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Full text of "The cyclopaedia of practical medicine: comprising treatises on the nature and treatment of diseases, materia medica and therapeutics, medical jurisprudence, etc., etc (Volume 3)"

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THE 



CYCLOPEDIA 



OF 



PRACTICAL MEDICINE. 



VOL. III. 



THE 



CYCLOPEDIA 



OF 



PRACTICAL MEDICINE: 



COMPRISING 



TREATISES ON THE NATURE AND TREATMENT OF DISEASES, MATERIA MEDICA 
AND THERAPEUTICS MEDICAL JURISPRUDENCE, ETC., ETC. 

EDITED BY 

JOHN FORBES, M.D. F.R.S. 

PHYSICIAN TO THE QUEEN'S HOUSEHOLD, ETC. 

ALEXANDER TWEEDIE, M.D. F.R.S. 

PHYSICIAN TO THE LONDON FEVER HOSPITAL, AND TO THE FOUNDLING HOSPITAL, ETC. 

JOHN CONOLLY, M.D. 

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

THOROUGHLY REVISED, WITH NUMEHOIIS ADDITIONS, BY 

ROBLEY DUNGLISON, M.D. 

PROFESSOR OF INSTITUTES OF MEDICINE IN JEFFERSON COLLEGE, PHILADELPHIA, 
LECTUR£R ON CLINICAL MEDICINE AT THE PHILADELPHIA HOSPITAL, ETC. 



Htec demum sunt quse non subgessit phantasite imaginatricis temeritas sed phenomena practica 
edocuere." — Sydenham. 



IN FOUR VOLUMES 
VOL. III. 

INFLUENZA — RAPE. 




JRGtO RAL'S OFFICE 

16.-18! 



}1>1> )3<j 



PHILADELPHIA: 

LEA AND BLANCHARD. 

1849. 



Ct)t>5 
v.5 



«> 



Entered, according to Act of Congress, in the year 1845, by 

LEA AND BLANCHARD, 

in the clerk's office of the District Court of the United States for the Eastern District 



of Pennsylvania. 



J. FAGAN, STEREOTYPES. 

T. K. AND P. G. COLLINS, PRINTERS. 






CONTENTS OF THE THIRD VOLUME. 



Contributors. Page 

Influenza ..Dr. Hancock 18 

Insanity Prichard 26 

Intussusception Dunglison 76 

Williams '76 

Burder ~i 



Irritation 
Jaundice 



91 



Kidneys, Diseases of . . 
Lactation 



Dunglison 

Carter 96 

Locock 99 



Laryngitis Cheyne 104 

Laryngitis, Chronic . . . Dunglison 115 

Latent Diseases Christison 117 

Lepra Houghton 125 

Leucorrhoea Locock 134 

Lichen Houghton 138 

Liver, Diseases of the . Venables 143 

" Inflammation of 

the 

Malaria and Miasma 



Medicine, History of- 



Medicine,PracticaI, Prin- 
ciples of Conolly 



Melsna . 

Melanosis 

Menorrhagia 

Menstruation,Pathology 

of 

Miliaria 



Stokes 159 

Brown 174 

Bostock ") 

Beck (.179 

Alison S 



..271 

Goldie' 279 

Carswell 284. 

Locock 303 

Locock 308 

Tweedie 312 

Milk-Sickness Dunglison ..... 314 

Mind, Soundness and C Prichard. ... 7 oik 

unsoundness of. .. £ Dunglison. . . 5 

Molluscum Dunglison .... 332 

Mortification Carswell 332 

Narcotics A. T. Thomson . 362 

Nauseants Dunglison 376 

Nephralgia and Ne- 
phritis Carter 377 

Neuralgia Elliotson 381 

Noli me tangere, or Lu- 
pus Houghton 385 

Nyctalopia Grant 391 



Obesity Dr 

(Edema 

Ophthalmia 

Otalgia and Otitis .... 
Ovaria, Diseases of the 

Palpitation 

Pancreas, diseases of the 

Paralysis 

Parotitis 

Parturients 

Pellagra, or Pelagra. . . 

Pemphigus 

Perforation of the Hol- 
low Viscera 

Pericarditis 

Peritonitis 3 

Phlegmasia Dolcns . . . 

Pityriasis 

Plague 

Plethora 

Pleurisy 

Plica Polonica 

Pneumonia 

Pneumothorax 

Porrigo 

Pregnancy and Delivery, 
Signs of 

Prognosis 

Prurigo 

Pseudo-morbid Appear- 
ances 

Psoriasis 

Ptyalism, or Salivation 

Puerperal Diseases. . . . 

Pulse 

Purpura 

Pus 

Pyrosis 

Rape 



Contributors. Page 

Williams 403 

Darwall 411 

Jacob ^4iq 

Dunglison ... 5 

Burne 436 

Lee 442 

*°P e \: 1 449 

Dunglison ... 5 

Carter 454 

R.B. Todd 457 

Kerr 475 

Dunglison 477 

Kerr 477 

Corrigan 482 

Carswell 487 

Hope 495 

Mac Adam. . . ? _ n _ 

Stokes $ 

Lee 529 

Cumin 538 

Brown 540 

Barlow 553 

Law 574 

Corrigan 587 

Williams 590 

Houghton 637 

A. T. Thomson. 653 

Montgomery . . . 659 

Ash 699 

A. T. Thomson. 720 

R. B. Todd. ... 723 

Cumin 733 

Dunglison 738 

M. Hall 740 

Bostock 752 

Goldie 762 

Tweedie 770 

Kerr 770 

Beatty 773 

(5) 



CYCLOPAEDIA 



PRACTICAL MEDICINE. 



INFLUENZA. {Epidemic Catarrh.) The 
disease now commonly known by this name, first 
given to it by the Italians, was not particularly 
noticed by physicians before the sixteenth century. 
Since that period it has many times appeared in 
Europe and in other quarters of the globe. In- 
fluenza seems to bear the same relation to ordinary 
catarrh that epidemic cholera bears to the common 
or sporadic cholera that occurs every year. Of 
all epidemic diseases it is the most universal ; and 
the rapidity of its march and extent of its range 
over land and sea, sometimes in both hemispheres 
and in different climates, in opposite seasons and 
in all varieties of weather, among people of all 
classes, naturally led to the supposition that some 
extraordinary influence could alone give rise to 
such a wide-spreading malady. The French call 
it la grippe, under which name Sauvages first 
described the epidemic catarrhal fever of the year 
1743. 

To collate the various accounts of any one visi- 
tation of this epidemic, such, for example, as that 
of 1775, or of 1782, or of 1803, in order to deduce 
some general principles respecting its mode of 
propagation, pathology, or treatment, would oc- 
cupy a considerable treatise : it must, therefore, 
be an elaborate task to draw general conclusions 
from all the records we now possess of this singu- 
lar disease, and to condense them in a space 
suitable for a work like the present. Limited by 
this circumstance, we shall take a brief survey, 
first, of the most remarkable dates of its appear- 
ance and progress in the last three centuries ; se- 
condly, its symptomatology ; thirdly, its treat- 
ment ; fourthly, facts and general inferences rela- 
tive to the causes of it, such as phenomena of the 
weather and diseases among brutes : fifthly, its 
contagious property ; and, sixthly, its influence 
on other diseases, and connection with diarrhoea, 
dysentery, and cholera. 

1. We find no medical description of the epi- 
demic catarrhal fever before the year 1510. "It 
was called coccoluche, because the sick wore a cap 
close over their heads." The symptoms of the 
disease, as it then occurred, nearly resembled 
those which it has assumed in later visitations, 
namely, severe pain over the eyes, sneezing, coryza, 
heaviness, difficulty of breathing, hoarseness, loss 
of strength and appetite, fever and harassing 
cough. Schcnk says that physicians then looked 
upon it as a new disease. Its course seems to 
have been in a north-westerly direction, from 
Malta to Sicily, Spain, Italy, Germany, France, 
and Britain ; and Short says that " it attacked at 
Vol. Ill 3 b* 



once, and raged over all Europe, not missing a 
family, and scarce a person, and that none died 
except some children. In some it went off with 
a looseness; in others by sweating. Bleeding 
and purging did hurt." (Short's Chronol. Hist. 
of the Weather, &c. vol. i. p. 204 ; and Diet, des 
Scien. Me-d. Art. Grippe, p. 351.) 

In 1557, an epidemic of the same nature pre- 
vailed in different countries. Fonseca says that 
in this year it infested Asia, thence came to Con- 
stantinople, and having spread itself all over 
Europe, afterwards attacked America, its course 
being westerly. Mercatus asserts that " before the 
beginning of autumn 1557, it attacked all parts of 
Spain at once, so that the greatest part of the 
population in that kingdom were seized with it 
almost on the same day." (See Report, bj r Dr. 
Glass, in Lettsom's Memoir of Dr. Fothergill, 4to. 
p. 625.) Riverius has transmitted to us an ac- 
count of this epidemic. Unlike that of 1510, 
it was fatal to many : in a small town near Madrid, 
Mantua Carpentaria, bleeding was said to be so 
fatal that two thousand patients died after it in 
September. (Short's Hist. vol. i. p. 223.) At 
Alkmaer, in Holland, two hundred died of it in 
October. 

The catarrhal epidemic fever of 1580 was dis- 
tinguished by its complication with malignant 
fever or plague, as related by Forestus and Sen- 
nertus. (Diet, ut supra.) The latter speaks of 
its ravages at the end of summer and the begin- 
ning of autumn all over Europe ; in some parts 
of which, as in Paris, it was the precursor of the 
plague. (Webster's Hist, of Epidemics, vol. i. p. 
2G3.) It was in Sicily in June, at Rome in July, 
in August at Venice and Constantinople, in Sep- 
tember in Hungary and Germany, in October on 
all the Baltic coast, in November in Norway, 
in December in Denmark, Sweden, Poland, and 
Russia ; its course being from E. and S. to W. 
and N. (Short's Hist. vol. i. p. 282.) Mercatus 
says that it raged also in Spain, and destroyed not 
a few. {Dr. Glass, ubi supra.) Grand Cairo 
lost a prodigious multitude the same year by the 
plague. It is a remarkable fact, and ought not to 
escape our notice, that France appears to have 
been the only country in Europe affected that 
year by the plague ; and it appears also to have 
been the first to be visited by the epidemic catarrh, 
its precursor; so that Buldutius even dates its 
origin from France. (Short's Hist. i. 202.) 

The influenza of 1058, of which Willis has 
left us an account, visited Euiope and this king- 
dom suddenly in April, and after excessive heat 

(17) 



18 



I N F L U E N ZA . 



in August was followed by a fatal epidemic fever. 
(Short's Hist. vol. i. p. 331 ; and Webster's Hist. 
310.) 

Sydenham and Etmuller have described the epi- 
demic catarrh of 1675, which began in Germany 
in September, and in England in October. Malta 
was afflicted by the plague the same year, from 
which it remained free till the last severe visitation 
of this scourge in 1813. 

The epidemic catarrhal fever which raged during 
the autumn and winter of 1729, in the space of 
five months' time visiting almost every part of 
Europe, was very fatal in many large cities, such 
as Paris and London. Loew says that in the 
latter more persons died than at any one time since 
the plague of 1 665, about one thousand being cut 
off weekly in September. In the beginning of 
winter it reached France. A few weeks after, it 
visited the upper part of Italy with great mortality. 
In February it afflicted Rome and the Rhine. 
Turin and Milan suffered extremely. It reached 
Naples in March, and after this disappeared. — 
(Short, ii. p. 54. Hoffmann, Opera, torn. ii. p. 
109.) 

The influenza of 1732-3 is described in the 
second volume of the Edinburgh Medical Essays, 
and hy Huxham ; and was so far remarkable that 
it affected the mucous membrane of the alimentary 
canal as well as that of the organs of respiration. 
It spread over all Europe, and appeared also in 
America. It was first noticed about the middle 
of November in different parts of Germany. Edin- 
burgh appears to have been the first place attacked 
in Britain, viz. on the 17th of December, and it 
raged at the same time in Switzerland, at Basle. 
It appeared at London and in Flanders the first 
week in January; towards the middle of the same 
month it reached Paris, and Ireland towards the 
end. Cornwall and Devonshire were visited about 
the beginning of February ; few only were attacked 
at Plymouth, where Huxham practised, so soon 
as this : but in March it prevailed on all sides. In 
February Leghorn was attacked, and near the end 
of it Naples and Madrid suffered. New England 
in America was invaded by the distemper about 
the middle of October, which travelled southward 
to Barbadoes, Jamaica, Mexico, and Peru, much 
at the same rate as it had done in Europe. It 
appears to have been at Paris . early in the year. 
" Bile se manifesta, dit de Jussieu, a la suite de 
brouiliards fetides, plus epais que les tenebres de 
l'Egypte." (Edinb. Med. Essays, vol. ii. p. 31. 
Huxham, de Aere, &c. torn. i. Diet, des Scien. 
Med. art. Grippe.') 

The epidemic catarrh of 1733 was followed by 
those of 1741 and 1742; the first described by 
Haller, and the second by Sauvages and Huxham. 
In 1743, towards the end of April, Huxham says 
that it was general in England, and in the spring 
spread over all Europe under the name of « influ- 
enza," or "grippe." This epidemic was the pre- 
cursor of the plague of Messina in Sicily the same 
year ; and it was more fatal in the southern parts 
of Europe than in England, though it increased 
the deaths in London in one week to a thousand. 
(De Aere, &c. torn. ii. p. 104.) 

The next remarkable visitation of the influenza 
was in 1762; and an elegant description of it is 
given by Sir George Baker, " De Catarrho Epi- 



demico anni 1762," who records its appearance 
in London about the 4th of April. KazoU *' a 
physician of Kismcs, has given an account ot me 
same disease, which was epidemic in Europe gene- 
rally in the spring. (Diet. art. Grippe.) It at- 
tacked Breslau at the end of February ; Vienna 
was visited in March, and Hamburg in April. In 
Venice it was more fatal than in other places. It 
spared, however, Paris and the greatest part of 
France ; nor can we find any particular cause for 
this exemption. Nismes most probably was visited; 
and Webster says that " Toulon lost one third of 
its inhabitants by an epidemic in 1761." The 
influenza of 1762 appeared sooner in London than 
in any other part of England, namely, the begin- 
ning of April. It was not observed in Edinburgh 
and°Dublin till May; but in June it was general 
and severe, according to Sir G. Baker, being seen 
no where earlier than February nor later than 
July. It had prevailed in America the preceding 
year. (Webster's Hist. i. p. 410.) It was not 
till July that it attacked the British sailors in the 
Mediterranean. It was immediately followed in 
London by an epidemic dysentery, which raged 
till November. While the influenza prevailed, 
the deaths in London scarcely exceeded the usual 
number. In Manchester they were even fewer 
than common ; and at Norwich far more died of 
it than fell victims to the more severe influenza of 
1743. (Baker, de Catarrho, p. 33.) 

The next epidemic catarrh, in order of time, 
was that noticed in London and different parts of 
the nation by Dr. Fothergijl and some of his 
friends in the latter end of the year 1775. It was 
observed also in France, Holland and Germany, 
and was supposed to be more fatal in those coun- 
tries than in Britain. (Lettsom's Memoir of the 
Life of Fothergill, 4to.; and Med. Obs. and In- 
quiries, vol. vi.) 

The influenza of 1782 was general over Eng- 
land, Scotland, and Ireland, between the months 
of May and July inclusive. A full account of it 
is given in the second volume of Memoirs of the 
London Medical Society, by Dr. R. Hamilton, 
which is the groundwork of the article " Influ- 
enza" in the Edinburgh Medical and Surgical 
Dictionary ; an account is also given in the first 
volume of Medical Communications by Dr. Gray, 
compiled from papers in the British Museum, 
which is the basis of a like article in the Cyclo- 
paedia of Dr. Rees. (See also the third volume 
of Transactions of the College of Physicians, 
London.) 

The influenza of 1782 seems to have pursued 
a course from the east, not very different from that 
of the epidemic cholera which is now ( 1 832) dis- 
playing its ravages in Great Britain and France. 
It is reported to have broken out in September 
1780, and to have become very general in the 
crew of the Atlas East Indiaman, whilst that 
ship was sailing from Malacca to Canton When 
the ship left Malacca, there was no epidemic dis 
ease in the place ; when it arrived at Canton, it 
was found that at the very time when they had 
the influenza on board the Atlas in the China 
seas, it had raged at Canton with as mud! vio . 
lence as it did in London in June 1782 and with 
the very same symptoms. In October and No- 
vember 1781 it appeared in the East Indies and 



INFLUENZA. 



19 



was said to have attacked the British army while 
it was besieging Negapatam in November 1781. 
Its progress is stated by Webster, to have been 
from Siberia and Tartary westward. At Moscow 
it prevailed in December 1781 ; at Petersburgh in 
February 1782; and it was traced to Tobolski. 
It was in Denmark in the latter end of April. 
From the shores of the Baltic it spread to Hol- 
land and the Low Countries, and thence to Eng- 
land. London was said to be attacked sooner 
than the west and north ; Ireland a few weeks 
later, and the south of Europe later still; for it 
prevailed in France in the months of June and 
July, in Italy in July and August, and in Portu- 
gal and Spain in August and September ; seldom 
continuing longer than six weeks in any place.* 

The influenza of the spring of 1803 afforded 
an occasion for collecting a great number of no- 
tices from different parts of the country on the 
subject of this epidemic. The London Medical 
Society set a laudable example by proposing a set 
of queries to its corresponding members in a cir- 
cular letter ; and the sixth volume of "Memoirs" 
contains reports from nearly sixty practitioners in 
England, Scotland, and Ireland, as to the date of 
its first appearance, its symptoms, treatment, &c. 
in their respective neighbourhoods. Dr. Beddoes 
also interested himself very zealously on the same 
occasion, and procured various testimonies from 
his friends and others, which, to the number of 
one hundred and twenty-four, are inserted in the 
ninth and tenth volumes of the " London Medical 
and Physical Journal." These documents contain 
a mass of very useful information. This epidemic 
was observed at Paris and in other parts of France 
and in Holland some weeks before it appeared in 
London ; and Dr. Bardsley says " the same length 
of time was occupied in its progress from the lat- 
ter city to Manchester." (Med. and Phys. Journ. 
vol. ix. p. 529.) Its course seemed to be from S. 
to N. It was in Cork and Dublin before it reached 
the north of Ireland, immediately after a S. E. 
wind. An epidemic ophthalmia followed it in 
France, (Diet, ut supra,') and a severe dysenteiy, 
such as had not been known for thirty years, in 
some parts of the United States, which it visited 
the same spring. (New York Med. Repos. 2d 
Hex. vol. ii. p. 141.) It was observed to be epi- 
demic in Sussex, and some of the counties in the 
S. W. as early as February ; in Shropshire, Not- 
tinghamshire, &c. in March ; in Yorkshire and 
Lancashire in April ; and at Sunderland in May. 
(Mem. of Med. Soc. of London, vol. vi.) It was 
evident that there was a degree of progressive 
movement northward, by marking the time when 
it was at the height in each place; yet many of 
the accounts above alluded to inform us clearly 
that sporadic or solitary cases exhibiting the true 
characters of influenza, occurred in several places 
long before the disease became established, so as 
to manifest a universal tendency to that form of 
complaints over the country, in some cases weeks 
before it was quite developed. It is worthy of 
notice that this has been remarkably the case with 
the epidemic cholera. Dr. Gray observes that, in 

* Transactions of the College of Phys. vol. iii., and 
Med. Communications, vol. i. Rees' Cyclopiedia, Art. In- 
fiuenia: and Trotter's Med. Nautica, i. 362. Observa- 
tions on Dis. of Seamen, by G. Blane, M. D. p. 151. 



1782, a complaint, similar to the influenza, was 
taken notice of in some parts of the kingdom 
several months before that disorder made its pro- 
gress through it. (Med. Commun. vol. i. p. 6.) 

The influenza of last year (1831), though 
generally mild in its character, was almost uni- 
versal ; for it would seem to have prevailed in 
both hemispheres in the same year. Accounts 
have been received of its appearance in India as 
well as in the United States of America. (Ameri- 
can Journ. of Science, &c. vol. xxi. No. 44, p. 
407.) In many places it has been the precursor 
of the epidemic cholera. About a month before 
the latter disease broke out in Warsaw, it pre- 
vailed in that city. (Brierre de Boismont sur le 
Cholera, p. 110.) It also swept over great part 
of England, Scotland, and Ireland, in the spring 
and autumn, and preceded the milder visitation 
of epidemic cholera which many parts of Great 
Britain experienced the same year. Late in the 
autumn it attacked Paris, the south of Spain, 
Gibraltar, and Italy, with more severity than it 
did the British islands. At Rome it was said to 
occasion great alarm. It has certainly skipped 
over many countries of Europe in its march from 
Poland to France through England, so far as we 
can judge negatively from the want of official re- 
ports ; but, with this exception, it has pursued a 
course not widely different from that of similar 
former epidemics, and has proved to be a true 
herald of the epidemic cholera in many places. 

[In the epidemic of 1831, according to Most, 
(art. Influenza, in Encyclop.der gesammt.Medi- 
cin. und Chirurg. Praxis, Leip. 1836,) 30,000 
people, it was asserted, were suffering at the same 
time in Berlin ; and, at a later period, 45,000 in 
Paris. Another severe epidemic prevailed in Eu- 
rope and the United States in 1837 ; and another 
in 1843. Of the European epidemics of 1831, 
1833, and 1837, the two first were less severe, 
and attacked fewer individuals than the last.] 

II. The influenza does not seem to have exhi- 
hibited a greater variety of symptoms, in its dif- 
ferent visitations, than other epidemics. It has 
varied a little in town and country, in spring and 
autumn, at the beginning and end of the epi- 
demic, in different persons, and according to the 
particular genus or tendency of the epidemic 
constitution ; but still it has maintained some 
prominent characteristics of its identity at differ- 
ent periods. The ordinary course of the disease 
has been marked by the following symptoms : — it 
usually commenced with slight chills, amounting 
sometimes to shiverings, and alternate flushings 
of heat, with languor and sense of extreme weari- 
ness : then, soreness over the eyes, or pain in the 
course of the frontal sinuses : these were quickly 
followed by frequent sneezing, a copious discharge 
of lymph or thin clear fluid from the nose and 
eyes, sometimes so acrid as to excoriate the upper 
lip ; heat and soreness in the top of the larynx 
and oesophagus, and along the course of the 
windpipe, with hoarseness and dry cough ; sense 
of stricture in the chest and difficulty of breath- 
ing, sometimes attended with darting pain in the 
muscles subservient to respiration ; weight and 
anxiety about the prrecordia, flying pains in the 
back, knees, calves of the legs, and various parts 
of the body ; depression of spirits, and sudden 



20 



INFLUENZA. 



and extraordinary prostration of strength. The 
tongue was mostly covered, at an early period of 
the complaint, with extremely white mucus, like 
cream — a symptom particularly noticed by Hux- 
ham, Baker, Pettit, and others : there was loss of 
appetite, the thirst was inconsiderable, and the 
pulse generally quick, weak, and soft. 

The preceding symptoms appeared in various 
degrees and combinations, as the violence of the 
disease fell more particularly upon the mucous 
membrane, in the head, in the throat and chest, or 
in the stomach and bowels. When the disease 
chiefly affected the head, vertigo, violent headach, 
greatly increased by the cough, and delirium, 
were not unfrequent : there was hemorrhage from 
the nose, and pain in the ears ; from which, in 
one case, a clear fluid was poured out like that 
from the nostrils. (Med. Trans, of the College 
of Physicians, vol. iii. p. 69.) In some rare cases 
the tonsils and back part of the throat were in- 
flamed, so that suppuration was the consequence. 
When the violence of the disease fell upon the 
lungs, as in old people, asthmatic patients, and 
those predisposed to phthisis, hemoptoe was not 
uncommon, and frequent troublesome cough which 
prevented sleep. It often degenerated into pleu- 
risy and peripneumony. In common cases the 
cough became loose in three or four days. The 
stomach was affected with nausea in many, and 
vomiting in some ; and a spontaneous diarrhoea 
relieved both head and lungs, and speedily cut 
short the complaint. But in many instances, and 
in several visitations of the epidemic catarrh, a 
morbid determination to the intestinal canal was 
manifest from the beginning ; which, so far from 
being considered a salutary effort of nature to 
relieve the system in that way, required especial 
care in the treatment, and the utmost caution in 
the use of purgatives. The fever was generally 
mild in the day-time, and it increased in the 
evening ; and it seldom abated till some critical 
amendment took place by perspiration or other- 
wise. There was little remarkable in the urinary 
secretion. The duration of the complaint was 
from a day or two to a week or fortnight. In 
some, the symptoms, after abating in two or three 
days, returned and raged with violence. The far 
greater part had critical sweats about the third 
day, which, attended with free expectoration, 
banished the fever on the fifth day. One of the 
most remarkable features of influenza is the de- 
bility ; so that many could not rise from the hori- 
zontal posture without sudden faintings, even in 
the state of convalescence ; and the debility often 
remained for a considerable time. The sudden- 
ness of the invasion, the pain and tightness in the 
forehead, with pain in the back, knees, and mus- 
cles, and singular prostration of strength, were 
thought to be distinguishing marks between the 
influenza and common catarrh. Indeed, the pain 
or soreness in the face, temples, and cheekbones, 
was considered the most certain pathognomonic 
symptom in 1782 ; " and now and then was felt 
previously to the catarrh, and not unfrequently 
was followed by very little or no catarrhal affec- 
tion." 

In one district in Gloucestershire, a practitioner 
states that "in no two persons in 1803 did he 
observe precisely the same symptoms." (Med. 



and Phys. Journal, vol. x. p. 309.) If 0a» was 

the case, the symptoms might be expected to vary 
considerably in different places, as well as in d f. 
ferent visitations of the distemper. And this has 
happened accordingly. The rarer occurrences 
were, an unusual disposition to sleep, strangury 
and bloody urine independent of blisters, peculiar 
slow and strong pulse, with excessive debility, as 
at Newark ; ringing in the ears and abscess, and 
abscess in the frontal sinus ; of which last Dr. 
Rush had three cases in 1790. (Trans, of Col. 
of Phys. iii. 68, and Rush's Med. Inquir. n. 354. 
Mem. of Med. Soc. vol. vi. p. 383.) 

The duration of influenza in any one place sel- 
dom has exceeded six weeks. Upon the whole 
few have died of this complaint, although it has 
often attacked more than one-half or even three- 
fourths of a whole community. The chief vic- 
tims have been the aged and asthmatic, those of 
tender lungs and of full oppressed habits. Those 
of middle age were more liable to be affected than 
old persons and children ; and persons exposed to 
the air than those who were confined. Many- 
recovered their strength very slowly, and some, 
especially in 1762, fell into incurable consumption. 

[Some epidemics have, however, proved ex- 
tremely fatal. The mortality of the epidemic of 
1837 in Europe was greater than that from 
cholera, although the disease was by no means so 
severe, or so rapidly fatal. This was owing to its 
attacking almost every one, whilst the ravages of 
cholera were comparatively limited. It has been 
estimated by Dr. Graves (Clinical Lectures) that 
in Dublin alone, 4,000 persons died of the influ- 
enza of 1837.] 

III. One general observation seems to apply 
to almost every epidemic disease, including even 
those of a pestilential nature, viz. that during 
its prevalence numbers are attacked in so slight a 
manner as to require but little medical care. 
Hence the influenza, which in all its visitations 
has had a favourable character in the majority of 
cases, has been easily removed by mild diluents, 
rest, and abstinence for a few days from animal 
food and fermented liquors. Besides this, a com- 
plaint so various not only in its symptoms but in 
the degrees of their intensity, modified too at dif- 
ferent periods by season, climate, and epidemic 
constitution, would of necessity call for the exer- 
cise of much discretion in the employment of 
remedies. But, making due allowance for all this 
variety of character in the complaint, and for the 
judicious adaptation of a corresponding treatment, 
physicians of eminence, in different countries, 
seem to have agreed remarkably in their testi- 
mony as to the general rules and principles of 
their practice ; and from the very beginning of the 
sixteenth century, in their reports, with respect to 
bloodletting, to the caution about active purga 
tives, to the employment of a cold regimen and 
to the restricted use of opiates, there is a very 
striking and satisfactory coincidence. 

In the mild attacks of the disorder, few if an> 
medicines have been required. In severe cases 
emetics at the beginning relieved the sufferings 
of the head and chest, and, combined with gentle 
aperients and antimonial or saline medicines, were 
found useful in mitigating the fever and pro- 
moting a salutary diaphoresis. 



INFLUENZA. 



21 



No observation is to be found more general in 
practical writers in this disease than that blood- 
letting could rarely be employed with safety, far 
less with benefit, on account of the alarming de- 
bility and weakness of the pulse ; and when it 
was strongly indicated, practitioners were sparing 
in the quantity of blood, and cautious in repeating 
the remedy. In the epidemic of 1510, Dr. Short 
tells us that "bleeding and purging did harm." 
In 1557, bleeding was said to be so fatal, that in 
a small town near Madrid two thousand persons 
died after it in September. In 1580, Scnnertus 
ascribes the death of two thousand persons in 
Rome to venesection, and states that, where it was 
omitted, the mortality was not greater than one 
in a thousand. " Experientia enirn hoc compro- 
bavit, omnes fere mortuos esse, quibus vena ape- 
riebatur." Forestus, in his Scholia on the same 
epidemic, suggests a good practical hint, that we 
ought to distinguish very carefully those cases 
which might require, from those which might not 
bear this remedy. Huxham, who had no preju- 
dice against bloodletting, remarks, " Imo, si vel 
peripneumonia; aliquid subesset, minime largam, 
sine maxima virium ruina, plus vice simplici 
vensesectionem tolerabat: nee in hue solum, sed 
in omni febre catarrhali epidemica hoc fere per- 
petuum notavi." (De Aere, &c. ii. 102.) In 
Edinburgh it was noticed that those who were 
bled, in 1733 and 1782, " recovered more slow- 
ly ;" though others at the commencement seemed 
to be relieved by the lancet. (Med. Essays, vol. 
vi. p. 29.) In the influenzas of 1733, 1775, and 
1803, in France, bloodletting was generally inju- 
rious. (Diet, des Sc. Med. Grippe, pp. 356, 359, 
363.) Dr. Glass reports that at Exeter, in 1775, 
venesection "weakened the patient without reliev- 
ing the pain ;" and Dr. Ash considered that " it 
was never necessary to bleed at Birmingham ; 
that in a neighbouring town, three died who were 
bled, and all recovered who were not bled." 
(Lettsom's Mem. of Dr. Fothergill, 4to. p. 627.) 
Dr. Gray gives it as a general inference from the 
accounts transmitted to a " Society of Physicians" 
in 1782, "that bloodletting was by no means 
conducive to the general cure of the disease." 
(Med. Com. vol. i. p. 80.) Many physicians bear 
testimony to the same good rule of practice in the 
influenza of 1803, as Dr. Bardsley of Manchester, 
Dr. Kinglake of Taunton, Dr. Rutter of Liverpool, 
and others. (Med. and Phys. Journ. vol. ix. and 
x.) Notwithstanding the foregoing authorities, 
it is admitted by some eminent physicians, that 
cases now and then occurred in which this remedy 
was useful. Sir George Baker made this obser- 
vation in 1762, in London (p. 29); and in the 
same city it is somewhat remarkable that in the 
epidemic of 1775 it was less hurtful than in other 
places, which was perhaps owing to the more fre- 
quent complication of the disease that year with 
pleurisy and peripneumony, at all times no unu- 
sual circumstance. 

Opiates at the commencement of the disease 
almost invariably increased the febrile heat, aggra- 
vated the headach, in some cases even to delirium, 
tightened the chest, and stopped the expectoration : 
but in the decline they proved salutary. A cool 
temperature, both in drinks, in the air of rooms, 
and in the quantity of bed-clothes, was found to | 



be useful ; while, on the contrary, warm rooms 
hot drinks, and cordial sudorifics, aggravated the 
violence of the disorder. Blisters to the chest, 
sides, or back, often greatly relieved the stitches 
and cough ; and ipecacuanha was much extolled, 
especially in France, for its efficacy, when given 
in small doses, in assisting expectoration, reliev- 
ing the oppressed lungs, and correcting the ten- 
dency to irritation of the mucous membrane of 
the bowels. A medicine often used with good 
effect to ease the cough when attended with viscid 
phlegm, was the solution of gum ammoniac com- 
bined with oxymel of squills. When recovery 
was tedious and the strength much impaired, 
even long before the cough was removed, some 
bitter infusion, such as that of calumba, cascarilla, 
or Peruvian bark, with wine-whey and some nu- 
tritious diet was of great service. The reason 
why purgatives have been so generally reprobated 
by practitioners in the influenza, appears to have 
depended on the fact, that a morbid state of the 
mucous tissue of the internal surfaces exposed to 
the air, was often closely connected with a mor- 
bid tendency in that of the alimentary canal ; 
and, therefore, drastic purgatives, though they 
might relieve one system or set of organs, yet too 
often only transferred the disease, as it were, to 
another, and produced a dangerous debility. 

[Lobelia inflata was recommended by Dr. Cart- 
wright of Natchez, (Medico- Chirurg. Rev. for 
April, 1837, p. 586,) for the not very cogent 
reason, that " in those diseases affecting the mu- 
cous lining of the bronchial tubes, the lobelia in- 
flata comes as near being a specific [1] as tartar- 
emetic and the lancet in pneumonia and pleu- 
risy." Lobelia, as elsewhere said, (Practice of Me- 
dicine, 2d. edit. i. 263, Philad. 1844,) is certainly 
a valuable sedative, but not deserving of the ele- 
vated rank that has been assigned to it. The 
diseases of the bronchial tubes differ, and no one 
remedy can be applicable to every pathological con- 
dition. When there was more than usual inflam- 
mation of the bronchia, in the epidemic of 1837, 
large doses of the ethereal tincture of lobelia, re- 
peated at short intervals, with counter-irritation, 
seemed, according to Dr. Blakiston, to be useful.] 

IV. Among the phenomena relating to the 
weather, which seem to have had a connection 
with epidemic catarrh, either as precursor or at- 
tendant signs, we may notice extraordinary vicis- 
situdes, easterly winds, thick or offensive fogs, and 
diseases, often of a similar kind, among horses, 
dogs, and cattle. Epidemic catarrh is a disease 
either of spring or autumn. The spring influen- 
zas have sometimes occurred when the first heat 
suddenly followed the winter's cold ; and the au- 
tumnal, when the cold moisture and raw fogs of 
November have succeeded to the heat of a dry 
harvest ; yet there has not been a uniform con- 
nection between any one sensible quality of the 
atmosphere as to heat or cold, rain or drought, 
wind or calm, and the prevalence of this epidemic; 
for in different places it has maintained itself un- 
der the dominion of each of these states of tho 
weather, " et tempori frigidiori et calidiori, et 
flante tarn austro quam Borea, et pluvioso et sere- 
no ccelo, peragravit hasce omnes Europse rcgiones, 
et omnia loca indiscriminatim." (Salius Diversus, 
cited by Dunning, Med. and Phys. Journ. x. p 



22 



INFLUENZA. 



143.) In fact, extraordinary vicissitudes have be^cn 
more remarkable than any thing else: in some 
places, one peculiar sign of atmospheric intem- 
perature has been observed, and in other places a 
different sign ; and the epidemic has frequently 
fallen capriciously or partially, like the blight over 
a country, or even over a garden. 

Short says that " thick, ill-smelling fogs pre- 
ceded, some days, the epidemic catarrh of 1567. 
July, August, and September had been very hot 
and dry ; and in the end of September came a 
very strong cold north wind." (History, &c. vol. 
i. p. 223.) 

Riverius, quoted by Saillant in his History of 
Catarrhal Epidemics, says that just before that of 
1580 appeared in France, (at Nismes or Montpe- 
lier?) "a prodigious quantity of insects appeared 
in April and May ; and the roads were covered 
with them in such a manner, that a person in 
walking might have destroyed them by thousands." 
(Diet, des Sc. Med. torn. xix. p. 359.) And Pe- 
trus Salius Diversus, cited by Dunning, tells us 
of the birds and brute animals suffering generally 
the same year. (Med. and Phys. Journ. x. 143.) 
To these facts we may add the observation of 
Short, that " after a long continuance of hot, 
moist weather, attended with southerly winds, at 
the rising of the dog-star came a cold, dry, north 
wind ; and from the middle of August to the end 
of September raged the malignant epidemic ca- 
tarrh." (Hist, &c. i. p. 260.) Great extremes of 
the weather preceded the epidemic catarrh of 
spring 1658, decribed by Willis, (Ibid.) ; and Sy- 
denham attests that " the epidemic catarrh of au- 
tumn 1675 immediately succeeded cold and moist 
weather, which suddenly followed an unusually 
warm summer." (Syd. Opera, sect. v. ch. 5.) 

We have no very particular account of the state 
of the weather in England attending the epidemic 
catarrh of autumn 1729; but Hoffmann does not 
hesitate to ascribe its origin in Germany to the 
uncommon " irregularity and frequent changes of 
the weather from heat to cold and from cold to 
heat, &c. which distinguished that and the pre- 
ceding year, such as he had never before witness- 
ed ; causing throughout all Germany, Belgium, 
England, and elsewhere, unusual sickness : " tarn 
uberi proventu enati fuerint morbi, quam vix alio 
tempore visum unquam." (Hoffmann, Op. torn, 
ii. pp. 83, 109.) 

Within the last century the number of obser- 
vations on the phenomena in question increases 
very considerably; and we are thus enabled to 
make some approximation to general principles. 
Saillaint's excellent work, (Tableau des Epidem- 
ics Catarrhales, depuis 1510,jusquecellede 1780), 
on the continent, and the facts which have been 
collected in this country, on the catarrhal epidem- 
ics of 1775, 1782, and 1803, afford us much as- 
sistance in this inquiry. 

De Jussieu says that " the influenza of spring 
1733 appeared in France immediately after offen- 
sive fogs, more dense than the darkness of 
Egypt," (plus epais que les tenebres de l'Egypte. 
(Diet. Art. Grippe.) Huxham remarks generally 
that the cause of epidemic catarrh seems to de- 
pend on a thick, moist, and cold air ; and that in 
the autumnal months preceding the spring catarrh 
ol 1733, epidemic diseases were very common 



and fatal among horses. (De Aere, &c.tom. i. pp 
73 75 ) We find, also, that about Edinburgh 
coughs and running from the nose in horses were 
universal in October and November, just before 
the disease attacked men. (Med. Essays, n. p. 31.) 

The influenza of spring 1743 was the precursor 
of the great plague in some parts of Sicily. In 
England it was not so severe and fatal as in some 
other parts. About Plymouth, according to Hux- 
ham, many horses were diseased, and deer per- 
ished in January. (Webster's Hist. i. 386 ; and 
Huxham, op. cit. ii. p. 95, &c.) 

Sir G. Baker says that the weather in spring 
1762, before the epidemic catarrh of that year 
broke out in London, was extremely irregular; 
wind, frost, snow, and rain following each other in 
rapid succession, and with unusual severity. In 
April and May, intense heat followed ; and beside 
this, the air underwent very sudden changes from 
heat to cold and from cold to heat. (De Catarrh. 
Epid. p. 7.) 

A hot dry spring and summer preceded the epi- 
demic catarrh of autumn 1775. Petit says that 
in France the disease was ushered in by thick 
noisome fogs (" brouillards fetides"), and a cold 
rainy autumn. (Art. Grippe, Diet. p. 359.) Dr. 
Anthony Fothergill says that disease among dogs 
and horses was general over England before the 
influenza broke out, (Mem. of Med. Soc. vol. iii. 
36) ; and we are also assured that it was preceded 
by foggy air as well as by disease among dogs and 
horses in Dorsetshire, and at Exeter ; and by un- 
usual haze, easterly winds, and almost universal 
cough among the horses in North Wales. (See 
the Reports of Drs. Pulteney, Glass, and Hay- 
garth, in Lettsom's Life of Fothergill.) About 
the 7th of October, 1775, it appeared in the shire 
of Galloway in Scotland ; " and a continual dark 
fog and particular smoky smell in the atmosphere 
prevailed for five weeks, the sun was seldom seen, 
and though October and November are particu- 
larly rainy months in that country, little or no 
rain fell, the wind E S E. and S." (Mem. of Med. 
Soc. vol. vi. p. 323.) 

With regard to the influenza of spring 1782, 
" the spring of this year was remarkably late, 
with a long prevalence of cold easterly winds ; the 
hedges were not full blown in Cornwall before the 
beginning of June. A similar state of weather 
has commonly ushered in this universal malady." 
( Trotter's Med. Naut. vol. i. p. 362.) Dr. Ham- 
ilton tells us that » from the first of January till 
the end of May, throughout most places in the 
kingdom, the weather was uncommonly unfavour- 
able ;" and it appears that the latter month " was 
remarkable in all the meteorological annals of 
Europe for its unusual degree of cold and hu- 
midity, with a gloomy and uncommonly dis- 
turbed state of the atmosphere." (Mem. of Med. 
Soc. vol. ii. p. 433 and 445.) Dr. Darwin adds 
his testimony, that in this year (1782) « the sun 
was for many weeks obscured by a dry fog, and 
appeared red as through a common mist :" and he 
supposes, « the material which thus rendered the 
air muddy, probably caused the epidemic catarrh 
which prevailed in that year." (Zoonom. c. ii. 1, 
3.) Dr. Parr says that horses were affected with 
a cold at the same time, near Exeter. (Med. Com- 
ment, vol. ix. p. 414.) Maertens records a strik- 



INFLUENZA. 



23 



ing fact relative to the first appearance of this epi- 
demic at Petersburg, and its connection with a 
particular change of the weather : " On a cold 
night the thermometer rose 30° of Fahrenheit ; 
the next morning forty thousand people were 
taken ill with the influenza." (Med. and Phys. 
Journ. vol. x. p. 524.) 

The influenza of spring 1803, as we have said, 
afforded an occasion for the collection of many 
valuable observations. It appeared in France 
some weeks before it invaded this country, and 
was supposed to be owing to a cold and humid 
autumn succeeding a dry and hot summer. At 
Paris it was immediately followed by a severe 
epidemic ophthalmia, about the time the influenza 
first appeared in Britain. (Diet, ubi supra.) With 
respect to unusual extremes in the weather, such 
are stated to have occurred in Hampshire, Lon- 
don, Somersetshire, and St. Andrews in Scotland, 
(Med. and Phys. Journ. x. 313, and Mem. of 
Med. Soc. vol. vi.) «I am of opinion," says Cu- 
ming, (Romsey, Hants,) » that the remote causes 
of this disease originated in the sudden change of 
atmosphere, a change, I believe, generally felt 
throughout the United Kingdoms, as well as upon 
the continent." Epizootic diseases preceded it, in 
some places among one or two species of animals 
only, in others among several, as cats, dogs, 
horses, cows, sheep, swine, in Shropshire, Wor- 
cestershire, Staffordshire, Cumberland, Hampshire, 
Lancashire, &c. (Ibid. pp. 288, 379, 316, 414, 
426, 444, 482, 576.) At Plymouth « many attri- 
buted the disorders among the horses to their 
having eaten insects, which for many weeks were 
innumerable, and covered the fields in a most ex- 
traordinary manner whorever there was any length 
of grass; and this, from the mildness of the season, 
was general in almost every field." (Med. and 
Phys. Journ. x. 137.) 

Disease was very prevalent among sheep in 
some parts of the north of England, last spring 
(1831), just before the influenza appeared; and 
an epidemic catarrh seems to have raged among 
horses in the south later in the year. The influ- 
enza of this year was remarkable for this, that it 
prevailed in some parts of Great Britain in spring, 
and in other parts in autumn. Its character was 
generally mild in all. With regard to the weather, 
an intelligent captain of a regular trader in the 
English channel declared to the writer of this ar- 
ticle, that for thirty years past he had no recollec- 
tion of such a long continuance of a thick and 
foggy atmosphere, as he has had occasion to ob- 
serve within the last eighteen months, between 
this country and the south of Ireland. He went 
so far as to state that he had scarcely made one 
clear passage from Liverpool and back again 
during this whole period. 

One general inference offers itself to our notice 
on reviewing the foregoing facts, viz. that no par- 
ticular phenomenon in nature universally charac- 
terizes the epidemic constitution which precedes, 
or that which accompanies the disease called in- 
fluenza ; and we are led to conclude that the 
causes of this epidemic, supposing them to take 
their rise in atmospherical changes of a universal 
nature, are far from being marked by uniformity 
in the signs At the same time we are bound to 
admit that the changes from warm weather to cold, 



and from cold weather to warm, with dampness, 
fogs, and easterly winds, have rarely been absent 
from the catalogue of natural indications. Disease 
among domestic animals is also to be noted as a 
very common precursor in many places, and in 
several distinct visitations of the influenza. 

[Dr. Graves (op. cit.) suggests that the disease 
may depend chiefly on telluric influence, or upon 
some agency connected with variations in the 
physical conditions, which operate on the external 
surface of the earth. The suggestion only indi- 
cates the little knowledge we have of the subject. 

In regard to the nature of the disease, various 
opinions have been entertained. Essentially it 
consists of the collection of symptoms to which 
the names of catarrh and bronchitis are applied ; but 
along with these, especially in the influenza of 
1837, the nervous system has been implicated. 
By one of the writers on the epidemic, Dr. Blak- 
iston,it has been designated " an affection of the 
nervous system, with its concomitant derange- 
ment in the organs of digestion, and circulation 
commonly known under the name of nervous 
fever, accompanied throughout its whole course 
by irritation of the pulmonary mucous mem- 
brane," and this view seems to have been embraced 
by most writers on the subject. Andral, however, 
( Cours de Pathologie Interne,} concludes that it 
is a general affection, the nature and cause of 
which are as unknown as those of the greater 
part of epidemics, which appear at irregular 
epochs.] 

V. The influenza, like every other epidemic 
disease, has given occasion to medical observers ta 
entertain very opposite views on the question of 
its contagious property. Were we to draw a 
general inference from the recorded statements of 
the majority, we should say that it was not con- 
tagious ; for the numbers who have given an 
opinion on this side far exceed the advocates of 
contagion. But we must not appeal to the ma- 
jority in order to decide a principle in science. It 
must, however, be acknowledged, that while indi- 
vidual or partial occurrences might lead to the 
supposition that influenza was propagated in many 
instances by contagious transmission, a compre- 
hensive survey of facts goes far to establish the 
contrary opinion ; for some things can hardly be 
explained on the principle of contagion without 
having recourse to suppositions that could not be 
warranted by a sound induction. Upon the whole 
it would appear that some general cause, if not 
originating, at least subsisting in the atmosphere, 
and depending on its changes, progressive also in 
its movements from place to place and from coun- 
try to country, gives rise to the disease ; but that 
it is probable that a limited propagation also takes 
place by personal intercourse, under the influence, 
and during the prevalence, of the epidemic con- 
stitution. 

We have writers affirming that persons who 
have been visiting or on business in an infected 
town, have been the first to introduce the epidemic 
into their own town or neighbourhood ; and it 
cannot be doubted that the members of a family 
and the inhabitants of a district have often been 
attacked by the influenza in succession. Hence 
these things would seem to indicate that the dis- 
ease was propagated by contagious transmission 



INFLUENZA 



more than by some universal medium. But the 
difficulty of proving the first to be actually the 
case, must, in the nature of things, be very con- 
siderable ; for it would appear, — and the remark 
applies to almost every epidemic disease, — that in 
many places a tendency to the epidemic has been 
recognised by clear indications some time before 
the peculiar combination of symptoms which cha- 
racterize it have shown themselves, making the 
moment of actual invasion very doubtful ; just as, 
it is well known, the epidemic imprints its own 
character for some time after upon the diseases 
that follow it. And though no epidemic disease 
with which we are acquainted is so sudden and 
simultaneous in its attacks as influenza, and there- 
fore none more emphatically deserves the name 
of epidemic, nor more decidedly proves a universal 
cause ; yet it is a striking fact that, with all its 
frequent rapidity of movement over the globe, it 
has in almost every country been more or less 
obedient to the laws which govern other epidemics, 
according to some progressive and consecutive 
operations that are as much hidden as the efficient 
cause of attraction. It does, in fact, mostly ob- 
serve some progressive law in moving over a 
country and in attacking a given multitude of 
people, which demonstrates that, however uni- 
versal may be the cause of an epidemic disease in 
its purest form, yet if we regard experience, the 
effects rarely if ever should be expected to appear 
without some degree of consecutive order. The 
difference of constitution, of age, of habits, of lo- 
cality, and of other things, may be quite sufficient 
to account for the phenomenon of successive 
attack ; and indeed it is what we might expect a 
priori. If to this we add the probability, and, 
indeed, necessary inference from the facts, that the 
cause itself is developed gradually, we shall have 
less difficulty in accounting for a continuous mode 
of attack on another principle than that of conta- 
gion. 

Though a successive mode of propagation over 
a country or city is most usual, yet on some occa- 
sions the spread of influenza over a whole king- 
dom, within the space of a few days, has been so 
general as to make the propagation by means of 
personal intercourse quite incredible, and almost 
impossible. Besides this, its sudden appearance 
in ships at sea, which have had no intercourse 
with land or with other vessels for a considerable 
time, can hardly be explained on any other sup- 
position than that of its atmospherical origin. Dr. 
Anthony Fothergill assures us that " both the 
epidemics of 1758 and 1775 seized whole families 
on the same day, often remote from one another, 
and without any intercourse. (Memoirs of Med. 
Soc. vol. hi. p. 36.) Again, " the influenzas of 
1775 and 1782 seized some persons at sea, while 
others were attacked on shore, and that without 
any perceptible communication." (Ibid. 38.) 
"The appearance of the Influenza in 1803, in 
England," according to Dr. Woodforde, " was 
very sudden, and its attack extremely general, so 
that it is difficult to say in what or in how many 
parts of the kingdom it prevailed at first. It is 
probable that the disease broke out in all at or 
nearly the same time." (Med. and Phys. Journ. 
vol. ix. p. 505.) 

The following fact is very conclusive as to the 



operation of some general cause ; for it is scarcely 
probable that contagion could be lurking a long 
time before, and then should burst forth at the 
same time in distant points in so remarkab e a 
manner. Two separate fleets left the coast of 
England for different points of destination in the 
year 1782 5 one, under Admiral Kempenfeldt, on 
the 2d of May, to cruise between Brest and the 
Lizard ; the other, under Lord Howe, on the 6th 
of the same month, for the Dutch coast : neither 
fleet had communication with any shore ; and the 
crews of each were perfectly healthy on sailing 
from Spithead. But on the 29th of the month, 
near four weeks after, the crew of the Goliah, one 
of the ships under Kempenfeldt, was attacked with 
influenza, and about the same time the epidemic 
appeared also in the Rippon, under Lord Howe. 
The other ships of both fleets were attacked in 
succession. In fact, so many men of both squadrons, 
on these remote stations, were rendered incapable 
of duty, that all were obliged to return to Ports- 
mouth about the second week in June. (Trans- 
actions of the Col. of Phys. vol. hi., and Trotter's 
Med. Naut. vol. i. 364.) 

If we pay attention to the course or direction 
of the several visitations of the influenza, we may 
observe that its general progress is not without 
some order. It either follows a westerly course, 
or one from the south tow r ards the north. If its 
course be westward, it does not usually take ex- 
tensive leaps over kingdoms, and then return to 
those it may have missed, as would be likely to 
happen if nothing more than personal intercourse 
and the various casualties of travellers' routes ex- 
erted an influence in determining its course. But 
it sweeps along the north from the east through 
Russia, Poland and the north of Germany to Eng- 
land ; and then wheels round through France and 
Spain to Italy. And here we cannot but trace a 
striking resemblance to the career of the epidemic 
cholera. But if influenza arises in the south, it 
takes a course from Italy through Spain, France, 
Britain and the Netherlands, along the shores of 
the Baltic. In the one case France is attacked 
before England, in the other after it. 

Were we to admit that the propagation of an 
epidemic disease over a space of some hundred 
square miles in the course of a few days or weeks 
might be accounted for on the doctrine of conta- 
gious transmission by means of travellers and the 
facilities of human intercourse, analogy might sup- 
ply us with an argument against the admission ; 
for in the case of some of the domestic animals, 
which do not travel from country to country like 
man, but are comparatively stationary, epidemic 
diseases are observed to spread among them ; 
sometimes in as extensive and simultaneous a 
manner as amongst human beings. 

VI. The facts we are now to notice seem to 
afford strong indications of the influence which 
the general cause that produces epidemic catarrh 
exerts over the human body with regard to other 
diseases; and so far they are opposed to the theory 
that contagion is the cause of it. Webster has 
remarked that catarrh or influenza is the disease 
which is most clearly connected with pestilence in 
the form of malignant angina, dysentery, yellow 
fever and plague, which it usually precedes fSee 
Hist, of Epid. vol. ii. p. 39 and 48.) This ob- 



INFLUENZA, 



25 



servation is partly confirmed by subsequent expe- 
rience. These facts also show how the general 
cause is controlled or modified by local peculiari- 
ties, as well as by constitutional varieties. 

Sir George Baker tells us, that '< while the in- 
fluenza of 1762 was prevailing in a very mild and 
tractable form in the villages near Lincoln, that 
were high and exposed, quinsies, pleurisies, and 
peripneu monies produced incredible destruction of 
life in the low neighbouring districts." (De Ca- 
tar, Epid. p. 19.) 

Dr. Carrick of Bristol says that " one of the most 
open and exposed of the buildings on Clifton Hill 
is Richmond Terrace, which forms three sides of a 
parallelogram, fronting respectively the east, south, 
and west. On the east side, not one family, 
scarcely an individual, escaped the complaint (in 
1803), while on the south side a great majority 
both of persons and families, in all other respects 
similarly circumstanced, escaped it entirely." — 
(Young's Med. Literature, p. 575. See also Mem. 
of Med. Soc. vol. vi. p. 345.) 

Dr. Binns states that at the time the scarlatina 
existed at Ackworth School in 1803, the influenza 
prevailed in the neighbouring towns ; yet that the 
latter did not attack a single individual of the 
family at the school, consisting of between three 
and four hundred persons." (Ibid. p. 351.) Bur- 
ton-on-Trent, also, in great measure escaped the 
influenza the same year; and scarlatina, with 
hooping-cough and measles, were epidemic there 
in its place. (Ibid p. 405.) 

" In London the influenza of 1 803 superseded 
or deferred the usual diseases of the spring, as the 
measles and scarlatina : this is also recorded by 
Lorry to have been the case in the epidemic catarrh 
that prevailed in France in 1775 ; but he adds, 
that during the summer these complaints appeared 
with more than usual violence and fatality." (Ibid, 
p. 520.) 

"At Aberdeen the influenza of 1775 began 
near the end of November and continued four or 
five weeks, but did not visit Fraserburg, where 
there was a putrid fever very fatal at that time." 
(Lettsom's Mem. of Fothergill, p. 642.) At Ches- 
ter, according to Dr. Haygarth, " the same epi- 
demic, in 1775, attacked many who were confin- 
ed to their houses and even to their beds with other 
ailments." (Ibid. 637.) 

Dr. Vaughan says, that at Rochester, when the 
influenza of 1803 ceased, "an exanthematous fe- 
ver prevailed, which did not appear to attack any 
except those whom the influenza spared." (Mem. 
of Med. Soc. vol. vi. p. 589.) 

Dr. Gibney reports that « at Navan in Ireland, 
after the influenza of 1803, a low fever, almost 
constantly prevailing in that town, disappeared for 
a considerable time." (Med. and Phys. Journ. vol. 
x. p. 527.) 

Dr. Currie says that " at Holywell, a populous 
town eighteen miles from Chester, and where there 
is a large cotton manufactory, a typhous fever of 
uncommon malignity had prevailed for a considera- 
ble time : the manufacturers and inhabitants of the 
town had not been free from it for more than two 
years. On the appearance of the influenza in the 
spring of 1803, the typhus entirely ceased, and 
only one case of fever has occurred since (nearly 
three months). I have not for many years known 
Voi. III. — 4 c 



this country so healthy as since the influenza dis- 
appeared." (Ibid. p. 214.) 

Dr. Rush remarks that, during the prevalence 
of the influenza at Philadelphia, he saw no sign 
of any other epidemic, and that the scarlatina an- 
ginosa, which prevailed during the summer, dis- 
appeared after the 1st of October, but appeared 
again after the influenza left the city. It blended 
itself with every species of chronic complaint." 
(Rush's Med. Inquiries, vol. ii.) 

" The influenza was the precursor of the ma- 
lignant yellow fever, which, commencing in the 
beginning of September, 1802, at Port Royal 
and St. Pierre's, Martinique, among the French 
seamen and soldiers lately arrived from France, 
committed the most frightful devastations amongst 
them." (Mem. of M. S. vol. vi. p. 599.) 

" During the prevalence of influenza at Vienna, 
from December 1788 to May following, there were 
scarcely any instances of real pleurisies or peri- 
pneumonies, though these often appeared during 
that season in former years." (Dr. Carenus, Med. 
Comment, vol. xvi. p. 161.) 

Dr. Chisholm mentions the exemption from the 
severe influenza of 1789 in its malignant form, 
after a remarkable change in the weather, of 
some estates in the island of Grenada, which had 
been attacked by it in its milder character before 
the change took place. (Med. Com. vol. xv.) 

While the influenza of 1762 was in London, 
peripneumony and angina were unusually and al- 
most universally prevalent in the country, (&V 
G. Baker, de Cat. Epid. p. 18); and Dr. Car- 
michael Smyth relates, that " although the epi- 
demical catarrh of 1782 quickly disappeared in 
the metropolis, it seemed to leave behind it an 
epidemical constitution which prevailed during the 
rest of the summer : and the fevers even in the 
end of August and beginning of September as- 
sumed a type resembling in many respects the fe- 
ver accompanying the influenza." (Med. Com 
vol. i. p. 71.) 

. After the disease had continued some weeks, it 
was observed to change its character in several 
places. In Dublin Dr. Cleghorn remarked that 
the fever with which the influenza of 1782 was 
accompanied, became remittent, and sometimes in- 
termittent ; in London it was intermittent, at 
Stamford and the Isle of Man, " low and putrid." 
(Med. Com. vol. i. p. 25.) 

We can scarcely look over the histories of influ- 
enza without perceiving a connection between this 
disease and morbid affections of the mucous sur- 
face of the stomach and intestines. Thus Huxham 
has recorded the frequent appearance of cholera 
and diarrhoea in July, September, and October, 
after the spring influenza of 1733. (De Aere, &c. 
vol. i. 86 and 88.) The same author describes 
the " dysenteria cruenta epidemica," which raged 
at Plymouth and the adjacent country, both befoie 
and after the influenza of 1743 : and he adds that 
" he did not know whether the former disease 
might not be considered a translation of the latter 
to the intestines ; but he had observed that epi- 
demic dysentery was very rarely to be met with 
in the spring. (Ibid. ii. 99, 103.) 

Sir George Baker follows up his account of the 
epidemic catarrh of 1762 in London with a de- 
scription of the epidemic dysentery which immo 



26 



INFLUENZA — INSANITY. 



diately succeeded it in that city, (Opus cit.) ; and 
both he and Dr. Reynolds remarked that in 1775 
diarrhoea sometimes followed the attack of influ- 
enza. (Mem. of Fothergill, supra cit.) 

Dr. Hamilton states that in the neighbourhood 
of Newcastle-upon-Tyne, "the influenza of 1782 
was accompanied with colic pains and cramps in 
the region of the abdomen and stomach, and some 
had purging." (Mem. of Med. Soc. vol. ii. p. 
435.) 

In France, in the influenza of 1S03, " gastric ir- 
ritation was one of the most frequent complica- 
tions of the disorder, and appeared in some mea- 
sure to constitute an essential part of it." (Diet, 
des Sc. Med. Art. Grippe, p. 362.) 

Dr. Bertram of Hull remarked that some of the 
attacks of influenza in 1803 nearly resembled cho- 
lera-morbus, others cynanche tonsillaris ; and he 
goes so far as to express » a firm conviction of 
the three diseases being different types of the same 
disorder, and occasioned by the same cause." — 
(Mem. of Med. Soc. vol. vi. p. 332.) 

Diarrhoea seems to have preceded, as an epi- 
demic, the influenza of 1803, at Plymouth Dock, 
as in 1743 and 1788 ; for Dr. May says that early 
in the year " diarrhoea and cholera were very 
prevalent ; so nearly similar to that preceding the 
influenza of 1788, that to many of his friends he 
hazarded a pretty confident opinion of an expected 
return; and in this he was not deceived." (Med. 
and Phys. Journ. x. p. 291.) 

It must be fresh in the recollection of most that 
the epidemic cholera which in a milder character 
appeared in many parts of Great Britain last year 
(1831), and is now running so fatal a career in 
its malignant type, was preceded by the influenza ; 
and we know that the same herald of that formida- 
ble epidemic was seen also at Warsaw, Paris, and 
other places ; and was lately announced even in 
the United States of America a short time before 
the cholera made its appearance in the transatlan- 
tic cities. 

These facts are collected to show that there is 
a closer connection between some epidemic dis- 
eases, both as to their affinity and their causes, 
than we commonly imagine ; and that it is only 
by a very enlarged view of their phenomena in 
different countries that we can hope to improve 
our knowledge in this obscure branch of science. 

Thomas Hancock. 

INSANITY. — Sect. 1.— Remarks on at- 
tempted definitions of Insanity.— Different 
varieties of the Disease referred to three 
principal Forms. 

Writers on insanity are generally agreed as to 
the difficulty of inventing a satisfactory definition 
of that disease. It is perhaps impossible to com- 
prise in a few words a characteristic description 
of mental derangement which may prove to be of 
practical use; and it is not an easy matter to 
discover one that even includes all the essential 
features of the object which it is proposed to 
define. The latter of these requisites will be 
obtained if we describe insanity as consisting in 
•< a disordered state of the functions of the brain, 
which gives rise to disturbances in the operations 
of the mind." This definition may correctly be 
applied to madness, but it also includes a variety 



of other diseases; and hence it becomes neces- 
sary to render the description more particular by 
exclusions and restrictions. It must be added, 
for example, that the disturbance in the mental 
operations ensuing from the morbid cause in the 
brain is not allied to coma or to loss of conscious- 
ness and sensibility, in order to exclude from the 
definition apoplexy and disorders of the same 
class. For a similar reason it has been common 
to observe that madness is a species of delirium 
distinct from that which is symptomatic of typhus 
and other febrile diseases. There are some other 
morbid states of the brain and of the faculties 
dependent for their exercise on the functions of 
that organ, which must in like manner be ex- 
cluded by express limitations. Such are congen- 
ital idiotism, and the imbecility of old age. Now 
it is obvious that a definition loses all its utility 
when it is found necessary to encumber it with so 
many particular restrictions, and it is therefore 
better to give up the attempt to define insanity in 
general terms. 

But the practical purpose of a definition, which 
is to give a clear and distinct conception of the 
thing to be described, will be secured if we can 
determine and classify the various disturbances 
which the mental operations undergo. These 
disturbances, however, present very different phe- 
nomena in different instances of the disease, and 
we cannot attempt to draw up a concise account 
of them until we have briefly noted their principal 
varieties. 

It is generally supposed that the intellect or the 
reasoning faculty is principally disordered in per- 
sons labouring under mental derangement. Mr. 
Locke made a remark, that "madmen do not 
appear to have lost the faculty of reasoning ; but 
having joined together some ideas very wrongly, 
they mistake them for truths, and they err as men 
do that argue right from wrong principles." 
From Mr. Lock's time it has been customary to 
observe that insane persons reason correctly from 
erroneous premises ; and some instances of hallu- 
cination, or some particular erroneous impression, 
have been looked for as the characteristic of the 
disease, or an essential circumstance in it. Dr. 
Cullen seems to have had Mr. Locke's observation 
in his mind when he laid down the definition of 
madness which occurs in his First Lines. He 
describes this disease to be " in a person awake a 
false or mistaken judgment of those relations of 
things which, as occurring most frequently in life, 
are those about which the generality of men form 
the same judgment; and particularly when the 
judgment is very different from whai the person 
himself had before usually formed." Cullen at- 
tempted to draw even this description within nar- 
rower limits, by observing that « there is generally 
some false perception of external objects, and that 
such false perception necessarily occasions a 
delirium or erroneous judgment, which is to be 
considered as the disease." That this is by far 
too limited an account of madness, and only com- 
prises one, and that by no means the most fre- 
quent form of mental derangement, every person 
must be aware who has had opportunities of ex- 
tensive observation. 

Of those lunatics whose intellectual faculties 
are manifestly disordered, there is always a con- 



INSANITY. 



27 



siderable proportion in whose minds it is impossi- 
ble to trace any particular hallucination or erro- 
neous perception or recollection. The rapid suc- 
cession of thoughts, the hurried and confused 
manner in which ideas crowd themselves into the 
mind in a state of incoherence, or without order 
and connection, is in very many instances among 
the most striking phenomena of madness. There 
are, likewise, cases of a different description, in 
which the intellectual faculties appear to have 
sustained but little injury, while the feelings and 
affections, the moral and active principles of the 
mind, are strangely perverted and depraved ; the 
power of self-government is lost or greatly im- 
paired ; and the individual is found to be inca- 
pable, not of talking and reasoning upon any 
subject proposed to him, for this he will often do 
with great shrewdness and volubility, but of con- 
ducting himself with decency and propriety in the 
business of life. His wishes and inclinations, his 
attachments, his likings and dislikings, have all 
undergone a morbid change, and this change 
appears to be the originating cause, or to lie at 
the foundation of any disturbance which the un- 
derstanding itself may have sustained, and even in 
some instances to form throughout the chief cha- 
racter or constituent feature of the disease. The 
older nosologists, Sauvages, Sagar, and Linnaeus, 
were not wholly unaware of these distinctions; 
for in their distributions of mental diseases, we 
' find (besides an order of Vesanias or Hullucina- 
tiones, in which erroneous impressions were sup- 
posed to affect the understanding) another depart- 
ment styled " Morositates" or "Morbi Pathetici," 
consisting of depraved appetites and other morbid 
changes in the feelings and propensities. The 
disorders, however, which are classed under these 
heads, are not, all of them at least, strictly forms 
of insanity ; and Pinel appears to have been the 
first writer who, with a clear conception of the 
subject, distinguished a class of maniacal affections 
under the term of " madness without delirium or 
hallucination." Pinel, who was an acute and 
original observer, and whose opinions carry much 
weight on account of his extensive opportunities 
of investigating the history of madness, has 
made the following remark in reference to the 
sentiments of Mr. Locke. « We may justly ad- 
mire," he says, " the writings of this philosopher, 
without admitting his authority upon subjects not 
necessarily connected with his inquiries. On re- 
suming at the Bicetre my researches into this 
disorder, I thought, with the above author, that it 
was inseparable from delirium," (meaning what 
is termed by English writers hallucination ;) 
« and I was not a little surprised to find many 
maniacs who at no period gave evidence of any 
lesion of the understanding, but who were 
under the dominion of instinctive and abstract 
fury, as if the active faculties alone had sustained 
injury. 

The examples given by Pinel in illustration of 
the above remark were not fortunately chosen, and 
they are all of one kind, namely, of that in which 
the principal phenomena of the disease were vio- 
lent fits of anger or rage. The general observa- 
tion which the author has so clearly enounced, 
that insanity consists, in certain cases, in a morbid 
perversion of the affections and moral feelings ex- 



clusively, and without any perceptible lesion of 
the intellectual faculties, is a fact of the highest 
importance pathologically and practically, and the 
opinion of Pinel in this particular deserves the 
most attentive consideration. It will be found 
that later practical writers, though they have not 
made the same statement in so decided a manner, 
have yet given a testimony which leads to the 
same result. The following remarks by M. Es- 
quirol, who is less systematic than Pinel, prove 
that he was led to a similar conclusion by the 
strict observation of facts. 

" The insane conceive an aversion for those per- 
sons who are most dear to them, revile them, ill- 
treat them, anxiously shun them, in consequence 
of their mistrust, their suspicions, and their fears. 
Prejudiced against every thing, they are afraid of 
every thing. A few appear to form an exception 
to this general rule, in preserving a sort of affec- 
tion for their relatives and friends ; but this feeling 
of attachment, which is sometimes excessive, sub- 
sists without confidence in those persons who be- 
fore the attack of the disease had been the direc- 
tors of the thoughts and actions of the patient. 
A melancholic, who is devotedly attached to his 
wife, is deaf to her counsels and advice. A son 
would sacrifice his life for his father, but will not 
make the slightest attempt, in compliance with 
the entreaties of the latter, to overcome the morbid 
impression which occasions him so much grief." 

" This moral alienation is so constant," says 
M. Esquirol, " that it appears to me to be the pro- 
per characteristic of mental derangement. There 
are madmen in whom it is difficult to discover any 
trace of hallucination, but there are none in whom 
the passions and moral affections are not disor- 
dered, perverted, or destroyed. I have in this par- 
ticular met with no exceptions." 

" A return to the proper and natural state of 
the moral affections," says the same writer, " the 
desire of seeing once more children or friends ; 
the tears of sensibility ; the wish manifested by 
the individual to open his heart and return into 
the bosom of his family, to resume his former 
habits, afford a certain indication of cure, while 
the contrary dispositions had been a mark of ap- 
proaching insanity, or the symptom of a threat- 
ened relapse. This is not the case when there is 
merely a disappearance of the hallucination, which 
then only is a certain sign of convalescence, when 
the patients return to their natural and original 
affections." (Esquirol, Diet, des Sc. Med., torn, 
xvi.) 

If the opinion expressed by these writers is 
founded on real facts, — and that it is so the writer 
of the present article is well assured from ample 
proofs afforded by his own observation, — it must 
be evident that it leads to very important results. 
It will be necessary, in conformity with it, and 
with the varieties of phenomena which the dis- 
ease really presents, to classify the different forms 
of madness or insanity under the following divi- 
sions. 

1. Moral insanity, or madness consisting in a 
morbid perversion of the natural feelings, affections, 
inclinations, temper, habits, and moral dispositions, 
without any notable lesion of the intellect or 
knowing and reasoning faculties, and particularly 
without any maniacal hallv.cination. 



29 



INSANITY. 



2. Intellectual insanity, or madness attended 
with hallucination ; in which the insane person 
is impressed with the belief of some unreal event 
as of a thing which has actually taken place, or 
irj which he has taken up some notion repugnant 
to his own experience and to common sense, as if 
it were true and indisputable, and acts under the 
influence of this erroneous conviction. 

3. There is another well-marked division of 
maniacal cases, in which the whole mind, if we 
may use the expression, seems to be equally de- 
ranged. The most striking phenomena in this 
form of the disease are the rapidity and disorder 
with which the ideas follow each other, almost 
without any discoverable connection or associa- 
tion, in a state of complete incoherence and con- 
fusion. It is impossible to fix the attention of the 
patient long enough to obtain a reply to the most 
simple question. His understanding is wholly 
lost in the constant hurry of ideas which crowd 
themselves upon him, and which appear to exceed 
the power of distinct utterance, while his habits 
betray a corresponding degree of restless activity 
and extravagance. 

The most appropriate designation in our lan- 
guage for this species of disease is incoherent mad- 
ness, a term given to it long ago by Dr. Arnold. 
It is named by Pinel dementia or demence, de- 
mentedness. Pinel has given an admirable defini- 
tion of it : " Rapid succession, or uninterrupted 
alternation of insulated ideas, and evanescent and 
unconnected emotions ; continually repeated acts 
of extravagance ; complete forgetfulness of every 
previous state; diminished sensibility to external 
impressions ; abolition of the faculty of judg- 
ment ; perpetual activity." 

If we are correct in assuming that all the va- 
rieties of mental derangement may find their place 
under one of the three descriptions we have thus 
marked out, a definition or short nosography of 
madness will be furnished by enumerating the 
characteristics of the three forms. We may then 
describe insanity as " a chronic disease manifested 
by deviations from the healthy and natural state 
of the mind ; such deviations consisting either in 
a morbid perversion of the feelings, affections, and 
habits, or in disturbances of the intellectual facul- 
ties, under the influence of which the under- 
standing becomes susceptible of hallucinations or 
erroneous impressions of a particular kind ; or, 
thirdly, in a state of mental incoherence, or con- 
stant hurry and confusion of thoughts." 

We shall now endeavour to trace an accurate 
description of the actual phenomena of insanity, 
containing the results of long and attentive obser- 
vation. In discriminating the different varieties 
of the disease, we shall neither deviate further 
than is necessary from the arrangements of former 
writers, nor shall we follow in every respect the 
nosological divisions which they have adopted. 
The reader will, if we are not mistaken, find data 
in the following outline sufficient to confirm and 
illustrate the preceding remarks, and to show how 
far the distinctions we have endeavoured to estab- 
lish are complete. 

Sect. II. — Phenomena of Madness de- 
scribed. 

1. First Appearances of the Disease. — The 



first appearance? of madness are very different m 
the various forms of the disease and in different 
cases. Sometimes the complaint breaks out at 
once, without any previous indications ; the man. 
ners of the patient are observed to be unusually 
impetuous; his conversation hurried; his mind 
full of projects, which he pursues with restless 
activity. He betrays the absolute derangement 
of his understanding by announcing some false 
and absurd impression, or by acting upon it. 
When his attempt is resisted, or when by acci- 
dent he explains the motive which incited him, 
his condition is at once made evident, and the 
necessity of restraint becomes obvious. Such is 
the mode in which insanity makes its attack in 
the greater number of cases. In other instances 
the actual appearance of disturbance in the intel- 
lect is preceded by a period of uncertain duration, 
in which an unsound state of mind exists, but 
displays itself in a different manner. A certain 
waywardness or singularity of character, an un- 
steadiness in pursuits and inclinations, a fickleness 
or capriciousness of temper and habit, is observed 
for some time before the individual is set down by 
his relatives as a lunatic. This stage of the dis- 
ease may last for years. M. Pinel mentions the 
case of a man who believed his wife to have been 
deranged only six months, at the commencement 
of which period she had sustained an attack of 
violent mania, but after repeated inquiries was at 
length convinced that she had not been in a sound 
state of mind for fifteen years. The same writer 
likewise observes that in many instances the 
origin of mental derangement has been referred, 
on tracing its history, to a period of four, ten, or 
even of fifteen or twenty years before the time 
when it became fully manifest, or when a disor- 
dered state, previously ambiguous, changed its 
character into that of ordinary or decided mania. 

Cases of disease affecting the mind, such as 
we have described, and in which the succession 
of symptoms and the development of the com- 
plaint follow the order just pointed out, — a certain 
period either of melancholy dejection or of morbid 
excitement, attended with a disturbed and unna- 
tural state of the feelings, temper, and habits, pre- 
ceding, and after a time ushering in a clearly 
marked attack of insanity — are in fact only exam- 
ples of a transition from one form or state of men- 
tal disorder to another, which is more strongly 
characterized and more easily distinguished. 
There are, however, numerous instances in which 
phenomena similar to those of the previous stage 
last for many years, perhaps during life, some- 
times maintaining their ambiguous and undefined 
character, at others becoming aggravated in degree, 
but without undergoing a transition into the pe- 
culiar form of madness attended with marked dis- 
turbance of the intellectual faculties. Of this 
description are the cases of mental disease which 
we purpose to distinguish under the term of moral 
insanity. 

First Form of the Disease—Moral Insanity. 
—This form of mental disease has been said above 
to consist of a morbid perversion of the feelings, 
affections, habits, without any hallucination or 
erroneous conviction impressed upon the under- 
standing; it sometimes coexists with an appa- 
rently unimpaired state of the intellectual faculties 



INSANITY. 



29 



There are many individuals living at large, and 
not entirely separated from society, who are affect- 
ed in a certain degree by this modification of in- 
sanity. They are reputed persons of singular, 
wayward, and eccentric character. An attentive 
observer may often recognise something remarka- 
ble in their manner of existence, which leads him 
to entertain doubts as to their entire sanity, and 
circumstances are sometimes discovered on inquiry 
which assist in determining his opinion. In many 
instances it is found that there is an hereditary 
tendency to madness in the family, or that several 
relatives of the person affected have laboured 
under other diseases of the brain. The individual 
himself is discovered in a former period of life to 
have sustained an attack of madness of a decided 
character. His temper and dispositions are found 
on inquiry to have undergone a change ; to be 
not what they were previously to a certain time ; 
he has become an altered man, and this difference 
has perhaps been noted from the period when he 
sustained some reverse of fortune, which deeply 
affected him, or since the loss of some beloved 
relative. In other instances the alteration in his 
character has ensued immediately on some severe 
shock which his bodily constitution has undergone. 
This has been either a disorder affecting the head, 
a slight attack of paralysis, a fit of epilepsy, or 
some fever or inflammatory disorder which has 
produced a perceptible change in the habitual 
state of the constitution. In some cases the alter- 
ation in temper and habits has been gradual and 
imperceptible, and it seems only to have consisted 
in an exaltation or increase of peculiarities which 
were always more or less natural or habitual. 

In a state such as that above described, many 
persons have continued for years to be the sources 
of apprehension and solicitude to their friends and 
relatives. The latter in many instances cannot 
bring themselves to admit the real nature of the 
case. The individual follows the bent of his in- 
clinations ; he is continually engaging in new 
pursuits, and again relinquishing them without 
any other motive than mere caprice and fickle- 
ness. At length the total perversion of his affec- 
tions, the dislike and even enmity manifested to- 
wards his dearest friends excite greater alarm. 
When it happens that the head of a family 
labours under this ambiguous modification of in- 
sanity, it is sometimes thought necessary from 
prudential motives, and to prevent absolute ruin 
from thoughtless and absurd extravagance, or from 
the result of wild projects and speculations, in the 
pursuit of which the individual has always a 
plausible reason to offer for his conduct, to make 
some attempt with the view of taking the manage- 
ment of his affairs out of his hands. The laws 
have made inadequate provision for such contin- 
gencies, and the project is often unsuccessful. 
If the matter is brought before a jury, and the in- 
dividual gives pertinent replies to the questions 
that are put to him, and displays no particular 
hallucination, — a feature which is ordinarily looked 
upon as essential to madness, — it is most proba- 
ble that the suit will be rejected. 

Several practical writers have left a testimony, 
which is sufficiently conclusive, as to the exist- 
ence of moral insanity, though they have not de- 



signedly and in set terms marked it as a distinct 
form of the disease. 

We have already observed that M. Esquirol has 
stated his opinion to be, that moral alienation, or 
a perverted state of the affections, is, rather than 
intellectual aberration, the characteristic of mental 
derangement. M. Georget likewise describes the 
state we have alluded to as a particular modifica- 
tion of madness. He observes " that individuals 
predisposed to mental disease by a faulty educa- 
tion or by previous attacks, have often continued 
for a long time, or perhaps even during their 
whole lives, to attract observation by caprices in 
their deportment, by something eccentric in their 
manner and habits of life, by an ill-regulated 
fondness for pursuits of the fancy, and the mere 
productions of the imagination, combined with a 
striking inaptitude in the study of the exact 
sciences." The last-mentioned particular will 
scarcely be allowed to constitute a characteristic 
trait of madness in this country, whatever may be 
the case in France. " These persons are noted," 
continues the same writer, " for singularity of 
opinions, of conduct, for transitory fits of intelli- 
gence, or sallies of wit, which are too strongly 
contrasted with their habitual state of nullity or 
monotony ; by a levity in thoughts, a weakness in 
judgment, a want of connection in their attempts 
at reasoning. Some individuals are presumptuous, 
desirous of undertaking every thing, and capable 
of applying themselves to nothing; others are 
extravagant and mobile in the utmost degree in 
their opinions and sentiments; many are sus- 
ceptible, irritable, choleric, and passionate ; some 
are governed by pride and haughtiness without 
bound ; a few are subject to vague anxieties or to 
panic terrors." 

It must be observed that, although M. Georget 
has described this state of disease as a first stage, 
or as the period of what he terms with M. Esqui- 
rol the incubation of madness, yet, as he says 
that it often lasts through the life of the indi- 
vidual, we may consider his testimony as given, 
in point of fact, in favour of the real existence 
of moral insanity as a particular modification of 
disease. 

Individuals labouring under this diaordei are 
capable of reasoning or supporting an argument 
on any subject within their sphere of knowledge 
that may be presented to them, and they often 
display great ingenuity in giving reasons for their 
eccentric conduct, and in accounting for and 
justifying the state of moral feeling under which 
they appear to exist. In one sense, indeed, their 
intellectual faculties may be termed unsound, but 
it is the same sense in which persons under the 
influence of strong passions may generally be 
said to have their judgment warped, and the sane 
or healthy exercise of their understandings im- 
peded. They think and act under the influence 
of strongly excited feelings, and a person ac 
counted sane is under such circumstances prover- 
bially liable to error both in judgment and conduct. 

We have already had occasion to observe that 
the existence of moral insanity as a distinct foim 
of mental derangement has been recognised by 
Pinel. The following example recorded by that 
writer is a characteristic one : 



INSANITY. 



" An only son of a weak and indulgent mother 
was encouraged in the gratification of every ca- 
price and passion of which an untutored and vio- 
lent temper was susceptible. The impetuosity 
of his disposition increased with his years. The 
money with which he was lavishly supplied re- 
moved every obstacle to the indulgence of his 
wild desires. Every instance of opposition or re- 
sistance roused him to acts of fury. He assaulted 
his adversary with the audacity of a savage ; 
sought to reign by force, and was perpetually em- 
broiled in disputes and quarrels. If a dog, a 
horse, or any other animal offended him, he 
instantly put it to death. If ever he went to a 
fete or any other public meeting, he was sure to 
excite such tumults and quarrels as terminated in 
actual pugilistic rencontres, and he generally left 
the scene with a bloody nose. This wayward 
youth, however, when unmoved by passions, pos- 
sessed a perfectly sound judgment. When he 
became of age, he succeeded to the possession of 
an extensive domain. He proved himself fully 
competent to the management of his estate, as 
well as to the discharge of his relative duties, and 
he even distinguished himself by acts of benefi- 
cence and compassion. Wounds, law-suits, and 
pecuniary compensations were generally the con- 
sequences of his unhappy propensity to quarrel. 
But an act of notoriety put an end to his career 
of violence. Enraged with a woman who had 
used offensive language to him, he precipitated 
her into a well. Prosecution was commenced 
against him, and on the deposition of a great many 
witnesses, who gave evidence to his furious de- 
portment, he was condemned to perpetual confine- 
ment in the Bicetrice." 

The morbid and irregular excitement of the ac- 
tive propensities, and the total want of self-control, 
which are so conspicuous in moral insanity, dis- 
play themselves in various ways. Almost every 
passion or feeling of the mind gives in different 
cases the character to the disease when displayed 
under a certain modification, which it would not 
be easy to describe in accurate terms. Violent 
gusts of passion breaking out without cause, and 
leading to the danger or actual commission of 
serious injury to surrounding persons, are the 
features of disease in most of the cases mentioned 
by Pinel. These were examples of madness, 
consisting in intense irascibility without lesion of 
the understanding. There are other instances in 
which malignity has a deeper die. The indivi- 
dual, as if actually possessed by the demon of 
evil, is continually indulging enmity and plotting 
mischief, and even murder, against some unfortu- 
nate victim of his malice. When this is con- 
nected with the false belief of some personal in- 
jury actually sustained, the case does not fall 
under the head of moral insanity, simply so 
termed. It involves hallucination or erroneous 
conviction of the understanding. But when the 
morbid phenomena include merely the expressions 
of intense malevolence, excited without ground 
or provocation, actual or supposed, the case is 
strictly one of moral madness. And such in- 
stances are more frequent than it will be easy for 
many persons to believe. 

Some maniacs display their condition by a 
propensity to commit every species of mischief, 



though devoid of any feeling of malevolence A 
case of this description, strongly marked, was 
lately pointed out to the writer of this article in 
the York Lunatic Asylum, by Dr. Wake, the able 
and intelligent physician to that institution. The 
individual is a youth of good temper, cheerful and 
active, having no defect of intellect whatever that 
could be discovered, even after long observation. 
He is continually prone to commit every kind of 
mischief in his power ; and not long ago escaped 
from his confinement and made his way to Bishop- 
Thorpe Palace, with the design to set it on fire. 
Dr. Wake has given his assurance that several 
cases have occurred precisely similar to that 
above related in all essential symptoms, during 
his attendance at the asylum, which has continued 
seventeen years, and that he considers no point in 
the history of madness better established by facts 
than the existence of moral insanity, strictly and 
exclusively so termed, and in conformity with the 
definition above laid down. 

A large number of cases falling into this divi- 
sion of diseases, are those in which a disposition 
to melancholy and dejection of mind exists, with- 
out any illusion of the understanding connected 
with it. A constant feeling of gloom and sadness 
clouds all the prospects of life: the individual, 
though surrounded with all the comforts of exist, 
ence, and even, exclusively of his disease, suffer- 
ing under no internal source of disquiet, at peace 
with himself, with his own conscience, with his 
God, yet becomes sorrowful and desponding. All 
things, present and future, are to his view involved 
in dreary and hopeless gloom. This tendency to 
morbid sorrow and melancholy, as it does not de- 
stroy the understanding, is often subject to control 
when it first arises, and probably receives a pecu- 
liar character from the previous mental state of 
the individual, from his education, and his reli- 
gious or irreligious character. Persons of well- 
regulated minds, when thus affected, express 
grief and distress at the inaptitude of which they 
are conscious to go through the active duties 
of life : frequently they feel a horror of being 
driven to commit an act of suicide or some other 
dreadful crime. This idea haunts them, and ren- 
ders them fearful of being a moment alone. It, 
however, subsides, and such cases often terminate 
in recovery. Persons of an opposite character 
give themselves up to txdium vitse, to morose 
disgust ; they loathe their very existence, and at 
length, unless prevented, put an end to it. 

A propensity to theft is often a feature of moral 
insanity, and sometimes it is the leading if not the 
sole characteristic of the disease. The writer of 
this article has lately seen a lunatic, confined in 
an asylum, who would only eat when he had 
stolen food, and his keeper made it a constant 
practice to put into some corner within his reach 
various articles destined for his sustenance, in 
order that he might discover and take them fur- 
tively. Many instances are upon record of indi- 
viduals noted for a propensity to steal, without 
the desire of subsequent possession, though in 
other respects of sound mind, or at least not gene- 
rally looked upon as deranged. Probably some 
of these would afford, if accurately scrutinized 
examples of moral insanity, whilst others might 
be found referable to eccentricity of character 



INSANITY. 



31 



The discrimination — if indeed the two things are 
essentially different — could only be made in par- 
ticular instances by taking into the account a 
variety of circumstances, such as the hereditary 
history of the individual and his consanguinity 
with persons decidedly insane, his former cha- 
racter and habits, and the inquiry whether he has 
undergone a change in these respects at some 
particular period of his life. 

This form of insanity has been, if we are not 
mistaken, in many instances the real source of 
moral phenomena of an anomalous and unusual 
kind, and of certain perversions of natural incli- 
nation which excite the greatest disgust and even 
abhorrence. 

In some instances moral insanity displays itself 
in a want of self-government, in a continual ex- 
citement, and unusual expression of feeling, or in 
thoughtless and extravagant conduct. A female, 
modest and circumspect, becomes violent and ab- 
rupt in her manners, loquacious, impetuous, talks 
loudly and abusively against her relations and 
guardians, before perfect strangers. Sometimes 
she uses indecent expressions, and betrays without 
reserve unbecoming feelings and trains of thought. 
Not unfrequently persons affected with this form 
of disease become drunkards ; they have an un- 
controllable desire for intoxicating liquors, and a 
debauch is followed by a period of raving mad- 
ness, during which it becomes absolutely necessary 
to keep them in confinement. Individuals are 
occasionally seen in lunatic asylums who under 
such circumstances have been placed under con- 
trol. After the raving fit has passed off, they 
demand their release ; and when they obtain it, at 
the first opportunity resort to their former excesses, 
though perfectly aware of the consequences which 
await them. 

A form of mental disease has been described by 
some writers, which, though not of frequent oc- 
currence, is occasionally seen, and is well known 
to those who have extensive means of observation. 
It is peculiar to old age, and has been termed deli- 
rium senile, and by Dr. Burrows, who has accu- 
rately distinguished it, senile insanity. It consti- 
tutes a variety of moral insanity. 

This disordered state makes its appearance in 
old men who have never before been insane or 
suspected of any tendency to mental derangement. 
It consists, like other forms of moral insanity, in a 
morbid excitement of passions and a remarkable 
perversion of the temper and propensities, The 
whole moral character of the person is changed. 
"The pious," says Dr. Burrows, "become impi- 
ous, the content and happy discontented and mis- 
erable, the prudent and economical imprudent and 
ridiculously profuse, the liberal penurious, the 
sober drunken." In some elderly persons, impulses 
which had long been effete become of a sudden 
excited, and a strong tendency to vicious habits is 
displayed. " In fact, the reverence which age and 
the conduct suited to it always command, is con- 
verted into shame and pity at the perversion of 
those moral and social qualities which, perhaps, 
have hitherto adorned the patient's declining days." 
This description coincides accurately with the 
character of moral insanity. There are instances, 
though rare, of the appearance of hallucinative 
madness in old persons, but the case we have now 



described is of a different character, and consists 
in a disordered condition of the moral or active 
powers alone. 

The following cases will afford some obser- 
vations illustrative of the history of moral in- 
sanity. 

J. K — , a farmer, several of whose relatives had 
been the subjects of mental derangement, was a 
man of sober and domestic habits, and frugal and 
steady in his conduct, until about his forty-fifth 
year, when his disposition appeared to have be- 
come suddenly changed in a manner which excited 
the surprise of his friends and neighbours, and 
occasional grief and vexation in his family. He 
became wild, excitable, thoughtless, full of schemes 
and absurd projects. He would set out and make 
long journeys into distant parts of the country to 
purchase cattle and farming-stock, of which he 
had no means of disposing ; he bought a number 
of carriages, hired an expensive house ready fur- 
nished, which had been inhabited by a person 
much above his rank, and was unsuitable to his 
condition ; he was irascible and impetuous, quar- 
relled with his neighbours, and committed an as- 
sault upon the clergyman of the parish, for which 
he was indicted and bound to take his trial. At 
length his wife became convinced that he was 
mad, and made application for his confinement in 
a lunatic asylum, which was consequently effected. 
The medical practitioners who examined him 
were convinced of his insanity by comparing his 
late wild habits and unaccountable conduct with 
the former tenor of his life, taking into considera- 
tion the tendency to disease which was known to 
prevail in his family. The change in his character 
alone had produced a full conviction of his mad- 
ness in his friends and relatives. When ques- 
tioned as to the motives which had induced him 
to some of his late proceedings, he gave clear and 
distinct replies, and assigned with great ingenuity 
some plausible reason for almost every part of his 
conduct. After a period of time passed in great 
seclusion, his mind became gradually tranquillized; 
the morbid excitement of his temper and feelings 
disappeared ; he was set at liberty, and has since 
conducted himself with propriety. 

A brother of the above patient has been at two 
different times confined in the same asylum, la- 
bouring under symptoms of derangement in all es- 
sential particulars resembling those above detailed. 
His disorder has consisted chiefly in morbid ex- 
citement, wildness and irregularity of conduct, dif- 
fering from his usual habits and character, with- 
out any hallucination or disturbance of the in- 
tellectual faculties. He has on both occasions 
remained in the asylum until he was fully con- 
valescent, and after his departure has acknow- 
ledged his conviction that he had been deranged, 
and in a state requiring control and seclusion from 
society. 

Abraham B , a working tradesman, of in- 
dustrious habits, conducted himself with propriety 
until about forty-six years of age, and had accu- 
mulated a considerable property from the fruits of 
his exertions. About that period he lost his wife, 
and after her death became more and more penu- 
rious. At length he denied himself the comfort*-, 
and in a great measure even the necessaries of 
life, and became half-starved and diseased ha 



32 



INSANITY. 



body was emaciated and beset with scaly erup- 
tions. Mr. S , a gentleman who had long 

known him, hearing of the condition into which 
he had sunk, sent a medical practitioner to visit 

him, by whose advice B was removed from a 

miserable dirty lodging to a lunatic asylum. Mr. 

S , who was present on the occasion, observed 

that Abraham B , previously to his quitting 

the room in which he had immured himself, kept 
his eyes fixed on an old trunk in the corner of the 
apartment. This was afterwards emptied of its 
contents, and in it were found, in the midst of va- 
rious articles, dirty bank-notes, which had been 
thrown into it apparently at different times, to the 
value of more than a thousand pounds. Abraham 

B , after his removal to an asylum, where he 

had wholesome food and exercise, soon began to 
recover from his bodily infirmities, and at length 
became anxious to be at large. The writer of this 
article visited him, and conversed with him for 
some time, in order to ascertain his mental condi- 
tion. He betrayed no sign of intellectual delusion, 
nor did it appear that any thing of that description 
had ever been a part of his complaint. His replies 
to questions were rational according to the extent 
of his natural capacity. He was determined to go 
and manage his property, and get a wife who 
should take care of him. In a few days after his 
release he was married to a servant belonging to 
the lunatic asylum where he had been confined. 
His new wife found after some months that it was 
impossible to endure the strange conduct of her 
husband, and after trying various experiments, 
brought him back to the asylum, with a certificate 
from a medical man, who had examined him and 
declared him to be insane. He still remains in 
confinement, and his derangement is now more 
complete than formerly, as it plainly involves his 
intellect. He now raves against his wife, declares 
that she is married to her own brother, vows bitter 
revenge for the injuries he has sustained, and ve- 
hemently demands his release whenever he is vis- 
ited by the inspecting magistrates. 

Abraham B 's case was at first merely a 

perversion of moral habits. If the real nature of 
this case was otherwise in any degree doubtful, it 
is rendered obvious by the more decided madness 
which has since appeared. Very clear indications 
of a disturbed intellect appeared in his manners 
and expressions soon after the commencement of 
his second confinement. 

It is probable that many instances of extreme 
avarice and penury, as those of Elwes and Dan- 
cer, and other celebrated misers, were in reality 
cases of disease. Whether such individuals were 
proper objects for confinement is quite another 

question. In the case of Abraham B the 

interference of others was necessary in order to 
preserve his existence. 

The cases above detailed resemble each other 
in many particulars, and especially in the circum- 
stance that the morbid perversion of habits which 
characterized each of them took its rise without 
any cause that could be distinctly traced. In the 
following instance the appearance of analogous 
derangement was preceded and probably caused 
oy constitutional disease, and by the suppression 
of a long-continued and habitual discharge from 
the lungs. 



The case we are about to relate is a tolerably 
characteristic example of moral insanity. During 
one period of its course, when aggravated by tern 
porary circumstances, it indicated some tendency 
to assume the form of monomania. The patient 
displayed a proneness to suspicion, and to enter- 
tain unfounded impressions connected with the 
motives and characters of individuals. But these 
impressions never became deeply fixed or took a 
permanent hold of the mind, and they soon dis- 
appeared. For some years both previously and 
subsequently to the period alluded to, the com- 
plaint wore that appearance which has, we trust, 
been correctly designated under the term prefixed 
to the present section. 

The account of this case is but slightly abridged 
from a narrative drawn up by a near relative of 
the patient. 

A. M is a maiden lady, aged about 48, of 

short stature, and somewhat deformed; her na- 
tural disposition was steady and industrious. She 
accomplished her undertakings by dint of applica- 
tion rather than by energetic or sudden efforts. 
She was constant rather than ardent in her attach- 
ments, free from resentment, never the subject of 
lively emotions; a great respecter of truth, just 
and very exact in all that she said or did. Her 
charitable acts were commensurate with her 
means, deliberate, and the result of principle 
rather than arising from the mere impulse of 
compassionate feeling. She was cautious and 
reserved in her communications, and scarcely if 
ever formed any familiar and particular intimacies 
with young persons of her own sex. Being de- 
barred by her infirmities from associating with the 
young and active, she seemed more like an adult 
member of the family than a child. She was very 
clever in arithmetic and in all matters of business, 
and was fond of regulating and controlling the 
little affairs of those who formed the domestic cir- 
cle surrounding her. Young persons and servants, 
finding that they derived advantage from her ad- 
vice, generally gave her an opportunity of gratify- 
ing her inclination. Her dress, which was always 
plain and in good taste, was to her an object of 
greater attention than it often is to persons of 
fashion. 

In March 1822 she was attacked by severe in- 
flammation in the lungs, attended by expectoration 
of bloody mucus. This was the first time in her 
life when it was necessary to confine her to bed. 
She submitted with great reluctance to the restric- 
tions that were needful for her recovery, and 
would not be persuaded until she had heard the 
opinion of an old friend of her family, who is a 
medical practitioner, that the means adopted were 
proper and required by her case. She was then, 
however, in a great measure reconciled, and after 
seven or eight weeks was so far recovered as to 
bear a removal into her native county. At this 
period nobody believed that she would survive 
another winter. Her restoration to her usual 
state of health was very slow, and her sister, who 
was her constant companion, perceived with sor- 
row that her temper was now much changed. 
She appeared restless, always wishing to go some- 
where, or to do something to which she was une- 
qual ; becoming unjustly irritated when she could 
not urge her sister, whose health and spirits were 



INSANITY. 



33 



declining, to fall in with her ideas, and occasion- 
ally giving way to reproaches which were keenly 
felt. She tried every method of persuasion to 
induce her sister to go to the neighbourhood of 
London, though for the preservation of her life 
the latter had been obliged to give up the custom 
of spending the winter there, and the attempt was 
considered dangerous to her. Every inducement, 
every argument was suggested to promote this 
favourite object : other towns were too warm and 
too cold, too hilly, too much intersected with 
water, too foggy. In 1827 she determined to go 

without her sister to H , near London. 

She went, and from her letters her sister perceived 
that she was living in a state of excitement far 
surpassing that of her former habits ; paying 
short visits to friends in the surrounding villages, 
going out in the common short stages, without so 
much regard to weather as was usual to her even 
in the summer ; receiving small parties at home, 
attending a very crowded church, writing a great 
many letters, &c. &c. She used to write to her 
sister in rather a boastful style, frequently men- 
tioning her good health and high spirits, as if to 
justify her choice of a residence near the metro- 
polis. When the sisters met during the summer 

at their house in shire, her high spirits were 

gone, she looked more aged than the time elapsed 
would have led any one to expect, took less in- 
terest in her garden, appeared exhausted, and, 
without contributing her share to the conversa- 
tion, used frequently to sleep in her chair. She 
lay much in bed, nursed herself up, and in Octo- 
ber went again to H , as much agog as ever. 

Another winter passed much as the preceding one 
had done. She spoke much again of her high 
spirits, visited much, was observed to be unusually 
liberal in her presents to most of her acquaintances. 
A second summer of inertness was succeeded by 
a winter at H . She was now weak, indis- 
posed for visiting, and, in fact, so much worse as 
to be unable to follow her inclinations. In the 
spring of 1830 she had an attack of the same na- 
ture as that in 1822, but not so severe or lasting. 
In the summer she was nearly as before, and quite 
as eager to resume her plans, as enthusiastic in 
her commendations of every body and every thing 

atH . 

About this time some riots took place in Lon- 
don, and more were apprehended. She now ex- 
pressed herself as apprehensive that " very awful 
times were at hand," wrote frequent letters to her 
sister full of indecision, and expressive of distrust 
in her servants, her host and his family. A friend 
who called upon her " was shocked to find her in 
so low a way." He thought her unfit to be alone, 
and she was unwilling to adopt any plan for 
leaving her lodgings, or having any one with her. 
She said she should be happy with her sister, and 
knew that she should be taken care of by the lat- 
ter, but dreaded becoming a burden to her and 
making her ill ; yet feared that if she did not go 
to her sister, "some one would put her where no 
one would know, and cause her to sign papers 
which she ought not to sign." She was evidently 
apprehensive of being sent to a lunatic asylum. 
She thought her host was a writer of " Swing 
ktlers,"* and dreaded that he might fill the house 

* It may hereafter require to be explained that, about 
Vol. III. — 5 



with combustibles, and blow it up with her in it. 
A medical man who was taken to see her, said 
that she was in a state of great mental excitement, 
and ought to be taken to her sister as soon as pos- 
sible. The frost was severe when she was escorted 
to her sister, who was then settled at Bristol, 
yet she took no cold, experienced no injury from 
fatigue, and lost that feeling of terror to which 
she had for some time been subject. Since she 
has been with her sister, she has been increas- 
ingly obstinate, suspicious, undecided, restless, 
parsimonious even to meanness, indisposed to any 
employment, bodily or mental, except as far as 
relates to a most troublesome interference with the 
most minute actions of others. Could she have 
her own way, she would control the food, dress, 
and employment of every one near her. She has 
become negligent in dress, and comparatively dirty 
in her habits, yet has an insatiable desire for new 
clothes, which she never finds the right time to 
wear. She is constantly predicting her utter ruin, 
is sure she will not have money enough to live 
until such and such a time ; knows that enough 

will not be found to pay Dr. ; knows he will 

not let any one of so shabby an appearance be long 
in his house ; does not know where she shall go 
when he is tired of her ; thinks that " it is the 
devil that makes her behave as she does ;" " that 
her heart is hardened to do what she ought not 
to do;" "she is like the man spoken of in the 
Gospel, who could not be bound even with fetters." 
She sees people look at her ; hopes they don't 
think she drinks too much ; is quite sure she 
never did. These impressions are continually 
varying ; but no sooner is her mind tranquillized 
on one subject than another source of disquietude 
arises, so that she exhausts every person who is 
long with her. Her bodily health is better than 
it was for years previous to her mental derange- 
ment. A constitutional asthma, to which she has 
been subject from the age of six or seven years, 
has nearly subsided, and the habitual profuse ex- 
pectoration has considerably diminished. She 
wears less clothing, and appears less sensible to 
cold or damp than heretofore. 

The writer of this article has had several inter- 
views with the subject of the foregoing relation, 
during some of which she gave replies to a va- 
riety of questions referring to the past and actual 
state of her health, both bodily and mental. No 
impression could be traced in her mind that bore 
the character of maniacal hallucination. The 
circumstance most observable in her condition was 
a perpetual disposition to find fault with every 
action, even the most trivial, that was witnessed 
by her. When asked if she was not aware of 
this propensity, she seemed to give an unwilling 
affirmative to the question, and she was plainly 
aware of the fact, for on the inquiry being made 
whether the habit had only existed of late years, 
or had been a part of her natural character, she 
steadily averred that such was not her natural dis- 
position, " that she was formerly very different." 

The preceding cases present no great difficulty 
as to the conclusion to be adopted respecting the 
nature of the disorder ; such, at least, was the 



the period above mentioned, the threatening letters of 
incendiaries in various parts of the country frequently 
bore the signature of Siring. 



34 



INSANITY 



opinion of all the medical practitioners who ex- 
amined personally the individuals. We now pro- 
ceed to mention an instance of moral peculiarity 
which will not allow of so decided an opinion. 

Miss A. N is a maiden lady of very sin- 
gular aspect and manners. She has for many 
years estranged herself from nearly all the friends 
of her family, formerly a large circle, and asso- 
ciates almost exclusively with her domestics, and 
one relative who lives with her. Her chief amuse- 
ment and delight is to invent and relate the most 
unfounded, and sometimes the most absurd and 
ridiculous stories. Sometimes she has displayed 
mortification when in danger of being detected in 
the invention of these falsehoods, or when ques- 
tioned respecting them. Her expression^of coun- 
tenance is sometimes very wild and peculiar. She 
has never shown any decided mark of mental de- 
rangement, nor is she considered as insane, though 
it has frequently been observed by those who have 
known her, " that they should not at any time be 
surprised to hear of her being mad." 

No person would venture to pronounce this lady 
to be insane, or at least to found any proceeding 
upon the opinion ; and yet it is highly probable 
that her eccentricity depends upon constitutional 
peculiarity. One of her parents was decidedly 
insane during a considerable period of life, and 
the other, as well as several ancestors and relations 
by blood, laboured under diseases of the brain, of 
which fatuity in different degrees was the result. 

It is generally admitted that there are few ques- 
tions which physicians are called upon to decide, 
of more difficult determination than that which 
relates to the existence or non-existence of insanity 
in examples which present no obvious and clearly 
discoverable disturbance in the state of the intel- 
lectual faculties. It may be apprehended that the 
perplexities with which this subject has been en- 
vironed, will rather be increased than diminished 
by the recognition of a form of mental derange- 
ment admitting the designation here adopted. But 
the real facts of a difficult question must be known 
and described in their true relations, before a solu- 
tion can be sought with any prospect of advan- 
tage ; and if we are not mistaken in the view of 
this subject and the facts connected with it, which 
we have adopted, it will be found that something 
is gained by admitting a position which places the 
inquiry relative to the existence of insanity in a 
different light from that in which it has most fre- 
quently been regarded. 

Those who are interested in studying the rela- 
tions of this disease will do well to consult the 
able and well-known work of Dr. Conolly. The 
question how far persons labouring under merely 
moral insanity are incapacitated for sustaining 
the relations of society, belongs to medical juris- 
prudence. 

3. Second Form of Insanity. Madness attended 
with Hallucination. — We now proceed to varieties 
of disease which are of far more easy discrimina- 
tion than that species of madness which involves 
merely a perversion of the moral affections and 
habits. When the patient is found to labour 
under a disturbed condition of the understanding, 
when a morbid delusion or hallucination is im- 
pressed upon his mind, no doubt can be enter- 
tained as to the actual existence of insanity. By 



the term hallucination we mean to express what 
Cullen and Pinel denote by that of delirium, viz. 
a belief of unreal events or relations, apprehended 
under the influence of disease to be actual and 
real, or some notion repugnant to common sense, 
impressed upon the mind as true and indisputable, 
the patient acting under the influence of his erro- 
neous conviction. 

There are two very different states of disease 
attended with this symptom. In one the under- 
standing is, when exercised on many subjects, 
comparatively clear, and the morbid impressions 
are partial ; in the other, the disturbed condition 
of the intellectual faculties involves all the opera- 
tions of the mind. These states are respectively 
termed monomania, and mania or ordinary mania. 
Each of them requires a separate consideration. 

Of Monomania. — Cases of partial insanity 
have been by former writers distinguished by the 
term melancholia, and it has been supposed that a 
majority of them are of the description by which 
that term was suggested, involving gloomy im- 
pressions and dejection of mind : the designation 
of mania has been at the same time applied to 
raving madness, or insanity accompanied by vio- 
lent excitement. This distinction is laid down in 
the most explicit terms by Van Swieten. " A ma- 
nia distinguiter melancholia, quod nondum adsit 
sasvus ille furor, qui in maniacis observatur. Pra> 
terea et illud signum diagnosticum melancholise est, 
quod uni et eidem cogitationi pertinacissime in- 
hsereant tales aegri, et fere circa hanc illamve opi- 
nionem delirant tantum ; in reliquis omnibus 
sanam ostendunt mentem et ssepe acutissimum in- 
genium." It was well observed by M. Esquirol, 
that the distinction connected with this appropria- 
tion of terms is not uniformly supported by facts, 
as the impressions of partial madness are not 
always of a gloomy character : the mind, in this 
form of disease, is not in every instance abandoned 
to sorrow and melancholy. The term monomania, 
meaning madness affecting one train of thought, 
or involving only a single morbid impression, was 
on these considerations substituted, and has gene- 
rally been adopted of late times instead of melan- 
cholia. 

The notion, however, which many persons en- 
tertain as to the nature of the disease thus desig- 
nated, is very far from being in general correct. 
It is supposed that the mind is perfectly sound 
when its faculties are exercised on any subject un- 
connected with a particular impression which con- 
stitutes the entire disease. Cases are on record 
which, if faithfully recorded, fully come up to this 
description. In general the real character of mo- 
nomania is very different. The feelings and affec- 
tions are in that state which has been described 
under the head of moral insanity, and on this it 
would appear that some hallucination or maniacal 
delusion has supervened. The following case will 
serve to illustrate the observation which we have 
just made. 

Mr. E. W , a gentleman about thirtv vears 

of age, has laboured for several years under symp- 
toms of moral insanity. He has been long de- 
jected in spirits and morose in temper, dissatisfied 
with himself, and suspicious of all that surrounded 
him. He was capricious and unsteady in his 
pursuits, frequently engaging in some new study 



INSANITY. 



35 



r n the most sanguine manner and soon abandon- 
ing it in despair of making any progress, though 
possessed of good talents and considerable acquire- 
ments of knowledge. He passed the requisite 
period of time at one of the Universities, but 
could not be prevailed upon to go in for his de- 
gree, either through timidity and want of resolu- 
tion, or, as it was conjectured by his friends, from 
a morbid apprehension that the examiners would 
not deal fairly with him and award him the station 
to which he aspired and believed himself entitled. 
He applied himself afterwards to the study of 
medicine, and then to that of metaphysics, and 
speedily relinquished both. He frequently changed 
his residence, but soon began to fancy himself the 
object of dislike to every person in the house of 
which he became the inmate. His peculiarities 
appearing to increase, he was visited by two phy- 
sicians, who were desired to investigate the nature 
of his case. On being questioned narrowly as to 
the ground of the persuasion expressed by him, 
that he was disliked by the family with which he 
then resided, he replied that he heard whispers 
uttered in distant apartments of the house indica- 
tive of malevolence and abhorrence. An obser- 
vation was made to him that it was impossible for 
sounds so uttered to be heard by him. He then 
asked if the sense of hearing could not, by some 
physical change in the organ, be occasionally so 
increased in intensity as to become capable of 
affording distinct perception at an unusual dis- 
tance, as the eyes of mariners are well known to 
be accommodated by long effort to very distant 
vision. This was the only instance of what 
might be termed hallucination discovered in the 
case after a minute scrutiny. It seemed to be a 
late suggestion. The individual had been for 
years labouring under a gradually increasing 
moral insanity. His judgment had become at 
length perverted by the intensity of his morbid 
feelings, and admitted as real an erroneous im- 
pression, suggested by his fancy, which happened 
to be in harmony with his feelings, and served to 
account for them. 

There are, indeed, cases of insanity attended 
with hallucination on a constant erroneous im- 
pression, in which this system will appear to 
many persons to afford but little evidence as to 
the real nature of the complaint. The delusive 
impression appears to be so blended with the pre- 
valent disorder of the feelings and affections, or it 
seems to be so much the result of the peculiar cir- 
cumstances by which the patient is surrounded, 
that it is scarcely contemplated as a distinct and 
peculiar phenomenon. These remarks will re- 
ceive illustration from the following case. 

Mr. H. P had been for many years con- 
fined in a lunatic asylum, when, an estate having 
devolved upon him by inheritance, it became ne- 
cessary to subject him anew to an investigation. 
He was examined by several physicians, who 
were unanimous in the opinion that he was a 
lunatic; but a jury considered him to be of sound 
understanding, attributing his peculiarities to 
eccentricity, and he was consequently set at 
liberty. 

The conduct of this individual was the most 
eccentric that can be imagined : he scarcely per- 
formed any action in the same manner as other 



men ; and some of his habits, in which he obsti- 
nately persisted, were singularly filthy and dis- 
gusting. For every peculiar custom he had a 
quaint and often ludicrous reason to allege, which 
indicated a strange mixture of shrewdness and 
absurdity. It might have been barely possible to 
attribute all these peculiarities, as well as the 
morbid state of temper and affections, to singu- 
larity in natural character and to the peculiar cir- 
cumstances under which this person had been 
placed. But there was one conviction deeply 
fixed on his mind, which, though it likewise 
might be explained by the circumstances of his 
previous history, seemed to constitute an instance 
of maniacal delusion. Whenever any person 
whom he understood to be a physician attempted 
to feel his pulse, he recoiled with an expression 
of horror, and exclaimed, " If you were to feel 
my pulse, you would be lord paramount over me 
for the rest of my life." The result has proved 
that confinement is not always necessary in cases 

of this description. Mr. H. P has remained 

at liberty for many years, and his conduct, though 
extremely singular, has been without injury to 
himself or others. 

We shall conclude our observations on this 
subject by the record of a remarkable case which 
illustrates the tendency of moral insanity to de- 
generate into, or ultimately assume, the character 
of monomania. The individual who was the 
subject successively of these forms of disease, was 
for several years in a state which gave rise to ap- 
prehension in many of his friends, while some 
who narrowly observed him were fully convinced 
of his insanity. The disease at length broke out 
in a form which admitted of no doubt. 

A gentleman remarkable for the warmth of his 
affections, and the amiable simplicity of his cha- 
racter, possessed of great intellectual capacity, 
strong powers of reasoning, and a lively imagina- 
tion, married a lady of high mental endowments, 
and who was long well known in the literary 
world. He was devotedly attached to her, but 
entertained the greatest jealousy lest the world 
should suppose that, in consequence of her talents, 
she exercised an undue influence over his judg- 
ment, or dictated his compositions. He accord- 
ingly set out with a determination of never con- 
sulting her, or yielding to her influence, and was 
always careful, when engaged in writing, that she 
should be ignorant of the subject which occupied 
his thoughts. His wife has been often heard to 
lament that want of sympathy and union of mind 
which is so desirable in married life. This pecu- 
liarity, however, in the husband so much in- 
creased, that in after years the most trifling pro- 
position on her part was canvassed and discussed 
by every kind of argument. In the meantime he 
acquired strange peculiarities of habits. His love 
of order, or placing things in what he considered 
order or regularity, was remarkable. He was 
continually putting chairs, &c. in their places ; 
and if articles of ladies' work or books were left 
upon a table, he would take an opportunity unob 
served of putting them in order, generally spread- 
ing the work smooth, and putting the other articles 
in rows. He would steal into rooms belonging 
to other persons for the purpose of arranging the 
various articles. So much time did he consua 



36 



INSANITY. 



in trifles, placing and replacing, and running from 
one room to another, that he was rarely dressed 
by dinner-time, and often apologised for dining in 
his dressing-gown, when it was well known that 
he had done nothing the whole morning but 
dress. And he would often take a walk in a 
winter's evening with a lanthorn, because he had 
not been able to get ready earlier in the day. He 
would run up and down the garden a certain 
number of times, rinsing his mouth with water, 
and spitting alternately on one side and then on 
the other, in regular succession. He employed a 
good deal of time in rolling up little pieces of 
writing-paper, which he used for cleaning his 
nose. In short, his peculiarities were innumer- 
able, but he concealed them as much as possible 
from the observation of his wife, whom he knew 
to be vexed at his habits, and to whom he always 
behaved with the most respectful and affectionate 
attention, although she could not influence him 
in the slightest degree. He would, however, oc- 
casionally break through these habits ; as on Sun- 
days, though he rose early for the purpose, he was 
always ready to perform service at a chapel a mile 
and a half distant from his house. It was a mys- 
tery to his intimate friends when and how he 
prepared these services. It did not at all surprise 
those who were best acquainted with his pecu- 
liarities, to hear that in a short time he became 
notoriously insane. He fancied his wife's affec- 
tions were alienated from him, continually affirm- 
ing that it was quite impossible she could have 
any regard for a person who had rendered him- 
self so contemptible. He committed several acts 
of violence, argued vehemently in favour of sui- 
cide, and was shortly afterwards found drowned 
in a canal near his house. It must not be omitted 
that this individual derived a predisposition to 
madness by hereditary transmission : his father 
had been insane. 

Of Mania. — The phenomena of mania in its 
ordinary form are very distinguishable from those 
of monomania. The aspect, the voice, the ges- 
tures of the lunatic in the active state of maniacal 
derangement, form a contrast with the retired and 
morose habits of the sullen monomoniac. In cases, 
however, of mania, distinctly so termed, one im- 
pression often occupies the mind of the individual 
for the time being, and this is frequently some 
hallucination respecting his own person, some 
magnific dream of self-importance and superiority. 
M. Pinel says, " I was frequently followed at the 
Bicetre by a general, who said that he had just 
been fighting an important battle, and had left 
fifty thousand men dead on the field. At my side 
was a monarch who talked of nothing but his 
subjects and his provinces. In another place was 
the prophet Mahomet in person, denouncing ven- 
geance in the name of the Almighty. A little 
further was a sovereign of the universe, who 
could with a breath annihilate the earth. Many 
of them seemed to be occupied by a multiplicity 
of objects, which were present to their imagina- 
tions. They gesticulated, declaimed, and vocife- 
rated incessantly, without appearing to see or hear 
anything that passed. Others, under illusive in- 
fluence, saw objects in forms and colours which 
they did not really possess. Under the influence 
Ol an illusion of that kind, was a maniac who 



mistook for a legion of devils every assemblage of 
people that he saw. Another maniac tore his 
clothes to tatters, and scattered the straw on which 
he lay, under the apprehension that they were 
heaps of twisted serpents." 

Ordinary mania, or madness affecting the mind 
with a general disturbance of the intellectual fa- 
culties, is sometimes preceded by occasional fits of 
excitement and confusion, in which the under- 
standing is hurried and disordered. But it differs 
from monomania in making its attacks for the 
most part suddenly and without any premonitory 
symptoms. An individual, after having undergone 
an unusual degree of mental and bodily exertion 
and fatigue, after a fit of intoxication, which in 
this country is one of the most ordinary of ex- 
citing causes of madness, after the excitement of 
violent passions or anxieties, after exposure to cold 
and the inclemencies of weather, passes sometimes 
a day or two in a state of feverish disorder and 
general uneasiness, and two or three restless nights. 
His mind is then found to be confused ; he appears 
scarcely to know what he says, talks nonsense, 
repeats his words frequently, expresses his feelings 
with an absurd degree of warmth and enthusiasm, 
cries, laughs, utters rapid and confused sentences 
in a hurried and impetuous manner. "In the 
course of a few days, or sometimes at first, he is 
seized with violent agitations, expresses vague and 
continual apprehensions, is subject to fits of terror; 
he is in a state of constant excitement and sleep- 
lessness ; he indicates the troubled state of his 
mind by unusual gestures, by singular appearances 
of the countenance, and by actions which cannot 
fail to strike in a forcible manner every observer. 
The various aspects which the symptoms of the 
disease assume at this period, have never been 
more graphically described than by M. Pinel. 
" The patient sometimes keeps his head elevated 
and his looks fixed on high ; he speaks in a low 
voice, or utters cries and vociferations without any 
apparent motive ; he walks to and fro, and some- 
times arrests his steps as if excited by the senti- 
ment of admiration, or wrapt up in profound re> 
verie. Some insane persons display wild excesses 
of merriment, with immoderate bursts of laughter. 
Sometimes, also, as if nature delighted in contrasts, 
gloom and taciturnity prevail, with involuntary 
showers of tears, or the anguish of deep sorrow, 
with all the external signs of acute mental suffer- 
ing. In certain cases a sudden reddening of the 
eyes and excessive loquacity give presage of a 
speedy explosion of violent madness, and the ur- 
gent necessity of a strict seclusion. One lunatic, 
after long intervals of calmness, spoke at first with 
volubility, he uttered frequent shouts of laughter, 
and then shed a torrent of tears ; experience had 
taught the necessity of shutting him up immedi- 
ately, for his paroxysms were at such times of the 
greatest violence. It is often observed that extatic 
visions in the night are the preludes to fits of ma- 
niacal devotion ; and by enchanting dreams, or by 
the fancied apparition of a beloved object, it some- 
times happens that erotic madness breaks out with 
violence, when it may either assume the character 
of a calm reverie, or display nothing but extreme 
confusion in the ideas and the entire subversion 
of reason." 

When the disease has taken a firm hold on its 



INSANITY. 



37 



unfortunate victim, it sometimes gives rise to all 
the internal effects, and displays all the external 
phenomena which the most intense feelings of 
human misery, resulting from the real calamities 
of life, may be imagined to produce. The maniac 
who becomes the subject of violent excitement " is 
seen in a state of extreme agitation, with his face 
flushed, his eyelids inflamed, and his eyes sparkling, 
his temples beating violently; he talks, cries, sings, 
grieves, gets into fits of rage by night and by day, 
and is incapable of taking rest. The melancholic, 
also, in extreme agitation, but wrapt up in himself, 
goes to seek in some quiet and dark recess a re- 
fuge from his panic terrors, from his gloomy and 
despairing thoughts ; or the means of putting into 
execution his baneful designs. The insensible 
and stupid, incapable of anything, remain un- 
conscious of surrounding objects, and do not even 
exert themselves to satisfy their most urgent wants. 
At this period of madness there is a constant want 
of sleep : the patient often experiences a feeling 
of tension and of heat in the head, without, how- 
ever, complaining of it. Sensibility to external 
impressions, as well as to all bodily changes, is so 
much lessened, that blisters, cauteries as well as 
exposure to intense cold, will sometimes produce 
but little expression of pain or distress. 

4. Of Incoherent Madness. — A very peculiar 
and well characterized form of mental derange- 
ment is that of incoherent madness, or incoherency, 
in which the mind is occupied by a rapid succes- 
sion of unconnected thoughts and evanescent emo- 
tions, and becomes entirely incapable of reflection, 
or even of distinct apprehension. Such cases are 
frequent, and are to be met with in every recep- 
tacle containing a considerable number of lunatics. 
Incoherent madness, or incoherency, is the most 
proper designation for this state of disease, as it 
describes the essential and characteristic feature. 
By Pinel the term demence, or dementia, has been 
adopted ; and to this there would be no objection 
if it were not for the circumstance that the same 
term has been used by Esquirol and Georget with 
a different meaning, and that confusion would 
hence arise from an ambiguous designation. Under 
the term demence, the writers last mentioned de- 
scribe that state approaching to fatuity or idiotism, 
which is the termination of protracted insanity, 
and in this sense the word is now commonly re- 
ceived. Since this is a morbid condition very 
distinguishable from that incoherency which is a 
primary and idiopathic form of mental derange- 
ment, each of these states of disease must have a 
particular epithet. 

This form of madness is in some instances a 
primary affection ; at least the tendency to inco- 
herency displays itself very early in the progress 
of the case. The disease commences with great 
excitement ; the patient is restless and unusually 
active ; his manners are full of bustle and violence ; 
his countenance flushed ; he has sleepless nights ; 
his thoughts follow each other with turbid rapidity; 
and his whole appearance strongly resembles that 
of a man of excitable temperament intoxicated 
with wine or spirituous liquors. In many cases 
there is no hallucination or erroneous impression 
on the mind that can be traced, but the violent 
and irrational activity of the patient is such as to 
require coercion. The succession of confused 

d 



and imperfect ideas becomes after a time so rapid 
as to preclude distinct utterance. The association 
which connects images in the mind seems to be 
lost, or at least cannot be traced, and the thoughts 
appear to be single and insulated. Words and 
sentences are half pronounced ; the voluntary 
movements are without design, and the effort to 
perform them is incomplete ; it is impossible to fix 
the attention of the patient sufficiently for obtain- 
ing a reply to the shortest question ; he becomes 
almost insensible to the existence of external ob- 
jects, talks incessantly, or repeats the same word 
or half sentence over to himself; he takes his food, 
when it is offered to him, by hasty snatches, and 
swallows it greedily, or spits it out again in order to 
continue his unmeaning jargon. After this state 
of excitement has continued for some time, it gra- 
dually subsides, and the disease either continues 
with mitigated violence, but still with the same 
form of incoherency and want of connection in 
the course of thoughts and feelings, or the expres- 
sions gradually appear to be more connected, the' 
patient becomes capable of sleep, and a slow pro- 
gress towards the restoration of the reasoning fa- 
culty is perceptible. The writer of the present 
article has witnessed several instances of complete 
recovery of the mental powers after the existence, 
during many weeks and even months, of maniacal 
phenomena answering to the above description ; 
and every physician who has had opportunities of 
inspecting lunatic asylums must have observed 
many cases in which the state of incoherency has 
terminated in recovery, and others in which it has 
become chronic and permanent. 

The following case described by Pinel is a well 
marked instance of the morbid state now under 
consideration, and it will be sufficient to prove 
that the affection termed by that writer demence 
is precisely what we have designated as incohe- 
rent madness. 

" An ardent but ill-informed patriot, and one of 
the warmest partisans of the celebrated Danton, 
was present at the sitting of the legislative body, 
when the writ of accusation was pronounced 
against that deputy. He withdrew in consterna- 
tion and despair, shut himself up in his own 
apartment for several days, and surrendered him- 
self to the influence of the most gloomy ideas. 
' What ! Danton a traitor !' he repeated without 
ceasing ; ' then is there no man to be trusted ; the 
republic is lost !' His appetite and sleep forsook 
him. Complete insanity ensued. Having under- 
gone the usual treatment at the ci-devant Hotel 
Dieu, he was removed to the Bicetre. He passed 
several months in the infirmary of this hospital 
in a state of tranquil reverie, uttering incessantly 
half-expressed and unconnected sentences. He 
talked alternately of daggers, sabres, dismasted 
vessels, green meadows, his wife, his hat. He 
never thought of eating but when food was actually 
put into his mouth ; and in respect to his func- 
tions he was almost levelled with an automaton." 
The chronic form of incoherence presents simi- 
lar phenomena, but in a milder degree. Patients 
in this last state have intervals of rest ; they 
sleep, and have periods of tranquillity during their 
waking hours, but seldom or never display cohe- 
rence and arrangement in their ideas, or mako 
any approach towards a sane and vigorous uso 



38 



INSANITY. 



of the reasoning powers. Neither have they any 
appearance of melancholy or abstraction, but they 
are capable of being momentarily excited by ob- 
jects which impress their senses and by the scenes 
around them, though their impressions are transi- 
tory and evanescent. They talk to themselves or 
to others for a long time in phrases scarcely con- 
nected by any perceptible link, and in which there 
is rarely a glimpse of meaning ; and if any asso- 
ciation can be traced in their thoughts, it is of the 
most trivial kind, and depending on a word or 
some sensible object which for a moment attracts 
their attention. They will sometimes repeat the 
same word or half sentence many times, but soon 
forget it. 

The disease which we have now described under 
the designation of incoherent insanity has been by 
some writers identified with dementia, or the first 
stage of fatuity. It is, however, a particular form 
of mental disease, assuming its peculiar character 
from the first, and displaying phenomena very 
different from those of dementia, though, like other 
forms of madness, it is liable, when long pro- 
tracted, to pass eventually into fatuity. The writer 
of this article has seen in private practice and in 
hospitals several well-marked cases of incoherent 
madness in the acute form, which ran their course 
and terminated in recovery without passing into 
the chronic stage. Of the chronic form, which 
approaches most nearly to dementia, but may yet 
be distinguished from that state of disease in its 
ordinary appearances, some illustrative cases have 
been pointed out to him in the Lunatic Asylum at 
Fishponds, near Bristol, by Dr. Bompas, the hu- 
mane and intelligent conductor of that establish- 
ment. Two of these occur in brothers, whose 
symptoms are very similar, though those of one 
are more strongly marked than of the other. Al- 
though the former of these individuals has been in 
confinement for many years, his countenance does 
not display the well-marked aspect of dementia, 
of which M. Esquirol has given so excellent a 
delineation. If questioned, he replies with an in- 
telligent look, but in words quite beside the sub- 
ject, and chatters about a hundred unconnected 
things in the course of a few minutes. If you re- 
peat the question, it only increases his volubility 
without apparently drawing his attention a whit 
more nearly to the subject of inquiry. 

5. Observations on the State of the Faculties 
i?i Madness. — It has been a question frequently 
agitated among medical writers, in what precise 
changes in the organic operations of the brain, as 
well as in the mental processes which result from 
these operations, madness consists. The present 
is not a suitable opportunity for entering into a 
full discussion of this subject. In a practical point 
of view, all that is requisite will be obtained by a 
brief inquiry into the actual condition of the intel- 
lectual faculties in insane persons. 

It may be observed that consciousness generally 
remains unimpaired in lunatics, though its exer- 
cise, in some cases of madness with hallucination, 
is connected with singular phenomena. The pa- 
tient is conscious of his sensations, but he some- 
times expresses himself as if his notion of personal 
identity were strangely confused. He talks and 
reasons about his feelings as if they were those 
of another individual. These are by no means 



frequent cases, and in general lunatics have a dis- 
tinct perception of their personal identity, and 
refer their sensations and ideas correctly to them- 
scl vcs. 

Sensation likewise remains unimpaired in the 
insane : the organs of sense at least are not the 
seats of disease, nor are those processes in the ner- 
vous structure on which sensation depends in a 
deranged state. The sensations produced by light 
and sound are sometimes morbidly acute, from 
temporary affection of the organs of sight and 
hearing ; but this is accidental, and by no means a 
circumstance characteristic of madness. The 
effects of cold and other painful impressions are 
in some instances disregarded by lunatics, but this 
seems to be merely a result of intense excitement 
of the mind and its direction to other feelings and 
operations. Such cases are not so frequent as 
they are supposed to be, and in general lunatics 
are sensitive of external impressions. 

Perception of external objects is generally un- 
impaired, but in some cases it is strangely affected 
and perverted by the morbid impressions on the 
mind, and by the influence of the prevailing hal- 
lucinations. 

Maniacal hallucinations are of two kinds. Dr. 
Cullen has remarked that " there is sometimes a 
false perception or imagination of things present 
that are not ; but this is not a constant nor even 
a frequent attendant of the disease. The false 
judgment is of relations long before laid up in the 
memory." This means that the hallucination sel- 
dom refers to the scene actually present, but to the 
impressions of memory. When, however, the 
maniacal reverie becomes very intense, it produces 
hallucinations or false impressions which represent 
unreal objects as actually present. Even in this 
case it does not appear that perception is impaired. 
Some particular phantasms, the creations of reve- 
rie, are presented to the mind in colours so vivid 
as to produce an effect similar to that of actual 
perception ; the patient in other respects makes 
no mistakes with regard to place or time ; his per- 
ceptions of external objects are correct and uni- 
form whenever his attention is directed to percep- 
tible things ; but he is so intent upon his reverie, 
that for the most part he totally neglects them ; 
his fancy becomes so intense in its operation as to 
carry him away from the influence of his external 
perceptions, and to environ him with visions of 
unreal scenes. 

We have often seen a lunatic under this form 
of disease walk up and down a frequented place, 
sufficiently alive to external objects to avoid falling 
in the way of horses and carriages, or running 
against foot-passengers, but so intent upon the 
scene presented by his excited imagination as to 
be busily employed in issuing commands to troops 
of which he imagined himself to be the general, 
and in directing them to enfilade to the right and 
left, and perform a variety of evolutions. °A11 this 
he performed with a voice and gesture that were 
perfectly natural and consistent with reality. To 
this modification of madness belong those mania- 
cal hallucinations termed by some writers idilo- 
mania or daemonomania, in which the lunatic fan- 
cies that he sees and holds converse with imagi- 
nary beings. The conception of the mind is so 
vivid and intense that it withdraws consciousness 



INSANITY. 



entirely from the sensations excited by surround- 
ing objects, which nevertheless exist, and occa- 
sionally under particular circumstances give rise 
to perception. Maniacal hallucinations have, 
however, a much firmer hold on the belief in some 
cases of madness than the strongest evidence af- 
forded by perception, and hence the futility of 
those projects which are occasionally suggested 
for surprising lunatics into a conviction of their 
false judgments. An insane female confined in 
an asylum had a firm persuasion that her husband 
was dead. When he came to visit her, she as- 
serted that it was the devil who had assumed his 
form. Her recollection and perception had re- 
mained unimpaired, but the insane hallucinations 
overcame their evidence and held possession of 
her mind. 

The power of reasoning or judgment does not 
appear to be so much impaired in madness as the 
disposition to exercise it on certain subjects. Of- 
ten there is a manifest unwillingness to admit any 
evidence unfavourable to the false notions impressed 
upon the mind, while great ingenuity is displayed 
in finding arguments which may tend to make it 
apparently more reasonable. A case illustrative 
of this remark has been already mentioned. 

In many instances of madness it would appear 
that the characteristic feature of the disease is a 
morbid inclination to indulge in reverie, and to 
yield the judgment and all the faculties to its con- 
trol. The impressions of reverie are so modified 
by disease as no longer to be distinguishable from 
those of memory or active reflection. We may 
venture to say that this observation will go far 
towards explaining the mental phenomena of the 
disease. 

6. Disorders in the state of the physical func- 
tions attendant upon madness. — The phenomena 
of madness which attract most observation, and 
which indeed characterize the disease, are those 
which depend upon the disordered state of the ce- 
rebral functions ; but other processes in the living 
body are likewise in a state of derangement. There 
is in most cases of insanity, besides the morbid 
condition of the brain and nervous system, more 
or less of disturbance in the physical functions ; the 
secretions, excretions, appetite, and digestive pro- 
cesses are frequently disordered. Medical writers 
have differed in opinion as to the relation which 
these affections bear to the cause of insanity. — 
Pinel has stated it to be the result of his inquiries 
that the primary seat of mental alienation is gen- 
erally in the region of the stomach and intestines, 
and that from that centre it propagates itself, as it 
were, by irradiation, and deranges the understand- 
ing. Others have looked upon the disorders in 
the functions of the viscera as merely contingent 
results of a primary disease, seated in or immedi- 
ately affecting the brain. 

Whichever of these opinions may be correct, 
the general, or at least the frequent co-existence 
of disorder in the physical functions with that 
affection of the brain from which the deranged 
state of the mind immediately results is an indis- 
putable fact. 

The physical functions are differently affected 
in different forms of madness. In disorders of 



slow and gradual accession, and especially in those 
cases in which the mind is melancholy and de- 
pressed, a torpid state of the vital and natural 
functions for the most part prevails ; the circula- 
tion is languid ; the pulse weak and generally- 
slow ; the extremities cold ; the skin cold and 
clammy ; most of the secretions are defective ; the 
bowels are torpid and sometimes obstinately con- 
stipated and flatulent, requiring strong doses of 
aperient medicine. The appetite is defective ; di- 
gestion is impaired ; sometimes there is a constant 
loathing of food, which, if the patient were not 
obliged to eat, would induce him to starve him- 
self, and it is often extremely difficult to persuade 
persons in this state to swallow nutriment suffi- 
cient for the preservation of life. Emaciation and 
loss of strength inevitably result from these cir- 
cumstances, but they are sometimes not so striking 
as any person would anticipate. 

Attacks of maniacal disease, which break out 
suddenly with great excitement of the passions, 
with general disturbance of the intellectual facul- 
ties, or with incoherence, are almost always ac- 
companied by symptoms of fever or pyrexia more 
or less acute. The pulse is rapid, often full, and 
beating with disproportioned strength in the 
carotid and temporal arteries ; the skin is hot and 
the tongue white ; there is thirst, with loss of ap- 
petite, headach, sleeplessness, and great irritabili- 
ty ; the secretions are deficient, the urine is high- 
coloured and scanty, and the bowels are consti- 
pated. The face is often flushed ; the eyes are 
glossy and suffused ; the conjunctiva is injected 
with blood, and the pupils are contracted. The 
patient sometimes complains of pain in the fore- 
head and temples, with a sense of weight upon 
the head, or of constriction, as if the scalp were 
tightly drawn. It has been observed that in some 
instances persons who had previously suffered 
severely from headach have ceased to complain of 
it when madness has supervened, and that it has 
returned when such patients have become con- 
valescent. Want of rest is often a troublesome 
and distressing symptom. Many patients pass 
whole nights without closing their eyes, or when 
they obtain sleep, it is short and agitated. In 
other instances a few hours of sound sleep are 
the prelude to a paroxysm of renewed excitement, 
the maniacal symptoms breaking out on waking 
with increased violence. 

All the symptoms which refer themselves in a 
perceptible manner to the head are liable to un- 
dergo occasional exacerbations during the con- 
tinuance of madness. Increased heat of the 
scalp, redness of the eyes, fulness and strong pul- 
sation of the carotid and temporal arteries, want 
of sleep and consequent irritability of the temper 
and feelings, indicate and precede or accompany 
renewed periods of violence in the symptoms 
of mental derangement. 

In many instances of maniacal disease there is 
much disturbance in the functions of the intestinal 
canal. This observation has been made more par- 
ticularly in persons whose general health has 
been previously much neglected ; in the inmates 
of some lunatic asylums ; in individuals of the 
lower class, who have been subjected to hardships 
and unwholesome diet, as well as to cold and a 



40 



clamp unwholesome atmosphere ; in cases in which 
the disease has followed excesses of various kinds, 
or confinement on ship-board, with the use of salt 
provisions. In many instances of this description 
it has been found that the bowels had been long 
in a confined and torpid state. In those instances 
in which it is stated that the bowels are open 
and even more loose than natural, it often appears 
on further examination that a long-continued 
torpor and constipation have given way to diar- 
rhoea; the abdomen, which had previously been 
swelled with indurated matter, has become more 
distended than before, flatulence being added to 
the load of solid contents but partially discharged. 
The evacuations are thin and watery, or contain 
mucus mixed with vitiated bile and recent aliment 
in an undigested state. Sharp and transient 
pains are experienced in various parts of the ab- 
domen, which is often tender on pressure ; at 
length, in very neglected cases, dysentery super- 
venes and brings on extreme emaciation. The 
tongue is often red or covered with a brown fur, 
and the mouth and fauces with a viscid mucus, 
which, together with saliva, the patient spits out 
in all directions. There is great thirst and a 
peculiar fetor of the breath, which extends to the 
whole person. The appetite is depraved ; in many 
cases the patient has an aversion to all food ; in 
other instances he has a keen and voracious 
desire for it, and greedily devours without selection 
every thing eatable that falls in his way. The 
skin is cold; there is a remarkable coldness of the 
extremities, resulting from the damp state of the 
skin and a want of energy in the circulation 
through the extreme vessels. In some cases 
of long duration, there are papular or scaly erup- 
tions ; and in exhausted and debilitated subjects, 
furunculi appear in various parts of the body 
which are much disposed to slough. 

[See an interesting case, by Dr. Prichard, of 
the connection of insanity with tuberculous forma- 
tions and ulceration in the intestinal canal, in 
Provinc. Med. Journal, Jan. 27th, 1844, or in 
Amer. Journal of the Med.Sciences, April, 1844, 
1 . 445.] 

Cases of madness, coming on with some degree 
or rapidity, are often preceded and sometimes 
accompanied or followed by suppressions of natural 
or customary discharges, by the disappearance of 
external diseases, or the cure or suspension of 
internal complaints. The relation which these 
changes bear to madness as causes or results may 
be different in different cases ; they are connected 
circumstances of that disease. The catamenia, 
if not suppressed previously to the manifestation 
of cerebral disorder, soon become scanty, or cease 
entirely after its actual appearance. Lochise and 
other analogous effluxes are suppressed ; ulcers, 
which had become habitual and had long dis- 
charged, are dried up; chronic eruptions generally 
disappear, or are materially lessened ; symptoms 
of pulmonary phthisis in various stages cease or 
become mitigated in a remarkable degree. On the 
decline of maniacal disease, it is often found that 
the return of such discharges, or the revival of 
suspended trains of morbid symptoms such as we 
have described, is the harbinger of restoration to a 



INSANITY. 

round state of mind, though not to complete 

bodily health. 

g ECT> HI. — Of the Duration of Insanity, 
and of the Modes of its Termination. 

The duration of insanity is various, and admits 
of no general estimate. In some instances this 
disease has subsided in the course of a few days 
after its commencement ; in others it continues for 
many years. M. Esquirol has remarked that it is 
not uncommon to meet with inmates of lunatic 
asylums who have been twenty, thirty, or even 
forty years in confinement. The same observa- 
tions must have occurred to every person who has 
been in the habit of visiting such establishments. 

Insanity has three different terminations : — 
first, in recovery ; secondly, in a state of fatuity, 
or of chronic and permanent failure or obliteration 
of the mental faculties; thirdly, in death. The 
last is generally the contingent result of some of 
those disorders in the physical functions of the 
body to which the insane are especially liable. 
We shall allot a separate consideration to the cir- 
cumstances connected with each of these events 
of insanity. 

1. Of Recoveries from Insanity. — Recovery 
from madness sometimes takes place suddenly, 
but more frequently it is gradual, and preceded 
by several periods of mitigation in the intensity 
of disease, and often by lucid intervals. 

The prospect of recovery is much greater in 
young persons than in those of advanced years, 
and it diminishes, other circumstances being equal, 
with the patient's age. M. Esquirol has observed 
that few lunatics are cured after the sixtieth year. 
It must, however, be taken into the account that 
few comparatively are for the first time attacked 
by madness after that period of life. 

The curability of madness, or, to speak more 
correctly, the proportion of maniacal cases which 
terminate in recovery, is likewise subject to great 
variation from circumstances which refer to the 
nature of the disease, its occasional complication 
with other maladies, the sex and constitution of 
the patient, the mode of treatment to which he 
is subjected, and the causes which have given 
rise to his disorder ; and hence any general calcu- 
lations on this subject are matters rather of cu- 
riosity than of practical value. One remark, how- 
ever, may be of use, as it may encourage medical 
practitioners in their efforts to remove or mitigate 
the disease. Of cases which present no peculiarly 
unfavourable combinations, a much larger propor- 
tion terminate in recovery than is generally sup- 
posed, or than any person could be led to believe 
from the inspection of reports from hospitals. In 
these reports it generally happens that a great 
number of inveterate cases, and of such as are 
incurable from their conjunction with other dis- 
eases dangerous to life, and indicating changes in 
the organic condition of the brain, are blended with 
those of simple insanity in the general averages. 

M. Esquirol has endeavoured, by comparing the 
reports of several extensive hospitals in Frlnce 
and England, to throw some light on the cura- 
bility of madness, or on the proportion of reco- 
veries. The following table presents some facts 
which are of great interest. 



INSANITY. 



41 



TABLE OF RECOVERIES FROM MADNESS. 

In England. Admissions. 

In Bethlem Hospital from 1748 to 1794 8874 . 

in 1813 422 . 

In St. Luke's from 1751 to 1801 6458 . 

In York. Asylum 599 . 

In the Retreat, near York from 1801 to 1814 1G3 . 



Totals.. 165 16 

In France. 

Charenton from Nov. 22, 1798 to 1800, 22 July 

1803 

Salp£triere from 1801 to 1805 

" from 1804 to 1813 

" from 1806 to 1807 

" from 1812 to 1814 

In M. Esquirol's private establishment, from 1801 to 1813 .... 



Recoveries. 

. 2557 

204 

2811 

286 

60 

. 5918 



Totals. .5360 



2691 



From the data contained in this table, M. Es- 
quirol concludes, " first, that the absolute number 
of recoveries from madness is about one in three ; 
secondly, that the number of recoveries varies 
from one in four to one in two, or to one-half of 
the number of persons affected : this difference 
depends upon particular circumstances of locality, 
on the nature of the cases, and of the treatment 
pursued : thirdly, that cures are more numerous 
in France than in England." He adds that they 
are much more rare in Germany and in Prussia. 

A much more extensive collection of reports 
from various lunatic asylums, both public and 
private, in England, France, and other countries, 
has been made by Dr. Burrows, who has con- 
structed from these materials a table exhibiting the 
proportion of recoveries. The evidence afforded 
by such collections is very much confused, and in 
many instances rendered wholly inconclusive from 
the variety which exists in the regulation of differ- 
ent establishments as to the nature of the cases 
admissible into them, and the time during which 
the patients admitted are kept. For instance, the 
hospitals of Bethlem and St. Luke impose cer- 
tain exclusions elsewhere unknown. They reject 
all patients who have been more than twelve 
months insane ; those affected by paralysis, how- 
ever slight, and by epilepsy or convulsive fits ; 
idiots, the aged and infirm ; those discharged un- 
cured from other hospitals : there are likewise 
other exclusions besides those above mentioned, 
and all persons who have not recovered at the ex- 
piration of one year are dismissed. Yet on com- 
paring the reports of these hospitals with those of 
other institutions, the regulations of which are 
less favourable to a high proportion of cures, and 
where no selection or exclusion exists, we do not 
find, as Dr. Burrows remarks, the relative number 
of recoveries to be so great as might be expected. 
It is indeed surprising to find that the reports of 
3cthlem Hospital, of a century and a half ago, 
give a greater proportion of cures than those of 
many years preceding 1817, when an improve- 
ment took place in the arrangements of that es- 
tablishment. Dr. Burrows remarks on the au- 
thority of Stow, who derived his information from 
Dr. Tyson, physician to Bethlem Hospital, that 
" from 1684 to 1703, 1294 patients were admitted, 
of whom 890 were cured, which is a proportion 
Vol. III. — 6 d * 



of two in three. But from 1784 to 1794, 1664 
patients were admitted, of whom 574, or rather 
more than one in three, recovered." It is proba- 
ble that there were circumstances in the former 
arrangements which, if they were known, would 
explain this difference. On the whole, the results 
of Dr. Burrows' inquiries are much more favoura- 
ble to British hospitals than those of M. Esquirol. 
It appears, indeed, from his statements that the pro- 
portions of recoveries in England are greater than 
those obtained in France, Germany, and, a for- 
tiori, in any other country in Europe. This may be 
in some degree judged of by comparing the follow- 
ing statements, taken during late years, with those 
previously given from M. Esquirol's collections. 

In Stafford Asylum, from 1818 to 1828, ad- 
missions 1000; cured 429 ; or about 43 in 100. 

In Lancaster County Asylum, from 1817 to 
1825, admissions 812; cured 322 ; or about 39 
in 100. 

In Wakefield County Asylum for the West 
Riding of Yorkshire, from 1819 to 1826, admis- 
sions 917; cured 384 ; or about 42 in 100. 

[The experience of the insane institutions of 
the United States has been highly encouraging. 
They are admirably conducted institutions; yet 
it is not easy to deduce from them, or from the 
European institutions more than an approximation 
to the number of cures. Annual reports are cer- 
tainly not well adapted to convey very positive 
information as to relative curability ; and this is 
sufficiently shown by the discrepancy amongst 
them ; — those which publish the smallest number 
of cases cured being by no means the least suc- 
cessful. The published ratio of cures is generally, 
indeed, higher than it ought to be, owing to the 
time being too short to enable an accurate judg- 
ment to be formed, and the patients being too 
often withdrawn or dismissed from the institution 
before they were wholly restored. Dr. Pliny Eai.e 
(Amer. Journal of the Med. Sciences, April 1843, 
p. 347) has drawn up the following table, which 
applies, in the case of all the institutions but one, 
to a series of years. In the Bloomingdale Asy 
lum, New York, many cases of delirium tremens 
are received, which may account for the greater 
proportion of recoveries among males; — as a gene- 
ral rule, the greater number of restorations ap- 
pearing to occur in the other sex. 



42 



INSANITY. 



A S Y L U H S , 



T I M K 



Hanwell 

Pennsylvania Hospital 

Bloomingdale 

Massachusetts State Hospital 

Total 



1S31 to 1840 

1841 

1821 to 1841 

1833 to 1841 



M E N , 



Admitted 
1013 

103 

1692 

680 



Cured. Pit Cent. 



34S8 



223 

15 
848 
365 

1451 




35.09 



Al?nTiT7^C"]^ri^^ 



1016 

73 

906 

637 

~2632" 



2261 22.24 

15 20.54 

352 3S.91 

39^ 61.53 

"985 35.80 



(See, also, Dr. Woodward, in Eleventh Annual 
Report of the State Lunatic Asylum, at Worces- 
ter, Mass., p. 39, Boston, 1844.)] 

From these statements it clearly appears that 
M. Esquirol's computation of recoveries is much 
below what really takes place under favourable 
circumstances. The results are so different under 
different circumstances, that no general average 
can be of much value in a practical point of view. 

Another inquiry, which admits of a more satis- 
factory elucidation, and which leads to results 
very interesting in their relation to prognosis, re- 
fers to the period of the disease during which re- 
covery is chiefly to be expected. Some facts, 
tending to illustrate this question, were contained 
in a memoir presented by M. Pinel to the French 
Institute in 1800. It appeared from this memoir 
that the greatest number of recoveries from mad- 



ness take place in the first month of its duration, 
the recoveries during the first being compared with 
those of succeeding months. The mean time for 
the duration of the disease, in cases terminating 
favourably, was fixed in the same document at 
from five to six months. This result was deduced 
from a selection of cases from which the author 
excluded all those which had been under previous 
treatment, as well as cases of long duration. A 
longer term is assigned to this disease, in cases 
terminating in recovery, by Mr. Tuke in his ac- 
count of the Retreat at York ; and M. Esquirol, 
whose accuracy of research in subjects of this na- 
ture gives to his authority the highest value, con- 
firms the opinion of Mr. Tuke. He has drawn 
this conclusion from a statement of the cases ad- 
mitted into the Salpetriere during ten years, as 
shown by the following table. 



TABLE OF 

Admissions. 

209 

212 

206 


RECOVER 

1804. 1805. 

64 . . 47 . 

73 . 


IES 

1806. 
. 7 . 
. 54 . 

78 . 


AT T 

1807. 
. 4 . 
. 4 . 
. 49 . 

60 . 


HE 

1808 
. 3 
. 2 
. 10 
. 55 

64 . 


SALPETR] 

1809. 1810. 

. 2 

. 2 . . 1 
. 3 .. 1 . 
. 11 .. 1 
. 57 . . 4 . 
48 . . 64 . 
48 . 


ERE 

1811. 
1 . 

. 1 . 

. 2 . 
9 .. 

51 .. 
44 . 


DUR 

1812. 
1 

1 

2 . 

1 

4 . 

7 . 
30 . 
75 . 


ING 
1813. 

1 . 

1 . 

8 . 
41 . 
50 . 


TEN 

1814. 

1 . 

2 . 
. 3 . 
. 3 . 
. 3 . 
. 11 . 

. 49 .. 


YEARS. 

Totals of 
Cures. 

129 
.. 137 
.. 143 


204 

188 






129 
.. 130 


209 

190 










.. 129 
.. 110 


163 














.. 85 


208 














.. 127 


216 
















.. 99 


2005 


















...1218 



It seems that the report on which this table was 
founded, extended from the year 1804 to 1813; 
2804 female lunatics were admitted during this 
interval, of whom 795 were considered as incur- 
able, on account of their advanced age, or because 
they were idiotic, epileptic, or paralytic subjects. 
The remaining 2005 were put under treatment 
without regard to the duration or peculiar charac- 
ter of their disease. Out of this number, 604 
were cured during the first year, 497 in the second, 
86 in the third, and 41 in the seven succeeding 
years. From these data M. Esquirol draws the 
following conclusions ; first, that the greatest num- 
ber of recoveries are obtained in the two first years; 
secondly, that the mean duration of cases that are 
cured is somewhat short of one year; thirdly, that 
after the third year the probability of cure is scarcely 
more than one in thirty. There are, nevertheless, 
examples which prove that we ought never to 
despair of the recovery of lunatics. M. Pinel, from 
Baumes, cites the case of a lady who passed twenty- 
five years in a state of lunacy, within the know- 
ledge of the whole country where she lived, and 
who suddenly recovered her reason. « I have seen," 
•ays the same writer, " a girl who from the age 



of ten years was in a state of dementia, with 
suppression of the catamenia. One day, on rising 
from bed, she ran and embraced her mother, ex- 
claiming, ' Mamma ! I am well !' The catame- 
nia had just flowed spontaneously, and her reason 
was immediately restored. Such facts are rare, 
but they serve to prove that from the duration of 
the disease alone there is no reason to despair al- 
together of recovery." [See the work of M. 
Esquirol, Des Maladies Mentales Paris, 1838.] 
A few instances of the same kind have occurred 
in several lunatic houses or public hospitals, from 
the superintendents of which the writer of this 
article has obtained information respecting them. 

From another table published by M. Esquirol, 
it appears that, out of 269 maniacal patients, 27 
were cured in the first month of their illness, 34 
in the second, 18 in the third, 30 in the fourth, 
24 in the fifth, 20 in the sixth, 20 in the seventh, 
19 in the eighth, 12 in the ninth, 13 in the tenth 
23 after the first year, and 18 after two years. 
This is perhaps an attempt at a greater degree of 
accuracy in calculation than is, from the nature 
of circumstances, attainable. The same writer 
has made a remark in illustration of the greater 



INSANITY. 



43 



proportion of recoveries observed in the early pe- 
riod of madness, which is worthy of attention. 
He says, " I have constantly observed that in the 
course of the first month from the commencement 
of the disease a very marked remission takes place. 
About that period the maniacal excitement, which 
had previously run its course as an acute disorder, 
seems to have reached its termination as such, and 
it is then that it passes into a chronic state, the 
crisis having been incomplete. This remission, 
which I have watched with the greatest accuracy, 
must be attributed to the complaints which are 
complicated with madness at its commencement." 
The author implies, though he does not clearly 
express himself, that the natural termination of the 
disease, when unimpeded by complication with 
other maladies, or by more or less of organic le- 
sion in the brain, is in the very early stage. 

[It is exceedingly important to bear in mind 
the immense difference in the curability of insanity 
in recent and in chronic cases, which has been 
observed in other institutions besides those cited. 
In two " Appeals to the People of Pennsylvania 
on the subject of a State Asylum for the Insane 
Poor," which the writer prepared as Chairman of 
a Committee, the results in various insane establish- 
ments of this country were brought together. In 
one, the ratio of recoveries of those in whom the 
insanity was of less than 12 months' duration, was 
stated to be 82^ per cent.; whilst of the old cases 
it was only 15^ per cent. At the York West 
Riding Asylum, of 318 cases that had existed, 
according to Sir William Ellis, (^4 Treatise on 
the Nature, Symptoms, Causes, and Treatment 
of Insanity, Lond. 1838,) from one to thirty 
years, only 26 were cured ; and of 173 old cases 
in the Bloomingdale Asylum, New York, in 1835, 
only 16 were restored. 

Few patients who are more than 60 years old 
when attacked — it would seem from the experience 
of M. Esquirol — recover ; and the result of the 
greater part of inquiries would appear to show, 
that restoration is most frequent in youth, and 
less so as age increases. Dr. Woodward, however, 
affirms, that in the Massachusetts State Hospital, 
at Worcester, persons attacked with insanity after 
forty years of age, recover in much greater pro- 
portion than those attacked before that age.] 

Recoveries from madness are in many instances 
complete. There are numerous persons who have 
been insane for six or twelve months, or during a 
longer period, and have afterwards entirely recov- 
ered the vigour of their intellectual faculties, so as 
to be capable of as great and effective mental ex- 
ertions as previously to the attack. Others, and 
perhaps these are the majority, are curable only to 
a certain point. These persons remain, as M. 
Esquirol has observed, in such a state of suscepti- 
bility that the slightest causes give rise to relapses, 
and they only preserve their sanity by continuing 
to live in a house where no mental agitation or 
inquietude, no unfortunate contingency is likely 
to fall to their lot, and throw them back into their 
former state. There are other individuals whose 
faculties have sustained such a shock that they are 
never capable of returning to the sphere which 
they had held in society. They are perfectly ra- 
tional, but have not sufficient mental capacity to 
become again military officers, to conduct com- 



mercial affairs, or to fulfil the duties belonging to 
their appointments. Such cases may be about 
one-tenth in the number of recoveries. 

Convalescents are as subject to relapse as those 
who are advancing towards recovery from other 
diseases. But lunatics are in many instances like- 
wise prone to a recurrence of the disease after it 
has been entirely removed, or at least after its ma- 
nifestations have long ceased to be observed. The 
same observation may be applied to other disorders 
of the nervous system. It would seem that one 
attack of disease has in these cases left the patient 
with a stronger predisposition than he formerly 
had to the complaint, whatever it may have been, 
and that the morbid tendency is strengthened after 
every renewed incursion. The most trifling cir- 
cumstances have in these instances sufficient in- 
fluence to produce the morbid condition of the 
brain and of the mind. At length the patient is 
scarcely ever in a lucid state ; the intervals lessen 
in duration, and become rfcore and more imperfect 
in degree, until disease finally becomes in a great 
measure permanent. 

The proportion of cases in which madness is 
recurrent has been overrated. According to M. 
Pinel, in 71 cases out of 444 recoveries, relapse 
took place, or, rather, the disease was in those in- 
stances recurrent. This gives somewhat less than 
one-sixth of the whole number as recurrent ; but 
the same writer allowed that out of the 71 cases 
20 patients had previously relapsed, or had under- 
gone several attacks, 16 had left the hospital at too 
early a period, 10 came afterwards under treatment 
and recovered without relapse, 14 had given them- 
selves up to grief and intemperance, and several 
others were under circumstances unfavourable to 
continuance in health. M. Esquirol published a 
report of 2804 recoveries, in which number only 
292 recoveries of disease took place, that is, a little 
more than one-tenth. M. Desportes, however, has 
stated that, in 1821, 52 recurrent cases were re- 
cognised at the Bicetre, out of 311 admissions, 
that is, about 17 in a hundred ; at the Salpetriere 
in 454 admissions there were 66 relapses, about 
15 in a hundred, or one-seventh. But in the pro- 
portion of recurrent cases indicated by this last 
report, it is probable that there were, as M. Georget 
has well observed, many cases which had been 
discharged in a state of incomplete recovery, as 
well as a considerable number of drunkards, who 
come habitually every year to spend a few weeks 
in the Bicetre or the Salpetriere, having been 
picked up in the streets in a state of intoxication. 
In all instances we may consider it as certain that 
the improbability of recurrence increases with the 
length of the interval of time during which the 
patient has existed without manifesting signs of 
renewed disease, and that it is also greater in pro- 
portion to the completeness of the recovery. When 
the energy of mind is fully restored, relapse is 
much less to be feared than when it remains weak 
and excitable. 

Second Termination — Fatuity — Dementia — 
Amentia. — The ultimate tendency of madness 
when protracted, and the state to which insane 
persons, if they do not recover, are in general 
sooner or later reduced, is that of fatuity. The 
fatuity which constitutes the last stage of mental 
derangement differs in its phenomena from con- 



44 



genital idiotism. It has more resemblance to the 
imbecility of extreme old age, but from this last 
affection, which we shall describe at the conclusion 
of the present treatise, it is distinguishable and in 
many instances very different. For the sake of 
greater precision we shall divide maniacal fatuity 
into two grades or stages. The first is that state 
which Esquirol and Georget have named demence 
or dementia, a term which is established by the 
authority of these writers, and has been received 
into general use ; the second stage of fatuity, which 
is the last period of mental decay, and presents an 
almost entire obliteration of the faculties, may be 
properly distinguished by the term amentia. 

1. Dementia The approach of dementation, 

or the first period of fatuity, is indicated by a 
comparative state of calmness succeeding to the 
previous excitement of the maniacal period. It is 
not the calmness of returning reason, but the result 
of mental activity worn out, the subsidence or 
obliteration of the affections or moral feelings, and 
the decay even of physical sensibility. It has 
been well remarked by M. Georget that the cha- 
racteristic of dementation is a forgetfulness of the 
past, with a total indifference as to the present and 
future. Demented persons are generally quiet and 
inactive ; they take little notice of persons or ex- 
ternal things, without appearing to be occupied by 
any internal emotion or train of thought. They 
often, however, smile or laugh without any appa- 
rent reason, or sing, or pronounce, as if accident- 
ally, single words or sentences. Some remain for 
days or weeks without uttering a word, or betray- 
ing by look or gesture the least consciousness of 
external impressions. Such impressions, however, 
are sometimes afterwards discovered to have been 
not entirely unobserved. Many appear, by their 
looks or replies to questions, to know and remem- 
ber their friends or relatives, but scarcely display 
signs of emotion or sensibility on being visited by 
them. Not a few even in this state are capable 
of being employed in mechanical occupations. 
Females knit or sew, or perform any work with 
their hands to which they have been previously 
habituated ; and men draw, or write letters or 
sentences, in which, however, their imbecility is 
generally conspicuous. Some patients have occa- 
sional periods of greater excitement, in which the 
symptoms of a more active state of madness re- 
sume their prevalence. In other instances mere 
physical activity displays itself at intervals in pe- 
culiar ways, as by running, jumping, or walking 
round continually in a circle or determinate figure. 

The physical health of patients thus affected is 
in general tolerably good ; they are often fat, have 
good appetites, digest their food, sleep well, and if 
in the previous stages of the disease they had been 
emaciated, they often recover their natural degree 
of plumpness on the approach of dementia. Hence 
the return of physical health without a correspond- 
ing improvement in the state of the mental facul- 
ties, is, as it has been remarked by the writer last 
cited, an unfavourable prognostic in cases of ma- 
niacal disease. 

There are, however, some rare cases of recovery 
from this first stage of fatuity. Pinel informs us 
that many, especially young persons, who had re- 
mained in the Eicetre several years or months in 
a state >f absolute idiotism, have been attacked by 



INSANITY. 

Tparoxysm of acute mania of twenty, or fivc-and- 
twenty, or thirty days' continuance. « Such pa- 
roxysms," he adds, "apparently from a reaction 
of the system, are in many instances succeeded by 
perfect rationality." The same result has been 
observed on the restoration of demented persons 
or of maniacs in the advanced stage of insanity 
after severe attacks of fever of that kind which is 
usually attended with delirium. Such attacks are 
often fatal to lunatics ; but of those who recover 
them not a few are subsequently restored to the 
possession of their faculties. 

These instances of restoration from fatuity 
take place only after the first stage. When the 



disease has passed into complete amentia, it is al- 
together hopeless. 

2. Amentia. — Scarcely any exhibition of human 
suffering can be more deeply affecting than the 
aspect of a group of lunatics reduced to the last 
stage of fatuity, and those who have never wit- 
nessed such a spectacle can hardly imagine so ab- 
ject a state of mental degradation. In a group 
of this description an individual may be seen 
always standing erect and immovable, with his 
head and neck bent almost at right angles to his 
trunk, his eyes fixed upon the ground, never turn- 
ing them round, or appearing by any movement 
or gesture to be conscious of external impressions 
or even of his own existence. Another sits, on a 
rocking-chair, which she agitates to and fro, and 
throws her limbs into the most uncouth positions, 
at the same time chanting or yelling a dissonant 
song, only capable of expressing a total inanity of 
ideas and feelings. Many sit constantly still, with 
their chins resting on their breasts, their eyes and 
mouth half open, unconscious of hunger or thirst, 
and almost destitute of the feelings which belong 
to merely physical life ; they would never lie down 
or rise were they not placed in bed and again 
raised by their attendants. A great proportion of 
the patients who are reduced to this degree of fa- 
tuity are found to have lost the use of their limbs 
in a greater or less degree by partial or general 
paralysis. 

From such a state it is scarcely imaginable that 
recovery ever took place, but patients in the last 
stage of fatuity often linger for many years. Their 
state, however, is not always uniform : some of 
them have comparatively lucid intervals, at which 
nature seems to make an effort to light up the 
mind and recall lost impressions and ideas. A 
patient has often been observed by the writer of 
this article, who sits all day in a wooden elbowed 
chair, with his chin hanging over his breast, ap- 
pearing hardly conscious of existence and unable 
to assist himself in the calls of nature, who would 
not eat if food were not actually put into his 
mouth. He has been for several years in the same 
state, except that he occasionally appears to rouse 
himself, and for a short time to recover an unusual 
degree of animation. At such periods he will 
sometimes read a chapter in the Bible with a clear 
voice and a distinct and intelligible articulation. 

3. Of the termination of madness in Death 

Madness is not to be reckoned among the diseases 
which are very dangerous to life. The state of 
the brain on which it depends, though incompati- 
ble with the continuance in a sound state of those 
functions on which the mental operations are as- 



1NSAJN1TY. 



45 



sociated, is yet such as to carry on other processes, 
dependent on the brain, which are subservient to 
physical existence. 

This conclusion is established in a most con- 
vincing manner by the duration of insanity, and 
the cases even of longevity which occur among 
lunatics. We are informed by M. Desportes that 
among the lunatics at the Bicetre in the beginning 
of the year 1822, one had been lodged there fifty- 
six years, 3 upwards of forty years, 21 more than 
thirty years, 50 upwards of twenty years, 157 
more than ten years. At the Salpetriere the 
entry of patients dated, 7 cases from fifty to fifty- 
seven years, 11 from fifty to sixty, 17 from forty 
to fifty. 

The morbid state of the brain is, however, liable 
to increase beyond the limit above adverted to, and 
then the usual phenomena dependent on severe 
cerebral disease are manifested. It is well known 
that lunatics are subject in a much greater propor- 
tion than other persons to apoplexy, palsy, epilep- 
sy, and all the trains of symptoms depending on 
different degrees or modifications of cerebral con- 
gestion. 

Another mode by which madness brings on a 
fatal termination is by the exhaustion arising from 
continued excitement. There are many cases of 
maniacal disease in which the ceaseless excitement 
of the feelings, the constant hurry of mind and 
agitation of body, the total want of rest and sleep, 
and the febrile disturbance of the system which 
frequently ushers in the attack of madness, and is 
always a prominent feature in cases of this de- 
scription, bring on a very marked reduction of 
strength as well as of flesh : the degree of emaci- 
ation is sometimes extreme. Generally this state 
of excitement gradually abates, or the means 
adopted to lessen it and tranquillize the system are 
attended with success ; but this is not uniformly 
the case, and some maniacs die completely worn 
out and exhausted. It is in part owing to this 
cause that the mortality among lunatics is more 
considerable during the two first years from the 
period of their attack than in the succeeding years, 
a fact which appears to be established by the cal- 
culations of M. Esquirol. In the Salpetriere the 
number of deaths is even much greater in the 
first year than in the second. Of 790 lunatics 
who died in that hospital between the years 1804 
and 1814, it appears that 382 died in the first 
year from their admission, 227 in the second 
year, and 181 during the seven succeeding years. 

Many lunatics are carried off by diseases of the 
abdominal and thoracic viscera, which are compli- 
cated with madness. Pathology does not enable 
us to explain the connection between organic dis. 
eases of the lungs or bowels and disordered action 
of the encephalon, and hence many have been 
inclined to regard the combinations of morbid 
states to which we now advert as accidental. 
They are perhaps too numerous to be attributed to 
chance. The combination of madness, as well as 
of some other diseases of the brain and nervous 
system, with diseased states of the liver and of the 
intestinal canal, was pointed out some years since 
by the writer of this article. The conjunction of 
insanity with pulmonary phthisis is a fact estab- 
lished beyond doubt by the observations of M. 
Esquirol, who remarks that phthisis often pre- 



cedes the appearance of melancholia, or accompa- 
nies it. The disease of the lungs is in these in- 
stances latent; the patients lose their strength, 
become emaciated and suffer under, slow fever, 
sometimes attended with cough and diarrhoea ; 
the phenomena of madness rather increase than 
abate under these circumstances, and continue 
until death. On the examination of the body, 
the lungs are found tuberculated or affected by 
melanosis. 

Diseases of the heart are not unfrequently com- 
plicated with madness. We are assured by M. 
Foville, that of the bodies of lunatics which he 
examined after death during three years, five out 
of six displayed some organic disease either of the 
heart or the great vessels. This was very fre- 
quently hypertrophy of the heart. These morbid 
changes, however, are probably, as M. Foville has 
observed, more frequently results of the continued 
agitation, the violent efforts and cries, which in 
such patients bring on diseases in the thoracic 
organs, than predisposing causes of cerebral dis- 
order 

Diseases of the intestinal canal, whether they 
exist or not at the onset of the maniacal attack, 
are subsequently among the frequent causes of 
death. A state of obstinate constipation often 
continues for a long time, attended by its usual 
accompaniments. It gives way, and is followed 
by or alternates with diarrhoea, which wastes the 
strength of the patient and terminates in a fatal 
dysentery. When the body is examined, the in- 
testines are found sometimes distended and loaded 
with indurated matter, at others empty and pale, 
with disease of the mucous coat, discoloured and 
abraded patches or ulceration, and gangrenous 
spots. 

In protracted cases death either results from in 
crease in the disease of the brain, which up to a 
certain degree had only subverted the operations 
of that organ subservient to the mental function, 
and at length becomes incompatible with the 
merely physical functions of the same viscus ; or 
it is the result of accidental disorders, which, 
owing to the peculiar state of the brain and other 
organs in lunatics, are more than usually fatal. 

Fatuity or inveterate lunacy becomes compli- 
cated with paralysis. M. Esquirol says that of 
the number of persons who die in a state of lu- 
nacy, one half are paralytics. This paralysis of 
the demented is a peculiar affection, for we are 
not now referring to hemiplegia, attacks of which 
are liable to occur at all periods of madness, either 
ushered in by apoplexy or without it, and which 
frequently carry off maniacal patients. The 
general paralysis to which lunatics in the advanced 
stage are most subject shows itself first in the mus- 
cles of articulation ; patients have some difficulty 
and imperfection in speech, which is in the be- 
ginning so trifling as to escape those whose atten- 
tion is not particularly directed to the circum- 
stance. The muscles of the limbs and trunk 
become subsequently affected ; the patient walks 
with a tottering or shuffling gait, and his trunk is 
bent forward ; his hands shake ; his limbs become 
emaciated and feeble ; sometimes he bends towards 
one side, and at length passes his time in a sitting 
posture, and bent forward, or takes to his bed 
when the sphincters gradually lose their power, 



46 



sloughs take place about the back, the sacrum, and 
elbows, followed by gangrene and death. 

Many lunatics in the advanced stage labour 
under a degree of cachexia bordering on scurvy. 
The skin is beset with scaly or papular eruptions, 
or discoloured in patches; furunculi appear in 
different parts of the body, which are much dis- 
posed to become sloughy ; the gums become red 
and sore, and bleed ; the surface of the body is 
cold with a clammy perspiration ; diarrhoea, and 
abdominal pains accompany these symptoms ; the 
patient apparently suffers under defective nutrition 
and a gradual decay of physical life, and dies in a 
state of extreme emaciation or marasmus. 

The preceding are perhaps the natural sequelae 
of the diseases under which lunatics suffer in con- 
nexion with their original complaint. A, great 
number, however, are carried off by disorders 
which may be considered as accidental, but to 
which the condition of body in patients of this 
description renders them more than other individ- 
uals liable. Fevers which assume more or less of 
the typhoid character, severe catarrhs, and pulmo- 
nary affections, are the most frequent of them. It 
will be supposed that fevers which affect the brain 
are fatal to lunatics, and such is the fact in a very 
marked degree. 

The diagnosis of accidental diseases in lunatics 
presents, as M. Georget has well observed, re- 
markable difficulties. Some patients of this de- 
scription are continually making unfounded com- 
plaints, deceived by their erroneous or fancied sen- 
sations. On the other hand, many lunatics labour 
under very severe affections without revealing 
them by an expression, either because these affec- 
tions are latent and do not occasion suffering, or 
because the disturbed state of their minds does 
not allow their sensations to reach the centre of 
perception. In this last relation the medical treat- 
ment of lunatics is much more obscure and diffi- 
cult than that of young children, because the lat- 
ter are conscious of their ailments, and express 
them by their cries. " When we observe a luna- 
tic, who had previously been agitated and furious, 
become morose and taciturn, and at the same time 
lose his appetite, seek repose, and display a suffer- 
ing and dejected expression, we ought to examine 
him carefully : he is threatened with some acute 
disease. The development of symptoms will soon 
point out the scat and nature of the complaint, 
and consequently by what sort of means it is to 
be opposed. But chronic affections are so slow 
in their approach and concealed in respect to their 
symptoms, that they often reach to a very ad- 
vanced stage before their existence is suspected, 
unless the organs affected are examined before 
their diseased condition has manifested itself. We 
find the lungs full of tubercles, with cavernous 
excavations and abscesses, or in a state of atrophy, 
in the bodies of individuals who had neither 
coughed nor expectorated, nor experienced pain 
or dyspnoea during life ; they had become gradu- 
ally debilitated, had taken to their beds, and after 
a continually increasing emaciation, had at length 
sunk. The disorganization of the lungs had only 
been discovered by the aid of auscultation and 
percussion. We must not then wait for the ex- 
pression of complaints on the part of lunatics in 
orde- to have our watchfulness excited to the 



INSANITY. 

~ans which are necessary for preserving their 

existence." ■,_„„„««•»• _ 

g ECT . IV. — Of the Canses of Insanity- 
Predisposing Causes. 

1. Natural Constitution.- Among the circum- 
stances in the previous condition of an individual 
which prepare him for sustaining the attack of this 
disease, the most important is a certain peculiarity 
of natural constitution. This consists chiefly, as 
it is probable, in a particular organization of the 
brain and nervous system, rendering those individ- 
uals so constituted liable to become insane when 
exposed to the influence of certain agencies, 
which in other persons either give rise to a differ- 
ent train of morbid phenomena, or are, perhaps, 
devoid of any injurious effects. The constitu- 
tional peculiarity which predisposes to madness is 
not distinguished by any remarkable external 
characters. That such a natural tendency, how- 
ever, actually exists, and in all instances is a ne- 
cessary condition to the development of maniacal 
disease, is to be inferred from the consideration 
that similar exciting causes exert their influence 
on other persons without producing a like effect. 
Among the agents that give rise to madness, there 
is none more influential than intemperance, or the 
frequent use of ardent spirits. A considerable 
proportion of lunatics in the lower classes of so- 
ciety owe their disease to this cause. But it is 
only in a certain proportion of persons addicted 
to intemperance that the phenomena of madness 
make their appearance. Others, under the influ- 
ence of the same noxious cause, are affected with 
apoplexy or paralysis ; in many, the brain escapes 
and the liver becomes disordered, or dropsy takes 
place, with or without disease of the liver ; in 
some, the lungs become the seat of morbid 
changes. It is evident that there must be an ori- 
ginal difference in the habit of body whence arises 
the diversity of results brought about by the same 
or very similar external agencies. This original 
difference is apparently a peculiarity in the con- 
genital constitution of each individual. It may 
be transmitted from parents, or it may arise de 
novo, as other varieties in the congenital structure 
are known to do. Hence it is comparatively of 
little moment, as far as an individual is concerned, 
to inquire whether his morbid predisposition has 
been derived by hereditary descent, or has sprung 
up with himself. It may, indeed, be observed that 
peculiarities which arise in a race are often com- 
mon to several individuals even in the first gener- 
ation. Albinos, for instance, though the offspring 
of parents of ordinary complexions, very frequently 
have brothers or sisters Resembling themselves. In 
like manner, diseases which appear for the first 
time in a family often affect several members of it, 
who partake of the same peculiarity of tempera- 
ment or congenital structure. 

If these remarks are well founded, it must be 
apparent that hereditary madness is not less cura- 
ble than a disease having symptoms of the same 
description, which has not been previously observ- 
ed in the family of the person affected by it. 

That the predisposition to madness, when it has 
once arisen, is frequently transmitted, is a fact too 
well established to admit of doubt ; it constitutes 
a feature in the history of the disease. 

The hereditary transmission of this tendency is 



INSANITY, 



47 



remarked by M. Esquirol to be more general 
among the opulent than the lower classes. He 
states the proportion of hereditary cases among 
the former to be one-half, among the latter to be 
one-sixth. This, however, seems to be a mistake, 
as it appears by his table that of 351 cases at the 
Salpetriere, 105, or nearly one-third, had the 
disease by inheritance. Among 264 patients of a 
superior class 150 cases were, according to the 
same writer, hereditary. He accounts for this 
difference by referring to the exclusive marriages 
of aristocratical families, a cause which had for- 
merly in France much influence. It remains to 
be determined whether the same difference is to 
be observed elsewhere under circumstances not 
admitting this explanation. 

The same writer affirms that persons born be- 
fore their parents had become maniacal are less 
subject to mental disease than those who are born 
after the malady had displayed itself. He makes 
a similar remark as to those who inherit the dis- 
ease only on one side, in comparison with persons 
whose paternal and maternal ancestors had been 
affected by it. According to Burton the offspring 
of parents advanced in years are more subject 
than others to melancholy madness. 

Another observation relating to the hereditary 
transmission of this morbid tendency is, that the 
disease is apt to show itself in different individuals 
of a family at a particular period of life, and in all 
of them under a similar character. M. Esquirol 
has made this remark, and he has mentioned 
several facts in illustration of it. " Two sons of 
a merchant of Switzerland died insane at the age 
of nineteen years. A lady, aged twenty-five 
years, was attacked by puerperal madness ; her 
daughter suffered in like manner at the same age. 
In one family the father, the son, and the grand- 
son, all committed suicide about their fiftieth year. 
There was at the Salpetriere a prostitute who 
had thrown herself into the river seven times ; 
her sister drowned herself in a fit of intoxication. 
There exists near Nantes a family in which seven 
brothers and sisters are in a state of dementia. 
A gentleman, affected by the first events of the 
Revolution, remained during ten years shut up in 
his chamber. His daughter, about the same age, 
fell into a similar state, and refused to quit her 
apartment. This predisposition, which manifests 
itself by external signs, by peculiarities in the 
moral and intellectual character of individuals, is 
not more surprising in connection with madness 
than are the instances of gout, of phthisis pulmo- 
nalis, and other diseases, in a different point of 
view. It may be traced from the age of infancy : 
it furnishes the explanation of a multitude of ca- 
prices, irregularities, and anomalies, which at a 
very early period ought to put parents on their 
guard against the approach of insanity. It may 
furnish useful admonitions to those who preside 
over the education of children. It is advisable in 
such cases to give them an education tending to 
render the habit robust, and to harden it against 
the ordinary causes of madness, and particularly 
to place them under different circumstances from 
those with which their parents were environed. 
It is thus that we ought to put in practice the 
aphorism of Hippocrates, who advises to alter the 
constitution of individuals in order to prevent the 



diseases with which they are threatened by the 
hereditary predisposition of their family." 

M. Esquirol affirms that many facts have oc- 
curred within the sphere of his information prov- 
ing a strong predisposition to madness to have 
arisen from some accidental fright sustained by 
the mother during pregnancy. Marked cases of 
this description are said to have occurred during 
the period of the Revolution. 

2. Age. — Persons in the middle period of life 
are most subject to attacks of insanity properly so 
termed. M. Esquirol has remarked that imbecility 
is the predominant mental disorder of childhood, 
mania of youth, melancholia of more advanced 
manhood, and dementia of old age. 

The years during which madness most fre- 
quently makes its first appearance are those be- 
tween thirty and forty in the age of the individual ; 
next to these are the years between twenty and 
thirty ; thirdly, are those between forty and fifty. 
Insanity is comparatively rare in the earlier as 
well as in the later periods. The case, however, 
of a child who had been maniacal from the age 
of two years was noted by Joseph Frank at St. 
Luke's in 1 802. M. Esquirol mentions besides 
three instances of maniacal children. Dr. Haslam 
and others have reported some cases of the same 
description, but they are not of frequent occur- 
rence. 

M. Georget has observed that out of the num- 
ber of 4409 lunatics in different hospitals in 
France and England, 356 were between the ages 
of ten and twenty, 106 from twenty to thirty, 
1416 from thirty to forty, 861 from forty to fifty, 
461 from fifty to sixty, 174 from sixty to seventy 
and only 35 upwards of 70. 

The following table, given by Dr. Burrows 
from Reports of the French hospitals, tends fur- 
ther to illustrate the proportional frequency of 
madness at different periods of life, and it has the 
advantage of distinguishing the sexes. 



Ages. 



Men. 



Women. 



From 10 to 19 — 78 
20 to 29 — 198 
30 to 39 — 248 
40 to 49 — 231 
50 to 59 — 132 
60 to 69—119 
70 to 79 — 76 
80 to 89 - 7 

Ages 
unknowr 



?n. 5 



62 
267 
324 
290 
218 
146 
101 
4 



1,095 



Under 50 years ~) ~ 5 
of age. 5 

Above 50 years 
of age. 



340 




1,412 

943 
469 



Total. 

. 140 

. 465 

. 572 

. 52' 

. 350 

. 265 

. 177 

. 11 



2,507 



2,507 

3. Sex. — If we may believe Cajlius Aurelianus, 
madness was among the ancients more frequent 
in males than in females. In France, according 
to M. Esquirol, the reverse of this statement is 
true. This writer attributes the greater compara- 
tive liability of modern females to the vicious sys 
tern of modern education, to the preference given 



48 



INSANITY. 



to mere accomplishments, to the reading of ro- 
mances, which gives to young persons a preco- 
cious sensibility, premature desires, and ideas of 
perfection which they nowhere find realized, to 
the frequenting of plays and assemblies, the abuse 
of music, and want of occupation. In England, 
he observes, where women have an education 
more strengthening to the mind, and where they 
lead a more domestic life, the proportion of female 
lunatics to the male is less considerable. These 
considerations may account for the facts in respect 
to the higher orders ; but as the observation in- 
cludes those who are the inmates of hospitals, we 
must have recourse, in order to explain it, to the 
physical circumstances in which the condition of 
females differs from that of the male sex. The 
difference is in fact so great in France, that M. 
Pinel, in 1802, calculated that there were two 
female to one male lunatic. According to the 
report " Sur le service des alienes," by M. Des- 
portes, made at Paris in 1823, it appeared that 
from 1801 to 1821 the number of males admitted 
at the Bicetre was 4552, and that of females at 
the Salpetriere during the same period, 7223. At 
Bethlem, according to Dr. Haslam, 8874 lunatics 
were admitted in the course of forty-six years, of 
whom 4832 were females, 4042 males. At St. 
Luke's, according to a statement made to a com- 
mittee of the House of Commons in 1807, the 
number of females is usually greater than that of 
males by about one-third. In comparing a num- 
ber of statements from different countries, M. Es- 
quirol, however, concludes that the excess in the 
proportion of female lunatics is not so considerable 
as it is generally supposed to be, and that it does 
not, in fact, greatly exceed the difference which 
exists between the sexes in the ordinary state of 
the population. It is greater in some countries 
than in others, and in France than in England. 

[Taking the result of inquiries in various parts 
of the civilized world, it would not seem that 
there is much difference between the sexes. Of 
76,526 cases, enumerated with this view, 37,825 
.vere males, and 38,701 females, — the ratio of 
males to females being thus as 37 to 38 nearly.] 

4. Celibacy. — M. Georget was inclined to 
reckon celibacy among the predisposing cairses of 
madness, from considering the following facts de- 
tailed in the report of M. Desportes. 

Out of 1726 female lunatics 980 were single 
women, 291 were widows, 397 were married per- 
sons. 

Out of 764 males 492 were single, 59 were 
widowers, and 201 were married. 

These relative numbers appear remarkable, but 
in estimating the result we must take into our 
account the fact that married persons lead in 
general more regular lives than the unmarried, 
that they are generally more fixed in their pur- 
suits and their condition as to maintenance and 
employment, and less subject to causes which 
agitate the mind and excite strong emotions. 
These remarks apply, however, principally to 
men, and the difference is equally great among 
females. 

5. Temperament. — A constitution of body pre- 
disposing to violent passions also predisposes to 
madness. 



With respect to complexion, which is generally 
supposed to denote varieties of temperament, it 
does not appear that there is any particular shade 
or hue of eyes or hair which marks a predisposi- 
tion to this disease. On a comparison of facts 
collected from several countries, M. Esquirol has 
not been able to discover any decided difference. 
In the Parisian hospitals a chestnut colour of both 
eyes and hair prevails, which is the general colour 
among the people of the north of France. 

6. Season. — M. Georget has given briefly the 
result of reports indicating the influence of sea- 
sons. It seems that during the six summer months 
a greater number of persons are received into the 
lunatic asylums than in the six months of winter. 

[According to Dr. Woodward, (Eleventh Report 
of the State Lunatic Asylum at Worcester, 
Mass., p. 41, Dec. 1844,) there were in winter the 
least number of admissions, the fewest discharges, 
and the fewest deaths. 

M. Andral (Cours de Pathologie Interne) esti- 
mates the average frequency of insanity in the 
different seasons in the following order — summer, 
spring, winter, autumn. This applies especially 
to mania. Monomania and dementia appeared to 
occur equally at all seasons. In Naples, mono- 
mania was observed to be more frequent in the 
month of September. 

As regards the termination of the disease, some 
have assigned the greatest number to autumn , 
and the greatest mortality to December, January, 
and February. 

6*. Moon Not many years ago, it was uni- 
versally believed that the full moon exerts a de- 
cided influence on the insane ; hence the names 
lunatic, moonstruck, &c, applied to these unfor- 
tunates. It is now, however, settled by the obser- 
vations of Drs. Haslam, Esquirol, Woodward, and 
others, that if the light of the moon be excluded, 
the insane are not more affected at the full of the 
moon than at any other period. Nor is the com- 
mon idea of a direct influence of the sun at the 
summer solstice better founded. The whole 
effect, in the first case, seems to be induced by 
the stimulus of light ; and in the latter, by that 
of heat ; — the two being conjoined at the summer 
solstice, in consequence of the length of the days 
at that period. (Sec on this subject, the writer's 
Human Health, p. 184, Philad. 1844, and Dr. 
Woodward, op. cit., p. 67, Boston, 1844.)] 

7. Among the most powerful of the causes 
which render persons obnoxious to madness, must 
be reckoned previous attacks of the same disease. 
When such attacks have been repeated, the pre- 
disposition becomes increased. There are in- 
stances, however, of persons who, during a cer- 
tain period of their lives, have been subject to 
repeated attacks of maniacal disease, but have 
recovered entirely, and have lived many years in 
a state of perfect sanity. 

8. Other diseases of the brain, such as apo- 
plexy and paralysis, sometimes predispose to mad- 
ness, or are followed by it. Epilepsy of a severe 
and inveterate kind is sometimes complicated 
with insanity. These cases are distinct from the 
fatuity which is often the result of long-continued 
epilepsy. The form of maniacal disease con- 
nected with epilepsy is peculiar, and this may be 
considered as constituting a distinct disease II 



1 IS SAIN ITY. 



49 



has been ably described by the late Dr. Edward 
Percival. 

9. Education. — An erroneous and unsuitable 
method of education is among the most influential 
causes of insanity. There are two different points 
of view under which the injurious effects of wrong 
education may be considered. By too great in- 
dulgence and a want of moral discipline, the pas- 
sions acquire greater power, and a character is 
formed subject to caprice and to violent emotions : 
a predisposition to insanity is thus laid in the 
temper and moral affections of the individual. 
The exciting causes of madness have greater in- 
fluence on persons of such habit than on those 
whose feelings are regulated. An overstrained 
and premature exercise of the intellectual powers 
is likewise a fault of education which predisposes 
to insanity, as it does also to other diseases of the 
brain. These are two considerations which are 
of the greatest importance with respect to the 
welfare of families to which an hereditary consti- 
tution may belong, rendering them more liable 
than others to cerebral diseases. They are dis- 
tinct in themselves, and each might furnish a 
theme for an extensive treatise, most valuable in 
a practical point of view. Under the first head 
it would be necessary to consider the efficacy of 
those plans of education of which the professed 
object is to form a character remarkable for sedate- 
ness, for the strict discipline of the feelings, and, 
as far as this is attainable, for the abolition of 
strong passions and emotions. Such, undoubt- 
edly, would be the kind of moral education best 
adapted for those who are constitutionally liable 
to insanity. The second remark, on the regula- 
tion of mental exercise in young persons whose 
nervous systems are feebly constituted, has a more 
extensive bearing than on the subject of insanity. 
It brings forward a suggestion which is of general 
interest in these times in which mental exertion 
is stimulated to the utmost, and when, in reality, 
all the physical and moral powers are sacrificed 
to the cultivation of intellect, or in many in- 
stances to the mere acquisition of knowledge. 

Exciting Causes of Madness. — The immediate 
causes of madness are in part physical agents, 
and in part moral. Perhaps it may be remarked 
that the former are the most prevalent causes of 
madness in the lower ranks of society, and the 
latter in the higher class, whose intellects are 
more developed, and whose minds are subjected to 
more extensive influences. 

1. Among physical causes of madness, one of 
the most frequent is the immoderate use of intoxi- 
cating liquors. There is hardly a tribe of the 
human race who have not succeeded in inventing 
some method of producing intoxication. Ardent 
spirits are perhaps, of all, the most injurious in 
their effects, particularly on the lower classes in 
the northern countries of Europe and America. 
It has been repeatedly observed that a large pro- 
portion of the cases admitted into pauper lunatic 
asylums arise from this cause. They are in 
general to be reckoned among the cases most 
easily cured; for, although this is not uniformly 
the fact, it often happens that when the exciting 
cause is removed, the effect begins to lessen, and 
eventually ceases. When these patients are pre- 
sented from obtaining stimulating liquors, and are 

Vol. III. — 7 « 



treated with sedative remedies, they quickly show 
signs of amelioration and the subsidence of disease. 

The use of opium and other stimulants is 
among the exciting causes of madness, though of 
much less general agency than the ordinary means 
of intoxication. 

[Alcoholic liquors are a common cause of one 
form of delirium — delirium tremens ,- but, so far 
as the writer has observed, not of insanity. In 
this country, where delirium tremens has pre- 
vailed to a great extent, and where a good oppor- 
tunity exists for noticing the effect of alcohol in 
inducing insanity, the writer's experience has not 
exhibited to him a great many that could be un- 
hesitatingly referred to it. The fact, too, of the 
number of insane among the Society of Friends, 
who rarely indulge in any form of alcohol pota- 
tions, is, so far as it goes, against the idea of 
alcohol being an extensive cause of mental aliena- 
tion. It is proper to add, however, that in the 
Reports of most of the insane asylums, intempe- 
rance is recorded as a common cause.] 

2. Blows on the head, and exposure to ardent 
solar heat, are well known to be occasionally the 
exciting causes of madness. It is plain that they 
act by bringing on inflammation, or a state border- 
ing on inflammation, in the encephalon. The 
same remark may be made with respect to mer- 
cury, as used in syphilitic diseases. It is proba- 
bly an error to suppose that syphilis is itself a 
cause of madness. 

'6. Intestinal Irritation. — A disordered state 
of the intestinal canal often becomes a cause of 
disturbance in the brain, by whatever antecedents 
the former disease may have been induced. The 
state of the intestinal canal, to which we allude, 
is itself much more frequently of an inflammatory 
nature than it has generally been imagined, or at 
least than it was formerly supposed to be. In 
that condition of the canal which gives rise to 
costiveness, alternating with diarrhoea, and ac- 
companied with indigestion, flatulence and eruc- 
tations, anorexia and nausea, transient but often 
acute pains in the hypochondria, livid and yellow 
suffusions of the skin, viscid secretions in the 
mouth, or redness of the fauces and palate, with 
a glazed and dry surface, the whole train of 
symptoms often depends upon a low degree of 
chronic inflammation in the mucous membrane 
of the intestinal canal ; and this is perhaps a fre- 
quent, if not an ordinary state in those cases in 
which disorders of the nervous system supervene 
on complaints of the stomach and bowels. This 
form of disease has been described by Dr. Ferriar 
and several other practical writers ; but it is to 
M. Broussais that we are indebted for a more 
ample development of its pathology. 

The enteric disorder, which lays the foundation 
for maniacal symptoms, as well as for other affec- 
tions of the nervous system, is the result in differ- 
ent instances of various and very diverse noxious 
causes. The most frequent is excess in the use 
of stimulant and indigestible food. Too great in- 
dulgence of the appetite among the more opulent, 
and among the lower classes long-continued con 
stipation, unwholesome diet, the use of salt provi- 
sions, exposure to cold and want, or neglect of 
warm clothing, give rise to diseases of the samo 
description. 



50 



INSANITY. 



Intestinal worms are one of the results of con- 
6lipation. Madness produced by the last men- 
tioned cause is probably of very rare occurrence. 
M. Esquirol has, however, mentioned a remarkable 
instance of maniacal disease, affecting a young 
man, who was cured at two different periods by 
the expulsion of a large quantity of worms from 
the intestinal canal. 

4. Causes depending on Stales of the Uterine 
System.— States of the general system connected 
with irregularity of the uterine functions are well 
known to coexist with or to display themselves in 
various affections of the brain. Among them 
madness is one. Maniacal affections of this class 
may be mentioned under three heads. 

a. Dysmenorrhnzal Affections. — Some females 
at the period of the catamenia undergo a consi- 
derable degree of nervous excitement : morbid dis- 
positions of mind are displayed by them at these 
times, a wayward and capricious temper, excita- 
bility in the feelings, moroseness in disposition, a 
proneness to quarrel with their dearest relatives, 
and sometimes a dejection of mind approaching to 
melancholia. These are distinct from the cases 
of hysterical affection connected with the same 
periodical causes of excitement. The former are 
sometimes the preludes of a far more permanent 
disease. 

b. Suppressions of the Catamenia. — Sudden 
suppressions of the catamenia are frequently fol- 
lowed by diseases of the nervous system of vari- 
ous kinds. Females exposed to cold, undergoing 
powerful excitements, sustain a suppression of the 
catamenia, followed in some instances immedi- 
ately by fits of epilepsy or hysteria, the attacks of 
which are so sudden as to illustrate the connec- 
tion of cause and effect. In attacks of madness 
the catamenia are for the most part wholly or par- 
tially suppressed during the early periods, and in 
many cases it is not easy to say whether the sup- 
pression is the effect or the cause of the disease. 
There are instances, however, in which the cir- 
cumstances sufficiently indicate the order of con- 
nection. Dr. Burrows has detailed a case in 
which suppression brought on by manifest causes 
was followed by mania. We have already alluded 
to the case of a young female mentioned by M. 
Esquirol, who suddenly exclaimed that she was 
cured of her disorder ; her catamenia had flowed 
spontaneously, and her restoration to sanity was 
the immediate consequence. Facts so decisive in 
their bearings on pathology are not of very fre- 
quent occurrence, but their evidence reaches far- 
ther than the individual cases recorded. 

It often happens that after some weeks or months 
in the duration of madness, the catamenia, though 
previously deficient, become restored nearly to their 
usual state. This, like the other indications of 
improvement in merely physical health, is only a 
favourable sign when it is accompanied by some 
amendment in the state of the mental faculties. 
Without any such change, it rather gives reason 
to apprehend that the disorder is becoming inve- 
terate, and perhaps already making it* transition 
from mania into an incipient stage of fatuity. 

c. Puerperal madness is another modification of 
tne disease connected with the state of the uterine 
functions. As this form of insanity is a most im- 
portant subject, and in circumstances very pecu- 



liar, we shall allot a distinct section towards the 
conclusion of this treatise to the consideration of 
its history and pathology. 

4*. [Excessive venery has been regarded by 
many as a cause of insanity, and especially of 
dementia. In the annual reports of several of our 
insane institutions and penitentiaries, many cases 
are referred to masturbation ; yet its influence 
would certainly seem to be exaggerated by some 
observers. It is a common vice everywhere, and 
is very likely to be practised to a greater extent 
in such institutions ; but it cannot be considered 
as by any means proved, that masturbation was 
the cause of the insanity in many of the reported 
cases. Often, doubtless, it is the effect. 

A table of the causes assigned for insanity in dif- 
ferent insane institutions of Great Britain and this 
country is given by Dr. Woodward, in the Ele- 
venth Report of the State Lunatic Hospital at 
Worcester, Mass., Boston, 1844.] 

5. Metastasis. — The pathological fact, that dis- 
eases of the brain, and among others that from 
which madness results, supervene on the cessa- 
tion of various discharges, on the healing of old 
ulcers, on the disappearance of cutaneous erup- 
tions, on the cessation of inflammatory disease in 
membranous and other structures, on the removal 
of tumours, has been observed with greater or less 
attention by practical writers on medicine from the 
time of Hippocrates. Many cases illustrative of 
this fact are to be found in the works of Hildanus, 
Tulpius, and Hoffmann ; and Sauvages, among the 
forms of madness, has reckoned one which he 
terms metastatic. M. Esquirol says that even a 
cessation of the usual discharge from the nostrils, 
of Ieucorrhcea, of blennorrhagia, as well as the 
disappearance of scabies, of herpes, of gout and 
rheumatism, has produced madness. In general 
it may be observed that the suppression of acute 
eruptions, whether pustular, exanthematic, or ery- 
sipelatous, is followed by acute inflammatory affec- 
tions of the internal organs ; in such cases the 
brain or its membranes are attacked by phrenitis 
or meningitis ; while the disappearance of chronic 
disorder of the same class is the precursor of 
mental aberration. The suppression of more copi- 
ous discharges, the removal of large tumours, the 
disappearance in dropsical cases by rapid absorp- 
tion of deposited fluids without increased excre- 
tion, has been followed by determinations of blood 
to the head, giving rise to fatal apoplexy or severe 
convulsions. 

6. Moral Causes of Insanity. — Among the 
moral causes of insanity we must reckon all the 
circumstances which are calculated to give rise to 
strong emotions, or to excite the passions. Strong 
emotions, by their operation on the nervous sys- 
tem, produce injurious effects on the brain, and 
give rise to disturbed actions in that organ, whence 
arises mental derangement. The passions and 
emotions are indeed the principal and most fre- 
quently productive causes of madness. 

In barbarous nations, among whom the mind is 
uncultivated, the passions are proportionally im- 
petuous, but their sphere is limited, and the intel- 
lectual and moral faculties arc very imperfectly 
developed. Madness is comparatively rare among 
such nations. According to Von Humboldt there 
arc very few lunatics among the native \meri 



INSANITY 



51 



cans, and a similar observation has been made 
with respect to other uncivilized tribes. In Rus- 
sia, Turkey, and China, madness is unfrequent. 
In the hospital of Grand Cairo, a city containing 
300,000 people, M. Desgenettes found only four- 
teen lunatics. It must, however, not be forgotten 
that in such places many deranged persons are 
suffered to wander about through neglect and the 
absence of regulations for police, and that their 
numbers thus escape observation ; yet this circum- 
stance is not sufficient to account for the entire 
difference between barbarous and civilized coun- 
tries, in respect to the apparent frequency and 
rarity of madness. It might be affirmed that 
mental derangement is the result of a deviation 
from the state of nature, if we were to agree with 
those who look upon barbarism as the natural 
condition of our species, and represent all that is 
ennobling and exalted, all that is good and really 
desirable in human life, as foreign or accidental, 
and the produce of forced and unnatural culture. 
In this as in other instances, it has pleased Provi- 
dence to mix up with the greatest blessings some 
portions of evil, some ingredients of intense suf- 
fering : " Medio de fonte leporum, Surgit amari 
aliquid, quod in ipsis floribus angat." 

[It has been maintained, that the number of the 
insane is in a direct ratio with civilization ; but 
the medical statistics of countries do not exactly 
establish this ; although there can be no question, 
that civilized man is more subject to insanity than 
the savage. From estimates made by M. Briere 
de Boismont, it would appear, that in England 
the proportion of the insane to the whole popula- 
tion is 1 in 783 ; in Wales, 1 in 911 ; in Scot- 
land, 1 in 573 ; in the Rhenish provinces, 1 in 
1000; in Norway, 1 in 551 ; in France, 1 in 
1000; and in Italy, 1 in 3785; yet it would 
scarcely be admitted, that the people of Norway 
are more civilized than those of France. The 
proportion of insane in the larger cities has been 
enumerated as follows : London, 1 in 200 ; Paris, 
I in 222 ; Milan, 1 in 242 ; Florence, 1 in 238 ; 
Turin, 1 in 344 ; Dresden, 1 in 466 ; Rome, 1 in 
481; Naples, 1 in 791; St. Petersburg, 1 in 
3133 ; Madrid, 1 in 3350; and Grand Cairo, 1 in 
30,714. There is certainly a singular difference 
between these countries, as there would appear to 
be between the different states of this Union in the 
number of the insane ; and the difference is by no 
means easy of explanation. In New Hampshire, 
when the population did not exceed 280,000, the 
number of lunatics was estimated at 600 ; in Con- 
necticut, in a population of 298,000, at 700 ; in 
Massachusetts, with a population of about 612,000, 
there were 1000 ; and in Virginia, taking the po- 
pulation at 1,200,000, it is estimated that there 
were, in 1838, not fewer than from 600 to 800 
insane persons. In New York, the ratio in 1835 
was considered to be 1 in 887 and a fraction ; and 
the probability is, that it is quite as great in Penn- 
sylvania, where, under the lowest estimate, there 
were probably in 1841 not fewer than 2000 per- 
sons, lunatic and idiotic, of whom, it has been 
estimated, that about 1200 may be idiots. The 
census of the United States has not been taken 
with sufficient accuracy to enable us to deduce 
any satisfactory results.] 
. Various kind<? <)f mental excitement have dif- 



ferent degrees of influence in producing madness, 
under different social and political circumstances. 
Among the patients of the Salpetriere, in 323 
cases admitted during the years 1811, 1812, M. 
Esquirol reckoned 105 originating in domestic 
chagrins, 77 occasioned by poverty and reverses 
of fortune, 45 by disappointments in love, 38 by 
fright, 8 by fanaticism. Cases of what is termed 
religious madness are supposed to be much more 
frequent than this small proportion seems to im- 
ply, but it is much to be desired that we could 
determine the meaning of the expression religious 
madness, and to what examples of disease it may 
be correctly applied. 

There can be no doubt that madness has often 
been produced by a vehement and impassioned 
style of preaching. " In the kingdom of Naples," 
says M. Berthollet, « a custom exists of preaching 
in favour of missions by a particular set of priests. 
In order to animate the faith of believers, they 
accompany their orations with particular acts, 
which are often of such a nature as to produce 
too powerful an effect on weak minds. They 
hold their hands over flaming torches, and whip 
themselves with scourges garnished with iron 
points. Their sermons are prolonged till the 
close of day, and the feeble glare of a few flam- 
beaus heightens the effect of the scene." " One 
of these sermons gave occasion to the case I am 
about to describe. The subject was hell: to 
heighten the colouring of the frightful picture 
which the preacher had traced, he took a skull in 
his hand, and having raised a question as to the 
abode of the soul to which it belonged, he 
exclaimed, invoking it, ' If thou art in heaven, 
intercede for us ; if thou art in hell, utter curses.' 
He then cast it from him with violence. The 
lady, whose case is subsequently described in M. 
Berthollet's memoir, was instantly affected by a 
morbid change in the nervous system. 

Strong emotions excited by vehement preach- 
ing produce continually in females and very sen- 
sitive persons, fits of hysteria, and in those who 
arc predisposed to mania there can be no doubt 
that similar causes give rise to attacks of madness. 
Cases, indeed, are of continual occurrence which 
establish the fact. 

But the terrors excited by a troubled conscience, 
which have given birth in the imagination to gor- 
gons and chimeras, and monsters of darkness, are 
sufficient of themselves to produce madness in 
persons predisposed. None can entertain a doubt 
on this subject who recollect the stories of men 
persecuted by the Furies, the appalling self-tortures 
and mutilations, the blood-stained altars and the 
hideous divinities, the sacrifices of wives and 
daughters, the gloomy and hopeless fatalism of 
the pagan world. There is no remedy for these 
evils, resulting as they do from the moral and 
physical disorders of human nature, but the mild 
and consoling influence of Christianity ; and 
if this religion has been made in some instances 
the instrument of evil rather than of good, we 
must recollect that the greatest blessings are capa- 
ble of becoming by perversion the fertile sources 
of severe calamities. Perhaps some persons may 
suppose that if it were possible to divest the minds 
of men of all religious anxieties at once, together 
with all belief, they would be gainers by the 



52 



INSANITY. 



change. But this experiment has heen already 
tried in Fiance, in a great part, during one period 
of the Revolution, and the following remarks of 
M. Esquirol display the results, as far as they 
relate to the increase or lessening of insanity. 

« The changes," he observes, « which have 
taken place during the last thirty years in our 
moral sentiments and habits, have produced more 
instances of madness in France than all our 
political calamities. We have exchanged our 
ancient customs and fixed habits, our old and 
established sentiments and opinions, for specula- 
tive theories and dangerous innovations. Religion 
now only comes forward as a formal usage in the 
solemn transactions of life ; it no longer affords 
its consolations to the afflicted, or hope to the 
desponding. Morality founded on religion is no 
longer the guide of reason in the narrow and 
difficult path of life. A cold egotism has dried 
up all the sources of sentiment ; there no longer 
exist domestic affections, respect, attachment, 
authority, or reciprocal dependencies ; every one 
lives for himself; none are anxious to form those 
wise and salutary provisions which ought to con- 
nect the present age with those which are des- 
tined to follow it." 

Sect. V. — Bfecroscopical Investigations 
of Madness. 

Recourse has been had to anatomical investiga- 
tions with a view to illustrate the pathology of 
madness, and although such researches have not 
answered fully the expectations with which they 
were entered upon, they have led to results by no 
means devoid of interest in their physiological 
bearing, and capable, though to a limited extent 
only, of practical application. 

This department, as well as most others, of 
pathological anatomy, may be said to begin with 
Morgagni. That celebrated writer has, however, 
related the details of but seven or eight dissec- 
tions referring to cases of insanity. In these he 
remarked several facts which later observations 
have confirmed. He found the substance of the 
cerebral hemispheres more firm, and that of the 
cerebellum softer than natural. In one instance 
the white substance of the cerebrum was hard 
and of a brownish hue, and its blood-vessels, as 
well as those of the plexus choroides, much dis- 
tended with blood : in another there was harden- 
ing of the hemispheres and softening of the fornix, 
fulness of the cerebral vessels, adhesion of the pia 
mater : in a third, injection of the meninges and 
the plexus, hardening of the brain, and softening 
of the cerebellum. This writer mentions also col- 
lections of serous fluid in the ventricles and in the 
tissue of the pia mater. 

The researches of Greding were much more 
extensive, and his observations more various. 
Among the facts remarked by him are thickenings 
of the cranium, either partially or generally ob- 
served in 167 ordinary maniacal cases out of 216, 
in 78 out of 100 cases of raving madness, and in 
22 out of 30 cases of idiotism or imbecility ; soft- 
ness of the brain in 51 cases out of 100, espe- 
cially in mania complicated with epilepsy ; wast- 
ing of the optic thalami in two cases of dementia; 
enlargement and contraction of the ventricles ; se- 
rosity in these cavities, or dryness of their sur- 
f-tees ; adherence of the dura mater to the skull ; 



thickened and blue colour of the pia mater; soft- 
ness of the tubercula quadrigemina ; osseous or 
stony concretions in the cerebellum. 

Dr. Haslam has given the details of 37 cases of 
madness with the appearances discovered on dis- 
section. In not one of these cases were the brain 
and its membranes free from morbid appearances. 
In almost all, the membranes either bore marks 
of former inflammation or were distended with 
blood: in 16 cases there was an effusion of serum 
between the membranes, and in the lateral ventri- 
cles this was observed eighteen times. In nine 
cases the consistence of the brain was firmer than 
usual ; in seven it was softer, but in 20 not per- 
ceptibly altered. In three cases, the cranium was 
thicker, and in three thinner than the natural 
state. In several cases a peculiar looseness of the 
scalp was observed. 

The following are the most remarkable of the 
observations made by M. Esquirol on the morbid 
appearances of the brain in madness. The cra- 
nium thick and compact ; in other cases thin and 
porous ; often injected with blood : crania irre- 
gular in respect to the different diameters, and to 
the cavity of the two sides. Membranes thickened 
in 11, injected in 19 cases. Basilary arteries 
ossified in 5 cases. Cerebrum dense in 1 5, soft 
in 19 cases. Cerebellum dense in 12, soft in 17 
cases. Grey substance abundant in five, disco- 
loured in 15 cases. White substance injected in 
19 cases. Adhesions of the lining membrane of 
the ventricles in 54 cases. Serous depositions 
frequent between the pia mater and the arachnoid, 
as well as in the ventricles. Plexus choroides 
displaying almost always serous vesicles, (kystes 
sereuses.) Many other morbid changes have been 
pointed out by the same writer, such as tumours, 
vesicles (kystes), partial softenings and ossifica- 
tions of the arachnoid. Two cases of acute 
maniacal disease, observed by M. Esquirol, are 
recorded by M. Georget, (Art. Encephalite, in the 
Diet, de Medecine,) in which the brain presented 
all the characteristics of intense inflammation. 

M. Georget has recorded with great precision 
the facts which he has himself observed. The 
following are the most remarkable. Irregular con- 
formations of the cranium, the prominences of 
which are developed irregularly, those of the right 
side being generally larger than those of the left ; 
some skulls having the lateral diameter of equal 
extent with the antero-posterior, and the cavities 
of the base irregular in extent; some skulls, one 
in 20, thickened partially or generally ; more fre- 
quently the bones hard, white, without diploe, 
resembling ivory ; some very light. Dura mater 
rarely changed ; sometimes adherent to the skull, 
thickened, containing deposits of bone. Arach- 
noid displaying in places additional laminae of a 
red or grey colour ; sometimes thickened but 
smooth. Pia mater injected ; or thickened and 
infiltrated with serum, giving at first the appear- 
ance of a gelatinous deposit. Volume of the brain 
sometimes less than the cavity. f the cranium 
seems to require. Some, brains very hard cut 
with difficulty; the white substance glutinous, 
elastic, and suflenng distension ; more frequently 
the brain is soft, the grey matter being pale and 
yellowish, and the white substance discoloured 
of a dirty white, the colour and consistence of 



INSANITY. 



53 



these portions almost confounded. The convolu- 
tions separated by serosity and the pia mater 
thickened. Interior cavities of the brain appear- 
ing in some instances very large, in others small, 
often filled with a serous fluid remarkably clear 
and limpid ; plexus choroides exanguious, contain- 
ing hydatidiform vesicles. Partial softenings of 
the brain ; erosions, ulcerations of the surface of 
the ventricles. Cerebellum generally softer than 
the cerebrum; sometimes partially softened. Meso- 
cephalon, medulla oblongata, and medulla spinalis 
rarely display morbid changes of structure. 

M. Georget has thus summed up in a short 
compass the morbid changes which have been 
observed in the heads of maniacal subjects. 1. 
Bones of the cranium sometimes thickened, some- 
times without diploe', thick and resembling ivory ; 
sometimes light and spongy ; inequalities in the 
form of the cranial cavity. 2. Injections, thicken- 
ings, serous infiltrations of the pia mater ; separa- 
tions and attenuations of the cerebral convolutions. 

3. Surface of the cerebrum softened and adhering 
to the pia mater, so that the latter, when pulled 
off, raises portions of the cerebral substance with 
it ; injected state of the cerebral substance, red- 
dened colour of the grey portion, marbled violet 
hues in the white portion, increased consistence 
of both ; discoloration and general softening of the 
cerebrum, grey substance yellowish, white sub- 
stance of a dirty white ; serous collections in the 
ventricles, particularly in the lateral ventricles ; 
partial softenings. Other alterations are much 
less frequent; the annular protuberance, and the 
four great nervous trunks which take their rise 
from it, the medulla oblongata and the medulla 
spinalis, are rarely found to have undergone any 
material change of structure. 

Some curious and interesting additions have 
been made to the morbid anatomy of madness by 
M. Foville, whose researches were conducted with 
great accuracy. It was a part of his plan to com- 
pare, in every instance on the spot, healthy brains 
with those which were the subjects of examination 
as having appertained to maniacal patients. By 
this method some minute peculiarities of structure 
seem to have been detected which might other- 
wise have escaped notice. M. Foville's inquiries 
were carried on at the Salpetriere in conjunction 
with his colleagues, MM. Delaye and Pinel Grand- 
champ, when that hospital was under the superin- 
tendence of M. Esquirol, and subsequently by 
himself at the establishment of the Lower Seine, 
an extensive receptacle for lunatics, which has 
been for some years under his immediate care. 
His observations are arranged under the following 
heads ; 1. morbid changes in the cortical sub- 
stance ; 2. changes in the white or fibrous sub- 
stance ; 3. changes in the nerves of sensation ; 

4. changes in the membranes ; 5. observations on 
the skull and the hairy scalp ; 6. changes observed 
in idiots. We shall abstract the most remarkable 
phenomena noticed under several of these divi- 
sions. 

1. Changes in the grey substance. — In the 
most acute cases the surface of the cortical portion 
presents, on the removal of the membranes, a most 
intense redness, approaching to that of erysipelas. 
This is still more marked in the substance of the 
grey matter itself ; it is more striking in the frontal 



region than on the temporal lobes, and in the 
higher regions than in the posterior parts of the 
brain. In brief terms the morbid changes observed 
by M. Foville in acute cases of madness are near- 
ly confined to the following : " Red colour, uni- 
form and very intense ; numerous mottled spots, 
varying from a bright to a violet red, bloody points, 
minute extravasations of blood ; diminished con- 
sistence in the thickness of the cortical substance, 
coincident mostly with a slight increase of con- 
sistence in its surface ; dilatation of the vessels, 
resistance of their parietes." In acute cases M. 
Foville has never observed adhesions of the mem- 
branes to the cortical substance. Such adhesions 
are very frequent in chronic cases, and hence, as 
he conjectures, may be explained the curable na- 
ture of recent maniacal affections, and the hopeless 
and incurable state of those patients who have 
long laboured under madness or dementia. 

Among the chronic changes of the cortical sub- 
stance, the most frequent is a very perceptible in- 
crease of firmness and density in the superficial 
part, extending to no great depth, but uniform, 
constituting a distinct lamina, smooth externally, 
but internally irregular, of a lighter colour than 
usual, which, when torn off, leaves the remainder 
of the cortical substance red, soft, and mammillated, 
somewhat resembling granulations. Something 
like this external pseudo-membrane of the cortical 
substance has been noticed in wild animals which 
have died in a state of confinement, by M. Fo- 
ville, and is conjectured by him to denote a cere- 
bral disease in them. The pale and almost bleached 
hue of the surface of the cortical portion is always 
connected with this increased density in its sub- 
stance. Sometimes the surface is rough and granu- 
lated, containing small grains of a yellowish white. 

In conjunction with these changes the volume 
of the convolutions remains natural, or is less than 
usual. When lessened, there are sometimes linear 
depressions or irregular pittings on the surface of 
the convolutions, and in the cortical substance it- 
self there are small yellowish lacuna; filled with a 
serosity of the same tinge. These lacuna? are sup- 
posed to correspond with the minute extravasa- 
tions observed in acute cases. In other instan- 
ces the diminution of volume is a real atrophy of 
the convolutions, which appear thin and angular, 
as if pinched up towards their extremities. This 
morbid change corresponds with what MM. Gall 
and Desmoulins have termed atrophy of the con- 
volutions. It is very frequent in the frontal re- 
gions of the hemispheres. It often comprises par- 
ticularly three or four convolutions on each side 
of the sagittal suture, a chasm filled with serosity 
occupying the place left by absorption of the cere- 
bral substance. Co-extensive with this appear- 
ance is that species of atrophy in the cranium in 
which the diploe disappears, and the external la- 
mina approaches the internal, leaving a superficial 
depression on the head. In these cases of atro- 
phy of the convolutions, the diminution of sub- 
stance is confined frequently to the cortical or 
grey matter. What remains of the cortical sub- 
stance is harder than natural, and sometimes pre- 
sents, when carefully examined, a really fibrous 
structure : it is of darker colour, or seems to sep- 
arate into layers, of which the exterior is pale and 
the interior of a rose colour. 



54 



I N 3 A N I T V . 



Another state of the cortical substance observed 
in chronic cases of madness is that of softening 
(ramollissement) ; this is entirely distinct from 
the softened state of the external portion already 
described. The whole thickness of the grey sub- 
stance is equally altered in these cases ; its colour 
is more brown than usual ; its consistence almost 
liquefied. 

This extreme and general softness of the corti- 
cal substance does not necessarily accompany a 
similar state in the white substance ; it is some- 
times conjoined with a hardened state of the me- 
dullary portion. In such instances the grey may 
be separated from the white matter by pouring 
water upon it. Appearances of this kind seem to 
belong to cases of the last degree of dementia, 
with general paralysis and marasmus. M. Fo- 
ville mentions cases apparently of the same 
nature, in which limited portions of the grey 
substance had disappeared previously to death. 
M. Calmeil, in his work on the paralysis connect- 
ed with insanity, has related two instances of a 
similar description. 

It seems that the grey substance in other parts 
of the brain is not subject to a similar change ; 
its morbid alterations coincide with those of the 
medullary portion. From this remark must be 
excepted the cortical substance of the cornu am- 
monis, which is sometimes softened, and at others 
of a scirrhous hardness. 

2. Morbid changes of the white substance. — 
Morbid alterations of the white or fibrous sub- 
stance in mad persons are in relation to its colour, 
its density, and its texture. 

The white substance is often the seat of vascu- 
lar injections ; sometimes vessels of a certain size 
being affected, the appearance of bloody points is 
produced on the section of the white substance. 
In other instances a finer injection gives rise to a 
mottled appearance of a deep red or violet colour. 
A magnifying glass is required in order to discover 
the vascular injection which produces this appear- 
ance. These injections of the white fibrous sub- 
stance do not always coincide with similar injec- 
tions of the surrounding cortical substance. 

It is not rare to find in lunatics the fibrous 
substance of a splendid white ; this particular 
aspect generally corresponds with an increased 
density of the parts. The hardness of such parts 
of the brain re sometimes almost fibro-cartilagi- 
nous. The induration of the medullary substance 
is, however, not always connected with this re- 
markable whiteness; sometimes the hardened 
medullary substance has a yellow tinge or a grey 
leaden colour. M. Foville attempts to account 
for this hardening of the fibrous portion of the 
brain by the supposition that each cerebral fibre 
has contracted morbid adhesions with the sur- 
rounding fibres, so as to render their separation 
impossible. This opinion is offered as more than 
conjecture with respect to the different planes of 
medullary substance, of which it is considered as 
proved that the white substance of the brain con- 
sists. The fibrous mass of the hemispheres re- 
sults, according to this writer, from the super- 
position of several distinct layers or planes, 
applied one upon the other, and connected by 
means of a very fine cellular tissue. These planes 
are easily separable in the healthy state, but in 



the state of maniacal induration they are inse- 
parable. 

Among lunatics affected with general paralysis, 
M. Foville has found these adhesions wanting in 
only two cases ; and in these two instances the 
cerebral nerves, the annular protuberance, and the 
medulla oblongata presented an extreme hardness. 
The same alteration has been found in the brains 
of old men whose voluntary movements have be- 
come uncertain or vacillating ; it has never been 
seen in lunatics whose muscular powers had re- 
mained unimpaired. 

The brains of some lunatics are so full of serous 
fluids, that an abundant serosity flows from the 
surface of incisions ; sometimes this serous infil- 
tration is so abundant as to deserve the name of 
cerebral oedema. A change more rare, which M. 
Esquirol has remarked, was the presence in the 
brain of a multitude of small cavities, from the 
size of a millet-seed to that of a nut, containing a 
limpid fluid. The section of a brain thus changed 
is compared to that of a porous cheese. The 
cavities are supposed to be the sequelae of extrava- 
sations. 

The changes in the structure of the cerebellum 
are analogous in kind to those of the cerebrum, 
but much more rare. 

Tubercles and other tumours in the brain are 
not considered by M. Foville among the causes 
of madness properly so termed. 

3. Morbid changes in the Nerves. — M. Foville 
is persuaded that he has traced morbid alterations 
in the nerves corresponding with peculiar phe- 
nomena of sensation. In a female lunatic, tor- 
mented by hallucinations of sight, the optic nerves 
were found hard and semi-transparent through a 
great part of their thickness. 

4. Morbid changes in the Membranes. — In 
acute cases the only morbid appearance discovered 
in the meninges is for the most part injection of 
the pia mater. This injection is generally pro- 
portioned to the degree of inflammation in the 
cortical substance of the convolutions. The small 
arteries and veins, passing from the membrane 
and penetrating the grey matter, are seen dis- 
tended with florid or black blood : the arachnoid 
in the mean time preserves its natural aspect. 

The chronic changes in the membranes consist 
for the most part in opacity, increased consistence, 
thickness of the arachnoid, the formation of gran- 
ulations, and pseudo-membranes on its surface, 
and the effusion of serosity into the cellular tissue 
of the pia mater and the ventricles. 

The arachnoid membrane displays either ex- 
tensively or in patches a pearly whiteness. The 
opacity never exists without thickening ; and in 
those places where the arachnoid and pia mater 
are naturally contiguous, they are found to be 
adherent. These opaque patches, as M. Foville 
supposes, result from the deposition of albuminous 
layers upon the arachnoid. 

The observations of the same writer on the pe- 
culiarities observed in the skulls of lunatics add 
little to our previous knowledge on this subject; 
and his remarks on the conformation and texture 
of the brain m cases of idiotism do not necessarily 
belong to the subject with which we are now en- 
gaged. We shall conclude our abstract of his ob- 
servattons by briefly citing his general inferences, 



INSANITY, 



55 



" The morbid changes which we have sur- 
veyed, present many of the anatomical characters 
of inflammation ; intense, general, diffused, red- 
ness ; in many cases tumefaction ; and lastly, in 
passing to the chronic state, the formation of ad- 
hesions between the cortical substance of the con- 
volutions and the contiguous membrane ; besides 
this, adhesion of the different planes or layers of 
the cerebral substance to each other in a certain 
number of cases. 

" If the simple redness, the perceptible tume- 
faction — if the general and partial softenings, the 
increased resistance which we have noted in acute 
cases, left any doubt of the true nature of the 
organic disorder, the adhesions observed so often 
in chronic cases certainly admit of none ; and we 
are forced to allow that there exists in the brains 
of lunatics a state of true inflammation, unless 
we cease to regard the adhesions observed in 
other parts as undoubted traces of such a state, 
and refuse to admit that adhesions of the pleura, 
peritoneum, and pericardium, afford evidence of 
the former existence of pleuritis, peritonitis, and 
pericarditis. 

" As the different traces of inflammation are 
more constant in the brain than in the membranes, 
it is necessary to conclude that the essential change 
has taken place in the brain, and that the change 
produced in the membranes is only accidentally 
complicated with it." In his remarks on this 
subject, M. Foville plainly means to express his 
dissent from the opinions maintained by M. Bayle, 
who, in his treatise " Des Maladies du Cerveau," 
attributes insanity to disease of the membranes. 

Among the morbid appearances of the brain, 
the varied changes of the cortical substance are 
the most constant in connection with symptoms 
of mental derangement. Although M. Calmeil 
maintained a different opinion, and was inclined 
to ascribe paralysis or the. loss of muscular power 
to disease of the cortical substance, the facts on 
which he founded this inference do not, as M. 
Foville contends, warrant such a conclusion. In 
all instances of the general paralysis of lunatics 
which he has examined by dissection, there was, 
besides the change in the cortical substance, some 
alteration, either hardening, serous infiltration, or 
softening of the white substance ; and in most 
cases, in addition to these appearances, there were 
adhesions of the principal planes of the cerebral 
substance to each other. A very remarkable case 
which occurred in the clinical course of M. Esqui- 
rol in 1823, affords strong evidence in favour of 
M. Foville's argument. The cerebrum of an idiot 
displayed the grey substance of both hemispheres 
in the last stage of atrophy and disorganization, 
while the white portion of the brain remained 
perfect on one side. In this person the intellect 
luid been entirely defective, but the muscular 
power on one side only had failed. From this, 
and similar observations, M. Foville concludes 
that the function of the cineritious portion of the 
brain is essentially connected with the intellectual 
operations, and that of the fibrous or white struc- 
ture with muscular action. His two principal 
inferences are expressed in the following terms : 

1st. Morbid changes in the cortical substance 
arc directly connected with intellectual derange- 
ment. 



2d. Morbid changes in the white substance are 
directly connected with disorders in the motive 
powers. 

The remarkable accuracy of these researches 
throws a strong shade of doubt, and even of im- 
probability, over those recorded cases of maniacal 
disease in which no morbid traces were discovered 
in the anatomical examination. There is much 
reason for suspecting that a more exact scrutiny, 
and a careful comparison of the state of the parts 
with the appearances displayed by the same organ 
in a natural and healthy condition, might have 
led, in some of these instances, to the detection 
of morbid lesions, greater or less in extent. Yet 
it is not improbable that degrees and modifications 
of maniacal disorder have taken place, in which 
such changes might have been, in an early stage, 
hardly to be traced with certainty. In cases of 
insanity displaying no general disturbance of the 
intellectual operations, and principally consisting 
in a morbid state of the temper and affections, 
and in recent examples of monomania, we should 
not expect to find strongly marked changes in the 
brain, and there is indeed but little proof that the 
brain is in some of these cases diseased. And 
where there is more considerable disorder in the 
functions of the brain, arising secondarily or by 
sympathy with the state of other organs, the traces 
of such disorder may be very evanescent. It has 
likewise been remarked by M. Foville, that in 
some accidental affections of the maniacal class, 
succeeding the action of debilitating causes, as in 
the puerperal state, nothing has been discovered in 
the brain more striking than its extreme and gene- 
ral paleness, and, that although there are in these 
instances some mottled appearances of a light red 
or rose colour on the cortical substance, such 
changes are too slight to be considered as idiopa- 
thic. The same writer adds that in the small 
number of cases of this description which he has 
had an opportunity of examining, the disorder in 
the brain has appeared to him to be sympathetic 
of some deeply-seated disease of the uterus or 
abdomen. In general, however, the fact is un- 
questionable that insanity depends upon organic 
lesion of the brain, and we have sufficient reason 
to conclude that this lesion is, in its commence- 
ment, a degree or modification of inflammatory 
action. 

Sect. VI. — Treatment of Madness. 
Division of the Subject. — Moral and Medical 
Treatment. — The proximate or immediate cause 
of mental derangement is so much concealed from 
our research, the phenomena of the disease are so 
complicated, and the morbid states of the constitu- 
tion with which they are connected so various, 
that we might foresee no ordinary difficulty in the 
attempt to lay down, with respect to this class of 
disorders, any general principles or indications of 
cure. In reality this task has been found to be a 
more arduous one than even the circumstances 
adverted to would have led us to anticipate ; and 
hence many writers have given it up, and rest 
satisfied with stating as merely experimental re- 
sults the effects which particular remedies have 
been thought to produce. 

It is usual to divide under two heads the differ- 
ent means which suggest themselves to our con- 
sideration for the cure of madness, and to take up 



56 



INSANITY, 



separately what relates to the moral treatment of 
the insane, or the means supposed likely to exer- 
cise a beneficial influence on the mind ; and, 
secondly, the medical or therapeutical remedies, 
properly so termed. As this mode of arrangement 
is attended with some advantages, and as no prac- 
tical objection has been raised against it, we shall 
keep it in mind in proceeding to the subject now 
to be considered, beginning with the medical or 
therapeutical treatment of insanity. 

Medical Treatment of Insanity.— The medical 
treatment of insanity may be referred in a great 
measure to two indications or principles, which in 
many cases may be followed more or less fully, and 
will in general serve the purpose of associating in 
the mind the different curative attempts which may 
be made with some hope of success. There are, 
indeed, instances of the disease to which these in- 
dications are either inadmissible, or can only be 
adopted in a very limited extent ; but such cases 
may be considered as exceptions. 

I. The first indication is to remove or lessen 
that diseased condition of the brain on which we 
have reason to believe that madness is, in some 
part at least, dependent. 

That the diseased condition of the brain here 
referred to is nearly allied to inflammation, that 
all its essential pathological characters are those 
of inflammation, may be concluded from the fol- 
lowing considerations. 

1. The morbid appearances displayed by ana- 
tomical researches in the brain and its investments 
are, as we have seen, generally referable to the 
immediate results or more remote vestiges of in- 
flammatory action. On this head we shall add 
nothing to what has already been said in the last 
section, and refer the reader particularly to the 
facts there accumulated, and the concluding re- 
marks upon them. 

2. The relations of madness to other diseases, 
which are known to be connected with increased 
vascular action, or at least with increased fulness 
in the vessels of the brain, tend to support the 
same inference. The connection of apoplexy and 
paralysis, of epilepsy and of other cerebral diseases, 
with madness, has been pointed out by medical 
writers. These diseases are occasionally converted 
into each other, or mutually succeed each other, 
and undergo alternations. They display such a 
relation as leads us to believe that t)ie proximate 
causes or the morbid changes on which the symp- 
toms immediately depend, are in all analogous. 
Therefore, as some of the class, apoplexy for in- 
stance, and paralysis, are connected with vascular 
fulness in the brain, it is hence probable that a 
state not far removed from this, and at least likely, 
under the influence of slight causes, to pass into 
it, gives rise to the phenomena of madness. 

The metastasis of inflammatory diseases from 
other parts of the body, among which is included 
the recession of cutaneous eruptions, is well known 
to be followed not unfrequently by the appearance 
of maniacal symptoms. Suppressions of catamenia 
and uther discharges, giving rise to similar dis- 
eases, strongly confirm the same pathological prin- 
ciples. 

3. The causes in general which excite madness 
bring us to the same conclusion. These are prin- 
cipally of a description likely to give rise either to 



inflammation in the brain, or to a full and defended 
state in the vessels of that organ. Exposure to 
severe heat or cold, insolation, concussion or other 
injuries of the head, intoxication, and generally 
excess in the use of stimuli, great mental excite- 
ment, are all of this class ; the condition of the 
brain, which it is the tendency of these agents to 
promote, is either inflammation, or something 
bordering upon it. 

These different considerations concur in render- 
ing it probable that the actual condition of the 
brain which immediately gives rise to the pheno- 
mena of madness, is in general one of high vascular 
excitement or turgescence, a state which, if it does 
not really constitute inflammation, is at least closely 
bordering upon it, and so liable to pass into it, that 
all the usual consequences of inflammation in many 
instances arise from it. 

But though we may be correct in drawing thii 
inference as a general one, there are great difficul- 
ties to be overcome, and much remains to be proved, 
before we can be authorized to insist upon it as 
universally applicable. The phenomena of mental 
disease are so various, and even so diverse, that 
they may be thought, not improbably, to arise from 
very different states of the system. There are 
instances of mental disease conjoined with so much 
atony and debility, subsidence of vascular action, 
coldness of surface, and diminished secretions, as 
to indicate a very different state from that of in- 
flammation. Anatomical researches display in 
these instances a pale discoloration of the brain, 
with abundance of serous fluid, softenings of sub- 
stance, and other phenomena of a similar descrip- 
tion. Here we trace a state different from inflam- 
mation, though perhaps its remote consequence. 

Are there not, likewise, cases in which we are 
scarcely authorized to conclude that any disease 
of the brain has ever existed 1 Instances of moral 
insanity, in which obliquity of character exists 
through life, and scarcely ever amounts to aberra- 
tion of intellect, and some cases of monomania, in 
which slight and transient hallucinations super- 
vene upon moral obliquities of the same description, 
and appear at intervals, cannot perhaps be referred 
with any degree of probability to an active state 
of disease in the encephalon. 

It is probable, on the whole, that such exceptions 
bear a small proportion to the number of cases to 
which the preceding remarks on the pathology of 
madness are applicable. 

If these remarks are well founded, they lead at 
least to one practical indication for the general 
treatment of madness. In proceeding with the 
medical treatment of maniacal diseases, we shall 
do well to bear constantly in mind the probable 
condition of the brain, and to direct our practice 
more or less with a reference to it. 

Yet we must not omit to observe that the phy- 
sician who proceeds to treat cases of madness as 
instances simply of inflammation in the brain, and 
who expects to cure it at once, like any other local 
inflammatory disease, by the direct operation of 
antiphlogistic means, will very often find himself 
greatly disappointed. He will meet with many 
cases in which no perceptible benefit arises from 
bleeding, evacuations of all kinds whether general 
or locally applied, and combined with the^whole 
series of remedies supposed to be required by the 



INSANITY, 



57 



existence of organic inflammation. Many patients 
will sink under such a course of treatment if car- 
ried on incautiously: it will leave the disease un- 
diminished, and exhaust the powers of life. This 
depends, perhaps, on the influence of diseased 
states in other structures and organs, or on dis- 
ordered functions of other parts which are compli- 
cated with, and in some instances give rise to, the 
disturbances existing in the brain. Inflammatory 
excitement is a part of the disease, but does not 
entirely constitute it, even in so far as the brain is 
concerned. 

Perhaps we may venture on the assertion, that 
there are few instances of madness in which the 
practical indication arising from the view which 
we have taken of the pathology of this disease will 
not be found applicable during some periods of the 
case, though in many its application is very limited. 
The degrees in which it is admissible are very 
various. 

In recent cases of mania, properly so termed, 
and of incoherent insanity, particularly in young 
and plethoric subjects, and where the disease has 
made its attack suddenly, and is accompanied with 
signs of considerable vascular excitement, much 
may be hoped from the antiphlogistic treatment, 
at least from certain parts of it judiciously modi- 
fied. We shall now consider the different means 
of which it consists, and advert to the opinions of 
some of the most eminent practical writers with 
respect to their use in cases of insanity. 

1. Of Bleeding. — Cullen recommends bleeding 
in the early stage of madness. He says that it 
has been common to employ this remedy in all 
cases of recent mania, and, as he thinks, with ad- 
vantage. He observes that when the disease has 
subsisted for some time, he has seldom found blood- 
letting to be of service. " It is," he says, " a pro- 
per and even a necessary remedy in those instances 
of madness in which there is fulness and frequency 
of pulse, and when marks are observed of increased 
impetus in the vessels of the head." He prefers 
bleeding from the arm, while the patient remains 
in somewhat of an erect posture, and bringing on 
a degree of deliquium, which, he says, is a pretty 
certain mark of diminished fulness and tension in 
the vessels of the encephalon. 

Pinel, whose authority could not fail to produce 
an impression, is in this respect decidedly opposed 
to Cullen. He considers the signs of vascular 
plethora in the head, or of determination of the 
blood thither, as very deceptive ; and although he 
allows bleeding to be in some instances capable of 
averting attacks of recurrent madness when they 
are anticipated, he carefully abstains from the use 
of the lancet after the disease has actually broken 
out. Care is always taken, he says, to question 
the relatives of patients admitted into the hospital 
over which he presided, whether bleeding has been 
practised, and if so, what were its results. " The 
reply always proves that the state of the patient 
has changed for the worse immediately after bleed- 
ing." Pinel held very firmly the opinion that 
bleeding, even in maniacal cases which are accom- 
panied by circumstances supposed to indicate ple- 
thora and local determination to the head, tends to 
retard recovery, to render it more doubtful. He is 
even persuaded that bleeding gives to the disease 
a tendency to degenerate into dementia or idiotism. 

Vol. III. — 8 



The facts, however, which this distinguished au- 
thor adduces as proofs of his opinion, afford, as 
M. Foville has remarked, but very equivocal evi- 
dence. " Two girls," he says, " nearly of the 
same age and temperament, were admitted into the 
hospital (the Salpetriere) on the same day: one 
of them, who had not been bled, was cured in the 
space of two months ; the other had undergone a 
copious bleeding. She sank into a state of idiotism, 
or rather of dementia, and did not recover the 
faculty of speech till the fifth month. Her perfect 
restoration took place at the end of the ninth 
month." Now, as most authors fix the mean du- 
ration of madness at the period of several months, 
and some at more than a year, this case of recovery 
at the end of the ninth month cannot afford a 
strong condemnation of the practice pursued. 
Another case, which the same author has adduced 
as affording evidence against bleeding, is not more 
conclusive in respect to the influence of remedies 
on the ultimate event of the disease. Yet the 
opinion of such a writer, founded as it was, at 
least by himself supposed to have been, on ex- 
tensive observation, ought not to be entirely dis- 
regarded because he happened to select but dubious 
illustrations. If bleeding occasions a state of 
collapse in the system, and is carried beyond what 
is necessary to reduce an over-excitement, a fatu- 
itous dejection of mind is likely, in some cases, to 
be the result. 

M. Esquirol coincides with Pinel in the opinion 
that the diseased state on which mental derange- 
ment depends, is sometimes changed for the worse 
by bleeding. He says that he has seen madness 
increased after an abundant flow of the cata- 
menia, and likewise after one, two, or three blood- 
lettings. In. such cases melancholy dejection has 
passed into furious madness. Yet M. Esquirol 
approves of moderate bleeding in plethoric cases, 
and where some habitual sanguineous evacuation 
has been suppressed. He has often, with advan- 
tage, applied leeches behind the head or to the 
temples of patients who are subject to sudden de- 
terminations of blood towards the head. His 
favourite remedies in such cases were the use of a 
few leeches at a time, repeated as often as neces- 
sary, and cold applications to the head. 

To outweigh the authority of those writers who 
either condemn the practice of bleeding in mad- 
ness, or allow of its adoption in so sparing a de- 
gree, strong evidence is requisite, but such evidence 
we possess. 

Dr. Haslam says that bleeding is the most bene- 
ficial remedy that has been employed in madness, 
and that it is equally beneficial in melancholic as 
in maniacal cases. He limits its use to recent 
cases and plethoric habits, and directs it to be per- 
formed by the application of six or eight cupping- 
glasses to the shaven scalp. The quantity of 
blood to be taken must depend on circumstances. 
" From eight to sixteen ounces may be drawn, and 
the operation repeated as circumstances may re- 
quire." When a stupid state has succeeded to one 
of high excitement, Dr. Haslam considers bleed- 
ing as contra-indicated. 

But Dr. Rush is the most strenuous advocate 
for bleeding in maniacal cases. He lays the great- 
est stress on this remedy, and has perhaps carried 
its use to a greater extent than any other medical 



58 



INSANITY 



practitioner of high repute. The arguments which 
he has given in support of the practice of large 
depletion in madness are the following: — 1. The 
force and frequency of the pulse, the sleepless and 
agitated state of maniacal patients. 2. The appe- 
tite being unimpaired in lunatics, and sometimes 
even stronger than usual, a plethoric state of the 
vessels easily arises in such habits. 3. The im- 
portance of the diseased organ, the delicate struc- 
ture of the brain, which prevents it from long 
supporting morbid action without being exposed 
to the danger of permanent disorganization. This 
danger, he says, is much increased by the want 
of sleep, the cries and exclamations, and the con- 
stant agitation of mad persons. 4. The want of 
any natural channel of discharge from the brain, 
by which the ordinary results of inflammation 
might be averted or got rid of, in that way by 
which serous discharges in other parts relieve the 
inflammatory state. 5. The accidental cures which 
have followed the loss of a large quantity of blood. 
Dr. Rush has seen several lunatics who had at- 
tempted self-destruction by cutting their throats, 
or opening the great vessels, cured by the abund- 
ant hemorrhages which have followed these at- 
tempts. 6. Lastly, he says that bleeding is indi- 
cated by the extraordinary success which has 
resulted from its use in the United States, and 
particularly at the hospital for lunatics in Penn- 
sylvania. 

Dr. Rush advises large bleeding at the first at- 
tack of mania. If the patient bears it without 
syncope, he ought to lose, according to this phy- 
sician, from twenty to forty ounces of blood. If 
possible, it should be taken from him while stand- 
ing ereet. Free bloodlettings practised early in 
the disease have, as he says, a surprising effect in 
calming the patient, and in many instances are 
sufficient for the cure unaided by any other reme- 
dies. In most cases, however, bleeding from the 
arm is to be followed by the application of leeches 
or cupping-glasses to the head or nape of the neck, 
by low diet, antiphlogistic remedies, refrigerants 
applied to the head, and the use of warm or tepid 
baths. 

Dr. Rush was of opinion that the evacuation of 
blood ought to be carried to a greater extent in 
madness than in any other acute disease what- 
ever. From a patient, sixty-eight years of age, 
he caused two hundred ounces of blood to be 
drawn in less than two months. Another patient 
of Dr. Rush lost four hundred and seventy ounces 
by forty-seven bleedings in the course of seven 
months. 

We shall conclude this survey of the conflicting 
opinions of practical writers on the expediency of 
bleeding in madness, by the following observations 
of M. Foville, which are deserving of the most 
* attentive consideration, and which in our opinion 
place the subject in the true point of view. He 
says, " Without ever having pushed the employ- 
ment of this remedy so far as Rush and Joseph 
Frank, I confess that it appears to me to be one 
of those on the efficacy of which the greatest 
reliance may be placed. MM. Pinel and Esquirol 
have proved that the ' expectant method,' assisted 
by a few simple rules, and a moral treatment wisely 
directed, have succeeded in a great many cases ; 
but although it is better to confine ourselves to the 



use of simple means, patiently continued, than 
to employ unadvisedly the method of interference, 
I believe that the physician devoted to the study 
of pathological anatomy can draw from the results 
which it furnishes, compared with the observation 
of symptoms, valuable therapeutic inductions; 
that he may place reliance on their efficacy, and 
recommend them with confidence when experience 
shall have demonstrated their good effects. Are 
not the anatomical characters which so constantly 
present themselves in acute cases, and the adhe- 
sions which are so frequent in chronic ones, evi- 
dent proofs of inflammation 1 And hence, are we 
not authorized to hope for advantages from the 
use of antiphlogistic means 1 

« If it be added," says M. Foville, " that in se- 
veral hundred lunatics, whose bodies my situation 
for nearly ten years has given me an opportunity 
of examining, I have never found adhesions in 
acute cases, while they have been very common 
in chronic cases ; if, with these facts, the results 
related in the works of MM. Bayie and Calrneil 
are compared, we may conclude, on seeing these 
adhesions so frequent in chronic cases, that they 
are incompatible with the regular exercise of an 
organ so delicate as the brain, and consequently 
incompatible with the return of reason. Hence 
we ought, in every acute case, to choose the most 
active means, in order to prevent this melancholy 
termination of the cerebral disease. 

" Such are some of the reasons which have led 
me to agree with several physicians who have 
been placed in circumstances favourable for making 
observations, that bleedings ought not to be en- 
tirely proscribed in the treatment of mental dis- 
eases. In the greatest number of cases of recent 
insanity which have been placed under my care, 
I have employed evacuations of blood, local or 
general, rare or frequent, abundant or in modera- 
tion, according to the strength of the patient, and 
the state of the pulse, the redness of the eyes, the 
heat of the head, the agitation and want of sleep. 
I have always preferred general bleeding, when 
there existed a state of plethora, which the force 
and frequency of the pulse evinced. In opposite 
circumstances, leeches on the neck, the temples, 
behind the ears, cupping upon the same part, and 
upon the shaved head, have produced decided 
benefit. Local bleeding having appeared to me 
to produce a marked effect upon the brain, I have 
often prescribed it at the same time with a general 
bleeding in the case where the intensity of the 
general phenomena has imperiously demanded the 
latter ; but I have never rested exclusively upon 
the efficacy of sanguineous evacuations, although 
in many cases I have seen all the morbid symp- 
toms disappear, as if by enchantment, under their 
use. 

" I have under my care several patients sub- 
ject for a number of years to attacks of intermit- 
tent madness, which, left to nature, would last 
three or four months, or longer. 

« During three years, that is, since they have 
been confided to my care, they have not experi- 
enced a single attack of a month's duration. Often 
in the space of five or six days all the symptoms 
have been dissipated. General or local bleedings 
proportioned to the intensity of the symptoms, 
warm baths with cold applications to the head at 



INSANITY, 



the same time, are the means by which I have 
constantly averted the attack. 

" I have several times prevented the return of 
these attacks by employing the same treatment, as 
soon as the redness of the eyes, the heat of the 
head, and wakefulness manifested themselves, even 
when there had been no delirium." 

The writer of the present article having super- 
intended during nearly twenty years a receptacle 
for maniacal paupers, has possessed adequate op- 
portunity of forming an opinion on the ground of 
his own experience as to the efficacy of different 
remedies, and among other practical questions 
with reference to the treatment of insanity, as to 
the extent to which bloodletting is advisable in 
this disease. The results of his own observation 
lead him to doubt the propriety of the copious 
bloodlettings of which Dr. Rush is the advocate. 
He believes the cases of madness to be compara- 
tively few, which can be cured at once by large 
depletions, and is sure that considerable danger to 
the existence of the patient would often be incur- 
red if such a practice were generally pursued. At 
the same time he is equally convinced of the pro- 
priety of moderate detractions of blood, as advised 
by Cullen, Haslam, and Foville. This remedy 
ought by no means to be neglected in cases of 
madness which have come on rather suddenly and 
with acute symptoms, unless some circumstance 
in the age, habit, or temporary condition of the 
patient, renders it unsafe. It is especially called 
for in young and in plethoric subjects ; when the 
disease is one of great excitement ; when there is 
constant agitation and want of sleep, and in such 
cases it should be adopted before these causes have 
induced exhaustion and collapse ; when there are 
marks of determination to the head, such as full 
and throbbing carotids and temporal arteries, red- 
ness of the face and conjunctiva, heat of the 
scalp, a contracted pupil, intolerance of light or of 
sound, headach, vertigo, startings, agitations, or 
convulsions. We are not to look for an aggregate 
of these symptoms before we prescribe bleeding, 
but more or fewer of them often occur to direct 
our proceedings. Less frequently we find the 
still stronger indications of which even M. Es- 
quirol allows the force as pointing out the neces- 
sity of bleeding. We allude to the circumstance 
that the disease has arisen from the sudden sup- 
pression of catamenia or of some morbid but, 
perhaps, also salutary discharge, from the disap- 
pearance of eruptions, or from the operation of 
powerfully exciting causes. Among these is the 
abuse of stimulating liquors. Madness, which is the 
effect of intoxication, requires antiphlogistic rem- 
edies, and bleeding cannot be dispensed with ; but 
care must be taken not to carry depletion too far 
in cases arising from this cause which assume in 
some degree the character of delirium tremens. 
We have reason to believe that patients labouring 
under delirium tremens have been killed almost 
instanter by large bleedings, which had been 
ordered by practitioners who were unaware of the 
nature of the case. This, however, is a form of 
disease easily distinguishable from ordinary mad- 
ness resulting from intoxication. It is frequently 
advisable to bleed once or twice from the arm to 
the extent of fourteen or sixteen ounces, and 
afterwards, if the indicatory symptoms continue, 



to apply cupping-glasses to the scalp, after it has 
been shaved, and repeat this operation or the ap- 
plication of leeches as often as the degree of ex- 
citement and signs of vascular fulness, the circum- 
stances of the patient otherwise admitting, seem 
to require. 

Many practical writers have insisted on the ne- 
cessity of bleeding in the early stage of madness, 
without adverting to the important advantages 
which are to be derived from the same remedy in 
the after periods of the disease. These, however, 
are highly important. The practice of bleeding 
to a small extent, either from the arm, or, what is 
commonly preferable, by cupping-glasses applied 
to the scalp or the nape of the neck, and repeat- 
ing the operation in some instances periodically 
when the tenor of symptoms has been nearly uni- 
form, or occasionally when the patient has been 
subject to fits of increased excitement, has ap- 
peared conducive to ultimate recovery in a great 
number of instances. When suppression of the 
catamenia or of hemorrhoidal evacuations has pre- 
ceded the attack, cupping on the sacrum or the 
application of leeches to the hemorrhoidal vessels 
may perhaps best supply the defect of the natural 
or habitual method of relief. 

The other resources, which are comprised un- 
der the antiphlogistic treatment of madness, will 
require a much less extensive consideration. 

Shaving the head should always be done when 
there is much vascular excitement and heat about 
the scalp. By the coolness afforded on the remo- 
val of the hair, more benefit and a greater degree 
of tranquillization is often produced than is antici- 
pated. Cutting the hair short is not sufficient : 
the head should be shaved once or twice a week. 

Blisters, setons, caustics, irritants of various 
descriptions, have been applied to the head and 
the nape of the neck in cases of madness, as well 
as in other diseases of the brain. 

While acute symptoms are present, with heat 
of the head and irritation of the general system, 
cold applications are preferable to blisters ; but 
when these indications are not prominent, and 
when there is rather a tendency to stupor than 
excitement, blisters on the head are frequently of 
service. They have been applied in most cases 
to the nape of the neck with some advantage, 
particularly when, as it has often happened, the 
discharge which follows their application has been 
very considerable. 

M. Esquirol has remarked that blisters, cup- 
pings, and other irritating applications, are used 
successfully in cases which follow a metastasis ; 
in monomania accompanied by stupor; in puer- 
peral madness ; and in dementia when not com- 
plicated with convulsions or paralysis. 

Issues and setons in the neck have been often 
tried, but the general result of experience is not 
favourable to their use. They afford little benefit 
in maniacal cases. In dementia connected with 
paralytic affections, they are more likely to be of 
service than in mania attended with excitemenr. 
In the ordinary chronic state of madness, these 
remedies are found to be rather injurious than 
beneficial. 

Irritating ointments have been applied in many 
instances, particularly since their use was strongly 
recommended by the late Dr. Jenner. Medical 



60 



INSANITY. 



practitioners have been generally disappointed in 
their expectation of benefit from this attempt. It 
is most likely to be successful, as hinted by M. 
Esquirol, in cases of metastasis. 

[It may be borne in mind, however, as a re- 
markable fact, that in the Gloucester Lunatic 
Asylum, England, which is under the superin- 
tendence of Dr. Shute and Mr, Hitch, the use of 
the lancet, leeches, cupping-glasses, blisters, dras- 
tic purgatives, and the practice of shaving the 
head are totally proscribed, and yet recoveries take 
place in a large proportion, and no cases of sudden 
apoplexy or hemiplegia have occurred. The 
practice of making an incision through the scalp, 
over the sagittal suture, with the view of establish- 
ing steady counter-irritation, has been employed 
for some years past by Dr. C. Evans, physician 
to the Frankford Insane Asylum, near Philadel- 
phia, in the treatment of chronic affections of the 
brain ; and, it is said, with very satisfactory re- 
sults. The actual cautery and the Pomrnade am- 
moniacale of Gondret have likewise been applied 
with advantage. (See Counter-irritation.)] 

Cold Water and Bathing. — Cold shower-baths, 
and affusions of cold water administered in various 
methods, have been extensively tried in maniacal 
diseases. Dr. Rush considered them to constitute 
a very important remedy, and recommended, in 
order to obtain the greatest advantage from them, 
that they should be repeated two or three times 
in a day. M. Esquirol used this remedy with 
advantage in some cases; he chiefly prescribed it 
for young subjects. M. Foville says that he was 
a witness to an almost immediate cure of a ma- 
niacal girl of delicate constitution and nervous 
temperament, who was subjected by M. Esquirol 
to the affusion of cold water at the degree fourteen 
of the centigrade thermometer. She was placed, 
with a garment covering her, in an empty bathing- 
tub, and water was poured in small quantities on 
her head till it covered her body, and shivering 
ensued. On a second application of this method, 
which was for some time resisted, it was followed 
by deep sleep, accompanied by copious sweating ; 
and when the patient awoke, she was found to 
have recovered her reason. 

The method of bathing adopted by M. Foville 
in the hospital under his management is free from 
the inconveniences and occasionally injurious re- 
sults attendant on cold affusions. He places a 
cap or bonnet, containing ice and closely fitting, 
on the head of the patient, and keeps the body 
immersed in a warm-bath for two or three hours, 
and renews this proceeding twice or three times 
in a day, according to the intensity of symptoms. 
On adopting it, as he was accustomed to do at 
first, only once in a day, he found the tranquillity 
produced by it followed not unfrequently by in- 
creased agitation ; but on repeating the bath, with 
the ice constantly applied to the head, he has fre- 
quently succeeded far beyond his expectation. It 
has been the apparent means of recovery in many 
acute cases, and has produced sleep and tranquillity 
in frequent instances of obstinate restlessness and 
agitation. 

The use of the shower-bath is often followed 
by re-action, when the patient, if excitable, be- 
comes violent. In old cases, attended with a dis- 
position to congestion of blood in the head, its 



use is precluded by the danger of producing pa- 
ralysis. It is chiefly serviceable in young subjects ; 
when the constitution is relaxed, and when it is 
predisposed to hysteric affections. 

Applications of ice, or, when more convenient, 
of cold water, are very generally serviceable in 
cases attended with heat of the head and irritabi- 
lity. 

Warm or tepid bathing has been found advan- 
tageous in the treatment of madness under a va- 
riety of circumstances. A cold state of the skin, 
languor of the general circulation, indicated by 
coldness of the extremities, a tendency to chronic 
eruptions, are among the phenomena which sug- 
gest its adoption. Sometimes it produces sleep 
after long-continued agitation. If the degree of 
heat be not such as to produce too much vascular 
excitement, it is generally an useful and safely 
applicable remedy. 

Purgatives. — No fact in medical practice has 
been longer established than the utility of purga- 
tives in madness; witness the fame of Anticyra 
and hellebore. To confirm a maxim so well sup- 
ported by the result of constant experience, it 
seems almost superfluous to adduce pathological 
facts. It is not, however, difficult to find this 
species of evidence in its favour. Many authors 
have remarked that spontaneous cure of madness 
has resulted from a supervening diarrhoea, in which 
the intestines have discharged in great quantities 
a variety of morbid secretions. 

M. Esquirol has well observed that purgative 
medicines ought not to be used indiscriminately 
in all cases of madness, and that they are injurious 
when the mucous membrane of the intestinal 
canal is in a diseased state. This is the case in 
many instances of insanity. We shall, under 
another indication for medical treatment, consider 
the method of practice which is advisable in dif- 
ferent states of intestinal irritation, as they occur 
in madness. At present it will be sufficient to 
observe that, unless any signs of disease exist in 
the structure of the alimentary canal, such as in- 
flammation or ulceration of the mucous coat of 
the intestines, the use of purgative medicines is 
one of the most important and generally availa- 
ble means for the cure of maniacal patients. The 
mildest cathartics are preferable to others in most 
instances, because their use can be long continued 
without injury to the structures on which they 
immediately act. The neutral salts, infusion of 
senna, rhubarb, jalap, castor oil, are in the majority 
of cases sufficiently powerful, and may be usei 
daily or frequently according to circumstances 
When there is decided tendency to constipation 
or the alvine evacuations are morbid, calomel 
scammony, colocynth, or croton oil, may be added 
due attention being paid to the cautionary circura 
stance above pointed out. 

Emetics. — Emetics have been strongly recora 
mended by some practical writers. M. Esquirol 
says that he has found them useful in most case* 
of melancholy accompanied by a torpid state of 
the system. Dr. Rush considered them to be 
chiefly indicated in hypochondriasis, or lowness 
of spirits connected with dyspeptic disease. Has- 
lam confirms their utility in cases attended with 
disorder of the stomach, merely with a view to 
the relief of that particular symptom, but he de- 



INSANITY, 



61 



clarcs that, " after the administration of many 
thousand emetics to persons who were insane, 
but otherwise in good health, he never saw any 
benefit derived from their use.'' « Perhaps no 
one," he says, « has enjoyed a fairer opportunity 
of witnessing the effects of remedies for insane 
persons than myself; and when emetics are em- 
ployed in Bethlem Hospital, they have the best 
chance of eiFecting all the relief they are compe- 
tent to afford, as they are given by themselves, 
without the intervention of other medicines ; and 
this course of emetics usually continues six 
weeks." " It has been for many years the prac- 
tice of Bethlem Hospital to administer to the 
curable patients four or five emetics in the spring 
of the year ; but on consulting my book of cases, 
I have not found that such patients have been 
particularly benefited by the use of this remedy. 
When the tartarized antimony given with this 
intention operated as a purgative, it generally 
produced beneficial effects." The most strenuous 
advocate, in late times, for emetics in madness is 
Dr. Cox, whose work on that disease contains 
many excellent practical observations. This au- 
thor goes so far as to say, that, " in almost every 
species and degree of maniacal complaints, from 
the slightest aberration of intellect that accompa- 
nies hypochondriasis, to the extreme of mania 
furibunda, emetics have proved a most valuable 
and efficacious remedy." Dr. Wake, physician 
to the York Lunatic Asylum, has assured the 
writer of this article, that, after extensive expe- 
rience in the use of different remedies on the 
patients of that hospital, he has found no other 
class of remedies so frequently efficacious as 
emetics. 

The use of emetics in madness requires cau- 
tion. Dr. Haslam says, that, " in many instances, 
and in some where bloodletting had been pre- 
viously employed, paralytic affections have within 
a few hours supervened on the exhibition of an 
emetic, more especially where the patient has 
been of a full habit, and has had the appearance 
of an increased determination to the head." As 
it is well established that lunatics are very subject 
to attacks of apoplexy and paralysis, this circum- 
stance ought always to be taken into considera- 
tion in the prescribing of emetics to maniacal 
patients. The use of medicines of this class is 
precluded by the signs of a plethoric habit and 
cerebral congestion ; but, as MM. Esquirol and 
Foville have well observed, they are likely to be 
of service, and this probability is confirmed by 
ample experience, in cases of melancholy or hy- 
pochondriacal dejection attended with stupor, and 
where the languid state of the functions, both 
animal and physical, appears to require the use 
of remedies which are fitted to excite new actions, 
and to stimulate the secretions of the abdominal 
viscera. It may be added that emetics are some- 
times useful during a state of furious excitement, 
and produce calmness and a mitigation of vio- 
lence. Sometimes under these circumstances their 
exhibition is followed by a restoration of sleep and 
tranquillity< 

Maniacal patients often require large doses of 
tartarised antimony, as from six to ten grains, 
before vomiting is excited ; and this is especially 
the case when the remedy is given during a pa- 



roxysm of violent excitement. It is, however, 
better to begin with moderate doses, and to com- 
bine ipecacuanha with the preparation of anti- 
mony. 

The use of antimony in nauseating doses is 
always safe, and very frequently beneficial in con- 
trolling maniacal excitement and the febrile state 
of the system which accompanies it. 

Rotation. — The use of a rotary swing, which 
occasions vertigo and nausea, and if continued a 
sufficient time, brings on vomiting with some de- 
gree of faintness, was suggested, chiefly from a 
theoretical notion, by Dr. Darwin. The benefi- 
cial effects of this remedy have been supported on 
the ground of experience by Dr. Cox. Some 
writers have ridiculed the idea of attempting such 
a remedy, and others have thought it difficult to 
imagine on what principle it can be of any ser- 
vice ; but those practitioners who have put the 
proposal to the test of experiment have, if we are 
not mistaken, in most instances been convinced 
of its utility. Among these may be mentioned 
Dr. Wake of York, who has assured us that he 
has long considered the rotatory swing as a remedy 
of great efficacy. It was used by Dr. Cox in 
cases of violent maniacal excitement, and proved 
a powerful sedative. The nausea and sickness 
induced were found to quiet the patient and put a 
speedy termination to the paroxysm. It was not 
requisite in all cases to bring on vomiting. Quiet 
sleep often followed the use of this remedy. 

The rotatory swing is also useful as a means of 
moral restraint. The effects are so disagreeable 
that the threat of repeating its use has a salutary 
influence upon turbulent and intractable patients. 

2. Second Indication. — The principle of medi- 
cal treatment hitherto considered, which has re- 
spect to the physical condition of the brain in 
cases of maniacal disease, is chiefly applicable to 
the acute stage and early period of its duration. 
The pathological fact on which it in part is 
founded, may be usefully borne in mind in the 
subsequent progress of the complaint, and acted 
upon more or less when circumstances allow or 
require it ; but it cannot, when the disorder has 
become confirmed, be the chief guide of the prac- 
titioner. The marks of determination to the head 
have generally, under such circumstances, in a 
great measure subsided. In these instances in- 
flammatory action in the brain has probably given 
way to a state of relaxation bordering on serous 
effusion, or to other changes which imply rather 
the consequences than the existence of increased 
vascular action. 

The second indication for the medical treatment 
of insanity, which has relation chiefly to the more 
advanced period and chronic aspect of such dis- 
ease, is to restore and maintain, as far as it can be 
done, a healthy condition of the physical or natu- 
ral functions, to obviate or remove disorders in 
other parts of the system, which may be connected 
or coincident with the diseased condition, of the 
brain. 

We have already observed that in a great pro- 
portion of maniacal cases there arc symptoms of 
disturbance in the natural functions, and that dis- 
eases of the thoracic and abdominal viscera coex- 
ist with that morbid state of the brain on which 
madness immediately depends ; — that the former 



62 



INSANITY. 



are in fact often the immediate causes of death. 
The relation in which these diseases stand to the 
cerebral disorder may be doubtful in many in- 
stances; in some it is the relation of cause, in 
others that of effect : even in the last instance 
there is a reaction of the secondary upon the pri- 
mary parts in the series of morbid changes, and 
the original disease is aggravated by its complica- 
tion with an accessory one. By relieving the lat- 
ter we obtain a proportional mitigation of the for- 
mer. It is indeed a fact that many lunatics 
have been cured by a course of remedies adapted 
to the restoration of their general health. The 
writer of this article has often seen persons who 
had laboured for some months, or even years, 
under menial derangement, brought from poor- 
houses in the country, or from their private dwell- 
ings, in a state of emaciation and squalid wretch- 
edness, suffering under various disorders which 
had become complicated with insanity, or had in 
some instances preceded it. These persons have 
been placed under medical treatment ; care has 
been taken to relieve the symptoms of visceral dis- 
order, to restore the functions to a healthy state, 
to afford them good and nutritious diet, and to 
remove complaints which occurred from time to 
time by occasional remedies. In many cases of 
this description, as the general health improved, 
the mental disorder has gradually lessened, and 
has finally disappeared. In the course of four, 
five, or six months from the period of their com- 
ing under medical treatment, very many patients 
of this description have been restored to their usual 
state of health, and to the exercise of their cus- 
tomary occupations, after having undergone the 
operation of few remedies except such as are 
adapted to the indication or principle of practice 
now pointed out. 

The mode of treatment required in following 
this indication must vary according to the state 
of the constitution and the modifications of dis- 
ease which particular cases may present. 

In examples of madness complicated with intes- 
tinal disorder, care must be taken to relieve the 
latter by the various remedies and modes of diet 
and regimen which the disorder of the intestinal 
canal and its functions requires. A torpid state of 
bowels must be overcome by the use of mild ape- 
rients, continued daily, or given occasionally ac- 
cording to circumstances. When constipation has 
given way to diarrhoea, with tenderness, abdomi- 
nal distension, with or without occasional symp- 
toms of dysentery, with emaciation, coldness of 
the skin, general debility, a disposition to erup- 
tions resembling those of scurvy or purpura, the 
cure can only be promoted by a careful attention 
to a variety of particulars. The action of the 
bowels should be restrained by absorbent medi- 
cines, combined with slight opiates and mercurial 
alteratives. The use of the warm bath, warm 
clothing, and a warm atmosphere, a mild and 
nutritious diet, should be enjoined at the same 
time. Bitters, vegetable tonics, and aromatics 
may be given to support the strength of the sto- 
mach and promote digestion : a liberal allowance 
of animal food, and sometimes malt liquors, and 
even a little wine are used with advantage in cases 
of debility and exhaustion when the digestive 
powwrs will bear their use. 



When the actions of the intestinal canal are 
irregular in chronic cases of madness, without 
giving rise to so great a degree of d.sease as in 
the instances above indicated, a healthy state of 
their function is sufficiently promoted by giving 
mild aperients, with bitter and neutral salts, two 
or three times in a week, and occasional doses of 
calomel. 

When madness has been the result of, or has 
been accompanied by, diminution or loss of any 
other natural function or habitual process, an effort 
should be made to restore it. If we were pos- 
sessed of any certain emmenagogue, it is highly 
probable that its successful application would in 
many cases promote the cure of maniacal diseases 
connected with the suppression of the catamenia. 
When habitual discharges from the hemorrhoidal 
veins have been coerced, or have ceased sponta- 
neously, derangement of the health has ensued 
similar to that occasioned by uterine suppressions. 
The want of this latter process seems to be more 
easily supplied by the powers of art than that of 
the uterine function. M. Foville has mentioned a 
case which occurred to M. Esquirol, in which 
paralysis became complicated with madness in con- 
sequence of the suppression of an habitual hemor- 
rhoidal discharge. The application of a single 
leech to the hemorrhoidal veins every day during 
a month was followed by a restoration of the flux, 
and the patient was cured of his complaint. 

Attempts to restore the catamenia when defec- 
tive in maniacal patients, as they very frequently 
are, seldom produce in a speedy manner the de- 
sired result. If any effort is perceptible at par- 
ticular times to set up the periodical discharge, it 
should be promoted by small bleedings ; by the 
application of leeches to the inguinal region of the 
thighs, or by cupping at the loins, together with 
the use of the hip-bath, pediluvium, general warmth 
of clothing and atmosphere, warm drinks, with 
doses of castor, camphor, and other odorous stim- 
ulants. At other times aloe, rhubarb, and aro- 
matic bitters should be given daily by way of pre- 
paration. 

Digitalis has been reckoned by some practition- 
ers, particularly in Germany, as almost a specific 
in maniacal cases. Dr. Cox speaks favourably 
of its effects. By M. Foville its use is very judi- 
ciously limited to those instances in which disor- 
der of the brain is coincident with, and, as he sup- 
poses, dependent upon disease, or at least increased 
action of the heart, and particularly increased ful- 
ness and pulsation of the carotid and temporal ar- 
teries. 

Opium and narcotics are generally injurious in 
madness. Their use is condemned by most prac- 
tical writers. Occasionally, however, opium has 
been of decided benefit. Dr. Hodgkin has wit- 
nessed two cases of madness with a strong propen- 
sity to suicide, in both of which a strong dose of 
opium procured sound sleep, followed by a resto- 
ration of health. The use of opium requires great 
caution in maniacal diseases. No precise rules 
are determined by which we can judge of the pro- 
priety of its use. 

[In large doses, it is strongly advised by some 
practitioners, as by Drs. Brigham and Woodward. 
The writer has administered it in the long pro- 
tracted sleeplessness of insanity, and often with 



INSANITY, 



decided benefit; but it requires to be given in large 
closes, at least two and a half or three grains, in 
the form of pill ; and the dose may be repeated 
should it be necessary.] 

The use of mercury has been highly recom- 
mended in madness by several writers, and par- 
ticularly by Dr. Rush. Mercury is by no means 
a general remedy for maniacal diseases ; but in 
cases of torpor, with suppression or a very scanty 
state of any of the secretions, mercury is frequent- 
ly employed with great advantage. It should be 
used in mild alterative doses, and discontinued as 
soon as the gums become slightly affected. 

Attention to diet and regimen is fully as im- 
portant for the fulfilment of the last-mentioned in- 
dication as any remedy whatever. In exhausted 
subjects, as before hinted, great advantage is ob- 
tained from the use of a liberal diet. A plentiful 
allowance of animal food of the most wholesome 
and digestible kind, with malt liquor, and in some 
instances a small portion of wine, is required. The 
adoption of a liberal diet is not only free in such 
cases from any exciting or too stimulant influence, 
but even appears to calm the irritation which pre- 
viously existed. But no rule respecting diet can 
be laid down that must not be subject to modifica- 
tion in particular circumstances, and according to 
the peculiarity of the case and the state of the con- 
stitution. 

Fresh air and exercise, for those patients who 
are in a condition that renders them fit for it, are 
among the most important restorative means. — 
Every asylum for the reception of lunatics ought 
to be provided with the means of affording regular 
employment in the open air to all the patients who 
are able to undertake it. Gardening and various 
agricultural works should as much as possible oc- 
cupy their time at stated periods of the day, and 
by system and judicious management a great ma- 
jority among the inmates of these receptacles may 
be brought into the habit of devoting themselves 
mechanically to such employments. M. Esquirol 
remarks that the best effects have resulted from 
the employment of these methods. They are fol- 
lowed with the greatest advantage in several lu- 
natic asylums, both public and private, in different 
parts of England. 

Of the moral treatment of Insanity. — We now 
proceed to the second division of the subject un- 
der consideration, viz. to the moral treatment of 
insanity. 

The moral treatment of this disease has by 
many writers been made to include a variety of 
methods proposed with the hope of inducing, by 
an unexpected and powerful influence on the feel- 
ings of deranged persons, a salutary change in the 
state of their minds. These are either motives ad- 
dressed to their passions, or a variety of ingenious 
schemes or stratagems for convincing them of the 
falsity of their hallucinations, and surprising them 
into a recognition of their erroneous impressions. 
It has been proposed to indulge the illusions of 
the insane to a certain degree in order to overcome 
their false notions by striking and undeniable 
proofs. We are told that a lunatic who fancied 
that he had a serpent in his stomach, was cured 
by giving him an emetic, and adroitly producing 
a reptile as if it had been thrown up during the 
operation of the medicine. Even such writers as 



M. Pinel and M. Esquirol, otherwise so enlight- 
ened and so judicious, appear to lay some stress 
on attempts of this description. The latter had a 
patient who fancied that she had a little animal in 
her head : her physician encouraged the idea, and 
proposed an operation ; an incision was made on 
the scalp, and an insect produced : the patient was 
immediately cured. A lunatic mentioned by the 
same writer refused to eat ; he had made a vow, 
and was bound in honour to abstain from food. 
After many days employed in the attempt to per- 
suade him of his mistake, a pretended order was 
brought, signed by his sovereign, which com- 
manded him to break through his resolution, and 
promised him a guarantee against any reproach 
on that account : after a moral struggle of some 
hours, he gave way with reluctance, took food, 
and was restored. Another individual, who had 
become insane in consequence of the political 
events of 1813, was informed of the revolution 
which occurred in the following year. He refused 
to believe. M. Esquirol led him into the midst 
of the foreign troops which surrounded Paris. He 
was convinced, and almost immediately cured. 

It is barely within the sphere of possibility that 
a conjuncture may occur in the treatment of an 
insane person, when an attempt may be advisable 
to destroy his hallucination by some practical and 
striking proof; but, generally, attempts to con- 
vince lunatics that their impressions are false, and 
that they labour under mental disease, either by 
reasoning or by any contrivances, are abortive, if 
not injurious. The moral treatment which such 
cases actually require is of a very different kind. 

The most important question which relates to 
the moral treatment of the insane turns upon the 
propriety of secluding them, and separating them 
from their families and from society. This is a 
subject which of late has excited much attention 
and serious consideration, both among medical 
practitioners and other persons in England. It has 
likewise been examined in every point of view by 
writers of just celebrity on the continent ; M. Es- 
quirol and M. Georget in particular have con- 
sidered this subject in all its bearings, and have 
expressed their sentiments upon it with great per- 
spicuity and soundness of judgment. We shall 
avoid all suspicion of prejudice or erroneous bias 
by citing the observations of these writers, whose 
authority will carry greater weight than that of 
most other individuals, removed as they have been 
from the influence of circumstances which have 
given rise to controversy and unreasonable varie- 
ties of opinion. 

" The first question," says M. Esquirol, " that 
presents itself in connection with the moral treat- 
ment of lunatics, relates to their separation. Ought 
every insane person to be withdrawn from his ac- 
customed habits, from his usual manner of living, 
separated from the persons with whom he habit- 
ually lives, to be removed into a place which i* 
unknown to him, and confided to the care of 
strangers ? All physicians, English, French, and 
German, agree upon the necessity and utility of 
separation. Willis, to whom we have so long and 
with so much advantage resorted in England to 
obtain a cure in cases of insanity, has remarked 
that strangers were restored much more often than 
the English. We can make a parallel observation 



64 



INSANITY, 



in France. Cures are more frequent among the 
invalids who come to Paris to be treated there, 
than among those who reside in the capital. The 
latter have not been sufficiently isolated. 

" The first effect of separation is to produce 
new sensations, by presenting new objects, and 
breaking the train of ideas which has laid hold on 
the mind ; these new objects strike, arrest, and 
excite the attention of the lunatic, and he becomes 
more accessible to advice which may be the means 
of restoring him to reason. Thus the first mo- 
ment in which a maniac is separated from his 
friends is always followed by a remission of the 
complaint, which is important for his physician, 
who, then finding the patient without preposses- 
sion, can more easily acquire his confidence. 

" It is principally upon the disorder of the moral 
affections that the necessity of separation depends. 

" The disturbed state, the exaltation of ideas of 
the insane patient, puts him in contradiction not 
only with those who live with him but even with 
himself. He persuades himself that his friends 
are determined to oppose him, because they do 
not agree with his excesses and extravagances. 
Not understanding what is said to him, he is im- 
patient ; generally he misinterprets the words that 
are addressed to him ; proofs of the most tender 
affection are taken for reproaches, or for enigmas 
that he cannot understand ; the most anxious 
cares are only intended to vex him ; his heart 
cherishes only sentiments of defiance ; he becomes 
timid and gloomy ; he fears every one who ap- 
proaches him ; his suspicions extend to persons 
who had been most dear to him. The conviction 
that every person is intent upon opposing him, de- 
faming him, rendering him miserable, destroying 
and ruining him, puts a completing stroke to this 
moral perversion." Thence arises that " symp- 
tomatic suspicion which increases under indispen- 
sable contradictions, which augments in strength 
as the intellectual faculties weaken, and which is 
painted so strongly upon the physiognomy of all 
insane patients." 

" With these moral dispositions, if you leave 
an insane person in the midst of his family, the 
affectionate son, whose happiness consists in the 
society of his father, will soon desert the paternal 
roof. The despairing lover believes that he can, 
by his councils, bring back the wandering reason 
of her to whom he is devoted ; he has the mis- 
fortune only to render the wound still deeper. 
The object of his affection soon sees in him only 
a perfidious traitor, who affects such eager anxiety 
the more easily to betray her. The tender and 
sincere friend hopes by affectionate cares to restore 
that sensibility and that reason which have been 
the source of his attachment and happiness. In 
a short time he will find himself included in the 
general proscription, and his cares will only appear 
to the afflicted person proofs that he has been cor- 
rupted by enemies. What hope can we entertain 
if we do not immediately change the situation of 
these unfortunate persons, who are so strongly 
prepossessed 1 And who has not felt the difference 
that there is in being deceived, opposed, and 
betrayed by our nearest relations and friends, and 
r*v individuals who are altogether strangers and 
indifferent to us] Another unhappy person be- 
comes, all at once, lord of the world, dictates his 



sovereign commands to all that surround him, he 
persuades himself that he is blindly obeyed by aU 
those who have been accustomed to yield to his 
will through respect or affection. His wife, his 
children, his friends, his servants, are his subjects; 
they are all obedient, for how dare they be other- 
wise i He is in his own territory ; his commands 
are despotic ; he is ready to punish with the great- 
est severity whoever shall dare to make the least 
remonstrance. What he requires may be impos- 
sible — it is of no consequence : should the com- 
mands of the 'potentates of the earth meet with 
invincible obstacles ? The affliction of his family, 
the chagrin of his friends, the anxiety of all, their 
deference to his will and caprices, the repugnance 
that each evinces to oppose him from the fear of 
exasperating his fury, — all contribute to confirm 
him in his silent possession of power and domi- 
nion. Withdraw him from his pretensions, trans- 
port him far from his house, from his empire, — 
removed from his subjects, surrounded by new 
scenes, he will collect his ideas, direct his attention 
to himself, and place himself on an equality with 
his companions. 

« Very often the cause of mental derangement 
is to be found in domestic causes. The malady 
takes its rise from chagrins, from family dissen- 
sions, from reverses of fortune, from privations, 
&c. ; and the presence of relations and friends 
increases the evil, often without their suspecting 
that they are the first cause of it. Sometimes 
an excess of tenderness seizes the patient; a 
husband persuades himself that he cannot make 
his wife happy ; he forms the resolution of flying 
from her, and threatens to put an end to his 
existence, since it would be the only means of 
securing her happiness. Her tears, her melan- 
choly countenance, are so many new reasons for 
persuading this unfortunate person that he can do 
nothing better than commit suicide. 

" Sometimes the first commotion given to the 
moral and intellectual faculties has arisen in the 
home of the insane person, in the midst of his 
relations and friends. All these external circum- 
stances being associated with the first attack and 
the disorder which followed, will often contribute 
to keep alive and foster the hallucination, — a phe- 
nomenon which easily explains itself, since ideas 
recur simultaneously with certain impressions, 
when these impressions and ideas have often been 
associated, or even when they have been connected, 
only once, but with remarkable force and energy. 
It is generally remarked that insane people feel an 
aversion towards certain individuals, without the 
possibility of diverting them from this feeling. 
The object of their hatred is almost invariably the 
person who before the attack possessed their ten- 
derest affection ; hence it is that they are so indif- 
ferent to their relations, and oftentimes so dan- 
gerous ; while, on the other hand, strangers are 
agreeable to them. The presence of strangers 
suspends the delirium of the insane, cither by the 
influence of new impressions, which is always 
useful, or from a secret feeling of self-love, which 
induces lunatics to conceal their state of mind. I 
have seen patients appear quite calm before their 
physician and strangers, while they were ai the 
same time abusing their relations or their friends 
in an under voice. 



INSANITY. 



65 



" Such are the obstacles and inconveniences 
that present themselves when patients are put un- 
der medical treatment, if they continue to live with 
their families ; and such arc the advantages that 
will accrue from their being placed in a house ap- 
propriated to their treatment, where they are sur- 
rounded by new circumstances and confided to the 
care of stiangers. 

" Under what circumstances ought they to be 
confined 1 We have already said that they ought 
to be placed in a house appropriated for the treat- 
ment of insane persons. We prefer such a house 
to a private one, where patients may be confined 
at a great expense. Such partial separations rarely 
succeed : they possess many of the inconveniences 
which it is desired to avoid in leaving patients in 
their own habitations, and they present very few 
of the advantages of a house destined to receive 
a number of individuals. The strongest objection 
against separation or the placing patients in a lu- 
natic asylum, arises from the distress which it is 
feared the patient will suffer when he observes 
that he is surrounded by companions in affliction. 
I reply that, generally, this does no injury to the 
patient, that it is not an obstacle to the cure, and 
that it oftentimes contributes to promote recovery. 
It leads maniacal persons to reflect upon their own 
state ; and while ordinary objects make no impres- 
sion upon them, they are diverted by the extrava- 
gances of their associates. The presence of their 
companions may serve as a text to the practitioner 
who wishes to act upon their imagination. The 
weariness of confinement, the desire of being at 
liberty, the wish of seeing their relations and 
friends, are so many means of drawing their at- 
tention outwardly : to be occupied with what 
passes around them, and in some manner to forget 
themselves, is a step towards recovery. However, 
there are cases where separation, as all other use- 
ful things, may be injurious to patients, when it 
is not modified with reference to the susceptibility 
of the individual, the character of his delirium, 
his passions, his habits, his manner of living. We 
ought never to lay down absolute rules in prac- 
tice ; the art consists in skilfully discriminating 
the circumstances which ought to modify general 
principles, whatever confirmation they may have 
derived from experience." 

The preceding observations of M. Esquirol 
have been confirmed, and in some particulars more 
strongly stated, by the late M. Georget. This in- 
telligent writer has remarked that all physicians 
who have habitually the care of lunatics have re- 
commended the seclusion of these invalids, in al- 
most every case, as the first condition, and one of 
the first means in their treatment. " Lunatics," he 
says, " ought to be separated from the objects 
which have excited their disease, or which foster 
or aggravate it ; from relatives or servants whom 
they dislike, whom they pretend to command, and 
to whom they will never submit ; from busybodies, 
who only irritate them by useless arguments or 
misplaced ridicule : they ought to be separated 
from society, and placed in an appropriate habita- 
tion, to ensure both the safety of the public and 
their own preservation. Their friends are always 
repugnant to put this plan into execution: a mo- 
ther, a wife, or a husband, can with difficulty be- 
lieve that the object dearest in the world to cither 

Vol. III. — 9 f * 



of them can be better placed in the hands of 
strangers than under the influence of those who 
are eager to devote the most affectionate cares; 
they fear likewise that in lunatic asylums the sight 
of the patients will have a bad effect upon their 
friend, and aggravate the disease ; that constraint, 
severity, and all kinds of bad treatment will be 
employed to manage the patients, and, if once 
cured, they will preserve a horrible impression of 
their abode, and resentment against their relations 
who have consented to their confinement. These 
last considerations induce rich families to place 
their deranged relatives in private houses destined 
to receive a single lunatic, who is surrounded by 
servants and inspectors whom he does not know. 
Besides that these private establishments are very 
expensive, they rarely answer the end proposed ; 
either some relation chooses to remain near the 
invalid, or the latter soon perceives that every 
thing by which he is surrounded is destined for 
his service ; in either case the objects of seclusion 
are imperfectly attained. Lastly, many things are 
often required which are only to be found in pub- 
lic establishments. This imperfect separation, 
however, is all that can be adopted in some fami- 
lies, and we must make as much advantage of it 
as we can. In public asylums the seclusion is 
complete ; the patients soon know that they are 
under the authority and even at the discretion of 
the director ; they are watched and constrained 
without difficulty, under the care of regular at- 
tendants. They find powerful sources of occupa- 
tion and of distraction in associating even with 
the other patients. The greater number of lu- 
natics never discover that they are in the midst of 
mad people, and find nothing to complain of in 
this circumstance. When their reason begins to 
return, they are removed into the apartment des- 
tined for the reception of convalescents, and hence 
are withdrawn from sights which might make un- 
pleasant impressions upon them. As long as the 
disease continues, they are angry with those who 
have deprived them of their liberty ; but as soon 
as they have recovered their reason, resentment is 
changed into gratitude. On this account, then, 
the friends of the insane incur no risk. We do 
not pretend to deny that this separation and abode 
among other lunatics has occasionally aggravated 
the disease, when of recent occurrence, in some 
individuals : on the other hand, we affirm that the 
same means have cured many lunatics almost im- 
mediately. Besides it is next to impossible to 
preserve and take care of maniacs or monomaniacs 
in the midst of their family, and all the inconve- 
niences of separation disappear under the absolute 
necessity of its use." 

The same writer has briefly summed up the 
principal circumstances to which attention ought 
to be paid in the construction or choice and in 
the management of an asylum or house of reco- 
very for lunatics. He has collected these remarks 
from the writings of Pinel and Esquirol. 

"1. M. Pinel has particularly insisted upon the 
necessity of classing lunatics, of separating such 
as are liable to injure themselves or others, and 
permitting those to associate together who may 
contribute to each other's cure. A lunatic asylum 
ought, then, to be composed of several parts more 
or less insulated. There should be a quarter ap- 



66 



INS A 



propriated for each sex, a division for violent 
lunatics, a second for those that are tranquil, a 
third for convalescents, a fourth for lunatics who 
labour under accidental disorders. It will De very 
useful to have a division for those who are of 
melancholy habits, and in a state of dementia, 
and another for furious and noisy patients, and 
for some lunatics who are of an untameable cha- 
racter, and are confined by way of punishment. 
It is above all things necessary to separate the 
sexes, the convalescents, and likewise those pa- 
tients who have depraved habits and indecent 
manners. Each division ought to have a court 
planted with trees, and, if possible, a garden for 
the patients to walk in. 

" 2. M. Esquirol, who has devoted his atten- 
tion to the arrangements which these establish- 
ments require for the convenience of the patients, 
to facilitate vigilant superintendence and attention, 
and to prevent accidents, is of opinion that such 
houses should be built on level ground ; that the 
cells destined for violent patients should be spa- 
cious, with a door and window opposite each 
other, and opening from without ; that they should 
be boarded and not paved, furnished with a bed, 
firmly fixed in the wall ; that all the cells should 
communicate with covered galleries or corridors, 
in which the patients may walk in bad weather, 
and by means of which the inspectors and ser- 
vants may easily traverse the different parts of 
the establishment ; that all the rooms should be 
warmed by pipes of hot air ; that abundance of 
water should be furnished by fountains to wash 
the dirty cells ; that the privies should be sepa- 
rated in such a manner as to occasion no incon- 
venience to the patients; that there should be 
places appointed for a general work-room, for a 
common dining-room, for baths and shower-baths. 
In this plan of M. Esquirol's there are dormito- 
ries only for convalescents, melancholy patients, 
idiots, and individuals who are debilitated. For 
others little cells with one bed are preferable, in 
almost every case ; during the day the patients 
can go out and associate with others, and in the 
night they do not require companions. 

" 3. Beings deprived of reason, who fancy them- 
selves reasonable, who incessantly desire and de- 
mand things that cannot be granted them, and 
who are nevertheless sensible to kind as well as 
to bad treatment, must needs be difficult to influ- 
ence, to govern, and to cure. As long as each 
person continues insane, he looks upon the director 
and inspectors of the establishment as accomplices 
in the power which has deprived him of liberty, 
and upon the attendants as inhuman jailors. 
Even after his cure he is not always very grate- 
ful. The director, the inspector, and the attend- 
ants, will invariably be objects of prejudice, sus- 
picion, and hatred to the patients; they will re- 
ceive abuse and often blows from them. On the 
other hand, it is impossible for one who has not 
had for a long time the care of them, and studied 
their disease, to know the mental disposition of 
lunatics. Without such preparation we should 
attribute to wickedness what is the effect of dis- 
ease, or look upon lunatics as beings deprived of 
all sensibility. In either case we might be in- 
duced to treat them with severity. It is almost 
impossible to make servants understand that mad 



NITY. 

Arsons have the use of some of their faculties, 
with the exception of those servants who have 
been themselves attacked by the disease. At the 
Salpetriere and the Bicetre great advantage is de- 
rived from employing persons who have been 
cured to take care of the patients. I he physician 
of a lunatic asylum ought to be particularly care- 
ful to instruct the individuals who are to have the 
management of the patients. 

« 4. It is absolutely necessary that a judicious 
arrangement of authority and subordination be 
established in lunatic asylums, and that the phy- 
sician be invested with a power superior to all 
with regard to every thing that concerns the pa- 
tients." 

The chief points on which the moral cure of 
madness turns are thus summed up by M, 
Georget. 

" We may refer to three principal heads all the 
regulations that can be put in practice with refer- 
ence to the discipline and exercise of the mental 
powers in lunatics. 1. Never to excite the ideas 
and passions of the patients upon the subject of 
their delirium. 2. Never directly to oppose their 
unreasonable ideas and opinions, either by argu- 
ment, discussion, opposition, contradiction, or ridi- 
cule. 3. To fix their attention upon subjects 
foreign to their hallucination, and communicate 
to their minds new ideas and affections by means 
of different impressions. 

" According to the first principle, we should 
withdraw the patient from the causes which have 
excited his madness, and even from objects which 
might recall these causes, or suggest any allusion 
to them. Lunatics attacked with religious melan- 
choly should be deprived of their books of devo- 
tion ; they should not be permitted to engage in 
offices of religion. Those who are tormented 
with sexual desires render these desires more im- 
perious by gratifying them, if they do not destroy 
their health. We ought never to flatter the chi- 
meras of kings, of princes, of gods, of queens. 
We should never put the patients attacked with 
the same kind of insanity together, because they 
would talk incessantly of their conceits, and thus 
cause to each other a great deal of injur) 7 . Thus, 
as in other diseases, we ought to leave the over- 
excited part at rest. 

" According to the second rule, we should never 
attempt to reason with lunatics in order to bring 
them to their senses, for their errors are necessa- 
rily connected with their disease. The most evi- 
dent proofs are of no weight upon the mind of a 
lunatic. He will suspect that there are secret 
reasons for deceiving him. Discussion, opposi- 
tion, contradiction, irritates the disease, and in- 
spires defiance and hatred. In accordance with 
the third rule, we should make it a point to oc- 
cupy the mind, and to direct it by different means, 
such as exercise, work, play, the society of other 
patients, sane persons presiding over them ; bv 
music, reading, conversation, the visits of friends, 
&C. We should oppose one passion to the ruling 
passion, and on some occasions excite the activity 
of feeling by strong emotions, by means of fear, 
or the sudden announcement of bad news. But 
these different means are applicable neither in 
every case nor at every period of the disease. It 
is in general very diiiicult to turn for any len|>ih 



INSANITY 



67 



of time the attention of the patients from the sub- 
ject of their delirium ; it is above all things dif- 
ficult to engage them in occupations either of 
work or amusement. Very often the disorder of 
their minds is such that they are continually 
under the influence of their delirium ; they exist 
in their illusions, and their attention is hardly 
arrested by the objects that surround them. Re- 
storation to their friends should never take place 
until the convalescence of patients is perfectly 
established, and even then great precautions must 
be used to manage the first interview, to prepare 
the mind of the patient and of the relatives, and 
to fix the subject and length of their conversa- 
tion. 

" An active and constant inspection exercised 
over the patients and the attendants is very ne- 
cessary in a lunatic asylum. Patients who evince 
a disposition to suicide should never be lost sight 
of for a single instant, whatever they may say or 
do to obtain their wish. It is often necessary to 
confine violent patients with the strait-waistcoat. 
Those who are addicted to indecent practices, — 
a circumstance by no means infrequent, — should 
be restrained by similar means. Occasionally it 
is better to confine them by shackles on the legs, 
fastened down in an arm-chair, or shut up in their 
rooms, according to circumstances. The use of 
chains is almost entirely abandoned, and we are 
indebted to the noble efforts of our venerable 
Pinel for this improvement in the lot of lunatics." 
(It may be observed that M. Foville ascribes to 
the Quakers who have managed the "Retreat" 
the credit of having been the first to discard these 
inhuman instruments of restraint.) " At the 
time of the abolition of chains at Bicetre, M. 
Pinel observed that the diminution of the number 
of furious lunatics, and the accidents which they 
occasioned, was very remarkable. The only mea- 
sures of punishment that ought to be put into 
practice are the strait-waistcoat, seclusion in a 
cell, removal from one division to another, the 
shower-bath, and some occasional privations. A 
violent or wicked lunatic, who all at once puts on 
a menacing appearance, or even commits repre- 
hensible actions, should be immediately surrounded 
by a number of attendants, approached and seized 
at the same time on all sides, particularly by those 
who are behind him. Sometimes great advantage 
has been found by suddenly enveloping the pa- 
tient's head in a napkin, which completely bewil- 
ders him. In other cases, while persons placed 
before the patient endeavour to occupy his atten- 
tion, others advancing from behind easily lay hold 
of and secure him. 

[Of late, it has been proposed, and practised, to 
abolish totally all personal restraint in the manage- 
ment of the insane; and the course is said to have 
been entirely effective. The plan is to substitute 
a rigid system of constant superintendence, of 
Well-preserved classification, and of humane and 
effective practical management. It has been 
affirmed, indeed, that in a properly constructed 
building, with a sufficient number of suitable 
attendants, " restraint is never necessary, never 
justifiable, and always injurious in all cases of 
lunacy whatever." Cases, in which the patients 
render their clothes and persons filthy, present 
considerable difficulty, but a warm bath is always 



ready, into which the patient is put, and well 
washed, and the clothes are changed as often as 
becomes necessary. In violent cases, the patient 
is at times placed alone in a room, well aired and 
lighted, where there is nothing destructible, and 
is treated with all the kindness that can be be- 
stowed upon him. If we admit, however, the 
practicability and efficiency of the system of non- 
restraint in a large mass of cases, it may be 
questionable, whether it be of universal applica- 
tion ; and were it so, it can rarely happen that 
establishments for the insane are so well provided 
with competent attendants, that corporeal restraint 
can be wholly dispensed with. The experience, 
however, of the large insane establishments of this 
country, has sufficiently shown that it can be but 
seldom necessary. 

By a proper classification of the insane, it will 
be found that there are comparatively few who 
are incapable of participating in labour or amuse- 
ment. Every well-devised insane asylum ought, 
therefore, to be able to employ such of the patients 
as are fitted for the task in agricultural or horti- 
cultural labours ; workshops should be provided, 
and employment of some kind or other be care- 
fully adapted to each individual. The attention, 
which such occupations require, produces a moral 
revulsion, and prevents the topic of hallucination 
from recurring, or, should it recur, from wholly 
engrossing the mind of the lunatic. This is now 
so well understood, that in the different insane 
establishments it is an object of solicitude on the 
part of the medical superintendent ; and the re- 
sults have been most salutary. The reports of 
these institutions sufficiently testify to the inte- 
resting fact, that however perverted may be the 
reasoning powers, there are but few who are un- 
susceptible of appropriate appeals, when judi- 
ciously made. Fifty years ago, it would not have 
been credited, that numbers have attended public 
worship in the chapels of those institutions, and 
conducted themselves with the greatest decorum, 
who in the halls were noisy, talkative, and pro- 
fane.] 

Sect. VII Puerperal Madness* 

This term is chiefly and most correctly applied 
to a form of insanity incident to puerperal women. 
By some writers, the same expression has been so 
extended in its meaning as to comprise that 
species of derangement peculiar to females who 
are debilitated by suckling, and which commences 
in general several months after child-birth. 

Symptoms of insanity occasionally display 
themselves during pregnancy, and under circum- 
stances which indicate that they are dependent on 
that state. These cases are rare in comparison 
with those which occur after delivery. M. Esqui- 
rol mentions the instance of a young woman, of 
very sensitive habit, who had attacks of madness 
on two occasions, each of which lasted fifteen 
days, having commenced immediately after con- 
ception. The same writer observes also that 
several women at the SalpStriere have become 
maniacal during the time of their pregnancy. 

Cases of puerperal madness, properly so termed, 
that is, coining on after child-birth, are by no 
means infrequent. M. Esquirol has related that 
among COO maniacal women at the Salpetriere, 



63 



INSANITY, 



there were 52 rases of this description. In an- 
other report by the same writer, there were 92 
similar cases among 1119 insane females admitted 
during four years into the above-mentioned hos- 
pital. M. Esquirol is of opinion that the propor- 
tion is still greater in the higher classes of society, 
since out of 144 instances of mental disorder, 
occurring in females of opulent families, the 
symptoms had displayed themselves, in 21, either 
soon after child-birth or during the period of lac- 
tation. Dr. Haslam enumerates S4 cases of puer- 
peral mania in 1644 cases admitted at Bethlem. 
Dr. Rush, however, reckons only five such cases 
in seventy, received into the hospital for lunatics 
in Philadelphia. 

There is no peculiarity in the phenomena of 
puerperal madness by which this disease is dis- 
tinguished from other examples of insanity. Dr. 
Gooch has remarked that " if a physician was 
taken into the chamber of a patient whose mind 
had become deranged from lying-in or nursing, 
he could not tell by the mere condition of the 
mind that the disease had originated in these 
causes." 

Those cases which are more properly termed 
puerperal, as occurring in the first period after 
child-birth, are generally of the character of 
mania, attended with excitement of the feelings 
and mental illusions ; while the disorder which 
displays itself in women exhausted by suckling, 
is most commonly connected with melancholy 
depression, a tendency to which may generally 
be perceived in females who nurse their children 
too long, with reference to the strength of their 
own constitutions. Cases of the former descrip- 
tion occur within a short period, and most fre- 
quently within a fortnight after delivery. They 
appear sometimes to be occasioned by fright or 
other accidental causes of disturbance ; some- 
times by errors in diet, or by premature exertions 
or excitements : in other instances they take place 
independently of any discoverable external cause. 
The patient passes one or two restless nights, ap- 
pears unusually excited and irritable, talks loudly 
and incessantly, and very soon betrays a disturbed 
intellect. The attack is often attended with febrile 
symptoms. This is the case especially, as Dr. 
Burrows has observed, if it takes place about the 
fourth or fifth day, when the secretion of milk is 
producing a new excitement. The state of the 
pulse is the most important symptom in reference 
to the nature and treatment of the case, as well 
as to the prognostic which is to be formed of its 
result. Dr. Gooch has laid particular stress on 
this circumstance, and he has extracted a valuable 
passage which bears upon it from the manuscript 
lectures of Dr. Hunter. " Mania," said this emi- 
nent practitioner, " is not an uncommon appear- 
ance in the course of the month, but of that 
species from which they generally recover. When 
out of their senses, attended with fever, like para- 
phrenitis, they ivill in all probability die; but 
when without fever, it is not fatal, though it (i. e. 
fever) generally takes place before they get well. 
I have had several private patients, and have been 
called in when a great number of stimulating 
medicines and blisters have been administered, 
but they have gone on as at another time, talking 
nonsense, till the disease has gone off, and they 



have become sensible. It is a species of madness 
they generally recover from, but I know of nothing 
of any singular service in it." 

Dr. Gooch's comment upon this passage is the 
remark, supported by his own observation, that 
there are two forms of puerptral mania : one of 
them is attended by fever, or rather by a rapid 
pulse ; the other is accompanied by a very mode- 
rate disturbance of the circulation. Cases of the 
latter kind, which happily are by far the most 
numerous, terminate in recovery ; the former are 
generally fatal. 

Terminations of Puerperal Madness. — Puer- 
peral madness terminates, in a great proportion of 
cases, either in death or in the recovery of reason. 
Few instances, comparatively, become cases of 
permanent insanity. It is, however, very difficult 
to obtain accurate information on this subject. 
Dr. Gooch has observed that the records of hos- 
pitals contain chiefly accounts of cases which 
have been admitted because they had been unusu- 
ally permanent, having already disappointed the 
hope, which is generally entertained and acted 
upon, of relief by private care : the cases of short 
duration, which last only a few days or weeks, 
and which form a large proportion, are totally 
overlooked or omitted in the inspection of hospital 
reports. This remark accounts for the unfavour- 
able nature of the results which are obtained 
from such tables as those given by M. Esquirol 
and others. By this writer, ninety-two cases are 
enumerated, of which fifty-five recovered, and six 
died, leaving thirty-one as the number of incura- 
bles, that is, one in three. Of the fifty-five reco- 
veries, thirty-eight took place within the first six 
months. Dr. Haslam says that of eighty-five 
cases admitted at Bethlem, only fifty recovered, 
leaving thirty-five as the number of incurables. 
Dr. Burrows mentions fifty-seven cases, of which 
thirty-five recovered, and eleven remained un- 
cured ; of the recoveries, twenty-eight took place 
within the first six months. Dr. Gooch has re- 
marked that these tables throw but little light 
upon the real proportions of recoveries, and pre- 
sent a prospect unnecessarily gloomy and dis- 
couraging. He adds, " Of the many patients 
about whom I have been consulted, I know only 
two who are now, after many years, disordered in 
mind, and of them one had already been so before 
her marriage." 

The question, on the solution of which there is 
the greatest reason for anxiety in reference to any 
particular case of puerperal madness, is, whether 
it is likely to be fatal ; because, if not fatal, there 
is great probability of ultimate recovery. The 
most satisfactory way of coming to a conclusion 
on this inquiry, in any individual case, is by the 
prognostications which the particular symptoms 
afford, and on this subject we can add" little to 
what has already been said. The principal danger 
which menaces life, in cases of this description, 
is a state of extreme debility ; the excitement of 
the vascular as well as of the cerebral functions, is 
so great as to wear out the strength, already at a 
low ebb, and neither recruited by nutrition nor by 
sleep, and the patient sinks from exhaustion Ex- 
perience has proved that a rapid circulation is the 
principal circumstance which tends to bring on 
this state. A very frequent pulse is the most 



INSANITY. 



unfavourable symptom. Long-continued resist- 
ance to sleep, and a state of complete restlessness, 
and the appearance of great weakness and inani- 
tion, give likewise reason for apprehension. If these 
signs are not found, the mental derangement of 
the patient need not give occasion to very serious 
alarm. 

Medical authors have sought to found a prog- 
nostic in puerperal madness on the estimate of the 
proportions which deaths bear to recoveries. This 
cannot afford evidence on which so much reliance 
may be placed as on the symptoms of individual 
cases. Out of the ninety-two cases mentioned by 
M. Esquirol, of which fifty-five terminated in re- 
covery, there were, as we have observed, six 
deaths, and in Dr. Burrows's table of fifty-seven 
cases there were ten deaths. The former calcula- 
tion gives one death in fifteen cases, and the latter 
one in six. But the patients in the Salpetriere 
are probably removed thither after the period in 
which the disease is most dangerous to life. There 
must have been some circumstance tending to ex- 
plain the discrepancy in the above-mentioned re- 
sults. The proportion of deaths given by M. 
Esquirol's table may be somewhat too low, but we 
are inclined to believe that the result afforded by 
that of Dr. Burrows gives a greater mortality than 
the average number afforded by general experi- 
ence. 

Pathology of Puerperal 31adness. — The pa- 
thology of this disease involves several disputed 
questions, which we must not pass over without 
stating them, although we by no means expect to 
furnish a solution that shall be satisfactory to all 
parties. 

The first inquiry is whether puerperal madness 
depends for its immediate or proximate cause on 
inflammation of the brain and its membranes. 

The arguments urged in proof of this opinion, 
are, in the first place, the result of anatomical ex- 
amination in cases of madness in general. We 
must refer to a former section of this treatise on 
the necroscopical researches into the state of the 
brain in the bodies of maniacal patients, for evidence 
on this subject, and for proofs of the general infer- 
ence that inflammation, or a state closely allied to 
inflammation, is really the condition of the brain in 
cases of insanity. As puerperal madness is iden- 
tified by its symptoms with other forms of insan- 
ity, this analogical argument has evidently some 
weight until it shall be proved that this particu- 
lar form of mental derangement furnishes an ex- 
ception to the general fact. 

Secondly, the phenomena displayed by dissec- 
tions in cases of puerperal madness itself, have 
been thought by some to afford evidence in favour 
of the same conclusion. Unfortunately there is 
some discrepancy in the results of anatomical re- 
searches in respect to such cases. We have no 
extensive record of accurately related dissections, 
which might illustrate on a large scale the patho- 
logy of this disease. M. Esquirol says that he 
has examined the bodies of several patients who 
have died under puerperal mania, without being 
able to detect any morbid traces that pointed out 
the seat of the disease ; and Dr. Gooch has given 
the details of a case, at the termination of which 
he says, in general terms, that although the body 
was examined by a very eminent anatomist, no 



vestiges of disease were discovered in the brain o, 
elsewhere. In several other cases, however, de- 
scribed by the same eminent writer, it must be 
observed, that although the complaint had occurred 
in bodies already exanguious from uterine hemor- 
rhage and other exhausting causes, there were dis- 
covered on dissection thickenings of the dura and 
pia mater, sinuses full of blood, serum effused 
under the arachnoid membrane, hardness of the 
brain, and numerous bloody points, on cutting the 
substance of the hemispheres. Dr. Burrows has 
likewise referred to several cases in which there 
were marks of cerebral congestion ; and in particu- 
lar to one of Newman's dissections, in which the 
arachnoid membrane was quite firm, and nearly 
as thick as the dura mater. On the whole there 
is sufficient evidence that in general the brain ot 
puerperal maniacs displays, in a greater or less 
degree, the phenomena which are accounted to 
indicate the presence of inflammation. 

The reasons which in the minds of some writers 
have over-weighed all the arguments furnished by 
these observations, are the following : first, that 
the disorder in question frequently attacks patients 
who are previously in a state of great exhaustion, 
and therefore thought unlikely to be assailed by 
complaints of an inflammatory nature ; and se- 
condly, that puerperal madness, as might be ex- 
pected from the circumstances under which it takes 
its rise, and the exhausted and debilitated state of 
many patients who are attacked by it, cannot be 
safely treated by powerful antiphlogistic measures, 
such as copious bleeding. " Are we," says Dr. 
Gooch, " to shut our eyes to the symptoms during 
life, to the effect produced by remedies, to the mode 
in which death comes on, — that is, with symptoms 
of exhaustion, and to the remarkable emptiness of 
the veins throughout the body; and because there 
was a little serum under the tunica arachnoides, 
and more bloody points than usual in the medullary 
substance of the brain, conclude that it was a dis- 
ease of congestion or inflammation, and that per- 
haps the patient died because she was not blooded 
sufficiently V This last part of the inference 
would, indeed, be much more than the premises 
would warrant; the question, what is, in a patho- 
logical point of view, the condition of the brain, 
becomes comparatively unimportant and almost a 
matter of mere curiosity, when the practical indi- 
cations are already given, and even become the 
data from which we are to deduce reasons as to 
the nature of the disease. Yet it must be allowed 
that the existence of inflammation is not disproved 
by either of the arguments advanced. The dis- 
ease supervenes on an exhausted state of the sys- 
tem, but so do many other inflammatory complaints. 
Pneumonic affections often attack women who 
have suffered much in childbirth from uterine he- 
morrhage, but we do not for this reason call into 
question the inflammatory nature of pneumonia. 
Neither are we authorised in asserting that the 
disorder is not inflammatory, by the fact that the 
patients labouring under it do not bear bleeding 
ad libitum. How many inflammatory complaints 
are there in which we cannot venture freely on 
the use of the lancet ! Dr. Gooch's observation 
is, in a practical point of view, of the highest 
value. Antiphlogistic and cvacuant remedies must 
not be used without the greatest caution in cases 



70 



I K S A N I T Y. 



of puerperal madness ; but the existence of inflam- 
mation in the hrain and its membranes, when evi- 
dence of it is displayed in the characteristics of 
vascular fulness and other usual phenomena, is not 
disproved by this consideration. 

The theory of this disease, in reference to the 
nature of its constitutional and proximate causes, 
may be different in cases which occur at different 
periods ; and this is the more likely, because these 
cases vary in respect to their phenomena. 

In those instances of maniacal affection which 
occur during pregnancy, it is probable that the dis- 
ordered state of the brain or of the cerebral functions 
is the result of sympathetic excitement, which the 
vascular system, perhaps that of the brain in par- 
ticular, sustains from the peculiar state of the ute- 
rine functions. The well-known complaints con- 
nected with temporary excitement of the brain in 
some females at the period of the catamenia, the 
symptoms thence resulting, such as the returns of 
nysterical, epileptic, cataleptic paroxysms, or of 
hysterical and sometimes maniacal excitement of 
the mind, are pathological facts sufficiently illus- 
trative of the affection alluded to, and show it to 
be in accordance with other morbid phenomena. 

When madness comes on after childbirth, the 
pathology of the case is, perhaps, different from 
that of the affection now described. Dr. Gooch 
said, " the cause of puerperal mania is that pecu- 
liar state of the sexual system which occurs after 
delivery 7 ." He afterwards thought this account 
of the matter not sufficiently explicit. " What I 
meant was this ; the sexual system in women is 
a set of organs which are in action only during 
half the natural life of the individual, and even 
during this half they are in action only at inter- 
vals. During these intervals of action they diffuse 
an unusual excitement throughout the nervous 
system, — witness the hysteric affections of puberty, 
the nervous susceptibility which occurs during 
every menstrual period, the nervous affections of 
breeding, and the nervous susceptibility of lying- 
in women. I do not mean that these appearances 
are to be observed in every instance of puberty, 
menstruation, pregnancy, and childbirth, but that 
they occur sufficiently often to show tha-t these 
states are liable to produce these conditions of the 
nervous system." He adds, " Dr. Marshall Hall 
thinks that the susceptibility of the puerperal state 
is to be explained by mere exhaustion, and does 
not at all depend on the influence of anything 
specific in the condition of the several organs at 
that time ; but would an equal or greater degree 
of exhaustion at any time occasion the disease? 
This is a question of fact which I should answer 
in the negative. I have seen patients who have 
been deranged in childbed, and who had recovered, 
at a future period much more exhausted by illness, 
and much more agitated in mind, without the 
slightest appearance of mental derangement." 

It would seem that we are here referred for an 
explanation of the maniacal affection which oc- 
curs soon after childbirth, to excitement produced 
by the state of the uterine system. A remark, 
however, which obviously suggests itself on this 
subject is, that the phenomena of puerperal mad- 
ness usually display themselves just at the period 
when uterine excitement is subsiding. If ever the 
uterine functions, or the activity of the whole sys- 



tem of organs connected with them, is suspended, 
it is during the time shortly following the puer- 
peral period. We should not, at this conjuncture, 
expect the brain and the mind to be excited by 
sympathy with organic actions, which are in fact 
in a slate of temporary cessation. But the ex- 
pression, excitement of the sexual system, which 
is allowed to be too indefinite to convey a very 
precise meaning, may include the process of lac- 
tation. Perhaps it is to the irritation produced by 
the secretion of milk that we are more particularly 
to direct our attention ; for this secretion is a part 
of the series of functions belonging to the sexual 
system. But here we only return to the popular 
notion, according to which the disorder depends 
on the flow of the milk. Such is the opinion of 
old women and nurses in general, and it may be 
the true one. The relations, however, of puer- 
peral madness to the different processes which are 
set up or cease in the animal economy subsequently 
to childbirth, will be illustrated, if susceptible of 
illustration, by an exact observance of the periods 
at which this affection most frequently displays 
itself. The information obtained on this subject 
is not so complete as we might desire, but still it 
is of some value. 

Sauvages and other writers have recognised two 
different forms of mental derangement incident 
to lying-in women. One of them has been termed 
" paraphrosyne puerperarum" and is observed 
to succeed labour, immediately or within a day or 
two, before the secretion of milk can disturb the 
system, and independently of any lochial suppres- 
sion. " These attacks," says Dr. Burrows, who 
assents to the above distinction of varieties in the 
disease, " will sometimes go off under the opera- 
tion of a smart purge and an opiate, and may 
then be considered as merely accessions of deli- 
rium ; in other instances they are more perma- 
nent, and become fully developed instances of 
puerperal insanity. Sauvages' second species is 
termed ' mania lactea / and Dr. Burrows is of 
opinion that maniacal symptoms in reality make 
their appearance most frequently about the third 
or fourth day after childbirth, which countenances 
the notion that they are connected with the lacteal 
secretion. This writer, however, has very candidly 
referred to the evidence deducible from the tables 
published by M. Esquirol, although it is rather 
opposed to the opinion above stated. From these 
tables it appears that in the years 1811, 1812, 
1813, 1814, eleven hundred and nineteen insane 
women were admitted into the Salpetriere, of 
whom ninety-two laboured under puerperal mad- 
ness : of these — 

16 became delirious from the first to the fourth 

day. 
21 from the fifth to the fifteenth day, which gene- 
rally includes the termination of the lochia. 

17 from the sixteenth to the sixtieth day. 

19 from the sixtieth day to the twelfth month of 

lactation. 
19 after forced or voluntary weaning. 

The result seems to be, as Dr. Burrows allows, 
that the disease is more frequently a consequence 
of delivery than of suckling. 

On the whole it appears evident that some 
cause more general in its influence than any 
one particular process must be referred to, if 



INSANITY. 



71 



we would explain the frequent occurrence of 
madness in pregnant, puerperal, and suckling 
females. 

A view of this subject which seems to us more 
illustrative of it, occurred to Dr. Ferriar, and has 
been thus stated by him. 

"I am inclined to consider the puerperal mania 
as a case of conversion. During gestation, and 
after delivery, when the milk begins to flow, the 
balance of the circulation is so greatly disturbed 
as to be liable to much disorder from the applica- 
tion of any exciting cause. If, therefore, cold 
affecting the head, violent noises, want of sleep, 
or uneasy thoughts, distress a puerperal patient 
before the determination of blood to the breasts is 
regularly made, the impetus may be readily con- 
verted to the head, and produce either hysteria or 
insanity according to its force and the nature of 
the occasional cause." 

That new determinations in the vascular sys- 
tem should ensue on the removal of one so long 
subsisting as that to the uterus during pregnancy, 
is in accordance with a well-ascertained principle 
in pathology. The natural and healthy determin- 
ation under these circumstances is to the lacteal 
glands, but owing to various causes, either exter- 
nal or of predisposition, morbid determinations 
occasionally take place. Some women become 
phthisical at a very early period after childbirth, 
or rather the symptoms of phthisis develop them- 
selves at that time in a manifest form. Other con- 
stitutional complaints are apt to arise at the same 
period, according to the prevalent tendency of the 
habit. When the brain is susceptible, it is likely 
to suffer in its turn, and become the seat of local 
disorder, the manifestations of which are affec- 
tions of the mind. If we consider the frequent 
changes of disturbances occurring in the balance 
of the circulation from the varying and quickly 
succeeding processes which are earned on in the 
system during and soon after the periods of preg- 
nancy and childbirth, we shall be at no loss to dis- 
cover circumstances under which a susceptible 
constitution is likely to suffer. The conversions 
or successive changes in the temporary local de- 
terminations of blood which the constitution under 
such circumstances sustains and requires, appear 
sufficiently to account for the morbid susceptibility 
of the brain. 

The cases of mental disorder which occur in 
the later periods of lactation are, as it is evident 
from M. Esquirol's table, of two kinds. In one 
the disease supervenes on weaning, and probably 
has its origin in the subsidence of the lacteal se- 
cretion. There are other instances which appear 
to arise from the continued excitement and ex- 
haustion of the system consequent on suckling. 
This state of exhaustion takes place at different 
periods in different constitutions. Some women 
can continue to give milk without injury for years, 
but by others, morbid feelings are experienced in 
the space of a few months or even of as many 
weeks, and do not subside for some time after 
weaning. The writer of this article has observed 
very numerous instances of melancholy dejection 
with symptoms of insanity more or less strongly 
marked, which have displayed themselves in the 
protracted period of nursing, and in females who 
were evidently suffering from exhaustion. In one 



instance a lady, who on former occasions had com- 
plained of feelings termed nervous, and had been 
much indisposed when giving milk, was persuaded 
to continue suckling a child until the thirteenth 
or fourteenth month. She was then attacked by a 
maniacal disorder, which, though of a mild cha- 
racter, was very decided in its nature. Nearly a 
year passed before her mind was perfectly restored. 
Treatment of Puerperal Madness. — If we con- 
sider that the greatest danger to be apprehended 
for patients labouring under puerperal madness 
arises from a state of extreme exhaustion, that 
many women die from this cause within a short 
interval from the commencement of the disease, 
and that if they survive this period, the healthy 
state of the mind is in most instances restored, it 
will be evident that our chief endeavours must be 
directed to the present support of life. If we can 
maintain and restore the general health, and keep 
the natural functions in a state compatible with 
continued existence for a time, the disease of the 
animal system will in all probability subside. An- 
tiphlogistic and particularly evacuant remedies 
must be used very sparingly and with great cau- 
tion. 

1. Bloodletting, as a general remedy for puer- 
peral madness, is condemned by all practical 
writers on whose judgment much reliance ought 
to be placed. M. Esquirol is decidedly opposed 
to it. Dr. Gooch's observations on this subject 
contain the best exposition of the rules which 
ought to guide medical practitioners as to the use 
of the lancet in cases of puerperal madness. He 
says, " The result of my experience is, that in 
puerperal mania and melancholia, and also in 
those cases which more resemble delirium tremens, 
bloodletting is not only seldom or never necessary, 
but generally almost always pernicious. I do not 
say that cases never occur which require this 
remedy ; no man's experience extends to all the 
possibilities of disease, but I have never met with 
such cases, and I would lay down this rule for the 
employment of bloodletting — never to use it as a 
remedy for disorder in the mind, unless that dis- 
order is accompanied by symptoms of congestion 
or inflammation of the brain, such as would lead 
to its employment though the mind was not dis- 
ordered. Even here, however, great caution is 
necessary ; local is safer than general bleeding. 
In one case the head was hot, and the face red, 
and the pulse was said to have become somewhat 
hard, yet a bleeding of eight ounces was followed 
by extinction of the pulse within three hours, and 
death in less than six. The only cases attended 
by a quick pulse which I have seen recover were 
those in which no blood was taken. In the really 
inflammatory disease of the brain, bloodletting of 
course is essentially necessary ; but these, I think, 
can never be mistaken for puerperal insanity ; they 
are febrile headachs, more or less acute. Pain of 
the head with fever is a much better indication for 
bloodletting than disorder of the mind without 
these symptoms." 

2. In cases attended with much heat about the 
scalp, flushing of the face, and strong puliation 
of the temporal and carotid arteries, it will be 
proper to shave the head and keep it cool by 
means of cold lotions, or an oil-skin cap filled 
with ice or iced water, or by evaporating lotions. 



72 



INSANITY. 



If the symptoms above mentioned an<l those of 
mental excitement are very acute, and the debility 
of the patient is not in an alarming degree, a few 
leeches may be applied with advantage. Blisters 
to the occiput or nape of the neck arc often ser- 
viceable ; they are much recommended by practi- 
cal writers. When the scalp is not hot, and the 
tendency of the disease is rather to stupor than to 
a high degree of excitement, blisters are usefully 
applied over the top of the head. 

The lower extremities, which are often cold, 
should be frequently immersed in hot water, or a 
hip-bath used. Dr. Burrows recommends bathing 
the legs and feet in a warm infusion of mustard 
or horse-radish. Heat should be applied in the 
most convenient form, and the circulation in the 
extremities promoted by other obvious means. 

3. Purgatives and emetics are among the most 
useful remedies in this disease. The alimentary 
canal is frequently in a disordered state, the 
tongue furred, the breath fetid, the skin discoloured, 
the evacuations dark and offensive. A few brisk 
purgative doses, calomel followed by castor oil or 
rhubarb and magnesia, should be given in such 
cases. Emetics of ipecacuanha, with small doses 
of tartarized antimony, are very valuable remedies 
in this state of the alimentary canal. Dr. Gooch 
has remarked that they should be used with cau- 
tion when the face is pale, the skin cold, and the 
pulse quick and weak ; and in general he prefers 
ipecacuanha to antimonials. 

4. After these evacuant remedies have been 
premised, great advantage is frequently derived 
from the use of opiates. Full doses are generally 
attended with the best success. Ten grains of 
Dover's powders may be given at night, or a grain 
and a half of solid opium, or thirty drops of the 
tincture. Several writers recommend Battley's 
solution of opium in preference to the tincture ; 
perhaps the acetate and muriate of morphia are 
the best preparations of opium ; they may be given 
in doses of a quarter or half of a grain, and re- 
peated every third or fourth hour until sleep is 
procured. When opiate disagrees, Dr. Gooch re- 
commends the use of hyoscyamus, mixed with 
camphor. He says that five grains of each should 
be given every sixth hour, and a double dose at 
night: a dram of the tincture will answer the 
same purpose. This writer is of opinion that 
narcotics are the most valuable remedy in the cure 
of puerperal mania ; he says " that they often 
produce nights of better sleep and days of greater 
tranquillity, and this calmness is followed by some 
clearing up of the disorder of the mind." He 
says that these remedies produce salutary effects 
much more frequently in the mania of lying-in 
women than in maniacal disorders occurring un- 
der other circumstances ; if, however, there is heat 
in the head, flushing in the face, and thirst, their 
use ought to be postponed until such symptoms 
shall have been removed. 

5. In the more protracted cases of puerperal 
madness, tonic and stimulant medicines are some- 
times requisite, especially when the appetite has 
failed. Ammonia is much recommended. It may 
be given with infusion of cinchona or any bitter 
infusion. When it is not offensive to the stomach, 
the rectified oil of turpentine is one of the best 
stimulants, especially if taken in the dose of a 



with cinnamon 



drachm three times in a day 
water, or any other aromatic fluid. 

6. A rule of great importance refers to the diet 
of women in puerperal madness. It may, perhaps, 
be safely asserted that the greatest risk which pa- 
tients in this disease incur is that of being starved 
through the mistaken notions of their attendants, 
who are too often disposed to consider the excite- 
ment of maniacal disease a reason for withholding 
food, when this very state, owing to the exhaus- 
tion produced by its long continuance, renders it 
especially necessary to support the strength more 
carefully. Farinaceous fluids of a nutritive quality, 
milk, rice, and other such matters should be given 
at short intervals, when febrile symptoms preclude 
the use of animal food. In most instances broth 
may be allowed and ought to be given. In the 
more protracted periods, solid meat, with malt 
liquors, should be taken. We have seen very 
many maniacal patients labouring under great 
weakness and exhaustion, with cold extremities, a 
clammy skin, passing sleepless nights, and under 
continual agitation, begin to improve as soon as 
their diet was changed, and meat with some ale 
or porter given daily. The pulse has become 
fuller and less frequent, the extremities warm, 
sleep has been restored, and convalescence has 
taken place in a surprisingly short period after 
such a system has been adopted. 

7. The last observation to be made refers to the 
management of such patients. We must here 
advert to the remarks to be found in a former sec- 
tion on the management and moral treatment of 
maniacal patients in general. The general rules 
only require modification in some particulars in 
relation to the peculiar circumstances of puerperal 
patients. The latter for obvious reasons cannot 
be soon removed from home. They require in 
other respects similar management. They should 
be separated from relatives and friends, and care- 
fully attended by persons who are fitted for the 
occupation by habit. It will not so often be 
necessary to send puerperal maniacs to lunatic 
asylums as deranged persons of a different descrip- 
tion. 

Sect. VIII.— Senile Dementia. 

Senile dementia is essentially distinct from in- 
sanity ; yet for various reasons that will be appa- 
rent, a short account of its phenomena will be 
properly introduced in this place. 

We have already described that species of 
fatuity which is the frequent result of protracted 
insanity. The term dementia has been adopted 
by late writers to designate this morbid state of 
the mental faculties. This expression, however, 
has been used in a somewhat more extensive 
sense, as equivalent to fatuity in general, and as 
denoting, besides the ordinary sequel of madness, 
various other morbid conditions, in which the in- 
tellectual powers are impaired or obliterated. It 
is applied to the fatuity which occasionally follows 
apoplexy, epilepsy, palsy, and other comatose dis- 
eases By many French authors the same term 
has also been made to comprehend the mental 
disease or decay peculiar to old age. In its last 
stage fatuity displays nearly the same phenomena 
in every case, by whatever causes induced or by 
whatever previous diseases it may have been 
ushered in ; but m the early periods, to which 



INSANITY. 



73 



for reasons already explained, we purpose to limit 
the application of the term dementia, there are 
many shades of difference between its different 
forms. The intellectual weakness which follows 
apoplexy is not precisely of the same character as 
that demented state which is the sequel of insanity, 
and which occasionally gives way either to a re- 
newal of maniacal excitement or to returning rea- 
son ; nor is either of these affections precisely 
analogous to the decay of mind incident to old 
age. We must, in. compliance with custom, con- 
tinue to use the received term, but we shall 
distinguish the last-mentioned affection by the 
additional epithet of senile dementia. 

The following is the description of dementia in 
general which has been given by M. Esquirol. 
" Dementia deprives men of the faculty of ade- 
quately perceiving objects, of seeing their relations, 
of comparing them, of preserving a complete re- 
collection of them ; whence results the impossi- 
bility of reasoning correctly. Demented persons 
are incapable of reasoning, because external ob- 
jects make too feeble an impression upon them ; 
because the organs of transmission have lost a 
part of their energy ; or, lastly, because the brain 
itself has no longer sufficient strength to receive 
and retain the impression which is transmitted to 
it ; hence it necessarily results that the sensations 
are feeble, obscure, incomplete : being unable to 
form a true and just idea of objects, these persons 
cannot compare them, or exercise abstraction or 
association of ideas ; they are not capable of a 
sufficiently strong attention ; the organ of thought 
has not energy enough : it has been deprived of 
that vigour which is necessary for the integrity of 
its functions. Hence the most incongruous ideas 
succeed each other ; independent of each other, 
they follow without order and connection ; pa- 
tients repeat words and entire sentences without 
attaching to them any precise meaning ; they talk, 
without being conscious of what they say. It 
seems as if unreal expressions were heard by 
them in their heads, which they repeat in obe- 
dience to some involuntary or automatic impulse, 
the result of previous habits or of fortuitous asso- 
ciation with objects which strike their senses." 

Senile dementia differs in many particulars from 
the state of disease just described, though in 
some others resembling it. There is in both cases 
the same speedy and almost momentary oblitera- 
tion of recent impressions, if the merely passive 
recognition of objects which present themselves 
to the senses may be so called. But in the dis- 
ease peculiar to old age it may often be observed 
that ideas which were long ago stamped upon the 
mind remain with nearly their original force, and 
are capable of being called up whenever associa- 
tion suggests them, or the attention is purposely 
directed to them. The impressions produced by 
present objects are often so slight and evanescent, 
and the notions connected with them are so con- 
fused and indistinct, that the individual affected 
scarcely knows where he is ; yet he recognises 
without difficulty persons with whom he has long 
been acquainted, and if questioned respecting his 
former life and the transactions and pursuits of 
his youth or manhood, he will often give perti- 
nent and sensible replies. The disorder of his 
mind consists not in defective memory of the past, 

Vol. III.— 10 G 



but in the incapacity for attention and for receiving 
the influence of present external agencies, which, 
in a different state of the cerebral organization, 
would have produced an effect upon the sensorium, 
or seat of sensation and perception. 

The following account briefly describes the 
state of a person labouring under senile dementia, 
who has been occasionally under the care of the 
writer of this article. It will serve to exemplify 
some of the foregoing remarks. 

A. M , aged about seventy years, was in 

his youth a farmer, but changed that occupation 
for the business of a baker, which he followed 
until he had accumulated property sufficient for 
his maintenance. He has been living for several 
years in retirement, and without any regular oc- 
cupation. His memory is said to have undergone 
a gradual decay. When he is questioned respect- 
ing present objects and circumstances, he gene- 
rally gives clear and distinct answers, but can sel- 
dom recollect what has occurred but a short time 
previously. In half an hour after he has been 
visited by his medical attendant, who is an inti- 
mate acquaintance, he will say, if asked, that he 
has not seen him for several days. His recollec- 
tion of persons whom he knew in the former pe- 
riods of his life, and of events which then hap- 
pened to him, is tolerably clear ; but at times, and 
especially after sleep, he does not know where he 
now is. He sometimes fancies, at night, on waking 
from a short sleep, that he is engaged in his for- 
mer occupations. He has risen from bed, and set 
himself busily to prepare for lighting a fire in his 
oven, beats the wall, calls his men up, and asks 
if the fagots are ready. He cannot be persuaded 

without great difficulty that he is in street, 

and has nothing to do with the baking business. 
At other times he will get up in great haste to go 
down and see somebody who is waiting for him 
on business, or thinks that there is a horse stand- 
ing for him at the door, calls for his clothes, and 
wonders that his friends are so tardy in assisting 
him. At these periods his state is not that of or- 
dinary somnambulism. He sees and knows some 
at least of the persons who are about him, and 
will converse with them. He sometimes, during 
the day-time, wonders where he is, does not know 
the place though he has resided in the same house 
for some years. The hostess, who is an old ac- 
quaintance, at length convinces him that he is at 
her home. When his recollection is roused, and 
his thoughts are drawn into the right channel, he 
has a correct knowledge of persons, and shows 
not the slightest trace of maniacal illusions, or of 
anything approaching to the character of insanity. 
He is glad to see his old friends, shakes hands 
with them in his wonted cordial manner, is on the 
best terms with his relatives, and never displays 
the least deviation from the natural and habitual 
state of his feelings and affections. 

Senile dementia, or the decay of the mental 
faculties, is not the lot of old persons universally, 
though it is a condition to which old age may be 
said to have a tendency, and to which in the last 
stage of bodily decay some approximations are 
generally to be perceived. The change which 
time alone will perhaps sooner or later bring on, 
in those who long survive the allotted duration of 
man's days, may be accelerated by a variety of 



INSANITY. 



circumstances. Among these is a life of too 
much activity and excitement, of mental exertion 
beyond what the constitutional strength of the 
individual is capable of supporting without con- 
stant effort; excessive anxiety and eagerness in 
the pursuit of business, or intense and unremitted 
application to studies of whatever kind. The 
minds and bodies of men are only fitted for exer- 
tion in certain degrees, which, however, differ in 
different individuals; but the powers of all are 
limited. All have need of occasional respite from 
labour, and the appointment of rest during one 
day in seven is, from physical considerations alone, 
calculated to promote the well-being of individuals 
and of society. We may observe that among 
those who neglect this ordinance, there have been 
many who have suffered the penalty in this life. 
Some have terminated a rapid and perhaps bril- 
liant career of unremitting and successful exer- 
tions by suicidal madness, of which too many and 
too well-known examples might be cited ; others, 
though in a longer measure of time, have accele- 
rated the period of intellectual decay. 

A second cause of senile dementia, next in the 
frequency of its operation to that which we have 
just mentioned, is the too liberal use of vinous or 
ether fermented liquors. There are many persons 
who lead active lives, who are not considered in- 
temperate, yet drink on an average nearly a bottle 
of wine a day. Such persons, if their lives are 
not shortened, have every reason to expect a pre- 
mature imbecility. The same affection has been 
observed frequently to make its appearance in men 
long engaged in active pursuits, soon after they 
have relinquished their business or professions, 
and have laid themselves by to enjoy ease and 
leisure for the remainder of their days. The dis- 
ease often appears in a more marked and sudden 
manner in elderly persons who have sustained a 
slight attack of apoplexy or paralysis, which has 
perhaps been speedily recovered, and expected to 
have left but slight traces of disease. That ex- 
pectation is verified so far as the sensitive and mo- 
tive powers are concerned, but the seat of intellect 
is found to have been shaken in its very centre. 

Senile dementia is entirely distinct from that 
species of moral insanity which appears occasion- 
ally, as we have already observed, in aged per- 
sons. The former is merely a loss of energy in 
some of the intellectual operations. It brings 
with it nothing morbid or unusual in the state 
of the feelings or affections, no tendency to de- 
praved or unaccustomed habits, nor, commonly, 
any change in the temper and general disposition 
of mind. Individuals to whose lot this complaint 
has fallen are seldom unhappy on account of it, 
and if they are in any degree aware of their con- 
dition, they bear it with patience and cheerful- 
ness. The state of the affections remaining natu- 
ral and unperverted, is indeed a general diagnostic 
between disorders consisting merely of impaired 
faculties, and the forms of madness. The reverse 
of the previous remark applies, as we have said in 
the former part of this treatise, to the various mo- 
difications of insanity, and probably in greater or 
less degree to every case which can with perfect 
propriety be designated by that term. 

This last observation, in its reference to senile 
dementia, may suggest a hint as to the justice and 



propriety of certain proceedings which are occa- 
sionally attempted and put in force with persons 
labouring under that affliction. As madness not 
only disorders the intellect, but likewise perverts 
the moral habits and the natural feelings of the 
afflicted individuals who are victims to it, there 
arises hence an obvious and unquestionable pro- 
priety in putting them under restraint. They are 
then not only placed under circumstances more 
favourable and sometimes essential to the cure of 
their complaint, but are likewise prevented from 
committing acts dangerous to themselves and others, 
and such as the same individuals would perhaps 
have shuddered to reflect upon in the days of sane 
and unclouded reason. To act otherwise with 
them would indeed be the height of cruelty. But 
the case is widely different when the moral dispo- 
sition and the entire mental character remain 
unimpaired, and the memory only fails, or the 
aptitude to intellectual exertion alone is dimin- 
ished through the weakness of years. If an old 
man, who has spent the greatest portion of his 
life in active exertion, and has accumulated pro- 
perty by habits of labour and parsimony, after 
some time passed in retirement, begins to lose his 
recollection of passing events ; if his faculties be- 
come impaired to a certain degree on account of 
that wealth which it has been the object of his life 
to accumulate, and for the amassing of which he 
has sacrificed all thoughts of ease and comfort 
during many successive years, he may now be- 
come the object of attack to some relative who 
may procure declarations of his incompetency to 
manage his estate. If such a person is brought 
before a jury and sharply interrogated, examined 
in figures, and puzzled by a variety of questions 
respecting matters of business, and other topics 
requiring accuracy in dates and calculations, it is 
not impossible that the affair may issue in his 
confinement in a lunatic asylum, or that at all 
events the management of his person and his 
affairs may be taken from the care of those to 
whom in the sound and entire state of his facul- 
ties he had confided both, and to whom, his moral 
affections and social feelings remaining yet un- 
changed, he still continues to be devotedly at- 
tached. 

In France it has been for many years not un- 
usual to confine aged persons of impaired faculties 
in the public hospices where deranged persons are 
admitted ; and this practice has so much prevailed, 
that M. Georget alludes to it as a source of error 
and embarrassment in the attempt to determine 
the relative frequency of madness in late and in 
former times ; these asylums being partly occupied 
by a number of old persons who remain till their 
decease, and whose disorders are not properly cases 
of insanity. Previously to the year 1790, out of 
411 persons admitted as labouring under disor- 
dered or decayed intellect, there were only 19 
whose age exceeded fifty years, whereas, in 2451 
admitted between 1814 and 1821, not less than 
880, or the third part of the entire number, were 
persons who had passed the period of life above 
mentioned. Of these, a great proportion were 
probably cases of senile decay. If the custom of 
thus getting rid of aged parents were a matter of 
choice and in general practice, without excuse on 
the ground of necessity, we might doubt whether 



INSANITY. 



75 



our enlightened neighbours displayed their filial 
piety in a more advantageous manner than the 
Battas, who knock their aged relatives on the 
head and eat them ; or than the old Irish, who, as 
Strabo assures us, xa\dv ti qyovvTo Karttrdieiv tov; 
vdrtpas TtKcuTtjaavras. But it is only among poor 
families that the custom prevails, and it is but 
parallel to the habit of the poor in England, who 
not unfrequently suffer their parents to die in 
parish workhouses. It is the greatest evil attend- 
ant on iron-handed necessity, that it so often 
breaks asunder the first and nearest bonds of duty 
and natural affection. 

The following table will, serve to illustrate the 
forms of disease which are included by medical 
writers under the common term of dementia. It 
is styled by M. Esquirol, from whom we extract 
it, a table of causes. The table exhibits the dis- 
tribution of 235 cases of dementia : the first co- 
lumn contains the number of patients admitted at 
the Salpetriere during the years 1811 and 1812 ; 
the second column is the report of the author's 
private establishment, and is limited to persons 
of the higher or more opulent classes of society. 

TABLE OF CAUSES. 



No. of Individuals. 
Physical Causes. 
Disorders connected with the ~> ^ . 

catamenia 5 

Critical period 29 

Consequences of childbirth ... 5 

Blows upon the head 3 

Progress of age 46 

Ataxic fever I 

Suppression of hemorrhoids . . 

Mania 14 

Melancholia 13 

Paralysis 3 

Apoplexy 3 

Syphilis and abuse of mercury 6 

Faults of regimen 

Intemperance 9 

Masturbation 4 

Moral Causes. 

Disappointed love 1 4 

Fright 4 3 

Political excitement 

Disappointed ambition 3 

Poverty 5 

Domestic griefs 8 4 



192 73 



U95 



40 



235 



It may be remarked in reference to the first 
column, that the cases placed under the heads, 
1, 2, 3, 8, 9, 12, 13, 14, 16, 18, 19, 20, 21, 
amounting altogether to 102, were probably in- 
stances of insanity in some of its forms, or of the 
stages of fatuity which are its consequence. There 
only remain 60 cases, which appear to have been 
instances of dementia not preceded by madness. 
Of this remainder, 46 cases are examples of senile 
decay, and these appear to form the great majority 
f»f cases, which are referred by the writer above 
cited to the head of idiopathic dementia, or de- 
mentia, unconnected with insanity. It therefore 
appears that this class of diseases nearly resolves 



itself into the sequela? of madness, and the decay 
peculiar to old age. 

It is obvious that the art of medicine in refer- 
ence to senile dementia must be limited as to its 
sphere, in a great measure to the means of pre- 
vention, as cure is scarcely to be hoped. The 
prevention of this melancholy termination must, 
however, depend upon the habits of the indivi- 
dual, and on the mode in which the previous 
years of life may have been passed. In the regu- 
lation of previous habits may be found resources 
adequate in general to averting the approach of 
mental decay. Much will depend upon the man- 
ner of living during the early period of old age, 
or when the physical powers are beginning to de- 
cline. Habits of indolence, and those of too great 
mental exertion, should be alike avoided ; since 
many are observed to lose the vigour of their 
minds after a sudden and total retirement from 
active business, while in others the disordered 
state seems to have been brought on by too close 
application to studies, and particularly to those 
which require a sedentary life. The former of 
the causes above mentioned is, however, by far 
the most powerful and frequent in its operation, 
and numberless instances may be cited of persons 
who have exercised professions requiring consi- 
derable labour of mind during advanced years, 
without experiencing in consequence any decay 
of faculties. 

The preservation of health in old age, both in 
other respects and in what regards the functions 
of the brain, will depend, in a very considerable 
degree, upon the adaptation of diet and regimen 
to the constitutional state of elderly persons. 
With the alteration of habits which advancing 
age implies, with the various changes in the state 
of the physical functions which it brings with it, 
a corresponding variation in diet and regimen is 
necessary, and if this is not made, disorder en- 
sues. Many of the diseases incident to elderly 
persons are diseases of plethora, as apoplexies, 
and paralysis, and vertigo, and these are not un- 
frequently the preludes of dementia. The decay 
of faculties is observed to occur without such 
preludes in persons who live too freely. These 
and other considerations render it probable that 
the disorder of the brain connected with senile 
dementia depends upon a state of vascular reple- 
tion. When the disorders of old age have com- 
menced, by a comparatively spare diet, consisting 
principally or entirely of farinaceous and other 
light vegetable food, by discontinuing in a great 
measure the use of wine and fermented liquors, 
the general health, and that of the brain in parti- 
cular, will be greatly promoted. If there are de- 
cided threatenings of cerebral disease, an issue or 
seton, and the frequent use of mild aperient medi- 
cines to maintain a copious alvine discharge, will 
contribute to the same end, and will not only 
ward off attacks of apoplexy and palsy, but like- 
wise lessen the tendency to senile dementia. 

[The preparation of the above article suggested 
to Dr. Prichard his Treatise on Insanity and 
other Diseases affecting the Mind, (Lond. 1835,) 
which was reprinted in this country. It is a com- 
prehensive and able work, and may be referred to 
for further developments of the subject. See, 
also, Art. Insaiutt, in Copland's Dictionary of 



76 



INTUSSUSCEPTION — IRRITATION. 



Practical Medicine ; Esquirol, Dcs Maladies Men- 
tales, Paris, 183S; unci, for the arrangement, &c. 
of insane hospitals, Jacobi, Art. Irrenanstalten, in 
Enci/clop. Wdrterb. der Median. Wissenschaft. 
xix. 62: Berlin, 1839; and On the Construction 
and Management of Hospitals for the Insane, 
with Introductory Observations, by Samuel Tuke, 
Lond. 1841. A good account of the American 
insane institutions is given in the First Report of 
the Insane Asylum at Utica, N. Y. ; also, in the 
Eleventh Annual Report of the Trustees of the 
State Lunatic Hospital at Worcester, Mass. Bos- 
ton, 1844. 

(For the medico-legal bearings of insanity, see 
Mind, Soundness and Unsoundness of.)] 
J. C. Prichard. 

INTERMITTENT FEVER.— See Feveh. 

[INTUSSUSCEPTION, (from intus, within, 
and suscipio — sus or sub and capio, to take.) In- 
tussusception or invagination of the intestines 
occurs when one portion of intestine passes into 
another. Owing to augmented peristaltic or spas- 
modic action of the intestines, an upper portion 
of intestine may be forced into a lower; or, should 
an inverted action cf the intestines occur, it may 
happen, that the lower portion is forced into the 
upper, and becomes arrested there. The first of 
these lesions is called progressive intussusception ; 
the latter retrograde intussusception. 

Invaginations are not unfrequently met with in 
the dead body, especially in children ; but these 
often occur, probably, as one of the last acts 
of life ; whereas, the invagination, that gives rise 
to the concatenation of phenomena termed ileus, 
is accompanied by an inflammatory process, which 
causes the adhesion of the peritoneal surface of 
the invaginated portion of intestine to the portion 
of the peritoneal surface of intestine with which 
it comes in contact, so that the intussusception 
cannot be reduced after death. Owing to the 
narrowness of the canal, and the resulting ob- 
struction, the phenomena induced by obstruction 
from whatever cause, or, in other words, those of 
ileus supervene. 

Intussusception may take place in any part of 
the alimentary canal ; but it is most frequently 
observed in the ileum near where it terminates in 
the colon. At times, the invaginated portion 
sloughs away ; and there have been cases in 
which as much as three feet of intestine have 
been discharged per anum, with more or less of 
the mesentery attached. In thirty-five cases, col- 
lected by Dr. Thompson, (Edinburgh Medical 
and Surgical Journal, October, 1835,) the ave- 
rage duration of the disease was between four and 
five weeks. In twenty-two, the evacuated por- 
tion belonged to the small intestine ; in the other, 
to the large, or to both. Where the invagination 
has proceeded to a great extent, or where the 
small intestines with the csecum have passed down 
into the sigmoid flexure of the colon, as in some 
cases that have been related, the seat of the dis- 
ease is manifested by a hard tumour ; and in 
less marked cases careful examination has detected 
the existence of a deep-seated tumour. 

Treatment. — From the obscurity that must 
necessarily exist as to whether the phenomena of 
ileus be produced by intussusception or some 



other cause of intestinal obstruction, i is difficult 
to direct an appropriate treatment. Should it be 
diagnosticated, or suspected, cathartics must of 
course be very questionable remedies; and the 
only hope we can have is, that the invaginated 
portion may be thrown off, and a cure be thus 
obtained ; although such a result, it must be ad- 
mitted, is extremely rare. The appropriate gene- 
ral treatment, in all such cases, is that advised 
under enteritis (q. v.) ;— bloodletting, general or 
local, or both, with full doses of opiates, the warm 
bath, &c. 

Metallic mercury has been recommended by 
most writers in intussusception, as well as in 
every case of obstruction of the bowels; but 
it is not easy to comprehend on what principle it 
has been advised in intussusception. If it be of 
the progressive kind, the mercury must proceed 
directly through it ; and if retrograde, the same 
thing might happen, or, if not, by passing be- 
tween the intestinal and the invaginated portion, 
it might aggravate the disease. 

It has been supposed that large quantities of 
water or air thrown into the bowels might cause 
the invaginated portion, in cases of progressive 
intussusception, to resume its proper position ; 
and it has been proposed in suspected cases to in- 
troduce long bougies, and even pieces of whale- 
bone, into the rectum, with the view of pushing 
back the intussuscepted portion ; but cases can 
hardly be imagined in which such agents can be 
appropriate. Emetics have been suggested in 
cases of progressive intussusception, yet they 
could only be of service before agglutination of 
the peritoneal surfaces has occurred ; and, be- 
sides, one of the evidences of intussusception is 
the antiperistaltic action and vomiting. Under 
the same reasoning, cathartics might be advised 
in the retrograde form ! 

Where evidence has happened to be very strong 
as to the existence of intussusception and its seat, 
the operation of laparotomy has been advised, 
with the view of disentangling the invaginated 
intestine ; but it has been wisely discountenanced 
by almost all therapeutists. The symptoms of 
intussusception are always, indeed, obscure and 
doubtful, and may be produced by other states of 
the digestive tube ; so that, if the abdomen were 
opened, it might be found that no intussusception 
existed ; or if it did, that, owing to the agglutina- 
tion, no separation could be effected without 
causing, if possible, a more speedily fatal lesion. 
These circumstances, consequently, render the 
operation wholly inadmissible. 

ROBLEY DUNGLISON.] 

IRRITATION. — It is remarkable that a term 
so commonly employed and so indispensable as 
this is, should never have received a definite and 
generally acknowledged application. The agents 
and subjects, the causes and effects, the influences 
and phenomena of disease, have all indiscrimi- 
nately passed under the name irritation, until the 
word has ceased to designate anything, and, 
« vox et praeterea nihil," is prostituted to pass off 
any obscure and unintelligible matter of patho- 
logy, for which more definite terms will give no 
quarter. If a case presents itself with bold and 
positive features, such as pain, convulsion, deli- 



IRRITATION. 



77 



rium, palpitation, jarring pulse, and highly disor- 
dered function, but without certain characteristics 
of inflammation, it is distinguished by some as 
irritation ; whilst others use irritation and inflam- 
mation almost as synonymous terms. If a per- 
son faints or dies under a surgical operation, or 
from a crushed limb, without hemorrhage, the 
result is ascribed to irritation : in another exam- 
ple, after the same accident, or the same opera- 
tion, fever arises, and the patient dies in raving 
delirium ; yet this is also termed irritation. 

We do not venture to impugn the high author- 
ities that have rendered the term conventionally 
applicable to such varied and opposite affections ; 
but we would warn the student not to be misled 
in his reading, by the etymology of the word ; nor 
to suppose that in the extended application which 
it has received from various writers, irritation 
means anything more restricted than a class of 
morbid states of very considerable variety. 

In further illustration of these remarks, and as 
an introduction to this subject, we shall extract 
some account of the views of irritation from the 
works of two distinguished writers, M. Broussais 
and Mr. Travers. 

M. Broussais ("Examen des Doctrines Medi- 
cales," and " Histoire des Phlegmasies Chroni- 
ques,' , ') bases his description of irritation on the 
particular physiological views which he entertains 
respecting the vital properties of animal structure. 
These properties he calls sensibility and contrac- 
tility ; they are possessed in various degrees by 
the different tissues, and may be locally increased 
by certain circumstances ; such local exaltation 
always causing a diminution or depression of vi- 
tality in some other organ or system. This exal- 
tation of vitality is accompanied by an excessive 
afflux or congestion of fluids to the part, and con- 
stitutes what M. Broussais throughout his writings 
designates as irritation. The cause or circum- 
stances which produce irritation are of four kinds: 
— 1. Excessive excitement by certain agents, call- 
ed stimulants or irritants, directly applied ; 2. 
sympathy with another irritated organ ; 3. the ab- 
sence of a stimulus which is habitual to the part ; 
4. repulsion of excitability from other part or 
parts. 

One of the most remarkable features of this doc- 
trine is, that irritation, when once formed in any 
part of the system, becomes a cause of irritation 
in other parts or systems ; the influence being 
propagated by sympathy through the medium of 
the nerves. The phenomena of irritation vary ac- 
cording to the part which it affects, but the afflux 
of fluids or active congestion, is common to all 
primary irritations, and this is prejudicial to the 
functions and regular nutrition of the part. The 
first scat of irritation is acknowledged to be in the 
nervous fibrils of the irritated part ; and even in 
this stage irritation may be so intense as by means 
of the sympathetic effects on the system to cause 
death. But M. Broussais looks to the effects on 
the vascular system as the most important ; and 
if he docs not in his pathology describe irritation 
us vascular universally, his therapeutics certainly 
imply this ; accordingly the terms irritation and 
inflammation are used indiscriminately through- 
out his works. The irritation may be confined to 
.the white vessels only, and then he designates it a 



sub-inflammation • but this, as well as what is 
generally understood by inflammation, is included 
under the general term irritation. 

The increase of sensibility and contractility im- 
plied in irritation is sometimes shown by pain, 
convulsion, &c, but it is not always directly man- 
ifest, and is frequently not so, when irritation has 
its seat in the viscera, where a system of nerves 
exists which do not transmit sensations to the sen- 
sorium. Frequently the sympathetic irritations are 
more manifest than the original one that excited 
them. These secondary irritations or sympathies 
are of two kinds, organic, and those of relation. 
The organic consist in organic phenomena, such 
as increased action, congestion, disordered secre- 
tion, nutrition, temperature, &c. Morbid sympa- 
thies of relation are shown by pain, convulsions 
of the voluntary muscles, and mental derangements. 
Any of these kinds of sympathy may be excited 
separately, but they more commonly coexist ; and 
in proportion to their intensity and number will 
be the severity of the disease ; these generally de- 
pend on the sensibility of the organ primarily irri- 
tated, and of the system generally. Sometimes 
the original irritation continues to be predominant; 
the organ which it affects being the only one to 
suffer from congestion and disorganization ; but 
occasionally it happens that a secondary irritation 
becomes the principal ; this constitutes metastasis. 
Again, the principal irritation may be transferred 
to some organ of secretion or exhalation, and is 
relieved by a discharge from the system ; this is 
what is called a crisis. When irritation causes 
an accumulation of blood in a tissue, so as to pro- 
duce swelling, redness, and heat, it is called in- 
flammation, this being only an irritation of an in- 
tense kind, observing the same laws as irritations 
in general, except that when unrestrained it pro- 
ceeds more speedily to disorganization. These 
appear to be the main features of M. Broussais' 
doctrine of irritation in general. In describing its 
further application to particular diseases, he gene- 
rally uses the terms irritation and inflammation as 
synonymous, and ascribes to such an affection va- 
riously multiplied by sympathy and reaction, and 
occupying various seats, all febrile diseases, he- 
morrhages, profluvia;, morbid growths, most of the 
nervous diseases, dropsies, and even occasionally 
scurvy itself. In all febrile diseases and consider- 
able inflammations, the heart is sympathetically ir- 
ritated, whence the quick pulse and hurried circu- 
lation ; but the main and most important seats of 
irritation, either primary or sympathetic, are the 
mucous membrane of the stomach and bowels, and 
the brain. In all fevers called idiopathic, these 
irritations are the primary evils : they are equally 
so in the exanthematous and some other diseases; 
and there is not an inflammation of an extent 
sufficient to quicken the pulse which does not 
sympathetically produce a decided irritation of 
these organs. The cerebral irritation is in most 
instances secondary to that in the stomach and , 
bowels, and it always reacts on and increases the 
latter. 

Without proceeding further in the details of 
this doctrine, which Coutanceau has well named 
the doctrine of irritation, we may sum it up by 
saying that there is not a disease to which the 
human body is liable which is not dependent more 



78 



IRRITATION. 



or less directly on irritation. Such an excessive 
generalization, it might be expected, would have 
Deen confined to the name only, and although it 
should give a new aspect to pathology, it could 
hardly be anticipated that a corresponding inno- 
vation would hive been extended to therapeutics. 
But the case is far otherwise. Broussais, in as- 
cribing all diseases to irritation, and in viewing in 
that irritation nothing but a grade of inflammation, 
recognises truly curative means only in antiphlo- 
gistics, and denounces all other descriptions of 
remedy as irrational aud hazardous. Nor is he 
less exclusive in his catalogue of antiphlogistic 
remedies : purgatives and emetics he prohibits as 
dangerous irritants of the gastro-enteric mucous 
membrane, that soul and focus of all sympathies : 
diuretics irritate the kidneys; expectorants the 
bronchial membrane : diaphoretics the skin ; and 
instead of counteracting the original disease, they 
may reflect on it a new and aggravating irritation: 
the same objection applies in most instances to 
blisters and epispastics in general. In short, the 
whole class of antiphlogistic measures is, with 
trifling qualification, reduced to bloodletting, absti- 
nence, and dilution. 

Whatever may have been the triumphant proofs 
of success appealed to by the sanguine advocates 
of this doctrine, we refer to the united experience 
of the enlightened practitioners of this country, we 
refer to the records of these pages, for abundant 
evidence that its absolute practical application 
would be dangerous and unnatural, and that to 
deprive medicine of the agents that it so sweep- 
ingly proscribes, would be to curtail the art of its 
most salutary aids. Nothing can more strikingly 
expose the danger of excessive generalization than 
a familiar and unbiassed study of nature in all the 
varieties of her powers ; and in our opinion the 
philosopher who would ascribe all natural pheno- 
mena solely to gravitation or some such general 
power, would not be more partial and incompre- 
hensive in his views than the physician who at- 
tempts to restrict the still more complicated and 
diversified derangement of the animal body to an 
acknowledged but ill-defined principle, and to still 
further limit the practice of his art by a partial 
view of that principle itself. 

Great credit is due to M. Broussais for having 
fully established the fact, hitherto but little noticed, 
that local inflammations, particularly in the stomach 
and bowels, are present in most febrile diseases ; 
that such inflammations are capable of producing 
great disorder and even inflammation in remote 
organs, by sympathy through the medium of the 
nerves ; and that similar affections frequently 
complicate themselves with and aggravate many 
chronic diseases. The most salutary results have 
oeen obtained from the application of this knowledge 
to practice, in the judicious use of adequate anti- 
phlogistic measures wherever these inflammations 
subsisted ; and a more qualified and cautious pre- 
scription of purgatives and other medicines in 
similar cases is another good flowing from the same 
source. But to make the word irritation the re- 
presentative of the origin of almost every disease ; 
to exclude from pathology all views of general 
morbid states, whether of plethora or inanition, 
excitement or depression ; to refuse to acknow- 
'edge in local diseases any diversity of mode of 



action, referring all morbid phenomena and pro- 
ducts only to excess or diminution ; to exclude 
from therapeutics the whole class of alteratives, 
and to exaggerate in numerous kinds of evacuants 
their stimulant (often unproved) above their 
evacuant or antiphlogistic effects : to disregard the 
operation of narcotics, antispasmodics, and other 
medicines which exert a direct influence on the 
nervous system, and through it often favourably 
affect the vessels ; — this is to deny ourselves the 
advantages of daily experience and unbiassed ob- 
servation, and to render us the slaves of a system 
instead of the followers of nature. 

If M. Broussais were a little more impartial and 
considerate towards his own principles, and would 
take more into view that state of the nervous sys- 
tem which he acknowledges to be primary in the 
state of irritation, and which, as existing alone, 
may properly be viewed as an object of distinct 
and specific treatment ; if he would admit that a 
certain state of the vascular system is required 
before the irritation can produce inflammation, and 
that, therefore, antiphlogistics are indicated only 
when this state is present ; and if he would take 
into consideration the secernent and exhalant 
power as well as the inflammability of the vascu- 
lar system, and recognise the salutary operation 
of certain alterative, evacuant, and astringent medi- 
cines ; then his physiological system would stand 
on a broad and comprehensive basis, and its appli- 
cation to practice would be consistent both with 
principle and with the general experience of the 
most successful practitioners. But in its present 
state we cannot but view this doctrine as partial 
and exclusive : and we would decline his use of 
the word irritation as vague in pathology, and 
fallacious in therapeutics. 

The sense in which Mr. Travers uses the term 
is considerably different, but as he does not attempt 
to give a definition of it, it is difficult to render in 
a few words an explanation of his views. He 
seems to apply the name irritation to any disorder 
of sensation or function, whether of the nature of 
depression or excitement, that is not attributable 
to inflammation or to injury of the mere mechanism 
of parts. It is chiefly through the nervous system 
that the phenomena of irritation manifest them- 
selves ; and this constitutes the character which 
most distinguishes irritation from inflammation : 
but the relation of these two states of disorder 
must be as intimate as the connection between the 
nervous and the vascular systems is close and re- 
ciprocal. But it will, perhaps, more nearly repre- 
sent Mr. Travers' view of irritation to say that it 
is a morbid modification of the irritability of a 
part or system. Here we are naturally led to in- 
quire what irritability is, and what is its healthy 
proportion and mode of action. Of irritability it 
can only be said that it comprises the vital proper- 
ties of a part or tissue, and is shared in various 
proportions and forms, by the different organs and 
texture of the body. If there is anv rule observed 
in the distribution of this natural irritability, it is 
not in the ratio of sensibility, vascularity, or' mus- 
cularity, but rather according to the importance 
of the organ in the functions of life. It is much 
more largely possessed by some individuals than 
others; and various circumstances, external and 
internal, are capable of producing a great variety 



IRRITATION, 



79 



in its proportion in the same individual. An ex- 
cess or deficiency of natural stimuli, or the opera- 
tion of noxious agents, will convert healthy into 
morbid irritability; and again, if the share of irri- 
tability possessed by an organ be morbid, natural 
stimuli will produce irritation. Thus an irritable 
stomach may be nauseated and disordered by many 
ordinary articles of diet ; an irritable bladder is 
continually parting with its contents before the 
stimulus of distension can be supposed to act : an 
irritable heart becomes tremulous and palpitating 
whensoever its action is excited ; an irritable skin 
breaks out in a rash from many slight causes of 
excitement both of diet and temperature. The 
description which Mr. Hunter gave of irritability 
in a morbid sense, " over-action to the strength of 
the parts," and an irritable habit defined as " an 
increased disposition to act without the power to 
act with," accord with Mr. Travers' views of the 
subject, which are further exhibited in the follow- 
ing passage : " Extreme susceptibility and conse- 
quent over-activity are invariably coupled with 
and most probably dependent on weak and insuf- 
ficient powers of constraint and resistance. The 
same principle which renders a part over-irritable 
renders it over-active. The balance of the system, 
adjusted by the state of even health, is disturbed 
by the preponderance or deficiency of either of its 
active functions, as by the imperfection and disease 
of either of its organs. A weak organ or consti- 
tution is one easily put out of order, because it is 
continually excited to greater activity than it has 
power to support, — greater, therefore, than is con- 
sistent with the harmony of the system. But 
action may be morbidly excessive or deficient, in- 
dependently of organization ; and this irregularity, 
although occasional at its commencement, may 
become habitual. A too irritable, nervous, or 
vascular function is, therefore, as marked a consti- 
tutional peculiarity as irritable lungs or skin. In 
a physical as in a moral sense, every individual 
has a weak part, and this observation would as 
often apply to the function as to the organ. Cir- 
culation, or respiration, or nutrition, in one or other 
of their many intricate processes, is below par in 
tone. The absorbent capillary function is below 
par in scrofulous habits, the arterial in the leuco- 
phlegmatic, the venous in those disposed to local 
congestions ; the exhalant in the dropsical ; and the 
pulmonary, gastric, hepatic, and renal, are respec- 
tively the failing functions in persons who eventu- 
ally become the subjects of asthma, gout, jaundice, 
and stone." (On Constitutional Irritation, p. 1 5.) 
This quotation, although referring only to sus- 
ceptibility of irritation, will be sufficient to show 
the extensive view in which Mr. Travers applies 
the term under consideration. Irritation in this 
sense cannot be defined otherwise than as a dis- 
order arising from a want of balance of functions. 
But as no disorder can exist without more or less 
of a loss of balance of function, it is obvious that 
there is nothing in this definition which can dis- 
tinguish irritation from disease in general. It is, 
in fact, more according to their causes than by 
any common character in their symptoms that 
Mr. Travers groups the cases of disease as in- 
stances of irritation, and this is perhaps (espe- 
cially as far as it relates to surgery) the most 
practical method of arrangement. 



Irritation may be either local or general ; that 
is, one or more organs or parts may be its seat, 
without the rest of the body partaking of the dis- 
order, in which case, it is local ; but when the 
principal functions become affected, the irritation 
may be called general or constitutional. Local 
irritation may sometimes become extended to the 
system, and thus become constitutional ; this oc- 
curs in cases of severe external injury or disor- 
ganization, such as extensive burns, compound 
fractures, &c. Mr. Travers makes a further divi- 
sion of cases of constitutional irritation into two 
kinds, direct and reflected. Direct irritation is 
that wholly and immediately derived from a local 
source of irritation, the constitution having no 
share in its production, and is, therefore, propor- 
tionate to the local cause. Reflected irritation, 
on the other hand, originates in a peculiar morbid 
state of the constitution, is purely idiopathic, and 
being oftener the cause than the effect of local 
disordered action, is seldom influenced by local 
treatment. The symptoms characterizing direct 
constitutional irritation, are, in the nervous sys- 
tem, rigor, delirium, convulsion, coma; in the 
vascular, the fever of phlegmonous, suppurative, 
ulcerative, and gangrenous inflammations. Those 
which belong to reflected constitutional irritation 
are, in the nervous system, epilepsy, tetanus in 
all its modifications, and other anomalous forms 
of spasm, mania, &c. ; in the vascular system, 
the fever accompanying erysipelas, scrofulous and 
carcinomatous inflammation, carbuncle, &c. 

The division which Mr. Travers has thus made, 
appears to be abstractedly just and natural, and in 
extreme cases it is sufficiently easy to distinguish 
between the local and the constitutional origin of 
disease. But the more numerous cases of a 
mixed description, where sympathies and re- 
actions are multiplied and complicated, and where 
local disease and a disordered constitution affect 
each other with equal or balancing forces, will 
seldom bear an exclusive reference to either of 
these divisions, and it would be unsafe to found 
practice generally upon them. They are unques- 
tionably more applicable to surgery than to medi- 
cine ; and it may be said that a principal part of 
the medicine of surgery consists in a due appor- 
tioning of the treatment between the local and 
the constitutional disease. The enumeration of 
symptoms, which we have quoted above from 
Mr. Travers' work, would give to the word irrita- 
tion nearly as extensive a sense as that in which 
it is accepted by M. Broussais, since inflammatory 
and all kinds of symptomatic fevers are included 
under it, and, physiologically speaking, they are 
so with great justice ; but in a practical point of 
view, seeing that these affections, whatever share 
irritation may have in them, have their distinct 
names, and their peculiar and varied forms of 
treatment, it would seem to us more desirable to 
limit the term irritation to those affections which 
partake of the character of excitement or increased 
vascular action, without the precise characters of 
fever and inflammation. Irritation undoubtedly 
attends all inflammations and fevers, but then its 
phenomena merge in those of the phlogosis or 
pyrexia, which in a specific and peculiar manner 
modify the course and determine the issue of the 
malady. Constitutional irritation is a state w 



80 



IRRITATION. 



distinct from inflammation, that it lias been re- 
marked, and very justly, that in its characteristic 
form it is incompatible with it ; the former ceasing 
to exist when the latter is established. It must, 
however, be admitted, that these two states pass 
into one another by gradations that it is often im- 
possible to distinguish. Irritation may be con- 
sidered to be the introduction or preliminary state 
to inflammation: it is the mobile part of it, and 
being transferred from one locality to another, 
draws the phenomena of inflammation after it. 
But it may exist independently of inflammation: 
certain additional circumstances are required for 
the production of the latter; if these are wanting, 
and the source of irritation still exists, a variety 
of phenomena ensue, expressive of excitement 
and disorder of function. What these additional 
circumstances are, we cannot absolutely specify ; 
but a certain degree of plethora and power in the 
vascular system are elements which seem to be 
required before irritation can produce a true in- 
flammation. It is such a plethora and suscepti- 
bility of the vascular system which constitutes the 
phlogistic or inflammatory diathesis ; and where 
this is strong, irritations even of a mild nature 
may readily become extended to the vessels, and 
pass into inflammation. Where, on the other 
hand, the vascular system is ill filled and of low 
power, any irritating cause failing to excite it to 
inflammation, develops its effects in various other 
modes, such as disorder of sensation, secretion, 
and other functions, the nervous system being ap- 
parently the medium through which the irritating 
influence acts. Between the states of pure irrita- 
tion and perfect inflammation there are, however, 
numerous intermediate gradations, in which the 
phenomena of irritation beyond what usually ac- 
company inflammation manifest themselves, and 
prove, even in disorder, an unequal balance in the 
systems. So general is this fact, that there is not 
a malady of any kind in which more or fewer of 
the signs of irritation are not occasionally appa- 
rent, and the history of irritation in this sense 
would extend to varieties of the whole catalogue 
of diseases. Such a view would be far too exten- 
sive for the due limits of this article. We shall, 
therefore, merely give a sketch of the pathology 
of irritation in general, and conclude by a notice 
of the most remarkable examples of the different 
kinds of irritation. 

Of Irritation in General. — The introduc- 
tory view which M. Broussais gives of irritation, 
is far less objectionable than the indiscriminate 
and unqualified application to which he afterwards 
extends it ; for truly, the reference of disease to 
changes in the physiological properties of tissues, 
if unbiassed and comprehensive, is, as far as dis- 
eases of the solids are concerned, a fair and natural 
basis of pathology. But to specify contractility 
and sensibility as the only properties of tissue, 
appears to us to be too hypothetical to be admitted 
as the ground-work of a doctrine ; and as there is 
no necessity for analyzing functions, it is better 
to treat them simply as they present themselves. 
Neither are we inclined to adopt the dogma of M. 
Broussais, which is only a modification of that 
of Brown, that there is always an equal quantum 
of excitability in the system, and that an increase 
in one part necessarily produces a diminution in 



the other, and, therefore, that there is no such a 
state as general asthenia or as general excitement. 
The functions of animal structure are relative ; 
certain circumstances excite or increase, and others 
diminish or depress them: exciting agents are 
called stimuli or irritants ; those which depress 
are called sedative. The relation of an irritant to 
a function is irritation ,■ but the signification of 
the word here is twofold, for it implies, 1, the 
agency or act of irritating ; 2, the effect or the ex- 
cited state of the function. It is not unimportant 
to observe this distinction ; and as the construction 
of our language does not admit of it in the word 
itself, we shall endeavour to restrict irritation to 
the latter meaning, and describe the other as the 
irritating influence or act. Without attempting 
to explain them, it will be convenient to represent 
the living properties in general by the word irrita- 
bility, which merely denotes their relation in the 
abstract to irritants. There is a certain share of 
irritability natural to the healthy state of every 
part, and the moderate operation of natural irri- 
tants upon this, constantly induces that degree 
of irritation which constitutes healthy function. 
Irritation in a morbid state implies excess, which, 
when great, sufficiently declares itself by the dis- 
order or loss of balance that ensues; but in 
smaller degrees, morbid irritation is as hardly dis- 
cernible from healthy as slight disease is from 
health. 

Irritation may arise from an excess of irritability 
in a part independent of external circumstances, 
so that the ordinary or habital stimuli become 
irritants; or it may proceed from an additional 
irritating influence from without. Thus vomiting 
is a symptom of irritation of the stomach : and it 
may arise from excessive irritability of that organ, 
as in gastritis, and in the sympathetic irritations 
of the stomach from concussion of the brain, dis- 
eases of the urinary organs, pregnancy, &c. ; it 
may on the other hand proceed from the additional 
irritating influence of an emetic or of indigestible 
food. So, likewise, irritation of the mucous mem- 
brane of the lower intestines may manifest itself 
by diarrhoea ; and this irritation may proceed from 
the over-irritating quality of the contents of the 
intestines as in bilious diarrhoea, and the opera- 
tion of a drastic purgative, or from the excessive 
irritability of their membrane, as in dysentery, 
lientery, &c. Again, the urinary bladder shows 
signs of irritation when subjected to the unusual 
stimulus of gravel or stone ; and the same phe- 
nomena are presented when, either from disease 
in its coats or by sympathy with some adjacent 
parts, as in stricture of the urethra and rectum, 
scirrhus uteri, ascarides, &c, the irritability of the 
bladder is inordinately increased, and it is con- 
tinually parting with its natural contents. This 
division of the modes of irritation is useful, inas- 
much as it points out a distinction which is some- 
times of the greatest importance in practice, but 
it is one that cannot always be made ; for the two 
modes frequently unite, and an excessive irritating 
influence very commmonly induces an unnatural 
irritability of the part to which it is applied. 
Thus, after an emetic or other irritating substance 
has been rejected from the stomach, the organ 
continues for a while morbidly irritable, and re- 
fuses to retain the bkndest liquids ; and the blad- 



IRRITATION. 



81 



der often remains irritable after all the gravel has 
passed away. Again, when the irritability of a 
part is low, what is commonly an irritant may 
fail to produce irritation. Thus an emetic some- 
times fails to excite vomiting ; crude and indigesti- 
ble food may pass through the stomach, and feces 
may accumulate in the intestines without injury ; 
worms may inhabit the viscera, and gravel lie in 
the bladder, without any remarkable signs of irri- 
tation in the respective organs. The same re- 
markable difference in the susceptibility of irrita- 
tion is observable in the same individual under 
different circumstances, and even simultaneously 
in different parts of the same system. To say 
that this susceptibility of irritation depends on the 
degree of sensibility is only to adopt another mode 
of expression without making the matter more 
plain. It is generally under the influence of a 
new or additional irritation that a part becomes 
awakened to the presence of irritating matters of 
which it was before insensible. Thus an ineffi- 
cient purgative frequently develops the irritating 
influence of feces long accumulated in the cells 
of the colon ; an excess of diet renders the urinary 
bladder sensible of the pressure of a calculus 
hitherto latent ; a fit of indigestion occasions irri- 
tation of a tumour or other organic disease in the 
brain to produce a fit of epilepsy. But it is 
through the medium of the nervous sympathies, 
which produce what is called constitutional dis- 
turbance, that local sources of irritation are most 
frequently excited. Any thing that disturbs the 
balance of the functions in general is sure to be 
felt in the weak or disordered part ; and a cause 
of irritation, which may be long latent during the 
quiet and equal action of functions, is thus called 
into activity by any general exciting influence, 
and, if extensive, often reacts with great energy 
on the constitutional disease. Again, a local irri- 
tation frequently extends itself to the various 
functions of the system, generally affecting them 
irregularly and singling out a weak organ, which 
becomes a new seat of irritation, whilst the origi- 
nal evil receives back with interest, by the same 
channels of sympathy, the disturbing influence 
that it had engendered. This interesting subject 
has been ably treated by Abernethy, Travers, and 
other eminent writers on medical surgery ; and 
its importance is generally admitted in modern 
practice. We here allude only to its principle, 
which is not dissimilar to that of the cases already 
noticed. 

We have hitherto represented irritation as the 
result of a stimulus or exciting influence, whether 
the undue relation reside in the irritability of the 
part, or in the external influence applied to it. 
The nature of this relation is necessarily obscure, 
as it is involved in the mystery of the properties 
of organized matter ; and we must therefore at 
present rest contented with observing the fact. 
But there is another source of irritation which it 
is important to notice, equally proceeding from 
the operation of a prevailing law of organized 
suueture. There is in the living powers a kind 
of resiliency, or disposition to reaction, which 
manifests itself after the application of any in- 
fluence that tends to depress or destroy them ; 
this property often converts sedative into indirect 
irritants. Thus cold is in itself a sedative ; but 
. Vol. Ill ^11 



the reaction, which succeeds to its application, 
renders it a fertile source of inflammation and 
irritation. The worst mechanical injuries and 
severe burns and scalds are likewise sedatives in 
their immediate effect ; and when extensive, this 
is sufficiently apparent in the syncope, suspension 
of sensation and function, and even death, which 
they occasionally produce. There are many in- 
stances on record of death supervening on severe 
accidents, such as the crushing or tearing of limbs, 
compound fractures, violent blows on the head, 
epigastrium, or thorax, &c. in which it could not 
be ascribed to loss of blood, or mechanical injury 
of any of the vital organs. The death of patients 
under severe surgical operations without hemor- 
rhage may be attributed to the same cause, assisted 
often by the powerfully sedative influence of fear 
and pain. A remarkable and instructive illustra- 
tion of the influence of mechanical injury may be 
drawn from the experiments of Legallois, Wilson 
Philip, Magendie, and others, in which it appeared 
that violent and extensive injury done to the brain 
and spinal marrow of animals caused an imme- 
diate cessation of the action of the heart, whilst 
the removal of the whole or any part of these 
organs in a state of integrity produced no such 
effect. Bruising or roughly lacerating the brain, 
or forcing a coarse instrument into the spinal 
marrow, seemed in these cases to exert a positive- 
ly noxious and sedative influence on the heart. 
A more intelligible cause of prostration is loss of 
blood ; but this, although it certainly is so when 
syncope and death are its immediate consequence, 
is not, as we shall presently see, so complete and 
general a sedative as some of the other influences 
which we have named. Other evacuations and. 
privation from food are essentially of the same 
nature, but the gradual manner of their operation 
gives occasion to various signs of reaction, which 
disguise their direct effect. 

The immediate operation of all these causes 
(and they constitute a most numerous class, for 
contagious effluvia, malaria, septic and other pes- 
tiferous influences may be added to the list,) is 
unquestionably sedative, or that of prostration ; 
and if the powers of the system should be insuffi- 
cient to resist or rally from it, they succumb under 
it. This is the very reverse of irritation, yet, 
strange to say, it has been commonly confounded 
with it ; and it is when applied in this way to 
such opposite affections, that the word has lapsed 
into an indefinite acceptation. If the powers of 
the system are not subdued by the prostrating or 
sedative influence, there will then be reaction, in 
which they usually tend to pass the limit of mode- 
ration and regularity, and irritation and excite- 
ment ensue in the functions, various in kind and 
degree, according to the share of power which 
they severally retain. This appears to be a gene- 
ral rule in the animal economy, and we are not 
required to go further for an explanation of the 
reaction which forms a prominent part in many 
diseases. This reaction may be partial and injuri- 
ous, as where it displays itself in convulsions, 
vomiting, hiccup, palpitation, cramps, &c. These 
symptoms have been called indications of prostra- 
tion, and so perhaps they may be admitted to be 
with regard to the system at large, but certainly 
not in respect of the organs which they affect, 



82 



IRRITATION. 



in these they arc unequivocal signs of excitement 
or increased action. They are proofs of impotent 
and indiscreet reaction, and if not seconded by a 
reanimation of the organs more immediately con- 
cerned in the support of life, they exhaust the ex- 
citability of the system, and accelerate the extinc- 
tion of life. 

Another remarkable symptom of reaction is 
rigor. The addition of this sign to those already 
mentioned implies a greater degree of power in 
the system ; and in many instances it precedes 
the development of the highest degree of reaction. 
Thus it is the first sign of fever, in which it is fol- 
lowed by a series of irritative movements of an in- 
tense and general kind. On the other hand it is 
the symptom of healthy and moderate reaction 
from syncope ; and it frequently succeeds to the 
sedative impressions of cold without any violent 
irritation ensuing. It may be represented to be a 
slight convulsive motion, the object of which is to 
give an impulse to the circulation of the surface. 
When reaction becomes more general and perfect, 
it verges on fever, which may be inflammatory or 
nervous, according to the prevailing strength of 
the sanguiferous or the nervous system. But it is 
to the degrees short of fever and inflammation that 
we here restrict the application of the term irrita- 
tion, and in these we find many, but not all, of 
the functional disorders which attend fever. There 
is a marked perversion of the functions of circula- 
tion, respiration, and digestion. In the former we 
see a quickened and irregular pulse, with defi- 
ciency of force and firmness in the heart's action; 
whilst alternations of pallidity and flushings be- 
token an equally irregular tonicity of the capillary 
■ vessels. The breathing is anhelatory and dis- 
tressed ; and this sometimes depends on the irre- 
gular state of the circulation, and sometimes on 
the irritation affecting with spasm the bronchial 
muscles. The powers of digestion may be often 
said to be almost annulled ; a total inappetency 
for food marks their defect; and we need only 
allude to the loaded state of the tongue and to 
the vitiated excrements, as a presumptive proof of 
the existence of an adequate cause in the depraved 
state of the visceral secretions. The sensorial 
functions are likewise variously affected by any 
irritation extensively present in the body. The 
sensation and perceptions are commonly exalted 
and acute, while the other mental powers are be- 
low par ; hence an irritability of temper and de- 
pression of spirits arc generally observed ; and 
the loss of balance sometimes amounts to delirium, 
which is usually of the morose or angry kind. 

In the various symptoms that are thus pre- 
sented in diseases of irritation, we should err were 
we to expect to trace constantly the features of 
excitement. It is the loss of balance which is 
most apparent ; and although there must be some 
undue and misdirected excitement or irritation in 
some part of the system, the remaining functions 
will generally (but not necessarily) suffer from 
prostration and weakness. The more general 
states of fever and inflammation, through the vas- 
cular system which they essentially affect, in their 
marked and acute forms, entail irritation and ex- 
citement of a more equally diffused kind ; but irri- 
tion, as we consider it, may be confined to a func- 
tion or organ, while the remainder of the system is 



suffering from decided asthenia. Thus the sto- 
mach and bowels may exhibit irritation in pro- 
fuse secretion and inordinate movements, whilst 
other secretory and motory organs are in a state 
of complete inactivity and prostration. The mamma 
and the testis sometimes present a form of irrita- 
tion in an excessive sensibility or constant pain, 
without any apparent excitement or weakness in 
their vascular structure. It is in fact a degree 
of relative, not absolute weakness, that charac- 
terizes irritation through all its range of degrees. 
The excitement takes effect partially only, and 
the parts unaffected do not contribute to carry 
the orgasm through a series of processes by which 
it is at length exhausted, as in the case of inflam- 
mation ; but if the cause continues, the irritation 
may persist for an indefinite time, occasioning 
more or less mischief and disturbance, according 
to the importance, in the system, of the balance 
which it destroys. In the greater number of in- 
stances of irritation, the vital powers are enfeebled; 
and this constitutional weakness is the reason why 
the excitement does not become general and pass 
to the state of fever or inflammation ; but abso- 
lute debility is not essential to the existence of 
irritation ; since the most perfect inflammations 
and sthenic fevers commence with simple irrita- 
tion, and this is a stage in all cases of reaction. 
The persistence or protraction of irritation cer- 
tainly implies relative, and in most instances, 
general weakness ; for the existence of power 
would lead either to general reaction and restora- 
tion of balance, or to the more powerful process 
of pyrexia and inflammation. The operation of 
the morbid virus received into the system through 
wounds in dissection strikingly illustrates two 
modes of irritation. Its local effect is that of 
direct irritation, while its action on the system is 
that of powerful prostration, against which the 
feeble and irregular reaction of the vital forces de- 
velops another kind of irritation. If in such a case 
inflammation begins in a part, it seldom exhibits the 
vigorous and decided character of healthy inflam- 
mation ; but occupying the capillaries principally, 
and unseconded by any energetic action of the 
other parts of the vascular system, it takes on an 
erythematous form, while the effusions are serous 
or sanious, destitute of coagulable lymph, the plas- 
tic effect of which tends to limit and restrain 
phlegmonous inflammation. The variety of signs 
which this complication of disorder may present 
is very considerable ; but they principally de- 
pend on these two causes — the noxious or seda- 
tive influence of the poison, and the irritation re- 
sulting from an imperfect and irregular reaction 
of the vital powers against it. For a full anil in- 
teresting detail of examples of this kind, we must 
refer our readers to the work of Mr. Travers, 
before quoted. 

We may, in conclusion, sum up the kinds ol 
irritation under three heads : 

1. Those caused by direct irritants or stimuli, 
whether acting immediately on the part, or medi- 
ately through the nerves. 

2. Those caused by a preternatural irritability, 
which, independently of any new exciting influ 
ence, renders the relation of ordinary circumstances 
a source of irritation. 

3. Those caused by indirect irritants, or those 



IRRITATION, 



influences which, although in themselves pros- 
trating or sedative, become irritant through the 
reaction of the vital powers against them. 

This division must be admitted to be in some 
measure artificial, inasmuch as few examples of 
irritation occur in which one only of these kinds 
of causes prevails. They, particularly the first 
and the second, frequently become engrafted on 
one another, and occasionally all coexist ; but still 
the greater number of cases are sufficiently stamped 
by the prevalence of one or other of these kinds 
of irritation, to render the distinction available in 
practice. 

1. Diseases of Direct Irritation. — Of this 
kind is the disorder resulting from all sorts of 
slight mechanical injury, whether by contusion, 
super-extension, puncture, incision, or laceration ; 
from extraneous substances, tumours, effusions, 
and accidental productions; chemical irritants, too 
long retained or vitiated excretions ; dentition, 
crudities, and worms in the alimentary canal, cal- 
culus in the urinary or biliary passages, and 
many others. Irritation in all these cases is un- 
doubtedly the result of a reaction of the vital pow- 
ers, the object of which is salutary, being the re- 
moval of an irritating matter or the reparation of 
an injured part. Whether there be a state prior 
to reaction which can bear the name of prostra- 
tion in these cases, as well as in those of the third 
class, is a matter of merely speculative and not prac- 
tical interest, since we can detect in their history 
no other than a direct mode of irritation. The 
reparation of an injured part depends mainly on 
the vessels obeying the impulse of irritation : and 
unless there be a peculiar defect of power in them, 
the disorder passes into the more healthy state of 
inflammation. Where this defect subsists, there 
may be either the imperfect inflammatory action 
which we see in erythema and erysipelas, or no 
inflammation at all, and then pain and disordered 
function or secretion are the signs which attend 
irritation. It is for the same reason that injuries 
of tendons, ligaments, fascia, and other fibrous 
membranes, commonly exhibit more of irritation 
than of inflammation ; they are not liberally sup- 
plied with vessels, and the irritation, instead of 
speedily terminating in the reparatory or suppu- 
ratory process, lingers longer in the part, with 
pain, serous effusion, &c, sometimes exciting, 
sympathetically, severe constitutional derange- 
ment, and even tetanus. In the irritation result- 
ing from the application of mechanical or chemi- 
cal irritants, the salutary object of the reaction is 
more apparent. Thus, if a grain of sand or salt 
fall on the conjunctiva, the pain and irritation ex- 
cite a copious secretion of tears, the tendency of 
which is to remove the offending matter. Mucous 
membranes, when irritated, throw out viscid mucus 
to protect themselves. When a thorn or a needle 
penetrates the skin, an irritation is produced, 
which tends to inflammation ; this by effusion 
limits the irritation to the immediate vicinity, and 
by suppuration removes the irritating matters. 
But, on the other hand, irritation may fail of its 
salutary end in all these instances. The grain of 
sand may remain lodged ; the mucous effusion be 
inefficient as a shield ; and the vascular power 
may be insufficient to effect the process of the 
expulsion of the thorn or needle ; and then the 



irritation becomes a disease of more permanent 
character. So worms in the intestinal canal will 
irritate the membrane of the bowels in every va- 
riety of way but a salutary one. Thus they may 
affect the nerves, occasioning by sympathy grind- 
ing of the teeth, convulsions, disordered appetite, 
various pains, palpitation, &c. The vascular sys- 
tem may likewise be excited, and mucus poured 
out in great quantity, the peristaltic motion acce- 
lerated, without dislodging the offending bodies ; 
whence diarrhoea, with tormina, depraved excre- 
tions, thirst, atrophy, and other constitutional dis- 
orders, may ensue. The same description tvill 
apply to scybalous faces lodged in the cells of the 
colon. Indigestible food and excessive acid or 
acrid secretions in the stomach irritate it in a va- 
riety of ways : if the sympathies of the muscular 
apparatus related to it are quick and susceptible, 
vomiting is excited, and the end of the irritation 
accomplished. But if these are not sufficiently 
roused, the irritation will cause other sympathies 
and uncomfortable feelings, both bodily and men- 
tal ; whence arise gastrodynia, pain in the chest, 
incubus, palpitation, asthma, headach, vertigo, 
hypochondriasis, &c. The signs of irritation may 
proceed from such a variety of organs that it ap- 
pears to be in a manner reflected from one to 
another. Thus irritation in the bowels is trans- 
mitted to the brain and spinal marrow, and from 
thence developes its effects on the voluntary 
muscles, producing spasms, convulsions, or cho- 
rea. If the original irritation persist long in this 
direction, it may become fixed on the nervous 
system, and there continue long after the irritating 
influence has been removed from the intestines ; 
the disorder of the nervous system may then be 
considered to be of the second kind of irritation, 
that, namely, of increased irritability. Calculus 
of the urinary organs frequently produces irrita- 
tion of a still more disturbing and unprofitable 
kind, which has worn down the feelings and 
functions of many a frame. Dentition is another 
fertile source of irritation in the bodies of sensitive 
children. As long as this is restricted to the pro- 
duction of a copious flow of saliva or a moderate 
diarrhoea, it can scarcely be said to be prejudicial ; 
but it not unfrequently amounts to general dis- 
ordered secretion, wasting diarrhoea, and atrophy, 
convulsions, and paralysis ; none of which effects 
tend in any intelligible way to promote the pro- 
gress of the tooth through the gum. Tumours in 
the brain or spinal marrow may excite epileptic 
convulsions, chorea, paralysis agitans, &c. Acci- 
dental productions, as tubercles, produce various 
signs of irritation, both local and sympathetic. 
Thus, in the lungs they occasion cough, in the 
bowels diarrhoea, &c, whilst their presence almost 
always irritates the heart and quickens the pulse. 
Foreign bodies or splinters of bone in the sub- 
stance of living structure frequently occasion 
severe irritation, with little or no decided inflam- 
mation. It may declare itself by pain and spasm 
in the part, and in the system by disorder of any 
of the functions, quickened pulse, hurried breath- 
ing, impaired digestion, delirium, convulsions, 
tetanus. Pus confined within the proper sheath 
of a tendon, under a fascia, or within any dense 
and unyielding tissue, may produce similar phe- 
nomena. 



84 



IRRITATION. 



Such are examples of direct irritation, and many 
others might be adduced ; as the history of nume- 
rous diseases, medical and surgical, abounds in 
instances of the same kind ; but we do not pro- 
fess to enter into details, and enough has been 
said to illustrate the principle. Nor shall we do 
more than allude to another important and exten- 
sive cause of irritation, which we cannot hesitate 
to call direct, — inflammation. It is a cause not 
only sympathetically, or through the intervention 
of the nerves, but likewise by mere contiguity. 
Thus inflammation of the pulmonary pleura ex- 
cites irritation and consequent inflammation in the 
corresponding part of the costal pleura ; and the 
same thing gives origin to the adhesions observed 
between the heart and pericardium, and the peri- 
toneum in its various points of contact. The phy- 
sical nature of this mode of the propagation of 
inflammation is involved in much obscurity; and 
although there are not sufficient grounds to iden- 
tify it with electric or galvanic action, it is ob- 
viously something beyond vascular or nervous 
communication. But through sympathy an organ 
or part affected with inflammation produces irri- 
tation in various other organs ; this is fully exem- 
plified in what is called symptomatic fever, which 
can be referred to no other principle. It is, more- 
over, especially remarkable in the sympathetic re- 
lations which subsist between particular organs, as 
the mucous membrane of the stomach and bowels 
and the brain. And here, while we would acknow- 
ledge the truth and importance of the views of 
M. Broussais on these points, we would insist still 
on the propriety of distinguishing between inflam- 
mation and irritation. The secondary or sympa- 
thetic irritations may truly pass into inflammation ; 
but they more generally fall short of it, and there- 
fore require a different treatment ; and it is a point 
important to be observed, that instead of being in 
proportion to the intensity of the primary inflam- 
mation, they are often most prevalent when this 
is very slight. Thus the cerebral and general ir- 
ritation accompanying well-marked gastritis is con- 
siderably less than that which ga&tric derange- 
ment, or what the French call " embarras gas- 
trique," will produce. It would, perhaps, more 
nearly represent the reality if we say that the 
sympathetic disorder is in proportion rather to the 
irritation of the organ primarily affected than to 
the intensity of the inflammation. This predomi- 
nance of irritation over inflammation, although 
occasionally occurring in the robust, is a character 
more remarkable in individuals in whom the ner- 
vous system has the ascendency, whether by natu- 
ral constitution, or in consequence of the depres- 
sion of the vascular power by evacuations or 
inanition. It is thus that in delicate females vis- 
ceral inflammations are often accompanied by 
irritation and disorder quite disproportionate to 
their intensity or extent. 

Certain mental emotions are frequent causes 
of bodily irritation, and they act in a variety of 
ways. Anger, joy, and surprise, (which act as 
general stimulants on a healthy body, and if they 
tend to produce disease at all, it is congestion or 
inflammation,) when the bodily powers are in an 
enfeebled state, become direct irritants, and de- 
velop that partial and irregular excitement among 
the functions and sensations which we understand 



by the word irritation. They exert their st,m u . 
lant relation almost exclusively on the nervous 
system, which in this condition of the body has 
already a disproportionate ascendency, and they 
may thus greatly increase that loss of balance 
which is so much opposed to the state of health. 
Thus we see the necessity of excluding all such 
influences from those whose functions are in that 
state of weakness or depression which continually 
verges on derangement ; such are convalescents 
from fever and other severe diseases. Grief, fear, 
and anxiety are indirect irritants, and must there- 
fore be referred to the third head. 

2. Irritation from Excessive Irritability. 
— We have already adduced examples of this 
kind in the case of the stomach after the evacua- 
tion of an emetic during pregnancy, or suppres- 
sion of urine, and under the influence of concus- 
sion of the brain, and other injuries or shocks to 
the system. The intestines, when once excited 
by an irritant, sometimes present a continuance of 
irritation apparently from the same cause ; and the 
irritability of the urinary bladder is known to be 
morbidly exalted in the diseases of the adjoining 
parts. Inflammation is, however, the most com- 
mon cause of excessive irritability ; and it is in 
some measure a question whether the above ex- 
amples may not be referred to a state more or less 
akin to it. But we see parts sometimes remain 
permanently irritable without any obvious increase 
of vascularity ; and as there is reason to suppose 
that sensibility is not always in proportion to the 
number and size of the vessels, it would not seem 
just to attribute the excessive irritability of an 
organ always to inflammation or even to conges- 
tion. Mr. Travers considers that the irritable 
joint, breast, testicle, and prostate gland, give no 
evidence of inflammation. He records instances 
of irritable breast and knee joint, attributed origi- 
nally to needles having entered the parts, which 
continued painful many months after the extrac- 
tion of the needles, in the total absence of inflam- 
mation. The facial nerves in those affected with 
tic douloureux present examples of excessive irri- 
tability ; a draught of cold air or the heat of a fire 
is enough to irritate them and the adjoining mus- 
cles into pain and spasm. The bronchial muscles 
are inordinately irritable in those subject to ner- 
vous asthma ; and trifling causes, such as the 
effluvia of a stable, excite them to spasm. Other 
idiosyncrasies might be quoted in proof of exces- 
sive irritability as a cause of irritation. After an 
irritation has been transmitted for a considerable 
length of time from one organ to another, the lat- 
ter sometimes adopts the habit, and continues to 
show signs of the same disorder after the original 
irritating cause has been removed. This is in- 
stanced in chorea, arising from feculent accumu- 
lations or disordered secretions in the intestinal 
canal. When these have been removed or re- 
stored to a healthy condition, the chorea some- 
times continues, and can only be removed by 
remedies directed to those parts of the nervous 
system in which the irritation has become fixed. 

The uterus in the irregular performance of its 
periodic function, is frequently the seat and focus 
of irritation. The nervous excitement, or innerva- 
tion as Andral terms it, by which a flow of blood 
is called to this organ at particular times, may fail 



IRRITATION. 



85 



of its purpose, and instead of being relieved by 
the establishment of the catamenial discharge, 
displays its effects in the various forms of what is 
called hysteria. In this there may be or there 
may not be local plethora; if there be, the fault 
of relief must be in the secernent vessels of 
the uterus ; but if there be not, the defect is 
probably in the sanguiferous system, so that they 
do not answer to the call. Each of these cases 
has its separate class of symptoms originating in 
irritation ; but as hysteria and other derangements 
of the uterine function are fully considered under 
their respective heads, we do no more than name 
them. Many other examples might be adduced 
to illustrate this mode of irritation ; particularly 
in that numerous class in which a congestion or 
increased vascularity is the cause of excessive irri- 
tability ; but it is unnecessary to go further. It is 
by producing a state of this kind, that direct irri- 
tants may become causes of this second order of 
irritations. We may remark that many of the 
following class of irritations might perhaps be re- 
ferred to the same head. 

3. Indirect Irritation, or the Irritation 
of Reaction. — In developing the principle of 
this mode of irritation, we have already cited 
many instances of its occurrence : these may be 
greatly multiplied, for they are as numerous as 
the sedative or prostrating agencies to which the 
animal frame is liable; but it will be sufficient if 
we notice generally the forms which they most 
commonly present. There is probably a succes- 
sive gradation of conditions from the slightest sign 
of partial reaction from the state of prostration, 
such as vomiting, rigor, and convulsion, up to a 
decided and violent reaction, bordering on inflam- 
mation and fever. All these we would designate 
as degrees of irritation dependent on the same 
physiological principle, and deriving the variety 
of their aspect from the number and force of the 
functions which take part in the reaction. We 
sometimes see it confined to a single organ ; thus 
the stomach shows it by vomiting, the diaphragm 
by hiccup, the brain by delirium ; whilst all other 
organs may remain in the state of prostration. Of 
this description is the effect of violent and exten- 
sive injuries or burns, and severe operations, in 
which the powers are almost overwhelmed by 
prostration, and the partial effort at reaction, in- 
stead of counteracting it, contributes to render it 
complete and fatal. The pulse here is quick and 
threadlike, the respiration short and suspirious, 
frequently with a general rhonchus throughout the 
chest ; if there be no delirium, the intellectual and 
sensitive faculties are in a state of hebetude ap- 
proaching to stupor; the pupils are dilated, and 
the eyelids half closed ; the countenance pallid 
or livid ; the surface and extremities cold ; the 
secretions, if not suppressed, are unnatural ; and 
the sphincters often fail in their office. All these 
are signs of direct prostration, and among them 
the irritation of reaction may declare itself in a 
solitary symptom, and in none more commonly 
than in vomiting, which is often indomitable to 
the last, and greatly hastens the fatal event. It 
6eems to proceed from extreme irritability of the 
stomach, which rejects the blandest liquids. A 
low delirium, with various hallucinations of the 
perceptions, may equally accompany this state ; it 



is a sign of the irritation of reaction in the brain, 
and is prejudicial both in being misplaced reaction, 
and by leading to bodily efforts which add to ex- 
haustion, and not uncommonly prove instantane- 
ously fatal. Convulsions arise in the same way, 
and produce similar effects. Such is exhaustion 
with the lowest signs of reaction. In other cases 
irritation takes a larger share in the diseased state 
consequent on the injuries under consideration. 
Thus, after rigors, the pulse may become sharp 
and bounding, with throbbing in the head ; the 
eyes glassy, with contracted pupils ; the delirium 
fierce, or there is great restlessness and morbid 
sensibility : spasms may occur in various parts 
of the body ; there may be pain in all degrees 
and positions ; the heat may be partially increased, 
although the extremities are generally cold. Here, 
although beginning in prostration, the chief features 
of the disease are those of misdirected and exces- 
sive reaction. They border very closely on fever 
and inflammation ; and it would be rash to say 
that they are always distinct from these states : 
but although the delirium and exalted sensibility 
are sometimes so marked as to give suspicion of 
the existence of phrenitis, examination of the 
brain after death discovers no sign of increased 
vascular action further than some turgescence of 
the vessels, which is totally disproportionate to the 
intensity of the symptoms. Other organs, the 
lungs, the heart, the stomach and intestines, but 
particularly the serous membranes, are occasionally 
the seat of this kind of irritation, which puts on 
the semblance of inflammation; but less com- 
monly in reaction after local injuries or operations, 
than after prostrating causes which have a more 
diffused seat in the system, such as cold, loss of 
blood, and inanition. The general tendency of 
all these irritations is to exhaust, and unless con- 
trolled and counteracted, they wear down and de- 
stroy the remaining irritability of the system, and 
death necessarily ensues. 

It is the continued impression of a sedative or 
prostrating influence that renders reaction imper- 
fect, and converts it into an injurious irritation. 
Thus the powers in general may be unable to 
rally after the first shock of any severe injury or 
operation ; but this inability is frequently depend- 
ent on some additional sedative influence, bodily 
or mental. Fear and anxiety are most powerful 
in this way ; and instances are on record in which 
operations, trifling and favourable in their surgical 
relation, have led under their influence to a fatal 
result. Women have died after successful and 
natural parturition, barely from the effect of a pre- 
sentiment that they would die. To such instances 
cited in Mr. Travers' work before mentioned, he 
adds a case of the death of a lady after a labour 
protracted unusually by the evolution of a polypus 
after child-birth ; and another of a gentleman who 
died in twelve hours after the escape of the con- 
tents of the stomach by perforation into the peri- 
toneal cavity — ascribing these fatal events to the 
sudden, extreme, and unremitting pain : but we 
question whether they may not be as fairly attri 
buted to exhaustion from muscular effort in the 
first case, and in the latter to the prostration of 
the heart's power by the severe and extensive in- 
jury to the peritoneum, as in other cases of acute 
peritonitis. Pain, though commonly at first a 



8C 



IRRITATION. 



powerful irritant, when exceedingly severe occa- 
sions syncope, and by fatiguing the powers other- 
wise produces a prostrating effect: in this way it 
will tend powerfully to subdue the disposition to 
general reaction. It implies the worst species of 
mental excitement, which entirely prevents the 
repose essential to restorative reaction ; but as we 
sometimes see the body bear pain even in its great- 
est degree with impunity, and as we know that a 
certain integrity of the function is necessary for its 
continuance, we can scarcely look on it as being 
ever alone a sufficient cause for fatal prostration. 
The sedative influence of grief and fear is so 
decided that they may not only aid other causes, 
but by themselves destroy by prostration ; and 
this may, as in other cases, be with or without 
irritative reaction. 

But the most remarkable species of causes of 
irritative reaction are those which depend on in- 
anition, whether arising from bloodletting or other 
evacuation, or from imperfect nutrition. We owe 
to Dr. Marshall Hall the first distinct notice of 
these morbid affections : his observations have 
been confirmed by Dr. Abercrombie, Mr. Travers, 
Dr. Gooch, and other subsequent writers; and he 
has since given a fuller account of them in his 
" Researches on the Effects of Loss of Blood," a 
work recording some new facts of great practical 
importance. 

The immediate morbid effect of loss of blood, 
if extensive, is the same as that of the other pros- 
trating influences which we have mentioned, syn- 
cope, coma, convulsions, and delirium. The two 
latter, although they appear closely allied to the 
others, we cannot but view as different in their 
nature, and as resulting either from a partial effort 
of reaction, or from a remnant of local power, 
preponderating unduly over general prostration. 
They most frequently occur where the excessive 
loss of blood has been gradual, as by atonic hemor- 
rhage, epistaxis, by bloodlettings often repeated, or 
through a small orifice and in the recumbent pos- 
ture. The gradual draining of the system in these 
ways, or by other excessive evacuations, such as con- 
tinued purging, and by starvation, which have the 
same effect in the feeble, after the lapse of these 
symptoms frequently gives rise to a train of signs 
of irritative reaction of more prominent and de- 
cided form. There will be palpitation of the 
heart, with quick and jarring pulse, and throbbing 
of the carotids, aorta, and other arteries, and the 
auscultator will perceive a purring or grating 
sound in these parts. If this irritated state of the 
circulation continue, it will induce its effects on 
the sensations and functions ; sensibility will be 
increased, with intolerance of light and sound, 
pain, throbbing, and noises in the head, an excited 
state of the mind amounting to delirium, a loaded 
tongue, and general disorder of the secretory 
functions. This condition, which is amply de- 
scribed by Dr. M. Hall in the work before quoted, 
and in the articles Bloodletting and Absti- 
nence in these volumes, is a fair example of irri- 
tation in its characteristic form. Here is great 
excitement and disposition to act, but no power to 
regulate or support it : here are the nervous phe- 
nomena of inflammation without that permanent 
and powerful state of the vessels which can lead 
it to any of its usual terminations. The sem- 
blance of inflammation which it frequently pre- 



sents often induces the practitioner to draw more 
Mood ; the evil consequences are sometimes im- 
mediate, syncope, convulsions, and death ; and 
when there is a temporary amelioration, it is only 
a prelude to a worse return of irritative reaction 
So great is the real weakness in the midst of all 
the apparent signs of excitement, that the erect 
posture or any kind of exertion may prove fatal. 
It may terminate fatally also in a more gradual 
way, by passing again into the state of sinking or 
pure prostration ; and here likewise it may put on 
a fallacious aspect in its resemblance to the signs 
of effusion on the brain. In children particularly, 
this imitation is so close that Dr. M. Hall has 
called it the hydrencephaloid disease. In favour- 
able cases irritation terminates in subsidence and 
a gradual restoration of power, and with it a re- 
covery of balance among the functions. But the 
irritation may pass into a chronic state, and of 
this description Dr. Hall considers puerperal 
mania, amaurosis, deafness, paralysis, &c. 

The delirium, mania, and increased sensibility 
in those suffering from privation of food, recorded 
in several eases by Dr. Currie, Dr. Latham, An- 
dral, and others, arc obviously of the same nature 
of irritations of reaction ; and in the pain of the 
head and stomach, and irritable state observed in 
those under the influence of a great and sudden 
lowering of diet, we see a more familiar illustra- 
tion of the same kind. Similar symptoms often 
accompany the wasted and atrophied condition of 
infants unduly nourished, with whom the mater- 
nal milk disagrees, or whose powers of digestion 
cannot master the food that is given them ; and 
they not unfrequently develop themselves in the 
asthenia lactantium, and in any form of undue nu- 
trition. For further illustrations, see the articles 
Abstinence, Chlorosis, and Lactation (Dis- 
eases of.) 

Treatment of Irritation. — Having described 
irritation as a general pathological principle rather 
than as a specific disease, our remarks on the re- 
medial measures calculated to counteract or remove 
it must be equally in the abstract, and merely 
illustrated by prominent examples. 

The removal of the irritating influence, if pos- 
sible, is the most obvious indication in the cure of 
direct irritation ; and in the slighter cases this may 
be a sufficient remedy. Thus, the removal of irri- 
tating matter from the stomach by means of an 
emetic ; from the intestinal canal by a purgative ; 
the counteraction of acidity by a dose of alkali ; 
relieving by a stroke of the lancet the tension of 
the swollen gum in dentition, or of the integu- 
ments or a fascia in a superficial or deep-seated 
abscess, may amount to a complete cure of the 
various forms of irritation, which these causes se- 
verally occasion. But it is not always possible 
thus to reach the root of the evil ; moreover, as 
we have already remarked, when once planted, 
the disease propagates itself so as in a degree to 
become independent of its first cause, and thus to 
belong to the second class of irritations. Hence 
it often becomes necessary to combine, with the 
measures directed to remove the irritating influence, 
others calculated to diminish irritability ; and 
where the original cause is obscure or baffles our 
efforts, this is the only system of medication that 
can be pursued. This combination is the more 
expedient in intestinal irritation, as the remedies 



IRRITATION. 



87 



suited to remove the offending cause in themselves 
for a time aggravate the irritation. Thus it is 
proper in such cases to give before or with the 
purgative some narcotic, such as hyoscyamus or 
opium, and further, if necessary, to allay the irri- 
tation of its operation by diluents, the warm bath, 
and other derivants. It is not easy to lay down 
any rule by which the relative importance of these 
measures can be decided ; but the sedative plan is 
generally more requisite in proportion to the length 
of time and the degree in which the constitution 
has suffered under the irritating influence. Where 
the irritation is vehement, and disturbs in a serious 
degree the vital functions, it becomes of more im- 
portance immediately to allay this by temporising 
measures, than to rest solely on those which are 
more radical, but of slower operation. A child suf- 
fering from worms or accumulated fasces may die of 
convulsions under the additional irritation of a 
purgative before its evacuant effect can be obtained; 
but if this medicine be preceded by or conjoined 
with others calculated to soothe, such as hyos- 
cyamus, Dover's powder, or the warm bath, accord- 
ing to the character of the irritation, its operation 
will be safe and seasonable. The purgative is, 
moreover, by the same means, often rendered more 
effectual for the removal of the irritating matter, 
since its slower progress enables it to act more 
generally on the canal, than where an excessive 
irritability hurries it precipitately through. So 
also, during the prevalence of violent spasm, an 
antispasmodic must often be promptly administered 
without regard to the duration of its effect. To 
give ether, laudanum, assafoetida, valerian, &c. in 
spasm of the glottis or bronchi, or in violent palpi- 
tation of the heart, may be, in relation to the cause 
of the irritation, a temporizing measure ; but it is 
using time to good purpose. 

We have enumerated inflammation among the 
causes of direct irritation, and we again allude to 
it for the purpose of remarking, that besides the 
removal of the cause itself, our attention may 
sometimes be usefully directed to the quieting of 
those nervous sympathies by which the irritation 
is communicated to the system at large. This, we 
apprehend, is the principle of the salutary opera- 
tion of opium in continued fevers and the less 
sthenic forms of inflammation ; and did we possess 
a medicine that should be sedative to the nervous 
system without exciting or disturbing the vascular, 
it would furnish a still happier and more satisfac- 
tory illustration. 

There are many cases in which the source of 
irritation is organic, or beyond the reach of reme- 
dies ; it is thus with tumours in the brain, spinal 
marrow, and other parts, accidental productions, 
cancer, and other forms of diseased structure ; 
here our only resource is in measures which allay 
morbid irritability. We shall have occasion pre- 
sently to revert to this subject ; but we see no need 
to dwell longer on means for the removal of irri- 
tating influences: they vary with the nature and 
locality of the influence. 

There is another mode of treating direct irrita- 
tions, which it may be convenient to notice in 
connection with direct irritation, although it is 
more frequently applicable to the indirect kind, 
namely, by stimulating applications. In enume- 
rating examples of direct irritation we named 



various mechanical injuries, and remarked that the 
object of irritation in these cases, the reparation 
of the injured part, is sometimes defeated, and the 
disorder prolonged in consequence of the low 
power in the vascular system, which is inadequate 
to take on the reparatory state of healthy inflam- 
mation. Here, then, an additional stimulus to the 
vessels, conjoined, if need be, with a sedative to 
the excited nerves, will often recall the irritation 
from its prejudicial wanderings through the sys- 
tem into a local and salutary channel. This treat- 
ment is obviously applicable only in cases where 
inflammation is not in itself a hurtful process, such 
as mechanical injuries and sores of the exterior, 
and especially burns and scalds. The efficacy of 
stimulating applications to the latter is now gene- 
rally admitted, and we would attribute it entirely 
to this principle in all the moderate examples of 
these lesions. The extreme heat has so paralyzed 
or weakened the vessels, that although they may 
be entire and congested with blood, they require a 
new and powerful stimulus to bring them to that 
activity of function which the reparation of the 
injury requires. When a part has been disorga- 
nized, and is insusceptible of revivification, and the 
adjoining vessels are weak and inactive, stimulant 
applications are still more obviously indicated to 
excite that inflammation which is necessary to 
effect the sloughing or separation of the noxious 
dead matter from the living structure. We can 
see the utility of a similar treatment in other forms 
of external disease, where the inflammation is at 
once irritative and powerless. 

We have already glanced at the treatment of 
our second order of irritations, that of excessive 
irritability, for the mixed manner of their occur- 
rence renders it inexpedient to consider each kind 
quite separately from the other ; but we return to 
the subject, in the endeavour, as far as is possible, 
to make this sketch of the principles of the treat- 
ment correspond with the preceding pathological 
history. Excessive irritability, as we have there 
remarked, most frequently depends on inflamma- 
tion or some of the states akin to it, or (to use the 
more comprehensive words of M. Andral) hyper- 
emia in its several forms. In such cases relief is 
to be sought in the various antiphlogistic measures, 
applied of course with due relation to the organ 
whose morbid irritability is to be reduced ; and 
thus evacuants, derivants, counter-irritants, and 
contro-stimulants, become remedies for irritation. 
These are considered in the article Inflammation 
sufficiently to supersede notice here, further than 
the remark that their anti-irritant may not always 
be in the ratio of their antiphlogistic effects ; and 
where irritation predominates over inflammation, 
those are to be preferred which act on the nervous 
as well as on the vascular functions ; thus, counter- 
irritants (and if they be admitted as a separate 
class, contro-stimulants also,) will avail more than 
mere vascular deplctories in fulfilling the indication 
in view. For example, in the vehement irritations 
connected with slight phlogoses of the mucous 
membrane of the lungs and of the alimentary 
canal, (notwithstanding Broussais' positive asser- 
tions to the contrary,) tartar-emetic frictions for 
the former, and sinapisms and blisters for the latter, 
are far more efficacious than local or general blood- 
letting. The irritations of serous membranes, 



IRRITATION 



which in persons of mobile sensibility frequently 
present the semblance, although they partake little 
of the real character, of inflammation, likewise 
receive most relief from this description of anti- 
phlogistic treatment. The contro-stimulant or 
sedative influence of cold directly applied is ex- 
erted equally on the vessels and nerves, and it 
would be, doubtless, a powerful means of subduing 
irritations, were it a more manageable agent ; as 
it is, we see its beneficial influence in the relief 
afforded to cerebral irritation, and in those of the 
limbs by applications of ice and cooling lotions. 
The expediency of using it, (as do the Broussaians) 
in abdominal and thoracic inflammatory irritations, 
is very questionable: the risks of repelling the 
inflammation more inwardly, and of its being ag- 
gravated by reaction if the application of cold is 
unsteady or insufficient, besides the obvious injury 
to the system of continually abstracting from or- 
gans that degree of heat which is almost neces- 
sary to their life, are surely sufficient objections 
against a practice that is far from being generally 
recommended by the experience of its advocates. 
External heat, whether dry, as applied by hot 
flasks, bricks, or air, and acting as a rubefacient, 
or combined with moisture in fomentations, baths, 
or poultices, and proving revulsive and sudorific, 
is a much less exceptionable remedy for internal 
irritations. In its moderate degrees the latter are 
more suited to inflammations, as their effect is 
principally on the circulation, which they soothe 
and equalize ; but in its highest tolerable degree, 
heat produces a strong impression on the nervous 
system ; very hot flasks, or flannel wrung out of 
water almost scalding, are among the most power- 
ful of antispasmodics or local anodynes, and we 
have seen them produce perfect and immediate 
relief in the irritative pains of colic and dysme- 
norrhoea, where many powerful narcotics had failed. 
As we are now verging on the subject of means 
directed particularly to lower nervous irritability, 
we may premise that there are some narcotic or 
sedative remedies which, if they do not act as 
such on the vascular system likewise, do not stim- 
ulate it ; they are, therefore, often admissible in 
inflammation itself, and are the more strongly in- 
dicated when it exhibits the character of nervous 
irritation. Of these, none for safeness and general 
applicability ranks before the hyoscyamus. Mr. 
Travers says, " In the ruffled states of the system 
generally, but especially in the over-active state 
of the vascular system, there is a charm in the 
operation of henbane altogether peculiar. It is 
feeble as an anodyne, feebler as a soporific, but 
' not poppy nor mandragora' soothe and still so 
unexceptionably as henbane." This remark, al- 
though true, requires a comment ; the over-activity 
of the vascular system here alluded to is not one 
of inflammation, but of irritation, dependent on 
excess of nervous irritability scattered through the 
different organic sympathies ; and it is in its 
sedative influence on these that the charm of hen- 
bane consists ; for it exerts little or no effect on 
inflamed vessels, that are, as it were, over-active 
in their own strength. We may almost say that 
on its little interference with the vascular system 
its general eligibility depends ; for, restraining no 
secretions, it can advantageously be given alone 
or combined, without the risk of purchasing tem- 



porary relief at the expense of that balance of 
functions which is so essential to health ; and 
unless where pain and excited sympathies are 
useful as guides in the employment of more active 
remedies, there is scarcely an instance of morbid 
irritation unfitted for its use. The main fault of 
hyoscyamus is its weakness as a narcotic ; it not 
unfrequently fails of its effect, and, perhaps sooner 
than other remedies of the same class, loses its 
power by continued use. 

Of the other remedies of this class we may 
mention favourably conium, belladonna, colchi- 
cum, digitalis, and hydrocyanic acid. Their fitness 
in various diseases is less extended than that of 
the medicine already named ; and it is particularly 
restrained by their greater liability to disagree with 
the stomach. The two first approach in then- 
properties most nearly to hyoscyamus. The three 
others exert a decidedly sedative effect on the vas- 
cular system, but rather through an influence on 
the heart, the force and number of whose pulsa- 
tions they diminish, than from any action on the 
vessels at large. Their beneficial effect is, there- 
fore, best seen in irritations of this organ and of 
the lungs, which stand in so close a relation to 
the heart. The directly sedative influence of hy- 
drocyanic acid is, however, sometimes remarkably 
evinced by its allaying the morbid irritability of 
the stomach ; and it is successfully applied exter- 
nally to allay the irritation of prurient eruptions. 
Colchicum is supposed to possess a specific seda- 
tive power in the irritations of gout and rheuma- 
tism. Whether this may depend on its carrying 
off through the kidneys an irritant matter from 
the blood is uncertain ; but the diuretic effect of 
this remedy and of digitalis should not be over- 
looked. Conium and belladonna, when the sys- 
tem can bear them in sufficient doses, are some- 
times very beneficial in allaying irritation of the 
pulmonary system, whether manifesting itself in 
spasm of the bronchi, or in an excessive irritability 
of the mucous membrane, exciting cough. The 
smoke of stramonium and of tobacco enjoys a 
similar reputation, but it is decidedly stimulant to 
the vascular system. Poultices of the recent 
leaves of various narcotic herbs, but particularly 
conium and belladonna, are very efficient in allay- 
ing the irritation of unhealthy ulcers : the leaves 
of the latter in form of ointment show great power 
over both vessels and nerves, in relieving and pre- 
venting the chordees of gonorrhoea. 

We pass over others of lesser note to the chief 
of narcotics, opium. This medicine, although 
under certain circumstances the most sure and 
most powerful of anti-irritants, has so many ulte- 
rior effects, that more than any other it requires 
judgment in its exhibition. Its first effect is to 
stimulate the vascular system, and this is sufficient 
to exclude it from all those instances of sthenic 
inflammation where it is wished to retard or arrest 
rather than to hasten this process. But in the 
asthenic phlegmasia:, especially where nervous 
irritation predominates, the administration of 
opium is counter-indicated only by the ulterioi 
effects which it may have in arresting the secre- 
tions. Combined with ipecacuanha, with anti- 
mony, and especially with mercury, it ceases to 
be liable to this objection, and its operation is 
often in the highest degree salutary. Even where 



IRRITATION, 



89 



it is wanted as a pure anti-irritant, to reduce mor- 
bid sensibility in the nerves, we should always 
prefer it in combination with ipecacuanha, which 
seems to equalize without injuring its narcotic 
virtues ; and in further combinations, it is not 
common to experience from this compound the 
inconveniences that frequently result from lauda- 
num or opium. The muriate and acetate of mor- 
phia, equally with Battley's liquor opii sedativus, 
enjoy the reputation of a purer sedative property 
than the common forms of the drug possess ; but 
unless where a speedy effect is desired, there are 
few cases in which we would not place greater 
confidence in Dover's powder, or tantamount 
combinations of ipecacuanha and the aqueous ex- 
tract of opium. It is an almost indispensable 
adjunct to purgatives in violent gastro-enteric 
irritation where hyoscyamus would be insufficient; 
and if the stomach will retain it, it seldom fails 
to quell the excessive disturbance that sometimes 
follows drastic and unguarded purgation. In 
dysentery, and in more chronic forms of excessive 
irritability of the intestinal canal, the proportion 
of ipecacuanha may with advantage be doubled 
or quadrupled, as in the dose of one-fourth or one- 
eighth of a grain of extract of opium, with one- 
half or a whole grain of ipecacuanha, repeated 
according to the urgency of the symptoms. 

We must notice a more obscure class of reme- 
dies, alteratives, which, whatever may be their 
mode of action, are unquestionably entitled to a 
place here. Under this unscientific but convenient 
title, we reckon the various non-purgative forms of 
mercury, whether simple or combined with opium, 
those of antimony and ipecacuanha in acute dis- 
eases, and in chronic disorders minuter doses of 
the same, sarsaparilla, mezereon, chalybeates, and 
a host of other medicines. The efficacy of the 
first-named of these in restraining and subduing 
inflammatory action would obtain for them, among 
the disciples of the new Italian doctrine, the ap- 
pellation of contro-stimuli ; but this, like cutting 
the Gordian knot, is only substituting a bold stroke 
of hypothesis for a solution of the difficulty. It 
is not impossible that tartar-emetic and mercury 
may exert on the coats of inflamed or irritated ves- 
sels such an influence as directly neutralizes or 
subdues their disorder, and restores their healthy 
function ; but this is a large assumption to take 
for granted ; and in the absence of any sort of 
positive proof, we think it safer and as philosophi- 
cal to arrange the remedies in question under the 
modest title of alteratives. These remedies are 
powerful in subduing irritation ; and on the basis 
of the views which we have given of this morbid 
state, we might equally well frame an hypothesis 
that they act by restoring a lost balance, and by 
equalizing the distribution of natural irritability. 
But we will content ourselves with remarking the 
fact, that mercury, antimony, and in a minor de- 
gree ipecacuanha, tend moderately and equally to 
restore all the secretions which inflammation and 
irritation arrest or pervert ; whilst opium, deprived 
in this combination of its restringent qualities, 
happily allays the excited sensibilities and sympa- 
thies of the nervous system. The alteratives pre- 
scribed in chronic irritations, although in greater 
variety, probably act on the same principle ; and, 
perhaps, the exhibition of what are called altera- 

Voi. III.— 12 H* 



tive doses of blue-pill, Plummer's pill, ipecacu- 
anha, dandelion, and sarsaparilla, and mineral 
waters in chronic diseases of the viscera and skin, 
is more generally acknowledged as an appeal to 
the various secretions. 

Before passing to the last class of remedies, 
tonics, 'we would advert for a moment to the salu- 
tary effect of friction and exercise in allaying 
morbid irritabilities of a part of the system. They 
hold an intermediate place between alteratives and 
tonics, and in affinity with either they well merit 
consideration. Friction, steadily and moderately 
applied, is an efficient anodyne. Although inju- 
rious in acute inflammations, it allays in a won- 
derful manner various nervous pains, spasms, and 
other disagreeable sensations connected with irri- 
tation and irregular circulation, and it is a valuable 
auxiliary to anodyne applications. It is an alter- 
ative to the vascular system, inasmuch as it re- 
moves congestions and obstructions, and promotes 
healthy circulation and secretion ; and in the 
regular continuance of these effects by exercise, 
increased by the contact of pure air, consists the 
tonic power of these hygeian agents. 

The utility of tonics in subduing morbid irrita 
bilities will, if we mistake not, be sufficiently 
apparent from the pathological views which we 
have endeavoured to expose. Agents which give 
tone and strength to the vascular system will de- 
stroy the preponderance of that nervous mobility 
which is the basis of irritation. Under their 
prosperous influence, disposition and power to act 
will go together, and within due bounds produce 
the harmonious balance of even health. Whether 
certain of them possess a specifically sedative pro- 
perty towards the nervous system, or whether this 
is their secondary effect after their tonic and as- 
tringent influence on the vessels, is beyond our 
means of decision ; but the fact is not less ascer- 
tained than important, that the continued use of 
nitrate of silver or sulphate of copper will cure 
the epileptic irritations independent of organic 
cause, and often diminish them where the cause 
is irremovable, by lowering in the nerves their 
susceptibility to its impressions. Thus, likewise, 
bark, carbonate of iron, arsenic, sulphate of zinc, 
or subnitrate of bismuth, sometimes remove the 
painful or spasmodic irritations of tic douloureux, 
hemicrania, sciatica, chorea, and gastrodynia, 
which the most powerful anodynes, antispasmo- 
dics, and counter-irritants fail to effect. The 
stomach and intestinal canal, likewise, under the 
influence of a bitter tonic, will often lose various 
signs of irritation, which, however they may occa- 
sionally be accompanied by slight hypersemia, or 
fancied inflammations, owe their being to weak- 
ness and want of tone. The cold shower or 
plunge-bath, or cold ablution, is another efficacious 
tonic ; the more eligible, often, because, without 
loading the system with medicine, it rouses it to 
the exertion of its own powers in a vigorous vas- 
cular reaction, under the habit of which nervous 
mobility is physically forgotten, and ceases. But 
it is needless to add to examples which have been 
adduced only as illustrations of a piwxiple. 

We have, finally, to glance at the leading pecu 
liarities required in the treatment of indirect irri- 
tation, or that arising in the reaction after pros'ra 
tion. The most obvious indication is to promote 



90 



IRRITATION. 



and regulate the reaction, so that it may rise to 
the point of a general and equal recovery of func- 
tion, without passing beyond it into a state of 
irritation or inflammation. The most common 
state which we have to deal with is that of irregu- 
lar reaction, local and misdirected excitement 
amidst general prostration. Whether this excite- 
ment consist in convulsion, hiccup, vomiting, de- 
lirium, palpitation or cough, it is of the utmost 
importance that it should be subdued ; and to effect 
this, it is of more avail to direct our efforts to ex- 
cite the powers generally, by diffusible stimuli, 
than to attempt to quiet the local irritation by 
sedatives ; for as the other powers rise from the 
prostration, this symptom will generally subside. 
But should this not be the case, and the local irri- 
tation be wearing down the strength, sedatives 
must be addressed to it: this part of the treatment 
will not differ from that of morbid irritability 
already considered. The point which character- 
izes the treatment of this form of disease is the 
necessity for counteracting the prostrating influ- 
ence which paralyzes the plurality of the functions, 
leaving others in proportionate predominance. 
This indication resolves itself into the removal, as 
far as is possible, of this influence, and the further 
obviation of its effects. 

Cold, and the resulting prostration, are removed 
by the same means, the gradual and cautious 
restoration of heat, beginning by frictions with 
snow, &c. and carefully restraining the disposition 
which is commonly manifested to excessive reac- 
tion ; on this account diffusible stimuli are only 
sparingly admissible. See Cold. 

The prostrating influence of a severe me- 
chanical injury, as of a crushed limb or bad com- 
pound fracture, seldom ceases on the removal of 
the limb ; on the contrary, the additional shock 
of the operation not unfrequently proves fatal. 
The absence of inflammation leaves the system 
open to the noxious influence of the shattered 
structure, which inflicts a stroke felt even after its 
removal. Were healthy inflammation soon ex- 
cited, this would probably in a degree counteract 
or interrupt this influence ; and we hazard the 
suggestion that stimulating applications made to 
the injured part previously to the operation, might, 
as in extensive burns, be of more avail than mere 
internal stimuli. The existence of inflammation 
in the system has been shown by Dr. M. Hall to 
protect it in a remarkable degree against the pros- 
trating effects of loss of blood, and the same thing 
obtains in some measure in other cases of prostra- 
tion ; hence asthenic inflammation may be useful 
not only as proving power in the system, but also 
as a general tonic, imparting a stimulus to the 
heart and vessels. This remark is most applicable 
to surgical cases, in which inflammation is an im- 
portant and necessary process ; but we see in it 
also an explanation of the utility of artificial in- 
flammations excited by sinapisms, blisters, and 
stimulant frictions, in failure of the powers from 
various causes, and in the state of sinking from 
any severe disease. Any of these measures, as 
local counter-irritants and general stimulants, 
often prove beneficial in arresting vomiting, hic- 
cup, convulsions, or any other partial reaction, 
amidst general prostration. In the worst cases, 
fsowever, they fail to excite inflammation ; for the 



skin, like oilier parts, seems to have lost the attri- 
butes of vitality. 

Of the diffusible stimuli fit to oppose the state 
of sinking or prostration, the most powerful are 
ammonia, alcohol, and opium. These are variously 
applicable, according to the degree to which the 
depression has extended. Ammonia is the most 
purely stimulant, and is, therefore, best adapted to 
cases in which there is least of local irritation, or 
where this manifests itself in spasms. The com- 
plete prostration induced by tobacco, digitalis, and 
other sedative poisons, and the asphyxia from the 
fumes of charcoal and sewers, are examples to 
which the stimulus of ammonia seems to be espe- 
cially adapted. The carbonate of ammonia is the 
most common preparation, and it is conveniently 
combined with alcohol in the spiritus ammonite 
aromaticus, which is the form most agreeable to 
the stomach. It is to be borne in mind, however, 
that it is a chemical agent as well as a vital 
stimulant; and this circumstance precludes its 
being given to a very large amount. Spirits in 
the various combinations, brandy, wine, and ether, 
is a highly valuable stimulant; and it is the one 
perhaps most to be depended on in general pros- 
tration with irregular reaction. It exhibits some 
narcotic virtue in its property of quieting the 
irritated sympathies of this state, and is peculiarly 
serviceable in arresting the severe vomiting which 
often severely and fatally aggravates various forms 
of exhaustion. It is of the greatest importance to 
watch most assiduously the state of a patient who 
requires a large exhibition of stimuli of this kind, 
both to ensure their being supplied often enough, 
which in case of sinking must be done every five 
or ten minutes, and to diminish or withdraw them 
the moment they produce an effect on the circu- 
lation, lest they stimulate it beyond the point of 
moderate and general reaction into a state of febrile 
excitement. Opium, as it partakes largely of nar- 
cotic as well as of stimulant properties, is less 
adapted to the extremest forms of prostration than, 
to those in which the irritability of the system iu 
misdirected. In the state of sinking, when the 
respiratory function is failing with the rest, opium 
might have the effect of destroying the sensibilities 
and sympathies on which this vital process depends. 
But for the different partial irritations attendant on 
general weakness, particularly delirium, spasm, 
palpitation, and hiccup, opium is generally the 
most satisfactory remedy. Solid opium and its 
tincture are here the most expedient forms; and' 
their stimulant effect is most fully developed 
by small doses frequently repeated. If the anti- 
spasmodic property is desired, larger quantities 
must be given ; and it is truly astonishing what 
doses the system will bear when under the influ 
ence of spasmodic disease. 

The first objects in extreme prostration are, to 
sustain the functions of respiration and circula- 
tion by diffusible stimuli, until there is a sufficient 
recovery of the forces to support these without 
further aid. The organic functions of secretion 
and assimilation then generally require some 
assistance; for the effects of the depressing influ- 
ence sometimes manifest themselves on them after 
the circulation has been restored to some degree 
of vigour. Here alteratives and tonics come into 
requisition ; and, as in direct irritation, they must 



IRRITATION — JAUNDICE. 



91 



be variously modified and combined, in order to 
ensure the most equal and natural excitement of 
the several organic processes. Where the pros- 
trating influence still remains in the system, coun- 
teracting vigorous reaction, and enfeebling or para- 
lyzing all the conservative powers, these several 
remedies must be conjoined. Thus, under the 
noxious influence of gangrene, asthenic erysipelas, 
or poisoned wounds, it becomes necessary to ad- 
minister wine or spirits, ammonia, opium, or cam- 
phor, with bark or sulphate of quinine, whilst the 
secretions are excited by calomel or blue pill. 
Bark has sometimes a signal power in combating 
with the depressing influences in question ; and 
its efficacy may, perhaps, depend on the same pro- 
perty which renders it so complete an antidote to 
the causes of intermittent fevers. 

The irritation of inanition, in respect to its 
symptoms, may require in great part the same 
treatment as that from other causes ; thus seda- 
tives to the nervous system, and the exclusion of 
all sensorial excitements, will be equally necessary. 
But the nature of the causes may modify the in- 
dications: as they consist in a loss from the sys- 
tem, the necessity of supplying nourishment for 
the reparation of that loss, giving to the assimila- 
tory organs the aid of additional stimuli, is obvious. 

It is necessary to be on our guard against the 
invitations which these forms of disease sometimes 
hold out for the use of antiphlogistic measures : 
these afford but temporary relief to the pseudo- 
inflammations which arise in this state, and which 
are more safely and effectually subdued by seda- 
tives, a judicious supply of nourishment, and an 
exclusion of all exciting or disturbing agencies. 
Thus we may see a disease following extensive 
evacuations, which puts on the semblance of vio- 
lent pleurisy, pericarditis, arachnitis, or hydroce- 
phalus, often completely relieved by hyoscyamus 
or opium, with a sustaining nourishment, such as 
sago, arrow-root, or jelly, with small quantities of 
brandy or wine. The state of the circulation is 
the safest guide in the conduct of this treatment ; 
as long as the pulse is weak or fluttering, with its 
quickness, and although sharp or jarring in its 
first impulse, yet leaves the artery in the intervals 
empty under the finger, the sustaining treatment 
must be continued, and local pains, palpitation, 
disturbance of the mind with beating or noises in 
the head, viewed as partial reactions, to be sub- 
dued by opium or hyoscyamus rather than by the 
lancet and evacuants. But if these symptoms 
have been relieved, and the pulse has recovered 
in a measure its steadiness and fulness, the spirits 
and other stimuli must be diminished or with- 
drawn, and the rest of the cure left to time and to 
whatever alteratives circumstances may suggest. 
These points are more fully described under the 
heads of the several diseases connected with this 
subject, and which have been already referred to. 

The prophylactic treatment of those liable to 
irritations will generally consist of those means 
which, by giving tone to the vascular system, re- 
move the preponderance of nervous influence or 
susceptibility. These are tonic medicines and a 
tonic regimen in general ; but if there be already 
a loss of balance in the vascular system, it will be 
generally necessary to direct some alterative to 
regulate it. There are various circumstances of 



diet and regimen which tend greatly to engender 
a general morbid irritability ; particularly an 
habitual and excessive indulgence in spirituous 
liquors, smoking, very strong tea or coffee, and 
opium-eating; close or crowded habitations, and 
a sedentary mode of life. Besides avoiding these 
predisposing causes, those who are of an irritable 
habit should rise early, and keep regular hours, 
use exercise in a bracing air freely, but not so as 
to induce much fatigue, live on food of the most 
wholesome and nutritious kind, and attend in 
every possible way to the promotion of equality 
and regularity of the functions. 

C. J. B. Williams. 

ISTHMITIS. (See Thro at, Diseases of the.) 

ITCH. (See Scabies.) 

JAUNDICE. ("1/crtpo?, icterus, morbus regius, 
aurigo, SfC.) Jaundice is a disease of rather fre- 
quent occurrence, characterized by a yellow colour 
of the eyes, skin, and urine, and by the white 
appearance of the alvine evacuations. In addi- 
tion to these general symptoms, the malady is 
frequently attended with extreme depression of 
spirits, languor, inactivity, and watchfulness ; 
with a bitter taste in the mouth, thirst, loss of 
appetite, nausea, or vomiting; a sense of fulness 
or other uneasiness, if not also actual pain, at the 
epigastrium ; occasional shiverings and profuse 
perspirations ; a distressing degree of itching in 
the skin, and rapid emaciation. The urine soon 
becomes of a deep mahogany colour, yet gives a 
bright yellow tinge to substances immersed in it. 
The state of the bowels is variable, being in some 
cases relaxed, in other cases confined, but gene- 
rally acted upon with facility by mild aperients. 

[Dr. Mackintosh (Principles of Pathology and 
Practice of Physic, 2d Amer. edit. i. 431, Philad. 
1837,) states, that he has known several indivi- 
duals affected with jaundice, who saw every ob- 
ject coloured. Most of the secretions are unques- 
tionably tinged yellow, but not all. The colouring 
matter of the bile is rarely found in mucus or 
milk, for example. Yellowness of the conjunc- 
tiva is, however, one of the pathognomonic phe- 
nomena. Bile is, also, necessarily present in the 
blood-vessels of the retina ; yet, as the writer has 
elsewhere said, (Practice of Medicine, 2d edit. i. 
625; Philad. 1844,) yellow vision is not common. 
In the experience of one observer, Dr. J. P. Frank, 
it was noticed but five times in about 1000 cases. 
Much difference of opinion has existed in regard 
to the cause of the phenomenon when it does exist. 
The most probable supposition is, that the hu- 
mours themselves are tinged yellow, and it has 
been suggested, that where vision is not yellow, 
they may have escaped the tinge. There is some 
plausibility, however, in the supposition, that the 
cause may be wholly nervous, inasmuch as pa 
tients, in other diseases, as in typhus fever, with- 
out being in the slightest degree jaundiced, have 
seen every thing yellow. It is possible that dif- 
ferent conditions may be occasionally concerned 
in the causation.] 

The circumstances which predispose the sys- 
tem to an attack of jaundice are numerous. The 
melancholic or leucophlcgmatic temperament, 
under mental excitement, whether of a pleasant 
or painful nature; an indolent mode of life, 
sedentary occupations, a fuN and stimulating diet, 



92 



JAUNDICE, 



and nabitual constipation, are among the most 
powerful. 

The occasional or exciting causes of the dis- 
ease arc chiefly such as either suddenly stimulate 
the liver to an increased secretion of bile, or ob- 
struct the free egress of that fluid. Thus, a 
heated atmosphere, strong muscular exertions, 
sudden and powerful emotions of mind, spirituous 
or other fermented potations, a large and indiges- 
tible meal, faces impacted in the transverse colon, 
pressure from a gravid uterus, may induce an at- 
tack of jaundice. 

The proximate cause or essential nature of the 
disease evidently consists in an obstruction to the 
passage of bile in its course from the liver or gall- 
bladder to the duodenum, in consequence of which 
it either retrogrades into the blood-vessels of the 
liver, or is absorbed from the surfaces of the biliary 
ducts. There are many morbid conditions of the 
liver and its appendages, as well as of the adja- 
cent organs, which may induce such an impedi- 
ment. Not a few of these have been ascertained 
by the most conclusive evidence. Others, origi- 
nally devised by the fertile imaginations of noso- 
logists, and considered as adequate to the produc- 
tion of jaundice, have been successively handed 
down from author to author, not as merely proba- 
ble causes, but as legitimate deductions from 
established facts. Instead, however, of specify- 
ing the greatest number of morbid conditions 
which may possibly give rise to jaundice, we shall 
endeavour to comprise, under a few leading divi- 
sions, those phenomena alone which pathology 
has clearly ascertained. Such, we think, may be 
conveniently arranged under four general heads. 

1. Obstructions arising from biliary concretions 
or other altered conditions of the bile, as well as 
from worms, hydatids, or other foreign bodies. 

2. Obstructions arising from diseased states of 
the liver, gall-bladder, or biliary ducts. 

3. Obstructions arising from morbid conditions 
of the duodenum. 

4. Obstructions produced by the pressure of 
enlarged contiguous viscera. 

I. The first class of obstructions — those aris- 
ing from Biliary Concretions or other al« 
tcred Conditions of the Bile itself — have 
received an almost disproportionate share of atten- 
tion from medical writers. The learned Heber- 
den, for example, scarcely seemed to recognise 
any other causes of jaundice. There can be little 
doubt that a highly inspissated state of the bile 
may alone produce temporary jaundice. In some 
instances, after great depression of mind and tor- 
por of bowels, the stools become white, and the 
skin of a dusky-yellow colour. Under the opera- 
tion of a brisk mercurial purgative, the patient 
voids a quantity of dark, pitchy, viscid matter, of 
sufficient tenacity to be drawn out in threads. 
He becomes immediately relieved, the skin and 
the alvine dejections gradually resuming their 
natural colour Such cases we may warrantably 
refer to a thickened and vitiated state of the bile, 
which, in other instances, has been found of the 
same pitchy tenacious character while contained 
in the gall-bladder itself. 

Biliary calculi unquestionably form a very fre- 
quent cause of jaundice. Their mere presence 
in the gall-bladder does not usually seem to pro- 



duce either general or local inconvenience. Out 
of nineteen instances of biliary calculi, which oc- 
curred to Morgagni, besides four to \ alsalva, in 
post-mortem examinations, not one had expe- 
rienced jaundice. Yet a general failure of health 
has been observed, where, after death, no morbid 
appearance could be discovered except that of 
calculi in the gall-bladder. (Abercrombie on the 
Diseases of the Abdominal Viscera, p. 370.) Dr. 
Heberden remarks that, " in nearly twenty per- 
sons, a supposed pain of the stomach, which had 
frequently afflicted them for months or years, was 
at length joined by a jaundice." (Transactions 
of the College of Physicians, vol. vii. p. 171.) 
In those, cases, it is probable that the occasional 
pain arose from some change in the position of 
the calculi in the gall-bladder. That they do not 
always remain in the bile-receptacle with impu- 
nity is clearly proved by the testimony of morbid 
anatomists. Soemmering repeatedly found the 
mucous lining of the gall-bladder in a state of 
ulceration, occasioned by the irritation of the con- 
tained calculi ; while other pathologists have ob- 
served a general thickening of its coats, and dis- 
organization of its whole texture. 

The number of calculi sometimes contained in 
the gall-bladder is almost incredible.- Morgagni 
took out of one body 3646 ; and in the Hunterian 
museum at Glasgow, 1000 are preserved which 
are stated to have been extracted from one gall- 
bladder. The form and size of these calculi are 
very various. In a few instances they have nearly 
taken the shape and attained the magnitude of 
the gall-bladder itself, but generally, are from an 
eighth to a one-half of an inch in diameter, and 
of a polygonal form. (See Mr. Brayne's very 
interesting cases in the Medico-Chir. Trans, vol. 
xii.) The broken or divided portions of the 
larger calculi have sometimes corresponding con- 
vexities and concavities, proving that they were 
once united. And it is not improbable that the 
smaller calculi are often subdivisions of a larger 
mass, formed into distinct calculi before consolida- 
tion was completed. The sides of these calculi 
are often flattened as if from close contact and 
pressure. 

The chemical and physical characters of biliary 
calculi have been already described in this work 
under the general title of Calculus. In that 
condensed but highly-interesting article the dis- 
tinguished author has given a very perspicuous 
account of the more frequent forms of biliary 
calculi ; but may not have thought it necessary to 
allude to one or two kinds of uncommon occur- 
rence, which yet, we conceive, may prove of some 
importance in a pathological point of view. We, 
therefore, make no apology for introducing them 
in this place. 

The first of these, as we are informed by Pro- 
fessor Turner, was discovered by M. Bizio, of 
Venice, in a peculiar fluid, quite different from 
bile, which was found in the gall-bladder of a 
person who had died of jaundice. It is of a 
green colour, transparent, tasteless, and of the 
odour of putrid fish. It is unctuous to the touch, 
may be scratched or cut with facility, and has a 
specific gravity of 1-57. M. Bizio has given it 
the name of erythrogen. (Dr. Turner's Ele- 
ments of Chemistry, p. 656.) 



JAUNDICE, 



93 



Another remarkable kind of biliary concretion 
is described by Dr. Marcet, in the following words. 
" Within the last few days, I have seen and ana- 
lyzed a large biliary calculus entirely different in 
its chemical composition from the above descrip- 
tion, and, as far as I know, presenting a new fact 
in the history of these bodies. This concretion 
contained no adipocire (cholesterine), and con- 
sisted wholly of carbonate of lime tinged by bile. 
It was of a bright yellow colour. It was heavier 
than water, and measured two inches five-eighths 
in length, and two inches and a quarter in its 
largest circumference." (Marcet on Calculous 
Diseases, p. 151, note.) This extraordinary pro- 
duction was found in the gall-bladder of a dead 
body by Mr. Green, (now Professor Green,) de- 
monstrator of anatomy in St. Thomas's Hospital. 

The formation of biliary calculi is still in- 
volved in much obscurity. Many of the circum- 
stances before enumerated as predisposing to 
jaundice generally, are found peculiarly to favour 
the formation of calculous concretion. Such are 
depressing emotions, deficient bodily exercise, a 
full diet and frequent constipation. Had biliary 
concretions been always found to consist merely 
of inspissated bile, there would have been no dif- 
ficulty in conceiving how the want of exercise 
and similar causes, by favouring the retention of 
bile and the gradual absorption of its thinner 
parts, should ultimately lead to an actual concre- 
tion of the residual mass. And that this has 
sometimes occurred is sufficiently proved. Van 
Swieten, in his Commentaries, relates the case 
of a boy whose gall-bladder contained eight pounds 
of a thick sort of bile, consisting of a number of 
concentric strata, each stratum becoming firmer 
as it approached the circumference. There had, 
however, been no jaundice, although the stools 
were of a white colour. Biliary concretions, 
however, very rarely consist of bile alone ; and 
even where an admixture of bile or a distinct 
stratum of bile does exist, the central portion is 
generally of a very different nature. Something 
more, therefore, than consolidation .must take 
place. Either the original secretion of bile must 
be faulty, or, in consequence of long retention in 
the gall-bladder, it must undergo some changes 
by which its constituent parts become disunited 
or converted into new products. Probably these 
different states of bile occur in different cases; 
inasmuch as calculi are sometimes found in the 
liver itself, and inasmuch, too, as some kinds of 
calculi approach nearly to the known constituent 
principles of the bile, whereas others exhibit cha- 
racters of a very dissimilar kind. May not also 
the mucous secretion of the gall-bladder become 
so altered in its nature, in consequence of the 
long retention of vitiated bile, as itself to furnish 
nuclei around which the dissociated constituents 
of the bile, or new formations from it, arrange 
themselves! The peculiar nature of some of the 
nuclei, as well as the effect of long-restrained 
secretions on other mucous surfaces, afford some 
countenance to this idea ; although it must be 
admitted that the gall-bladder, from the adaptation 
of its structure to its peculiar function as a recep- 
tacle, is less likely to suffer from the detention of 
its contents than other mucous tissues exposed to 
the long-continued contact of their secretions. 



An inquiry into the power by which biliary cal- 
culi are propelled forward necessarily involves 
some interesting points connected with the struc- 
ture of the gall-bladder and the biliary ducts, 
which would lead us into a discussion somewhat 
foreign to the practical object of this paper. We 
shall merely remark that the effort of vomiting, 
whether spontaneous or otherwise, has probably a 
considerable influence in the extrusion of these 
concretions. Dr. Pemberton, indeed, does not 
ascribe any such effect to vomiting, unless where 
a calculus, from its peculiar size and form, entirely 
blocks up the duct, and obliges the bile to accu- 
mulate behind it, thus forming a kind of wedge 
which thrusts it further forward. To us, on the 
contrary, the impulse given in the act of vomiting 
would promise to be more effectual if the calculus 
did not very firmly or entirely close up the duct, 
but rather permitted the fluid bile, when strongly 
impelled, to slip along its sides ; in which case, if 
the quantity of bile were too considerable to pass 
off quickly by the portion of the duct anterior to 
the calculus, it must necessarily swell it out, and 
thus prepare a way for the freer egress of the de- 
scending concretion. 

We are not aware that any examples are re- 
corded of very large calculi having passed through 
the biliary ducts; yet there is ample proof of the 
great distensibility of these passages. Dr. Baillie 
has seen both the ductus hepaticus and the ductus 
choledochus enlarged to the diameter of half an 
inch. When such a degree of distension takes 
place, there is generally a proportional thickening ; 
in truth, an actual growth in every direction. 
Most commonly, however, if not always, when 
concretions much exceed the diameter just men- 
tioned, they are expelled from the system by a 
different process ; an adhesion is formed between 
the gall-bladder and the duodenum, and a suffi- 
cient opening effected by ulceration. The calcu- 
lus thus brought into the duodenum is either then 
propelled along the intestinal tube and evacuated 
by the bowels, or a further adhesion takes place 
between the duodenum and the abdominal pa- 
rietes ; an abscess is formed ; ulceration proceeds ; 
and, at length, the irritating substance is protruded 
through the opening in the integuments. 

The cases related by Mr. Brayne, to which we 
have before adverted, afford beautiful and striking 
illustrations of the former and more perfect mode 
of extrusion. The patients, in at least two in- 
stances, recovered. Of the latter mode of expul- 
sion, to wit, that by an external opening, many 
examples are recorded, from which we may adduce 
one as related by the venerable Heberden. The 
patient, after having suffered for years from a dis- 
charging tumour near the umbilicus, was seized 
with acute pain, nausea, and vomiting, " et post 
paucos dies exiit calculus fellis tres pollices lon- 
gus, totidemque ambitu, quique pendebat grana 
ccxlv." (Commentarii de Morborum Historia, &c. 
p. 213.) 

Jaundice may be presumed to arise from biliary 
calculi, or other similarly acting obstructions, 
when its accession is sudden and accompanied by 
acute pain either in the epigastrium, or shooting 
towards that part from the back or right hypo- 
chondrium ; especially if there be also vomiting 
and occasional shiverings, or profuse perspirations, 



94 



JAUNDICE. 



without any manifest fever or an increased force 
or frequency in the pulse. Not uncommonly, the 
pain precedes the appearance of jaundice, return- 
ing, perhaps, with great severity for several suc- 
cessive days, and remaining for several hours at 
each return. Unlike the rigors which forebode 
an attack of inflammation, the shiverings in jaun- 
dice rarely precede the pain, but occur irregularly 
during a paroxysm, and seem to mark a further 
propulsion of the calculus along the irritated ca- 
nal, or its final extrusion through the distended 
opening of the common duct into the duodenum. 
The character of the pain is very important : it is 
acute, and occurs in paroxysms. Sometimes it is 
intense and excruciating in the highest degree, far 
exceeding what is felt in the most acute inflam- 
mation. The perspiration which sometimes drops 
from the patient may be ascribed chiefly to the 
severity of his suffering. The position of the pa- 
tient also deserves attention. He bends the body 
forward upon his knees, when not writhing in 
other directions, and seems to find some relief from 
pressing upon the seat of pain. Not unfrequently 
the pain subsides on the appearance of jaundice. 
The state of the pulse will materially assist in the 
diagnosis. During the state of simple irritation it 
is seldom much accelerated or preternaturally firm. 
When, indeed, it becomes materially harder and 
quicker, the utmost vigilance should be exercised 
lest irritation should proceed to inflammation ; in 
which case, the pain usually becomes more con- 
stant, the tongue whiter, and vomiting more inces- 
sant. These symptoms sometimes rise to such a 
degree as to resemble those of the ileus, to which, 
indeed, they then become nearly allied. 

It may be proper here to intimate that the entire 
subsidence of the pain, vomiting, and other charac- 
teristic symptoms, does not necessarily imply the 
passage of the calculus into the duodenum. Very 
frequently it slips back again into the gall-bladder, 
there to remain for a time, with little comparative 
inconvenience to the patient. We need scarcely 
add, therefore, that the evacuations from the bowels 
should be carefully examined, inasmuch as the 
discovery of a calculus cannot fail to afford relief 
and comfort to the mind of the patient. 

The treatment of calculous jaundice should be 
specially directed to three points : — 

1. To facilitate the progress of the inhering 
concretion. 

2. To mitigate the pain and other symptoms of 
irritation. 

3. To guard against the inflammation which is 
to be apprehended from the irritation of the calcu- 
lus. 

In endeavouring to fulfil these indications, 
opium may be regarded as our sheet-anchor. The 
first dose, consisting of one or two grains, or an 
equivalent proportion of the sulphate or acetate of 
morphia, may be advantageously combined with 
five or six grains of calomel. If the pain and 
sickness do not abate, a grain of opium may be 
repeated at the end of the first hour, and reiterated, 
after similar or sl*orter intervals, until ease be pro- 
cured. After a few doses have been given, a solu- 
tion of some neutral salt, particularly the sulphate 
of magnesia, either with or without the carbonate, 
or the carbonate of magnesia with lemon-juice in an 
effervescing form, may be administered, in combi- 



nation with some aromatic water, and repeated at 
fitting intervals, until a free evacuation from the 
bowels is obtained. Soda-water, well charged with 
carbonic acid gas, or simple saline draughts ma 
state of effervescence, are sometimes useful m 
allaying the urgent vomiting. If opium by the 
mouth should not procure ease, a drachm of the 
tincture may be mingled with a few ounces of thin 
starch or barley-water, and administered as an 
enema : prior to which, however, it is sometimes 
advisable to throw up a large quantity of warm 
water, which alone sometimes proves very soothing 
to the patient. As soon as possible, recourse should 
be had to a warm bath, in which the patient may 
remain until a degree of faintness supervene,— a 
state of relaxation peculiarly favourable to the 
passage of the calculus. Should these various 
methods be unavailing, and the patient be in a 
state to bear depletion, it will be expedient to with- 
draw from ten to sixteen ounces of blood from the 
arm, in a full stream, and, if practicable, while in 
the bath and in a half-erect posture. Topical 
bleeding may be also needful if the continued 
irritation of the calculus indicate inflammatory 
action, which may be apprehended from the pain 
becoming more constant, and accompanied with 
tenderness on pressure. 

Emetics have been strongly recommended in 
calculous jaundice, and are doubtless powerful 
agents, though not always safe ones. When we 
consider the structure and the tortuous course of 
the common bile ducts, as well as the sharp and 
angular forms of the calculi, we shall not regard, 
without considerable apprehension, the action of a 
powerful emetic. In many instances inflamma- 
tion, adhesion, and actual obliteration of the ducts, 
have resulted from the spontaneous passage of a 
calculus. Is it not, then, highly hazardous forcibly 
to impel these irritating substances against the 
already irritated mucous lining of the tubes ? 

Nauseating doses of ipecacuanha may, how- 
ever, prove safer and more availing, if the patient 
be not already in a state of nausea. Such an 
exception is, however, very uncommon. The ad- 
vantage to be expected from nauseating doses is 
of a twofold character. We may hope to pro- 
mote more general relaxation, as well as to aug- 
ment the biliary secretion ; and thus, while relax- 
ing the affected duct, and carrying down an in- 
creased flow of bile, nature may be assisted not a 
little in her efforts to expel the irritating substance. 

We have already stated that the bowels are 
sometimes in a relaxed state. In other cases, how- 
ever, they are obstinately constipated, and require 
strong and repeated doses of active purgatives, 
such as calomel, with the compound extract of 
colocynth, and an additional quantity of aloes. 
Even after the expulsion or retreat of the calculus, 
it will be desirable to exhibit occasionally a mer- 
curial purgative, at the same time supporting the 
tone and regular action of the chylopoietic organs 
by small doses of a neutral salt in some mild bit- 
ter infusion. 

We have mentioned hydatids, worms, and other 
extraneous matters, as occasionally producing 
jaundice. In some instances substances may be 
passed by stool which will enable the physician, 
in subsequent attacks, to form a reasonable conjec- 
ture respecting the nature of the obstruction. But, 



JAUNDICE. 



95 



generally, no such intimation can be obtained. 
The treatment, however, of jaundice from such 
causes must be very similar to that recommended 
for the removal of calculi. 

II. Jaundice arising from Diseased States 
of the Idver, Gall-bladder, or Biliary- 
Ducts, will of course be attended by the symp- 
toms peculiar to each affection, in addition to 
those which characterize an obstructed state of the 
biliary passages. General or partial hypertrophy 
of the liver (a state not uncommon in great 
eaters); a tuberculated or schirrhous condition of 
that organ ; with many other forms of disorgani- 
zation, may so interrupt the egress of the bile as 
to occasion jaundice. When the disease is de- 
pendent on such causes, there is sometimes no 
pain, or pain of a less acute, though more con- 
tinued, character. The approach of the super- 
vening jaundice is also generally gradual ; and 
symptoms of hectic fever too often succeed. It is 
a remarkable circumstance that, notwithstanding 
the prevalence of liver complaints, calculi are 
rarely found in the interior of that organ. Mor- 
gagni affirms, " vix uno in jecinore mihi olim ac- 
cidit ut invenirem ; Valsalva? autem in nullo, quod 
sciam." (Ep. xxxvii. Art. xi.) 

Diseased conditions of the ducts themselves 
form, we believe, more common cases of jaundice 
than is generally supposed. Of these, inflamma- 
tion and its consequences are among the principal. 
The mucous tissue of the ducts may become ulcer- 
ated, or so adherent as actually to obliterate the 
<~anal. It may, also, be so studded with tubercles 
<to to be no longer permeable to the bile. Jaundice 
from such causes is often incurable and fatal. 

III. Our third general division of jaundice com- 
prises those niorbid states of tlie Duodenum, 
which have been found to occasion the 
disease. Of such we may specify the following: 
1. viscid mucus adhering to the inner membrane 
of the bowel, and sealing up the opening of the 
ductus communis choledochus. 2. a highly tur- 
gid or inflamed state of its mucous membrane. 3. 
a thickened, tuberculated, or otherwise disorgan- 
ized condition of the duodenum. 

1. Viscid mucus, we are persuaded, is a frequent 
cause of temporary jaundice. Many of the cases 
which have been gratuitously attributed to spasm, 
were probably of this nature.* If we attentively ob- 
serve the peculiar structure of the termination of the 
common duct in the duodenum, we shall more accu- 
rately conceive how readily its small orifice, in the 
midst of a papillary projection, may be closed up 
by a thick and tenacious layer of mucus. Such 
a cause may be reasonably inferred when the dis- 
ease has come on rather suddenly, has been unat- 
tended by acute pain or other inflammatory indi- 
cation, yet has been preceded by dyspepsia and a 
torpid state of bowels. A mucous film upon the 
tongue, and the absence of the usual marks of 
chronic visceral disease, will give additional pro- 
bability to the opinion. A large dose of calomel, 
followed by a draught containing magnesia and 
rhubarb in infusion of senna or some other vehi- 
cle, will sometimes quickly remove the disease. 
Much circumspection as to diet, the regular use of 

* No special reference is made in this article to " spas- 
modic jaundice," because we have no evidence of its 
existence. 



active exercise, with an occasional recourse to pur- 
gatives, may equally ensure a freedom from re- 
lapse. 

2. A turgid or inflamed condition of the mu- 
cous membrane of the duodenum probably seldom 
exists without the lower portion of the common 
bile-duct being similarly affected. This form of 
disease is characterized by uneasiness or pain in 
the course of the bowel, which sometimes becomes 
tender on pressure, the uneasiness being more 
particularly felt at the expiration of three or four 
hours after eating, and being often accompanied 
with vomiting. The tongue has usually a white 
or yellow surface, and there is considerable thirst. 
The pulse is also somewhat accelerated. In dis- 
tinguishing this affection from a diseased state of 
the pylorus, attention should be paid to the period 
after eating at which the vomiting occurs. Where 
the pylorus is alone affected, vomiting generally 
commences within two or three hours of the meal, 
and affords almost immediate relief. In the chro- 
nic inflammation of the duodenum, of which we 
are treating, the vomiting seldom occurs until four 
or five hours have elapsed, and does not alleviate 
the distressing sensations of the patient. He 
gains, however, sensible relief by taking a tea-cup 
full of warm fluid, which seems to excite an in- 
creased peristaltic action, and thus to liberate the 
oppressed duodenum from the undigested mass. 

It is of extreme importance to overcome this 
kind of jaundice as soon as possible, lest disor 
ganization of the duodenum, obliteration of tho 
orifice of the bile-duct, or adhesion of its sides 
should ensue. 

Whether simple turgescence or actual inflam- 
mation be the cause, the treatment should be essen- 
tially the same, varying only in degree. A mode- 
rate bleeding from the arm, if the strength of the 
patient admit of it; repeated local depletion; the 
warm bath ; counter-irritants, particularly in the 
form of the antimonial ointment; with mild doses 
of saline aperients, and the most scrupulous at- 
tention to diet, — constitute the treatment which 
experience, no less than general principles, points 
out as best adapted for the purpose. 

IV. Jaundice produced by the pressure 
of enlarged contiguous viscera is of frequent 
occurrence, although less susceptible of relief from 
medicine. Cases of simple distension of the 
transverse colon, from a collection of impacted 
faces, are, of course, to be generally removed by 
appropriate remedies. Compression, too, by the 
gravid uterus, obviously admits of a natural cure. 
But a scirrhous enlargement of the pylorus, or of 
the round head of the pancreas, — two of the most, 
frequent causes of this species of jaundice, — arc 
among the most intractable as well as the most 
distressing disorganizations which human nature 
can sustain. In these cases, the most deplorable 
depression of mind, and an extreme degree of 
emaciation, are often observable. We have 
already alluded to some points of diagnosis in 
reference to the enlargement of the pylorus. As 
the disease advances, the tumefaction will be dis- 
tinguishable by the hand : so may also, generally, 
though with more difficulty, the enlargement of 
the pancreas. 

Affections of the head, irrespective of any pre- 
vious disease in the biliary oigans, have been sup- 



96 



JAUNDICE — KIDNEYS, (DISEASES OF) 

In the more chronic 



posed to occasion jaundice. Where, however, a 
serious injury has been inflicted on the head, such, 
for example, as is sometimes occasioned by a jump 
or a fall, it is highly probable that the liver or its 
appendages received some simultaneous injury, 
although the effect was not so quickly perceived. 
This is also the opinion of the judicious Aber- 
crombie. We have, however, long felt assured 
that the state of the brain and nervous system has 
been too little considered in the pathology of jaun- 
dice. When we regard the influence of the brain 
and nerves in secretion generally, as well as their 
influence upon the moving powers, we may rea- 
sonably suppose that any considerable deviation 
from their sound and vigorous condition will be 
likely to lessen or deteriorate the biliary fluid ; and 
also, by withholding a due supply of nervous 
energy from the moving forces, retard its trans- 
mission through the biliary passages into the duo- 
denum. The remarkable influence which power- 
ful emotions have upon the secretion of bile, and 
probably, also, on its propelling powers, should 
lead us more attentively to mark this connection, 
and the morbid changes thence resulting ; by 
which attention, we may hope, at some future 
period, to clear up many obscure points relating 
to the biliary secretion, both in its healthy and 
diseased states, and ultimately arrive at more suc- 
cessful methods, not only of removing jaundice, 
but also, in many instances, of preventing its 
occurrence. T H BuRDER . 

[Jaundice of the Infant, Icterus In» 
fantum, Yellow Gown or Cnni, is a 
common affection of children everywhere. It 
comes on soon after birth, without any obvious 
cause, continues for some days, and disappears : 
the only other symptom generally observed being, 
perhaps, unusual drowsiness. It has been pre- 
sumed to depend upon some irritation of the in- 
testinal canal, resulting from the digestive system 
being called into active exertion for the first time, 
and receiving a new stimulus from the maternal 
milk. It is more probably owing to the ductus 
communis choledochus being obstructed by inspis- 
sated mucus, or by the meconium, which has col- 
lected in the intestines during utero-gestation. By 
some, it has been referred to too viscid a state of 
the bile ; and by others to a congested condition 
of the liver. It is, however, an affection of no 
consequence. Even in torrid climates, recovery is 
so general, that opportunities have not occurred 
for discovering the precise pathological condition 
by dissection. It rarely exists at birth, but is 
commonly observed from the third to the seventh 
day — seldom in the second or third week ; and 
terminates in death in the course of a week or 
two. 

The disease would generally yield, probably, 
without any treatment ; but inasmuch as the cause 
would seem to be, in many instances at least, 
obstruction of the choledoch duct, it may be well 
to facilitate its removal by gentle laxatives, as the 
syrupus rhei, magnesia, or castor oil. The writer 
has never found it necessary to adopt any other 



bath, may be employed, 
form, remedies have been prescribed by some, the 
precise object of which is not very intelligible; 
and hence their action has been uncertain, if not 
null. (Condie, A Practical Treatise on the Dis- 
eases of Children, p. 520, Philad : 1844.) 

ROBLEY DuNGLISON.] 

KIDNEYS, DISEASES OF. Notwithstand- 
ing the activity with which the kidneys perform 
their functions, the constancy of their action, and 
the extraordinary rapidity with which their secre- 
tion becomes affected, not only when other parts 
of the system are suffering under actual disease, 
but even when they are simply and slightly disor- 
dered, these organs are not peculiarly liable to 
alteration of structure. On the contrary, as it 
has been well observed by a distinguished patho- 
logist of the present day, " in the greater number 
of diseases, whether chronic or acute, we cannot 
discover by dissection any change in the structure 
of the kidneys." 

Of the diseases incidental to the kidneys, the 
most important, perhaps, are ischuria renalig, 
nephralgia, and nephritis. To these might 
be added diahetes, were pathologists agreed as 
to its primary seat ; but though several eminent 
writers have considered it to originate in the kid- 
neys, there are others of equal name and authority 
who have referred it to a different source. Ischu- 
ria renalis has been discussed in a former article; 
and it is proposed, likewise, to treat, under their 
respective titles, both nephralgia and nephritis. 

In the present article, it will be our object 
briefly to notice those other renal affections which, 
on account of the rareness of their occurrence, or 
the obscurity and uncertainty of their symptoms, 
or their hitherto uncontrollable nature, may pro- 
bably be deemed of minor importance so far as 
practice is concerned ; yet which, by those who 
are truly devoted to medicine as a science, can 
never be deemed insignificant or uninteresting. 
The renal affections which we are about to con- 
sider may conveniently be arranged, after the plan 
adopted by M. Andral, under three heads : the 
first comprising morbid conditions of the circula- 
tion of the kidneys ; the second, lesions of nutri- 
tion ; the third, morbid formations. 

1. Lesions of Circulation. — The kidneys 
are sometimes found gorged with blood — in that 
state to which the term hypertemia has been 
appropriated without any other alteration. One 
or both organs may be thus congested, and the 
congestion may affect both the cortical and tubular 
parts, or only one of them. When they are in a 
high state of hyperemia, they assume a dark 
chocolate hue. 

The kidneys are also found in a state precisely 
opposite to that just mentioned, namely, in a state 
of paleness or anremia, either partial or general, 
either complete or incomplete ; sometimes existing 
in a few scattered points only. This is the con- 
dition of the kidneys which is frequently observed 
in persons who have sunk under chronic diseases, 
especially in dropsical patients, and those who 



plan of treatment in the cases that have presented have been the subjects of the affection named by 

Dr. Good marasmus anemia. When this 
paleness exists in an exquisite degree, it may be 



themselves to his notice ; but should there be 
signs of hepatic inflammation, a few leeches, fol- 
lowed by an emollient cataplasm, and the warm | regarded as in itself a diseased hut* hitW^ Ithai 



KIDNEYS, (DISEASES OF THE) 



97 



not been discovered to occasion any functional 
derangement during life. 

The yellow colour, either general or partial, 
which is occasionally observed in the kidneys, is 
probably owing, as M. Andral has remarked, to a 
less advanced stage of anaemia. 

It may suffice thus briefly to have noticed that 
congestion of the kidneys, or extreme paleness of 
them, may occur without their presenting any 
other morbid appearance. Such instances, how- 
ever, arc rare; hyperemia, as well as anaemia, is 
usually found in connection with other degenera- 
tions of those organs : the former, for example, 
conjoined with softening, or with induration 
together with hypertrophy; the latter with soften- 
ing, or occasionally with induration and atrophy. 

2. Lesions of Nutrition* — The kidneys are 
sometimes much larger than natural, though 
otherwise unaltered. Both kidneys may be thus 
affected, but more commonly the hypertrophy 
is confined to one only. As was observed while 
treating of ischuria renalis, great augmentation 
of volume of one kidney is not unfrequently met 
with when the other is, by disease or obstruction, 
rendered incapable of performing its office. The 
enlarged gland takes upon itself the duty of its 
fellow. Hypertrophy of the kidney seems occa- 
sionally to depend upon its being doubly nour- 
ished, by receiving its supply of blood from two 
renal arteries. This state of kidneys, generally 
combined with increased vascularity, is the most 
usual morbid appearance observed in cases of dia- 
betes. An extreme paleness of their tissue, with 
softening, has indeed been often mentioned as the 
principal alteration which takes place in them in 
that disease ; but in various cases upon record, 
and in every instance which has occurred in our 
own experience, the kidneys have been more vas- 
cular, and generally larger than natural. 

To this variety of morbid alteration — hypertro- 
phy — may, perhaps, be referred those cases where 
the kidneys are united by an intermediate sub- 
stance ; a sort of middle lobe, resembling them in 
its texture, and passing over the vertebral column 
from the one to the other. 

With respect to the nature of those hard, 
whitish, globular bodies, of various sizes, which 
are mentioned by authors as existing in the cor- 
tical substance of the kidneys, and which in some 
few instances have been detected in the tubular 
substance also, little is known. Some have re- 
garded them as serving to secrete the urine, while 
others have supposed them to consist of a mass 
of vessels interlaced : but it is clear that granula- 
tions like these sometimes constitute a really 
morbid state. They nearly resemble the yellow 
granulations of the liver, which Laennec thought 
an accidental tissue, and to which he gave the 
name of cirrhosis,- but which, in all probability, 
are the result of an unusual development of one 
of its elementary tissues, namely, of its white sub- 
stance. These granulations in the kidneys are 
sometimes thinly scattered, sometimes so very 
numerous as to leave hardly any trace of their 
cortical portion, and even to occupy the intervals 
between the cones of the tubular portion of them. 
Such a state of the kidneys may, it would seem, 
produce dropsy ; for in various cases of dropsical 
patients no other morbid appearance of importance 

Vol. III.— 13 I 



has been detected. Although, as M. Andral ob- 
serves, it is difficult to comprehend how dropsy is 
produced by this affection, the fact is nevertheless 
certain. 

[Under the head of Dropsy, (vol. i. p. 707,) 
attention has been drawn to the Granular Disease 
of the Kidney, Morbus Brightii, which is attended 
with the secretion of albuminous urine — hence 
termed Albuminuria. Yet the appearance of 
albumen in the urine is by no means diagnostic 
of this condition of the kidneys, as has been shown 
by the observations of the writer, and of others, 
{Practice of Medicine, 2d edit. ii. 29, Philad. 
1844); and cases have been published recently, 
in which, on the one hand, Bright's disease existed 
without albuminous urine; and on the other hand, 
albuminous urine was present without Bright's 
disease. We cannot, indeed, with certainty, infer 
the existence of any particular organic disease of 
the kidney from the existence of albuminous urine. 

By those who look upon all morbid derange- 
ments to be the result of inflammation, granular 
disease of the kidney has been thus regarded, and 
hence the term nephritis albuminosa, which has 
been given to it. Like other morbid degenerations, 
however, it is owing to a vice of the system of 
nutrition, which is inexplicable. (Christison on 
Granular Degeneration of the Kidneys, Edinb. 
and Philad. 1839 ; or an abstract of the same in 
Tweedie's Library of Medicine, 2d Amer. edit* 
iii. 271, Philad. 1842; also, Rayer's Traite des 
Maladies des Reins, 2e livr. Paris, 1837; Martin 
Solon, De I' Albuminuric, &c, Paris, 1838, and 
A. Dalmas, Diet, de Med. xxvii. 364, Paris, 
1843.)] 

The kidneys, again, are subject to general or 
partial atrophy. In the former case, one or both 
of them may be diminished in size, without being 
altered in structure, and without any symptoms 
of disorder of the urinary apparatus having been 
present during life. Such a condition of kidney 
may have been coeval with the patient's birth ; or 
the atrophy may have been the result of mecha- 
nical compression; of a tumour in the vicinity of 
the gland ; or of a collection of pus formed around 
it. One kidney may be wholly wanting; and this 
defect may be either congenital, or the consequence 
of disease. Of the former occurrence, a remark- 
able example has been given by Morgagni, Letter 
31, Art. 25. In the patient there referred to, 
there was no trace of the left kidney, but the de- 
ficiency was supplied by the right, which was 
double the natural size, and furnished with a 
double pelvis and ureter ; and both ureters went 
to the right side of the bladder. When one kid- 
ney has been destroyed by disease, no inconveni- 
ence may arise, provided the remaining one be 
sound ; but if that be also degenerated, it is obvious 
that the patient will experience much and severe 
suffering. An instance is given by M. Andral, 
where dropsy, of which the organic cause could 
not be discovered during life, was ascertained to 
have arisen from great disease of the urinary appa- 
ratus ; the left kidney was totally gone ; the righ» 
was enlarged, softened, and studded with those 
whitish granulations which have been already 
noticed. 

Several curious varieties in the form and the 
situation of the kidneys are occasionally mej 



98 



KIDNEYS, (DISEASES OF THE) 



with ; but they can scarcely be considered as dis- 
eases, or, if they be so considered, they are not to 
be recognised by any peculiar symptoms, nor can 
they ever be influenced by medical treatment. 

The morbid states we are next to mention, are 
softening and induration. The former state is 
not unfrequently conjoined with turgescence or 
hyperemia, and this combination may be regarded 
as affording strong evidence of inflammation. In 
patients who, during life, have suffered under 
symptoms of nephritis, a very soft state of the 
kidneys, with intense redness, has been observed. 
The same condition has also been found accom- 
panying certain chronic affections of the bladder, 
as thickening of its inner membrane. 

There is a peculiar softening of the kidneys, 
which has been described by Dr. Baillie, and by 
Mr. Wilson, in his lectures. The kidneys are 
converted into a soft loose mass, resembling in 
appearance common sponge. When shaken in 
water, the parts all separate from each other, 
somewhat like the unravelling of the shaggy ves- 
sels of the placenta. In one such case, small 
shreds, apparently portions of blood-vessels, had 
been passed by the urethra ; and upon examina- 
tion after death, Mr. Wilson conceived that they 
might have come from the kidneys during life. 
This is one of those lamentable states of disease 
«>ver which, even if known to exist, our art can 
exercise no power. 

There is another kind of softening, in which 
the substance of the kidneys is extremely pale, or 
of a grey tint. This alteration has been found 
where no symptoms of the disease of the urinary 
organs had manifested themselves. 

Induration of the kidneys may be attended by 
congestion or by paleness of their tissue. In the 
former variety, the organs are generally enlarged ; 
i r the latter, they are also occasionally enlarged, 
but most commonly diminished in size. In the 
pale induration, the kidneys, though firmer than 
ordinary, may yet retain their natural structure ; 
or they may be almost as hard and as white as 
cartilage, their natural structure being entirely 
lost. This is the state which has been called 
scirrhus of the kidney. It is very rarely met 
with, and the symptoms attending it are not to be 
distinguished from those which belong to other 
renal affections. When both kidneys are thus 
diseased, very little urine will be secreted, or there 
may be complete ischuria renalis. The remedies 
we must employ, must of course be those which 
have been useful in nephralgia and in suppression 
of urine. Opium and hyoscyamus are more likely 
to afford relief than any other medicines. 

3. Morbid Formations. — Of the diseases 
belonging to this division of our subject, the most 
important is that very formidable and intractable 
malady first accurately described by Mr. J. Burns, 
under the title of spongoid inflammation ; but 
more generally known by the appellation of fun- 
gus hxmatodts, assigned to it by Mr. Hey. 
Until of late years, it was commonly confounded 
with cancer, of which, indeed, it is still reputed a 
species by some writers of high reputation. In 
this light it is regarded by M. Roux. Mr. War- 
drop has named it soft cancer; and Mr. Langstaff 
lias remarked that sometimes the scirrhous, medul- 
lary, and fungoid structures, are so blended in 



various parts of the same subject, that they ap- 
pear like different stages of morbid growth, and 
the difficulty the pathologist experiences is m de- 
ciding whether the disease is of the cancerous or 
hasmc-aotal kind, or whether they are not of the 
same class. The same author refers to Sir Eve- 
rard Home, as stating that the fungoid and the 
cancerous sore arc the effects of one disease, only 
varying according to the structure of the parts 
which it attacks. As, however, it is now ascer- 
tained that the same structure, the female breast 
for example, is liable to either disease, and that 
fungus haematodes has been observed in almost 
every part of the body, the position of the last- 
mentioned pathologist is no longer tenable. It 
may be admitted that, in the malignancy of their 
character, as well as in some other points, fungus 
haematodes and cancer bear a strong resemblance 
to each other; but at the same time we must 
maintain that the former disease wants the pathog- 
nomonic signs by which cancers are distinguished. 
(See Fdxgus Hjematodes.) 

Mr. Wardrop first noticed fungus haematodes as 
affecting the kidney ; but he acknowledges that, 
in the case he relates, the morbid alterations of 
structure would not have been alone sufficient to 
warrant him in calling it fungus haematodes. He 
conjectured it to be such, because there was fungus 
haematodes over the hip-joint. Since the publica- 
tion of his work, however, several well-marked 
cases have been given in detail by M. Langstaff. 
In one of these, the subject of which was a man 
aged seventy, affected by hemiplegia for several 
years, the symptoms were, for a length of time, 
difficulty of voiding the urine, which was usually 
tinged with blood, and afterwards retention ; great 
pain in the region of the left kidney, and uneasi- 
ness of the rectum. He died apoplectic. 

In another very interesting case, that of a young 
lady, the symptoms were frequent desire to relieve 
the bladder, and in the course of a few hours an 
immense quantity of limpid urine was discharged, 
without alleviation of the urgent propensity to 
void more ; then, the irritability of the bladder in- 
creasing, arterial-looking blood was discharged in 
considerable quantity. Some doubt existed at 
first as to the source of this hemorrhage; there 
was some reason for suspecting it might proceed 
from the uterus, but the introduction of the catheter 
at once settled the question. After several recur- 
rences of hemorrhage, accompanied by great irri- 
tability of stomach and bilious vomitings, the dis- 
charge of blood ceased for a time, but then the 
urine was very turbid, and deposited a muco- 
purulent sediment. About six weeks subsequent 
to the first attack, dull pain was complained of in 
the right side, and upon examination a tumour 
was distinctly felt in the right hypochondrium, 
and traced into the iliac region : there was pain 
upon pressure, and pulsation of the part. The 
discharge of blood afterwards returned at intervals, 
and the tumour increased greatlv, in despite of all 
the means that could be devised for checking its 
growth. The patient's general health of course 
suffered dreadfully, and sometimes she appeared 
to be reduced to the last degree ; yet, in the in- 
tervals of the attacks of pain, sickness, and hemor- 
rhage, she rallied in a surprising manner; nor 
was it until five years and a half from the com- 



KTDNE5TS, (DISEASES OF THE ) — L AC T ATION. 



99 



mencement of her sufferings that she sank under 
them. Upon examination after death, it was 
found that the right kidney occupied the principal 
part of the abdominal cavity : the diseased mass, 
with a portion of the liver, which adhered to it, 
weighed eleven pounds and thirteen ounces. It 
was almost entirely formed into protuberances of 
different sizes, and the peritoneal surface was 
greatly condensed. When that part of the tumour 
which constituted its chief bulk was cut into, it 
was found to contain a coagulum of blood, not 
adhering to the sac, and weighing three pounds, 
and composed of concentric layers, as in an aneu- 
rism which has formed rapidly. 

The left kidney, which weighed twelve ounces, 
was much altered in structure, being chiefly occu- 
pied by pulpy tubera, which were rendered red 
by minute injection. 

In the Medical Gazette for May, 1831, is re- 
lated a case of fungus nematodes of the kidney, 
in a subject only four years of age. In this in- 
stance, the symptoms of renal affection were so 
trifling, that no suspicion existed in the mind of 
the medical attendant that such affection was the 
sole, or even the chief cause of the little patient's 
distress. It had been conjectured, as in Mr. 
Langstaff's case just mentioned, that the liver 
was enlarged ; but the apparent hypertrophy of 
that viscus was occasioned by the enlarged kid- 
ney, which pushed it upwards and outwards to- 
wards the diaphragm. These unhappy cases have 
hitherto resisted every mode of treatment. When 
fungus hasmatodes attacks external parts, it is still 
one of the opprobria medicine ; what, therefore, 
can be expected from our art, when its ravages 
are obscurely going on in internal organs ] 

The formation of hydatids has been stated as 
being no uncommon disease of the kidney. It 
would, however, seem that the true hydatid is not 
often met with in that situation ; while those cysts 
with thin and nearly transparent parietes, and 
which contain a limpid colourless fluid, very like 
water, but having some coagulable matter, are of 
frequent occurrence. These may be dispersed 
over the surface of the kidney, or be imbedded in 
any part of its substance. They often attain an 
enormous size, so as to occupy by much the larger 
portion of the gland; and they vary in number, 
from a single one to many hundreds. Each is a 
distinct bag, and does not contain others within it. 
It is probable that these cysts depend upon a mor- 
bid alteration of the structure of the kidney. 

In the true hydatid the cyst is thicker and 
much firmer : and, when cut into, appears lami- 
nated. Within the bag there is sometimes only 
one hydatid, but generally there are a considerable 
number; some attached to its parietes, others 
loose and floating in the fluid. These hydatids 
sometimes have numerous others adhering to their 
inner surface, or floating freely in their cavity. 
(See Hydatids.) 

We possess no other distinct evidence of the 
presence of hydatids than that which their being 
passed by the urethra with the urine affords. All 
the other symptoms, such as pain of back, symp- 
tomatic fever, nausea and vomiting, belong equally 
to other renal diseases. Every modification of 
treatment has been tried, when their existence has 
been positively known, or has been suspected, but 



in vain. An artificial outlet cannot be made for 
them. When they obstruct the flow of urine, as 
sometimes happens, the bougie or catheter must 
be employed. Under the steady exhibition of tur- 
pentine the pain of the loins has been known to 
cease, as well as the passing of hydatids ; but in 
many instances the same remedy has totally failed. 
The muriated tincture of iron has been given, but 
with no permanent good effect. 

Of the remaining morbid formations in the kid- 
neys, tubercle is the only one which merits the 
least attention. It is very rarely found in them, 
and, when it is,- generally exists in other organs 
also. The tubercle of the kidney is said by Dr. 
Baillie to resemble exactly the common tubercle 
of the lungs. 

Fatty matter and gelatin} form matter are now 
and then observed in the kidneys, and they have 
been found converted into a bony or earthy sub- 
stance. But these morbid appearances are of ex- 
treme rarity. 

We have thus endeavoured to furnish a sketch 
of those diseases of the kidneys which, though 
hitherto little understood, could not, in a work like 
the present, be passed over with propriety. In the 
actual state of our knowledge, our descriptions 
must necessarily be imperfect. The period may 
be distant in which their nature and symptoms 
will be thoroughly comprehended. The most pa- 
tient attention to the phenomena of certain dis- 
eases, the most diligent search into the morbid 
changes produced in the structure of parts by 
morbid actions, may for a long time seem to be 
unproductive of any important practical results; 
still, patient investigation should never be aban- 
doned. It may be the good fortune of others 
hereafter to elucidate what is obscure in the affec- 
tions of which we have just given a brief account ; 
it was our duty to record what is already known 
respecting them. R w Carter< 

LACTATION.— Lactation in the human fe- 
male, when naturally conducted, cannot be called 
a disease ; but even under the most favourable 
aspect there are often circumstances which require 
attention and regulation, both for the purpose of 
alleviating pain and of preventing mischief. There 
are, moreover, so frequently interruptions to this 
usually healthy process, and there are so many 
important questions connected with the flow of 
milk at various periods, that it becomes necessary, 
in a work on practical medicine, to discuss them, 
although somewhat briefly. 

The close sympathy between the uterus and the 
mamma? is evident even in the unimpregnated con- 
dition. At puberty the breasts enlarge and their 
glandular structure is developed ; a day or two 
before menstruation, and during the period itself, 
the breasts become tumid and more or less painful. 
There is an affection which may be termed spu- 
rious pregnancy, described by Dr. Gooch, where, 
apparently from uterine irritation, the breasts are 
swollen and affected with shooting pains, and even 
a serous fluid resembling thin milk oozes from the 
nipple, being precisely what takes place in real 
pregnancy, wanting only the darkened areola. In 
some diseases of the uterus, particularly in hyper- 
trophy of that organ, a similar state of the breasts 
is often observed. In real pregnancy the altera- 



100 



LACTATION. 



tion in the breasts is strongly marked, and the 
quantity of milky si-rum which is secreted is 
sometimes very copious, especially towards the 
close of utero-gestation. Sauvagcs mentions an 
instance where as much as a pint and a half was 
daily poured out as early as the fifth month. Many 
women, however, show no appearance of milk at 
all before delivery, who yet have abundance after- 
wards. After parturition it is usual to place the 
child to the breast within the first twenty-four 
hours, partly to draw out and form the nipple be- 
fore any hardness of the breast occurs to render 
that difficult, and partly to encourage the flow of 
milk, — for at a later period the contact of the 
child's mouth will immediately excite it. With 
first children there is rarely any quantity secreted 
before the third day ; about that period, but often 
a day or two later, the breasts become hard and 
swollen, hot and painful ; the pulse is quickened, 
the skin above the natural temperature, the thirst 
urgent, the sleep broken and troubled with un- 
pleasant dreams, and the sensorium disturbed, so 
that the patient, whilst yet awake, will fancy 
strange objects about the bed. The process goes 
on, more or less rapidly, till the milk is at the 
height, as it is termed, when the breasts are ex- 
tremely hard, and the gland is felt knotted and 
loaded, and is at the same time very tender ; the 
swelling may extend quite to the clavicles and 
under the arms, the axillary glands being similarly 
affected ; a small quantity of milk will often ooze 
out from the nipples, particularly if the breasts be 
fomented, or gently pressed with the hand. If the 
child be put to the breast, the action of suckling 
is attended with great pain to the mother, but fol- 
lowed by much relief. As the milk flows, the 
hardness diminishes, and the swelling subsides. 
After a few hours, if the milk be freely and fre- 
quently drawn off, the sensations become more 
comfortable, the pain is removed, the breasts are 
only distended when the child has been long away, 
the pulse and skin are restored to their natural 
state, and the process of lactation is then fairly 
established. 

In the management, up to this period, much 
may be done for the relief of the patient. As soon 
as the symptoms begin, a purgative may be ad- 
ministered with great advantage, and one which 
contains the neutral salts in combination, as it will 
promote watery discharges from the bowels, is 
preferable : this should be repeated in twenty-four 
hours, or earlier, if the case is severe. There is 
distressing thirst, but if we allow a too free indul- 
gence in liquids, the distension of the breasts is 
increased ; it is therefore better to allow only a 
small quantity of drink at a time, and perhaps 
nothing is so effectual in a small bulk as an effer- 
vescing saline draught frequently repeated. As a 
new-born infant will often experience much diffi- 
culty in drawing out the nipple of a hard and 
swollen breast, or in extracting the thick milk 
itself, it is often advisable to have this done by an 
older child or a grown person, or by artificial 
means. These consist of various sorts of breast- 
pumps, where a smooth-edged glass tube is placed 
over the nipple, and a vacuum being produced by 
suction or by syringes, or by heat, the milk is thus 
drawn off, and the buried nipple made to project. 
Great benefit may be obtained by fomenting the 



hardened breasts with hot water, or by applying 
mild poultices, which promote the easy flow of 
the milk and relieve the distension. This is also 
often effected by small wooden bowls soaked in 
boiling water, and wrapped up in flannel, which 
are then placed over each breast. As a more per- 
manent application, hare-skins are often used; 
cabbage-leaves were also formerly much in vogue 
to promote a copious perspiration over the surface; 
the smell, however, is very unpleasant, and the 
same advantage may be gained by oiled silk. 

The milk first drawn has a purgative quality, 
and thus serves to carry off the meconium which 
is loading the large intestines. On this account, 
when a child does not get the first draught of the 
breast, from being nursed by a wet-nurse, or from 
being brought up by hand, a gentle purgative 
should always be given ; diarrhoea of an irritable 
character, and even convulsions, often being pro- 
duced from retained meconium. In this country 
it is usual to give a purgative under all circum- 
stances, but it is not customary in many parts of 
the continent, and it is doubtful whether it be not 
often superfluous. By the experiments of Dr. 
Robert Lee, it would appear that the meconium is 
an excrement, and does not contribute to nourish- 
ment ; but that above the situation of the meco- 
nium a quantity of highly nutritious albumen is 
found in the intestines, serving for the sustenance 
of the infant till lactation is established. A pur- 
gative given before that period will therefore carry 
off this substance, and artificial nourishment must 
be given to make up for the loss of the natural 
provision. 

The milk varies considerably in condition during; 
lactation. At first it is thick, yellowish, and having 
a very large proportion of cream ; several days 
elapse before it possesses its natural appearance, 
which should be thin, bluish, and sweet. The 
quantity of cream varies very much according to 
the diet, and the frequency with which the breasts 
are drawn. Some milk has a decidedly saline 
taste ; and at other times it has been distinctly 
bitter, so that the child will turn away from the 
breast in disgust. Its taste and qualities may be 
easily affected by articles of diet, by passions of 
the mind, repletion, hot rooms, &c. and the child 
is more or less disordered by the alteration. Medi- 
cines will often affect the milk in a very striking 
manner ; a purgative given to the nurse will fre- 
quently act violently upon the child, without in 
the least affecting the individual herself; in the 
same way, alkalies given to the nurse will relieve 
acidity in the child's stomach ; and mercury given 
through a similar medium will cure syphilitic 
symptoms in the infant at the breast.* 

Milk has been said to be sometimes black or 
green, but there is in such cases most probably a 
mixture of blood, from the exterior or interior of 
the nipple. The writer has seen four instances 
where it was of a golden yellow colour, and where, 
upon standing, a thick layer of bitter cream, as 

* On the authority of Mr. Koate, it may be here stated 
that a foreign gentleman, a patient of his, was in tlie 
habit of regulating his hepatic system, when there was 
a deficiency of bile in his motions, by taking asses' milk 

medicated by giving the animal a certai antity of a 

mercurial preparation (the nitrate of mercurvV The 
£&£*? """**' ™* " e «" "«ar mJrcuryia 



LACTATION, 



101 



yellow as pure bile, floated on the surface. In 
neither of theso cases was the patient jaundiced ; 
but a very copious flow of bile being kept up from 
the intestines by mercurial purgatives, after a few 
days the yellowness gradually disappeared ; the 
child, till then, having been mucli griped and 
affected with diarrhoea. In no cases where wet- 
nurses have been jaundiced, has the writer seen 
the milk yellow ; and it is no uncommon thing 
for them to become thus disordered, upon a sud- 
den transition from poverty and a scanty diet to a 
full and luxurious mode of living. Milk will dis- 
order an infant from merely being too rich, with- 
out its being otherwise altered in character. The 
remedy here will consist in purging the nurse, 
making her take plenty of active exercise, and 
putting her upon a more spare diet. The proper- 
ties of the milk will also be considerably influenced 
by pregnancy or by menstruation. 

There are some popular errors upon this point, 
which it is not difficult to expose. One is, that 
women will not become pregnant during lactation. 
This is far from being the case, and Mr. Roberton 
of Manchester (vide Edinb. Med. and Surg. Jour- 
nal, No. 110) has taken the trouble to inquire 
minutely into the result of 160 cases, in which 
he found that eighty-one women had become im- 
pregnated during suckling. Mr. Roberton has 
stated " that the appearance of the catamenia du- 
ring lactation does not appear to have any in- 
fluence in disposing to conception." In this respect 
the writer's experience leads him to a different 
conclusion : he is decidedly of opinion that those 
women who menstruate during pregnancy will 
more readily conceive than those who do not ; 
and he has also remarked, as Dr. Hamilton has 
done, that both these occurrences are more com- 
mon with first children ; hence women under such 
circumstances are not, caeteris paribus, so eligible 
for wet-nurses. Dr. Mason Good has recom- 
mended cohabitation with the husband during lac- 
tation, as likely to increase the quantity of milk ; 
arguing upon the fact that the Tartars are accus- 
tomed to irritate the vagina of their mares for a 
similar purpose. The objection to his proposal 
will only apply to hired wet-nurses, lest they 
should become pregnant. Wet-nurses have very 
frequently recommended themselves to the writer 
on the plea that they have still continued to men- 
struate, by which they believe that their milk is 
renewed, as they term it, every month, so as to be 
rendered fit for much younger children than it 
would otherwise have been. This occurrence, 
however, much impairs the milk, in its probable 
duration, and in its properties at the period itself. 
The infant becomes unusually fretful, brings up 
the milk by vomiting, and has frequent watery 
motions of a spinach-green colour. These symp- 
toms are so peculiar, when arising from no very 
obvious cause, that it may be generally safely 
guessed that the nurse is either menstruating at 
that moment, or will do so on that day month ; 
for it is not uncommon to find the effects on the 
child brought on, although the alteration in the 
uterine condition of the nurse is not complete. 

One of the most early and most troublesome 
attendants upon suckling is soreness of the nipples, 
as the pain recurs as often as the infant is put to 
the breast. Very few escape some degree of ten- 



derness, with first children especially, but the in- 
convenience is soon obviated, and the delicate skin 
becomes callous, like the fingers of a harp-player 
— an effect which may be hastened by some slightly 
astringent or gently stimulating lotion, as green 
tea, brandy, weak solutions of the sulphate of 
zinc or of alum. If more severe and intractable, 
a solution of one to two grains of nitrate of 
silver in one ounce of rose-water will be found 
of service. Should the skin become excoriated, 
or should a crack take place at the junction of the 
nipple to the areola, a shield of glass, wood, ivory, 
or silver, should be used, with an artificial or pre- 
pared cow's teat, through which the child may 
suck without biting or much disturbing the nipple. 
The surface of the sore may then be freely touched 
once a day or oftener with the lunar caustic, and 
in the intervals the part may be kept well smeared 
with ointment containing honey, or a minute 
quantity of Peruvian balsam. Preparations con- 
taining lead or mercury in any form are scarcely 
advisable, as they may be swallowed by the infant. 
Where the surface of the nipple is not chapped, 
but unusually hot and dry, and very tender to the 
touch, all astringent lotions and stimulating appli- 
cations aggravate the mischief; the simplest oint- 
ments, of wax and oil alone, will be found to agree 
best, or the part may be covered with powdered 
gum arabic or a bread-and-water poultice. The 
dress should, in all cases, be carefully kept from 
irritating the sore nipple, by means of wax cups, 
shells, or glasses for the purpose. 

There is one species of sore nipple not often 
noticed by practitioners, (who are too apt to leave 
these cases to the management of the nurses,) 
which the writer has found more intractable than 
any others, and the means frequently of inducing 
the mother to give up suckling entirely, from the 
constant torture to which she is exposed. There 
is little or nothing to be seen but a small spot at 
the orifice of the nipple, which is elevated and 
irregular in appearance, extremely painful to the 
touch, and exuding a sanious ichor. When the 
child is put to the breast, the pain is most acute, 
and seems to come from the interior of the nipple 
and breast; and the first and last milk is generally 
mixed with blood. It would appear as if the in- 
terior or lining membrane of the lactiferous tubes 
was in a morbid condition. Little or nothing can 
be done for this affection. The free application 
of caustic to the external orifice, and poulticing 
the breast, has now and then effected a cure, along 
with careful attention to the stomach, bowels, and 
general health, which is highly essential. Those 
who have uniformly suffered from sore nipples on 
former occasions have frequently seemed to prevent 
them by using, previously to parturition, for several 
weeks, either an astringent or demulcent lotion, 
according to the state of the skin. 

Inflammation will occasionally attack the breast 
itself at any time during lactation, but most fre- 
quently at a very early period, when there has 
been exposure to cold, much trouble in the first 
management of the milk, or soreness of the nip- 
ples ; it does not so frequently happen where the 
milk is at once driven back without suckling the 
child. If not immediately treated by leeches, by 
fomentations, and poultices, hot and frequently 
changed, or, as some prefer, by cold lotions, abscess 



102 



LACTATION 



will take place, accompanied by great pain and 
much constitutional disturbance. The treatment 
of this state comes within ihe immediate province 
of the surgeon ; but there are one or two circum- 
stances respecting milk abscess deserving of notice 
in this place. It is very customary when abscess 
is threatened, to persevere in keeping the child to 
the breast, or otherwise drawing the milk off; 
partly to enable the patient to continue suckling, 
and partly to prevent the milk collecting in and 
distending the inflamed breast. If the inflamed 
portion be not extensive, there is no objection to 
this, as a small abscess will not much interfere 
with the functions of the remaining sound parts ; 
but if the whole, or nearly the whole, of the breast 
be implicated, the pain of suckling will be very 
violent indeed, and the frequent disturbance and 
irritation will contribute to increase the inflamma- 
tion, and diminish or entirely obviate the chances 
of preventing the formation of matter. Should 
abscess be formed, and matter be felt fluctuating, 
the most experienced practitioners agree upon the 
propriety of puncturing early and freely? other- 
wise in such a peculiar structure most extensive 
mischief will take place, and the surface remain 
disfigured afterwards in the most unsightly manner. 
It is curious to notice in subsequent confinements 
how little the real glandular apparatus has been 
destroyed, even where large collections of pus have 
formerly been evacuated, so that the patient will 
sometimes be enabled to nurse with but little 
trouble ; although from some partial obliteration 
of the ducts, there is always rather more difficulty 
in the flow of the milk. 

Milk Fever. — What is called milk fever, is an 
aggravated and morbid form of the healthy and 
natural excitement which takes place at the onset 
of lactation. The febrile symptoms are much 
more severe ; there is a well-marked precursory 
rigor ; there is great pain and throbbing of the 
head ; a flushed countenance; intolerance of light 
and sound ; the pulse is full, hard, and rapid ; the 
thirst excessive ; the skin hot and dry, and the 
tongue covered with a thick fur. These attacks 
may be usually traced to a too stimulating diet, a 
neated atmosphere, much exertion and disturbance, 
or mental agitation. They are much less frequent 
than formerly, when great fires, loads of blankets, 
and brandy caudle were the usual appendages to 
a lying-in chamber. If the flow of milk be en- 
couraged, and gently yet freely drawn off; if the 
room be kept cool ; agitation soothed or avoided ; 
purgatives duly administered, and perhaps diapho- 
retic medicines ; a remission of the symptoms will 
usually take place in a few hours, accompanied by 
a copious perspiration and tranquillity of pulse. 
On the contrary, by bad management phrenitis may 
supervene, of a very dangerous character ; when 
the milk will be entirely suppressed, and nothing 
but the free use of the lancet will save the patient. 

A very common expression is, that in such 
cases the milk flies to the head. In phlegmasia 
dolens the milk was also supposed to fly to the leg, 
and hence the French writers formerly called it, 
" depot du lait." It has several times happened 
in the writer's experience, that where bleeding has 
been had recourse to in inflammatory diseases with 
sudden suppression of milk, the serum of the 
blood, when separated by rest, has been white, 



opaque, and bearing nearly all the characters of 
milk, except the formation of cream on the surface. 
It may here be observed, also, that where the milk 
is driven back artificially, and active purgatives 
are employed, a great quantity of milk-like fluid 
may be generally seen in the motions. Depress- 
ing passions, fear, and anxiety, will suddenly drive 
off every vestige of milk ; but the only genuine 
translation may be said to be those extraordinary 
instances where the milk has receded more or less 
rapidly from the breast, and a vicarious discharge 
has taken place from other parts, the general 
health remaining but little affected. The most 
common example of this is where the discharge 
has taken place from the vagina in the form of 
leucorrhcea ; but it has also occurred from the 
fauces, the navel, the eyes, the kidneys, the whole 
surface of the mammse, &c. 

Where the child is to be weaned, or where a 
mother does not wish to suckle, or is not able from 
constitutional debility, or local defect, or where the 
death of the child has taken place, it becomes 
necessary to " backen" the milk, as it is vulgarly 
termed. This may be done the most safely lor the 
mother by her not being too impatient. If cold 
evaporating lotions are applied to the breasts, there 
is a more rapid dispersion of the milk, but there 
is more risk of fever, phrenitis, &c. It so happens, 
however, that these cold lotions rarely are allowed 
to act as such, for nurses in general are so par- 
ticularly careful to cover up the patient's neck 
with the bedclothes and wrappers, that the .lotions 
very rapidly become warm fomentations. In the 
writer's opinion, the best and safest applications 
consist of stimulating liniments, applied warm and 
also constantly, by means of layers of lint or 
flannel. The breasts should also occasionally be 
gently pressed and rubbed with warm oil ; and if 
they are very hard and distended, a small quantity 
may be now and then squeezed out or drawn oil" 
artificially. The bowels are to be actively kept 
open by saline purgatives f the diet is to be low, 
and the quantity of drink lessened. It will be but 
a few hours before the extreme distress is mitigated, 
but it will be often several days before the milk is 
thoroughly dispersed, or the remedies can be dis- 
continued. The sensation of " draught of milk" 
in the breasts will sometimes be felt two or three 
times a-day for weeks afterwards. In weaning a 
child, however, it is often the plan to do it so gra- 
dually, by accustoming it to partial feeding for 
some time previously, that little trouble is at last 
experienced in dispersing the milk. It is still very 
desirable that opening medicine should be plenti- 
fully given, even under such circumstances; as 
from this discipline being neglected, patients will 
often suffer for months afterwards, with great de- 
pression of spirits, loss of appetite, feeling of 
weight and lassitude, and general ill health,— sen- 
sations which are soon relieved by having recourse 
to opening medicine. 

An excessive secretion of milk will sometimes 
be met with ; but in nearly all these cases there is 
apparently some defect in the organization of the 
nipple, or the lactiferous tubes have lost their 
elastic property of retention, for in the intervals 
of suckling a constant and very copious discbarge 
of the milk takes place. The daily waste and 
drain cannot exist long without materially affecting 



LACTATION. 



103 



the health and strength ; and unless the flow can 
be kept in check, there is no remedy except weaning 
the child, ami repelling the milk altogether. Various 
plans have been proposed, but the trial is not often 
successful. Local strong astringent applications, 
as lotions of alum, oak-bark, zinc, &c, sometimes 
do good, but they are apt to effect too much, and 
drive away the secretion entirely. The astringent 
tonics internally, particularly the mineral acids, 
steel, kino, and alum, have occasionally been of 
service. Belladonna has been advised, both locally 
and in small doses internally. The breasts should 
be kept as cool as possible, and cold bathing be 
daily had recourse to. 

The period of lactation is generally one of the 
most healthy of a woman's life ; but there are 
many exceptions to this ; and many who have 
begun with success, by continuing to suckle too 
long, by a too limited diet, by much loss of rest, or 
by other causes, have had their own health and 
that of their infants considerably and even fatally 
impaired. A recent writer has attempted to de- 
fine the exact period to which suckling should be 
limited, as far as the advantage of the infant is 
concerned ; but all such definitions are constantly 
contradicted by experience. There is much fal- 
lacy also in the arguments to prove that protracted 
lactation is the cause of various infantile diseases, 
especially hydrocephalus. Putting aside altoge- 
ther the striking fact that the dangerous disturb- 
ance of dentition is proceeding at the same time, 
it may be allowed that hydrocephalus and the 
other diseases mentioned may and often do occur 
after or during protracted lactation ; but they hap- 
pen quite as frequently, and indeed more so, 
where a child has been brought up by hand, with- 
out the breast at all ; or where it has been badly 
fed, or over-fed, whilst still suckling. In all the 
cases of mothers who have nursed their children 
for two years and upwards, in the class of life 
alluded to by Dr. Morton, it may be, perhaps, 
fairly assumed, from the known habits of the pa- 
rents, that the children have been fed at the same 
time, and generally fed upon exactly the same 
sort of food as would be more adapted to older 
children. " The child eats whatever we eat" is 
the common expression, though the child is still 
allowed to apply to the breast at pleasure, to pre- 
vent the chance of a fresh pregnancy. Many chil- 
dren, particularly in the higher classes, where 
hired wet-nurses are employed, are kept for a 
long time at the breast because they are backward 
with their teeth, have had their bowels disordered 
by a premature attempt at weaning, or because 
they are in delicate health ; but if hydrocephalus 
supervene in such instances, it is quite as likely 
that the previous disordered health may have been 
the cause, as the protracted lactation. In savage 
nations, in many parts of America, the east, and 
the polar regions, it is the constant custom for 
mothers to suckle their infants for two years at 
least, and without any of the pernicious conse- 
quences which Dr. Morton has imagined. (See 
Edinburgh Medical and Surgical Journal, No. 
110.) 

It is certainly true, that if the mother's health 
be impaired by undue lactation at either an early 
or a late period, the child will suffer from defec- 
tive nutrition, but in no other manner. 



[According to M. Desormeaux (Art. Lacta- 
tion, in Diet, de Medecine, xxii. 425, Paris, 
1838,) some women are able to continue suckling 
almost indefinitely, provided the child be put lo 
the breast. It is not uncommon, he says, in 
France to see nurses suckle three children in suc- 
cession, comprising a period probably of from 30 
to 36 months ; and cases are not rare of women 
who have suckled their children for four years, 
and four years and a half. He himself saw a 
nurse from Normandy, who had suckled several 
children successively on the same milk for up- 
wards of five years ; and a lady, worthy of all cre- 
dit, informed him, that she knew a woman who 
nursed five children in succession, so that her 
lactation continued at least seven years. 

It has been a common opinion, that when men- 
struation recurs during lactation, the milk of the 
nurse is unfit for the perfect nutrition of the child. 
M. Gendrin would on no account permit a woman 
to continue nursing after the catamenia had re- 
turned. The subject has been recently investi- 
gated by M. Kaciborski (Dublin Medical Press, 
Aug. 2, 1843, cited in Amer. Journ. of the Med. 
Sciences, Oct. 1843, p. 455.) whose inferences arc 
as follows : — contrary to generally received opin- 
ions, the milk of nurses who menstruate during 
suckling does not differ sensibly in physical, che- 
mical, or microscopical characters from that of 
nurses whose catamenia are suspended; — the 
only difference which can be detected between the 
kinds of milk is, that, in most cases, the milk of 
menstruating nurses contains less cream during 
the menstrual period than in the intervals ; hence 
arises the bluish appearance presented occasionally 
by such milk ; and he concludes that a nurse 
should never be rejected merely because she men- 
struates.] 

Dr. Marshall Hall has well described the state 
of disorder of the general health in females, which 
is induced by exhaustion of the frame, arising 
from protracted lactation, or from the original 
powers not having been equal to the continual 
drain on the system. One of the earliest symp- 
toms of failure is a dragging sensation in the 
back, when the child is in the act of sucking, and 
an exhausted feeling of sinking and emptiness at 
the pit of the stomach afterwards. The appetite 
fails gradually, but entirely ; there are thirst, a dry 
tongue, a quick feeble pulse ; costive bowels, head- 
ach, with giddiness, lightness, and failure of sight. 
The skin is hot and cold alternately ; there are 
profuse night-perspiration ; generally leucorrhcea, 
great debility, and emaciation. The memory is 
impaired ; the spirits are weak, irritable, and de- 
pressed. [Occasionally, too, aphthous stomatitis 
occurs, and it would seem to occur more fre- 
quently in some localities than in others : (see 
Aphthae.)] Symptoms resembling phthisis wdl 
sometimes come on, and mania is not an unusual 
result. Though much may be done in the first 
instance by the proper use of tonics, cold or sea 
bathing, change of air, a regulated diet, and local 
applications, to restrain the leucorrhcea ; and though 
we may now and then effect a portion of good by 
partially feeding the child, yet the quickest and 
most effectual remedy is to wean the child. The 
different symptoms resulting from the exhausting 
process require appropriate treatment, according to 



104 



circumstances; l>ut all treatment will generally 
fail, unless we remove the cause of exhaustion. 

Before leaving the subject of lactation, it may 
be remarked that males have also the organs for 
supplying milk, in a dormant state, which under 
peculiar circumstances have been excited into 
action, and have supplied milk in abundance, suf- 
ficient to suckle children. Instances have been 
given in recent times by Humboldt and Captain 
Franklin, and many others are on record. Very 
old women* and virgins have also had milk in 
considerable quantities, the nipples in all these 
cases having been frequently stimulated by the 
contact of the child's mouth purposely applied. 

[Several instances not only of very old women 
and virgins but of men having suckled children 
have been given by the writer in his Human 
Physiology, 5th edit. ii. 436, Philad. 1844.] 

It is by no means uncommon to meet with 
newly-born infants, of either sex, who have their 
oreasts turgid with a milk-like fluid, which is dis- 
persed with difficulty. Q LocOCK. 

LARYNGITIS.— Of inflammations of the 
larynx there are many varieties, to which we 
mean briefly to allude before we enter upon a 
description of that formidable disease which has 
of late years obtained the title of laryngitis, and is 
the proper subject of this article. 

Beginning with the slighter inflammations, we 
may, 1st, advert to that affection of the membrane 
lining the larynx, which is distinguished by hoarse- 
ness, or complete loss of voice, and by slight 
cough, an affection which, arising from exposure 
of the body, or part of it, to a current of cold or 
damp air; from partial or general wetting; or from 
an incautious laying aside of some article of dress, 
especially during changes of the weather, is so 
slight, as seldom formally to be brought under the 
observation of the physician. 

2dly. Similar symptoms not unfrequently occur 
in connection with common sore throat {cynancht 
tonsillaris), and for the most part they also form 
a case for domestic prescription, unless the inflam- 
mation is so considerable as to threaten suppura- 
tion. 

These two affections are chiefly prevalent about 
the beginning of winter and in the spring, and 
for the most part yield to confinement to the house 
for a day or two, and the antiphlogistic regimen. 
The latter affection, like the former, is of little 
importance, unless considered in connection with 
laryngitis, which has sometimes commenced like 
an ordinary sore throat attended with hoarseness ; 
or unless it give rise to chronic disease of the af- 
fected part ; for it is observable of both these 
slight inflammatory attacks, that when neglected, 
or when, from exposure to frequent vicissitudes 
of temperature, to foggy and cold weather, or to 

* A very interesting account is given (in the Medico- 
Cliirurgical Review, for July 183'2) by Dr. Kennedy of 
Ashby-de-la-Zouch, of Judith Waterford, of that place, 
and now alive, With milk still in her breasts at the age 
of eighty- one: the summary may be given in Dr. Ken- 
nedy's own words. "Here, then, are the remarkable 
circumstances of a woman who menstruated during lac- 
tation, who suckled children (many not her own) unin- 
terruptedly through the full course of forty-seven years 
(three years Of which time she was a widow), and in her 
eighty-first year has a moderate but regular secretion of 
milk." 



LARYNGITIS. 

the night-air, they are from time to time renewed, 
a state of permanent irritation is sometimes pro- 
duced which is indicated by hoarseness, slight 
muco-sibilant inspiration, and cough, and by some 
difficulty of swallowing; symptoms which, espe- 
cially in persons advanced in life, end in chronic 
laryngitis, a disease always intractable and often 
fatal." In these attacks, relief, if sought in time, 
may in general be obtained by bleeding, especially 
topically, and blistering ; by a course of calomel 
and ipecacuanha, or calomel and antimonial pow- 
der, one grain of each given three times a day, 
and continued until the gums become slightly 
affected by the mercurial ; by pure air of mode- 
rate and equable warmth ; and rest and quiet. 

3dly. Sometimes the membrane of the larynx 
is inflamed in gastric fever, and in various fevers 
of the exanthematous order, especially in small- 
pox, measles, scarlatina, and erysipelas, fevers 
which we apprehend are all essentially gastric. 
In small-pox, the epiglottis and larynx are often 
inflamed and beset with pustules, from which 
very great distress arises. In the beginning of 
measles, inflammation of the upper part of the 
windpipe is so considerable as to give rise to an 
attack which, for a short time, advances with all 
the violence of croup. In the winter of 1807, 
and more especially in the spring of 1808, when 
measles were epidemical in Edinburgh and the 
neighbourhood of %hat city, and of so unfavoura- 
ble a kind that we witnessed the death of more 
than 100 patients in the course of a few months, 
the disease corresponding with the putrid measles 
of Watson, (Med. Obs. and Inquiries, vol. iv. p, 
132,) not only was the larynx often affected be- 
fore the efflorescence took place, but in several 
instances after the rash had disappeared it became 
inflamed ; in all which cases, to the best of our 
recollection, the patients died. In one dissection 
which we procured, of laryngitis after measles, 
the following were the appearances discovered. 
The investing membrane of the epiglottis was 
considerably thickened, particularly at its edges; 
such also was the state of the membrane of the 
glottis; the sacculus laryngeus was nearly obli- 
terated, and, below the sacculus, ulceration had 
taken place. When the epidemic commenced, 
bleeding was often useful, but after it had conti- 
nued for some time, and had become more fatal, 
the attending fever being typhoid, bleeding ap- 
peared injurious ; indeed we then observed that 
scarcely a child recovered which had been bled, 
so that bleeding was not had recourse to when 
the larynx became inflamed. Nor were blisters 
applied, most blistered surfaces having a strong 
tendency to run into ulceration and gangrene. 
Were we again to be called to such cases, we 
would recommend immediate change of dwelling, 
a remedy not yet duly appreciated in acute dis- 
eases ; an emetic and calomel, with small addi- 
tions of opium. 

We have frequently known inflammation in 
scarlatina and in some forms of cynanche to affect 
the fauces, whereon perhaps a plastic membrane 
was formed, and to ascend into the nares and de- 
scend into the windpipe. Several soldiers of a 
militia regiment, stationed at Woolwich, were 
daily brought into the general hospital with scar- 
The disease was unusually fatal. One 



latina. 



LARYNGITIS. 



105 



of these patients, who had been only a few hours 
in the hospital, died after symptoms which the 
surgeon on duty thought proper to investigate by 
dissection. He cut out the trachea, and found it 
lined with a membrane as in croup. The prepa- 
ration was preserved, and afterwards presented to 
the writer of this article by his late friend Dr. 
Rollo, surgeon-general to the artillery : an en- 
graving of it was given by the writer in his work 
on the " Pathology of the Membrane of the La- 
rynx." At page 37 of the same work, will be 
found an account of two cases of inflammation 
of the larynx, one occurring about the eighth or 
ninth day of fever in a girl eight years of age, 
who was relieved by bleeding; the other in a girl 
of eleven, in whom an attack of bilious remittent 
fever was ushered in by laryngeal inflammation. 
A fatal case of laryngitis occurring during appa- 
rent convalescence from remittent fever, published 
in the first volume of the Transactions of the 
Physico-Medical Society of New York, was re- 
published in the Medico-Chirurgical Review for 
April, 1827. 

In erysipelas the fauces are often inflamed, and 
the inflammation extends to the larynx, in which 
case the respiration resembles that of croup, and 
the disease is generally fatal. A female thirty- 
four years of age, had been in the hospital at 
Cochin for disease of the heart, when, on the 23d 
of February, she was seized with violent rigor ; 
24th, erysipelatous eruption of the face with fe- 
brile re-action ; 25th, 26th, the erysipelas was 
extended to the hairy scalp and to the neck, eyes 
closed ; 27th, acute pain in the throat, difficult 
deglutition, respiration impeded ; 28th, swelling 
and inflammation in the anterior part of the 
throat ; inability to expectorate ; suffocation threat- 
ened. March 1st, swelling of the neck enormous 
— asphyxia — death. 

Dissection* — The mucous membrane lining 
the mouth, larynx, and pharynx, red and inflamed. 
The epiglottis and its ligaments thickened ; the 
rima glottidis nearly annihilated by the swelling 
and by tough mucus. The cellular tissue of the 
larynx, face and neck injected, red, and cedema- 
tous; the lungs sound. (Bow /laud.) 

4thly. The larynx is often inflamed in those 
diseases in which the inflammation extends over 
the whole of the mucous membrane of the lungs. 
In common and also in epidemic bronchitis, the 
inflammation, apparently commencing in the 
Schneiderian membrane and fauces, often affects 
the larynx in its descent into the bronchi. The 
membrane of the larynx is also liable to be af- 
fected in those varieties of chronic bronchitis, 
which, according to the season or age at which 
they occur, or according to the symptoms of the 
attack, have been termed winter cough, catarrhus 
senilis, suffocative catarrh, or peripneumonia 
notha. In pertussis, inflammation often obtains 
in the mucous membrane of the larynx as well as 
in that of the trachea and bronchi. Lastly, in 
croup, the symptoms referable to inflammation of 
the larynx are so obvious and remarkable as to 
have exclusively engrossed the attention of most 
observers, leading them to overlook proofs, scarcely 
less equivocal, of an inflamed condition of the 
bronchi. 

5thly. We have known many cases of inflam- 

Yol.III.— 14 



mation of the glottis arising from an accident, to 
which the children of the poor are liable. Slat- 
ternly mothers often permit their children to drink 
from the spout of the tea-kettle, and the children 
are thus led to a habit which, if the kettle should 
happen to contain boiling water, may prove fatal. 
The symptoms produced by this accident are in- 
flammation and vesication of the fauces, difficult 
breathing, audible inspiration, whispering voice, 
leaden countenance, watery eyes, and cold ex- 
tremities — symptoms which we were wont to 
think were as much dependent upon bronchitis as 
upon inflammation of the glottis ; but a dissection 
published by Dr. Marshall Hall, in his satisfactory 
account of this affection in the twelfth volume of 
the Medico-Chirurgical Transactions, would lead 
to a conclusion that the inflammation does not 
extend even to the trachea. We have been ac- 
customed to treat this affection by bleeding, blis- 
tering, and a preparation of calomel and ipecacu- 
anha. Our confidence in bleeding is not, how- 
ever, very great. The children soon acquire that 
peculiar expression which livid paleness with 
oedema imparts, when asphyxia, in an advanced 
state of bronchitic inflammation, is impending, a 
state which contra-indicates free bleeding. Bron- 
chotomy is recommended by Dr. M. Hall, and this 
operation his view of the case would amply justify. 
He also recommends scarifying the epiglottis. 
Probably small doses of opium, given at an in- 
terval of two or three hours, would be useful, as 
they generally are in burns attended with much 
suffering. In the third volume of the Dublin 
Hospital Reports there is a case given by Dr. 
Burgess, of a girl of three years of age, who 
drank boiling water from the pipe of a tea-kettle, 
by which great swelling of the parts immediately 
ensued, thereby preventing deglutition and impe- 
ding respiration. In about two hours after the 
accident, in looking into the mouth, it appeared 
as if a large piece of raw flesh had been forced 
into the fauces, and had completely filled up the 
passage. Respiration was performed with very 
great difficulty, and was rapidly becoming more 
laborious, — in fact the child appeared to be dying, 
when bronchotomy was performed, by which life 
was saved. 

Gthly. Inflammation of the mucous membrane 
of the larynx sometimes arises when the system 
is under the influence of mercury. We think we 
have seen inflammation extending to the wind- 
pipe in severe cases of mercurial glossitis, and 
hence we are unwilling to reject, as one of the 
species of laryngitis, that caused by mercury. But 
we are not satisfied that the cases of alleged mer- 
curial laryngitis, which have been recently pub- 
lished, did not owe their origin to other influences, 
such as lues venerea, or exposure to cold, rather 
than to the mercury. 

7thly and 8thly. There are yet two inflamma- 
tory affections of the membrane lining the larynx 
which must be briefly described, in order to com- 
plete this part of the subject : these are scrofulous 
inflammation of that portion of the mucous mem- 
brane, and inflammation symptomatic of secondary 
syphilis. 

Scrofulous inflammation is an affection of a 
very dangerous nature, not, as we arppienend, 
generally accompanied with tubeiculated lung» 



106 



LARYNGITIS. 



This affection is not confined to youth or adoles- 
cence ; sometimes it appears at or after the me- 
ridian of life, as the commencement of a very 
chronic variety of phthisis, which some physicians 
have imagined depends upon indigestion, and is to 
be cured by blue pill, &c. We have frequently 
witnessed this affection in an acute form in per- 
sons who had abandoned themselves to the habit- 
ual use of ardent spirits, in muddlers, as they are 
called, who drink at all times, but seldom to com- 
plete intoxication. Such patients lose their appe- 
tite ; become emaciated ; usually have a patchy 
purplish complexion; gradually acquire a dry 
hard cough, which at first appears nothing more 
than an aggravation of that cough observable in 
drunkards, which is attended with white and 
scanty expectoration, and is followed, especially 
in the morning, by retching or even vomiting of a 
little clear ropy fluid. If we examine these pa- 
tients, we shall find the pulse accelerated, the 
tongue and fauces florid, the former glazed. This 
disease is always fatal, but generally not until 
purulent expectoration, colliquative diarrhoea, and 
night sweats, have existed for some time. It often 
is to be met with in publicans, and such as are 
engaged in the occupation of vending ardent 
spirits. It is attended with a sense of exhaustion, 
a depression of mind, a fear of death, and a con- 
sciousness of the disease being self-produced, which 
it is most painful to witness. The patient may, 
in the commencement, derive some advantage from 
change of air, exercise on horseback, very small 
topical bleedings, not more than three or four 
leeches being applied, followed by counter-irritants 
and light bitters. The bowels must be properly 
regulated, avoiding all medicines which lower the 
strength ; and a mild alterative pill may be given 
for ten days or a fortnight, namely, 
R Pilule hydrargyri, scrupulum. 
Pulveris conii, scrup. ii. 
Ipecacuanha?, gr. xv. 
Ammoniaci contriti, sesquidrachmam, M. et di- 
vide in pilulas xl. Sumat duas mane et meridie ; 
superbibendo poculum lactis asinini. 

Milk, shell-fish, broiled, tender but lean meat, 
and vegetable jellies will form the most suitable 
nourishment. 

The more common form of scrofulous inflam- 
mation of the larynx and trachea belongs to 
youth, and occurs in those families of which the 
members are liable to consumption. It has seemed 
to us often to arise from night-air and fatigue, es- 
pecially when these causes operate during a sea- 
son of mental anxiety and over-exertion. This 
is a frequent disease with those wretched females 
who frequent the streets of our cities in the night, 
and their obscene haunts during the day. The 
hue which may be observed on their cheeks is not 
always the glow of intemperance or of shame, nor 
yet the factitious blush of effrontery, but is often 
the crimson of a consuming hectic, which is ra- 
pidly hurrying them from misery to misery. It 
is little known how large a portion of the tenants 
of the brothel actually labour under consumption : 
but the subject is too horrible to be pursued. 

At first the disease is attended with a dry bark- 
ing cough, a single bark, often supposed to be a 
stomach cough ; but the symptom which is most 
distinctive of this very treacherous complaint, and 



which in consumptive families ought ever to excite 
the liveliest apprehension of danger, is a change 
in the sound of the voice, winch the paUent can 
no longer extend without difficulty. It is slightly 
raucous, and acquires that hollowness which, both 
as if proceeding from a vault and in reference to 
its tendency, is not unaptly called sepulchral. 
When, the attention being arrested by the cough 
and the sound of the voice, which often have ex- 
isted for many weeks or even months before they 
become objects of regard, we more closely examine 
the patient, we shall find that there is some un- 
easiness in the region of the larynx, or in the su- 
perior part of the thorax ; a degree of quickness 
of the pulse is discoverable, as also some emacia- 
tion and decay of the strength, but the latter so 
slight as to have escaped notice. Indeed so insi- 
dious is this disease, that in many instances it has 
passed undiscovered until some acquaintance, who 
had not for a considerable time seen the patient, 
discerning a great change in his looks, expresses 
his apprehension. Then the truth, in all its na- 
kedness, flashes on his alarmed relatives, and a 
physician is obtained who detects the nature of 
the disease by discovering that there are irregular 
chills followed by heats and perspirations, and 
confirms all their fears. The patient soon loses 
the power of extending his voice ; he can only 
speak in a whisper ; his cough becomes stridulous, 
his expectoration purulent, and laryngeal or tra- 
cheal consumption is incurably established. If a 
patient, fortunately for himself, should in the com- 
mencement of his disease be visited by a person 
possessed of medical skill, his life may sometimes 
be saved. In the treatment of this complaint, if 
the disease should not have reached the suppura- 
tive stage, we must disregard the diathesis, and 
address ourselves to the local affectjon. First, we 
must apply leeches to the upper part of the ster- 
num ; we prefer three or four leeches every third 
or fourth day to a greater number ; secondly, the 
tartar-emetic ointment (taking care that it does 
not reach the leech-bites) to the sides of the 
larynx, first to one side and then to another; 
thirdly, we must give the solution of tartar-emetic 
(so as to excite slight nausea) with the addition 
of nitre. 

R Antimonii tartarizata, gr. duo. 
Nitratis potassae, scrup. ii. 
Aquae distill, unc. sex : M. et divide in 
haustus sex. Sumat unum, ter, quaterve de die. 
Lastly, a diet consisting of milk, farinacea, and 
fruits, will be necessary. This plan may be fol- 
lowed for eight or ten days ; if without efficacy, 
new measures must be tried, as change of air and 
scene, and restoratives, such as a return to the use 
of animal food, a glass or two of claret, and 
sponging the surface with very diluted nitro-mu- 
riatic acid, which may also be taken internally. 
If the expectoration be considerable, a drachm of 
Riga balsam in a glass of water may be taken 
three times a day, or the following draught : 
R Tinct. benzoini compositae, zi. 
Mucilaginis acacia?, gii. 
Syrupi papav. albi, gi. 
Aquae cinnamomi, ^vi. M. 
together with such treatment as would apply to 
impending laryngeal or tracheal phthisis. 

There are certain cases of scrofulous inflamma* 



LARYNGITIS. 



107 



tion of the windpipe that are invariably overlooked 
in the first stage, of which the first symptoms 
detected are round and pretty deep ulcers in the 
fauces. The affection of the larynx so commen- 
cing, according to our observation, always ends in 
phthisis. 

The syphilitic inflammation of the larynx, like 
the last variety, is seldom discovered in its very 
beginning. This disease is introduced by anoma- 
lous symptoms of constitutional disorder, and an 
obscure febrile state. The patient's expression 
appears altered and anxious, his complexion pale 
or mixed, his skin opaque and, as it were, dirty, 
his eyes hollow, the tarsi slightly inflamed ; some 
degree of emaciation takes place ; then the voice 
becomes husky. These symptoms will naturally 
suggest that line of inquiry which we adopt when 
we are endeavouring to detect a syphilitic taint ; 
and here it will not be irrelevant to observe that a 
change in the sound of the voice, whenever it ac- 
companies a cachectic state of the body, demands 
the utmost attention, — attention which will some- 
times be rewarded by enabling us to discover the 
approach of a disease that would shortly assume 
a hopeless expression. In syphilitic inflammation 
of the larynx, when the head is suddenly turned 
to a side, uneasiness will be felt in the organ, 
which, when pressed, feels tender. The patient 
suffers much from a stridulous cough, attended 
with little or no expectoration. These symptoms 
being neglected, ulceration of the membrane of 
the larynx next ensues, which may be discovered 
by difficult and suffocative inspiration and cough, 
by purulent expectoration, and by unequivocal 
hectic, attended with great irritability of the ner- 
vous system, and, lastly, by permanent loss of 
voice. In the commencement of this affection, 
we must endeavour to subdue the inflammation 
by means of leeches, blisters, and the antiphlogis- 
tic regimen. Then we must give the muriate of 
mercury in decoction of sarsaparilla, and employ 
mercurial fumigations. 

In this manner, with the help of change of air, 
a remedy often of surprising efficacy in specific 
inflammations, a cure may sometimes be accom- 
plished ; but syphilitic inflammation of the larynx, 
which we apprehend will be most likely to occur 
in strumous habits, will, in general, like the pro- 
per scrofulous inflammation, terminate in laryn- 
geal consumption, unless a termination should 
take place in the inflammatory stage, such as was 
exemplified in one of Bouillaud's patients, who 
died of suffocation so early as the fifth day, the 
cellular membrane being so thickened, infiltrated, 
and gorged, as almost to obliterate the rima glot- 
tidis ; and on the left side of the larynx an ulcera- 
tion being formed with the characters of chancre. 
(Med. Chir. Journ. for July, 1 825, p. 206.) When 
syphilitic ulcers exist, they will generally be found 
in the sacculi laryngis. We have, in a specimen 
of diseased larynx, seen fimbriated excrescences 
in the glottis, which were probably syphilitic, but 
we were not able to obtain a history of the prepa- 
ration. 

As we learn from an ably written paper by the 
late Mr. Wood, in the seventeenth volume of the 
Medico-Chirurgical Transactions, on the effects 
of inflammation of the larynx, that a patient 
lately died in St. Bartholomew's Hospital, of a 



disease of the larynx, which was discovered after 
death to be cancerous ; and as Dr. Monro, in the 
2d volume of his Outlines of Anatomy, informs 
us that he has seen in some cases the arytenoid 
and thyroid cartilages thickened and covered by a 
scirrhous substance, by which the glottis was 
straitened; it is probable that our successors in 
pathology, when facts accumulate, will add a 
ninth species, viz. scirrhous inflammation of the 
larynx, to the foregoing catalogue of diseases of 
that organ. 



We proceed to the consideration of laryngitis, 
which is a more suitable designation for the dis- 
ease now under review, than angina adematosa, 
as applied to it by some authors : it has been well 
observed that " the term cedematosa is unneces- 
sary, as oedema constitutes no fundamental cha- 
racter of laryngitis, but is an effort or consequence 
of inflammation of the affected organ," (Med. Chir. 
Journal for July, 1825, p. 206,) in what manner 
soever excited. 

Of laryngitis, it is true, notices and cases were 
previously published, but the disease was not 
generally understood prior to the publication, by 
Dr. Farre, of a valuable paper on cynanche laryn- 
gea, in the third volume of the Medico-Chirurgi- 
cal Transactions. 

Our knowledge will often be advanced by 
examining a specimen of a disease before we 
apply ourselves to the study of its general history. 
We therefore beg to call the attention of the read- 
er to a case of laryngitis in every way interest- 
ing, but especially so to the pathologist, as being 
the first accurately reported history of that disease 
which, as far as we know, is to be found in the 
annals of medicine. 

" Some time on the night of Friday, the 10th 
December, 1799, having been exposed to rain on 
the preceding day, General Washington was at- 
tacked with an inflammatory affection of the 
upper part of the windpipe, called in technical 
language cynanche trachealis. The disease com- 
menced with a violent ague, accompanied with 
some pain in the upper and fore part of the throat, 
a sense of stricture in the same part, a cough, 
and a difficult rather than a painful deglutition, 
which were soon succeeded by fever and a quick 
and laborious respiration. The necessity of blood- 
letting suggesting itself to the General, he pro- 
cured a bleeder in the neighbourhood, who took 
from his arm in the night, twelve or fourteen 
ounces of blood. He could not by any means be 
prevailed on by the family to send for the attend- 
ing physician till the following morning, who ar- 
rived at Mount Vernon at about eleven o'clock on 
Saturday. Discovering the case to be highly 
alarming, and foreseeing the fatal tendency of the 
disease, two consulting physicians were immedi- 
ately sent for, who arrived, one at half after three, 
and the other at four o'clock in the afternoon. 
In the mean time were employed two pretty 
copious bleedings, a blister was applied to the 
part affected, two moderate doses of calomel were 
given, and an injection was administered, which 
operated on the lower intestines ; but all without 
any perceptible advantage, the respiration becom- 
ing still more difficult and distressing. Upon the 
arrival of the first of the consulting physicians, 



108 



LARYNGITIS 



it was agreed, as there were yet no signs of accu- 
mulation in the bronchial vessels of the lungs, to 
try the result of another bleeding, when about 
thirty-two ounces of blood were drawn, without 
the smallest apparent alleviation of the disease. 
Vapours of vinegar and water were frequently 
inhaled ; ten grains of calomel were given, suc- 
ceeded by repeated doses of emetic-tartar, amount- 
ing in all to five or six grains, with no other effect 
than a copious discharge from the bowels. The 
powers of life seemed now manifestly yielding to 
the force of the disorder ; blisters were applied to 
the extremities, together with a cataplasm of bran 
and vinegar to the throat. Speaking, which was 
painful from the beginning, now became almost 
impracticable ; respiration grew more and more 
contracted and imperfect, till half after eleven on 
Saturday night, retaining the full possession of 
his intellect, when he expired without a struggle. 
He was fully impressed at the beginning of his 
complaint, as well as through every succeeding 
stage of it, that its conclusion would be mortal ; 
submitting to the several exertions made for his 
recovery, rather as a duty than from any expecta- 
tion of their efficacy. He considered the opera- 
tions of death upon his system as coeval with the 
disease ; and several hours before his death, after 
repeated efforts to be understood, succeeded in 
expressing a desire that he might be permitted to 
die without further interruption. During the 
short period of his illness, he economized his 
time, in the arrangement of such few concerns as 
required his attention, with the utmost serenity ; 
and anticipated his approaching dissolution with 
every demonstration of that equanimity for which 
his whole life had been so uniformly conspi- 
cuous."* 

The violent ague with which this case com- 
menced was doubtless the rigor of incipient in- 
flammation ; the pain in the upper and fore part 
of the throat, the sense of stricture in the same 
part, and the labour of respiration, showed that 
inflammation was seated in the larynx. The dif- 
ficult deglutition arose from the state of the tonsils, 
in which probably the inflammation commenced. 
The inflammation did not descend into the bron- 
chial vessels of the lungs, wherein we are told 
there were no signs of accumulation. It may be 
inferred, therefore, as will be apparent from the 
sequel, that this was a genuine specimen of laryn- 
gitis. 

Laryngitis generally arises from exposure of 
the body, or a part of it, to cold or wet, or from 
sudden transitions of temperature. It affects those 
persons who are liable to cynanche tonsillaris, and 
often commences as one of their accustomed at- 
tacks ; and hence the patients are seldom alive to 
danger until a feeling of suffocation convinces 
them that their illness is one of unusual severity. 
In the Richmond Surgical Hospital, House of In- 
dustry, Dublin, we saw a case of inflammation of 
the larynx, which commenced in the tonsils, and 
was by malpractice extended to the larynx. The 
patient was a robust young man ; his face was 
much flushed, his pulse quick. He was com- 
pletely hydrophobiac. When he tried to swallow, 

* This account is dated Alexandria, Vir.. Dec. 21, 1799, 
nnd signed by Dr. James Craik, attending physician, and 
Dr Elisha E. Dick, consulting physician. 



the effort was followed by extraordinary difficulty 
of inspiration, and every attempt to articulate 
was productive of a sense of strangling. I here 
were pain and great tenderness on pressure on 
either side of the pomum Adami. He was at- 
tacked, two days before he entered the hospital, 
with cynanche tonsillaris, when an old woman, 
partial to stimulants, as such practitioners gene- 
rally are, rubbed the inflamed tonsils with pepper 
and salt, and immediately difficult deglutition 
came on, which was followed by constriction of 
the glottis. He fell under the care of an excel- 
lent surgeon, the late Mr. Todd, who soon re- 
stored him to health by copious general and local 
bleeding. 

If, when the throat first becomes sore, the pa- 
tient is examined, probably the uvula will appear 
inflamed, and the tonsils and arch of the soft pa- 
late redder than natural ; and in some few in- 
stances exudations of coagulable lymph will be 
seen on those parts ; the tongue perhaps is swell- 
ed ; the face flushed ; the pulse frequent, full, and 
hard; and the skin hot. The breathing soon 
becomes affected ; the inspiration " is long in 
being completed," audible, and as if the air were 
drawn through a dry and narrow reed ; the patient 
points to the larynx as the seat of uneasiness ; he 
frequently coughs, and the cough is very peculiar 
in sound, not so ringing as that of croup, but 
harsher and more stridulous, and attended with 
scanty, viscid, and transparent expectoration. 
Pain is sometimes complained of in the chest. 
The voice, at first acute and piping, gradually 
becomes thick, then hoarse and whispering, and 
at last it is completely suppressed. There is 
sometimes great difficulty in swallowing, from the 
epiglottis ceasing to perform its valvular office, 
whence it happens that, when the patient begins 
to drink, a portion of the fluid escapes into the 
larynx, and produces a fit of coughing, which 
seems to threaten instant suffocation. 

Laborious respiration and an inadequate supply 
of air before long affect the appearance of the 
patient. His expression becomes full of anxiety; 
his countenance pallid ; his lips leaden ; his eyes 
protruded and watery ; his pulse is quick, feebler, 
and less uniform ; and the surface of his body 
colder. Sometimes the integuments which sur- 
round the larynx, especially in the fore part of the 
neck, are swollen. In a case operated upon by 
Mr. Macnamara of Dublin, the trachea was laid 
bare at a depth of two inches and a half below 
the surface, to such an extent had the integu- 
ments of the neck become oedematous. The pa- 
tient is restless and apprehensive, often changing 
his position, in the vain hope of obtaining relief; 
walking or rather staggering to and fro, or from 
one room to another, in great distress : feeling 
that he is on the point of suffocation, he cannot 
be ignorant of the danger to which he is exposed; 
hence he is willing to submit to any means of re- 
lief, and is impatient of delay. 

In this stage of the complaint the patient sel- 
dom sleeps for many minutes at a time ; when he 
begins to doze, he starts up in a state of the utmost 
agitation, gasping for breath, every muscle being 
brought into action which can assist respiration, 
now a convulsive struggle. He is quite enfeebled, 
becomes delirious, drowsy, and at last comatose, 



LARYNGITIS, 



109 



the circulation being more and more languid, and 
he dies on the fourth or fifth day of the disease, or 
even earlier. Instances have come to our know- 
ledge in which the disease has terminated fatally 
within twelve hours, (one of Dr. Armstrong's 
patients died in eight hours, and another in seven ;) 
and therefore, if a person dies suddenly in the 
night, who had complained on the foregoing day 
of sore throat, laryngitis may be suspected as the 
cause of his death. Instances have also come 
under our observation, in which the disease has 
lasted three or four weeks, of which the following 
case is an example. 

We have inserted the first recorded case of la- 
ryngitis, that of General Washington ; and we 
beg to insert the first case of the disease recorded 
as such.* In so doing, the reader will obtain a 
glimpse of the second Monro, who, at a time when 
the most eminent of his contemporaries in England 
were ignorant of its existence, perfectly understood 
and explained to the writer of this article the nature 
of laryngitis. 

Mr. A. at. forty-three, robust and corpulent, in 
the spring and summer of 1805 was for three 
months under a mercurial course for secondary 
symptoms of syphilis. In spring 1S06, he was 
affected with fever and pains in his limbs. In July 
1806, he laid aside his flannel shirt, and thought 
he caught cold. July 10th, severe fits of coughing 
in the night; 11th, 12th, 13th, troublesome nights 
from the cough. V. S. ad ^xvi. 14th to 19th, 
emetic, squills, opiates ; 20th, respiration not 
quickened, but difficult, constriction felt in the 
larynx; long-continued fits of stridulous cough; 
tongue white and swelled; pulse 120; by an ef- 
fort he can completely inflate the lungs without 
raising a cough. On this day the patient was first 
seen by the writer of the case, at whose request 
Dr. Monro was called into consultation, whose 
opinion was that the symptoms arose from in- 
flammation and thickening of the mucous mem- 
brane of the windpipe. Twelve leeches to the 
left of the windpipe, and a blister to the right, pulv. 
jalapae comp. ^ss. calomelanos gr. v. July 22d, 
during the night he slept not many minutes at a 

* Abridged from the Pathology of the Larynx and 
Bronchia, by J. Cheyne, M. D. Edin. 1809. 

May we be permitted to introduce Dr. Monro to the 
student of pathology as a physician worthy of the closest 
imitation. In his writings we have somewhat too much 
of the ardour of controversy, into which he was betrayed 
ill support of his reputation as a physiologist, ungene- 
rously assailed ; but in the common intercourse of pro- 
il life he was scrupulously correct in conduct, and 
in his manners urbane. He was a strict economist of 
time, —a man of industry and order. His mind was un- 
ceasingly occupied in the acquisition of knowledge, so 
that no allurement, not even the pleasure of his garden, 
for which he had a genuine relish, was permitted to se- 
ll ice in in from his daily task of recording the results of 
Ins observation, by carefully arranging and registering 
the facts which he judiciously collected ; and hence, after 
he had passed tile common period of life, when between 
his seventieth and eightieth year, he was still to be found 
ni his study, with his case-book before him, adding to his 
stock of pathological knowledge. In the investigation 
of disease he could not be viewed without admiration. 
His digested experience, his keen observation, and the 
excellent method of inquiry which he pursued, rendered 
linn a personification of medical sagacity, and enabled 
him, in consultation, to tower above the great competi- 
tors of his youth and age, the one a man of genius, the 
other of talent— Cullen and Gregory, who were children 
compared with Monro in the power of discovering the 
nature and predicting the course of an obscure and un- 
common disease. He was remarkable for the possession 
of tact, employing (hi term not merely as expressive of 
discrimination, but also of that quality which, in the 



time ; cough threatening suffocation ; expectora- 
tion of clear ropy mucus ; hissing inspiration ; 
tongue furred and swelled ; evident fulness as well 
as tenderness on the left side, and in front of the 
thyroid cartilage, which is painful when the head 
is turned. When in bed his head is low, and 
thrown to the left side ; when sitting, his chin is 
projected ; countenance anxious. Opinion : as 
the disease appears to be confined to the upper 
part of the windpipe, it was resolved, should 
suffocation be imminent, to perforate the larynx 
between the thyroid and cricoid cartilages. — 
Leeches, blister, steam of warm water and vinegar. 
July 24th, miserable nights; often on the point 
of suffocation ; pain on pressure in every part of 
the trachea, pulse 128 ; tongue more swelled. 
July 27th, in the last three days a pound of blood 
was drawn each day. The first blood sizy and 
cupped. Laudanum produced sleep, but he awoke 
gasping, dyspnoea being then more severe. Some- 
times he started from his chair, and staggered from 
one room to another ; then his face was quite livid ; 
his pulse, an hour after a paroxysm, was 136. 
Tongue swelled, and indented from the impression 
of the teeth. Emetic of ipecacuanha proved 
nearly fatal. When he began to vomit, his inspi- 
ration was interrupted and crowing ; his face was 
pale, and his lips livid. Gr. ii. calomelanos ter 
quotidie. Evening, haustus cum tinct. opii et vini 
ant. gutt. x. August 4th, sickness after the eve- 
ning draught, which lasted all night. At 7 a. m. 
breathed with great difficulty; extreme cold. He 
was taken out of bed and seated on a sofa, sup- 
ported with cushions and pillows, after which his 
head fell upon his breast, and he ceased to respire. 
When his head was raised, respiration was re- 
sumod, but it was stertorous, and his complexion 
was changed from the purple of imperfect respira- 
ration to the paleness of a cadaver. Bronchotomy 
was performed without effect ; he died in about 
two hours after the operation. We were not per- 
mitted, to examine the body, but concluded that 
death arose from closure of the rima glottidis, 
owing to thickening of its lining membrane. 
At one time it was conjectured that this case 

exploration of diseases in the thorax, abdomen, and pel- 
vis, enables the physician, by manual examination, to 
detect the nature of the altered structure of the organs 
contained in these cavities. Monro, in his inquiries, 
brought not merely his touch, but all his senses to his aid 
in an extraordinary manner. Long before the time of 
Laennec he availed himself of the aid of auscultation 
(immediate) in ascertaining the existence and nature of 
diseased conditions of the heart. We have known him 
sit for a long time, with his ear applied to the thorax, 
deriving information from a mode of inquiry at that 
time peculiar to himself. Finally, though remarkable for 
caution, he possessed great decision of character, of 
which his practice, never rash, but often extremely bold, 
afforded sufficient evidence. The therapeutic agents 
which he employed were skilfully combined, und while 
mere effect was despised by him, while 

" His vigorous remedy displayed 
The power of. art without the show" — 

nothing was omitted in weak compliance with the pre- 
judices of his patient. Tins sketch will be pardoned by 
all those who think that, even with advancing age there 
ought to be no abatement of zeal in the cultivation of 
professional science; that improvement in all things is 
promoted by placing models Of excellence Inline the eyes 
of the student ; and that an expression of gratitude is 
seemly. The writer, having derived many useful lessons 
from studying the character of Monro, has never lost an 
opportunity of paying an humble tribute to his memory. 
It appears surprising that tins great pathologist should 
have been allowed to retire from the theatre of his use- 
fulness without receiving one valedictory plaudit. 



110 



LARYNGITIS, 



was connected with syphilis ; but if such a com- 
plication had existed, it is probable that the inflam- 
mation would, in four weeks, have reached the 
ulcerative stage, of which the expectoration afforded 
no evidence. This case, with several others which 
fell under our care, induced us to attempt a defini- 
tion of the disease in the following terms. " Pain 
in the larynx not very acute, unless on pressure ; 
some degree of fulness externally; a change in 
the sound of the voice, difficult and even crowing 
inspiration, but slow rather than quick ; an altered, 
sometimes stridulous voice; fits of suffocative 
coughing; and all those symptoms which arise 
from obstructed circulation in the lungs." (Vide 
Pathology of the Larynx, p. 161.) 

Causes* — Persons advanced in life are more 
liable to laryngitis than the youthful ; and of the 
former the disease most frequently occurs in such 
as are liable to indigestion, connected with a dis- 
ordered condition of the liver. Several of our 
patients had been habitually intemperate. The 
exciting causes of laryngitis, as we have already 
mentioned, are such as usually are productive of 
common cynanche or catarrh, the principal being 
exposure to cold. 

Prognosis* — In some new cases of laryngitis 
the inflammation recedes, and the disease termi- 
nates favourably. This favourable change we 
may presume is taking place when we discover 
that the swelling of the epiglottis is subsiding, 
that the difficulty of breathing and pain of the 
larynx are abating, and when freedom of expecto- 
ration is restored, and deglutition becomes easy. 
On the other hand, the danger increases with an 
increasing struggle of breathing. Paleness and 
lividity of the complexion, a prominent watery 
eye, and lethargy or stupor, are symptoms which 
indicate great urgency of danger. It may fairly 
be affirmed that laryngitis is the most fatal of the 
phlegmasia? ; consequently the prognosis, in every 
stage of the disease, must be delivered with the 
utmost caution. " Of seventeen cases of laryngeal 
angina observed by Bayle during six years, only 
one ended favourably." 

Diagnosis. — The diseases which are most 
liable to be mistaken for laryngitis are — 

1. Ossifications and caries of the cartilages of 
the larynx. This state of these bodies gives rise 
to extensive ulceration, of which the diseased car- 
tilage is the centre. This affection is often of slow 
growth, beginning with uneasiness in the region 
of the larynx, followed by hoarseness ; then occur 
cough, difficulty of breathing, which is croaking, 
sibilous, and in paroxysms; and difficulty of 
swallowing ; purulent expectoration, which is often 
of extraordinary fetor; sometimes diseased portions 
of cartilage on which the fetor depends, being ex- 
pectorated. We learn from Dr. Monro's Outlines 
of Anatomy, that the cartilages of the larynx, 
especially the thyroid, and sometimes even those 
of the trachea, are occasionally found ossified. In 
examining the body of an old man, who for the 
last six years of his life had been subject to a se- 
vere and almost unremitting cough, « I found," 
says Dr. Monro, " the cartilages of the larynx os- 
sified, a considerable quantity of viscid mucus 
within the trachea, and its internal coat thickened, 
spongy, and red. In such cases the mobility of 
the different component parts of the larynx being 



lessened or destroyed, the voice becomes much 
feebler ; and there have been instances, as I have 
been informed by my father, of these morbid ossi- 
fications exfoliating internally, and portions of the 
bony matter expelled by coughing." By a patient 
labouring under disease of the cartilages of the 
larynx, who was under the care of Dr. Colles of 
Dublin, one of the arytenoid cartilages was ex- 
pectorated ; and Dr. Hunter, as we learn from Dr. 
Baillie, " knew an instance in which the cricoid 
being converted into bone was separated by exfo- 
liation, and afterwards coughed up." Abscesses 
thus formed sometimes burst into the oesophagus, 
sometimes into the cavity of the windpipe, and 
sometimes they open externally. When the pa- 
tient escapes sudden suffocation, this disease, which 
admits of treatment similar to that of simple la- 
ryngitis, usually ends in hectic fever. In general 
it is not attended with inflammation of the epi- 
glottis, and instead of terminating within four or 
five days, its course is tardy. To this disease, 
rather than to simple laryngitis, we apprehend 
belonged the case of the Right Hon. Isaac Corry, 
as detailed by the late amiable and accomplished 
Dr. Edward Percival, in the fourth volume of the 
Medico-Chirurgical Transactions. In Mr. Corry's 
case, as we learn from Dr. Colles, who was one 
of his attendants, the epiglottis was in a natural 
state, and the rima glottidis little if at all reduced 
in its capacity. Of the same nature appears to 
have been the first of Mr. Lawrence's cases, pub- 
lished in the sixth volume of the Medico-Chirur- 
gical Transactions, and the case furnished by Dr. 
Latham, and published in the same paper, in which, 
on dissection, there were found two distinct ulce- 
rations through the substance of the thyroid carti- 
lage, which contained pus. Mr. Goodeve's case, 
published in the London Medical Journal, July, 
1825, was probably of the same nature, as the 
patient's voice and respiration improved after the 
expulsion of a piece of bone from the glottis. 

2. Abscesses in the vicinity of the windpipe, 
compressing that tube, are sometimes formed in 
the neck, under the fascia, and are discoverable by 
hardness, swelling, and pain on pressure, oedema, 
and inability to open the mouth widely ; they are 
often accompanied with fever of a typhoid nature, 
which we have more than once considered as the 
primitive disease ;* but as, by an incision, relief 
may occasionally be obtained, the treatment chiefly 
belongs to surgery. The usual situation of these 
abscesses, according to Mr. Porter, is behind the 
broad portion of the cricoid cartilage, where it 
presses on the rima glottidis. The progress of 
this disease is sometimes rapid ; sometimes the 
abscess bursts behind the rima glottidis, and hectic 
ensues. 

3. It will be necessary to recollect that aneu- 
rismal tumours have given rise to symptoms re- 
sembling those of laryngitis, of which there is an 
example in Mr. Lawrence's paper. We learn 
from that eminent surgeon, that a patient laboured 
under great difficulty of drawing air into the chest, 
coming on mJits^jv^hJVL^awrence supposed 

♦These abscesses are frequently fatal as in t mse re- 
lated byDr Tweedie. which occurred during co„™i 1 
cence from fever. Dr. Tweedie has also me wUh cases 
of symptomic laryngitis, both in continued and scarlS 
fever, winch generally rapidly destroys ife by cawiol 
ccdema of the glott.s.-C/uuca^ Ulustrationsof^T^ 



LARYNGITIS. 



Ill 



might be relieved by bronchotomy, and therefore 
he desired that he might be sent for on the occur- 
rence of a fit. After the patient's death, her dis- 
ease was found to be an aneurism of the arteria 
innominata, situated between the first bone of the 
sternum, and pressing on the trachea. Mr. Wood 
knew an instance, in which tracheotomy was per- 
formed, which was attended with bursting of the 
aneurism into the trachea, and he refers to several 
such cases. 

Pathology. — In several dissections which we 
have superintended, we have observed appearances 
corresponding with those described by Drs. Farre 
and Baillie, and Mr. Porter. Swelling, and other 
remains of inflammation of the tongue, velum, arch 
of the palate, and fauces, may occasionally be seen. 
The following appearances are always visible. 
The epiglottis thickened and erect, by which it 
ceases to protect the aperture of the windpipe ; 
the mucous membrane of the glottis and larynx, 
as well as the epiglottis, thickened and vascular ; 
underneath the mucous membrane, an infiltration 
of serum. This thickening of the mucous mem- 
brane and distension of the submucous tissue, 
from inflammation and effusion, bring the sides 
of the rima glottidis nearly into contact, and thus 
at length almost obliterate the passage. 

Coagulable lymph has occasionally been found 
on the free surface of the mucous membrane. In 
the second case, related by Dr. Farre, in the third 
volume of the Medico-Chirurgical Transactions, 
coagulable lymph was effused from the inflamed 
surfaces about the glottis and epiglottis, and thus 
assisted in closing the rima. The tumefaction of 
the mucous membrane generally ceases at the 
junction of the larynx and trachea, but increased 
•vascularity may sometimes be discovered in the 
trachea and bronchi. 

The two phenomena which invariably charac- 
terize the anatomy of laryngitis, (the latter a con- 
sequence of the former,) are — 1st, inflammation 
and some thickening of the mucous membrane ; 
and 2dly, oedema underneath, which latter state, 
although it cannot be called peculiar to this affec- 
tion, is a very unusual attendant upon any other 
disease of the mucous membrane. 

[M. Cruveilhier divides laryngitis into two varie- 
ties, according as the diseased action is more con- 
spicuous upon the surface of the mucous membrane 
of the larynx, or in the submucous cellular tissue, 
designating the former mucous laryngitis, the lat- 
ter submucous laryngitis, which is the cedema 
of the glottis of others. In the consideration of 
this disease elsewhere, (Practice of Medicine, edit, 
cit. i. 227,) the writer has divided laryngitis into 
the acute, the chronic, and the cedematous.'] 

That laryngitis is an inflammatory affection, 
we have abundant proof. The fever which be- 
longs to the disease is attended with increased 
heat of surface, and frequent and strong pulse. 
The blood is sizy. The parts affected are swelled 
and painful, and we may sometimes obtain a view 
of a portion of the affected organ in a state of in- 
tense inflammation. When the tongue is not 
much swelled, by depressing its root, by pushing 
the root downwards and forwards by means of a 
spatula, elevating at the same time the handle of 
the spatula, we can discover the epiglottis erect, 
florid, swelled, and rounded. One writer on the 



disease has well described the epiglottis as bein<» 
enlarged, red, glossy, and nearly of the size and 
appearance of a plum (Mr. Wilson, vol. v. Medico- 
Chirurg. Transactions, p. 158) : inflammation, 
thus denoted by swelling and glossy redness, is, 
doubtless, the state of the glottis as well as of the 
epiglottis. 

Mere inflammation of the membrane will be 
productive of uneasiness and occasional difficulty 
of breathing, from spasmodic stricture. But'effu- 
sion into the submucous tissue must render the 
difficulty of breathing permanent, and lead to 
asphyxia, when, from narrowing of the glottis, 
the supply of atmospheric air becomes insufficient 
to effect the removal of the venous character of the 
blood during its passage through the lungs, and 
when, consequently, those functions which depend 
upon the arterial properties of the blood being 
restored, and more especially the function of the 
brain, are interrupted. 

In laryngitis, asphyxia may take place under a 
variety of circumstances. 1st. We have known 
asphyxia take place, in the course of the first 
night of the disease, from strangulation, the 
patient being found in the morning quite dead. 
2dly. Asphyxia much more generally arises from 
gradual depravation of the circulating fluid. 3dly. 
Death may also take place after the obstruction 
has been removed by means of a surgical opera- 
tion, as in the case of Mr. A. In such case, the 
brain, in consequence of the transmission to it of 
blood in a state of imperfect oxidation, receives a 
shock from which it never recovers, even when 
the lungs are again abundantly supplied with air. 
This is like the shock from submersion, which we 
have known to be fatal after the pulse and respira- 
tion had been restored. In the two latter cases, 
fhe patient dies from disease of the brain, and not 
from strangulation. (Edema productive of death 
may be the work of one night ; yet, generally, the 
morbid process is prolonged for four or five days ; 
the difficulty of breathing, at first often remitting, 
we apprehend must be referred partly to spasm, 
caused by inflammation of the membrane. In the 
progress of the disease, however, the dyspnoea be- 
comes unremitting, which cannot be accounted for 
unless on the supposition of a permanent narrow- 
ing, the effect of cedema. If we had any certain 
means of ascertaining when the membrane is 
merely inflamed, and when it is cedematous as 
well as inflamed, much of the difficulty which 
attends the treatment of the disease would be re- 
moved. 

Treatment. — But as we have no certain means 
of establishing the condition of the windpipe, we 
must be guided by the symptoms of the disease in 
deciding the question of bloodletting, which is one 
of the most difficult points in therapeutics. Al- 
though bloodletting may be expected to remove 
the inflammation of the mucous membrane, it 
cannot be expected to remove the effusion from 
the tissue beneath it: as well might we expect 
that bloodletting would remove phlegmon after 
matter is formed, as that it will remove laryngitis 
after cedema is established. It may prevent the 
further deposition of serum, and render it easier 
for the absorbents to act upon that which has been 
already effused ; but mor« than this we are not to 
expect. 



112 



LARYNGITIS. 



The practice of the physicians who attended 
the great American President during his last ill- 
ness, was, we conceive, very unfairly decried by 
some of their professional brethren on this side of 
the Atlantic; and this is the more remarkable, as 
medical criticism was not so grossly vituperative 
thirty years ago as it is now. In a medical journal 
of 1800 we find the following specimen of gratu- 
itous illiberality :— « Think of a man being, with- 
in the brief space of little more than twelve hours, 
deprived of eighty or perhaps ninety ounces of 
blood, after swallowing two moderate American 
doses of calomel, which were accompanied by an 
injection ; then five grains of calomel, and five or 
six of emetic tartar ; vapours of vinegar and wa- 
ter frequently inhaled ; blisters applied to the ex- 
tremities ; a cataplasm of bran and vinegar to his 
throat, upon which a blister had been already 
fixed : is it surprising that, when thus treated, the 
afflicted general, after various ineffectual struggles 
for utterance, at length articulated a desire that he 
might be allowed to die without interruption ! To 
have resisted the fatal operation of such Hercu- 
lean remedies, one should imagine that this ven- 
erable old man ought at least to have retained the 
vigour of his earliest youth. A British physician 
may be deemed not competent to ascertain the 
propriety of transatlantic practice : the current of 
blood in the inhabitants of the new world may 
bear some proportion to the current of its rivers ; 
in that case the medical treatment ought likewise 
to be conducted on a larger scale," &c. In an- 
swer to this rhapsody, in which the writer has 
tried to destroy the character of two respectable 
physicians, it may with truth be affirmed, that 
when these gentlemen pronounced the disease of 
which their illustrious patient died to be cynanche 
trachealis, they proved that they were not igno- 
rant men. They showed that they were not igno- 
rant of the seat and nature of the disease ; they 
knew it to be seated in the upper part of the wind- 
pipe, and to be of an inflammatory nature. We 
venture to say that their critic would not have 
been nearer the mark. Perhaps there was not in 
Britain more than one individual, namely Monro, 
who was acquainted with the true nature of the 
disease of which General Washington died. The 
late Dr. Pitcairn, a physician in London, of de- 
served reputation and character, ten years after 
the death of General Washington, being attacked 
with the same disease, when no longer able to ar- 
ticulate, " wrote down with a pencil on a slip of 
paper that his complaint was to be considered as 
croup." Nay more ; Dr. Pitcairn's case was the 
first which the late Dr. Baillie, then at the head 
of the medical profession in England, had ever 
witnessed ; and that great physician, with his 
characteristic candour, admits that he was ignorant 
of the nature of the disease of which his friend 
Dr. Pitcairn was dying. Dr. Pitcairn, the day 
before he died, did not consider himself in danger, 
but thought that he was suffering under an attack 
of cynanche, such as he had often experienced, 
with a little more than its usual severity ; and 
this, adds Dr. Baillie, was so much impressed on 
my mind, " that I did not even examine his throat, 
•ior did he seem to wish it." Moreover, four 
hours before his death, when drowsiness was 
coming on, Dr. Baillie " thought him somewhat 



better " Hence it is probable that the best in- 
formed physicians in England, prior to the pubh- 
cation of Dr. Farre and Dr. Baillie's papers on 
cynanche laryngea, would have pronounced Gen- 
eral Washington's case to be one of cynanche 
trachealis. This being admitted, the American 
physicians ought not to have been charged with 
ignorance, nor their practice so mercilessly im- 
pugned. What are the most approved remedies 
for croup 1 Bleeding, tartar-emetic, blisters, and, 
according to many, calomel : these were the reme- 
dies which General Washington's physicans pre- 
scribed, and which they administered, it must be 
admitted, with boldness. Whatever injury the 
patient sustained from the measures employed 
ought to be charged, not to the account of the in- 
telligent physicians who attended him, but to the 
less perfect state of pathology at the end of the 
eighteenth century than at present. 

General Washington died within twenty-four 
hours of the commencement of his illness; and 
we cannot deny that in this supposed case of 
croup, the remedies employed, however justifiable 
in the then state of medical information, probably 
shortened the general's life. If bleeding fails to 
subdue an inflammatory disease, it will be hurtful 
" by depressing the power by which the muscles 
act ;" and on» the vigorous action of the muscles 
which expand the chest, depends a continuance 
of that struggle by which the lungs are supplieu 
with air sufficient for the arterialization of the 
blood. 

We acquire a juster view of laryngitis by con- 
trasting that disease with croup. They are both 
truly inflammatory diseases, but in that point alone 
do they resemble each other. Croup is a disease 
occurring before puberty, generally affecting, not 
merely the larynx, but the whole of the bronchial 
membrane, ending in an effusion of lymph on the 
free surface of the membrane, to be cured, proba- 
bly, in ninety-nine cases of a hundred, by emetics 
and bleeding timely employed ; and it is a disease 
in which a surgical operation will only add to the 
danger to which, in the second stage, the patient 
is exposed. Laryngitis, on the other hand, is a 
disease which rarely occurs before puberty ; is 
confined to the upper extremity of the wind-pipe; 
ends in a serous effusion into the cellular tissue 
beneath the mucous membrane ; will probably 
terminate unfavourably, in a great majority of 
cases, under any method of treatment; in which 
emetics aggravate the danger, and bleeding is often 
a doubtful remedy ; and in which, when the pa- 
tient is in extremis, bronchotomy will afford the 
only reasonable hope of safety. 

Bloodletting has been successfully practised in 
this disease, as the reader may be convinced by 
several recorded cases : for example, by a case to 
be found in a paper on laryngitis, published by Dr. 
Beck, of New York, in the twelfth number of 
Dr. Beck's Journal. The case occurred in the 
person of Dr. Francis, one of the editors of the 
Journal, who, having for three days had soreness 
of the fauces and thirst, was attacked with pain, 
difficulty of breathing and swallowing, and a sense 
of strangulation, for which symptoms 152 ounces 
of blood were abstracted, as follows : On the 17th 
Nov., .1823, V. S. ad gxL ; evening, gxx. 18th 
Nov. 3XV1. ; evening, gxvi. 19th Nov# 5 xvi , ; 



LARYNGITIS. 



118 



evening, §xvi. 20th Nov. 3xvi. 22d Nov. 
gxii. — Total, gclii. For three or four days after, 
tiie patient was still in a precarious condition, 
and required a repetition of the bloodletting. 
Other cases are published, in which the lancet 
was successfully employed : in one of these, to be 
found in the sixth volume of the Medico-Chirur- 
gical Transactions, viz., that of Sir J. Macnamara 
Hayes, as reported by Dr. Roberts, of Bishop 
Stratford, we learn that the first bleeding " was 
attended with considerable relief," the second 
" with manifest advantage ;" by the third, " his 
safety appeared to be ensured." In the case of a 
young woman who earned a pittance by gathering 
cockles on the strand at ebb-tide, and afterwards 
hawking them through the streets of Dublin, who, 
on the 13th of July, 1813, presented herself at the 
county of Dublin Infirmary, on the second day 
of laryngitis, pale, scarcely able to articulate or 
swallow : the effort producing a convulsion as 
when a crumb enters the wind-pipe, the voice 
sounding as if she were throttled, — inspiration 
being slower than natural and sibilous, — the fol- 
lowing treatment proved successful. At noon, she 
was bled ad deliquium, which, by the way, had 
nearly proved fatal. The venesection was repeated 
twice in the course of the evening. On the fol- 
lowing day, respiration was rendered difficult by 
the least exertion ; hitherto unable to swallow. 
She was again bled, and a purgative enema and 
blister prescribed. Next day she began to expec- 
torate yellow mucus, and could swallow fluids. 
On the 16th July, convalescent. 

It is observable that the lividity of complexion 
which, especially in the more advanced stages of 
laryngitis, arises from imperfect arterialization of 
the blood, did not exist in any of these cases. 

On the other hand, bloodletting has been un- 
successfully practised in laryngitis, not only in the 
case of General Washington, but also in many 
others. In the second attack of laryngitis, that to 
which Sir John Hayes fell a victim, he was three 
times bled from the arm on the second day of his 
illness ; and the result of his case, and the other 
cases reported by Dr. Baillie, in which also blood- 
letting was practised, led Dr. Baillie to affirm that 
" venesection, even when employed strenuously 
and early, was of no real use." But the most 
remarkable instance of the inefficacy of bloodlet- 
ting may be found in Dr. Armstrong's Practical 
Illustrations of Typhous Fever, p. 393. The 
loss of one hundred and sixty ounces of blood 
within six hours, gave temporary respite to the 
difficulty of breathing, yet was so far from arrest- 
ing the inflammation, that death took place within 
twenty-four hours. As, then, there are cases in 
which bloodletting is salutary, and cases in which 
it is hurtful, let us try to ascertain when and to 
what extent that remedy ought to be practised ; 
and let us be permitted to premise that cases will 
occur in which it may be difficult to come to a 
satisfactory conclusion with respect to bloodletting 
— in which the considerations for and against that 
remedy will be balanced, so as to make the most 
skilful and experienced physician pause. In such 
a dilemma, however, it will be well that the phy- 
sician should not allow his doubts to transpire ; 
as doubts which may be the result of an accurate 
weighing of indications against contra-indications, 

Vol. III.— 15 K* 



and which prove that he is a pathologist, will, 
perhaps, by the world and by his unreflecting 
brethren, be thought to proceed from inexperience 
and perplexity. 

We conclude, first, that bloodletting will be 
more clearly indicated in youth than in age. It 
may be observed that the same means by which 
Sir John Hayes was relieved during his first 
attack, which took place in the meridian of life, 
failed fifteen years after : — and, secondly, that we 
may bleed with most hopes of success, when the 
symptoms of inflammatory fever are most evident. 
In Sir John Hayes, during the first attack, the 
face was swollen and flushed ; the eyes were pro- 
truding and bloodshot ; there was fulness about the 
neck, the muscles feeling very turgid, and the 
breast being suffused with a purplish colour; 
whereas, in the second attack, we find that his 
skin was not hot, nor his pulse more frequent than 
in health. 

" At the beginning of the attack, it may be ad- 
visable," says Dr. Baillie, " to take as much 
blood at once as to produce fainting. We beg to 
submit to the reader, that blood in laryngitis is 
sometimes so imperfect a stimulus to the heart, 
that if the action of that organ is interrupted, it is 
not improbable that it will never be resumed. In 
certain conditions of the circulation in this disease, 
I have found bloodletting a very dangerous mea- 
sure. I think it was fatal to a patient who came 
to the County of Dublin Infirmary about twenty 
years ago, when I was one of the physicians to 
that hospital. By my orders he was let blood, not 
till he fainted, but till he became pale and fainty ; 
very shortly after the operation, which sensibly 
reduced his strength, he was seized, upon slightly 
exerting himself, with a paroxysm of difficult 
breathing, not more violent than many from which 
he had emerged, during the two or three previous 
days, and expired." In Dr. Beck's paper, already 
referred to, we learn that Dr. Hoffmann of the 
United States Navy was called to a patient in 
laryngitis whose countenance was anxious, flushed, 
and covered with sweat; eyes staring, and dys- 
pnoea insufferable ; that a vein was opened in each 
arm, which bled freely, and that death took place 
in a few minutes after. Mr. Porter, in the eleventh 
volume of the Medico-Chirurgical Transactions, 
after drawing a very lively and accurate portrait 
of laryngitis in a man about thirty years of age, 
who came to the Meath Hospital with his face 
pale and swollen, his lips livid, his mouth closed, 
his nostrils widely extended, his eyes protruded 
and starting from their sockets, but at the same 
time with the conjunctiva very white, and covered 
with a watery suffusion, and with an expression 
of indescribable anxiety ; his pulse hurried, and 
his breathing very laborious, making two or three, 
or even more attempts at inspiration for one expi- 
ration, and his convulsive struggles for breath 
truly painful to behold, breathing with a hissing 
or whistling sound, while the utmost endeavour 
at speech was only an indistinct whisper ; — tells 
us that he ordered from thirty to forty ounces of 
blood to be taken from both arms, and adds that 
in about two hours afterwards, when he returned 
to the hospital to perform bronchotomy, there was 
scarcely a pulse to be felt at the wrist; the ex- 
tremities were cold ; the patient lay on his back 



114 



LARYNGITIS. 



almost insensible, and seemed sinking with amaz- 
ing rapidity. Knowing the candour of the intel- 
ligent and skilful reporter of this case, we are not 
afraid to observe that this was a combinalion of 
symptoms in which bloodletting was not likely to 
improve the condition of the patient, for whose 
sufferings the proper remedy was the knife, which 
was afterwards successfully employed. Indeed, 
Mr. Porter, in his valuable remarks on the case, 
has affirmed that it presents a strong illustration 
of the inefficacy, in laryngitis, of bleeding, blis- 
ters, and the various internal means usually re- 
sorted to for the purpose of subduing inflamma- 
tion. We conclude, that although we may bleed 
in certain states of the disease so as to influence 
the pulse, it would be unsafe under any circum- 
stances to bleed usque ad deliquium. 

The question of bleeding may with most safety 
be determined by the condition of the circulating 
fluid. We may, with comparative safety, bleed 
while the complexion is good, or, in other words, 
so long as the quantity of atmospheric air admit- 
ted into the lungs is sufficient to produce that 
chemical change by which venous blood, in passing 
from the right ventricle to the left auricle, is con- 
verted into arterial; but when the alteration in 
the appearance of the patient takes place remarked 
in the advanced stages of the disease, which indi- 
cates that the blood is no longer arterialized in its 
passage through the lungs; when the face and 
lips, especially the latter, become livid, the expres- 
sion anxious, the eyes protruded and watery, and 
when these appearances are established perma- 
nently, we may conclude that the stricture of the 
glottis is of a nature not to be relieved by blood- 
letting, and if so, that the patient will be injured 
thereby. 

In the early stages of laryngitis, would not the 
application of leeches to the palate and tonsils be 
deserving of a trial 1 This question the reader 
will be better able to answer after he shall have 
read a short but valuable paper by Surgeon Ge- 
neral Crampton, in the third volume of the Dub- 
lin Hospital Reports, on the application of leeches 
to internal surfaces. Mr. Crampton informs us, 
that in no instance in which leeches have been 
applied to the tonsils within the first twelve hours 
of the attack of inflammation, has the disease pro- 
ceeded to suppuration. 

We would bleed the patient freely during the 
first twenty-four hours ; we should be disposed to 
do more — so long as the complexion of the patient 
is good, we would have recourse to venesection, 
keeping a finger on the artery while the blood 
flows, and closing the orifice when the pulse is re- 
duced : we would have leeches applied, or blood 
removed from the nucha by cupping ; and should 
be disposed to bleed again, or even a third time, 
so as to abstract forty or fifty ounces of blood, and 
at the same time let the patient have a powder 
containing two or three grains of calomel, three 
or four of pulvis Jacobi veri, and one-half or one- 
third of a grain of opium, every third or fourth 
hour, till the gums become affected. This we 
prefer to an exhibition of tartar-emetic, not wish- 
ing to expose the patient to the danger of vomit- 
ing, which is productive of a frightful struggle in 
laryngitis. Blistering the neck is of very ques- 
tionable efficacy, and by the inflammation, stiff- 



ness and soreness which it occasions, add* much 
to the sufferings of the patient, and, when bron- 
chotomy becomes necessary, to the inconveniences 
which attend that operation. If the physician 
reposes much confidence in the antiphlogistic 
power of a blister, let it be deferred till bleeding 
has been carried as far as is expedient, and then 
let it be applied to the upper part of the sternum. 

« From bleeding and opiates," says Dr. Baillie, 
"if no substantial advantage is produced in thirty 
hours, it might be advisable to perform the opera- 
tion of bronchotomy at the upper part of the tra- 
chea, just under the thyroid gland." We appre- 
hend, however, that a consideration of the mere 
duration of the disease will lead us astray ; thirty 
hours may be too long to wait, or it may be too 
short. If the circumstances of the patient, espe- 
cially the condition of the circulating fluid, be 
such as to contra-indicate bleeding, and to show 
that asphyxia is imminent, it may be improper to 
put off the operation for thirty minutes. If the 
complexion is good, if asphyxia is not threatened, 
the operation may be delayed for thirty days. 

In Dr. Baillie's second case already referred to, 
it is stated, " in the night time, the patient becom- 
ing much worse, Mr. Tegart, who scarcely ever 
left him night or day, went for Mr. Home and 
Mr. Wilson to perform the operation of broncho- 
tomy. Mr. Wilson was out of town on profes- 
sional business, but Mr. Home came about four 
in the morning. The patient, however, was be- 
ginning to sink, so that no advantage from an 
operation was now to be expected." It is, indeed, 
probable that bronchotomy would not have saved 
the patient ; but as that operation in an adult can 
be performed without difficulty, and as there are 
instances of its having been successful even when 
the brain was oppressed, which is the most alarm- 
ing symptom in this disease, we humbly think 
that no patient who is not in the article of death 
ought to be deprived of the chance of escape 
which it affords. The patient operated upon by 
Mr. Goodeve, surgeon to the Clifton Dispensary, 
was quite insensible when the operation was per- 
formed ; " no pulse could be found at the wrist, his 
face was suffused with blood and his lips livid, 
and it was hard to say whether he breathed or 
not," and yet he recovered. 

There can be little doubt but that in most cases 
the aperture ought to be made between the thyroid 
and cricoid cartilages, but in this matter the sur- 
geon must be the arbiter.* The operation has 

* On this subject consult Mr. Lawrence's paper in tlie 
sixth vol. of the Medico-Chirurgical Transactions. 

'Die writer of this article many years aso recom- 
mended the introduction of a trocar and canula, with- 
out previous incision. This operation is justly con- 
demned by Mr. Wood in his valuable paper published in 
the seventeenth vol. of the Medico-Chirurgical Transac- 
tions. Mr. Wood observes : •• Dr. Chej ne has advocated 
an operation equally reprehensible with that of Dessairlt, 
who recommended the introduction of an elastic tube 
through the nostril into the trachea, that of introducing 
into the trachea a trocar and canula without previous in- 
cision. The reflection that the canula must irritate by 
being moved up and down with the larynx which does 
not move in association with the skin, combined w itli 
the danger of wounding a large blood-vessel irreeularin 
its ^course the oesophagus and contiguous important 
parts, and the depth it may be necessary to pern- rate 10 
fonaequence of the unusual depth of the trachea from 
the surface on,,, to preclude this use of the trocar," 
&.C. This quotation is introduced as an amende for the 



LARYNGITIS, [CHRONIC] 



115 



often proved perfectly successful, and a canula has 
been worn for a long time without much inconve- 
nience. Thus the patient operated upon by Mr. 
Goodeve wore a tube for more than six months ; 
he was then able to lay it aside, and his voice was 
quite restored. In the fourth volume of the Dub- 
lin Hospital Reports, we learn from Mr. White 
that one of his patients was wearing a tube with- 
out being prevented from working at his trade, 
which was that of a cabinet-maker, two years 
after the operation; the sides of the opening, 
which was of an oval shape, and one inch in 
depth to the trachea, being perfectly healed, smooth, 
and covered with a thin cuticle. But the most 
remarkable proof of the relief which the canula is 
capable of affording, is that which is supplied by 
the case of Mr. Price of Portsmouth ; we learn in 
the twenty-ninth number of the Medico-Chirurgi- 
cal Review, in which journal there is much valu- 
able information to be found on laryngitis, that 
Mr. Price had been breathing for about fifteen 
years through a canula. 

Laryngitis sometimes is more of a chronic than 
acute affection, in which case the affected organ 
probably undergoes a considerable change of 
structure ; in the case in Mr. Lawrence's paper, 
which we have already alluded to, which conti- 
nued for nearly four months, the mucous mem- 
brane had assumed a thick and puckered condi- 
tion, and had partially thrown out coagulable 
lymph of a stringy and fimbriated texture, which 
obliterated the ventricles of the larynx. In one of 
our cases which had lasted four months, the mem- 
brane lining the glottis, and arytenoid cartilage, 
was like a thin layer of flexible cartilage. In 
chronic laryngitis, mutatis mutandis, the same 
principles of treatment are applicable as in the 
acute species. Bronchotomy may be necessary to 
prevent that fatal exhaustion arising from conti- 
nued disturbance of the respiratory function, as it 
was in the case related by Dr. M. Hall in the tenth 
volume of the Medico-Chirurgical Transactions ; 
but medical means alone will often prove suffi- 
cient for the removal of the inflammation, if it be 
unaccompanied with ulceration, The remedies 
chiefly to be relied on in chronic succeeding acute 
laryngitis, are, change of air — this remedy we 
again specify, even at the risk of being thought to 
harp a little too much upon one string ; — the 
establishment of a discharge from both sides of the 
larynx by means of small caustic issues ; and mild 
mercurials, with the infusum sarsaparillae compo- 
situm of the Dublin pharmacopoeia. 

J. Cheyne. 

[Chronic Laryngitis has received more atten- 
tion of late years than formerly, and will, therefore, 
require further consideration. This term has been 
employed synonymously with Laryngeal phthisis, 
Phthisis laryngea ; whilst laryngeal phthisis it- 
self has been employed by MM. Trousseau and 
Bclloq, so as to comprise " any chronic alteration 
of the larynx, which may bring on consumption 
or death in any way." It has been used, indeed, 
to include all chronic diseases of the larynx. In 
this place, the epithet " chronic" is employed in 
regard to laryngitis, in the same manner in which 
it is applied to other inflammations of mucous 
membranes: — to signify inflammation of the lining 



membrane of the larynx, or of the subjacent parts, 
the duration of which is long, or whose symptoms 
proceed slowly. 

Diagnosis* — The commencement of chronic 
inflammation of the various structures composing 
the larynx is often extremely insidious, and its pro- 
gress so tardy, that much, and often irreparable 
mischief is accomplished before any alarm is taken 
by the patient, and he applies for medical assistance. 
Pain is felt in the larynx, but its precise situation 
may vary ; at times, it extends over the larynx ; 
but, at others, is restricted to a small space, and 
generally to the region of the thyroid cartilage. 
Commonly, a kind of tickling sensation exists, 
which provokes coughing. The pain, too, is ex- 
asperated by coughing, speaking, and deglutition, 
especially when ulcerations exist, and they are 
situate above the ventricles of the larynx. The 
breathing of cold air, and pressure upon the larynx 
likewise augment it. The voice is almost always 
changed, being hoarse, and, at times, so much en- 
feebled, as to be inaudible. The aphonia may 
supervene suddenly or gradually, and ultimately 
be complete. Cough is a constant concomitant, 
and when the mucous membrane is much swollen, 
it becomes hoarse and even croupy. In the first 
instance it is dry, but subsequently it is accompa- 
nied with the expectoration of mucus, mixed oc- 
casionally with pus or blood. At other times, a 
membraniform matter is expectorated for months; 
and at others a considerable quantity of false 
membrane is thrown off, after which the patient 
rapidly recovers. Occasionally, portions of carti- 
lage are mixed with the mucous or bloody sputa, 
and in such cases, there is always accompanying 
hectic. Chronic laryngitis has, indeed, been di- 
vided into two heads ; — the first comprising that 
which affects the mucous membrane and the sub- 
mucous tissue ; and the second, that which im- 
plicates the cartilages ; the latter — it has been con- 
ceived — having perhaps the best claim to the name 
phthisis laryngea, from the incurable nature of 
the affection, and the hectic and emaciation, which 
invariably accompany its latter stages. 

When chronic laryngitis is slight, and there is 
not much narrowness, the difficulty of breathing 
may not be great ; but if it be attended with much 
tumefaction of the lining membrane, the dyspnoea 
is considerable, and the sound, on inspiration, so- 
norous and peculiar. It is evidently, too, aug- 
mented by paroxysms. The air of inspiration 
likewise gives rise to a snoring (ronjtemenl) or 
whistling, (sifflement,) which may be continuous, 
or recur in paroxysms. These local symptoms 
may be so slight, that the general health does not 
suffer to any great degree. Commonly, however, 
more or less sympathetic febrile disorder is appa- 
rent, under which nutrition is impaired, and atro- 
phy supervenes. The disease now merits the 
term Laryngeal Phthisis, which is, however, in 
the immense majority of cases, connected with the 
presence of pulmonary tubercles. 

Chronic laryngitis may be primary, or it may 
succeed to acute laryngitis, and when apparently 
terminating in health, it is readily reproduced by 
exposure to cold, errors in diet, &c. &c. Its du- 
ration varies from a few months to several years. 

When the fauces are inspected, but little evi- 
dence of disease may be perceptible ; at other 



116 



LARYNGITIS, [CHRONIC] 



times, however, the mucous membrane is injected, 
and the follicles are so huge as to resemble split 
peas. Whether this enlargement of the follicles 
be the cause or effect, may admit of a question. 
The enlarged follicles probably exist lower down, 
where they cannot be inspected. This form of 
laryngitis is the one often known under the name 
•' Clergymen's sore throat." 

Chronic laryngitis may terminate in health ; but 
it is more likely to end fatally; and this may occur 
in different modes, — either by the lungs becoming 
implicated, or by the extent of the laryngeal le- 
sions themselves, which may excite severe irritative 
fever, or interfere with the entrance of air into the 
lungs, and thus induce asphyxia. In almost all 
cases of phthisis laryngea, the disease is compli- 
cated with pulmonary tubercle. Dr. Stokes, indeed, 
asserts, (On Diseases of the Chest, Amer. edit., 
Philad. 1844,) that after ten years of hospital and 
private practice, he never saw a case presenting 
the symptoms of laryngeal cough, purulent or muco- 
purulent expectoration, semi-stridulous breathing, 
hoarseness, or aphouia, hectic, and emaciation, in 
which the patient did not die with cavities in his 
lungs. In some, the laryngeal affection seemed to 
be primary; but, in the great majority, symptoms 
of pulmonary disease existed previous to its ap- 
pearance. Such, also, is the result of the writer's 
observation. 

In many cases of pulmonary phthisis, — sore 
throat, hoarseness, or aphonia, with cough, occur; 
but the case is different, when the laryngeal symp- 
toms have been primary. 

Causes* — The same causes, that give rise to 
acute laryngitis, may induce the chronic form also. 
It may be caused, hke the acute, by the inspira- 
tion of acrid substances, or by extraneous bodies 
received into the larynx. The habitual and in- 
temperate use of ardent spirits has likewise been 
esteemed a cause, as well as the effects of mercury. 
These act either as predisposing or exciting causes. 
It is often the result of phthisis pulmonalis ; whilst, 
on the other hand, the pulmonary irritation, in- 
duced by it, may occasion the development, and 
augment the course of tuberculosis of the lungs 
in those who are predisposed to pulmonary con- 
sumption. The coexistence of ulceration of the 
lungs, and of suppurated pulmonary tubercles, has 
often been proved. In one-fourth of the cases of 
phthisis, ulceration of the larynx has been observed; 
in one-sixth, ulceration of the epiglottis ; and ul- 
ceration of the trachea was met with by M. Louis, 
more frequently than either of the other lesions. 
(On Phthisis, 2d edit., translated by Dr. Walshe 
— Sydenham Society edit. Lond. 1844.) It is 
probable, however, that the idiopathic chronic la- 
ryngitis rarely produces the symptoms of phthisis ; 
but the two diseases are frequent concomitants. 

Amongst the exciting causes are mentioned — 
prolonged action of the vocal organs ; hence the 
disease is said to be frequent among actors, singers, 
lawyers, preachers, &c. It has already been re- 
marked, that it is so common among the last as 
to have received the name of the clergymen's sore 
throat; yet why it should prevail among them 
more than among lawyers, professors, &c, who 
use their vocal organs more, is not so clear. It 
has, indeed, been suggested, by Professor Chap- 
man of Philadelphia, that clergymen, as a class, 



arc of feebler constitutions, which circumstance 
may have originally led them to embrace their 
avocation ; and, hence, that they are more liable 
to such derangements than more healthy individ- 
uals; but this does not seem sufficient to account 
for the difference. Another explanation has been 
offered by Dr. Stokes— ( Op. cit.) that the clergy, 
man begins to exercise his vocal organs at a much 
earlier period than the lawyer, for example. The 
young clergyman, often of a feeble and nervous 
constitution, and acting under conscientious mo- 
tives, to the neglect of bodily health, not only 
reads the service, and preaches once or twice, or 
even more frequently in the week, but is exposed 
to night air and the inclemency of the weather. 
He is compelled to do so, while both the larynx 
and constitution of the lawyer have generally full 
time for maturity, before he need employ the one 
or expend the other in the duties of his profession. 

Syphilis would appear to be a frequent cause of 
chronic laryngitis, and especially of the ulcerative 
form, — the ulcers extending, at times, from the 
throat by continuity of surface. 

As to age, the disease has certainly been ob- 
served most commonly between twenty and forty; 
but, as to sex, discrepancy of sentiment exists ; — 
some, as Ryland, ( On the Diseases and Injuries 
of the Larynx and Trachea, Amer. Med. Lib. 
edit. Philad. 1838,) affirming, that the number of 
females, attacked by it, is infinitely greater than 
that of males ; others, as Andral, ( Cours de Pa- 
thologie Interne,') that males are more frequently 
affected than females. 

Pathological Characters. — Chronic inflam- 
mation induces the same changes in the laryngeal 
mucous membrane as in other membranes of the 
class; for example, redness, increased thickness, 
and alteration of consistency, over a greater or less 
extent of surface. Occasionally, too, vegetations 
of considerable size, and white and hard granula- 
tions are perceptible. Pus, too, is generally found 
covering its surface. The mucous follicles, both 
of the lining membrane of the pharynx and la- 
rynx, are frequently enlarged, especially in that 
form of the disease to which clergymen are sub- 
ject, and they seem filled with a yellowish matter. 
Ulcerations are likewise very common, so as even 
to destroy the vocal cords. The submucous cel- 
lular tissue is often infiltrated by a thin fluid ; and, 
at times, collections of pus exist in it ; at others, 
it is indurated, and tubercles are found in different 
stages of development. The intrinsic muscles of 
the larynx have been found much reduced in size, 
softened and occasionally destroyed. At other 
times, they have been hypertrophied. The epi- 
glottis may be thickened, ulcerated, carious, and 
even completely destroyed ; yet the patient may 
have been able to swallow to the last. Of the 
cartilages of the larynx, the cricoid and the aryte- 
noid are most frequently diseased the thyroid 

least so. Occasionally, they are ossified, or ossific 
points are deposited on the mucous membrane. In 
broken down constitutions, in which large quanti- 
ties of mercury have been used, it has been re- 
marked, by Drs. Graves and Stokes, that chronic 
laryngitis is very apt to terminate in ulceration of 
the cartilages. 

Treatment. — In the treatment of chronic 
laryngitis, at all stages, rest of the vocal organs is 



LARYNGITIS, [CHRONIC] 



117 



indispensable ; but it is difficult to have it rigor- 
ously enforced. In the early periods, bloodletting 
from the arm is sometimes demanded, and in al- 
most every case, it will be advisable to apply cups 
to the nape of the neck, or top of the chest ; or, 
what is better, leeches freely over the seat of the 
disease. Emollient fomentations and poultices, 
likewise afford relief, but they have been objected 
to — probably altogether on hypothetical considera- 
tions — under the idea that they solicit an increased 
flow of blood towards the throat, and thus aggra- 
vate the disease. Revellents are, certainly, impor- 
tant remedies. A blister may be applied to the 
top of the sternum, or over the trachea, and as 
soon as it heals, another should be applied, so as 
to keep up an intermittent, which is preferable to 
a permanent, irritation. Hence blisters, thus em- 
ployed, are better than setons ; and the ointment 
of the tartrate of antimony and potassa, or the 
croton oil, is, perhaps, preferable to either. 

With the view of procuring rest, opium and 
its preparations may be given. They are useful, 
likewise, in allaying cough. The salts of morphia 
may also be employed endermically, and advan- 
tage has been derived from frictions over the 
larynx, with the extract of belladonna. 

Where the affection of the larynx has lost its 
inflammatory characters, and any of its termina- 
tions remain, topical remedies may be employed. 
These have, indeed, been regarded by MM. Trous- 
seau and Belloq (Practical Treatise on Laryn- 
geal Phthisis, translated by Dr. Warder, Amer. 
Med. Lib. Edit. Philad. 1S38) as the most effica- 
cious of all. They may be made to come into 
immediate contact with the diseased surface itself. 
At an early period of the disease, inhalations of 
the steam of warm water may be employed with 
advantage, but subsequently more excitant appli- 
cations are needed, to induce a new action in the 
diseased surface. Inhalations, however, are liable 
to the inconvenience, that they cannot be restricted 
to the larynx ; and, consequently, no agents are 
administered, in this manner, in cases of chronic 
laryngitis, except such as do not over-excite the 
mucous membrane of the lungs. The vapour of 
hot water, to which one of the essential oils has 
been added, may be used in the way of inhalation, 
with safety and occasional benefit. Various forms 
of apparatus have been devised for this purpose ; 
but MM. Trousseau and Belloq frankly confess, 
that a simple teapot is as well adapted to the pur- 
pose as the most complicated machines. In this 
way, chlorine, creasote, and iodine, may be inhaled 
under the circumstances laid down under Tuber- 
cular Phthisis. 

Topical remedies in solution are more to be 
relied on. Of these, nitrate of silver, corrosive 
sublimate, sulphate of copper, nitrate of mercury, 
and Lugol's caustic solution of iodine, (see the 
writer's New Remedies, 4th edition, Philad. 1843,) 
have been employed ; but the nitrate of silver is to 
be preferred, on account of its rapidity of action 
and harmlessness. It may be used in the propor- 
tion of ten or fifteen grains to the ounce of water, 
and it has been prescribed as strong as one part 
of the nitrate to two parts of water. Various 
plans have been adopted for applying it. The 
author uses a mop of rag at the extremity of a 
piece of whalebone. Others attach a piece of 



sponge to the end of a quill, dip it in the solution, 
and having slightly squeezed it to prevent the fluid 
from dropping, they touch the posterior fauces ; 
raise the outer extremity of the quill so that the 
sponge may touch the epiglottis and superior part 
of the larynx, and draw it gently out in this man- 
ner. Thus, the solution is made to come into 
immediate contact with the inflamed surface. By 
others, it has been advised to take up a drop of 
the strong solution on the bent extremity of a 
piece of firmly rolled paper, or whalebone, and to 
cause this to touch the lining membrane of the 
larynx. It has been suggested, that the solution 
may be thrown, in the form of a shower, into the 
larynx, from a small silver syringe, like Anel's ; 
but the plans, already recommended, have the 
merit of being more easy of application. 

A plan — before mentioned — proposed by Mr. 
Cusack, of Dublin, has been regarded by a com- 
petent witness, Dr. Stokes, (Op. cit.) as the best 
of all. A brush of lint, of the requisite size, is 
sewed on the end of the finger of a glove, which 
is then drawn on the index finger of the right 
hand. The patient is made to gargle with warm 
water, and the lint being dipped in the solution, 
can be readily applied to the larynx. 

When the disease is dependent upon any 
syphilitic vice, it may be necessary to administer 
mercury, or some other revulsive agent — iodine, 
for example. When mercury is pushed so as to 
affect the mouth, it sometimes breaks in upon the 
morbid chain where no vice is suspected or present. 
It should be given, under such circumstances, so 
as to exert its ordinary influence slightly on the 
mouth. When, however, pulmonary tubercles 
are coexistent, care must be taken in the adminis- 
tration of this potent remedy, as the dyscrasy, in- 
duced by it, is apt to cause their development. 
Where the disease is dependent upon the use of 
mercury, it should, of course, be carefully abstained 
from, and an appropriate treatment, in which rest 
and the free use of iodine are combined, should 
be prescribed. 

In many cases, the spasmodic exacerbations are 
very severe and distressing : they may be assuaged 
by opiates, or by the application of the empla&lrum 
belladonnse or emplastrum opii. 

Lastly, — a question may arise as to the neces- 
sity for the operation of tracheotomy. Although 
frequently demanded in acute laryngitis, and not 
to be postponed, it is rarely necessary in cases of 
chronic laryngitis; but should symptoms, similar 
to those of acute laryngitis, which demand the 
operation, arise, it must be unhesitatingly per- 
formed. It is probable, however, that in such a 
case, the operation could be of but transient ben- 
efit; so much disorganization must have occurred 
as to render ultimate recovery almost wholly, if 
not wholly hopeless. RoBLEy Dungli3On0 

LATENT DISEASES.— It is a fact familiar 
to every physician practically conversant with 
the features of disease, that many disorders, even 
those of which the presence is commonly indicated 
by well-marked symptoms, will in particular cases 
present, throughout the whole or a great part of 
their course, a material deficiency or total absence 
of their usual external characters; and that on 
this account they are frequently on the one hand 



113 



LATENT DISEASES. 



confounded with other diseases, on the other en- 
tirely concealed from observation. 

'Considering the obvious importance of this sub- 
ject in a practical point of view — especially, it 
may be added, to those just entering on their pro- 
fession, — it scarcely seems to have hitherto re- 
ceived from pathological authors in modern times 
that systematic attention to which it has an un- 
doubted claim. In ordinary practice every ob- 
servant physician is subject to be taken at una- 
wares by the sudden transformation or sudden de- 
velopment of the symptoms of diseased action, 
long latent in the system, and secretly advanced 
beyond the reach of a remedy. And in the prac- 
tice of one particular branch of his art, that of 
medical jurisprudence, nothing is more common 
than to find his opinion and conduct embarrassed 
by sudden death arising in the like circumstances 
— by the discovery of appearances in the dead 
body adequate apparently to account for death, 
yet unconnected with any traces of the existence 
of corresponding disease during life. It would be 
an object of some consequence then to investigate 
the subject of latent diseases systematically in both 
of its relations now mentioned, — to present a 
classification of the several diseases which are apt 
to assume a latent course, a sketch of the circum- 
stances in which they are liable to occur in this 
form, and an exposition of the phenomena in the 
living body which may lead to a suspicion or con- 
viction of their presence, as well as a statement 
of the evidence by which, in the case of the sud- 
den extinction of life, we may determine from the 
appearances in the dead body, taken along with 
other collateral considerations, what has been the 
real cause of death. 

The great extent of the subject, combined with 
other circumstances, prevents us from undertaking 
at present what must be to the generality of the 
profession the more important and interesting de- 
partment of this inquiry, — that, namely, which 
concerns latent diseases in their relations to ordi- 
nary practice. In undertaking to give some ac- 
count of their medico-legal relations, it is almost 
unnecessary to observe, that the writer was first 
led to review the subject in consequence of its 
having been often brought forcibly under his at- 
tention during a period when he was frequently 
consulted in medico-legal cases, and that the hints 
which follow are chiefly derived from a consider- 
ation of what then appeared defective in our 
knowledge. 

The importance of latent diseases in respect to 
medical jurisprudence depends on the considera- 
tion that sudden death, as one of their results, 
often leads to a judicial inquiry into its cause, 
even where no suspicions exist in regard to its 
manner ; that sudden death from latent diseases 
frequently occurs where collateral circumstances 
lead to a suspicion of violence ; that they are apt 
to prove suddenly fatal from the operation of slight 
violence or of circumstances incidental to violence, 
such as anger, struggling, or the like ; and that 
the appearances they leave in the dead body may 
exist in the same organs, or even also present the 
same characters, with the appearances occasioned 
by death from violence of various kinds. On all 
these accounts latent diseases come frequently be- 
fore the physician in his medico-legal capacity, 



and may give rise to medico-legal questions of 
much nicety. The remarks which follow are in- 
tended to exemplify what is now stated, and to 
supply as far as possible the means of investiga- 
ting the cases here alluded to. These objects 
will be best attained by considering, first, wlmt 
diseases are apt to put on a latent character and 
occasion sudden death ; and next, by what means 
it may be proved in special cases that they have 
really been the occasion of death. 

There are many diseases which may exist for a 
long time, and even advance so far as to cause 
decided injury to organs important to life, without 
seriously incommoding the patient and without 
occasioning death. Nay, there are many diseases, 
among those usually marked by prominent symp- 
toms throughout, which may go on for a length of 
time and occasion most extensive organic derange- 
ment, without attracting the attention of the patient 
or his friends by any external sign, without produ- 
cing ill health of any kind, and still more without 
being the occasion of death. In many such in- 
stances indeed the symptoms proper to the disease 
are incidentally developed after a time, and then 
follow their usual course to a favourable or unfa- 
vourable termination. But often, too, no such 
development takes place, and death may ensue 
suddenly, nay instantaneously, either from the 
disease attaining a certain point incompatible with 
the further continuance of life, or from some cir- 
cumstances connected with it of which the opera- 
tion cannot be satisfactorily traced : and, which 
is perhaps still more common, death may be oc- 
casioned by some other unconnected cause, and 
the first hint of the existence of latent disease is 
the discovery in the dead body of extensive alter- 
ations of structure, such as might be regarded, 
were it not for such occurrences, wholly inconsis- 
tent with the discharge of the most important 
vital functions. 

It would not be easy to give a complete cata- 
logue of the diseases which may thus run a latent 
course. Probably, indeed, such a catalogue would 
be found to comprise all or nearly all the diseases 
which give rise to important derangements of 
structure in the chief internal organs of the body. 
But it may be of use to indicate those which are 
most apt to assume the latent form, because such 
alone appear of material consequence to the prac- 
titioner. 

Among the diseases of the head, those which 
are chiefly apt to present themselves in a latent 
form are sanguineous apoplexy, inflammation of 
the cerebral membranes, and inflammation of the 
substance of the brain. 

Sanguineous Apoplexy often runs its course 
so rapidly, although with distinct symptoms, that 
in reference to practical questions of a medico- 
legal nature, it presents all the peculiarities and 
all the importance of a truly latent disease ; but 
it would be out of place to treat of it in that re- 
spect at present. In numerous instances, how- 
ever, sanguineous effusion within the head may 
take place without occasioning the usual apoplec- 
tic symptoms, and the individual may live so long 
that complete recovery takes place by organization 
and absorption of the clot, or he may be cut off 
at an earlier period by some other cause. The 
proof of this is, that clots both old and recent are 



LATENT DISEASES. 



119 



not uncommonly found within the head, and more 
especially in the substance of the brain, where 
the individual was cut off by a wholly different 
disease, and where there was sufficient evidence 
that symptoms of an apoplectic nature never had 
presented themselves. In a case therefore where 
the manner of death is doubtful, and a medico- 
legal examination becomes necessary, it is not 
enough to account for death that a clot be found 
in the brain, particularly if it be plainly of some 
standing. Further evidence may be necessary to 
connect this appearance with the death of the in- 
dividual. 

It is seldom that inflammation of the 
membranes of the brain assumes a latent 
form throughout its whole course, yet in some 
instances the symptoms are extremely obscure for 
a time, so that the nature of the disease is at first 
misunderstood ; and occasionally it has happened 
that no well-marked indications of disease are de- 
veloped till a short time before death, and even 
then the symptoms are merely such as may termi- 
nate organic affections of the head in general, — 
namely, stupor, coma, and convulsions. One 
distinct case in point has been related by the 
writer elsewhere, that of a middle-aged female, 
who died suddenly from chronic and circumscribed 
inflammation of the membranes of the brain. In 
this case the membranes and also a part of the 
bjain were covered with pus, the corresponding 
portions of the temporal and occipal bones were 
denuded and similarly lined with purulent matter, 
and a portion had even escaped into the cavity of 
the ear. This affection had commenced in the 
bones at least a twelvemonth before, because the 
patient had been affected for that time with a 
purulent discharge from the ear. There can be 
no doubt, too, that the inflammation of the mem- 
branes which was the immediate occasion of 
death, and was produced by the disease of the 
bone being propagated inwards, must have ex- 
isted for a considerable length of time, yet no 
symptom of its existence was detected till she 
was suddenly seized with acute pain in the head, 
and then with stupor and convulsions, under 
which symptoms she died within twenty hours. 
A case somewhat like this, but where the menin- 
geal inflammation was more extensive, has been 
related by Dr. Powell, in the fifth volume of the 
Transactions of the London College of Physi- 
cians. 

But even meningitis of a more diffused cha- 
racter, and commencing without previous disease 
in adjacent parts, may likewise put on this singu- 
lar form, as will appear from the following re- 
markable case related by Dr. Crispin, in the 
" Annali Univ. di Medicina." A stout healthy 
young woman complained for two days of slight 
headach, without any other indication either of 
disorder within the head or of any other affection, 
and was then quite suddenly seized with loss of 
speech, complete coma, and febrile reaction, under 
which symptoms she died in the course of the 
ensuing night. On dissection, there was found 
suppuration of the arachnoid membrane, while all 
the other parts of the brain and its membranes, as 
well as all the other organs of the body, were in 
the healthy state. (Prospetto Clinico, in Annali, 
&c. Maggio, 1833.) 



It is not improbable that to the same head of 
latent chronic meningitis should be referred those 
remarkable cases where extensive serous effusion 
over the brain or within the ventricles has been 
found after death in persons either dying suddenly 
without any pre-existing symptoms, or expiring 
slowly under symptoms wholly unconnected with 
the morbid appearances. Dr. Abercrombie re- 
lates an instance of the latter description from the 
experience of Professor Turner of Edinburgh, 
where serosity was extensively effused under the 
membranes of the brain as well as in the ventri- 
cles, and where the patient presented no signs of 
an affection of the head, but appeared to be gra- 
dually worn out by some chronic disorder of the 
pelvic viscera, which, however, were found to be 
healthy. (On Diseases of the Brain, p. 214, third 
edition.) The same author mentions two similar 
cases from the works of Morgagni and Heberden, 
in one of which the effused fluid amounted to 
eight ounces, without any corresponding symptom 
during life. (Ibid. p. 143.) Perhaps the follow- 
ing extraordinary instance may be classed with 
the foregoing. But whether it be viewed as an 
example of latent meningitis or not, it is well 
worthy of notice as an illustration of the great 
difficulty which the occasional occurrence of cases 
of an allied nature may introduce into medico- 
legal inquiries, and of the importance of the 
whole subject of latent diseases. A man of the 
name of Kennoway was tried in Edinburgh, in 
1825, for parricide, under the following circum- 
stances. His sister left him in a state of furious 
intoxication, quarrelling and struggling with his 
father, an old man of seventy, of passionate dis- 
position, but enjoying good health. On his quit- 
ting the house she returned — not above seven 
minutes after she left them together — when she 
found the old man lying dead on his back, with 
the marks of two blows on the nose and forehead, 
not particularly severe. On dissection there was 
found no fracture of the bone, no extravasation 
beneath it, no laceration of the brain, but an effu- 
sion of half a pint of reddish serum in the ven- 
tricles, and also towards a pint of serum in the 
cavity of the pleura on each side of the chest. 
This case presented several other features of in- 
terest foreign to the object for which it is now 
referred to. At present it may be observed, that 
the medical gentlemen who conducted the exami- 
nation ascribed death to the effusion in the ven- 
tricles, and the effusion to the blow. But it is 
quite clear that the latter statement is untenable — 
that the effusion must have taken a much longer 
time to collect than seven minutes, and the most 
rational view of the case seems to be, that the 
effusion was the result of latent chronic menin- 
gitis. 

Among diseases which leave their traces within 
the head, none is more subject to assume a la 
tent form than inflammation of the cerebral 
substance. From numerous cases which have 
been related by various authors, it follows that in 
its chronic form inflammation of th* cerebral tis- 
sue — that form of disease which is now familiarly 
known to terminate in suppuration or in softening 
of the brain — is seldom marked at the beginning 
by characteristic symptoms; that it often advances 
to a great height with scarcely any apparent 



120 



LATENT DISEASES, 



signs of its existence, or even of ill health of any 
kind, till only a few days before death ; and that 
not unfrequently it even proves suddenly or al- 
most instantaneously fatal during a state of appa- 
rently perfect health. The following illustrations 
have been already given by the writer in another 
work, but may be here briefly recapitulated. In 
a case related by M. Louis, where death slowly 
terminated an attack of diseased heart, and where 
no symptoms of an affection of the head occurred 
at any time, an extensive softening was found in 
the thalamus and corpus striatum of one side. 
(Recherches Anat. Pathol. 313.) In another, 
mentioned by Lancisi, where slight occasional 
fits of lethargy succeeded an attack of apoplexy, 
death occurred suddenly more than a year after- 
wards, and an extensive suppuration of the brain 
was found surrounding a clot. (De Mort. Subit. 
p. 12.) In another, which occurred to the writer 
himself, and which from its circumstances led to 
a medico-legal investigation, a twelve hours' ill- 
ness consisting of coma and convulsions preceded 
death, and there was found superficial circum- 
scribed ulceration of the anterior lobe of the brain. 
In another, which likewise occurred in the prac- 
tice of the writer, a similar superficial softening 
and ulceration of the surface of the brain over 
the left orbit was found, although the patient had 
been affected with coma for an hour and a half 
only, and had previously enjoyed good health. 
(Treatise on Poisons, 574.) Lastly, in a remark- 
able instance described in the London Medical 
Repository, where death took place instantaneous- 
ly, without any precursory illness at all, while the 
individual, a sailor, was pulling an oar, there was 
discovered on dissection in the central parts of the, 
brain an extensive softening and suppuration, 
which in the form of an abscess had made its way 
to the outer surface of the organ. (Vol. ii. 318. 
N. S.) 

Diseases of the chest run an obscure or com- 
pletely latent course much more frequently than 
diseases of the head, and among these the most 
remarkable are pleurisy, peripneumony, and or 
ganic diseases of the heart. 

As to pleurisy, it is remarked that sometimes 
the early, and at other times the middle stage is 
latent. There are either no symptoms at all, or 
they are so slight as to escape notice ; or, though 
obvious at first, they disappear afterwards, and 
seem to be succeeded by convalescence or even 
complete re-establishment of health. Lymph and 
serum, however, or sometimes purulent matter, 
have in the mean time been effused into the cavity 
of the chest, and the effusion goes on silently in- 
creasing till one side of the chest is completely 
filled, and the corresponding lung compressed and 
unserviceable. And at length, occasionally after 
a long interval, the individual is seized with la- 
borious breathing, and dies in a few days or hours, 
or even instantaneously. 

An instance where the interval of obvious ill- 
ness lasted for a few days, occurred in Edinburgh 
in January, 1826, and led to a medico-legal in- 
vestigation, in consequence of the patient's friends 
having neglected to obtain medical advice, and 
refused information to the neighbours who after- 
wards inquired into the case. The symptoms 
were difficult breathing, cough and pain of chest, 



.light at first and severe only for a short time be- 
fore death, which took place in the course of the 
third day. On dissection one side of the chest 
was found filled with serous fluid, together with 
evident collateral signs of the effusion having 
been of old standing ; and it was ascertained that 
several months before, recovery had to all appear- 
ance been attained from a severe attack of pleu- 
risy and consequent hydrothorax. A more re- 
markable instance, where the pectoral symptoms 
subsisted for a few hoars only, is related in Cor- 
visart's Journal. In this case the patient, who 
was convalescent from an attack of simple fever, 
was suddenly taken ill with great oppression in 
the chest, and died within twenty-four hours, and 
the left side of the chest was found filled with 
five pints of serum, and the heart covered with a 
net-work of lymph, evidently showing the exist- 
ence of an old pleuro-pericarditis. (Journ. de 
Med. xxviii. 100.) But the most common cases 
of the kind under consideration are where the 
disease is concealed throughout its whele progress, 
or becomes so after a time, and death takes place 
instantaneously. Of such a course the following 
are apt illustrations. A girl in the wards of the 
Edinburgh Infirmary, under the writer's care, 
while convalescent apparently from nothing more 
than a mild attack of simple fever with insignifi- 
cant pectoral symptoms, suddenly dropped down 
dead while sitting by the fire and laughing with 
her fellow-convalescents, and on dissection there 
was found a copious effusion of serum and lymph 
into the right side of the chest, with complete 
condensation of the right lung. An elderly man 
under the care of another physician of the same 
hospital was admitted in the agony of suffocation 
from hydrothorax consequent on pleurisy, but re- 
covered apparently, and in six weeks was consi- 
dered nearly fit for being discharged. But one 
morning, while in the act of making his bed and 
exerting himself with unusual force, he was seen 
to drop down on the floor, and the nurse running 
up to him, found him quite dead. Five pints of 
serum were found in the right side of the chest, and 
no other morbid appearance could be discovered. 
Peripneumony is similarly circumstanced. 
It is a matter of daily observation, as Laennec 
has pointed out, that very great differences prevail 
in different cases in the amount of organic altera- 
tion which takes place in ordinary cases of inflam- 
mation of the lungs, before death ensues from 
oppression of the breathing. It follows that, even 
in acute inflammation, the function of the lungs 
may be much interfered with by the inflammatory 
process, without necessarily endangering life. It 
is not surprising, then, that where the local inflam- 
mation is chronic, and the constitutional derange- 
ment slight or wholly absent, very extensive 
ravages may be committed by the disease without 
its giving any local sign of its presence. Many 
cases might be quoted in illustration of the fact 
that chronic peripneumony may advance till it 
completely obstructs a whole lung, without any 
sign of oppression of the functions of the lungs'; 
and in such cases death may occur suddenly, 
without any fresh cause appearing to act, or it 
may he occasioned by some other disease or agent 
of a different kind, such as violence. The follow 
ing are examples. 



LATENT DISEASES. 



121 



A man, who, with the exception of a slight 
cough, enjoyed excellent health, died suddenly one 
night, while making a slight effort ; and one lung 
was found wholly disorganized and formed into a 
sac of purulent matter, which had burst into the 
general cavity of the pleura. (Diet, des Sc. Med. 
art. Mart Subite.') Wildberg relates a similar 
case, which is very striking on account of the cir- 
cumstances in which it proved fatal. A woman 
having charged a neighbour with having pilfered 
herbs in her garden, an altercation ensued, which 
was brought to a close by the neighbour seizing 
her by the arms, shaking her violently, and shov- 
ing her away. She fell down, and in fifteen 
minutes expired. On opening the body it was 
found that a large vomica of the left lung had 
burst into that side of the pleura, and filled it 
with four pounds of bloody pus. (Prakt. Hand- 
buch fur Physiker, hi. 255.) It was ascertained 
that the woman had an attack of peripneumony 
a year before ; but from that time enjoyed good 
health, except that she complained of trivial cough, 
and some tightness in the chest. Two similar 
cases are related in Sedillot's Journal by a French 
physician, M. Mouton. One was the case of a 
custom-house officer, who died almost instantly 
after making a sudden effort in getting on board a 
vessel; the other was that of a sailor-lad who was 
found dead in bed, having retired in good health 
the previous evening. In the former, the right 
lung was one entire mass of suppuration ; in the 
latter it was almost entirely in a state of carnifica- 
tion. In referring these cases to peripneumony, 
it must at the same time be admitted that several 
of them may be conceived to be instances rather 
of chronic pleurisy and empyema, having occurred 
before the late improvements in the pathology of 
diseases of the chest had led to a more accurate 
diagnosis of them. 

Of all the diseases, however, which are the 
subject of the present sketch, none are of such 
frequent occurrence as organic diseases of tlie 
heart. Diseases of the heart often exist for a 
long time without a single symptom to attract the 
attention of the patient or his friends, and often 
prove instantly fatal without a single precursory 
warning. Nothing can exceed the irregularity of 
the circumstances in which such diseases prove 
fatal. Not only may one man sustain, without 
inconvenience, an amount of organic injury which 
cuts short the life of another ; not only may one 
suffer long and cruelly from the same affection in 
kind as well as degree, which kills another without 
a moment's previous suffering; but likewise one 
person may die of a limited extent or degree of a 
disorder which, in another, reaches an extraordi- 
nary height without giving a single indication of 
its presence. It is almost unnecessary to illustrate 
by examples statements so familiar to all prac- 
titioners. But as they are nevertheless apt to 
escape attention in medico-legal investigations, a 
few instances will be subsequently mentioned, 
which will at the same time place in a clear light 
the importance of the present description of dis- 
eases in the practice of medical jurisprudence. 
Meanwhile it may be mentioned that, as sudden 
death from latent organic affections of the heart 
is the moet common of all the varieties of sudden 

Vol. m. — 16 i 



death from latent diseases, so is it medico-legally 
the most interesting and the most important. 

It would not, at first view, appear probable that 
pneumothorax ought also to be enumerated 
among diseases of the chest which may put on a 
latent course, and prove suddenly fatal. In the 
most frequent variety of it, which is occasioned by 
a softened tubercle opening a passage into a bron- 
chial tube on the one hand, and through the 
pleura into the cavity of that membrane on the 
other, the progress of matters is usually marked 
both by the antecedent symptoms of tubercles in 
the lungs, and by dyspnoea and other symptoms 
which succeed the passage of air into the cavity, 
and precede the fatal termination for a considera- 
ble interval of time. But at times the antecedent 
symptoms of tubercles are obscure or wholly absent, 
and death takes place suddenly at the moment of 
rupture of the pleura and passage of air into its sac. 
The following interesting case, which occurred ii> 
1831, in the clinical wards of the Edinburgh In- 
firmary, under the care of Dr. Graham, establishes- 
the statement now made. An elderly man had been 
six weeks ill, and during four of these in the hos- 
pital, on acccount of a dyspeptic complaint, and 
never presented any symptom to draw attention 
towards the chest as the seat of disease. At 
length he suddenly complained of an uneasy feel- 
ing in the pit of the stomach, and expired at once. 
The left lung was all studded with tubercles, so 
as to be almost impervious throughout to the air, 
and consequently unserviceable in the function of 
respiration ; the right side of the chest was filled 
with air, so that the right lung, itself not very 
materially tuberculated, was compressed, and thus 
rendered unserviceable also ; and the air had 
obviously issued from a recent ulcerated opening 
in the lower lobe, establishing a communication 
between the sac of the pleura and a considerable 
bronchial tube. The cause of the man's sudden 
death was here quite obvious ; and the whole cir- 
cumstances of the case prove how pneumothorax 
may be the occasion of instantaneous death, where 
no reason existed for suspecting the presence of 
any of the pathological conditions in which it is 
known to originate. 

This case leads to the observation, that pul- 
monary tubercles are very frequently latent 
for a very great part of their progress. So long 
as they do not undergo the process of softening, 
they may gradually invade a large portion of one 
or even of both lungs, without occasioning any 
material disturbance to the general health, or even 
so far disturbing the function of respiration as to 
attract forcibly the patient's attention. Cases 
even occur from time to time where tubercles of 
considerable size have softened and suppurated 
without the process being indicated by the usual 
outward symptoms, and without any marked dis- 
turbance to the general health. These facts are 
so familiar to every one who is extensively engaged 
in practice, — especially in hospitals, — that it 
seems unnecessary to illustrate them by any ex- 
amples. The writer even knew an instance where 
numerous tubercles, evidently old, and some of 
them completely suppurated, were found in the 
lungs of a friend, who died of a totally different 
disease; namely, spreading cellular inflammation, 



1J2 



LATENT DISEASES. 



and who, till within a few Jays of death, was 
much addicted to athletic exercises. 

Pulmonary tubercles, which have pursued a 
silent course, may even prove suddenly fatal ; but 
in such cases there is always some accessory and 
obvious pathological condition superadded, which 
is the real cause of the fatal termination. One of 
these has just been exemplified ; namely, pneumo- 
thorax. Another, of much more frequent occur- 
rence, is rupture of one of the larger blood-vessels 
in the lungs, by erosion of its coats, occasioned 
by the proximity of a tubercle. 

Diseases of the great vessels within the 
Chest come under the same designation with 
diseases of the heart, inasmuch as their course is 
frequently altogether latent, and their termination 
in death instantaneous. But in cases of instanta- 
neous death, the immediate cause of death is 
always apparent in rupture of the vessel and sud- 
den hemorrhage. It does not appear that diseases 
of the great thoracic vessels are ever circumstanced 
as in those frequent cases of diseases of the heart, 
where death takes place suddenly without any 
discoverable accessory pathological phenomenon, 
to explain why death occurred at the particular 
period, and not days, weeks, or even months 
before. 

Of Diseases of the Abdomen there are 
several which may run a latent course for a very 
long time ; but there are few which will remain 
latent to the last, like many of the diseases men- 
tioned under the preceding heads. 

Ulceration of the membranes of the stomach, 
proceeding from within outwards ; ulceration of 
the intestines, of the same nature ; ulceration of 
the gall-bladder, or of the biliary ducts ; chronic 
organic derangement of the great secreting viscera, 
— more especially of the liver or kidneys ; chronic 
disease of the coats of the large abdominal vessels ; 
extra-uterine conception, of various kinds ; — may 
exist for a great length of time, without occasion- 
ing any characteristic symptoms, or even, at times, 
any derangement of the health at all. In general, 
however, as they approach a fatal termination, 
they develop themselves fully by their external 
characters. But, on the other hand, they fre- 
quently prove fatal suddenly, or in a much shorter 
space of time than usual, in consequence of some 
incidental pathological change being produced 
during their progress. Rapid death, from perfora- 
tion of the stomach or intestines ; from rupture 
of one of the biliary ducts ; sudden death from 
the rupture of a perforated vessel, or of a brittle 
spleen ; or of an extra-uterine conception, &c, 
are more or less familiar illustrations of such a 
course of things. Of the last-mentioned remarka- 
ble and rather rare accident, the following import- 
ant example occurred to the writer, a few years 
ago. The case was a medico-legal one ; a judicial 
inspection having been ordered in consequence of 
various circumstances, which it is unnecessary to 
notice here, having led to a very strong suspicion 
of poisoning. The female died of a few hours' 
illness, referable, as it seemed, to irritation in some 
organ in the abdomen. She had enjoyed good 
health for some time before, except that four 
weeks previously she had miscarried about the 
middle of the second month of pregnancy. On 
dissection, the abdomen was found to contain 



several pounds of recently effused blood ; and Ua 
source was a lacerated opening in a Fallopian 
conception, to all appearance in the course of the 
third month. The state of advancement of the 
ovum, the absence of the membrana decidua, and 
the exact correspondence in the appearances of a 
corpus luteum in each ovary, showed that the 
woman had had a twin-conception ; one uterine, 
the other Fallopian. Another abdominal affection, 
which it may be right to specify as occasionally 
assuming the latent form, is the accumulation of 
worms in the intestines. Intestinal worms com- 
monly occasion characteristic symptoms; and in 
some instances they have been known to produce 
death under symptoms of epilepsy, not merely in 
children, but likewise in adults. (Treatise on 
Poisons, p. 590.) But in other circumstances 
they have been observed to accumulate to an 
enormous amount, without their presence being 
suspected till the supervention of a convulsive 
affection, a short time before death ; and in not a 
few instances worms have been found abundantly 
in the intestines, after death from some uncon- 
nected disease, although they were not indicated 
by any symptom during the life of the indivi- 
dual. 

It is probable that various Diseases of the 
Spine may put on a latent course; but as the 
greater part of the organic disorders of this re- 
gion of the body have been accurately discrimin- 
ated only in recent times, facts are still wanting 
on the subject. Meanwhile it is well ascertained 
that caries of the bones of the spine, though in 
general it leads sooner or later to the production 
of symptoms which no observant practitioner can 
pass over or mistake, will nevertheless proceed at 
times to an advanced stage of its progress, and 
extend widely its devastations without any pro- 
minent sign of its presence being given forth. In 
one variety of it, which terminates in dislocation 
of the processus dentatus of the second vertebra 
of the neck, instant death may occur, where no 
suspicion existed of the presence of any disease 
in the actual seat of mischief. Under this head 
too may perhaps be arranged a very extraordinary 
case of sudden death related by Dr. W. Thomp- 
son of Edinburgh, where the individual, while 
recovering from an ordinary cold, was found dead 
in bed, and the only unusual appearance to be 
discovered was fracture and dislocation of the 
processus dentatus, without any disease in the 
bones or ligaments, and without the slightest 
possibility of a suspicion of violence. (Edin. Med. 
and Surg. Journ. xlii. 277.) In cases like this it 
may not always be easy to feel assured that the 
injury was not inflicted after death in the course 
of the twisting to which the neck is often sub- 
jected in opening the head. 

The preceding remarks on the various diseases 
which may run a latent course must be taken by 
the reader as mere illustrations of the subject, and 
by no means as intended to exhaust the list. 
Other diseases are similarly circumstanced. But 
those which have been specified comprehend by 
far the greater number of them ; and they have 
appeared to the writer, on reference to his own 
medico-legal experience, as well as to the valua- 
ble and extensive records of medico-legal cases in 
German and French journals, to be the most fre- 



LATENT DISEASES, 



123 



qucnt, and to bear the most important relations to 
medical jurisprudence. 

The practical inference to be drawn from what 
has been already stated is, that, while latent dis- 
eases by occasioning sudden death frequently 
give rise to medico-legal investigations which are 
at once cleared up by the inspection of the dead 
jody, we are not always entitled to infer, in cir- 
cumstances of justifiable suspicion, that the dis- 
covery of such morbid appearances as indicate the 
pre-existence of latent disease will account for 
death, — that the latent disease was the occasion 
of death. For, during the latent period of the 
disease, death may have arisen from a different, 
perhaps a violent cause. This inference is not 
a mere theoretical deduction, but is amply sup- 
ported by facts. For example, in Rust's Magazin 
is related the case of an apothecary who poisoned 
himself with prussic acid, and in whose body the 
lower lobe of the left lung was found consolidated 
and partly cartilaginous. (Mag. fur die gesammte 
Heilkunde, xiv. 104.) In Corvisart's Journal 
there is a more remarkable case of a soldier who 
died of a few hours' illness, and whose right lung 
was found after death forming, it is said, one 
entire abscess, — the case being probably one of 
chronic pleurisy and empyema. Yet this man 
clearly died of poisoning with hemlock, of which 
he partook accidentally with several of his com- 
rades ; and it is not unworthy of notice, as a far- 
ther illustration of what has been said of pleurisy 
as a latent disease, that he daily underwent to the 
very last day of his existence the duties and 
fatigues of a military life. (Journal de Med. xxix. 
107.) In Pyl's memoirs there is a similar account 
of a woman who enjoyed tolerable health, and 
died of a fit of excessive drinking, and in whose 
body the whole left lung was found in one mass 
of suppuration. (Aufs. und Beobacht. v. 103.) 

One of the leading peculiarities which renders 
these singular cases important in a medico-legal 
point of view, in so far as it tends, on the one 
hand, to bring such cases forward in a medico- 
legal shape, and on the other to render the deci- 
sion of them sometimes a matter of no small diffi- 
culty, — is that latent diseases are apt of themselves 
to prove suddenly fatal under the operation either 
of slight violence, or of the circumstances acces- 
sary to violence, such as passion, fright, struggling, 
and the like. The following are apposite illustra- 
tions. A foreigner, who was supposed to labour 
under no other disease except the natural infirmi- 
ties of a rather advanced period of life, quarrelled 
one evening with his bed-fellow, and in the course 
of the quarrel received but one blow, which was 
inflicted with a stick over the back of the hand. 
But he immediately fainted, and in three minutes 
was dead. The heart presented induration of its 
valves, but in particular was unusually vascular 
throughout its whole substance, and was covered 
with a layer of coagulable lymph, clearly showing 
the pre-existence of one of the most common per- 
haps of all latent diseases, pericarditis. (London 
Medical Repository.) A more remarkable and 
much more difficult case occurred to the writer 
not many years ago. A pawnbroker who had for 
a long time been often and severely maltreated by 
his wife, returned home one afternoon very tired, 
and immediately afterwards was heard by a neigh- 



bour undergoing the customary domestic disci 
pline. Fifteen minutes after he entered the house, 
a friend, who called for him, found him in bed in 
the agonies of death ; and in a few minutes more 
he expired without having been able to answer 
any questions. His wife was accordingly appre- 
hended under the charge of having poisoned him. 
A variety of medical as well as moral circumstan- 
ces, however, precluded the idea of poisoning ; 
and, although evident marks of the woman's vio- 
lent conduct were visible in the shape of both old 
and recent contusions of the arms and legs, there 
was no indication of any violence adequate to oc- 
casion death ; and the only way of satisfactorily 
accounting for death was by supposing, that amidst 
the circumstances accessary to the quarrel, he died 
of latent organic disease of the heart ; for there 
was found, throughout the septum of the ventri- 
cles, and extensively also in the external parietes 
of the heart, a conversion of the muscular fibre 
into a substance resembling tubercular matter. Of 
this disease he had not presented during life a 
single symptom, although he was much accus- 
tomed to active exercise. 

It is plain from the whole of the preceding line 
of statement, that in medico-legal cases involving 
the question of sudden death from latent disease, 
something more will be necessary for elucidating 
their nature than the mere discovery from appear- 
ances in the dead body that a latent disease had 
existed. In cases of death from obscure causes, 
it is in general considered sufficient in ordinary 
practice to explain its nature, if appearances are 
found in some important organ of the body of a 
kind which clearly indicates pre-existing disease. 
But this loose habit of inquiry will not answer in 
the practice of medical jurisprudence, for the ap- 
pearances may be those of a disease latent to the 
last, and death may have arisen from a cause of a 
totally different nature, — possibly from the very 
kind of violence which is suspected to have been 
applied. It is necessary therefore to obtain some 
further evidence of the connection of the morbid 
appearances with the fatal event, otherwise we are 
not entitled to say that the cause of death has 
been natural. 

The evidence to this effect may be taken from 
a variety of sources. 

1. The first and most satisfactory evidence is 
where the morbid appearances indicate that the 
disease has brought into action one of the proxi- 
mate causes of death, — that derangements of 
structure or function have been induced which 
must have been incompatible with the continu- 
ance of circulation or respiration. Thus we can 
have no difficulty in pronouncing the occasion of 
death to have been latent tubercles, where there is 
found along with tubercles either apoplexy of the 
lungs in connection with an opening in a large 
vessel, or pneumothorax attended with the pecu- 
liarities mentioned in a preceding part of this arti- 
cle. The cause of death is equally clear where 
chronic disease of a large vessel has been brought 
to a close by perforation of its coats and the dis- 
charge of several pounds of blood into the chest, 
or where latent disease of the heart has terminated 
in effusion of blood into the pericardium and 
stoppage of the heart's action by mechanical 
pressure. It is not often, however, that eviderce 



124 



LATENT DISEASES. 



of the kind now referred to can be obtained. It 
happens much more generally that morbid appear- 
ances, which in ordinary professional language 
are said to be sufficient to account for death, are 
nevertheless such both in kind and degree as indi- 
cate an amount and progress of disease which 
numerous facts have proved to be quite compatible 
with the further maintenance of life, or even with 
apparently good health. 

2. The next kind of evidence is furnished by- 
certain peculiarities in the morbid appearances, 
which, though not, according to our knowledge 
of the animal functions, incompatible with the 
continuance of life, — and not indicating that any 
of the proximate causes of death have been 
brought into action, — nevertheless are known by 
experience seldom or never to occur except where 
death does immediately or speedily follow. Thus, 
where in a case of sudden death, the circumstances 
immediately antecedent to which are unknown, a 
recently completed perforation of the stomach or 
intestines be found, or a rupture of the gall-ducts 
or gall-bladder, and effusion of the contents of the 
ruptured organ into the peritoneum, death from 
this concatenation of causes may be safely in- 
ferred. It further appears from various cases, of 
which a few have been related above, that the 
same inference may be drawn where an extensive 
abscess of the lungs seems to have just burst into 
the cavity of the pleura through the investing 
membrane of the lungs. We cannot exactly say 
why death should supervene rapidly in such cir- 
cumstances; for it often ensues long before in- 
flammation can arise in the membrane with the 
surface of which the foreign fluid comes in con- 
tact : but the fact is undoubted that speedy death 
is almost invariably the result; and this fact may 
fairly be made the basis of induction where the 
circumstances preceding death are unknown or 
doubtful, and an opinion must be formed on mor- 
bid appearances alone. 

It would be a matter of very great importance 
to discover some peculiarity of the kind we are 
now considering, in the instance of cases of sudden 
death from latent diseases of the heart. No species 
of sudden death is more common ; yet pathologists 
have not yet furnished any explanation of the im- 
mediate cause of death. Does it arise from sudden 
paralysis of the heart, or from spasm, or sometimes 
from the one, at other times from the other, — from 
excessive gorging of the heart's cavities, or from 
the blood not being supplied in sufficient quantity 1 
Or, leaving these questions in pathological phy- 
siology, by what characters, either in the morbid 
appearances or in the circumstances collateral to 
them, such as the state, quantity, or seat of the 
blood, may it be ascertained that an organic affec- 
tion of the heart, presented to view in a case of 
doubtful or suspicious death, has or has not been 
the occasion of death 1 This query may probably 
receive a reply after a more careful examination 
of the appearances where death has unequivocally 
been produced by disease of the heart ; but at 
present it must remain unanswered. 

3. Another description of evidence by which 
death may be presumptively connected with mor- 
bid appearances found in the body where the 
cause of death is obscure, is derived from the 
occurrence of symptoms immediately before death, 



which correspond with the appearances discovered. 
Thus where an individual dies under symptoms 
of sudden dyspnoea, and an extensive chronic 
pleurisy or peripneumony is found in the dead 
body, death is clearly to be referred to the latent 
disease. The same inference is allowable where 
symptoms of fainting precede death, and the ap- 
pearance found is organic disease of the heart, or 
where coma and convulsions immediately precede 
dissolution, and suppuration and softening of the 
brain, or the traces of chronic meningitis, are dis- 
covered. In many cases of this kind, however, 
regard must also be had to the particular species 
of violent death which may happen to be sus- 
pected ; because it may be that the symptoms an- 
tecedent to death are common both to the natural 
and the violent cause. 

4. Hence, in many instances, before inferring 
death to have arisen from a latent disease, of which 
the traces are found in the dead body, it is farther 
necessary to determine, by as many proofs as the 
nature of the case will supply, that violence is 
improbable, if not out of the question, — and in 
particular, that the circumstances will not bear out 
the suspicion of the particular kind of violent death 
which is imputed. It is seldom that cases occur 
where this cannot be done, provided a skilful use 
be made of those mixed medical and general cir- 
cumstances which no one but a medical man can 
properly collect or appreciate, but which, at the 
same time, it is right to observe that even medical 
men are apt to overlook or mismanage, from in- 
sufficient acquaintance with the principles of 
medical jurisprudence. This observation applies 
with peculiar force to that very common class 
of medico-legal cases where extraneous circum- 
stances, in the instances of sudden death from 
latent disease, have given occasion to a suspicion 
of poisoning. A skilful toxicologist, who is also 
a medical jurist, will almost always discover proofs 
enough to decide the question of poisoning. 

5. Additional information, by which much light 
may be often thrown on medico-legal cases involv- 
ing the question of sudden death from latent dis- 
ease, is derived from attending to the collateral 
conditions under which latent diseases are usually 
observed to prove suddenly fatal. These condi- 
tions are at least three in number. Many cases 
of latent disease have their symptoms first deve- 
loped, or even prove suddenly fatal, during the 
additional constitutional disturbance occasioned 
by a fresh disease. Thus, it is not unusual for 
death to take place suddenly, in the early stage 
of convalescence from other diseases. A few 
years ago, a convalescent in the Royal Infirmary, 
an athletic young man, who was recovering from 
a slight attack of fever, followed by a relapse, 
suddenly called aloud for help, dropped down 
deadly pale, and died apparently in a faint; and 
on dissection, there was found considerable en 
largement and hypertrophy of the heart, with con- 
plele adhesion of the pericardium. This is a 
single characteristic instance of an incident by nc 
means uncommon in hospitals. A second still 
more common circumstance which concurs with 
sudden death from latent disease, is some unusual 
or violent exertion. Several of the cases mentioned 
above, in illustration of various general facts, will 
likewise illustrate the present statement. The 



LATENT DISEASES — LEPRA. 



125 



two following, which are related by Lancisi, are 
also excellent additional examples. A corpulent 
footman, liable to occasional dropsy of the legs, 
unequal pulse and uneasy breathing, dropped 
down dead one day while running after his mas- 
ter's chariot. The heart was much enlarged, par- 
ticularly the right ventricle ; and the left ven- 
tricle, usually empty of blood after death, was 
found much distended, as if it had been unable to 
expel the blood which was transmitted to it. (De 
Mort Subit. i. 46.) Another footman, subject to 
palpitation and difficult breathing, yet so little in- 
commoded as to be able to run habitually with his 
master's chariot, died suddenly after coition ; and 
Lancisi found the heart enlarged to a size exceed- 
ing that of an ox. A third condition, in which 
latent diseases have been known to prove suddenly 
fatal, is during some violent emotion of the mind. 
This circumstance is even sufficient to occasion 
death, where the immediate cause of that event is 
some new accessary derangement of structure in- 
compatible with the farther maintenance of life. 
It is a common cause, for example, of rupture of 
the great thoracic vessels. An interesting medico- 
legal case of this nature has been related by the 
late Professor Chaussier. Two men, who had 
been long on bad terms with each other, met one 
day in the street, when one of them, who was on 
horseback, struck the other across the shoulders 
with a whip. The man who received the blow 
immediately pursued the rider in a tempest of 
passion ; but he had scarcely advanced a dozen 
steps when he dropped down, muttered a few in- 
distinct words, and died. Many people witnessed 
the affray, and they all believed the deceased had 
been killed outright by the blow. But on the 
body being examined, no outward mark of injury 
could be seen ; and it was subsequently found 
that an aneurism of the aorta had burst into the 
cavity of the chest. It is plain from the case for- 
merly noticed of sudden death from latent pericar- 
ditis during a quarrel, as might likewise be reason- 
ably inferred from physiological considerations, 
that latent diseases may prove suddenly fatal 
during violent emotions of the mind, even though 
no new accessary pathological injury be occa- 
sioned. 

The general result of the observations on the 
present head of evidence seems to be, that any 
circumstance which produces either sudden violent 
excitement or sudden violent depression of the 
circulation, may cause instant or speedy death, 
where extensive organic derangement has accu- 
mulated silently in any of the important organs 
of the body. 

By attending to one or other, or several of the 
criterions now laid down, it will seldom happen 
but that an opinion, strongly presumptive, if not 
even positive, may be formed on the question of 
the cause of death in the cases which are the 
subject of the antecedent comments. In some in- 
stances, however, this is impracticable ; and an 
excellent illustration is the singular case noticed 
above of instant death after a blow, where there 
was extensive serous effusion into the ventricles, 
the effect probably of chronic latent meningitis. 
The circumstances of death were conformable 
with the idea of sudden death from violent pas- 
sion, operating on a frame already brought to a 



peculiar condition by latent disease ; for it was 
proved that the old man was in a state of high- 
wrought passion, in consequence of the miscon- 
duct of his son. But it may also be readily con- 
ceived that a blow on the head might have the 
same effect, though quite insufficient to occasion 
such a result in ordinary circumstances. The 
prisoner was found guilty of culpable homicide, 
and transported for life. R# C HRISTIS0N. 



LEGITIMACY. (See Succession of Inhe- 
ritance.) 

LEPRA. — A/n-po: from heirpb;-pa, scaly; th. 
\t-nU, or Ai-of, a scale. A scaly disease of the 
skin, occurring generally in circular patches. At 
a very early period of medical literature, the con- 
fusion, which afterwards became " worse con- 
founded," began to reign concerning the terms 
lepra and leprosy. The Arabian physicians had 
described the tubercular elephantiasis, the elephan- 
tiasis of the lower extremity, and some varieties 
of scaly disease, under distinct appellations, which 
became frequently misapplied. When, at the re- 
vival of learning, the works were rendered into 
the European languages, the Latin translator 
multiplied the perplexity by interpreting the Arab 
word juzam by the term lepra, which the Greeks 
had applied to designate the scaly disease defined 
above. In the middle ages the term leprosy was 
indiscriminately applied to the different forms of 
elephantiasis, the scaly diseases, and, in fact, to 
any form of chronic skin-disease which was bad 
enough to entitle the subject of it to admission to 
the lazar- houses which were established over 
Europe at that time, where the indigent were glad 
to get the subsistence they provided at the ex- 
pense of being called lepers. This confusion has 
been a subject of complaint with writers from age 
to age, yet it became perpetuated. Hensler's 
learned treatise,* written with a view to elucidate 
the subject, left it nearly as complicated as ever ; 
for he and Sprengel treated under the term leprosy 
the various forms of elephantiasis, the Greek leuce, 
and the proper scaly lepra. Many modern writers 
do not appear to desire the removal of this ob- 
scurity, as they persist in describing the former of 
those under the name of leprosy. We trust, how- 
ever, that medical men will now see the expedi- 
ency of adhering to Willan's correct nomencla- 
ture in this instance, which restores to the term 
lepra its proper and original signification, namely, 
the scaly disease, the subject of this article. 

History of the Disease. — Lepra generally 
begins on the extremities, below the larger joints, 
where the skin covers but thinly the tibia and ulna 
respectively. It commences by small, roundish, 
smooth points, slightly prominent above the sur- 
face of the skin, which soon become red and shin- 
ing from being overlaid by minute transparent 
scales. These become soon detached and replaced 
by others. The eminences by degrees enlarge ; 
the scales become thicker, and are chiefly formed 
on the circumference of each spot. They observe 
the circular form in spreading, and attain the size 
of a shilling or a half-crown piece ; and as they in- 
crease, the circular border becomes raised and en- 

* P. O. Hcnsler. Vom Abendlandischen Aussatz im 
Mittelalter, nebst einem Beitrag zur Keantnisa mid 
Gescliiclite des Aussatzes. Hamburg, 1793 



126 



LEPRA. 



closes a red area, which is free from the squamous 
development. A red areola is also perceived ex- 
ternal to the raised circumference where the scales 
collect. These orbicular patches, in spreading, 
touch and intersect one another ; and though in 
this stage the circular form is lost, we may still 
trace the segments sufficiently well to show their 
original conformation. They unite usually first 
at the elbows and knees, the parts, as we have 
said, where the disease first shows itself. In the 
progress of the affection, while the existing patches 
are enlarging in this manner, new ones arise ; the 
abdomen, the back, and the chest become affected; 
and in some cases it spreads to the head, face, and 
hands. 

The scales fall off and are renewed very fre- 
quently. Sometimes they are so easily detached 
and form so rapidly, that the patient's clothes and 
bed arc filled with scales, which cause some irrita- 
tion : in other instances they adhere more firmly, 
and accumulate in such quantity as to impede the 
motions of the joints, — a still greater source of 
troublesome annoyance. 

By their multiplication the scales become aggre- 
gated apparently in an irregular manner ; yet 
each one is propagated from a centre, and is at- 
tached by a pulp to the dermoid tissue : this fact 
is proved by tearing one off, when a slight red 
speck is seen to project from the middle of the 
inferior surface, corresponding to a depression in 
the spot whence it has been displaced. When 
the disease has lasted long, or is in process of cure, 
the scales, as they fall, present the reticular emi- 
nences proper to the cuticle, and leave the surface 
red, smooth, and marked by corresponding reticu- 
lations. 

The description here given will apply to the 
great majority of cases of lepra, but it presents 
varieties derived from its extent, duration, and treat- 
ment. The accidental circumstances of situation 
and colour also impart to it certain peculiarities. 

It sometimes covers the whole body, commenc- 
ing for the most part from the extremities ; it be- 
gins usually on the two arms and legs at once, 
and propagates itself, as described, to the trunk ; 
it rarely spreads to any extent on the face : the 
forehead, the temples, and the external angles of 
the orbits are, however, often the seat of some 
scaliness spreading from the hairy scalp. When 
the scalp becomes affected, the scales are very 
minute, and generally cover an exudation derived 
from the inflamed bulbs of the hair ; a moisture is 
also remarked to accompany the scaliness when 
the disease invades parts where there is a neces- 
sary friction, or places furnished with many seba- 
ceous follicles, — as the nates and inside of the 
thighs, the axilla, the verge of the arms, &c. 
These form exceptions, however ; for it is one of 
the essential characters of the disease that the de- 
squamation is quite dry. 

In cases of a very chronic nature, where the 
disease is of such extent as to spread over the 
hands and invade the root of the nails, these be- 
come much altered in structure, curved, and of a 
dirty yellow colour. It has been observed in some 
rare instances that the dermoid tissue which 
secretes the nail has become inflamed and fur- 
nished a sanious discharge. (Rayer.) In the 
cases which are complicated by any of those acci- 



dental secretions, the lymphatic glands sometimes 
inflame and swell, as Richter remarks ; but we can- 
not admit into the description of lepra the rha- 
gades and ulcerations which are mentioned in 
his excellent work. (Specielle Therapic, vol. vi. 
p. 440.) 

A remarkable appearance which lepra some- 
times assumes has induced accurate observers to 
recognise in it a peculiar species of the disease. 
It has been observed on parts of the trunk that a 
complete desquamation over a considerable sur- 
face takes place without being followed by any re- 
production of scales in this particular place : it re- 
mains red and smooth, and still affects the circular 
form ; and not only is the whole area round and 
bordered by a slightly raised margin, but it con- 
tains within it some patches, either circular or ob- 
viously showing a disposition to that form, yet 
without scales either on the centres or the raised 
borders — their usual nidus. What makes this 
variety more remarkable is, that whilst the patches 
exhibit this feature probably on the back, it is as 
scaly as ever on the extremities. We must not, 
however, suppose that this partial absence of scali- 
ness in such rare cases makes any exception worth 
notice in the history of lepra ; in some instances 
it probably depends on idiosyncrasy, but we think 
it is more frequently a partial curative effort of 
nature, or the effect of medicine, which from some 
unaccountable cause is arrested after having pro- 
ceeded only so far as to check the morbid secre- 
tion of the cuticle, the vascularity still remaining. 
This explanation is rendered the more plausible 
if we consider the locality of the phenomenon, and 
the manner in which the disease usually advances 
towards a cure in the cases where we can trace its 
disappearance under the influence of medicine. Its 
situation, as we have said, is on the trunk, almost 
invariably on the back ; and it is here that, when 
lepra begins to yield to any of the methods of 
treatment to be mentioned afterwards, the effect 
is first visible.* 

The constitutional disturbance attending on 
lepra is for the most part very trifling, particularly 
when we consider the large cutaneous surface 
which is frequently engaged ; sometimes a slight 
fever, accompanied with gastric symptoms, coin- 
cides with its first attack ; but when established, 
it goes on for months and years without constitu- 
tional symptoms of any import arising from it. 
Its most troublesome accompaniment is a disa- 
greeable pruritus, which attends its commence- 
ment and increase. This occurs particularly when 
the circulation is excited by exercise or full diet, 
and when the warmth of bed exalts the cutaneous 
action : it is sometimes aggravated to a burning 
heat which is most intolerable. This itching and 
tingling is not peculiar to lepra, but is met with 
in most diseases of the skin attended with inflam- 

. * U a PPeafs to be a law in pathology that the resolu- 
tion of a disease commences from the place to which it 
has last extended: ot this pneumonia is an instance fa- 
miliar to stethoscopists, yielding first where it is most 



v, '„. ,t "i 8 "'" 61 "! 165 affords an example of a state 
■ I \ "'r 1S a,lalo e°" s t0 "<« appearance of lepra 

S n ^ , : SC " SS '"r" 1, mean »"<"* «ses wmdl 
will, no doubt, present themselves to the memory of ac- 
curate observers, where the pneumonia, afl.r proceeding 
a certain way towards resolution, remains 8 U°i3 
us?o be?he n nat^ k e W f r ^ "° r forwards - ™s appea» to 
Ucularlv bv MM r- ■ "' W*™"™ adverted to P 3'- 
ucuiarij uy mm. Cazenave and Schcdel 



LEPRA. 



127 



mation, and is often present in a greater or less 
degree as a symptom of internal disease. Mr. 
Plumbe's explanation of this phenomenon is too 
mechanical, and, though ingenious, inadmissible. 
He thinks that it is to be referred to the raising up 
of the scales by the increasing development of the 
" inflamed margin, and fresh growth of scales, the 
centre which was attached to the cutis being thus 
forcibly torn from such attachment." He sup- 
ports this opinion by the observation that the 
pricking occurs most constantly at the commence- 
ment, when the new scales are oftenest detached, 
and seldom happens when the disease is subsiding. 
We consider this pruritus to be a morbid sensa- 
tion, depending probably on an altered secretion 
in the skin, and the reason appears to be very ob- 
vious why it happens in the commencement. The 
morbid secretion which forms the scale affects the 
sensibility of the skin more strongly at first, when 
the impression is new, than afterwards, when the 
squamous deposits become an accustomed stimulus 
to it ; and besides at this period the cutaneous sen- 
sibility becomes somewhat impaired : the subsi- 
dence of the disease is of course not marked by 
pruritus, as the vascular irregularity producing the 
scaly secretion is now returning to the physiolo- 
gical state. This explanation is applicable to the 
itching and tingling of other cutaneous affections, 
and to that which is symptomatic of hepatic and 
other visceral derangement.* Hippocrates re- 
marked that the pruritus increased before rain. 

Although much constitutional disturbance be 
rare, yet if lepra spread over the whole body, and 
is severe in degree, it often produces some anxiety 
and febrile excitement, partly from the general ex- 
tension of the sub-inflammatory state of the skin, 
and partly from the mere mechanical annoyance that 
the scaly incasement gives rise to by obstructing 
the free motion of the joints, which become some- 
times painfully tense, and so stiff as to oblige the 
patient to keep his bed. 

Willan and Bateman, endeavouring to systema- 
tise different terms used by the Greek writers, 
divide their genus lepra into three species, a divi- 
sion which is considered unnecessary by the most 
judicious writers. Their lepra vulgaris is the dis- 
ease we have described here, and comprehends all 
the varieties. 

Lepra alphoides is a mere variety of the com- 
mon lepra, possessing the same essential charac- 
ters, and requiring similar treatment. It is a form 
in which there is less redness of the skin and ele- 
vation of the circular margins : the scales also are 
smaller, and of a more pearly whiteness. It sel- 
dom reaches the trunk, and it generally attacks 
children, aged persons, or those of a weakly habit 
of body. It appears to be a variety of the dis- 
ease in which the morbid action is less energetic, 
modified probably by some constitutional pecu- 
liarity. 

Lepra nigricans is confessedly a rare form. 
M. Biett insists that this has invariably a sy- 



* There is an analogy between those morbid sensa- 
tions of itching, pricking, tingling, &c, and the iiiusce 
volitantes, flashes of light, and tinnitus aurium. They 
are all irregular impressions on the sentient extremities 
of the nerves; in the latter on those of vision and hear- 
ing, in the former on the nerves of touch, Diseases of 
the chylopoietic viscera and the brain give rise to both 
classes of vitiated sensations. 



philitic origin, and we agree with him in this 
view of it. 

Secondary syphilis, as it assumes almost every 
form of cutaneous disease, appears sometimes 
under that of lepra. It is a question with patho 
logists whether the syphilitic diseases of the skin 
are to be separated from the others in nosological 
arrangement : they agree in anatomical characters, 
put on the same form, and in many instances 
yield, temporarily at least, to the same treatment. 
Notwithstanding these points of agreement, how- 
ever, the most esteemed authors consider that they 
should form a separate class. Their venereal 
origin furnishes a much more important reason 
for distinguishing them than any consideration 
arising from their agreement in form affords for 
keeping them together, as it is an indication for a 
special line of treatment, the disregard of which 
might be attended with disastrous consequences. 

Lepra more commonly affects men than women, 
but the difference as to sex is inconsiderable. 
Youth and middle life are more liable to it than 
infancy or old age ; but no age is exempt from it, 
after the first dentition to the latest period of life. 
It appears to be less affected than the other skin- 
diseases by the influence of seasons ; but it is ob- 
served to be most common in autumn. Differ- 
ences of condition and circumstances in life have 
not a decided influence on it, except so far as they 
favour the development of the predisposing cause. 
Willan considered cold and moisture to be a fre- 
quent cause of it, and says that it is often excited 
by external irritants and dry sordes on the skin. 
Bateman differs with him in this, as he has seen 
it frequently in persons whose respectable rank 
and circumstances precluded these causes, while 
he has not observed that certain classes of work- 
men, necessarily exposed to them, were particu- 
larly affected with it. Like the other cutaneous 
diseases, it has been known to succeed to a disor- 
dered state of the digestive tube and of the biliary 
organs ; but we must consider in these cases that 
there has been a great predisposition present ; and 
it is one of the diseases where the latter acts a 
principal part. Where a predisposition prevails, 
the slightest causes are sufficient to give rise to it ; 
thus it has been produced by highly seasoned 
food, spirituous potations, violent exercise, and 
strong emotions of the mind ; anger is said to be 
a frequent exciting cause of it: mental depression 
also produces it, especially that arising from un- 
expected poverty and the bad diet accompanying 
it, as in the interesting case narrated by Dr. 
Mackintosh. (Practice of Physic, vol. ii. p. 217.) 

It is quite certain that lepra is not contagious ; 
and discussions on the subject could only have 
been entertained when a total disregard of preci- 
sion permitted diseases of the most distinct na 
ture to be classed under this most abused term. 

Pathology. — It is sufficiently obvious from 
the enumeration of occasional causes, that we are 
not aware of any determinate conditions in its 
origin. That lepra is an inflammatory disease 
there can be no doubt ; but as the term inflamma- 
tion does not convey any very defined notion as 
to proximate causes, this is but a vague account 
to give of its etiology. We cannot in fact con- 
ceive any change taking place in the organization 
of the skin without a change in the organic action 



12S 



LEPRA. 



of its ultimate tissue or capillary vessels ; and 
wherever this takes place, it constitutes a pheno- 
menon which has hitherto been denominated in- 
flammation. Observation of the mottled arms of 
healthy infants shows that the cutaneous capilla- 
ries in their physiological state affect something 
like an orbicular arrangement ; and this might be 
in some measure connected with the fact, that 
most inflammations of the skin originally observe 
a rounded form. Further than such a simple step, 
however, our knowledge does not permit us to 
advance in the etiology of this, or indeed of any 
other skin-diseases. In Mr. Plumbe's work an 
attempt is made to ground the pathology of cuta- 
neous diseases on the part of the dermoid tissue 
affected, and to specify the class of vessels diseased 
in each morbid alteration. This would be very 
desirable, but is wholly unattainable in our pre- 
sent state of knowledge. Anatomy teaches us 
hardly any thing about the arrangement of the 
capillaries of the skin. We are totally ignorant 
as to whether there be separate vessels for the se- 
cretion of the tissue of the corium, the rete mu- 
cosum, and cuticle ; and whether the transpiration 
and sebaceous matter are furnished by these, or 
have separate vessels for their elaboration : it is 
gratuitous, therefore, to say that the seat of the 
inflammatory action which constitutes lepra is in 
the vessels which secrete the cuticle, merely be- 
cause cuticle is the product of the inflammation ; 
for this is to assume that the different tissues are 
formed by different vessels, a conclusion which 
has never been proved, and which modern physi- 
ology gives reason to suspect is untrue. If the 
argument were admitted, it would infer a separate 
set of vessels for every product of inflammation 
of the skin. It is, however, unsuitable to proceed 
with a discussion of this nature in this place. 

Diagnosis. — The disease which most resem- 
bles lepra is psoriasis. The earliest observers of 
squamous diseases marked the difference which 
exists between them. Paul of Egina marks the 
distinction which depends on their form, in these 
words : « \iirpa per profunditatem corporum, cutem 
depascitur orbiculutiori modo, et squamis piscium 
squamis similes dimittit. VSpa (psoriasis of the 
moderns) autem magis in superficie hseret, varie 
figurata est ;" but if no other difference existed 
than their configuration, we might be induced to 
follow the example of some respectable authori- 
ties, and to describe them together as mere varie- 
ties of the same disease. They differ, however, 
in more essential respects. Lepra is a more 
chronic disease than psoriasis, both as to duration 
and effects ; it does not excite the same amount 
of sympathetic disturbance in the constitution, 
and is less affected by the relations of tempera- 
ment, seasons, climate, &c. j in fact when it once 
sets in, it appears to become more inveterately 
wedded to the constitution than its congener, 
which, although it produces greater local and ge- 
neral irritation, is yet more amenable to the re- 
sources of medicine. Its general aspect, indeed, 
sufficiently distinguishes it from every species of 
psoriasis except one. The circular margins en- 
closing the central red part free from scales are 
quite contrasted with the irregular scaliness of 
psoriasis, cracked often by rhagades and ulcera- 
tions. The psoriasis guttata, however, appears to 



be a near approach to the character of lepra, and 
to constitute a natural alliance between them: the 
same round spots, gradually increasing and be- 
coming covered with scales, characterize both, but 
it is only at the very first stage and at its declen- 
sion that they are very similar ; for when it is 
fully formed, the patches are much larger, and 
have assumed the annular form mentioned above, 
whereas the smallness of the patches, their whole 
surface being covered with minute furfuraceous 
scales in psoriasis, is sufficiently characteristic, so 
that whilst their agreement in some things shows 
them to belong to the same family, yet there ap- 
pear to be sufficient points of peculiarity in each 
to enable a careful observer to make a tolerably 
confident diagnosis. Several eminent writers are 
strenuous advocates for their being united on the 
grounds of similarity, and lean much on the fact 
that sometimes in psoriasis there are present some 
patches which have all the characters of lepra. 
We acknowledge this fact, but we do not think it 
a valid argument, as it would hold good for uni- 
ting many cutaneous diseases which all agree to 
separate, as, for instance, eczema and impetigo, 
because the vesicles of the former are frequently 
intermixed with the pustules of the latter. While, 
therefore, we acknowledge their affinity, and that 
their treatment is similar, yet, from the differences 
detailed above, and these as particularly affecting 
their prognosis, we are for maintaining them dis- 
tinct, and the weight of authority is on our side. 

There is a possibility of confounding some 
other diseases, which affect a circular form, with 
lepra. In the state of the ring-worm of the scalp, 
when the purulent incrustations are detached, a 
red ring remains, which is sometimes covered with 
a slight scaliness. This might be mistaken for a 
lepra of the scalp, and the more so if the porrigo 
be a little developed on the body ; but a little atten- 
tion will detect the difference between the aspect 
of the ring-worm and the leprous patches ; the for- 
mer is "covered over with a small laminar scab 
rather than a semi-transparent scale : the hair, 
which falls in the ring-worm, is preserved in lepra, 
and a few days' watching will develop the favous 
pustules from which the scab is secreted. If con- 
tagion can be established, as it generally can in 
the porrigo scutulata, it decides the question at 
once ; but the chief element in the diagnosis is 
derived from considering that it is much rarer for 
the porrigo to be found on the trunk and extremi- 
ties, than for lepra to be seen on the head, and 
that respectively they for the most part spread in 
contrary ways, the lepra from the extremities and 
trunk to the head, the porrigo from the head to 
the body. (MM. Cazenave et Schedel, Maladies 
de la Peau d apres M. Biett.) 

With respect to the syphilitic eruptions which 
assume the guise of lepra, their diagnosis is not 
difficult, and this fortunately, as it is of more im- 
portance to be positive in this case than the for- 
mer, the consequences of mistake being much 
more serious. The syphilitic squamous disease, 
called by Willan and others lepra nigricans, re- 
presents the figure of lepra ; but the violet, cop- 
pery, or black colour, which is its essential cha- 
ractenstic, is quite sufficient to stamp its origin. 
The round, flattened, circumscribed concretions 
constituting the tubercular syphilis, called some- 



LEPRA. 



129 



times by us incorrectly pustular eruption, might 
impose on us also for lepra ; but here the coppery 
colour, which is happily for our diagnosis an in- 
separable companion to the venereal taint, comes 
again to our aid. But even if we had not this 
unerring distinction, a little examination evinces 
that the tubercular spots, although disposed in 
rings, are very different from the circular patches; 
and the thin squamous lamina, which is some- 
times observed on the tubercles, is disposed just 
the reverse of the leprous scales : it spreads from 
the centre, and is only a partial covering, never 
large enough to conceal the circumscribed indura- 
tion which projects beneath. 

Prognosis* — Lepra is to be reckoned, under the 
most favourable circumstances, as a disease very 
difficult of cure, and in many cases incurable. In 
old or debilitated subjects, scarcely any means are 
sufficient to eradicate it ; but in those of an oppo- 
site habit success is never to be despaired of, as 
there are many cases on record of its being quite 
removed after twelve and sixteen years' standing. 
It is not dangerous when it is a primary disease ; 
for even when nearly the whole skin is encased 
by its scaly concretions, the injury of its function 
seldom involves the system in general disorder. 
This is a statement of a general rule, to which, of 
course, exceptions will be found in those whose 
organization is bound together by a greater sym- 
pathy — idiosyncrasies* of constitution, which it is 
impossible to foresee as it is to explain when de- 
veloped. The obstinacy with which it adheres 
when once engrafted on the system, shows itself 
sometimes by the inefficacy of every means to pre- 
vent it spreading over the whole body ; and again, 
in other cases it disappears spontaneously or under 
the influence of medicine, in one place, and while 
the patient is congratulating himself on its depar- 
ture, it suddenly appears in another part of the 
body. On the other hand, it has been known, 
after lasting for months, or even for years, gradu- 
ally to subside of its own accord under the influ- 
ence of some of those inexplicable changes to 
which the human body is liable. It appears to 
have sometimes gone on to a fatal termination ; 
and the description of its ultimate encroachment 
on the vital functions, while it suggests phthisis, 
presents some singular features. " The local dis- 
ease having reached its highest degree, a remark- 
able constitutional affection appears. The patient 
now becomes very languid ; asthmatic, particularly 
at night-time ; smothering fits seize him ; he 
coughs violently and spasmodically, and spends 
the night in perfect sleeplessness, falling into ex- 
cessive, colliquative, clammy sweats, which give 
an intolerably fetid odour. His voice becomes 
weaker and hoarser ; the appetite for food and 
drink is preternaturally increased; and the temper 
becomes gloomy. Finally, various nervous symp- 
toms arise, faintings, convulsions, paralysis of some 
Darts, and death arrives preceded by the highest 
degree of exhaustion." (Richter, Specielle The- 
rapie, vol. vi. p. 440.) 

Treatment. — The history of the treatment 



* We owe an apology for the use of this word, which 
is, indeed, but a confession of ignorance, although 
cloaked by so learned a term. It really means that the 
fact which is referred to it cannot be explained by any 
recognised law in pathology. 

Vol. III.— 17 



which has been from time to time employed pre- 
sents a picture of the prevailing medical dogmas, 
and at the same time indicates the obstinate na- 
tine of the disease ; for where so many various 
remedies have been lauded for their success, it 
only proves that experience has not established 
that any one has been generally successful. It 
would take up a large space to furnish a mere 
catalogue of the various substances which the 
three kingdoms of nature have been ransacked to 
supply for the cure of this disease in different 
ages. Empiricism, aided by superstition, was, in 
the early times, perpetually devising something 
new from the animal kingdom ; from the flesh of 
the harmless ass, recommended by Hippocrates 
and mentioned with appjause in the writings of 
T. Bartoline, and the bull-frogs of Myzaldus, to 
the poisonous viper, which Galen hails as one of 
those great discoveries which accident has fur- 
nished to mankind. (De Simpl. Med. Facult. lib. 
xi.) In the vegetable and mineral kingdoms, al- 
most every article used as a drug has had, at one 
time or other, its favourers, from the most inno- 
cent herb to arsenic ; and each has been extolled 
as a specific. In describing the treatment, how- 
ever, we shall only take notice of those remedies 
of which the efficacy has been proved by the ex- 
perience of men who have made their therapeutic 
virtues the subject of investigation since cutane- 
ous diseases have been studied after the modern 
improvements in pathology. 

One great reason why remedies have been ex- 
tolled beyond measure by some as certain speci- 
fics, and denounced unmeritedly by others as quite 
useless, is, that former writers have mostly ne- 
glected to mark the particular features of each 
case in which their remedy succeeded or failed. 
Having determined that it was the leprosy they 
had to do with, they appear to have gone to work 
with their favourite nostrum, without taking into 
account, or at least without recording, the most 
important therapeutical indications of the affection. 
The first grand consideration in a rational treat- 
ment has respect to the cause. Can we trace its 
dependence on any internal disease 1 If so, it is 
vain to expect its cure until the primary disorder 
be successfully attacked ; while it is unpathologi- 
cal to make it the object of chief attention : we 
say chief, because, although only a symptom, yet 
it is not, even in this case, to be entirely neglected, 
as its reaction may have a powerful influence on 
the original focus of the disease, and this in two 
ways, which it is highly important to distinguish. 
Its appearance on the skin may afford a salutary 
natural derivation, and in this case it would of 
course be injurious to endeavour by treatment to 
repel it : in another instance the disease of the skin 
may be only an additional source of morbid action, 
and react on the primary affection in a prejudicial 
manner ; so that here, although but a secondary 
phenomenon, it must become an object of treat- 
ment. It is only tact and much observation that 
can discern these different circumstances ; they 
do not often, however, fall under consideration, as 
lepra is one of the cutaneous inflammations least 
frequently complicated with organic disease of the 
viscera. 

It needs scarcely be mentioned that if the skin 
affection can be traced to any external cause, whe- 



130 



LEPRA. 



Iher it be mechanical irritants peculiar to any 
trade or locality, or endemic agents operating 
through the atmosphere, the patient must he with- 
drawn from their influence. Thus, if it occurs 
from the influence of a cold and moist climate, or 
that it can be imputed to sordes on the skin, (both 
which circumstances Willan reckoned as common 
causes,) in the first instance the patient should re- 
move to a dry atmosphere ; and in the latter he 
should change his occupation to some that would 
not necessarily expose him to the exciting cause ; 
and it is the medical man's duty, if he have ascer- 
tained any of these sources, to insist upon the ab- 
solute necessity of taking this step, being aware 
that the comfort which flows from health may be 
taken from the patient for the remainder of his 
life if he neglect it. 

The cause being investigated, and the treatment 
with respect to it having been considered, the age 
and constitution of the patient, and the extent and 
duration of the cutaneous affection, are the cir- 
cumstances upon which we ground our judgment 
in proceeding to apply remedies for its cure. If 
the patient be young and strong, (and lepra usu- 
ally occurs in such patients,) general bleeding 
must be performed ; and if the disease has not be- 
come very widely extended, and inveterately chro- 
nic, the abstraction of blood by the lancet will fre- 
quently be attended with great benefit. The ap- 
plication of leeches in the neighbourhood of the 
leprous patches is also very effectual ; and the dis- 
ease in some instances yields to a few general 
bleedings, accompanied by leeching. The local 
bleeding by leeches is inadmissible when the ma- 
lady has extended over the whole or a great part 
of the body ; but when it is confined to one or 
both arms or legs, we can speak in the most de- 
cided manner of the great benefit derived from 
their use. In the comparatively recent cases the 
application of leeches two or three times, preceded 
by abstraction of blood from the arm, will be ge- 
nerally followed by a great diminution of the 
central and external redness and of the desquama- 
tion ; in fact, sometimes by a speedy disappear- 
ance of the disease without the use of any other 
measures of importance. 

The circumstances which peculiarly demand 
the abstraction of blood are, an active irritable 
Btate of the patches, and the existence of feverish- 
ness or great uneasiness from the prickling sensa- 
tions ; but it has of late years been proved that 
bloodletting is an excellent adjuvant to other 
means. In fact, a great improvement in the treat- 
ment of skin-diseases generally has taken place 
since the utility of bloodletting has been recog- 
nised in reducing the inflammation from an active 
to a passive state. It will much facilitate the cure 
of even the smallest extent of the disease to be- 
gin by a good bleeding; but it is in cases where 
it has spread very generally over the body that the 
bleeding is to be mainly depended on, at least at 
the outset of the treatment. 

Dr. Duffin, whose large experience of this 
remedy is very favourable to its use, after pointing 
out its striking usefulness in the circumstances 
adverted to above as peculiarly requiring it, adds, 
"but supposing that there exist no general symp- 
toms, still this mode of treatment is very often 
proper, were it had recourse to with no other view 



than to subdue the irritability of the skin or its 
extreme susceptibility to disease. But it has 
another good effect— it induces a state of the sys- 
tem that admits of being much sooner affected by 
the use of arsenic, when the active symptoms 
have been so far subdued as to allow of the em- 
ployment of that medicine." Its effect as a pre- 
parative is, indeed, the chief improvement we al- 
luded to ; and since it has been so employed, 
many remedies whose efficacy was much debated 
are now found decidedly useful, their exhibition 
being preceded by a bloodletting, and recourse 
being had to it during their use occasionally, if 
any symptom of the active inflammation re-appear. 
It would be obviously improper to employ it if 
the patient be in a debilitated state, the effects of 
a bad constitution, of the long duration of the 
disease, or of old age. 

Amongst the external remedies the bath is in- 
disputably the most effective, and most generally 
used. The simple tepid water is very much em- 
ployed, and is not superseded by the many new 
methods of bathing or vapourizing the surface. 
The painful stiffness and irritation are almost al- 
ways relieved by a twenty minutes' immersion in 
water at 90° : it appears to us to promote clean- 
liness, and a softening and falling off of the scales, 
just as well as the vapour-bath ; but the latter is 
preferred by many experienced practitioners. The 
tepid salt-water bath is still more effectual as a 
stimulant to the skin; but it is to be used only 
when the inflammatory state has been entirely re- 
moved by the antiphlogistic measures. 

Much expectation had been raised as to the 
efficiency of medicated vapours in this and the 
other squamous diseases ; but their superiority to 
the ordinary baths has not been demonstrated. 
The sulphur vapour-bath is the most powerful 
stimulant amongst them, and it has certainly been 
used successfully in some obstinate cases ; it must, 
therefore, be kept on the practitioner's list, to be 
employed where other remedies are inapplicable 
or have already failed. The vapours of tar and 
of acetic acid have been much used, but they are 
not so highly esteemed as those of sulphur; but, 
indeed, experience has not established for any of 
those fumigations the virtues which were pro- 
claimed at their first trials. Bathing in the medi- 
cinal waters containing sulphur, such as Harrow- 
gate, Lucan, Leak, St. Gervaise, &c. is decidedly 
a means of great power in scaly diseases, and 
many extraordinary cures are attributed to their 
use. When they are recommended, and the pa- 
tient cannot remove to any sulphureous spring, a 
useful substitute may be readily made by dissolving 
six ounces of the sulphuret of potash in ten gal- 
lons of tepid water, and adding a small quantity 
of the sulphate and muriate of soda (eight ounces 
of each.) Bathing, however, whether it be local 
or general, and medicinal fumigations, are only to 
be relied on as a secondary remedy ; they are not 
to be used till the active irritation be removed by 
depletory measures ; and it follows from this that 
they are particularly applicable in the chronic 
cases, and in patients of a debilitated habit, where 
the disease is but little energetic: they must be 
' persisted in for some time to produce a beneficial 
| effect, and the vulgar opinion that they weaken 
i the constitution is to be entirely disregarded, for 



LEPRA 



131 



the contrary is the fact, as the patients will be 
found to derive strength from every means that 
exerts a salutary influence on the cutaneous dis- 
ease. In many states of the skin where tepid 
bathing is advisable, its action will be much aided 
by gentle friction with a soft flesh-brush, the use 
of which is deservedly extolled by some writers. 

Topical applications in the form of ointments 
and lotions are very useful in many cases. They 
are intended either to allay irritability, or, from 
their stimulating effects, directly to attack the dis- 
ease by altering the action of the skin. In the 
former kind is reckoned the Carron liniment, 
which, spread over the leprous patches has been 
found to cool the skin, and keep it soft and com- 
fortable ; the addition of two drachms of oil of 
turpentine to eight ounces of it, renders it a gen- 
tle stimulus which can be borne in almost all 
cases, and adds much to its good effects ; it 
is one of the simplest applications, and can be 
used over a greater surface than others of a more 
powerful nature. Dr. Duffin prefers an ointment 
composed of equal parts of diluted citrine oint- 
ment and tar ointment to any other topical remedy 
in the chronic cases, and states that it may be 
applied very extensively over the body without 
dreading its affecting the mouth, or producing any 
other of the effects peculiar to mercury. The 
patient is to be directed to remove the old oint- 
ment perfectly previously to laying on a fresh ap- 
plication, and to use for this purpose an alkaline 
lotion, made of two drachms of liquor potassse to 
six ounces of water. The ointment adheres with 
great tenacity, and he " thus unconsciously sub- 
mits the parts to a very perfect ablution and con- 
siderable friction, two agents of the utility of 
which no person can doubt in the case of lepra." 

M. Biett, who thinks that ointments in general 
are of but little service, yet places confidence in 
one composed of the ioduret of sulphur and lard, 
twelve or fifteen grains of the former to the ounce 
of the latter. It is a very valuable remedy in 
recent lepra, occurring in a weakly individual who 
could not tolerate active internal medicines : it 
should be applied by a gentle friction to a few 
patches at a time, after a tepid bath : the skin's 
activity increases under its use ; the circular eleva- 
tions are reduced to its level, and the scales fall ; 
and when the natural state is nearly restored in 
one part, new patches are to be attacked, until the 
resolution becomes complete. 

Besides the Carron liniment mentioned before, 
the smearing of the patches with cream or with 
fresh butter, [or with cod-liver oil,] has been ex- 
tolled as very efficacious in allaying irritation from 
the rigidity of the skin ; and we can recommend 
with confidence the use of these emollients as ex- 
cellent adjuncts to the general means of bleeding 
and purgatives, (which must be the chief reliance 
as we have mentioned before,) when the heat, 
itching, and stiffness give great annoyance. 

A lotion that was held in much repute for de- 
taching the scales when they adhere tenaciously, 
is a decoction of the stalks of dulcamara with 
some alkali : it is said even to bring the skin to a 
healthier condition. We should remark that benefit 
from these external applications, liniments, oint- 
ments, &c., is to be looked for chiefly when the 



disease is confined to the extremities, and shows 
little disposition to spread. 

[In chronic cases, the ointment of iodide of 
mercury ; or a liniment of the red iodide, or an 
ointment of the same ; or the solution of iodide of 
mercury and arsenic, diluted with an equal quan- 
tity of water; or the tar ointment; or an ointment 
of creasote, or a liniment of the same ; or an 
ointment of the sesqui-iodide of carbon, or of the 
iodide of ammonium, has been prescribed in the 
same cases as the iodide of sulphur. It has, also, 
been advised, that the patches should be touched 
with a liniment, composed of olive oil and rose- 
water, each an ounce, liquor potass^, half an ounce; 
and, when they are small, they may be sometimes 
touched with advantage with strong acetic acid, 
or aromatic vinegar, or the mineral acids, when 
diluted : but, as elsewhere remarked, (Practice of 
Medicine, 2d edit. p. 137,) care, it need scarcely 
be said, must be had in the employment of these 
potent agents, and they never can be proper in the 
early and inflammatory stage. Recently, anthra- 
kokali and fuligokali — simple and sulphuretted — 
have been recommended, both internally and ex- 
ternally; and Mr. E. Wilson (On Diseases of the 
Skin, Amer. edit. p. 360, Philad. 1843,) affirms, 
that he has employed fuligokali in several cases of 
lepra and psoriasis, and especially in psoriasis pul- 
maris, and with better success than he had obtained 
by the usual remedies. The preparation and mode 
of administering these remedies are given else- 
where. (New Remedies, 4th edit. p. 57, and p. 
321.) 

Cantharides have likewise been prescribed ex- 
ternally. Dr. Davidson of Glasgow, (Lond. and 
Edinb. Monthly Jour, of Med. Science,Dec. 1841,) 
noted the comparative effect of iodide of sulphur, 
and the Acetum Cantharidis of the Edinburgh 
Pharmacopoeia, in an inveterate case of several 
years' standing, in which a variety of remedies had 
been tried in vain. The iodide of sulphur was 
applied to the lower extremities, and the acetum 
cantharidis to the arms ; and, from the result of 
his observations, he is satisfied that the latter had 
more power as a local agent. He found, however, 
the proportion of cantharides in the official formula 
too small, and therefore doubled it. Dr. Davidson 
recommends the following liniment, which is a 
modification of the Emplastrum Cantharidis of 
the Edinburgh Pharmacopajia, as superior to any 
preparation he has tried. It is sufficiently soft 
during warm weather to be applied with a brush ; 
but requires to be heated when the temperature is 
low. (Adipis, OlRapii, Cantharid, pulv. ua gi.) 
In order to succeed with any of these vesicating 
agents, the skin should be previously softened, 
either by the warm bath, or by sponging with 
warm water.] 

The most effectual means for combating lepra 
are, however, to be sought for in the internal me- 
dicines ; and the experience of able observers has 
proved a great number of these to possess undeni- 
able power. 

The use of different medicated waters, as those 
of Harrowgate and Leamington in England, and 
of the different waters on the continent which 
contain sulphur, has been a long time established 
as very beneficial ; we have of late had occasion 
to know of several cases that have been cured by 



132 



LEPRA, 



blinking the water of Lucan Spa which resembles 
the Harrowgate, but is not so strongly impregnated 
with sulphuretted hydrogen. This is a much 
better way of administering the sulphur internally 
than either the simple florcs sulphuris, or in com- 
bination with antimony, the golden sulphuret of 
which was once a favourite remedy in cutaneous 
diseases. The mineral waters should, if possible, 
be drunk at the source, or at least be procured from 
it: as it is a fact that their imitations are not so 
efficacious as the waters of the springs. 

The dulcamara has certainly properties which 
entitle it to notice. Dr. Crichton's testimony was 
very strono- in its favour, and brought it much 
into use in the treatment of lepra. He states that 
out of twenty-three cases in which he employed 
it, only two resisted its action ; two or three ounces 
of the decoction of the twigs and leaves were used 
by him thrice a-day; but we cannot help being 
inclined to attribute his success rather to the 
other means which he used, as the experience of 
other physicians who have used it still more ex- 
tensively does not corroborate its virtues : it is still 
used, however, as an adjunct, in chronic cases. 

Decoctions of the acrid stimulant plants, daphne 
mezereon, d. enidium, and of guaiacum, have been 
used with success in different instances. The 
compound decoction of sarsaparilla has also en- 
joyed much reputation, and may be recommended 
for its stimulant effects on the skin : its use should 
alternate with some of the more powerful remedies 
to be mentioned. 

A remedy which at one time was extolled to an 
extravagant degree, and has fallen in late times 
into as undeserved disrepute, is the tar-water; but 
we are persuaded on the grounds of experience 
that it does possess real efficacy A case has been 
communicated to us, which had been treated by 
some of the most eminent practitioners with the 
most powerful remedies: but no effect was pro- 
duced on the disease till tar-water was tried by a 
physician whose experience of it led him to place 
much confidence in it ; and under its use the pa- 
tient got quite well. Half-a-pint of it should be 
drunk three times a-day. In the case alluded to 
the patient was made to walk rapidly until he 
began to perspire, and then to sit for a time in a 
warm room, and much importance was attached 
to this manner of exhibiting it. Pitch pills arc 
also to be mentioned as a remedy to which expe- 
rience bears a very satisfactory testimony; six or 
eight of them, each five grains, should be taken 
for a dose three times a day, and this will have to 
be increased by degrees according to circumstances. 

Some English writers praise very highly the 
treatment by mercurial preparations ; and in some 
cases minute doses of corrosive sublimate have 
proved of unquestionable utility, salivation by 
mercury being, however, seldom undertaken in the 
cure of lepra. The naive relation which that re- 
spectable writer, Dr. Turner,* gives of its effects 
in two cases where he employed it, would answer 
for its history in most cases ; and as a purgative, 
indeed, calomel will be very beneficial in occasional 
doses, no matter what plan of treatment be pre- 

• A Treatise of Diseases incident to the Skin, by 
Uamel Turner, of the College of Physicians, London, 3d 
edit. 1726, p. 30, et seq. 



ferrcd ; and in children particularly it is a very 
useful means. 

We now come to speak of arsenic, a remedy 
that has been of late years much investigated as 
to its effects in squamous diseases. While some 
have found it to possess uncommon virtues, others 
have decried it as not only useless but dangerous. 
It is, without doubt, a very dangerous remedy in 
the hands of incautious practitioners, and will 
never prove useful if it be employed where cir- 
cumstances contra-indicate it. But we must ex- 
press our suspicion that where it has failed, it has 
been for want of discriminating between the states 
which are favourable to its action, and where its 
administration is improper. It is superfluous to 
say that its exhibition requires the most cautious 
attention on the part of the practitioner ; and we 
are confident, that where it is judiciously em- 
ployed, it is not only a safe but a very valuable 
remedy. It seems to be peculiarly applicable in 
those cases which are seldom benefited by other 
medicines — we mean those instances in which 
the lepra has lasted for several years, and has in- 
vaded nearly the whole skin, so that it has taken 
on such a diseased habit, that nothing less than 
the most powerful means will restore its original 
state. In cases which have not run on to a very 
chronic state, the other means will prove as effec- 
tive, and probably should be tried before we should 
have recourse to the arsenic, although some able 
practitioners advocate its propriety in almost every 
case. In the inveterate cases, however, when all 
other means have failed to produce any salutary 
effect, its well-regulated exhibition has been fre- 
quently known to effect the dispersion of the 
disease. 

Having determined on its use, we must watch 
its effects, and persevere so as to give it a fair 
trial. Fowler's solution of arsenic is the prepa- 
ration most approved of. It is best to commence 
with the small dose of three drops, to be taken 
three times a day in a glass of water ; or it may 
be deemed advisable to use the decoctions of dul- 
camara, mezereon, or of sarsaparilla as a vehicle, 
as Dr. Duffin recommends. The dose must not 
be raised beyond eight drops three times a day, or 
at the very highest ten. When it first affects the 
system, the pulse becomes quickened, smaller, anil 
hard ; and there arises a prickly soreness about 
the eyelids, accompanied by some puffy swelling, 
particularly of the lower one. The gastric symp- 
toms which are the signals for suspending its 
exhibition, are, sickness of the stomach, griping 
pains all over the abdomen, headach and whitish 
tongue, with a peculiar taste in the mouth. When 
there comes on a pain in the chest, accompanied 
with anxiety of the prsecordia, and a certain con- 
sciousness of serious constitutional disturbanct, 
which is indicated by uncommon gravity of the 
countenance, the medicine has been either given 
in too large doses or continued too long. When 
the pain in the chest and any of the latter symp- 
toms occur shortly after its commencement, it is 
probably a case which will not bear its adminis- 
tration at all, and other means should at once be 
substituted. It will generally be found that an 
impression has been made on the disease when 
its effects are recognised in the constitution, and 
often before this. At first the patches become 



LEPRA. 



133 



less indolent, and a long-unaccustomed sensation 
of heat and activity is felt ; the scales first clear 
off in the centre, (for in those inveterate cases 
the whole patch is overgrown with scales ;) by 
degrees the circular eminences sink and clean ; 
and thus a disease which had become engrafted 
on the habit for years, retires under the influence 
of this powerful medicine. 

[Of late, a solution of arseniate of soda, the 
iodide of arsenic, and an iodide of arsenic and 
mercury, under the form of the liquor arsenici et 
hydrargyri iodidi, or " Donovan's .solution," as it 
has been called from its proposer, have been used 
with advantage.] 

Some of the favourable symptoms ought to 
show themselves by the time that the medicine 
has affected the pulse, or when the stiffness and 
puffiness are perceptible under the eyelids. If 
the skin do not discover its action when these 
characteristic signs appear, there is no necessity, 
— indeed it would be improper, — to continue its 
use. In others, nausea and loss of appetite, with 
some epigastric soreness and oppression, are the 
first signs of its operation ; but we should not 
consider these latter symptoms as unequivocal 
reasons for laying aside its use altogether ; a few 
days' intermission will often remove this gastric 
disorder, when a further trial may be made ; and 
it has frequently happened that the good effects 
have begun to show themselves soon after its 
being resumed. But in deciding how far it may 
be pushed, the discretion and tact of the practi- 
tioner must guide him : we only wish to lay 
down as a principle that the arsenic is not so un- 
safe a means in judicious hands as it has been 
vulgarly thought; and that after its use is com- 
menced, ill-grounded" fears should not deprive the 
patient of the steady trial of a remedy which 
experience has proved to be so valuable. Dr. 
Duffin states that he has prescribed it in very 
near four hundred cases, and has never yet seen 
it do any mischief; and his testimony and that of 
M. Biett, (two gentlemen who have investigated 
its effects the most assiduously amongst modern 
observers,) agree that it is a most important re- 
medy in this intractable disease. 

The tincture of cantharides is another very 
energetic medicine in lepra. It was brought into 
notice by the eulogy of Mead, although it is 
nearly certain that it was against the tubercular 
elephantiasis that he employed it. (Medical 
Works of Richard Mead, M. D. Dublin, 1767; 
of the Leprosy, p. 455.) However that may be, 
it has been used ever since in the scaly disease, 
and it has been found of great effect, particularly 
of late years. It is applicable in the same invete- 
rate description of cases as the arsenic, and re- 
quires quite as much caution in its administration. 
Four or five drops three times a day should be 
the utmost dose for the first month of its use, and 
at the same time the patient should use demul- 
cent drinks of gruel, barley-water, flax-seed tea, 
<tc. When given at an improper stage, or in 
too large a dose, it is very prone to produce serious 
disturbances in the alimentary canal and the 
genito-urinary organs, so that when we perceive 
painful heat at the epigastrium, vomiting and 
purging, or stranguary and erections to follow its 
use, it must of course be intermitted ; but unless 



these symptoms show an unusual degree of vio- 
lence, it may be often advantageously resumed. 
By a cautious gradation of the dose, (very small 
at first,) and the use of the demulcent drinks, 
with an occasional dose of purgative medicine, 
those sinister consequences may in general be 
avoided. 

In some remarks on the use of tincture of can- 
tharides in hooping-cough by Dr. Graves, in the 
fourth number of the Dublin Journal of Medical 
and Chemical Science, Dr. G. states that it pro- 
duces its good effects without causing urinary 
irritation when given in the formula recommended 
by Dr. Beatty, which we here subjoin : — R Tinct. 
cinchonse compositae^v; tinct. cantharidis ; tinct. 
opii camphorae, ua ^ss. M. There is nothing in 
the other ingredients of this mixture which 
should preclude its trial in lepra; and it would 
be very desirable if this combination would allow 
of its free use, by averting its ill effects on the 
urinary organs. Bateman's disparaging notice 
of cantharides kept it out of use for some time ; 
but its value has been confirmed by the experience 
of the Hopital St. Louis, where it is esteemed as 
only second to arsenic in the chronic cases. 
Where either of these two remedies is found to 
create constitutional disorder forbidding its conti- 
nuance, it may advantageously be replaced by the 
other : but we repeat, to derive good effects from 
either of them, the greatest care must be taken to 
use them in the proper stages ; for if they be 
given whilst any activity of inflammatory action 
remains, instead of benefit we must only expect 
to aggravate the whole disease. 

A course of purgatives is at the present time a 
favourite practice in the less severe cases of lepra 
with some French practitioners, who speak with 
much applause of the good effects of calomel, 
jalap, sulphate of magnesia, and of soda, aloes, 
&c. in its removal. We rather suspect that this 
may arise from the novel introduction of cathar- 
tics into their practice, and the reaction in their 
favour which naturally follows on the apprehen- 
sion and horror they had of this valuable class of 
medicines up to a recent period. It is, doubtless, 
of the highest importance to keep the bowels free 
by the occasional use of laxatives ; and for this 
purpose a few grains of calomel will be generally 
found the most suitable. Much purging, how- 
ever, as far as our experience goes, is decidedly 
injurious, excepting probably in children, where 
we can have recourse to scarcely any other class 
of remedies, and where purgatives answer very 
safely and conveniently. 

The external and internal means of treatment 
have been noticed separately for the sake of ar- 
rangement, but in practice they are almost always 
employed together; and, when judiciously com- 
bined, they mutually assist each other's action. 
The tepid bath may be used in almost every plan 
of treatment, and will be found a useful adjunct. 
In those cases which have not spread extensively 
nor lasted long, the treatment should be com- 
menced by an abstraction of blood, which is to be 
repeated either generally or by leeches, whenever 
the inflammation shows any signs of having re- 
sumed an active state: at the same time the patient 
should use some one of the internal remedies, and 
probably daily the bath. With those it will bo 



134 



LEUCORRHCEA. 



often judged advisable to apply some of the un- 
guents or lotions already mentioned, so as to con- 
join the operation of the different classes of reme- 
dies ; and it is in such cases that this combination 
is most effective. In the inveterate cases, our re- 
liance must be placed in the steady use of the 
internal medicines. We can go no farther on 
these points ; each particular case will doubtless 
present its peculiarities, which must be considered. 
Having adverted to the most approved principles, 
and mentioned the remedies whose virtues have 
been best confirmed by experience, it remains for 
the judgment of the practitioner to guide him in 
each particular instance in the application of the 
former, and the choice and conjunction of the 
latter. 

[A thorough change of the diet and regimen to 
which the patient has been accustomed, as well 
as of all the influences surrounding him, by 
travelling, is advisable, whenever it is practicable ; 
and this has been, perhaps, the main agency, 
when a visit to sulphurous springs has effected a 
cure in rebellious cases : at the same time, as be- 
fore remarked, the sulphur has doubtless been an 
important adjunct.] j HOUGHTON. 

LEUCORRHCEA, from \cvkos, albus, and jiiw, 
fiuo. Properly, this name ought to be restricted to 
a white vaginal discharge, but every sort of dis- 
charge, not sanguineous or menstrual, has been at 
various times considered as leucorrhoea, whether 
mucous, serous, purulent, or of a mixed description. 
Besides " leucorrhoea" and " vaginal discharge," 
this complaint has been called "fluor albus," 
"jluor muliebris," " lesjleurs blanches," "sexual 
weakness," or " a weakness," and, vulgarly, « the 
whites." All these are more or less objectionable, 
and the one chosen for the title of this article as 
much so as any other; but it is one which is so 
well known and universal, that it can scarcely 
lead to error in practice, and is, therefore, the 
most convenient. It would, no doubt, be very 
useful in practice to discriminate between the dif- 
ferent discharges, because very frequently their 
character will depend upon, and therefore be a 
guide to the knowledge of, the nature of the dis- 
ease which produces them, or the particular part 
which has become disordered or disorganized. Sir 
Charles M. Clarke has classed the diseases of the 
female genital organs by the nature of the vaginal 
discharges which are peculiar to them ; and 
although there are many serious objections to 
such a mode of classification, yet it proves how 
important it is to note their several and distin- 
guishing peculiarities. Of the diseases to which 
females are liable, there is none more common 
than vaginal discharge, of one sort or another ; 
it attends most of the uterine diseases, and it is 
extremely common as the result of either local or 
constitutional disturbance, or of general debility. 
It is looked upon by the patients themselves as 
the cause of ill health, or of the symptoms under 
which they may happen to labour ; whereas, in 
the majority of instances, the discharge itself can 
only be considered as a symptom, the effect and 
result of local or general disorder. By prac- 
titioners in general, vaginal discharges have been 
carelessly attended to ; there has been one com- 
mon routine of treatment, without investigation ; 



and it is only when the complaint has been obsti- 
nate, that at a later period more minute inquiry 
has been made, and more rational and scientific 
plans adopted. So many of the vaginal discharges 
depend upon uterine disorganization, or some alte- 
ration in the position of that organ, that it is ad- 
visable in every case, where possible, to make a 
minute examination per vaginam, so as to ascer- 
tain the exact condition. It is foreign to this 
article to enter upon the question of the numerous 
uterine diseases which give rise to vaginal dis- 
charges ; we must here only consider idiopathic 
leucorrhoea, a simple vaginal discharge, uncon- 
nected with any alteration of structure. 

The simplest form of leucorrhoea is a mere in- 
crease of the natural secretion from the mucous 
membrane of the vagina. As this membrane is 
continued to the interior of the uterus and the 
fallopian tubes, it is easy to suppose that now 
and then the lining of these organs may become 
affected, and the leucorrhoea have a more exten- 
sive seat. Frank has mentioned a case of unusual 
obstinacy, where, after death, the fallopian tubes 
were found to be the origin of the disorder ; and 
numerous cases are on record, where, in prolapsus 
uteri, the leucorrhoeal discharge was found to pro- 
ceed from the os uteri itself. By many of the 
older writers, it was thought to be merely a variety 
of menstrual discharge, and hence the term "men- 
strua alba," &c. Hoffmann, Cullen, and others, 
considered that the discharge issued from the 
same vessels which secreted the menstrual fluid in 
their healthy condition. Dr. Jewel, in his recent 
work on this disease, states his impression to be, 
that it seldom issues from the uterine cavity, and 
proposes a test to ascertain that point in individual 
cases. Dr. Jewel assumes, that in the night-time, 
when in bed, the discharge from the interior of 
the uterus is suspended, which is not the case 
when it arises only from the vagina or the cervix 
uteri; and hence he advises that a piece of sponge 
be introduced into the vagina at bed-time, and if 
the uterus only is affected, the sponge will be 
withdrawn dry in the morning. The accuracy 
of this test must depend upon the assumption 
being correct. 

[When it takes place from the uterus, it occurs, 
according to M. C. A. Tott, (Art. Leucorrhoea, in 
Most's Encyclopiid. der gesammten Medicin. und 
Chirurgisch. Praxis, Leipz., 1836,) more inter- 
mittently, and is accompanied by clots of blood and 
mucus, or by pain in the uterus. It, moreover, aug- 
ments before and after each menstrual period, and 
is accompanied by more constitutional suffering.] 
This is, however, by far the most common form 
ofthe complaint, which takes place from the vagina 
alone, or, perhaps, as this gentleman states, from the 
cervix uteri. There is an altered action of the 
mucous lining of the parts, and in what that 
particularly consists, depends the peculiarity of 
the cases. It has been by far too common to con- 
sider all such cases as arising from debility, local 
as well as constitutional, and hence the remedies 
have most frequently been merely strengthening. 
In general, we shall find great symptoms of de- 
bility accompanying long-continued leucorrhoea, 
but the debility is nearly always the consequence 
and not the cause of the disease. It is the ac- 
knowledged fact, that whenever the general health 



LEUCORRHCE A. 



135 



has been broken down, and much constitutional 
weakness occasioned, local disorder is often the 
result, and such disorder may attack the uterine 
organs or vaginal passage, though it is not debility 
which affects them, but through debility a diseased 
action arises. This diseased action is sometimes 
acute inflammation ; in others, and more com- 
monly, sub-acute ; whilst, in chronic cases of 
long standing, a relaxed condition of the secretion 
apparatus may take place from habit, as we see 
in the diseased discharges from other sources; 
this Dr. Dewees has called the " leucorrhoea of 
habit." Besides inflammatory action, a very large 
proportion of cases of leucorrhoea depend appa- 
rently upon irritation, different from inflammation, 
and yet easily running on into it — a state easily 
recognised, but difficult to be described. The 
irritation which excites leucorrhoea is very often 
remote from the vaginal membrane itself, so that, 
upon alleviating or removing the distant irritating 
cause, the complaint will cease. 

The discharge of simple leucorrhoea is mucous — 
merely an increase of the natural moisture of the 
part ; it becomes more abundant than in health, 
but retains its character of mucus, being clear, 
transparent, colourless, and glutinous to the touch. 
This rarely goes on to a great extent without 
being altered in its appearance, and much more 
watery. In general, this sort of discharge is ac- 
companied with but moderate symptoms, is more 
gradual in its progress, and is unattended by pain ; 
there is little or no inflammatory action present. 
[It has, indeed, in moderation, according to Dr. 
Simpson, (Tweedie's Library of Medicine, iii. 
314,) been regarded as an indication of the general 
vigour and activity of the organs of generation.] 
In other cases, the discharge is whitish and opaque, 
becoming creamy when rubbed between the fingers, 
and rendering water turbid. This sort of discharge 
has been considered by Sir C. M. Clarke, and 
others, to depend chiefly on an inflamed condition 
of the cervix uteri; it is rarely abundant, but 
occasions much disorder of health, and local pain. 
A watery discharge, resembling serum, is a very 
common result of more acute inflammatory action 
in the mucous surface, and in general appears 
suddenly, as the effect of cold or any active ex- 
citement. It occasionally becomes very abundant, 
is attended with much local heat and soreness, 
and soon becomes puriform, or mixed with puru- 
lent matter, and sometimes with bloody streaks. 
When it is fetid, brown, or coming away in vio- 
lent gushes, organic disease of the uterus is to be 
ieared, the nature of which can only be detected 
by an examination per vaginam. Purulent dis- 
charge from inflammatory action may also take 
place from the vagina, independent of gonorrhoea 
from impure connection; and this may be said to 
form one variety of leucorrhoea, as, although it 
may often arise from organic disease of the uterus, 
it is not unfrequently met with in a perfectly 
healthy condition of that organ. Many will hesi- 
tate, perhaps, to class either the watery or the 
purulent discharge under the term leucorrhoea ; 
but it is quite certain that all the above-mentioned 
discharges arise from the mucous surface of the 
vagina alone, without organic disease, and solely 
from a diseased condition of the natural secretion 
of the part. 



Patients, in general, content themselves with 
stating the existence of a weakness ; and too 
many medical men are satisfied with such a slight 
description, and neglect to inform themselves more 
accurately of the nature of the discharge. 

The symptoms vary, as will be supposed, and 
there is a marked connection, in general, between 
the symptoms and the character of the discharge. 

The mildest form of the disease is often of long 
standing before a practitioner is consulted : it is 
generally found that it has been preceded by what 
is called " delicate health." The countenance is 
pale and sallow ; the frame weak ; the pulse fee- 
ble, and easily quickened by the least exertion ; 
the appetite impaired or capricious: the spirits are 
languid, and exercise is taken with difficulty ; 
menstruation is either scanty, or too profuse ; the 
digestion is disordered, and the bowels are irregu- 
lar : there is pain in the back when the individual 
is fatigued, or when she remains long in the erect 
posture ; but it is a pain of debility, relieved by 
rest, and not permanent. The discharge, which 
has been referred to weakness, is a disordered 
action of the mucous membrane, and is the effect 
of a state of indifferent health. The discharge, 
in these cases, is mucous only ; is never very 
abundant, and is unattended by local pain, except 
in the back. It may easily be altered in character, 
and then the symptoms are also changed ; as in 
such cases a very slight cause will increase the 
disordered local action. 

The most acute form of leucorrhoea is most 
commonly the effect of cold, of metastatis, or of 
some local, irritating cause, and consists of a pro- 
fuse watery or purulent discharge, accompanied 
with local soreness and pain. The vagina is hot, 
very tender to the touch ; there is much fever, 
heat of skin, quickness of pulse : these symptoms 
being often preceded by a distinct rigor. When 
the discharge is more scanty and glairy, like the 
white of an egg, or creamy and opaque, the cer- 
vix uteri is considered to be principally affected, 
and may be felt by the finger to be hot and tumid, 
the pulsation of the minute arteries being easily 
distinguished. In these cases there is much pain 
of the back, extending round the hips and down 
the thighs, and, though relieved, not removed by 
the recumbent posture. This description of leu- 
corrhoea may occur in the most debilitated or in 
the most healthy frames, and may be considered 
accidental. All of these forms may end in chronic 
leucorrhoea, where the discharge is more or less 
profuse and constant, mucous or purulent, or a 
mixture of both : it may become green and offen- 
sive, and yet be the result only of functional dis- 
order. The quantity poured out is sometimes 
very abundant, even to the extent of a pint and a 
half in the twenty-four hours ; it will then be 
expelled in gushes on any change of posture. 
There is in these cases a very relaxed vagina, 
often accompanied by prolapsus of the uterus : 
the mucous surface appears smooth and glossy, 
and has lost its natural ruga? ; there is great ema- 
ciation and debility : the eyes are hollow ; the 
face pale or chlorotic ; the pulse feeble and rapid ; 
the feet often anasarcous ; the respiration short 
and laboured, to which succeed palpitation of the 
heart, dragging pain in the back, inability to ex- 
ertion, profuse nocturnal perspirations. Unless 



136 



LEUCORRHCE A. 



remedial measures he successful, after a protracted 
scene of much general suffering, the patient dies, 
exhausted. 

The causes of leucorrhoea are either those which 
induce inflammation of the parts or irritation, or 
which weaken the action of the secreting vessels, 
although by far too much stress was formerly laid 
upon the latter. Catching cold, as it is commonly 
termed, is a very frequent cause of the acute leu- 
corrhcea ; so also is metastasis of a discharge from 
some other part, though of a different character. 
The suppression of the menses, the repelling of 
milk in the breasts, the sudden checking of 
catarrh, and perhaps any sudden check to the 
perspiration, may be considered as causes of acute 
leucorrhoea : a severe labour, in which the vagina 
has been kept long upon the stretch, or where it 
has been injured by officious manual interference, 
or the use of instruments, will often cause the 
inflammatory leucorrhoea. Violent exercise, par- 
ticularly dancing, or riding on horseback, the 
excessive use of venery, or pollution, have the 
same effect. Of the irritating causes, we may 
mention local displacements of the uterus, espe- 
cially prolapsus ; local tumours of the vagina or 
uterus, and, of the latter, polypus in particular ; 
stone in the bladder, disease of the urethra, a 
loaded state of the rectum, the presence of hard 
scybala, or of ascarides. A pregnant uterus may 
act in this manner, and also by the increased local 
determination of blood which pregnancy produces. 
The impaction of a pessary, or of a piece of 
sponge introduced for other purposes into the 
vagina, has sometimes been the unsuspected cause 
of a long-standing leucorrhoea. [Hence, it is all- 
important, in obstinate cases, to make an examina- 
tion per vaginam.] Of the debilitating causes, 
may be mentioned frequent child-bearing, repeated 
abortions, profuse menstruation, and, in general, 
all the usual tendencies to disordered health, such 
as hot rooms, luxurious habits, indolence, poverty 
of living, protracted lactation, over-exertion, &c. 

Treatment. — It is in this point that the 
greatest errors have prevailed, from the disposition 
to follow carelessly an established routine. As- 
tringent tonics — bark and acid for instance, are 
prescribed in the majority of cases, and perhaps 
an astringent injection, which would aggravate 
many of the forms of leucorrhoea we have been 
mentioning. The plan of treatment ought to be 
regulated solely by the character of the complaint. 
It must be recollected that it is not always safe to 
check suddenly a long-standing leucorrhoea, if 
profuse. Many instances arc on record of mischief 
resulting from such a course, and the following 
case is a striking illustration. We were consulted 
by a soldier's widow, several years ago, for a com- 
plete prolapsus of the uterus, produced by violent 
exertion during the retreat from Corunna, within 
a few days of her confinement, and which had 
never been reduced. There was profuse semi- 
purulent discharge from the inverted vagina. 
After some difficulty, the uterus was replaced 
within the pelvis, and a pessary worn, consisting 
of sponge soaked in an astringent lotion. The 
discharge from the vagina ceased ; and in twenty- 
four hours a quantity of muco-purulent fluid began 
to be copiously expectorated from the bronchial 
membrane, which amounted, after a few days, to 



nearlv three pints in the twenty-four hours : and, 
in less than a fortnight from the replacement of 
the uterus, the patient sank from exhaustion. 

In the leucorrhcea from constitutional debility 
or disordered health, of the first class described, 
the usual remedies for restoring the vigour of the 
frame arc required. Tonics of every description 
are admissible, according to the circumstances of 
the case ; but those containing or combined with 
the mineral acids have most efficacy. The vege- 
table bitters, or the sulphate of quinine or the bark 
itself, may be given three times a-day, combined 
with from ten to twenty drops of the diluted sul- 
phuric acid, or double that quantity of the old 
vitriolic elixir. From one to two grains of the 
■ sulphate of zinc, or any of the preparations of 
iron, will often agree exceedingly well, and as the 
health improves, the discharge becomes less and 
less abundant ; the diet should be nourishing, the 
air good and occasionally changed. Besides these 
remedies, the shower-bath or cold bathing may be 
used, and especially hip-bathing, or sponging the 
back and loins freely with cold vinegar and water 
or salt water. Local remedies are rarely required 
in these milder cases. In the acute form of the 
complaint, it is often necessary to apply leeches 
to the neighbourhood, to the groins, labia, or back; 
and if the cervix uteri is particularly affected, to 
the os uteri itself, by means of a proper tube. 
This is much more easily effected than is supposed, 
and the liability of the leech remaining at the 
lower end of the tube instead of crawling up to 
fasten upon the uterus, may be prevented by in- 
serting a piston to push the leech higher up the 
tube. Bleeding from the arm is rarely necessary, 
though in plethoric habits it may now and then 
be desirable. A low diet, perfect rest, and anti- 
phlogistic general treatment are necessary ; the 
bowels should be kept fairly open with saline pur- 
gatives or castor oil, avoiding aloes, scammony, 
or others of a drastic character ; warm hip-bathing 
is very useful, and injections into the vagina of warm 
water, decoction of poppies, or solutions of the 
super-acetate of lead. Dr. Jewel advises, very 
confidently, weak solutions of the nitrate of silver 
as injections, in the proportion of one to three 
grains of the salt to an ounce of distilled water, 
or even the application of the caustic itself to the 
cervix uteri. We doubt, however, whether this 
treatment is applicable to this very acute form of 
the disease. 

When more chronic, when there may be sai' 1 
to be subacute inflammation only present, or per- 
haps only irritation, the general health must be 
attended to, according to the nature of the gene- 
ral symptoms ; but in such cases the greatest ben- 
efit will arise from local treatment, or from reme- 
dies more especially directed to the local mischief. 
It is this form of the disease which is most obsti- 
nate, and for which it is advantageous to possess 
a variety of remedial measures. Of the internal 
medicines which have been found serviceable, the 
balsams, particularly the copaiba, have been men- 
tioned ; but their efficacy is not nearly so marked 
as in the gleet or gonorrhoea of the male : the 
cubebs has also much about the same remedial 
powers. The cicuta has been found of service 
by some practitioners. The tincture of cantha- 
rides has been perhaps more successful, pushed to 



LEUCORRHCEA. 



137 



as large a dose as can be borne without producing 
irritation of the bladder. Astringent medicines 
are also found occasionally serviceable, particularly 
the mineral acids with the infusion of roses and 
alum ; the latter may be given in doses of from 
five to twenty grains three times a-day. The ace- 
tate of lead has been often successful, catechu, 
kino, uva ursi, powder of galls, which may be 
given in large doses. At the Lock Hospital, Mr. 
R. B. Walker is in the habit of giving ten to 
twenty grains of the latter in decoction of tormen- 
tilla. Dr. Copland recommends small doses of 
the sulphate of copper. Emetics are said to have 
been of use, but perhaps in the more acute form 
of the complaint. The local remedies, however, 
are most to be depended upon in these cases, and 
may be applied freely and several times a-day, 
either hy means of the female syringe, or of a 
piece of sponge or lint introduced carefully into 
the vagina, and occasionally withdrawn for a fresh 
supply of lotion. Most of the female syringes 
are too small, and produce irritation by the fre- 
quent necessity for withdrawing the pipe for the 
purpose of refilling the instrument. The writer 
has been in the habit of obviating the inconve- 
nience by a gum-elastic tube of three to four inches 
in length, and about half an inch in diameter, 
perforated with several holes at the apex, which 
is rounded off, and the tube made to fit to the 
stomach or lavement pumps, which are now so 
common : in this way any quantity of fluid may 
be injected into the vagina without withdrawing 
the tube. The applications may be classed into 
the irritating, the sedative, and the simple astrin- 
gent ; and as a general rule, it may be stated that 
the first are most applicable to the chronic states 
of subacute inflammation, rousing the vessels into 
a more healthy action. These consist of solutions 
of nitrate of silver (as just mentioned), of the 
sulphate of copper, of oxymuriate of mercury, 
&c. ; inunctions of mercurial ointment, fumiga- 
tions of cinnabar, or the local application of co- 
paiba or turpentine. Dr. Jewel limits his lotions 
to the strength of three grains to an ounce of 
water, preferring the application of the lunar 
caustic itself to a stronger solution ; but at the 
Lock Hospital, solutions of the strength of half a 
drachm, or even two scruples to the ounce, are not 
unfrequently employed. [Dr. Huston, of Phila- 
delphia, has seen more advantage from injections 
of the oil of turpentine, than from any other: 
01. Tereb. f.ji. mucilag. Acacias, aqua? ia f.^iss.] 
The sedative injections consist of decoction of 
poppies, of solutions of opium or belladonna, and 
of the superacetate of lead, the last being by far 
the most efficacious. The writer is in the habit 
of using the common Goulard's extract in the 
proportion of two or three drachms to the pint of 
distilled or rain water, warm or cold according to 
the sensations of the patient, and he prefers as 
much as half a pint to a pint to be used at a time, 
three or four times a day. The sedative lotions 
are most serviceable where there is an acrid dis- 
charge, with heat and excoriation, or where there 
is much inflammatory action with local pain. In 
some severe cases he has seen benefit from intro- 
ducing a piece of lint soaked in a liniment con- 
sisting of equal parts of Goulard's extract, Bat- 
tlev's laudanum, and mucilage. The astringent 
Vol. III.— 18 v* 



injections are applicable to the cases which appear 
to be attended by great relaxation of the vagina 
and its mucous membrane, with chronic discharge 
of a muco-purulent or simply thin mucous cha- 
racter. All the vegetable astringents are then oc- 
casionally serviceable, as well as the mineral. 
Alum, the sulphate of zinc, iron, or copper ; the 
acetate of zinc ; decoctions or infusions of oak- 
bark, galls, green tea, kino, catechu, rose-leaves, 
&c, may be alternately used, or some may be 
combined together ; but a great deal depends upon 
their being used freely and frequently. In using 
astringent injections, particularly alum, it is ad- 
visable to wash out the vagina directly afterwards 
with cold water, as the discharge will sometimes 
become coagulated, and, remaining in the vagina, 
produce irritation and an increase of the symp- 
toms. Leucorrhcea has been said now and then 
to be owing to want of cleanliness, and no doubt 
this may cause it, but it would be difficult to prove 
that no other cause existed. The remedy is ob- 
vious. 

"When there is reason to believe that the leucor- 
rhcea depends upon a loaded state of the rectum 
or the presence of ascarides, a soap or a turpen- 
tine clyster will readily remove both cause and 
effect. In the leucorrhcea of pregnancy, more 
caution is to be observed. In the early months it 
is desirable to check it, as an excess of it will be 
very likely to bring on abortion; but it must be 
done gradually, and the lead injections are the 
safest. Where the discharge arises principally 
from the uterus, conception rarely takes place ; 
and when it has occurred, the ovum is easily sepa- 
rated by the slightest causes, so that extreme quiet 
is always necessary for the first fi^w weeks. In 
the latter months of pregnancy, leucorrhcea may 
be looked upon rather as a relief, unless excessive ; 
the pressure of the gravid uterus and the greater 
determination of blood to the neighbourhood fre- 
quently producing symptoms of heat, weight, and 
discomfort, which are alleviated by the escape of 
the discharge. Rest and cooling laxatives, with a 
spare diet, are generally all that will be required. 

[Uterine leucorrhcea is by no means as much 
benefited by astringent injections as the vagi- 
nal. It would appear, indeed, that, at times, they 
cause great irritation, and an aggravation of the 
local distress. The acute form requires cupping 
on the loins, with the hip-bath, and warm emollient 
injections into the vagina and rectum ; and, after 
the active stage has passed away — or at any time, 
in the chronic form — counter-irritants may be ap- 
plied to the sacrum, as the ointment of tartrate of 
antimony and potassa, croton oil, or dry cups. If 
a blister be applied, it ought not to be kept on too 
long, and its surface should be covered with tissue- 
paper, to prevent, if possible, the absorption of the 
flies or of their active principle. The same inter- 
nal remedies, directed to the special pathological 
condition of the frame, are needed as in vaginal 
leucorrhcea. Of late, it has been affirmed that 
ergot has succeeded where other remedies had 
failed, in both the uterine and vaginal variety. It 
may be given in the dose of five grains three times 
a day.] 

Very young children are liable to leucorrhcea. 
It occasionally occurs in infants shortly after birth ; 
in these cases it is more or less purulent, and at- 



138 



L E U C R R H CE A . 



tended by a redness and tumefaction of the orifice 
of the vagina. It is very apt to occur also during 
dentition, and not only when the first set of teeth 
are in progress, but at the time of the second set, 
and even when the dentes sapientiae are irritating 
the system at a more mature age. Young girls 
are also sometimes affected with leucorrhcea, at- 
tended with debility, disordered health, and pain 
in the back. This usually arises from intestinal 
irritation or from gravel, though probably the lat- 
ter may be equally the effect of the visceral disor- 
der. It must be borne in mind that the appear- 
ances above described are not unfiequently the 
effects of improper habits. The curative measures 
are simple ; the portion of the vagina affected is 
usually very limited, generally near the external 
orifice, so that the Goulard lotion is readily and 
effectually applied. Alkalies and gentle purgatives 
with a mild diet and rest, will in most cases be 
sufficient to remove the complaint. An epidemic 
vaginal catarrh has occasionally existed, as men- 
tioned by Professor Capuron to have prevailed in 
Paris. It has also been observed in this country 
among children, but attended by much local in- 
flammation and constitutional disturbance of a 
typhoid character, and which, unless treated very 
early, has ended in ulceration, sloughing of the 
pudenda, and death. These cases have been de- 
scribed by Dr. Percival of Manchester, as having 
occurred there in 1791. Again, in 1815, the at- 
tention of the profession was called to them by 
Mr. Kinder Wood, who had then seen twelve of 
them, all occurring at Oldham, or the immediate 
neighbourhood of Manchester. Dr. Mackintosh, 
of Edinburgh, has described four cases, of which 
two followed immediately after measles ; and it is 
not uncommon to find a milder sort of leucorrhcea 
making its appearance after the subsidence of that 
eruptive disease. Except those mentioned by Dr. 
Mackintosh, it is curious that nearly all the others 
have been noticed in the neighbourhood of Man- 
chester ; for Dr. Ferriar, who practised there also, 
states, in his " Medical Histories and Reflections," 
that he had " met with several instances" of a 
similar nature. The cases related by Dr. Percival 
are important on another ground, as the first in- 
stance which fell under his notice led to the com- 
mittal of a youth for a supposed rape, the appear- 
ances on the pudenda of the child having led to 
the suspicion that violence had been committed. 
The rapid occurrence of several similar cases alone 
saved the youth from trial and probably execution. 
The recollection of such facts is of real conse- 
quence when an opinion is required upon sup- 
posed instances of defloration. 

There is one material point connected with 
cases of leucorrhcea, and especially those where 
the discharge is purulent or of an acrid character. 
In such instances it is well known that sexual in- 
tercourse will often bring on a train of symptoms 
very much resembling gonorrhoea in the male. 
This, when occurring between husband and wife, 
has often led to much domestic unhappiness, from 
the supposition of one party or the other having 
contracted gonorrhoea from impure connection. It 
is important to be able to distinguish between 
gonorrhoea and common leucorrhcea to remove or 
confirm the suspicions, but it is very doubtful 
whether any very accurate diagnosis can be formed. 



It has been stated that in a recent gonorrhoea there 
is ardor urins, which does not accompany leucor- 
rhoea, unless unusually acrid. But how are we 
to distinguish in a case of this unusually acrid 
leucorrhcea, or where a gonorrhoea is not recent? 
The redness and tumefaction of the labia, nymphs, 
&c. only can be seen in a recent gonorrhoea, and 
they may be seen in severe cases of leucorrhcea, 
particularly in those following local irritation, or 
possessing more acute inflammatory action. One 
other test is mentioned by authors, that in leucor- 
rhcea the discharge ceases during menstruation, 
but does not in gonorrhoea. This, however, is 
denied by other authors, and, as Dr. Jewel ob- 
serves, " this is a point which cannot easily be 
decided, as from the colour of the menstrual se- 
cretion, that of the leucorrhoeal or gonorrhoea! 
must necessarily be in a great measure obliterated." 
From what has been stated, it is quite evident 
that it is extremely difficult to distinguish between 
the two diseases, and particularly when we recol- 
lect how ready the party in fault will be to con- 
ceal or distort the facts. In all such cases it be- 
comes the duty of the medical man to give his 
assistance not only in curing the disease, but in 
preserving domestic harmony. q LOCOCK 

LICHEN, Xti^v. The cutaneous affection 
known formerly under this term was supposed to 
be, with several others, a mere modification or 
symptom of the lepra Grsecorum (about which 
disease we have seen what confusion reigned — see 
Lepra) ; and we find that this improper notion 
was still held by writers at the beginning of the 
last century. It was also erroneously represented 
to be synonymous with impetigo. All this origi- 
nated in its not being quite clear what was intended 
by the term Xa^nv in the Hippocratic writings, and 
in a misconception of Celsus. The latter describes 
under the name of papulx, a form of cutaneous 
eruption which the best authorities consider to be 
the same as the Xa^jiv of Hippocrates, and it is 
quite evident that he means a perfectly different 
disease by the term impetigo. Able commentators 
assert that the Xn^ws of Hippocrates (Aphorism, 
sect. iii. aph. 20,) signify what they denominate 
" pustulre siccae," — an expression which accords in 
sense with the papulae of Celsus, and the same 
term (or pimple) which is adopted in modern 
nomenclature from the Roman author. Since the 
time of Willan, indeed, his application of lichen 
has been in universal acceptation, and it now al- 
ways signifies an eruption of small, solid, reddish 
papulae, which terminate with a scurf, and are very 
liable to recur. 

The papulae of lichen usually occur in adults, 
and are often connected with internal disorder, but 
not so exclusively as to be admitted into the defi- 
nition : they are accompanied always with more 
or less pruritus, and are situated on the arms, face, 
or legs, and sometimes are developed all over the 
body. 

But the closer description of the disease and its 
course requires that we notice its varieties ; and 
here we may remark that we differ from those 
authors who deny the utility of entering into 
more minute distinctions than arc necessary merely 
to denote the generic relations of the cutaneous 
affections. It is true that multiplying terms u«- 



LICHEN. 



139 



lessly would only tend to embarrass the student 
of those diseases ; but it is equally certain that 
classifying phenomena according to the various 
relations of form, colour, situation, extent, and 
other conditions, and thereby establishing real va- 
rieties, not only is highly conducive to the advance- 
ment of the pathology of those affections, but very 
much facilitates the attainment of a practical ac- 
quaintance with them. It appears to us to be as in- 
dispensable to the study as it is to the description 
of them, to have specified varieties fixed in the mind 
by distinctive appellations ; and we confidently 
affirm that students who were really interested in 
acquiring a knowledge of skin-diseases have ever 
found material aid from the division into species 
accomplished by Willan. Their imperfections are, 
of course, manifold, but it is a proof of their 
utility to observe that every systematic writer, 
whatever his sentiments be with regard to them, 
whether he admire them or call for their abroga- 
tion, is obliged to notice them. The fact is, that 
they burden the memory of those only who make 
the vain endeavour to learn skin-diseases by books, 
while they assist in a very efficacious and pleasing 
manner the labours of the patient observer of 
nature. 

The principal species, or rather varieties, of this 
affection are the following. 

1. Lichen Simplex. — This is the species most 
commonly met with. It consists of small red 
papulae, more or less elevated and acuminated, 
which contain no fluid of any kind, and are quite 
opaque and solid. It mostly commences on the 
face and the back of the hands, and, when more 
generally extended, it affects in preference the 
posterior and exterior parts of the arms and thighs. 
It may be stated generally, that it occurs most 
frequently in those parts of the skin which are 
most delicate and exposed to external influences. 
The eruption of papulae is accompanied with a 
tingling formication, which is very disagreeable, 
particularly during the night, or when the person 
becomes heated by exercise or otherwise. 

This variety is either acute or chronic in its 
course and character, but much oftener the latter. 

In the acute form the papulae are very red, and 
the inflammatory action accompanied with much 
heat and itching. After three or four days their 
redness diminishes, and having thrown off a mi- 
nute furfuraceous scurf, they disappear. They are, 
however, at the same time followed by others. In 
about a fortnight after four or five successive erup- 
tions, it generally subsides altogether. This acute 
form of the affection mostly occurs on the face and 
trunk. 

The chronic form is generally situated on the 
limbs, and prefers, as before mentioned, the pos- 
terior and exterior surface of these. The papula? 
have scarcely any inflammatory character, and the 
pruritus with which their manifestation is preceded 
or accompanied gives but trifling annoyance. — 
While some are sufficiently red, it requires that 
we pass the fingers over the great majority which 
stud the surface to distinguish them, so little do 
they differ from the rest of the skin in colour. The 
papulae remain from a week to a fortnight, and 
leave the branny desquamation behind on waning ; 
but the duration of the affection in the chronic 
form is quite indefinite, as fresh successive crops 



of pimples protract it often to many months. It 
manifests its tenacity sometimes by breaking out 
in a different part of the body after disappearing 
from its original situation, and it is liable to recur 
from the slightest cause, when the patient thinks 
that he is at length clear of it ; such as changes 
of weather, errors in diet, or unusual exercise. 

2. Lichen circumscriptus. — This variety is dis- 
tinguished by a marked peculiarity of form. The 
papulae, which in the former species are scattered 
without order, assume in this a circular arrange- 
ment. At the first view nothing may be observed 
beyond a ring of red papulae, but on closer inspec- 
tion these are found to inclose areas covered with 
a minute farinaceous desquamation, which is de- 
tached from small papular eminences beneath. 
The external papulae alone manifest any inflam- 
matory redness, or if those inside the circles differ 
from the rest of the skin in colour, it is only by a 
light pinkish hue. The circumferences of these 
circles, at first so small that the papulae lie clus- 
tered in contact, soon spread by new eruptions, 
while the old borders fall into the desquamating 
centres. They seldom enlarge beyond the size of 
a shilling, and when the eruption is extensive, 
they mingle their circumferences, yet not so inti- 
mately but that it is always easy to recognise their 
circular form. This variety occurs as frequently 
on the trunk and face as on the extremities. From 
its tendency to spread and to propagate by form- 
ing new patches, it is not to be speedily eradicated. 
We have observed it occurring most frequently 
in early youth : it is called by boys at school 
wildfire. 

3. Lichen pilaris. — This differs from the lichen 
simplex probably in no pathological character 
save that the papulae are developed at the root of 
the hairs, which perforate their centres. This 
variety is remarked to be more chronic in its dura- 
tion, and to be accompanied with greater irritabil- 
ity of the skin, than any of the preceding. Bate- 
man's observation accounts for this : he states 
that it is often connected with derangement of the 
digestive organs, produced by ardent spirits. 

4. Lichen lividus. — This is a kind which 
almost always occurs in persons with constitutions 
broken up by misery and privation. It consists 
in dark violet pimples scattered here and there on 
the legs and thighs ; they are flat and broad, and 
are generally mixed with specks, which differ in 
nothing from purpura, to which disease this form 
of lichen is evidently allied. It is not so rare as 
some authors assert, but it is of little importance 
in a medical point of view, as in most cases its 
cure is to be promoted rather by the charity than 
the professional services of the physician. 

5. Lichen agrius. — This is the severest form 
of this disease, as its name implies. ('Aypids, 
ferus, agrestis.) The papulae are smaller than 
in the lichen simplex ; they occur in congregated 
masses, and are very numerous. Their colour is 
deep red, and the skin where they arise is affected 
with a vivid erythematous inflammation, which 
spreads between them and beyond them. The 
heat or pruritus which accompanies their erup- 
tion is of the most violent character, and often 
deprives the patient, night after night, of rest : he 
cannot avoid scratching the pimples, and often 
employs a hard brush for this purpose. This pro- 



140 



LICHEN 



ceeding, although rendered irresistible by the in- 
tolerable burning and itching, only tends to make 
matters worse; it aggravates the inflammation, 
and encourages the development of new patches. 
Besides this, where the papula? become forcibly 
abraded, small ulcerations ensue, and a liquid oozes 
from them which forms thin crusts or scaly con- 
cretions. In some rare cases the affection appears 
to be relieved by the discharge, and having soon 
thrown off the soft incrustation which the latter 
formed, the cutaneous inflammation and its effects 
subside. The general course of the disease is, 
however, very different ; painful exacerbations and 
new eruptions take place for many weeks ; and at 
length it falls into a chronic condition, in which 
the inflammation nearly ceases, and the pruritus 
becomes much mitigated. In this condition it 
remains for an indefinite period, the serous secre- 
tion being checked, and the scaly crusts becoming 
dry, and diminished to a farinaceous exfoliation. 
After a severe attack of this affection the skin 
remains for a long time thickened and rough, and 
retains a morbid sensibility, which persists for a 
considerable space. 

This aggravated form of lichen is sometimes 
produced from the lichen simplex by causes, gen- 
eral or local, which determine a higher inflamma- 
tory action. In such a case the inconsiderable 
itching which accompanied the pimples of the 
original species is changed into a burning pruritus ; 
the papulre become in some places apparently con- 
fluent, and surrounded with a deep red inflamma- 
tory areola ; and thus it proceeds in the course 
described. It more generally, however, com- 
mences as a distinct form, putting on its charac- 
teristic severity from the very beginning. In that 
state where the lymphy fluid which exudes from 
the abraded and ulcerated papulae concretes into 
crusts, it approaches very nearly to the character 
of eczema. If it persist without showing any 
tendency to heal, after some time a purulent secre- 
tion forms, and may become, as Celsus remarked, 
really converted into impetigo. 

The situation of this species is uncertain. It 
occurs with about equal frequency on the face, 
trunk, and extremities. It is not peculiar to any 
period of life, as it happens at all times from child- 
hood to old age ; but it appears to be more fre- 
quently and easily excited in those vitiated habits 
of body produced by addiction to spirituous liquors. 
This is more particularly the case among the 
poor, who, in addition to the injury done by the 
drinking itself to their organization, deprive them- 
selves of a wholesome nutrition to indulge this 
miserable propensity. It is always preceded or 
accompanied by some fever and gastric derange- 
ment, sometimes of a serious nature; such as 
headach, nausea, vomiting, and loss of appetite, 
also general soreness and pains. Internal disor- 
der is also very apt to occur if the eruption be re- 
pelled by the unseasonable application of cold. 

6. Lichen urticatus. — This is a variety which 
well deserves to be separately specified. It con- 
sists of an eruption of large red papula?, like the 
wheals produced by the stinging of nettles. They 
are found on the neck and arms of young persons, 
and those of a delicate skin, in spring and sum- 
mer. It disappears with a slight exfoliation after 
a short time, and recurs again generally several 



times before it is finally removed. The pruritus 
which accompanies it is not of the acrimonious 
character of the last species, but it gives consider- 
able annoyance, particularly at night, when it also 
is accompanied by a slight feverish access. 

M. Biett describes a variety distinguished from 
any other by the papulce displaying a spiral or 
circularly twisting arrangement. He has given it 
the name of lichen gijratus. (Cazenave et Sche- 
del, Maladies de la Peau d'apres M. Biett, p. 269.) 

Lichen tropicus is a species which appears to 
differ in no respect from the other varieties except 
in the rapidity of its invasion, and the greater in- 
tensity of the itching, which are caused by the 
high activity of the cutaneous action, and the ge- 
neral exaltation of sensibility which the solar heat 
gives rise to in the torrid zone. It is appropriately 
called the " prickly heat" in the tropical countries. 
" The sensations arising from it," says Dr. James 
Johnson, " are perfectly indescribable, being com- 
pounded of pricking, itching, tingling, and many 
other feelings." It is usually, but not invariably, 
accompanied by an eruption of vivid red pimples, 
not larger in general than a pin's head, which 
spread over the breast, arms, thighs, neck, and oc- 
casionally along the forehead, close to the hair. 
This eruption often disappears in a great measure 
when the patient is sitting quiet and the skin is 
cool ; but no sooner does he use any exercise that 
brings out perspiration, or swallow any warm or 
stimulating fluid, such as tea, soup, or wine, than 
the pimples become elevated, and but too sensibly 
felt. As would be anticipated, the new comers 
are much more liable to this unpleasant affection 
than natives or long residents ; for the susceptibil- 
ity of the skin is greater, while the contrast be- 
tween the cold and hot climate is still sensibly 
present ; but even natives are not exempt from it. 
The fears which Hillary and Mosely express about 
dangers accruing to the patient from repulsion of 
the eruption by cold bathing are ungrounded ; but 
Dr. Johnson states "that the cold bath rather 
aggravated than appeased the eruption and ting- 
ling, especially during the glow which succeeded 
the immersion." " The only means," says he, 
" which I ever saw productive of any good effect 
till the constitution got assimilated to the climate, 
were light clothing, temperance in eating and 
drinking, avoiding all exercise in the heat of the 
day, open bowels, and, last not least, a determined 
resolution to resist, with stoical apathy, (the 
temptation to scratch,) its first attacks." Mr. 
Plumbe remarks with justice, "that the prickly 
heat is not confined to the climates from which it 
derives its name. In fact, the lichen urticatus 
occasionally occurs in these countries with an in- 
tensity of itching and tingling that must be quite 
as tormenting as the tropical affection. The 
writer knew a person who for several successive 
nights was obliged to jump out of bed from the 
sudden supervention of an intolerable heat and 
itching, produced by an eruption of this nature. 
The pimples which arose on the head in particular 
produced such irritation, that the patient felt as if 
they would make him mad. After remaining in 
the cool air for a while, and taking a draught of 
water, they subsided, and allowed him to go to 
sleep at an advanced period of the night, leaving 
him quite free till the next night. It is often 



LICHEN. 



141 



brought on in spring- and autumn, in young per- 
sons, by violent exercise, and it is a penalty not 
unfrequently paid for dancing in these seasons. 
Mr. Plumbe mentions a case where a public per- 
former was obliged to forego this manner of ob- 
taining a livelihood from the severity of its at- 
tacks. (Practical Treatise on Diseases of the 
Skin, p. 251, third edition, 1832.) 

Diagnosis. — To some of the foregoing varie- 
ties may be referred every example of lichen ; but 
these papular eruptions are so manifold, and pass 
so readily into one another, that it may be difficult 
to assign its proper place to individual cases : 
this, it will be conceived, is pot of essential im- 
portance. Although we have adopted this divi- 
sion into species because we are convinced of its 
convenience and exactness, and think that it tends 
to forward the study of cutaneous pathology, yet 
it is not intended to impose a notion on the stu- 
dent that we derive at present much assistance 
from them in the treatment. Their diversity con- 
sists, at least chiefly, in the degree of inflammatory 
action, and is much influenced by the previous 
constitution of the person, their circumstances 
and habits, local relations, &c. The causes which 
produce them afford, also, a proof of their agree- 
ment. They may be comprised under two gene- 
ral heads : —1st. Heat, either of the atmosphere or 
artificial. This is a common source of them, 
from the slightest summer rash (lichen simplex) 
to the prickly heat. Blacksmiths and glasshouse- 
men are very constantly affected by some form of 
it, from the heat of their furnace and forge. 2d. 
Derangement of the digestive organs, either from 
improper diet and spirituous liquors in excess, or 
defective and unwholesome aliment. To this head 
are often to be traced cases of lichen agrius, lichen 
urticatus, and to the latter cause particularly the 
lividus. 

An accurate diagnosis of lichen is not always 
easily made. It is of considerable importance in 
practice, however, to be able to distinguish it, 
more indeed for the sake of determining what it 
is not, than for establishing its own identity. We 
must be particularly cautious not to confound it 
with any of the exanthematous eruptions, with 
measles or scarlatina for instance ; but it is only 
necessary to point out here the possibility of this 
mistake : if the description of the varieties above 
given be fixed in the mind, it cannot occur. 

From scabies, prurigo, and eczema, the lichen 
simplex is not so easily distinguished. We will 
observe, in drawing the distinction, that scabies 
comes out in vesicles which discharge a fluid on 
breaking, that it occupies the intervals, between 
the fingers, and the flexures of the wrist and 
finger phalanges ; on the other hand the solid red 
papulse of lichen are very different from the trans- 
parent vesicle of scabies; they are situated, as wc 
have seen, on the exterior parts of the arms and 
thighs ; and if they appear on the hands, where 
scabies almost universally begins, they occupy the 
dorsal surface, and do not affect the joints or the 
intervals of the fingers. The contagion of scabies 
would settle the question if this were ascertained, 
but this is never the case where there is a doubt 
as to the diagnosis. It is, in fact, to procure in- 
formation as to the contagious nature of the erup- 
tion under consideration that diagnostic marks 



are valuable between scabies and lichen, in order 
that proper precautions may be taken, in case it 
be the former, to prevent it spreading. Lorry 
sums up the difference between them with con- 
ciseness and accuracy. " Primo a scabie differ- 
unt, quod papulae ilia; (lichenis scil.) vulgo magis 
confertaj sint et elatiores ; 2°. quod rubicundae 
magis et minus aridae sint ; 3°. quod sanatis febri- 
bus superveniant ; 4°. quod latiores sint, et saepius 
rccidivam patiantur quam vera et legitima scabies; 
5°. quod in furfur abeant notabile ; 6°. demum 
quod remediis sanentur a scabiei curatione alie- 
nis." (Bateman's Synopsis, note, p. 8.) 

The papular nature of prurigo comes nearer the 
external character of lichen simplex, but the pim- 
ples of the former are larger, much more separated, 
and seldom differing in colour from the surround- 
ing skin ; they are not acuminated as in lichen, 
and are covered generally with a speck of dark 
blood : this is produced by abrasion in scratching, 
the pruritus being of a peculiarly acrimonious na- 
ture ; whereas in lichen simplex it is compara- 
tively mild. Lichen may simulate eczema so 
closely as to require much tact and consideration 
to decide between them. When the eruption of 
lichen simplex is very vivid, there often appear, 
here and there, some vesicles ; and when with this 
occurrence it happens that the patient abrades the 
summits of the papules, the excoriations give out a 
fluid which concretes and forms soft crusts ; in 
this state many of the features of eczema are pre- 
sent. On inquiry it will be ascertained that at 
first the eruption was entirely papular, and that 
the few stray vesicles are merely adventitious. 
They generally come out after the excoriations 
have been made, and in their immediate neigh- 
bourhood. 

The lichen agrius is still more difficult to dis- 
tinguish from eczema. We must rely on the his- 
tory of the eruption, and the character of the ele- 
vation of the skin, which is vesicular in the latter 
case, and papular in the former. This can gene- 
rally be determined by examination after the crust 
which covers it is removed. Besides this, the irri- 
tation which the real eczema causes is strongly 
contrasted with the burning itching of the papu- 
lar eruption ; but this distinction may fail after a 
long duration of the latter disease, and the others 
become so confounded, that it is often impossible 
to distinguish between them. 

It has been already stated that lichen agrius 
sometimes takes the characters of impetigo, but 
the reverse never takes place ; the latter ought 
never to be mistaken for the former. The small 
psydracious pustules of impetigo are manifest from 
the beginning, and the coarse crusts which form 
on their breaking are different from the thin layer 
which the excoriations of lichen furnish. 

When lichen agrius subsides into a very chro 
nic state with a tendency towards cure it is often 
so much overlaid with furfuraceous exfoliation as 
to be taken for a scaly disease. Some authors, 
indeed, assert that it is not uncommon for it and 
for the lichen simplex to be converted into psoria- 
sis. The writer has lately seen a gentleman who 
had on the arms and chest an eruption of lichen 
simplex, which in the axillx- and the folds of the 
buttock was changed in character so as to resemble 
ptyriasis more than any other cutaneous affection. 



142 



LICHEN. 



Lichen circumscriptus has often been mistaken 
for herpes circinnatus ; we have lately seen a skil- 
ful observer make this oversight. It is to be borne 
in mind that the circular patches of the papular 
eruption are smaller, and show no vestiges of vesi- 
cles or their remains, which are always discernible 
on closely inspecting the rings of herpes circinna- 
tus. Moreover the central space of the latter is 
quite untouched, but in the lichen the papulae are 
still recognised, paler than the external circle, and 
overlaid with the farinaceous scurf. It is proper 
to remark that the psoriasis guttata has been also 
mistaken for lichen circumscriptus. 

The difference between lichen urticatus and 
urticaria will be ever easily recognised by any one 
that has seen both affections. Besides the exan- 
thematous character of the latter, the form is quite 
distinct. The papula? in the lichen are large, ele- 
vated, distinct, and are more or less permanent. 
The wheals of nettle-rash are confluent, flat, and 
scarcely ever remain beyond a few hours at a 
time. This lichen may also be mistaken for the 
venereal eruption called by some authors lichen 
syphiliticus. The latter disease is marked by its 
coppery hue ; besides it is destitute of the pruritus 
which accompanies all proper lichens, and it is 
more steadily persistent than lichen urticatus. 
Again, it is seldom found alone, almost invariably 
accompanied by some of the other attendants on 
secondary syphilis. 

Prognosis. — In none of its varieties can lichen 
be considered as a dangerous disease, and in the 
less scarce forms, almost the only importance that 
attaches to its presence is the troublesome itching 
which the pimples occasion. When it arises from 
merely local or temporary causes, such as the di- 
rectly irritating action of the spring or summer 
heat, it is of little consequence and of short dura- 
tion ; but if its origin be more deeply seated in the 
constitution, if it be liable to frequent recurrence 
and exacerbation, it leads to more unpleasant con- 
sequences. It is in such instances that it gives 
rise, after a long duration, to a thickened rugous 
state of the skin, which completely obstructs its 
function of exhalation. At other times, as we 
have before stated, under similar circumstances it 
becomes complicated with eczema and impetigo, 
and, according to Biett, sometimes degenerates 
into ecthyma. The lichen agrius, as it is the most 
severe of all the varieties, so is it also the most 
difficult of cure ; when situated in the face, it more 
particularly resists with uncommon obstinacy all 
therapeutic means. It may be stated as a general 
rule, that this and the other varieties are difficult 
of removal in proportion as they are of long dura- 
tion. 

Treatment. — In the lighter forms of this erup- 
tion, the treatment is simple. It demands, indeed, 
but little interference from the physician. His 
services here are seldom required further than in 
making an accurate diagnosis, tracing the eruption 
to its true cause, and laying down principles of 
treatment. As they generally occur in warm 
weather, and depend more or less on it, the indi- 
vidual should keep the house for some time, and 
thus abstract himself from the direct heat of the 
sun and from exercise, which last is one of the 
most common exciting causes of it. It will be 
Useful to employ every day towards evening the 



tepid bath. Some even prefer the cold bath ; the 
warm bath is too stimulating to the skin. To 
coincide with these cooling means, it will be requi- 
site to adopt a diet in which the allowance of 
animal food is diminished. It will rarely be neces- 
sary to inhibit it altogether, but the greater propor- 
tion that vegetable and farinaceous matters make 
in the meals the better. Wine and spirituous 
drinks should be laid aside, but there is no objec- 
tion to a moderate quantity of table-beer. As to 
medicines, it will be sufficient to give a saline 
laxative occasionally, so as to keep the bowels 
open : sometimes it will be judicious to use a few 
grains of calomel or blue pill for this purpose ; 
potions of lemonade are much used in France. 
Bateman extols the use of dilute sulphuric acid 
where a grateful tonic is called for. For allaying 
the itching, various topical applications have been 
used. Mucilaginous decoctions, as that of marsh- 
mallows, are said to have a soothing effect. A 
lotion with two drachms of prussic acid to a pint 
of water has been also recommended highly. We 
believe that one of the best applications for this 
purpose is milk of almonds, in the composition of 
which a few bitter almonds have been mixed ; with 
this the skin should be gently moistened three 
times a-day, or whenever the pruritus become 
troublesome. 

In some of the acute cases where a good deal 
of fever accompanies the eruption, or where much 
sympathy is evinced in the digestive organs by 
vomiting, loss of appetite, or pain in the head, it 
will be highly advisable to take away some blood 
from the arm, and to pursue a more decidedly 
antiphlogistic plan. Stimulating applications, 
such as sulphur fumigations, or ointments with 
camphor, &c. are not to be used in the acute 
forms ; but when much of the activity of the 
eruption is subsided, and the harsh chronic state 
of the skin, mentioned before, supervenes, then 
baths of the sulphuret of potash or of the sulphu- 
reous mineral waters will be very proper. In this 
state the ointment of the proto-ioduret of mercury, 
mentioned in the article Lepra, has been used 
with decided benefit. 

In lichen agrius it is advisable to commence the 
treatment almost always by a venesection. No- 
thing tends so much to allay the vehemence of the 
burning pruritus. This practice will be more 
pointedly indicated if the patient be young and 
vigorous, but we consider that it is not less useful 
in an opposite condition. The application of 
leeches in the neighbourhood of the inflamed pa- 
pulae will also prove a very effectual sedative for 
the painful itching, but in their use it must be 
carefully observed to place them exterior to the 
inflammatory area. Every thing said with respect 
to the necessity of an antiphlogistic diet is still 
more indispensable to observe here while any fever 
remains, or while the inflammation displays any 
activity. Under these conditions, every local sti- 
mulant must be avoided as worse than useless. 
Emollient poultices, with some Goulard's extract 
sprinkled in them, will sometimes be found to 
assuage the irritation, but if used more than barely 
lukewarm, they will only increase it. The almond- 
milk embrocation will answer this end probably as 
well as any other. Dr. Elliotson recommends, as 
the best means for allaying the tingling and itching, 



LIVER, (DISEASES OF THE) 



143 



a lotion of chloride of lime or soda, to be used 
very dilute. 

If under depletory means the eruption loses 
much of its intensity, then the exhibition of tonics 
will often prove highly serviceable. The decoction 
of cinchona with sulphuric acid is preferable to 
any other. This is especially useful in the cases 
of broken-down, dissipated subjects, and where 
the constitution has been brought rather low by 
antiphlogistic measures. It is not to be imagined 
that there is any thing contradictory in this prac- 
tice of first reducing the system by depletory 
means, and then administering tonics as it were to 
restore it ; on the contrary, the practice is found 
not only compatible with theory, but experiment- 
ally good. In fact, where we have to do with im- 
paired constitutions, the abstraction of blood will 
be useful, as the tonics will act with greater cer- 
tainty and efficacy after it, than if they be trusted 
to without it. With respect to the diet in this 
stage of the affection, it should be still kept of a 
very light kind ; but it is to be borne in mind, that 
where the disease has supervened in an individual 
whose digestive organs and system generally have 
been greatjy impaired by habitual drinking, it is 
expedient to allow him a small portion of his ac- 
customed stimulus. This is another fact confirmed 
by experience and reconcileable to pathological 
principles. 

Where it has fallen into an inveterately chronic 
state, lichen is a very intractable malady. Sulphur 
fumigations, sulphur and alkaline lotions, have in 
this case been found beneficial. Mercurial pre- 
parations have also been recommended. If obliged 
to have recourse to this mineral, we would prefer 
trying the proto-ioduret of mercury to any other 
preparation, from what is known of its effects in 
some other cases ; one grain twice a-day is a suf- 
ficient dose for an adult. With its internal use, 
might be properly joined the local application of 
the ointment of the same preparation. We believe, 
however, that Fowler's arsenical solution is the 
best internal remedy in those inveterate cases ; it 
is to be given in doses of from three to eight drops 
thrice a-day, and continued for at least a month. 
The cautions usual in its exhibition are of course 
to be strictly observed. j Houghton. 

LIVER, DISEASES OF.— The liver, in com- 
mon with other organs, is liable to certain morbid 
changes of structure, usually designated « organic 
disease." The application, however, of the epithet 
" organic," has been neither very precise nor cor- 
rect ; for it is used to express every description of 
alteration, from simple congestive tumefaction to 
complete disorganization or alteration of structure 
or tissue. In the present [general] article, we 
propose to consider the diseases of the liver (hepa- 
titis excepted) [which will follow in a distinct 
article] and its membranes, and the general effects 
of them upon the economy at large. Many of 
these are purely the effects of inflammatory action 
of some kind ; many the result of morbid growths 
or accretions, and present morbid changes of struc- 
ture, induced by causes the nature and operation 
of which are not satisfactorily ascertained. These 
affections may be arranged under two general 
heads or divisions, namely, those, affecting the in- 



vesting membrane, and those affecting the more 
immediate substance of the liver. 

I. Diseases affecting the Investing Mem- 
biiane of the Liver. 

The diseases affecting the investing membrane 
of the liver are mostly the result of inflammatory 
action. Inflammation, when confined to the mem- 
brane, is generally also confined to the anterior or 
convex covering. Sometimes, however, it occu- 
pies those portions in contact with the stomach 
and duodenum. The effect is a layer of coagu- 
lable lymph. This layer gradually concretes, be- 
comes more or less organized, and firmly attaches 
the peritoneal covering of the liver to the conti- 
guous parts, producing what are termed " adhe- 
sions." In some cases, the adhesions are so gene- 
rally diffused over the whole surface, and the 
contiguous membranes so closely united, as to 
seem one simple but thickened membrane, nor 
can the separation be effected without sufficient 
violence to lacerate the original membranes, and 
separate them from their natural connections. 
More frequently, however, these adhesions are 
formed by membranes of considerable length, in 
many instances resembling the processes known 
more commonly as " the ligaments of the liver." 
The substance of these adventitious membranes 
varies in different cases ; in some, it is extremely 
delicate, pellucid, transparent, and beautifully in- 
terwoven. In others, it is much denser and firmer, 
and frequently crossed or intersected with strong, 
inelastic, ligamentous-like bands. The author has 
now in his possession a membranous connection 
of this sort, about five inches in depth, and which 
is traversed on each side by strong unyielding 
bands of this description, several lines in thickness. 
In many cases the membranes present no ap- 
pearance of unusual vascularity ; but it not un- 
frequently happens that the whole surface is 
covered with minute vessels, intersecting each 
other in every possible direction. These vessels 
are sometimes of a bright vermilion, sometimes of 
a purple colour. In such cases, these adventitious 
membranes are in a state of inflammation, and 
give rise to all the local symptoms of severe in- 
flammation of the contiguous viscus, without the 
constitutional excitement so invariably accom- 
panying a true phlegmasia. It may be as well to 
explain the nature of symptoms which frequently 
prove embarrassing to the practitioner. 

These connecting membranes, being of foreign 
origin and the production of disease, are not so 
intimately connected with the system as those 
which are more immediately and essentially parts 
of the natural organization, and exert no direct in- 
fluence upon the animal economy. Consequently, 
when diseased or inflamed, they become mecha- 
nical sources of impediment, rather than causes 
of constitutional derangement. Like all other 
organized parts, they exhibit sensibility and all 
the other manifestations of vitality, but still the 
sensibility is probably much inferior to that of the 
essential organizations ; or, at all events, from 
their loose connections, and the total absence of 
all functional contribution, they do not appear 
capable of influencing the economy, like the other 
parts, more intimately connected, when labouring 
under disease. It is obvious that the treatment 



144 



LIVER, (DISEASES OF THE) 



will consist in mere local measures, such as leech- 
ing, cupping with scarification, blistering, &c. 
Dry cupping is often very efficacious in such 
cases. 

Sometimes the coats of the liver are converted 
into cartilage. Dr. Baillie, however, states that 
this happens much more frequently in the spleen 
than in the liver. The cartilaginous conversion 
is generally smooth, thin, and soft in its texture. 
Sometimes small fat-like excrescences are observed 
upon the surface of the peritoneal covering. They 
vary in size, from that of a pin's head to that of a 
pea. They often partake of the character of 
tuberculous accretions, and their consistence varies 
from a mere pulp to a hard fatty mass. They are 
not important in a practical point of view. 

II. Diseases of the Liver. -t" 

The diseases of the liver may be divided into 
those affecting its immediate structure and those 
affecting its appendages. 

Morbid Anatomy of Diseases of Structure 

A very common effect of previous disorder is pre- 
ternatural evolution of volume from simple tume- 
faction. It is the consequence of an unnatural 
accumulation of blood in the vessels of the liver. 
It is that condition described by the French 
writers under the term liypersemia, and may be 
either general, that is, pervading or occupying 
uniformly the entire of the organ, or more partial 
in its extent. When general, the liver presents a 
degree of redness uniformly diffused throughout. 
Its volume is considerably enlarged, but of the 
natural consistence ; and its absolute weight, as 
well as specific gravity, is increased. 

If an incision be made into a liver in this con- 
dition, black fluid flows out very abundantly. It 
often happens, however, that the hyperoemia is 
more partial, appearing in distinct patches, and 
forming red spots, varying both in figure and ex- 
tent, in different parts of the liver. These spots 
are rendered more conspicuous from the contrast 
presented by the surrounding paler parenchyma. 
The colour arising from hyperemia will vary ac- 
cording to circumstances. In some instances it 
assumes a dull brick red ; but in most cases it is 
of a reddish purple, which is readily reconcilable 
with the sources of supply. -/" 

Andral asserts that hypersemia is of three kinds. 
The first he considers as arising from irritation, 
which may be either idiopathic or sympathetic 
of — "subsequent to" — a similar affection of the 
alimentary tube. The second description he con- 
siders to be wholly of a passive nature, the blood 
accumulating in the parenchyma, exactly as it 
accumulates in the gums in scurvy. The third 
kind he looks upon as purely mechanical, arising 
from obstruction of some description or other in 
the right side of the heart; "the blood then stag- 
nates in the supra-hepatic veins, and obstructs the 
liver." (Vol. ii. p. 588.) 

The same authority asserts that "congestion of 
the liver from a mechanical cause" often takes 
place in infants during parturition. Such infants 
have the liver so gorged with blood, that the ves- 
sels give way, and the blood is extravasated under 
the investing membranes on the anterior or convex 
surface. M. Billard states that effusions of blood 
into the cavity of the abdomen, in consequence of 



such a turgid condition of the liver, are by no 
means uncommon. 

Hy peramia may be considered as comprehending 
several distinct varieties, differing as to their seat 
and nature. It may take place, for example, in 
the larger vessels, producing that species of ple- 
thora more properly designated engorgement. In 
this species the larger arteries and veins are pre- 
ternaturally distended ; and the flow of blood on 
section of the substance will be immense. It 
may also be complicated with a sub-inflammatory 
condition of the vessels, particularly of the veins. 

When we consider the peculiar character of the 
circulation through the liver, and the nature of the 
vascular structure by which the function of the 
organ is performed, we can have no great difficulty 
in understanding the subacute character of the 
symptoms even of what may be termed the more 
active diseases of the organ. The function of the 
liver, contrary to that of most other organs, is 
performed through a venous rather than an arterial 
tissue ; and hence almost all the diseases of the 
liver manifest the congestive or the veno-conges- 
tive character ; that is, symptoms are either almost 
altogether absent, or they are of the more obtuse 
description. Very often in the congestive affec- 
tions there is no obvious manifestation of disease, 
till the liver has acquired a volume incompatible 
with the space naturally assigned for its accom- 
modation ; and the attention of the patient is 
attracted, not by the primary affection, but by the 
secondary ones. But when the disease partakes 
of the nature of veno-congestive inflammation, 
then we find those subacute symptoms character- 
istic of this species of inflammatory action ; such 
as dull pain, a slightly excited circulation, and the 
other symptoms of constitutional participation. 

The inflammatory affections of the liver are 
always more slow in their course, and their termi- 
nations, unless by resolution, are more protracted. 
Hence suppuration, abscess, &c, are much longer 
deferred than in organs the structure of which 
renders them liable to real inflammation. Upon 
these principles we can understand, or at least 
plausibly account for, the utility of mercury in 
the early periods even of what are named inflam- 
matory affections of the liver. They are all mostly 
of the congestive or veno-congestive character, and 
mercury seems to exert a specific exciting influ- 
ence upon those parts of the vascular system 
which are more especially the seat of such con- 
gestions. 

The structure of the liver is found to consist of 
two substances : one apparently formed by the 
ramifications of its capillary vessels, presenting a 
reddish appearance ; the other a yellowish white, 
and which is supposed to be chiefly concerned in 
the secretion of the bile. Although these two 
substances are in the natural state distinct, yet 
some care is necessary to prevent their being con- 
founded. In engorgement, however, they are not 
to be distinguished, and, consequently, a uniform 
redness — purply redness— pervades the entire 
viscus. 

The blood sometimes escapes from the vessels, 
and is effused into the parenchyma, producing a 
species of bloody infiltration, named by the French 
writers hepatic apoplexy. Sometimes it arises 
from the rupture of a single, bltf large vessel, dis- 



LIVER, (DISEASES OF THE) 



145 



tributcd in the liver. In other instances, there is 
no perceptible rupture of any of the vessels ; but 
spots are perceived dispersed in various parts 
throughout the organ. These spots, on being- 
examined, are found to consist of blood, either in 
the fluid state or coagulated. Andral relates an 
instance in which, besides various collections of 
fluid and semi-coagulated blood, there were found 
some spots of a firmer consistence, in the centre 
of which were several fragments of hardened 
fibrine, deprived of the colouring matter. The 
examination of this condition induced him to 
investigate the question, whether fibrine thus 
deprived of its colouring matter might not be the 
origin of certain accidental productions, encepha- 
loid and others, frequently found in the liver ; a 
conjecture in which he was confirmed by the exa- 
mination of another liver, in which he was able 
to trace the different changes of the blood, from 
its perfectly fluid state till it passed into a sub- 
stance resembling precisely the encephaloid in all 
its characters. (Vol. ii. p. 589.) Cruveilhier 
states that the first degree of hepatic phlebitis is 
often a circumscribed infiltration of blood into the 
tissue of the liver. (Dictionnaire de Medecine et 
de Chirurgie, t. viii. p. 326.) 

Anaemia is a condition directly the reverse of 
the foregoing, in which the viscus does not receive 
its due proportion of blood. This, however, more 
frequently arises from some morbid condition of 
the organ diminishing or obliterating the calibre 
of its vessels, as induration and various other 
organic changes. If, for instance, the white sub- 
stance of the liver be preternaturally developed, 
the red remaining either in its natural condition, 
or becoming altered in its colour, while its bulk 
diminishes as the red part wastes, it becomes less 
vascular; condensation takes place ; it is converted 
into a species of cellulo-fibrous tissue, and the 
vessels are obliterated. 

2. Derangements of the nutritive functions. — 
The process of nutrition and growth is subject to 
morbid derangements in the liver as well as in 
other organs ; and in fact there are, perhaps, but 
few parts of the animal body in which such 
derangements are so frequent. They are not only 
very various in their nature, but give rise to 
various and frequently very opposite results. 

Hypertrophy of the Idver is a condition in 
which its volume is increased. This condition 
may be confounded with simple hyperemia, in 
which the bulk is also increased ; but they are 
affections of a very different character, the one 
being a preternatural accumulation of blood in the 
vessels; in the other the increase of volume 
depending upon the preternatural development of 
substance. 

The hypertrophy may be general, that is, the 
entire structure hypertrophied ; or it may be par- 
tial, confined to particular portions ^pf the struc- 
ture. The organ, also, may present various 
appearances as regards colour, consistence, and 
form. It may be pale, or red, or of various other 
tints, as green, grey, or brown ; this last in parts 
degenerating into complete black. The consist- 
ence may be either increased or diminished ; it 
may be firmer and harder, — having a denser and 
more solid feel, — or it may be softer, and more 
approaching to flabby. If the hypertrophy be 

Vol. III. — 19 w 



equally and uniformly diffused, the change of form 
will be simply enlargement. But in some in- 
stances the hypertrophy is partial, and one con- 
stituent may be hypertrophied, while the other 
remains in the natural state, or even runs into 
atrophy. This may give the liver " a lobulated, 
mamillated, or granular appearance." (Andral.) 

Hypertrophy may also be considered in refer- 
ence to extent. Thus it may occupy the whole 
of the liver, or only one or more of its lobes. 
When one lobe only is hypertrophied, it appears 
to constitute the entire of the organ, the remaining 
parts appearing more like appendages. When the 
right lobe is extensively hypertrophied, the left 
seems quite diminished, or to have nearly vanished. 
In the case of hypertrophy of the left lobe, the 
right seems to have diminished in size. The 
hypertrophy of the right lobe is sometimes such 
as to cause it to project considerably below the 
ribs, and in children sometimes to extend nearly 
to the ileum, occupying the whole lumbar region, 
and a great portion of the epigastrium. When 
the hypertrophy exists in the left lobe, it will often 
extend into the left hypochondrium, and not only 
may be, but has been, mistaken for an enlarged 
spleen. More frequently, however, it occupies 
the epigastrium, and the practitioner should be 
aware of this fact, because such projections, by 
careless or hasty observers, may be mistaken for 
gastric tumours, or for diseases of the transverse 
colon. 

The lobulus Spigelii, it has been asserted, is 
found frequently enlarged. More modern observa- 
tion, however, has not confirmed the assertion. It 
certainly is sometimes enlarged, but it does not 
appear that it is often found in a state of isolated 
enlargement. 

According to Cruveilhier, a considerable de- 
velopment may arise from accidental productions 
found in the substance of the organ. But this is 
not hypertrophy properly so called. It is not un- 
common, however, to observe such tumours ac- 
companied with a true hypertrophy of the tissue 
of the liver itself; so that there is at the same 
time with adventitious tissues an augmentation 
of the proper substance of the organ. In other 
cases the liver is the seat of an extravasation, 
from which results a pure and simple augmenta- 
tion of volume without any alteration in its sub- 
stance. (Diet. &c. p. 326.) 

In the foetus, and for some time after birth, the 
liver maintains a volume very disproportionate to 
that which it subsequently preserves. As age 
advances, the size of the liver comparatively di- 
minishes, and it appears much reduced ; it is 
consequently retracted, or rather drawn upwards, 
and its edge can be no longer felt projecting below 
the margin of the ribs. This is the natural con- 
dition ; but in some cases this natural reduction 
in volume is so far from occurring, that the growth 
increases, and the liver becomes still more dispro- 
portionately enlarged. Thus the hypertrophy 
may continue progressively after birth, or it may 
cease for a while ; and the liver, after having re- 
tired nearly within its boundaries, will suddenly, 
and without any manifest cause, continue to in- 
crease, until it arrives at an incredible and most 
distressing size. This state of the liver is very 
often merely one of that combination of pcrver- 



146 



LIVER, (DISEASES OF THE) 



sions in the nutritive functions which together 
constitute the scrofulous diathesis. 

Atropliy is the directly opposite condition of 
that just considered. Atrophy, though generally 
accompanied with reduction in volume, yet is not 
necessarily so. It may extend to all the lohes, or 
affect only one. Like the preceding condition, 
it may also be attended with induration or soft- 
ening. 

Though generally attended with a diminution 
of size, yet an augmentation of volume is by no 
means incompatible with an atrophied condition. 
Sometimes the size of the organ, though atrophied, 
exceeds the natural, and the atrophy consists in 
the removal of the proper tissue, cellular tissue 
being substituted in its stead. In these cases 
there is a defect in the organization, and the 
structure, as it were, reduced to its primitive 
frame-work, presents extensive patches of cellular 
tissue. This tissue is sometimes formed into 
serous, or contains hydatids, or it may become 
hypertrophied ; which, it is argued, so far from 
implying an increase of organic action, rather in- 
dicates a deficiency ; the tissue being unequal to 
the production of the true parenchyma, degene- 
rates into a serous cyst. The atrophy may be 
partial, and then the glandular grains which have 
not been atrophied become enormously developed, 
to supply, as it were, the deficiency caused by 
those which have been removed. 

Cruveilhier states that he has sought in vain in 
the vessels of the liver, whether arterial or venous, 
for the cause of the atrophy of the organ. They 
are diminished in a ratio directly proportioned to 
that of the liver, but nothing tends to show that 
this diminution has been a primary operation. 
(Loc. cit.) 

Atrophy of the liver is observed in a great 
variety of circumstances. In some cases of re- 
tention of bile in consequence of the extreme 
distension of the hepatic ducts, the liver has been 
reduced to half its natural size. In indurations, 
too, it has appeared atrophied, so that its glandular 
structure was hardly to be recognised. 

The partial atrophy seems in general to arise 
from pressure upon the liver, either by tumours 
found in the immediate neighbourhood of the 
organ, or from those formed in the substance of 
the viscus itself. 

Induration. — This state may exist simply, 
or combined with hypertrophy or atrophy. The 
colour varies, being either a purple or lighter red, 
or grey olive or brown. On cutting into a liver 
in this condition we observe no peculiarity of 
structure, but it appears rather a confused and un- 
defined mass. The surface of such livers not 
unfrequently presents the appearance of mem- 
branous threads, of a radiated figure, the lower 
edge bent a little forwards. Baillie considered 
this the first step in the formation of the common 
tubercular liver. He observes, «< I have some- 
times seen very small tubercles formed upon a 
part of the surface of such a liver, which were 
exactly of the common sort. From this appear- 
ance it is probable that additional matter is depo- 
sited in the interstices, through the general mass 
of the liver, rendering it much harder, and that 
this matter, together perhaps with part of the 
jrdinary structure of the liver, is converted into 



tubercles." (Morbid Anatomy, c. ix. Diseased 
Appearances of the Liver.) 

Cruveilhier has often found indurated livers of 
a green olive colour, of great density, tearing or 
giving way with extreme difficulty, and of a vo- 
lume less than in the natural state. The glands 
appear atrophied, and the fibrous envelope of 
each granulation thickened. In place of bile, the 
biliary vessels contained a kind of serosity tinged 
of a bright yellow. In a patient who died, after 
a tedious green jaundice, in a manner similar to 
those who died of cancer in the liver, the only 
alteration discoverable on dissection was that above 
described. By far the greater proportion of indu- 
rations of the liver are accompanied with a dimi- 
nution of its volume. 

Softening. — This condition is said to be as 
common as the foregoing, which, however, does 
not accord with the writer's experience, at least 
among the troops ; still it must be allowed that 
softening is a very frequent morbid condition. 
There seem to be two degrees of it : in the one 
the softened consistence is not perceptible unless 
it be compressed between the fingers ; it then 
readily gives way, becoming a kind of pultaceous 
mass. 

In some cases the liver is so softened that it is 
impossible to detach it without tearing it into 
shreds ; and when the peritoneal covering and 
proper investing membrane are broken, they re- 
duce to a sort of brownish yellow pulp. This 
alteration has been looked upon as cadaveiic, a 
view, however, which appears to be unfounded. 
The liver itself appears a kind of pulp deprived 
of every semblance of organization. It has no 
fetid odour. When put into water, an immense 
number of small yellowish granules appear. 
These are quite distinct, seem as if dissected, and 
resemble the small seeds which present in dried 
grapes or raisins, attached to the large vessels by 
vascular pedicles. In the other the softening ap- 
pears evident to the eye, and somewhat resembling 
that acquired during long-continued maceration. 
The vessels, or at least the extreme branches, 
seem to float in a reddish or greyish-looking pulpy 
mass, and which seems to be nothing more than 
the dissolved parenchyma. 

The colour is in some instances natural; if, 
however, there be hyperemia, the colour will be 
purple or brown, but it frequently happens that 
in consequence of some modification of structure, 
the colouring matter of the blood cannot pene- 
trate the tissue, and it appears remarkably pale. 
In such cases the only traces of blood are confined 
to the large vessels. 

Baillie, under the head of softened substance 
of the liver, states that it is found much more 
flaccid than natural, without any other appear- 
ance of disease. It feels as soft as the spleen to 
the touch, and is then mostly of a leaden (q. v. 
purple) colour. This change he considers must 
arise from a process similar to what Hunter 
named "interstitial absorption," the absorbents 
removing insensibly the very minute parts of 
structure without ulceration. This state he looks 
upon as mostly confined to advanced age, being 
rarely, if ever, found in very young persons. 

Tubercle of the Liver Baillie notices 

several forms of tubercle in the liver; such as 



LIVER, (DISEASES OF THE) 



147 



common tubercle of the liver, large white tubercle 
of the liver, soft brown tubercle, and scrofulous 
tubercles. 

Common tubercle is confined to persons of 
middle or advanced age, being very seldom met 
with in young persons. It is likewise more com- 
mon in men than in women, and more apt to 
occur in persons addicted to spirituous liquors. 
Baillie describes such tubercles as near each other, 
of a rounded form, and giving an appearance of 
irregularity to the surface. They consist of a 
brownish or yellowish white solid matter. They 
vary in size from that of a pin's head to that of 
a hazel-nut, some of them even exceeding this. 
The liver is in such cases indurated, and its lower 
edge bent a little forward. The liver itself is of 
the healthy size, or sometimes smaller, and on 
section of the substance the patulous vessels seem 
reduced in their calibre. The colour of the liver 
is yellow, which is attributed by Baillie to the 
accumulation of bile in its substance ; and as this 
condition is almost uniformly accompanied with 
ascites, the fluid accumulated in the peritoneum 
is almost always tinged yellow, from mixture 
with bile. The gall-bladder is described as being 
much contracted and white, from being empty. 
The bile, it is asserted by the same authority, 
from the pressure of the hard liver upon the pori 
biliarii, does not reach the ductus hepaticus, and 
consequently cannot pass into the gall-bladder. 
Permanent jaundice is also established, because it 
depends upon an unchangeable morbid condition 
of liver. When the jaundice has continued for 
a considerable time, the blood in all the blood- 
vessels of the body is found either not coagulated 
at all, or very imperfectly so ; and this is attri- 
buted to the chemical influence of a mixture of 
bile with the blood. This is the appearance of 
what is named " scirrhous liver ;" but it bears 
only a remote similarity to scirrhus as it appears 
in other parts of the body. (Morbid Anatomy, 
c. ix.) 

Large white tubercle of the liver. — Under this 
name Dr. Baillie describes hard white masses 
sometimes formed in the liver, varying in size, 
being in some cases considerably larger than a 
chesnut, and in others a good deal less. They 
are more numerous near the surface than in the 
middle of the substance. They are in clusters, 
with the healthy structure interposed ; are of a 
firm consistence, and constituted of an opaque 
whitish substance ; they are hollow, or depressed 
upon their outer surface ; and the liver is gene- 
rally enlarged. 

This form seems to be generated round the 
blood-vessels, as appears from making sections. 
It may or may not be attended with ascites. 
Sometimes bile is accumulated, tinging the sub- 
stange of the liver, the colour remaining natural 
between the tubercular masses. Dr. Baillie as- 
serts that he has observed a sort of pus lodged in 
these tubercles very much resembling that from 
scrofulous sores ; and he therefore concludes that 
this species may be of a scrofulous nature. 

Soft brown tubercle. — These generally consist 
of a soft, smooth, brownish matter; are about the 
size of a walnut, and mostly occupy the surface 
of the liver. They are a rare form. 

Scrofulous tubercles. Tubercles Tesembling 



those found in the lungs of scrofulous or phthisi- 
cal patients, are said to be occasionally found in 
the liver. They are said to resemble them pre- 
cisely, except in being a little browner in colour. 
They are dispersed and solitary, and do not give 
that irregularity of appearance attendant on the 
other forms. 

The liver in children is frequently found in a 
tuberculated state. The tubercles are about the 
size of a millet-seed, hard and semi-transparent, 
so as to be sensible to touch as well as sight from 
their density, but yet would escape a careless ob- 
server. 

Such are the forms and varieties of tubercle 
enumerated by Baillie ; but there is reason to be- 
lieve that the nature of these appearances was not 
thoroughly understood in the days of that highly 
distinguished anatomist. 

It has been already observed that the structure 
of the liver consists of two distinct substances ; 
the one a reddish purple, formed by the capillary 
ramifications ; the other of a whitish or yellowish 
colour, and which seems to be the part which se- 
cretes the bile. In the natural state these two 
substances are distinct, but an excess of blood 
destroys all distinction. On the other hand, a de- 
ficiency of blood renders the yellow substance 
more distinct and evident ; and the privation may 
be such that the reddish substance may be de- 
prived altogether of colour, and the liver assume 
a whitish tinge throughout its entire substance. 

This appearance may be very much modified as 
changes predominate in the texture of the parts 
forming the hepatic mass. The yellowish sub- 
stance may become hypertrophied, and this admits 
of various degrees. In one kind the substance is 
marked by the transit of whitish lines; in the 
other it is granulated ; and these granulations, 
whether isolated or agglomerated, assume the ap- 
pearance of yellow wax. These granulations 
Laennec considered as an accidental (adventitious) 
tissue generated in the liver, and named it, from 
its colour and appearance, " cirrhosis." He also 
asserts that what he terms cirrhosis is accompa- 
nied by a shrivelled state of the organ ; and it is 
almost always accompanied by ascites. (See 
Baillie on the common tubercle of the liver.) 

Cruveilhier, who has given an excellent plate of 
this condition, (Anatomie Pathologique du Corps 
Humain, 12e livraison, planchelre,) has examined 
and described its minute anatomy very attentively 
and accurately. He found the liver reduced to 
about a third of its ordinary weight and volume : 
the right and left lobes nearly equal in size, but 
remarkably altered. This double character, dimi- 
nution in volume and change, is a very constant 
occurrence in these affections. The tissue is also 
denser than is natural. 

The surface of the liver is not smooth but 
roughened by a number of granulations (tuber- 
cles), between which there are depressions, 
wrinkles, and thickenings, and the organ might 
be said to be dried up, as it were, withered, its in- 
vesting membranes irregularly thickened, and 
opaque in many parts. Cartilaginous laminae 
were found upon the inferior surface of the left 
lobe, and which were part of the peritoneum. 

The colour is yellow, varying from a bright or 
canary to a brown yellow, depending upon the 



148 



LIVER, (DISEASES OF THE) 



fluid with which the tubercles are penetrated. 
These tubercles, if squeezed upon white paper, 
tinge it yellow. The quantity of colouring mat- 
ter, though various in the different tubercles, 
seemed in direct proportion to their size. The 
blood-vessels traversing the tissue were found 
healthy, but the blood which they contained was 
serous (watery) ; the biliary-ducts and the gall- 
bladder full of a yellow bile, more or less inspis- 
sated. 

On removing the investing membrane, which 
was done in several places, the tubercles were 
found to differ in size ; and some, of the size of 
large peas, had a number of others beside them of 
the size of millet-seeds ; and this gave the irregu- 
larity of surface to the liver. Each tubercle was 
found to be perfectly distinct and unconnected with 
the neighbouring ones, was provided with its own 
proper membrane, and was connected with the 
liver only by a mere vascular pedicle. 

On a section of the liver these observations 
were confirmed ; that is, the separate existence of 
the tubercles and their colour. But farther, it 
demonstrated that there existed, independently of 
the tubercles, a very dense fibro-cellular tissue, 
altogether foreign to the natural state. A section 
of one of these tubercles, examined by the micro- 
scope, presented precisely the same characters as 
the section of a healthy liver, namely, a spongy 
tissue analogous to the pith of a rush. 

On examining into the characters of these tu- 
bercles, they seem to be nothing more than an un- 
natural development of one structure at the ex- 
pense of the other — « une dissociation des deux 
elemens naturels de cet organe : les masses jauncs, 
fauves, constituant le tissu accidentel appele cyr- 
rhose, ne sont autre que les granulations secre- 
taires, se desorganisant graduellemen par l'effet de 
l'obliteration du lacis vasculaire, et 1' obstacle a la 
circulation hepatique qui en resulte." (Memoire 
par M. Bouillaud insere parmi ceux de la Societe 
Medicale d'Emulation, torn. ix. p. 170.) The ex- 
amination also proved that nothing more is neces- 
sary to give a tuberculated appearance to the liver 
than an unusual development of the acini, and 
hence it is unnecessary to suppose the production 
of a new tissue to account for the phenomenon. 

[M. Cruveilhier, however, does not admit that 
the granules are formed of two distinct substances. 
His views of cirrhosis are, that it consists essen- 
tially in atrophy of the greater number of granu- 
lations, and hypertrophy of the remainder to sup- 
ply the deficiency thus engendered. The two dis- 
tinct substances in the liver — the yellow, the se- 
creting tissue, and the red formed by ramifica- 
tions of blood-vessels — are, however, by no means 
generally admitted, and until their existence is es- 
tablished, any theory founded upon them cannot 
be implicitly received. The views of Mr. Kiernan 
in regard to the minute anatomy of the liver 
{Philosophical Transactions, for 1833, p. 711, or 
the writer's Human Physiology, 5th edit. ii. 268, 
Philad. 1844) have given rise to another explana- 
tion which is considered by Dr. Carpenter {Prin- 
ciples of Human Physiology, § 659. Amer. edit. 
Philad. 1843) to be satisfactory. The small masses 
are regarded as uncongested patches, composed of 
parts of several adjoining lobules, and having one 
or more interlobular spaces as a centre ; and the 



biliary plexus of these, being filled with bile, gnes 
them' their yellow colour. In the other, there is a 
more or less complete atrophy of the portions of the 
substance of the liver intervening between them, 
so that the size of the liver is much diminished. 
This may be the true explanation ; but, as else- 
where remarked, {Practice of Medicine, 2d edit, 
i. 600, Philad. 1844,) the opinion of Laenncc has 
appeared to the author to be most entitled to fa- 
vour ; and the circumstance, that, in certain forms 
of cirrhosis, little granules, having the appearance 
of adipocire, can be washed out of their cellular 
fibrous capsules, after a maceration of some days 
in water, is greatly in favour of their adventitious 
formation. The matter, of which the rounded 
masses in cirrhosis consists, is not considered by 
Mr. Goodsir {Land, and Edinb. Monthly Jour, of 
Med. Science, May, 1842) as a new deposit, but 
merely as the natural tissue of the liver, altered 
by the pressure exerted by its fibrous envelope. 
These alterations consist in constriction, more or 
less powerful, of the vessels and ducts which pass 
out of and into the rounded mass ; the necessary 
difficulty with which the circulation is carried on, 
and the bile advanced along the ducts; and, lat- 
terly, in a change in the constitution of the nu- 
cleated cells themselves, which, instead of being 
distended with bile containing oil-like globules, 
contains matter of a darker colour than oil. The 
cells may at last contain matter perfectly black, 
and then the rounded mass assumes the appear- 
ance of a melanotic tubercle, — the black cells, in 
some instances, being pyriform and caudate. Mr. 
Goodsir does not state the exact nature of these 
various changes in the liver, although he is in- 
clined to believe that the forms of cirrhosis and 
melanosis are due to the contractile tissue, as a 
product of inflammatory action more or less acute. 
His remarks on the whole subject can only be 
regarded, however, in the light of suggestions.] 

Tubercles in the livers of adults are very rare, 
and Cruveilhier asserts that he never met with 
them in the numerous cases of pulmonary and 
abdominal phthisis which he has had occasion to 
examine.* He states that he has seen the liver 
of an individual full of tubercles, each formed by 
a dense cyst containing a drop of pus; at the 
same time there were a great number of calculi in 
the biliary passages. The small multilocular or 
unilocular cysts formed by the roots of the ex- 
cretory biliary ducts are often confounded with 
and mistaken for tubercles, when containing small 
calculi, or a liquid tinged with the bile. Cruveil- 
hier has very often met with this kind of altera- 
tion in both the livers of newly-born children and 
in adults.f 

Erectile Tumours of the Iiiver. — Cruveil- 
hier describes an affection of the liver in which 
the tumours resemble the tissue of the corpus ca- 
vernosum penis. They are very common not only 
in the liver but in other organs. Sometimes they 
are solitary, sometimes numerous. They appear 
to be formed of a greater or less mass of granu- 
lations, and are capable of an indefinite increase. 

*"Les tuhercules du foie sont tres rare chez 1'adulte; 
je ne les ai jamais rencontre dans les cas noinbreus de 
phthjsie pulmonaire, de phthisie abdominale, cine i'ai eu 
occasion d'esaminer." Dictionnaire de Mcdecine etde 
Chirurgie, torn. viii. p. 3-j'j. 

f Ibid. p. 330. 



LIVER, (DISEASES OF THE) 



149 



In one instance, in the centre of the tumour there 
was a mass of fibrous tissue, from which prolonga- 
tions extended, which in their growth passed in 
all directions. In another instance a carcinoma- 
tous tumour accompanied the erectile. (Diction- 
naire de Medecine, &c. p. 330.) 

Flaccid Liiver with Reddish Tumours is 
a state noticed by Baillie, in which the liver is un- 
usually flaccid, and studded with large reddish 
soft tumours, containing a thick pus. They were 
found in a person presenting the leading charac- 
ters of the scrofulous diathesis. He considers 
them in some measure analogous to fungus hcema- 
todes. 

Fatty Iji-ver. — This is a condition more com- 
mon in the lower animals than in man. While a 
fatty or adipose state of the other organs and the 
muscles in particular seems to be the last stage of 
atrophy in them, the same appears to be the last 
stage of hypertrophy in the liver. The fatty liver 
in the human subject never assumes that complete 
adipose transformation induced in the livers of 
geese, ducks, &c. by the agency of the most ab- 
solute rest or inactivity, darkness, and the artifi- 
cial ingestion of an immense quantity of ali- 
mentary matter. The liver, however, in the hu- 
man subject undergoes, to a limited extent, a true 
fatty transformation. The discoloured liver ob- 
served in cases of phthisis is frequently confounded 
with the true fatty transformation ; but chemical 
analysis disproves this opinion, by showing that 
the fatty material does not exceed the proportion 
naturally belonging to the normal condition of the 
organ. 

[Recently, Mr. Bowman has suggested, and Mr. 
Goodsir accords with him, that the fat in adiposis 
of the liver is deposited within the nucleated cells 
of the organ, and that the disease is to be con- 
sidered, in part, as a redundancy of the oil-globules 
naturally existing in these cells, with atrophy of 
the other structures.] 

Phlebitis off the Liver. — This affection is 
frequently a consequence of inflammation of some 
of the other veins. It frequently follows large 
wounds or surgical operations, and is thus not un- 
frequently an antecedent to traumatic abscess. 
Cruveilheir asserts that he has often induced it by 
the injection of irritating agents, into either the 
general venous system or into the vena ports. 
(Dictionnaire de Medecine, p. 327.) The circum- 
scribed inflammations of the liver consequent 
upon phlebitis present every degree from the red 
induration to the actual formation and collection 
of pus. It has also been caused by inflammation 
of the hemorrhoidal veins. Thus Cruveilhier re- 
lates an instance in which long-continued, violent, 
but ineffectual efforts to reduce an old prolapsus 
ani produced so much irritation of the rectum, 
that inflammation of the hemorrhoidal veins suc- 
ceeded, which extended to the veins of the liver, 
and terminated in a number of abscesses, both 
superficial and deep-seated, in this organ. The 
phlebitis may be confined wholly to the capillary 
system, as it may at the same time occupy both 
the large veins and the capillaries. 

Cysts are often observed in the liver, of which 
the causes arc various. 

Hydatids are very often seen in the liver, and 
are mostly contained in a cyst. The cyst is 



formed of dense, firm, unyielding material, some- 
thing like leather or fibro-cartilage. It is generally 
laminated. The lamina; are composed of white 
matter ; and the cavity is sometimes divided by a 
partition formed of the pulpy substance lining the 
laminae. (BaHHe.} The cyst may contain a sin- 
gle hydatid, or they may be numerous. 

The hydatids are found loose in the cavity, and 
floating in a clear transparent fluid. They appear 
like small, rounded, sometimes oval-looking bags, 
which are said to consist of a white semi-opaque 
pulpy matter, containing a fluid capable of coagu- 
lation. (Ibid.) In an examination of a liver con- 
taining a cyst full of hydatids, which occupied 
more than three-fourths of its volume, leaving but 
a small portion of the right and left lobe free, the 
writer found the hydatids perfectly transparent 
and pellucid. In this case the liver was reduced 
in size, and the emaciation and contraction of the 
intestines were such that the bodies of the vertebra 
could be distinctly felt through the abdomen, and 
counted. It might be almost truly said the perito- 
neum lining the interior muscles of the abdomen 
rested upon the bodies of the vertebra. 

In some cases the colour is of a lightish amber. 
The bag in which the hydatid is contained seems 
to consist of two laminae, and to possess a con- 
tractile power. The larger hydatids are occasion- 
ally found to have smaller ones attached to them. 
In some cases the hydatids are connected, and 
even found to enclose each other like a set of pill- 
boxes; in other instances they are distinct and 
unconnected. 

Hydatids are generally found occupying the 
substance of the liver, but occasionally they are 
attached merely to the outer surface, hanging pen- 
dulous into the cavity of the abdomen. 

Cruveilhier (Planche v. troisieme livraison,) 
describes a curious instance of ascites, anasarca, 
and icterus with "deux kystes acephalocystes du 
foie." The patient, a man of thirty-eight years of 
age, and vigorous constitution, had been wounded, 
in 1814, in the epigastrium by a musket-shot. 
About the year 1828 he was troubled with vomit- 
ings, and with pains in the stomach, every fifteen 
days, and which had commenced about a year 
after his accident. He was bled, and leeches 
were applied, with other treatment. Scarifica 
tions were made on the extremities, subcutaneous 
inflammation followed, and he died comatose. 

On opening the abdomen, instead of perito- 
nitis, as was anticipated, nothing but a citron- 
colour fluid appeared. The liver presented a 
singular appearance. The antero-posterior diam- 
eter equalled the transverse and the vertical very 
nearly the same at the right as at the left extre- 
mity. The left lobe was atrophied, and the sur- 
face of the liver shrivelled, and roughened by 
granulations of unequal volume and differing in 
form. There were two large fluctuating tumours, 
one on the right and the other on the left. Supe- 
riorly they did not extend beyond the level of the 
organ; but inferiorly the left formed a kind of 
spheroidal bulging of considerable size. Both 
tumours presented superiorly a very bulging sort 
of appendix traversed by sanguineous vessels 
with very thin walls, and which would have soon 
burst into the peritoneal cavity. The cysts ou 
being opened were found filled with a muddy ye] 



150 



LIVER, (DISEASES OF THE) 



lowish fluid, in the midst of which were both en- 
tire and empty accphalocysts connected together 
and coloured yellow. On examining one in its 
perfect state there appeared some white points, 
like small grains of sand, more resisting than the 
other points, vulgarly but erroneously regarded as 
the germs or eggs of accphalocysts. The figures 
or shapes were very singular and varied, and 
which it is asserted the partisans of the vitality 
of these organized globules will refer to defects 
in the conformation arising from a straitened de- 
velopment. On examining the primary mem- 
brane lining the left cyst there were agglomerated 
tubercles roughening the internal surface, which 
might be compared to small eggs. In a portion 
from the right there were vesicles in clusters, 
some regular, some irregular, and which Cruveil- 
hier thinks we should feel some difficulty in re- 
garding as the germs of acephalocysts ready to 
detach themselves. 

The enveloping cyst was fibrous and a quarter 
of a line in thickness. The internal surface ru- 
gous, as it were torn, and studded with concre- 
tions, in some places brown, in some green, in 
others yellow, and in some a most beautiful orange 
yellow ; all which shades arise from the colouring 
matter of the bile some way modified. These 
concretions, which Cruveilhier asserts he has seen 
several times forming a thick lining or bed similar 
to biliary calculi, lining the entire of the cysts, 
prove evidently, he says, the communication, a 
temporary one at least, of the cyst with the biliary 
tubes or canals. , 

The cyst was easily detached ; and a loose cel- 
lular filamentous tissue connected it with the liver, 
to the substance of which it was attached merely 
by a number of arterial and venous vessels and 
hepatic tubes, of which a great proportion was 
obliterated. 

The cyst of the left lobe, which extended below 
the level of the liver, compressed the left division 
of the vena ports, which was narrowed in an 
extraordinary degree, to which circumstance the 
atrophy of the left lobe in this case is attributed. 
The corresponding branch was on the contrary 
dilated. 

On examining a portion of the liver by making 
incisions, it was found tuberculated, the tubercles 
separated by interspaces of different extent. In 
the interspaces the liver had a fibrous aspect, 
and did not present, in a given proportion, above 
half the glandular structure belonging to the na- 
tural state. 

The subcutaneous phlegmonous inflammation 
with infiltrated pus, occupying the lower extremi- 
ties and extending to the thighs, is considered by 
Cruveilhier to have been occasioned by the scari- 
fication of the anasarcous extremities, and to have 
been the cause of the succeeding coma, and ulti- 
mately of death. 

Cysts containing an Earthy Matter have 
been found in the liver. They are generally 
formed of a kind of fibro-cartilaginous, dense, firm 
membrane. Sometimes it is partially ossified. 
The earthy matter is gritty, sometimes plastic, and 
of a whitish colour. It consists chiefly of phos- 
phate of lime, and very probably is merely the 
commencement of osseous deposits in the sub- 
stance of the liver. 



Cysts containing Worms have been said to 
be found in the liver and likewise in the biliary 
ducts. Lieutaud relates instances of this sort, but 
they are very rare, and the fact seems even rather 
doubtful. 

Rupture of the Liver is an injury to which 
it is exposed from external violence, and is an ac- 
cident to which it is more liable than any other 
gland in the body. This greater liability Dr. 
Baillie attributes to two causes ; first, its more 
exposed or rather less protected situation in thin 
persons, if the liver be enlarged ; secondly, be- 
cause its structure is such that it yields to external 
violence more readily than any of the others. The 
accidents from which such ruptures occur are 
heavy weights falling upon the abdomen or pass- 
ing over it. The writer saw an instance of this 
sort at Chelmsford some years ago. A carter fell 
from his wagon, which was heavily laden, and 
the wheels passed over him in the region of the 
liver. He lived a very little time, but did not 
complain of much pain, except from the bruise. 
On opening the abdomen the cavity of the perito- 
neum contained an immense quantity of blood, 
the liver and spleen were ruptured, as was also 
the vena cava, from whence the haemorrhage took 
place. 

Traumatic Abscess of tlie I«iver. — Ab- 
scesses after wounds, &c. are apt to form in dif- 
ferent organs, but in none more frequently, after 
the lungs, than in the liver. These abscesses vary 
both in number and extent. Sometimes there 
exists but one, sometimes there are two or three 
small clusters. In some cases there is but a single 
abscess ; and in an instance mentioned by Cru- 
veilhier, of death in consequence of gangrenous 
inflammation of the pelvic cellular tissue, induced 
by infiltration of urine, on examination there was 
found but a single abscess in the liver, and seated 
in the loose cellular tissue which surrounded one 
of the divisions of the vena porta?. In other cases 
the liver presents an immense number of small 
spots or foci of a tubercular appearance. 

On tracing these abscesses through their pro- 
gress from their first formation, they appear at first 
as brownish bloody spots, which seem to be situ- 
ated in the glandules themselves. 2. Infiltration 
of white concrete pus, which gives an appearance 
of granite to the liver, with a slate brown colour 
all round, without any other evident trace of in- 
flammation. Sometimes a great number of the 
glandules are affected ; in other cases it is limited 
to a very few, which with the density of the pus, 
the number of foci or clusters, and the irregularity 
of the masses affected, has given rise to the idea 
of their tubercular nature. The surface of the 
liver next the cluster always appears of a slate- 
brown colour, which is probably cadaveric. 3. A 
collection of pus of abscess, the dimensions of 
which exactly equal those of the masses first af- 
fected. 

The causes of such abscesses are wounds of 
different kinds, surgical operations, and phlebitis. 
They seem to arise from the transmission of pus 
with the blood through the veins ; a fact which 
accounts for the much greater liability of the lungs 
and liver to these kinds of abscess, the diagnosis 
is extremely difficult ; sometimes there is pain in 
the right hypochondrium and right shoulder. In 



LIVER, (DISEASES OF THE) 



151 



other cases the region of the liver may be pressed 
upon it in every way without the slightest indica- 
tion of sensibility. Jaundice is very uncertain. 
If, however, several days after a wound or sur- 
gical operation a patient should be seized with 
shivering, and suddenly sink into the extreme of 
a typhoid state, with no manifestation of disease 
in any of the other organs, a suspicion of the ex- 
istence of this result may be entertained. 

Abscesses sometimes, it is said, form in the liver 
in consequence of injuries done to the brain. 
This form is said to arise from irritation. The 
subject, though considered at some length by Cru- 
veilhier and some other writers, requires further 
researches. 

Melanosis* — The liver is liable to become 
melanotic. During the progress of the disease 
the liver sometimes enlarges to such an extent as 
to occupy nearly the whole of the abdomen, and 
in a female might be mistaken for pregnancy. A 
case of this kind is related by M. Ruyer in the 
Encyclographie des Sciences Medicales. The 
patient, a woman about thirty-three years of age, 
had enjoyed very good health till the month of 
June, 1833, about which time she was ill-treated 
by her husband, and in a very violent manner. 
He kicked her upon the chest and abdomen in 
several places, and several contusions were the 
consequence, which were wholly neglected. After 
some days, dull pains were felt in the region of the 
stomach, extending to the lumbar spine. In the 
course of a few days the pains disappeared with- 
out any treatment, reappearing however at uncer- 
tain intervals, with various degrees of severity, 
according to the exercise to which she was forced 
to subject herself. The abdomen at this period 
was of its natural size. In January, 1834, she 
was confined of a healthy child, which she suckled 
for eleven months. After confinement the .belly 
diminished very little in size, and felt eqlially 
hard. She perceived that the abdomen enlarged, 
and she felt all the symptoms of pregnancy : she 
became much emaciated, and at last died. The 
abdomen was extremely hard and enlarged, and 
on opening it about three pints of a serous-looking 
fluid escaped. The liver filled up completely the 
whole of the abdomen, pressed the diaphragm high 
up into the thorax, extended into the right iliac 
region, and terminated by a protuberance of a 
spherical form. The entire structure was altered 
from the normal condition presenting a confused 
mass. Extensive adhesions existed between the 
anterior part of the stomach, a considerable por- 
tion of the transverse colon, and this hepatic de- 
generation. It pressed the whole of the intestines 
and other viscera against the vertebral column. 
It weighed twenty-four pounds. It was softer, 
more friable, and more easy of incision than in 
the normal state. It was of a violet brown slate 
colour, and studded with a number of whitish tu- 
mours, varying in size from that of a millet-seed 
to that of a hen's egg. The abscesses contained 
a homogeneous liquid of a purulent consistence. 
The gall-bladder was much enlarged ; its contents 
almost black. The other abdominal viscera were 
natural. The vertical diameter of the thorax was 
reduced one-half; the heart of its usual volume, 
but displaced, its apex directed upwards ; the 
lungs reduced in volume ; their tissue soft, little 



crepitous, and easily torn ; and there were nu- 
merous adhesions between them and the pleura 
costalis. 

Cancer of the Iiiver. — The term cancer, as 
applied to diseased appearances in the liver, com- 
prehends certain morbid productions deposited in 
its parenchyma. They are of different kinds, 
produce masses of various sizes and extent. They 
are mostly white, the white being sometimes 
mixed with red. Cruveilhier observes — " Of all 
the diseases of the liver, the most frequent and 
the most severe is, perhaps, the cancerous degen- 
eration in the form of disseminated masses." 
They vary in extent, are somewhat spheroidal, and 
deposited in different parts of the substance of the 
liver, or near its surface in the midst of the per- 
fectly healthy tissue, the organ appearing, as it 
were, filled with them. There is mostly a perfect 
line of demarcation between the tissue of these 
tumours and that of the liver, and the transition 
is abrupt, not gradual. 

These tumours seldom appear solitary, that is, 
a single and only one, and in the few instances 
which Cruveilhier met with, upon close examina- 
tion there existed a number of small miliary 
tumours, which from their tenuity would readily 
escape hasty observation. They vary in number 
from eight or ten to several hundreds or more. 

These cancerous tumours are commonly con- 
fined to the surface. In a liver containing twenty 
tumours of this description, sixteen were found 
near the surface or superficial. (Cruveilhier.} 
The superficial ones are generally prominent, so 
that they can be felt through the abdominal pari- 
etes ; and they may often be recognised by touch 
after the operation for ascites, frequently necessary 
in the advanced periods of this disease. But 
when they become large or extensive, they lose 
their spherical shape and become hollowed out or 
cupped in the centre, in consequence, probably, of 
the thickening of the corresponding cellular tissue 
under the peritoneum. The peritoneum itself 
often becomes thickened, fibrous, and cartilaginous; 
and adhesions take place between the liver and 
contiguous parts. 

The situation in which the larger cancerous 
masses generally appear is the part which cor- 
responds to the suspensory ligament, and conse- 
quently the antero-posterior ridge. Hence, per- 
haps, the reason why adhesions occur so frequently 
between the liver and stomach, and why these 
cancers open in the latter. The lobulus Spigelii 
is frequently affected, even throughout its entire 
substance, so as to appear a prominent encepha- 
loid tumour. (Cruveilhier.) 

These tumours also vary in size, from that of 
millet-seed to a turkey's egg, or the two fists, or 
even the head of a full-grown foetus. From all 
the facts, their size, appearance, consistence, &c, 
it may be inferred that they are formed at differ- 
ent periods. There seem to be two varieties of 
them, which do not exclude each other ; the hard 
or scirrhous, and the soft or encephaloid. These 
are generally considered but degrees of the same 
disease; but, according to Cruveilhier, this is in- 
correct, and the expressions, " period of crudity, 
period of softening," are improper. 

The hard kind appears with an areolar web, 
which grates under the scalpel, composed of ex< 



152 LIVER, (DISEA 

tremely dense, fibrous, and sometimes even carti- 
laginous meshes. It may be said that the tissue 
is fibrous, or even cartilaginous. There are small 
cavities in the centres of the tumours, filled with 
a fluid, crossed by fibrous bands more or less re- 
gular. On the pressure a lactescent cancerous 
juice exudes. If macerated in water or a weak 
solution of chlorine, the cancerous matter is dis- 
solved, leaving a marginal fibrous tissue behind, 
somewhat analogous to the erectile. Sometimes 
the centres of the tumours are overrun by blood- 
vessels well developed ; in others the vessels are 
so reduced in calibre, that it requires some atten- 
tion to discover them. The soft kind is of a 
greyish white colour, resembling the infant brain. 
It is the encephaloide cancer of Bayle and Laen- 
nec. In some cases it is very white when not 
much overrun with blood-vessels, but where the 
vessels are numerous the quantity of blood gives 
it the character of apoplectic spots. 

Ossification* — Bony depositions are some- 
times found in the liver. The writer once met 
with a piece of bone imbedded in the substance, 
about the size and somewhat of the shape of the 
human patella. It resembled common bone, con- 
sisting almost entirely of phosphoric acid and 
lime, with a very small proportion of the carbonate 
of this earth. The upper surface rose very little 
above the level of the liver, and its entire dppth or 
thickness was imbedded in the parenchyma. 

Diseases of the appendages may be divided 
into those of the ducts and those of the gall- 
bladder. 

Dilatation of the biliary etnets. — The cystic, 
the hepatic, and the ductus communis choledochus 
are liable to dilatation ; mostly effected by large 
gall-stones making their passage through the duct, 
which sometimes is so far dilated as to measure an 
inch in diameter. (Baillie.) 

Obliteration is frequently produced by in- 
flammation, especially of the inner surface, termi- 
nating in adhesion. Hyperemia of the mucous 
lining may cause such a swelling as will totally 
obstruct the passage of the duct, and this obstruc- 
tion, however induced, may give rise to jaundice. 
Long-continued irritation may induce hypertrophy 
of the sides of the ducts, and produce an oblitera- 
tion, the duct itself being transformed into a 
fibrous cord". Thickening and hardening of the 
duodenum or pancreas may, by compressing the 
ducts, obliterate them. 

The gall-bladder is likewise subject to cer- 
tain alterations ; such are adhesions, ulcerations, 
thickening, and ossification. 

Gall-stones are frequently found in the biliary 
ducts and in the gall-bladder. Sometimes the 
gall-bladder is completely filled with them, and 
then it is usually much enlarged. The number 
varies, but it is occasionally very great :* some- 
times but one is found ; it, is generally very large ; 
when numerous, they acquire different shapes 
from friction. The writer was furnished with two 
passed by a lady, which were flattened somewhat 
like a bean ; the area about half as large again as 
a shilling, and much thicker than a bean. They 
were brown, smooth, and polished outside ; sawn 
through they presented a bluish slate-coloured ap- 

* In Dr. Hunter's collection was an instance of above 
a thousand in one gall-bladder. 



SES OF THE) 

pearance ; fracture rather striated ; they consisted 
of phosphate of lime, trace of carbonate, and some 
animal matter. There was very little cholesterine 
in proportion to the other components. They 
were extremely hard.f These biliary concretions 
occupy all parts of the liver, the biliary ducts as 
well as the gall-bladder, and the larger ducts for 
the transmission of the bile. They produce fre- 
quently great irritation, inflammation of the mu- 
cous tissue, ultimately terminating in ulceration. 
In some cases the dilatation of the gall-ducts will 
allow them to pass into the intestines, and they 
are then voided by stool. Cruveilhier has given 
two very excellent plates illustrating the different 
situations and effects of these concretions upon 
the tissues. 

Bile. — The bile, as might a. priori be inferred, 
is liable to morbid changes, and it possibly might 
be presumed that the extent of these changes 
would in some degree correspond with the altera- 
tions in structure of the secretory organ. This, 
however, is far from being the case ; and observa- 
tion has been unable to establish any uniform 
connection between the alterations in the liver and 
the qualities of the bile. In many cases of severe 
organic disease of the liver, the bile appears to 
undergo little change ; and the most obvious 
changes in the bile, and the most considerable 
augmentation in quantity, are sometimes accom- 
panied by no recognisable change in the normal 
condition of the secreting organ. It is true we 
very often estimate the quantity secreted by a very 
uncertain scale, namely, the quantity discharged 
from the intestinal canal or the stomach in bilious 
diarrhoea and in cholera. Neither the quantity 
nor quality of the fluids secreted from the blood 
depend absolutely and essentially upon the nor- 
mal conditions of the organic structure of the or- 
gans ; and the experiments of Magendie have 
shown that the composition of the bile, and even 
its quantity, may be altered and increased at plea- 
sure by changing the food of the animal. 

Cholesterine. — Chevreul detected in human 
biliary calculi a peculiar crystalline matter, which 
he named cholesterine. Fourcroy considered it 
analogous to adipocire, and so named it; but 
Chevreul has shown that it is an independent 
principle. It is a brittle, lamellated, brilliant 
crystalline solid, somewhat like spermaceti in ap- 
pearance, from which it differs by being infusible 
under 278° Fah., and in not being converted into 
soap by a solution of potass. It is devoid of taste 
and smell, and is insoluble in water. It dissolves 
in boiling alcohol, but is deposited on cooling in 
white pearly scales. According to Chevreul, its 
analysis yields — 

Carbon 85.095 

Hydrogen 1 1.880 

Oxygen 3.025 

100.000 
Nitric acid converts it into an acid, which has 
been named cholesteric acid, insoluble in water, 
but perfectly soluble in alcohol, especially if 
heated. Taste styptic, odour that of butter; 
lighter than water, and fusible at 13GA° Fah. In 
quantity it is_c£^ n _^rang^j^lio W ji nt) but eva- 

t As these calculi were voidcTTbTlt^ol their oriein 
may seem somewhat doubtful. g 



LIVER, (DISEASES OF THE) 



153 



poratcd spontaneously it is deposited from its so- 
lution in alcohol in white acicular crystals. It 
reddens litmus paper, and neutralizes the alkaline 
bases, and hence is an acid. 

Cholcsterine has been found in parts of the 
body wholly unconnected with the hepatic circu- 
lation, and from these facts it would seem to be a 
product of morbid vascular action under peculiar 
circumstances. Breschet found it in cancer of the 
intestines, and in the fluid of hydrocele and of 
ascites. Caventou found it in an abscess of the 
jaw, produced by a carious tooth. Christison 
found it in an osseous cyst of the kidneys, and in 
the membranes of the brain in epilepsy. 

The bile of the human subject is liable to be- 
come diseased. In some cases, if tasted, it pro- 
duces no other inconvenience than bitterness and 
a nauseous sensation ; but in others, it will pro- 
duce pustular affections, ulcers, and all the acridity 
which belongs to the most powerful agents of this 
class upon the tongue and lips. This must be 
owing to the bile having acquired some acrimoni- 
ous properties, derived, no doubt, from certain 
morbid changes in its chemical constitution. The 
sensible changes exist in its colour and consistence: 
thus it presents every shade, from the deepest and 
most intense black to a nearly white tint. Its 
consistence is sometimes that of pure water; in 
other cases it is like pitch ; and in others like glue 
or thick mucilage. 

The chemical composition varies, as well as the 
relative quantity of the constituents. In some 
cases there is a considerable predominance of the 
resinous principle ; in some there is an excess of 
the yellow, while in others the cholesterine is the 
superabundant principle. In some cases it has 
consisted almost entirely of albumen and water, 
and this has been observed more especially in con- 
nection with a fatty state of the liver. It may be 
observed generally, however, that little has been 
as yet ascertained as to the causes of these alter- 
ations. It is this alteration in the proportions of 
the constituents which gives rise to the formation 
of biliary calculi. They consist of the inspissa- 
ted bile ; of its resinous matter ; of cholesterine ; 
of picromel ; and of the phosphates. Calculi 
are never found of any one of these principles 
solely, but some one or other predominates, giving 
the character. They may, by obstructing the re- 
gular course of the bile, cause its absorption, and 
thus give rise to jaundice. 

Such are the anatomical characters and gene- 
ral nature of the principal organic diseases of the 
liver. We shall now proceed to their symptom- 
atology. 

Symptoms. — Perhaps there is no order of or- 
ganic diseases in the whole human frame in which 
symptoms assist less than in that under considera- 
tion. In some of the more acute forms of disease 
the symptoms are urgent; but, except in a few 
instances, they convey little or no information with 
respect to the nature or progress of the disease ; 
and in the more chronic and obscure forms, irre- 
parable mischief is often established before the 
patient even suspects that there is anything 
wrong. 

Many of these diseases, and indeed all of them 
in particular cases, produce certain constitutional 
symptoms, which, taken into account with the 

Vol III. — 20 



local ones, should any be present, will enable us 
to suspect, indeed confirm us in the belief of the 
existence of some sort of hepatic disease. But 
most commonly we obtain no farther instruction, 
and the real or precise nature of the disease re- 
mains in obscurity. We have nothing to do with 
inflammatory affections here : they have been al- 
ready considered. But as hypersemia may be ac- 
companied with considerable enlargement of the 
organ, it will always be right in all suspected 
cases to examine the region of the liver, and as- 
certain whether any indication can be drawn 
from it. 

When it extends or projects considerably below 
the ribs, it can, unless some obstacle exist, be felt, 
and its size pretty accurately determined ; but in 
cases of ascites there may be considerable diffi- 
culty. The writer has often found the following 
plan succeed : — Place the hand upon the right 
side of the abdomen, and make the patient sud- 
denly turn upon his belly inclining upon the right 
side ; the enlarged liver will gradually sink through 
the fluid, and striking the parietes, will communi- 
cate a distinct impulse to the hand. Although 
this, should it occur, at once indicates the projec- 
tion of the liver and the probability of its enlarge- 
ment, yet the absence of this sign does not infer 
the converse, nor preclude the possibility of en- 
largement. Adhesions, for instance, by tying 
down the liver, will prevent the floating motion 
essential to the development of this sign. 

Percussion often enables us to determine the 
height, or rather the encroachments, made by the 
liver upon the capacity or boundaries of the tho- 
rax. By this means the margin of the liver may 
be completely and accurately defined, and a tole- 
rably accurate idea formed of its volume and ex- 
tent. 

There are no peculiar symptoms which will en- 
able us to determine the presence of anxrnia of 
the liver. Induration and, softening may in par- 
ticular cases be determined by the touch. Hyper- 
trophy and atrophy may be discovered, — the for- 
mer by the great increase of volume evident to the 
touch ; the latter by the diminution ascertained by 
percussion. With respect to hypertrophy, it may 
be observed that there is no accurate means of 
diagnosis between it and hypersemia. Tubercles 
may be felt in very thin persons, and if situated 
anteriorly ; but there is no symptom peculiarly 
characteristic of them. The other diseases afford 
no symptoms by which they may be distinguished. 
Even gall-stones, unless passed by stool, afford no 
symptom by which their existence can be posi- 
tively determined. Gall-stones passing through 
the ducts very often excite excruciating pain, 
cramps, sickness, vomiting, hiccup, &c; but these 
symptoms indicate but little while they last ; and 
more frequently it is after the passage of the stone, 
and after the subsidence of the symptoms, that we 
are able to form some opinion as to their natuiu 
and cause. 

There are, however, certain general symptoms, 
which, when present, enable us to pronounce 
pretty positively as to the existence of hepatic dis- 
ease, though they will not assist in determining 
its nature. These are dropsy, certain forms of 
indigestion, and jaundice ; subjects already fully 
treated of in different parts of this work. 



154 



LIVER, (DISEASES OF THE) 



Other functions, as the respiration, circulation, 
those of the tongue, skin, and urinary apparatus, 
— the last especially, become deranged. The re- 
spiration and circulation merely present the com- 
mon indications of irritation — a hurried or acce- 
lerated action. The tongue is generally coated, 
and commonly furred. A disagreeable taste is 
felt in the mouth, and eructations take place. 
What is brought up by eructation exerts various 
effects. Sometimes it is bitter, cutting, acrid, 
even excoriating the lining of the pharynx. This 
in general depends upon over-acidity, or upon 
chlorine. The fur on the tongue is yellow ; some- 
times moist, sometimes dry ; sometimes perma- 
nent, and in some cases it appears only in the 
morning, disappearing in the course of the day. 
The skin may be hot and dry, parched and rough; 
or it may be too relaxed, giving rise to cold 
clammy sweats. 

There is no excretion, not even excepting the 
alvine evacuations, which is more frequently de- 
ranged in the diseases of the liver than the urine. 
Thus, bile may be detected in the urine when no 
other irregularity is present, by the application of 
muriatic acid ; it is sometimes necessary to con- 
centrate it by slow evaporation, when the addition 
of muriatic acid strikes a green colour. 

But organic disease of the liver is almost always 
attended with a deposition of the lithate of ammo- 
nia from the urine on cooling, of a bright pink 
colour. It receives this colour from the generation 
and intermixture of purpurate of ammonia. The 
urine when passed, though of a deep pinkish 
colour, is generally clear and transparent ; but on 
cooling, the pink sediment separates ; and if col- 
lected upon the filter and examined while moist, 
exhibits a remarkably deep pink colour. This 
sediment is re-dissolved by heating the urine. 

The urine, after filtration so as to separate the 
sediment, likewise presents a deep colour, owing 
to retaining a portion of the purpurate of ammonia 
in solution. In some cases the urine will remain 
of a deep pink colour, nor will any sediment sepa- 
rate. This arises from a deficiency of lithic acid. 
The purpurate of ammonia has a strong tendency 
to combine with lithate of ammonia, which latter, 
being rather insoluble at the ordinary tempera- 
ture, precipitates on the cooling of the urine, car- 
rying down the purpurate along with it. But if 
there be a deficiency of lithic acid, no lithate of 
ammonia can be formed, and consequently no 
precipitate will take place. Hence the purpurate 
remains in solution, and gives this very deep pink 
colour to the urine, and which remains on the 
cooling of the urine without the formation of any 
precipitate. (Vide Prout, p. 125.) "The most 
perfect specimens of this kind of sediment which 
I have ever seen," says Prout, " were obtained 
from the urine of dropsical individuals ; they occur 
also, occasionally, in the urine of the hectic, and 
of those obviously labouring under certain chronic 
visceral affections, especially of the liver" (Prout, 
loc. cit.) 

Such are the circumstances which individually 
and conjointly may be considered as furnishing 
tolerably certain indications of an hepatic affec- 
tion ; but it is only from the combination of seve- 
ral of these together that we can form any esti- 
mate of the degree or extent of hepatic disease. 

o 



It must be evident, however, that we possess no 
certain or unequivocal means of determining the 
nature of the morbid condition with which we 
have to contend. And, indeed, even if we could, 
in the present state of our therapeutical knowledge, 
it would afford no guide to the adoption of any 
special mode of treatment. 

Treatment. — In considering the treatment 
applicable to the organic affections of the liver, it 
will be useful to arrange it under two heads — 
general and local ; understanding by the first, 
those means which act on the system generally ; 
and by the second, those which are supposed to 
act by some particular local derivation. 

General Treatment. — The first of this order 
which naturally comes under consideration is 
bloodletting. As the general circulation not only 
frequently produces, but afterwards tends to keep 
up the state of hyperemia, or one of irregular vas- 
cularity in the liver, the means of controlling this 
function naturally presents itself as the most effec- 
tual as well as the most powerful of affecting a 
condition depending upon it. There are several 
points of view, however, in relation to different 
objects, in which bleeding may be considered. If 
the substance, or rather the vessels of the liver be 
gorged, bleeding generally, according to the cir- 
cumstances, will be advisable. This means, also, 
will be applicable in what may be termed conges- 
tion, in which the capillary trunks are distended. 
Bleeding acts, not by abstracting blood from the 
distended organ, but by reducing the force of the 
circulation — the vis a tergo, as it is called — and, 
consequently, lessening the quantity of blood di- 
rected to the part, as well as the impetus with 
which it is driven. 

An active state of the bowels will also prove 
beneficial ; and the choice of the purgative will 
often be a consideration of some moment. When 
the object is to prevent the irritation arising from 
fa?cal accumulations, those purgatives should be 
selected which merely excite the bowels to propel 
their contents ; these are rhubarb, aloes, colocynth, 
&c. But when there is an active state of circula- 
tion, with symptoms denoting any thing approach- 
ing to an inflammatory condition, the purgatives 
which produce watery discharges are found the 
most serviceable. In such cases the neutral salts, 
largely diluted and combined with a small quan- 
tity of tartar-emetic, are the most powerful reme- 
dies. 

When the disease is a simple hyperemia, and 
has not produced any considerable tumefaction, a 
short perseverance in the above means will often 
be found adequate to all the urgencies of the case. 

Emetics are not indicated in organic diseases 
of the liver, although nauseating remedies, by the 
power which they exert upon the circulation, are 
well adapted to reduce its force in the phlogistic 
diathesis. But emetics are occasionally useful 
when the functions of the stomach have been in- 
volved. In cases of this description, the stomach 
becomes overloaded with a collection of foul, 
crude, acrimonious matter, which proves highly 
irritating to that viscus, and by its reaction disturbs 
the system at large, and often aggravates the dis- 
ease of the liver. When indicated, the mildest in 
operation of this class are to be preferred, and the 



LIVER, (DISEASES OF THE) 



155 



practitioner will find ipecacuanha most suited to 
his purpose. 

It should never be lost sight of that lingering 
diseases are highly debilitating, and that emetics 
also exert a debilitating agency ; and, therefore, 
caution is necessary in their use, and more espe- 
cially in their repetition. The more mildly and 
the more speedily an emetic operation is effected 
and terminated, the less its debilitating effects ; 
consequently, means calculated to effect such an 
object will be beneficial. The most effectual 
method of ensuring this, according to the writer's 
experience, consists in the previous ingestion of a 
considerable quantity of warm water ; the advan- 
tages of which are, that a much less dose operates; 
there is no retching, nor are there any of those 
abortive efforts to evacuate the stomach which 
prove so distressing and so debilitating to weakly 
patients ; and the stomach being emptied of its 
contents, there is an end to all the involuntary 
exertions of the patient. 

Sudorifics are only admissible where there is 
considerable inflammatory excitement, with a harsh 
dry state of skin. In such cases those medicines 
which determine to the surface and induce a re- 
laxation of the skin will prove highly beneficial. 
The most efficacious of this class is antimony ; and 
the preparation must be selected according to the 
circumstances of the case. Tartar-emetic, in 
small and nauseating doses, not only relaxes the 
skin, but at the same time reduces the vital pow- 
ers and prostrates the strength ; while James's or 
antimonial powder effects the first object without 
influencing to so great an extent the strength of 
the patient. 

Under the head of corroborants or tonics may 
be included two orders of remedies — stimulants 
and restoratives. The first are inadmissible in 
almost any description of organic disease ; and, 
indeed, those of the viscus under consideration are 
often attributable solely to a too free indulgence 
in the use of stimulants. Restoratives, however, 
are of a different nature, and they are such as are 
calculated to improve the health and to give to 
the organs their due activity. The two most im- 
portant of this description are sarsaparilla and 
taraxacum. 

Sarsaparilla certainly at one time attained a 
high reputation as a restorative, owing, probably, 
to its being resorted to immediately upon the 
breaking up of the health by a too free use of 
mercury. Much of the good under such circum- 
stances having arisen from laying aside the mine- 
ral, practitioners were disappointed in its powers, 
having anticipated too much from it in cases of a 
different nature, and, as mostly happens, not only 
refused to allow the virtues thus inconsiderately 
assigned to it, but denied even those to which it 
has unquestionably a claim. Hence it was nearly 
proscribed, and its use, in fact, almost laid aside. 
However, sarsaparilla certainly has considerable 
powers as a restorative, and will be found emi- 
nently useful in fortifying the system, and in pre- 
paring it for more active remedies. Dr. Philip 
observes that sarsaparilla is highly useful in pro- 
tracted cases of indigestion, and especially " where 
the languor of the secreting surfaces has become 
permanent." (On Indigestion, p. 203. See, also, 
p. 258.) It may be administered in the form of 



decoction or of extract, or, what is still preferable, 
the extract rubbed down in the compound decoc- 
tion. 

Taraxacum is also a remedy which has been 
extolled, and it certainly seems in many instances 
to exert a very beneficial influence. According to 
Dr. Philip, it not only assists the use of mercury, 
but may, under certain circumstances, be substi- 
tuted for it. (Ibid. p. 221.) But he asserts, that 
to be beneficial it must be given in large quantity, 
which often oppresses. The writer of this article 
has often found it a very useful plan to combine 
the extract of dandelion with the decoction of 
sarsaparilla, in which way — that is, rubbed down 
with the decoction — it can be given in much 
larger doses, and to a much greater extent, with 
much less inconvenience than simply in the form 
of extract. 

The mineral acids are tonic and restorative ; the 
principal of these are the sulphuric and the mu- 
riatic. They will be found highly useful in those 
passive relaxations of the skin attended by profuse 
night-sweats. The sulphuric acid is the most 
powerful in these cases. 

It often occurs, however, that in these cases the 
bowels are constipated ; and the profuse discharge 
by the skin may be considered as a vicarious, 
though morbid, substitute for that of the bowels. 
If the sulphuric acid should check the discharge by 
the skin without exciting the bowels, it will aggra- 
vate the symptoms. The plan most effectual in 
such cases is the exhibition of the bisulphate of 
potass or of soda, according to either of the follow- 
ing formulae ; — R. Infus. ros. £x ; bisulph. pot. 
gii ; syrup, caryoph. gi ; m. fiat haustus ter qua- 
terve in die sumendus. — R. Infus, caryoph. gx ; 
sodae bisulph, giss ; syrup, zingib. gi ; m. fiat 
haustus ter quaterve in die sumendus. 

The nitric, and a combination of the nitric with 
the muriatic acid — nitro-muriatic acid — have been 
supposed to exert a special influence upon the 
liver. The nitro-muriatic acid has been supposed 
to act through the chlorine disengaged by the re- 
action of some of the constituents. Special vir- 
tues, however, have been denied, and the flow of 
bile attendant upon their application as a bath, 
ascribed to the action of a weak or diluted acid 
upon the skin. (Paris, Pharmacologia et aliis 
locis.) A solution of chlorine, however, in water, 
according to the experience of the writer, has some 
claim to specific agency, and will be well suited 
to the class of diseases under consideration. It 
may be prepared readily by passing a current of 
chlorine gas into distilled water, kept cold by 
being surrounded with ice, and in a dark place, as 
chlorine under exposure to light decomposes a por- 
tion of the water, and muriatic acid is formed. 
The chlorine may be readily degenerated by ex- 
posing either a mixture of muriatic acid and per- 
oxide of manganese, or of common salt, peroxide 
of manganese, and sulphuric acid, to a gentle heat 
in a proper gas bottle fitted with a tube for con- 
ducting the evolved chlorine into the distilled 
water.* The solution thus prepared may be given 
in small doses, at intervals during the day ; and 
we have in many very severe cases seen the best 
effects result from this plan. The effects are 

* It should be conducted into the water, and retained 
in it by a due degree of pressure. 



i56 



healthy discharges from the bowels, bracing the 
skin, improving digestion, and correcting the 
secretions, and not un frequently a considerable 
reduction of the pain and swelling of the epigas- 
trium and right hypochondrium. 

The powers of chlorine are frequently enhanced 
by colchicum, and it will often happen that a com- 
bination of these two remedies produces beneficial 
results which cannot be obtained by either sepa- 
rately. The preparation best adapted to the pre- 
sent object, is either the vinegar or tincture. In 
habits which show a tendency to gout or rheuma- 
tism, and in which temperaments, in the advanced 
stages of organic diseases of the liver, hemorrhages 
of various descriptions are apt to occur, colchicum 
proves a valuable auxiliary, and therefore should 
be administered. 

It may happen, from some peculiar nervous 
idiosyncrasy, or from extreme susceptibility of 
the alimentary tube, that any of these means will 
produce severe effects, purging for example, fol- 
lowed by extreme prostration. Such must be 
corrected by the exhibition of appropriate remedies. 
Opium naturally presents itself; but in many 
cases there will be found strong objection to the 
use of opium. The salts of morphia are in many 
cases less objectionable, and as they do not pro- 
duce the disturbance so frequently caused by 
opium, they ought perhaps, as a general rule, to 
be preferred. The most suitable of the above 
salts are the sulphate and the muriate, and the 
■writer has been in the habit of using a formula 
analogous to that of Dover's powder. It consists 
of one part of the muriate or sulphate of morphia, 
two of ipecacuanha, and eight of neutral alkaline 
salt — sulphate of potass or muriate of soda. This 
powder may be given in small doses, or it may be 
formed into pills with extract of hyoscyamus or 
conium. The advantages, according to the writer's 
experience, are, that it does not affect or suppress 
the natural secretions so much or so certainly as 
opium, and consequently is not so likely to give 
rise to fever, with thirst, dry tongue, and hard 
pulse, which should always be most carefully 
avoided. 

The means just detailed, are calculated to make 
but a slight impression upon an organically dis- 
eased liver. Tumefaction, hypertrophy, &c. may 
in slight cases be removed ; but more commonly, 
very little impression can be made upon the seat 
of the disorder. The object, therefore, is rather to 
improve the health, and to fortify the system so as 
to enable it to endure the debilitating effects of 
more active and more powerful remedies, which 
may now be considered. 

The efficacy of mercury in the treatment of the 
disorders of the liver is well known. It is the 
remedy to which all resort ; and, as it frequently 
occurs in the exhibitions of medicines without 
principle, the prescriber is often doomed to expe- 
rience disappointment. The first thing to be con- 
sidered is, what is the action of mercury upon 
•which we depend, and what the system to which 
we ought to direct its action for the relief of 
organic disease. 

One of the principal effects of mercury is to 
excite the absorbent system ; and it is upon this 
action that the practitioner must rely for its effi- 
cacy in diseases of the liver. The diseases of this 



LIVER, (DISEASES OF THE) 

organ too, pflrtakc mostly of the congestive cha- 
raetcr, in which the vessels become distended with 
their natural contents, and consolidate from a de- 
gree of stagnation. This effect of defective or 
suppressed circulation is very perfectly shown in 
the consequences of peripneumony, in which we 
first perceive engouement — a gorged condition of 
the vessels, with impeded circulation terminating 
in consolidation — hepatization, as it is termed, of 
the lung. Mercury, by acting on the absorbent 
system, causes or rather promotes the removal of 
the solidified mass. But mercury likewise pro- 
motes or excites the activity of the circulating 
vessels. This is indicated by various phenomena 
— the fever induced by the mercurial action, the 
hardening, quickening, with frequency of the 



pulse. Therefore mercury appears to give an im- 
pulse to the circulation, and in all probability pro- 
motes the action and functions of the extreme 
vessels ; consequently it excites their contractile 
powers, and thus enables them to force forward 
their contents. This appears to be the principle 
upon which mercury acts in removing such mor- 
bid conditions. 

To ensure such results, we next inquire in what 
way the remedy should be given, or under what 
circumstances will such an effect be produced. 
The mercury must accumulate and produce its 
specific effects in the system. Hence it must not 
be suffered to pass off by the bowels ; but it must 
be exhibited in such a manner as will ensure its 
accumulation without either purging or great irri- 
tation, which latter, by its reaction on the circula- 
tion, will tend greatly to increase the mischief and 
aggravate all the symptoms. 

There are several modes of introducing mercury 
into the system ; the principal are inunction, fumi- 
gation, and its internal exhibition. Inunction is 
frequently practised in liver affections, and was 
often considered the preferable mode ; the remedy 
being applied in the neighbourhood, was supposed 
to pass into the organ ; a principle which, even 
if well founded, would confer no particular benefit. 
The advantages occasionally derived from inunc- 
tion, are referable rather to the friction than to the 
medication, the ointment merely serving to dimi- 
nish the irritation from friction. Therefore, the 
circumstances which would lead the practitioner 
to prefer inunction or friction, are a peculiar irri- 
tability of the stomach and digestive tube, and a 
morbid sensibility to the local influence of the 
remedy. This is sometimes considerable, and 
frequently a source of great embarrassment to the 
practitioner. 

Fumigation is applicable when the object is to 
bring the system under the influence of mercury 
in the least possible space of time. 

The internal exhibition of mercury, however, is 
that upon which practitioners mostly depend ; and 
it should be continued till its specific effects appear 
in a slight tenderness and tumefaction of the gums. 
Various preparations of mercury are resorted to for 
this purpose, and it may perhaps be useful to con- 
sider concisely the pretensions of the most active. 

The preparations of mercury in most repute, are 
calomel and blue pill ; the former is the more ac- 
tive but irritating, the latter the milder but more 
oppressive to the stomach. In some constitutions 
at all times, and in some only under particular 



LIVER, (DISEASES OF THE) 



157 



circumstances, calomel so irritates the stomach 
and bowels as to do much more harm than good. 
It is possible occasionally to correct this tendency 
by combination with a narcotic, as extract of hen- 
bane, hemlock, or Dover's powder, which last not 
only corrects the irritability of the bowels, but also 
favours the entrance of the mineral into the system. 
If, notwithstanding all these precautions, this pre- 
paration should irritate, some other formula must 
be substituted. The oppressive action of blue pill 
arises from the sugar and the vegetable matter of 
the confection of roses, and the fibrous matter of 
the liquorice-root used in its preparation ; its com- 
parative inertness, upon the large proportion of the 
metal which escapes oxidation. Blue pill, how- 
ever, will often answer the purpose, and prove 
even sufficiently active when calomel could not be 
administered. 

The stomach may be strengthened so as to resist 
the irritating action of calomel, or the oppressive 
influence of blue pill, by exhibiting a mild tonic or 
aromatic draught about an hour before giving the 
mercury. The writer has found the infusion of 
cloves with the aromatic spirit of ammonia the 
most effectual for this purpose. 

We have frequently found it an efficient prac- 
tice to resort to the grey or protoxide of mercury. 
This is uniform in strength, and is not necessarily, 
as in the preparation of the blue pill, combined 
with agents which exert an oppressive action upon 
the stomach. The requisite dose may be com- 
bined with extract of hyoscyamus, or any other 
similar extract, or it may be given in powder. It 
is asserted by Dr. Barker, that a portion of the 
protoxide is apt to pass to the state of peroxide. 
The contamination, however, probably results from 
original impurity. The London College direct it 
to be prepared by the action of lime-water upon 
calomel ; and as calomel is occasionally contami- 
nated with oxymuriate, of course in such cases 
there will be an intermixture of peroxide. The 
best way of preparing protoxide of mercury is to 
form a proto-nitrate by the action of diluted nitric 
acid unaided by heat, and then precipitating by 
means of potass, and washing the precipitate. 
The protoxide thus prepared gives no indication 
of peroxide, even when kept for a considerable 
time. 

Other preparations of mercury have been used, 
as the oxymuriate, but this is not generally the 
best for employment, although the writer has met 
with many instances in which it superseded all the 
other preparations. In general, the best way of 
giving it is with the decoction of sarsaparilla. 

The acetate and the phosphates of mercury are 
very active preparations, and agree very well with 
the stomach. The advantages of the latter prepa- 
rations are that much smaller doses answer, an 
object of moment when the stomach is apt to be 
oppressed ; and in the case of the acetate, the 
readiness with which its acid is decomposed in 
the stomach or in the system, and the mineral in- 
troduced. 

Sometimes the irritation arising from mercury, 
depends upon the existence of a free acid, or per- 
haps free chlorine in the stomach. In such cases 
not only is the sensibility of the mucous lining 
morbidly acute, but a more irritating preparation 
is formed. This may be corrected by some ab- 



sorbent earth, as chalk, lime, magnesia, or an 
alkali ; and this probably will explain the advan- 
tages experienced by the writer, and mentioned in 
a preceding column, from exhibiting spirit of am- 
monia in infusion of cloves, before taking the mer- 
curial. In similar cases, the hydrargyrum cum 
creta., or with magnesia,* will frequently answer 
the purpose: but the most certain plan consists 
in giving the absorbent an hour or so before the 
mercurial. 

Many years since it occurred to the writer that 
the powers of mercury might be greatly enhanced 
by combination with iodine, in accordance with 
an acknowledged rule or principle in pharmacology, 
that the virtues of remedies exerting singly a 
similar specific agency, would be greatly increased 
by combination ; and the preparation of the proto- 
and deuto-iodurets of mercury^ were consequently 
administered in various tumours and enlargements; 
such as bronchocele, hepatic and other visceral 
enlargements, and indeed all descriptions of ab- 
dominal swellings. The results were highly satis- 
factory. One or two cases even of white swelling 
and hip-joint disease perfectly recovered by the 
use of the iodurets of mercury with the means to 
be presently detailed. It is, however, in glandular 
swellings and in the vascular congestions of paren- 
chymatous structures, and the consecutive organic 
changes which these structures undergo, that this 
combination is most effectual. In a treatise on or- 
ganic disease, printed in 1824, we have entered 
fully upon this subject and the different objects to 
be kept in view. 

More recently we have had some opportunities of 
again proving the efficacy of this preparation. A 
young woman in the country began to swell about 
the abdomen, and was considered pregnant by her 
medical attendant. She came to town, and a 
medical friend was requested to attend her in her 
accouchement. He, however, doubted the preg- 
nancy, and her time having elapsed without any 
diminution of size, calomel and hydriodate of po- 
tass were given, and an abdominal swelling of 
nearly eleven months' duration, and which con- 
fined the patient to bed for more than two months, 
was reduced in about three weeks, and the patient 
restored to perfect health. A second instance oc- 
curred in the practice of another medical friend. 
It was an abdominal swelling, probably of an 
ovarian description. We recommended the plan 
pursued in the last case. It was, however, some 
time before it could be put into execution, and the 
swelling remained unabated. At last, however, it 
was adopted, and in about three or four weeks the 
abdomen was reduced to its natural size. This 
patient, however, died, (the constitution having 
been completely broken up by previous dissipation,) 
but on examination no indication whatever could 



* To these preparations the same objections apply as 
to blue pill — namely, the partial or imperfect oxidation 
of the metal. The grey or protoxide prepared as above, 
and mixed with the chalk or magnesia, (the latter pre- 
ferable,) will be found the preferable formula? for exhibi- 
tion. 

tThe proto- and deuto-iodurets of mercury may be 
prepared extemporaneously, by mixing calomel or oxy- 
muriate of mercury with the equivalent of hydriodate 
of potass; an interchange of principles takes place even 
in the dry way. Jt is, of course, intermixed with mu- 
riate of potass, which might be washed out if it wera 
of importance to free the preparation from such an iin< 
purity. 



158 



be traced of the part which had been enlarged. 
One ovary, probably the diseased one, had entirely 
disappeared. 

The iodurets affect the mouth in the same way 
as the more ordinary preparations of this mineral. 
They may be given in similar doses, and the deuto- 
ioduret in larger doses than the oxymuriate. They 
may also be introduced by friction ; but the deuto- 
ioduret almost always produces a bright scarlet 
efflorescence of the skin, which mostly terminates 
in desquamation. The precautions as to correc- 
tives, when considering mercury generally, are 
equally applicable to the iodurets. 

Some constitutions powerfully resist the mercu- 
rial action ; such stubborn resistance is to be over- 
come, in plethoric habits, by bleeding, by nausea- 
ting doses of emetics, by opiates, and other well- 
known means. The introduction of mercury also 
is often attended with a febrile irritation or excite- 
ment, which, reacting on the diseased viscus, 
counteracts whatever benefit might otherwise be 
obtained. This must be kept in subjection by 
bleeding and other antiphlogistic measures, and by 
local measures which will also prove auxiliary upon 
other principles. 

The affections which will be benefited by this 
plan are hjpjraemia of every description, hyper- 
trophy and all sorts of enlargement, induration, 
scirrhus, tubercular conditions, even the scrofulous, 
and most adventitious deposits, excepting the os- 
seous, and even this perhaps if incipient. Its 
efficacy is questionable in abscess, ulceration, and 
cancer ; but still it may be likewise questioned 
whether the iodurets should be wholly proscribed 
in such affections were we satisfied of their exist- 
ence. It is not improbable that if the absorption 
of the diseased structure were effected, healthy 
deposition might be substituted in its stead. 

It may be inquired for what length of time the 
mercurial preparations should be continued. Mer- 
cury, it has been already observed, not only excites 
a febrile irritation, but also exerts a noxious influ- 
ence upon the economy at large, and this influence 
is directly as the quantity and its effects. There- 
fore, the object is to induce the specific effects with 
as little irritation as possible, and with the least 
possible quantum of the mineral. But in many 
instances the effects having been induced, the 
mercury must be laid aside, and the disease will 
remain stationary; and the practitioner must again 
and again have recourse to the remedy. Each 
succeeding application to mercury is attended with 
severer consequences, and it often happens that on 
the subsidence of the organic affection the patient 
finds it effected only by a total breaking up of the 
constitution, and a fatal sacrifice of health. The 
debilitating or rather exhausting effects of mercu- 
rial courses are too generally understood to need 
any comments in this place. Upon reviewing 
these facts it occurred to the writer that the good 
effects resulting from the iodurets of mercury 
might be kept up and a beneficial influence exerted 
on the disease by some other of the metallic iodu- 
rets. With this view, upon the first indication of 
the mercurial influence, whether the development 
of the specific influence upon the gums, or a re- 
duction of the disease, the ioduret of iron or of 
zinc was given, or the hydriodates of these metals 
in solution. The result was extremely satisfactory; 



LIVER, (DISEASES OF THE) 

and morbid conditions which had been but slightly 
affected by the mercurial iodurets were completely 
dispersed under the ioduret of iron or of zinc. 
These preparations will be found much better 
adapted to weakly, irritable, and lcuco-phlegmatic 
habits. Of these two the ioduret of iron is per- 
haps the most irritating and inflammatory, that of 
zinc the least so. They may be given either in 
pills, or in solution, as hydriodates, readily ly 
mixing a solution of the equivalent of sulphate of 
iron or of zinc with one of hydriodatc of potass ; 
an interchange of principles and the formation of 
the new salts, hydriodate of iron or zinc, is the 
result.* Whatever objections may offer to the 
employment of the mercurial iodurets in cancer- 
ous, scrofulous, and other cachectic diseases of the 
liver, none such can be urged against those of 
iron and zinc, and therefore, the practitioner may 
safely appeal to them under the assurance that he 
is not employing a destructive or injurious remedy. 
The doses of these salts must be regulated in a 
great measure by their effects. From one grain to 
ten, according to circumstances, may be given 
three or four times a day; the practitioner recollect- 
ing that the smallest doses should -be tried at first. 
Another circumstance to be attended to is that the 
system becomes blunted by habituation to a re- 
medy. Increasing the dose is often carried to an 
extreme without benefit, and frequently not with- 
out injury. The susceptibility cannot be kept up 
by over-doses, but when dormant it may be awak- 
ened by a temporary suspension of the medicine. 
Thus, when the average extent of dose fails to 
produce its accustomed effects, the medicine should 
be laid aside for a time ; and when a respite has 
been thus granted to the system, we shall find all 
its sensibility restored, and we may again resort to 
our means, confident of finding the usual suscep- 
tibility to impression. 

The state of the urine has been noticed in a 
previous part of this article, and an examination 
of it will often afford useful information. There 
are two conditions of it, however, which deserve 
attention in hepatic diseases, namely, an excess of 
urea, and its ready coagulation by heat. This 
latter property arises from albumen or chyle, and 
is often present in the dropsies consequent upon 
hepatic disorder. It may be laid down generally 
that such conditions forbid any active use of mer- 
cury. It betokens a state of system altogether 
hostile to the use of this mineral. But the me 
tallic iodurets just considered, according to the 
writer's experience, are not liable to the same in- 
conveniences. 

During the pursuance of all the above means, it 
will be necessary to attend not only to all the 
functions, but to the conditions of* the organs 
which perform them. When we find urea in ex- 
cess, or the curdy coagulation depending on the 
presence of chyle, there exists an irritability of 
system which must be soothed by morphia, hyos- 
cyamus, and the acetic extract of colchicum, which 
will be found a most valuable auxiliary under 
such circumstances. The denser coagulation arising 
from albumen indicates not only irritabilitv, but 
an excitability of the phlogistic character, which 
must be subdued by venesection (especially if 

* tn this case sulphate of p ,tass remains in the mix- 
ture, but the impurity is of no moment. 



LIVER, (DISEASES OF THE) 



159 



attended with local pain) and other suitable modes 
of evacuation. It is almost unnecessary to ob- 
serve that the digestive functions should be closely 
watched, and the condition of the organs attended 
to, and any degree of aberration immediately cor- 
rected. Hence the advantage of occasional sto- 
machics, &c. Should the disorders of organs 
secondarily affected remain unheeded, they will 
soon, by their reaction, aggravate all the symptoms 
of the primary disease. 

Local Means. — While the practitioner is en- 
deavouring to subdue disease by what are termed 
general means, he should frequently examine the 
region or seat of the diseases. This will in many 
cases be found swelled, painfully sore or tender. 
These states are to be relieved by those means 
which directly deplete the part itself. Leeches 
therefore should be applied : and it is often useful 
to repeat the leeches at regular intervals, that is, 
every three days, every week, every fortnight, &c, 
according to the extent or severity of the pain or 
tenderness. 

It is often useful to alternate leeches and blisters, 
and the most surprising improvement frequently 
results from this practice. In some cases, how- 
ever, blisters alone prove most serviceable, leeches 
only debilitating and distressing the patient, and 
in others the converse of this will prove the case. 
It is almost impossible to determine, a priori, 
which of the two plans or whether a union of 
both will be found the most effectual. 

Various plasters which excite or irritate the skin 
sometimes do good, when neither leeches nor blis- 
ters can be endured. Burgundy pitch is of this 
description ; but the most effectual is the " em- 
plastrum ammonise," — a combination of muriate 
of ammonia and soap, in which the alkali gradu- 
ally abstracting the acid, the ammonia is disen- 
gaged, and applied in its escape to the skin, which 
produces a beneficial irritation. It should, how- 
ever, be applied immediately on its preparation, 
and to insure fully its beneficial effects it should 
be frequently renewed. 

Of all the local means, however, there is nothing 
equal to a perpetual drain in those chronic con- 
ditions termed organic disease. Setons and issues 
are not so often resorted to as their remedial effi- 
cacy would lead us to expect. Organic disease is 
a result accomplished by a very slow and gradual 
process, and is not, like acute disease, to be imme- 
diately suppressed or removed. The constant 
drain effected by an issue from the general system 
will also greatly tend to keep down febrile excite- 
ment, which it is well known greatly aggravates 
local disease of every description. A caustic issue, 
therefore, which is perhaps the most convenient 
and the most manageable, should be inserted in 
the region of the diseased viscus ; and its exact 
position and extent should be regulated by the 
nature, extent, and severity of the tenderness. 

The effects of setons, issues, &c, are slow, 
though progressive, and sometimes a depression 
of strength supervenes during the continued action 
of the permanent drain. This proves as embar- 
rassing to the physician as distressing to the 
patient. In such cases a little more generous diet 
must be allowed, and mild, unirritating tonics 
administered ; and if the loss of strength prove 
extreme, the issue must be dried up for a time, or 



the discharge reduced by the removal of an ade- 
quate proportion of the peas. 

When we find it necessary to heal the issue, 
and at the same time to support the strength by 
tonics, in certain temperaments of the nervo-san- 
guineous character, languid inflammatory action 
is apt to be excited. This is best kept down by 
occasional cupping, leeches, &c. Where even so 
small a loss of blood seems prejudicial, the best 
effects result from dry cupping, repeated at short 
intervals. Dry cupping often proves the most 
effectual remedy in some forms of hypercemia 
and engoument, and its effects upon the accompa- 
nying tumefaction are as surprising as they are 
inexplicable. 

Organic diseases of the liver induce a train of 
consequences both severe and troublesome. The 
functions and structure of other parts become 
deeply engaged ; and hence dyspepsia, dropsies, 
apoplexies, and inflammatory affections. In all 
cases, the complication must be attended to, and, 
as far as possible, its reaction on the system at 
large, and on the primary affection counteracted. 
The means of accomplishing this consist in those 
peculiarly adapted to the removal of the secondary 
disease itself, modified, however, by the existing 
circumstances. The practitioner, however, must 
be prepared for a tedious disease, and he must not 
relax in his endeavours, nor give up in despair, if 
the amendment should not keep pace with his 



wishes. 



R. Venaeles. 



Iiiver, Inflammation of tlic. Hepatitis, 
from Lat. hepar, Gr. rjirap, the liver. 

The history and symptoms of inflammations of 
the liver have been peculiarly dwelt on in all 
works on medicine, from the earliest periods. In 
fact, until very recent times, when the attention 
of physicians was more especially called to the 
diseases of the gastro-intestinal mucous mem- 
brane, — heretofore a comparatively unexplored 
field, — this affection and its subsidiary diseases 
were more studied than any other lesion of the 
digestive apparatus. (See Gasth.o-Enteb.itis.) 

Pathology. — The liver may labour under the 
effects of increased quantity of blood in its paren- 
chyma, from several causes. Of these, the two 
most important are — 1. active congestion, the 
result of irritation in its tissue, either primary, or 
the consequence of some other lesion originating 
in its own substance, or some other organ with 
which it sympathizes; and 2. passive congestion, 
induced by mechanical obstruction to the exit of 
its venous blood. This obstruction may be seated 
in the hepatic veins, the heart, lungs, or even in 
the aorta, (mechanical hyperemia of Android) In 
addition to these, two other sources of congestion 
are mentioned ; one a stasis of blood, similar to 
that which occurs in organs attacked with scorbu- 
tic disease, and the other the congestion which 
occurs so remarkably in intermittent fever; a con- 
gestion sometimes so intense as to induce hepatic 
apoplexy.* 

The results of inflammatory action on the liver 
vary according to the intensity, length of duration, 
and situation of the disease. In general, the first 

* Bai/lij, Traite anatomico-pathologique des fievreft 
intermittentes, Simples, et pernicieuses, 1825. See, also 
Mackintosh, Cleghorn, &c. 



1G0 



LIVER, (DISEASES OF THE) 



visible effect is the production of increased vascu- 
larity of the parenchyma, which may be either 
general or partial ; but we believe that in the 
majority of cases the latter is most frequent. This 
is accompanied with tumefaction of the part, and 
is the first stage of acute inflammation, as far as 
this can be demonstrated by the knife: under these 
circumstances the hepatic tissue is extremely red, 
and blood flows copiously when it is divided by 
the scalpel. 

In a still more advanced stage, in addition to 
the vascularity, we observe a remarkable softening 
of the part, sometimes so great that a slight pres- 
sure will reduce it to a mere pulp. This stage 
is analogous to the second stage of acute pneumo- 
nia, and, like it, may be accompanied by the 
formation of pus or lymph on the serous surface. 
In this respect, however, there is a great difference 
between the liver and lung, as we seldom meet 
with pneumonia without serous inflammation, 
while the reverse often obtains in hepatitis. This 
is a point of great importance in the surgical 
treatment of the disease, and one to which we 
.shall recur. 

On this subject Mr. Annesley makes the follow- 
ing remarks : — " When the surfaces are the seat 
of inflammatory action, the internal structure of 
the organ generally participates in it to a greater 
or less extent, and likewise, when morbid vascular 
action commences in the parenchymatous struc- 
ture, it sometimes extends to the external surface ; 
but this more rarely occurs in India than the 
former mode of extension, the internal structure 
appearing to us to be more frequently the seat of 
the inflammatory state than the surfaces, which 
seldom participate in it till the more advanced 
stages of the disease. We frequently observe in 
India the internal structure of the liver inflamed 
to the greatest possible extent, without any effusion 
of lymph from its surfaces, and the inflammation 
of structure may go on to the production of 
several abscesses in both its lobes, or of one very 
large abscess in the eighth lobe only, without any 
decided marks of inflammation of the envelop of 
the organ, except some alterations of colour 
merely, which are usually occasioned by the states 
of the parts immediately underneath ; nay, even 
abscesses of the liver may proceed to the utmost 
extent, and ultimately break into the abdominal 
cavity, without having induced inflammation of 
the serous surface where they point, and conse- 
quently without forming adhesions to the parts 
with which they are in immediate and close con- 
tact. (Annesley's Diseases of India, vol. i. p. 
406.) 

In the report of the Meath Hospital, by Dr. 
Graves and the writer of this article, (Dublin 
Hospital Reports, vol. v.) the important fact of the 
rarity of adhesions in cases of hepatitis, even after 
the formation of abscess, is noticed. This is a 
fact which we had observed long before the 
appearance of Mr. Annesley's work, and one from 
which it would appear that both in the warm and 
temperate climates acute inflammation of the liver 
is much more seldom complicated with serous 
inflammation than a similar state of the pulmo- 
nary parenchyma. It is not easy to explain this 
singular but most important difference ; but it is 
obvious that the only mode of arriving at a solu- 



tion of the difficulty is to compare the physiologi- 
cal relations of the two membranes. 

It has been long admitted that the peritoneum 
is less liable to the adhesive inflammation than the 
pleura, as, in our examinations after death, we 
commonly meet with adhesions of the pleura, 
while those of the peritoneum are comparatively 
rare. This fact, however, may, to a certain 
degree, be explained by the greater fatality of ab- 
dominal inflammations, a greater portion recover- 
ing from pleuritis than from peritonitis. The more 
fre°quent affection of the pulmonary serous mem- 
brane in cases where the subjacent parenchyma is 
engaged, may be explained partly by the greater 
degree of motion which, in consequence of the 
function of respiration, the two pleural surfaces are 
exposed to ; as in this way the parts are not only 
predisposed to inflammation, but a slight effusion 
of lymph may become an exciting cause of dis- 
ease by its mechanical action over an extensive 
surface. Again, — if, as there is great reason to 
believe, the air-cells are in reality white tissues, 
the propagation of inflammation from them to a 
similar structure ought more readily to take place 
than from the glandular acini of the liver to an 
essentially different tissue. 

The next stage of hepatic inflammation which 
has been described is that of purulent formation 
or abscess ; but we believe that between this con- 
dition and the red softening of the liver there is 
an intermediate stage, in which the hepatic tissue 
is found of a yellow colour, exceedingly soft, and 
leaving a puriform exudation on the scalpel. Be- 
tween this state and the third stage of pneumonia 
there appears to be a great analogy, as it is an in- 
terstitial suppuration immediately preceding the 
formation of abscess. In several instances we 
have observed this alteration to extend to some> 
distance around an hepatic abscess, and in cases 
where numerous small purulent collections existed, 
the hepatic tissue which separated them had un- 
dergone this change. The tissue thus altered va- 
ries considerably in consistence, in some instances 
being almost semifluid, in others possessing a cer- 
tain degree of firmness. As yet this condition 
does not appear to have been recognised in the 
systematic works on pathology. 

Lallemand, in his " Lettres sur L'Encephale," 
speaks of a softening of the liver, in which, in 
consequence of severe inflammation, its tissue is 
reduced into a diffluent sanies of the colour of 
wine-lees ; but this condition is obviously different 
from that we have just described. 

Abscess of the liver, so common in India, is of 
rare occurrence in these countries. A few isolated 
cases are to be met with in medical records, but 
no series of cases was published as occurring in 
Europe until the appearance of Louis's researches 
on this subject. (Recherches Anatomico-patholo- 
giques. Paris, 1826.) Subsequently, the writer 
of this article, in conjunction with Dr. Graves, 
published several examples of this lesion. (Dublin 
Hospital Reports, vol. v.) 

Puriform matter, as the result of inflammation, 
is met with in the liver under several forms. We 
may find it, as it were, infiltrated into the hepatic 
tissue, as described above, — a condition to which 
the name of yellow softening of the liver may be 
given; it may occur in numerous minute ab- 



LIVER, (DISEASES OF THE) 



161 



scesses ; or, lastly, it may form one or more large 
collections of matter, in some cases encysted, in 
others bounded only by softened and yellow he- 
patic substance. These collections of matter are 
generally isolated, though in a few cases they have 
been found to communicate by fistulous passages. 
As yet we are not fully aware of the circum- 
stances which dispose to the formation of a cyst 
around these puriform collections. The more 
chronic the abscess, the greater will be the likeli- 
hood of a cyst existing, but it will often be found 
even in recent cases. We have seen these cysts 
under very opposite circumstances. Thus, in a 
case which occurred in the Meath Hospital, where, 
after acute hepatitis, the patient sank with suppu- 
ration of the liver, we found numerous abscesses, 
some the size of an orange, others that of a hazel- 
nut, the smaller being encysted, the larger not so. 
In another case, however, the reverse of this was 
observed. A patient had laboured under gastro- 
enteric fever for some time, when attention was 
directed to his liver, from his complaining of pain 
in that situation. The organ was then found en- 
larged, and it soon became evident that matter was 
forming. The patient died, and on dissection, a 
vast abscess in the right lobe, capable of containing 
several pints, was discovered : this was encysted, 
while in the remainder of the liver were numerous 
small abscesses, only separated by softened hepatic 
tissue. In another case, the particulars of which 
we shall detail hereafter, a very chronic abscess, 
communicating with the duodenum, existed in the 
right lobe, while a recent one, which had opened 
into the peritoneal cavity, was found in the left. 
In the first abscess, which had existed under our 
observation for two months, we found the cavity 
empty, and lined with a strong semi-cartilaginous 
membrane, of a dark greyish colour ; while in the 
second there was no cyst whatever, its parietcs 
being formed of yellow softened hepatic tissue. 
The last case which we shall notice on this sub- 
ject is that of a woman who sank under a very 
chronic abscess of the liver. Here the cavity 
was of enormous dimensions, and presented an 
imperfectly formed cyst, most developed where the 
parietes of the abscess were thinnest — that is to 
say, immediately under the serous covering of the 
convex surface. In the more deep-seated parts it 
could hardly be detected. 

The appearances of structure of these cysts are 
various. In some cases we only observe a pseudo- 
membranous layer, of a line or two in thickness, 
yellowish white, and resembling semi-concrete pus. 
In other cases the cyst appears organized, and 
may strongly resemble a mucous membrane ; pre- 
senting villosities more or less completely devel- 
oped, which we can easily demonstrate by im- 
mersing the part in water. A third variety pre- 
sents the lining membrane of a reticulated struc- 
ture, for which the name of fibro-mucus has been 
proposed ; while in the last species the membrane 
is semi-cartilaginous, of an iron-grey colour, and 
very similar to the investment of chronic tubercu- 
lous cavities in the lung. 

Nothing can be more various than the size of 
these abscesses. We have seen them so large as 
to be capable of containing four pints, and, on the 
other hand, they may be so minute as to represent 
suppurated tubercles, from which indeed it is 

Vol. III. — 21 o* 



sometimes difficult to distinguish them. The 
surrounding hepatic tissue is generally in a state 
of red or yellow softening, but cases are on record 
where it has been found perfectly unaltered ; in 
these the disease was generally chronic. The 
same variety is observable in the nature of their 
contents. In all our cases, but with one exception, 
the matter was healthy, though sometimes mixed 
with portions of softened hepatic substance. In 
the case of exception, in which the operation of 
opening the abscess was performed successfully, 
the matter was of a dirty green colour, and mixed 
with sanious fluid. Andral states that in all the 
cases in which he found puriform matter in the 
liver, it was white and consistent, like the pus of a 
phlegmon, and that those who have described it as 
similar in colour to the lees of wine have con- 
founded other diseases, particularly the occurrence 
of encephaloid matter, with the inflammatory sup- 
puration. In warm climates, however, great va- 
riety is observed in this respect. " The matter," 
says Mr. Annesley, " contained in an abscess pre- 
sents various appearances. In some it is a thin, 
watery pus ; in others, it is thin, watery, and 
with thick curd-like clots floating in it ; in many 
cases it is perfectly purulent, and of varying 
degrees of consistence. As respects colour, there 
is also considerable difference ; most frequently 
the matter is of the usual yellow colour. Some- 
times it presents a yellowish-brown or sanious 
tinge, and occasionally a greenish-brown or green- 
ish-yellow hue; sometimes it is watery or reddish 
brown ; at other times it is observed of a creamy 
consistence, and nearly white. (Op. cit. p. 533.) 

It is to be regretted that the relations which 
exist between the vessels of the organ and these 
collections of matter have not as yet been made 
the subject of any accurate investigation. We 
cannot find any instance recorded, where, as in tu- 
berculous and other cavities in the lung, vessels 
were found traversing the puriform collections. 
They have been observed, however, forming pro- 
jections on the internal surface of the cysts ; but 
when we consider the vast size to which hepatic 
abscesses may attain, the inquiry as to what has 
become of the vessels becomes a matter of extreme 
interest, and in the present state of pathological 
anatomy offers a new field for inquiry. 

The abscess once formed may open in a great 
variety of situations both internally and externally. 
Of the internal openings we have witnessed the 
following examples : — 1. perforation of the dia- 
phragm and communication with the lung ; 2. 
communication with the duodenum; 3. perfora- 
tion of the peritoneum, and effusion into the ab- 
dominal cavity. 

The first of these terminations appears to be a 
not unfrequent and perhaps the most favourable 
of the internal openings of the abscess. Many 
patients have recovered where this lesion undoubt- 
edly occurred, as indicated by the fact of their 
presenting all the symptoms of hepatic abscess, 
both constitutional and local, which subsided upon 
the occurrence of a sudden and copious expecto- 
ration of purulent matter, which had not been 
preceded by any symptoms of pulmonary disease. 
We have known of cases where pressure exercised 
on the hepatic region was immediately followed 
j by a free expectoration of pus. The easy exit of 



162 



LIVER, (DISEASES OF THE) 



the purulent matter, the result of its entrance into 
the bronchial tubes, is in all probability a princi- 
pal reason why this termination of the disease 
should be so often favourable. The abscess may 
open either into the right or left lung ; and though 
there are some cases where the pulmonary pleura 
was not perforated, yet the communication with 
the pulmonary parenchyma and bronchial tubes is 
much more frequent than the formation of an 
empyema, — a circumstance explicable by the 
great tendency to adhesion presented by the pleura. 
Dr. Smith, an American writer, details a case 
where the hepatic abscess opened into the pericar- 
dium. The liver, which was almost entirely oc- 
cupied by an enormous abscess, adhered closely to 
the upper portion of the diaphragm, through 
which the opening between the abscess and the 
pericardium existed ; the pericardium was in- 
flamed, and contained about two pints of a puru- 
lent liquid similar to that which existed in the liver. 
It would appear, then, with respect to the tho- 
rax, that the abscess may open into the lung, 
pleura, or pericardium. Of these, the first is by 
far the most frequent. With respect to the abdo- 
men, the abscess may communicate with some 
portion of the gastro-intestinal tube, the perito- 
neal cavity, the gall-bladder, the vena cava, or 
kidney. In the cases where the opening has 
taken place into some portion of the digestive 
tube, its seat has been in the stomach, duodenum, 
or colon. 

Lastly, the abscess may open externally in a 
great variety of situations upon the abdomen, and 
also on various places on the side and in the ax- 
illa. When the opening takes place externally, 
it is seldom by a direct, but commonly by a sinu- 
ous and fistulous passage. Louis, in his Recker- 
ches Anatomico-Pathologiques, declares that he 
has never yet known of the occurrence of a cica- 
trix in the liver, the result of a cured hepatic ab- 
scess. We feel satisfied that this is a pathologi- 
cal appearance rarely observed in the dissecting- 
room, — a circumstance to be explained by the 
rarity of the disease in this country and its general 
fatality. In one case, however, we have witnessed 
this rare appearance. A patient who had been a 
soldier in the East-India Company's service, and 
who had, while in India, suffered from an attack 
of hepatitis, accompanied, as he described, by great 
tumefaction of the liver, died in the Meath Hos- 
pital of a chronic enteritis. On dissection the 
right lobe of the liver was found greatly dimin- 
ished in volume ; while in the centre of its con- 
vex surface existed a very deep stellated depression, 
around which the hepatic tissue was puckered, 
rising in the form of crests with intervening sulci 
of nearly an inch deep. From the centre, which 
was occupied by a mass of cartilage nearly the 
size of a walnut, emanated prolongations of thin 
plates of cartilage, answering in number to and 
forming the base of the sulci which appeared on 
the surface. In this case we are not able to deter- 
mine by what aperture the contents of the abscess 
had been evacuated, but in all probability it was 
through the duodenum. The appearances on dis- 
section in this case were almost identical with 
those in a case of cicatrices of the liver, of which 
Mr. Annesley gives a beautiful drawing, (see 
j>late 15 of his book.) This gentleman states that 



he has met with several cases of these cicatrices 
in India. There is a form of disease which is 
very liable to be confounded with hepatic abscess, 
as it has many symptoms in common with this af- 
fection ; we allude to a circumscribed inflammation 
and suppuration in the parietcs of the abdomen, 
immediately over the liver. The disease sets in 
with fever, pain, tumefaction, and tenderness in 
the affected part; and, in addition, we have many 
of the constitutional symptoms of hepatitis. In 
one case, which occurred in the Meath Hospital, 
a slight jaundice existed for several days, analo- 
gous, in all probability, to that arising from dia- 
phragmatic pleurisy. These cases are generally 
of little severity as compared with true hepatitis. 
Matter forms speedily under the integuments, and, 
on this being evacuated, the patient rapidly reco- 
vers. In a case, however, which we have wit- 
nessed, the disease proved fatal under very remark- 
able circumstances ; we shall therefore notice it at 
greater length. A woman aged twenty-three, 
who had laboured under amenorrhoea for twelve 
months previously, was attacked with cough and 
hemoptysis, followed, after some days, by fever, 
pains in the back and limbs, and prostration of 
strength. Soon after this she complained of pain 
in the right side of the chest and hypochondrium, 
increased by coughing, pressure, or motion. She 
had a distressing short cough, with yellow tena- 
cious expectoration. The inferior portion of the 
right side of the chest sounded dull, and the re- 
spiration in this situation was almost inaudible 
except when she made a forced inspiration. The 
symptoms having continued for about a fortnight, 
an uncircumscribed puffy tumour made its appear- 
ance over the lateral portion of the liver ; the he- 
moptysis returned, with a hard teasing cough, but 
the fever disappeared ; poultices were diligently 
applied to the tumour, which rapidly enlarged and 
presented evidences of extensive suppuration. On 
the thirteenth day after its appearance it was 
opened by means of an abscess-lancet, when a 
great quantity of matter mixed with blood was 
discharged ; at this time the spitting of blood 
ceased. In about three weeks, however, the ab- 
scess again appeared, and rapidly increased to a 
size much greater than its former dimensions; it 
was again opened, and a large quantity of puru- 
lent matter given exit to. On the next day the 
abscess presented the appearance of an enormous 
anthrax, with edges about two inches high, from 
which a quantity of whitish slough could be de- 
tached by pressure ; the patient was now emaci- 
ated, had diarrhoea, with cough and sanguinolent 
and puriform expectoration. We endeavoured to 
trace the extent of the disease by introducing a 
probe; but although this was found to pass ex- 
tensively under the muscles and cellular substance, 
yet it could not be introduced either into the tho- 
racic or abdominal cavity. After some time it 
was found that when the patient coughed, or took 
a deep inspiration, air escaped with great violence 
from the base of the ulcer, towards the upper por- 
tion of which a circular fistula, through which a 
probe could be passed, was observed ; through 
this the probe passed for about three inches, when 
it met with a solid resisting body. The infra- 
mammary region sounded clear on percussion. 
Examined by the stethoscope, the respiration was 



LIVER, (DISEASES OF THE) 



163 



cavernous, and accompanied during inspiration by 
a sound like the tick of a watch. When the pa- 
tient coughed or made a forced inspiration, a loud 
guggling was audible. There was no metallic 
tinkling, bourdonnement , or pectoriloquism ; but 
the voice resounded strongly from the sixth rib 
upwards, while anteriorly and posteriorly the re- 
spiratory murmur appeared natural. She died on 
the following day. 

Dissection. — Great emaciation. The external 
sore extended from the sixth to the tenth rib : it 
was about four inches in breadth. Between the 
eighth and ninth ribs the fistula was plainly ob- 
servable. On opening the abdomen, the serous 
membrane was found healthy, with the exception 
of that portion which covered the liver laterally 
and superiorly. Here the liver adhered to the 
diaphragm. 

On the centre of the convex surface of the liver 
we found the base of the abscess formed by a cir- 
cular portion of thick, false membrane, of about 
two inches in diameter, external to the hepatic 
peritoneum, but producing a depression on its 
surface. The costal portion of the diaphragm, for 
an extent corresponding to the base of the abscess, 
was destroyed, but adhered round its edges. This 
abscess communicated with the lung by a perfora- 
tion through the diaphragm of about the same size 
as the external fistula, which led into an abscess 
in the lower lobe of the right lung. This was 
narrow, elongated upwards, and presented many 
of the characters of pneumonic abscess. It had 
no lining membrane, and communicated with 
numerous bronchial tubes. Around it the pulmo- 
nary tissue was of a greyish-white colour, softened 
but not granular. The diseased portion did not 
terminate by any distinct line, and occupied about 
two-thirds of the lower lobe, which was univer- 
sally adherent to the diaphragm, and for about 
three inches to the costal pleura ; the remainder 
of the lung was healthy. The mucous membrane 
of the stomach was pale and soft ; the lower por- 
tion of the ileum red, and presenting some aph- 
thous ulcerations : the mucous membrane of the 
colon was covered with fungous elevations, and 
numerous aphthous ulcerations. (Meath's Hos- 
pital Reports.) 

In this case the diseased action had in all pro- 
bability a double seat from an early period, namely, 
the lower portion of the lung and the integuments 
over the liver ; it is remarkable for the double per- 
foration of the diaphragm through its costal and 
thoracic portions, and for the direct communica- 
tion made by the latter with the substance of the 
lung : the pleural and peritoneal adhesions pre- 
vented the escape of the matter either into the 
thoracic or abdominal cavity ; a circumstance 
illustrative of the powers of nature in availing 
herself of diseased action to promote an ultimate 
cure. 

Some authors have described gangrene as a 
result of hepatic inflammation ; but facts are still 
wanting for the elucidation of this subject, and 
there can be but little doubt that, if it ever does 
occur, it must be a circumstance of extreme rarity. 
On this subject we shall quote from Mr. Annes- 
ley : — 

"Gangrene has been remarked by many writers 
and teachers as one of the terminations of acute 



inflammation of the liver ; but although we have 
observed this disease, and made post-mortem exa- 
minations of it, the number of which certainly 
has not been exceeded by any other inter-tropical 
practitioner, we have never seen a single case of 
gangrene of this viscus. We are inclined to 
believe that the appearances that have been taken 
for gangrene have been merely that black, con- 
gested and softened state of the organ which is 
sometimes observed in the more acute attacks of 
the disease, supervening to congestion, or at least 
this state of the viscus having speedily run into 
gangrene after the death of the patient; and 
therefore, if gangrene had actually existed at the 
time of dissection, it is to be considered as a con- 
sequence of death rather than a termination of the 
disease." {Op. cif. vol. i. p. 435.) 

In the works of the modern pathological ana- 
tomists of Europe, the same infrequency of gan- 
grene of the liver is observed ; so that we may 
conclude that both in warm and temperate climates 
the termination of hepatitis by gangrene is of 
extreme rarity. Andral relates one decided case 
of gangrene of the liver, where the disease sur- 
rounded an abscess of the left lobe, and states that 
this is the only instance he has seen of gangrene 
of the liver. When we reflect on the vast num- 
ber of dissections which this great pathologist has 
made, the fact of his having seen the disease but 
once is a decided proof of its rarity. Here is 
another circumstance in which the pathological 
relations of the liver differ remarkably from those 
of the lung, as, in the latter viscus, gangrene is a 
not unfrequent occurrence ; but when we consider 
the greater liability to a stasis or effusion of blood 
in the pulmonary parenchyma, as compared with 
the hepatic, and also that in the lung the diseased 
portion is exposed to the action of air, we may 
find in these circumstances an explanation of the 
fact. 

The effects of chronic inflammation on the liver 
are exceedingly various, and its results greatly 
influenced by the constitution or habit of the 
patient. Among them may be enumerated the 
different forms of hypertrophy, either partial or 
general, either of the red or white substance, or 
of both ; induration ; scirrhous or tuberculous 
tumours ; and hydatids. We are far from believ- 
ing that these latter lesions are always the result 
of an inflammatory process ; as there is undoubted 
evidence that these new tissues may be the result 
of a lesion of secretion and nutrition, not induced 
by any previous irritation of the part ; while, on 
the other hand, cases are on record where these 
different diseases appear to have been first brought 
about by an acute or chronic hepatitis. The fol- 
lowing observations by Andral on this subject are 
highly philosophic : — 

" There is scarcely one of the alterations of the 
liver which have been described which has not 
been designated by the name of hepatitis. In my 
opinion, there is hardly one of them which may 
not be the result of an irritation whose first effect 
was to cause an hyperemia of the liver. For 
example, four individuals receive an externas 
injury on the same region of the liver : in one an 
abscess is developed in the liver ; in the second 
this organ becomes cancerous ; in the third it 
becomes filled with hydatids ; and in the fourth "t 



164 LIVER, (DISEASES OF THE) 

is atrophied. In all these four cases irritation has expected when wc recollect the general comphca- 
been manifestly the point of departure : but what tion of hepatitis with gastrointestinal disease, 
has been its mode of action ? It has deranged the 



normal nutrition of the organ ; there its influence 
is confined: the predisposition of the individual 
has done the rest. On the other hand, I do not 
know an alteration of secretion or nutrition of the 
liver, not even a collection of pus in its parenchy- 
ma, that can be considered as necessarily arising 
from an antecedent process of irritation. I do not 
know one of which we can say that its formation 
has been necessarily preceded by a hypersemia. 
What, then, does the word hepatitis express] 
Nothing more than the common link by which 
the different lesions of secretion and nutrition of 
the liver are often united. But this link is neither 
constant nor necessary ; and if we have seen a 
case where an hyperaemia of the liver by external 
violence has been followed by the formation of 
hydatids, I may cite many other cases where 
nothing has demonstrated a similar point of de- 
parture, and where, from analogy, we would arrive 
at an opposite conclusion, and admit that the de- 
velopment of these entozoarcs is found connected 
with a diminished activity of the normal nutrition of 
the liver. (Precis d' Anatomie Pathologique, torn . ii.) 

Observations are still wanting to establish the 
exact relative frequency of suppuration as the re- 
sult of hepatitis in its acute and chronic stage ; 
there can be little doubt, however, that this lesion 
is much more frequently the result of an acute 
than of a chronic inflammation. 

With respect to the frequency of peritoneal ad- 
hesions it may be stated that these, which we have 
seen to be by no means constant in the acute dis- 
ease, are commonly met in chronic hepatitis. In 
this disease the convex surface of the liver is gen- 
erally found adherent to the parietal peritoneum 
by strong and organized adhesions. On its con- 
cave surface we may also meet adhesions with 
several portions of the abdominal viscera, though, 
as far as we have seen, these are not so frequent 
nor so general as those of the convex portion. 

Symptoms of Hepatitis. — Inflammation of 
the liver has long been described as occurring 
under two forms, the acute and chronic ,- but al- 
though numerous cases will be met with where it 
would be difficult to declare to which of these 
species the disease belongs, yet in a practical point 
of view the division is convenient. Let us ex- 
amine the symptoms, progress, and termination of 
the first or acute species. 

Acute Hepatitis. — In the different elementary 
works on the practice of physic, the symptoms of 
this disease are described as occurring in a manner 
much more constant than the state of the science 
can permit us to believe, and in this way the 
student is misled, and gets a very false and con- 
tracted view of the affection. In fact, there is no 
one symptom mentioned that may not occasionally 
be absent ; and, on the other hand, all may arise 
from other causes besides hepatitis. The symp- 
toms may be considered as local and general ; the 
local being, principally, pain, tenderness, and tu- 
mefaction ; the general, fever, and lesion of the 
digestive and in some instances of the nervous and 
respiratory systems. Of these, the first two, 
lamely, fever and lesion of the digestive function, 
are by far the most frequent, a circumstance to be 



(See Gastro-Exteritis.) 

Acute hepatitis may be generally described as 
commencing with that group of symptoms indica- 
tive of inflammation in the digesti\e system ; in 
other words, the patient at first appears to be at- 
tacked with gastric or bilious fever, to which suc- 
ceed, sooner or later, symptoms of the hepatic dis- 
ease. There is often then high fever, the type 
being generally more inflammatory and less typhoid 
than that which results from a simple gastro-ente- 
ritis. The pulse is more frequently strong and 
full ; there is thirst, a furred and yellowish tongue, 
and frequently vomiting, sometimes of a bilious, 
at other times of a dark-coloured matter. The 
bowels are commonly irregular or costive, and the 
discharges present a great variety of appearances 
according as the biliary secretion is more or less 
affected, and also according to the degree of com- 
plication with gastro-intestinal disease. The urinary 
secretion is also affected, being almost always 
scanty and very high coloured. 

In addition to these symptoms we have the 
local indications of hepatitis, which are, principally, 
pain, tenderness, and tumefaction. The pain is 
felt in various situations, and occurs with various 
degrees of intensity. In some cases the patients 
describe it as a stitch in the side, aggravated by 
respiration or motion ; in others the pain occurs 
about the cartilages of the lower ribs, or it may be 
felt in the lumbar region. Much has been written 
about the occurrence of pain in the right shoulder 
in cases of hepatitis ; from our experience we 
would say that this is an extremely rare symptom, 
and one by no means pathognomonic of the dis- 
ease, an opinion borne out also by the experience 
of Dr. Mackintosh (Elements of Pathology and 
Practice of Physic, vol. i.) in these countries, and 
of Andral hi France. (Clinique Medicale, Mala- 
dies de 1'Abdomen.) There can be no doubt that 
practitioners are often misled from attaching an 
unmerited degree of importance to the presence or 
absence of this symptom. Generally speaking, 
the pain is more acute when the inflammation is 
superficial, — a circumstance illustrative of the ge- 
neral law, that in parenchymatous inflammations 
the pain is more severe when the disease ap- 
proaches or involves the surface of the organ. 

The symptom which we regard as next in im- 
portance to the pain is the tumefied and tender 
condition of the organ. When the belly is flaccid 
and the intestines are empty, there is seldom much 
difficulty in detecting the hepatic enlargement. 
We then generally observe the right hypochon- 
drium and the epigastric region full, and the edge 
of the liver can be felt descending more or less 
below the costal cartilages. Sometimes the ribs 
appear tilted out, but the intercostal spaces pre- 
serve their relative positions with respect to them; 
a point of great importance in the diagnosis be- 
tween hepatic and pulmonary diseases. But 
where the belly is distended by either faecal matter 
or air, it becomes extremely difficult to ascertain 
the enlargement of the liver. In such a case we 
would always recommend that a dose of opening 
medicine should be given, followed after some time 
by a purgative injection, after the operation of 
which the examination of the hepatic region will 



LIVER, (DISEASES OF THE) 



165 



be greatly facilitated. We shall also derive im- 
portant information by the use of mediate percus- 
sion by means of the pleximeter, as recommended by 
M. Piorry, from whose recent work we shall quote. 
" In some acute cases of hepatitis, or rather in 
sanguineous congestions of the liver, it has been 
easy to demonstrate, at the Salpetriere, the Pitie, 
and at the Hotel Dieu, that the liver is susceptible 
of great increase of volume, and that the dimen- 
sions of this gland diminish rapidly after a copious 
bleeding, and sometimes also by strict regimen, 
which by itself produces a loss of blood. The 
diminution of the hepatic organ varies from one 
to three inches, from above downwards, in the 
twenty-four hours ; this is still greater in propor- 
tion as the blood drawn is more considerable. Not 
only has this fact been observed with old men in 
whom the venous circulation, embarrassed by dis- 
ease of the heart, and particularly its weakness, 
explains the tumefaction of the liver, but also in 
adults, in cases of plethora and acute fevers. I 
could easily accumulate twenty observations to 
support this proposition. M. Vidal, one of the 
house pupils connected with my attendance, has 
just related to me three most remarkable facts 
taken most carefully. I shall confine myself to 
the following : A young man discharges a loaded 
pistol direct against the region of the liver; the 
ball, however, does not penetrate, which singular 
fact may be attributed to the presence of air be- 
tween the muzzle of the piece and the ball, the 
pistol being applied to his clothes so firmly as to 
stop up the muzzle : his clothes are, however, torn, 
and the foreign body, after having violently con- 
tused the skin, falls at the feet of the wounded 
man. The first few days no accident of import- 
ance occurred ; the circumference of the liver was 
bounded by a black line. The fourth day there 
was fever, flushed face, and dyspnoea very intense: 
this was referred to the liver ; this organ above 
and below exceeded by an inch or more the former 
line of demarcation. A copious bleeding was 
tried ; the next day the liver had resumed its former 
dimensions, and the severe symptoms disappeared. 
The cure was rapid. (Piorry, du Procede Ope- 
ratoire, etc. Paris, 1831.) 



In using the pleximeter we should employ it 
over the epigastrium and hypochondrium, and also 
over the lower portion of the chest both anteriorly, 
laterally, and posteriorly. By this means, the ex- 
tent of the hepatic tumefaction can be generally 
determined with ease. In some instances the 
tumefaction is more evident in the superior, in 
others in the inferior portions of the liver ; when, 
however, the belly is much distended, this mode 
of observation is liable to many difficulties : thus, 
when the intestines contain much solid and fluid 
matter, we cannot estimate the extent of dulness 
inferiorly ; and on the other hand, when they are 
distended by flatus, the liver is pushed upwards, 
under which circumstances the dulness of the 
lower part of the chest ceases to be a measure of 
the hepatic tumefaction. 

Jaundice has been described as an attendant on 
hepatitis, but it is not a constant symptom. The 
patients have generally a slightly yellowish tinge, 
particularly in the face, similar to what is observed 
in gastric or bilious fevers, but very different from 
true icterus. In none of the cases observed by us 
at the Meath Hospital was there jaundice ; and 
Andral relates numerous cases of hepatitis where 
this symptom was absent : it may, however, occur 
in acute hepatitis ; but facts are still wanting to 
explain its absence in some cases, and its presence 
in others. Of one fact we are certain, that 
jaundice, when induced by inflammation, is much 
more frequently the result of a duodenitis than of 
an inflammation of the liver. From the known 
effect of a duodenitis, simple or complicated with 
gastric inflammation, in the production of icterus, 
(Marsh, on Jaundice, Dublin Hospital Reports. 
Broussais, Commentaries, &c.) it becomes an in- 
teresting question to determine how far the com- 
plication of gastro-intestinal inflammation in he- 
patitis may act in producing the symptom of 
jaundice. The following table of cases, taken 
from the writings of Andral, Louis, and from the 
report of the Meath Hospital, may assist in throw- 
ing some light on the subject. The first column 
states the condition of the liver, the second that 
of the gastro-intestinal apparatus and ducts, and 
the third that of the skin. 



State of the liver. 

Acute hepatitis 

Red softening 

Red induration 

Numerous abscesses 

Abscess 

Ditto 

Ditto 

Hepatitis with tumefaction 

Hypertrophy 

Vast abscess 

Numerous small abscesses. 

Ditto ditto , 



Numerous abscesses 
Hypertrophy 



Numerous abscesses 

Ditto ditto 

Vast abscess 



Digestive tubes and ducts. 

Healthy ; ducts free 

Healthy ; ducts free 

Ditto ditto 

Ditto ditto 

Ditto ditto 

Ditto calculus 

Ditto healthy 

Chronic gastritis 

C Chronic gastro-duodenitis ; ducts ~) 
I free 5 

Gastro-enteritis ; ducts healthy. 

Slight enteritis ; ducts free .... 
C Gastritis ; gall-bladder atrophied; ^ 

(_ calculus in cystic duct 3 

C Colitis ; ulcerations of gall-blad- 
C der 

Chronic gastro-duodenitis 

Chronic gastro-enteritis ; duode- 
num healthy 

Gastritis 

Ditto ^ 



Skin. 
Jaundice. 
Jaundice (slight). 
Jaundice. 
Jaundice. 
Jaundice. 
Jaundice. 
Jaundice (slight). 
Jaundice. 

Jaundice. 

Jaundice. 
Jaundice (slight). 

Jaundice (deep). 

Jaundice. 

No jaundice. 

No jaundice. 

No jaundice. 
No jaundice. 



166 

State of the liver. 
Abscess and gangrene. . 

Abscess 

Chronic abscess in right 
Acute ditto in left lobe . 
Vast hepatic abscess . . . 
Numerous abscesses . . . 
Red softening 



LIVER, (DISEASES OF THE) 



Digestive tubes and ducts. 



Duodenitis 
I Chronic gastro-duodenitis 



Healthy No jaundice. 

Colitis No jaundice. 

Gastro-enteritis No jaundice. 



Skin. 
No jaundice. 
No jaundice. 

No jaundice, (slight yellow- 
ness at the commencement.) 



It is obvious, from the inspection of this table, 
that we cannot arrive at any explanation of the 
presence or absence of jaundice in cases of hepatic 
inflammation, from the consideration of the cir- 
cumstance of gastro-intestinal complication. We 
see here cases of hepatitis with jaundice, in which 
the digestive tube was free from disease, and the 
same symptom with gastro-intestinal inflamma- 
tion ; and, in the cases of hepatitis without jaun- 
dice, the tube was healthy in some and diseased 
in others. 

We may remark, while on this subject, that in 
hepatitis the biliary secretion is variously affected. 
In some it appears to be suspended, while in others, 
even after extensive suppuration of the liver, the 
gall-bladder has been found filled with healthy bile. 
We have observed these facts repeatedly in the 
Meath Hospital. Thus, in a case where a great 
number of abscesses were formed, the gall-bladder 
contained a perfectly transparent viscid fluid which 
did not coagulate by heat or the addition of nitric 
acid ; the fluid was perfectly colourless, and in 
short presented all the characters of pure mucus. 
Notwithstanding this appearance of the contents 
of the gall-bladder, it is most remarkable that the 
intestines contained a quantity of yellow mucous 
and fecal matter. In this case the mucous mem- 
brane presented indications of inflammation. 

In two other cases, where the most extensive 
destruction of the liver had taken place, the gall- 
bladder was found to contain a bile healthy to all 
appearance. In the first of these a chronic ab- 
scess existed in the right, and a recent abscess in 
the left lobe. In the second, the organ was com- 
pletely burrowed by numerous abscesses. In the 
different cases of hepatic abscess recorded by 
Louis, the greatest variety in the contents of the 
gall-bladder occurred. From these facts we seem 
justified in concluding that in acute hepatitis, and 
probably also in the chronic disease, we cannot 
form any exact diagnosis of the state of the liver 
from the appearance of the biliary secretions in 
the stools, inasmuch as in one case it is altered in 
its quality in a variety of ways, while in another, 
apparently the same condition of the organ, no 
perceptible change is observable. The truth is, 
that neither its presence, absence, nor alterations, 
give us any data to enable us to conclude as to the 
stage, extent, progress, or termination of the in- 
flammation ; and it is plain that under these cir- 
cumstances the state of the stools will but little 
assist our prognosis. It is probable, however, that 
a very copious secretion of bile is more favourable 
than the contrary, as the inflammation of secern- 
ing organs is generally more inveterate when their 
secretion is arrested. 

When hepatitis is once formed, it may termi- 
nate by resolution or by suppuration ; or the irri- 
tation may continue in a modified manner, so as 
lo be classed among chronic diseases of the liver. 



The indications of resolution are, in the first in- 
stance, the subsidence of the fever, the gastric 
symptoms, and the pain : this is followed by the 
disappearance of the tumefaction, which, though 
generally the last in the order of symptoms, often 
occurs with great rapidity. The infra-mammary 
and postero-inferior portions of the chest recover 
their clearness of sound on percussion ; the dila- 
tation of the side is no longer observed ; the right 
hypochondrium and epigastric region lose the ten- 
sion and fulness which occurred during the acuity 
of the disease. Although a few cases of suppu- 
ration without perceptible tumefaction of the organ 
have been met with, yet from our own experience 
we would say that the subsidence of the swelling 
is one of the most certain indications of the reso- 
lution of the disease, certainly more so than the 
disappearance of the fever and pain. 

But when suppuration is to occur, we often find 
that the tumefaction, so far from diminishing, be- 
comes increased, and this at a time when the fever 
is frequently changed in character and assumes a 
hectic type. Shiverings, more or less severe, are 
observed, with or without perspirations ; the pulse 
becomes small and rapid ; the countenance is 
pale, and a sour smell of the surface is perceptible. 
In one case we have observed a miliary eruption. 
There is generally a constant sense of weight and 
uneasiness in the right hypochondrium, and the 
pain has in some instances been found as it were 
to concentrate itself on a particular spot, probably 
corresponding to the principal collection of pus. 
After some time a fluctuating tumour may appear 
generally in the epigastrium or some part of the 
right hypochondrium, which is followed by dis- 
coloration of the integuments ; but in other cases 
no such occurrence takes place, and we must be 
guided by the history of the case and the consti- 
tutional symptoms in forming the diagnosis of 
suppuration. Should the tumefaction persist, with 
a fever either of the continued or remittent type, 
we may suspect the formation of matter. When, 
however, the abscess forms so as to be perceptible 
by manual examination, we may observe the fol- 
lowing conditions : — 1, a generally enlarged state 
of the organ, in which, though no perceptible fluc- 
tuation exists, a doughy or boggy feel is commu- 
nicated over a greater or less portion of the tu- 
mour; 2, distinct tumefaction below the margin 
of the rib ; 3, a tumour in the epigastrium ; and, 
4, a bulging of the false ribs, with more than usual 
fulness of the intercostal spaces. 

But it must be always borne in mind, that al- 
though the constitutional symptoms frequently 
undergo a remarkable change at the moment of 
suppuration, yet there are abundance of cases in 
which the change is scarcely if at all perceptible. 
To this we shall recur in speaking of the difficul- 
ties in the diagnosis of this disease. 

The constitutional symptoms which are of 



LIVER, (DISEASES OF THE) 



167 



most value are, the supervention of night pcrspi- I 
rations, shivcrings, cold sweats, clamminess of the j 
skin, and frequent fainting sensations. If this 
state has arisen in a case where it has been found 
impossible to affect the system with mercury, the 
diagnosis of abscess may be made with a great 
degree of certainty. In this last and most im- 
portant statement, the best East India practitioners 
agree, and we have heard one gentleman, who 
occupies a high rank in the service, declare that 
he never yet knew a case of abscess of the liver 
in which ptyalism was induced, even although 
the largest quantities of mercury had been ex- 
hibited. Mr. Annesley says, " that there can be 
no doubt that the system will not be brought 
under the full operation of mercury, or that ptyal- 
ism will not follow on the most energetic employ- 
ment of this substance, when abscess exists, al- 
though a slight tenderness of the gums will be 
produced by it." As far as our experience in the 
Meath Hospital has gone, we should say that the 
same circumstance holds good in the case of 
hepatic suppuration in these countries ; but it is 
not peculiar to inflammation of the liver, as it is 
observed in other cases of intense visceral inflam- 
mation, in which, when ptyalism is induced, it is 
obviously the effect and not the cause of the re- 
duction of the visceral disease ; and we have no 
doubt that, from not properly estimating this cir- 
cumstance, practitioners have erred with respect 
to the curative powers of mercury, and have done 
injury by the introduction of enormous quantities 
of this mineral into the system at a time when 
the violence of the local action prevents its specific 
and sanative effects on the economy. 

The terminations of these cases of hepatic ab- 
scess are various. We have already alluded to 
the internal openings of the abscess in describing 
the pathological anatomy of the liver in a state 
of inflammation. In these cases the diagnosis^ is 
to be made on the same principles which Louis 
has laid down in speaking of peritonitis from per- 
foration of the intestine : there is a sudden ap- 
pearance of a new train of symptoms, accompa- 
nied in almost all cases by subsidence of the 
hepatic tumour. Thus, when the matter makes 
its way into the lungs by the mechanism which 
we have before described, a sudden and copious 
expectoration of puriform matter has been com- 
monly observed : this is accompanied by a re- 
markable diminution in the hepatic tumour. 
Should these symptoms arise in a case where 
previously there had been no evidence of disease 
in the pulmonary parenchyma, the diagnosis may 
be still more certain. We had once an oppor- 
tunity of making a stethoscopic observation of 
this most interesting lesion ; the patient had reco- 
vered from an attack of that violent gastric fever 
accompanied by yellowness of the skin which we 
have described in the article Enteritis, when he 
again came under our care, labouring under symp- 
toms of hectic fever, which proved ultimately to 
proceed from hepatic suppuration. This patient 
had a constant dry cough, which led us to make 
repeated stethoscopic examinations without our 
being able to detect any disease whatsoever in 
either lung : in less than twelve hours after the 
last stethoscopic observation the patient was sud- 
denly seized with a feeling of suffocation, and 



began to expectorate large quantities of perfectly 
formed pus, of which in the course of the night 
he discharged upwards of a pint and a half. On 
the following morning the left lung, which the 
day previously had presented no morbid sign 
whatever either by the stethoscope or percussion, 
was found completely dull over the whole region 
of the lower lobe, with complete extinction of the 
respiratory murmur : there was no bronchial re- 
spiration, no resonance of the voice, dilatation of 
the side, nor displacement of the heart; nor was 
there any constitutional symptom indicative of 
either pleuritic or pneumonic inflammation. The 
patient continued to expectorate copiously for 
some days, and after the second day the morbid 
phenomena of the chest began to subside. We 
had, first, a mucous rattle audible at the root of 
the lung, which gradually extended over the dull 
portion, and was followed by a return of the re- 
spiratory murmur and resonance of the voice. 

This stethoscopic observation, for the accuracy 
of which we pledge ourselves, is explicable only 
by the sudden filling of all the bronchial tubes 
with purulent matter. Let us observe, first, the 
sudden supervention of dulness and absence of 
respiration in a patient whose chest a few hours 
before presented no morbid phenomenon ; this is 
accompanied by a copious expectoration of puru- 
lent matter, and there are no constitutional symp- 
toms of pleurisy or of pneumonia. The absence 
of these symptoms is of great importance, be- 
cause if the disease had proceeded from either of 
these lesions, it must have been of extraordinary 
violence, and would have certainly been accom- 
panied by high constitutional and local symptoms, 
There was no dilatation of the side, or displace- 
ment of the heart, so that the diagnosis lay be- 
tween hepatization of the lung and the sudden 
filling of the tubes with pus ; but there was no 
bronchial respiration nor resonance of the voice, 
which would have occurred had it been hepatiza- 
tion, but which were absent because the large 
tubes were completely filled ; and further, during 
the recovery of the patient the phenomena of the 
voice were exactly the reverse of those in pneu- 
monic resolution. Thus, in the latter the reso- 
nance decreases, while in this case it increased; — 
in hepatization, because the air-cells recover their 
permeability, and the morbid subsides into the 
natural bronchophony ; — in the case under con- 
sideration, because the emptying of the tubes 
permitted the return of the natural resonance of 
the voice. The resolution of pneumonia is ac- 
companied by decrease of bronchophony, while 
in the case before us it was accompanied by in- 
crease. 

In the majority of cases the matter discharged 
from the chest consists of well-formed pus. In a 
case, however, reported by Annesley, the opening 
of an hepatic abscess was followed by a violent 
purulent and bloody expectoration ; the patient 
experienced a great sense of suffocation when he 
lay on his back, and on dissection a vast hepatic 
abscess was found communicating with the poste- 
rior portion of the lung. We have witnessed a 
case of the same lesion, in which, whenever the 
patient turned on the left side, a large quantity of 
purulent matter was dischaiged from the trachea. 

It is hardly possible to confound this accident 



168 



LIVER, (DISEASES OF THE) 



with any disease of the lung, properly so called, 
particularly if by stethoscopic observation we have 
been satisfied of the previously healthy condition of 
the organ. The only cases which might possibly 
be confounded with it arc the rare instances of the 
opening of an empyema into the lung, or the sud- 
den secretion of purulent matter in quantity by 
the bronchial mucous membrane, of which a few 
instances are recorded.* 

We have already spoken of the rarity of hepa- 
tic abscess opening into the general cavity of the 
pleura — a circumstance explicable by the adhe- 
sions which are formed between the two surfaces 
of the pleura, and which have the effect of direct- 
ing the matter into the substance of the lung. 
From the rarity of these cases, it is difficult to 
state the symptoms of this lesion ; yet in a case 



abdominal parietes as far as the peritoneum, and 
keeping the wound plugged with lint. This was 
done, yet after six days had elapsed, no matter 
made its appearance. Soon after this a circum- 
scribed tumour, evidently containing fluid, sud- 
denly appeared between the median line of the 
epigastrium and the termination of the wound. It 
is important to remark that this tumour was not 
preceded by any local induration, but at once pre- 
sented fluctuation. In consultation, however, it 
was determined to open it cautiously by means 
of a lancet, when, in place of matter, there was a 
gush of dark-coloured bile : the tumour disap- 
peared, but fulness of the side continued. About 
four hours after this operation the patient ex- 
pressed a sudden desire to go to stool, and passed 
two copious discharges of purulent matter with 



where a sudden occurrence of the signs of effu- j bilious fseces. This was followed by remarkable 

improvement, and the tumefaction rapidly dimin- 
ished, so that in a few days all swelling of the 
right hypochondrium had disappeared. A diarrhoea, 
however, continued from the time of the disappear- 
ance of the tumour, and resisted every attempt to 
check it. Twenty-three days after the subsidence 
of the first tumour, a small hard swelling was ob- 
served in the epigastric region, about the size of 
an egg ; this increased daily, and soon becamo 
fluctuating. On the thirteenth day after this, 
sudden and violent peritonitis set in, with subsi 
dence of the epigastric tumour. He lived eight 
days longer, the diarrhoea continuing until his 
death. 

From considering the various symptoms in this 
case, we made the following diagnosis publicly, 
before dissection; viz. 1. that the gall-bladder 
would be found to have been punctured, but that 
from peritonitis not having set in on that occasion, 
it was probable that its fundus was adherent ; 2. 
that a chronic abscess would be found in the right 
lobe of the liver, which was the cause of the first 
symptoms, and in all probability of the persistent 
diarrhoea, from a communication remaining open 
between it and some portion of the digestive tube; 
3. that a recent abscess would be found in the left 
lobe, which had opened into the peritoneum, and 
had caused death by peritonitis. 

On dissection, the peritoneum was found of a 
deep-red colour, containing a quantity of serous 
fluid, in which was a large quantity of flocculi, 
forming masses having the consistence of jelly ; 
the liver was generally adherent to the diaphragm 
and abdominal parietes, the adhesions of the right 
lobe being strong and ancient, those of the left soft 
and recent. In the left lobe an abscess of the size 
of an orange was discovered a little above its lower 
edge, and communicating with the peritoneal 
cavity by a fistulous opening, sufficiently large to 
admit a quill. In the right lobe we found a 
cavity of the size of an egg, empty, and lined 
with a semi-cartilaginous membrane of a dark 
iron-grey colour : this communicated with the 
duodenum by an opening large enough to admit 
the finger with case. The gall-bladder presented 
superiorly a spot exactly corresponding to the 
size and form of a lancet puncture, which was 
covered by a thin transparent membrane. (Dub- 
lin Hospital Reports, vol. v.) 

But hepatic abscess frequently proves fatal 
without any rupture internally or externally. In 



sion into the pleura, accompanied by the disap- 
pearance of those of the hepatic abscess, were ob- 
served, the diagnosis might be made with a great 
degree of probability. 

A not unfrequent termination of hepatic ab- 
scess is by the establishment of a communication 
with some portion of the digestive canal. The 
stomach, duodenum, and colon, are the parts in 
which the communication has been most com- 
monly observed ; and the circumstances which 
appear to influence the point of communication 
are principally the situation of the abscess and the 
general volume of the hepatic tumour. When the 
matter makes its way into the stomach, a sudden 
vomiting of purulent fluid, with subsidence of 
hepatic tumour, has been observed. When, on 
the other hand, it opens into the intestine, we 
have a sudden diarrhoea, followed by the same 
phenomenon. From instances of recovery under 
these circumstances, it seems fair to infer that a 
cure by cicatrization of the opening is not unfre- 
quent ; but the opening may become fistulous, 
and continue until the fatal termination of the 
case. This occurred remarkably in a case the par- 
ticulars of which we shall just now detail, and 
which we before alluded to. 

Rupture into the peritoneal sac seems to be 
more frequent than the opening into the pleura, a 
circumstance to be expected from the smaller de- 
gree of liability of this membrane to form adhe- 
sions. When it does occur, we have violent 
peritonitis supervening; but the full evacuation 
of the abscess is not a necessary consequence. 
The following unique case is highly instructive, 
as illustrating the rupture of hepatic abscesses both 
into the digestive canal and peritoneum. 

A man, aged 39, was admitted into the Meath 
Hospital in August, 1828, labouring under hectic 
fever, with cough and nausea. He complained 
of great soreness from the fourth rib on the right 
side downwards. The hypochondrium was full 
and tender, and the side dilated one inch and a 
half, without distension of the intercostal spaces. 
Having recognised that the disease was hepatic, 
and suspecting that an abscess, deep-seated, had 
formed, we determined on performing the opera- 
tion, first proposed by Dr. Graves, of dividing the 



* See Van Swieten, Comment, vol. iv. p. (;o. Lps Ephc- 
merides ties curieux de la Nature. Baumcs, Traite de la 
Pbthisie. Hippocrat. de morbus vulgaribus. jSndral, 
Olinique Medicate. 



LIVER, (DISEASES OF THE) 



169 



these cases, as Broussais has well observed, the 
diseased action is seldom confined to the liver, but 
commonly occurs in some other organ, such as 
the gastro-intestinal mucous membrane, the lungs, 
or brain ; of these the first is by far the most fre- 
quent. The actual state of pathology, however, 
does not permit us to adopt the opinion of Brous- 
sais as to the constancy of this complication, but 
the fact of its frequency is well established, and 
becomes of great importance in practical medi- 
cine. In all the cases of abscess of the liver re- 
corded by Andral, there is but a single instance 
where the disease occurred without complication 
with lesion of other organs. 

Suppuration of the liver has occurred without 
any of the characteristic symptoms of hepatitis. 
Thus, in the twenty-sixth observation of Andral, 
numerous abscesses, with redness and softening 
of the hepatic tissue around them, were found, 
yet the patient never had pain or tumour in the 
region of the liver, nor was he jaundiced : in this 
case there was complication with acute pneumonia 
and gastritis. In another case, where a scirrhous 
state of the stomach existed, numerous partial in- 
flammations of the liver and an abscess were dis- 
covered ; the patient never had either icterus or 
pain either in the hypochondrium or right side 
of the chest. The same author details a case 
where an hepatic abscess with gangrene was dis- 
covered after death, and in which all the charac- 
teristics of an hepatic affection were absent. The 
patient laboured under a chronic bronchitis and 
gastritis. We have known two cases where nu- 
merous abscesses were found in the liver, and in 
which the symptoms were merely those of con- 
tinued fever, without any indication which could 
lead to the suspicion of the disease. Other in- 
stances might be quoted, but such cases are com- 
paratively rare, and should not discourage the 
student, or render him too sceptical as to the 
powers of diagnosis. 

In certain cases, the gall-bladder becomes dis- 
tended with bile so as to form a tumour in various 
situations along the margin of the liver, represent- 
ing in many particulars the phenomena of an 
hepatic abscess so completely, that the most emi- 
nent practitioners have been deceived in their 
diagnosis. It is extremely difficult to lay down 
rules by which this affection can be distinguished 
with absolute certainty. The obstruction of the 
ducts in most cases has been preceded by more 
or less of indications of hepatic disturbance, which 
it is impossible to say did not proceed from dis- 
ease of the parenchyma of the liver. In the case 
which we have recorded, there was actually an 
hepatic abscess at the time when the distension 
of the gall-bladder occurred, and which was evi- 
dently its cause, so that in this case we had 
the local and constitutional symptoms of hepatic 
suppuration preceding the tumour, caused by the 
gall-bladder. In this case, then, the previous 
symptoms could only mislead us as to the nature 
of the tumour. We are not, however, aware of 
any other case where the tumefaction of the gall- 
bladder was preceded by an hepatic abscess. 

In the first volume of the Dublin Hospital 
Reports, a most interesting case of enlargement 
of the biliary duct is recorded by Mr. Todd. The 

Voi. III. — 22 p 



patient, a delicate girl, had been in bad health for 
some months previous to her death, during which 
she had had severe fever, with several relapses. 
When she was first seen by Mr. Todd, she was 
nearly insensible ; she moaned incessantly, and 
frequently screamed, as if seized suddenly with 
acute pain ; the skin was of a deep orange colour, 
and she was greatly emaciated. On examination, 
it was found that the abdomen was distended 
with fluid, and that the epigrastic and right hypo- 
chondriac regions were occupied by a tense swell- 
ing, which could be traced extending even below 
the umbilicus. A distinct fluctuation was per- 
ceptible at the most prominent point, a little below 
the ensiform cartilage, and a little to the right of 
the linea alba. This part was extremely sensible, 
and hence it was thought probable that a large 
abscess of the liver was here approaching the sur- 
face. With this impression, and anxious to afford 
immediate relief, Mr. Todd made an opening into 
the most prominent part of the tumour, when a 
thin fluid coloured with green bile escaped ; a 
canula was then introduced with a view to pre- 
vent the escape of the fluid into the peritoneal 
cavity, when upwards of two quarts of a viscid 
green bile were discharged. After the operation, 
all the tumefaction of the abdomen had subsided, 
and no enlargement of the liver nor any other 
swelling could be detected. In the evening, how- 
ever, the belly became swollen, painful, and tense, 
and the patient died on the following day. On 
dissection, the peritoneum was found inflamed, 
and containing a serous and bilious fluid : the 
liver was perfectly healthy, and the gall-bladder 
was found empty and contracted ; but the hepatic 
and common • ducts were found to be enormously 
distended, forming a sac, which still contained 
more than a quart of bile, and extending from 
the porta of the liver to the os sacrum, lying be- 
hind the duodenum, pancreas, and root of the 
mesentery, and stretching in a transverse direc- 
tion, so as to cover the anterior surface of the 
right kidney, and the greater part of the left. 

Andral relates several cases of distended gall- 
bladder forming an evident and fluctuating tu- 
mour in various portions of the abdomen. He has 
seen it, 1st, immediately below the