteen minutes till it operated, and found it necessary to give from 
eight to sixteen grains before the effect was obtained. Much more than the 
largest quantity mentioned was sometimes necessary; as the stomach or rather 
brain is remarkably insusceptible of the emetic impression. The symptoms 746 
[part II. 
LOCAL DISEASES.-NERVOUS SYSTEM. 
were immediately ameliorated after vomiting, and the patient rapidly reco- 
vered. (Eclectic Repertory, vii. 251, A. D. 1817.) This plan has also proved 
successful in other hands; but it has sometimes failed, and sometimes been 
attended with fatal results. Indeed, when it is considered that, in simple 
delirium tremens, debility is almost the only danger, it seems to be a neces- 
sary inference, that a remedy which must add to the debility, however quickly 
effectual in many cases, cannot but prove injurious in others, if indiscrimi- 
nately employed. Besides, the stomach is often inflamed in drunkards, and 
it would seem that the large amounts of tartar emetic, sometimes necessary, 
cannot but seriously aggravate the gastric disease. The practice has not been 
generally adopted; but cases sometimes occur, in which it might be prefera- 
ble to the opiate plan, when the debility is not great, and the stomach in no 
degree inflamed. 
Dr. Alexander Peddie, of Edinburgh, has treated upwards of eighty cases 
with uniform success, chiefly by means of tartarized antimony, given, not as 
an emetic, but in moderate doses as a sedative. He gives from one-quarter to 
one-half a grain, every two hours, and conjoins with the antimonial preparation 
purgatives when necessary, freedom of bodily movement, nourishing food, and 
abundance of light. (Ed. Month. Journ. of Med. Sci., June, 1854, p. 506.) 
Still another mode of treatment is that mentioned by Dr. Chapman as 
having been the practice of Dr. Kuhn, formerly one of the most respectable 
physicians of Philadelphia. It consisted simply in " confining the patient in 
a dark cell, and leaving the disease spontaneously to work itself off." Dr. 
Kuhn was known to declare that, after an extensive trial in the Pennsylvania 
Hospital, he had found no measure to answer as well as this. (Phil. Journ. 
of Med. and Phys. Sci., iii. 242.) This plan has been followed by other 
practitioners, and something very similar to it is recommended by M. Cal- 
med, who does not, however, insist on darkness. There can be no doubt that 
great numbers will recover under this plan; and it is certainly better than 
the depletory; yet it will not prevent death from prostration, which is the 
greatest danger of the simple cases. In the paper of Dr. Coates before re- 
ferred to, Dr Kuhn is stated, on the authority of Dr. Currie, to have em- 
ployed the opiate practice so early as the year 1783. (N. Am. Med. and 
Surg. Journ., iv. 235.) 
Perhaps the most dangerous method of treatment is that of bleeding, with 
other modes of depletion, founded on the notion of the inflammatory nature 
of the complaint. Though these remedies may be necessary in certain com- 
plicated cases, they are, I think, altogether contraindicated in the unmixed 
disease; and the experience of the profession is certainly not opposed to what 
seems to be the clear deduction of common sense. 
Prophylactic Treatment.-This should consist in a gradual abandonment 
of the habit of drinking alcoholic liquors. Individuals who are unable by 
their own unaided will to break this habit, often voluntarily place themselves 
in public institutions, in order to supply their deficiency of resolution by a 
species of exterior compulsion. I have frequently treated such cases in the 
Pennsylvania Hospital, and have never found any difficulty in safely with- 
drawing the accustomed stimulus, and dismissing the individual released, at 
least for a time, from his disgraceful thraldom. The plan is simply to give 
daily the least quantity of alcoholic liquor, generally ale or porter, that is 
necessary to ward off an attack of delirium tremens. This quantity diminishes 
each succeeding day, and, in a period varying from one to three or four weeks, 
the stimulus can be altogether dispensed with. Advantage will sometimes 
accrue from counteracting nervous symptoms by opium. But the patient 
should not be dismissed until he has been entirely without both of these 
stimulants for a week or more. CLASS III.] 
EPILEPSY. 
747 
Article VIL 
EPILEPSY. 
Epilepsy (from erti'k^ia, attack or seizure) is characterized by paroxysmal 
attacks of convulsions, with loss of sensibility and consciousness, without fever, 
and followed usually by coma. This definition is probably as correct as can be 
given, though not quite satisfactory, as it may include cases not strictly epi- 
leptic, certain hysterical convulsions, for example, and excludes others usually 
attached to epilepsy, and having the same essential nature, such as the verti- 
ginous paroxysms to which attention will be called directly. But entire pre- 
cision in a definition, which is founded on symptoms alone, can scarcely be 
expected; for it almost always happens, especially in nervous affections, that 
phenomena apparently similar may result from very different pathological 
conditions. 
Symptoms, Course, &c.-I shall consider first, the paroxysms ; then, their 
relations towards each other, with the condition of the system in the interval; 
and lastly, the general course and termination of the disease. 
1. There are often premonitory symptoms, sufficient to warn the patient 
of the approach of the paroxysm. Very different statements are made by 
authors as to the relative frequency of their occurrence. The result of the 
statistical researches of M. Beau (Archives Centrales, tom. ii.) is, that the 
paroxysms are preceded by symptoms of this kind in about one-half of the 
cases ; and this is probably near the truth. The precursory phenomena differ 
greatly in duration and character. They may continue but for an instant, 
may last several minutes, or may extend to hours or days. They are gene- 
rally brief, not longer than may afford opportunity to the patient to seek a 
favourable position, and often not long enough for that purpose. The follow- 
ing are among the symptoms alluded to; though it must be recollected that 
often not more than one or two of them are manifested in the same case. 
Sometimes the premonition consists only in a general alteration of the state 
of feeling; the patient being either, on the one hand, unusually depressed, 
gloomy, morose, or irritable, or, on the other, unusually elevated and cheer- 
ful. There may be a failure of memory, or confusion of thought, or a state 
of apparent revery, in which the look is fixed and vacant. Headache, drow- 
siness, vertigo, flushing or paleness of the face, and a feeling of fulness or 
emptiness of the head, are not unfrequently experienced. Among the most 
common symptoms are disordered sensations or perceptions, such as dimness 
of sight, or temporary blindness; double, partial, or luminous vision ; optical 
illusions; noises in the ears; the perception of unreal odours and flavours; 
general uneasiness; and feelings of pain, tingling, or formication in the limbs, 
and other parts of the body. Strabismus, an altered state of the pupil, oscil- 
latory movements of the iris, sneezing, sighing, hiccough, and various singu- 
lar movements, as running, leaping, dancing, whirling round, &c., are also 
mentioned among the preliminaries. Sometimes the premonition consists in 
a deficiency or excess of appetite, or the coming on of nausea and vomiting. 
All writers on epilepsy treat of a singular and characteristic phenomenon, called 
aura epileptica, which consists in certain strange sensations, as of a stream of 
cold water or of cold air, or feelings of heat, pain, itching, or tingling, com- 
mencing at some point of the body distant from the brain, in a finger or toe 
for example, or in the leg, arm, uterus, testicle, top of the head, lips, breast, 
Syn.-Falling sickness. 748 
[part II. 
LOCAL DISEASES.-NERVOUS SYSTEM. 
&c., and proceeding towards the brain. When the sensation reaches the head, 
or the epigastrium, if this lie in its route, there is an immediate loss of con- 
sciousness, and the patient remembers no more. This phenomenon, however, 
is comparatively rare. In the great majority of cases, nothing occurs to 
which the name of aura epileptica can be attached. 
Either after a longer or shorter duration of one or more of the above 
mentioned symptoms, or suddenly, without any premonition whatever, the 
patient falls as if struck down by a blow, frequently uttering a shrill pecu- 
liar cry, which is sometimes startling, and almost fearful. At the moment 
of falling he is seized with general convulsions, which are often so pow- 
erful as to require the strength of several persons to restrain them. The 
spasms usually alternate rapidly with relaxation; but some of the muscles, 
especially those of the trunk, are apt to be affected with rigid or tonic con- 
tractions ; and, though the limbs are thrown about with great violence, the 
body does not in general move far from the spot in which it falls. One side 
is frequently more affected than the other. The head is twisted round ; the 
features are drawn to one side as by jerks, and frightfully distorted; the eyes 
are turned up so as to show only the whites, or roll from one side to the other, 
or are fixed with a rigid stare; the eyelids are closed or half-open, or widely 
and spasmodically distended; the jaws often grind together by an oblique 
motion, and the tongue which is thrust out of the mouth is sometimes badly 
wounded; the arms and legs are thrown about with violence, striking against 
neighbouring objects, and not unfrequently both receiving and inflicting in- 
jury; and, while the muscles of the arm generally suffer alternate contraction 
and relaxation, the thumb is often rigidly flexed; and the same is said to be 
sometimes the case with the toes. The pupil may be either contracted, or 
dilated, or neither; but is usually insensible to light and immovable. All the 
senses are for the moment paralysed. Impressions which in health are most 
powerful, the brightest light, the loudest sounds, the most pungent odours, 
the severest wounds, are quite unfelt. The face is usually swollen, flushed, 
and of a purplish or livid hue; and- the veins of the neck also are swollen ; 
though, in some instances, the opposite condition of shrunk and pallid fea- 
tures is observable. Respiration appears to be difficult and imperfect. The 
rigidity or irregular contraction of the muscles prevents the due expansion of 
the chest; the air does not fully enter the lungs, and seems to be stopped in 
some measure at the glottis, which is probably sometimes spasmodically con- 
stricted; and hence in part the dark suffusion of the countenance. The strug- 
gle in the throat causes the air to be intimately mixed with the mucus, which 
appears in the shape of foam at the mouth. The pulse is generally small, 
frequent, and irregular; while the heart palpitates rapidly and often tumul- 
tuously. In some instances, involuntary evacuations from the rectum and 
bladder, and priapism with seminal emissions take place. After an uncertain 
but generally brief duration, the convulsive movements subside, the rigid 
spasm relaxes, the face becomes pallid and shrunken, a profuse perspiration 
often breaks out, and, though the insensibility still continues, the body is 
quiet, and nothing remains of the previous disturbance, except perhaps some 
noise in respiration. At length consciousness gradually returns, though at first 
accompanied with some confusion of thought; and the patient, sitting up or 
rising upon his feet, looks about him with a stunned, astonished, vacant, or 
stupefied air, highly characteristic of the affection. This may soon pass off, and 
the patient return to his ordinary state; but very frequently the fit is followed 
by various unpleasant symptoms, which will be detailed immediately. 
The duration of the paroxysm varies from a few moments to many hours. 
The average is probably somewhere between five and twenty minutes. When CLASS III.] 
EPILEPSY. 
749 
it continues several hours, or, as sometimes happens, for a day or more, there 
is scarcely ever a steady perseverance of the convulsions; but these alternate 
with periods of quiet coma; as if the whole consisted of distinct paroxysms, 
succeeding each other so rapidly that the second stage of one has not fully 
ended, before the first stage of the following one begins. More than fifty 
paroxysms may thus occur, in the course of one or two days. 
The symptoms which immediately follow the paroxysm are various. Some- 
times, as before stated, after a short period of mental confusion, the patient 
returns to his ordinary condition. Very frequently he falls asleep, and after 
a time awakes in the possession of his faculties, and feeling well, except that 
he often has a sense of fatigue or exhaustion, and is sometimes bruised or 
wounded in consequence of his fall, or of the violent movements of the par- 
oxysm. In other instances, he is affected with headache, vertigo, mental 
confusion, and occasionally with nausea and vomiting. Instead of mere 
drowsiness, from which the patient can be roused, there is sometimes stupor 
or coma, lasting for hours or days. Temporary insanity, in some cases, fol- 
lows the paroxysm, varying, in different instances, from the slightest mental 
alienation to the most violent mania. In this latter form, the affection is 
sometimes designated as the epileptic fury. These symptoms generally subside 
in the course of two or three days. It may be mentioned here that, in- 
stead of following the convulsions, the mental affection occasionally precedes 
them; and instances have been noted in which the disease began with an 
attack of maniacal delirium. Sometimes, upon emerging from the paroxysm, 
the patient is found to be slightly paralytic; and instances of chorea have 
occurred under the same circumstances. There is an utter unconsciousness 
of all that passes during the paroxysm. The interval between the first shock 
of the disease and the period of awaking is a complete blank; and the patient 
only knows that be has had a fit by his soiled clothes, his bruises, his feelings 
of fatigue, or other derangements of which frequent experience has taught 
him the significance. 
Death sometimes takes place in the paroxysm, in consequence either of 
apoplectic congestion or effusion, or of apnoea resulting from suspended respi- 
ration. But this event is rare. 
The affection, as above described, is epilepsy in its full developement. Not 
unfrequently the paroxysms are much milder; and instances every now and 
then occur, in which, instead of convulsions and coma, the attack is merely 
vertiginous, being attended with giddiness, mental confusion, and inability to 
stand, but without a complete loss of consciousness. I have known the fit to 
consist of this condition, attended with something like paralytic sensations, 
and loss of power of particular limbs. In cases somewhat more severe, the 
patient becomes suddenly unconscious, has a fixed, open, meaningless eye, 
and slight, partial convulsions as of a hand, an arm, one of the muscles of 
the face, &c. If standing at the time of attack, he may fall; but if sitting 
or lying, the condition may pass over almost without notice; and the patient 
himself, upon recovering, sometimes resumes his discourse where he had left 
off, as if nothing whatever had happened. These spells are usually very 
brief, sometimes lasting less than a minute. They are known to be epileptic, 
because it is not unfrequently in this-way that the disease commences, be- 
cause these slighter paroxysms occasionally alternate with the severe in the 
same case, and because, in different cases, there is every grade between the 
mildest and the most violent. It is no uncommon event for these vertiginous 
spells to continue for several years, gradually increasing in intensity, and at 
length ending in the fully-formed convulsive and comatose paroxysms. 
Epileptic attacks may occur at any period of the twenty-four hours. Not 750 
[PART II. 
LOCAL DISEASES.-NERVOUS SYSTEM. 
infrequently they take place at night, during sleep, and in some persons only 
at night. It is said that they are sometimes confined to this period at the 
commencement of the disease, and again near its close, when it is about to 
terminate favourably. This would seem to indicate that there is something 
promotive of epileptic convulsions in the condition of being in bed at night. 
Is it in the position, which favours the afflux of blood to the brain? This is 
not probable; for it is not till after sleep has begun that the effect is ex- 
perienced. The cause is probably connected with the sleeping state, which 
certainly has a tendency to favour spasmodic muscular movements. Every 
one is familiar with the sudden start which is so apt to arouse us from the 
first sleep. In febrile diseases, too, and in complaints of debility, attended 
with nervous disorder, the muscular twitchings and subsultus are much more 
marked in the sleeping than the waking state. The most plausible explana- 
tion appears to me to be, that, in the repose of the functions of animal life, 
the organic nervous centres acquire increased excitability, and are thrown 
into irregular and violent action by a degree of irritant influence, which they 
do not feel when the animal functions are in full exercise. 
2. The interval between the paroxysms is not less variable than their 
degree of intensity. Sometimes, after the first attack, another does not fol- 
low for months or years, even for several years. In such cases, the succeed- 
ing paroxysms are apt to occur at gradually diminishing intervals. In other 
instances, the paroxysms are very frequent and numerous in the beginning, 
and afterwards become less so, settling down at last into a more or less regu- 
lar recurrence at longer or shorter intervals. The period of recurrence may 
be a year, six months, three months, a month, a week, a day. Several par- 
oxysms may take place upon one day, or within two or more succeeding days; 
and afterwards they may not recur for weeks or months. Some patients 
have one fit upon each recurrence; others have two or more. In general, 
though there may be a tendency to a particular interval, yet the recurrence 
of the fit is liable to great uncertainty. Often there is a total want of regu- 
larity, and not the least calculation can be made as to the period of attack. 
In some few instances, a regular periodicity is observed. This is most apt 
to occur in females, and has some connexion with their menstrual function. 
Occasionally it appears to be connected with the causes of intermittent fever, 
in which case the disease has been regarded as a concealed intermittent. But 
I have no doubt that regular periodical attacks of epileptic convulsions occur, 
without any such obvious cause, in the same way precisely as we have inter- 
mittent headache, and intermittent neuralgia. 
Though epileptic patients may have excellent health in the intervals of 
their attacks, and their organic functions may go on with apparently perfect 
order, yet there is usually something in them different from the condition of 
other persons, some peculiarity which evinces that the cerebral functions are 
more or less deranged. They are often, for example, headstrong, obstinate, 
capricious; determined for the time being in what they will, but changing 
their will continually; with memories frequently feeble or defective, and an 
inability to fix the mind continuously upon any course of laborious thought 
or investigation. Perhaps this character is in part ascribable to the inju- 
dicious indulgence with which such patients are apt to be treated from their 
youth up. 
3. The course of epilepsy is generally one of deterioration. The paroxysms 
are apt to return with greater frequency, and to assume a higher grade of in- 
tensity, if originally very mild. But this is not all. The brain appears to 
be gradually more and more deranged in its functions, in the intervals of 
attack. The memory and intellectual powers in general become enfeebled. CLASS III.] 
EPILEPSY. 
751 
Sometimes positive mania ensues, ending at last in dementia. Sometimes 
the mental disorder has the character of debility from the commencement of 
the process of deterioration. In rare instances, an increased intellectual im- 
pairment may be seen after each paroxysm; much more frequently it is very 
gradual, and the effect is rendered striking only by comparing distant points 
of time. The altered cerebral condition exhibits itself also in various effects 
upon the exterior. There is a striking change in the features. They become 
enlarged, coarse, less intellectual, and more sensual, not to say brutish in 
character. Beauty suffers greatly, in relation both to form and expression. 
The gait is slouching, often somewhat one-sided, partly perhaps from deficient 
power in some of the limbs, but quite as much from the loss of that conscious- 
ness of inherent strength and dignity, which tends to give erectness to the 
person, and firmness and precision to the movements. At last the patient 
sinks into complete imbecility. Not unfrequently he is very troublesome 
from the unequal deterioration of his intellect and animal propensities; the 
latter being often violent, because no longer restrained by the former. Along 
with the progress of imbecility, disorder in the motor functions becomes evi- 
dent, in strabismus, rigid contraction of certain muscles, distortion of the fea- 
tures, a one-sided position of the head, &c. With these changes, the organic 
functions often continue little if at all impaired. Digestion and nutrition are 
vigorous, the generative faculty remains, and the female menstruates regularly, 
and may become pregnant. 
This course may be accomplished in a few months or years; but much more 
frequently occupies a great number of years ; and epileptic patients may grow 
up from infancy to middle age, and even to a somewhat advanced age. The 
progress towards imbecility is said to be more rapid in cases commencing be- 
fore than after puberty. Its rapidity also bears some proportion to the fre- 
quency of the paroxysms. It is probably increased by habits of life and 
other causes which lower the general tone of the system, such as masturbation, 
excessive venery, and the abuse of alcohol and opium. 
Though the general course of epilepsy is thus towards imbecility, it is not 
always so; and individuals occasionally reach a good old age without any ma- 
terial impairment of their mental faculties. 
Anatomical Characters.-Anatomy has revealed nothing that can throw 
light upon the pathology of epilepsy, except to show that it is not connected 
essentially with any peculiar organic derangement of the brain. This organ 
has often been found to all appearance healthy, in epileptic persons who have 
died of other diseases. It has also been found affected with every possible 
variety of lesion, which has in some instances probably stood in the relation 
of cause, sometimes of effect to the epileptic paroxysms, and has sometimes 
had no other than an accidental connexion with them. Lesions have been 
detected also in other vital organs, especially the lungs, heart, and alimentary 
canal. This is only what might have been anticipated. Epileptic patients 
are liable to the same diseases as other individuals, and generally die of some 
other affection than that under which they have been long labouring. Of 
course, the traces of these diseases are discovered after death; but they afford 
no clue to the origin or nature of the convulsive affection. 
When death has resulted from a recent paroxysm, the brain and its me- 
ninges appear greatly congested; the white substance being of a reddish colour, 
and the cineritious substance deep-red, purple, or violaceous. But no lesion 
is exhibited, implying the existence of disease anterior to the congestive move- 
ment, which is probably simultaneous with the paroxysm. 
In old cases, in which death has been preceded by dementia, and perhaps 
something like paralytic symptoms, the marks of chronic inflammation have 752 
LOCAL DISEASES.-NERVOUS SYSTEM. 
[PART II. 
been observed; as partial induration or softening of the gray and white sub- 
stance of the brain, and of the cerebellum, general injection and dilatation of 
the vessels, a dull white appearance of the medullary substance, and a mar- 
bled or rose colour of the cortical, disease of the pineal and pituitary glands, 
adhesions of the membranes to the surface of the brain, thickening of the mem- 
branes, and various effusion into the arachnoid cavity, or into the ventricles. 
These are probably rather results than causes of the epileptic disease. 
Other lesions, however, have been occasionally noticed, to which the epi- 
lepsy might be referred, as thickening of the cranium, projections of its inter- 
nal table consequent upon external violence, caries of the inner table, exos- 
toses pressing on the brain, thickening of the membranes, abscesses, hemor- 
rhages, and different kinds of tumours, especially carcinoma and tubercles. 
Causes.-The causes which predispose to epilepsy are not well understood ; 
though, that a predisposition to it exists in many of those attacked, is quite 
obvious. Inheritance is usually considered among these causes ; and there is 
probably some truth in the general opinion. The time of life has certainly 
some influence over the tendency to the disease. It is more common in early 
than in advanced life. It very seldom originates in old age. More indivi- 
duals are attacked before the period of puberty than after it. The nervous 
system is naturally very excitable in infancy, and easily thrown into disorder 
by disturbing causes. Many cases occur about the age of puberty; and the 
changes which the system undergoes at that period are thought by some to 
predispose to the disease. Whether sex has any influence in forming a pre- 
disposition to epilepsy is uncertain. From the statistics which have been 
given to the world, it might be inferred that females are somewhat more fre- 
quently affected with epilepsy than males; but the reports are not sufficiently 
numerous and precise to determine the point. I am quite certain that, within 
my own circle of observation, there have been more male patients than female. 
Celibacy has by some been supposed to predispose to epilepsy, because a very 
large proportion of those affected with it are unmarried. But this is more 
reasonably ascribable to the fact, that the occurrence of epilepsy very often 
serves as a bar against marriage; and thus patients are unmarried because 
they are epileptic, not epileptic because unmarried. 
The exciting causes are very numerous. Judging from my own observa- 
tion, I should say that a considerable proportion of the cases occurring in early 
life have their origin in an attack of cerebro-meningitis. Injury of the brain 
from external violence not unfrequently induces the disease. This cause 
sometimes apparently operates by a direct lesion of the brain or the conse- 
quent inflammation, sometimes by the depression of a portion of the skull or 
of its inner table. Other tangible causes of the disease are congenital mal- 
formation of the head, and various organic affections of the cranium or ence- 
phalon, such as were mentioned among the anatomical characters. 
Whatever strongly disturbs the cerebral functions may prove an exciting 
cause of epilepsy; and some of these causes appear by their continued ope- 
ration to create a predisposition, which either an excess of the same cause, or 
some other one of a disturbing character may bring into action. Exposure to 
the direct heat of the sun, and excitation from violent bodily exertion have 
sometimes brought on an attack. Among the most fruitful sources of the 
disease is undoubtedly excess of the stronger passions. Terror is thought by 
some to have induced it more frequently than any other cause. The origin 
of the disease can often be traced directly to fright; and the same cause often 
induces paroxysms in individuals subject to the complaint. It has been ob- 
served that congenital cases are apt to have been preceded by some occasion 
of great terror to the mother during pregnancy. The forcing of early intel- CLASS III.] 
753 
EPILEPSY. 
lectual culture is probably a not unfrequent cause of the disease in delicate 
children. It is said that a strong excitement of the imitative principle has 
sometimes resulted in epilepsy; children, and especially girls, having, in many 
instances,, been attacked by the complaint from merely witnessing the con- 
vulsive paroxysms in others. Some have even supposed that persons who 
have often feigned to have epileptic fits, have sometimes ended by becoming 
really subject to them. Masturbation and excessive venery are accused of 
very often inducing epilepsy. The abuse of alcoholic drinks and of opium is 
another fruitful exciting cause. 
The sexual functions appear to have some influence; at least the disease, 
as already stated, is apt to appear at the age of puberty, and in women has 
been observed to occur frequently during the menstrual period. There has 
been reason also occasionally to ascribe it to the irritation of pregnancy. 
Other diseases are frequent causes of this. Attacks of it sometimes follow 
the retrocession of gout and rheumatism, the disappearance of a cutaneous 
eruption, the healing of old ulcers, and the suppression of some habitual dis- 
charge, whether morbid or physiological. It is sometimes associated with, 
and probably dependent upon disease of the kidneys. Various febrile dis- 
eases, especially smallpox, give origin to convulsive attacks which take on 
the form of epilepsy; and, as before stated, the regular periodical form of the 
disease has by some been considered as a masked intermittent fever. The 
complaint is said to have been sometimes induced by syphilis. 
Irritation from disease situated in various parts of the body, is among the 
most frequent provocatives of epilepsy. How could it be otherwise, when 
every part of the body has a centre of communication in the brain, to which 
it imparts all impressions made upon itself, and which must, therefore, par- 
ticipate in all its disturbances? Irritation of the stomach is a notorious excit- 
ing cause of epilepsy. Hence it is, probably, that corrosive poisons, such as 
arsenic, have occasionally induced the disease. Numerous instances have 
been recorded in which it was supposed to originate from worms in the bowels. 
Various functional and organic disorders of the heart, lungs, liver, and urinary 
organs have been accused as causes of epilepsy. The same is the case with 
the uterus, and amenorrhoea is supposed to be a fruitful source of it. The 
occurrence of pregnancy is said to suspend, if not to remove, this variety of 
the disease. Tumours along the course of nerves, or hard bodies, as spicula 
of bone, wounding them, are said to have occasioned epilepsy. There is every 
reason to think that spinal irritation may sometimes excite it. The affection 
has received special names from its supposed origin in these extra-cerebral 
affections; as epilepsia gastrica, enterica, verminosa, hepatica, hysterica, &c.; 
but this is a useless complication of nomenclature. 
Nature.-The disease probably consists in a morbid excitability of the 
brain, and each paroxysm in a morbid excitement or irritation. A prominent 
effect of irritation, when beyond a certain point, is first to derange, and, if 
still further increased, to abolish function. This law is applicable as well to 
the brain as to other organs. The irritation which occasions the paroxysm is 
sufficient to suspend all the cerebral functions connected with the mind; sen- 
sation, perception, consciousness, intellectual action, emotion, volition; but, in 
relation to the motor function, is sufficient only to derange, not to abolish it. 
In this respect epilepsy differs from apoplexy. In the latter affection, not 
only are all the mental functions suspended, but to a great extent that of 
motion also. The difference may be owing to a less degree of the irritant or 
disturbing force in epilepsy, or to its more especial direction to the cortical 
substance, whereby the mental functions, which are probably connected with 
the latter, may suffer most, while the motor function, connected essentially 754 
LOCAL DISEASES.-NERVOUS SYSTEM. 
[part II. 
with the medullary substance, being as it were in the outskirts of the irritant 
influence, feels only enough of it to be excited into a morbid increase of action, 
and not enough to be overwhelmed entirely. It has been supposed that 
the involuntary muscular movements of the epileptic paroxysm must depend 
on irritation in the spinal centres, while the mental phenomena have their 
origin in the brain. But there does not appear to me to be any ground for 
this belief. It is true that the spinal centres are capable of producing invo- 
luntary muscular contractions; but they are not exclusively so. Every volun- 
tary muscle has a centre in the brain, and nervous cords of connexion, through 
which the will operates upon it. It is easy to conceive that the influence of 
the will may be suspended by a morbid or irritant action, which shall equally 
have the power of sending down motor influence from the brain; and this is, 
I think, undoubtedly the case in epilepsy. All the symptoms point to the 
brain as essentially the seat of the disease; and, when the originating point of 
irritation is in the spinal marrow, it is only like any other external source of 
irritation, as in the stomach, bowels, or uterus; it produces its effects second- 
arily through cerebral intervention. 
Now it is clear, if the above views are correct, that organic derangement 
of the brain is not essential to epilepsy. The cerebral anatomy may be per- 
fectly healthy; and yet the functions greatly deranged through irritation 
alone. But organic disease in the brain would be apt to excite the affection, 
if not carried so far as to destroy function altogether. Epilepsy may, there- 
fore, originate in and be sustained by inflammation of the brain, or by any 
other organic alteration, as tumours, osseous spicula or exostosis, depressed, 
bone, thickened membranes, effusion, &c., which shall produce a certain 
amount of irritation in the cortical substance, sufficient to suspend function, 
and a somewhat less amount in the white substance, sufficient only to excite 
and derange function. If the cause operated on the former substance alone, 
we should have coma or delirium; if on the latter alone, we should have 
spasm or paralysis, as in cerebritis. It is clear, too, that an irritation sent to 
the brain from any point of the body whatever, which shall be equally forcible 
as that originating in the brain, and have the same special directions, will 
produce the same effect. The epilepsy, strictly speaking, is the same in both 
cases. It is only the cause of it which differs. The true pathological condi- 
tion is only a morbid excitability of the brain, which enables ordinary causes 
to produce the proper epileptic derangement of its functions, or a morbid ex- 
citement from some powerful cause capable of producing the derangement 
without predisposition. 
There does not, therefore, appear to be any strict basis for the division of 
epilepsy into idiopathic and symptomatic, or, according to the 'nomenclature 
of Dr. Hall, into centric and eccentric. It is the same affection, whether de- 
pendent upon a tumour within the encephalon, worms in the bowels, or a 
mere morbid excitability of the brain, through which it is thrown into de- 
rangement from ordinary causes. Nor is there sufficient ground for this dis- 
tinction in relation to prognosis or therapeutics. It is true that the prognosis 
is more favourable, when the disease can be shown to have its origin in an 
external source; and it is also true that, in such a case, we know where to 
direct our remedies. But the fact is, that we can seldom be certain, perhaps 
never, that the disease does depend upon an external cause, until it ceases upon 
the removal of that cause; and it is always a good rule of treatment to re- 
move any external possible source of the disease that may exist, whether the 
real cause be internal or external; so that nothing is gained practically by a 
mere conjectural reference of the disease to one or the other source. 
This view of the nature of epilepsy enables us, in some measure, to account CLASS III.] 
755 
EPILEPSY. 
for its paroxysmal character. The morbid excitability is not equal. It is 
liable to all the fluctuations of the healthy excitability. Excessive excitement 
diminishes or exhausts it for a time; the parts subsequently become insensi- 
ble to ordinary causes of disturbance; and the actions remain healthy. Such 
an exhaustion is produced by the epileptic paroxysm, which, therefore, leaves 
the brain in its ordinary state until the excitability shall again accumulate. 
A strong cause of irritation may produce a paroxysm at any time, provided 
its strength be more than proportionate to the diminution of excitability. As 
the excitability accumulates, less and less of the cause is required to produce 
the paroxysm, and when it becomes again greatly in excess, the paroxysm will 
occur under the operation of ordinary healthy influences. 
The tumours, the spicula of bone, the thickened membrane, and all the 
other organic alterations within the brain operate in the same way. They act 
upon the portion of brain not organically affected as external sources of irri- 
tation. By their irritating influence they throw the brain into epileptic func- 
tional disorder. This diminishes or exhausts the excitability, so that the 
sound parts of the brain cease for a time to be sensible to the morbid influence. 
When the excitability is recovered, the organic cause is again felt, and again 
we have a paroxysm, and so on indefinitely. It is thus seen that, though the 
source of irritation may be always in existence, it does not follow that it should 
sustain a constant paroxysmal condition. Indeed, the organ could not long 
support such an excess of irritation. 
It has been supposed that, in cases attended with the epileptic aura, the 
source of irritation probably exists in the point from which the sensation 
proceeds. This may be the case in some instances; but experience has shown 
that it is not generally so; nor is the supposition at all nec6ssary; for. though 
the sensorial centre may be the part really deranged, it very often refers the 
sensation to some point in the exterior with which it communicates. This 
is constantly the case in health. It is the brain which feels the pain of a 
wound, but it refers the sensation to the wounded part. 
Habit has undoubtedly great influence in sustaining epilepsy. When the 
brain has once acted in an unusual manner, it much more readily acts in the 
same manner a second time, and at length falls into the new mode of action 
perhaps under ordinary influences, without the aid of the original cause. In- 
dividuals who are with the greatest difficulty put into the mesmeric state, I 
have known at length to be able to throw themselves into that morbid state 
at will. So it is also, in some measure, with epilepsy.. The brain acquires 
a certain habit of acting, which may remain after the original cause has ceased 
entirely. 
It can be easily conceived how an epileptic patient should gradually fall 
into a state of dementia and paralysis. The brain, frequently stimulated to 
excess in the paroxysm, and engorged with blood, gradually takes on a slow 
inflammation, which in the end results in organic change. It is only another 
illustration of the general rule, that repeated irritation tends ultimately to 
inflammation. The healthy excitability of the organ is also impaired by the 
excess of irritation, and a state of debility ensues, because the brain ceases to 
feel duly the ordinary mental influences essential to just thought and proper 
feeling. Hence a gradual approach to imbecility, even independent of in- 
flammation, and organic change. 
It is probable that the organic alterations found in old epileptic patients, 
indicative of chronic inflammation, have generally resulted in the manner above 
explained from the epilepsy itself. But sometimes they are the consequence 
of a continuance of an organic disease of the brain, in which the epilepsy may 
have originated. 756 
LOCAL DISEASES.-NERVOUS SYSTEM. 
[part II. 
Diagnosis.-The only affections with which epilepsy can be confounded are 
apoplexy, certain forms of hysteria, and convulsions arising from some tem- 
porary cause, as meningitis, fever, the puerperal state, dentition, and intestinal 
irritation in children. 
There can be no difficulty in distinguishing an ordinary epileptic fit, in its 
early stage, from apoplexy. The violent convulsions of the former, and the 
comparatively motionless state of the latter are sufficiently diagnostic. But, 
when the epileptic paroxysm has subsided into quiet coma, there may be more 
difficulty. The paleness of the face, however, in this stage, the comparative 
feebleness of the pulse, the foam at the mouth, the general absence of snoring, 
and the want of paralytic symptoms, though not absolutely certain criteria, 
are generally sufficient to enable the physician to draw a just conclusion. 
The comparatively brief duration of the epileptic paroxysm, and the previous 
history of the case, will also enter into the means of judgment. 
The diagnosis between epilepsy and hysteria will be given under the head 
of the latter complaint. 
Occasional convulsions cannot be distinguished with any certainty from the 
epileptic, except by the circumstances which attend them. Thus, if the fit 
occur during the course of a febrile disease in children, from the irritation of 
swollen and painful gums, from obvious intestinal irritation, from acute me- 
ningitis, or from the disturbance of system attending the puerperal state, 
immediately anterior or subsequent to delivery, there may be good reason to 
hope that the tendency to convulsions may pass away with the temporary 
cause; in which case, the affection would hardly be looked upon as epileptic, 
though it might be difficult to decide in what respect the convulsions differed 
in the two cases. In these occasional convulsions, there is very often a more 
sudden recovery of mental activity after the cessation of the convulsive move- 
ments, especially when the exciting cause is without the cranium. There is 
too, perhaps, as a general rule, less foaming at the mouth, and less embar- 
rassment of respiration. Should these convulsive fits be repeatedly experi- 
enced, at somewhat distant intervals, with a return to health in the mean time, 
there would be good reason to regard them as truly epileptic. 
Epilepsy is for various reasons not unfrequently feigned; and it sometimes 
becomes necessary for the physician to decide whether the case is real or a 
counterfeit. If the individual be seen during the paroxysm, there can be 
little difficulty. In real epilepsy there is profound insensibility. In the 
supposititious, the sensibility remains, and may be acted on. Thus, the indi- 
vidual will sneeze if snuff' be blown up his nostrils; will shed tears or make a 
motion of avoidance, if strong solution of ammonia or a burning match be 
held near the nose; will often start upon the occurrence of sudden loud sounds 
near his ear; or will show some sign of consciousness of what is said in his 
hearing, if ingeniously calculated to affect him strongly. Painful impressions 
made upon the surface, or threats of such impressions sometimes exceed his 
fortitude; but the former of these measures should in general be avoided in 
consequence of the subsequent effects on real sufferers. The froth at the lips 
is said to be sometimes imitated by means of soap in the mouth, but I should 
suppose that the imitation would be clumsy. The immobility of the pupil on 
exposure to light, the dark-red or livid turgescence of the face, the irregu- 
larity of the pulse, and the peculiar vacant or astonished look of the patient 
on recovery, are signs which cannot easily be counterfeited. 
In the absence of the paroxysms, the counterfeiter wants the peculiar fea- 
tures of the habitual epileptic; does not usually display the marks of injury 
on his person from bruises, wounding of the tongue, &c.; and, upon inquiry, 
will generally be found to have selected his place for falling, and never to 
have had a fit unless when he supposed himself in the sight of others. CLASS III.] 
757 
EPILEPSY. 
Prognosis.-When not dependent on any permanent organic disease, epi- 
lepsy may often be cured, if taken at the outset; and there is reason to believe 
that the germ of many an epileptic case is destroyed by the proper treatment 
of the occasional convulsions, which so frequently come under the notice of 
the physician. Cures sometimes also take place in cases of considerable dura- 
tion; and there is no reason to despair in any case, unless obviously connected 
with incurable organic disease, or evidences of deteriorated brain. The longer, 
however, the disease continues, the less, as a general rule, is the probability 
of a favourable issue. After six months the chances are much diminished ; 
and cases of a year's duration are often intractable, especially if, during that 
time, they have resisted judicious measures. When the disease appears be- 
fore puberty, some hope may be indulged of a favourable change at that 
period. The cases dependent on some source of irritation exterior to the 
encephalon are more easily cured, as a general rule, than those in which the 
brain is exclusively affected; but there is always difficulty in ascertaining the 
fact of such dependence. 
Congenital cases, or those beginning in early infancy, are generally unfa- 
vourable. So also are those which have supervened upon an attack of hydro- 
cephalus. Inheritance usually gives obstinacy to the disease. The prognosis 
is always unfavourable, when, from long-continued and deep-seated pain in 
the head, or from evidences of a scrofulous or cancerous constitution, there is 
reason to apprehend the existence of tuberculous, carcinomatous, or other 
organic disease within the cranium. Epileptic patients scarcely ever recover, 
in whom a gradual deterioration of the mind, and the occurrence of paralytic 
symptoms, or rigid contractions of the muscles, are observable. 
The disease often undergoes amendment without obvious cause, and the 
patient escapes his paroxysms so long that he begins to hope they may never 
return ; but the favourable promise is very generally illusory. Many reputed 
cases of cure are probably of this kind. According to Herpin, permanent 
spontaneous cures take place in about four per cent, of the cases. (See Brit, 
and For. Medico-Chir. Rev., April, 1853.) 
It is a fact often noticed, that a patient is apt to improve under any new 
medicine or plan of treatment, no matter what it may be. This is an evidence 
of the influence of the mind over the disease; and of how much a cheerful, 
hopeful, and confident temper may do towards ameliorating the condition of 
the patient. In judging of the effects of their remedies, practitioners should 
bear this fact in mind, and guard themselves against a too hasty conclusion 
in favour of certain remedies which they may have prescribed. 
Treatment.-There is no one exclusive course of treatment applicable to 
epilepsy. It is necessary to consult the state of the system, to ascertain every 
irregularity of function or organization which can have any bearing on the dis- 
ease, and to apply our remedies accordingly. The treatment divides itself 
into that which is adapted to the paroxysm, and that required in the interval. 
1. In the paroxysm, little treatment is demanded. The patient should be 
placed upon a bed, with his head somewhat elevated; all tight parts of the 
dress should be loosened, especially about the neck and trunk; the air of the 
chamber should be fresh and pure ; a piece of soft wood should be placed 
between the teeth to prevent injury to the tongue; and the convulsive move- 
ments should be restrained so far as may be necessary to guard the patient 
from injury. In general, the fit will spontaneously subside in a few minutes. 
Depletory measures, or strong impressions of any kind are unnecessary; and 
the former may be injurious, if frequently practised, by deteriorating the 
general health. 
But, should the congestion of brain be so great as to threaten apoplexy, it 758 
LOCAL DISEASES.-NERVOUS SYSTEM. 
[part it. 
would be proper to take blood from the arm, to make cold applications to the 
head, and produce revulsion towards the extremities by rubefacients, or by 
hot water if the movements of the patient will admit of its application. Should 
the paroxysm continue much longer than usual, or protracted coma follow, it 
will also be proper to bleed if the pulse be sufficiently strong; and cups or 
leeches to the temples and back of the neck may be used as adjuvants to the 
lancet, or as substitutes for it in doubtful cases. 
When the pulse is rather feeble than strong, and the convulsions persist, 
enemata of assafetida or oil of turpentine may be administered* In the pro- 
tracted paroxysm, after depletion, or when it is not required, the happiest 
effects sometimes proceed from ipecacuanha given as an emetic. The exter- 
nal application of certain nervous stimulants is also useful in some of these 
cases, especially in children. Garlic and brandy, or oil of amber mixed with 
olive oil, may be applied occasionally along the spine. The warm-bath is 
beneficial in infantile cases. 
Should danger from apnoea be apparent, ammoniacal liquids should be 
placed near the nostrils, sinapisms or hot water should be applied to the ex- 
tremities, and, in cases of suspended breathing, the electro-magnetic current 
may be directed through the diaphragm, and recourse may even be had to 
artificial respiration. 
After the paroxysm has subsided, the patient should be kept quiet; and, 
if comatose symptoms continue, thjeatening serious mischief to the brain 
from persistent congestion, blood should be abstracted, generally or locally, 
according to the violence of the symptoms and the strength of the patient. 
Saline cathartics, and the warm bath may also be useful in guarding against 
subsequent mischief. 
It is necessary, throughout the paroxysm and its sequelae, to guard the 
patient from injuring himself or others. Sometimes, when maniacal violence 
is exhibited, it may be necessary to resort for a time to the strait-jacket. In- 
dividuals subject to epilepsy should not walk alone in the vicinity of water, 
even though shallow; for instances of death sometimes occur from falling 
with the face under water, even in a small puddle. Neither should they ride 
on horseback, or in an open carriage from which they may possibly fall, nor 
should they frequent precipitous places. It is recommended that epileptic 
patients, who are apt to be attacked during their sleep, should lodge in beds 
with a ledge around them, so as to prevent their falling out. But a better 
plan is to sleep on beds so low, that falling out would do them no injury. 
2. In the treatment of the interval, there are two prominent indications, 
namely, first, to remove all appreciable or possible sources of irritation to the 
brain, and secondly, to render that organ less sensitive to morbid impressions, 
or better able to resist them. 
To meet the first indication, it is necessary to study well the state of the 
system, and, whenever any deviation from the healthy condition can be found, 
to remedy it if possible. If the blood-vessels are too full, and the blood too 
rich, it will be proper to administer occasional doses of the saline cathartics, 
to confine the patient to a diet exclusively vegetable, or of vegetables and milk, 
and to recommend moderate exercise so as to cause the blood to be duly ex- 
pended by the various functions. This treatment may be confined to periods 
of temporary excitement, or may be continued for a long time when the tend- 
ency is strong and constant. In some instances of inordinate excitement, it 
may be proper to take blood; but this is seldom necessary. 
Should the patient, on the contrary, be anemic, the indication is scarcely 
less strong to correct this abnormal condition of the blood. When this fluid is 
deficient in nutritious qualities, all parts of the body.suffer; and from all parts CLASS III.] 
EPILEPSY. 
759 
there go up to the brain intimations of this suffering, in order that, through 
the processes of circulation, respiration, digestion, &c., the deficiency may be 
supplied. The brain is the centre of communication between the suffering 
tissues and the organs, by the agency of which the suffering is to be relieved. 
The brain is, therefore, excited powerfully, and a state of great irritation is 
produced, which, though it may not exhibit itself in inflammation, is capable 
of inducing functional disorders, and among the rest convulsions. Anaemia, 
therefore, attending epilepsy, should be corrected; and excessive bleeding, even 
in plethoric cases, should be avoided for fear of inducing this condition. The 
chalybeates, simple bitters, sulphate of quinia, a nutritious diet, the cold bath 
if followed by reaction, sea-bathing, and passive exercise, are the remedies 
here indicated. 
Besides the general state of health, particular sources of irritation should 
be attended to. In infants, the gums should be lanced, if swollen and painful, 
and other measures adopted to relieve the local inflammation. (See Morbid 
Dentition, i. 510.) Acidity of stomach, and other sources of gastric irritation 
should be corrected, and enfeebled digestion treated as directed fox dyspepsia. 
(See Irritation of Stomach, i. 55'2.) Verminose affections should be met with 
the ordinary anthelmintics. Cases of epilepsy, dependent on tape-worm in 
the bowels, have been permanently cured by large doses of oil of turpentine. 
Constipation, deficient or deranged hepatic action, and any existing nephritic 
disorder, should be corrected by appropriate remedies. A cure of epilepsy 
connected with splenitis has been effected by the continued use of aloetic purges. 
When epilepsy is associated with organic diseases of the heart, little good can 
be expected from medicines; yet some relief may be obtained by pursuing the 
course recommended in these affections. Any existing disease of the kidneys 
should be corrected. Amenorrhoea should receive especial attention, as also 
should other uterine disorders; but this is not the place to detail the neces- 
sary remedies. Dr. Pritchard placed great reliance upon oil of turpentine in 
cases of epilepsy connected with uterine derangement; attention being paid of 
course to the general state of the system. Spinal disease must be treated by 
local depletion and counter-irritation. 
Should a tumour exist in the course of a nerve, or a spiculum of bone serve 
as a point of nervous irritation, the offending cause should be removed, if pos- 
sible, by a surgical operation. Cures are recorded, which have been effected 
in this way. When the epileptic aura exists, it may be well to make pressure 
upon the limb, above the point at which the peculiar sensation commences, by 
means of a ligature or tourniquet. It is said that the paroxysm may often be 
suspended by such a proceeding. Amputation has even been resorted to; and 
a cure of epilepsy is said to have been effected by Tissot, by cutting off the 
great toe in which the sensation of the aura commenced. In a case reported 
by Frank, in which the aura began in the testicle, a permanent cure is asserted 
to have followed castration. A division of the radial nerves is stated by Por- 
tal to have effected a cure, in a case in which the paroxysm began with violent 
pain in the index finger. But success, in cases of this kind, has scarcely been 
sufficient to justify a resort to such extreme measures as amputation or castra- 
tion under ordinary circumstances. Many cures are reported as having been 
effected by the operation of trephining, whereby depressed or diseased portions 
of the skull have been elevated, or spicula of bone penetrating the brain have 
been removed. Instances of this kind have occurred in our own country, to 
Dr. Dudley, of Lexington, Dr. Rogers, of New York, and Dr. Guild, of Ala- 
bama. (See Am. Journ. of Med. Sci., ii. 489, and iv. 97.) Such an opera- 
tion might be justifiable in severe cases of the disease, in which a fixed pain 
in one part of the skull, with tumefaction, might indicate disease of the bone, 760 
LOCAL DISEASES.-NERVOUS SYSTEM. 
[part II. 
or in cases following a blow or fall upon the head, and probably dependent on 
depressed bone. But that it should be resorted to, in ordinary cases of epi- 
lepsy, upon the principle of relieving the brain from pressure, or with the vague 
hope of discovering and removing the offending cause, is hardly consistent with 
sound therapeutical principles. Should the disease be associated with syphi- 
litic affection of the skull or pericranium, a course of mercury or of iodide of 
potassium should be resorted to. Cures of epilepsy have sometimes followed 
a cure of syphilis by means of mercury. 
In order completely to fulfil the first indication, it is necessary to correct 
those habits, or counteract those exterior influences, which may have caused, 
or may sustain the disease. All sensual excesses, including the habit of mas- 
turbation, must be abandoned; and to aid the patient in overcoming his vicious 
propensities, dulcamara or other reputed antaphrodisiac medicine may be em- 
ployed. Regular and moderate occupation, not calculated to overtask the men- 
tal or bodily powers, is among the most efficient measures for accomplishing 
this purpose. Excessive and premature mental exertion is highly injurious. 
All excess of the passions, of whatever kind, should be avoided. It need 
scarcely be said that abandonment of intemperate drinking is absolutely essen- 
tial. In those cases in which the paroxysm is apt to occur in the night, the 
patient should avoid suppers, and should lie with his head elevated. 
Under this head may also be ranked the use of revulsive measures, calcu- 
lated to call off irritation from the brain, and to fix it in some safe external 
position. When the disease has followed the cure of a cutaneous eruption or 
an old ulcer, or the retrocession of a gouty or rheumatic disease, the measures 
alluded to are especially important; and, under these circumstances, they should 
be applied to the original seat of the affection. In other cases, they may be 
applied to the nape of the neck, behind the ears, or between the shoulders. 
Repeated blistering, pustulation by tartar-emetic or croton oil, issues, setons, 
and cauterisation by moxa, are the means referred to. Several cases have been 
related of the efficacy of tartar-emetic ointment, rubbed upon the scalp so as 
to induce free suppuration. (See Ranking's Abstract, vii. 174.) In cases at- 
tended with evidences of chronic inflammation of the brain and its membranes, 
it may not be amiss to make an incision, as has been recommended, on the 
top of the scalp, along the sagittal suture, and keep it open by means of issue 
peas. A remedy, however, so harsh and disagreeable should not be thought- 
lessly resorted to. It may be proper, also, in some comatose cases, to blister 
the whole scalp, once or oftener. 
The second indication of treatment,'during the interval, is to diminish the 
excitability of the brain, so as to render it less sensible to irritant impressions, 
or better able to resist them. The remedies calculated to meet this indication 
are the narcotics, which diminish tlYe sensibility of the brain; and the tonic's 
and nervous stimulants which strengthen the nervous system, and tend to 
equalize its excitements. These remedies may often be advantageously con- 
joined. Of course, before they are resorted to, the system should, in compli- 
ance with the first indication, be freed as far as possible from any incom- 
patible state of disease that may exist. 
Of the tonics, those derived from the mineral kingdom are usually preferred. 
Nitrate of silver holds, perhaps, the highest rank among them. Many cures 
by that medicine have been reported, and its occasional efficiency in purely func- 
tional cases of the disease can scarcely be doubted. It should be given at first 
in doses of one-quarter or one-third of a grain, three times a day, to be gradually 
increased to one or two grains. The dose has sometimes been enormously 
increased, and even a scruple has been given daily. But this is an abuse of 
the remedy, and may lead to serious evil. The mucous membrane of the CLASS III.] 
761 
EPILEPSY. 
stomach may be corroded, and a permanent dark stain fixed upon the skin. 
Esquirol mentions the case of a woman who had taken the nitrate for eigh- 
teen months, and whose stomach, upon her death at the expiration of that 
period, was found destitute of the mucous membrane over one-half of its inner 
surface, and in several points corroded to the peritoneal coat. Of the disco- 
loration numerous instances are on record. I have not seen these effects in 
my own practice, though much in the habit of employing the salt; but I 
never exceed the quantity of a grain three or four times a day, and never 
continue the remedy longer than two or three months, without an intermis- 
sion of as many weeks. The chloride, iodide, or oxide of silver might be 
substituted for the nitrate, and probably with equal effect, while there would 
be less danger of irritating the stomach. I should expect from them, how- 
ever, the same effect upon the skin, if used very largely. For the dose of 
these medicines, the reader is referred to the dispensatories. 
Next, probably, in efficacy to the nitrate of silver, are the salts of copper. 
Either the sulphate of copper or ammoniated copper may be used. I have 
seen apparent benefit in epilepsy from a mixture of the latter of these pre-v 
parations with assafetida. They should be employed in doses insufficient 
to irritate the stomach, and continued steadily for months. Both with these 
preparations and with nitrate of silver, a little opium may in general be use- 
fully associated. 
The preparations of zinc have also been used with asserted benefit. The 
sulphate and oxide are those usually employed. The oxide to be efficient 
must be given in large doses. From five grains at first, the dose may be 
increased to ten or fifteen grains three times a day, if found not to offend the 
stomach. Valerianate of zinc has also recently come into notice, and is said 
to have been used advantageously in the dose of a grain or two several times 
a day, increased as the stomach will bear it. 
The preparations of iron may be employed with the same view. Acetate 
of lead is said to have effected permanent cures in some cases; and its influ- 
ence in directly depressing nervous action, when freely taken, would render 
this result probable; but it should be used with caution. 
Of the vegetable tonics, a large number have been employed, but none 
probably with much other effect than to improve the digestion, except Peru- 
vian bark or sulphate of quinia, which might be expected to produce favour- 
able effects in functional epilepsy, from its influence upon the brain. It is 
especially adapted to cases which assume a regular periodical form. 
Of the antispasmodics, or nervous stimulants, valerian has probably enjoyed 
most credit. Assafetida, musk, and camphor, have been much used; and 
formerly some reliance was placed on Dippel's animal oil, which, however, 
has gone out of use. I have seen a monthly recurring case, in a young 
female, yield apparently to cimicifuga or black snakeroot. 
Among the narcotics, stramonium and belladonna are probably the most 
efficacious. When the system is free from plethora, opium might sometimes 
prove useful; but it must be employed with caution. 
In the condition of great cerebral irritation, approaching or amounting to 
insanity, which sometimes follows an epileptic paroxysm, and may even occur 
without any immediately preceding convulsive attack, I have obtained the 
happiest effects from a mixture of chloroform and camphor, made into an 
emulsion with water by means of the yolk of an egg. From forty to sixty 
drops of the chloroform and five grains of the camphor, in a tablespoonful of 
the mixture, may be given every hour or two till relief is obtained, or it 
shall be found inapplicable to the particular case. I have seen it produce 
perfect calmness almost instantaneously. 762 
[PART II. 
LOCAL DISEASES.-NERVOUS SYSTEM. 
A great number of remedies have been given empirically in epilepsy, and 
acquired a temporary reputation, to be lost, revived, and lost again, in the 
fluctuation of medical experience. There can be no doubt that many wholly 
inert substances have attained some credit, partly from having been given on 
one of those occasions when the disease was about to undergo spontaneously 
a temporary amelioration, and still more, it is probable, from the influence 
of novelty, hope, &c., on the mind of the patient, and through this on the 
condition of his brain. 
zYmong the remedies recently introduced, indigo has attracted consider- 
able attention. It is asserted to have been effectual in many cases. A scru- 
ple may be given at first, and gradually increased to one or even two drachms, 
three times a day; and the medicine must be continued for two or three 
months. It is usually associated with some aromatic powder, and if it purge 
should be combined with a little Dover's powder. Artemisia vulgaris or 
mugwort, an old remedy in this complaint, has within a few years been re- 
vived in Germany. A species of Scutellaria, given freely in the form of 
decoction, has been successfully used by Dr. R. W. Evans, of West Canada. 
(See Am. Journ. of Med. Sci., N. S., xvii. 495.) Dr. Thos. Salter, of Poole, 
and Dr. Joseph Bullar, of Southampton, England, claim extraordinary powers 
for the inspissated juice of the cotyledon umbilicus {Ibid., xviii. 214); and the 
late Dr. Graves, of Dublin, related several cases in which it appeared to effect 
cures, or to afford relief. {Dub. Quart. Journ. of Med. Sci., xiv. 257.) M. 
Michea found valerianate of atropia successful in six cases of the recent dis- 
ease, originating in moral causes. {Va. Med. and S. Journ., ii. 285, from 
Gaz. Med. de Paris.') Cures are said to have been effected by the selinum 
palustre of Europe. {Herpin.) Oil of turpentine and oil of cajeput, have been 
recommended. The mistletoe, peony root, and orange leaves, are old remedies. 
Various aromatic, stimulant, and antispasmodic mixtures have met with par- 
tial and temporary success. Of this nature is the mixture of equal parts of 
powdered sage, ginger, and mustard, of which a teaspoonful given three times 
a day is said to have effected some cures. Cantharides, phosphorus, and gal- 
vanism or electricity, have had their advocates. Strychnia may be employed 
with some hope of advantage in paralytic cases. Emetics, repeated every 
three or four days, have had the effect of postponing the paroxysms, and are 
reputed to have cured the disease in some instances. Mercury will no doubt 
occasionally prove serviceable, by correcting some of the organic affections 
without or within the cranium, which may have produced, or may aggravate 
the disease. 
Dr. Marshall Hall has proposed the operation of tracheotomy, on the ground 
that spasmodic closure of the glottis in epilepsy is a necessary element in the 
convulsion; but the operation has not been attended with such success as to 
justify its employment, unless in extraordinary cases, in order to prevent 
asphyxia. Another surgical measure which has been proposed, and occasion- 
ally tried, is to tie one or both of the carotids; and still another, to secure 
the arteries which supply the soft parts without the cranium, the temporal 
for example, with the view of diminishing intra cranial congestion by cutting 
off the supply of blood through the bone. But neither operation has been 
followed by very satisfactory results. 
The patient may sometimes succeed in keeping off a paroxysm when he has 
warning of its approach, by smelling of ammoniacal substances, or one of the 
nervous stimulants, as musk or assafetida. Dr. Eberle knew an epileptic in- 
dividual, who used to produce this effect by drinking freely of cold water in 
anticipation of the fit. Anything that will make a strong impression on the 
nervous system, whether directly, or through the mind, will often have the CLASS III.] 
763 
CHOREA. 
same effect. Allusion has already been made to the plan of arresting the 
paroxysm, in cases attended with the epileptic aura, by a ligature or tourni- 
quet round the limb. 
Article rill. 
CHOREA. 
Syn.-St Vitus's Dance.-Chorea Sancti Viti.-Danse de Saint Guy. (French.) 
Chorea (from %opua, a dance) is characterized by involuntary muscular con- 
tractions, without loss of consciousness, and withouta complete loss of the 
power of the will. The contractions are somewhat peculiar, being neither 
rigid and persistent like those of tetanus, nor so quick and jerking as those 
of ordinary convulsions, but rather resembling the voluntary movements, for 
which they may be easily mistaken. The name St. Vitus's dance is said 
to have arisen from the custom, formerly prevalent, for those affected with the 
disease to make a pilgrimage to the shrine of St Vitus, called by the French 
St. Guy, near Ulm, where they were miraculously healed. 
Symptoms, Course, &c.-Chorea in general comes on gradually, and is often 
preceded by symptoms of gastro-enteric derangement, such as irregular appe- 
tite, constipation, swollen abdomen, &c., which are sometimes also accompanied 
with depression of spirits, or other signs of nervous disorder. The first un- 
usual movements are often noticed more especially in some one part of the 
body, as the face, the shoulders, or the hands; the patient making ludicrous 
grimaces, or shrugging the shoulders, or incessantly working with the fingers, 
and perhaps incurring blame for behaving rudely, or acting absurdly, as if the 
motions were voluntary. But they are soon found to be beyond the control 
of the will. The irregular muscular action increases, and at length the whole 
body becomes more or less involved. Head, trunk, and extremities are in 
almost constant movement. The features undergo various whimsical distoN 
tions, as if the patient were making faces for the amusement of the spectators. 
The head is moved grotesquely upon the neck; the limbs execute diversified, 
meaningless little gesticulations; and the muscles of the trunk pull it how one 
way and now another, making the patient appear exceedingly fidgety, without 
greatly altering his position. If any voluntary motion is attempted, there is 
a curious and often ludicrous mixture of the regular and irregular actions 
of the muscles, which seem to be influenced by two opposite forces; but, unless 
the disease be very violent, or the object aimed at require some nicety or 
steadiness of movement, the will is generally in the end successful. Thus, 
patients cannot use the hand in writing, sewing, &c., but they can ordinarily 
convey objects to their mouth, or move from one place to another, though, in 
accomplishing the former object, the arm is jerked about in various opposite 
directions, before it reaches the point aimed at^and, in attempting the latter, 
the body often goes through numerous zig-zag operations, advances with a 
sort of hitching gait, and the appearance as if one foot were dragged after 
the other, and not unfrequently falls. 
The interior muscles of the mouth and of the fauces may participate in the 
morbid action; the tongue is rolled out occasionally between the lips; the 
patient stammers or hesitates in speaking; and even deglutition is sometimes 
performed with difficulty. 
In very bad cases, the patient loses the power of maintaining a standing 
or even sitting posture, and is compelled to lie in bed. One side is some- 
times observed to be much more affected than the other. It seldom happens 764 
LOCAL DISEASES.-NERVOUS SYSTEM. 
[part II. 
that the muscles are entirely quiescent except during sleep, when the motions 
usually cease entirely, or are very much diminished. In some instances, how- 
ever, they are so incessant as to interfere with sleeping. The disease is subject 
to exacerbations and remissions; and sometimes assumes a paroxysmal, and 
even an irregularly periodical or intermittent character. Indeed, cases have 
been noticed in which there was considerable regularity in the return of the 
paroxysms, with entire exemption in the interval. 
The irregular motions are often greatly increased by any. emotion; and it 
has been noticed that the patient is generally worse when conscious that others 
are observing him. It appears that, if the will cannot accurately regulate the 
movements of the muscles, it has the power of calling them into abnormal 
action; for the spasmodic contractions are much more frequent when the patient 
endeavours to execute any movement with peculiar precision, than when the 
will is quiescent. By the exertion of a strong determination, the patient can 
also often control the muscles in some degree, so as to keep them quiet for a 
time, though, if he allows or encourages them to move, it is impossible to pre- 
vent them from moving in their own way. 
Chorea is sometimes attended with headache. The bowels are generally 
constipated, and the discharges often unhealthy. The appetite is in some 
instances natural, in others morbidly craving, deficient, or capricious. There 
is no fever. It is a singular fact, noticed by writers, that there is much less 
sense of fatigue in consequence of the incessant muscular action, than would 
result from an equal amount of it under the direction of the will. The tem- 
per is not unfrequently affected. It is more capricious, excitable, or appre- 
hensive than in health. The patient often weeps without apparent cause, or 
is gloomy, or apathetic, in short evinces various nervous disorder not unlike 
that attendant upon hysteria, which is, indeed, not unfrequently associated 
with this disease, when it attacks females about or beyond the age of puberty. 
The mental disturbance sometimes amounts to delirium. Neuralgic affections, 
moreover, are not uncommon in patients who have been labouring under cho- 
rea; and some authors have noticed a connexion between the latter complaint 
and rheumatism of the muscles, pericardium, and spine. 
The course of chorea is not uniform. Under proper treatment, it may 
continue only a few days, or it may run on for months or years. There is 
reason to believe that it will generally, sooner or later, cease spontaneously. 
When long continued, it is thought to weaken the mental powers; and it is 
accused of inducing imbecility, epilepsy, paralysis, &c. The probability is, 
that these affections, when they occur, are merely effects of a common cause 
with chorea, and not the results of that disease. A partial palsy of the 
limbs sometimes follows a convulsive paroxysm. 
Instead of affecting the whole* body, chorea is sometimes confined to a sin- 
gle part, as to the face, a leg, or an arm; and the patient, though well in all 
other respects, is unable to prevent himself from making the most uncouth, 
whimsical, or ludicrous movements of this part, which subject him occasion- 
ally to inconvenience and mortification. I know an instance of this kind, in 
which a gentleman gives now and then offence to strangers by making faces, 
as if mocking or laughing at them, when in fact perfectly serious and well- 
disposed. This partial chorea is more difficult of cure than the general, and 
not unfrequently continues during life. It is probably, in many instances, 
rather the result of early habit confirmed by time, than a real disease. 
Dr. Addison has called the attention of the profession to the frequent ex- 
istence of a bellows murmur of the heart in chorea. It accompanies the first 
sound, and though sometimes aortic is more frequently mitral. It is proba- 
bly dependent in general upon anaemia, which, if the views of the heart's CLASS III.] 
CHOREA. 
765 
actions given at page 1'22 of this volume are correct, may readily produce the 
mitral as well as the aortic murmur with the first sound. Dr. H. Bence 
Jones has found the urine deficient in the phosphates, but with great excess 
of the sulphates and urea, ascribable to the excessive muscular action. {Land. 
Med. Gaz., July, 1851, p. 81.) 
Another morbid state is frequently ranked with chorea, though, as appears 
to me, improperly. The affection alluded to consists in an irresistible pro- 
pensity to make and repeat incessantly, and without reason, certain strange 
motions, such as dancing in a whimsical manner at the sound of a musical 
instrument, jumping, whirling the body rapidly round upon the heel as a 
pivot, rotating the head backward and forward, beating the hand incessantly 
upon the knee, and a thousand other extravagances, such only as a diseased 
imagination could suggest. In these cases, the movements are voluntary, 
and therefore quite different from those of chorea. They are the result of a 
species of insanity, controlling the will, or possibly sometimes a mere derange- 
ment of the will, without involving the general emotional or intellectual 
functions, a kind of monomania, of the motor faculty of the brain.* 
Anatomical Characters.-The evidences which anatomy affords of the na- 
ture of chorea are entirely negative. In uncomplicated cases, in which death 
has occurred either from the disease, or from some accidental cause, the brain 
and spinal marrow have, in many instances, after a most careful scrutiny by 
the most skilful pathological anatomists, been pronounced quite healthy. It 
is true that others have observed various lesions, such as serous effusions into 
the meningeal cavity of the spinal marrow, injection of the spinal marrow 
itself, injection, softening, &c., of the brain and its membranes, serum in the 
ventricles, and tumours and calculous concretions in the encephalon. But 
these were obvious complications, the results of diseases altogether independent 
of the chorea in their origin. 
Causes.-An unsteady, excitable state of the nervous system constitutes a 
predisposition to chorea. Such a state is apt to attend a feeble condition of 
the general health; and hence the disease has been frequently observed in 
* An affection has recently been described, with the designation of electrical chorea, 
by an Italian physician named Dubini, which, however, appears to me to have a closer 
relation to epilepsy than to the disease under consideration. It consists in rapid and 
almost constant movements of certain muscles, resembling those produced by electrical 
shocks, with violent convulsive paroxysms in the same muscles, recurring twice or 
oftener in the day, attended by a rapid pulse, and followed by profuse sweating, and a 
more or less complete temporary paralysis of the part affected. At first the disease is 
confined to a limited space, as to a finger, an extremity, or one side of the face; but 
gradually it extends to the whole of one side of the body. The same identical muscles 
are always the seat of the convulsive movements, which are generally also limited to 
one side of the body, and that the right side. As the disease advances, the convulsions 
become more incessant, and sometimes invade the other half of the body. The least 
touch will occasionally bring on the most violent clonic spasms of the whole of the side 
affected. Articulation is difficult during the paroxysms. Towards the close of the dis- 
ease, the convulsions give way to coma, and the patient at length dies with apoplectic 
symptoms. Sometimes pain in the head or spine precedes the attack. The intellect 
does not appear to be disordered until the Supervention of the comatose phenomena. 
The appetite is at first good, but ultimately fails. Most of the patients void worms. 
The duration of the complaint is from one to five months or more. It is almost always 
fatal. Dissection has failed to reveal its nature. Venous congestion of the cerebral 
and spinal meninges is the only uniform abnormal condition observed. The persons 
attacked are usually between the ages of seven and twenty-one. In the majority of 
cases the disease could be traced to fright, but in some no cause could be discovered. 
Various treatment has been tried, but none for which decided efficiency could be 
claimed. The best palliative appeared to be extract of hyoscyamus. (Med.-Chirurg. 
Rev., October, 1846; from Annal. Universal, vol. 117.)-Note to the second edition. 766 
LOCAL DISEASES.-NERVOUS SYSTEM. 
[PART II. 
individuals with disordered digestion, and defective nutrition; but this is by 
no means universally the case, and, in many instances, it has come on in 
persons previously healthy and robust. A predisposition to chorea is said 
to be often inherited. 
Age has great influence over the occurrence of the disease^ It very seldom 
attacks either young infants or old persons; and is beyond all comparison most 
frequent between the ages of six or seven and fifteen, that is between the second 
dentition and the period of puberty. Since my connexion with the Pennsyl- 
vania Hospital, I recollect only three instances in which the disease has ex- 
isted in adults. Two of these were females between twenty and thirty years 
old, in whom the complaint was complicated with hysterical or epileptic con- 
vulsions, and the other a man of about forty-five or fifty, in whom it had long 
existed. Nevertheless, no time of life is absolutely exempt; and cases now 
and then occur both in infancy and old age. It would appear that the modi- 
fications produced in the nervous system by the irritation of the second denti- 
tion, and the changes connected with the developement of the sexual func- 
tions, are favourable to the attacks of chorea. 
Sex also has a powerful influence. Females are much more liable to the 
disease than males. From a comparison of numerous statistical reports on this 
point, it results that the proportion of females is between two-thirds and three- 
quarters of the whole number. 
M. Rufz has inferred from his inquiries that the disease is little known in 
hot climates, and consequently that the rigorous or changeable weather of 
northern latitudes predisposes to it; yet it is said to occur more frequently 
in the hot than the cold seasons of the year. 
Whatever tends to debilitate the system generally, and to impoverish the 
blood, may be considered, in connexion with age and sex, as predisposing to 
chorea, through the frequent disturbance which such a state of system occa- 
sions in the nervous centres. 
The exciting causes are strong and disturbing emotions, especially terror; 
excessive excitement of all kinds, whether mental or bodily, and the conse- 
quent over-exertion of the faculties ; various extra cranial irritations, as those 
of dentition, decayed teeth, disordered stomach and bowels, hepatic derange- 
ment, worms, uterine disease, spinal tenderness, &c.; suppression of the men- 
ses, repelled cutaneous eruptions, and translated rheumatism; depraved habits 
of life, and especially masturbation ; and, finally, various organic affections of 
the brain or spinal marrow, which sometimes combine the symptoms of chorea 
with others more characteristic, as epilepsy, fatuity, and paralysis. It is said 
that, if a female happen to be affected with chorea at the approach of puberty, 
she is almost always relieved of it upon the establishment of the menstrual 
function, proving the great influence which disorders of that function may ex- 
ercise in the production of the disease. 
Nature.-Of the nature of chorea we know little or nothing more than that 
it is afunctional disease of the brain. That it is not organic is proved by the 
absence of the ordinary symptoms of such disease, and by the evidence of dis- 
section. Some believe that it is essentially an affection of the spinal marrow; 
and that the involuntary movements are owing to the reflex action of the 
nervous centres in that structure. But the following considerations are op- 
posed to this view. The motions are unlike those believed to proceed directly 
from spinal irritation, as the spasms of tetanus, and those induced by nux 
vomica, and much more closely resemble the voluntary motions, which are 
all of cerebral origin. The irregular movements of chorea can in some mea- 
sure be restrained by the will, which would hardly be the case were they 
spinal. They cease generally during sleep, in this respect differing from the CLASS in.] 
CHOREA. 
767 
movements springing directly from the spinal marrow, which does not sleep. 
The headache which not unfrequently accompanies the complaint is further 
evidence of its cerebral locality. It is probably a perversion of that function 
of the brain through which the will acts ; rendering it partially subservient to 
other powers than the legitimate one. An intimate association between chorea 
and pericarditis or endocarditis has been noticed by some writers; and the 
complaint has been ascribed to a rheumatic constitution of the blood. It is 
very possible that rheumatic irritation affecting the cerebral centres may oc- 
casionally be an exciting cause; and acute rheumatism has undoubtedly been 
sometimes associated with chorea. The frequent existence, moreover, of 
cardiac murmurs has tended to give plausibility to the theory. But, though 
chorea frequently comes under my notice in hospital practice, I have never 
happened to meet with it connected with rheumatism, or with positive evidence 
of cardiac inflammation. The murmurs I believe to be generally dependent 
either on the anemic state of the blood, which is a frequent attendant, or on 
irregular contraction of the columnae carneae under disordered nervous in- 
fluence. 
Diagnosis.-This is seldom difficult. The absence of fever, coma, delirium, 
and rigid spasm, together with the whimsical and often ludicrous character of 
the movements, and the partial control of the will, are sufficient to distinguish 
chorea from all other diseases of the brain or spinal marrow. There are, 
however, cases in which this disease is in various degrees complicated with 
epilepsy, hysteria, and palsy; and it is not always easy to determine how much 
belongs to the one affection, and how much to the other. 
Prognosis.-Pure chorea is very rarely fatal. Nevertheless, instances have 
occurred in which the system has been worn out by its violent and incessant 
agitations, or in which some vital function has been interrupted sufficiently long 
to occasion death. In complicated cases, it is not the chorea, but the accom- 
panying affection that is dangerous. The probability is, that this disease 
would, in most instances, sooner or later end favourably without the interfer- 
ence of medicine. By proper treatment, timely employed, its course is un- 
doubtedly much shortened, its inconveniences greatly diminished, and what 
little danger may belong to it generally obviated. Its duration, under treat- 
ment, varies from a few days to several months; but on the average may be 
stated at from two to six weeks. A few cases will not yield to remedies, and 
run on for years, or indefinitely; and this is more especially apt to happen 
with those in which the long continuance of the disease has added the force 
of habit to the other causes. In the course of my practice I have met with 
only one instance of pure chorea which resisted treatment. This was the case 
already alluded to, of a man of middle age who entered the Pennsylvania 
Hospital with the disease already inveterate, and who left the institution, after 
a residence of several months, uncured. What a longer continuance of treat- 
ment might have effected cannot be determined. It is said that the local 
affections, before described as being usually classed with chorea, are much 
more obstinate than the general, and are often quite incurable. Relapses in 
this disease are not uncommon. 
Treatment.-The indications are first, to remove all obvious disease which 
may exist independently of the involuntary movements, and secondly, to give 
vigour to the nervous system, and equalize its actions. 
1. Constipation should be promptly corrected by cathartics. It is highly 
probable that purgation is useful, not only by removing a source of irritation 
from the bowels, but also by acting revulsively from the brain, and by deple- 
tion in plethoric cases. Repeated daily, or every second or third day, as the 
strength will permit, cathartics will often of themselves cure the complaint in 768 
LOCAL DISEASES.-NERVOUS SYSTEM. 
[part II. 
the course of a few weeks. Some discrimination should be exercised in the 
choice of the medicine. Should the system be plethoric, sulphate of magnesia, 
or one of the saline cathartics, senna and salts, or jalap and bitartrate of potassa, 
would best answer the purpose. Acid in the stomach would indicate magne- 
sia ; debility of digestion with dyspeptic symptoms, rhubarb; amenorrhoea, 
aloes or black hellebore; deficient or disordered hepatic action, calomel or 
the blue mass. The co-existence of several indications should lead to accord- 
ant medicinal combinations. Care should always be taken not materially to 
debilitate the patient, or irritate the stomach. 
In cases attended with headache, advantage will often accrue from local 
bleeding, which would be especially called for by the existence of a flushed 
face, and a full strong pulse, indicating active congestion of the brain. There 
may even be instances in which it would be proper and requisite to take blood 
from the arm. But these are rare. I have never seen a case of uncomplicated 
chorea in which it appeared to me that general bleeding was indicated. If 
abused, it may do harm by inducing anaemia, which, as before explained, would 
probably aggravate the cerebral symptoms. 
Spinal tenderness would require cups or leech^b to the tender spot, followed 
by repeated blisters, or antimonial pustulation. Amenorrhoea, if existing, 
should be treated by appropriate measures. (See Amenorrhoea.') Chlorosis 
or anaemia would demand the chalybeates. For worms in the bowels, anthel- 
mintics should be added to the cathartic medicine ; and oil of turpentine, or 
oil of chenopodium would be especially applicable. 
2. Measures for fulfilling the second indication should in general be em- 
ployed conjointly with those which may be deemed necessary, in accordance 
with the first. The only exception to this rule, are those rare cases in which 
there may be plethora and cerebral congestion. In these it would be pro- 
per to postpone the measures referred to, until by purging, leeching, low diet, 
&c., the excitement shall have been sufficiently subdued. 
To give strength and equability to the nervous actions, tonics and anti- 
spasmodics or nervous stimulants are required. Of the former class, though 
sulphate of quinia is sometimes very efficient, the mineral tonics are generally 
preferred. The preparations of iron and of zinc are, on the whole, the best 
and safest. Of the former, subcarbonate of iron may be given in the dose of 
a scruple or half a drachm twice or three times daily, with a little ginger to 
qualify its effects on the stomach ; but any one of the officinal preparations may 
be selected; and ferrocyanuret of iron, or Prussian blue, has been specially 
recommended. Of the preparations of zinc, the sulphate has probably been 
most used, and is often very efficient. It is the tonic which I most frequently 
employ in chorea. It should be given in quantities as large as can be borne 
without irritating the stomach. Two grains, given at first three times a day, 
may be gradually increased to six or eight grains. The oxide and valerianate 
of zinc have also been used; but they have no decided advantage over the 
sulphate, and the oxide is less certain. Besides the metallic tonics mentioned, 
sulphate of copper, ammoniated copper, nitrate, oxide, chloride, and iodide of 
silver, and subnitrate of bismuth have been used; but they have no supe- 
riority over those first mentioned, while most of them are liable to act more 
harshly upon the stomach. 
With the tonic which may be selected, it will be proper to combine the use 
of one of the nervous stimulants. Valerian has enjojed much reputation in 
chorea, and will often act advantageously. Assafetida is highly beneficial in 
many instances, especially when the disease is associated with hysteria. Cam- 
phor and musk have also been recommended. But the remedy of this class 
which I prefer in chorea, is our indigenous cimicifuga or black snakeroot. CLASS III.] 
769 
CHOREA. 
This was introduced into use by Dr. Jesse Young, and is much employed. I 
have, in repeated instances, found it of itself adequate to the cure of the disease. 
From half a drachm to a drachm of the powder, from one to two fluidounces 
of the officinal decoction, or one or two fluidrachms of a saturated tincture, 
should be given three or four times a day, and continued for several weeks; 
the dose being gradually increased until it produces some sensible effect, as 
nausea, headache, vertigo, or disordered vision. It is important that the root 
should be selected of good quality, which is to be judged of by its sensible 
properties of smell and taste. The fresher it can be obtained the better. 
In addition to these measures, the cold or shower-bath will sometimes pro- 
duce the happiest effects; and sea-bathing is a highly valuable remedy. The 
cold bath should be employed only when followed by reaction. In Russia, 
the practice has been adopted of first placing the patient for half an hour in 
a bath as hot as he can bear it, and then, after he has been thrown into pro- 
fuse perspiration, of plunging him suddenly into cold water. The sulphur- 
bath has been used with great asserted advantage in France. In obstinate 
cases it should be tried. Fresh pure air, and moderate exercise are very use- 
ful, especially towards completing a cure. All these advantages, as well as 
that of pleasing occupation of the attention, may be gained by a visit during 
summer to the sea-shore, or some one of the sulphur springs; and this mea- 
sure should be resorted to after others have failed, or to confirm convalescence 
in those whose general health may be delicate, and constitutional tendency to 
the disease strong. To maintain the mind in a cheerful state, and the temper 
free from excitement, are points of some importance in the treatment of chorea. 
In relation to the diet, the only general rule is that it should be accommo- 
dated to the state of the system. If this be full and excited, a vegetable or 
milk diet would be advisable; but in general the patient may be permitted to 
use ordinary food, taking care to avoid indigestible and acescent substances. 
The habitual use of tea and coffee should be abandoned; and temperance in 
all things observed. 
Besides the above remedies, many others have been employed in chorea, 
and most of them with more or less apparent benefit. 
The narcotics have been recommended; and belladonna, stramonium, hyos- 
cyamus, and hydrocyanic acid have been chiefly employed. Friction with 
chloroform has been resorted to; and, in some very severe cases, relief has 
been afforded by the same remedy inhaled. Opium also has had its advo- 
cates, These medicines may be occasionally added with advantage to those 
above mentioned, when particularly called for by neuralgic pains or wakeful- 
ness. Opium is frequently useful in counteracting the effect of the irritant 
metallic tonics upon the stomach and bowels. 
Emetics occasionally repeated, tartar emetic in large doses upon the contra- 
stimulant plan, Fowler's solution or other preparation of arsenic, the prepa- 
rations of iodine, oil of turpentine, chenopodium ambrosioides, cardamine 
pratensis, artemisia vulgaris, orange leaves, strychnia, gymnastic exercises 
with the sulphur bath, electricity or galvanism, and antimonial pustulation 
over the shaved scalp, are remedies in favour of which respectable authority 
might be cited. They may be tried when other methods have proved 
abortive. 
Dr. Bardsley, of Manchester, England, tried a great number of distinct 
remedies, and different plans, in the treatment of chorea, and came at last to 
the conclusion, that purgatives followed by antispasmodics were the most 
effectual. He gave purgatives until the discharges became healthy, and then 
administered musk and camphor, in the dose of four grains of each every four 
or five hours, with an enema of assafetida or a little laudanum at bedtime. 770 
LOCAL DISEASES.-NERVOUS SYSTEM. 
[PART II. 
SUBSECTION II. 
DISEASES OF THE SPINAL MARROW. 
A strong analogy exists between the spinal marrow and the brain, in their 
pathological relations. There is in both the same liability to inflammation 
of the membranes and the nervous matter, to derangement from non-inflam- 
matory organic affections including hemorrhagic and serous effusion, and to 
various functional disorder; and these different affections in the one are not 
unfrequently merely extensions of the same affections in the other. Like 
the brain, too, the spinal marrow contains at once nervous centres and con- 
ducting filaments, and may suffer disease in these constituents separately or 
conjointly. 
It is a fact which must always be borne in mind, in estimating the diseases 
of the cord, that it has a double office; first, that of receiving impressions 
from other parts of the body and of transmitting influence to those parts, 
which it may do independently of the brain; and secondly, that of conveying 
influence to and from the brain. By the former office it regulates, conjointly 
with the ganglia, most of the organic functions so far as nervous influence is 
concerned; by the latter, it is necessary to sensation and voluntary motion 
over the greater portion of the body. Two sets of phenomena, therefore, are 
consequent upon disease of the cord. In the first place, we have as the result 
of a perversion of its direct original action, symptoms of disorder in the diges- 
tive, respiratory, circulatory, nutritive, secretory, and reproductive functions, 
all of which are more or less under the control of the spinal centres; and, in 
the second place, those indicative of interrupted or deranged cerebral influence, 
such as perverted, deficient, or abolished sensation, and in various degrees the 
loss of the power of voluntary motion. Involuntary or spasmodic muscular 
contractions may arise either from disorder of the reflex spinal function seated 
in the centres, or from disease of the conducting filaments. 
As different parts of the spinal marrow preside over different functions, and 
the nerves which convey influence to and from the brain leave the cord in 
different parts of its course, it follows that the morbid phenomena must vary 
with the portion of the cord affected. Sd far as the several spinal centres are 
concerned, the expression of their disease will be confined chiefly to the organ 
or function over which they preside; but it is obvious that, in relation to 
cerebral influence, if interrupted by disease of the conducting portion of the 
spinal marrow, it must be so for all parts supplied with nerves below the seat 
of disease, while those above may be unaffected. Thus, disease of the cervical 
portion of the cord will affect speech, deglutition, respiration, and all the or- 
ganic functions in the neck and upper extremities; while sensation and volun- 
tary motion may be deranged in all parts of the body supplied with spinal 
nerves. Disease in the upper dorsal portion affects especially the digestive 
function, more or less also respiration and circulation; while paralytic symp- 
toms are confined to the trunk and lower extremities. The lower dorsal and 
lumbar portion may involve in their disorder the bowels, and the urinary and 
genital apparatus, and produce palsy in the lower extremities, without affect- 
ing the chest and arms. 
In the following articles, the diseases of the spinal marrow are treated of 
under the several heads of 1. inflammation, 2. organic affections not necessa- 
rily inflammatory, and 3. functional disorder. CLASS III.] 
771 
SPINAL MENINGITIS. 
Article I. 
INFLAMMATION OF THE SPINAL MARROW AND ITS 
MEMBRANES. 
There is in the spinal marrow the same difficulty as in the brain in distin- 
guishing between inflammation of the membranes and that of the nervous 
matter. The fact is, that they are generally in a greater or less degree asso- 
ciated ; and probably almost always so, when they occupy any considerable 
portion of the cord. Nevertheless, they appear sometimes to be distinct; and, 
even when connected, often exhibit phenomena which indicate that one of 
these structures is more prominently affected than the other. It is not im- 
proper, therefore, to treat of them distinctly; and I shall do so, under the 
names of spinal meningitis and myelitis; though it is important that the 
reader should be aware that, in neither case, is the name exclusive; the former 
term admitting the idea of attendant inflammation of the nervous matter, and 
the latter, that of the meninges. 
1. Spinal Meningitis.-This is inflammation of the membranes of the 
spinal marrow, with or without inflammation of the medullary substance. 
The membranes are primarily and chiefly affected; and it is probable that 
the grade of action in the medullary matter often scarcely exceeds the point 
of high vascular irritation ; at least not to any considerable depth. 
The student will recollect that the membranes of the spinal cord are the 
same as those of the brain, with which they are continuous; the pia mater 
immediately enveloping the proper cord, the dura mater lining the bony 
canal, and the arachnoid lying between them, and giving a coating to both. 
The arachnoid cavity of the spine is continuous with that of the brain. 
Of the membranes, the dura mater is sometimes chiefly affected, but very 
seldom exclusively. The arachnoid, from its want of vascularity, scarcely 
appears tt) suffer. The pia mater is almost always the prominent seat of the 
inflammation. 
It is chiefly through irritation of the nervous matter, either of the cord, or 
of the nerves passing out from it, that the'disease makes itself known; almost 
all its peculiar symptoms being such as result from disturbance of the spinal 
functions. 
Spinal meningitis may be acute or chronic, and may exist separately, or in 
connexion with cerebral meningitis. In its highly acute forms it is very often 
thus complicated. It will be most conveniently considered, in relation to the 
symptoms, in the three divisions of the acute, cerebro-spinal, and chronic. 
Acute Spinal Meningitis.-1This is sometimes preceded by soreness or dull 
pains in the back, and feelings of heaviness or other uneasiness in the ex- 
tremities; but not unfrequently it begins abruptly with severe pain in the 
spine, either confined to one part of the column, or beginning in one part, and 
extending through a greater or less portion of its length. The cervical por- 
tion is said to be attacked more frequently than the dorsal or lumbar. The 
pain is much increased by motion ; and is very often attended with a feeling 
of constriction around the body, either in the chest or abdomen, according to 
the precise seat of the inflammation. This, indeed, is one of the most striking 
characteristics of spinal inflammation of whatever kind. 
Nor is the pain confined to the seat of the disease, or its immediate vicinity. 
In all parts of the body supplied with nerves from the affected part of the 
spine, there are uneasy sensations of various kinds, sometimes acute neuralgic 772 
LOCAL DISEASES.-NERVOUS SYSTEM. 
[part II. 
pains, but more frequently tingling, formication, or numbness, especially in 
the extremities. 
Another very frequent and characteristic phenomenon is spasmodic rigidity 
of the muscles, more particularly of those lying along the spine. The head 
is drawn firmly backward, and long kept in that position; and sometimes the 
whole trunk is stiffly bent in the same direction, constituting complete opis- 
thotonos. Spasmodic closure of the jaws, and cramps of the extremities are 
not uncommon. Clonic spasms are also experienced amounting in some cases 
almost to convulsions, in others, only to twitching of the tendons. Creneral 
convulsions are rare unless the brain is involved. 
The limbs are enfeebled; but the power of voluntary motion is seldom 
entirely lost, at least in the earlier stages. 
The attack is accompanied with febrile symptoms. The pulse is hard and 
frequent, though sometimes small; the impulse of the heart is strong; the 
skin is hot and often perspiring, sometimes profusely so; the respiration is 
laborious, hurried or slow, and almost always restricted; anorexia and consti- 
pation are ordinary symptoms; and retention of urine is very apt to occur, 
requiring the use of the catheter. 
The symptoms occasionally remit considerably, as in cerebral meningitis, 
and are said even to intermit, but afterwards to return with increased violence. 
At length, if relief is not obtained, the pulse becomes irregular, small, and 
feeble; symptoms of drowsiness, perhaps of delirium, occur, ending finally 
in coma; sometimes paralysis of the extremities maybe observed; involun- 
tary evacuations take place from the rectum and bladder; and the patient 
dies, at a period varying from four or five days to two weeks from the com- 
mencement of the attack. 
When the spinal canal is opened after death, the cord usually appears 
swollen; but this is owing to thickening or effusion in the membranes; and 
not to increased bulk of the medulla itself, which may even be compressed. 
The dura mater is deeper coloured than usual in health; the arachnoid ex- 
hibits little change; the pia mater is reddened, injected, and swollen; and 
these phenomena are observed more especially on the posterior face of the 
cord. A turbid serum is often seen, especially in the lower part of the spinal 
canal, where it is carried by gravitation. Coagulable lymph and pus are 
found between the arachnoid and pia mater, spread over the surface of the 
membranes. The medullary substance may be somewhat injected, but is 
rarely softened, unless in the cases attended with paralysis. 
Cerebro-spinal Meningitis.-This form of the disease most commonly oc- 
curs epidemically, and has been observed, under such circumstances, to attack 
more especially young persons and males. Thus, in France it has prevailed 
among the young recruits, and in Ireland has been described as occurring 
almost exclusively in boys under twelve years of age. Commencing in 1837 
in the South of France, it gradually extended over most of that country, at- 
tacking preferably the garrisoned towns. An epidemic of it in Ireland was 
described by Drs. Darby and Mayne, in the Dublin Journal.* A similar epi- 
demic has prevailed of late years in limited districts in our South-western, 
and in the New England States.f 
In the severest cases, the attack is ushered in with a chill, during which 
* See Banking's Abstract, vol. ii. No. 1, p. 151, and No. 2, p. 191. 
j- See papers by Dr. Hicks, of Vicksburg, Mississippi, and Dr. Taylor, of Whiteville, 
Tennessee, in the N. 0. Med. and Surg. Journ., iv. 49; an elaborate paper by Dr. Ames, 
of Montgomery, Alabama, Ibid., v. 295; and a paper by Dr. A. Stone, in the Boston 
Med. and Surg. Journ., xl. 201. CLASS III.] 
CEREBRO-SPINAL MENINGITIS. 
773 
the patient complains of acute abdominal pains, is not unfrequently affected 
with vomiting and purging, and sometimes sinks into a- state resembling the 
collapse of cholera. After a time reaction takes place, and the characteristic 
phenomena of the disease are developed. In milder cases, the earlier symp- 
toms are general uneasiness, a feeling of fatigue, headache, pain in the neck, 
back, or along the whole length of the spine, a feeling of prickling and pain 
in the limbs, stiffness of the jaws, some difficulty in swallowing, perhaps also 
difficult micturition, and constipation. When the disease is completely 
formed, there are violent headache, increased sensitiveness to light and sound, 
delirium, convulsions; and, along with these cerebral symptoms, others in- 
dicating the spinal disease, such as already described under simple spinal 
meningitis, among the most striking of which are the rigid spasms or cramps, 
drawing the head stiffly backward, and sometimes rendering the whole body 
almost as rigid as a board. The countenance is said in some cases to assume 
the peculiar tetanic expression. High febrile excitement occurs, with a hot 
skin, very frequent pulse, insatiable thirst, vomiting, and epigastric tender- 
ness. Not unfrequently typhoid phenomena manifest themselves, as a dry 
tongue with sordes, feeble pulse, prostration of strength, petechias, &c. 
Should a favourable change not take place, comatose and paralytic symptoms 
make their appearance; and death soon follows. The disease sometimes com- 
pletes its course in less than forty-eight hours; but more frequently termi- 
nates about the fifth day; and sometimes runs on for two or three weeks. 
The mean duration of fatal cases is stated at about ten days. 
The appearances after death are those already detailed under cerebral and 
spinal meningitis. There is said, in some cases, to be an extraordinary ab- 
sence of cerebral lesion ; no induration, softening, or unusual vascularity 
being observed; and instances occur in which both the brain and spinal cord 
are free from signs of inflammation. {Arch. Gen., 4e ser., xix. 391.) In 
general the most striking appearance is that of an effusion of yellowish or 
greenish lymph between the arachnoid and pia mater, rather scanty on the 
hemispheres, more abundant at the base of the brain, and, in the spinal 
column, investing the cord completely, sometimes extending to the extremity 
of the caudex equina, and giving a coat to each of the spinal nerves. None 
of this secretion is ordinarily found in the cavity of the arachnoid, whether 
cranial or spinal. Sometimes the serous membranes generally, including also 
the synovial, show purulent manifestations. {Ibid., 392.) 
M. Boudin has identified this disease, as it has appeared in France, with 
typhus fever, from the more ordinary forms of which it differs simply in the 
seat of the local lesion. He believes it to be contagious, and thus accounts 
for its tendency to attack crowded populations, as military depots and garrisons. 
Another strong argument in favour of this view of its nature is the power- 
lessness of purely antiphlogistic measures in its cure, while it yields not 
unfrequently to an opposite treatment. {Arch. Gen., 4e s6r., xix. 392.) Large 
doses of opium have proved very useful. The disease, as it has occurred epi- 
demically in the United States, is probably of the same character. This is a 
point of great importance in relation to the treatment. If pure cerebro-spinal 
meningitis, it must be encountered by the energetic employment of antiphlo- 
gistic measures; if a malignant febrile disease, simply attended with the 
cerebro-spinal inflammation, it is to be treated on other principles altogether. 
I have little doubt that, wherever it occurs as an apparent epidemic, present- 
ing the grave characters above described, it is in fact a form of malignant 
fever, belonging to the group of typhous diseases, and bearing a close analogy 
in general character to the typhous epidemic which prevailed in the United 
States in 1812 and for several years afterward, and to the malignant affection 774 
[part II. 
LOCAL DISEASES.-NERVOUS SYSTEM. 
which has of late visited and still continues to visit isolated tracts of our 
country, under the name of black tongue, or malignant erysipelas.* 
Chronic Spinal Meningitis.-This is much less frequent than the acute, 
unless as a consequence of organic disease of the cord, or the vertebras. It 
comes on with dull pains in some portion of the spinal column, with deranged 
sensations in the extremities, such as formication, tingling, &c., and disorder 
in the functions of the thoracic, abdominal, or pelvic viscera. The charac- 
teristic rigid or tonic spasms take place after a time; the limbs become con- 
tracted, the head is sometimes drawn to one side, or permanently backward, 
and even the trunk distorted. The patient often suffers much from acute 
pains in the limbs, abdomen, &c. An acute attack sometimes supervenes, 
and proves speedily fatal; or death takes place from the consequences of 
paralysis, exhaustion, or a gradual failure of the vital functions, after many 
months or years of suffering. There is reason, however, to believe, that re- 
covery often takes place under judicious treatment. 
2. Myelitis (from gvf\oi, marrow) is here employed to signify inflam- 
mation of the substance of the cord. Like spinal meningitis, it may be 
acute or chronic. In very acute cases, there is much spinal pain, which is 
greatly increased by motion and pressure, and convulsions sometimes attend 
the early stage. Pains too are experienced in various parts of the body, 
supplied with nerves from the affected portion of the cord. Formication, 
tingling, numbness, and a feeling of coldness in the limbs are ordinary sen- 
sations. These may occur in a single limb, in both of the lower extremities, 
or in one-half of the body. Along with deranged sensation there is also dimi- 
nished power of the muscles, which is at first indicated by uncertainty of 
movement, and ends, if the case advance, in complete paralysis. Upon the 
occurrence of this affection, the pains generally cease. Sometimes the para- 
lysis begins at the remotest part of the extremities, and gradually ascends, 
until it involves the vital organs. Not unfrequently involuntary contrac- 
tions of the muscles, either rigid or clonic, accompany this loss of voluntary 
motion. Sensation may continue, or be abolished. The continuance of sen- 
sation, when the power of motion is lost, is explained by the different origin 
of the nerves belonging to these functions. When there is paralysis of 
motion alone, the anterior nerves only are affected; when both functions are 
paralyzed, the disease has seized upon both sets of nerves. 
It was supposed that disease of the anterior and posterior spinal columns 
might have differences of effect, corresponding with the nerves proceeding 
respectively from them; and a case of paralysis, as detailed by Abercrombie, 
in which the sensibility of the limbs continued unimpaired, and after death 
the anterior fasciculi of the dorsal portion of the cord were found diffluent, 
while the posterior retained their consistence, gave some countenance to the 
supposition. But another case has been recorded by Mr. Stanley, in which 
a precisely similar condition of the limbs, during life, was found, after death, 
to be accompanied with softening of the posterior column exclusively. ( Wat- 
son's Lectures, 2d Am. ed., p. 296.) This apparent anomaly may be ex- 
plained, upon the supposition that the conducting fibres cross each other 
before leaving the spinal column. 
The paralysis extends to the bowels, producing obstinate constipation, and 
* In a communication'to the 2V. Orleans Medical and Surgical Journal (ix. 184), Dr. 
R. F. Taylor states that he has found the ordinary antiphlogistic remedies almost use- 
less, but has obtained great advantage from a combination of sulphate of quinia and 
opium, given freely until they produced a decided impression on the system, and then 
followed by twenty grains of calomel, combined with compound extract of colocynth, 
so as to produce full and free purgation. (Note to the fourth edition.) CLASS III.] 
MYELITIS. 
775 
to the bladder, causing retention of urine; but ultimately, the sphincters 
becoming involved, these conditions are followed by incontinence. 
At the same time that the muscles thus lose their power, the organic func- 
tions are deranged. The stomach, the liver, the kidneys, the genital organs, 
are liable to various disorder. Palpitations, dyspnoea, and hiccough are not 
unfrequent attendants on the disease. 
Febrile symptoms are not usually developed in any considerable degree. 
The pulse is seldom much accelerated, and is often slower than in health. 
The respiration is also slow and confined. 
Death sometimes takes place very speedily, even during the first or second 
day. This may be readily understood, when the affection occupies the cord 
above the point at which the respiratory nerves pass off. Respiration must 
cease, if the spinal marrow above this point become incapable of conveying 
influence from the respiratory centre. In the lower part of the spine, an 
equal amount of disease would be longer in producing death, because the func- 
tions immediately essential to life are not interrupted. 
When the case is at all protracted, eschars are apt to form upon the back 
and hips, in consequence of pressure; and the fatal issue is hastened by the 
exhausting discharges which take place. There is no fixed period for the 
fatal termination of the disease. Though, as already stated, it may, in the 
acute form, end in less than forty-eight hours; yet, much more frequently, it 
runs on for a week or ten days, or longer; and its term may vary, according 
to its degree of acuteness or chronicity, from the period mentioned, to weeks, 
months, or years. 
The chronic form of the disease, which is more frequent than the acute, 
commences almost insensibly, with a little uneasiness in the spine, slightly 
disordered sensations in the extremities, and unusual fatigue after exertion; 
but little apprehension is felt, until, at length, paralytic symptoms begin to 
be experienced. These slowly increase. The patient may be affected with 
tremors, which are sometimes almost constant. The gait becomes uncertain, 
vacillating, tottering. The limbs no longer support the body. The paralysis 
encroaches upon the trunk, affects the urinary organs, and ascends at last to 
the chest. Involuntary startings of the muscles, and sometimes rigid con- 
tractions mingle with the advancing paralysis. Sloughs and ulcers, with 
exhausting discharges, form upon the sacrum, hips, &c., and the patient loses 
all power over his evacuations. The pulse is usually slow and feeble, the 
surface pale, and the limbs frequently edematous. Death takes place as the 
result of exhaustion, and sometimes of asphyxia, the paralysis rising gradu- 
ally, until it involves the chest. 
The chief anatomical character of myelitis is softening of the medulla. This 
exists in various degrees, from a slight diminution of consistence to complete 
diffluence. Sometimes the colour of the softened part has some shade of red, 
but more frequently it is yellowish, or of the natural whiteness. The soft- 
ness may occupy a portion only of the diameter of the cord, passing upward 
and downward in the direction of the column, or may involve its whole thick- 
ness. Doubts have been entertained whether the yellow and white softening 
are really the result of inflammation. They are attended with the same 
symptoms during life. Signs of meningitis are often observed in connexion 
with the myelitis, but not always. 
Diagnosis.-It has been suggested that meningeal inflammation might be 
recognized by the existence of tonic spasms or rigidity; but these happen also 
in pure myelitis, though less frequent or striking. Paralysis may generally 
be considered as an evidence of the latter complaint, when attended with other 
marks of inflammation in the spinal column. It is, however, of little con- 776 
[PART II. 
LOCAL DISEASES.-NERVOUS SYSTEM. 
sequence to distinguish the two affections, as their treatment is essentially the 
same. It is more important not to mistake spinal inflammation, whether me- 
ningeal or medullary, for rheumatism. Cases of the former diseases have often 
been fatally neglected, under the impression that they belonged to the latter. 
It is only in the early stages that there can be any danger of such a mistake. 
The occurrence of tonic spasms, or of paralytic symptoms, would sufficiently 
distinguish the spinal inflammation. When these are absent, a just inference 
can sometimes be drawn from pressure, which, in spinal inflammation, will 
occasion most uneasiness when made upon the spinous processes, in rheuma- 
tism, commonly, when made alongside of the spine. In rheumatism, moreover, 
the pain on motion, is generally very obviously dependent on the contraction 
of the muscles. There may be some danger of confounding inflammation of 
the spinal marrow, or its membranes, with spinal irritation; but the reader is 
referred to the latter affection for the diagnostic symptoms. 
Causes.-Among the most common causes of spinal inflammation are falls, 
blows, great and frequent straining, and fatiguing muscular exertion of all 
kinds. Abuse of the venereal propensity is also said to produce it, especially 
that form of it attended with softening. Vicissitudes of weather, alcoholic 
drinks, and other ordinary sources of inflammation occasionally act as causes. 
Sometimes it appears to result from epidemic influence. Other diseases of 
the spine occasion it, such as caries, tubercles, &c. It is very apt to be pro- 
pagated from inflammation of the corresponding tissue in the brain. Spinal 
softening has often been observed in the epileptic and insane. 
Prognosis.-1The severe forms of spinal and cerebro-spinal inflammation are 
very dangerous, though not so necessarily fatal as some writers appear to be- 
lieve. Cures of this, as of cerebral meningitis, may be effected in many cases 
by prompt and energetic treatment. In some instances, it is true, especially 
in the epidemic form of the disease, the death-blow seems to be given at the 
very commencement. Very discouraging opinions are also given of the prog- 
nosis in myelitis. After it has advanced to confirmed paralysis, there may 
not be much to hope for; but I am convinced that, in its early stages, it is 
often set aside by judicious remedies. In no case should the practitioner de- 
spair, unless when the powers of life are obviously giving way, when the patient 
loses command of the sphincters, and a tendency to the formation of sloughs 
is evinced. 
Treatment.-The treatment of spinal inflammation is to be conducted upon 
the same plan as that of inflammation elsewhere. In the acute affection, 
bleeding as freely and as frequently as the pulse and general strength will 
permit; copious and repeated local depletion by cups and leeches along the 
spine, with emollient lukewarm cataplasms in the intervals; purging with 
calomel in the beginning, and subsequently with the saline cathartics, but 
never violently; and, lastly, should the disease not yield to depletion, blis- 
ters over the whole length of the inflamed portion, with the use of mercury 
in reference to its constitutional impression, constitute the sum of the treat- 
ment. Some recommend cold to the spine, as to the head in cerebral inflam- 
mation ; but I should apprehend the production of other internal diseases from 
this remedy, applied to the naked surface of the body with such steadiness as 
to be at all efficient. Refrigerant diaphoretics and cooling drinks may be 
given during the existence of febrile symptoms. Perfect rest should be en- 
joined; and the patient should never be permitted to rise even for the pur- 
poses of a stool. The diet, of course, must be rigidly antiphlogistic. Care 
should be taken to prevent undue accumulation of urine in the bladder, and 
for this purpose recourse should be had, if necessary, to the catheter. 
The chronic affection is to be treated upon the same principles precisely, CLASS III.] 
777 
ORGANIC DISEASES OF THE SPINAL MARROW. 
but less energetically. Repeated leeching and cupping will here be prefer- 
able to general bleeding. A constant succession of blisters must be main- 
tained; or their place supplied by issues, setons, copious antimonial pustula- 
tion, or moxa. Some writers strongly recommend the actual cautery. Much 
may be expected from a moderate and long sustained mercurial impression; 
but it will be important so to manage the remedy as scarcely to produce any 
effect upon the mouth. One of the most important measures is absolute rest 
in bed. For the treatment of any paralytic affection, which may remain 
after the subsidence of the inflammation, the reader is referred to paralysis. 
The disposition to slough should be guarded against, as far as possible, by 
means of alcoholic lotions, the lead plaster, hollow cushions, down pillows, 
and occasional change of position; and, when ulcers have formed, they should 
be dressed frequently and carefully, so as to preserve cleanliness; and fetor 
should be corrected by creasotic or chlorine washes. 
In epidemic cerebro-spinal meningitis, reference must be had to the state 
of the system, which often requires the support of tonic and stimulant mea- 
sures, such as are adapted to typhus fever, while the local inflammation is to 
be encountered by leeches or cups, followed by blisters to the back of the 
neck and along the spine. Copious depletion is out of the question in the 
malignant cases. 
Article IL 
ORGANIC DISEASES OF THE SPINAL MARROW. 
Allusion is here had to affections not essentially inflammatory in their cha- 
racter. As they all produce certain common effects, they may be most con- 
veniently considered under one head. These effects, so far as the symptoms 
are concerned, resolve themselves into those of pressure upon the cord, and 
of irritation, inflammation, or disorganization of its substance. 
Symptoms.-Pain of various degree and character is felt in the spine; 
moderate or severe, dull or acute, burning, gnawing, lancinating, heavy, pul- 
sative, &c. There are also morbid sensations of different kinds in those 
portions of the body supplied with nervous influence from the part affected. 
Peelings of tingling, pricking, or formication, of numbness and coldness, and 
frequently of acute pain, sometimes stationary, sometimes shooting along the 
course of the nerves, are experienced in the limbs, and different parts of the 
trunk and neck. Uneasy sensations of almost infinite diversity are felt in the 
chest, abdomen, or pelvis, according to the situation of the spinal affection; 
and among these sensations sharp or neuralgic pains are not unfrequent. A 
sense of stricture, as of a band about the body, is very common. 
Superadded to deranged sensation, there is a gradually increasing weakness 
of the muscles, which at length ends in palsy, sometimes both of sense and 
motion, sometimes of the latter exclusively; and the paralytic affection may 
be confined to one limb or one side, may extend to several limbs, or may em- 
brace almost the whole body. Paraplegia is among the most common results. 
Constipation and retention of urine, or the contrary cAidition of incontinence, 
are apt to occur, consequent on paralysis of the rectum and bladder in the 
former case, and of the sphincters in the latter. The palsied limbs undergo 
atrophy, and often become the seat of serous effusion. 
Involuntary muscular contractions very often accompany the loss of volun- 
tary power, and either tetanic rigidity, or clonic spasms, are experienced in 
different parts of the body. The digestion, respiration, and circulation un- 778 
[PART II. 
LOCAL DISEASES.-NERVOUS SYSTEM. 
dergo various disorder. Vomiting, dyspnoea, and palpitation are not unfre- 
quent. When the disease is near the foramen magnum, deglutition is dif- 
ficult, and respiration especially disturbed. The brain sometimes becomes 
involved directly or sympathetically ; and headache, delirium, convulsions, 
strabismus, stupor, coma, &c., are added to the other symptoms. Finally, 
sloughs upon the surface result from pressure, and are followed by exhausting 
ulcers. Death takes place either from pure exhaustion, or from interruption 
of one of the vital functions. The disease may be a few months, or many 
years, in completing its course. 
Of the affections alluded to, most are inevitably fatal. But I rank under 
the same head, effusion into the spinal canal, when sufficient to give rise to 
the above phenomena, or most of them; and this may end favourably. The 
following is a brief enumeration of the several affections. 
Hemorrhage.-Blood may be effused without the dura mater, in the cavity 
of the arachnoid, between that and the pia mater, or in the substance of the 
marrow. It is very generally consequent upon active congestion, and there- 
fore often associated with signs of inflammation; nor are we in possession of 
any means of forming an accurate diagnosis. But, when the symptoms of 
compression of the spinal marrow come on suddenly, we may suspect the 
existence of hemorrhage. As the blood sometimes travels from one part to 
another, the symptoms may be expected to change their seat. When effused 
around the cord, it may produce only a moderate degree of numbness or mus- 
cular weakness; when into its substance, it generally gives rise to complete 
paralysis. Either death may ensue, or the blood may become encysted and 
absorbed, as in the brain. When there is reason to suspect the existence of 
hemorrhage, the remedies indicated are perfect rest, cold applications to the 
spine when the symptoms are threatening, depletion as far as the state of the 
system may warrant, and, finally, should signs of inflammation present them- 
selves, the various measures applicable to that affection. 
Serous Effusion.-Hydrorachis.-As the spinal arachnoid cavity, and the 
space, if we may call it such, between the pia mater and arachnoid, are con- 
tinuous with those of the brain, liquid effused within the cranium often finds 
its way into the spinal canal, and produces the symptoms resulting from pres- 
sure upon the cord. This not unfrequently takes place in hydrocephalic 
patients; and when, as occasionally happens, there is imperfection in the bony 
parietesof the canal, as in spina bifida, a tumour, disappearing or diminishing 
upon pressure, is apt to show itself upon the spine. Serous effusion may also 
originate within the spinal cavity, either occupying the spaces before alluded 
to, infiltrating the substance of the marrow, hollowing out for itself cavities 
in that substance, or confined to the space without the dura mater. In the 
last case it is necessarily spinal in its origin, as the dura mater adheres to the 
bone at the foramen magnum, in such a manner as to cut off any communica- 
tion with the cranium. But, except in the instance of spina bifida above 
mentioned, we have no means of deciding upon the nature of these cases. At 
best we can only conjecture that there is serous effusion in the spinal canal, 
when the symptoms of compression of the spinal marrow, palsy, namely, of 
sense and motion, in various degrees, accompany evidences of cerebral effusion. 
When the fluid travels*readily, it is rational to suppose that the erect posi- 
tion, through the influence of gravitation, may cause it to accumulate in the 
lower part of the spinal column, and thus produce the symptoms more espe- 
cially of compression of this part. When, therefore, we find numbness and 
debility of the lower extremities increased by the erect posture, we may infer 
that there is probably serum in the canal. For the treatment of spina bifida 
the reader is referred to works on surgery. In other cases of supposed serous CLASS III.] 
FUNCTIONAL DISEASE OF THE SPINAL MARROW. 
779 
effusion, the remedies must be addressed to the pathological condition in which 
it may be thought to originate. 
Hypertrophy and Atrophy.-These affections have been occasionally noticed 
upon dissection, without being traceable to any other pathological state. They 
are, however, merely matters of anatomical curiosity; for they cannot be known 
during life. 
Aneurisms, Hydatids, Tubercles, and Carcinomatous Tumours occasionally 
form within the spinal canal, and give rise to the phenomena already detailed. 
Aneurisms and carcinoma sometimes also press on the spine from without, and, 
producing absorption of the bony matter, come into an irritating or destructive 
contact with the cord, and occasion the most harassing symptoms. The diag- 
nosis in all these cases is very uncertain, and especially so when the disease 
is within the spinal canal. Sometimes a probable conclusion may be formed 
from the nature of some existing disease elsewhere. Thus, when the symp- 
toms enumerated occur in an individual who presents obvious signs of tuber- 
culous or cancerous affection, they may without any great violence be referred 
to the same origin. The prognosis is almost always unfavourable. The treat- 
ment is wholly palliative. To enjoin rest, to adapt the diet to the state of 
the system and of the digestive organs, to keep the bowels regular, to draw 
off the urine when requisite, to guard as much as possible against eschars, and 
to relieve pain by the internal and local use of anodynes, is all that is left for 
the physician in most of these cases. Happily they are rare. 
Article III. 
FUNCTIONAL DISEASE OF THE SPINAL MARROW. 
When it is considered that from the spinal centres probably flows an in- 
fluence, which is requisite to sustain the various organic functions in their 
healthy condition, it can be readily understood that a great diversity of de- 
rangement in these functions may result from deficient, excessive, or per- 
verted action in the centres, without the necessary existence of any organic 
disease. It is, indeed, highly probable that many disorders of the digestive, 
respiratory, and circulatory organs, many derangements of the secretory and 
nutritive processes, of which the causes are obscure, might be traced to the 
spinal marrow as their source, had we the means of investigating accurately 
the functional disorders of that structure. But, with our present knowledge, 
such a reference must be conjectural, except in those cases in which some 
direct evidence exists of spinal disturbance. Still, even a conjectural refer- 
ence may lead to useful results; and remedies may often be advantageously 
addressed to the spine, when no other proof of disorder in the cord is offered 
than morbid phenomena of the organs over which it presides. It is, indeed, 
a good practical rule, in all those cases of functional disease in any part of the 
body supplied with spinal, nerves, of which the cause is obscure, to bear in 
mind their possible origin in the medulla spinalis, and to be prepared, should 
other measures fail, to have recourse to such as may be calculated to influence 
that portion of the system. 
But, while it is probable that much disorder may depend on the spinal 
marrow, which cannot be clearly traced to it, there are numerous instances in 
which that structure affords direct evidence of a diseased condition, and thus 
enables us to refer various morbid phenomena existing elsewhere, with great 
confidence, to their true origin. A vast addition to our means of successfully 
combating disease has been made by the comparatively recent opening of this 780 
LOCAL DISEASES.-NERVOUS SYSTEM. 
[part II. 
new field in therapeutics. The evidence of functional spinal disorder above 
alluded to is that offered by tenderness upon pressure on the spinous processes, 
when there is no reason to suspect the existence of spinal meningitis or mye- 
litis. This symptom has been so frequently found associated with various 
disorders in different parts of the system, which have yielded to remedies ad- 
dressed to the seat of it, that it has come to be regarded as the characteristic 
sign of a peculiar affection, which for want of a better name is generally de- 
nominated spinal irritation. The remainder of this article will be devoted 
especially to the consideration of that affection. 
Spinal Irritation.-It will be understood that, in this particular ap- 
plication of it, the term spinal irritation is not intended to embrace every 
example of morbidly increased excitement of the medulla spinalis, or a part 
of it, but only those cases in which the particular phenomenon above alluded 
to is offered; that, namely, of tenderness upon pressure on one or more of the 
spinous processes of the vertebrae. 
Symptoms.-These are immensely diversified. They are, indeed, almost 
as numerous as the possible derangements of function in all parts of the body, 
supplied with nerves from the spinal marrow. The only symptom common 
to all the cases is the pathognomonic one above referred to. Upon making 
pressure on the spinous processes, beginning at the neck and proceeding down- 
ward, we may find either- a general tenderness along the whole or the greater 
portion of the column, or, what is much more common, the tenderness may 
be confined to one or a very few of the vertebrae; and, not unfrequently, one 
is more acutely sensitive, while above and below it the tenderness gradually 
diminishes until it ceases to be evident. The dorsal vertebrae are most fre- 
quently affected. There is not less difference in the degree of tenderness, than 
in its precise seat. In some instances it is slight, requiring rather heavy pres- 
sure to develope it; in others it is exquisitely keen, so that a touch produces 
uneasiness, and the slightest pressure occasions intolerable pain. I have re- 
peatedly known patients to start as if struck with a pistol ball, or pierced with 
a knife, upon gentle pressure being made with the finger on one of the spinous 
processes; and, even in a state of apparent coma, with all other parts of the 
body insensible to painful impressions, the most marked evidence of suffering 
will be presented by the face of the patient, and the movements of the body, 
when the tender vertebra is touched. The pain is often described as shooting 
through the body anteriorly, and is not unfrequently attended with sensations 
of nausea, or sickening faintness. A remarkable circumstance is, that, in the 
greater number of cases, there is little or no pain in the affected portion of 
the spine except when pressure is made, so that the real seat of disease might 
escape notice, were not the attention of the physician directed towards it by 
symptoms existing elsewhere. 
I shall not pretend to enumerate all these symptoms; but shall content 
myself with calling attention to some of the more prominent. They vary 
with the portion of the spine affected; those parts especially showing signs of 
disorder, which receive nerves directly or indirectly from the vicinity of the 
tender vertebrae. But it will be more convenient to consider them in rela- 
tion to the functions than the particular structures. Beginning with the 
digestive function, we have difficult deglutition, stricture of the oesophagus, 
gastrodynia, spasm of the stomach, excessive thirst, morbid appetite or ano- 
rexia, nausea and vomiting, and various most distressing and indescribable 
sensations in the epigastrium, such as attend the worst cases of dyspepsia. 
Some of the most obstinate instances of vomiting that I have witnessed 
appeared to be dependent on this cause. In the bowels there are neuralgic 
and colicky pains, flatulence, and the most diversified uneasiness. CLASS III.] 
781 
SPINAL IRRITATION. 
The respiratory organs are also liable to be attacked. The voice is some- 
times altered; violent cough from laryngeal irritation is not uncommon, and 
alarming spasm of the glottis occasionally has a similar origin. The dyspnoea 
which attends the disease is sometimes very distressing, scarcely falling short 
of a violent paroxysm of asthma. 
Palpitations of the heart are very frequent, and other signs of functional 
cardiac disorder are occasionally offered, such as faintness or syncope, and 
pains resembling those of angina pectoris. 
Deranged hepatic secretion, uneasy sensations in the liver, various urinary 
disorder, tenesmus, and derangements of the sexual functions, especially 
amenorrhoea, are not uncommon. 
Neuralgic pains are experienced in the muscles of the chest, extremities, 
shoulders, neck, and occiput. Pains, too, resembling those of rheumatism, 
are felt in various parts of the body. Other kinds of uneasiness, such as 
tingling, formication, pricking, intense itching, burning, numbness, coldness, 
and diversified anomalous sensations, occur in the limbs and trunk. Cramps, 
convulsive movements, and paralytic symptoms in various parts of the body 
may be added to the list. I have repeatedly witnessed comatose symptoms 
apparently dependent on the same cause; the irritation being in such cases 
probably sympathetically conveyed to the brain. 
In short, there is scarcely a morbid sensation or perversion of function, 
occurring in any part of the body beneath the head, which may not originate 
in spinal irritation; and, whenever the cause of any existing disorder of this 
kind is obscure, it should be sought for in the spine. 
The affection often attends other diseases. It is very common in hysteria, 
so much so as to be almost characteristic of that complaint. It is also occa- 
sionally observed in chorea and epilepsy. There is reason to believe that cases 
resembling tetanus and hydrophobia, and which have been mistaken for these 
complaints, have depended upon this kind of spinal irritation. 
Causes.-These are not well understood. The disease occurs most fre- 
quently in women, and especially during the menstruating period, or between 
the ages of fourteen and forty-five. It would seem, therefore, to have some 
connexion with the uterus; but such a connexion is certainly not essential, for 
the disease often occurs in children, and sometimes in men. Spinal distortion 
seems also to constitute a predisposition. Of the exciting causes, changes in 
the weather are probably among the most frequent. Mental disturbance ap- 
pears to be capable of inducing it, and perhaps any other cause calculated 
strongly to impress the nervous system. 
Nature.-Some difference of opinion has existed on this point. While the 
affection is generally considered as residing in the spinal cord, some have 
been unable to conceive that the extreme tenderness evinced in many cases 
could depend upon the cord itself, enclosed as it is within a firm bony case, 
and not even in close contact with that. The most rational view of the 
affection appears to be, that it is seated essentially in the ligaments of the 
vertebrae, and is generally of a rheumatic or gouty character. It is readily 
conceivable that irritation may be propagated from this structure to the 
nervous tissue of the cord, or at least to the nerves which proceed from the 
cord, and receive as they pass an envelope probably of the diseased tissue. 
The character of the affection in the ligaments may be inferred to be that 
of subacute rheumatic inflammation, and not merely neuralgic, from the 
circumstance that it yields often with so much facility to local depletion. 
Diagnosis.-The affection which this most resembles is inflammation of 
the spinal cord. It is distinguished by the absence of fever, the greater ten- 
derness upon slight pressure, with the comparative want of pain under other 782 
[part II. 
LOCAL DISEASES.-NERVOUS SYSTEM. 
circumstances, the ability to move with little or no uneasiness, and the more 
shifting character of the complaint. The facility with which it is generally 
relieved is another diagnostic sign. 
Prognosis.-This is almost always favourable, at least in relation to any 
one attack. But there is in some a strong tendency towards it, so that, though 
relieved for a time, it often recurs; and this tendency may persist for many 
years. It disappears, however, usually in advanced life. The disposition to 
frequent return is another point of resemblance with rheumatism. When the 
affection is neglected, it may, probably, sometimes occasion serious organic 
disease in the parts at first only functionally disturbed. 
Treatment.-This must be directed chiefly to the spinal affection. A few 
cups or leeches applied to the tender spot, or its immediate vicinity, will often 
afford complete relief. Should one application of the remedy not answer, it 
may be repeated again, and again. After sufficient depletion in this way, a 
blister may be created immediately over the tender vertebrae, and renewed as 
it heals. Should the disease be obstinate, pustulation with croton oil or tartar 
emetic, may be resorted to. The latter is the most effectual. Advantage 
will sometimes accrue from morphia sprinkled upon the blistered surface. 
Sometimes the rubefacients will answer instead of blistering or pustulation. 
Mustard, or solution of ammonia, more or less diluted* should be preferred. 
Sometimes, when the tendency to the affection is strong, it is necessary to 
sustain the antimonial pustulation for several months before it can be eradi- 
cated. Issues may be preferred in some of these cases. 
The constitutional treatment must be accommodated to the circumstances of 
the case. The bowels should be kept regular, hepatic or urinary disorder 
should be corrected, the menses, if retained or suppressed, should be restored, 
and anaemia treated in the usual manner. The neuralgic pains occurring in 
different parts of the body sometimes require attention; and any existing 
rheumatic or gouty tendency should be obviated. To treat of the means 
requisite for these various ends would be merely to repeat what has been 
detailed elsewhere. It not unfrequently happens that spinal tenderness, in 
women, is associated with retroversion or other abnormal position of the 
uterus, and yields to measures calculated to obviate this condition of things. 
Article IK 
TETANUS. 
Syn.-Locked Jaw. 
Tetanus (from fsivo, I stretch) is a disease in which the muscles are in a 
state of rigid lasting contraction, with paroxysms of brief and painful spasm, 
alternating with irregular intervals of more or less complete relaxation, with- 
out coma, or any essential disturbance of the mental faculties. 
Different names have been conferred upon the tetanic condition, according 
to the obvious effects of the spasm. Thus, when it produces a closure of the 
jaws, the affection has been denominated trismus; when a curvature of the 
body backward, opisthotonos ; when forward, emprosthotonos ; when to one 
side, pleurosthotonos. These'conditions are now treated as mere symptomatic 
diversities of the same disease. 
Tetanus has been divided into the idiopathic and symptomatic ; the former, 
independent of any other known pathological condition ; the latter, produced 
by some other distinct affection existing within or without the spine. The 
symptomatic variety, when originating in wounds or other external injury, is CLASS III.] 
TETANUS. 
783 
called traumatic tetanus. This latter name, as embracing cases of very fre- 
quent occurrence, of a certain identity of origin, and peculiar violence of cha- 
racter, is very convenient, and almost universally employed. As, in relation 
to the disease from other sources, there is always much uncertainty; some 
ascribing it to one pathological condition, others to another, and all acknow- 
ledging its obscurity; there is a propriety in adopting some designation, which, 
whether in itself correct or incorrect, may be generally received and under- 
stood. Most writers at present include under the title of idiopathic tetanus 
all cases not traumatic, whether strictly independent, or symptomatic of some 
other affection; and their example is followed in this work. 
Still another distinction of tetanus is into the acute and chronic; but, 
though cases of the disease do differ greatly in their degree and duration, 
there is no such peculiarity of character attached to their diversity of grade 
and persistence, as to require a separate grouping; and the terms, if employed 
at all, should be considered as mere epithets expressive of certain differences 
of quality in one common affection. 
Symptoms, Course, &c.-Various symptoms are enumerated by authors 
as occasionally preceding an attack of traumatic tetanus; such as depression 
of spirits, an unaccountable feeling of terror, general uneasiness or lassitude, 
twitching in the wounded limb, deep pains in the affected part sometimes 
extending towards the spine, a sense of chilliness, &c.; but these symptoms 
are very uncertain, and cannot be relied on. The first signs of a commencing 
attack, are commonly feelings of uneasiness and stiffness in the back of the 
neck; an unusual rigidity about the jaws, with some pain in attempting to 
open the mouth widely; and occasionally a disagreeable sensation in the 
throat, and slight embarrassment in swallowing. There is also frequently 
uneasiness in the epigastrium, which soon amounts to acute pain, shooting 
from the pit of the stomach towards the spine, and attended with a sensation 
of stricture or dragging, dependent, no doubt, upon spasm of the diaphragm. 
Other muscles become quickly involved, especially those of the face and 
trunk; the disease then extends to the limbs; and ultimately almost all the 
voluntary muscles of the body are more or less affected. 
There is a permanent rigidity or tonic spasm of the muscles, which exists 
in various degrees throughout the complaint, seldom undergoing complete 
relaxation. Slight at the commencement, it increases with the advance of the 
disease, and, when this is fully formed, imparts a degree of hardness to the 
muscles, almost like that of a board. But, besides this state of permanent 
rigidity, there are paroxysms of spasm, approaching to the clonic character, 
which are much shorter, but proportionably more violent, and alternate with 
periods of comparative relaxation. These paroxysms are at first slight, and 
at somewhat distant intervals; but gradually increase in frequency and violence, 
until at length they occur every ten or fifteen minutes, or even more frequently, 
so that the patient is scarcely out of one before he falls into another; and 
their force is such that they sometimes throw the whole body about in dif- 
ferent directions, and endanger injury from this cause. 
These spasms produce extreme pain, of which some idea may be formed, 
when it is considered that the same feeling that attends ordinary cramps in 
the extremities is, in these cases, experienced in many muscles at once. The 
rigidity or permanent contraction is less painful, and is sometimes productive 
of no other sensation than a disagreeable stiffness. It is asserted, on high 
authority, that even the spasmodic paroxysms are not always painful; and 
one instance is related in which the sensation was said to be rather pleasura- 
ble than otherwise. The violence of the spasm is occasionally such as to 
produce a rupture of some of the muscular fibres or of the whole muscle, to 784 
LOCAL DISEASES.-NERVOUS SYSTEM. 
[part II. 
fracture the bones, and to dislocate the joints. Even the teeth have been 
broken by the excessive force with which the jaws have been closed. But 
these effects are comparatively rare. 
The slightest causes are often sufficient to induce a paroxysm, such as an 
attempt to speak, or to swallow, any sudden noise, a draught of cold air, &c. 
The effects of tetanus on particular parts and functions require notice. 
One of the most striking of these effects is the firm closure of the jaws, 
which has given rise to the name of locked jaw by which the disease is often 
designated. In some instances, this takes place suddenly, as if by a snap; 
but generally it is effected slowly; the first feeling being that of stiffness, 
which increases until the patient becomes wholly unable to open the mouth ; 
and the violence of the contraction is said sometimes to be so great as even 
to break the teeth. The other muscles of the face are also affected. The 
angles of the mouth are drawn upward and outward, the alas of the nose are 
elevated and expanded, the brows are contracted, the forehead wrinkled, the 
orbicularis muscle of the eyelids rigid, the eyes themselves sometimes fixed 
and staring; and the whole face is much distorted, sometimes having an ex- 
pression of anxiety and distress, sometimes exhibiting that fearful mockery 
of a smile, denominated the risus sardonicus, and generally presenting an 
aspect which the experienced eye at once recognizes as tetanic. The effect 
of the distortion is said occasionally to give an appearance of great age to the 
features even of the young. The pupil is in some instances contracted, in 
others dilated, and in others again probably unchanged. The tongue is liable 
to be thrust between the teeth while the jaws are somewhat relaxed, and 
then to be fearfully wounded by their sudden closure. Hence bloody froth 
or saliva sometimes issues from the mouth. 
The trunk is often erect and rigid, as hard and firm almost as a wooden 
statue, in consequence of the equal contraction of the muscles. But occa- 
sionally the body is distorted by the partial action of the muscles; those of 
one part contracting while the opposing muscles are relaxed, or act less 
forcibly. One of the most common distortions is that of opisthotonos, in 
which the whole body is bent backward into the form of an arch, so that only 
the occiput and the heels touch the bed. In this case the abdominal muscles 
are also in general rigid, but their strength is insufficient to counteract that 
of the more powerful muscles placed along the spine. The forward curvature, 
or emprosthotonos, in which the shoulders are drawn towards the hips ante- 
riorly, and the thighs flexed upon the pelvis, is comparatively very rare; and 
the lateral curvature is still more so; for, though it is no uncommon event 
for the muscles of one side to contract much more powerfully than those of 
the other; yet they very seldom act in such a manner as to bend the body 
laterally. The muscles of the extremities, as a general rule, are later and less 
affected than those of the trunk; though it is said that, in some instances of 
traumatic tetanus, the spasms commence in the wounded limb, and are severer 
there than elsewhere. It is a singular fact, that the muscles which move the 
wrists and hands are generally under the control of the will, though the trunk 
and arms may be rigid with spasm. 
The muscles of the fauces, and those of the larynx, participate in some 
degree in the general tendency, giving rise to difficulty of deglutition, and 
occasionally to suffocative paroxysms, which are extremely distressing and 
dangerous. It is undoubtedly to spasm of the diaphragm that the violent 
and dragging pains at the scrobiculus cordis, extending through to the back, 
are to be ascribed. These pains are among the most characteristic symptoms 
of tetanus, being rarely quite wanting throughout the whole course of the 
disease. They generally begin and increase with it; but sometimes do not CLASS III.] 
785 
TETANUS. 
come on till in the advanced stage, or near the close. When very severe, 
they are apt to be attended with some degree of opisthotonos. 
The sphincters of the anus and bladder are sometimes rigidly contracted, 
favouring constipation in the one case, and retention of urine in the other; 
and it has been observed, under these circumstances, that there is sometimes 
considerable difficulty in introducing the injection pipe and the catheter. 
It will have been noticed that all the muscles, hitherto spoken of as liable 
to spasm, are in health either wholly or partially under the control of the 
will. Indeed, it is thought by some that the disease is confined to the volun- 
tary muscles. They are certainly first and most violently affected. Life 
could be sustained but for a short time, if the involuntary muscles were 
equally liable to the disease. But there is no proof that they do not some- 
times in the end participate; and it is not improbable that sudden death in 
tetanus may occasionally be owing to the disease seizing upon the heart. 
An account of the state of the several functions will close this enumeration 
of the symptoms. 
Deglutition, as before observed, is often difficult. When the attempt is 
made, in this case, to swallow liquids, they are apt to be thrown back 
through the mouth and nostrils; or, by entering the glottis, give rise to the 
most distressing paroxysms of dyspnoea, threatening suffocation. Hence, 
tetanic patients have in some cases a dread of liquids which is almost hydro- 
phobic. Notwithstanding this difficulty of swallowing, the patient generally 
retains his appetite. The tongue is at first, in complicated cases, moist and 
natural; but is liable in the end to become dry or clammy, probably in part 
owing to "the deficiency of liquid in the blood-vessels. Constipation of the 
bowels is an almost constant attendant on the disease. This has been ascribed 
to a spasmodic constriction of the intestinal muscles, to constriction of the 
sphincter ani, and to the deficiency of secretion into the alimentary canal con- 
sequent on excessive secretion from the skin. But the chief cause is probably 
the diversion of the nervous influence requisite to the due sensibility of the 
bowels, and its powerful concentration upon the voluntary muscles. The 
discharges are often unhealthy. 
Respiration suffers greatly. The breathing is often short, hurried, and 
anxious; and, in consequence of the rigidity of the diaphragm and other 
respiratory muscles, the chest is so imperfectly expanded, that a feeling of the 
most painful dyspnoea is sometimes experienced. In its highest grade, this 
amounts to absolute suffocation; the air in the lungs is unchanged; the face 
becomes livid; and death takes place from apnoea. Another source of dis- 
tress and danger is spasm of the glottis, an accession of which, there is reason 
to believe, is sometimes the cause of those sudden deaths which occur in the 
midst of a spasmodic paroxysm. The patient, under these circumstances, 
evinces signs of intense agitation and suffering, and by clutching at his throat 
seems to show that the difficulty exists in the larynx. The disagreeable 
harshness of voice which is occasionally observed in tetanus, probably has its 
source in constriction of the muscles of the glottis. 
The circulation, in pure cases of tetanus, when not excited by the action of 
the muscles, is often nearly or quite natural. But, as muscular contraction 
always calls for an expenditure of blood, the heart is stimulated to a more 
frequent action during the spasmodic paroxysms; while the intense nervous 
disturbance gives irregularity and inefficiency to its efforts. Hence, under 
these circumstances, the pulse is apt to be frequent, small, irregular, and 
feeble, especially towards the close of the disease, when the heart is exhausted 
by the combined influence of intense irritation, and defective nutrition. 
During the most violent paroxysms, the frequency is occasionally very great; 786 
[part II. 
LOCAL DISEASES.-NERVOUS SYSTEM. 
and Mr. Curling mentions a case in which it amounted to 180 in the minute. 
There is no fever, strictly speaking, in tetanus unassociated with inflamma- 
tion ; and blood drawn from the body does not exhibit the buffy coat. The 
temperature of the surface, however, is often above the natural standard, and 
sometimes very greatly so. In the case of a boy twelve years old, under the 
care of M. Prevost, of Geneva, a thermometer with the bulb in the axilla 
stood between 110° and 111° F., and Dr. Bright describes a case in which 
the temperature in the axilla was 105°. (Curling on Tetanus.') 
The patient often perspires profusely, probably in consequence of the vio- 
lent muscular action, and great suffering. A miliary eruption sometimes 
attends the profuse sweats. The other secretions are ordinarily diminished. 
The bile flows less freely, exhalation from the mucous membranes is some- 
what checked, and the urine is generally scanty and high-coloured. 
The mind is in general remarkably clear throughout the complaint. There 
is no stupor, no delirium, and little other cephalic affection, until near the 
close of the case, when the intellect sometimes wanders. The patient is apt 
to be sleepless from excess of pain, or, if he falls asleep during the lull of the 
paroxysms, is soon awakened by their recurrence. It is said that the spasm 
is relaxed during sleep. This is true of the paroxysmal spasm, but not gene- 
rally of the tonic rigidity. The fact probably is, not that sleep suspends the 
paroxysm, but that it takes place in consequence of the suspension. Mr. 
Mayo relates the case of a boy, in whom the muscles were completely relaxed 
during sleep, and the spasmodic rigidity returned when he was awakened. 
Other similar cases have been observed. But it is well known that instances 
now and then occur, in which there is a complete suspension of the muscular 
contraction, either spontaneously or under the effect of remedies. It could 
scarcely be otherwise in such cases, than that the interval should be occupied 
by sleep. The spasm returns when the patient is awakened, because the 
slightest agitation often serves to bring about this result. 
It is a singular fact, that, though the violent spasms exhaust the excita- 
bility of the heart, they are not attended with the sense of fatigue that fol- 
lows great muscular exertion under the influence of the will. 
It should be borne in mind that all cases of tetanus do not present the 
whole series of phenomena above detailed. This disease has every possible 
grade, from a moderate stiffness of the muscles of the neck, of the jaws, of 
the back, perhaps of a single limb, up to those terrible cases in which almost 
every voluntary muscle assumes in its turn a board-like rigidity, alternating 
occasionally with the most fearfully painful spasm. 
The course of the disease, moreover, differs in different cases. In some 
quite continuous, and advancing with an uninterrupted progress to a fatal 
result, it is in others remittent, and in others again intermittent; and this 
tendency to relaxation in the symptoms may be regarded as a favourable sign. 
In regard to its duration, it may terminate fatally in less than a day, or may 
continue for a week or more. Some doubtful cases are related, in which death 
has taken place almost immediately after the reception of the injury, or the 
commencement of the symptoms, and others, less suspicious, in which it has 
been postponed for two, three, or four weeks. But the greater number of 
patients die between the end of the first and beginning of the fifth day, and 
very few survive the eighth day, who do not ultimately recover. 
Death occurs either from apnoea, consequent on spasm of the glottis or 
immobility of the respiratory muscles, or from pure exhaustion of the vital 
powers through excessive nervous excitement and want of nutrition, or pos- 
sibly, sometimes, from a spasmodic seizure of the heart. 
Recovery is usually slow and gradual. The spasms diminish in violence CLASS HI.] 
787 
TETANUS. 
and frequency, the rigidity relaxes, and not unfrequently the patient expe- 
riences a sense of formication in the limbs, as the muscles again come under 
the control of the will. Some cures take place in less than a week ; but not 
unfrequently the disease runs on for several weeks, and sometimes two or 
even three months elapse before complete recovery. A certain degree of stiff- 
ness often remains long after the patient is deemed well. It is more espe- 
cially the idiopathic variety of tetanus that assumes the protracted form. 
The disease is occasionally complicated with other affections. Sometimes 
epilepsy assumes something of the tetanic character; and we have, along with 
the coma and convulsions of that disease, a more or less extensive tonic 
rigidity of the muscles. Hysteria too is now and then associated with te- 
tanic symptoms. Inflammation of the spinal marrow and brain, or of their 
meninges, is a more common accompaniment. In such cases, with the spasms 
of tetanus, we have the symptoms of the other affections respectively, pain 
along the spine or in the head, fever, loss of appetite, a furred tongue, a 
frequent pulse, perhaps delirium, paralysis, and ultimately coma before death. 
There is an exceedingly fatal variety of tetanus which merits a distinct no- 
tice; that, namely, which occurs in infants soon after birth, and has received 
the name of trismus nascentium. It is much more common in hot than 
in temperate latitudes; and is very destructive among certain classes of the 
population in the West Indies, and portions of our Southern States. It is 
said to affect especially the children of the blacks, and in some situations, 
while more than one-half of the coloured infants who are born die of the dis- 
ease, scarcely a white child is attacked. The seizure takes place usually 
within the first week from birth, and has scarcely ever been noticed after the 
end of the second week. It is especially apt to be attended with spasmodic 
closure of the jaws, whence its name of trismus nascentium, though other 
muscles also are affected. It is usually ascribed to irritation arising from the 
cutting of the cord, and dissection has generally revealed ulceration at the 
umbilicus, with more or less inflammation of the investments of the umbilical 
vessels, and of the peritoneal membrane. Much influence has been ascribed 
to improper or careless dressing of the umbilicus, so common with the class 
of people among whom this affection is generally found.* A bad state of the 
infant's constitution, arising from the hot and foul air in which it has been 
born, and by which it has been influenced while in the fetal state, through 
the system of the mother, probably constitutes an essential predisposition. 
The disease is very seldom cured. Many extensive practitioners, who have 
seen a great deal of it, declare that they have never known an instance of 
recovery. Prophylactic measures are all important under these circum- 
stances ; and experience has proved that attention to ventilation, cleanliness, 
* This cause of trismus nascentium is much insisted on by Dr. John M. Watson, Pro- 
fessor of Obstetrics, &c., in the Nashville University, in a pamphlet«upon this disease, 
published at Nashville, in 1851. Among the careless negro population of the South, 
where the disease most prevails, there is often extreme neglect of proper dressings to the 
umbilicus, which is not unfrequently found irritated by the urine and fecal matter with 
which the dressings are soaked, and offensive from the putrefaction of the cord. After 
extensive inquiries, Dr. Watson has found that the disease rarely, if ever, occurs when 
due attention is paid by an intelligent person to the dressing of the cord. As the disease 
is almost necessarily fatal, prevention is all important; and this is one of the most effect- 
ive prophylactic measures. Peculiai- attention should be paid to the keeping of the part 
dry, and free from all sources of irritation, and especially from that of the urine or feces. 
After the separation of the funis, should there be the least appearance of irritation or 
inflammation, an emollient poultice should be applied. Besides this prophylactic mea- 
sure, it is also important to provide for the general health, by attention to the usual 
hygienic influences, such as cleanliness, pure and fresh air, and wholesome diet, both 
in reference to mother and child, before and after delivery. (Note to the third edition.) 788 
[part it. 
LOCAL DISEASES.-NERVOUS SYSTEM. 
and the proper management of the infant, has vastly diminished the preva- 
lence of the disease.* 
Anatomical Characters.-It often happens that no material traces of disease 
can be discovered either in the brain or spinal marrow. Dr. Gerhard declares 
that he has examined these parts with great care in ten or twelve subjects, 
and could detect no lesion which seemed to have the least influence in the 
production of the symptoms. (Tweedie's Syst. of Pract. Med., Am. ed., Ar- 
ticle Tetanusd) Dr. Todd has repeatedly examined, by means of the micro- 
scope, the spinal cords of animals killed by strychnia, without ever having 
been able to detect the slightest morbid change; and it is well known that the 
effects of this poison are closely analogous with the symptoms of tetanus. 
(Lond. Med. Gaz., Sept. 1850, p. 915.) In many instances, however, sanguin- 
eous injection of the cerebral and spinal meninges, and of the roots of the 
spinal nerves, serous effusion into the cavities, and increased vascularity of 
the brain and spinal marrow, have been observed. Blood has been noticed 
within the spinal sheath. In a few cases, stronger evidences of inflammation 
have been offered in thickening of the meninges, softening of the medulla or 
brain, and cerebral abscess; and tubercles and other concretions have been 
found within the cranium. Small bony or cartilaginous plates have been 
repeatedly seen beneath the spinal arachnoid; and these have been supposed to 
have some agency in the production of the disease; but they are often quite 
wanting. Mr. Curling, though he has examined the spine with care in at 
least a dozen instances, has never met with them. (Treat, on Tetan., Am. 
ed., p. 38.) • 
The nerves involved in the wound, and proceeding from it towards the spine, 
have been found lacerated, reddened, thickened, softened, and otherwise vari- 
ously altered; but the same phenomena have been observed in wounds not 
attended with tetanus. The ganglia, especially the cervical and semilunar, 
* In communications by Dr. J. Marion Sims, of Montgomery, Alabama, to the Ame- 
rican Journal of the Medical Sciences (April, 1846, and July and October, 1848), new views 
have been advanced in relation to the cause of trismus nascentium, and very encourag- 
ing statements made in relation to its curability. According to Dr. Sims, the proper 
pathological condition is undue pressure upon the medulla oblongata and the nerves 
originating from it, produced by some displacement of the cranial bones, and especially 
of the occipital. In the far greater number of cases, the occiput is displaced inwardly, 
with its edges overlapped by those of the parietal bones. This the author considers as 
an ordinary physiological result of the parturient state, and as becoming a pathological 
condition only by persistence for some time after birth. Pressure made on the occiput 
by the position of the infant on its back is a cause of this persistence. The remedy is 
to restore the bone to its proper position, which may be done generally by placing the 
infant upon its side. In some instances, it may be necessary to resort to a surgical ope- 
ration. (See the account of such an operation by Dr. Harrison, in the Am. Journ. of 
Med. Sci., N. S., xvi. 75.) In twelve cases, the disease was cured by simply rectifying 
the position of the occiput. (Note to the second edition.) 
Since the publication of Dr. Sims' paper, a case of trismoid disease has been success- 
fully treated by Dr. Ostrander, of Brownsville, Missouri, upon his principles; but it is 
propei' to state that real trismus had not been fully developed. (St. Louis Med. and Surg. 
Journ., vi. 315.) Dr. John M. Watson, however, in the treatise above referred to, 
denies altogether the origin of trismus nascentium in displacement of the cranial bones; 
and Dr. A. G. Mabry, in a paper on the diseases of Selma, Alabama, published in the 
New Orleans Med. and Surg. Journ. (vi. 620), states that he has never been able to dis- 
cover any displacement of the bones of the cranium or vertebral column in this affection. 
(Note to the third edition.) 
Two cases of trismus nascentium have been treated successfully with cannabis indica 
(Indian hemp) in Charleston, S. C., one by Dr. P. C. Gaillard, the other by Dr. H. W. 
De Saussure. The quantity given varied from about 6 to 15 minims of the tincture, at 
intervals of from half an hour to two hours. (Charleston Med. Journ. and Rev., viii. 
808.) Note to the fourth edition. CLASS III.] 
789 
TETANUS. 
have also been found injected. Other occasional phenomena noticed after 
death have been rupture of the muscles, particularly of the rectus abdominis; 
an unusual rigidity of the muscles; worms in the alimentary canal; and signs 
of inflammation in the stomach, bowels, and peritoneum. The larger papillae 
at the base of the tongue have been seen swollen, and the larynx injected, 
and lined by a frothy mucus. A greatly diminished bulk of the heart, with 
extraordinary firmness of its parietes, has been observed in one case; but 
this is a rare phenomenon. 
Causes.-A peculiar predisposition is probably requisite to the production 
of tetanus; as comparatively few are attacked of those exposed to the exciting 
causes, though these may be to all appearance similar. In what this predis- 
position consists is unknown. That a long continued prevalence of heat favours 
its production is highly probable; for the disease is incomparably more fre- 
quent between the tropics, than in cold or temperate latitudes; and, in vary- 
ing climates, is more apt to occur in the hot than the cold seasons. This at 
least has been generally admitted to be the case; but, from the account by 
Dr. Laurie of the cases treated in the Glasgow Hospital, and from the re- 
ported deaths from the disease in London for the ten years ending in 1851, 
it appears that, in Great Britain, the number of cases in the winter months 
is quite equal to that of the summer months, if not greater. (Loud. Med. 
Times and Gaz., June, 1854, p. 620.) 
The disease appears sometimes to occur under epidemic influence, espe- 
cially in the idiopathic form. Dr. J. E. Thompson, of Missouri, in a com- 
munication published in the Boston Med. and Surg. Journal (L. 314), states 
that in the months of March, April, May, and June, 1853, he had attended 
no less than forty cases, of which two only were traumatic. 
It has been supposed that a depraved state of health, resulting from bad 
diet, vitiated air, and a residence in low, damp situations, sometimes consti- 
tutes a predisposition; and yet the traumatic form of the disease often occurs 
in the young, robust, and vigorous. 
Males are much more frequently and severely affected than females. This, 
no doubt, arises in part from the much greater exposure of the former to 
wounds, and other exciting causes; yet there is probably a constitutional dif- 
ference in the two sexes in relation to nervous disease, corresponding in some 
measure with their respective physical energies; women being more liable to 
the mild affections of hysteria and chorea, while men suffer more from apo- 
plexy and tetanus. 
Persons are most subject to the disease from ten to fifty; but no age is ex- 
empt. It is rare in advanced life. As already stated, infants soon after birth 
are exceedingly apt to suffer from it, in certain regions within the tropics. 
It appears to be a well ascertained fact, that the negro is more disposed to 
tetanus than the white. Some have ascribed the difference to the greater 
exposure and worse living of tl e former; but, under apparently the same 
circumstances, negroes have appeared to suffer most. 
Of the exciting causes incomparably the most frequent, in cold and tem- 
perate countries, are wounds or other kinds of external violence. Much stress 
has been laid by different writers upon the condition and character of the 
wound. Dr. Rush observed that it was destitute of inflammation; and other 
writers have noticed an unhealthy appearance, such as a pale or livid colour, 
an ichorous secretion, dryness, &c. But the general impression at present is, 
that tetanus is equally liable to occur in all conditions of the wound, whether 
healthy or unhealthy, before or after suppuration, in the process of healing, 
or after the healing has been completed; and the circumstance of the occa- 
sional vicious state of the wound is rather ascribed to the same constitutional 790 
[PART II. 
LOCAL DISEASES.-NERVOUS SYSTEM. 
tendencies which lead to tetanus, than considered as a cause of it. Whether 
the wound is trifling or severe seems to be of little consequence. The slightest 
scratch will sometimes cause the disease, the most severe injury often fails to 
do so. As examples of the kinds of wounds which have given rise to tetanus, 
may be mentioned those produced by needles in the fingers, a splinter under 
the nail, the extraction of a tooth, a fishbone in the fauces, the insertion of 
artificial teeth, the cutting of corns, running nails in the feet, the insertion of 
a seton, cupping, fractures and dislocations, contusing and lacerating bodies, 
and all kinds of surgical operations. It is believed that lacerated and punc- 
tured wounds are worse in this respect than smooth cuts, and injuries of the 
fingers, soles of the feet, and joints, than wounds elsewhere. It is highly 
probable that, when the disease has been ascribed to slight injuries, perhaps 
already healed, it has sometimes originated from other causes. The interval 
between the reception of the wound and the occurrence of tetanus is very 
uncertain. According to the statement of authors, it may be a few minutes, 
a few hours, several days, or even weeks. Most commonly the attack comes 
on between the fourth and fourteenth day after the injury. If it should not 
supervene before the end of three weeks, the patient may be considered safe. 
The longer the interval, the milder generally is the attack said to be, and the 
more likely to end in recovery. The disease is thought to occur less fre- 
quently than formerly, in consequence of the greater care extended to the 
wounded, and the greater skill exhibited in their treatment. Soldiers wounded 
in battle are said to be more apt to suffer than those wounded in civil life, 
because so often exposed to cold, wet, and privations after their injuries, and 
often so badly cared for from the want of suitable surgical assistance. 
Other local irritation besides that of wounds may occasion the disease. 
Thus, it is thought to have arisen from swollen gums, ulcers, intestinal worms, 
calculi in the bladder, and a dead foetus in the womb; and has been ascribed 
to inflammation of the stomach and bowels. Inflammation of the spinal me- 
ninges is probably an occasional cause of it. Violent mental emotion, espe- 
cially terror, has been accused of producing tetanus; and Dr. Rush relates a 
case in which it was ascribed to harsh grating sounds. Nux vomica and its 
kindred substances, in poisonous quantities, produce effects which cannot be 
distinguished from tetanus. I think it highly probable that rheumatism or 
gout may sometimes seize upon the medulla spinalis, and produce the pheno- 
mena of this disease. But infinitely the most common cause of that variety 
of tetanus which is independent of wounds, and is here denominated idiopathic, 
is exposure to cold, when the body has been hot and perspiring. Sleeping out 
upon the damp ground is a frequent cause; and the use of a cold bath when 
perspiring, and of very cold water as a drink under similar circumstances, are 
said to have produced it. Such exposure is the most frequent cause of the 
disease in tropical countries. It is apt to come on within a few hours after 
the exposure. When arising from this cause, it is more apt to be chronic and 
curable than when from wounds. The occurrence of traumatic tetanus is much 
favoured by the co-operation of cold, and other causes of irritation; and it is 
probable that the two causes together may give rise to the disease, when 
neither separately would have been sufficient. 
Nature.-There is little doubt that the proper seat of tetanus is in the spinal 
marrow, including the medulla oblongata. The morbid action may extend 
also to the white matter of the brain. The absence of coma and delirium 
would indicate the want of participation of the cortical substance. That the 
disease does not reside in the muscles is proved by the instant cessation of the 
spasm, in any particular muscle, when the nerve by which it communicates 
with the spine is divided. CLASS III.] 
791 
TETANUS. 
By some authors the disease is looked upon as simply a form of spinal me- 
ningitis or myelitis. But inflammation of an organ seldom leads to such an 
excess of function. On the contrary, it generally diminishes or abolishes 
function. Hence one of the most common results of inflammation within the 
spine is paralysis. It is true that inflammation of one part may extend an ir- 
ritant action to another and sound part; and hence we do really have tetanic 
spasm sometimes mingled with the other symptoms of myelitis. Hence tetanus 
does occasionally originate in inflammation within the spinal column. But the 
inflammation does not constitute the disease. It is only a cause of it; and in 
such cases there are symptoms of the myelitis or spinal meningitis, as pain 
and tenderness on pressure, fever, furred tongue, loss of appetite, and paraly- 
sis, mingled with the tetanic symptoms. 
Dissection often exhibits an injected state of the spinal and cerebral me- 
ninges, and, to a certain extent, of the nervous substance; but this is only con- 
gestion, not inflammation. It is in all probability the result, and not the cause 
of the disease. Besides, even this indication of an excess of vascular action 
is sometimes wanting. 
The phenomena, as well during life as after death, are best explained upon 
the supposition, that the disease is a mere irritation of the spinal marrow, in- 
cluding the medulla oblongata, and possibly, to a certain extent, the white 
cerebral fibres. This irritation may be propagated from the injured extremities 
of the nerves, as in wounds; or from other sources of excessive excitement, as 
the intestinal mucous ^membrane in verminose affections; or it may originate 
in the spinal marrow itself through causes acting on that structure, such as 
cold, or rheumatic influence. The irritation thus excited in the medullary 
columns, is extended to the muscles, and produces tetanic spasm, exactly as the 
same effect is caused by irritating the spine directly by running an iron wire 
into it, or by mechanical injury of one of the motor nerves proceeding from it. 
As before suggested, spinal meningitis may sometimes produce tetanus by ex- 
tending an irritation to the nervous matter; and even myelitis, in one part, 
may give rise to a mingling of tetanic spasms with paralysis, by propagating 
irritation to a neighbouring sound part. 
The vascular injection, without other marks of inflammation within the 
spinal canal, is the result of the irritation, just as redness of the conjunctiva 
is produced by neuralgia of the eye. How it should happen that the nerves 
of the wounded part should remain apparently quiescent for some time, occa- 
sionally even till the wound has healed, is one of the mysteries of which so 
many remain unsolved in relation to nervous action. We may coujecturally 
say that, at one period of the wound, the requisite irritability of the spinal mar- 
row which constitutes the predisposition is not yet in existence, and is to become 
developed by the circumstances under which the patient may be placed. But, 
if this were true, it would only remove the difficulty a single step. It has 
been well ascertained that, though the spinal irritation may be set on foot by 
the local cause, it is afterwards capable of sustaining itself, and may continue 
even though the cause has quite ceased to operate. 
We may infer that the upper portion of the column is first and most severely 
irritated, as it is in the parts of the body supplied with nerves from that region 
that the spasms are first produced, and are most violent, as in the face, back 
of the neck, and muscles of the chest. 
The mode in which death is produced has been already explained ; and it 
will have been observed that it is not inflammatory disorganization of the spinal 
marrow which causes the result, but an interference of the exterior effects of 
the irritation with the vital processes. 
Diagnosis.-1Tetanus is so striking in its characteristics that it can scarcely 792 
[part II. 
LOCAL DISEASES.-NERVOUS SYSTEM. 
be confounded with any other disease. Hydrophobia resembles it in some 
points, but is very different in others. (See Hydrophobia.') Hysteria some- 
times imitates it, as it imitates most other nervous diseases; but there are 
peculiarities which almost always render diagnosis easy. (See Hysteria.) The 
rigid, permanent muscular contraction of tetanus, with the paroxysms of acutely 
painful and more fugitive spasm; the peculiar pain at the scrobiculus cordis; 
the trismus, difficult deglutition, and embarrassed respiration; the peculiar 
expression of countenance; and the absence of coma and delirium, except 
a little of the latter in the very last stage, are sufficiently characteristic. There 
may be occasionally some embarrassment in deciding, how far certain cases 
which appear to be a mixture of tetanus with other diseases, as with spinal 
meningitis, epilepsy, and perhaps we might add rheumatism and gout, should 
be considered as belonging to the one or the other complaint. The poisonous 
effects of nux vomica may be looked on as a variety of tetanus. They can be 
distinguished only by a careful view of the circumstances which attended the 
origin of the affection. 
Prognosis.-Traumatic tetanus is exceedingly fatal. Some who have seen 
much of the disease assert that they have scarcely known a case of recovery. 
The most successful report but a small proportion of cures. The journals, 
however, teem with cases which have ended favourably under one or another 
kind of treatment; and, though some allowance must be made for the probable 
idiopathic character of some of the cases considered as traumatic, yet there can 
be little doubt of the accuracy of the statements in the greater number ; and 
sufficient encouragement is offered to the practitioner to persevere in an ener- 
getic use of measures which he may consider as indicated. The means of 
determining the general ratio of cures are altogether wanting; for it is not the 
custom to report unsuccessful cases. Out of forty-six traumatic cases, men- 
tioned in Curling's Treatise as having occurred to several surgeons in tropical 
climates, ten, or rather more than one in five recovered; and, as the disease is 
more severe in hot than cold climates, the average of recoveries may be con- 
sidered as greater than that stated. 
The idiopathic form of the disease is much less fatal; and, as it occurs in 
temperate latitudes, is generally curable, 
It is highly probable that the milder cases of tetanus, whether traumatic 
or idiopathic, would sometimes end spontaneously in health; so that caution 
is always necessary, in judging of the effects of remedies, not to confound them 
with the workings of nature. 
Favourable circumstances are original mildness of the symptoms, complete 
relaxation between the spasmodic paroxysms, the absence of any great embar- 
rassment of the respiration, a natural state of the circulation, the occurrence 
of sleep under the influence of remedies, and the protraction of the case beyond 
the seventh day. Extreme severity of the paroxysms, uninterrupted rigidity 
of many of the muscles, great difficulty of deglutition and respiration, an ap- 
parent tendency to spasm of the glottis, insusceptibility to the action of pow- 
erful remedies, and a very feeble, frequent, and irregular pulse, are symptoms 
of very bad augury.* 
* Mr. Colles believes that there are two distinct spasmodic affections resulting from 
wounds, which have hitherto been confounded under the name of tetanus. Confining 
the name of tetanus to the one which presents the ordinary phenomena of that disease, 
as described by authors, he, draws the distinction between the two affections in the 
following manner. Tetanus seldom appears before the second or third week; begins 
with stiffness in the throat; presents a constant rigidity of the muscles, rendering deglu- 
tition very difficult, and giving a peculiar aspect to the features; is attended with pain 
not in the wound but at the scrobiculus cordis; may continue for three or four weeks; CLASS III.] 
TETANUS. 
793 
Treatment.-One who depends upon authority alone would find extreme 
difficulty in coming to any satisfactory conclusion as to the treatment of this 
disease; for occasional, and perhaps equal success, is claimed for the most op- 
posite plans of management; and numerous remedies have been employed, 
each one of which is reported to have produced signal cures. But the fact 
appears to be, that the disease occasionally gets well of itself, and the credit 
is given to the medicine or medicines which may have been used, though 
possibly without the least influence over the result. Another difficulty in 
coming to a conclusion arises from the complexity in the means employed, so 
that it is impossible to determine how much of the resulting good is due to 
one, how much to another, or how much to their combination. In this uncer- 
tainty, the physician is thrown upon his principles; and will be justified in 
employing such measures as, according to his best judgment, may be indicated 
by the circumstances of the case, or may flow from his views of its pathology. 
The reader will bear in mind the views taken in the preceding pages of the 
nature of the disease; to wit, that it consists essentially in irritation of the 
spinal axis, giving a vast increase to the motor influence of that structure; and 
that, though it may occasionally be associated with inflammation, it is in no 
degree essentially connected with that condition. 
The following indications appear to be offered under this view of the disease; 
1. to remove any existing source of irritation; 2. to lessen the susceptibility 
of the nervous centres to any irritating influence which may exist ; 3. to di- 
minish the irritation by means calculated to depress nervous excitement; and 
4. to support the strength of the system, and especially of the heart, under the 
exhausting influence of the enormous muscular action. 
1. To remove any source of irritation.-Attention should be directed to the 
state of the wound. It was at one time the custom to recommend the appli- 
cation of irritant and caustic substances, with the view of bringing about in- 
flammation and suppuration. But satisfactory evidence is wanting that these 
measures have ever been beneficial; and it appears to me more accordant with 
a rational view of the pathology of the disease, to endeavour to diminish 
irritation in the wound, by emollient and anodyne applications. Poultices, 
having solution of sulphate of morphia, or some narcotic extract incorporated 
with them, would seem to be indicated. 
Early in the disease, if there is reason to believe that a nerve has been par- 
tially divided, contused, or lacerated, an incision may be made above the wound, 
so as to cut off its communication with the spine, provided the operation can 
be performed without considerable inconvenience. Several cases are on record 
in which such a measure apparently proved effectual. 
Upon the same principle, amputation of the limb above the wound has been 
proposed; and the operation has been frequently performed in cases of trau- 
matic tetanus, in which the wound was of such a nature as to require it, inde- 
pendently of the nervous affection. In a few instances, it appears to have 
arrested the disease when early performed; but it has failed in the great ma- 
jority, and cannot, therefore, be with propriety employed merely for the tetanus. 
Indeed, this disease has frequently supervened upon amputation. The most 
that can be said in its favour is that, when the practitioner, in a case of severe 
is in no degree benefited by amputation; and is in some measure a constitutional affec- 
tion. The other form of spasm comes on in three or four days; commences in the 
wounded limb; has intervals of relaxation in which the patient can swallow; is attended 
with pain in the limb, which is excruciating during the spasm; runs its course in three 
oi' four days; is relieved by no other means than amputation, which affords some chance 
of cure; and seems to have more of a local character than the other. (Du6. Quart. 
Journ. of Med. Sci., xiii. 39.) 794 
[PART II. 
LOCAL DISEASES.-NERVOUS SYSTEM. 
injury, may be balancing between the propriety of amputation, and an en- 
deavour to save the limb, the occurrence of commencing tetanic symptoms 
might be allowed to determine him in favour of the operation. 
The division of the main nervous trunk, at a convenient point above the 
wound, has been practiced in more than one instance with success. Decided 
symptoms of commencing tetanus, consequent upon a wound in the foot by a 
rusty nail, immediately gave way when the posterior tibial nerve was divided. 
(Curling, Am. ed., p. 71.) It is only, however, in the early stages that such 
operations can be performed with much hope of benefit. It is obvious that 
they can be at best but partially effectual, when the irritation has become 
established in the spinal marrow.* 
The cauterization of the wound by iron heated to redness, or even whiteness, 
was recommended by Larrey, and has been since employed with supposed ad- 
vantage. (See Am. Journ. of Med. Sei., N. S., xix. 217.) 
When there is any reason to suppose that the disease depends upon a decayed 
tooth, or upon one artificially inserted, it should be removed. 
Feculent accumulation, as a source of great irritation to the nervous centres, 
should be removed at the beginning of the treatment. Practitioners are al- 
most universally agreed upon the propriety of purging. Some brisk cathartic 
should be given, which will operate without materially irritating the mucous 
membrane. Senna and sulphate of magnesia; calomel combined with jalap 
or the compound extract of colocynth; calomel and castor oil; the compound 
cathartic pill of the U. S. Pharmacopoeia; or, in case of any existing difficulty 
of deglutition, croton oil might be selected. The bowels should be thoroughly 
cleansed at first, and afterwards kept open by mild cathartics, or enemata, as 
the case may require. Should worms exist at the same time, and especially 
the tape-worm, the best remedy would be a dose of oil of turpentine in con- 
nexion with castor oil, in the proportion of half a fluidounce or a fiuidounce 
of the former to a fluidounce of the latter. Cases of the disease have given 
way after the expulsion of the tape-worm by this remedy. 
To meet the same indication, bleeding should be employed when the pulse 
is tense and voluminous, and suspicion of spinal inflammation exists; as, for 
example, when tetanus has followed an injury directly to the spine, or when 
the tetanic symptoms are associated with pain and tenderness of the spine on 
pressure, formication or numbness of the lower extremities, and fever. Here 
the bleeding is intended to cure the inflammation, which may aggravate, if 
it does not cause the tetanic symptoms. Blood should be taken freely from 
the arm, and by cups from the spine. But bleeding in simple tetanus, with- 
out symptoms of spinal or cerebral inflammation, and especially when the 
pulse is not strong, appears to me not only uncalled for, but, in view of the 
great tendency to prostration in the advanced stage, highly hazardous. 
In similar cases, mercury may be employed as an adjuvant to the lancet 
for the cure of the spinal inflammation; and it should be pushed energeti- 
cally to the point of salivation. For this purpose calomel may be given 
very freely by the mouth, and mercurial frictions employed externally. To 
be useful, the impression must be promptly made. Mercury has often been 
used in ordinary cases of tetanus, and has been highly recommended by some 
practitioners. But, though many successful cases are on record, yet it is 
impossible in most of them to determine whether the result was ascribable 
to the mercury or the other means employed; and ample evidence might be 
adduced to prove, not only that it has very often failed, but that patients 
* Several successful cases of this kind are reported by Dr. Moses Sweat, of North 
Parsonsfield, Maine, in the New York Journ. of Med., N. S., vi. 194. CLASS III.] 
795 
TETANUS. 
have in numerous instances been attacked by tetanus while under the mer- 
curial influence. It possesses, therefore, no specific curative powers; and as, 
in case of ptyalism, the presence of saliva in the mouth proves not unfre- 
quently a source of excessive distress to the patient, from his dread of swal- 
lowing it, and yet inability to discharge it conveniently through his closed 
teeth, the medicine should be used only when the indication for its powerful 
antiphlogistic influence is called for. 
2. To diminish the susceptibility of the nervous centres.-The remedies cal- 
culated to meet this indication are chiefly the narcotics or cerebral stimulants. 
One of the most effectual of these, and the one which has been most employed, 
is opium. Much difference of opinion has existed in relation to the propriety 
of using it. Notwithstanding the contrary judgment of some distinguished 
authors, I cannot but think that the weight of testimony is greatly in its 
favour. It has probably been employed as one of the remedies in the great 
majority of cures. It is true that it has often failed. But in many cases all 
remedies fail. It is true, moreover, that it has been vastly abused, and that 
it has been murderously administered in some cases. What can be thought, 
for example, of a practitioner, who in the course of ten days should prescribe 
half a gallon of laudanum, and half a pound of opium? And yet this is 
said to have been done in tetanus. Should the violent nervous symptoms 
yield in such cases, what could be expected but death from the opium remain- 
ing in the stomach ? There is in tetanus an extraordinary insusceptibility 
to the action of opium; and the most enormous doses have been without 
apparent narcotic effect. In such cases, it is probable that the greater portion 
remains unabsorbed and inert in the stomach; but it is there, prepared to act 
when the insusceptibility, or the obstacle to absorption shall cease. If good 
do not accrue from opium in less than poisonous doses, it is useless to perse- 
vere. The liquid forms should always be preferred to the solid, as more 
readily absorbed. From half a fluidrachm to a fluidrachm of laudanum, from 
thirty to sixiy drops of the vinegar of opium, or from half a grain to a grain 
of one of the salts of morphia in solution, may be given every two hours until 
some narcotic effect is experienced, or the patient relieved; and, if no effect 
is produced in due time, the dose may be somewhat augmented; but I should 
prefer applying the medicine additionally to other surfaces, without increasing 
the quantity by the stomach. Thus, a grain or two of the sulphate of mor- 
phia may be injected into the rectum; or twice the quantity sprinkled upon 
a denuded surface in the epigastrium, obtained either by means of a fly blis- 
ter, or more speedily by the application of the strongest solution of ammonia. 
In idiopathic cases, or when there is much strength of pulse, the opiate may 
be usefully associated with ipecacuanha or tartar emetic. 
When a narcotic effect can be obtained by the opium, relief is generally 
experienced, and the symptoms ameliorated. Should opium fail, recourse can 
be had to extract of hemp, which has been highly recommended, and is 
thought to have effected cures in several cases. The great disadvantage of 
this remedy is the uncertainty of its strength ; and the dose of any particular 
parcel must be ascertained by its effects. Two or three grains of the extract 
may be given at first, and repeated every half hour, until its narcotic effect is 
experienced. In three or four hours, should it produce no effect, the quantity 
may1 be increased gradually till the dose amounts to ten grains; but the in- 
terval should now be lengthened to two or three hours. 
Alcohol is another remedy by which the same indication may sometimes be 
fulfilled. The object in the use of this medicine is to bring about its cerebral 
influence; in other words to intoxicate the patient, so that his brain and 
spinal marrow may be blunted to all impressions. Cures have repeatedly 796 
[part II. 
LOCAL DISEASES.-NERVOUS SYSTEM. 
followed this plan of treatment. The nervous system has the same insuscep- 
tibility to the influence of this cerebral stimulant as to that of opium, and it 
is necessary to employ large quantities. The use of wine was strongly re- 
commended by Dr. Rush, and has had many advocates. Brandy would be 
more effectual; and alcohol has been recently employed. The quantity to be 
used is almost indefinite. Quarts and even gallons of wine have been used 
daily for many days together. As soon as symptoms of stupefaction appear, 
the stimulant should be suspended, and resumed when they cease, should the 
tetanus not have yielded. I confess that I prefer the opiate plan, and would 
resort to the alcoholic only in case of obvious weakness of the circulation, or 
as an adjuvant of the opium. It should, of course, never be used where 
there are symptoms of spinal inflammation. 
Stramonium and belladonna have also been administered; but when opium 
and hemp fail, little good can be expected from these narcotics. Frictions 
over the whole body with a strong tincture made by rubbing up five parts of 
the extract of belladonna, and eleven of'alcohol, are said to have proved 
effectual in one case. (See Lond. Med. Gaz., Aug. 1850, p. 263.) 
Since the publication of the first edition of this work, numerous cases have 
been recorded in which recovery from tetanus followed the inhalation of ether 
or chloroform, and others in which these remedies afforded great relief, with- 
out preventing a fatal issue. Chloroform, however, must be used in this 
manner with great caution; as it is powerfully and sometimes fatally seda- 
tive; while one of the great dangers of the disease is from exhaustion. The 
same remedy is said to have been used successfully, applied by means of 
friction over the whole surface of the body. 
3. To diminish directly the nervous irritation.-This indication may be 
met by two sets of measures; first, those which are sedative to the nervous 
system; and secondly, those which act revulsively. Of the former the most 
efficient is tobacco. Many cures, said to have been effected by this powerful 
sedative, are on record; and it is probably among the most efficacious reme- 
dies in tetanus. It is singular that, while the nervous system is so insuscepti- 
ble to the influence of opium and the other cerebral stimulants, it should be 
easily impressed by tobacco and the nervous sedatives generally. But this 
remedy must be used with caution. The system may be easily prostrated be- 
low the point of reaction. The best form of administration is by enema. 
Half a drachm may be infused in half a pint of boiling water, and the whole 
administered by injection. In an hour, if no effect is experienced, the dose 
may be repeated; and afterwards at intervals of two or three hours till its re- 
laxing effects are obtained. The tobacco bath has also been used; but, while 
immersed in this, the patient should be closely watched, and removed imme- 
diately upon the occurrence of signs of prostration. The same sedative may 
be applied in the form of a cataplasm along the spine. Should prostration 
ensue, it must be counteracted by carbonate of ammonia, brandy, or ether; 
and tobacco has been successfully employed conjointly with stimulants. 
Digitalis and hydrocyanic acid have been employed for the same purpose as 
tobacco; but they are less efficient and not so manageable. Another remedy, 
indicated from its powerful sedative properties, is aconite. A case has been 
recorded in which it proved successful, in doses of four drops of the saturated 
tincture of the root, repeated until symptoms of its peculiar poisonous action 
w£re induced. (Ranking's Abstract, vol. ii. part 1, p. 155.) Dr. Poitevin, 
of Mobile, succeeded in one case of the disease with tartar emetic and lauda- 
num, given so as to sustain a profuse and constant perspiration; but Dr. 
Dowler, of New Orleans, found the remedy to fail in a case in which he 
subsequently tried it. (A( 0. Med. and Surg. Journ., x. 769.) CLASS III.] 
TETANUS. 
797 
The external application of cold water is another sedative measure which 
has often proved effectual. It is necessary that the water should be little 
above the freezing point, say 40° F., or between that and 50°. It may be 
poured from a considerable height by pailfuls on the naked patient, or may 
be used as a bath. Great reduction of the vital actions is induced, with re- 
laxation of the spasms; and the remedy must be reapplied at proper intervals 
on their return. After its use the patient should be put into bed, wiped dry, 
and stimulated by carbonate of ammonia, and hot spirit if requisite. But the 
plan is hazardous, and immediate death from syncope has resulted in at least 
one instance. Ice to the spine has been successfully used.* 
The warm bath is another sedative which has sometimes been employed, 
though scarcely energetic enough to produce much effect in the more violent 
cases. It is recommended in the muscular rigidity which is apt to remain 
during convalescence. Cures by the vapour-bath have been reported. 
The second mode of meeting the indication is by revulsives. A blister 
along the whole length of the spine has been employed. But the most effec- 
tual plan is that put into practice by the late Dr. Jos. Hartshorne of this city. 
It consists in applying along the spine, from the occiput to the sacrum, a 
solution of caustic potassa, containing two or three drachms of the alkali in 
four fluidounces of water. This is rubbed upon the skin by means of a 
sponge, until the surface is much reddened, and signs of a caustic action are 
displayed, in some one point, by the discoloration of the skin. The remedy 
may be repeated when the inflammation disappears. It has been used with 
much success in a number of cases. The late Dr. Hartshorne relied chiefly 
upon this measure, with opium moderately employed, and purging. He in- 
formed me that he had effected cures of tetanus in six or seven instances. 
4. To support the strength of the system.-This becomes all-important in 
the advanced stages, when the heart begins to give way. Whenever the 
pulse is feeble, no matter what may be the stage of the disease, cordial 
medicines and nutritious food should be employed. Wine and the different 
forms of ardent spirit, milk, animal broths, the yolk of egg, &c., should be 
freely used. Sulphate of quinia may be administered with the same view. 
Besides the remedies above enumerated, many others have enjoyed more 
or less credit. One which promises fairly, and which experience has shown 
to be apparently efficacious, is sulphate of quinia, used not merely as a tonic, 
but with a view to its powerful and peculiar influence on the system in heroic 
doses. It may be given to the amount of a drachm in twenty-four hours, un- 
less found to produce its characteristic effects on the brain in smaller doses. 
Subcarbonate of iron is another tonic which has been employed with asserted 
success. It has been used in enormous quantities, in one instance to the 
extent of half an ounce every two or three hours, and even of a pound daily. 
These enormous doses are probably quite unnecessary; for of the quantity 
taken, a very large proportion must remain inert in the bowels. 
Oil of turpentine has had no little reputation in the treatment of tetanus. 
Cures effected by it have been reported. It may be given in the dose of a 
fluidrachm repeated every two hours, until it evinces some disagreeable effect, 
or the patient recovers. 
Acetate of lead in large doses, musk, carbonate of potassa, colchicum, 
strychnia, electricity or galvanism, and extract of stramonium or other nar- 
* Dr. B. D. Carpenter, of Cutchogue, Suffolk Co., Long Island, reports two cases of 
severe traumatic tetanus, which recovered under the use of ice applied to the head, 
and along the whole length of the spine. The application was repeated at intervals 
varying from two to eight hours, and continued from ten to thirty minutes each time. 
[New York Med. Times, ii. 46 J 798 
LOCAL DISEASES.-NERVOUS SYSTEM. 
[part it. 
cotic injected into the veins, are remedies, which, alone, or conjointly with 
some of the measures above enumerated, are said to have effected cures. 
A patient recovered, under the care of Cruveilhier, by sustaining through 
voluntary effort a constant regular respiration, in measured time, the inspira- 
tions being made as deep as possible. This was kept up for four hours, 
when the patient fell into a profound sleep. It was renewed again when he 
awoke, and continued until he again fell asleep. After this the paroxysms 
were milder, and he gradually recovered. {Braithwaite's Retrospect, xxi. 96.) 
The following is a brief summary of the remedies which seem to be indi- 
cated, viz., the removal or correction of obvious sources of irritation ; active 
purgation ; bleeding when the pulse is strong, and symptoms of spinal or 
cerebral inflammation exist; the use of opiates, hemp, tobacco, or aconite, 
and the inhalation of ether or chloroform; the cautious use of the cold bath; 
the application of a solution of caustic potassa or of a blister along the spine, 
or of ice to the same part; and the free employment of alcoholic stimulants, 
and nutritious food, when symptoms of debility appear. 
In consequence of the closure of the jaws, there is occasionally some diffi- 
culty in introducing food ; but a vacancy can generally be found either from 
the loss of a tooth, or behind the last teeth, large enough for the admission 
of liquids. A greater difficulty is that often attendant upon deglutition. To 
obviate this it may be necessary to inject food into the stomach through a 
tube; or to attempt to supply the place of food by nutritious enemata. 
Article F. 
HYDROPHOBIA. 
Syn.-Rabies.-Rabies Canina. 
Hydrophobia (from £3wp, water, and $o/3o$, fear) is a peculiar disease, re- 
sulting from the entrance into the system of the poison of a rabid animal. 
The poison is almost always received through a wound, generally the bite of 
the animal. This heals like any other wound, and for some time no peculiar 
or constitutional effects are experienced. It is seldom that the first symp- 
toms of the disease appear before the twentieth day after the injury. 
Symptoms, Course, &c.-The first warning of the approaching attack is 
frequently a feeling of pain in or near the seat of the wound, extending to- 
wards the trunk. If not acute pain, there is some unusual sensation, such as 
aching, tingling, burning, coldness, numbness, or stiffness, in the cicatrix, 
which swells, becomes of a reddish or livid colour, sometimes opens, and, if 
yet unhealed, assumes an unhealthy appearance, and discharges a thin ichor- 
ous fluid instead of pus. Along with these local symptoms, some nervous 
disturbance is generally experienced; the patient becomes dejected, morose, 
irritable, restless; light is disagreeable to him; his sleep is troubled; pains 
are felt in various parts of the body; and signs of digestive disorder are not 
unfrequent. After the continuance of one or more of these preliminary symp- 
toms for a period, varying from a few hours to five or six days, and sometimes 
without any of them, the patient becomes sensible of a stiffness or stricture 
about the throat, and, in attempting to swallow, experiences some difficulty, 
especially in the deglutition of liquids. This may be considered as the com- 
mencement of the attack. The difficulty of swallowing rapidly increases, and 
soon the act becomes impossible unless with a resolute effort, exciting the 
most painful spasms in the fauces, and other indescribable sensations, which 
appear to appal the patient, and cause him to dread the very thought of CLASS III.] 
HYDROPHOBIA. 
799 
liquids. Singular nervous paroxysms come on. Sensations of stricture or 
oppression are felt about the throat and chest; the breathing is painful, em- 
barrassed, interrupted with frequent sighs, or a peculiar kind of sobbing 
movement; there is a sense as of impending suffocation, and of necessity for 
fresh air; shuddering tremors run through the whole frame, sometimes 
amounting almost to convulsions; and a fearful expression of anxiety, terror, 
or despair, is depicted on the countenance. The paroxysms are brought on 
by the slightest causes, and are frequently associated with the attempt to 
swallow liquids, or with the recollection of the sufferings experienced in 
former attempts. Hence, anything which suggests the idea of drinking to 
the patient will throw him into the most painful agitation, and convulsive 
spasms. The sound of water poured from one vessel into another, the sight 
of liquids or of objects which bring them to mind, as of the shining surface 
of a mirror, a current of cold air, or other cold substance touching the skin, 
may have this effect. 
Another characteristic feature of the disease is a copious secretion of a 
viscid mucus in the fauces, which the patient spits out, with a sort of frantic 
vehemence and rapidity, upon everything around him, as if the idea of swal- 
lowing occasioned by the liquid induced this eager expulsion of it, lest a drop 
might pass down the throat. This to a by-stander is sometimes one of the 
most striking phenomena of the case. 
Acute, and, as it were, electric shocks of pain are now and then felt in the 
epigastrium, the back of the neck, and other parts of the spine. 
The mind is sometimes calm and collected in the intervals between the 
paroxysms, and consciousness is generally retained; but, in most cases, there 
is at times more or less mental irregularity, and occasionally spells approach- 
ing to insanity come on. Not unfrequently he is aware of the approach of 
these spells, and, fearful of doing injury to those around him, begs that he 
may be restrained. The mental aberration is often exhibited in groundless 
suspicion or apprehension of something extraneous, which is expressed on the 
face and in the manner of the patient. Sometimes, on the contrary, he takes 
a curious fancy to individuals, and lavishes on them marks of fondness and 
confidence. In comparatively rare instances, he gives way to a wild fury, 
like that of a savage beast when enraged; roars, howls, curses, strikes at per- 
sons near him, rends or breaks everything within his reach, bites others or 
himself; till, exhausted at length, he sinks into a gloomy, listless dejection, 
from which another paroxysm rouses him. 
The tongue is usually somewhat furred. There is often«burning in the 
throat, with thirst which cannot be gratified. Sometimes there is a sense of 
hunger, sometimes nausea with vomiting. The pulse is excited, sufficiently 
strong at first, but weaker as the case advances, and extremely feeble and fre- 
quent before its close. The skin is warm or natural in the beginning, but 
becomes cool in the end, and is often covered with a viscid, offensive sweat. 
Not unfrequently paralytic symptoms come on before death. 
Remissions of the symptoms sometimes occur in the course of the com- 
plaint; during which the patient can drink, though with some difficulty, and 
can take food. Towards the close, such a remission is not uncommon with an 
absence almost complete of the painful symptoms, so that the patient and the 
physician begin to entertain some hope. But if the pulse is now felt, it is 
found to be extremely feeble, and sometimes wanting. During this apparent 
relaxation of the disease, the patient occasionally falls into a sleep, from which 
he awakes only to die. The closing scene is marked by an excessively feeble 
or absent pulse, a cold skin, involuntary evacuations, and wandering or deli- 
rium ; and death approaches either quietly, as a consequence of complete 
exhaustion, or in strong convulsions. 800 
LOCAL DISEASES.-NERVOUS SYSTEM. 
[PART II. 
The disease generally terminates between the second and fifth day, though 
it sometimes runs on to the seventh, eighth, or ninth. 
Anatomical Characters.-Nothing has been found which can throw any 
satisfactory light upon the disease. Not unfrequently the brain and spinal 
marrow are both perfectly sound. In a case examined by Dr. Sidey, of Edin- 
burgh, the brain and its membranes were found quite healthy, as were also 
the medulla oblongata, the spinal cord, and the eighth pair of nerves at their 
origin and in their course, though inspected with great care both microsco- 
pically and by the naked eye. (Ed. Month. Journ. of Med. Sei., Dec. 1850, 
p. 505.) It is true that turgescence of the vessels, and injection of the spinal 
and cerebral meninges, have often been observed, and, in some rare cases, 
softening of portions of the medulla spinalis. But the congestion might well 
be a mere consequence of the terrible agitation of the nervous centres, without 
of itself contributing in any degree to the disease; and the admissible signs 
of inflammation are too seldom seen to warrant the belief, that this process 
has any essential connexion with the phenomena. 
The mucous membrane of the fauces, trachea, and oesophagus is in some 
instances reddened, in others pale, and in either case, is apt to be covered 
with an adhesive mucus. The papillae on the back part of the tongue are 
sometimes very much enlarged. Signs of inflammation of the inner coat of 
the stomach have often been noticed. The lungs, too, have been frequently 
found to be engorged. The blood is altered in appearance, and sometimes 
confined exclusively to the arteries. The body is strongly disposed to putre- 
faction, and quickly becomes very offensive. 
Causes.-There is one cause, and probably but one of genuine hydrophobia. 
Some believe that it may originate in man independently of any poison from 
without; but the cases are extremely rare in which this is supposed to have 
occurred; so much so as by their very rarity to excite suspicion as to the 
accuracy with which they have been reported, or the soundness of the diag- 
nosis. It is certain that some of the symptoms of hydrophobia are imitated 
by spontaneous nervous disease. The difficulty of swallowing, and dread of 
fluids have often been noticed. Terror has sometimes induced trains of symp- 
toms closely resembling those of the genuine disease. Hysteria also occa- 
sionally counterfeits it. But these are comparatively trivial affections, and 
undeserving of the name of hydrophobia. In the very rare cases which have 
pursued exactly the course, and had the termination of that disease, it is much 
more probable that the patient may in some way, forgotten or unknown to 
himself, have received the poison into his system, than that the complaint 
should have arisen from any other cause.* 
The poison is contained in the saliva or mucus of the mouth of the rabid 
animal, and, as before stated, is generally imparted by a bite. It is from the 
dog that the disease is most frequently received. But many others are capable 
of imparting it. The cat, fox, badger, wolf, and jackal, are known to have 
communicated the disease. There is good reason to believe that the saliva of 
the horse, ass, ox, &c., labouring under hydrophobia, will produce the same 
effect, if introduced into the system; but, as these animals do not usually 
bite, the result does not often occur. The same remark may be made of birds. 
I attended with the late Dr. Otto, of Philadelphia, a young man affected with 
clearly marked hydrophobia, who informed us that he could remember no 
* Since the publication of the second edition of this work, two cases of seemingly 
spontaneous hydrophobia, both ending fatally, have been recorded, one by Dr. Mom- 
bert, in the eighth volume of Walther and Ammon's Journal (see Am. Journ. Med. Sei., 
N. S., xvii. 476); and the other by Dr. Condie in the Transactions of the College of Phijsi- 
cians of Philadelphia, ii. 450. CLASS III.] 
HYDROPHOBIA. 
801 
other bite than one which he had received from a hog, about three months 
previously, as he was crossing one of the streets. The question has not been 
certainly decided, whether the saliva of the human subject affected with hydro- 
phobia is in like manner poisonous. But one experiment of MM. Magendie 
and Breschet strongly supports the affirmative of this question. Two healthy 
dogs were inoculated with the saliva of a hydrophobic patient. One of them 
was seized with the disease, and imparted it to other dogs by biting them. 
This may have been a mere coincidence, and cannot be admitted as positive 
proof without the support of additional facts. On the whole, it appears to me 
highly probable that the saliva of any animal, affected with hydrophobia, is 
capable of imparting the disease to others. 
An important point of inquiry is by what means the poison can find access 
into the system. We know that it commonly enters through a wound. But 
will it produce the effect if applied to the skin with the cuticle sound? The 
probabilities are that it will not. There is, I believe, no authentic instance 
of the disease having been communicated in this way, though there have been 
numerous opportunities. But the question is not so certain in relation to the 
mucous membranes. Mr. Youatt, who has had ample opportunities of obser- 
vation, thinks that the disease may be communicated through these membranes 
with the epithelium entire. It is asserted that persons have been attacked with 
hydrophobia, in consequence of having wiped their mouths with linen which 
had been impregnated with the saliva of a mad dog; and a case is mentioned, 
in which the disease originated from an attempt to untie by the teeth a knot 
in a cord by which one of these diseased animals had been fastened. Horses, 
oxen, and sheep are said to have contracted the disease by eating the straw 
on which mad dogs have lain. 
Another very interesting question is, how long the poison remains in the 
system before producing its effect. The period is very uncertain. The dis- 
ease seldom makes its appearance earlier than the eighteenth day after the 
bite, or later than the third month. The most common period is from the 
twentieth to the sixtieth day. But the period of incubation is sometimes 
much longer than the longest mentioned. Thus, instances are on record in 
which the attack did not occur until six, nine, twelve, or eighteen months 
after the wound; and', in some very rare cases, it is asserted to have been 
postponed for two, three, and even ten or twelve years. These last cases, 
however, are liable to the suspicion of inaccuracy. Other diseases may have 
been mistaken for hydrophobia; or there may have been some more recent 
and unknown or forgotten source of contamination. If it be admitted that 
the saliva of a hydrophobic animal can produce the disease by contact merely 
with the mucous membrane, it can be readily perceived how many opportu- 
nities for its occurrence may happen, altogether without the knowledge of the 
individual affected. 
It may be considered as highly probable that, in persons into whose system 
the poison has been received, certain exciting causes may produce a more 
speedy developement of the disease than would ordinarily take place. Among 
the causes of this kind enumerated by authors, are insolation, excessive fatigue, 
intemperate drinking, a blow on the cicatrix, and terror. 
Of those bitten, many are never attacked with the disease. It is possible 
that some systems are insusceptible to the poison; but a better explanation is, 
that the saliva is wiped from the teeth by the clothing through which the 
bite is made, and therefore does not penetrate the wound. Besides, in our 
ignorance of the precise source of the poison, we do not know that it is at all 
times present in the saliva; and it may happen that, a certain amount only 
being produced in a given time, that quantity may be exhausted when the 802 
LOCAL DISEASES.-NERVOUS SYSTEM. 
[part II. 
animal bites frequently; and consequently that those bitten last will stand the 
best chance of escape. This is stated to be actually the case. It is said that 
some animals are more poisonous than others. Thus, of those bitten by the 
wolf, a much larger proportion is attacked than of those bitten by the dog. 
This, however, is explained by the asserted fact, that the wolf generally flies 
at a naked part, as at the face. Of 114 cases of persons bitten by mad wolves 
collated by Dr. Watson, 67 died; while of 15 persons bitten by a mad dog 
only three died, and John Hunter states that he knew an instance in which 
21 were bitten and only one died. 
How does the poison operate, and why should it lie so long apparently 
inert, and then be suddenly excited into such fearful virulence ? The only 
plausible explanation is, that the poison of hydrophobia, like that of small- 
pox, is capable of propagating itself,.either by a chemical action analogous to 
that of fermentation, allowing it to be unorganized, or by the developement of 
germs, if it be supposed to be organized. The germ, lodged within the body, 
requires time for the reproductive process to be completed; and this process 
may be hastened or retarded by various conditions of the recipient not readily 
appreciable. Common poisons, as arsenic, hydrocyanic acid, and the venom 
of the rattlesnake, which are absorbed, and operate directly upon the system, 
produce their effects immediately. The hydrophobic poison requires a period 
of incubation; and often remains long undeveloped in the nest provided for it. 
When at length circumstances favour the hatching process, the new brood 
leaves its birthplace in the cicatrix, and carries destruction into the system. 
A consolatory inference from this view is, that, if the nidus be wholly re- 
moved before the hatching is completed, the mischief may be prevented. 
It has been conjectured that the bite of an enraged animal, not labouring 
under disease, might produce hydrophobia; but the conjecture is improbable, 
and wholly wanting in proof. 
Among the undecided points, in relation to hydrophobia, is that of its mode 
of origin. While it is generally thought that certain animals, as the dog, wolf, 
cat, and others of the genera canis and felis, may be affected originally with 
the disease at any time, and then propagate it by biting; some believe, and 
among them Mr. Youatt, that no attack now takes place except in consequence 
of the reception of the poison from without, and that, whenever a dog is seized 
with hydrophobia, it may be inferred that he has at one time or another been 
bitten by, or in some other way received the infection from a mad animal. 
This view is supported by the fact, that in certain countries hydrophobia is 
wholly unknown, and in others appears only at distant intervals. Should it 
be correct, the inference follows, that, by confining all dogs separately for a 
certain period, say six or eight months, the disease might be eradicated in 
any particular region. 
It has been supposed that great heat and severe cold favour the develope- 
ment of the disease in the dog; and that it may be produced by unwholesome 
food or drink, violence of the sexual passion, and excessive irritation of any 
kind. But, from a comparison of 140 cases, M. Trolliet has inferred that, 
though the disease occurs at all seasons of the year, it is most frequent in the 
mild months of May and September. Attempts, moreover, to produce it 
artificially in the dog by certain kinds of food, and various bad treatment, 
have quite failed. It appears to be unknown in the hot regions of Egypt and 
Syria, where dogs abound. 
It is highly important to be able to recognize the disease in a dog, when it 
occurs. The popular notions, that mad dogs dread water, and are to be known 
by running forward with their tail between their legs, appear to be mistaken. 
The fact is said to be, that they not unfrequently swim rivers, and that they CLASS III.] 
803 
HYDROPHOBIA. 
eagerly lap water in consequence of excessive thirst The following is a brief 
summary of the symptoms they present, as given by the best practical writers. 
The animal at first .has an altered, and as it were suspicious look; is restless 
and frequently changes his position; often licks diligently some part of his 
body, where upon examination a scar may usually be seen; exhibits a strange 
disposition to pick up and swallow small objects of any kind, such as bits of 
thread, straw, hair, excrement, &c.; and occasionally vomits. As the com- 
plaint advances, he becomes irritable, flies at strangers or at other dogs, and, 
though he may obey the voice of his master, resists correction, and is enraged 
instead of being terrified by the sight of the whip. There is a profuse secre- 
tion of saliva, which flows from the mouth, and occasions foam about the lips. 
This is followed by extreme thirst, and apparently the secretion of a viscid 
mucus in the fauces, which the animal, seems desirous of getting rid of by 
working with his paws at both angles of the mouth. The breathing is la- 
boured ; a peculiar sound is made in inspiration; and the character of the 
voice is changed. The bark is said to be peculiar and characteristic, some- 
thing between the ordinary barking and a howl. If at liberty, the animal is 
incessantly in motion, snaps at other animals when they meet him, and some- 
times seems to seek occasion to attack them. It is only when fatigued that 
his tail falls between his legs. Occasionally he appears to have visual illu- 
sions, acting as if he saw objects which have no existence. At length symp- 
toms of paralysis appear; the under jaw becomes powerless; the legs give 
way; the animal totters and falls; and usually dies on the fourth, fifth, or 
sixth day, with or without slight convulsions. Mad dogs are not subject to 
convulsive epileptic fits during the course of the disease. Dissection shows 
nothing remarkable, except the presence of a great quantity of heterogeneous 
matters in the stomach, which the animal has swallowed, and, in the absence 
of these, a dark chocolate or coffee-coloured liquid. 
A dog supposed to be mad, instead of being chased and killed, after having 
bitten human subjects, should be caught and confined if possible, so that the 
question may be decided whether he was really affected with the disease. If, 
notwithstanding that he receives wholesome food and drink, he should die in 
a few days, the suspicion would be confirmed; and the requisite measures for 
safety on the part of the individuals bitten might be resorted to. Should he 
recover, a great source of anxiety would be removed. 
The period of incubation in a dog is shorter than in man. It is, however, 
differently stated by writers, one author fixing its furthest ordinary limits at 
eight or nine days, and another extending them to forty days. 
Nature.-Little need be said on this subject; for almost nothing is known. 
No lesion has been discovered which can satisfactorily explain the phenomena. 
A poison seems to pervade the system, which first deranges, and then anni- 
hilates the nervous power. Everything else is mere conjecture. 
Diagnosis.-Tetanus is said somewhat to resemble hydrophobia; but it is 
chiefly in the difficulty of swallowing liquids. In tetanus, however, there is 
not usually the insane hydrophobic dread of water. The spasms in hydro- 
phobia are brief or clonic, those of tetanus generally rigid, lasting, or tonic. 
The jaw is not set, nor the trunk rigid in the former complaint as in the latter. 
There is greater disorder of the circulation, of the digestive organs, and of the 
mental functions in hydrophobia; and tetanus, though it may be attended 
with a profuse secretion of mucus or saliva, does not present the characteristic 
hydrophobic manner of excreting those fluids. 
It has before been stated that hydrophobia is sometimes imitated by hys- 
teria, or analogous nervous disorders, the result of fright, or other profound 
impression on the nervous system. Such cases, however, are rare; and the 804 
[part II. 
LOCAL DISEASES.-NERVOUS SYSTEM. 
general sagacity of the practitioner must be relied on for detecting the coun- 
terfeit. He will always be much aided by the absence of any knowledge, on 
the part of the patient, of having been bitten by an inferior animal within 
eighteen months or two years. 
Prognosis.-This may be considered as uniformly unfavourable. The cases 
of cure now and then recorded are so exceedingly rare; and the means said 
to have proved efficacious, have so uniformly failed when employed in other 
cases, that they must be looked on as at best doubtful. The practitioner may 
have been deceived as to the nature of the complaint. It is possible that 
symptoms analogous to hydrophobia may be induced by terror after a bite 
from a mad dog, though really none of the poison may have entered the sys- 
tem. The probability of this is quite equal to that of a cure of genuine 
hydrophobia. Certainly no cure thabl have seen or heard of has taken place, 
within the sphere of my personal observation, in an undoubted case of the disease. 
Treatment.-The whole magazine of therapeutics has been exhausted, and 
vainly exhausted, in the treatment of hydrophobia. Remedies the most vio- 
lent have been used unsparingly; and practitioners have not been deterred by 
the apparent inertness of any medicament from giving it a full trial. Bleeding 
in every degree, mercury, opium and other cerebral stimulants, chloroform, 
tobacco, lobelia, and all other nervous sedatives, the acids and alkalies, oil of 
turpentine, cantharides, white hellebore, cevadilla, the salts of lead and those 
of iron, nitrous oxide inhalations, the injection of warm water and narcotics 
into the veins, electricity and galvanism, the hot vapour and hot air bath, 
even the poison of the viper, have all been employed, and with the same sad 
result. The practitioner is, therefore, left to bis own judgment in the case. 
I do not pretend to recommend any course of treatment, where I can adduce 
neither experience, nor sound therapeutical principles in its support. 
But happily an effectual prophylactic treatment seems to be in our power. 
To remove completely the nidus of the poison, before the period of incuba- 
tion is passed, is a measure dictated at once by reason and experience. 
There is scarcely a case on record, where this measure has been thoroughly 
carried out at an early period, in which it has not proved successful. Nume- 
rous internal prophylactics have been recommended, and enjoyed a short- 
lived popularity; but all have proved ineffectual upon repeated trials. The 
source of error in these cases is the circumstance, that of persons bitten but 
a small proportion are affected with the disease; and any inert substance 
which the exempt individuals may happen to have taken acquires the repu- 
tation of a preventive remedy. These pretended remedies are not only use- 
less : they are worse than useless, by producing a false confidence, and induc- 
ing the bitten person to trust in them, rather than undergo the pain and 
inconvenience of the only effectual measure. As to the discovery, some years 
since announced, that, from the third to the ninth day, vesicles are developed 
under the tongue of bitten persons, in which the poison is concentrated, and 
the removal of which, with subsequent cauterization, would save the patient; 
it has met with the fate which its apparent absurdity merited. The vesicles 
have been sought for in vain by numerous observers. 
Several questions here present themselves; to wit, at what time, upon 
what individuals, and in what manner, the operation should be performed. 
In the first place, as to the time, certainly the sooner after the wound has 
been received the better; but at any time whatever, within eighteen months 
or two years after the reception of the wound, and before the actual develope- 
ment of the disease. Even after the premonitory sensations, swelling, and 
discoloration in the cicatrix have occurred, it is not too late. Indeed, their 
occurrence should lead to an immediate employment of the measure. CLASS III.J 
NEURITIS. 
805 
In the second place, as to the individuals upon whom the operation should 
be performed; I would unhesitatingly say, upon all bitten by an animal well 
understood to have been mad. In many instances, the operation may be un- 
necessary; but no one can foretell what is to be the result in any particular 
case; and it is better that many should suffer a slight inconvenience than 
that one should perish so horribly. But the question is not so easily deter- 
mined, when there is only suspicion of madness in the animal. Even here, 
however, sound policy would dictate the operation, should the suspicion have 
the least groufiid of probability in its favour. 
Thirdly, how is the removal of the bitten part to be effected? Certainly, 
best by the knife. The surface should be thoroughly washed, and the wound 
itself, as far as practicable, so that not a particle of the loose saliva shall 
remain. The whole surface of the wound should then be excised. To give 
additional security, a stick of lunar caustic should afterwards be thoroughly 
applied to every part of the cut surface. After this, nothing more than mild 
dressings are necessary. But there are cases in which this plan cannot be 
carried into effect. The wound may be so lacerated, or may penetrate parts 
of such a structure, as to render impossible the complete separation of its 
surface by the knife. Here, if the limb is small and of little comparative 
value, amputation may be recommended, as of one of the fingers for example; 
but when an important member is concerned, the case should be fairly stated 
to the patient, and he should be allowed to choose between the inconvenience 
of losing his limb, and the chance of losing his life. Should he determine to 
incur the risk, it should be diminished as much as possible by long continued, 
repeated, and thorough washings of the wound by means of a stream of warm 
water, or chlorinated water, with the use, in the intervals, of a cupping glass 
exhausted by means of a pump. This should be placed over the wound, in 
the hope that the poison might be eliminated with the blood. Caustic may 
then be applied to the surfaces as far as they can be reached; and it may be 
a question whether the mineral acids or other liquid caustic should not be 
preferably used, in order to penetrate depths or sinuosities that may be inac- 
cessible to a solid stick. Lastly, repeated blisterings may be employed to the 
wound, so as to establish suppuration, and favour the elimination of the 
poison. After this, should premonitory evidences of an approaching attack 
of the disease be given by the alterations already referred to in the wound or 
cicatrix, amputation should be recommended. 
SUBSECTION III. 
DISEASES OF THE NERVES. 
Article I. 
INFLAMMATION OF THE NERVES, or NEURITIS. 
This subject has not yet been fully investigated. There has been much 
conjecture in relation to it; and numerous cases of disease have been ascribed 
to inflammation of the nerves upon purely theoretical grounds. But, stand- 
ing upon the basis of experience and observation alone, we are compelled to 
admit that the complaint is rare. The nervous matter is well protected by 
its investing membrane from external influences, and the neurilemma, being 
scantily supplied with blood-vessels, and partaking of the nature of the fibrous 806 
[part II. 
LOCAL DISEASES.-NERVOUS SYSTEM. 
tissues, appears itself to be peculiarly insusceptible of the inflammatory pro- 
cess. Hence, nerves have been seen perfectly sound in the midst of inflamma- 
tion of the surrounding structures. A distinction has been made between 
inflammation of the neurilemma and that of the nervous matter, and it 
certainly happens that the former sometimes presents appearances of the 
disease upon dissection, when none can be discovered in the latter. But the 
distinction is unnecessary in a practical point of view, as there is no material 
difference either in the symptoms or treatment. 
Symptoms.-The most prominent symptom of neuritis is pain at the seat 
of the inflammation, and in the course of the nerve, extending sometimes to 
its remote ramifications. Indeed, it is not unfrequently felt more intensely 
in the parts in which the =nerve is distributed, than in the inflamed trunk. 
The pain is severe, rending, darting, tingling, often mingled with a feeling of 
numbness, and not unlike that with which every one is familiar as resulting 
from a blow upon the nerve at the elbow. It generally remits more or less, 
but is perhaps never entirely absent, when the patient is awake, has his atten- 
tion directed to the subject, and is not under the influence of narcotics. Along 
with the pain, there is tenderness, sometimes exquisite, at the seat of the 
affection; and, when the nerve is superficial, it may occasionally be perceived 
to be enlarged. Should the disease not yield spontaneously or to remedies, 
it either ends in disorganization of the nerve, with consequent palsy of the 
parts supplied by it, or assumes the chronic form, in which it may continue 
for a long time, a source of great distress and inconvenience to the patient; 
producing pain, numbness, formication, and various indescribable sensations 
in the limb or part affected, and rendering that part unfit for the due perform- 
ance of its functions. Probably, the nerve most'frequently affected is the 
sciatic, and the portion of body in which the effects are felt, one of the lower 
extremities. But the nerves which supply the trunk, upper extremities, and 
head, are liable to the disease. Inflammation, no doubt, also attacks occa- 
sionally the nerves of special sense, as those of sight and hearing; variously 
deranging, and sometimes abolishing the function; though it is very difficult 
to refer the effects always to their proper source. 
Anatomical Characters.-The whole nerve is usually enlarged; the neu- 
rilemma is reddened, its vessels dilated, and specks of extravasated blood are 
sometimes visible; serous, sero-purulent, and purulent infiltration has been 
observed; and the nervous substance has been seen injected, softened, even 
diffluent, and, in chronic cases, indurated and variously altered. 
Causes.-These are not well known. One of the most obvious, and per- 
haps the most frequent, is external injury. Another is exposure to cold and 
wet. There seems to be a close analogy with rheumatism in the mode of 
origin; and it is highly probable that, in a large proportion of cases, this 
affection lies at the foundation of the disease. 
Treatment.-Bleeding, when the state of the pulse and of the general 
strength admits, repeated leeching in the vicinity of the inflammation, the 
persevering use of emollient cataplasms, purging with the saline cathartics, 
rest, and low diet, are the chief remedies in the acute disease. Should a cure 
not be effected by these means, recourse must be had to repeated blistering 
over the affected spot, and, this failing, to the additional employment of mer- 
cury. These latter remedies are also chiefly to be relied on in the chronic 
form; though issues, setons, antimonial pustulation, or moxa may sometimes 
be substituted for blistering. Throughout the complaint, anodynes are re- 
quired for the relief of pain; and the most appropriate is a combination of 
opium and ipecacuanha, or some of their preparations. CLASS III.] 
NEURALGIA. 
807 
Article IL 
NEURALGIA. 
Neuralgia, from vevgov, nerve, and d\yo$, pain, is a term of recent origin, 
employed to designate pain of a purely nervous character; and introduced 
into use as a substitute for the name of tic douloureux, formerly applied to 
pain of this kind seated in the face. 
It may be extended so as to embrace all cases of pain, not spasmodic, which 
cannot be traced directly to vascular congestion, inflammation, or other or- 
ganic lesion. Some authors appear disposed to limit it to certain parts of the 
body; but the probability is that it may occur wherever there are nerves of 
general sensation; and even the organs chiefly supplied with nerves from the 
ganglionic system are capable of the affection, either through the connexion 
of that system with the common sensorium, or through nerves running directly 
from the organs to the brain. 
Symptoms.-The pain is of every possible degree and variety of character ; 
but is generally severe, acute, and more or less darting or lancinating. It is 
sometimes described as piercing, tearing, screwing, pulsating, aching, burning, 
tingling, benumbing, &c.; and language has been ransacked to find terms 
strong enough, and expressive enough, to represent at once its intensity and 
extreme diversity. Sometimes the paroxysm of pain is preceded by certain 
warnings, such as epigastric distress, nausea, chilliness, or shivering, and a 
.vague feeling of general discomfort. More frequently it approaches without 
any such premonition, either beginning moderately with a sense of aching, 
tingling, burning, itching, &c., and gradually increasing till it becomes almost 
insupportable, or darting at once through the part with its utmost intensity, 
as it were in electric flashes, which make the muscles even of a strong man 
quiver as they pass. The paroxysm may consist of a continuous pain, varying 
in degree, or of a succession of violent twinges, with comparative ease in the 
intervals. In the latter case, there is often a slight aching, tingling, or sense 
of numbness between the several shootings of pain; and the patient some- 
times complains of a feeling of coldness scarcely less disagreeable. 
The pain may either be confined to the course of a single nerve and its 
ramifications, or may be diffused without reference to such limits, and some- 
times darts rapidly from one point to another, between which there is no 
immediate nervous communication. 
In some instances, there is tenderness of the part, occasionally exquisite 
tenderness; but more frequently strong pressure, instead of being painful, 
affords some alleviation; and, what appears very singular, in these very cases 
of insensibility to forcible impression, a slight touch, the flapping of a hand- 
kerchief, for example, will bring on a violent attack; while I have repeatedly 
known gentle friction with a soft hand to produce complete relief where strong 
pressure was intolerable. 
With the pain thete is frequently spasmodic twitching of the neighbouring 
muscles, and sometimes rigid spasm; and the whole frame is occasionally 
shaken by the ferocious violence of the attack. 
In accordance with the general law, that where there is irritation there 
will be an afflux of blood, the paroxysm is often attended with more or less 
flushing and vascular turgescence, and occasionally, if the affected part has 
the power of secretion, with a copious extravasation of liquid, as, for example, 
of tears when the disease is seated in the eye, and of mucus when in the nos- 808 
LOCAL DISEASES.-NERVOUS SYSTEM. 
[part II. 
trils; but the exceptions are numerous, and it not unfrequently happens that 
the blood-vessels exhibit no sign of participating in the irritation. 
The course of the affection is scarcely less diversified than the character of 
the pain. . In one patient the paroxysm is brief, disappearing after a few 
minutes, or a few hours, not perhaps to return for a considerable time. In 
another it is much more durable, continuing for days or weeks; but in this 
case there are always remissions, occurring more or less frequently, and in 
greater or less degree. Generally these remissions are quite irregular, but 
sometimes they approach a periodical form, the exacerbation occupying a cer- 
tain portion of the twenty-four hours, while during the remainder the patient 
is comparatively comfortable. It not unfrequently happens that the neuralgic 
attacks are quite intermittent; and, as in the remittent cases, they may be 
regular or wholly irregular in the recurrence of the paroxysms. 
Regular intermittent or periodical neuralgia may be quotidian or tertian, 
but is much the most frequently, so far as my observation has gone, of the 
former type. In one instance, I have known the interval to be regularly two 
weeks. The patient was a boy of ten years old, who had been for several 
years affected with the disease. At first the attacks had been at longer in- 
tervals ; but, when he first came under my notice, they had been long bi-weekly, 
each paroxysm continuing for thirty-six or forty-eight hours. The pain was 
seated in and about the eyes. There is no particular time of day at which the 
paroxysms are peculiarly disposed to recur. They vary much in duration, on 
some occasions occupying the greater portion, on others but a small portion 
of the twenty-four hours. 
The attacks of neuralgic pain occur less frequently in the sleeping than the 
waking state, in part, because the patient is less exposed to the exciting causes, 
but chiefly, in all probability, because, in the former state, the brain is less 
sensible to impression from the disordered nerve. 
The pain upon disappearing may do so gradually, leaving occasionally, as 
it departs, a sense of tingling or formication for a short time behind it; or it 
may vanish at once and completely, so that the patient passes immediately 
from a state of torture to one of entire and exquisite relief. 
Neuralgia is occasionally attended or followed by palsy, more or less com- 
plete, of the parts affected, or of neighbouring parts. Thus, amaurosis has 
followed neuralgia of the side of the head, and palsy of the muscles of the 
eye that of the fifth pair of nerves; and, in one of the worst cases of tic 
douloureux that I have seen, the cheek of the affected side was, for a limited 
extent, pale, and insensible to the touch. 
In relation to the condition of system associated with neuralgia, it maybe 
perfectly healthy, or in various degrees debilitated; it may be plethoric or 
anemic; and the patient may be subject to rheumatism or gout, or affected with 
dyspepsia, amenorrhoea, or anomalous nervous disorder of the respiratory, cir- 
culatory, and reproductive functions; and all these abnormal conditions may 
have some bearing on the complaint. 
The duration of the disease is quite indefinite. The patient may have only 
one attack, which may last more or less continuously for minutes, hours, days, 
weeks, or months; or he may be liable to recurring attacks for a number of 
years, or during his whole life. It is seldom, however, that the disease occurs 
but once. Much more frequently the patient continues more or less subject 
to it so long as he lives. In the latter case, the recurring attacks may be 
distant, comparatively mild, or in a greater or less degree under the control 
of remedies; or they may increase in duration, violence, and frequency, until 
at length the patient scarcely experiences any exemption, and life becomes a 
protracted torture. Death very seldom occurs directly from neuralgia; but 809 
CLASS III.] 
NEURALGIA. 
the pain may by its severity and persistence so far undermine the health, as 
to prove indirectly fatal by causing the system to sink under diseases which 
it might otherwise surmount. In some instances, death is welcomed as an 
escape from insupportable misery, and it has not unfrequently happened that 
relief has been sought in suicide. 
Seats of Neuralgia.-Jt has been already stated that the disease may attack 
any part of the body where there are nerves. But all parts are not equally 
susceptible; and in certain positions it is so common, or so peculiar, as to 
have received distinct designations. The neuralgic affections of various in- 
ternal organs have been noticed, in previous parts of this work, in connexion 
with other diseases of the same parts; as of the heart, under the name of 
angina pectoris; of the stomach, under that of gastralgia; of the intestines, 
under that of neuralgic colic ; and of the urinary organs, under that of nephral- 
gia. It has been noticed also as occurring in the encephalon, and in the liver. 
At present I wish merely to call attention to some of its more prominent 
external seats. It sometimes appears to affect the skin exclusively, but is 
more frequently seated in the subcutaneous nerves. 
Perhaps in no part of the body does the affection occur so often as in the 
head. In the scalp it may be confined to one limited spot, or may extend over 
one-half of its surface. In the latter case, it is denominated hemicrania. 
The affection which goes by that name is sometimes cerebral, and appears to 
be connected with the stomach, as one of the forms of sick headache. But it 
is often, and perhaps most frequently, nothing more than neuralgia of the 
scalp. When of this character, it is exceedingly painful, and sometimes of 
considerable duration. I have known it almost incessant for several weeks. 
In the face, the disease in its most violent forms, has been called tic doulour- 
eux. It may affect especially certain regions of the face, as the neighbour- 
hood of the eye; the temporal region; the cheek, lips, and alae nasi; and the 
dental arches; following apparently the ramifications of one of the branches 
of the fifth pair of nerves; or it may shoot from one part to the other with an 
impartial violence, as if proceeding from some common source. It is not un- 
frequent in and about the eye, producing redness of the lids and of the con- 
junctiva, occasionally swelling of the external parts, and a copious flow of 
tears. Sometimes the eyeball is peculiarly affected; and then there is excessive 
susceptibility of the organ, so that the least ray of light produces exquisite 
pain; and I have known a patient to complain of intense and painful bright- 
ness, though the shutters were closed, and the apartment perfectly dark to 
ordinary vision. This painful sensibility of the eye may be acute and tem- 
porary, or chronic; and, in the latter case, .sometimes continues for many 
years, bidding defiance to treatment. When the disease attacks the jaws, it 
produces one of the most painful varieties of toothache. The tongue, fauces, 
and mucous membrane of the nostrils are liable to be severely affected. In 
the throat, the disease sometimes imitates angina, and in the nostrils coryza. 
Otalgia or earache is another form of it. This is apt to occur in children, and 
is often exquisitely painful. It may be confined to the ear, or may radiate to 
the temples and the cheeks; and is usually accompanied with some disorder of 
hearing, as excessive sensitiveness, partial deafness, or abnormal sounds. 
The disease is not common in the neck. In the upper extremities, though 
it may occur in any part, it seizes preferably upon the forearm; and one of 
the most obstinate cases that I have met with was in this position. It was 
in a man about thirty years of age; and, after having resisted all the means, 
whether local or general, that could be thought of, yielded at last to a resi- 
dence of one year abroad. 
Neuralgia occurs in different parts of the trunk. It is not uncommon in 810 
[part II. 
LOCAL DISEASES.-NERVOUS SYSTEM. 
the intercostal spaces, and in the lumbar region. In the walls of the chest, 
it is said to occur most frequently between the sixth and ninth ribs, on the 
left side, and especially in females, in connexion with uterine disorder. In 
the female mamma it is sometimes very violent. When originating in the 
small of the back, it occasionally shoots forward and downward to the groin, 
and into the scrotum and labia pudendi. The anus and the genitals in both 
sexes are sometimes affected with great severity. 
Next to the head, the lower extremities are probably most frequently at- 
tacked. The disease sometimes pursues the course of the crural or femoral 
nerve, along the inner and anterior part of the thigh and leg, down to the 
top of the foot. But much more frequently it occupies the sciatic nerve or 
its branches, constituting a variety of the affection so well known under the 
name of sciatica, and so notorious for its obstinacy. This is characterized by 
irregular pains about the hip, more particularly between the great trochanter, 
and the ischium, spreading thence into neighbouring parts, and extending 
downward upon the outside and back of the thigh to the leg and foot; or the 
pains may begin below and shoot upwards; or they may occupy distinct and 
isolated spots in this long course, sometimes in one part of the limb, and 
sometimes in another, as the knee joint, the calf of the leg, and the sole of 
the foot. I have known neuralgia to be exceedingly violent and obstinate in 
the knee, imitating inflammation of the joint, though more painful, and, after 
a long and ineffectual antiphlogistic treatment, including confinement to bed, 
yielding at length completely to the subcarbonate of iron and narcotics. The 
patient was a middle-aged negro man. 
Anatomical Characters.-The evidence afforded by dissection as to the 
nature of the disease is of a negative character. It is true that, in some cases 
of apparent neuralgic pains, signs of inflammation or other source of irritation 
have been detected in the course of the nervous trunk, or within the spinal 
canal, or cranium; but in others nothing whatever of an abnormal character 
could be found; and the necessary inference is, that, so far as anatomical evi- 
dence goes, neuralgia may exist independently of any structural derangement, 
and that it is essentially a functional disease. 
Causes.-There is not less diversity upon this than upon other points con- 
nected with neuralgia. In reference to its etiology, this affection may be 
regarded in two lights; as originating, namely, in some other morbid affec- 
tion local or general, beyond the seat of the pain, or as dependent upon some 
modification in the nerves of the part immediately affected. In either case, 
it is nothing more than a symptom of the real pathological condition; for a 
mere sensation cannot be a disease in the strict sense of the term. 
In searching beyond the seat of pain for its true source, we may trace it 
either to some disordered state of the nervous trunk from which the part may 
be ^supplied with nervous tissue, to the centres of nervous influence in the 
spinal marrow, brain, or ganglia, to some organ with which the part may be 
sympathetically connected, or to the condition of the system. 
In relation to the nervous trunk, the condition may be inflammation, in 
which case the disease comes under the head of neuritis, or it may be irrita- 
tion produced by various causes, such as tumours pressing on the nerve from 
without, or originating in its own substance; roughness of a bony surface 
with which the nerve may be in contact, as when it passes through an osse- 
ous canal; or any foreign body lodged in the vicinity of the nerve. It is pos- 
sible that rheumatism or gout may affect some portion of a nervous trunk, and 
cause it to radiate neuralgic pain to those parts in which it ramifies. In every 
case of neuralgia, therefore, it is important to investigate, as far as possible, 
the condition of the main nerve, proceeding from the seat of pain towards the CLASS III.] 
811 
NEURALGIA. 
nervous centres. If this be found peculiarly sensitive to pressure in any part 
of its course, or if any abnormal condition can be detected which may serve 
as a cause of irritation to it, we may consider that we have advanced at least 
one step towards tracing the affection to its cause. 
It is very certain that neuralgic pains of the trunk and extremities often 
originate in a morbid state of the spinal column. In every case of the kind, 
the condition of the spine should be carefully examined. Tenderness on pres- 
sure will often be found, and we shall be. enabled quickly to remove the com- 
plaint by attacking it in its source. 
Very obstinate cases of neuralgia have sometimes been traced to tumours 
or other disease within the cranium; but, in such instances, there are gene- 
rally other obvious effects of a still more serious character, so that the pain 
ceases to be regarded in any other light than as a mere symptom. 
Neuralgia often originates in diseases of distant organs. In some instances, 
possibly, an irritation may be transmitted directly from the diseased organ 
through nervous cords connecting it with the painful part; but generally, if not 
universally, it is through the brain, or other nervous centre, that the communi- 
cation is affected. The stomach, bowels, liver, urinary organs, and genital appa- 
ratus, and especially the uterus, are very apt thus to make their disorder known. 
Acid or acrid secretions, or some offending article of diet or drink in the sto- 
mach, not unfrequently occasions severe neuralgic pains in distant parts of the 
body. I am confident that I have witnessed such pains in the extremities 
and external parts of the trunk, connected with organic disease of the liver 
and kidneys. Indeed, I look upon violent neuralgia, occurring for the first 
time in a person advanced in life, and resisting obstinately the ordinary means 
of relief, as always a very suspicious symptom. It has been more than once 
within my experience the immediate precursor, or rather the first obvious sign 
of Bright's disease of the kidneys, and cirrhosis of the liver. Milder and 
curable derangements of these two viscera may also occasion neuralgic attacks, 
which will give way with their cause. The correction of functional disease of 
the liver has often led to the relief of such affections. The uterus, in disease, 
is notorious as the source of external pains. From these facts the importance 
may be understood of directing attention, in cases of neuralgia, to the condi- 
tion of all the great internal viscera. 
The condition of the system has also been mentioned as contributing to the 
production of neuralgic pains. A gouty or rheumatic diathesis strongly pre- 
disposes to them, and I have before expressed my conviction, that much of 
the neuralgia now so prevalent is merely gout and rheumatism in the nervous 
form. (See Nervous Gout, i. 479.) 
Another state of system disposing to neuralgic attacks is debility. The 
affection is a frequent attendant upon convalescence from long-continued and 
exhausting diseases, especially from the idiopathic fevers. The anemic con- 
dition is very favourable to it. Chlorotic females are extremely subject to 
neuralgic pains. How debility or anaemia may produce pain, I have attempted 
to explain in another place. (See Functional Diseases of the Brain.') 
As to the state of the nerves, in those cases of neuralgia, if there be such, 
in which the true pathological condition is limited to the part where the pain 
is felt, we know absolutely nothing. 
Hitherto I have treated rather of the pathological condition, giving rise to 
neuralgic pains, than of the proper causes. These are predisposing or ex- 
citing. To the former belong such causes as induce general debility, or any 
other of those derangements which have been enumerated as occasional sources 
of the affection. Among these may be mentioned, as peculiarly operative, 
all kinds of exhausting excesses, and especially those having reference to the 
sexual propensities. The state of system produced by miasmatic influence 812 
[part II. 
LOCAL DISEASES.-NERVOUS SYSTEM. 
strongly predisposes to the affection. The nervous temperament is supposed 
to have a similar effect. It is doubtful whether sex has any special influence. 
There are peculiarities in the female constitution which predispose it to certain 
forms of neuralgic disease, especially the rheumatic or gouty, aud those origi- 
nating in the spine; but these are probably balanced by the greater liability of 
men to the complaint from fatigue, exposure, and intemperance. 
Of the exciting causes, the most frequent is probably cold. Exposure to 
a keen cold air is very apt to bring on the neuralgic paroxysm; and cold and 
wet conjoined are still more effectual. Fatigue, strong mental emotion, ex- 
cesses of the table, intemperate drinking, the abuse of tea, coffee, and tobacco, 
retrocession of gout and rheumatism, and the sudden removal of cutaneous 
eruptions are exciting causes. So is frequently a wound or bruise. In those 
predisposed to the affection, a slight local injury very often becomes the centre 
of afflux for the morbid tendency; and the practitioner is made aware of the 
existence of the neuralgia by a degree of severity and persistence in the pain, 
much beyond what the accident alone ought to occasion. Severe headache 
following contusions of the scalp is well known to surgeons. The same thing 
may occur in any other part of the body; and I have noticed it especially 
after slight bruises on the leg. 
Nature.-Neuralgia is strictly functional or nervous. Some, it is true, are 
disposed to consider it the result of inflammation of the nervous tissue or 
neurilemma; and there is no doubt that pains similar to those of neuralgia 
do sometimes originate in that condition of the nervous trunks. But, in most 
instances, there is an absence of all proof of inflammation; and the mode of 
attack, the sudden onset and sudden departure, the intermittent character of 
the pain, its occurrence especially in states of debility, the frequent want of 
tenderness on pressure, the ordinary absence of fever, and the fact that it is 
often aggravated by depletion, and cured by tonics and stimulants, are suffi- 
cient evidences that it is not inflammatory. 
Treatment.-A vast diversity of remedies have been used in the treatment 
of neuralgia, and most of them with some apparent success. Being a purely 
nervous affection, it might be expected to be influenced by means calculated 
to make an impression on the mind. The brain, when strongly preoccupied, 
is less sensible to disturbing causes of all kinds; and, by directing the current 
of nervous excitement from the seat of disease towards that of intellect and 
emotion, a powerful revulsive influence is exercised. Engage therefore the 
faith, the fears, the wishes, the attention, or any other mental function of the 
patient strongly, and relief will be apt to follow. Hence the occasional 
efficacy of metallic tractors, of magnetized rings, of homoeopathic pills, and 
of numberless scarcely less inert applications. An illustration familiar to 
every one is the temporary cure of toothache upon the approach of the dentist. 
Even really efficacious means are frequently very much aided by the co- 
operation of mental influence; and the physician who can most strongly bring 
this to bear upon the case, will be most likely to obtain at least temporary 
success. I shall not pretend to enumerate all the remedies which have been 
recommended in this complaint; but shall be content with stating the princi- 
ples upon which it appears to me that it should be treated, and the measures 
that have real efficacy, or considerable pretension. 
In the first place, efforts should be made to discover any hidden source of 
the pain, and to remove it if discovered. If, upon examining any of the 
nervous trunks proceeding from the affected part, a tender spot should be 
found, it may be proper to apply leeches once or oftener to the seat of tender- 
ness, and subsequently, if necessary, to effect revulsion by small blisters or 
other means. Should any mechanical cause of irritation along the course of CLASS III.] 
813 
NEURALGIA. 
the nerve be detected, as a tumour, foreign body, spiculum of bone, &c., it 
should be removed if possible. If, proceeding onwards to the nervous centres 
in our investigation, we find disease of the spine or of the brain, we must di- 
rect our remedies accordingly; and violent neuralgia may often be cured by 
obviating spinal irritation. (See Spinal Irritation.') The removal of carious 
teeth often affords relief in cases of facial neuralgia; and cases are recorded 
by Dr. S. P. Hullihen, of Virginia, in which injections of a solution of nitrate 
of silver into the antrum, through the socket of an extracted tooth, have cured 
severe cases of tic douloureux, probably connected in some unknown manner 
with disease of that cavity. {South. Journ. of Med. and Phys. Sci., i. 217.) 
Next, it will be proper to interrogate the various organic functions, and 
ascertain whether some disorder in these may not be the source of the mischief. 
The digestive function especially deserves attention. Dyspepsia, if existing, 
must be duly treated; and care must be taken to prevent hurtful impressions 
on the stomach. Acid in the stomach, and flatulence should be corrected, 
acrid accumulations removed by cathartics or otherwise, and any article of diet 
that may prove a cause of offence prohibited. Neuralgia may not unfrequently 
be cured by abstaining from certain kinds of food or drink, or certain luxuries 
which may have been habitually indulged in. A little watchfulness will enable 
the patient to detect the particular source of the mischief. It will occasionally 
be found in the use of strong coffee, tea, tobacco, or alcoholic drinks; and a 
good general rule, in the treatment of neuralgia, is to abandon all these for a 
time at least, until it shall be satisfactorily ascertained that they do not in 
any degree contribute to the disease. The bowels should also be attended to, 
and a tendency to constipation corrected. Sometimes an active purge will be 
found highly useful; and, when there is no debility, this may be occasionally 
repeated. Cures of neuralgia have been effected by croton oil. But in cases 
of debilitated digestion laxatives should be preferred. 
The hepatic function also requires attention. The happiest effects some- 
times follow a little blue mass or calomel, or the use of nitro-muriatic acid. 
In like manner, disease of the kidneys and urinary passages, and of the 
generative organs, should be cared for; and amenorrhoea especially should be 
removed by the requisite means. 
Regard must also be had to the condition of the system. If there be a ple- 
thoric tendency, which is not common, it may be corrected by a restricted 
diet, an occasional saline laxative, and exercise. The opposite condition of 
anaemia is much more, common, and frequently demands treatment. 
But probably the most frequent of these general sources of neuralgia is the 
gouty or rheumatic tendency; and cures may often be effected by remedies 
applied in accordance with this view. The physician should never allow a 
case of neuralgia to pass from under his observation, without having investi- 
gated its possible relation to gout and rheumatism. (See Nervous Gout.) 
Not unfrequently a close examination will detect a syphilitic origin. Un- 
der these circumstances, or when there is only a strong suspicion of the kind, 
recourse should be had to iodide of potassium in doses of five or ten grains 
three times a day, and, if this fail, to a gentle mercurial course. 
Neuralgia is often intermittent, and, when not so at first, often becomes so. 
The physician should always be on the watch for this state of the disease; as, 
by availing himself of the power of anti-periodical remedies, he will almost 
invariably be able to arrest it. I do not think I have ever failed, except in 
one instance, in curing regular intermittent neuralgia, of the quotidian or 
tertian character, by means of sulphate of quinia. In general, moderate doses 
of this medicine will answer, say from ten to twenty grains between the 
paroxysms; but, if these should not succeed, the quantity may be aug- 814 
LOCAL DISEASES.-NERVOUS SYSTEM. 
[part II. 
mented to half a drachm, or a drachm if necessary. Cases which refuse to 
yield to the smaller quantity will sometimes immediately give way to the 
larger. The remedy will often also succeed in the regularly remittent variety; 
and sometimes, after failure at the commencement, will answer the purpose 
effectually, if tried at a later period. Occasionally a case of neuralgia, com- 
mencing in an irregularly continuous form, may be brought to the remittent 
or intermittent form by treatment addressed to the state of the system. 
Arsenic is another anti-periodic remedy, which has often proved effectual 
in periodical neuralgia; but it is less to be relied on than quinia, and does 
not so well accord with the condition of system generally attendant on the 
disease. Nevertheless, it might be tried, if quinia should fail, or from con- 
stitutional peculiarities of the patient, be inadmissible. 
Other means calculated to interrupt periodical diseases will also occasionally 
succeed, such as an emetic, opium, a blister, the tourniquet, &c., employed in 
anticipation of the paroxysm. For a particular account of these, the reader 
is referred to the subject of Intermittent Fever. 
But we are not without remedies for pure uncomplicated neuralgia, not 
periodical in its character. So far as my experience has gone, the most 
effectual of these is subcarbonate of iron, given in connexion with one of the 
narcotic medicines, especially extract of belladonna. The subcarbonate should 
be administered in large doses, from half a drachm to a drachm, or even two 
drachms, three or four times a day. Each dose may be mixed with ten grains 
of powdered ginger; and care should be taken always to keep the bowels well 
opened once daily, in order to prevent the injurious accumulation of the medi- 
cine. If requisite, this may be effected by the addition of rhubarb to the 
powder; or by giving separately, as circumstances require, pills of rhubarb 
and aloes, made a little more active, if necessary, by the addition of one- 
quarter or one-third of a drop of croton oil. The iron probably acts by 
improving the blood, and invigorating the nervous system. 
Sulphate of quinia will also frequently prove efficacious in this form of 
neuralgia, though much less to be relied on than in the regularly periodical. 
It should be given largely. There is one form of the disease, in which I have 
found it, in connexion with oil of valerian, almost uniformly successful; I 
allude to hemicrania,. This is an old practice; but, in former times, Peruvian 
bark was given in substance with the infusion of valerian; and it was dif- 
ficult to induce the patient to swallow the requisite quantity of the medicine. 
From ten to thirty grains of the sulphate, and about twenty drops of the oil 
of valerian, should be given daily, divided into six or eight doses, and per- 
sisted in if necessary for a week or more. Enough of the salt of quinia should 
be given to induce its peculiar effects upon the brain, such as buzzing in the 
ears, &c. It very often happens that the pain is increased for the first day 
or two, after which it gradually subsides. The two medicines may be con- 
veniently conjoined in emulsion, to which a little aromatic sulphuric acid may 
be added to effect a solution of the quinia; or the sulphate may be given in 
pill, and the oil in emulsion. 
Besides the chalybeates, various metallic tonics have had some reputation 
in the treatment of neuralgia. Among them may be mentioned nitrate of 
silver, the salts of copper, and the sulphate and oxide of zinc. Valerianate 
of zinc is highly esteemed by some practitioners. 
Iodide of potassium has been highly recommended. It certainly, in some 
cases, appears, in doses of from five to ten grains three or four times a day, 
to act like a charm; but in many other cases it fails entirely; and I have 
been unable to ascertain satisfactorily what are the precise circumstances 
under which it is most favourable. It is undoubtedly very useful in neuralgia CLASS III.] 
815 
NEURALGIA. 
connected with a syphilitic taint; but I am unwilling to infer that all other 
cases in which it proves serviceable are syphilitic. 
In very obstinate cases, it may not be amiss to try the effects of a mild 
mercurial impression, after failure with other measures. Not to speak of its 
beneficial influence in syphilitic cases, this remedy is so efficient in the removal 
of chronic inflammation, and neuralgia is so often connected with some con- 
cealed organic affection of the viscera or nervous centres, that some good from 
it might be reasonably hoped for in the cases alluded to. 
Muriate of ammonia, in the dose of half a drachm three or four times a 
day, has been given with asserted advantage in neuralgia. 
Oil of turpentine is another alterative which has occasionally proved useful, 
especially in cases connected with the sciatic nerve. It should be given in 
the dose of half a fluidrachm or a fluidrachm, three times a day. 
The alterative effect of sulphur may be tried with hope of benefit, espe- 
cially when the case is complicated with rheumatism or gout. The natural 
sulphur waters have sometimes proved advantageous. 
A repetition of emetics has occasionally cured obstinate neuralgia. This 
remedy was recommended by Dr. Physick in those very painful affections of 
the head, sometimes consequent upon a contusion or wound of the scalp. 
The narcotics are almost indispensable in the treatment of the disease. 
Sometimes they are of themselves adequate to its temporary cure; and at all 
times are necessary to render the complaint endurable. The most efficient 
beyond all comparison is opium in one or another of its forms. I generally 
prefer one of the salts of morphia; but sometimes the black drop or acetum 
opii agrees still better with the patient. The medicine should be given in such 
doses as may be necessary to procure ease during the most violent paroxysms; 
but great care should be taken not to increase the dose too rapidly, so as to 
accustom the system to its effects. It is best to fix some limits which should 
never be exceeded, except under extraordinary circumstances; and a good 
rule is, after having used it for some time, to substitute another narcotic for 
it, so that the system may recover its susceptibility. The great danger in the 
use of opium is that the patient may contract a pernicious habit, which he may 
be unable or unwilling to break, when there may be no longer occasion for 
the medicine. The physician should bear this danger in mind, and regulate 
his prescription accordingly. I usually combine morphia with wine of colchi- 
cum, so that much increase in the dose will produce sickness of the stomach, 
and indispose to a further augmentation. Besides, the effect of the colchicum 
is itself often beneficial, and in gouty cases generally so. 
Should opium disagree with the patient, or circumstances forbid its use, re- 
course may be had to extract of hemp, or large doses of hyoscyamus or lactu- 
carium as a substitute. I have found considerable advantage from the internal 
use of chloroform, in neuralgic pains; but it is liable to the objection that 
it is apt to occasion nausea and vomiting. This is probably owing, in part 
at least, to its insolubility in water and the fluids of the stomach, Where 
camphor is admissible, and still more where it is indicated, the objection may 
be obviated by rubbing this substance with chloroform, and suspending the 
resulting liquid in water, by the intervention of the yolk of eggs. A perma- 
nent mixture is thus made, which may be diluted to any desirable extent with 
water, without the separation of the chloroform.* 
* The following formula will answer the purpose. Take of chloroform fgij, camphor 
ji, the yolk of one egg, and of water f^vj. Mix, and direct a tablespoonful to be taken 
every half hour, every hour, or every two hours, according to the urgency of the case, 
until relief is obtained, or some decided effects are experienced from the medicines, 
either on the stomach or the brain. {Note to the second edition.) 816 
LOCAL DISEASES.-NERVOUS SYSTEM. 
[part it. 
But opium, and the substitutes for it just mentioned, are in general only 
palliative. There are some narcotics, which, with an anodyne, combine an 
alterative influence that appears to be somewhat curative. Of these, I have 
already expressed my preference for belladonna. Stramonium possesses similar 
powers. Conium is also useful in large doses. The three may sometimes be 
combined with advantage. They should be given in such quantities as to 
produce a slight vertigo, or other evidence of action on the brain. 
The nervous sedatives have also been much used in neuralgia. Aconite 
enjoys considerable reputation. I have used it occasionally with benefit; but 
confess that I have been much more frequently disappointed. The saturated 
tincture is the best preparation, and should be given in the dose of from five 
to ten drops, or in such quantities as may be necessary to induce its peculiar 
tingling effects upon the fingers or other parts, or some unusual feeling in the 
head. Tobacco and hydrocyanic acid have sometimes proved useful. The 
effects of the former may be obtained by smoking it. 
Of course, the narcotics are to be given in connexion with the more per- 
manently effective remedies already mentioned. 
The nervous stimulants or antispasmodics, as musk, assafetida, camphor, 
valerian, garlic, &c., may sometimes be advantageously combined with the 
remedies already mentioned, when, besides mere pain, there may be other 
nervous irregularity. 
Local Remedies.-The local treatment of neuralgia is important. Much 
may be done in this way to afford relief to the patient. The means recommend- 
ed are even more numerous than those internally employed. On the whole, 
the most efficacious are the narcotics. Laudanum may be applied by lotion, 
or in the form of a cataplasm; care being taken to guard against injurious 
effects from its absorption, if the cuticle should be broken. The liquid pre- 
parations of opium and camphor may sometimes be usefully combined. The 
strong tincture of aconite is highly recommended. It should be rubbed upon 
the part, till it produces its tingling and benumbing effect. Aconitina mixed 
with lard, in the form of ointment, in the proportion of one or two grains to 
a drachm, has been greatly praised; but it is expensive, and probably in no 
degree superior* to the tincture. Ointments made with the extracts of stramo- 
nium and belladonna may also be applied by friction. A belladonna plaster, 
made according to the officinal directions, is sometimes undoubtedly beneficial. 
Tobacco cataplasms may be used occasionally with great benefit; but their 
depressing effect, when too freely or too long applied, should be borne in mind. 
The same remarks are applicable to hydrocyanic acid and cyanuret of potas- 
sium, which have been commended. The latter may be applied in the pro- 
portion of one or two grains to the fluidounce of water. Chloroform has 
been employed locally with great benefit. The first to use this remedy, for 
its local anodyne effect in neuralgia, was, I believe, Dr. Isaac Hays of Phila- 
delphia. The liquid should be applied upon a piece of linen saturated with 
it, and this should be covered with oiled silk to prevent evaporation. Some 
burning and superficial pain may be experienced at first, and even a blister 
has been produced; but the relief of the neuralgic pain is often speedy and 
entire, and lasts for a considerable time. I have experienced from no local 
remedy more prompt and complete anodyne effects than from this. In some 
instances, it may be preferably applied, mixed with some emollient substance 
in the form of a cataplasm, or rubbed on the part in the state of an ointment. 
When the pains affect the anus, uterus, urinary organs, or neighbouring 
parts, the anodyne may be most efficiently employed in the form of enema. 
Laudanum, under such circumstances, affords speedy relief. 
The endermic method is sometimes also highly useful. A small blister may CLASS III.] 
NEURALGIA. 
817 
be made in the near vicinity of the pain, the cuticle removed, and half a grain 
of powdered acetate of morphia sprinkled upon the surface. 
Ice or ice-cold water, locally applied, occasionally affords relief. The same 
may be said of steaming with hot vapour, or the employment of the hot douche; 
and great success has been claimed for the cold douche, employed after perspi- 
ration induced by heat. Covering the part with oiled silk, and then keeping 
it warm by a layer of carded wool, probably operates usefully in the same 
mode as the local vapour bath. Dry heat, applied by means of burning coals 
near the part, and continued as long as the patient can well bear it, is another 
mode of obtaining ease, that may be resorted to. 
Rubefacients, such as oil of turpentine, Cayenne pepper, and tincture of 
cantharides; repeated blistering over tender points that may be discovered 
near the seat of pain; revulsion by means of setons, issues, and moxas; the use 
of electricity, galvanism, and electro-magnetism; and acupuncture, are all mea- 
sures which have strong testimony in their favour, and which undoubtedlv 
often produce a beneficial impression upon the disease. Pustulation, by means 
of croton oil, over the nervous trunk in the ramifications of which the pain is 
seated, is said to be sometimes very efficacious. 
Indeed, anything which for the time modifies the nervous condition of the 
part may occasionally afford temporary relief; and I have never known more 
speedy effects from any remedy, than I have sometimes witnessed from gentle 
friction with a soft hand upon the surface. 
In a disease so painful, often so obstinate, and so lasting; and in one, too, 
so much temporarily under the influence of the imagination, it is highly de- 
sirable that the physician should have at command an inexhaustible fund of 
remedies, so that he may vary his means to suit the circumstances of the case. 
But there is one rule which he should never forget; that, while skirmishing 
with the lighter auxiliary measures, he should not be induced too hastily to 
relinquish the really efficient and curative means which he may have brought 
to bear on the disease. 
After having employed all the resources of the materia medica, there yet re- 
main measures which promise most favourably, and which sometimes succeed 
in apparently desperate cases. The nervous system has, in some instances, 
been so long accustomed to the neuralgic affection, that pain has become its 
natural mode of action; the condition into which it spontaneously falls when- 
ever remedial impressions are for a moment removed. It now becomes im- 
portant to change entirely the circumstances under which the patient may be 
placed, to habituate his nervous system to new influences, and to sustain the 
novel impression until the system shall have forgotten the old altogether. 
Such an effect occasionally results from a dangerous and protracted disease, 
from which the patient emerges, created as it were anew. A safer and more 
agreeable mode of accomplishing the same end is to send him into a foreign 
country, to be absent at least a year, and if practicable several years; or upon 
protracted voyages, the longer the better; or, if neither of these objects be 
attainable, to change completely his mode of life at home. No remedy, with- 
in my observation, has been so effectual in obstinate neuralgia as a journey to 
Europe, and a residence abroad for a year or more, amidst the exciting novel- 
ties, and the various incidents pleasing or otherwise, belonging to foreign travel. 
I have no doubt, moreover, that the course of life pursued at the hydropathic 
institutions, may sometimes strongly co-operate with such influences in revo- 
lutionizing the nervous system. But such a powerful instrument should not 
be rashly employed, nor without due medical advice. 818 
LOCAL DISEASES.-NERVOUS SYSTEM. 
[part II. 
Article III. 
CRAMP. 
Cramp is painful involuntary contraction of a muscle, attended with rigidity, 
and of more than momentary duration. Its title to a place among the diseases 
of the nerves might be disputed ; but as the pain is certainly a nervous phe- 
nomenon, as the affection is often induced through nervous intervention, and 
as no distinct category of muscular diseases is admitted in the classification 
adopted in this work, I have been able to find no more suitable position for it. 
Cramp affects both the exterior and interior muscles, and the involuntary 
as well as the voluntary. In general, it is a mere symptom or attendant on 
other affections, such as dyspepsia, cholera, the different forms of colic, spinal 
irritation, tetanus, hysteria, &c.; but not unfrequently also it appears to be 
idiopathic, being traceable to no other pathological condition; though it must 
be admitted that, in most instances, its real source is probably some concealed 
derangement, either in the nervous centres, or in organs operating through 
those centres, or possibly in the blood. So far as it is a symptom of recog- 
nized diseases, it has been sufficiently considered elsewhere. It has also been 
treated of, as affecting the interior muscles, particularly those of the stomach, 
the bowels, and the bladder. In this place, the remarks upon it will be 
limited to its occurrence as an external and seemingly idiopathic affection. 
Symptoms.-Any of the muscles may be the seat of cramp; but it occurs 
most frequently in the calf of the leg, the sole of the foot, the muscles which 
move the fingers, and those of the neck. It is generally sudden in its attack, 
causing the muscular fibres to gather up into a hard knot, readily perceived 
by the touch, and not unfrequently visible. The contraction is attended 
with pain, sometimes excruciatingly severe, so as to extort screams from 
the sufferer ; and instances have occurred in which syncope has resulted 
from its insupportable violence. Its duration is very variable, from a few 
seconds, to minutes, and even hours. The spasm may cease abruptly; but 
perhaps more frequently passes into relaxation by a sort of vibratory move- 
ment very sensible to the patient; and usually leaves behind it more or less 
soreness to the touch, which may last a considerable time. Sometimes the 
same muscle is the seat of repeated contractions; sometimes the affection 
extends to several conjointly or successively; and instances occur in which 
it rapidly changes its seat, now perhaps attacking the leg, then the side, then 
again the arm or the neck, scarcely deserting one place before it seizes upon 
another. It may leave the patient entirely after a brief duration, or may 
recur at shorter or longer intervals for days, weeks, or months, and even 
during life. Some persons are apt to be affected especially while in bed at 
night, and are often awakened by it out of sleep. 
Causes.-These are not very obvious. It is probable that a gouty or rheu- 
matic diathesis often constitutes the predisposition to the affection. The same 
may be said of general debility, and of anaemia. Whatever favours the oc- 
currence of neuralgia may in like manner predispose to cramp, which is a 
very analogous affection. It frequently has its origin in gastric or intestinal 
disorders. Of the exciting causes, perhaps the most frequent is sudden ex- 
posure to cold. The complaint is apt to affect swimmers; and death by 
drowning has often been ascribed to this cause. Yet, like rheumatism, it 
sometimes, as already stated, makes its attacks preferably when the patient is 
warm in bed. An extended or otherwise uncomfortable position of the mus- 
cles may occasion it. Some persons can bring it on at any time by a con- CLASS III.] 
HICCOUGH, OR SINGULTUS. 
819 
tinued forcible voluntary contraction, particularly of the gastrocnemius, or one 
of the plantar muscles. It is apt to occur in pregnant women. 
Treatment.-This may be directed either to the relief of the cramp, or to 
its prevention. The first object may often be gained by forcibly extending 
the contracted muscle through the agency of its antagonistic muscles. Com- 
pression and friction over the affected part are also useful. The friction may 
be made with the naked hand, or by a flesh-brush, and may be aided by the 
simultaneous use of an anodyne liniment, as the solution of camphor in olive 
oil, camphorated tincture of soap, laudanum and brandy, &c. Vigorous ex- 
ercise sometimes gives relief, probably by a revulsive influence. On the 
same principle is explained the relief which is asserted to result from the 
popular remedy of forcibly compressing a roll of sulphur in the hand until it 
cracks. Faith, however, or the strong engagement of the attention, has pro- 
bably quite as much to do with the result. The warm or hot bath may be 
employedin obstinate cases; and, should the affection not yield to some of 
the measures mentioned, recourse may be had to any or all of those directed 
for the neuralgic paroxysms, of which the local application of chloroform 
would be likely to be among the most efficient. (See page 815.) 
To meet the second indication, all obvious derangement of the digestive 
organs or the system at large should be corrected; and the remedies suitable 
for gout and rheumatism will often be found beneficial. I am in the habit 
of employing sulphur as an alterative in those cases in which no obvious 
indication is presented for other treatment. Great advantage is said to have 
accrued from the use of tar-water. Dr. S. A. Bardsley succeeded, in his own 
case, in preventing the nightly attacks to which he had been a martyr for 
many years, by the simple expedient of sleeping on an inclined plane; the 
foot of the bed being twelve inches lower than the head. {Land. Med. Gaz., 
May, 1847.) Should the disease exhibit an obstinate disposition to return, 
recourse may be had to the remedies which have been found useful in the 
cure of neuralgia. Persons subject to attacks of cramp should be careful, in 
swimming, not to venture beyond their depth, or out of the reach of aid, or, 
what is still better, should avoid the exposure altogether. 
Article IV. 
HICCOUGH, or SINGULTUS. 
This consists of sudden, short, convulsive inspirations, attended with a 
slight peculiar laryngeal sound, and followed immediately by expiration. The 
affection is placed in this subsection, with the same doubtful propriety, and 
for the same reason, as the complaint treated of in the last article. 
Hiccough is probably, in almost all instances, the result of some derange- 
ment exterior to its apparent seat, and is, therefore, strictly speaking, merely 
a symptom. But, though frequently an attendant upon obvious diseases, it 
very often also occurs without being clearly traceable to any other affection ; 
so that it is necessary to consider it in description, as it is in fact often treated 
practically, as a distinct complaints 
The movements concerned in the production of hiccough are probably a 
spasmodic contraction of the diaphragm, and a certain degree of constriction 
in the glottis, which occasions the sound upon' inspiration, and limits the 
amount of air inspired. 
Symptoms, Course, and Effects -The convulsive inspirations are usually 
productive of some uneasiness about the pnecordia, and sometimes painfully 
agitate the abdominal and thoracic viscera, or even the whole frame. They 820 
[part if; 
LOCAL DISEASES.-NERVOUS SYSTEM. 
commonly occur in spells or paroxysms, and succeed each other with some 
degree of regularity, at intervals of a few seconds. The paroxysm may last 
only a few minutes, or it may extend to hours, or days; and is in general 
quite irregular in its recurrence. It is said that the hiccough has been some- 
times almost continuous for weeks, and even months; and instances are on 
record in which it has persisted for three or four months with little interrup- 
tion. A case is reported in the Journal des Progrts (xviii. 208), in which a 
man had been affected with it for four years, and had been reduced so much 
that his life was despaired of. But such cases are extremely rare. Almost 
always, whatever may be the duration of the complaint, the patient has more 
or less respite in its course; and it is very seldom quite continuous through 
one whole day. Sometimes it is very fugitive, being limited to one or a few 
brief paroxysms. In general, even in the worst cases that have come under 
my notice, I have found it to yield speedily to treatment; and I have seldom 
known it to last more than a week or ten days. 
Though rarely dangerous, it is often exceedingly annoying, and sometimes 
wearing in its effects upon the health by interfering with the natural rest. 
Not unfrequently, however, the patient, when exhausted by its long continu- 
ance, will sleep through its attacks. It may add to the danger of diseases 
with which it is associated, and in some instances is asserted to have ended 
fatally without any other discoverable cause of death. It is probable, how- 
ever, that there was in these cases some concealed lesion, which was the cause 
at once of the obstinacy of the hiccough and of its fatal issue. 
Like most other nervous affections, this is sometimes regularly intermit- 
tent, occurring at a particular hour every day, every other day, or at longer 
intervals. Some persons are said to be subject to attacks of it once a year, at 
about the same time. 
Causes.-An anemic or otherwise debilitated state of system predisposes 
to hiccough. The intemperate are very subject to it. The same is said to 
be the case with pregnant and hysterical women. The young and the old 
are more frequently affected than persons of middle age. Certain diseases 
are very apt to be attended with it, especially the phlegmasiae of the ab- 
dominal viscera, in which its occurrence sometimes marks the approach or 
existence of collapse. The same remark is applicable to malignant diseases 
in general, in which it is looked on as an unfavourable sign. But it so fre- 
quently occurs in the course of diseases which are in no degree violent or 
dangerous, that little importance need be attached to it as a prognostic 
symptom. 
The slightest causes are often sufficient to induce an attack in the predis- 
posed. Anything which disorders the stomach may have the effect. So 
great is the influence of this organ in producing hiccough, that for a long 
time the affection was considered as essentially gastric, and was supposed by 
many to consist mainly in spasmodic contractions of the stomach. This 
peculiar influence may be explained by the nervous connexion existing be- 
tween the stomach and the diaphragm through the semilunar ganglia. 
Among the exciting causes are emptiness and over-distension of the stomach, 
indigestible or irritating food, draughts of cold water, flatulence, excess in 
the use of alcoholic drinks, acid and bile in the stomach, worms, any sudden 
emotion, the passage of urinary or biliary calculi, the disturbance of system 
following surgical operations, inflammation or irritation of the spinal marrow, 
nervous derangements in general, the retrocession of cutaneous eruptions, the 
suppression of wonted discharges especially the menstrual, and gout or rheu- 
matism acting on the diaphragm or its nervous centres. Habit has probably 
some influence in sustaining it, and it is thought to be sometimes induced 
through the agency of the imitative principle. CLASS III.] 
PALSY. 
821 
Treatment.-The remedies should be addressed, first, to the relief of the 
hiccough, and, secondly, to the prevention of its return. 
1. When the affection is slight, it may often be set aside by making a very 
full inspiration, and then holding the breath as long as possible, so as to keep 
the diaphragm in a state of voluntary contraction; and this process should be 
repeated, uutil the disposition to a return of the hiccough is observed to 
cease. Another mechanical measure, said to be sometimes effectual, is to 
make pressure strongly upon the epigastrium. A fit of sneezing, and the act 
of vomiting probably operate partly in the same way in its relief. Sudden 
impressions, whether bodily or mental, will often suspend the paroxysm; 
even though of the same nature with those which may, under other circum- 
stances, induce it. A very common mode of cure is to cause sudden alarm, 
anger, or surprise. The same effect results from strongly engaging the atten- 
tion in any way. A draught of cold water will sometimes give relief. Du- 
puytren succeeded in a very obstinate case by applying the actual cautery to 
the epigastrium. 
In cases in any degree obstinate, the nervous or cerebral stimulants may 
be resorted to, such as musk, assafetida, aromatic spirit of ammonia, camphor, 
opium, &c. I have on the whole found nothing so effectual as musk. This, 
when of good quality, will almost always check hiccough, and very frequently 
effect a permanent cure. It is especially adapted to it, when occurring in low 
febrile diseases; but may be employed in all obstinate cases, when not con- 
traindicated by the state of the system. A combination of chloroform with 
camphor sometimes also acts very promptly and efficiently. Various other 
remedies have been found occasionally useful, among which sharp vinegar and 
sulphuric acid may be mentioned. The latter of these substances has proved 
promptly effectual in a case which had resisted other treatment for a very 
long time. 
2. To prevent the return of the paroxysm, sulphate of quinia is the most 
effectual remedy in the regularly intermittent cases. In others, it is neces- 
sary to consult the state of the system, and treat the patient accordingly. 
Debility, anaemia, general nervous disorder, amenorrhoea, gastric flatulence and 
acidity, excessive abstinence, repletion of stomach, dyspepsia, constipation, &c., 
are to be corrected by measures pointed out elsewhere. Combinations of the 
bitter tonics, chalybeates, antispasmodics, laxatives, and carminatives, will 
often be found useful. The same may be said of cold bathing, pure air, ex- 
ercise, and a proper regulation of the diet. It is asserted that bleeding has 
proved of advantage in some instances in which the complaint has been con- 
nected with plethora. When of gouty or rheumatic origin, it must be treated 
in the same manner as other nervous affections of a similar character. The 
spine should be examined, and, if found tender, treated as directed for spinal 
irritation. 
SUBSECTION IV. 
DISEASES BELONGING TO THE NERVOUS SYSTEM GENERALLY. 
Article L 
PALSY, or PARALYSIS. 
Paralysis, from the Greek is a loss, partial or complete, of sensa- 
tion and the power of motion. This, however, though the usual definition, is 822 
LOCAL DISEASES.-NERVOUS SYSTEM. 
[part II. 
not exact. Coma would fall under it, yet is not looked on as paralysis. Palsy 
is sometimes known to accompany coma; as when the absence of sensation 
and motion is observably more complete in one part of the body than in the 
remainder. Not unfrequently, a paralytic condition continues after the sub- 
sidence of coma; and must have previously existed along with it, though con- 
cealed by the general want of sensation. But if, in a comatose affection, an 
attack of apoplexy for example, no inequality is observable in different parts 
in relation to the two properties alluded to, and if, after the disappearance of 
the stupor, no deficiency of sensation and motion remains, the case is not ranked 
with palsy. In syncope there is an equal absence of the two properties; yet 
no one would class that affection with the one under consideration. Again, 
loss of the power of motion in a part may arise from mechanical impediment, 
from inflammation, or disorganization of the part, or from excessive pain; and 
in neither of these cases would the affection be looked on as paralytic. The 
definition, therefore, above given, must be received with considerable restric- 
tion. To entitle an affection to be regarded as paralysis, it must be independ- 
ent of other obvious disease in the part, and must either be unattended with 
coma, or be shown to exist by inequality of sense and motion in different parts 
of the body during the continuance of the coma, or must appear upon the re- 
turn of consciousness. 
It is obvious that universal palsy must be instant death; so that no such 
affection can be recognized by the physician. But all or nearly all the volun- 
tary muscles, and organs of external relation may be paralyzed, and yet life 
continue for a time. Such an affection would be denominated general palsy; 
and the term is extended to all cases, in which the upper and lower extremi- 
ties on both sides, and more or less of the trunk, are involved. Very fre- 
quently only one-half of the body laterally is affected, the other side remaining 
sound. The disease is then called hemiplegia. Sometimes the palsy is con- 
fined to the lower half of the body, or to the two lower extremities, and in 
this Case is named paraplegia. When one part of the body, as a limb, 
the face, the eye, the tongue, &c.., is exclusively attacked, the affection is dis- 
tinguished by the title of local palsy. Some writers have a distinct name for 
cases in which an arm on one side, and a leg on the other, are jointly affected; 
but such instances are rare, and may without violence be ranked with local 
palsy when they occur. 
In some cases, the loss of sensation and the power of motion in the paralyzed 
part is entire, in others not so. In the former, the palsy is said to be complete, 
in the latter partial. 
In the greater number of instances, sensibility and motion are simultane- 
ously lost or impaired; but not unfrequently one property is affected without 
the other; or the two are affected in different degrees. When motion is lost 
without the loss of sensibility, the affection is sometimes called acinesia. In- 
stances of this variety of palsy have been noticed, in which the sensibility has 
been exalted, at least the susceptibility to painful impressions. More rarely, 
there is a loss of sensibility, with retention of the power of voluntary motion. 
Such cases are designated by the term anaesthesia. This affection occurs 
most frequently in the organs of sense; as in the eye, for example, in which 
the nerve of vision may be paralyzed, and yet the ball may obey the muscles, 
and in the tongue, in which taste may be lost, without any defect of move- 
ment. These, it may be said, are cases in which the part really paralyzed is 
a mere organ of sense, and has no inherent power of motion to be affected. 
But there are cases in which paralysis of sensation is attended with the power 
of voluntary motion, even though nervous influence is transmitted through the 
same nervous cords. Thus the hand may be deprived of feeling, yet the CLASS III.] 
PALSY. 
823 
fingers may move under the will; but, in such instances, it is necessary that 
the attention should be strongly directed to the act, and it is said that the 
patient must see the limb that he attempts to move. 
Pathological Conditions.-In most cases, palsy is a mere symptom of a 
morbid state existing in some other part than the one apparently affected. It 
may depend upon disease, either in the nervous centres, incapacitating them 
for the reception of impressions or the origination of influence, or in the con- 
ducting filaments which form the communication between all parts of the body 
and these centres. But it may also be strictly local, and depend on an altered 
state of the terminal nerves. The nervous centres are probably in the gray 
matter of the brain, the spinal marrow, and the ganglia; the conducting fila- 
ments probably make up the white matter of the brain, spinal cord, and nerves. 
It follows that the true seat of the disease may be in the encephalon, the 
spinal marrow, the conducting nerves, or the nervous ramifications of the 
paralyzed part. 
The particular conditions of the brain, which occasion palsy, have, for the 
most part, been already fully considered under other heads. It will be suffi- 
cient here to mention simple sanguineous congestion, hemorrhagic and serous 
effusion, softening and induration from inflammation or other causes, fatty 
degeneration, fibrinous exudation, suppuration, hydatids and morbid growths 
of various kinds, and depressed bone or other injury from external violence. 
For an account of these lesions, the reader is referred to meningitis, cerebritis, 
apoplexy, organic diseases of the brain, cerebral congestion, &c. It is a fact 
worthy of notice, that the degree or extent of the paralysis is by no means 
proportionate to the magnitude of the lesion, as disclosed by post-mortem 
examination; a speck of organic change in the brain sometimes producing 
greater effect than extensive disorganization. The cause of this may be partly 
in the more rapid production of the more limited injury; but is probably also 
in part, perhaps chiefly, the more precise correspondence of the lesion with 
the centres presiding over the apparent seat of the palsy, or with the filaments 
connecting the two. It is highly probable, also, that the cerebral centres are 
sometimes disabled functionally; and that, consequently, palsy may result 
without any apparent lesion. At least search for such lesion has sometimes 
been made in vain. The temporary palsy, which is not unfrequently observa- 
ble in cases of artificial somnambulism, is certainly of the functional character; 
as is generally also the hysterical. 
It is clear that, as the brain is the organ of sensation, and of all action of 
the will, cases of palsy, involving these two functions, may arise exclusively 
in that organ, and can depend upon derangement of any other part only as 
that derangement interrupts the communication between the brain and the 
extreme nerves. 
The pathological conditions of the spinal marrow producing palsy are pre- 
cisely the same as those of the brain, and do not require repetition. (See 
Diseases of the Spinal Marrow.) The spinal centres may possibly originate 
palsy of the reflex or automatic movements, or those concerned merely in the 
organic functions, as the peristaltic movement of the bowels; but so far as 
concerns sensation and voluntary motion, disease of the spinal marrow can act 
only by interrupting the communication with the brain. It follows that, in 
cases of palsy from spinal disease, so far as these two functions are concerned, 
those parts only of the body will be affected, which are supplied with nerves 
issuing from the cord below the seat of the lesion. It is also a neces- 
sary result that, when the cord is completely disorganized at any one part, 
throughout its whole thickness, a complete loss of sensation and voluntary 
motion must be experienced in the regions supplied by nerves from beneath 824 
[part II. 
LOCAL DISEASES.-NERVOUS SYSTEM. 
that part, because the brain has no other medium of communication with 
those regions. Cases, however, are said to have occurred, in which the cord 
has been found completely diffluent or quite divided, and yet the will has been 
obeyed by the muscles of the lower extremities. The probability is, in rela- 
tion to these cases, that the complete diffluence has been cadaveric, and that, 
when division of the spinal marrow has been observed, it may have resulted 
from post-mortem violence in the opening of the spinal cavity. 
In relation to the influence of the ganglia in producing paralysis, too little 
is known to justify any extended observations. It is at least highly probable 
that their disorganization, from various causes, occasionally gives rise to loss 
of power in the organic functions which they influence or preside over; but 
they probably have nothing to do, as nervous centres, with palsy of sensation 
or voluntary motion. 
The conditions in the course of the nerves which occasionally constitute the 
true pathological state of palsy, are compression from without, or by tumours, 
congestion, extravasation, &c., in their neighbourhood, mechanical division 
or other destructive violence, and inflammatory softening or disorganization. 
The main nerves proceeding from paralyzed parts have been found, after death, 
enlarged or atrophied, softened or indurated, and sometimes quite disor- 
ganized; the nervous matter within the membrane being completely diffluent. 
The extreme nerves may be rendered unfit for receiving impressions from 
without or from the brain, and thus become the immediate seat of palsy, by 
a long want of use, by an interruption of a sufficient supply of blood to sus- 
tain the due nervous action, by long or severe pressure, and by inflammatory 
congestion or disorganization of their own tissue, as probably sometimes hap- 
pens in gout and rheumatism. There are also certain agents which appear 
to have the property of directly depressing nervous power and action, without 
any instrumentality of the nervous centres or conducting filaments. Such are 
the metallic poisons, especially lead and arsenic. Cold is another agent of 
this kind. Every one is familiar with the loss of sensation and motion in 
parts of the body, consequent on their direct exposure to severe cold. 
That palsy should sometimes be partial is easily understood. The nervous 
centre may suffer in a degree insufficient wholly to destroy its recipient and 
productive powers, or the conducting fibrils may be but partially injured, so 
as still to convey the nervous current, though imperfectly, to its destination. 
The injury in different degrees of the properties of sensation and motion, 
or the abolition of one while the other remains unaffected, is also readily ex- 
plicable, since the beautiful discovery that the transmission of impressions to 
the nervous centres, and of motor influence from these centres, is effected by 
distinct nervous cords, and probably by distinct fibrils in the conducting por- 
tion of the brain and spinal marrow. It may readily happen that the lesion 
producing the palsy may affect one of these cords, or one set of these fibrils, 
chiefly or exclusively, so as to impede the transmission of one kind of influ- 
ence only, or of the two unequally. Thus, it is well understood that the pos- 
terior roots of the spinal nerves convey impressions towards the brain, and the 
anterior, motor influence from the brain; and there is good reason to believe 
that these different transmitting powers continue in distinct tracts of the white 
matter of the spinal cord and the brain to the centres in the latter organ. 
Should the lesion, therefore, in the course of the nerve, or of the spinal mar- 
row, or of the cerebral fibres, be seated in the afferent tract only, we shall 
have loss of sensation without loss of motion; if in the efferent only, loss of 
motion without that of sensation. 
A third fact, explicable upon the principles here admitted, is that, though 
palsy may originate in the brain or spinal marrow, it may yet be very nar- CLASS III.] 
PALSY. 
825 
rowly limited; to a small portion of one limb, for example, or even to a single 
muscle, notwithstanding that the conducting nerve may communicate with 
many parts unaffected, as well as with the one diseased. Each part must have 
its peculiar centre in the brain, and its peculiar nervous fibril to maintain a 
connexion with that centre, though a number of these fibrils may be included 
within one general sheath. Should one only of these special centres, or one 
only of the special connecting fibrils be affected by the paralyzing lesion, it 
necessarily follows that the palsy must be confined to the one part constituting 
the peripheral extremity of this connexion. 
Still another interesting fact in the pathology of palsy, requiring explana- 
tion, is the occurrence of the paralysis on the side opposite to that of the 
cerebral lesion, in which it may originate. In relation to palsy arising from 
lesions of the brain, this fact is almost universal. A few instances are on 
record in which the cerebral and paralytic affections were apparently on the 
same side; but they are so few that the presumption is wholly in favour of 
the opinion, either that they were insufficiently investigated, or that the palsy 
might have arisen from some cause independent of the observed lesion. Nor 
is the occurrence of difficult explanation. It is ascribed, and no doubt justly, 
to the decussation of the cerebral fibres in the medulla oblongata; the ante- 
rior pyramids mutually changing sides as they pass out of the cranium. An 
apparent anomaly exists in palsy of the facg, which obeys the general law, 
notwithstanding that the fifth pair of nerves, and the portio dura of the seventh, 
arise from roots above the point of decussation. But there can, I think, be 
little doubt, that these nerves will be traced ultimately to a lower origin, if, 
indeed, they may not be considered as having been already thus traced by 
Sir Charles Bell and Mr. Solly. There is some difficulty, however, in rela- 
tion to the cerebellum. The fibres of this portion of the encephalon do not 
decussate; yet the palsy which follows lesions of its tissue, obeys the general 
law, in occurring upon the side opposite to the lesion. This apparent anomaly 
is explained by the connexion between the fibres of the anterior pyramids and 
the pons varolii, which consists chiefly of filaments from the cerebellum. The 
shock producing the paralytic phenomena very probably passes in this direc- 
tion ; and the paralysis does not depend immediately upon injury of the cere- 
bellum, but upon that of the cerebral fibres in close connexion with it. Phy- 
siologists are disposed to believe that the cerebellum has nothing to do directly 
with the power of voluntary motion; but is only the instrument through 
which the motions are associated. The palsy which results from any lesion 
of the spinal cord is upon the same side as the lesion.* 
General Symptoms.-Palsy may come on suddenly or gradually. In the 
latter case, the paralytic phenomena are usually preceded by deranged sensa- 
tions, such as prickling, formication, coldness, weakness, &c.; feelings, which 
are ordinarily indicated when a part, as the foot or hand, is said to be asleep. 
* Dr. Marshall Hall, believing that muscular irritability depends on the spinal centres, 
while voluntary motion and sensation are cerebral functions, and also that by impairing 
or abolishing these functions, muscular irritability is increased, inferred that we might 
distinguish paralysis exclusively spinal from that exclusively cerebral, by the quiescence 
of the muscles under galvanic influence in the former, while their contractility under the 
same influence is increased in the latter. But Mr. Brown-Sequard has shown by experi- 
ment that no reliance can be placed upon this test {Med. Examiner, N. S., ix. 25); and Dr. 
R. B. Todd, of London, infers from his experiments that the excitability of a paralyzed 
limb under galvanic influence, is proportionate to the degree of force in the nerves of 
the limb, without having any special reference to the brain or spinal marrow; and that 
the practical conclusion to be drawn from an increased sensitiveness to this influence is, 
that the lesion in which the paralysis originates is of an irritant or inflammatory cha- 
racter. {Medico-Chirurg. Trans., xxxvi. 480.)-Note to the fourth edition. 826 
[part II. 
LOCAL DISEASES.-NERVOUS SYSTEM. 
A large portion of the body may be attacked at once; or the affection may 
begin in one small spot, and gradually extend more or less over the system. 
In the latter case it is called creeping palsy. Not unfrequently the paralysis, 
in its incomplete state, is attended with tonic or clonic spasms, which some- 
times amount, in the one case to convulsions, in the other to tetanic rigidity. 
In some instances, there is permanent flexion of the limbs, with stiffness of the 
joints. Pains in the palsied part are not uncommon. They may be slight 
and dull, or sharp and lancinating. The limb generally wastes, the muscles 
become flaccid and diminish in bulk, the skin is pale, the circulation is usu- 
ally more languid than in health, and the temperature is somewhat lowered. 
There is a diminution of the power of regulating temperature, so that the 
part becomes colder or warmer more easily, according to the degree of heat 
of the surrounding medium. The atrophy is ascribable partly to want of use, 
partly to the diminution of the nervous influence necessary for the perfection 
of the organic actions; and, as this influence is supplied more especially by 
the spinal marrow, paraplegia, which usually depends on lesions of that struc- 
ture, is more apt to be attended with atrophy, than hemiplegia, which gene- 
rally originates in the brain. From obvious causes, the palsied limb some- 
times becomes edematous. The system is variously affected, according to the 
character of the lesion upon which the palsy depends; but the general tendency 
of the complaint is to produce a feeble state of health, consequent, probably, 
in part at least, upon deficient exercise. The mind is also very often weak- 
ened, but rather as a result of the cerebral disease which produces the palsy 
than of this affection. The memory is very apt to fail, especially for recent 
incidents and for words. Sometimes there is a striking change of temper; 
good-natured persons becoming peevish, fretful, and very troublesome, while 
those before haughty or irascible, become gentle, meek, and amiable. There 
is a strong tendency to the feeble emotions; and paralytics are apt to shed 
tears upon slight occasions. It is said that palsy is now and then regularly 
periodical in its attacks, with perfect intermissions. 
The character of the paralytic symptoms often affords a certain degree of 
evidence as to the special origin of the affection. Should the palsy be incom- 
plete, and attended with clonic spasm or convulsions, we may infer the pro- 
bable existence of cerebral or spinal meningitis. Should it come on gradually, 
and be attended with rigid muscular contraction, especially of the flexors, 
there may be reason to apprehend the existence of cerebral or spinal softening 
of an inflammatory character. Occurring gradually, without contraction, it 
may possibly arise from non-inflammatory softening, as from fatty degenera- 
tion, either in the centres, the conducting nerves, or in the nerves of the muscles 
affected. Sudden attacks, as quickly disappearing, without obvious depend- 
ence upon some other cause, may be referred to congestion. Similar attacks, 
preceded by signs of congestion in the brain or spinal marrow, and having a 
certain degree of persistence, and especially when attended with apoplectic 
symptoms, may be considered as probably the result of hemorrhage. 
To complete an account of the symptoms of palsy, it will be necessary to 
notice its several varieties, both in reference to the position, and to the nature 
or origin of the affection. 
General Palsy.-This may depend on disease of the brain, or of the cer- 
vical portion of the spinal marrow, or upon some cause affecting the whole 
nervous system without obvious lesion. It is in some instances quite sudden, 
as when dependent on injury of the brain or upper part of the spinal marrow, 
or upon apoplectic effusion. In other cases it may be slow, beginning in some 
one point, generally in the extremities, and advancing with greater dr less 
rapidity until it involves most of the voluntary muscles, and perhaps at last CLASS III.] 
PALSY. 
827 
putting an end to life by paralyzing respiration. It is exceedingly painful 
thus to see the disease rising irresistibly upward, like the tide around an in- 
dividual unable to change his place, and drowning him at last by the mucus 
of his own lungs, which the palsied muscles have not strength enough' to 
expectorate. It is wonderful, however, to what an extent general palsy some- 
times proceeds without immediately destroying life. Voluntary motion has 
been almost completely lost, and several of the senses paralyzed, so as nearly 
to shut out communication with the exterior world; yet the organic actions 
have been maintained for a considerable time. In the end, however, degluti- 
tion becomes involved, the sphincters give way, and, if asphyxia or syncope 
do not result from the participation of the lungs and heart in the disease, the 
patient sinks under a general failure of the vital functions. Yet the disease 
is not necessarily fatal. Sudden cases, dependent on sanguineous congestion, 
sometimes get well, and the same event may occur after effusion of blood, 
though recovery is tedious and generally imperfect. The 'tost discouraging 
cases are those which begin at a point, and gradually spread over the system. 
They usually indicate incurable lesions of the spinal marrow, advancing until 
most of the cord becomes involved. Yet even such cases have recovered. 
Hemiplegia.-Palsy of one side of the body is most frequently an attend- 
ant upon apoplexy, and, even when not accompanied by comatose symptoms, 
generally depends upon cerebral hemorrhage. It may, however, arise from 
lesions of the spinal marrow. Sometimes it begins in one of the extremities, 
and thence slowly advances until the whole side becomes affected; but, in the 
great majority of cases the attack is sudden. The leg, the arm, the trunk, 
and the face, may all be involved, even the intercostals of the affected side; 
and both sensation and motion are usually impaired or lost. The line between 
the diseased and sound side often precisely follows the median line; even the 
tongue and lips being half paralyzed. It often, however, happens that dif- 
ferent parts are affected in different degrees; and, in such cases, the lower 
extremity, as a general rule, is less diseased than the upper. Patients often 
recover from hemiplegia, sometimes completely and permanently, but much 
more frequently only partially. The lower limb almost always recovers its 
powers before the upper, and not unfrequently the patient is able to walk, 
while the arm hangs useless by his side. Unless the symptoms disappear 
speedily, indicating a mere congestion as the cause, the amendment is usually 
very slow, and the patient, though he may sometimes be restored to activity 
and usefulness, more frequently remains with impaired powers of mind and 
body, and almost always carries to the end of life some remnant, less or greater, 
of the attack. The disease, moreover, is very liable to return. 
Paraplegia.-This may affect only the lower extremities, or may involve 
also a part of the trunk, the paralysis being bounded above by a transverse 
line. It generally proceeds from lesions of the spinal marrow; but sometimes 
has a cerebral origin. In the former case, it is generally attended with some 
direct evidence of disease in the spine, such as pain, tenderness on pressure, 
or deformity; in the latter, with headache, vertigo, disordered vision, tinnitus 
aurium, &c. Occasionally its attack is sudden; but in most instances it comes 
on slowly, commencing with sensations in the lower limbs before alluded to as 
frequent precursors of palsy, such as tingling, &c., with slight muscular weak- 
ness, evinced by unusual fatigue after exertion, and some unsteadiness in the 
gait. As the affection increases, the patient walks with gradually increasing 
difficulty, seems to drag his feet along the ground, often stumbles, and requires 
the aid of another's arm to support him. At length he loses all command 
over the limbs, and is confined to his chair or bed. Not unfrequently he 
complains of the want of proper feelings when his bowels or bladder are 828 
[PART II. 
LOCAL DISEASES.-NERVOUS SYSTEM. 
evacuated; constipation and retention of urine take place, requiring enemata 
and the use of the catheter; and finally the sphincters give way, and incon- 
tinence is added to his other troubles. It has been observed that the urine is 
apt to be offensive, alkaline, ropy, and disposed to the deposition of inorganic 
matters; a condition probably owing to the defective innervation of the 
urinary organs. Sloughing of the back and hips usually takes place before 
death. It is an interesting fact, that, by tickling the sole of a paraplegic 
limb, or otherwise irritating it, involuntary contractions of the muscles may 
sometimes be produced; though they utterly refuse to obey the will. This 
is ascribed to the reflex action of the spinal centres; and may take place when 
all communication is cut off with the brain, by complete destruction of the 
spinal cord at some point above the origin of the nerves of the limb. 
When the result of acute myelitis, paraplegia may have a rapid course; but 
it is usually chronic, and not unfrequently continues for years. Sometimes 
it appears to be purely functional, depending upon debility of the spinal 
centres, whether from over-excitement through venereal excesses, severe mus- 
cular exertion, the abuse of ardent spirits, &c., or from some direct sedative 
agency, as that of cold. 
In its early stages, paraplegia is often cured; but, when it is far advanced, 
with complete palsy of the limbs, involving the rectum and bladder, the prog- 
nosis is unfavourable. It is important to attend to the first signs of tingling, 
numbness, and weakness of the limbs, and to address the remedies efficiently 
to the seat of the lesion. 
Local Palsy.-Local palsy is exceedingly diversified in position, degree, and 
character. It may affect one limb, a portion of a limb, a single muscle, or a 
number of muscles associated in a particular function, as, for instance, deglu- 
tition and voice; it may be complete or partial; and, finally, it may affect mo- 
tion exclusively, or sensation exclusively, and the sensation affected may be 
general or special. It is unnecessary, nor would our space permit us, to fol- 
low it in all its diversities. There are, however, some points of interest on 
which it is proper to touch. 
The face is sometimes the exclusive seat of palsy. Generally only one side 
is affected, and that variously. The disease may originate in a cerebral lesion, 
or in some injury to the nerves of the face in their course. The portio dura 
governs the general movements of the face; and paralysis of that nerve involves 
the loss of command over the features. In such a case, even when the coun- 
tenance is at rest, there is a slight difference between the opposite sides; as a 
sound muscle is scarcely ever so thoroughly relaxed, as one that is perfectly 
paralyzed; but this difference becomes very striking when the patient smiles, 
or in any other way moves his features. In doubtful cases, the paralysis may 
be at once detected by inducing the patient to smile or laugh. When the 
disease is confined to the portio dura, sensation remains in the face, and mas- 
tication is not affected; as the masseter and temporal muscles derive their 
nervous influence from another source. Should the fifth pair be diseased, 
there is then palsy of sensation, with or without deficient power of mastica- 
tion. One-half of the face is insensible to the touch, and the lip is equally 
divided between the morbid and healthy state. Hence, when the patient 
drinks, he receives the impression that the bowl which he puts to his lips is 
broken. The fifth pair of nerves appears to have two roots, like the spinal 
nerves, one being exclusively sensorial, and the other motor. It is the latter 
which supplies the muscles that close the jaws, which may therefore be para- 
lyzed when the whole of this nerve is affected, or may escape, if the disease 
be confined to the sensorial portion. Occasionally the paralysis of sensation 
is confined to one small isolated portion of the cheek. This I have seen in a 
case of severe facial neuralgia. CLASS III.] 
PALSY. 
829 
The eyelids may ho paralyzed so that they cannot close, or cannot open, 
under the influence of the will. Palsy of the muscles of the ball occasions 
strabismus. There may also be a loss of general sensation in the eye, so 
that the conjunctiva shall cease to feel the contact of irritating substances. 
Under these circumstances, severe and even disorganizing inflammation of the 
organ is apt to occur. 
The muscles of deglutition are sometimes exclusively affected with palsy; 
as also are those concerned in the formation of voice. In some instances, the 
disease is confined to the tongue, in which case the patient, without losing his 
voice, is unable to articulate. He can make a sound, but he cannot speak. 
There may be exclusive palsy of the rectum or of the bladder, leading to 
constipation and retention on the one hand, or to incontinence on the other, 
according as the sphincters may or may not be involved. 
The organs of special sensation are not unfrequently paralyzed; and the 
same general observations in relation to the real seat of the disease apply to 
them, as to the parts already referred to; that is, the paralytic affection may 
originate in the nervous centres, the connecting nervous cords or filaments, or 
in the nervous expansion of the several organs. Paralysis of sight is called 
amaurosis, and is usually treated of in works upon the surgery of the eye, to 
which the reader is referred. Loss or diminution of the sense of smell is 
named anosmia. It may depend on disease at the source of the olfactory 
nerve, in its course, or in the pituitary membrane itself. The abuse of snuff 
is said sometimes to induce it, by wearing out the excitability of the nerve. 
It may be produced also by chronic inflammation of the membrane. With 
some it appears to be congenital. Paralysis of taste, or ageusia, is occasion- 
ally met with. The temporary loss of taste arising from inflammation of the 
tongue, or a coating of fur upon its surface, scarcely deserves this name. 
The true palsy of the function is connected with an altered condition of the 
proper nerves of taste, or of the centres from which they proceed. Both in 
this affection and in anosmia, the general sensation may remain; so that 
irritant substances shall occasion uneasiness, though odours and tastes, even 
of the strongest kinds, may not be perceived. Deafness or cophosis may be 
a paralytic affection, though not necessarily so. Thus, when it depends upon 
stoppage of the Eustachian tube or external meatus, or inflammation of the 
tympanum, it has no relation to palsy. The true paralysis of hearing may 
be cerebral, may be produced by injury of the nerve of hearing in its passage 
into the temporal bone, or by disease affecting the nervous expansion within 
the cavities of the petrous portion. As in all other forms of palsy, the affec- 
tion may be organic, or merely functional. As to palsy of the sense of touch, 
or anaesthesia, most that could profitably be said, on the present occasion, has 
been embraced in the preceding observations. Strictly speaking, the nerves 
of touch are probably distinct from those of general sensibility, and there may 
be palsy of one without a similar affection of the other. Thus, when the sense 
of touch is quite lost in a part, so that the shape and other sensible proper- 
ties of a body cannot be appreciated, the sensibility to pain not unfrequently 
remains; while, in the state of artificial somnambulism, we occasionally observe 
a complete loss of sensibility to painful impressions, though the sense of touch 
may be acute. Yet the two generally go together; and I do not know that 
any therapeutical advantage can accrue from separating them.* 
* The degree of anaesthesia may be measured, with some degree of accuracy, by a 
method suggested by E. H. Weber. When the two blunted points of a pair of com- 
passes are applied to the surface, within a certain distance apart, they are felt as one 
upon the healthy skin: beyond this distance both points are felt; and in proportion to 
the loss of sensibility is the distance between the points at which they produce but a 830 
[part II. 
LOCAL DISEASES.-NERVOUS SYSTEM. 
It yet remains to speak of peculiar kinds of palsy, differing either by their 
characters, or their causes, from the ordinary affection. 
Paralysis of the Insane.-This has attracted much attention, and has been 
the subject of close research by MM. Bayle, Delaye, Calmeil, Parchape, and 
others. It comes on usually in the course of certain cases of insanity, but 
sometimes begins simultaneously with the mental disorder, and sometimes 
precedes it. It seldom occurs in the young, and does not become frequent 
until after the age of thirty-five. In general, the first symptoms of paralysis 
are observed in the organs of speech. The patient hesitates in speaking, or 
stammers, pronounces words imperfectly, and has a tremulous motion of the 
lips and tongue. The expression of the countenance changes. Weakness in 
the lower extremities comes on, indicated by an unsteady gait, and a dragging 
movement of the feet in walking. The disease extends to the upper extremi- 
ties. The bladder becomes enfeebled, the urine is passed with difficulty, and 
a resort to the catheter is often necessary. At length the power of locomo- 
tion ceases, and the patient is confined to his chair or bed. Along with the 
paralysis, there is frequently contraction of the muscles, especially of the lower 
extremities, one or both of which become stifly flexed. Sometimes the patient 
is attacked with convulsions, or tetanic paroxysms, which may occur on both 
sides, or be confined to one. In the end, incontinence of urine and involun- 
tary feculent discharges occur, gangrenous ulcers form, and the mind is reduced 
to the lowest state of imbecility. In this condition, the organic actions go on 
often with considerable vigour, and the patient may live for months or years. 
Finally, however, deglutition becomes paralyzed, respiration enfeebled, the 
heart beats more and more feebly, and the patient dies either from a gradual 
failure of the organic processes, or from a supervening attack of cerebral con- 
gestion. Dissection almost invariably reveals softening of the gray matter of 
the brain, induration or softening of the white matter, and signs of chronic 
meningitis. The duration of the disease is indefinite, varying from a few 
weeks to many years. Calmeil states the average at thirteen months. The 
disease is generally fatal, almost invariably so when it becomes confirmed. 
Shaking Palsy.-Paralysis Agitans.-This affection is characterized by a 
continued tremulousness, generally first observed in the upper extremities 
and the head, but extending in a greater or less degree over the whole body. 
It is most striking in the hand. In the beginning it is little noticed, unless 
upon the occasion of some unusual exertion or mental emotion; but in the 
end it becomes constant, and continues even during sleep, with which it some- 
times interferes by its violence. The muscular debility gradually increases, 
until at last locomotion becomes impossible, and articulation and deglutition 
difficult; the patient loses command over the sphincter muscles; and, coma 
or mild delirium supervening, the case terminates in death. The disease affects 
especially the old, and those worn out by excessive intellectual or corporeal 
labour, intemperance in drinking, and other sensual indulgences. Some con- 
stitutions are strongly disposed to this form of palsy, and fall into it without 
any exciting cause. 
Very similar to the complaint just noticed is the tremulousness sometimes 
experienced by certain artisans, and which is ascribed to mercury, because it is 
more especially the workers in that metal who are affected. Along with the 
tremors, there are occasionally spasmodic twitchings of the muscles, and the 
single impression. Sometimes in this mode a commencing paralysis of touch can be 
detected when it would be scarcely sensible otherwise. Ascertain what is the distance 
requisite for the singleness of impression on a part of the surface undoubtedly sound, 
and, if the distance is considerably greater in another part, the latter may be inferred 
to be paralyzed in proportion to the distance. (Note to the fourth edition.) CLASS III.] 
PALSY. 
831 
agitation sometimes amounts almost to convulsions. In its course and termi- 
nation, the disease is similar to that last mentioned; but it is susceptible of 
cure, if not far advanced, by the removal of the cause. 
Lead Palsy.-Under the poisonous influence of the preparations of lead, a 
variety of palsy not unfrequently occurs, sometimes originally, but much 
oftener as a sequel to colica pictonum. The affection usually first attacks the 
hand and forearm. Weakness is felt in the hand and wrist, which increases 
until the patient becomes unable to use them. A peculiarity of this form of pa- 
ralysis is that the extensor muscles are chiefly affected, in consequence of which 
the fingers are usually flexed on the hand, and the hand on the forearm. But 
the flexion is not rigid, and the parts can be easily placed in their proper 
position. Neuralgic pains are occasionally felt in the arm, and in other parts 
of the body. The muscles affected become flabby, wither, and undergo a 
change in colour, which has led to the erroneous supposition that they are 
converted into fatty matter. Should the action of the poison continue, the 
paralytic phenomena extend to other portions of the body, the special senses 
are invaded, and the patient dies at length from debility of the brain. There 
is reason to believe that the lead acts directly on the paralyzed tissue; for it 
has been observed that the muscles affected by it have lost their irritability, 
which is often retained in cases of palsy dependent on disease of the nervous 
centres, or the connecting cords. (See Arch. Gen., 4e ser., xxii. 12.) 
Other metals are accused of occasionally inducing palsy, and the effect is 
especially ascribed to arsenic. 
Causes.-Upon thi§ point sufficient has been said already, in connexion 
with the several pathological conditions of which palsy is a symptom. In 
general terms, it may be repeated that whatever interferes with the structural 
integrity of the nervous centres, the conducting nervous filamelits, or the ulti- 
mate nervous ramifications, and whatever greatly depresses, either by a direct 
agency, or through a previous excessive excitement, the nervous functions, 
whether at the periphery or at the centre, may become a remote cause of 
paralytic symptoms. The causes of the special forms of palsy have been re- 
ferred to, in the preceding accounts of its several varieties. 
Diagnosis.-There is in general little difficulty in recognizing palsy. Some- 
times, however, it is so masked by stupor that the diagnosis is uncertain. 
But, even in cases of this kind, unless the coma is very profound, there is some 
degree of sensibility or power of motion left in the unparalyzed parts, which 
enables us, upon a close inspection and comparison, to detect the disease in 
the parts affected. There may be occasionally some difficulty in deciding 
whether a part, deprived of the power of motion, is labouring under palsy, or 
under chronic inflammatory disease of a rheumatic or gouty character. But, 
in such cases, the history of the disease will usually decide the question. I 
believe, however, that the two affections are not unfrequently mingled; that, 
in consequence of rheumatism in the course of a nerve, paralytic symptoms 
may be produced in the parts supplied by its ramifications; and that the 
same disease may partially paralyze the nerves of the part in which it has long 
existed. Such a condition has long been recognized under the name of rheu- 
matic palsy. 
Prognosis.-This varies so much according to the particular origin, and 
the remote etiology of the affection, that no definite rules can be given. In 
general terms, it may be said that cases dependent on mere congestion are 
curable, and often yield speedily to remedies. When connected with cerebral 
or spinal hemorrhage, the disease is more serious, but still not unfrequently 
ends favourably, though apt to be lingering, often imperfectly cured, and 
liable to relapse. The palsy consequent upon inflammatory disorganization 832 
[PART II. 
LOCAL DISEASES.-NERVOUS SYSTEM. 
is very unpromising, when far advanced generally incurable, yet frequently 
amenable to remedies in its incipient stages. Still more discouraging are the 
cases connected with fatty degeneration, tumours, hydatids, &c., within the 
cerebro-spinal cavity. If merely functional, dependent on habits of life, me- 
tallic poisoning, &c., there is good ground for the hope of a favourable issue, 
upon the removal of the cause, provided the system has not been too deeply 
prostrated, and the nervous excitability quite exhausted. Cases originating 
in local and removable causes may be expected to recover, as when dependent 
on compression, want of use, external inflammations, tumours in the course 
of the nerve, &e. The slight cases resulting from temporary compression, 
such as palsy of the arm produced by lying upon the humeral nerves during 
sleep, generally get well without difficulty. 
Treatment.-The first point, in the treatment of palsy, is to ascertain the 
pathological condition on which the affection depends, and to address our 
remedies to that condition. Of the requisite measures it is unnecessary to 
treat in this place, as they have been fully detailed under other heads. The 
reader is referred to the subjects of inflammation of the brain and its mem- 
branes, apoplexy, cerebral congestion, and diseases of the spinal marrow. It 
may not be amiss to state, in general terms, that the remedies in cases of 
active congestion, active hemorrhage, or inflammation, are bleeding, general 
and local, proportioned to the energies of the system, purging, refrigerants, 
low diet, rest, and, if these fail, blisters, and a mercurial impression. In 
chronic cases, much may be expected from a constant succession of blisters 
as near to the seat of the true disease as possible, with steady- but moderate 
purgation, graduated to the strength of the patient. In hemiplegia, the 
blisters should be applied to the back of the neck and between the shoulders; 
in paraplegia, when dependent on spinal disease, immediately over the affected 
part of the spine. Antimonial pustulation, issues, setons, or moxa may be 
substituted for blistering, if circumstances seem to require them. The same 
treatment must be directed to the local palsies having a similar origin ; care 
being especially taken to make the depletory and revulsive measures bear as 
precisely as possible upon the real seat of mischief, whether in the brain, spinal 
marrow, or course of the nerves. Should the local lesion on which the palsy 
depends arise from depressing influences affecting the organization, as in 
cases of fatty degeneration connected with defective nutrition or impoverished 
blood, a tonic and supporting treatment becomes necessary; and, under these 
circumstances, recourse should be had to the preparations of iron, the vegetable 
tonics, and nutritious food. 
It need scarcely be said that, when the palsy originates in tumours, or any 
other removable cause affecting one of the nervous trunks, attention should 
be promptly directed towards the correction of the evil; and it is a primary 
rule, applicable to all varieties of the disease, to prevent the continued action 
of the cause whatever that may be. 
When there is reason to believe that the original cause of the palsy has 
been remedied, and the affection remains only in consequence of debility, or 
a habit of inaction in the nervous centres, or the nerves themselves, an indi- 
cation is offered for a new course of treatment. It now becomes advisable 
to make use of measures calculated to excite the nervous actions. It is a 
very common error to resort to these measures early in the disease, and while 
the organic cause is still in operation. Nothing could be worse than such a 
proceeding. Some evidences of muscular action, or restored sensibility, may 
occasionally result from stimulating the nervous centres, or the nervous ex- 
tremities, under these circumstances; but the apparent advantage is tempo- 
rary and delusive. The real source of the evil is increased. What good can CLASS III.] 
PALSY. 
833 
possibly arise from stimulating a portion of brain, already goaded by inflam- 
mation, or weltering in effused blood? or from exciting a palsied limb, when 
cut off from the sources of its power? The indication is clearly, first to cor- 
rect all organic derangements, to put the vital instrument into the best pos- 
sible order, and then to excite it if necessary into action. There are cases in 
which the palsy is dependent on a depressing agency, and the affection is 
functional, from the commencement. 'To such cases, the treatment suitable 
to the advanced stages of the former variety may be applied in the beginning. 
Of this kind, for example, is the disease produced by lead. 
The remedies of a stimulant character operate either through the system, 
or locally. The most efficient of the constitutional remedies is nux vomica, 
or its alkaline principles, strychnia and brucia. These act by a direct stimu- 
lant influence upon the nervous tissue, and especially promote the motor 
power. When properly timed, they are undoubtedly sometimes very bene- 
ficial ; though capable of doing great mischief if prematurely or improperly 
used. All evidences of excitement and of inflammation should have subsided 
before they are resorted to. In hemorrhagic cases, time should have been 
allowed for the clot to become isolated from the cerebral tissue (see Apoplexy f 
and thus to cease acting as a source of irritation. Two or three months at 
least should, as a general rule, have elapsed before the remedy is resorted to, 
and often a much longer time than this. When employed, it should be with 
great caution; and, if the complaint is in any degree aggravated, it should be 
withdrawn at once. The best preparations, upon the whole, are probably the 
alcoholic extract and strychnia. Of the latter, not more than one-twelfth of 
a grain should be given at first, and this should not be repeated oftener than 
twice or three times a day. Should it produce no effect, the dose may be 
increased gradually until slight startings or involuntary contractions of the 
muscles take place, or some feeling of stiffness about the neck or elsewhere. 
One of the first observable effects of the remedy is to occasion a pricking sen- 
sation in the affected limb; and it has been noticed that the first involuntary 
contractions which it produces are usually in the paralyzed part. Sometimes 
strychnia may be beneficially applied endermically. One-quarter of a grain 
of it may be sprinkled upon a blistered surface in the epigastrium, or on the 
inside of the arm or thigh, dr in the vicinity of the affected nervous centre; 
and the application may be repeated twice daily. 
Other internal stimulants ,may also be occasionally used with advantage. 
Oil of turpentine and cantharides are especially applicable to cases of para- 
plegia or local palsy, dependent on spinal affection, or to the disease when 
limited to the urinary organs. They are often of great use in retention and 
incontinence of urine, of paralytic origin. They probably have a special 
affinity for the spinal centres. The poisonous species of rhus, especially the 
toxicodendron, have been recommended in palsy, and are applicable to this 
stage of the disease; but I have no experience with them. Mustard and 
horseradish are sometimes useful in old cases, attended with general debility, 
and especially with oedema of the limbs. Sulphurous waters, internally, and 
as a bath, have also been recommended, and are occasionally useful. The 
hot-bath is sometimes beneficial when there is decided debility; but it should 
be avoided in cerebral cases. General debility should be treated with mild 
tonics, moderate exercise, pure air, the shower-bath when followed by reaction, 
and measures calculated to sustain an agreeable but not excessive mental ex- 
citement. Hence, travelling is very useful in some old paralytic cases. It 
is peculiarly important that the body should be protected against changes of 
temperature. Flannel, therefore, should always be worn next the skin. The 
diet should be nutritious, and of easy digestion. 834 
[part II. 
LOCAL DISEASES.-NERVOUS SYSTEM. 
Local applications to the paralyzed part are sometimes useful, by exciting 
the nervous extremities. Simple friction is one of the first measures of this 
kind that may be resorted to. It may be made with the hand, a flesh-brush, 
a coarse towel, &c. Rubefacient lotions are often used. Of these, oil of 
turpentine, and the ammoniacal preparations, are among the best. Tincture 
of capsicum or of cantharides may also be employed. Blisters are sometimes 
advantageous; but must be used with caution lest they occasion sloughing. 
They are more especially applicable to cases of small extent, and in which 
the circulation is not materially enfeebled; as to the wrist and forearm in 
lead palsy. Electricity or galvanism is one of the most efficacious of these 
local remedies, and should never be neglected in obstinate cases. Acupuncture 
has been recommended, and a union of this with electricity is said to have 
been sometimes singularly beneficial. Needles are introduced into the flesh 
at some distance apart, and, by being connected with the opposite galvanic 
poles, enable a current of the fluid to be carried through the palsied muscle 
itself. Firing by means of a heated instrument of iron has been employed 
with advantage. (See vol. i. p. 471.) The douche of hot water, and, when 
there is sufficient energy for prompt reaction, of cold water, will sometimes 
be found useful. The hot-water douche is especially beneficial in cases con- 
nected with long-standing gout or rheumatism. Another method of exciting 
the part is by its exercise. The patient should be encouraged to make habit- 
ual efforts to use it, and means should be contrived especially calculated to 
bring the paralyzed muscles into play. 
Local measures should also be addressed to the vicinity of the nervous 
centres. Rubefacients, blisters in constant succession, and electricity are the 
most effectual. 
Of the particular forms of palsy little need be said. General palsy, hemi- 
plegia, paraplegia, and local palsy, are to be. treated on the same principles, 
reference being always had to the seat of the disease. Ergot has recently 
been employed with supposed efficacy in paraplegia, after the cessation of all 
inflammatory excitement in the spinal column, supposing the affection to 
have originated in this condition. In paralytic affections of the tongue and 
fauces, the local stimulants, when used, should be employed in the manner 
of masticatories or gargles. The former mode is probably the best. Ginger 
root, horseradish, mezereon, pellitory, or, if something exceedingly acrid is 
wanted, the root of the Arum triphyllum, may be used. In palsy of the 
sense of smell, stimulating errhines may be employed, such as veratrum 
album or yellow sulphate of mercury, duly diluted. In the shaking palsy, 
after the removal of any known cause, gentle tonics, the nervous stimulants 
or antispasmodics, and, when not contraindicated by cerebral disease, the 
narcotics may be used; care being taken to keep the bowels regularly open. 
M. Piorry has treated the mercurial palsy very efficiently by causing the 
patient to drink very copiously of cold water, even to the amount of three 
gallons daily, and conjoining the use of baths long-continued and friction. 
(Am. Journ. of Med. Sci., xiv. 100.) The lead palsy generally gets well 
under the measures recommended for colica pictonum. When unattended 
with that affection, it may be treated with nux vomica or strychnia internally, 
the warm or hot-bath, the sulphur-bath, and the various local measures above 
recommended, especially repeated blistering to the forearms. Alum, sul- 
phuric acid, and a moderate continued mercurial impression, may.be tried 
one after the other, in obstinate cases. Iodide of potassium has also been 
recommended, upon the ground that it displaces the lead from the tissues, 
and causes its elimination from the system. It is asserted to have proved prac- 
tically useful. In the falling of the hand, consequent on palsy of the extensor CLASS III.] 
HYSTERIA. 
835 
muscles, the hand should be supported in an extended position by splints, or 
otherwise, so as to prevent the mechanical stretching of the relaxed muscles; 
blisters being at the same time successively applied along the back of the 
wrist and forearm. 
In all cases of palsy, the temperature of the part affected should be guarded. 
As it is at the same time insensible to the changes of heat and cold, and more 
liable to be injured by them than in health, because possessed of less vital 
power of resistance, it is especially necessary to have a watchful care over it. 
As the bowels are apt to become loaded with feculent matter, in consequence 
of the insensibility of the rectum, and the bladder to be distended with urine 
from a similar want of sensibility, as well as from paralysis of its muscular 
coat, the attendant must keep a careful watch over these functions, employing, 
in the former ease, mild laxatives, enemata, or, when these fail, mechanical 
means for emptying the rectum, and in the latter case, if necessary, the 
catheter. 
Article IL 
HYSTERIA. 
Hysteria (from vtfttpa, uterus) is a disease consisting in a morbid excite- 
ment of the nervous system, showing itself in occasional convulsive parox- 
ysms, and diversified functional disorder. It is characterized by the extreme 
diversity and changeableness of its symptoms, which come rapidly and as 
rapidly disappear, occur singly or in groups with every possible variety of 
association, and, though often presenting an alarming aspect, are almost 
never really dangerous; being a mere ebullition upon the surface of life, 
while its depths are undisturbed. One of the most striking circumstances 
connected with the disease, is the general integrity of the nutritive process, 
amidst the seeming almost universal insurrection and uproar of the functions. 
Through long periods of intense suffering, and great apparent disorder of 
system, the patient often continues plump and even rosy, as if in good health. 
The subjects of the disease are generally females between the ages of puberty 
and the cessation of the catamenia. 
Symptoms, Course, &c.-The morbid phenomena of hysteria are very apt 
to cluster, forming paroxysms, which occur at irregular periods. In some, 
these paroxysms constitute the chief signs of the disease; the health being 
tolerably good, and sometimes almost perfect in the intervals. In others, 
there is scarcely ever complete exemption, even through a long course of 
years; and the paroxysms are merely exacerbations of a never ceasing dis- 
order. In most, the slightest causes are sufficient to occasion some disturb- 
ance, and, though the inter-paroxysmal symptoms are not constant, they are 
very frequent, and often the source of great discomfort. Perhaps the best 
view of the disease can be attained by first fixing attention upon the parox- 
ysms, and then passing in review the most prominent of the phenomena, 
connected with the derangement of the several functions. 
The hysterical paroxysm is often preceded, for a longer or shorter time, by 
various distressing sensations and nervous irregularities, which become at 
length more than the nervous centres can tolerate; and relief is sought in 
violent muscular disturbance, and a more or less complete loss of conscious- 
ness. But frequently also these phenomena come on suddenly, without any 
premonition whatever, under the influence of occasional exciting causes, es- 
pecially those of a mental character. The patient is sensible of distress at 836 
[part II. 
LOCAL DISEASES.-NERVOUS SYSTEM. 
the epigastrium, or oppression about the chest, or perhaps has the feeling as 
of a ball ascending from some point in the abdomen, usually the left iliac 
region, to the throat; loses the ordinary expression of countenance, which is 
replaced by a vacant stare; becomes agitated; falls, if before standing; throws 
her limbs about convulsively; twists the body into all kinds of violent con- 
tortions; beats her breast or epigastrium; sometimes tears her hair, and 
attempts to bite herself or others; and, though a delicate female, evinces a 
muscular strength which often requires four or five persons to restrain her 
effectually. The jaws work with a sort of grinding motion, the chest heaves, 
the heart palpitates tumultuously, the carotids throb, the features become 
flushed and swollen, and the patient now and then utters inarticulate sounds 
or cries, which have been compared to the baying of a dog. Sometimes, in- 
stead of the convulsive movements, there is a tetanic rigidity of the muscles, 
and the body is thrown back into an arch, or the limbs are stiffly contracted; 
and not unfrequently there is a mixture of the two conditions. The spasms 
often relax for a time, and are again renewed; and this may occur repeatedly 
during the paroxysm. There is during all this time an apparent want of con- 
sciousness, which, in severe cases, is real and complete, but often is only par- 
tial; the patient having a confused knowledge of what is said and done about 
her, and being able to recall the incidents of the paroxysm imperfectly after 
it is passed. The features are seldom greatly distorted; and, though there is, 
to a considerable extent, an absence of expression, there is yet an indefinable 
appearance, as if the inner life were not sympathizing with the outer violence, 
and as if there were something unreal in the whole show. After a variable 
continuance, the convulsions subside, consciousness partially returns; and the 
patient, sometimes breaking out into a fit of laughter or sobbing, or of one 
after the other, sometimes falling into a quiet state resembling sleep, gradu- 
ally returns to her ordinary condition, though with feelings of fatigue and 
soreness, occasionally with temporary cataleptic stiffness, or partial palsy of 
some part of the body, and not unfrequently with a copious flow of colourless 
urine. All these symptoms, however, at length disappear; and then the pa- 
tient experiences great relief, often feeling better than for a long time pre- 
viously; as if the morbid excitability had exhausted itself, and given place, 
for a time, to a healthy state of the nervous system. 
The duration of the paroxysm varies from fifteen minutes to several 
hours, and sometimes it continues for two or three days, though with re- 
missions of the convulsions, and intervals, if not of consciousness, yet of 
calm stupor. In many instances, there is a rapid succession of convulsions, 
the patient being quite conscious in the intervals; and in this condition, 
with longer or shorter respite, the affection may continue for many days or 
weeks. 
But the paroxysm varies exceedingly in character and intensity. Some- 
times it consists simply in feelings of abdominal or pectoral distress, with 
troubled breathing, sensations as of choking in the throat, bursts of weeping 
or of laughter, and slight twitchings of the muscles, not amounting to con- 
vulsions, and without loss of consciousness. Sometimes the prominent sen- 
sation is that before alluded to, of the globus hystericus, as of a ball in the 
abdomen, rising to the epigastrium and the throat, and probably owing to a 
spasmodic constriction of the intestinal tube, and of the oesophagus. But 
this symptom is much less frequent than might be inferred from the descrip- 
tions in most of the books. 
Another variety of the paroxysm is that of quiet coma. The patient lies 
perfectly motionless, with the eyes closed, apparently without consciousness, 
and incapable of being roused by the loudest sounds, shaking, pinching, &c., CLASS III.] 
HYSTERIA. 
837 
to which she seems to be quite insensible. The respiration is sometimes so 
feeble as hardly to be perceptible, the surface is cool, and bystanders are apt 
to think that the patient is dead; but the pulse, so far as I have observed, is 
always perceptible, and the countenance, though calm and motionless, wants 
the sunken aspect of death, and is rather as of one sleeping. In these cases 
I have generally found, since the custom of examining the spine has come into 
vogue, that there was great sensitiveness to pressure upon some one or more 
of the spinous processes, evinced by the starting and writhing of the patient, 
though without being thoroughly roused. This comatose state sometimes 
continues for one, two, or three days. 
The occurrence of the paroxysms is usually quite irregular, at intervals 
varying from a day, or less than a day, to months, depending partly on the 
degree of accumulated excitability in the nervous system of the patient, partly 
on the variable incidents which may disturb her physical or mental equability. 
There is one circumstance, however, which tends to give a periodical character 
to the nervous symptoms. They are very apt to be worse about the menstrual 
period, and some women have a regular hysterical paroxysm at that time. 
Hence, probably, the origin of the notion that the moon exercises some influ- 
ence over the affection. When the monthly changes of that planet coincide 
with the return of the menses, some confusion in relation to the etiology of 
the paroxysms may readily happen in the minds of those who are addicted to 
the mysterious. Like most other purely nervous affections, the hysterical 
paroxysms occasionally assume the types characteristic of intermittent fever, 
and are then regarded by some, though without sufficient reason, as nothing 
more than that disease in a concealed form. 
It is highly important for the practitioner not only to be able to recognize 
the hysterical paroxysm, but also to be familiar with the irregular pheno- 
mena of the disease, which often so closely counterfeit other more dangerous 
affections, that there is great liability to error of diagnosis, and consequent 
serious mistakes in practice. The following is a list of the most striking of 
these phenomena, taken in the order of the several functions. To enumerate 
all the deranged'-actions and sensations incident to the complaint, and their 
various associations, would be an endless task. 
In the digestive function, we not unfrequently witness difficulty of deglu- 
tition. The patient oannot, or thinks she cannot swallow, and the attempt is 
attended with strangling sensations. In its highest intensity, this symptom 
is only temporary; but I have known it to continue in some degree for 
months, very much limiting the diet of the patient, and producing considera- 
ble debility. The sensation of choking, of stricture in the throat, or of a 
foreign body lodged in the oesophagus, is very common, and is of the same 
nature, probably, as the well-known phenomenon of the globus hystericus. 
The stomach is much and• variously disordered. Craving, deficient, or de- 
praved appetite; desire for strange articles of food, or a disposition to swal- 
low substances altogether unfit for food, even those of the most disgusting 
nature; various dyspeptic sensations, flatulence, spasmodic pains, and vomit- 
ing sometimes excessive and obstinate; are among the occasional gastric symp- 
toms; and yet digestion goes on; and it is wonderful how, with so much 
seeming disorder of stomach, the general fulness and appearance of health 
should suffer so little. There has no doubt been much deception in cases of 
asserted entire abstinence from food for long periods of time; but such cases 
usually have some foundation in fact; and the minuteness of the quantity of 
nourishment, sufficient to support life for months in some nervous females, has 
often been an object of surprise to physicians. The bowels are usually dis- 
posed to flatulence and constipation. Great distension is sometimes produced 838 
LOCAL DISEASES.-NERVOUS SYSTEM. 
[part II. 
by collection of air in the intestines, so as even to imitate, and to have been 
mistaken for pregnancy. This is often accompanied with rumbling, irregular 
protrusion of the abdomen, the gathering of the abdominal muscles into knots, 
and various distressing sensations; and is one of the greatest sources of trouble 
to hysterical patients. Sometimes attacks of violent intestinal spasm come 
on, so characteristic of the affection, as to have received the name of hysteric 
colic. The constipation will sometimes continue for weeks if not cared for. 
Occasionally there is diarrhoea, with unhealthy evacuations. Another abdo- 
minal affection is acute pain and excessive tenderness upon pressure, which,, 
coexisting with distension, and a frequent pulse, have sometimes been mis- 
taken for signs of acute peritonitis, and led to corresponding treatment. But 
the affection may be distinguished by the want of that profound impression 
which peritoneal inflammation makes upon the features, by the frequent coex- 
istence of other hysterical symptoms, by the presence of a similar sensitive- 
ness in other parts of the surface, and by a general appearance of superficial 
character about the symptoms, of which the practitioner is sensible, though 
he might find some difficulty in analyzing it. 
The function of respiration also suffers. The larynx may be the seat of 
various irritation, in 'some instances modifying or suppressing the voice, in 
others giving rise to spasm of the glottis, which for a time completely ob- 
structs the entrance of the air into the lungs, and yields only on the ap- 
proach of asphyxia. In this way the disease occasionally imitates laryngitis 
and croup. A bard, dry, sonorous cough, sometimes occurring in convulsive 
paroxysms, like those of hooping-cough, is another symptom. Great oppres- 
sion of the chest, with laboured breathing, is not uncommon; and dyspnoea, 
with a sense of constriction, bearing a close resemblance to the paroxysms of 
spasmodic asthma, is every now and then noticed. Deep sighs, yawning, and 
hiccough are frequent hysterical phenomena. 
The circulation scarcely suffers less than the other functions mentioned. 
Palpitations of the greatest violence, attended even with the bellows murmur, 
are very frequent, alarming the patient and the practitioner with the fears of 
organic disease of the heart; from the phenomena of which, however, they 
may be distinguished by their exceeding capriciousness, and the frequent per- 
fect calmness of the circulation. Troublesome aortic pulsations are also some- 
times felt at the epigastrium; and the pulse is exceedingly irregular, being at 
one time very frequent, at another time perhaps slower than natural, and almost 
always easily disturbed by slight causes. 
Secretion, which is so much under nervous influence, could not but be 
affected by derangements of that influence such as occur in hysteria. The 
liver and kidneys are especially liable to suffer, and almost all the functional 
disorders incident to the biliary and urinary organs may be looked for in this 
complaint. Both secretions may be deficient, excessive, or variously altered. 
The urine is sometimes so copious as to imitate diabetes, and in some rare 
cases has been almost or entirely suppressed. In the latter condition, the 
constitution appears occasionally to •protect itself by a secretion of the urinary 
principles through some other outlet; and it is impossible to resist the evi- 
dence in favour of those cases, in which a liquid having the odour of urine is 
asserted to have been thrown out by the umbilicus, the external meatus, the 
stomach, &c.; though it must be confessed that great allowance should be 
made for the insane propensity to deception, evinced by some females under 
these circumstances. The excretion of urine is liable to still greater irregu- 
larity, as it is more under the influence of the deranged will. Sometimes a 
temporary paralysis of the bladder renders the excretion for the time impos- 
sible; but much more frequently the retention is in some degree voluntary; CLASS III.] 
839 
HYSTERIA. 
and it is of great importance not to encourage this morbid propensity by 
unnecessary instrumental aid. A general irritation of the urinary organs is 
occasionally evinced, which it may be difficult to distinguish from nephritis 
and inflammatory affections of the passages. A phenomenon connected with 
this branch of the subject, now and then met with in hysterical patients, is 
the secretion from the mucous membranes, especially that of the fauces and 
air passages, of a red fluid resembling diluted blood, though not coagulable. 
This has sometimes been noticed in amenorrhoea, and has been supposed to be 
vicarious to the menses; but I have seen it in cases in which the menstrual 
function was apparently healthy. 
One of the most singular facts in this singular disease is that already 
alluded to, of the apparent vigour of the nutritive function, in the midst of 
the general disorder. Sometimes, however, this function suffers with the rest, 
and the patient becomes emaciated; but, in cases of this kind, there is always 
some reason to suspect the existence of organic disease. 
The reproductive function is peculiarly liable to derangement. So com- 
mon, indeed, is disorder of the uterus, that it has given its name to the com- 
plaint. Occasionally the uterus, upon examination, is found displaced, being 
either prolapsed or retroverted. Menstruation may be painful, excessive, 
scanty, or suppressed; and there may be a general irritable state of the organ, 
with or without disorder of the secretion. Yet the disease constitutes no 
necessary bar to conception and pregnancy. Cases, too, of hysteria are not 
uncommon, in which no derangement of the sexual organs can be discovered. 
The nervous system exhibits above all others a proneness to derangement. 
This system is, indeed, the very seat and throne of the disease; and, in its 
various ramifications, are displayed almost all the fantastic vagaries of this 
curious affection. Of the general nervous phenomena, pain of one kind or 
another, is among the most frequent. Neuralgia is very often a purely hys- 
terical affection. Headache is very common, and sometimes almost insupport- 
ably violent. A frequent form of it is that denominated clavus hystericus ; a 
fixed pain in one spot, generally over the eye. But it is often also more or 
less diffused, and is liable to all the diversities incident to this affection from 
other causes. (See Headache.') Pains in the chest, too, are very frequent, 
especially on the left side, under the mamma. In this situation they are some- 
times very severe and obstinate. The mamma itself is occasionally acutely 
painful, giving rise even to the suspicion of cancer, and causing great distress 
on this score. It is unnecessary to speak individually of the neuralgic pains 
in the abdomen, the spine, the urinary and sexual organs, and the extremities. 
The joints sometimes become the seat of violent pains, much increased by 
pressure and motion; which have occasionally been mistaken for evidences of 
inflammation. One of the best diagnostic symptoms, in these cases, is the 
superficial character of the tenderness. The patient is apt to complain as 
much, when the skin is merely pinched, as when the surface of the joint is 
pressed upon. Morbid cutaneous sensitiveness is indeed a common symptom 
of the disease. Pressure on any part of the body will, in hysterical cases, 
often occasion much apparent uneasiness; and not unfrequently, when the 
physician supposes that he has detected inflammation of some internal organ, 
in consequence of the pain on pressure over it, he will find upon trial that the 
patient will make similar complaints, no matter what part of the surface may 
be made the subject of experiment. This tenderness is peculiarly apt to be 
evinced by the skin in the vicinity of the spine. One of the most common 
complaints by hysterical patients is of general and vague discomfort, of sen- 
sations in various parts of the body which they cannot describe, of feelings of 
soreness, uneasiness, and aching in the limbs, which induce a constant rest- 
lessness, and disposition to motion. 840 
LOCAL DISEASES.-NERVOUS SYSTEM. 
[part II. 
The special senses frequently suffer. Intolerance of light and sound, per- 
verted vision, noises of various kinds in the ears, and derangements of the 
senses of smell, taste, and touch, are not uncommon. 
The function of voluntary motion is notoriously perverted. The charac- 
teristic convulsions of hysteria have already been spoken of. The muscles 
sometimes contract rigidly, as in tetanus. Instances every now and then occur 
in which permanent contractions take place, with deformity of the limbs, and 
even distortion of the body. Catalepsy is also sometimes imitated; and it is 
asserted that hysteria has even put on the characters of hydrophobia. The 
opposite condition of palsy sometimes occurs; and hysterical paralysis is not 
a very rare affection. Like other affections connected with the hysterical 
state, this is distinguishable from most other varieties of palsy by its com- 
paratively ready curability. 
The sensorial functions are greatly disturbed. Attention has been already 
called to the headache, tinnitus aurium, and perverted vision of hysteria. 
Vertiginous sensations are very common. Sleep is often greatly disturbed. 
The occasional attacks of stupor have been noticed. These may be taken for 
cerebral meningitis by the inexperienced. They are, however, readily distin- 
guishable by the expression of the face, which is not that of profound coma, 
and by the state of the skin and the pulse, which are often natural, not to 
speak of the spinal tenderness, which, when observed, is an almost infallible 
test. The patient is exceedingly liable to spells of causeless low spirits, with 
various marks of nervous disorder, which are popularly called the vapours. 
Occasionally the spirits are, equally without cause, excessively elated. The 
patient will at one time burst into tears or sobbing, at another time into gig- 
gling or laughter; and in either case without any assignable reason. The 
temper is apt to be impatient, capricious, and whimsical. Slight causes excite 
anger and bring on convulsions, or other nervous paroxysms. Occasionally 
the cerebral functions are so much deranged that the disease amounts to in- 
sanity. This shows itself in a great variety of modes. Sometimes the patient 
is obstinately silent, hides her head under the bedclothes, refuses to show her 
tongue, to take her medicine, &c. Sometimes, on the contrary, she is talka- 
tive, and tells of strange sights that she has seen, or incidents in which she 
has been concerned, both equally unreal; sings, dances, or makes other whim- 
sical motions. One of the strange tendencies of hysterical insanity is to 
deceive others in relation to the state of the urinary and genital functions; 
and the patient will sometimes take great pains, and contrive the most skilful 
plans, to convince her attendant that she has retention of urine, or passes 
calculi from her bladder, or throws up urine from her stomach, &c. This tend- 
ency in hysteria is sometimes, in part, founded upon a desire to attract com- 
miseration and sympathy, or to become an object of attention or notoriety/ 
sometimes upon a prurience in the sexual propensities; but quite as frequently 
it is probably real insanity. It is important to distinguish this form of mental 
alienation from insanity of the ordinary kind. The former is often a trivial 
affection, is generally harmless, and should not be allowed to condemn the 
patient to a residence among lunatics, which might convert it into a serious 
disease. It is distinguishable by its changeableness, its frequent disappearance 
and return, and the presence of various other symptoms characteristic of hys- 
teria. 
In every case of hysteria, the practitioner should examine the state of the 
spine. He will often find tenderness when the spinous processes are pressed; 
and this is not only an important diagnostic sign, but also affords valuable 
indications of treatment. 
It is necessary that the student should understand that he is not to look CLASS III.] 
HYSTERIA. 
841 
for all of the above phenomena in every case of hysteria. Some patients pre- 
sent one, others another set of symptoms, and the same patient exhibits very 
different symptoms at different times. There is every grade of the disease, 
from the mild attacks called the vapours, to the most violent convulsive or 
comatose paroxysms; from a few slight nervous irregularities, occurring now 
and then, to an almost uninterrupted continuance for months or years of the 
most distressing complications of functional disorder. In some instances, the 
disease gradually yields to time and remedies; in others, it disappears abruptly, 
either not to return, or only as a new attack after a long interval. It is apt 
to decline with advancing life, and to go off entirely about or after the cessa- 
tion of the catamenia. Pregnancy is said occasionally to suspend it. Should 
it persist, with severity, for several years, there is some danger that it may 
end in more serious diseases, such as epilepsy, mania, or disease of the heart. 
Sometimes it degenerates into hypochondriasis, with failure of memory, and 
mental weakness. It is almost never directly fatal. Instances have occurred 
in which fatal apoplexy supervened upon the hysterical paroxysm ; but they 
are very rare, and probably purely accidental; such as might result from any 
cause producing a determination of blood to the head. 
Anatomical Characters.-Nothing has been discovered upon post-mortem 
examination calculated to throw light upon hysteria; except in so far as the 
absence of observable lesions, having any reference to this affection, in patients 
who have died of other complaints while labouring under it, may be considered 
as a proof of its purely functional nature. 
Causes.-An unusual degree of excitability or mobility of the nervous 
system constitutes a predisposition to hysteria. This is sometimes received 
by inheritance. Parents affected with severe nervous diseases are apt to have 
hysterical children. The female constitution is especially favourable to the 
attacks of the disease; and it is very apt to occur in women between the ages 
of twelve and thirty. But a predisposition may also be created, when it does 
not pre-exist. Whatever impairs the energy, and increases the excitability 
of the nervous system may have this effect. Sedentary habits, confinement 
to an impure air, living in hot rooms and sleeping in hot beds, too much in- 
dulgence in sleep, vicious practices in the young, and the premature forcing 
by light and imaginative reading in early life of the emotional part of the 
character, have a strong tendency to generate the hysterical constitution. 
The difference in the education and subsequent habits of the two sexes, has 
a powerful effect in confirming their respective natural tendencies in relation to 
hysteria. The boy is strengthened against it by free exercise in the open air, 
the man by the invigorating influence of his bodily and mental struggles for 
a livelihood or pre-eminence. In the female, the predisposition which she 
derives from nature is too often fostered by confinement in girlhood, and by 
a pernicious system which affords her, in opening womanhood, at once the 
leisure and the means for the indulgence of the feelings and imagination, at 
the expense of the hardier mental qualities. The debility of convalescence 
from acute and exhausting diseases, as well as that which follows excessive 
depletion, encourages the approaches of hysteria. The anemic state is highly 
favourable to it by the irritable condition which it maintains in the nervous 
centres? The notion has been entertained that continence predisposes to the 
disease; but this appears, from the statements of those most experienced, to 
be a mistake. The complaint is most prevalent among persons of irregular 
lives and vicious habits. 
Among the exciting causes may be ranked everything capable of producing 
a strong impression upon the nervous system. Startling sights and sounds, 
astounding intelligence, surprise, terror, anger or vexation, jealousy, grief, and 842 
[part II. 
LOCAL DISEASES.-NERVOUS SYSTEM. 
disappointment, especially of the affections, are apt to induce the first symp- 
toms of the disease, and, when the morbid state of the system has become 
established, to provoke the paroxysmal attacks. The imitative principle is a 
powerful cause; and instances are frequent, in which the sight of one female 
in hysterical convulsions has thrown others, previously exempt from the dis- 
ease, into similar paroxysms. Extremes of heat and cold, and certain elec- 
trical conditions of the air, are also ranked among the causes. 
But more frequent exciting causes are probably various morbid states of the 
system, which serve as sources of irritation to the nervous functions. Thus, 
the origin of hysterical attacks has been traced to the retrocession of cutane- 
ous eruptions, and the checking of habitual discharges. I have no doubt 
that gouty and rheumatic disease often exhibits itself in this kind of dis- 
turbance of the nervous system. I have before expressed my belief that spinal 
irritation, which is so frequent an attendant on hysteria, and is probably in 
many instances the immediate cause of the morbid phenomena, very often ori- 
ginates in these two disorders. Diseases of the alimentary canal, and of the 
uterus and its appendages, are among the most frequent exciting causes of 
hysterical phenomena. There is undoubtedly a strong connexion of some kind 
between hysteria and the condition of the sexual organs in the female. Most 
women experience, at one time or another of their lives, symptoms at least 
analogous to the hysterical, at the catamenial periods. 
Nature.-There is only one opinion in relation to the functional character 
of this disease. Authors, however, differ greatly as to its primary seat. Some 
place it essentially in the uterus, and, in support of their opinion, appeal to 
the facts that hysteria is a feminine disease; occurs during the period of life 
when the uterine functions are in full vigour; is very frequently attended with 
disorder of the uterus; and is peculiarly apt to exhibit its characteristic symp- 
toms at the menstrual periods. But this exclusive uterine theory cannot be 
supported. Almost all the best writers admit that the disease now and then 
occurs in males, and in women, though it is certainly most frequent between 
puberty and the change of life, it is yet occasionally noticed before the 
former, and subsequent to the latter of these periods. Besides, cases are not 
uncommon in which the uterus and its functions are, so far as can be ascer- 
tained, perfectly sound. 
Another theory places the disease exclusively in the brain. But the evi- 
dences of spinal participation are at least as strong as those which point to 
the brain; and the frequent disorders of almost all the organic functions would 
seem to prove, that the ganglionic centres are not without their influence. 
The very frequent complication of' spinal tenderness has induced Dr. Tate 
and others to make the spinal marrow the special seat of the disorder; but 
cases occur in which this symptom is quite wanting, and many of the pheno- 
mena can scarcely be ascribed to any other than a cerebral origin. 
It appears to me that all these exclusive hypotheses are too partial. The 
whole nervous system, in all its centres, and in all its ramifications, exhibits 
signs of derangement; and as each part of it is occasionally, to all appearance, 
independently deranged, it would seem to follow that no one part was the essen- 
tial or exclusive seat of the disease. The nature of the complaint seems to be 
a morbidly excessive excitability of the whole nervous system, which renders 
it liable to be thrown into disorder by causes insufficient materially to disturb 
its action in health. The influence of the uterine system is probably that 
which its very existence exerts over the nervous. The office of reproduction 
in the female is a most complicated and important function, which, in order 
that its several operations may be sustained in due harmony, requires the con- 
fitant oversight and interference of the nervous system. This must, therefore, CLASS III.] 
HYSTERIA. 
843 
be in a condition of excitability, capable of answering quickly to the calls that 
may be made upon it, and of consequence peculiarly liable to be disturbed by 
morbid causes. Hence the more frequent occurrence of the disease in women, 
and at that age when the uterine functions are in full vigour. Uterine dis- 
order may give rise to hysterical symptoms, just as intestinal disorder is 
known to do. Neither is essential; and probably both are quite as frequently 
the results of the hysterical condition, as they are themselves exciting causes 
of its peculiar phenomena. 
Diagnosis.-The affection with which the hysterical paroxysms are most 
liable to be confounded is epilepsy. It is important to be able to distinguish 
them; as the one is often curable, the other when fully established but too 
frequently bids defiance to medicine. Hysteria compared with epilepsy is in 
general a trivial disease. The most prominent diagnostic symptoms are, on 
the part of the epileptic paroxysm, the comparative unpreparedness of the 
patient, the sudden cry at the commencement of the fit, the frightful distor- 
tion of the features, the permanent dilatation or contraction of the pupil, the 
livid turgescence of the face, the foaming at the mouth, the small quantity of 
air admitted into the lungs in respiration, the comparative brevity of the 
convulsive portion of the fit, and the profound coma which attends the con- 
vulsions, and continues for some time after they have ceased. In hysteria, 
the paroxysm generally comes on less suddenly, or if sudden has an obvious 
cause; there is no loud cry at the outset; the features are seldom distorted, 
and foam seldom appears at the lips; the pupils often change upon exposure 
to the light; the face, though flushed, is usually bright red, and not livid; 
the respiration is less embarrassed; there is throughout the paroxysm an ap- 
pearance as of a concealed will, obscurely mingling with the causes of the 
phenomena, and sometimes an obvious degree of consciousness; there is an 
absence of deep coma after the subsidence of the convulsions; and, finally, 
the hysterical laughter and sobbing are, when they occur, quite characteristic. 
In the intervals between the paroxysms, the epileptic patient of long standing 
almost always exhibits the marks of the disease in a peculiar physiognomy; 
while in hysteria, the face, under similar circumstances, has usually all the 
appearance of health both in its physical character and its expression. 
But now and then hysteria and epilepsy co-exist; and the practitioner will, 
therefore, be prepared to meet with a mixture of their respective diagnostic 
symptoms in the paroxysms. Laughter on one side of the face is mentioned 
as one of the most prominent indications of this union of the two affections. 
In the preceding remarks on the symptoms of hysteria, occasion has been 
taken to point out some of the diseases which this affection is apt to coun- 
terfeit, and the means by which it may be distinguished. Inflammation of the 
brain, apoplexy, palsy, laryngitis, asthma, organic disease of the heart, gastri- 
tis, peritonitis, nephritis, and inflammation of the joints and spine, are among 
the complaints alluded to. Tetanus and hydrophobia, and, indeed, numerous 
other affections, might be added to the list. In all these cases, it is in gene- 
ral only necessary to bear in mind the distinguishing features of hysteria, to 
be able to recognize it in its disguise. The superficial character of the affec- 
tion, which often shows itself to an experienced eye in the midst of the greatest 
apparent violence; its fickle, shifting tendency; the want of correspondence 
between the violence of the functional disorder, and the usual evidences of 
organic disease; the frequent intervals of apparent health; the tendency to 
causeless laughter and weeping; the want of an expression of deep disease 
upon the countenance; the frequently normal state of the skin and pulse, and 
the fitful character of the latter when excited; and, lastly, the very frequent 
presence of tenderness of one or more of the vertebrae; are signs which, if 844 
[part II. 
LOCAL DISEASES.-NERVOUS SYSTEM. 
the practitioner is upon his guard, can scarcely fail to prevent mistake, at 
least in all ordinary cases. 
Treatment.-The treatment may be divided into that required for the 
paroxysm, and for the relief of the prominent symptoms, and into that calcu- 
lated to cure the disease by correcting the causes of irritation, and changing 
the irritable condition of the nervous system. 
1. During a convulsive paroxysm, the patient should be placed in bed, the 
dress should be loosened so as to prevent stricture anywhere, and so much 
restraint used as to obviate personal injury. It is scarcely possible to coerce 
every limb or muscle; nor is it desirable to do so; for the convulsions are to 
be looked on rather as a safe outlet for the excessive irritation of the nervous 
centres, than as in themselves hurtful. To rouse the patient, cold water 
may be sprinkled upon the face, and spirit of ammonia or other strongly odor- 
ous and somewhat irritant substance applied to the nostrils; but care must 
be taken not to use such substances in so concentrated a state as to excite in- 
flammation of the nasal membrane or respiratory passages. The vapour from 
burnt feathers is an old and popular remedy. If the paroxysm persist, sina- 
pisms may be applied to the insides of the legs, and ice or cold water to the 
head. If the patient can swallow, as sometimes happens in the intervals of 
the more violent spasms, one of the nervous stimulants may be administered, 
such as mixture of assafetida, oil of valerian, compound spirit of sulphuric 
ether, or aromatic spirit of ammonia; but in general it is better to abstain 
from medicines by the mouth; as there is often difficulty if not impossibility 
of deglutition, and unpleasant laryngeal irritation may be superadded to the 
paroxysm. Injections, however, are often useful. Even the ordinary pur- 
gative enema, by evacuating the bowels, and thus removing a source of irri- 
tation, may afford relief; but the best material for exhibition in this way is 
assafetida or oil of turpentine, the former of which may be injected in the 
quantity of one or two drachms, the latter of one or two tablespoonfuls, tho- 
roughly mixed with half a pint of warm water'. The injection of ice-cold 
water, and of vinegar and water, has been strongly recommended. 
Should the convulsion continue, notwithstanding these measures, the spine 
should be examined, and, if tenderness on pressure of the spinous processes 
be found, blood should be taken by cups from the spot. This measure will 
often afford instantaneous relief. When the pulse is full and strong, the face 
flushed, and our previous acquaintance with the case justifies the belief that 
the system is plethoric, blood may be drawn from the arm; but this remedy 
should be used cautiously; as, though it may prove immediately useful, it 
may do ultimate harm by inducing or increasing an anemic state of the sys- 
tem, which is highly favourable to hysteria. 
In very obstinate cases, consisting of frequently repeated convulsions, with 
partial returns of consciousness, I have found nothing more effectual than the 
nauseating influence of tartar emetic, given in doses of half a grain every half 
hour, or more largely if necessary, until its effects are felt. 
Inhalations of chloroform will generally control the convulsions by induc- 
ing a quiet soporose condition; but this remedy should be employed only in 
extreme cases, and always cautiously, in consequence of the danger to life. 
Ethereal inhalation has also been employed successfully. 
It will sometimes be advisable to speak, in a decided tone, in the presence 
of the patient, of the necessity of shaving the head and applying a blister, 
should she not be soon relieved. Strong mental impressions have a powerful 
influence over the disease; and sufficient consciousness often remains, during 
the apparent coma, to appreciate an observation of this kind. It does not 
follow that, because such a mental impression may prove useful, the patient CLASS III'.] 
HYSTERIA. 
845 
has been counterfeiting illness. It acts by replacing one impression by an- 
other even more powerful for a time. Perhaps the sedative influence of fear 
may allay the excitement of the nervous centres; perhaps a strong impression 
upon the emotional centres may act revulsively within the cerebro-spinal 
cavity, by calling off irritation from those which govern the convulsive move- 
ments. The patient may herself often do much in controlling the tendency 
to the hysterical paroxysm, by a determined exertion of her own will. 
Milder nervous disturbances may often be quieted by the antispasmodics 
before alluded to, given either at the time of their occurrence, or steadily at 
certain intervals, in order to exercise a continued control over the nervous 
system. The pill, mixture, or tincture of assafetida; the infusion, oil, or 
tincture of valerian; Hoffmann's anodyne or sweet spirit of nitre; aromatic 
or fetid spirit of ammonia; or camphor water, may be given in moderate 
doses three or four times a day, or occasionally as circumstances may seem 
to require. It is well to be provided with a long list of substances of this 
kind; for in many cases the calls upon the practitioner for additional means 
of relief are incessant; and not only is the attention of the patient occupied, 
but the impression upon her nervous system beneficially varied by this diver- 
sity of remedies. Oil of amber, compound galbanum pills, dracontium, and 
cimicifuga may, therefore, be added to the above list. 
The severe pain of hysteria often calls irresistibly for anodynes; audit 
becomes necessary occasionally, both in answer to this call, and in order to 
procure sleep, to have recourse to the preparations of opium, or some one of 
its narcotic substitutes. Extract of hemp, hyoscyamus, belladonna, stramo- 
nium, conium, and the internal use of chloroform may be tried; and in fact 
all the measures before pointed out as applicable to the treatment of neuralgia; 
but care must be taken not to habituate the system to narcotic influences, if 
such a result can be avoided. Aconite may be employed when vascular ful- 
ness or irritation contraindicates the stimulant narcotics. 
Rigid muscular contractions may often be removed by firm pressure upon 
the affected muscle, or by the pouring of a stream of cold water from a height 
of two or three feet upon the part. Thus, trismus may be relieved by com- 
pressing the masseter and temporal muscles; and obstinate flexion of the 
extremities by the cold douche. 
Local determinations to the head, chest, heart, &c., may be treated with 
occasional leeching, and blistering. These measures often afford great relief, 
and are urgently called for by the patient after having experienced their 
good effects. But the danger of too frequent a resort to local depletion must 
be guarded against; lest present ease be given at the cost of still greater 
future evil. The same end may often be effected by revulsion towards the 
extremities, by means of hot pediluvia or maniluvia, consisting of hot water 
alone, or of this rendered more stimulating by means of common salt, mus- 
tard, cayenne pepper, &c. General revulsion to the surface is also extremely 
beneficial in numerous instances. This is most advantageously effected- by 
means of general frictions, either simple, or with rubefacient substances. 
The cold bath, or shower-bath, if followed by reaction, will sometimes act 
like a charm. 
Disorder in the various functions, consequent upon the disease, must be 
attended to. But the measures requisite for this purpose will be found de- 
tailed elsewhere, under the heads of functional disease of the several organs. 
The derangements especially requiring attention are spasm of the oesophagus, 
obstinate vomiting, gastralgia and gastric spasm, flatulence., colic, laryngeal 
irritation, severe cough, hiccough, dyspnoea, palpitations, syncope, functional 
disorder of the liver, retention or incontinence of urine, functional disorder of 846 
LOCAL DISEASES.-NERVOUS SYSTEM. 
[part II. 
the kidneys, spinal irritation, headache, and delirium, to all of which the 
reader is referred, under their respective headings. 
2. We now come to the treatment which is to be directed towards the cure 
of the complaint. Two indications are here offered, one to remove or coun- 
teract the exciting causes, and the other to correct the extreme irritability of 
the nervous system. In order to fulfil the first of these indications, it is neces- 
sary to search diligently for any disorder in the system which may serve as a 
source of irritation, and, if any such can be found, to address our remedies 
to that disorder. I have before stated my belief that gout and rheumatism 
not unfrequently lie at the foundation of hysteria. If any grounds for such a 
suspicion should exist, the remedies for these affections when they assume the 
nervous character should be employed. (See Nervous Gout, i. 489.) Should 
any reason for referring the complaint to repelled eruptions exist, blisters, 
rubefacients, or pustulating applications should be freely employed, to invite 
irritation again to the surface. Should the healing of an old ulcer have been 
followed by the appearance of the hysterical symptoms, its place should be 
supplied by a seton or issue. The immediate cause of the nervous derange- 
ments will often be found in spinal irritation, which should be corrected by 
cups or leeches, blistering, or pustulation by croton oil or tartar emetic, of 
which the last is probably the most effectual. (See Spinal Irritation.) An- 
other frequent exciting cause is disease of the alimentary canal. Constipation 
should be corrected by purgatives, at first somewhat active, and afterwards 
such as may be calculated to keep the bowels regular, without debilitating, as 
aloes, rhubarb, magnesia, sulphur, &c. The hepatic secretion should be cor- 
rected if deranged, and any exciting symptoms of dyspepsia should be treated 
as directed under that disease. But the uterus demands a peculiar care, and 
its derangements whether of function, position, or organization, should be cor- 
rected as far as possible. For the means of accomplishing this object, I must 
be content with referring to works devoted especially to the peculiar diseases 
of women, which do not fall within the scheme of the present treatise. There 
is, however, one uterine affection, of so frequent an occurrence, and so vari- 
ously mingled with other.diseases which have engaged our attention, either 
as cause, effect, or modifying coincidence, that I cannot pass it by without a 
more particular notice, especially as it has been referred to repeatedly in the 
preceding pages. Allusion is had to that condition of retained, deficient, or 
suppressed menstruation, which is known under the name of amenorrhoea. It 
is not my intention to enter into an account of the pathology of that affection, 
or even to consider it therapeutically at much length; but simply to indicate 
briefly what seems to me the appropriate treatment, in order to answer the 
references made on former occasions. 
Treatment of Amenorrhoea.-As in the case of all other deficient or sup- 
pressed discharges, this may be connected with excessive or deficient vascular 
action in the organ; and the treatment must be accommodated to these two 
conditions. When the discharge ceases from vascular irritation of the uterus, 
if there is at the same time general plethora, with a full and strong pulse, 
pain in the back or head, flushing of the face, &c., it will be proper to take 
blood from the arm, to administer a saline cathartic, to put the patient upon 
a low diet, and administer the warm hip bath, or a general warm bath. 
With a gentle form of the same condition, the bleeding may be omitted, and 
the remainder of the treatment carried into effect. Should there be consider- 
able uneasiness in the uterine region, with little or no general excitement, it 
may be proper to apply cups to the sacrum or leeches to the vulva, or inner 
and upper part of the thigh, and to repeat the application once or oftener, 
should the symptoms persist. If the pain and irritation be severe, it may be CLASS III.] 
HYSTERIA. 
847 
advisable, after the warm bath, to administer a full dose of the Dover's pow- 
der at bedtime, to be repeated if necessary to procure ease. Under this plan, 
the menses will usually return if the suppression be recent. Not unfrequently, 
when the affection is consequent upon taking cold, and is quite recent, it will 
yield to a hot pediluvium, and the administration of warm herb teas at bed- 
time, with or without a dose of the powder of opium and ipecacuanha. Some- 
times, however, it happens that, though the general and local excitement may 
have been subdued, the suppression continues, consequent probably upon the 
depression following excitement, or upon a habit of inertness in the uterine 
vessels. Under these circumstances, it becomes necessary to resort to some 
one of the emmenagogue measures enumerated below. 
The opposite state of uterine depression may be entirely local, or may 
depend upon an anemic, or otherwise debilitated condition of the system. In 
the latter case, it is necessary primarily to address remedies to the general 
affection; and it is especially important to correct the condition of the blood, 
when that is in fault. It is probable that the great majority of cases of 
amenorrhoea are of this kind. Certainly it is so, in relation to the females 
who come under my notice in the Pennsylvania Hospital. In such cases, 
attention having been paid to the hepatic secretion, which should always first 
be corrected if deranged, the strength should be recruited by mild tonics, 
moderate exercise on foot, on horseback, or in a somewhat rough vehicle, pure 
air, the shower-bath, gradually made cooler as the system is found to react 
under it, and a nutritious, easily digestible diet. In an anemic condition, the 
chalybeates should be preferred to other tonics. The bowels should at the 
same time be kept regular by laxatives, and especially by aloes. It happens 
that these remedies, while they tend to improve the general health, have a 
direct favourable influence upon the uterine function, which is thus restored 
along with the strength of the patient. 
Supposing, however, the uterine affection to be quite local, or to persist 
after the correction of the state of the system, whether of excitement or de- 
pression, we are then to have recourse to emmenagogues. Of these, so far 
as my own experience permits me to decide, the preparations of iron and aloes 
are the most efficient. These may be indicated merely in reference to their 
tonic and laxative effect; but, independently of these, they have, I believe, a 
direct influence upon the uterine function, and may be employed, with hope 
of benefit, in all cases in which over excitement of the organ does not con- 
traindicate them. I see much of this affection among the female patients 
who resort to the Pennsylvania Hospital, and generally find it to yield to a 
combination of these remedies. One or two grains of aloes, and from five to 
ten of the pill of carbonate of iron (U. N. Ph.}, may be given in the pilular 
form three times a day; or the same medicines may be employed in the liquid 
form, by combining the tincture of aloes, or the tincture of aloes and myrrh, 
with the tincture of chloride of iron. Other modes of administration may be 
resorted to if preferred; the great object being the administration of iron and 
aloes. The dose must be regulated by the effects, care being taken,- on the 
one hand, not to irritate the bowels or too much to excite the system, and, on 
the other, to obtain one or two passages daily, and to bring about a decided 
influence of the chalybeate on the blood. Myrrh is often added to the aloes 
and iron. The treatment should be persisted in, if necessary, for two or three 
months. It need not interfere with any active pursuits of the patient; on the 
contrary, such pursuits might be in themselves useful. Advantage will some- 
times accrue, when the regular period of menstruation is known, from antici- 
pating it by a full purgative dose of aloes. 
If this plan fail, or if a more rapid effect is desired, we may employ one of 848 
[part II. 
LOCAL DISEASES.-NERVOUS SYSTEM. 
the more stimulating emmenagogues. Among the most efficient of these is 
the ammoniated tincture of guaiac, in the dose of a fluidrachm three or four 
times a day. This sometimes acts most happily. A still more stimulating 
medicine, which has a strong tendency to the uterus, as well as to the other 
pelvic viscera, is tincture of cantharides. This may occasionally be employed 
with great effect. It may be pushed till it produces some slight symptoms 
of strangury, and afterwards should be kept within that point. The oil of 
turpentine has also been recommended. Savine, too, is decidedly emmena- 
gogue. Seneka has been thought to be useful, and, being a general stimulant 
to the secretions, may sometimes bring on the menstrual discharge; but it 
cannot be relied on. The preparations of iodine act on the same principle, 
and occasionally with very good effects. Biborate of soda has been recom- 
mended. (A7". K Journ. of Med., N. S., i. 387.) Black hellebore has, from 
high antiquity, enjoyed great reputation as an emmenagogue, and is still 
much relied on by many. It may be given when aloes is too irritant to the 
rectum, or cannot be employed on account of the existence of piles; and when, 
at the same time, there is an indication for cathartic medicine. 
Local measures addressed to the uterus are sometimes advantageous. A 
hot hip-bath is strongly stimulant to that organ. A blister to the sacrum 
may be useful. Electricity should be tried if other means fail. The injec- 
tion of solution of ammonia into the vagina has been recommended. Ten 
drops of the liquor ammoniae may be added to a fluidounce of water, and in- 
jected three times daily, the quantity of the stimulant being increased or dimi- 
nished according to its effects; the object being so to regulate it as to produce 
a feeling of warmth or slight uneasiness, without considerable irritation. In 
very chronic cases, advantage may accrue from wearing constantly on the 
small of the back a compound galbanum plaster, or a warm plaster. 
Correction of the irritability of the nervous system.-To return to the more 
immediate subject of hysteria, we are next to consider the means calculated 
to answer the last indication; that, namely, of correcting the irritability of 
the nervous system. This must be done by giving it increased vigour. Hence, 
the tonic plan of treatment is indicated, when not forbidden by the existence 
of plethora or a disposition towards it. But those tonics should be selected 
which have a special tendency to the nervous system. Such is quinia, which 
may sometimes be used advantageously; especially when the complaint as- 
sumes the intermittent form, or exhibits any approach towards it. But, on 
the whole, the metallic tonics are here most advantageous. Sulphate of cop- 
per or ammoniated copper, sulphate or valerianate of zinc, and nitrate, oxide, 
or chloride of silver, are those from which most good may be expected. They 
may often be advantageously associated in prescription with laxative medi- 
cines, and with the narcotics, when these are at the same time indicated. 
Other means calculated to meet the same end are the daily use of the cold or 
shower-bath, exercise in the pure air, and a wholesome nutritious diet. To- 
bacco, coffee, strong tea, and alcoholic drinks, should as a general rule be 
forbidden. Hot and crowded rooms, the dissipations of society, and all causes 
of excessive excitement, including the reading of pernicious novels, should be 
shunned. The patient should rise early, exercise in the morning air, and re- 
tire early to bed; but the exhaustion of excessive sleeping should be avoided. 
Mattrasses should be preferred to feather beds, unless in the coldest weather. 
The surface should be protected against changes of temperature, and espe- 
cially against the cold of winter, by flannel next the skin. All vicious habits, 
that have a tendency to produce or foster the diseased state of the nervous 
system, should be corrected. 
But the most effectual plan of cure is completely to change the circumstances CLASS III.] 
849 
HYSTERIA.-CONCLUSION. 
under which the patient may be placed, and to bring a new set of influences 
to bear upon the nervous system. The remarks made upon this point in the 
treatment of neuralgia are equally applicable to the disease under considera- 
tion. (See Neuralgia, page 817.) A change of residence from town to country, 
a sea-voyage, a long journey, a residence abroad, are among the most efficient 
measures. ♦ 
The work has now been brought to a close. A survey has been taken of 
all the diseases belonging exclusively to the Practice of Medicine, as distin- 
guished from the other practical branches of our art. Certain affections, 
which have usually been regarded as common property by medical writers on 
the one hand, and surgical or obstetrical writers on the other, have been 
omitted in this treatise; because it has seemed to the author, that the space 
they would have occupied might be more profitably devoted to ampler details 
in relation to diseases strictly medical. Among the affections alluded to are 
those of the eyes, the ears, and the male generative organs, and the diseases 
peculiar to women. In reference to the mode in which the author has ac- 
complished his task, he has but one remark to make. Occasional repetitions 
of the same pathological views, and the same principles and modes of practice, 
will have been noticed by the reader in his progress through the work. But 
a certain amount of repetition could not be avoided without great inconvenience. 
The close analogy between many diseases required the same train of thought 
for their elucidation, and an enumeration of the same remedies in the account 
of their treatment. A reference, under each successive disease, to previous 
observations and conclusions whenever applicable, would have implied a 
memory such as few readers can boast of, or the necessity of a constant re- 
currence to the past, more irksome, and more likely to consume time, than 
a restatement of the principles and facts required. Whether the proper 
medium in this respect has been preserved, must be left, with all other ques- 
tions in relation to the execution of the work, to the impartial judgment of 
the reader. INDEX. 
Abdominal aneurisms ii. 230 
Abdominal dropsy ii. 376 
Abdominal typhus i. 325 
Abscess, metastatic ii. 244 
Abscess of the pharynx i. 532 
Abscesses i. 33 
Absorbent glands, inflammation of the i. 733 
Absorbent glands, scrofulous inflam- 
mation of the i. 735 
Absorbent system, diseases of the i. 729 
Absorbents, inflammation of the i. 730 
Abstinence i. 218 
Acarus scabiei ii. 415 
Acephalocystis i. 135 
Achor ii. 385 
Achorion Schonleini ii. 463 
Acinesia ii. 822 
Acne ii. 430 
Acne indurata ii. 431 
Acne punctata ii. 431 
Acne rosacea ii. 434 
Acne sebacea ii. 432 
Acne simplex ii. 431 
Acrodynia ii. 388 
Active congestion i. 83 
Active hemorrhage ii. 283 
Adenitis, scrofulous i. 735 
Adhesive inflammation i. 29 
Adipose tissue, inflammation of the i. 55 
JEgophony , i. 762 
African fever i. 265 
Age, as a cause of disease i. 170 
Agenesis ii. 653 
Ageusia ii. 829 
Ague cakes ii. 525 
Albinism ii. 459 
Albumen in the urine, tests of ii. 342 
Albuminous diuresis ii. 584 
Albuminous nephritis ii. 539 
Albuminuria ii. 539 
Alteration, as a therapeutic process i. 228 
Amaurosis ' ii. 829 
Amenorrhoea ii. 846 
American leeches, always meant when 
leeches are directed in this work i. 216 
American leeches, quantity drawn 
by each i. 217 
Amphoric resonance i. 763 
Amphoric respiration i. 757 
Amygdalitis i. 529 
Anjemia ii. 251 
Ancesthesia ii. 822 
Anal leucorrhoea i 667 
Anasarca ii. 364 
Anazoturia ii. 584 
Aneurism ii. 217 
Aneurism of the aorta ii. 228 
Aneurism of the heart ii. 170, 171 
Aneurisms, abdominal ii. 230 
Aneurisms, thoracic ii. 224 
Angeioleucitis i. 730 
Angina i. 521 
Angina, follicular i. 522 
Angina, granular i. 522 
Angina maligna i. 529 
Angina membranacea i. 525 
Angina pectoris ii. 206 
Angina simplex i. 521 
Angina tonsillaris i. 529 
Angina trachealis i. 813 
Animal effluvia as a cause of disease i. 152 
Animal magnetism ii. 686 
Anorexia i. 573 
Anosmia ii. 829 
Antiphlogistic diet i. 218 
Anureous diuresis ii. 584 
Anuria ii. 597 
Anus, fissures of the i. 672 
Anus, prolapsus of the i. 674 
Aorta, aneurism of the ii. 228 
Aphonia i. 833 
Aphthae i. 501 
Apnoea ii. 106 
Apoplexy . ii. 656 
Apoplexy of the lungs ii. 300 
Appetite in disease i. 178 
Appetite, morbid i. 570 
Apyrexia . i. 94 
Arachnitis ii. 622 
Areolar tissue, inflammation of the i. 55< 
Arterial palpitation ii. 235 
Arterial sedatives i. 225 
Arteries, inflammation of the ii. 210 
Arteries, organic diseases of the ii. 213 
Arteries, ossification of the ii. 215 
Arteriotomy i. 215 
Arteritis ii. 210 
Arthritis i. 472 852 
INDEX. 
Ascarides i. 649, 656 
Ascaris lumbricoides i. 649, 654 
Ascaris vermicularis i. 649, 656 
Ascites ii. 376 
Asiatic cholera i. 680 
Asphyxia ii. 106 
Asthma i. 845 
Atelectasis i. 797 
Atheromatous cysts i. 120 
Atheromatous deposition in the arte- 
ries ii. 214 
Atmospheric impurity as a cause of 
disease i. 149 
Atonic gout i. 472 
Atrophia mesenterica i. 748 
Atrophy i. 75 
Aurigo ii. 512 
Auscultation i. 204, 753 
Auscultation, cerebral ii. 620 
Auscultation in diseases of the heart ii. 127 
Azoturia ii. 583 
Barbadoes leg ii. 468 
Bath, cold i. 222, 225 
Bath, hot i. 223 
Bath, hot vapour i. 252 
Bath, Jenning's vapour i. 252 
Bath, warm i. 225 
Bellows murmur ii. 130 
Bengal fever i. 265 
Bile in the urine, tests of ii. 515, 579 
Biliary calculi ii. 509 
Biliary passages, diseases of the ii. 508 
Bilious colic i. 621 
Bilious diarrhoea i. 614 
Bilious dysentery i. 595 
Bilious erysipelas i. 432 
Bilious fever i. 264 
Bilious pleurisy ii. 17 
Bilious pneumonia ii. 17, 28 
Bilious remittent fever i. 264 
Black measles i 409 
Black smallpox i. 379 
Black tongue i. 434 
Black vomit i. 311 
Bladder, inflammation of the ii. 556 
Bladder, irritable ii. 570 
Bladder, paralysis of the ii. 571 
Bladder, spasm of the ii. 569 
Bleeding, general i. 215 
Bleeding, local i. 216 
Bleeding piles ii. 322 
Blind piles i. 664 
Blood, as a sign of disease i. 188 
Blood, buffy coat of the i. 38 
Blood, constitution of the i. 4 
Blood, cupped i. 38 
Blood, diseases of the ii. 248 
Blood, morbid states of the i. 3 
Blood, proportion of ingredients of i. 6 
Blood, sizy i. 38 
Bloody flux i. 593 
Bloody urine ii. 324 
Blue disease ii. 193 
Borborygmus i. 710 
Bothriocephalus latus i. 650, 657 
Boulimia L 570 
Bowel, twisting of the i. 646 
Bowels, cancer of the i. 609 
Bowels, diseases of the i. 583 
Bowels, hemorrhage of the ii. 317 
Bowels, inflammation of the i. 583 
Bowels, invagination of the i. 645 
Bowels, irritation of the i. 611 
Bowels, obstruction of the i. 642 
Bowels, stricture of the - i. 644 
Brain, active congestion of the ii. 675 
Brain and its membranes, inflam- 
mation of the ii. 620 
Brain, atrophy of the ii. 653 
Brain, depression of the ii. 677 
Brain, diseases of the ii. 620 
Brain, dropsy of the ii. 366 
Brain, functional diseases of the ii. 672 
Brain, hypertrophy of the ii. 652 
Brain, nervous irritation of the ii. 673 
Brain, organic diseases of the ii. 652 
Brain, partial inflammation of the ii. 633 
Brain, passive congestion of the ii. 679 
Brain, softening of the ii. 636 
Brain, tubercles in the ii. 654 
Brain, tumours in the ii. 654 
Brain, vascular irritation of the ii. 675 
Brawny liver ii. 500 
Breakbone fever i. 444 
Bright's disease ii. 539 
Broad tape-worm i. 650, 657 
Bronchia, inflammation of the i. 791 
Bronchial dilatation ii. 62 
Bronchial glands, disease of the i. 744 
Bronchial glands, inflammation of the i. 745 
Bronchial glands, scrofulous i. 746 
Bronchial glands, tuberculous i. 746 
Bronchial respiration i. 757 
Bronchial sound i. 755 
Bronchitis i. 791 
Bronchitis, acute i. 791 
Bronchitis, chronic i. 802 
Bronchophony i. 761 
Bronchorrhoea i. 803 
Bruit de diable ii. 134 
Bruit de pot fele ii. 82 
Bruit de soufflet ii. 130 
Buffy coat i. 38 
Bulam fever i. 306 
Caecum, inflammation of the i. 587 
Calcareous degeneration i. 78 
Calculi in the bladder ii. 610 
Calculous disease ii. 601 
Calculous nephralgia ii. 567 
Callipers i. 204 
Calor mordicans i. 190 
Camp fever i. 351 
Cancer i. 121 
Cancer cells i. 123 
Cancer, epithelial i. 127 
Cancer of the bowels i. 609 
Cancer of the stomach i. 549 
Cancroid tumours i. 127 INDEX. 
853 
Cancrum oris i. 502 
Canine appetite i. 570 
Canker i. 502 
Capillaries, as signs of disease i. 187 
Carbonic acid, as a cause of disease i. 150 
Carbonic oxide, as a cause of disease i. 150 
Carburetted hydrogen, as a cause of 
disease i. 151 
Carcinoma . i. 121 
Carcinomatous sarcoma i. 130 
Cardiac dropsy ii. 362 
Cardialgia i. 555 
Carditis ii. 157 
Caries i. 32 
Caries of the teeth i. 514 
Carnification ii. 8 
Cartilaginous tissues, inflammation of i. 58 
Catalepsy ii. 695 
Catarrh i. 807 
Catarrh, epidemic i. 809 
Catarrh fever i. 808 
Catarrh of the bladder ii. 559 
Catarrh, suffocative i 794 
Catarrhal consumption i. 803 
Catarrhal croup i. 814 
Catarrhal diarrhoea i. 613 
Catarrhus senilis i. 794 
Causes of disease i. 138 
Cavernous rale i 759 
Cavernous respiration i. 757 
Cellular tissue, hemorrhage of the ii. 337 
Cellular tissue, inflammation of the i. 55 
Cephalalgia ii. 679 
Ceramuria ii. 604 
Cerebral auscultation ii. 620 
Cerebral stimulants i. 223 
Cerebriform disease i. 131 
Cerebritis ii. 633 
Cerebro-spinal meningitis ii. 772 
Chalk stones i. 478 
Cheloidea ii. 457 
Chemical influence in therapeutics i. 229 
Chest, dropsy of the ii. 371 
Chest measurer i. 770 
Chickenpox i. 405 
Chill of fever e i. 89 
Chin-cough i. 834 
Chiragra i. 472 
Chloasma ii. 445 
Chloroform and camphor, mixture of ii. 815 
Chlorosis ii. 252 
Cholera asphyxia i. 680 
Cholera, epidemic i. 680 
Cholera infantum i. 703 
Cholera morbus i. 676 
Cholerine i. 683 
Chorea ii. 763 
Chorea Sancti Viti ii. 763 
Chronic inflammation i. 37 
Chylo-serous urine ii. 577 
Chylous diuresis ii. 577 
Cicatrization i. 35 
Circulatory system, diseases of the ii. 119 
Cirrhosis ii. 496 
Cirrhosis of the lungs ii. 20 
Clavus hystericus ii. 839 
Climate as a cause of disease i. 172 
Clonic spasm ii. 689 
Coagulable lymph i. 28 
Cod-liver oil in phthisis ii. 95 
Coelelmintha i. 136 
Coherent smallpox ' i. 379 
Cold as a cause of depression i. 69 
Cold as a cause of disease i. 143 
Cold bath i. 222, 225 
Cold in the head i. 772 
Cold, morbid effects of extreme ii. 114 
Cold water, syncope from drinking ii. 204 
Colic i. 619 
Colic, bilious i. 621 
Colic, dyspeptic i. 620 
Colic, flatulent i. 620 
Colic, hysterical i. 620 
Colic, lead i. 627 
Colic, neuralgic i. 622 
Colic, rheumatic i. 621 
Colic, simple spasmodic i. 620 
Colic, verminose i. 620 
Colica pictonum i. 627 
Colitis i. 593 
Colliquative secretions i. 188 
Colloid cancer i. 132 
Colo-rectitis i. 593 
Coma ii. 683 
Common continued fever i. 325 
Compound granular corpuscles i. 45 
Compression in therapeutics i. 229 
Confluent smallpox i. 376 
Congestion i. 82 
Congestion, active i. 83 
Congestion, passive i. 84 
Congestive fever i. 293 
Constipation i. 635 
Constituent forms of disease i. 2 
Constitutional diseases i. 447 
Constitutional hemorrhage ii. 285 
Contagion j. 164 
Continued fever i. 325 
Convalescence i. 197 
Convulsions ii. 689 
Convulsions, infantile ii. 690 
Convulsive cough of children i. 834 
Cophosis ii. 829" 
Corpuscles, compound granular i. 45 
Corpuscles, exudation i. 45 
Corpuscles, pus i. 46 
Corpuscles, tuberculous i. 116 
Corymbose smallpox i. 379 
Coryza i. 772 
Cough, as a symptom i. 181 
Cough, nervous i. 843 
Counter-irritation i. 226 
Country fever i. 265 
Coup de soleil ii. 683 
Couperose ii. 434 
Course of disease i. 194 
Cowpox i. 392 
Cracked-metal sound ii. 82 
Cramp ii. 818 
Cramp of the stomach i. 559 854 
INDEX. 
Crapulous diarrhoea i. 612 
Creaking sound i. 761 
Creeping palsy ii. 826 
Crepitant rale i. 759 
Crepitation i. 202 
Crisis i. 196 
Critical days i. 92, 196 
Critical hemorrhage ii. 286 
Critical symptoms i. 196 
Croup i. 813 
Croup, catarrhal i. 814 
Croup, pseudo-membranous i- 817 
Crowing disease i. 830 
Crude tubercle ii. 65 
Crural phlebitis ii. 242 
Crusta lactea ii. 411, 427 
Cryptogamous affections ii. 386, 460 
Crystalli i. 405 
Crystalline pock i. 379 
Cupped blood i. 38 
Cupping i. 216 
Cutaneous tissue, inflammation of the i. 58 
Cyanosis ii. 193 
Cynauche laryngea i. 779 
Cynanche maligna i. 418, 529 
Cynanche parotidea ii. 474 
Cynanche tonsillaris i. 529 
Cynanche trachealis i. 813 
Cystic oxide ii. 579 
Cysticercus i. 136 
Cystine ii. 579 
Cystirrhoea ii. 559 
Cystitis ii. 556 
Cystitis, chronic ii. 559 
Cysts i. 119 
Dandy fever i. 444 
Danse de Saint Guy ii. 763 
Deafness ii. 829 
Death i. 198 
Debility i. 65 
Defecation in disease i. 179 
Definition of disease, i. 2 
Deglutition in disease i. 177 
Delirium as a symptom of disease i. 192 
Delirium tremens ii 734 
Dementia ii. 704 
Dengue i. 444 
Dentition, morbid i. 510 
Depletion i. 214 
Depletion, indirect i. 218 
Depraved appetite i. 571 
Depression i. 65 
Derivation i. 226 
Desquamative inflammation of the 
kidneys ii 539 
Devonshire colic i. 627 
Diabetes ii. 584 
Diabetes insipidus ii. 581 
Diabetes mellitus ii. 584 
Diagnosis i. 199 
Diagnostic symptoms i. 200 
Diarrhoea i. 611 
Diarrhoea, bilious i. 614 
Diarrhoea, catarrhal i. 613 
Diarrhoea, crapulous i. 612 
Diarrhoea, mucous i. 613 
Diarrhoea, serous i. 613 
Diatheses i 168 
Diet, antiphlogistic i. 218 
Diet, stimulating i. 223 
Digestible food i. 577 
Digestive system, diseases of the i. 496 
Dilatation and hypertrophy of the 
heart ii. 168 
Dilatation of the heart ii. 170 
Dilution, as a therapeutic process i. 220 
Diphtheritis i. 525 
Dipsomania ii. 734 
Discolorations ii. 386, 458 
Disease, constituent forms of i. 2 
Disease, definition of i. 2 
Disease from influences upon the 
vital properties i. 14 
Disease from mechanical or chemical 
causes i. 11 
Disease of the fluids i. 3 
Disease of the solids i. 11 
Disease with peculiar products i. Ill 
Diseases, constitutional i. 447 
Diseases, definition of i. 231 
Diseases, general i. 232 
Diseases, local i. 496 
Dissecting aneurisms ii 221 
Distension in therapeutics i. 229 
Distinct smallpox i. 374 
Distoma . i. 136 
Diuresis ii. 581 
Dothinenteritis i. 325 
Drink, desire for, in disease i. 178 
Dropsy ii. 338 
Dropsy, abdominal ii. 376 
Dropsy, encysted ii. 382 
Dropsy of the brain ii. 366 
Dropsy of the chest ii. 371 
Dropsy of the heart ii. 374 
Dropsy of the lungs ii. 375 
Dropsy, ovarian ii. 382 
Drowning ii. 112, 118 
Dry asthma i. 846 
Dry cholera i. 711 
Dry mucous rale i 758 
Dunga i. 444 
Duodenitis i. 583 
Duodenum, diseases of the i. 584 
Duration of disease i 194 
Dysentery i. 593 
Dysentery, acute i 593 
Dysentery, adynamic i. 595 
Dysentery as a cause of dropsy ii. 347 
Dysentery, bilious i. 595 
Dysentery, chronic i. 607 
Dysentery, epidemic i. 596 
Dysentery, intermittent i. 595 
Dysentery, remittent i. 595 
Dysentery, rheumatic i. 596 
Dysentery, typhous i. 596 
Dyspepsia i. 572 
Dyspeptic colic i. 620 
Dyspeptic consumption ii. 78 INDEX. 
855 
Dyspnoea as a symptom i. 179 
Earache ii. 809 
Echinococcus i. 136 
Eclampsia ii. 689 
Ecstasy ii. 685 
Ecthyma ii 423 
Ecthyma, acute ii. 423 
Ecthyma, chronic ii. 424 
Ecthyma luridum ii. 424 
Ecthyma vulgare ii. 424 
Eczema ii. 408 
Eczema, acute ii 408 
Eczema, chronic ii 409 
Eczema impetiginoides ii. 409 
Eczema rubrum ii. 408 
Eczema simplex ii. 408 
Electrical chorea ii. 765 
Electricity as a cause of disease i 149 
Elephantiasis of the Arabians ii. 468 
Elephantiasis of the Greeks ii. 449 
Elimination i. 228 
Emphysema of the lungs ii. 56 
Emprosthotonos ii. 782 
Empyema ii. 44, 50 
Encephalitis ii. 622 
Encephaloid disease i 131 
Encephalo-meningitis ii. 622 
Encysted dropsy ii. 382 
Endemic i. 159 
Endocarditis ii. 151 
Endocardium, inflammation of the ii 151 
Enteric fever i. 325 
Enteritis i. 585 
Enteritis, acute i. 586 
Enteritis, chronic i. 590 
Entero-mesenteric fever i. 325 
Entozoa i. 132 
Enuresis ii. 618 
Ephelis ii. 459 
Ephemera i. 94, 234 
Epidemic i. 159 
Epidemic catarrh i. 809 
Epidemic cholera i. 680 
Epidemic erysipelas i. 434 
Epidemic influence i 159 
Epigastric pulsation ii. 236 
Epilepsy ii. 747 
Epistaxis ii. 292 
Epithelial cancer i. 127 
Equinia i. 441 
Error loci i. 54 
Eructation i. 710 
Erysipelas i. 427 
Erysipelas ambulans i. 431 
Erysipelas, epidemic i. 434 
Erysipelas erraticum i. 431 
Erysipelas from wounds in dissection i. 435 
Erysipelas gangraenosum i. 431 
Erysipelas neonatorum i. 432 
Erysipelas oedematodes i. 431 
Erysipelas phlegmonodes i. 431 
Erysipelatous fever i. 432 
Erysipelatous inflammation i. 432 
Erythema ii. 386 
Erythema circinatum ii. 387 
Erythema fugax ii. 387 
Erythema Imve ii. 387 
Erythema marginatum ii. 387 
Erythema nodosum ii. 387 
Erythema papulatum ii. 387 
Erythema tuberculatum ii. 387 
Erythematous lupus ii. 453 
Essence of beef, mutton, &c. i. 224 
Essential fever i. 103 
Etiology i. 138 
Exacerbation i. 95 
Exanthemata ii. 385 
Exanthematous fevers i. 233 
Excitability i. 20 
Exostosis, toothache from ' i. 518 
Expectant plan i. 209 
Expectoration, as a symptom i. 182 
External scrofula i. 735 
Extravesicular emphysema ii. 57 
Exudation corpuscles i. 45 
Facial expression as a symptom i. 193 
Falling of the teeth i. 519 
Falling sickness ii. 747 
False croup i. 814 
False membranes i. 29 
Farcy glanders i. 441 
Fatty degeneration i. 78 
Fatty degeneration of the heart ii. 189 
Fatty degeneration of the kidneys ii. 549 
Fatty liver ii. 499 
Fauces, diseases of the i. 521 
Favus ii. 460 
Favus confertus ii. 462 
Favus dispersus ii. 4.61 
Fever i. 87 
Fever, adynamic i. 96 
Fever and ague i. 241 
Fever, asthenic i. 96 
Fever, bilious i. 264 
Fever, causes of i. 98 
Fever, congestive i. 293 
Fever, course of i. 93 
Fever, definition of i. 88 
Fever, enteric i. 325 
Fever, essential i. 103 
Fever, grade of i. 95 
Fever, hectic i. 41 
Fever, idiopathic i. 103 
Fever, inflammatory i. 95 
Fever, intermittent i. .241 
Fever, irritative i. 234 
Fever, miasmatic i. 240 
Fever, nature of i. 105 
Fever, pernicious i. 293 
Fever, phenomena of i. 88 
Fever, relapsing i. 361 
Fever, remittent i. 264 
Fever, scarlet i. 414 
Fever, symptomatic i. 41 
Fever, theories of i. 100 
Fever, typhoid i. 325 
Fever, typhous state of i. 96 
Fever, typhus i. 351 856 
INDEX. 
Fever, yellow i. 306 
Fevers, idiopathic i. 232 
Fibro-cartilaginous tissue, inflam- 
mation of the i. 58 
Fibrous tissue, inflammation of the i. 58 
Filaria medinensis i. 137 
Filliping i. 203 
Firing, as a remedy i. 471 
Fish-skin disease ii. 447 
Fissures of the anus i. 672 
Flatulence i. 710 
Flatulent colic i. 620 
Fluids, disease of the i. 3 
Follicular angina t i. 522 
Follicular enteritis i. 325 
Follicular inflammation i. 61 
Follicular inflammation of the mouth i. 501 
Fomites i. 165 
Food, easily digested i. 577 
Food of difficult digestion i. 576 
Food, stimulating i. 223 
Framboesia ii. 455 
Freckles ii. 458 
Freezing ii. 114, 119 
Friction in therapeutics i. 230 
Friction sound i. 760, ii. 133 
Fungus haematodes i. 131 
Gall-bladder, diseases of the ii. 508 
Galloping consumption ii. 82 
Gall-stones ii. 509 
Gangrsena oris i. 505 
Gangrene i. 33, 79 
Gangrene of the lungs ii. 30 
Gangrene, spontaneous ii. 211 
Gangrenous inflammation of the 
fauces i. 529 
Gangrenous inflammation of the 
mouth i. 505 
Gastralgia i. 556 
Gastritis i. 536 
Gastritis, acute i. 536 
Gastritis, chronic i. 541 
Gastrodynia i. 556 
Gastrorrhagia ii. 310 
Gastrorrhoea i. 544, 548 
Gelatinous carcinoma i. 132 
Gelatinous infiltration ii. 65 
General bleeding i. 215 
General diseases i. 232 
General indications, in therapeutics i. 209 
General palsy ii. 822, 826 
General pathology i. 1 
General therapeutic processes i. 214 
General therapeutics i. 208 
Glanders i. 441 
Glandular tissue, inflammation of i. 63 
Globus hystericus ii. 836 
Glossitis i. 508 
Glottis, infantile spasm of the i. 830 
Glottis, spasm of the, in adults i. 833 
Glucosuria ii. 584 
Gordius aquations i. 651 
Gourd-worm i. 650 
Gout i. 472 
Gout, acute i. 472 
Gout, chronic i. 477 
Gout, nervous i. 479 
Gouty toothache i. 518 
Granular corpuscles, compound • i. 45 
Granular degeneration of the kidneys ii. 539 
Granular degeneration of the liver ii. 496 
Granulation i. 35 
Granulations, tuberculous i. 112 
Gravedo i. 773 
Gravel ii. 601 
Gray granulations ii. 64 
Grease in horses i. 441 
Grippe i. 809 
Grocers' itch ii. 438 
Gum cancer i. 132 
Gutta rosea ii. 434 
Habit, as a cause of disease i. 171 
Haematemesis ii. 310 
Haematuria ii. 324 
Haemoptysis ii. 297 
Hmmorrhoea petechialis ii. 269 
Hallucinations ii. 710 
Hanging ii. 114 
Hay asthma i. 798, 801 
Headache 'ii. 679 
Heart, action of the ii. 122 
Heart, atrophy of the ii. 186 
Heart, cartilaginous degeneration of ii. 188 
Heart, chronic valvular diseases of 
the ii. 158 
Heart, dilatation of the ii. 168 
Heart, disease of, as a cause of 
dropsy ii. 348 
Heart, diseases of the ii. 119 
Heart, dropsy of the ii. 374 
Heart, fatty degeneration of the ii. 189 
Heart, functional diseases of the ii. 197 
Heart, hypertrophy of the ii. 168 
Heart, impulse of the ii. 121 
Heart, induration of the ii. 188 
Heart, inflammation of the ii. 157 
Heart, malformation of the ii. 193 
Heart, modes of exploring diseases 
of the ii. 120 
Heart, neuralgia of the ii. 206 
Heart, obesity of the ii. 190 
Heart, organic diseases of the ii. 186 
Heart, polypous concretions of the ii. 192 
Heart, position of the ii. 121 
Heart, position of the valves of ii. 120 
Heart, pulsation of the ii. 121 
Heart, rupture of the ii. 190 
Heart, softening of the ii. 187 
Heart, sounds of the ii. 127 
Heart, valvular disease of the ii. 158 
Heartburn . ii. 556 
Heat as a cause of disease i. 142 
Heautophonics i. 763 
Hectic fever i. 41 
Hemicrania ii. 809 
Hemiplegia ii. 822, 827 
Hemorrhage ii. 275 
Hemorrhage, active ii. 283 INDEX. 
857 
Hemorrhage, constitutional ii. 285 
Hemorrhage, critical ii. 286 
Hemorrhage, passive ii. 284 
Hemorrhoidal colic i. 623 
Hemorrhoidal flux ii. 322 
Hemorrhoidal tumours i. 665 
Hemorrhoids i. 664, ii. 322 
Hepatic colic i. 623 
Hepatitis ii. 479 
Hepatitis, acute ii. 485 
Hepatitis, chronic ii. 486 
Hepatization, gray ii. 5 
Hepatization, red ii. 4 
Hereditary tendency as a cause of 
disease i. 171 
Herpes ii. 404 
Herpes circinatus ii. 405 
Herpes exedens ii. 406 
Herpes iris ii. 406 
Herpes labialis ii. 407 
Herpes phlyctmnodes ii. 405 
Herpes prseputialis ii. 407 
Herpes zoster ii. 404 
Hiccough ii. 819 
Hippocratic face i. 193 
Hives i. 813 
Homicidal monomania ii. 711 
Honey diabetes ii. 584 
Hooping-cough i. 834 
Horn-pock i. 379 
Hospital fever i. 351 
Hot bath i. 223 
Humid asthma i. 846 
Humming sound ii. 134 
Humoral asthma i. 803, 846 
Humoral pathology i. 100 
Hutchinson's spirometer i. 770 
Hydatids i 135 
Hydrocephalus ii. 366 
Hydrocephalus, acute ii. 623, 640 
Hydrocephalus externus ii. 367 
Hydrocephalus internus ii. 367 
Hydropericardium ii. 374 
Hydrophobia ii. 798 
Hydro-pneumothorax ii. 52 
Hydrorachis ii. 778 
Hydrosulphuric acid as a cause of 
disease i. 151 
Hydrothorax ii. 371 
Hydruria ii. 581 
Hygiene i. 1 
Hypertrophy . i. 24 
Hypertrophy and dilatation of the 
heart ii. 168 
Hypertrophy of the heart ii. 169 
Hypochondriasis ii. 710 
Hypostatic congestion i. 85 
Hypostatic pneumonia ii. 8 
Hysteria ii. 835 
Hysterical colic i. 620, ii. 838 
Hysterical insanity ii. 839 
Hysterical palsy ii. 840 
Ichthyosis ii. 447 
Ichthyosis cornea ii. 448 
Ichthyosis simplex ii. 448 
Icterus ii. 512 
Idio-miasmata i. 153 
Idiopathic fever i. 103 
Idiopathic fevers i. 232 
Idiosyncrasy, as a cause of disease i. 169 
Ignis sacer i. 427 
Ileitis i. 585 
lleo-colitis i. 585 
Ileus i. 620, 643 
Iliac passion i. 620 
Impetigo ii.,426 
Impetigo erysipelatodes ii. 426 
Impetigo figurata ii. 426 
Impetigo granulata ii. 428 
Impetigo larvalis ii. 427 
Impetigo scabida ii. 427 
Impetigo sparsa ii. 427 
Impulse of the heart ii. 121 
Incontinence of urine ii. 618 
India cholera i. 680 
Indications, general i. 209 
Indigestion i. 572 
Induration i. 31 
Infantile convulsions ii. 690 
Infantile pneumonia ii. 16, 27 
Infantile remittent i. 235 
Infantile sore-mouth i. 498 
Infantile spasm of the glottis i. 830 
Infection i. 164 
Inflammation i. 25 
Inflammation, adhesive i. 29 
Inflammation, chronic i. 37 
Inflammation, microscopic observa- 
tions in i. 43 
Inflammation, scrofulous i. 114 
Inflammation, specific i. 64 
Inflammation, subacute i. 37 
Inflammation, theory of i. 46 
Influenza' j. 809 
Inheritance as a cause of disease i. 171 
Inoculation i. 390 
Insane impulse ii. 712 
Insanity ii. 696 
Inspection i. 201, 767 
Inspection in diseases of the heart ii. 126 
Interlobular emphysema ii. 57 
Interlobular pneumonia ii. 5 
Intermission j. 94 
Intermittent fever i. 241 
Intertrigo ii. 386 
Intervesicular pneumonia ii. 5 
Intestinal hemorrhage ii. 318 
Intussusceptio i. 645 
Invagination of the bowels i. 645 
Inward fits i. 830 
Irregular gout ' j. 472 
Irritable bladder ii. 570 
Irritation i. 17 
Irritations, specific i. 25 
Irritative fever i. 234 
Ischuria renalis ii. 597 
Itch ii. 414 
Jail fever j, 351 858 
INDEX, 
Jaundice ii. 512 
Keiis ii. 457 
Keloid ii. 457 
Kidneys, desquamative inflammation 
of the ii. 548 
Kidneys, disease of the, as a cause 
of dropsy ii. 349 
Kidneys, fatty degeneration of the ii. 549 
Kidneys, inflammation of the ii. 531 
Kidneys, intimate structure of the ii. 548 
Kidneys, organic diseases of the ii. 554 
Kine-pock i. 392 
Komo-miasmata i. 153 
Lacerta aquatica i. 651 
Lake fever i. 265 
Large intestine, inflammation of the i. 593 
Laryngeal diphtheritis i. 817 
Laryngeal nervous disease i. 830 
Laryngeal pains i. 834 
Laryngeal phthisis i. 786 
Laryngismus stridulus i. 830 
Laryngitis i. 778 
Laryngitis, chronic i. 786 
Laryngitis, edematous i. 779 
Laryngitis, mucous i. 778 
Laryngitis, pseudo-membranous i. 782 
Laryngitis, sub-mucous i. 779 
Larynx, inflammation of the i. 778 
Larynx, neuralgia of the i. 834 
Lead colic i. 627 
Lead palsy ii. 831 
Leeches, American, always directed 
in this work * i. 216 
Leeches, American, the quantity of 
blood drawn by each i. 217 
Leeching i. 216 
Lentigo ii. 458 
Leontiasis ii. 449 
Lepra ii. 441 
Lepra alphoides ii. 442 
Lepra nigricans ii. 442 
Lepra prominens ii. 443 
Lepra tuberculosa ii. 449 
Lepra vulgaris ii. 442 
Leprosy ii. 441 
Leucocythemia ii. 257 
Leucopathia ii. 459 
Leucorrhcea, anal i. 667 
Lichen ii. 396 
Lichen agrius ii. 398 
Lichen circumscriptus ii. 397 
Lichen gyratus ii. 397 
Lichen lividus ii. 397 
Lichen pilaris ii 397 
Lichen simplex ii. 397 
Lichen tropicus ii. 397 
Lichen urticatus ii. 398 
Lientery i. 613 
Light as a cause of disease i. 148 
Lithiasis ii. 601 
Lithic gravel ii. 601 
Lithuria ii. 601 
Liver, disease of the, as a cause of 
dropsy ii. 348 
Liver, functional diseases of the ii. 504 
Liver, inflammation of the ii. 479 
Liver, intimate structure of the ii. 498 
Liver, organic diseases of the ii. 495 
Liver-fluke i. 136 
Lobar pneumonia ii. 4 
Lobular pneumonia ii. 6, 16, 27 
Local bleeding i. 216 
Local diseases i. 496 
Local palsy ii. 827 
Locked jaw ii. 782 
Long tape-worm i. 650 
Long thread-worm i. 649, 657 
Loss of breath ii. 106 
Low diet i. 218 
Lumbago i. 455 
Lumbrici i. 649 
Lunacy ii. 696 
Lungs, apoplexy of the ii. 300 
Lungs, dropsy of the ii. 375 
Lungs, emphysema of the ii. 56 
Lungs, gangrene of the ii. 30 
Lungs, hemorrhage from the ii. 297 
Lungs, inflammation of the ii. 3 
Lungs, organic affections of the ii. 104 
Lupus ii. 452 
Lupus, erythematous ii. 453 
Lupus, exedens ii. 452 
Lupus non exedens ii. 453 
Lymphadenitis i. 733 
Lymphangeitis i. 730 
Maculae ii. 386, 458 
Madness ii. 696 
Madrid colic i. 623 
Malaria i. 153 
Malignant cholera i. 680 
Malignant erysipelas i. 432 
Malignant growths i. 121 
Malignant sore-throat i. 418, 529 
Mania ii. 698 
Mania a potu ii. 734 
Marsh fever i. 265 
Marsh miasmata i. 153 
Maw-worm i. 649, 656 
Measles i. 406 
Measurement, as a means of diag- 
nosis i. 204, 769 
Mechanical influence in therapeutics i. 229 
Mediterranean fever i. 265 
Medullary carcinoma i. 131 
Medullary sarcoma i. 131 
Melsena ii. 317 
Melanopathia ii. 459 
Melanosis i. 117 
Melasma ii. 446 
Melicerous cysts i. 120 
Mellituria ii. 584 
Melted butter in dysentery i. 600 
Membranous angina i. 525 
Meningitis ii. 622 
Meningitis, acute ii. 623 
Meningitis, cerebro-spinal ii. 772 859 
INDEX. 
Meningitis, chronic ii. 631 
Meningitis, spinal ii. 771 
Meningitis, tuberculous ii. 640 
Meningo-encephalitis ii. 622 
Menorrhagia ii. 328 
Menstrual colic i. 623 
Mentagra ii. 435 
Mental derangement ii. 696 
Mercurial inflammation of the mouth i. 507 
Mercurial stomatitis i. 507 
Mesenteric glands, disease of the i. 747 
Mesenteric glands, inflammation of 
the i. 747 
Mesenteric glands, scrofulous i. 748 
Mesenteric glands, tuberculous i. 748 
Mesmerism ii. 686 
Metallic colic i. 623 
Metallic tinkling i. 760 
Metastasis i. 18 
Metastatic abscess ii. 244 
Meteorism i. 710 
Miasmata i. 153 
Miasmatic fever i. 240 
Miasmatic fever, as a cause of 
dropsy ii. 347 
Miasmatic remittent fever i. 265 
Miliaris sudatoria ii. 419 
Miliary eruption ii. 417 
Miliary fever ii. 419 
Miliary tubercles i. 112. ii. 64 
Milk-leg ii. 242 
Millar's asthma i. 830 
Misplaced gout i. 472 
Modified smallpox i. 379 
Moist tetter ii. 426 
Molluscum ii. 454 
Molluscum contagiosum ii. 454 
Monomania ii. 708 
Moore's test for sugar ii. 586 
Moral insanity ii. 706 
Morbid appetite i. 570 
Morbid dentition i. 510 
Morbid vigilance ii. 684 
Morbilli i. 406 
Morbus arquatus ii. 512 
Morbus coeruleus ii. 193 
Morbus regius ii. 512 
Mortification ' i. 33 
Morve i. 441 
Mouth, diseases of the i. 496 
Mouth, hemorrhage from the ii. 295 
Mouth, inflammation of the i. 497 
Muco-enteritis i. 585 
Mucous diarrhoea i. 613 
Mucous rale i. 758 
Mucous rale, dry i. 758 
Mucous tissue, inflammation of the i. 60 
Muguet i. 498 
Mumps ii. 474 
Myelitis ii. 774 
Naevus, pigmentary ii. 459 
Nausea and vomiting i. 561 
Necrosis i. 82 
Necrosis infantilis i. 505 
Nephralgia, calculous ii. 567 
Nephritic colic i. 623, ii. 567 
Nephritis ii. 531 
Nephritis, acute ii. 532 
Nephritis, chronic ii. 534 
Nerves, diseases of the ii. 805 
Nerves, inflammation of the ii. 805 
Nervous cough i. 843 
Nervous fever i. 325 
Nervous gout i. 479, 493 
Nervous rheumatism i. 459 
Nervous sedatives i. 225 
Nervous stimulants i. 222 
Nervous system, diseases of the ii. 620 
Nettle-rash ii. 391 
Neuralgia ii. 807 
Neuralgia of the bowels i. 622 
Neuralgic colic i. 622 
Neuritis ii. 805 
Noli me tangere ii. 452 
Nostrils, chronic inflammation of the i. 776 
Nostrils, hemorrhage from the ii. 292 
Nostrils, inflammation of the i. 772 
Nursing-women, sore mouth of i. 504 
Nutmeg liver ii. 501 
Obstruction of the bowels i. 642 
Occupations, as a cause of disease i. 172 
Odontalgia i. 512 
(Edema ii. 364 
(Esophagitis i. 533 
(Esophagus, inflammation of the i. 533 
(Esophagus, stricture of the i. 534 
Oleo-albuminous urine ii. 577 
Opisthotonos ii. 782 
Orthopnoea i. 180 
Ossification of the arteries ii. 215 
Otalgia ii. 809 
Ovaiian dropsy ii. 382 
Oxalic lithiasis ' ; ii. 606 
Oxaluria ii. 606 
Oxyuris vermicularis i. 649 
Oza-na i. 776 
Pain as a symptom of disease i. 190 
Painter's colic i 627 
Palpation i. 201, 768 
Palpitation ii. 198 
Palpitation, arterial ii. 235 
Palsy ii. 821 
Pancreas, diseases of the ii. 476 
Pancreatitis ii. 476 
Papulae ii. 385, 395 
Papulous diseases ii. 395 
Paralysis ii. 821 
Paralysis agitans ii. 830 
Paralysis of the insane ii. 830 
Paraplegia ii. 822, 827 
Parasitic animals i. 132 
Parenchymatous tissue, hemorrhage 
of the ii. 337 
Parotitis ii. 474 
Paroxysm i. 94 
Passive congestion i. 84 
Passive hemorrhage ii. 284 860 
INDEX, 
Pathognomonic symptoms i. 200 
Pathology i. 1 
Pectoral resonance i. 761 
Pectoral vomiting i. 182 
Pectoriloquy i. 762 
Peculiar morbid products i. Ill 
Pellagra ii. 470 
Pemphigus ii. 420 
Pemphigus, acute . ii. 420 
Pemphigus, chronic ii. 421 
Percussion i. 202, 764 
Percussion in diseases of the heart ii. 126 
Pericardial dropsy ii. 374 
Pericarditis ii. 136 
Pericarditis, chronic ii. 145 
Pericardium, inflammation of the ii. 136 
Peripneumonia ii. 3 
Peripneumonia notha i. 794 
Peritoneal inflammation i. 715 
Peritonitis i. 715 
Peritonitis, chronic i. 726 
Peritonitis from perforation i. 719 
Peritonitis, puerperal i. 719 
Perityphlitis i. 587 
Pernicious fever i. 293 
Pernicious intermittent i. 293 
Pernicious remittent i. 293 
Pertussis i. 834 
Pestis i. 368 
Petechial fever i. 351 
Phagedenic ulceration i. 32 
Phalmna pinguinalis ' i. 651 
Pharyngitis i. 532 
Pharynx, inflammation of the i. 532 
Phlebitis ii. 237 
Phlebitis, chronic ii. 246 
Phlebitis, portal ii. 239 
Phlebolites ii. 246 
Phlegmasia alba dolens ii. 242 
Phlegmasia dolens ii. 242 
Phlegmon i. 55 
Phlegmonous inflammation i. 55 
Phlyzacium ii. 385 
Phosphatic lithiasis ii. 604 
Phrenitis ii. 622 
Phthisis ii. 63 
Phthisis, acute ii. 82 
Phthisis pulmonalis ii. 63 
Physical signs i. 173 
Pica i. 571 
Piles i. 664 
Piles, bleeding ii. 322 
Pimples ii. 385, 395 
Pitting i. 202 
Pituitous catarrh i. 803 
Pityriasis ii. 443 
Pityriasis capitis ii. 444 
Pityriasis nigra ii. 446 
Pityriasis rubra ii. 444 
Pityriasis versicolor ii. 445 
Plague i. 368 
Plastic inflammation i. 61 
Plethora ii. 248 
Pleura, inflammation of the ii. 34 
Pleural dropsy ii. 371 
Pleurisy ii. 34 
Pleurisy, chronic ii. 36, 43, 50 
Pleuritis ii. 34 
Pleurodynia i. 455 
Pleuro-pneumonia ii. 37, 45 
Pleurosthotonos ii. 782 
Pleximeter i. 203 
Pneumonia ii. 3 
Pneumonia, bilious ii. 17, 28 
Pneumonia, chronic ii. 8, 19, 30 
Pneumonia, lobular ii. 6, 16, 27 
Pneumonia, typhoid ii. 8, 18, 29 
Pneumonia, vesicular ii. 8 
Pneumonitis ii. 3 
Pneumothorax ii. 52 
Podagra i. 472 
Polydypsia ii. 582 
Polypous concretions of the heart ii. 192 
Pompholyx ii. 420 
Pompholyx benignus ii. 420 
Pompholyx diutinus ii. 421 
Pompholyx solitarius ii. 420 
Porcupine disease ii. 448 
Porrigo ii. 460 
Pqrrigo decalvans ii. 467 
Porrigo favosa ' ii. 461 
Porrigo larvalis ii. 427 
Porrigo lupinosa ii. 461 
Porrigo scutulata ii. 462, 466 
Portal phlebitis ii. 239 
Portal veins, inflammation of ii. 239 
Predispositions i. 168 
Pressure, as a means of diagnosis i. 202 
Prickly heat ' ii. 397 
Prognosis i. 206 
Prolapsus ani i. 674 
Prostate, diseases of the ii. 563 
Prostate, enlargement of the ii. 564 
Prostate, inflammation of the ii. 563 
Prostatitis ii. 563 
Prurigo ii. 400 
Prurigo formicans ii. 400 
Prurigo mitis ii 400 
Prurigo senilis ii. 401 
Pruritus, sympathetic ii. 403 
Pseudo-membranous croup i. 817 
Pseudo-membranous inflammation i. 61 
Pseudo-membranous inflammation of 
the fauces i. 525 
Pseudo-membranous laryngitis i. 782, 817 
Psora ii. 414 
Psoriasis ii. 437 
Psoriasis diffusa ■ ii. 437 
Psoriasis dorsalis ii. 438 
Psoriasis facialis ii. 438 
Psoriasis guttata ii. 437 
Psoriasis gyrata ii. 438 
Psoriasis inveterata ii. 438 
Psoriasis labialis ii. 438 
Psoriasis ophthalmica ii. 438 
Psoriasis palmaria ii. 438 
Psoriasis praeputii ii. 438 
Psoriasis scrotalis ii. 438 
Psoriasis unguium ii. 438 
Psychodiaria i. 135 INDEX 
861 
Psydracium ii. 885 
Ptyalism ii. 472 
Puerile respiration i. 755 
Puerperal peritonitis i. 719 
Pulmonary consumption ii. 63 
Pulmonary granulations ii 64 
Pulmonary oedema ii. 375 
Pulmonitis ii. 3 
Pulsation of the heart ii 121 
Pulse in disease i. 182 
Purpura ii. 269 
Purpura hemorrhagica ii. 269 
Purpura senilis ii. 271 
Purpura simplex ii. 269 
Purpura urticans ii. 271 
Purpurine ii. 580 
Purring tremor ii. 126 
Purulent infection ii. 244 
Pus i. 29 
Pus corpuscles i. 46 
Pus, test for, in the urine ii. 560 
Pustule ii. 385 
Pustular diseases ii. 423 
Pustules ii. 385 
Pyelitis ii. 531 
Pyogenic fever ii. 244 
Pyrosis i. 558 
Quain's stethometer i. 770 
Quinsy i. 529 
Rabies canina ii. 798 
Rales i. 758 
Rales, dry i. 758 
Rales, moist i. 758 
Rash, scarlet ii. 389 
Rashes ii. 385, 386 
Rectum, hemorrhage from the ii. 322 
Rectum, stricture of the i. 661 
Red gum ii 395 
Regular gout i. 472 
Relapse i. 197 
Relapsing fever i. 361 
Remission i. 95 
Remittent fever i. 264 
Remittent, infantile i. 235 
Renal dropsy ii. 362 
Renal retention ii. 615 
Repletion, as a therapeutic process i. 220 
Respiratory murmur i. 754 
Respiratory organs, diseases of the i. 753 
Respiratory passages, inflammation 
of the i. 771 
Respiratory passages, nervous dis- 
eases of the i. 830 
Retention of urine ii. 615 
Retrocedent gout i. 472 
Revaccination i. 402 
Revulsion, as a therapeutic process i. 226 
Rheumatic colic i. 621 
Rheumatic palsy ii. 831 
Rheumatic toothache i. 518 
Rheumatism i. 447 
Rheumatism, acute i. 448 
Rheumatism, chronic i. 458 
Rheumatism, nervous i. 459 
Rheumatism, subacute i. 453 
Ringworm ii. ,397, 405 
Ringworm of the scalp ii. 462, 466 
River fever i. 265 
Ronchi i. 758 
Rosacea ii. 434 
Rose i. 427 
Roseola ii. 389 
Roseola aestiva ii. 390 
Roseola annulata ii. 390 
Roseola autumnalis ii. 390 
Roseola infantilis ii. 390 
Roseola miliaris ii. 390 
Roseola vaccini ii. 390 
Roseola variolosa . ii. 390 
Rough respiration i. 755, 756 
Round worm i. 649, 654 
Rubbing sound ii. 133 
Rubeola i. 406 
Rubeola nigra i. 409 
Rubeola sine catarrho i. 408 
Rubeola spuria i. 408 
Rude respiration i. 755, 756 
Rupia ii. 422 
Rupia escharotica ii. 422 
Rupia prominens ii. 422 
Rupia simplex ii. 422 
Rupture of the heart ii. 190 
Saccharine diabetes ii. 584 
Saint Anthony's fire i. 427 
Saint Vitus's dance ii. 763 
Saliva, alteration of the ii. 472 
Salivary glands, diseases of the ii. 471 
Salivary glands, inflammation of the ii. 473 
Salivation ii. 472 
Salivation, mercurial i. 507 
Sarcina ventriculi i. 565 
Sarcoptes hominis ii. 415 
Saturnine colic i. 627 
Satyriasis > ii. 449 
Scabies ii. 414 
Scald head ii. 460 
Scales ii. 385 
Scaly diseases ii. 437 
Scarlatina i. 414 
Scarlatina anginosa i. 416 
Scarlatina latens i. 420 
Scarlatina maligna i. 418 
Scarlatina simplex i. 416 
Scarlet fever i. 414 
Scarlet fever as a cause of dropsy ii. 346 
Scarlet rash ii. 389 
Sciatica i. 455 
Scirrhus i. 130 
Scorbutus ii. 258 
Scrofula, external i. 735 
Scrofula mesenterica i. 748 
Scrofulosis i. Ill 
Scrofulous adenitis i. 735 
Scrofulous disease i. Ill 
Scrofulous inflammation i. 114 
Scrofulous liver ii. 500 
Scurvy ii. 258 862 
INDEX 
Sea-sickness i. 566 
Seat-worm i. 649 
Secretory organs, diseases of the ii. 337 
Sedation, as a therapeutic process i. 225 
Semeiology i. 173 
Senile respiration i. 755 
Serous cysts i. 120 
Serous diarrhoea i. 613 
Serous membranes, hemorrha ge from 
the ii. 335 
Serous tissue, inflammation of the i. 56 
Sex, as a cause of disease i. 169 
Shaking palsy ii. 830 
Shingles ii. 404 
Ship-fever i. 351 
Sibilant rale . i. 758 
Sibson's chest-measurer i. 770 
Sick headache i. 567 
Signs of disease i. 173 
Siliceous lithiasis ii. 607 
Singultus ii. 819 
Sizy blood i. 38 
Skin, disease of the ii. 384 
Skin diseases, unclassified ii. 468 
Skin, hemorrhage from the ii. 334 
Sleep-walkers ii. 686 
Sloughing phagedaena of the mouth i. 505 
Small intestines, inflammation of the i. 585 
Smallpox i. 373 
Soft'cancer i. 131 
Softening i. 31, 77 
Softening of the brain ii. 636 
Solids, disease of the i. 11 
Somnambulism ii. 685 
Somnambulism, artificial ii. 686 
Sonorous rale i. 758 
Sore-mouth, infantile i. 498 
Sore-mouth, mercurial i. 507 
Sore-mouth of nursing-women i. 504 
Sore-throat i. 521 
Sore-throat, malignant i. 418, 529 
Sore-throat, ulcerated i. 528 
Sounds of the heart ii. 127 
Spasm, clonic ii. 689 
Spasm of the bladder ii. 569 
Spasm of the glottis in adults i. 833 
Spasm of the glottis, infantile i. 830 
Spasm of the oesophagus i. 534 
Spasm of the stomach i. 559 
Spasm of the ureters ii. 567 
Spasm, tonic ii. 689 
Spasmodic asthma i. 845 
Spasmodic cholera i. 680 
Spasmodic colic, simple i. 620 
Spasmodic croup i. 830 
Spasmodic laryngitis i. 814 
Special pathology i. 231 
Special therapeutics i. 231 
Specific inflammation • i. 64 
Specific irritations i. 25 
Spinal irritation ii. 780 
Spinal marrow, diseases of the ii. 770 
Spinal marrow, functional diseases of 
the ii. 779 
Spinal marrow, inflammation of the ii. 771 
Spinal marrow, organic diseases of 
the ii. 777 
Spinal meningitis ii. 771 
Spirometer, Hutchinson's i. 770 
Spitting of bood ii. 297 
§pleen, diseases of the ii. 520 
Spleen, non-inflammatory diseases of 
the ii. 529 
Splenitis, acute ii. 522 
Splenitis, chronic ii. 525 
Splenization ii. 8 
Spotted fever i. 351 
Squamae ii. 385 
Steatomatous cysts i. 120 
Sterelmintha i. 136 
Stethometer i. 770 
Stethoscope i. 205 
Stiff-neck i. 455 
Stimulation, as a therapeutic process i. 221 
Stomach, cancer of the* i. 549 
Stomach, diseases of the i. 536 
Stomach, hemorrhage of the ii. 310 
Stomach, inflammation of the i. 536 
Stomach, irritation of the i. 552 
Stomach, spasm of the i. 559 
Stomatitis i. 497 
Stomatorrhagia ii. 295 
Stone cancer i. 130 
Stone in the bladder, symptoms of 
the ii. 610 
Stone-pock i. 379 
Strangulation ii. 113, 119 
Strangury ii. 571 
Stricture of the bowels i. 644 
Stricture of the oesophagus . i. 534 
Stricture of the rectum i. 661 
Stridulous angina i. 814 
Stridulous laryngitis i. 814 
Stroke of the sun ii. 683 
Strongylus gigas i. 137 
Strophulus ii. 395 
Strophulus albidus ii. 395 
Strophulus candidus ii. 396 
Strophulus confertus ii. 396 
Strophulus intertinctus ii. 395 
Strophulus volaticus ii. 396 
Strumous disease i. Ill 
Stupor ii. 682 
Subacute inflammation i. 37 
Subacute rheumatism i. 453 
Sub-crepitant rale i. 759 
Sub-mucous rale i. 759 
Subsultus tendinum ii. 689 
Succussion i. 202 
Sudamina ii. 417 
Sudor miliaris ii. 419 
Suffocative catarrh i. 794 
Sugar in the urine, tests of ii. 586 
Suicidal monomania ii. 711 
Sulphuretted hydrogen, as a cause of 
disease i. 151 
Summer complaint of children i. 703 
Sun-stroke ii. 683 
Supersession, as a therapeutic pro- 
cess i. 227 863 
INDEX. 
Suppression of the voice i. 833 
Suppression of urine ii. 597. 
Sweating miliaria ii. 419 
Sycosis ii. 435 
Symptomatic fever i. 41 
Symptomatology i. 173 
Symptoms of disease i. 173 
Syncope ii. 202 
Synocha i. 95 
Synochus i. 96 
Tabes mesenterica i. 748 
Taenia cucurbitina i. 650 
Taenia lata i. 650, 657 
Taenia solium i. 650, 657 
Tape-worm, broad i. 650, 657 
Tape-worm, common i. 650, 657 
Tape-worm, long 4. 650 
Teeth, caries of the i. 514 
Teeth, falling of the i. 519 
Teigne tondante ii. 466 
Temperament, as a cause of disease i. 168 
Termination of disease i. 197 
Tetanus ii. 782 
Tetter, moist ii. 426 
Therapeutic indications, general i. 209 
Therapeutic processes, general i. 214 
Therapeutics i. 1 
Therapeutics, general i. 208 
Thirst in disease i. 178 
Thoracic aneurisms ii. 224 
Thread-worm i. 649, 656 
Thrush i. 498 
Thymic asthma i. 830 
Tic douloureux ii. 809 
Tinea capitis ii. 460 
Tinea decalvans ii. 467 
Tinea favosa ii. 460 
Tinea sycosa ii. 435 
Tinea tonsurans ii. 466 
Tongue in disease i. 174 
Tongue, inflammation of the i. 508 
Tonic gout i. 472 
Tonic spasm ii. 689 
Tonsillitis i. 529 
Tonsils, inflammation of the i. 529 
Toothache i. 512 
Torticollis i. 455 
Touch, as a means of diagnosis i. 201, 768 
Touch, in diseases of the heart ii. 121 
Trachea, neuralgia of the i. 834 
Tracheal pains i. 834 
Tracheal sound i. 755 
Tracheitis i. 791, 813 
Tracheophony i. 761 
Trichina spiralis i. 137 
Trichosis ii. 466 
■Trichosis decalvans ii. 467 
Trichosis furfuracea ii. 466 
Tricocephalus dispar i. 649, 657 
Trismus ii. 782 
Trismus nascentium ii. 787 
Triton palustris i. 651 
Trommer's test for sugar ii. 586 
Tuf>al respiration i. 757 
Tubal sound i. 755 
Tubercles i. Ill 
Tubercula ii. 385 
Tuberculated diseases of the skin ii. 449 
Tubercules ii. 385 
Tuberculosis i. Ill 
Tuberculous consumption ii. 63 
Tuberculous corpuscles i. 116 
Tuberculous disease i. Ill 
Tuberculous granulations i. 112 
Tuberculous infiltration ii. 65 
Tuberculous meningitis ii. 640 
Tumours, organized non-malignant i. 120 
Tussis convulsiva i. 834 
Tussis spasmodica. i. 834 
Tussis strangulans i. 834 
Twisting of the bowel i. 646 
Tympanites i. 710 
Tympanitic sound i. 202 
Type of fever i. 94 
Typhlitis i. 587 
Typhoid fever i. 325 
Typhoid pneumonia ii. 8, 18, 29 
Typhus fever i. 351 
Typhus gravior i. 351 
Typhus icterodes , i. 306 
Typhus mitior i. 325 
Ulcerated sore-throat i. 528 
Ulceration i. 32 
Ulcerative inflammation of the fauces i. 528 
Ulcerative inflammation of the mouth i. 502 
Ulcerative stomatitis i. 502 
Union by the first intention i. 35 
Union by the second intention i. 35 
Ureous diuresis , ii. 583 
Ureters, spasm of the ii. 567 
Uric acid lithiasis ii. 601 
Urinary deposits, effects of the ii. 608 
Urinary organs, functional disease 
of the ii. 566 
Urinary organs, hemorrhage from the ii. 324 
Urinary organs, neuralgia of the ii. 567 
Urine, bloody ii. 324 
Urine, changes of colour of the ii. 580 
Urine, constituents of the ii? 574 
Urine, disorders in the secretion 
and excretion of the ii. 572 
Urine, incontinence of ii.. 618 
Urine, morbid constituents of the ii. 576 
Urine, quantity of the ii. 573 
Urine, retention of ii. 615 
Urine, specific gravity of the ii. 573 
Urine, suppression of ii. 597 
Uro-erethrine ii. 580 
Urticaria ii. 391 
Urticaria conferta ii. 392 
Urticaria evanida ii. 392 
Urticaria febrilis ii. 391 
Urticaria persistans ii. 392 
Urticaria subcutanea ii. 393 
Urticaria tuberosa ii. 392 
Uterine colic i. 623 
Uterine hemorrhage ii. 328 
Uterus, hemorrhage of the ii. 828 864 
INDEX. 
Vaccina i. 392 
Vaccination i. 400 
Vaccine disease i. 392 
Valvular disease of the heart ii. 158 
Vapour bath, hot i. 252 
Vapour bath, Jenning's i. 252 
Varicella i. 405 
Varicose veins ii. 247 
Variola i. 373 
Variola cornea i. 379 
Variola sine variolis i. 379 
Variola verrucosa i. 379 
Variolse nigrae i. 379 
Varioloid i. 379 
Vascular sounds ii. 134 
Vegetable colic i. 623 
Veins, diseases of the ii. 237 
Veins, inflammation of the ii. 237 
Veins, varicose ii. 247 
Venesection i 215 
Verminose colic i. 620 
Vertiginous spells ii. 749 
Vesical retention ii. 616 
Vesicles ii. 385 
Vesicular ii. 385 
Vesicular bronchitis ii. 8 
Vesicular diseases ii. 404 
Vesicular emphysema ii. 56 
Vesicular inflammation of the mouth i. 501 
Vesicular pneumonia ii. 8 
Vesicular sound i. 754 
Vicarious hemorrhage ii. 276 
Vitiligo ii. 460 
Vocal resonance i. 761 
Voice, suppression of the i. 833 
Volvulus i. 643 
Vomiting i. 561 
Vomiting of blood ii. 310 
Voracious appetite i. 570 
Voracity i. 570 
Wakefulness ii. 684 
Walcheren fever i. 265 
Warm bath . i. 225 
Wart-pock i. 379 
Water as a cause of disease i. 147 
Waterbrash i. 558 
Waxydiver ii. 500 
White gum ii. 395 
White piles i. 667 
Worm fever , i. 651 
Worms in the alimentary canal i. 649 
Wry-neck i. 455 
Yaws ii. 455 
Yeasty vomiting i. 565 
Yellow fever i. 306 
Zona ii. 404 
Zymotic diseases i. 167